Augusta Nursing and Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review, and facility document review, the facility failed to implement abuse policies for two of seven residents, Resident #'s 203 and 207. The Findings Include: 1. The facility did not implement facility abuse policy in regards to reporting suspicion of physical abuse/mistreatment for Resident #203 (R203). According to the clinical record, diagnoses for R203 included, Multiple sclerosis, quadriplegia, pulmonary embolism, and depression. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 11/6/24, which assessed R203 with a cognitive score of 15 out of 15, indicating cognitively intact. Review of R203's clinical record documented a social workers note, dated 12/3/24, that indicated a certified nursing assistant (CNA) had been rude and rough during care (when turning R203) and alluded to R203 not feeling safe during the care provided. On 12/9/24 at 1:50 p.m., R203 was interviewed regarding the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review, and facility document review, the facility failed to report suspicion of physical abuse/mistreatment for one of 7 residents (Resident #203) and failed to report suspicion of physical abuse/mistreatment timely for one of 7 residents (Resident #207) to the state agency. The Findings Include: 1. The facility did not report suspicion of physical abuse/mistreatment for resident #203 (R203). According to the clinical record, diagnoses for R203 included Multiple sclerosis, quadriplegia, pulmonary embolism, and depression. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 11/6/24. R203 was assessed with a cognitive score of 15 out of 15, indicating cognitively intact. Review of R203's clinical record documented a social workers note dated 12/3/24 that indicated a certified nursing assistant (CNA) had been rude and rough during care (when turning R203) and indicated that R203 was not feeling…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interviews, staff interviews, clinical record review, and facility documentation review, the facility staff failed to complete a thorough and accurate investigation of a serious elopement incident involving one resident (Resident #113-R113), in a survey sample of 29 residents. The findings included: On 10/15/24 at 10:50 a.m., an interview was conducted with R113 regarding her 10/2/24 fall outside. R113 said that she walked out to the parking lot and then went on down to the road to smoke a cigarette. R113 said that she stepped in the grass and slid into the mud. R113 said that it took her about half an hour to crawl out of the mud. R113 said that she managed to get out of the mud and to the side of the road, when an employee saw her and picked her up in her vehicle. R113 stated. I go outside whenever I want to go out. No signing out or telling anyone. On 10/16/24 at 10:10 a.m., an interview was conducted with the administrator. The administrator said that education for the wander…

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 documentation review, the facility staff failed to implement the comprehensive care plan interventions for one resident (resident #113- R113) in a survey sample of 29 residents. The findings included: For R113, who had a care plan intervention for staff to monitor location every 30 minutes and prn [as needed], the facility staff failed to implement this intervention. On 10/15/24, in the afternoon, R113 was visited in her room. During the interview, R113 verbalized a desire to leave the facility and return home to live. On 10/15/24 and 10/16/24, at varying times, multiple observations were conducted of R113. There was no indication that facility staff were providing any type of monitoring of the resident every thirty minutes. On 10/16/24, during a clinical record review, R113's care plan was reviewed. According to the care plan, a focus area was initiated on 9/24/24, that read in part, [R113's name redacted] is an elopement risk & wanderer r/t [related to] dementia and being a smoker. She exit seeks to try to…

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

Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to review and revise the care plan for one resident (resident #113- R113) in a survey sample of 29 residents. The findings included: For R113, who the facility staff identified was no longer an elopement risk, the facility staff failed to review and revise the care plan to indicate this. On 10/15/24, in the afternoon and on multiple occasions on 10/16/24, R113 was visited in her room. During the interviews, R113 verbalized a desire to leave the facility and return home to live. On 10/16/24, during a clinical record review, R113's care plan was reviewed. According to the care plan, a focus area was initiated on 9/24/24, which remained active at the time of survey that read in part, [R113's name redacted] is an elopement risk & wanderer r/t [related to] dementia and being a smoker. She exit seeks to try to go outside to smoke. On 10/2/24, according to a nursing note and facility documentation, it captured that certified nursing assistant #1…

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

Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to follow professional standards of care during medication administration for two residents (Resident #111- R111 and resident #121- R121) in a survey sample of 29 residents. The findings included: 1. For R111, the facility nurse failed to follow professional standards of practice during medication administration by not observing the resident to take the medications before exiting the room. On 10/15/24 at 11:10 a.m., R111 was observed sitting in a wheelchair at the bedside. R111 had an over bed table in front of her and on the table was a cup of medication that included two round, white tablets. When asked what it was, R111 stated she didn't know. A visitor in the room, told R111, that's your morning medications, you need to take those. Upon the surveyor exiting the room, licensed practical nurse (LPN #4) was in the hallway at the medication cart. When asked about mediation administration and R111 having 2 white tablets in a cup in her 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.

Based on observation, resident and staff interviews, clinical record review and facility documentation review, the facility staff failed to ensure medications were stored in a secure manner for two residents (Resident #114-R114 and Resident #126-R126) in a survey sample of 29 residents. The findings included: 1. For R114, the facility staff failed to ensure Vicks vapor rub, which was at the bedside unsecured, was stored appropriately. On 10/15/24 at approximately 10:45 a.m., during a tour of the resident, R114 was observed to have Vicks vapor rub at the bedside. When R114 was asked about the Vicks, the resident stated she applied it under her nose every night to prevent her nose from getting stopped up. On 10/15/24 at 2:20 p.m., an interview was conducted with registered nurse (RN #3). RN #3 was asked about R114's medications and stated, we give her, her medications. RN #3 went on to say that no medications should be at the patient's bedside. When asked about the Vicks vapor rub, RN #3 said, I can't speak to that, I don't leave medication at the bedside. RN #3 accompanied 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, staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain a complete and accurate clinical record for two residents (resident #121- R121 and resident #113-R113) in a survey sample of 29 residents. The findings included: 1. For R121, who had been readmitted to the facility on [DATE], the facility staff failed to enter the resident's physician orders, nursing assessment and documentation of administration of medications into the correct clinical record, therefore leaving R121's record incomplete. On 10/15/24 at 2:06 p.m., R121 was visited in his room. R121 reported that he had just recently been readmitted to the facility following hospitalization for an ulcer in his esophagus that was bleeding. The surveyor noted that R121 had at the bedside an IV (intravenous) pole with an antibiotic of Zosyn 4.5 grams hanging. The antibiotic line set was dated 10/14 23:45 [10/14/24 at 11:45 p.m.]. On 10/15/24 at 2:11 p.m., an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interviews, staff interviews, observations and facility documentation the facility staff failed to allow the residents to exercise their rights as a citizen of the United States for multiple residents residing on 2 of 2 units and failed to treat residents with and provide an environment that promoted respect and dignity for residents on 1 of 2 nursing units. The findings included: 1. The facility staff failed to ensure the resident rights regarding voting was upheld, affecting multiple residents on 2 of 2 units. On 10/15/24 at 11:15 am during the initial tour of the facility nursing units Resident #114 (R114) and Resident #123 (R123) asked the surveyor if they were allowed to vote. R114 and R123 both stated that no one from the facility had talked with them about voting. R114 stated, I want to vote and need to know what to do. R123 stated, I have a voter's card and would like to vote. On 10/15/24 at 11:40 am, an interview was conducted with the social service director. The social service…

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 interviews, facility documentation review, and clinical record review, the facility staff failed to assess and determine if four residents were safe to self-administer medications, Resident # 16 (R16), Resident # 17 (R17), Resident # 18 (R18) and Resident # 19 (R19), in a survey sample of 28 residents. The findings included: 1. For R16, who had medications stored in their room, the facility staff failed to assess if R16 was safe to self-administer medications. On 7/30/24 at approximately 4 p.m., a tour of the facility's 2 nursing units was conducted. During the tour R16's room was observed with nose spray and eye drops on the overbed table. On 7/30/24 in the afternoon, an interview was conducted with R16. During the interview, R16 said, I use my nose spray every morning and the eye drops when my eyes are dry. An interview was conducted with unit manager on unit 2, LPN# 2 (LPN2) on 7/31/24 at 10:05 a.m. During the interview LPN2 stated that medications are stored in the cart unless the medications need to be in the refrigerator, then…

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 interviews, staff interviews, observations, and facility documentation, the facility staff failed to ensure multiple residents on 2 of 2 units had the opportunity to exercise autonomy regarding voting interests and preferences. The findings included: 1. The facility staff failed to ensure that multiple residents were able to pursue an activity that was important them. On 10/15/24 at 11:15 am, during the initial tour of the facility, Resident #114 (R114) and Resident #123 (R123) asked the surveyor if they were allowed to vote. R114 and R123 both stated that no one from the facility had talked with them about voting. R114 stated, I want to vote and need to know what to do. R123 stated, I have a voter's card and would like to vote. Also during this tour, no signage with voting information was observed. On 10/15/24 at 11:40 am, an interview was conducted with the social service director. The social service director said she had only been in this position since 9/26/24. The social service director said, If the resident is not registered to vote, then we will get them…

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 interviews and facility documentation review, the facility staff failed to have sufficient nursing staff to provide nursing and related services to multiple residents on 1 of 2 units. The findings included: The facility staff failed to have adequate nurse staffing to provide for resident care on 1 of 2 nursing units. On 10/17/24 at 4:15 p.m. an observation was completed on unit 2 nursing unit. When the surveyor entered the unit there were two nurses at the nurse's station and they were the only staff observed on the unit at that time. There were 4 call bells (rooms 223, 238, 241 and 410) sounding and a family member was standing at the nurse's station. The family member needed assistance, and the surveyor was unable to find any staff on the unit that could assist the family member, and the two nurses were no longer on the unit. The surveyor started toward the front offices to get assistance, and the regional traveling director of nursing was coming toward the unit, so she assisted the…

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

Based on observation, resident interview, staff interviews, facility documentation review, and clinical record review, the facility staff failed to assure that medications were secure and inaccessible to unauthorized staff and residents, for four residents (Resident # 16 (R16), Resident # 17 (R17), Resident # 18 (R18), and Resident # 19 (R19)) in a survey sample of 28 residents. The findings included: 1. For Resident R16, who had medications stored in their room, the facility staff failed to remove and secure the medications. On 7/30/24 in the afternoon, an interview was conducted with R16. During the interview R16 said, I use my nose spray every morning and eye drops when my eyes are dry. An interview was conducted with unit manager on unit 2, LPN# 2 (LPN2) on 7/31/24 at 10:05 a.m. During the interview LPN2 stated that medications are to be stored in the medication cart unless the medications need to be in the refrigerator, then the medication is stored in the medication room. LPN2 said, No medicine should be at bedside. LPN2 stated that nursing staff is aware residents should not…

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

Based on observation, resident and staff interviews, clinical record review, and facility documentation review, the facility staff failed to respond to a grievance for one resident (Resident #7- R7) in a survey sample of 28 residents. The findings included: For Resident #7- R7, the facility staff failed to respond to a grievance and take measures to ensure the resident felt safe from other residents entering their room. On 7/30/24, in the late afternoon, at approximately 4:30 p.m., observations were conducted, and it was noted that R7 did not have a stop sign mesh banner across her door. R7's door was closed. On 7/31/24 at 3:20 p.m., an interview was conducted with R7. R7 told the surveyor of a prior incident that occurred at the vending machine involving resident #10 (R10) talking to her about having sex and that R10 had said, My belly button is pushed out because a 250-pound lady was on top of me R7 stated that it had made R7 feel very uncomfortable. R7 reported having returned to her room, turned the lights off, and got into bed. R7 reported Someone came in and didn't say…

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, clinical record review, and facility document review, the facility failed to implement abuse policies for two of seven residents, Resident #'s 203 and 207. The Findings Include: 1. The facility did not implement facility abuse policy in regards to reporting suspicion of physical abuse/mistreatment for Resident #203 (R203). According to the clinical record, diagnoses for R203 included, Multiple sclerosis, quadriplegia, pulmonary embolism, and depression. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 11/6/24, which assessed R203 with a cognitive score of 15 out of 15, indicating cognitively intact. Review of R203's clinical record documented a social workers note, dated 12/3/24, that indicated a certified nursing assistant (CNA) had been rude and rough during care (when turning R203) and alluded to R203 not feeling safe during the care provided. On 12/9/24 at 1:50 p.m., R203 was interviewed regarding the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to develop and implement a comprehensive resident centered care plan for one resident (Resident #10- R10) in a survey sample of 28 residents. The findings included: For R10, the facility staff failed to develop and implement a comprehensive resident centered care plan to address the resident's medical and nursing needs. On 7/31/24 and 8/1/24, a clinical record review was conducted. According to the census tab of the record, R10 was admitted to the facility on [DATE], and remained an active resident at the time of survey. Review of the care plan for R10 revealed the following focus areas: activities, refusal of care, discharge plan/plan to stay long-term, mood problem/depression, nutritional risk, psychosocial well-being, and code status of full code. There were no care plans to address R10's nursing or medical needs. On 7/31/24 at 4:49 p.m., an interview was conducted with R10. During the conversation,…

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 2. The facility staff failed to revise the care plan for Resident #1 (R1) following a fall, to indicate interventions that were put in place to prevent recurrence. A review of R1's clinical record was performed on 8/6/24. R1 had an unwitnessed fall on 7/2/24. A review of R1's care plan was conducted. This review revealed that the fall care plan had no interventions added or revised since 9/25/23. No interventions were put in place following R1's fall on 7/2/24, to prevent recurrence. A review of the fall incident report was conducted on 8/6/24. R1 had a fall in his room and the report had poor lighting and gait imbalance was the predisposing factors of the fall. The report had that R1 had on normal socks and not non-skid socks. A change in condition note was reviewed on 8/6/24. On 7/2/24 a change in condition form was completed for R1's unwitnessed fall. No new interventions following the fall was noted on the form. R1 had new pain and discoloration to the sacral area due to the fall. The pain section of R1'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, clinical record review, and facility documentation review, the facility staff failed to follow professional standards of care during medication administration for two residents (Resident #111- R111 and resident #121- R121) in a survey sample of 29 residents. The findings included: 1. For R111, the facility nurse failed to follow professional standards of practice during medication administration by not observing the resident to take the medications before exiting the room. On 10/15/24 at 11:10 a.m., R111 was observed sitting in a wheelchair at the bedside. R111 had an over bed table in front of her and on the table was a cup of medication that included two round, white tablets. When asked what it was, R111 stated she didn't know. A visitor in the room, told R111, that's your morning medications, you need to take those. Upon the surveyor exiting the room, licensed practical nurse (LPN #4) was in the hallway at the medication cart. When asked about mediation administration and R111 having 2 white tablets in a cup in her 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 interviews, clinical record review, and facility documentation review, the facility staff failed to develop and implement an effective discharge plan for one resident (Resident #11-R11), in a survey sample of 28 residents. The findings included: For R11, the facility failed to develop and implement a discharge plan to include assisting with post-discharge services to ensure the resident was able to receive assistance with daily care and medications. On 7/31/24, the survey team was made aware of a concern from R11's spouse who reported the resident discharged and no home health services or arrangements for the resident to receive medications were made by the facility staff. On 7/31/24, a clinical record review was conducted of R11's closed chart. This review revealed that R11 was admitted to the facility on [DATE], following a left hip replacement. On 7/29/24, the resident discharged home. According to a nursing progress note dated 7/29/24 at 12:37 p.m., the note read, Pt [patient] discharged home…

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 interviews, resident interviews and facility documentation review, the facility staff failed to provide services to residents by answering the call bell(s)/requests for assistance, in a timely manner on one of two nursing units. The findings included: Observations were made on 8/6/24 at 10:25 a.m. on unit three. It was noted that several call lights were on, which was indicated by a light illuminated outside of resident rooms in the hallway and a bell was sounding at the nurse's station. The surveyor was standing at the nurse's station, which is in the middle of the unit and there were call bells alarming on each of the four hallways. When the surveyor arrived on the unit, it was three call bells sounding and two additional came on while the surveyor was on the unit. Facility staff were observed walking up and down the hallways and not responding to or answering the call bells. There were two housekeepers on one hallway and a CNA across the hallway folding linen, and none of them answered the lights. The administrator and social worker came to the floor…

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 interviews, resident interviews, clinical record reviews and facility documentation the facility staff failed to ensure residents received the appropriate treatment and services for incontinence of bowel and bladder for two residents (resident #20 and resident #21) in a survey sample of 28 residents. The findings included: 1. The facility staff failed to provide incontinence care in a timely manner for Resident #20 (R20). On 8/2/24 at approximately 1:30 p.m., an observation was conducted of facility staff providing incontinence care to R20. CNA#4 (CNA4), CNA#13 (CNA13) and CNA#14 (CNA14) was in R20's room to provide afternoon incontinence care to the resident. This surveyor observed feces and urine on the sheet and incontinent pad under the resident from R21's shoulders to her knees. There was a strong smell of ammonia and odor from the bowel movement. The brief was saturated, and urine and feces had leaked out of the incontinence brief onto the incontinent pad under the resident and the bed sheets. The CNA's had to change the linen on the entire bed. 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 interviews and facility documentation the facility staff failed to complete a yearly performance review for one staff member (Certified nursing assistant, CNA #15) in a sample of eight staff records reviewed. The findings included: The facility staff failed to conduct a yearly performance review for one certified nursing assistant, CNA#15 (CNA15). A review of CNA15 personnel record was conducted on 8/5/24. According to the file, CNA15 was hired on 11/16/21. There was a performance review in the file dated 7/21/22. There were no other performance reviews within the personnel file. An interview was conducted with the Human Resource Coordinator on 8/5/24 at 4:41 p.m. The human resource coordinator stated that performance evaluations were printed and given to the supervisors to do for the month. She stated, we have 90-day evaluations and annual evaluations, and the annual evaluations are due one week prior to the anniversary date or one week after the anniversary date but no earlier or later. A facility document review was conducted on 8/5/24. A policy titled, Employee…

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 interviews, clinical records and facility documents the facility staff failed to provide therapeutic diets for two residents, Resident # 1 (R1) and Resident #2 (R2) in a survey sample of 28 residents. The findings included: 1. The facility staff failed to ensure R1 received fortified foods and large portions with his meal as ordered. An observation was made on 7/30/24 at 4:30 p.m. in the main kitchen during plating of evening meal. During the plating of R1's meal for dinner it was observed that the meal ticket noted fortified foods and large portions. The dietary manager, OS #1 (OS1) was plating the food and prepared R1's plate with regular portions of the meal and no fortified food was observed on his meal tray. R1's meal ticket read, Regular Dysphagia Advanced Fortified Foods and Large portions. On 7/30/24 at approximately 5:10 p.m., an observation was made of R1's meal tray once it had been delivered to the resident. There was no change to the tray/meal provided to the resident from what was observed when prepared in the kitchen, no large portions or…

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, and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for one resident (Resident #9) in a survey sample of 28 residents. The findings included: For Resident #9 (R9), the facility staff failed to maintain a complete and accurate clinical record to include documentation with regards to R9 having a [NAME] on her neck which was from another resident. On 7/31/24 at 2:55 p.m., an interview was conducted with R9's roommate, resident #15 (R15). R15 reported that R9's boyfriend put a [NAME] on her neck. On 7/31/24 at 4:49 p.m., an interview was conducted with resident #10 (R10). R10 was asked about his relationship with the female residents within the facility. R10 confirmed he had put a [NAME] on R9's neck. On 7/31/24 at 2:55 p.m., an interview was conducted with certified nursing assistant (CNA) #11. CNA #11 reported R9 did have a [NAME] on her neck the end of June or early July. On 7/31/24 at 2:58 p.m., an interview 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.

Based on staff interview and facility documentation review, the facility staff failed to provide employee QAPI training for six employees in a survey sample of eight employee records reviewed. The findings included: The facility failed to provide QAPI training to six of the eight employee's, who's personnel files were reviewed. An interview with the facility consultant and regional director of clinical services was conducted on 8/5/24. The interview was a discussion about the lack of training that was in the employee's files, and they said that they would look through and see what they would be able to find for proof of education but we have what we have, and the rest is missing, and we will do better going forward. A review of eight personnel files, RN#1,RN#3, LPN#1, CNA#15, CNA#17, CNA#18, CNA#19 and CNA#20 was conducted on 8/5/24. The employee personnel files reviewed had no QAPI training in eight of the personnel files, but the regional director of clinical services was able to locate proof of two employee's that had the QAPI training. A review of a facility documents 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 staff interviews, facility document review, and closed record review, facility staff failed to follow physician's orders to obtain a physician ordered stat x-ray for one of three residents, Resident #3 (R3). The findings included: According to the clinical record review on 1/29/24, R3 was admitted to the facility on [DATE], with diagnosis that included fracture of first lumbar vertebrae, lower back pain, muscle weakness, abnormalities of gait and mobility, atrial fibrillation, and hypertension. According to a 5 day Scheduled Minimum Data Set, with an Assessment Reference Date of 1/1/24, R3 was assessed under Section C (Cognitive Patterns) as being cognitively intact with a summary score of 13 out of 15. According to the facility incident/accident committee minutes, R3 was trying to get out of bed on 12/30/23 at 12:30 a.m. and was found on the floor. According to the physician order dated 12/31/23, a stat x-ray of the ribs was ordered due to R3 presenting with pain and swelling to the right ribcage.…

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 clinical record review and staff interview, the facility staff failed to ensure immediate care orders upon admission for Resident #293 regarding diet. Findings include: Resident #293 was admitted to the facility on [DATE] and discharged from the facility on 08/29/22. Diagnoses for Resident #293 included, but were not limited to: CHF (congestive heart failure), high blood pressure, renal insufficiency, DM (diabetes mellitus), seizure disorder, anxiety disorder, depression, acute osteomyelitis of the left foot with toe amputation, and chronic pain syndrome. Resident #293's most recent MDS (minimum data set) was an admission assessment dated [DATE]. This MDS assessed Resident #293 with a cognitive score of 13, indicating the resident was intact for daily decision making skills. Resident #293 was also assessed as requiring extensive assistance of at least one or two staff members for mobility, toileting, and bathing. Resident #293triggered in the CAAS (care area assessment summary) section of this MDS 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 medication pass and pour observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure professional standards of nursing were followed during medication administration on one of three units (Unit 2) and one of 29 residents, Resident #293. Findings were: 1. A medication pass and pour observation was conducted with RN (registered nurse) #3 at approximately 8:45 a.m RN #3 was observed preparing medications for three residents, Resident # 294, Resident #397, and Resident #40. RN #3 prepared medications for Resident #294. RN#3 obtained a Lovenox injection from the cart, a lidocaine patch, and a 12.5 mg tablet of Carvedilol 12.5 mg. When the medications were given to the resident, Resident #294 stated, Only one pill today? RN #3 responded, Yes, that is the pill for your heart. Medications for Resident #297 were prepared and included Farxiga, Aspirin, Magnesium Oxide, Atorvastatin, Fluoxetene, Glimepiride, Vitamin D, Ferrous Sulfate, Metformin, and…

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

Based on medication pass and pour observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure a medication error rate of less than five percent. A total of thirty-three medication opportunities were observed with seven errors. This resulted in a medication error rate of 21.21%. Findings were: 1. A medication pass and pour observation was conducted with RN (registered nurse) #3 at approximately 8:45 a.m RN #3 prepared medications for Resident #294. She obtained a Lovenox injection from the cart, a lidocaine patch, and a 12.5 mg tablet of Carvedilol 12.5 mg. When the medications were given to the resident, Resident #294 stated, Only one pill today? RN #3 responded, Yes, that is the pill for your heart. Medications for Resident #297 were prepared and included Farxiga, Aspirin, Magnesium Oxide, Atorvastatin, Fluoxetene, Glimepiride, Vitamin D, Ferrous Sulfate, Metformin, and Pantroprazole. While in the room with Resident #297, RN #3 inquired about any pain that she may be experiencing. Resident #297 complained of a headache, RN…

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 properly store liquid narcotics in two of three refrigerators, Unit 2 and Unit 3. Findings were: On 02/27/2023 at approximately 12:30 p.m., the refrigerators on all three units were observed with the DON (director of nursing). The locked refrigerator on Unit 2 had two bottles of liquid Ativan stored directly on the shelf of the refrigerator. There was no permanently affixed locked box observed in the refrigerator. The DON stated that they had attempted to add the permanently affixed locked boxes without success. The locked refrigerator on Unit 3 was observed. A locked tackle box was removed from the refrigerator. Inside were two bottles of liquid Ativan. On 02/27/2023 at approximately 4:30 p.m., the DON came to the conference room and stated, We have installed the locked boxes today. The facility policy, Storage and Expiration Dating of Medications, Biologicals contained the following: Store all drugs .in locked compartments, including the storage of Schedule II-V medications 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 a closed clinical record review, staff interview and facility document review, the facility staff failed to ensure one of 29 residents' (Resident #293) dietary preferences were taken into consideration. Findings include: Resident #293 was admitted to the facility on [DATE] and discharged from the facility on 08/29/22. Diagnoses for Resident #293 included, but were not limited to: CHF (congestive heart failure), high blood pressure, renal insufficiency, DM (diabetes mellitus), seizure disorder, anxiety disorder, depression, acute osteomyelitis the left foot with toe amputation, and chronic pain syndrome. Resident #293's most recent MDS (minimum data set) was admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 13, indicating the resident was intact for daily decision making skills. Resident #293 was also assessed as requiring supervision with set up only for meals. An allegation within a complaint regarding Resident #293 documented that the resident was not provided…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide alternate menu options of similar nutritive value for three of twenty-nine residents in the survey sample when they chose not to eat food initially served (Residents #20, #25 and #45). Alternate menu options of similar nutritive value were not routinely provided to residents in the facility and not posted and/or communicated in advance for choices prior to the meal. The findings included 1. Resident # 25 in the survey sample was admitted with diagnoses that included discitis, anemia, diverticulitis, congestive heart failure, hypertension, gastroesophageal reflux disease, hyperlipidemia, Vitamin D deficiency, obstructive uropathy, morbid obesity, and generalized muscle weakness. According to the most recent Annual Minimum Data Set, with an Assessment Reference Date of 12/8/2022, the resident #25 was assessed under Section C (Cognitive Patterns) as being cognitively…

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 sanitary manner in the main kitchen. Finding include: On 02/26/23 at 3:00 PM, a tour of the kitchen was conducted. OS #1 (other staff), also known as the cook, along with two Dietary Aides (OS #12 and OS#13) were working the kitchen. OS #1 stated that the DM (dietary manager) had left for the day. During the tour, the tops of the sugar, flour and thickner bins were visibly soiled and tacky to touch when opened. The sugar bin had a piece of black debris in the sugar. The thickner had specs of brown matter scattered on top of the thickner. The sink with the eye washing station had a pile of brown paper towels on the right side, with bunched up towels on the left side (unable to determine if they were used). OS #1 stated that he thought they were clean, but gathered them and put them in the trash. OS #1 stated that the paper towels were on the side of the sink because they (kitchen staff) didn't have a key to load the towel dispenser. Several gnats were…

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

Based on observation, staff interview, and facility document review, the facility staff failed to ensure essential equipment was in good working order. Finding include: On 02/26/23 at 3:15 PM during the initial tour of the kitchen, OS #13 (Other Staff) was observed operating the dishwasher. OS #13 stated it was high temperature washer, but was unsure of the water temperature requirements/specs. The water temperature specs were found on the underside of the dishwasher and were listed as: wash 150 degrees F (Fahrenheit) minimum and rinse 180 F minimum. At 3:16 PM, OS #13 ran the dishwasher for observation of water temps, the wash temperature was 120 F and the rinse was 170 F. At 3:20 PM, OS #13 ran the dishwasher again, the wash temperature was 130 F and the rinse temp was 170 F. At 3:24 PM, OS #12 (dietary staff) ran the dishwasher, The wash temperature was 130 F and the rinse temperature was 160 F. OS #12 stated that they (dietary staff) had problems with the dishwasher a couple of months back and that the maintenance director looked at it. OS #12 stated that the hot water comes 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 observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to assess two of twenty-nine residents in the survey sample for self-administration of medications (Residents #20 and #293). The findings include: 1. Resident #20 had prescription Flonase (fluticasone propionate) nasal spray at the bedside and self-administered the spray with no prior assessment of the resident's ability to safely administer the medication. Resident #20 was admitted to the facility with diagnoses that included hypothyroidism, duodenal ulcer, restless leg syndrome, depression, anxiety, seasonal allergic rhinitis, anemia, and gastroesophageal reflux disease. The minimum data set (MDS) dated [DATE] assessed Resident #20 as cognitively intact. On 2/26/23 at 3:40 p.m., a box containing a bottle of Flonase 50 mcg (micrograms) nasal spray was on top of the resident's bedside table. With the resident's permission, the Flonase was inspected. The Flonase was labeled…

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

Based on staff interview and clinical record review, the facility staff failed to notify the responsible party (RP) for one of 29 residents (Resident #289). This was a closed record review. The findings include: Resident #289's RP was not notified of Resident #289's discharge. Diagnoses for Resident #289 included: Alzheimer's, edema, dementia, depression, and delirium. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 1/15/22. Resident #289 was assessed with a cognitive score of 6 indicating severely cognitively impaired. On 2/28/23, a review of Resident #289's clinical revealed (via the current MDS) that Resident #289 was discharged to another facility. Review of the nursing progress notes did not evidence a note had been written indicating the discharge or any notification to the RP that a discharge was taking place. On 2/28/23 at 10:15 AM, the regional nurse consultant (Administrative Staff, AS #4) was asked to review Resident #289's clinical record for RP notification of discharge and any other information regarding…

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, family interview, staff interview, and clinical record review, the facility staff failed to provide a clean, homelike environment for one of twenty-nine residents in the survey sample (Resident #2). The findings include: Resident #2's room was observed with food, spills, and trash on the floor, as well as a broken bedside table. Resident #2 was admitted to the facility with diagnoses that included cerebral infarction, hernia, congestive heart failure, protein-calorie malnutrition, atherosclerotic heart disease, and hypothyroidism. The minimum data set (MDS) dated [DATE] assessed Resident#2 as cognitively intact. On 2/27/23 at 7:56 a.m., Resident #2 was observed in bed with her eyes closed. There were two pieces of partially eaten bread and an empty medicine cup laying on the floor between the bed and the heating unit. There was a medication caplet on the floor to the right of the heating unit. There were multiple spills on the floor beside the Resident #2's bed and under the over-bed table.…

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 medication pass and pour observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure One of 29 residents was free from misappropriation of property, Resident #57. Resident #57's medication was borrowed by a staff member to be administered to another resident. Findings were: A medication pass and pour observation was conducted with RN (registered nurse) #3 at approximately 8:45 a.m RN #3 was observed preparing and administering medications to Resident # 294. At the conclusion of the medication pass, the medicines were reconciled against the physician orders. Resident #294 had four medications scheduled for the 9:00 a.m. medication pass that were not observed as given, but were each signed off on the MAR (medication administration record) as administered. The four medications were: Gabapentin 100 mg, Ferrous Sulfate 325 mg, Acidophilus Capsule, and Bacid. RN #3 was interviewed at approximately 10:30 a.m., regarding the described omitted medications for Resident #294. RN #3 stated, I had her [Resident #294] confused…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, and clinical record review, the facility staff failed to ensure a discharge summary was completed for one of 29 residents. This was closed record review. The findings include: The facility did not complete a discharge summary for Resident #289. Diagnoses for Resident #289 included: Alzheimer's, edema, dementia, depression, and delirium. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 1/15/22. Resident #289 was assessed with a cognitive score of 6 indicating severely cognitively impaired. On 2/28/23 Resident #289's clinical record was reviewed and documented (via the current MDS) dated [DATE], that Resident #289 was discharged to another facility. Review of the nursing progress notes and physician progress notes did not evidence a discharge summary had been completed. On 2/28/23 at 10:15 AM, the regional nurse consultant (Administrative Staff, AS #4) was asked to review Resident #289's medical record for a discharge summary.…

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, and clinical record review, the facility staff failed to provide Activities of Daily Living (ADL's) for two of 29 residents (Residents #40 and Resident #293). The Findings Include: 1. Facility staff failed to provide a scheduled shower for Resident #40. Diagnoses for Resident #40 included; Adult failure to thrive, diabetes, major depression, and stage three pressure ulcer. The most current MDS (minimum data set) was an admission assessment with an ARD (assessment reference date) of 1/12/2023. Resident #40 was assessed with a cognitive score of 13 indicating cognitively intact. During the interview with Resident #40 conducted on 2/26/23 at 4:10 PM, Resident #40 verbalized that the staff had not given her a shower on Friday (2/24/23) as scheduled, and went on to say that one of the nursing staff said there wasn't enough towels or washcloths. On 2/27/23 Resident #40's clinical record was reviewed. Section G, Functional Status indicated Resident #40 needed extensive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to ensure a complete medical record for one of twenty-nine residents in the survey sample (Resident #2). The findings include: Resident #2's clinical record did not include documentation of nursing visits by hospice. Resident #2 was admitted to the facility with diagnoses that included cerebral infarction, hernia, congestive heart failure, protein-calorie malnutrition, atherosclerotic heart disease, and hypothyroidism. The minimum data set (MDS) dated [DATE] assessed Resident#2 as cognitively intact. Resident #2's clinical record documented a physician's order dated 11/1/22 for hospice care. The resident's clinical record included a hospice plan of care and care visits by hospice certified nurses' aides. The clinical record from 11/1/22 through 2/27/23 documented no ongoing visits from hospice nurses. On 2/28/23 at 8:30 a.m., the licensed practical nurse unit manager (LPN #5) was interviewed about any hospice nurse visits for Resident…

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

Based on observation, staff interview and facility document review the facility staff failed to ensure proper hand hygiene for one of 29 residents (Resident #40). The Findings Include: Proper hand hygiene was not performed during a dressing change for Resident #40. Diagnoses for Resident #40 included; Adult failure to thrive, diabetes, major depression, and stage three pressure ulcer. The most current MDS (minimum data set) was an admission assessment with an ARD (assessment reference date) of 1/12/2023. Resident #40 was assessed with a cognitive score of 13 out of 15, indicating cognitively intact. On 2/27/23 at 9:53 AM, registered nurse (RN #6) performed a dressing change on Resident #40. RN #6 removed the old dressing, cleaned the wound using wound cleanser, removed gloves and reached into her pocket and pulled out another pair of gloves, applied the gloves (without doing any hand hygiene), applied wound medication, and redressed the wound. After the dressing was completed, RN #6 was asked about cleaning or washing hands in-between glove changes. RN #6 verbalized that she 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.

Based on review of employee files, and staff interview, and facility document review, the facility failed to fully implement their policy and procedure for licensure and certification verification of new employees. The facility failed to verify the license and/or conduct a criminal background check for eight of 25 employee files reviewed. The findings were: A sample of 25 employee files of all employees hired within the last two years was reviewed. The files were reviewed for a criminal record check, sworn statement, valid license, and references. Out of the 25 employee files reviewed, eight did not have criminal record check and/or a sworn statement. The eight employee files included the following: CNA (Certified Nursing Assistant) hired 10/29/2020 missing a licensure verification. CNA hired 12/1/2020 missing a licensure verification and criminal record check. CNA hired 4/20/2021 missing a licensure verification, criminal record check, and sworn statement. CNA hired 11/15/2021 missing a licensure verification and criminal record check. LPN (Licensed Practical Nurse) hired 3/31/2020…

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, facility document review, and in the course of a complaint investigation, the facility staff failed to provide information regarding bed holds at the time of transfer/discharge for four of 24 residents, Resident #70, Resident #320, Resident #67, and Resident #61. Findings were: 1. Resident #70 was admitted to the facility after falling down the cellar stairs at home and sustaining multiple fractures. Additional diagnosis included but were not limited to: hypertension, anemia, osteoporosis, and chronic kidney disease. The admission MDS (minimum data set) with an ARD (assessment reference date) of 12/02/2021, assessed Resident #70 as moderately impaired with a cognitive summary score of 10. Resident #70 was sent to the emergency room on [DATE] and 01/02/2022. The only documentation in the clinical record either time was a physician order to send her to the emergency room. On 04/06/2022 at 8:30 a.m., the DON (director of nursing) was interviewed regarding 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 and clinical record review, the facility staff failed to provide a therapeutic diet and nutritional supplements as ordered/recommended for one of twenty-four residents in the survey sample, Resident #51. Resident #51, with severe protein-calorie malnutrition, significant weight loss and poor intake, did not have fortified foods provided as ordered, and was not provided Pro-Stat, Magic Cup or a liberalized regular diet as recommended by the registered dietitian (RD) and/or physician. Resident #51 was not provided assistance with meals when having trouble with eating and drinking. The findings include: Resident #51 was admitted to the facility with diagnoses that included chronic kidney disease, cirrhosis of liver, diabetes, severe protein-calorie malnutrition, hypertension, anemia, portal vein thrombosis, metabolic encephalopathy, gastroesophageal reflux disease, breast cancer, anxiety, depression, cognitive communication deficit and hemiplegia of left leg. The minimum data…

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 medication pass and pour observation, staff interview, and clinical record review the facility staff failed to ensure a medication error rate less than 5 percent. There were 5 errors out of 26 opportunities resulting in a medication error rate of 19.23 percent. Findings include: A medication pass and pour observation was conducted 4/6/22 beginning at 7:45 a.m. with LPN (licensed practical nurse) # 2. LPN # 2 prepared the medications for resident # 222. LPN # 2 provided a bottle of house stock aspirin 81 mg (milligrams) and stated (name of Resident # 222) gets one of these and put it in the medication in a cup with the other medications. The medications were then administered. Medications for Resident # 272 were then prepared, and LPN # 2 made the same comment about the aspirin. LPN # 2 then stated Resident # 8 would be administered two tablets of Baclofen 5 mg, and 2 tablets of Famotidine 20 mg. Resident # 8 was also to receive a Spiriva inhaler 18 mg with directions on the label to be administered over 2 inhalations. The labels on the Famotidine and Baclopfen both…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, the facility staff failed to provide dignity/respect for two of 24 residents in the survey sample, Resident #51, and #42. Resident #51 was dressed in a soiled hospital gown and was provided physical therapy services with her back, incontinence brief and legs exposed in the presence of a visitor. Resident #42 was abruptly awakened and positioned for breakfast while stating she did not want to eat. The findings include: 1. Resident #51 was admitted to the facility with diagnoses that included chronic kidney disease, cirrhosis of liver, diabetes, severe protein-calorie malnutrition, hypertension, anemia, portal vein thrombosis, metabolic encephalopathy, gastroesophageal reflux disease, breast cancer, anxiety, depression, cognitive communication deficit and hemiplegia of left leg. The minimum data set (MDS) dated [DATE] assessed Resident #51 with moderately impaired cognitive skills and as requiring the extensive assistance of one person for dressing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, the facility staff failed to meet discharge/transfer documentation requirements for three of 24 residents, Resident #70, Resident #320, and Resident #67. Findings were: 1. Resident #70 was admitted to the facility after falling down the cellar stairs at home and sustaining multiple fractures. Additional diagnosis included but were not limited to: hypertension, anemia, osteoporosis, and chronic kidney disease. The admission MDS (minimum data set) with an ARD (assessment reference date) of 12/02/2021, assessed Resident #70 as moderately impaired with a cognitive summary score of 10. Resident #70 was sent to the emergency room on [DATE] and 01/02/2022. The only documentation in the clinical record either time was a physician order to send her to the emergency room. On 04/06/2022 at 8:30 a.m., the DON (director of nursing) was interviewed regarding the discharge/transfer process specifically when residents are sent to the hospital. She…

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 follow professional standards of practice for one of twenty-four residents in the survey sample, Resident #42. Nursing failed to document an assessment and the circumstances regarding a fall in Resident #42's clinical record and incident reports had conflicting details regarding the fall with injury. The findings include: Resident #42 was admitted to the facility with diagnoses that included fractured tibia/fibula, congestive heart failure, osteoporosis, bradycardia, cognitive communication deficit, diabetes, morbid obesity, dysphagia, delusional disorder, chronic respiratory failure, COPD (chronic obstructive pulmonary disease), insomnia, psychotic disorder with delusions, depression, atrial fibrillation, dementia with behaviors, anxiety and sleep apnea. The minimum data set (MDS) dated [DATE] assessed Resident #42 with severely impaired cognitive skills and as requiring extensive assistance of two people…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to obtain a physician's order prior to obtaining palliative care services for one of twenty-four residents in the survey sample, Resdient #51. Resident #51 had consultation by a transitional/palliative care provider when there was no physician's order or plan of care for palliative/comfort care. The findings include: Resident #51 was admitted to the facility with diagnoses that included chronic kidney disease, cirrhosis of liver, diabetes, severe protein-calorie malnutrition, hypertension, anemia, portal vein thrombosis, metabolic encephalopathy, gastroesophageal reflux disease, breast cancer, anxiety, depression, cognitive communication deficit and hemiplegia of left leg. The minimum data set (MDS) dated [DATE] assessed Resident #51 with moderately impaired cognitive skills. A physician's assistant's (PA) progress note dated 2/4/22 documented under resident problems, .Palliative care - Onset 2/4/22 .being placed in our 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.

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure a hand splint was applied for one of 24 residents in the survey sample, Resident # 8. Findings include: Resident # 8 was admitted to the facility following a history of strokes and left hand contracture. The most recent MDS (minimum data set) was a quarterly review dated 1/19/22 and had Resident #8 coded with moderate impairment in cognition with a summary score of 11 out of 15. On 4/5/22 at 11:30 a.m. during initial tour, Resident # 8 was observed sitting in a chair in her room. Resident # 8 was not wearing a splint. The clinical record was reviewed 4/5/22 at approximately 2:30 p.m. The POS (physician order summary) included an order with a start date of 4/15/21 for, Contraction brace to left hand at all times except during bathing, and manual therapy. Check for pressure areas every 1-2 hours. A review of the care plan revealed the following: Focus: (name of resident) has a contracture to her left hand. Has edema (swelling) to left wrist at times. Goal: Will remain free from pain…

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 care interventions regarding a urinary catheter for one of twenty-four residents in the survey sample, Resident #50. Resident #50's Foley urinary catheter tubing was not stabilized to prevent tension at the insertion site and the urine collection bag was observed in the floor. The findings include: Resident #50 was admitted to the facility with diagnoses that included benign prostatic hyperplasia, obstructive uropathy, hypertension, atherosclerotic heart disease, cognitive communication deficit, cerebral infarction, dementia with behaviors, anemia and dysphagia. The minimum data set (MDS) dated [DATE] assessed Resident #50 with severely impaired cognitive skills. Resident #50's clinical record documented a physician's order dated 11/24/21 for a Foley urinary catheter due to failed voiding trials due to obstructive uropathy with instructions for catheter care each shift. The 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, resident interview, and clinical record review, the facility staff failed to obtain a physician's orders for hemodialysis, along with care and maintenance of a dialysis resident, for one of 24 resident in the survey sample, Resident #69; and failed to assess a new dialysis graft site for one of 24 residents in the survey sample, Resident #21. Findings include: Resident #69 was admited to the facility with diagnoses that included, but were not limited to: anemia, acute kidney failure with hemodialysis, hyponatremia, atrial fibrillation and pulmonary embolism. The most current MDS (minimum data set) was an admission assessment dated [DATE]. This MDS assessed Resident #69 with a cognitive score of 15, indicating the resident was cognitively intact for daily decision making skills. The resident was also assessed as receiving dialysis treatments while a resident and while not a resident in Section O. Special Treatments, Procedures, and Programs: J. Dialysis. Resident #69 was interviewed on…

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

Based on observation, staff interview, and facility document review, the facility staff failed to ensure drugs and biologicals were labeled appropriately on one of two nursing unit medication rooms, Unit 2. The facility failed to appropriately label one, multi dose vial of Tuberculin on Unit 2. Findings include: On 04/07/22 at 8:25 AM, the Unit 2 medication room was observed with the ADON (assistant director of nursing). The refrigerator was observed with two multi dose vials (5 milliliter vial each) of Tuberculin, each in the original box. One vial had been opened and accessed and had approximately 1/8 to 1/4 of medication left in the vial. There was an illegible mark on the opened vial that was smeared off and could not be read. The ADON stated, I can't make it out .it looks like a 3. The ADON was asked when should multi dose vials be discarded after being opened/accessed. The ADON stated, I'll say 30 days after opening. The ADON was asked for a policy at that time. On 04/07/22 at approximately 10:00 AM, the corporate nurse presented a policy titled, Storage and Expiration Dating…

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

Based on observation and staff interview, the facility staff failed to follow professional standards for food safety in the main kitcehn. Sheet pans identified as clean, dry, and ready to use were not nested wet in the main kitchen. Findings include: On 4/5/22 at 10:47 a.m. the kitchen was inspected with the dietary manager. A stack of sheet pans and quarter sheet pans were stacked on the bottom shelf of a table in the main kitchen. The dietary manager was asked if the pans were clean and ready to use. He stated Yes. The dietary manager was asked to lift the sheet pans to check for wetness. In the stack of full size sheet pans, 5 of 12 pans were observed nested wet, and one pan had debris on it. The dietary manager put the five pans aside stating Those will be rewashed. He then lifted the quarter size sheet pans, and 2 of 4 pans were nested wet. Those were removed and put with the full size sheet pans to be rewashed. The dietary manager stated Looks like some re-education in order to ensure pans are completely dry and free of debris before they are stacked as ready to use . The…

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

Based on observation, staff interview and facility document review, the facility staff failed to provide scheduled oversight/consultation to the dietary manager regarding the facility's food/meal service to residents by the registered dietitian. The findings include: During the current survey, the survey team observed and identified issues with improper food storage, lack of proper dating/labeling of food in the kitchen refrigerator, inaccurate meal tickets for residents, failure to honor resident food preferences and unnecessary use of plastic utensils with residents. On 8/27/19 at 2:51 p.m., the facility's registered dietitian (RD) was interviewed about out of date and undated meat items stored in the walk-in refrigerator. The RD stated there was supposed to be a tracking system in the kitchen to ensure proper food storage. The RD stated there should have been a date on the meat products when they were removed from the freezer. The RD stated the dietary manager was responsible for food receipt and storage. On 8/28/19 at 11:15 a.m., the dietary manager was asked about his…

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 and serve food in a sanitary manner. An opened package of refrigerated sandwich meat was stored and available for use beyond the discard date. Ten thawed packages sandwich meat, without designated expiration and/or discard dates, were stored in the refrigerator. Three packages of the turkey, identified during the survey with an undetermined storage status, were served during the lunch meal. The findings include: On 8/27/19 at 11:21 a.m., accompanied by the dietary manager, the main kitchen and food storage areas were inspected. Stored in the walk-in refrigerator was an opened package of ham sandwich meat with a discard date of 8/26/19. Five unopened packages of turkey sandwich meat were stored in a cardboard box. Another box was stored that contained five packages of salami sandwich meat. There were no dates of any type, including expiration or use by dates printed on the meat packages from the manufacturer. Printed labels on the ends of the boxes were partially torn with no…

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

Based on observation, staff interview, and facility document review, the facility staff failed to ensure medications were locked in the medication cart during a medication pass and pour observation; failed to properly store insulin in one of three medication carts inspected, and also failed to label and date opened tuberculin solution and Lorazepam (an anti-anxiety medication) in one of three medication rooms inspected. Findings include: 1. On 8/28/19 beginning at 8:10 a.m. a medication pass and pour observation was conducted with LPN (licensed practical nurse) # 6. After preparing medications for Resident # 61, LPN # 6 left the medications laying on the top of the cart and went in the resident's room to administer the medications. After administering the medications, LPN # 6 was asked about the medications left out on the top of the cart. LPN # 6 stated I just forgot to put them up before going in the resident's room. On 8/28/19 at 9:30 a.m. the DON (director of nursing) was asked for a policy on medication storage. The policy Storage and Expiration Dating of Medications,…

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 complaint investigation, the facility staff failed to notify the physician of a change in condition for one of 23 residents in the survey sample. There was no notification to the physician when Resident #95 was assessed with edema and diminished lung sounds/wheezing. The findings include: Resident #95 was admitted to the facility on [DATE] and died in the facility on [DATE]. Diagnoses for Resident #95 included cerebral infarction, dysphagia with gastrostomy, high blood pressure and abdominal aneurysm. The nursing admission assessment dated [DATE] assessed Resident #95 with short and long-term memory problems and moderately impaired cognitive skills. Resident #95's clinical record documented the resident was assessed upon admission on [DATE] at 4:00 p.m. with diminished breath sounds in the lower lungs and wheezing in the upper right lung. A nursing note dated [DATE] at 4:00 p.m. documented, .L [left] side diminished wheezing 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, staff interview and clinical record review, the facility staff failed to apply physician ordered Ace wraps for one of 23 residents in the survey sample (Resident #151). The findings include: Resident #151 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis, cellulitis of lower limb, pneumonia, anxiety, hypokalemia, depression, osteoarthritis, hypertension, asthma and hyperlipidemia. The nursing admission assessment dated [DATE] assessed Resident #151 as cognitively intact. Resident #151's clinical record documented the resident had surgical wounds on the top of her left knee and outer lower leg/ankle. The resident's clinical record documented a physician's order dated 8/20/19 for dressing changes to the left knee and lower leg wounds with an Ace wrap applied over the gauze pads on each wound. On 8/27/19 at 12:50 p.m., Resident #151 was observed in her room. The resident had a gauze dressing applied to her left knee and left foot/ankle. 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, and clinical record review the facility staff failed to properly assess one of 23 residents in the survey sample for the use of bed rails: Resident # 41. Findings include: Resident # 41 was admitted to the facility 9/26/17 with a readmission date of 6/29/18. Diagnoses for Resident # 41 included, but were not limited to: heart failure, high blood pressure, and GERD. The most recent MDS (minimum data set) was a quarterly assessment dated 712/19. Resident # 41 was assessed as having severe cognitive impairment with a total summary score of 04 out of 15. An Adult Protective Services (APS) report received by the State Agency 5/28/19 documented: (name of resident) did have a skin injury caused by sticking her arm through the bed rail and scraping the skin. The unit manager contacted the physician and the skin tear was treated. The unit manager also instituted an immediate intervention by having a body pillow placed between (name of resident) and the bed rail and will add…

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, resident review and clinical record review, the facility staff failed to honor the food preferences for two of 23 residents, Resident #37 and Resident #152. Findings include: 1. Resident #37 was admitted to the facility on [DATE] with the following diagnoses but not limited to: COPD (chronic obstructive pulmonary disease), heart failure, atrial fibrillation, GI (gastrointestinal) hemorrhage, hypothyroidism and hypertension. The most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 07/01/2019, assessed Resident # 37 as cognitively intact with a summary score of 15. On 08/27/19 at 11:00 a.m., Resident #37 was interviewed regarding life at the facility. She was asked about the food served. She stated, The food is terrible .they bring you what they want to bring you. I've told them over and over I don't like fish, I don't want it. What do they send? Fish! I'm not eating it, I don't care how they cook it. I want coffee 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 observation, staff interview, facility document review and clinical record review, the facility staff failed to follow infection control practices during a dressing change for one of 23 residents in the survey sample (Resident #151). The findings include: Resident #151 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis, cellulitis of lower limb, pneumonia, anxiety, hypokalemia, depression, osteoarthritis, hypertension, asthma and hyperlipidemia. The nursing admission assessment dated [DATE] assessed Resident #151 as cognitively intact. Resident #151's clinical record documented the resident had surgical wounds on the top of her left knee and outer lower leg/ankle. The resident's clinical record documented a physician's order dated 8/20/19 for daily dressing changes to the left knee wound and ankle wound with wound cleanser, an ABD pad covered with an Ace wrap. A physician's order dated 8/20/19 documented daily dressing changes to the left outer ankle wound with cleanser,…

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.