Holly Manor Rehab And Nursing

2. For Resident #10 (R10), the facility staff failed to notify the resident representative the resident was vomiting and placed on contact precautions on 2/19/25. A review of R10's clinical record revealed a nurse's note dated 2/19/25 that documented the resident was placed on contact isolation precautions due to vomiting during the previous day. Further review of R10's clinical record failed to reveal the resident's representative was notified regarding this change in condition on 2/18/25 or 2/19/25. On 6/4/25 at 2:40 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated a resident's representative should be made aware of the resident's change in condition as soon as possible and this is evidenced by documenting a nurse's note. On 6/5/25 at 2:59 p.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern. The facility policy titled, Change in a Resident's Condition documented, The facility will promptly notify the resident, his or her physician/practitioner, and representative of changes in the resident'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 and clinical record review, it was determined that the facility staff failed to review or revise the comprehensive care plan for one of 13 residents, Residents in the survey sample, Resident #11 (R11). The findings include: For R11, the facility staff failed to review or revise comprehensive care plan following a fall on 03/10/2025. R11 was admitted to the facility with diagnosis that included but was not limited to dementia (1). On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 05/14/2024, R11 scored 4 (four) out of 15 on the BIMS (brief interview for mental status), indicating R11 was severely impaired of cognition for making daily decisions. The facility's nursing note for R11 dated 03/10/2025 documented, Writer was informed by activities worker that resident was on floor. writer went in room with cna (certified nursing assistant). resident was lying on floor, alert and oriented, resident did not hit head, no bruising lacerations or bleeding, neuro checks in place per facility…

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 #12, the facility staff failed to administer antibiotics, Flagyl and Cipro, per the physician orders. The physician orders dated 5/20/25, documented, Ciprofloxacin HCL (hydrochloride)(1) Oral Tablet 500 MG (milligrams); Give 1 tablet by mouth one time a day related to diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding for 4 days. The physician order dated, 5/21/25, documented, Flagyl Oral Tablet (2) 500 MG; Give 1 tablet by mouth three times a day related to Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding for 3 days. The May 2025 MAR (medication administration record) documented the above order. The medication was to be administered at 4:00 a.m. On 5/20/25 at 4:00 a.m. the space to sign off the medication was blank. The May 2025 MAR documented the above order. On 5/24/25 for the 10:00 a.m. and 2:00 p.m. dose, a 9 (See progress notes) was documented. There were no nurse's notes dated 5/20/25 at 4:00 a.m. that addressed the missing dose of Cipro. The nurse' note dated 5/24/25 at…

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, it was determined that facility staff failed to provide respiratory care and services for one of 13 residents in the survey sample, Resident #5 (R5). For R5, the facility staff failed to obtain a physician's order for the use of oxygen. The findings include: R5 was admitted to the facility with diagnoses that included but were not limited to respiratory failure (1). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 03/23/2025, R5 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R5 was cognitively intact for making daily decisions. On 06/03/2025 at approximately 12:25 p.m. an observation revealed R5 receiving oxygen at three liters per minute by nasal cannula (2). The physician's order for R5 dated 06/03/2025 documented in part, Oxygen 3 (three) via (by) NC (nasal cannula) continuous. Order Date: 06/03/2025. Audit Details. Created Date: 06/03/2025. 1445 (2:45 p.m.). On 06/04/2025 at approximately 3:00 p.m. 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 staff interview, facility document review, and clinical record review, the facility staff failed to provide physician services for three of 13 residents in the survey sample, Residents #1, #5, and #9. The findings include: 1. For Resident #1 (R1), the facility staff failed to provide an individualized response to a nurse's inquiry regarding medication administration when the nurse was responsible for caring for 54 residents. A review of a nursing schedule dated 12/25/24 revealed one nurse worked during the day shift on the [NAME] unit. A resident census form dated 12/25/24 documented 54 residents resided on the [NAME] unit on that date. R1 resided on the [NAME] unit. A review of R1's clinical record revealed the following physician's orders: 12/27/23-Pseudoephedrine 30mg (milligrams)-one tablet by mouth three times a day for seasonal allergies. 5/15/23-Baclofen 20mg-one tablet by mouth three times a day for spinal stenosis (narrowing of the spine). 1/23/24-Azelastine 137mcg (micrograms)-two sprays in…

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 sufficient nursing staff for three of 13 residents in the survey sample, Residents #1, #5, and #9. The findings include: 1. For Resident #1 (R1), the facility staff failed to provide a sufficient number of nurses during the day shift on 12/25/24. One nurse cared for 54 residents. A review of an as-worked nursing schedule dated 12/25/24 revealed one nurse worked during the day shift on the [NAME] unit. A resident census form dated 12/25/24 documented 54 residents resided on the [NAME] unit on that date. R1 resided on the [NAME] unit. A review of R1's clinical record revealed the following physician's orders: 12/27/23-Pseudoephedrine 30mg (milligrams)-one tablet by mouth three times a day for seasonal allergies. 5/15/23-Baclofen 20mg-one tablet by mouth three times a day for spinal stenosis (narrowing of the spine). 1/23/24-Azelastine 137mcg (micrograms)-two sprays in both nostrils two times a day…

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 the garbage areas in a sanitary manner for one of one trash compactor and two of ten trash bins. The findings include: The facility staff failed to ensure the door/lids on the trash compactor and two trash bins were kept closed when not in use. On 8/26/24 at 4:00 p.m., an observation of the trash compactor was conducted. The side door of the compactor was open and multiple bags of trash were observed in the compactor. On 8/27/24 at 1:52 p.m., an observation of the outside trash bins was conducted. The lids on two bins were open and multiple bags of trash were observed in the bins. On 8/27/24 at 2:43 p.m., an interview was conducted with OSM (other staff member) #2 (the regional director of maintenance) and OSM #3 (the maintenance director). OSM #2 stated the side door on the trash compactor and the lids on the trash bins should be kept closed to keep animals out. On 8/27/24 at 4:21 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director 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 observation, staff interview, and facility document review, the facility staff failed to maintain a complete infection control program and implement infection control practices for one of 50 residents in the survey sample, Resident #33. The findings include: 1. The facility staff failed to evidence infection surveillance for January 2023 through December 2023. A review of the facility infection control program for January 2023 through December 2023 failed to reveal a system of surveillance. There was only a binder containing multiple Antibiotic Timeout forms for multiple residents. On 8/28/24 at 9:16 a.m., an interview was conducted with RN (registered nurse) #4 (the infection control nurse who was not employed at the facility during 2023). RN #4 stated every day he documents all infections on a tracking log spreadsheet then color codes the infections on a floor plan of rooms so he can evaluate if there is a group of a certain infection and so he knows if there is an infection control challenge that he needs to address. RN #4 was shown the 2023 binder of antibiotic timeout…

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, facility staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services in a manner to promote resident dignity for four of 50 residents in the survey sample, Residents #96, #31, #67, and #157. The findings include: 1. For Resident #96 (R96), the facility staff failed to treat him with dignity after he vomited. On the most recent MDS (minimum data set), an admission assessment dated [DATE], R96 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). He was coded as requiring staff assistance for ADLs (activities of daily living). On 8/26/24 at 2:46 p.m., R96 was sitting up in bed. He stated that last Saturday, 8/24/24, he woke up very early in the morning, around 6:00 a.m. LPN (licensed practical nurse) #4 was at his bedside administering a tube feeding. As LPN #4 walked away from his bed towards the bathroom, he…

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, it was determined that the facility staff failed to evidence written notification of a facility-initiated hospital transfer was provided to the resident and/or Ombudsman, for five of 50 residents in the survey sample; Residents #52, #69, #22, #45 and #11. The findings include: 1. For Resident #52, the facility staff failed to evidence a written notice was provided to the resident representative for a hospital transfer on 7/11/24. A review of the clinical record revealed a nurse's note dated 7/11/24 that documented, Resident has complaint of shortness of breath and states My chest feels heavy. On call MD notified of current condition and order given to this nurse to send to ER (Emergency Room) for evaluation and treatment as indicated Further review of the clinical record failed to reveal any evidence of a written noticed being provided to the resident representative regarding the hospital transfer. On 8/30/24 at 8:50 AM 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 7. The facility staff failed to implement the comprehensive care plan for wound care for Resident #116. Resident #116 was admitted to the facility on [DATE] with diagnosis that included but were not limited to dementia, sacral ulcer and ASCVD (atherosclerotic cardiovascular disease). The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 3/6/23, coded the resident as scoring a 00 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for bathing/transfer/dressing/toileting and supervision for eating. A review of the comprehensive care plan dated 9/14/22 revealed, FOCUS: Resident has a skin tear to her right shin. INTERVENTIONS: Treatment as ordered. A review of the physician orders dated 12/24/22 revealed, Cleanse wound to right lower leg and Left forearm with wound cleanser, apply…

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, the facility staff failed to provide ADL (activities of daily living) care for dependent residents for four of 50 residents in the survey sample, Residents #96, #108, #32, and #67. The findings include: 1. For Resident #96 (R96), the facility staff failed to clean him and his bed linens after he vomited. On the most recent MDS (minimum data set), an admission assessment dated [DATE], R96 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). He was coded as requiring staff assistance for ADLs (activities of daily living). On 8/26/24 at 2:46 p.m., R96 was sitting up in bed. He stated that last Saturday, 8/24/24, he woke up very early in the morning, around 6:00 a.m. LPN (licensed practical nurse) #4 was at his bedside administering a tube feeding. As LPN #4 walked away from his bed towards the bathroom, he experienced…

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 the facility staff failed to provide care and services to promote a resident's highest level of well-being for eight of 50 residents in the survey sample, Residents #157, #34, #114, #113, #108, #112, #117 and #53. The findings include: 1.a. For Resident #157 (R157), the facility staff failed to obtain blood sugars as ordered by the physician. During an interview with R157 on 8/26/24 at 3:55 p.m. the resident stated that the nurses come in to do her blood sugar either while she is eating or after she finishes eating. Then they try to give her insulin and the blood sugar is high due to eating. The physician order dated 8/9/24, documented, Humalog Solution 100 units/ML (milliliters) inject as per sliding scale: if (blood sugar) 1-70 = 0 (insulin) notify MD (medical doctor); 150 -199 = 1 unit; 200 - 249 = 2 units; 250 - 299 = 3 units; 300 - 349 = 4 units; 350 + = 5 units Notify MD > (greater than)…

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, clinical record review and facility document review, it was determined that the facility staff failed to provide care and services to promote healing of pressure injuries for three of 50 residents in the survey sample, Residents #67, #111 and #116. The findings include: 1. For Resident #67 (R67), the facility staff failed to provide treatment as ordered to a pressure injury (1) on multiple dates from 6/1/24 through 8/28/24. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 7/3/24, the resident scored seven out of 15 on the BIMS (brief assessment for mental status), indicating R67 was severely impaired for making daily decisions. The assessment documented R67 having one Stage II pressure injury that was not present on admission. On 8/26/24 at 2:13 p.m., an observation was made of R67 in their room. R67 was observed in bed watching videos on an electronic device. A family member was…

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, staff /resident interviews facility document review and clinical record review, it was determined the facility staff failed to provide respiratory care services for 2 of 50 residents, Resident #108 and #407. The findings include: 1. The facility staff failed to provide respiratory care services per physician orders for Resident #108. Resident #108 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CAD (coronary artery disease), COPD (chronic obstructive respiratory disease), hyponatremia and asthma. The most recent MDS (minimum data set) assessment, a discharge assessment, with an ARD (assessment reference date) of 5/20/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as being dependent for toileting, bathing and hygiene. A review of the comprehensive care plan 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to implement a complete pain management program for two of 50 residents in the survey sample, Residents #96 and #72. The findings include: 1. For Resident #96 (R96), the facility staff failed to assess the resident's need for an increase in his scheduled pain medication. On the most recent MDS (minimum data set), an admission assessment dated [DATE], R96 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). He was coded as requiring staff assistance for ADLs (activities of daily living). On 8/26/24 at 2:46 p.m., R96 was sitting up in bed. He stated he was concerned about having to ask so frequently for pain medications. He stated sometimes the staff was too busy to bring the medications in a timely manner, and he did not feel he should have to ask for pain medication so many times during the day…

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 the facility staff failed to provide care and services related to dialysis for five of 50 residents in the survey sample, Residents #101, #109, #56, #63 and #22. The findings include: 1a. For Resident #101, the facility staff failed to ensure a resident was transported to dialysis, thus the resident did not receive dialysis on 8/24/24. The nurse's notes dated 8/24/24 at 10:49 a.m. documented, Resident was not picked up for dialysis this morning. Attempted to locate contact information for transportation, unable to locate. Called (initials of company) Dialysis spoke to the nurse, and she was also unable to located contact information for transportation, but there also was no more chair time availability for resident. I updated the resident, nursing supervisor and left a vm (voicemail) for the resident's niece. The physician order dated 8/27/24 documented, Dialysis Tues, Thurs, Sat, at (initials 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 staff interview and facility document review, the facility failed to provide adequate nursing staff for two of 50 residents in the survey sample, Residents #107 and #112. The findings include: 1. For Resident #107 (R107), the facility failed to provide adequate nursing staff on the resident's unit for night shift (11:00 p.m. through 7:30 a.m.) on multiple nights in September and October 2023. A review of nursing staff records for September and October 2023 revealed one licensed nurse and one CNA (certified nursing assistant) on the night shift on 9/22, 9/24, 9/30, 10.4, 10/5, 10/6, 10/7, 10/8, 10/9, 10/14, and 10/16 's on R107's unit during the resident's stay. The resident census on this unit was between 25 and 30 on each of these nights. On 8/29/24 at 10:21 a.m., CNA #6, the staff scheduler, was interviewed. She stated she assigns staff to units according to a form given to her by corporate. She stated this form tells her how many staff each unit needs according to census and acuity. She stated: We talk to the unit managers about acuity, then we schedule according 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, clinical record review and facility document review, it was determined the facility staff failed to ensure residents were free of unnecessary medications for two of 50 residents in the survey sample, Resident #113 and Resident #26. The findings include: 1.The facility staff failed to ensure Resident #113 was free of unnecessary medications by administering anticoagulant as ordered. Resident #113 was admitted to the facility on [DATE] with diagnosis that included fractures and hypertension. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 7/26/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for mobility/transfers, dressing, hygiene toileting and independent for eating. A review of the baseline care plan 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 observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to serve palatable food for five of 33 residents in the survey sample, Residents #24, #96, #34, #157, and #32. The findings include: The facility staff failed to serve food with a palatable flavor and at an appetizing temperature. On R24's most recent MDS (minimum data set), a significant change in status assessment with an ARD (assessment reference date) of 7/14/24, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 8/26/24 at 2:18 p.m., an interview was conducted with R24. The resident stated the food at the facility was edible but that was all they would say about it. R24 stated that they had lost weight since they were at the facility, but it was desired due to the food quality and the food was usually cold. On R96's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 7/16/24, 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, and facility document review, the facility staff failed to ensure CNAs (certified nursing assistants) completed required in-services trainings for three of five CNA record reviews. The findings include: The facility staff failed to evidence 12 hours of annual training was provided to CNA #3, #4, and #5. CNA #3 was hired on 5/19/22. A review of CNA #3's employee record revealed the CNA only received 10 hours of annual in-service trainings. CNA #4 was hired on 6/22/22. A review of CNA #4's employee record revealed the CNA only received 4.5 hours of annual in-service trainings. CNA #5 was hired on 3/24/23. A review of CNA #5's employee record revealed the CNA only received 2.75 hours of annual in-service trainings. On 8/28/24 at 11:45 a.m., an interview was conducted with ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing). ASM #2 stated the facility recently began utilizing a computer software for trainings. ASM #2 stated she would have to put something in place to make sure required trainings are being completed by…

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, staff/resident interviews facility document review and clinical record review, it was determined the facility staff failed to accommodate resident needs for three of 50 residents in the survey sample, Resident #92, Resident #50 and Resident #91. The findings include: 1. For Resident #92, the facility staff failed to maintain the call light in a position where they could access it. Resident #92 was admitted to the facility on [DATE] with diagnosis that included but were not limited to CHF (congestive heart failure), Parkinson's disease and dementia. The most recent MDS (minimum data set) assessment, a significant change assessment, with an ARD (assessment reference date) of 6/12/24, coded the resident as scoring a 03 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring supervision for transfer/dressing/toileting and eating. 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 staff interview, clinical record review and facility document review, it was determined that the facility staff failed to notify the physician and/or the resident's representative of a change in condition or treatment, for three of 50 residents in the survey sample; Residents #53, #101, and #110. The findings include: 1. For Resident #53, the facility staff failed to evidence that the resident and/or the responsible party was notified of a change in medication on 11/3/23. A review of the clinical record revealed a physician's progress note dated 11/2/23 that documented, Patient seen resting in bed. He reports that his left great toenail has been sore. He would like it examined to make sure there is no acute problem . Cardiovascular: No chest pain, tightness or palpitations Blood Pressure: 100/57 . Heart has a regular rate and rhythm Plan: Recertify. The patient meets criteria for long-term care. Follow blood pressure per facility protocol. Assist with ADLs (activities of daily living) and hygiene as necessary. The patient is at risk for skin breakdown. Monitor the patient…

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, the facility staff failed to issue a beneficiary notice of non-coverage in a timely manner for one of three beneficiary notice reviews, Resident #257. The findings include: For Resident #257 (R257), the facility staff failed to provide an advance beneficiary notice of non-coverage in a timely manner. A review of a list of residents discharged from a Medicare covered Part A stay with benefit days remaining revealed R257 was discharged from services on 5/22/24. A Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage documented, Medicare doesn't pay for everything, even some care that you or your health care provider think you need. The Skilled Nursing Facility (SNF) or its Utilization Review Committee believes that the care listed below does not meet Medicare coverage requirements. Beginning on 5/23/24, you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs . The notice was signed by OSM (other staff member) #4 (the discharge planner) 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 staff interview and clinical record review, it was determined the facility staff failed to maintain a complete and accurate MDS (minimum data set) assessment for one of 50 residents in the survey sample, Resident # 115. The findings include: The MDS assessment, an admission assessment with an assessment reference date of 5/7/23, in Section B - Hearing, Speech and Vision, coded the resident as usually being understood and usually understands. In Section C - Cognitive Patterns, there were dashed documented in the section for the resident interview and the section for staff interview. Under C0100 - Should Brief Interview for Mental Status Be Conducted, a dash was documented. An interview was conducted with RN (registered nurse) #6, the MDS coordinator, on 8/29/24 at 9:29 a.m. When asked who does Section C, RN #6 stated sometimes she does it but normally it's the social worker that does it. RN #6 was no employed at the facility at the time of the assessment above. The above assessment was reviewed with RN #6. RN #6 stated there shouldn't be dashes, the staff interview should…

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, staff/resident interviews facility document review and clinical record review, it was determined the facility staff failed to develop a baseline care plan for two of 50 residents in the survey sample, Resident #113 and Resident #407. The findings include: 1. The facility failed to develop a baseline care plan to include monitoring of anticoagulation therapy for Resident #113. Resident #113 was admitted to the facility on [DATE] with diagnosis that included fractures and hypertension. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 7/26/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for mobility/transfers, dressing, hygiene toileting and independent for eating. A review of the baseline care plan dated 8/3/23…

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, clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to review and/or revise the comprehensive care plan for three of 50 residents in the survey sample, Residents #11, #114 and #110. The findings include: 1. For Resident #11 (R11), the facility staff failed to revise the comprehensive care plan to include the use of grab bars. On the most recent MDS (minimum data set) assessment, a significant change assessment with an ARD (assessment reference date) of 7/12/24, the resident scored 10 of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. On 8/26/24 at 3:00 p.m., an interview was conducted with R11 in their room. R11 was observed in bed with bilateral grab bars on each side of the upper portion of the bed. R11 stated that the bars assisted them to turn and position themselves in the bed. The physician orders for R11 documented in part, Bilateral grab bars applied to the bed. Order 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.

Based on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to follow professional standards of practice for three of 50 residents in the survey sample, Residents #157, #34 and #72. The findings include: 1. For Resident #157, the facility staff failed to clarify two physician orders for blood sugar checks with insulin coverage in the clinical record at the same time. The physician order dated 8/9/24, documented, Humalog Solution 100 units/ML (milliliters) inject as per sliding scale: if (blood sugar) 1-70 = 0 (insulin) notify MD (medical doctor); 150 -199 = 1 unit; 200 - 249 = 2 units; 250 - 299 = 3 units; 300 - 349 = 4 units; 350 + = 5 units Notify MD > (greater than) 400, subcutaneously before meals and at bedtime for diabetes. D/C (discontinue date) 8/18/24. This order was documented on the MAR (medication administration record) from 8/9/24 through 8/18/24. The physician order dated 8/12/24, documented, Humalog Solution 100 units/ML (milliliters) inject as per sliding scale: if (blood sugar) 1-70 =…

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, clinical record review and facility document review, it was determined that the facility staff failed to provide care and services for an indwelling catheter for two of 50 residents in the survey sample, Residents #67 and #24. The findings include: 1. For Resident #67 (R67), the facility staff failed to provide urinary catheter care on multiple dates from 6/1/24 through 8/28/24. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 7/3/24, the resident scored seven out of 15 on the BIMS (brief assessment for mental status), indicating R67 was severely impaired for making daily decisions. Section H documented R67 having an indwelling urinary catheter. On 8/26/24 at 2:13 p.m., an observation was made of R67 in their room. R67 was observed in bed watching videos on an electronic device. A family member was observed sitting at R67's bedside. At that time, an interview was conducted with R67's family member who stated that on R67 had recently declined and been placed under…

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, the facility staff failed to complete nutritional assessments and obtain daily weights for one of 50 residents in the survey sample, Resident #34. The findings include: A. For Resident #34 (R34), the facility failed to obtain physician ordered daily weights. An interview was conducted with R34 on 8/26/24 at 3:45 p.m. R34 stated that she is supposed to have daily weights done. She stated if she didn't go to the scales to get weighed, no one would come get her to do it. She has missed a few weights. The physician order dated, 7/12/24, documented, Daily weights every day shift for sig (significant) weight gain. Use same scale/method for each wt (weight). The MAR (medication administration record) for July 2024 and August 2024 documented the above order. On 7/13/24, 7/14/24 and 7/20/24, there were blanks where the weight was to be documented. The comprehensive care plan dated 8/17/23 and revised on 8/9/24, documented in part, Focus: (R34) is at risk for alteration in nutritional status…

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 perform safety assessments for the use of side rails for one of 50 residents in the survey sample, Resident #93. The findings include: For Resident #93 (R93), the facility staff failed to assess the resident for safe side rail usage. On 8/27/24 at 9:02 a.m., R93 was observed sitting up in bed eating breakfast. Both quarter side rails were up on his bed. A review of R93's clinical record, including assessments, physician orders, and care plan, revealed no evidence of an assessment for R93's need for the use of side rails and for R93's ability to use the side rails safely. On 8/28/24 at 8:41 a.m., ASM (administrative staff member) #2, the director of nursing, stated she could not locate any evidence of a safety assessment for R93's use of side rails. On 8/29/24 at 12:40 p.m., RN (registered nurse) #5, a unit manager, was interviewed. She stated before a resident's bed is equipped with side rails of any kind, PT (physical therapy) and OT (occupational therapy) must…

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, the facility staff failed to provide physician oversight for the care of four of 50 residents in the survey sample, Residents #96, #72, #112, and #117. The findings include: 1. For Resident #96 (R96), the facility physician and/or nurse practitioner (NP) failed to assess the resident's prn (as needed) pain medication usage. For Resident #96 (R96), the facility staff failed to assess the resident's need for an increase in his scheduled pain medication. On the most recent MDS (minimum data set), an admission assessment dated [DATE], R96 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). He was coded as requiring staff assistance for ADLs (activities of daily living). On 8/26/24 at 2:46 p.m., R96 was sitting up in bed. He stated he was concerned about having to ask so frequently for pain medications. He stated sometimes…

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, the facility staff failed to provide a physician ordered medication for administration to two of 50 residents in the survey sample, Residents #96 and #34. The findings include: 1. For Resident #96 (R96), the facility staff failed to provide Avonex (a medication to treat multiple sclerosis) for timely administration. On the most recent MDS (minimum data set), an admission assessment dated [DATE], R96 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). He was coded as requiring staff assistance for ADLs (activities of daily living). On 8/26/24 at 2:46 p.m., R96 was sitting up in bed. He stated he was concerned about not receiving a weekly injection to treat his multiple sclerosis weekly on Saturdays. He stated he thought it was important that this medication be given on time, every seven days. A review of R96's clinical…

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, it was determined that the facility staff failed to ensure the physician reviewed and acted upon a pharmacy recommendation for one of five residents reviewed for the monthly pharmacy regimen review task. The findings include: For Resident #22, the facility staff failed to ensure the physician reviewed and addressed a pharmacy recommendation on 5/20/24. A review of the clinical record revealed a pharmacy note dated 5/20/24 that documented, See Consultant Pharmacist's Medication Regimen Review. A review of the pharmacy recommendation dated 5/20/24 documented, Resident is currently receiving Ramelteon (1) 8 mg (milligrams) tablets, 1 QHS (every night at bedtime) for hypnotic therapy and has been on it beyond the manufacturer's recommendation for duration of use. Please consider gradual tapering of the medication to ensure Resident is on the lowest dose possible, or continues to need the medication. The physician did not review and address this recommendation. The resident remained on this medication at 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.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure that one of five residents reviewed for the monthly pharmacy regimen review task was free of an unnecessary psychoactive medication; Resident #22. The findings include: For Resident #22, the facility staff failed to ensure the resident was free of an unnecessary psychoactive medication. A review of the clinical record revealed a physician's order dated 5/14/24 for Ramelteon (1) Oral Tablet 8 MG (milligrams) Give 1 tablet by mouth at bedtime for insomnia. A review of the pharmacy recommendation dated 5/20/24 documented, Resident is currently receiving Ramelteon (1) 8 mg (milligrams) tablets, 1 QHS (every night at bedtime) for hypnotic therapy and has been on it beyond the manufacturer's recommendation for duration of use. Please consider gradual tapering of the medication to ensure Resident is on the lowest dose possible, or continues to need the medication. The physician did not review and address this recommendation. The resident remained on 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.

Based on observation, staff interview, and facility document review, the facility staff failed to store, prepare, and serve food in a safe and sanitary manner in one of one kitchen, and one of three nourishment rooms (the grace unit), and failed to maintain the dishwasher in good repair in one of one kitchen. The findings include: 1. The facility staff failed to store sugar in a safe and sanitary manner. On 8/26/24 at 12:10 p.m., an observation of the kitchen dry goods storage room was conducted. A container of sugar was observed with the lid open, exposing the sugar to air. On 8/27/24 at 1:32 p.m., an interview was conducted with OSM (other staff member) #1 (the dietary manager). OSM #1 stated the lid should cover the sugar container at all times so nothing will drop into the sugar. On 8/27/24 at 4:21 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Receiving and Storage of Food documented, Foods shall be received and stored in a manner that complies with safe food…

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 provide a sanitary environment for one of one kitchen. The findings include: The facility staff failed to ensure the floors in the kitchen were clean and free from debris. On 8/26/24 at 12:10 p.m., and 8/27/24 at 9:15 a.m., observations of the kitchen were conducted. Several crumbles of black and brown debris were easily visible and observed on the floor under the three-compartment sink, under shelves, under the dishwasher, and in a gap (approximately 12 inches) between the stove and ovens. Several crumbles of black and brown debris and black and brown stains were observed on the floor in the dry goods storage room. On 8/27/24 at 1:32 p.m., an interview was conducted with OSM (other staff member) #1 (the dietary manager). OSM #1 stated the dietary staff should sweep and mop the kitchen floors after every meal and this should be done under the sink, under shelves, under the dishwasher, and between the stove and ovens. OSM #1 stated the dietary staff could not remove the stains on 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 observation, resident interview, facility document review, and clinical record review, the facility staff failed to treat a resident with dignity by not answering a call bell for one of six residents in the survey sample, Resident #6. The findings include: For Resident #6 (R6), the facility staff failed to answer her call bell in a timely manner on 5/6/24. A review of R6's admission nursing assessment dated [DATE] revealed the resident had no cognitive impairment for making daily decisions. On 5/6/24 at 2:02 p.m., the call light outside R6's room was on. Between 2:02 p.m. and 2:52 p.m., six different staff members walked by R6's room without acknowledging or answering the call bell. During this time, two staff members were seated at the nursing station talking to each other, one staff member was seated in the day room working on the computer, and one nurse was on R6's hall administering medications to other residents. At 2:52 p.m., a staff member entered R6's room and turned off the call bell. On 5/7/24…

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 implement the care plan for two of six residents in the survey sample, Residents #5 and #6. The findings include: 1. For Resident #5 (R5), the facility staff failed to implement the care plan for the administration of respiratory medications. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/29/24, R5 was coded as having no cognitive impairment for making daily decisions. She was admitted to the facility on [DATE] with diagnoses including COPD (chronic obstructive pulmonary disease) (1), pulmonary edema (2), and chronic respiratory failure. On 5/6/24 at 2:02 p.m., R5 was observed sitting up in bed. She was receiving oxygen via nasal cannula. She stated she has trouble breathing, and is concerned that she is not receiving her breathing treatments on time. She stated: They give them to me when they feel like it. 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 resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to administer and/or accurately document administration of medications according to professional standards of practice for one of six residents in the survey sample, Resident #5. The findings include: For Resident #5 (R5), the facility staff documented that the resident refused a nicotine patch when it was not yet available from the pharmacy, and documented the medication was applied when it actually had not been applied. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/29/24, R5 was coded as having no cognitive impairment for making daily decisions. On 5/6/24 at 2:02 p.m., R5 was interviewed. She stated she had been having trouble getting her nicotine patch applied. She stated it had not been applied daily, and some nurses told her she was not to receive a new patch every day. She stated she needed the patch because she is addicted to cigarettes, and cannot smoke in the facility. A review of R5'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, the facility staff failed to follow a physician's order for one of six residents in the survey, Resident #4. The findings include: For Resident #4 (R4), the facility failed to obtain daily weights as ordered to monitor the resident's cardiac status. R4 was most recently readmitted to the facility on [DATE] with diagnoses which included congestive heart failure (1). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/22/24, R4 was coded as being moderately cognitively impaired for making daily decisions. On 5/7/24 at 9:22 a.m., R4 was observed sitting up in a wheelchair in her room. When asked if the facility staff had been weighing her every day, she stated: I'm not sure. But I don't think so. A review of R4's clinical record revealed the following order dated 4/20/24: Daily Weights one time a day for Daily Weight. Call Cardiology at [phone number] 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 resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide respiratory services in a timely manner for one of six residents in the survey sample, Resident #5. The findings include: For Resident #5 (R5), the facility staff administered nebulizer treatments more than an hour late on multiple occasions between 4/24/24 and 5/3/24. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/29/24, R5 was coded as having no cognitive impairment for making daily decisions. She was admitted to the facility on [DATE] with diagnoses including COPD (chronic obstructive pulmonary disease) (1), pulmonary edema (2), and chronic respiratory failure. On 5/6/24 at 2:02 p.m., R5 was observed sitting up in bed. She was receiving oxygen via nasal cannula. She stated she has trouble breathing, and is concerned that she is not receiving her breathing treatments on time. She stated: They give them to me…

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, facility document review, and clinical record review, the facility staff failed to store equipment in a manner to prevent infection for one of six residents in the survey sample, Resident #5. The findings include: For Resident #5 (R5), the facility staff failed to store the resident's nebulizer mask in a manner to prevent infection. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/29/24, R5 was coded as having no cognitive impairment for making daily decisions. She was admitted to the facility on [DATE] with diagnoses including COPD (chronic obstructive pulmonary disease) (1), pulmonary edema (2), and chronic respiratory failure. On 5/6/24 at 2:02 p.m., R5 was observed sitting up in bed. The drawer to the resident's bedside table was open. The resident's nebulizer mask, still attached to the nebulizer machine with tubing, was lying unprotected in the resident's drawer. The resident stated: That's where they…

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, and facility document review, the facility staff failed to serve food at a palatable texture and appetizing temperature, on one of three facility units, the [NAME] unit. The findings include: A test tray from the [NAME] unit at breakfast on 9/12/23 contained cold, soggy toast and a lukewarm cheese omelet. On 9/12/23 at 6:50 a.m., OSM (other staff member) #2, a cook, was observed as he took temperatures of the hot breakfast foods on the tray line prior to resident meals being served. OSM #2 removed the toast from the toaster and put it in a steam table pan on the serving line. When he tested the cheese omelets, they registered a temperature of 197 degrees (Fahrenheit). On 9/12/23 at 7:51 a.m., the test tray was prepared, covered, and placed on the cart with other meals for [NAME] unit residents. The cart arrived on the unit at 7:56 a.m. On 9/12/23 at 8:08 a.m., the last resident on the [NAME] unit had been served breakfast. OSM #1 (the dining services manager) took 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 resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to implement the care plan for two of six residents in the survey sample, Residents #3 and #2. The findings include: 1. For Resident #3 (R3), the facility staff failed to implement the care plan for pain management. R3 was admitted to the facility with diagnoses including COPD (chronic obstructive pulmonary disease) and lung cancer that had spread to other parts of the body. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 8/30/23, R3 was coded as having no cognitive impairment for making daily decisions. A review of R3's provider's orders revealed the following order dated 8/29/23: Morphine Sulfate Oral Solution 100 mg/ml (milligrams per milliliter) Give 0.75 ml by mouth every 6 hours for pain related to [lung cancer.] A review of R3's August and September 2023 MARs (medication administration records) revealed R3 received Morphine more than an hour past the time they were due on the following dates…

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, the facility staff failed to administer medications according to the provider's orders and professional standards of medication administration for two of six residents in the survey sample, Residents #3 and #2. The findings include: 1. For Resident #3 (R3), the facility staff failed to administer Potassium Chloride (1), Famotidine (2), Colace (3), and Albuterol (4) in a timely manner. R3 was admitted to the facility with diagnoses including COPD (chronic obstructive pulmonary disease) and lung cancer that had spread to other parts of the body. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 8/30/23, R3 was coded as having no cognitive impairment for making daily decisions. On 9/11/23 at 2:48 p.m., R3 was interviewed, and stated: I'm not sure I get my medicines at the right time always. They do give them to me pretty regularly. A review of R3'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 resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to administer medications in a manner to prevent significant medication errors for two of six residents in the survey sample, Residents #3 and #2. The findings include: 1. For Resident #3 (R3), the facility staff failed to administer Morphine Sulfate (1) in a timely manner. R3 was admitted to the facility with diagnoses including COPD (chronic obstructive pulmonary disease) and lung cancer that had spread to other parts of the body. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 8/30/23, R3 was coded as having no cognitive impairment for making daily decisions. On 9/11/23 at 2:48 p.m., R3 was interviewed. She stated: I'm not sure I get my medicines at the right time always. They do give them to me pretty regularly. A review of R3's provider's orders revealed the following order dated 8/29/23: Morphine Sulfate Oral Solution 100 mg/ml (milligrams per milliliter) Give 0.75 ml by mouth every 6 hours…

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 in the course of a complaint investigation, the facility staff failed to continuously employ a registered dietitian (RD) or qualified nutritional professional. The findings include: The facility staff failed to employ a registered dietitian or qualified nutritional professional from 4/30/22 until 6/15/22. A complaint submitted to the state agency on 6/29/22 alleged there was no registered dietitian employed by the facility since 5/1/22. A review of facility documents/timesheets revealed a RD began employment on 6/15/22. On 11/16/22 at 5:52 p.m., an interview was conducted with ASM (administrative staff member) #4, the interim administrator. ASM #4 stated the former RD left the facility right before the facility was sold to another company. ASM #4 stated another RD was not employed until 6/15/22. On 11/17/22 at 12:35 p.m., ASM #4 stated the former RD's last day of employment was 4/30/22 (no RD or qualified nutritional profession was employed at the facility from 4/30/22 until 6/15/22). On 11/17/22 at 12:55 p.m., ASM #4 and ASM…

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 implement a QAPI (Quality Assurance and Performance Improvement) program potentially affecting all residents in the survey sample. The findings include: The facility staff failed to provide evidence of a QAPI program prior to August 2022. On 11/17/22 at 10:24 a.m., ASM (administrative staff member) #2, the director of nursing (hired on 7/25/22), stated she could not provide evidence of any QAPI program/documentation prior to August 2022. ASM #2 stated the QAPI program is supposed to consist of identifying issues through concerns from department heads and their staff, the concerns should be taken to the QAPI meetings, the QAPI team should develop action plans, staff should be educated, processes should be implemented, the plan should be evaluated, and if the plan is not working then new interventions should be started. On 11/17/22 at 12:55 p.m., ASM #4, the interim administrator and ASM #2 were made aware of the above concern. The facility policy titled, Quality Assurance Performance Improvement…

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 implement policies and procedures for QAPI (Quality Assurance and Performance Improvement) program feedback, data systems and monitoring potentially affecting all residents in the survey sample. The findings include: The facility staff failed to implement policies and procedures for a systematic approach to determine underlying causes of problems impacting larger systems, corrective action and monitoring of the effectiveness of performance improvement activities prior to August 2022. On 11/17/22 at 10:24 a.m., ASM (administrative staff member) #2, the director of nursing (hired on 7/25/22), stated she could not provide evidence of any QAPI program/documentation prior to August 2022. ASM #2 stated the QAPI program is supposed to consist of identifying issues through concerns from department heads and their staff, the concerns should be taken to the QAPI meetings, the QAPI team should develop action plans, staff should be educated, processes should be implemented, the plan should be evaluated, and if…

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 conduct required QAPI (Quality Assurance and Performance Improvement) meetings potentially affecting all residents in the survey sample. The findings include The facility staff failed to evidence quarterly QAPI meetings were conducted prior to August 2022. On 11/17/22 at 10:24 a.m., ASM (administrative staff member) #2, the director of nursing (hired on 7/25/22), stated she could not provide evidence of any QAPI meetings prior to August 2022. ASM #2 stated the QAPI committee should meet quarterly and consists of the social worker, director of nursing, administrator, dietary manager, activities director, laundry manager, a CNA (certified nursing assistant) and the medical director. On 11/17/22 at 12:55 p.m., ASM #4, the interim administrator and ASM #2 were made aware of the above concern. The facility policy titled, Quality Assurance Performance Improvement (QAPI) Committee documented, 4. The facility will maintain a QAPI committee consisting at a minimum of: a. The director of nursing service; b.…

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, it was determined the facility staff failed to implement an ongoing infection prevention and control program (IPCP) potentially affecting all residents in the survey sample. The findings include: There were no infection control tracking logs available for review. Upon entrance on 11/14/2022 a request was made for the infection control tracking logs. A second request was made on 11/16/2022. ASM (administrative staff member) #2, the director of nursing, stated on 11/16/2022 at 5:25 p.m. the facility has no infection control tracking logs before August 2022. They presented a notebook with the floor plans of the facility. It had colored lines on rooms with infections. On 11/17/2022 at 10:08 a.m. an interview was conducted with ASM #2, and ASM #3, the assistant director of nursing. When asked if they had a line listing of the infections in the facility with type of infections, source, culture results and/or x-ray results, ASM #2 stated, no. When asked the process for tracking and trending infections in the facility, ASM #2 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 staff interview, facility document review and in the course of a complaint investigation, the facility staff failed to continuously employ an infection preventionist (IP) potentially affecting all residents in the survey sample. The findings include: The facility staff failed to employ an infection preventionist from 6/18/22 until 7/25/22. A complaint submitted to the state agency on 6/29/22 alleged that as of 6/18/22, there was no one in the facility certified to fill the role of infection preventionist. On 11/16/22 at 5:32 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated she could not provide evidence that the facility employed an infection preventionist with required credentials from the time the former director of nursing left (6/18/22) until she was hired (7/25/22). On 11/17/22 at 12:55 p.m., ASM #4, the interim administrator and ASM #2 were made aware of the above concern. The facility policy titled, Infection Preventionist documented, The Infection Preventionist is responsible for coordinating 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.

4. For Resident #15 (R15), the facility staff failed to honor a resident's preferences for bed rails to maintain their level of ADL (activities of daily living) self-performance and promote their sense of self-determination and independence. R15 used the bed rails on their bed to increase their ADL self-performance with staff assistance in transferring and bed mobility and requested their use however they were removed from the bed causing R15 to require more physical assistance from staff when transferring to the recliner. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/30/2022, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. Section G documented R15 requiring extensive assistance of two or more persons for bed mobility, one person for transfers and limited assistance of one person for walking in the room. Section G further documented R15 using a walker and a wheelchair. The previous quarterly MDS with an ARD 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and facility document review, it was determined the facility staff failed to maintain grievance logs from 7/20/2022 through 11/15/2022 potentially affecting most of the 33 residents in the survey sample. The findings include: Upon entrance to the facility on [DATE] at approximately 7:00 p.m. a request was made for the grievance logs. A second request was made on 11/15/2022 at approximately 9:00 a.m. On 11/15/2022 the survey team received a document titled, Concern Log. The document dated concerns from 1/13/2022 through 7/20/2022. On 11/15/2022 at 1:06 p.m., an interview was conducted by another surveyor with OSM (other staff member) #4, long term care ombudsman. OSM #4 stated that they had received multiple calls from residents and family members regarding the bed rails being removed from residents beds. OSM #4 stated that they had been told that maintenance had removed all of the bed rails about two or three weeks ago. OSM #4 stated that they were told that there were new regulations…

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 the facility staff failed to develop and/or implement the comprehensive care plan for four of 33 residents in the survey sample, Residents #53, #51, #63 and #54. The findings include: 1. For Resident #53, the facility staff failed to develop a care plan for the use of oxygen. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with the assessment reference date of 10/15/2022, the resident coded as having no short or long term memory issues. In Section O - Special Treatment, Procedures and Programs, the resident was coded as using oxygen while a resident at the facility. Review of the comprehensive care plan, last updated 11/14/2022, failed to evidence documentation of the use of oxygen for R53. R53 was observed on 11/15/2022 at approximately 8:45 a.m. with oxygen on via a nasal cannula. The oxygen concentrator was set at 2 LPM (liters per minute). A second observation was made on 11/15/2022 at 11:53 a.m. R53 was in the wheelchair with the oxygen 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 resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to facilitate communication with the dialysis center for one of 33 residents in the survey sample, Resident #63 (R63). The findings include: For Resident #63, the facility staff failed to have a communication system in place to facilitate communication between the facility and the dialysis center. On the most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 10/5/2022, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is not cognitively impaired for making daily decisions. In Section O - Special Treatments, Procedures and Programs, R63 was coded as receiving dialysis while a resident at the facility. An interview was conducted with R63 on 11/15/2022 at approximately 8:45 a.m. When asked if they took any papers or a notebook to give to the dialysis staff when they go to dialysis, R63 stated, no. R63 stated they go 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 staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide performance evaluations and mandatory training for three of five CNA's (certified nursing assistants) reviewed CNA #2, #3, and #5. The findings include: During the Sufficient and Competent Staffing facility task review on 11/15/22 at 3:00 PM there was no evidence of performance evaluations for three of five CNA's (certified nursing assistants) reviewed. On 11/15/22 at 9:00 AM, ASM (administrative staff member) #1, the regional director of operations was provided with the list of five CNA's with a request for evidence of performance review. On 11/15/22 at 12:30 PM, ASM #1, the regional director of operations, provided the employee files requested. Upon review, the following was revealed: 1. CNA #2 with a date of hire of 11/17/20 had an initial orientation evaluation in 3/2021. There was no performance evaluation in the last 12 months. 2. CNA #3 with a date of hire of 3/16/92 evidenced the last evaluation in 3/2020. There was no performance evaluation…

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 ensure one of 33 residents in the survey sample was free of unnecessary medications, Resident #16. The findings include: For Resident #16 (R16), the facility staff failed to hold the Hydrochlorothiazide (1) as ordered when the resident's systolic blood pressure (2) was less than 140 ten times during October 2022 and five times during November 2022. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 7/26/2022, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) assessment indicating the resident was cognitively intact for making daily decisions. R16 was coded as receiving a diuretic during the look back period and having high blood pressure. The physician orders for R16 documented in part, Hydrochlorothiazide 12.5 MG (milligram) * Give 1 tablet orally every day shift related to Essential (Primary) Hypertension. HOLD IF SBP (systolic blood pressure) < (less…

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 administer medications in a manner free of significant errors for one of 33 residents in the survey sample, Resident #16. The findings include: For Resident #16 (R16), the facility staff failed to hold the Hydrochlorothiazide (1) as ordered when the resident's systolic blood pressure (2) was less than 140 ten times during October 2022 and five times during November 2022. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 7/26/2022, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) assessment indicating the resident was cognitively intact for making daily decisions. R16 was coded as receiving a diuretic during the look back period and having high blood pressure. The physician orders for R16 documented in part, Hydrochlorothiazide 12.5 MG (milligram) * Give 1 tablet orally every day shift related to Essential (Primary) Hypertension. HOLD IF SBP (systolic blood…

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 interview, and facility document review, it was determined that the facility staff failed to properly store food products in the walk in refrigerator, discard expired food, and maintain the dishwasher in good repair in one of two kitchens in the facility. The findings include: On 11/14/2022 at 6:37 p.m., an observation of the kitchen on the Grace unit was conducted with OSM (other staff member) #8, dietary cook. Observation of the walk in refrigerator revealed a 12 pound container of homestyle potato salad with a use by date of 10/25/2022 on the lid. The container was observed to be unopened. OSM #8 observed the container and stated that the potato salad was old and needed to be thrown away. OSM #8 stated that the container was available for use. Observation of the walk in freezer revealed a 10 pound box of diced grilled chicken breast sitting on the freezer floor, a 16.72 pound box of oven ready four cheese pizzas sitting on the freezer floor and a 10 pound box of hotdogs sitting on the freezer floor. OSM #8 stated that they did not have a lot of room…

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 employee record review, it was determined that the facility staff failed to evidence maintenance of required certification for five of five CNA (certified nursing assistant) record reviews. The findings include: The facility staff failed to provide the evidence of required certification for five of five CNAs that were employed for greater than on year, CNA #1, CNA #2, CNA #3, CNA #4 and CNA #5. During the Sufficient and Competent Staffing facility task review on [DATE] at 3:00 PM revealed that the following CNA certifications were verified after expiration from the Virginia Department of Health Professions (DHP) as follows: 1. CNA #1 with a date of hire of [DATE], the previous certification expired [DATE], however verification was not obtained from the DHP until [DATE]. 2. CNA #2 with a date of hire of [DATE], the previous certification expired [DATE], however verification was not obtained from the DHP until [DATE]. 3. CNA #3 with a date of hire of [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.

Based on staff interview, facility document review and in the course of a complaint investigation, the facility staff failed to provide abuse and dementia management training for five of six agency employee reviews. The findings include: The facility staff failed to provide abuse and dementia management training to RN (registered nurse) #5, LPN (licensed practical nurse) #3, CNA (certified nursing assistant) #12, CNA #13 and LPN #9. A complaint submitted to the state agency on 6/29/22 alleged a concern regarding agency staff training. RN #5 was hired on 9/2/22. LPN #3 was hired on 8/21/22. CNA #12 was hired on 2/12/22. CNA #13 was hired on 6/9/22. LPN #9 was hired on 3/31/22. A review of employee records failed to reveal evidence of abuse and dementia management training for the above staff. On 11/16/2022 at 5:37 p.m., an interview was conducted with ASM (administrative staff member) #4, the interim administrator. ASM #4 stated contracted staff go through training prior to working at the facility. ASM #4 stated contracted staff are provided an orientation packet which includes…

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, responsible party interview, staff interview, clinical record review, facility document review and in the course of a complaint investigation, it was determined that the facility staff failed to honor a resident's right to make choices about their bathing preferences for two of 33 residents in the survey sample, Resident #47 and Resident #29. The findings include: 1. For Resident #47 (R47), the facility staff failed to provide showers as per their preference. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 7/24/2022, the resident was assessed as being moderately impaired for making daily decisions. Section G documented R47 being totally dependent on one staff member for bathing. On 11/15/2022 at 11:15 a.m., a telephone interview was conducted with R47's responsible party. R47's responsible party stated that showers were supposed to be given twice a week, however on most weeks R47 was only receiving a shower once a week. R47's responsible party stated that they felt that this was due…

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 failed to ensure one of 33 residents were free of misappropriation of property, Resident #10. The findings include: For Resident #10 (R10), the facility staff failed to ensure they were free of misappropriation of prescribed controlled medication. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/2/2022, the resident scored 12 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. Section J documented R10 receiving scheduled pain medication and having pain almost constantly. Section N documented R10 receiving opioid medications during the assessment period. On 11/16/2022 at 9:19 a.m., an observation was made of R10 in their room. R10 was observed in bed watching television. An interview was conducted with R10. R10 stated that they often had pain and the nurses administered pain medication to them. R10…

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 implement the facility abuse policy for screening staff for one of four agency staff reviewed, LPN (licensed practical nurse) #3. The findings include: The facility staff failed to implement their abuse policy for staff screening for LPN #3. During the course of a FRI (facility reported incident) review for Resident #10 (R10) regarding misappropriation of resident property, it was determined that LPN #3 did not have a background check completed prior to working at the facility. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/2/2022, the resident scored 12 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. Section J documented R10 receiving scheduled pain medication and having pain almost constantly. Section N documented R10 receiving opioid medications during the assessment period. Review of the FRI'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 observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to review and revise the comprehensive care plan for one of 33 residents in the survey sample, Resident #206. The findings include: The facility staff failed to review and revise Resident #206's (R206) comprehensive care plan for the use of an incentive spirometer. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 10/30/22, 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. R206's comprehensive care plan revised on 11/9/22 failed to reveal documented information regarding an incentive spirometer. On 11/15/22 at 9:36 a.m., R206 was observed sitting in a wheelchair in the bedroom. An incentive spirometer was on the resident's over bed table. An interview was conducted with R206. R206 stated they use the incentive spirometer every two hours. On 11/16/22 at 3:26 p.m., 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 staff interview, facility document review and clinical record review, it was determined the facility staff failed to obtain weights as ordered by the physician, for one of 33 residents in the survey sample, Resident #22. The findings include: The facility staff failed to follow physician orders for initial admission weights ordered x 3 days, and weekly weight x 4 for Resident #22. Resident #22 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CAD (coronary artery disease), hypertension, dementia, and anxiety. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 8/22/22, coded the resident as scoring a 09 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the comprehensive care plan with a revision date of 8/16/22 did not include a concern with weights. A review of the physician orders dated 8/15/22,…

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, clinical record review and in the course of a complaint investigation, the facility staff failed to provide ADL (activities of daily living) care for two of 33 residents in the survey sample, Residents #61 and #22. The findings include: 1. The facility staff failed to assist Resident #61 (R61) with eating on 11/2/22. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/27/22, the resident scored 0 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely cognitively impaired for making daily decisions. Section G coded R61 as requiring extensive assistance of one staff with eating. An occupational therapy note dated 6/15/21 documented, Pt. (Patient) was self feeding when OTR/L (occupational therapy employee) arrived into room, taking tray to her mouth and trying to pour it in, getting food on lap. OTR/L provided pt. with a towel to wipe her clothing off/protect it…

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, facility document review and clinical record review, it was determined the facility staff failed to provide incontinence care in a timely manner for one of 33 residents in the survey sample, Resident #51 (R51). The findings include: On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 8/23/2022, the resident was coded as having no short or long term memory difficulties. In Section H - Bladder and Bowel, the resident was coded as always being incontinent of both bowel and bladder. On 11/15/2022 at 9:04 a.m. R51 stated, We don't get changed. R51 stated they were changes at 6:30 a.m. and not since then. R51 stated, It's now 9:00 a.m. and I have moved my bowels. The call bell was initiated by the resident. At 9:06 a.m. a staff member entered the room and then exited without changing the resident. The staff member went into the next room. At 9:26 a.m. the resident stated they still had not been changed. The resident was changed at 10:00 a.m. CNA (certified nursing assistant) #14, the restorative…

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 the facility staff failed to provide respiratory care and services consistent with professional standards of practice for three of 33 residents in the survey sample, Residents #53, #98 and #206. The findings include: 1. For Resident #53 (R53), the facility staff failed to obtain a physician order for the use of oxygen. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with the assessment reference date of 10/15/2022, the resident was coded as having no short or long term memory issues. In Section O - Special Treatment, Procedures and Programs, the resident was coded as using oxygen while a resident at the facility. R53 was observed on 11/15/2022 at approximately 8:45 a.m. in their bed with oxygen on 2 LPM (liters per minute) via a nasal cannula. A second observation was made on 11/15/2022 at 11:53 a.m. R53 was in the wheelchair with the oxygen on at 2 LPM via a nasal cannula with a portable tank secured to the wheelchair.…

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, facility document review and clinical record review, the facility staff failed to implement bed rail requirements for two of 33 residents in the survey sample, Residents #68 and #20. The findings include: 1. The facility staff failed to review the risks and benefits of the use of bed rails with Resident #68 (R68) (and/or the resident's representative) and failed obtain informed consent. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 9/13/22, R68's cognitive skills for daily decision making were coded as moderately impaired. A review of R68's clinical record revealed a side rail (bed rail) and entrapment risk assessment dated [DATE] that documented the use of side rails during care provided by staff would optimize resident safety and security, and the use of 1/2 upper rails was recommended. Further review of R68's clinical record failed to reveal documentation that the facility staff reviewed the risks 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, resident observation, facility document review and clinical record review, it was determined that the facility staff failed to provide sufficient staffing to meet resident needs for one of 33 residents, Resident #22. The findings include: The facility staff failed to provide sufficient staffing to meet resident needs. A request was made during the entrance conference on 11/14/22 at approximately 6:45 PM to ASM (administrative staff member) #2, the director of nursing to provide as worked staffing schedules from 10/14/22-11/14/22. When asked during the entrance conference if there were any staffing waivers, ASM #2 stated, No, there are no waivers. As a part of the sufficient staffing facility task and a complaint investigation the as worked staffing sheets for 10/14/22-11/14/22 sheets for [NAME] Unit were reviewed. [NAME] Unit has 60 available beds with 58 beds occupied during survey. A review of the [NAME] Unit as worked nursing schedule for 10/14/22-11/14/22 revealed, 2 CNAs (certified…

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 in the course of a complaint investigation, the facility staff failed to maintain an effective training program for two of 5 employee reviews. The findings include: The facility staff failed to train LPN (licensed practical nurse) #8 and CNA (certified nursing assistant) #11 regarding the new electronic medical record system. A complaint submitted to the state agency on 6/29/22 alleged concern over the amount of time employees received regarding the new electronic medical record system. The facility transitioned to a new electronic medical record system on 6/15/22. A review of CNA and licensed nurse training/orientation checklists revealed CNAs and nurses were supposed to be trained regarding the new electronic medical record system. A review of five employee records failed to reveal evidence that LPN #8 (hired on 6/6/20 and last worked on 11/10/22) and CNA #11 (hired on 9/3/21 and last worked on 10/21/22) received training regarding the new electronic medical record system. On 11/16/22 at 2:55 p.m., an interview was conducted…

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, facility document review and clinical record review, it was determined the facility staff failed to ensure pain management was provided consistent with professional standards of practice, and the comprehensive person-centered care plan for one of 38 residents in the survey sample, Resident #27. The facility staff failed to complete a pain assessment of Resident #27's pain, prior to the administration of a pain medication on multiple occasions in April, May and June 2021. The findings include: The facility policy, Pain Assessment documented in part, Purpose: Establish uniform guidelines concerning pain assessment and management. Definition: Pain can be described as an unpleasant sensory or emotional experience. Procedure: 1. Pain Assessments: .b. A routine pain assessment will include intensity of pain (level of pain) and location. Nonpharmacological measures and their effectiveness may be assessed and discussed with the resident. c. A pain assessment may include 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 observation, staff interview, facility document review and clinical record review it was determined the facility staff failed to ensure one of 38 residents in the survey sample was free of unnecessary medications, Resident #27. On multiple occasions during April, May and June 2021, the facility staff failed to ensure Resident #27 was free from unnecessary medication, as evidenced by the staffs failure to complete a pain assessment, and failure to attempt/offer non-pharmacological interventions prior to administering the physician prescribed as needed pain medication Norco to Resident #27, and as evidenced by staff administering the medication for documented/reported pain levels of 7, which were below the physician ordered parameter of eight (8) for administration of the medication. The findings include: Resident #27 was readmitted to the facility on [DATE] with diagnoses that included but were not limited to: chronic pain, high blood pressure and rheumatoid arthritis (A chronic, destructive disease…

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 the facility staff failed to implement the comprehensive care plan for two of 38 residents in the survey sample, Resident #27 and Resident #89. 1. The facility staff failed to implement Resident 327's comprehensive care plan for the management of pain. Facility staff administer a as needed pain medication when the residents pain level rating was below the physician parameter of eight, without a pain assessment and without attempting non-pharmacological interventions on multiple occasions during April, May and June 2021. 2. a. The facility staff failed to implement Resident #89's comprehensive care plan for treatment of a pressure injury. LPN #6 was observed cleaning Resident #89's left buttock wound using a piece of gauze wiping the wound from top to bottom and then wiped back up the wound using the same gauze. 2.b. The facility staff failed to implement the comprehensive care plan for the care of Resident #89'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 observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide wound care in a manner to promote healing and prevent infection for one of 38 residents in the survey sample, Resident #89. LPN #6 failed to change gloves between cleaning Resident #89's right and left buttock wound and wiped down the left buttock wound from top to bottom and then wiped back up the wound using the same gauze. The findings include: Resident #89 was admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses that included but were not limited to: diabetes, benign prostatic hypertrophy (an enlarged prostate) (1), and psychotic disorders (Psychotic disorders are severe mental disorders that cause abnormal thinking and perceptions.) (2) The most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 6/13/2021, coded the resident as scoring a 3 on the BIMS (brief interview for mental…

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, facility document review and clinical record review, it was determined the facility staff failed to maintain an indwelling catheter consistent with professional standards of practice, and the comprehensive person-centered care plan for one of 38 residents in the survey sample, Resident # 89. The nurse failed to maintain the indwelling catheter collection bag below the resident's bladder. Observation revealed the staff placed Resident #89's Foley catheter bag on the bed while the resident received wound care. Urine was observed flowing up towards the resident and not towards the collection bag. The findings include: Resident #89 was admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses that included but were not limited to: diabetes, benign prostatic hypertrophy (an enlarged prostate) (1), and psychotic disorders (Psychotic disorders are severe mental disorders that cause abnormal thinking and perceptions. People with psychoses lose touch with…

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 interview, and facility document review, it was determined that the facility staff failed to store, and prepare, food in accordance with professional standards for food service. The facility staff failed to maintain the fryer in a sanitary manner after use the previous evening and failed to dispose of expired or opened food during the facility task- kitchen observation on 6/28/21 at 11:30 AM. The findings include: On 6/28/21 at 11:30 AM, an observation was conducted in the main kitchen. The deep fryer was observed with food liked appearing particles on the basket drain area and (two) 16-ounce boxes of cornstarch, both open to the air were observed on shelf next to sink. An interview was conducted on 6/28/21 at 11:45 AM with OSM (other staff member) #3, the dietary cook. OSM #3 was asked when the fryer was last used. OSM #3 stated, I'm not sure. I wasn't here yesterday, but probably yesterday. The fryer was noted to be off and not in use for the lunch meal. When asked if the fryer had been used for breakfast, OSM #3 stated, No, we don't use it 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.