Fairfax Rehabilitation And Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure residents were free of unnecessary psychotropic medications for 2 of 41 sampled residents (Resident #167 and Resident #138). The findings included: 1. For Resident #167, the facility staff failed to monitor behavioral symptoms indicating the continued need for psychotropic medications. Resident #167's diagnosis list indicated diagnoses, which included, but not limited to Severe Dementia with Behavioral Disturbance, Psychosis, Generalized Anxiety Disorder, Major Depressive Disorder, and Adult Failure to Thrive. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/04/25 coded the resident as being severely impaired in cognitive skills for daily decision making with short-term and long-term memory problems. Resident #167's comprehensive person-centered care plan included focus areas stating in part the resident was at risk for adverse reactions related to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, resident interview, clinical record review and facility document review, the facility staff failed to prepare or orient residents for transfer to the hospital for 1 (one) of 41 current residents in the survey sample, resident #434. The findings include: For resident #434 (R434) the facility staff failed to provide evidence of preparing the resident for a transfer to the hospital on 6/19/2025. On 6/24/2025 this surveyor interviewed R434 at bedside. They stated they were readmitted to the facility on [DATE] after a brief hospitalization. I had pneumonia and sepsis they said. I didn't know I was sick. The ambulance showed up to get me and took out. I guess it was a good thing though. This surveyor asked resident if the staff had explained that they were calling 911 due to a change in condition. No, I didn't know what was happening. The clinical record was reviewed. According to the demographic sheet, R434 is their own responsible party (RP). R434's minimum data set (MDS) assessment with an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and clinical record review, the facility staff failed to ensure an accurate minimum data set (MDS) assessment for 2 of 41 residents, Residents #44 and #85. The findings included: 1. For Resident #44, the facility staff failed to code an antiplatelet medication on an annual MDS assessment and coded the MDS assessment to indicate a gradual dose reduction (GDR) had been completed in May 2025 when a GDR had not been attempted. Resident #44's diagnoses included bipolar disorder and schizoaffective disorder. Section C (cognitive patterns) of Resident #44's annual MDS assessment with an assessment reference date (ARD) of 06/06/25 included a brief interview for mental status (BIMS) score of 14 out of a possible 15 points. Indicating Resident #44 was cognitively intact. Section N (medications) was coded to indicate this resident was currently taking an antipsychotic, antianxiety, antidepressant, and anticonvulsant medication. It was not coded to indicate that the resident was receiving an antiplatelet. Section N was coded to indicate a GDR was last attempted on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to review and revise the comprehensive person-centered care plan for 1 of 41 sampled residents (Resident #3). The findings included: For Resident #3, the facility staff failed to revise the comprehensive person-centered care plan (CPCCP) following the discontinuation of a left-hand splint. Resident #3's diagnosis list indicated diagnoses, which included, but not limited to Vascular Dementia, Hemiplegia and Hemiparesis, and Osteoarthritis of the Left Hand. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 4/28/25 assigned the resident a brief interview for mental status (BIMS) summary score of 5 out of 15 indicating the resident was severely cognitively impaired. Resident #3's current CPCCP included a focus area stating, Resident post CVA [cerebrovascular accident] with LUE [left upper extremity] hand and wrist Hemiplegia and Contracture with an intervention dated 5/29/18 stating in part .assess skin integrity around splint as needed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

2. For Resident #167, the facility staff failed to provide assistance with the removal of facial hair. Resident #167's diagnosis list indicated diagnoses, which included, but not limited to Severe Dementia with Behavioral Disturbance, Aphasia, and Adult Failure to Thrive. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/04/25 coded the resident as being severely impaired in cognitive skills for daily decision making with short-term and long-term memory problems. Resident #167 was coded as requiring substantial/maximal assistance with personal hygiene. Resident #167's comprehensive person-centered care plan included a focus area stating the resident requires assistance with their activities of daily living. The resident's care plan did not address their desire regarding facial hair. Surveyor observed Resident #167 on 6/24/25 at 10:52 AM, 6/25/25 at 8:41 AM, and 6/25/25 at 2:30 PM and on each occasion the resident had a large amount of thick, white facial hair present on her chin. On 6/25/25 at 2:32 PM surveyor spoke with the Unit Manager (UM)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to follow the provider orders for medication administration for 1 of 41 current residents Resident #33 and failed to follow the providers orders for treatments for 2 of 41 current residents, Residents #99 and #390. The findings included: 1. For Resident #33, the facility staff failed to administer the provider ordered medication Gabapentin. Resident #33's diagnoses included polyneuropathy, osteoarthritis, and anxiety. Section C (cognitive patterns) of Resident #33's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 05/29/25 included a brief interview for mental status (BIMS) score of 15 out of a possible 15 points. Indicating this resident was cognitively intact. Resident #33's comprehensive care plan included the focus area at risk for complications related to the use of opioid secondary to neuropathy and arthritis. Interventions included administer medications as ordered. Resident #33's clinical record included a provider order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, resident and staff interview and clinical record review, the facility staff failed to flush the peripherally inserted central catheter (PICC line) per the provider orders for 1 of 41 current residents in the survey sample, resident #433. The findings include: For resident #433 (R433) failed to flush the resident's PICC line (a device inserted into a large vein in the upper arm that is used to draw blood and give treatments, including intravenous fluids, drugs, or blood transfusions), per the provider order dated 6/21/25. R433 was a recent admission and there was no minimum data set completed yet. R433 was alert and oriented to self, time and place. On 6/24/25 at 10:30 AM, this surveyor interviewed R433 at bedside. R433 stated they were newly admitted to the facility and was there due to a wound infection on their foot. I have to be here for 6 weeks for antibiotics. This surveyor observed a PICC line in the upper left arm and there was an empty bag of intravenous ertapenem on an IV pole at the bedside. This surveyor asked if the staff were flushing the line…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to use appropriate alternatives prior to installing a side/bed rail for (1) one of (41) forty-one sampled residents. (Resident #75). The findings included: For Resident #75, the facility staff failed to provide evidence of appropriate alternatives prior to the installation of a 1/8 side rail and the current side rail evaluation failed to indicate the need for a side rail. Resident #75's diagnosis list indicated diagnoses that included, but were not limited to, Hypertension, Insomnia, Localized Swelling-Mass and Lump-Trunk, Weakness, Anxiety Disorder, Adjustment Disorder with Disturbance of Conduct, Dementia, Polyneuropathy, Congestive Heart Failure, and Depression. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/16/25 assigned the resident a brief interview for mental status (BIMS) summary score of 10 out of 15 for cognitive abilities indicating the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview, clinical record review, and facility document review the facility staff failed to ensure a medical provider reviewed medication regimen reviews in a timely manner and the facility staff failed to ensure a medical provider acted upon and/or provided rationale of pharmacy recommendations in a timely manner for (2) two of (41) forty-one sampled residents, (Resident #88 and Resident #138). The findings included: 1.For Resident #88 the facility staff failed to provide evidence of medication regimen reviews (MRRs) being reported to and acted upon by the medical provider in a timely manner. Resident #88's diagnosis list indicated diagnoses that included, but were not limited to, Right Femur Fracture, Chronic Kidney Disease-Stage 3, History of Falls, Dementia, Depression, Atherosclerotic Heart Disease, Weakness, Irritable Bowel Syndrome, Seizures, Hypertension, and Dysphagia. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 4/3/25 assigned the resident a brief interview for mental status (BIMS) summary score of 9 out of 15 for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure a medication error rate of less than 5%. There were 2 errors in 30 opportunities for a medication error rate of 6.67%. These medication errors affected Resident #59. The findings included: The facility nursing staff failed to administer the correct dosage of the medications Sertraline and B12. On 06/26/25 at 8:13 a.m., the surveyor observed Licensed Practical Nurse (LPN) #1 prepare and administer Resident #59's morning medications. LPN #1 placed 1 tablet of Sertraline 25 mg and 1 tablet Vitamin B12 500 mcg in a medication cup with Resident #59's other medications and administered these medications to Resident #59. A review of Resident 59's clinical record included the following provider orders. Sertraline 25 mg give 1.5 mg tablets by mouth one time a day for depression. For a total of 37.5 mg. Cyanocobalamin tablet (B12) 500 mcg give 2 tablets by mouth one time a day for B12 deficiency. After the medication reconciliation the surveyor interviewed LPN #1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

2. The facility staff failed to follow infection control guidelines during a medication pass and pour observation. The facility staff were observed dropping a medication on top of the medication cart, picking it up with their bare hands, and placing it into a medication cup for administration. On 06/26/25 at 8:18 a.m., during a medication pass and pour observation with Licensed Practical Nurse (LPN) #1 this nurse was observed to drop the medication Bupropion on top of the medication cart. LPN #1 picked this medication up with her bare hands and stated you didn't see that and then put the medication in the medication cup with 3 other medications. LPN #1 placed 2 other medications in this cup. The surveyor stopped LPN #1 prior to them entering the residents room and asked the nurse about administering the contaminated medications. LPN #1 stated they were going to administer the medications they had cleaned the top of their cart. When asked about touching the medication with their bare hands LPN #1 stated what should I do. LPN #1 asked the Unit Manager LPN #9 for guidance. The Unit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, the facility staff failed to offer a resident a pneumococcal vaccine in accordance with nationally recognized standards for 2 of 5 sampled residents (Resident #3 and Resident #108). The findings included: 1. For Resident #3, the facility staff failed to discuss and/or offer the resident/resident representative a pneumococcal conjugate vaccine 20 (PCV20) or pneumococcal conjugate vaccine 21 (PCV21). A review of the Centers for Disease Control and Prevention (CDC) guideline titled Shared Clinical Decision-Making PCV20 or PCV21 Vaccination for Adults 65 Years or Older dated 9/11/24 read in part that adults [AGE] years of age or older have the option to receive supplemental PCV20 or PCV21 (not both) if they previously completed the pneumococcal vaccine series with both PCV13 and pneumococcal polysaccharide vaccine (PPSV23) and meet the following criteria: Previously received one dose of PCV13 at any age, and previously received all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, the facility staff failed to offer an updated 2024-2025 COVID-19 vaccine for 2 of 5 sampled residents, Resident #3 and Resident #108. The findings included: 1. For Resident #3, the facility staff failed to offer the resident/resident representative a 2024-2025 COVID-19 vaccine. Resident #3's diagnosis list indicated diagnoses, which included, but not limited to Vascular Dementia, Chronic Kidney Disease, Congestive Heart Failure, and History of Recurrent Pneumonia. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 4/28/25 assigned the resident a brief interview for mental status (BIMS) summary score of 5 out of 15 indicating the resident was severely cognitively impaired. According to Resident #3's immunization history documented in the clinical record, the resident had previously received a COVID-19 vaccine on 10/23/23. On 6/25/25, surveyor reviewed Resident #3's clinical record and was unable to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and resident interview the facility staff failed to provide a way for residents to call for staff assistance through a communication system for one of 41 current residents in the survey sample, resident #433. The findings include: On 6/24/2025 at 10:30 AM this surveyor interviewed resident #433 (R433). During the course of the interview, the resident stated, They don't have one of those call buttons like the hospital, I just have to wait until one of them comes in to ask for anything. This surveyor informed resident that he has to have a call light and began looking for it. The call light was attached to the bottom bedsheet below R433's knees where it could not be seen. Call light was placed with reach of #433. On 6/25/2025 at 8:20 AM this surveyor observed resident in bed with eyes closed. The call light for R433 was in the floor by the bed. On 6/25/2025 at 9:44 AM this surveyor observed Registered Nurse (RN) #8 and the wound care Nurse Practitioner (NP) perform wound care and a skin assessment on R433. The call light was in the floor throughout the encounter.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interviews, the facility staff failed to store food in accordance with professional standards for food service safety in the facility kitchen. The findings included: The facility staff failed to discard out of date perishable food items, failed to store food preparation pans clean, failed to promptly discard unused food items, failed to utilize beard restraints for male dietary aides, and failed to ensure foods were stored at safe temperatures. On 6/24/25 at 9:39 AM, surveyor entered facility kitchen for an initial tour with dietary manager-other staff #9 (OS#9) and regional dietary manager-other staff #11 (OS#11). Surveyor observed three reach-in refrigerators in the kitchen food prep area. The thermometer on refrigerator #1 was 50 degrees, no food items were present in the refrigerator. Refrigerator #2 had a sign on the door which read, Out of Order and inside was one tray of peaches in individual bowls with no lids, one tray of pudding in individual bowls with lids, and one tray of a small salad containing cucumber slices in souffle cups with no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, the facility staff failed to notify the Ombudsman of transfer or discharge for 2 of 41 residents and failed to provide the receiving entity with proper documentation upon transfer for 1 of 41 residents. (Resident #155, #138, and #434) The findings were: 1. For Resident #155, the facility staff failed to notify the ombudsman of the resident's discharge on [DATE]. Resident #155's minimum data set (MDS) assessment with an assessment reference date of 05/19/25 was signed as completed on 05/23/25. Resident #155's brief interview for mental status summary score was documented as a 15 out of 15; this indicated intact cognition. Resident #155's clinical record was reviewed and indicated the resident was discharged home with home health services on 06/07/25. The Discharge Instructions/Post Discharge Plan of Care - V6 document read the resident's discharge status/facility was Home. The summary/discharge arrangements read in part, Resident will…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and facility document review, the facility staff failed to act with accepted professional standards and principles that apply to professionals providing services to the facility. The findings included: The facility administration failed to operate and provide services with accepted professional standards and principles that apply to professionals providing services to the facility as related to an outstanding balance owed to a contracted staffing agency for services rendered from May 19, 2023, through September 29, 2023. On 6/24/25, this surveyor spoke with regional vice president of operations and requested information pertaining to a staffing agency that the facility owed an outstanding balance to over $911,000.00. On 6/25/25 at 9:15 AM regional vice president of operations informed surveyor he located a lawsuit from a staffing agency that is suing the facility. He provided surveyor with a copy of Complaint for Damages served on 6/17/25, a copy of the staffing agency/facility contract, and a copy of the outstanding balance due indicated on an invoice dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview, clinical record review and facility document review, the facility staff failed to administer medications per the physician's orders for one of _ residents in the survey sample, resident # 2 (R2). The findings included: For R2 the facility staff failed to administer scheduled Gabapentin, a medication for nerve pain for three days after admission to the center. R2s diagnosis included but were not limited to, diabetes, muscle weakness, hypertension and depression. R2s minimum data set (MDS) assessment with an assessment reference date of 6/20/24 assigned the resident a brief interview for mental status (BIMS) score of 14 out of possible 15 indicating resident was cognitively intact. Further review of the MDS revealed that resident had rated their pain in the last five days as height as an 8 out of 10 on the pain scale. They indicated that their pain was frequent and had interfered with sleep over the last five days. R2s Discharge Summary from the hospital was reviewed. Listed under the heading Discharge Meds the document read in part, Gabapentin (neurtontin)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and clinical record review, the facility staff failed to follow the medical provider orders for 1 of 4 sampled residents (Resident #2). The findings included: For Resident #2, the facility staff failed to administer Amlodipine and Propranolol as ordered on 10/11/24. Amlodipine and Propranolol are used to treat high blood pressure. Resident #2's diagnosis list indicated diagnoses, which included, but not limited to Essential Hypertension, Hemiplegia and Hemiparesis following Cerebral Infarction, and Chronic Myeloid Leukemia. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 10/04/24 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 indicating the resident was cognitively intact. Resident #2's current comprehensive person-centered care plan included a focus area stating the resident was at risk for cardiac complications secondary to hypertension with an intervention to administer medications as ordered. Resident #2's current provider orders included an order dated 9/30/24 for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to provide enteral feeding as ordered by the medical provider for 1 of 4 sampled residents (Resident #1). The findings included: For Resident #1, the facility staff failed to provide an ordered bolus tube feeding. Resident #1's diagnosis list indicated diagnoses, which included, but not limited to Acute Kidney Failure with Tubular Necrosis, End Stage Renal Disease, Hemiplegia and Hemiparesis following Cerebral Infarction, and Dysphagia following Cerebral Infarction. The minimum data set (MDS) with an assessment reference date (ARD) of 10/04/24 assigned the resident a Brief Interview for Mental Status (BIMS) summary score of 10 out of 15 indicating the resident was moderately cognitively impaired. Resident #1 was seen by Registered Dietitian (RD) #1 on 9/30/24. The assessment dated [DATE] at 10:09 AM read in part .rt [resident] reports >50 lbs. [pounds] weight loss in the past 6 months. Per transfer records, rt was on enteral nutrition…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure residents were free of significant medication errors for 1 of 4 sampled residents (Resident #3). The findings included: For Resident #3, the facility staff failed to administer the oral antibiotic Levofloxacin on three (3) separate occasions as ordered by the medical provider. Resident #3's diagnosis list indicated diagnoses, which included, but not limited to Malignant Neoplasm of the Larynx and Dysphagia. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/29/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #3 was seen by the physician on 10/08/24, the progress note read in part .The patient with pneumonia in the setting of chronic respiratory failure, status post tracheostomy with a history of cancer of the larynx. Complicated case with multiple comorbidities.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, facility document review, and clinical record review, the facility staff failed to notify the required individuals related to issues affecting residents' care and/or room assignments for three (3) of 15 sampled residents (Resident #3, Resident #5, and Resident #7). The findings include: 1. The facility staff failed to notify a medical provider of a decrease in Resident #7's urine output. The facility staff failed to ensure a medical provider was promptly notified each time Resident #7 refused their medications. Resident #7's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 6/1/24, was signed as completed on 6/14/24. Resident #7 was assessed as able to make self understood and as able to understand others. Resident #7's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact and/or borderline cognition. On 8/21/24 at 2:06 p.m., the surveyor interviewed the Director of Nursing (DON), Assistant DON (ADON),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interviews, facility document review, and clinical record review, the facility staff failed to maintain complete and/or accurate clinical records for one (1) of 15 sampled residents (Resident #7). The findings include: The facility staff failed to document who was notified of Resident #7's refusal of medications. The facility staff failed to document the response of the medical provider when notified of Resident #7 refusing medications. The facility staff failed to document how the medical provider was notified (e.g., via telephone, face-to-face, secure messaging, etc.). Resident #7's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 6/1/24, was signed as completed on 6/14/24. Resident #7 was assessed as able to make self understood and as able to understand others. Resident #7's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact and/or borderline cognition. On 8/21/24 at 2:06 p.m., the surveyor interviewed the Director of Nursing (DON), Assistant DON (ADON), and Nurse Practitioner…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interviews, facility document review, and clinical record review, the facility staff failed to develop and/or implement an activities care plan which addressed the findings of a resident's activity assessment for one (1) of 15 sampled residents (Resident #7). The findings include: The facility staff failed to ensure that Resident #7's care plan addressed the desire to participate in outdoor activities. Resident #7's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 6/1/24, was signed as completed on 6/14/24. Resident #7 was assessed as able to make self understood and as able to understand others. Resident #7's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact and/or borderline cognition. Resident #7's activities assessment, dated 9/17/23, indicated the resident reported it was 'very important' for the resident to go outside to get fresh air when the weather is good. The following information was found in a facility policy titled Care Planning (with an effective date of 11/1/19):…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and clinical record review, the facility staff failed to provide medications per the providers orders for 1 of 15 residents, Resident #4. The findings include: For Resident #4, the facility staff failed to provide Zofran per the providers orders. The facility nursing staff failed to transcribe an order for Zofran making the medication unavailable for administration. Resident # 4 diagnoses included, but were not limited to, peripheral vascular disease, diabetes, dependence on renal dialysis, and cellulitis of right lower limb. Section C (cognitive patterns) of Resident #4's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/20/23 included a brief interview for mental status (BIMS) summary score of 13. Per the MDS manual a score of 13=cognitively intact. Resident #4's clinical record included the following progress notes. 01/13/24- .Change in condition .Resident noted vomiting on 1/15/24. States it has been occurring since 1/13/24 .Primary Care Provider responded with the following feedback .Recommendations: Zofran . This…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to obtain provider ordered X-rays for 1 of 15 Residents, Resident #5. The findings include: For Resident #5, the facility staff failed to obtain provider ordered X-rays. One of these X-rays was ordered by the provider to be completed STAT (immediate). Resident #5's diagnoses included displaced fracture of base of neck of right femur, multiple sclerosis, type 2 diabetes, dementia, and muscle weakness. Section C (cognitive patterns) of Resident #5's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 10/19/23 included a brief interview for mental status (BIMS) summary score of 0. Per the MDS manual a score of 0=severe impairment. The clinical record included information to indicate this resident had a fall on 12/15/23 and on 12/16/23. On 12/15/23 the nursing staff documented resident was found in .the floor both legs pointing out to the exit door. Resident moves upper extremity and left leg without any…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview, the facility staff failed to provide a clean, homelike dining experience in one of four dining rooms. On 5/3/22, the facility staff provided lunch to residents in the fourth floor dining room without removing meal trays and trash on meal trays before the residents dined. The findings include: On 5/3/22 at 1:20 p.m., observation of staff serving 14 residents lunch in the fourth floor dining room was conducted. Staff served the meals and did not remove the trays containing the meals before the residents dined. Also, staff was observed removing plastic wrap that covered dessert bowls and plastic lids that covered some of the beverages. Staff placed the plastic wrap and plastic lids on the trays beside the meals and the trash remained on the trays while the residents dined. On 5/4/22 at 1:27 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated all items on the food trays should be removed from the trays and the tray should be set aside out of the residents' reach. LPN #1 stated trash articles such as plastic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and facility document review, it was determined the facility staff failed to develop and/or implement the comprehensive care plan for 14 of 55 residents in the survey sample; Residents #98, #144, #50, #132, #85, #9, #97, #18, #76 #419, #52, #82, #147 and #4. The findings include: 1. The facility staff failed to develop the comprehensive care plan for the use of bed rails for Resident #98. Resident #98 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: traumatic subdural hemorrhage, Parkinson's disease, encephalopathy and dementia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/1/22, coded the resident as scoring a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to monitor a resident's fluid intake while on a fluid restriction for one of 55 residents in the survey sample, Resident #52 (R52). The facility staff failed to record in April and May 2022, the amount of fluid consumed each shift by R52, who was on a physician ordered fluid restriction . The findings include: On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/14/22, R52 was coded as having no cognitive impairment for making daily decisions. R52 was coded as receiving dialysis services during the look back period. On 5/3/22 at 1:38 p.m., an interview was conducted with R52. R52 stated that the resident was on a fluid restriction ordered by his physician. R52 also stated that sometimes they were not compliant with the restriction. When asked if staff members consistently asked how much fluids R52 had consumed in a shift, R52 stated: No, almost never. A review of R52's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide care and service for a complete dialysis [1] program for one of 55 residents in the survey sample, Residents #97 (R97). The facility staff failed to assess R97's dialysis access site for bruit and thrill per physician order. The findings include: (R97) was admitted to the facility with diagnoses included but were not limited to: end stage renal disease [2], dependent on renal dialysis. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 04/05/2022, the resident scored 2 (two) out of 15 on the BIMS (brief interview for mental status), indicating the resident is moderately impaired of cognition intact for making daily decisions. Section O Special Treatments, Procedures and Programs coded (R97) for Dialysis while a resident. The physician's order sheet for (R97) documented in part, DIALYSIS: Hemodialysis Order set every shift Monitor AV (arterial/venous ) fistula (3) to L (left) arm Monitor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement bed rail requirements for 6 of 55 residents in the survey sample, Residents #368, #144, #50, #132, #4 and #147. The findings include: 1. The facility staff implemented bed rails for Resident #368 (R368) without a recommended need and failed to obtain informed consent for the use of bed rails. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/26/22, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident is not cognitively impaired for making daily decisions. A review of R368's clinical record revealed a bed rail evaluation dated 4/19/22. The evaluation documented, 20. Is the use of bed rail(s) likely to increase the risk of an accident or pose as a barrier for this patient? (i.e. Is it likely that the resident might attempt to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, resident interview, staff interview and facility document review, the facility staff failed to provide food at a palatable temperature during dinner service on 05/03/2022 with potential to affect 46 of 46 residents on the fourth floor receiving a meal tray. The findings include: On 5/3/22 at 1:38 p.m., Resident #52 (R52) was interviewed. (R52) had multiple complaints about the temperature of food that is delivered to the room. (R52) stated the meals rarely arrive at the meal times posted on the unit, and that the food is consistently on the cold side. (R52) stated staff are too busy helping feed dependent residents to heat the food to a more palatable temperature. (R52) stated they did not want to bother staff to reheat the food, and that reheated food just is not as appealing. On 05/03/2022 at approximately 4:15 p.m., the holding temperatures of dinner meal, obtained from the service line in the kitchen were: Whole crab cakes - 171 degrees Fahrenheit Chopped crab cakes - 169 degrees Fahrenheit Pureed crab cakes - 181 degrees Fahrenheit Vegetables- 180 degrees…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview and facility document review, the facility staff failed to maintain five of five dumpsters in a sanitary manner. Two outside dumpsters were observed with their door open and approximately eight pairs of used plastic gloves and numerous pieces of debris, including several pieces of cardboard and trash were found lying on the ground around and behind the facility's dumpsters. The findings include: On 05/03/2022 at approximately 12:20 p.m., an observation of the facility's dumpsters was conducted with OSM (other staff member) # 6, director of maintenance. When asked who was responsible for maintaining the dumpsters and the immediate area around the dumpsters in a clean and sanitary manner OSM # 6 stated that it was the maintenance department. The observation revealed that the facility had five trash dumpsters located toward the rear of the facility. An observation of the dumpsters revealed the sliding side doors on two of the dumpsters were fully open. Observations of the area between and behind the five dumpsters revealed a broken mop handle next…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, facility document review and in the course of complaint investigation, the facility staff failed to uphold a resident's dignity for two of 55 residents in the survey sample, Residents # 76 and # 419. The findings include: 1. Facility staff failed to respond to Resident # 76's (R76) vocalizations/yelling. (R76) was admitted to the facility with a diagnosis that included by not limited to: slurred speech. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 03/24/2022, the resident scored 3 (three) out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely impaired of cognition for making daily decisions. On 05/03/22 at 1:54 p.m., auditory (hearing) observations from the hallway outside of (R76's) room revealed vocalizations/yelling coming from (R76) appeared to indicate a need for attention or assistance. Visual observation from the hallway outside of (R76's) room revealed CNA (certified nursing assistant) # 16 walking past (R76's) room while they were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview and clinical record review, the facility staff failed to provide accommodations of resident needs by ensuring the call bell [a device with a button that can be pushed to alert staff when assistance is needed] was within reach for one of 55 current residents in the survey sample, Resident # 76 (R76). The findings include: The facility staff failed to keep (R76's) call bell within their reach. (R76) was admitted to the facility with a diagnosis that included by not limited to: slurred speech. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 03/24/2022, the resident scored 3 (three) out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely impaired of cognition for making daily decisions. Section G Functional Status coded (R76) as no impairment of upper extremities (shoulder, elbow, wrist, hand). On 05/03/22 at 1:54 p.m., an observation of (R76) in their room revealed they were sitting in wheelchair toward the foot of the bed. Observation of the call…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to notify the provider (physician/nurse practitioner) when medications were not available for administration for one of 55 residents in the survey sample, Resident #52 (R52). The facility staff failed to notify the provider that R52's scheduled medications were not available for administration on 4/14/22, 4/24/22, and 4/26/22. The findings include: On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/14/22, R52 was coded as having no cognitive impairment for making daily decisions. R52 was coded as receiving dialysis services and as receiving insulin injections during the look back period. On 5/3/22 at 1:38 p.m., an interview was conducted with R52. R52 stated that during the previous few weeks, they did not receive medications related to diabetes and to dialysis because they were not in the medication cart…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and facility document review, it was determined the facility staff failed to preserve a resident's privacy during a physical examination by the nurse practitioner for one of 55 residents in the survey sample, Resident #419 (R419). R419 was seated in a wheelchair in full public view when the nurse practitioner (NP) performed an examination of the resident on 5/4/22. The findings include: On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/29/22, R419 was coded as having short term and long term memory problems, and as being severely impaired for making daily decisions. R419 was coded as requiring the extensive assistance of two staff members for transferring and moving around the unit. On 5/4/22 at 12:09 p.m., R419 was sitting in a wheelchair outside the doorway to the dining room, adjacent to the nurses' station, in full public view. ASM (administrative staff member) #7, a nurse practitioner, knelt in front of the resident. ASM #7 placed her hands on R419's ankles, lower legs, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview it was determined that the facility staff failed to complete and electronically submit a significant change MDS (minimum data set) assessment for one of 55 residents in the survey sample, Resident #33 (R33). The facility staff failed to complete a significant change MDS assessment after R33 began receiving hemodialysis for chronic kidney disease stage 4 on 4/6/2022. The findings include: On the most recent MDS, an admission assessment with an ARD (assessment reference date) of 2/27/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was not cognitively impaired for making daily decisions. Section O did not document R33 receiving dialysis at the time of the assessment. Review of the clinical record revealed a list of R33's MDS assessments. The list revealed an entry tracking record was completed on 2/22/2022 and an admission assessment was completed on 2/27/2022. The list failed to evidence documentation of a significant change assessment completed for R33. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview, facility document review, and clinical record review, it was determined that the facility failed to accurately complete an MDS (minimum data set) for one of 55 residents in the survey sample, Resident #419 (R419). The facility staff failed to accurately code R419's interview status on the 3/29/22 MDS. The findings include: On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/29/22, R419 was coded as having short term and long term memory problems, and as being severely impaired for making daily decisions in Section C. On the 3/29/22 MDS, in section B, R419 was coded as always being understood by others, and as always understanding others for communication. However, in Section C, question C0100 documented: Should Brief Interview for Mental Status be Conducted - Attempt to conduct interview with all residents, R419 was coded as zero, meaning the resident is rarely/never understood for communication. The Brief Interview for Mental Status interview was not attempted. This section was signed by OSM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview, facility document review, clinical record review and in the course of a complaint investigation, the facility staff failed to provide a written summary of the baseline care plan for 1 of 55 residents in the survey sample, Resident #369. The facility staff failed to provide a written summary of Resident #369's (R369) baseline care plan to the resident and/or the resident's representative. The findings include: On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 11/20/20, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. Resident #369 was discharged from the facility on 12/28/20. A review of R369's clinical record revealed the resident's baseline care plan was initiated on 11/17/20. Further review of R369's clinical record (including progress notes and care conference notes) failed to reveal the resident and/or the resident's representative was provided a written summary of the care plan. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to correctly transcribe an order according to professional standards of practice for one of 55 residents in the survey sample, Resident #52 (R52). The facility staff failed to accurately transcribe R52's order for Eliquis (1), which was held on 3/28/22. The findings include: On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/14/22, R52 was coded as having no cognitive impairment for making daily decisions. R52 was coded as receiving and anticoagulant on all seven days of the look back period. On 5/3/22 at 1:38 p.m., an interview was conducted with R52. R52 stated they had been diagnosed with atrial fibrillation (2) during a recent hospitalization. R52 stated the physician ordered Eliquis for the atrial fibrillation. R52 stated they underwent an outpatient skin graft procedure on 3/29/22. R52 stated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide activities per a resident's assessed interest for one of 55 residents in the survey sample, Resident #419 (R419). The facility staff failed to provide R419 with preferred activities of watching television or listening to music by leaving the resident seated in a wheelchair at the entrance to the dining room, adjacent to the nurses' station, sleeping and eating in public view, during the day and evening on 5/3/22 and 5/4/22. The findings include: On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/29/22, R419 was coded as having short term and long term memory problems, and as being severely impaired for making daily decisions. R419 was coded as requiring the extensive assistance of two staff members for transferring and moving around the unit. On the following dates and times, R419 was sitting in a wheelchair outside the dining room, adjacent to the nurse station. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to have medications available for administration to the resident in a timely manner for one of 55 residents in the survey sample, Resident #52 (R52). The facility staff failed to have R52's scheduled medications available for administration on 4/14/22, 4/24/22, and 4/26/22. The findings include: On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/14/22, R52 was coded as having no cognitive impairment for making daily decisions. R52 was coded as receiving dialysis services and as receiving insulin injections during the look back period. On 5/3/22 at 1:38 p.m., an interview was conducted with R52. R52 stated that during the previous few weeks, the resident did not receive medications related to diabetes and to dialysis because they were not in the medication cart for the nurse to administer. A review of R52's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to ensure one of 55 residents in the survey sample Resident #52 (R52) was free from a significant medication error. The facility staff failed to administer Eliquis (1) as ordered after the hold period related to a procedure ended. The findings include: On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/14/22, R52 was coded as having no cognitive impairment for making daily decisions. R52 was coded as receiving and anticoagulant on all seven days of the look back period. On 5/3/22 at 1:38 p.m., an interview was conducted with R52. R52 stated they had been diagnosed with atrial fibrillation (2) during a recent hospitalization. R52 stated the physician ordered Eliquis for the atrial fibrillation. R52 stated they underwent an outpatient skin graft procedure on 3/29/22. R52 stated the physician wanted the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide food per the dietician's recommendation, and failed to serve food that matched the published menu for one of 55 residents in the survey sample, Resident #52 (R52). At lunch on 5/3/22 and 5/4/22, R52 did not receive double portions per the dietician's recommendation; R52's food items did not match the published menu and meal ticket. The findings include: On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/14/22, R52 was coded as having no cognitive impairment for making daily decisions. R52 was coded as being on a therapeutic diet, and as receiving dialysis services during the look back period. On 5/3/22 at 1:38 p.m., Resident #52 (R52) was interviewed. R52 had multiple complaints about food served to him. R52 stated the dietary staff consistently failed to provide double portions, as recommended by the dietician. R52 stated the food on the meal tray…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, and staff interview, the facility staff failed to provide written information to concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive by ensuring an accurate durable do not resuscitate (DDNR) form for two of 42 residents in the survey sample, Resident # 11 and Resident # 35. The findings include 1. The facility staff failed to ensure that the DDNR form for Resident # 11 was filled out correctly. The DDNR form for Resident # 11 reflected that Resident # 11 had an advanced directive when she did not have an advanced directive in place. Diagnoses included but were not limited to, dementia with behavioral disturbance and type 2 diabetes mellitus. On 10/22/19 at 2:39 pm, the surveyor reviewed the DDNR form for Resident # 11. The surveyor observed a handwritten x next to the statement While capable of making an informed decision, the patient has executed a written advanced directive which appoints a Person Authorized to Consent on the Patient's Behalf with authority to direct…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and clinical record review the facility staff failed to review and revise the comprehensive care plan for 2 of 42 residents, Resident #87 and Resident #360. The findings included: 1. For Resident #87 the facility staff failed to review and revise the care plan for behaviors. Resident #87's face sheet listed an admission date of 08/20/14 and a readmission date of 05/10/17. The resident's diagnosis list indicated diagnoses, which included but not limited to Parkinson's disease, dementia without behavioral disturbance, depression, atrial fibrillation, hyperlipidemia, anxiety, and hypertension. Resident #87's most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 09/12/19 assigned the Resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, cognitive patterns, indicating the resident is cognitively intact. Section E, behavior, coded the resident as not having any indicators of psychosis, nor any behavioral symptoms. Subsection E0800 coded the resident as not exhibiting any rejection of care.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview and clinical record review the facility staff failed to provide care and treatment based on the comprehensive person-centered care plan to meet the needs of the resident for 1 of 42 residents, Resident #117. The findings included: For Resident #117 the facility staff failed to follow physician's order for the use of a resting hand splint. Resident #117's face sheet list an admission date of 02/07/16 and a readmission date of 11/16/18. The diagnosis list includes diagnoses of, but not limited to dementia, hemiplegia or hemiparesis, and cognitive communication deficit. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 09/26/19 assigned the resident a BIMS (brief interview for mental status) score of 9 out of 15 in section C, cognitive patterns. Section G, functional status, coded the resident as having functional limited range of motion on one side of both upper and lower extremities. Resident #117's comprehensive care plan was reviewed and contained a care plan for 'Splint r/t (related to) contracture.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.