Vierra Falls Church

Based on record review, interview and policy review, the facility failed to ensure accurate clinical documentation was entered into the resident's medical records for one of one resident (Resident (R)162) in the sample of 31 residents. Specifically, pictures of R162's wound were not posted in the resident's record (EMR). This failure had the potential to affect the quality of care for R162 and to assist with the resident's treatment plan.Findings include: Review of 162's electronic medical record (EMR) titled admission Record located under the Profile tab indicated that the facility admitted the resident on 04/02/25 with a diagnosis of an unstable burst fracture of the first lumbar vertebra. Review of R162's EMR titled admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/08/25, located under the MDS tab indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which revealed the resident was cognitively intact. The assessment indicated that the resident had an impairment on one side of her upper body but no impairment of…

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 interview, record review, facility policy review, document review and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer two of five residents (Residents (R) 25 and R51) reviewed for flu/pneumonia vaccinations and/or their representatives, the opportunity for the residents to be vaccinated in accordance with nationally recognized standards. This practice had the potential to increase the risk for residents to contract pneumonia.Findings include:1. Review of a document provided by the facility titled Patient Vaccination View/Audit indicated R25 was overdue on receiving the pneumococcal vaccine as of 01/25/2000. Review of R25's electronic medical record (EMR) titled admission Record located under the Profile tab indicated that the facility admitted the resident on 03/23/23. Review of R25's EMR titled quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/03/26 located under the MDS tab indicated the resident had a Brief Interview for Mental Status (BIMS) score of nine out of 15 which revealed 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 staff interview, facility document review, and clinical record review, the facility staff failed to ensure a resident was free from unnecessary medication for one of five residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to administer the physician prescribed dose of the IV (intravenous) medication Acyclovir (1). Instead, the facility staff administered ten times the prescribed dose. R1 was transferred to the hospital for evaluation. Acyclovir injection is used to treat herpes simplex (a herpes virus infection of the skin and mucus membranes), herpes zoster (shingles; a rash that can occur in people who have had chickenpox in the past), and herpes simplex encephalitis (brain infection with swelling caused by the herpes virus). This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a681036.html. A review of R1's clinical record revealed a physician's order dated [DATE] that documented, Acyclovir Sodium…

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, the facility staff failed to implement infection control practices for one of five residents in the survey sample, Resident #3. The findings include: For Resident #3 (R3), the facility staff failed to implement enhanced barrier precautions (a gown) while administering IV (intravenous) medication to the resident. A review of R3's clinical record revealed a physician's order dated 5/15/24 for enhanced barrier precautions for the resident's PICC (1) line on the left upper arm, and a physician's order dated 5/15/24 for Unasyn (2) three grams IV every six hours for empyema (3). On 6/4/24 at 8:26 a.m., LPN (licensed practical nurse) #2 was observed administering IV Unasyn to R3. LPN #2 did not wear a gown while administering IV medication to R3. A sign on R3's door documented, ENHANCED BARRIER PRECAUTIONS. EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services to promote a resident's highest level of well being for three of four residents in the survey sample, Residents #3, #1, and #4. The findings include: For Resident #3 (R#3), the facility staff failed to provide evidence of assessment, orders, and care for bilateral compression wraps on the resident's legs and failed to provide evidence of routine central venous access line care. 1.a. The facility staff failed to provide evidence of assessment, orders, and care for bilateral compression wraps on the resident's legs. R3 was admitted to the facility on [DATE] with a history of congestive heart failure, lymphedema (swelling caused by an absence of lymph nodes), and right leg cellulitis (skin infection). On the admission nursing assessment dated [DATE], he was found to be oriented to person, place, and situation. On 2/21/24 at 9:16 a.m., R3 was observed…

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, facility document review, and clinical record review, the facility staff failed to notify the physician of medications not administered to two of four residents in the survey sample, Residents #1 and #2. The findings include: 1. For Resident #1 (R1), the facility staff failed to notify the physician of medications not administered on 11/23/23 and 11/24/23. R1 was admitted to the facility on [DATE] and discharged from the facility on 11/26/23. A review of R1's physician orders revealed the following orders: 11/22/23 Apremilast Oral Tablet (1) 30 MG (milligram) Give 1 tablet by mouth one time a day for PSORIASIS. 11/22/23 Clobetasol Propionate E External Cream (2) 0.05 % (Clobetasol Propionate Emollient Base) Apply .TOPICALLY two times a day for PSORIASIS. 11/22/23 Procrit Injection Solution (3) 10000 UNIT/ML (Epoetin Alfa) Inject 1 ml (milliliter) subcutaneously one time a day every 7 day(s) for ANEMIA. 11/22/23 Sodium Bicarbonate Oral Tablet (4) 650 MG (Sodium Bicarbonate (Antacid))…

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, the facility staff failed to formulate a baseline care plan to address the resident's basic needs for two of four residents in the survey sample, Residents #3 and #1. The findings include: For Resident #3 (R#), the facility staff failed to formulate a baseline care plan for bilateral compression wraps on the resident's legs and failed to formulate a baseline care plan for his central venous access line (1). 1.a. For Resident #3 (R#3), the facility staff failed to formulate a baseline care plan for bilateral compression wraps on the resident's legs. R3 was admitted to the facility on [DATE] with a history of pneumonitis, sepsis, congestive heart failure, lymphedema (swelling caused by an absence of lymph nodes), right leg cellulitis (skin infection), and a history of rectal cancer requiring chemotherapy treatment. On the admission nursing assessment dated [DATE], he was found to be oriented to person,…

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, the facility staff failed to implement interventions to treat a pressure injury for one of four residents in the survey sample, Resident #3. The findings include: For Resident #3 (R3), the facility staff failed to implement interventions to treat a right toe pressure injury. On 2/21/24 at 9:16 a.m., R3 was observed sitting up in bed. He stated: I am fairly comfortable, well, as comfortable as I can be with these. R3 pulled the linens away from his lower body, exposing his legs. Both legs were wrapped with a thick compression wrapping extending from just below the knee to just below the ankle. Both feet had socks and a separate compression device. A review of R3's admission nursing summary dated 2/16/24 revealed, in part: Deep tissue injury on right heel, open area on (sic) under the right big toe with drainage. A review of R3's skilled nursing notes dated 2/16/24, 2/17/24, 2/18/24 and 2/19/24 all revealed, in part: Skin issue .Right toe(s). Wound odor: Yes. A review of R3's clinical record,…

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, the facility staff failed to provide physician supervision of care for one of four residents in the survey sample, Resident #3. The findings include: For Resident #3 (R3), the attending physician and wound NP (nurse practitioner) failed to provide supervision and care for the resident's bilateral leg compression wraps. R3 was admitted to the facility on [DATE] with a history of pneumonitis, sepsis, congestive heart failure, lymphedema (swelling caused by an absence of lymph nodes), right leg cellulitis (skin infection), and a history of rectal cancer requiring chemotherapy treatment. On the admission nursing assessment dated [DATE], he was found to be oriented to person, place, and situation. On 2/21/24 at 9:16 a.m., R3 was observed sitting up in bed. He stated: I am fairly comfortable, well, as comfortable as I can be with these. R3 pulled the linens away from his lower body, exposing his legs. Both…

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, facility document review, and clinical record review, the facility staff failed to provide medications for administration to two of four residents in the survey sample, Residents #1 and #2. The findings include: 1. For Resident #1 (R1), the facility staff failed to provide medications for administration on 11/23/23 and 11/24/23. R1 was admitted to the facility on [DATE] and discharged from the facility on 11/26/23. A review of R1's physician orders revealed the following orders: 11/22/23 Apremilast Oral Tablet (1) 30 MG (milligram) Give 1 tablet by mouth one time a day for PSORIASIS. 11/22/23 Clobetasol Propionate E External Cream (2) 0.05 % (Clobetasol Propionate Emollient Base) Apply .TOPICALLY two times a day for PSORIASIS. 11/22/23 Procrit Injection Solution (3) 10000 UNIT/ML (Epoetin Alfa) Inject 1 ml (milliliter) subcutaneously one time a day every 7 day(s) for ANEMIA. 11/22/23 Sodium Bicarbonate Oral Tablet (4) 650 MG (Sodium Bicarbonate (Antacid)) Give 1 tablet by mouth two…

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, facility document review and clinical record review, it was determined that the facility staff failed to follow professional standards of practice for one of four residents in the survey sample; Resident #1. The facility provided an acceptable plan of correction, having already identified the concern on 10/27/23. This is cited at past non-compliance. The findings include: The facility staff failed to implement the physician's order to provide orthopedic follow up aftercare for staple removal for Resident #1. Resident #1 was admitted to the facility on [DATE] and discharged on 10/20/23 and had the diagnosis of but not limited to osteoporosis with current pathological fracture status post surgery with staples to the right hip. A review of the clinical record revealed the hospital discharge instructions dated 10/2/23 (from the hospital to the facility). These instructions included, Date of most recent surgery 9/21/23 .ORIF (Open reduction internal fixation) Please contact the office as…

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, facility document review and clinical record review, it was determined that the facility staff failed to arrange for the provision of follow up care for one of four residents in the survey sample; Resident #1. The facility provided an acceptable plan of correction, having already identified the concern on 10/27/23, therefore, this is cited at past non-compliance. The findings include: The facility staff failed to arrange follow up aftercare with the orthopedic surgeon per the physician's order. The resident was admitted on [DATE] with 24 staples in a right hip surgical incision. Multiple orders and notes documented the need to follow up with the orthopedic surgeon. The follow up was never obtained and the resident was discharged to home on [DATE] with 24 staples still intact. This was approximately one month after the surgery, which was 9/21/23. The facility policy, Special Needs documented, 3. If necessary, the facility will assist residents in making appropriate appointments with a…

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 and facility documentation reviews, the facility staff failed to provide copies of the clinical record as per written request for one resident (Resident #3) in a survey sample of eight (8) residents. The findings included: For Resident #3, the facility staff failed to complete a request for medical records timely and failed to provide all the requested records. On 09/06/2023 and 09/07/2023, a closed clinical record review of Resident #3's chart was conducted. This review revealed no documentation regarding a request from the family of Resident #3 for copies of the clinical record. On 9/6/23 at 11:21 a.m., an interview was conducted with the Medical Records Employee. The medical records employee provided Surveyor C with a paper chart of Resident #3's documents. There was a second folder of documents that read, [facility name redacted] Copies of requested med rec by family 3/27/23 not completed as of yet and had Resident #3's name. Enclosed in this folder was a form entitled, Consent to Release Medical Information, which had been completed by Resident #3'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 interview, clinical record review, and facility documentation review, the facility staff failed to notify the family of a resident's change in condition in a timely manner for one resident (Resident #3) in a survey sample of eight (8) residents. The findings included: For Resident #3, the facility staff failed to notify the family of the resident's expiration, the family came in to visit and found that the resident was deceased . On [DATE] and [DATE], a closed clinical record review of Resident #3's chart was conducted. This review revealed the following: A progress note dated [DATE] at 7:25 a.m. read, Around 07:15 am, Patient was found unresponsive to all stimuli, pupils fixed and dilated, no BP, Pulse, Respirations, Patient was pronounced dead at 07:20 am by Supervisor on duty. And family and Hospice will be contacted soon to notified them about patient passing [sic]. There was no indication that a call was made to the family until a note at 11:59 a.m. that read, Mortician picked up the body at 11:30…

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 documentation review, the facility staff failed to provide care based on standards of nursing practice for two residents (Residents #3 and #5) in a survey sample of eight (8)residents. The findings included: 1. For Resident #3, the facility staff failed to administer morphine and prednisone within accordance with physician orders. On 09/06/2023-09/07/2023, a closed clinical record review was conducted of Resident #3's clinical chart. It was noted that the resident went on hospice care on 03/16/2023. Resident #3 had several changes to his orders for morphine that increased the dosage and frequency. The medication administration records (MAR) and the Controlled Drug Receipt/Record/Disposition Form were reviewed regarding the morphine. It was noted on several occasions the morphine was not given timely, in a few instances it was greater than 4 hours after the scheduled time being administered. On several occasions it was documented that the wrong dosage…

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 interviews, clinical record review, and facility documentation review, the facility staff failed to ensure a complete clinical record was maintained for two residents (Residents #3 and #5) in a survey sample of eight (8) residents. The findings included: 1. For Resident #3, the facility staff failed to ensure the clinical record was complete and accurate regarding the times and quantity of morphine administered. On 08/06/2023 and 08/07/2023, a closed clinical record review of Resident #3's chart was conducted. Review of the medication administration record (MAR), medication audit report and controlled drug receipt/record/disposition forms were conducted. Special attention was paid to the administration of morphine. There were three instances on 03/23/2023, that morphine was signed out on the controlled drug receipt/record/disposition form and not documented on the MAR as having been administered. A review was conducted of the facility's Medication Administration policy. This policy read, . 15. Administer medication as ordered in accordance with manufacturer specifications.…

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, representative interview, staff interview, and facility documentation review, the facility staff restricted resident rights for visitation for all Residents. The findings included: The CMS (Centers for Medicare and Medicaid Services) memorandum entitled, QSO-20-39 NH REVISED updated on 03/10/2022, documented the following excerpt: Visitation is allowed for all Residents at all times. On 08/02/2022 at approximately 11:30 A.M., a sign posted on the front door of the facility documented, Visting [sic] hours 11:00AM-6:00PM. The sign was observed on the front door on 08/03/2022 and 08/04/2022 as well. On 08/02/2022 at 1:45 P.M., the Responsible Party (RP) for Resident #16 was interviewed. When asked about visiting hours, the RP stated that visiting hours were from 11:00 A.M. until 6:00 P.M. Resident #16's RP also stated that they would like to have more liberal visiting hours and be able to have more time for visits. The RP added that it limits visitation for people who work during the day. On 08/04/2022 at approximately 8:45 A.M., the front desk receptionist,…

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 documentation review, the facility staff failed to employ a dietary manager with the appropriate credentials. The findings included: On 08/03/2022 at approximately 12:25 P.M., the Director of Nursing provided the credentials for the dietary manager as requested. The Director of Nursing stated that the dietary manager does not have the right credentials because he did not complete the full course for certification. The credentials document provided was an identification (ID) card entitled, Northern Virginia Food Manager ID. On 08/03/2022 at 3:30 P.M., the dietary manager was interviewed. The dietary manager confirmed he was not a certified dietary manager. When asked about the ID entitled Food Manager, the dietary manager stated that he received that ID as a result of obtaining ServSafe certification. The dietary manager then provided a copy of his ServSafe certification dated 11/11/2019. On 08/04/2022 at approximately 3:45 P.M., the Administrator and Director of Nursing were notified of findings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility documentation review, the facility staff failed to maintain safe holding temperatures for 3 out of 3 cold beverages tested on [DATE]. The findings included: On 08/03/2022 at 11:45 A.M., this surveyor observed the facility staff on the tray line in preparation to distribute lunch to the Residents. There were trays lined up with cold beverages on them in preparation to be delivered to Residents. This surveyor observed the dietary manager check the temperature of the milk on one tray. The temperature was 57.2 degrees Fahrenheit. The dietary manager disposed of that milk. The dietary manager checked the temperature of another milk from a different tray. It was 55.4 degrees Fahrenheit and the dietary manager disposed of that milk as well. The dietary manager checked the temperature of a cup of apple juice from another tray and the temperature was 65.3 degrees. When asked about the expectation for holding temperatures for cold beverages, the dietary manager stated,…

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, interview, and facility record review the facility staff failed to implement a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. There were 17 empty spaces where one or both nurses did not sign off for the narcotic count between 7/3/22 and 8/3/22. The findings included: For the facility the facility staff failed to ensure the system of verifying narcotics was completed by the oncoming and off-going nurses both counting and signing the narcotic book. On 8/3/22 at 09:02 AM, an interview was conducted with LPN C who stated that he had already finished all of his medication pass for the morning. On 08/03/22 at 09:34 AM an interview was conducted with LPN B who was asked the process for signing off narcotics. LPN B stated the oncoming and offgoing nurses count together to be sure that the count is correct. They both sign the narcotic count sheet before the keys are handed over. A review of the Narcotic Book revealed that nurses were not signing off on narcotic counts together. There 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, interview, clinical record review, and facility documentation, the facility staff failed to ensure Residents are treated with dignity for 1 Resident (#53) in a Survey Sample of 16 Residents. The findings included: For Resident #53, the facility staff referred to the Resident as A Feeder while speaking to the Surveyor as well in progress notes in his clinical record. On 8/3/22 at approximately 12:00 PM while observing medication administration for Resident # 53, LPN B stated she was unsure of how the Resident would take his medication. She stated she usually crushes the medications but she was not sure how he would take the capsule of neurontin. When asked how she usually does it, she stated that she usually opened the capsule, But I am not sure if I should do that or not. She further stated that Resident #53 is a Feeder and has trouble swallowing at times. Sometimes he does ok sometimes he doesn't. She then proceeded to get ice cream and put the whole pills in the ice cream. When asked what she meant by the term Feeder she stated that meant someone has to feed…

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, interview, clinical record review and facility documentation the facility staff failed to ensure a clean comfortable homelike environment for 1 Resident (#8) in a survey sample of 16 Residents. The findings included: For Resident #8 the facility staff failed to assist her in cleaning and organizing her room as she is physically unable to do so, and they told her she could not hang up her personal artwork in her room. On 8/2/22 at approximately 12:00 PM the Surveyor E knocked on the door and was told to enter. Upon entering the room it was noted that the bed was filled with several large folded blankets and a box. A large display table with 2 levels contained various pieces of artwork pottery and ceramic masks, paintings were tucked between the table and the dresser. Resident #8 was sitting in a recliner chair and she greeted the surveyor. The Resident immediately apologized for the clutter on the bed and dresser. Resident #8 stated she had resided at the facility since 4/19/22 and was unhappy about a couple of things. Resident #8 stated that she had diagnoses…

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 interview observation, clinical record review and facility documentation the facility staff failed to develop and implement a comprehensive care plan for 1 Resident (#8) in a survey sample of 16 Residents. The findings included: For Resident #8 the care plan does not address Resident #8 sleeping in a recliner instead of her bed. On 8/2/22 at approximately 12:40 PM an interview was conducted with Resident #8 stated that she did not sleep in the bed. She stated that it is her preference to sleep in her recliner due to her mobility issues and pain. She further explained that no one Makes her bed. Resident #8 stated that they make the bed and change the sheets however she does not sleep in the bed. She stated the staff never fluff the pillows behind her or change the sheet under her (referring to recliner where she sleeps). Resident #8 stated that she can feel every wrinkle in the pad and sheet under her. She also stated that it has been a month since anyone has offered to make up recliner with fresh linens. She stated that she has been at the facility since 4/18/22 and has…

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, representative interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to revise the care plan for one Resident (Resident #16) in a sample size of 16 Residents. For Resident #16, the facility staff failed to revise the care plan to include a goal and interventions after Resident #16 pulled out her peripherally-inserted central catheter (PICC) on 06/24/2022. The findings included: On 08/02/2022 at 1:45 P.M., the Responsible Party (RP) for Resident #16 was interviewed. When asked if they were notified for changes in Resident #16's condition, the RP stated, Yes and explained that the facility staff called him when Resident #16 pulled her PICC line out. When asked what the facility staff implemented to mitigate that happening again, the RP stated that [Resident #16]'s arm is wrapped to prevent her from fiddling with it. On 08/03/2022, Resident #16's clinical record was reviewed. Resident #16's admission Minimum Data Set, dated [DATE]…

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 and staff interview the facility staff ailed to initial and date the PICC (peripherally-inserted central catheter) line site dressing as observed on 08/04/2022 for one residents (#16) in a survey sample of 16 residents. The findings include: On 08/03/2022, Resident #16's clinical record was reviewed. A physician's order dated 07/11/2022 documented, PICC-LINE DRESSING CHANGE EVERY 7 DAYS AND AS NEEDED PER PROTOCOL. every day shift every Tue[Tuesday] for IV Therapy for 8 Weeks. The Treatment Administration Record entry associated with this order was signed off as administered on 08/02/2022. On 08/04/2022 at approximately 9:35 A.M., this surveyor and Registered Nurse B (RN B) entered Resident #16's room to observe the PICC line site. The PICC line site was in the antecubital region (where the arm bends at the elbow) of the right arm and dressed with a transparent dressing. The transparent dressing was not initialed or dated. When asked about the expectation, RN B indicated that the PICC…

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, interview, and clinical record review the facility staff failed to provide activities to meet the interests of the Resident for 1 Resident (#8) in a survey sample of 16 Residents. The findings included: For Resident #8 the facility staff failed to provide the Resident with painting materials, or craft projects. On 8/2/22 at approximately 12:00 PM, Surveyor E knocked on the door and was told to enter. Upon entering the room it was noted that the bed was filled with several large folded blankets and a box. A large display table with 2 levels contained various pieces of artwork pottery and ceramic masks, paintings were tucked between the table and the dresser. Resident #8 was sitting in a recliner chair and she greeted the surveyor. The Resident immediately apologized for the clutter on the bed and dresser. Resident #8 stated that she would like to have some form of Art Projects to do. When asked if she had expressed that to the Activities Director she stated that they had done an evaluation when she was admitted but no one has offered her more than Bingo, word…

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, representative interview, staff interview, and clinical record review, the facility staff failed to ensure the environment remained free of accident potential for one Resident (Resident #16) in a sample size of 16 Residents. For Resident #16 (with a known behavior and history of pulling out the peripherally-inserted central catheter (PICC)), the facility staff failed to ensure the intervention of wrapping the PICC line site was effective and in place. The PICC line was exposed and accessible to Resident #16 on 08/04/2022. The findings included: On 08/02/2022 at 1:45 P.M., the Responsible Party (RP) for Resident #16 was interviewed. When asked if they were notified for changes in Resident #16's condition, the RP stated, Yes and explained that the facility staff called him when Resident #16 pulled her PICC line out. When asked what the facility staff implemented to mitigate that happening again, the RP stated that [Resident #16]'s arm is wrapped to prevent her from fiddling with it. 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, interview, clinical record review and facility documentation the facility staff failed to ensure Residents were free from unnecessary psychotropic medications for 1 Resident (#2) in a survey sample of 16 Residents. The findings included: Resident #2 was prescribed Remeron (an antidepressant) For appetite stimulation. On 8/2/22 at 12:43 PM Resident # 2, was observed in her room alone with the lunch tray in front of her head of bed elevated to 45 degrees. Resident #2 was eating a cookie from her tray. The sandwich, and juice untouched. The soup still covered in the bowl. A review of the clinical record revealed progress notes from the RD that read: 4/21/22 -Resident requires set-up and assistance with meals. Mechanical soft with pureed meats and thin liquids. On 8/3/22 during clinical record review it was discoursed that Resident #2 had an order that read as follows: Mirtazepine Tablet 15 MG [Trade name Remeron; an antidepressant] Give 1 tablet by mouth at bedtime for appetite stimulant -Start Date- 04/06/2021 2000 On 8/4/22 at approximately 1:00 PM an interview…

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, interview, clinical record review and facility documentation the facility staff failed to maintain an accurate clinical record for 1 Resident (#52) in a survey sample of 16 Residents. The findings included: For Resident # 52 the facility staff failed to accurately assess Resident #52 for elopement risk. Resident #52 was admitted to the facility on [DATE] a review of the care plan revealed the following excerpt: FOCUS: The resident is an elopement risk. Date Initiated: 07/08/2021 Revision on: 08/18/2021 GOAL: The resident's safety will be maintained through the review date. Date Initiated: 07/08/2021 Target Date: 08/10/2021 INTERVENTIONS: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: (space left blank) Date Initiated: 07/08/2021 Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Date Initiated: 07/08/2021 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 observations, staff interviews, and facility documentation review, the facility staff failed to adhere to The Centers for Disease Control and Prevention (CDC) guidance for the proper wearing/removing personal protective equipment (PPE) for 2 Residents (Resident #3, Resident #53) in a sample size of 16 Residents. 1. For Resident #3, a known COVID-19 positive Resident on isolation precautions, the facility staff failed to do the following: a) doff (remove) their PPE before exiting the room on 08/03/2022 and b) properly wear their PPE while giving care on 08/04/2022. 2. For Resident #53, a known COVID Positive Resident who is on isolation precautions, the facility staff failed to properly wear PPE in the Residents room and failed to perform proper hand washing prior to exiting the room. The findings included: 1. For Resident #3, a known COVID-19 positive Resident on isolation precautions, the facility staff failed to do the following: a) doff (remove) their PPE before exiting the room on 08/03/2022 and b) properly wear their PPE while giving care on 08/04/2022. On 08/03/2022…

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 documentation review, one facility unvaccinated staff member (staff 8), in a sample of 8 staff failed to wear a source control N-95 or higher respirator during the course of an active COVID-91 facility outbreak. The findings included; Staff #8 failed to comply with CDC (Centers for Disease Control) and CMS (Centers for Medicare/Medicaid Services) guidelines for the prevention of COVID-19 infections. On 8-2-22 upon initial entrance the survey team was greeted by the Staff #8. Staff #8 was wearing a paper procedure mask. The survey team was told that the building was experiencing an active outbreak of COVID-19, and all other staff were wearing source control N-95 respirators. During the course of the survey it was determined that Staff #8 was not vaccinated against COVID-19, however, was being tested twice weekly. Staff #8 was seen in close contact with the Social Worker, Director of Nursing, Regional Corporate Registered Nurse, Maintenance Director, Surveyors, and other staff who work with, and were in close proximity to, 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.