Carriage Hill Health & Rehab Center

Based on staff interview, clinical record review and facility document review, the facility staff failed to review and revise the comprehensive care for two of 41 residents in the survey sample, Residents #23 and #83. The findings include: 1. For Resident #23 (R23), the facility staff failed to review and review the comprehensive care plan after the resident was hospitalized with a small bowel obstruction. The resident's diagnoses included but was not limited to: personal history of malignant carcinoid tumor of large intestine. The nurse's note dated, 3/26/2023 at 12:06 a.m. documented in part, Reason for transfer and requires higher level of care: Resident having increased episodes of emesis and decreased BP (blood pressure), last taken was 67/40 .left with rescue squad. The comprehensive care plan dated, 3/30/2023, failed to evidence documentation related to the resident's bowel conditions. An interview was conducted with 6/7/2023 at 10:37 a.m. with LPN (licensed practical nurse) #6. When asked who updates the care plans, LPN #6 stated she does on her unit, each department does…

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

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to perform blood sugar checks per the physician order for one of 41 residents in the survey sample, Resident #4. The findings include: For Resident #4 (R4) the facility staff failed to obtain weekly fingerstick blood sugar on two out of four Wednesdays in the month of May 2023. The physician order dated, 3/15/2023 documented, Check BS (blood sugar) at HS (bedtime) on Wednesdays (Wed) at bedtime every Wed for DM (diabetes mellitus). Notify MD (medical doctor) if BS greater than 250 or less than 60. The May 2023 Medication Administration Record (MAR) documented the above order. On 5/24/2023 and 5/31/2023, there was no documented blood sugar, just the nurse's initials with a check mark. Review of the Blood Sugar Summary, failed to evidence the blood sugar reading for 5/24/2023 and 5/31/2023. Review of the nurse's notes failed to evidence documentation of the blood sugar readings on 5/24/2023 and 5/31/2023. An interview was conducted with LPN (licensed practical…

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

Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to implement safety interventions and/or maintain a safe environment for three of 41 residents in the survey sample, Residents #130, #278 and #4. The findings include: 1. For Resident #130 (R130), the facility staff failed to transfer the resident with a Hoyer lift, per the resident's plan of care on 3/8/23. R130's comprehensive care plan revised on 3/2/23 documented, (R130) demonstrates the need for ADL (activities of daily living) assistance r/t (related to) weakness d/t (due to) cerebral infarction (stroke), Stage IV breast cancer, medication, and medical deficit. Interventions/Tasks: Resident Hoyer lift/two person assist with transfers . R130's CNA (certified nursing assistant) kardex dated 3/8/23 documented, Transferring 2 person/Hoyer . On 6/6/23 at 10:22 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that on 3/8/23, she entered R130's room and two CNAs were attempting to transfer the resident [without…

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

Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide appropriate care and services for an indwelling urinary catheter, for one of 41 residents in the survey sample; Resident #121. The findings include: For Resident #121 the facility staff failed to ensure the Foley catheter was maintained off the floor to prevent infections. A Foley catheter is a common type of indwelling catheter. It has soft, plastic or rubber tube that is inserted into the bladder to drain the urine (1). On 6/6/23 at 8:38 AM, Resident #121 was observed sitting on the side of the bed awaiting his breakfast tray. The Foley catheter bag was noted on the floor under the edge of the bed, the tubing was laying on the floor and the resident was stepping on the tubing. A review of the physician's orders revealed one dated 5/20/23 for catheter care every shift. On 6/7/23 at 11:50 AM an interview was conducted with CNA (Certified Nursing Assistant) #2 who stated that the catheter bag should be hanging on the side of the bed…

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

Based on observation, staff interview, and facility documentation review, the facility staff failed to allow all residents to receive visitors from 7:00 P.M. through 10 A.M. for an undetermined length of time. The findings included: On 01/25/2022 at 12:15 P.M. upon survey entrance, a sign was observed on the front door of the facility which read: Visiting Hours 10AM to 7PM Please wear a face mask, sanitize hands upon entry and departure, and social distance during your visit. If you have any questions or concerns, please ask the Charge Nurse. The sign was also observed on the front door on the morning and afternoon of 01/26/2022. On 01/26/2022 at 2:05 P.M., an interview with Employee G, the front desk receptionist, was conducted. Employee G verified that she worked from 11:00 A.M. through 7 P.M. When asked when visiting hours were, the receptionist stated the visiting hours were from 10:00 A.M. through 7 P.M. The receptionist also stated that the front doors get locked around 7:00-7:05 P.M. nightly. When asked why visiting was limited to that time frame, the receptionist stated 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.

For Resident #410, who reported an allegation of abuse, the facility staff failed to report the allegation or investigation results to the state survey agency (Office of Licensure and Certification), adult protective services and other officials as required. On the afternoon of 1/25/22, an interview was conducted with Resident #410. During this interview, the Resident verbalized that previously she had reported that CNA B dumped a pan of hot water on her during a bath. Review of the facility grievances revealed that a grievance form dated 12/6/21, read, Resident reported her CNA, [CNA B name redacted], threw hot water on her back while assisting her with getting cleaned up and bed bath [sic]. The facility conducted an investigation, which included a head to toe assessment of the Resident, checking the water temperature in the room and obtaining statements from staff. On 1/25/22, a request for all FRI's (facility reported incidents) was requested and received. The FRI's were reviewed with no report of Resident #410's allegation being sent to the State Agency. On 1/26/22, an interview…

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

Based on interview, clinical record review, facility documentation and in the course of a complaint investigation, the facility staff failed to ensure Residents were free from neglect for 3 Residents (#'s 310, 311, and 312) in a survey sample of 52 Residents. The findings included: For Resident #'s 310, 311, and 312 the facility staff neglected to ensure that Fentanyl patches remained on the Resident for the appropriate length of time. The 3 Residents involved were all on comfort care measures and receiving Fentanyl patches every three days to manage pain. The facility submitted 2 documents related to the diversion of narcotics by a former employee (RN D). The documents included a letter reporting the incident to the board of nursing, and a document entitled Summary of Findings in the Investigation of Suspected Diversion of Fentanyl at [name of facility redacted]. Per the above mentioned documents, it was found that the RN D admitted to diverting medications and did overdose at the facility, on Fentanyl patches. The RN involved denied removing patches prior to the scheduled times…

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

Based on Resident interview, staff interview and facility documentation review, the facility staff failed to implement their abuse policy for one Resident (Resident #410) in a survey sample of 52 Residents. For Resident #410, who reported an allegation of abuse to the facility staff, the facility staff failed to carry out their abuse policy with regards to protecting the Resident while an investigation was being conducted and failing to report an allegation of abuse. The findings included: On the afternoon of 1/25/22, Surveyor C conducted an interview with Resident #410. During the interview Resident #410 reported that in the past CNA B had poured a pan of hot water onto her back while bathing her. Review of the facility grievances revealed that a grievance form dated 12/6/21, read, Resident reported her CNA, [CNA B name redacted], threw hot water on her back while assisting her with getting cleaned up and bed bath [sic]. The facility conducted an investigation, which included a head to toe assessment of the Resident, checking the water temperature in the room and obtaining…

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

Based on Resident interview, staff interview, facility documentation review and clinical record review, the facility staff failed to implement measures to protect the Resident while an abuse investigation was conducted, for one Resident (Resident #410) in a survey sample of 52 Residents. For Resident #410, who reported an allegation of abuse, the facility staff failed to protect the Resident by not allowing the alleged perpetrator to have continued access to the Resident while an investigation was being conducted. The findings included: On 1/25/22, an interview was conducted with Resident #410. During this interview, the Resident verbalized that previously she had reported that CNA B dumped a pan of hot water on her during a bath. Review of the facility grievances revealed that a grievance form dated 12/6/21, read, Resident reported her CNA, [CNA B name redacted], threw hot water on her back while assisting her with getting cleaned up and bed bath [sic]. The facility conducted an investigation, which included a head to toe assessment of the Resident, checking the water temperature…

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

Based on resident interview, staff interviews, facility documentation review and clinical record review, the facility staff failed to provide notice in writing before a facility transfer or discharge of a Resident to the Resident and Resident Representative (RP) for 1 Residents (Resident #410) in a survey sample of 52 Residents. The findings included: On 1/25/22 at 3:00 PM, Surveyor C interviewed Resident #410. Resident #410 stated she recalled going to the hospital and actually requested the transfer herself. Review of the clinical record for Resident #410 revealed on the census tab of the electronic health record (EHR), Resident #410 had discharged on 1/16/22. There was no further indication in the clinical record to indicate Resident #410 and/or her representative had received reason for the transfer in writing, prior to, or at the time of transfer/discharge. Review of the progress notes for Resident #410 revealed the following entry on 1/16/22, Resident c/o [complained of] nausea/vomiting around 2030, chest pain started at approx. 0400. VS: BP = 105/52, pulse = 139, Temp = 97.3,…

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

Based on resident interview, staff interviews, facility documentation review and clinical record review, the facility staff failed to provide written information about bed-hold policy before the transfer of a Resident (Resident #410) to the hospital in a survey sample of 52 Residents. The findings included: On 1/25/22 at 3:00 PM, Surveyor C interviewed Resident #410. Resident #410 stated she recalled going to the hospital and actually requested the transfer herself. Review of the clinical record for Resident #410 revealed on the census tab of the electronic health record (EHR), Resident #410 had discharged on 1/16/22. There was no further indication in the clinical record to indicate Resident #410 and/or her representative had received in writing information regarding the facility bed-hold policy. Review of the progress notes for Resident #410 revealed the following entry on 1/16/22, Resident c/o [complained of] nausea/vomiting around 2030, chest pain started at approx. 0400. VS: BP = 105/52, pulse = 139, Temp = 97.3, Resp = 18, O2 = 97%. Color pale, skin warm and dry. [Doctor Name…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to revise the care plan for for three Residents (Resident #55, #97, and #64) of the 52 residents in the survey sample. The findings included; 1. For Resident #55, the staff failed to revise the care plan for pressure sore interventions. Resident #55 was originally admitted on [DATE]. Diagnoses for Resident #55 included but were not limited to; acute pubic and lumbar fracture resulting from a fall at home. Resident #55's admission Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 10-22-21 coded Resident #55 as alert, oriented to person, place, time and situation, with a BIMS (brief Interview for Mental status score of 14 out of a possible 15 points indicating no cognitive impairment. The Minimum Data Set further coded Resident #55 as being extensively dependent, on 1-2 staff members for all Activities of Daily Living care. The Resident was coded as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review, the facility staff failed to transcribe orders for 2 Residents (Resident #64, Resident #2) in a sample size of 52 Residents. The findings included: 1. For Resident #64, the facility staff failed to transcribe the wound physician's wound treatment orders into the facility's electronic health record on 01/24/2022 resulting in the wrong wound treatment on 01/26/2022 and 01/27/2022. On 01/25/2022 and 01/26/2022, Resident #64's clinical was reviewed. An active physician's order dated 01/10/2022 documented, left heel DM [diabetic mellitus] ulcer. clean with normal saline. pat dry. skin prep wound edges apply small piece of calcium Alginate over wound bed secure with DD [dry dressing] Q MWF and PRN [every Monday, Wednesday, and Friday and as needed]. The Treatment Administration Record for the above order with a start date of 01/12/2022 was signed off as administered as ordered including on 01/24/2022 and 01/26/2022. The wound physician document dated…

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

Based on interview, clinical record review and facility documentation the facility staff failed to ensure that Residents receive assistance to carry out Activities of Daily Living necessary to maintain good grooming and personal hygiene for 4 Residents (# 's 45, 43, 14, and 410) in a survey sample of 52 Residents The findings included: 1. For Resident #45, the facility staff failed to provide the resident's preference of 2 showers per week. A review of the minutes from the 12/21/21 Resident Council meeting read: Residents reporting baths/ showers are not getting done 2x a week and some of the more dependant Residents (roommates of Council Members) were not being toileted promptly. On 1/26/22 at approximately 2:30 PM a Resident Council meeting was held and the subject of not getting 2 showers per week was brought up. The Residents complained of not getting 2 showers per week. They stated they believe it is due to lack of staff. They stated that had been told this by CNAs but declined to mention anyone by name. When asked if this issue has gotten any better since it was brought up 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.

Based on staff interview and clinical record review, the facility staff failed to provide appropriate dialysis care for one Resident (Resident #64) in a sample size of 52 Residents. Specifically, the facility staff obtained blood pressures in the same arm where Resident #64's fistula was located which is contraindicated. The findings included: On 01/25/2022 at approximately 1:15 P.M., Resident #64 was interviewed. When asked about receiving dialysis, Resident #64 nodded 'yes' and lifted her left sleeve to reveal 2 small white dressings (clean, dry and intact) covered with tape. On 01/25/2022 and 01/26/2022, Resident #64's clinical record was reviewed. A physician's order dated 08/18/2021 documented, Monitor LUE [left upper extremity] fistula for bruit/thrill [sound/vibration] Qshift [every shift]. A physician's order dated 08/18/2021 documented, Monitor LUE fistula for s/s [signs and symptoms] of infection Qshift [every shift]. There was no physician's order prohibiting obtaining blood pressures in the left upper extremity where Resident #64's fistula was located. The care plan 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, clinical record review, and facility documentation review, the facility staff failed, for one resident (Resident # 105) in the survey sample of 52 residents, to administer physician-ordered medication. The facility staff failed to administer Levothyroxine Sodium Tablet 25 mcg. On 1/27/22 at 2:00 P.M., an observation was conducted of Resident #105. She was in the activity area of the memory unit. Resident #105 was dressed appropriately, and appeared to be clean and well-groomed. On 1/27/22, a review was conducted of Resident #105's clinical record. The Medication Administration Record (MAR) dated December, 2022 was reviewed. On 12/11/22 at 6:00 A.M., Levothyroxine Sodium Tablet 25 mcg. was not documented as having been administered. There was no documentation regarding why it had not been administered on the MAR. In addition, the Nurse's Progress note dated 12/11/21 did not document the reason that the medication had not been administered. The signed physician's order was reviewed. It read,12/1/21. Levothroid Sodium Tablet 25 mcg. Give 1 tablet by mouth 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 observation, family interview, staff interview, clinical record review, and in the course of a complaint investigation, the facility staff failed to adhere to infection control standards of practice for one Resident (Resident #64) in a sample size of 52 Residents. Specifically, 1) Resident #64 was on Contact Precautions for Klebsiella in the urine and the family was allowed to enter and remain in Resident #64's room without wearing the proper personal protective equipment (PPE) on 01/27/2022 and 2) the nurse failed to wash hands between glove changes during wound care on 01/27/2022. The findings included: 1) On 01/25/2022 and 01/26/2022, Resident #64's clinical record was reviewed. A physician's order dated 01/20/2022 documented, Contact Isolation - ESBL [extended-spectrum beta-lactamase]. A urine culture laboratory results with a report date of 01/19/2022 under the header Organism documented the following excerpt, Klebsiella pneumoniae [opportunistic pathogen], ESBL. On 01/27/2022 at 9:50 A.M., this…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, and clinical record review, facility staff administered normal saline and heparin IV (intravenous) flushes through a Midline access without a physician order for one (1) of 31 residents in the survey sample, Resident #74. Findings included: Resident #74 was admitted on [DATE] with diagnoses including, but not limited to: Dementia with Behaviors, Chronic Kidney Disease - Stage 4, BPH (Benign Prostatic Hypertrophy), Diabetes - Type II, and Anxiety. The most recent MDS (minimum data sheet) was an initial assessment with an ARD (assessment reference date) of 07/08/2019. Resident #74 was assessed as severely impaired in his cognitive status with a total cognitive score of four (4) out of 15. Resident #74's clinical record was reviewed on 08/06/2019 at 10:19 a.m. During review of the MAR (medication administration record) the following entries were noted, Sodium Chloride Solution 0.45%. Use 100ml/hr [milliliters per hour] intravenously every shift 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, resident interview, staff interview, and facility document review, the facility staff failed to answer call bells in a timely manner for three of 31 residents in the survey sample, Resident #58, Resident #44 and Resident #121. Findings include: 1. Resident #58 was admitted to the facility originally on 6/11/18. Diagnoses for Resident #58 included, but were not limited to: COPD (chronic obstructive pulmonary disease), DM (diabetes mellitus), anxiety and depression. The most current MDS (minimum data set) was an annual assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 15, indicating the resident was cognitively intact for daily decision making skills. The resident was also assessed as requiring extensive of one staff person for bed mobility, toilet use and personal hygiene. On 08/06/19 at 9:30 AM, Resident #58, was observed in her room, laying in bed, eating breakfast. The resident stated that the staff didn't have time to get her up this morning and that they…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, facility staff failed to provide a timely response to a pharmacy recommendation for one of 31 residents in the survey sample. Resident #104's physician failed to respond to a pharmacy recommendation dated 06/05/19 regarding the administration times for the appetite stimulate Dronabinol (Marinol). The findings include: Resident #104 was admitted to the facility on [DATE] with diagnoses that included dementia without behavioral disturbance, hypertension, adult failure to thrive, and hypercholesteromia. The minimum data set (MDS) dated [DATE] which was a quarterly assessment, assessed Resident #104 as severely cognitively impaired for daily decision making with a score of 2 out of 15. Resident #104's clinical record was reviewed on 08/07/19. Observed on the order summary report and carried forward monthly was the following medication order: Marinol Capsule 5 MG (milligrams) (Dronabinol), give 1 capsule by mouth two times a day 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, resident interview, staff interview and clinical record review, the facility staff failed to notify the physician that one of 31 residents (Resident #241) was not wearing a cervical collar prescribed due to spinal fractures. The findings include: Resident #241 was admitted to the facility on [DATE] with diagnoses that included metastatic breast cancer, heart failure, pathological spinal fractures, anemia and gastroesophageal reflux disease. The admission nursing assessment dated [DATE] assessed Resident #241 as alert and oriented. Resident #241's clinical record documented the resident was admitted to the facility on [DATE] following a hospitalization due to bilateral lower extremity weakness and numbness. The hospital discharge report dated 7/26/19 documented the resident had breast cancer with metastasis to the thoracic and cervical spine. The discharge diagnoses included, Pathological fractures of T3, T5, T7, T11 [thoracic vertebrae] with paraplegia without evidence of cord compression…

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 develop a baseline care plan that included immediate problems, goals and/or interventions for care of spinal fractures for one of 31 residents in the survey sample (Resident #241). The findings include: Resident #241 was admitted to the facility on [DATE] with diagnoses that included metastatic breast cancer, heart failure, pathological spinal fractures, anemia and gastroesophageal reflux disease. The admission nursing assessment dated [DATE] assessed Resident #241 as alert and oriented. Resident #241's clinical record documented the resident was admitted to the facility on [DATE] following a hospitalization due to bilateral lower extremity weakness and numbness. The hospital discharge report dated 7/26/19 documented the resident had breast cancer with metastasis to the thoracic and cervical spine. The discharge diagnoses included, Pathological fractures of T3, T5, T7, T11 [thoracic vertebrae] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review, the facility failed to develop a comprehensive care plan for 2 of 31 residents. Resident #86 did not have a care plan for prevention of a urinary tract infection, and Resident #121 did not have a care plan for emotional distress. The Findings Include: 1. Resident #86 was admitted to the facility on [DATE]. Diagnoses for Resident #86 included; Urinary tract infection, muscle weakness, and hypertension. The most current MDS (minimum data set) was an initial assessment with an ARD (assessment reference date) of 7/10/19. Resident #86 was assessed with a score of 9 indicating moderately cognitively intact. During an interview with Resident #86, conducted on 8/6/19 at 9:47 AM, Resident #86 stated that she was admitted to the facility with a severe UTI (urinary tract infection) and felt that she was getting another UTI and had told the night shift nurse and that the night shift nurse was supposed to be getting an order for a urine sample to send to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review, the facility staff failed to review and revise the comprehensive care plan (CCP) for one of 31 residents in the survey sample. Resident #47's CCP was not reviewed and revised for the use of TED (Thrombo-Embolic Deterrent) hose. The findings include: Resident #47 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection (UTI), muscle weakness, dementia without behavioral disturbance, hypertension, gastro-esophageal reflux disease (GERD), and angina. The minimum data set (MDS) dated [DATE] which was an admission assessment assessed Resident #47 as severely cognitively impaired for daily decision making with a score of 3 out of 15. During the initial tour on 08/06/19 at 8:30 a.m., Resident #47 was observed sitting at a table near the nurses station on the 400 hall. Resident #47 was observed wearing white TED hose to her bilateral lower extremities. On 8/06/19 at 12:59 p.m., Resident #47's clinical record 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 observation, staff interview, and clinical record review, facility staff failed to follow physician orders for the use of a bed alarm for one of 31 residents in the survey sample, Resident #74 and failed to follow physician orders for the use of TED (Thrombo-Embolic Deterrent) stockings for one of 31 residents, Resident #105. Findings included: Resident #74 was admitted on [DATE] with diagnoses including, but not limited to: Dementia with Behaviors, Chronic Kidney Disease - Stage 4, BPH (Benign Prostatic Hypertrophy), Diabetes - Type II, and Anxiety. The most recent MDS (minimum data sheet) was an initial assessment with an ARD (assessment reference date) of 07/08/2019. Resident #74 was assessed as severely impaired in his cognitive status with a total cognitive score of four (04) out of 15. Resident #74's clinical record was reviewed on 08/06/2019 at 10:19 a.m. Review of the POS (physician order sheet) dated August 2019 included, .Bed alarm-check placement and function Q [every] shift every shift 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, resident interview, staff interview and clinical record review, the facility staff failed to provide social services regarding assessed emotional distress for one of 31 residents in the survey sample (Resident #121). The findings include: Resident #121 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, hypothyroidism, depression, anxiety, chronic obstructive pulmonary disease, diabetes and history of hip fracture. The minimum data set (MDS) dated [DATE] assessed Resident #121 with moderately impaired cognitive skills. On 8/6/19 at 9:38 a.m., Resident #121 was interviewed about quality of life/care in the facility. Resident #121 was tearful and stated she wanted to go home. Resident #121 stated she was upset because her insurance coverage for therapy had been stopped and if she did not get therapy then she would not get well enough to go home. Resident #121 stated an appeal with her insurance was denied and she did not want to stay in the 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 medication pass and pour observation, staff interview, clinical record review, and facility document review, facility staff failed to ensure a medication error rate of less than 5 percent. There were 3 errors observed from 28 opportunities, resulting in an error rate of 10.71 percent. Findings were: A medication pass and pour observation was conducted on 08/06/2019 beginning at approximately 8:20 a.m. RN (registered nurse) #1 removed two packets from the medication cart. The packets (called Paxit) were labeled with Resident #74's name, medications in the packet, and dosage instructions. Each medication in the packet was in a bubble pack and individually labeled. Three medications in the packet, Aspirin EC (enteric coated), Divalproex (Depakote), and Alfuzosin ER (extended release), were labeled with pharmacy instructions Do Not Crush. RN #1 compared each medication in the packet to the electronic MAR (medication administration record). RN #1 was asked if she reviewed the packets to ensure the medications and labeling were correct. She stated, No, I look at the MAR, those…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and facility document review, facility staff failed to date opened insulin on 2 of 6 medication carts. Findings included: During the inspection of a medication cart on the CD (skilled) Unit on 08/07/2019 at 10:25 a.m., a Lantus Insulin Pen 100u/ml (100 units per milliliter), total of 3ml, was observed as opened without an opened date. LPN#1 (licensed practical nurse) stated, Can I label it now? Look, here is the sticker right here. LPN#1 pointed to the Opened Date sticker located on the plastic bag storing an insulin pen. When asked if she knew when the pen had been opened, LPN #1 stated, No, I don't. A bottle of Humalog Insulin 100u/ml, total of 3ml was opened and not dated. LPN #1 inspected the bottle and stated, She isn't even here anymore. This doesn't even need to be in the cart. Regarding dating of opened medications LPN #1 stated, All medications should be dated when opened. The Administrator and DON (director of nursing) was informed of the above information during a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review and facility document review, the facility staff failed to provide food and supplement preferences for one of 31 residents in the survey sample, Resident #40. Findings include: Resident #40 was originally admitted to the facility on [DATE], with the most current readmission on [DATE]. The resident's diagnoses included, but were not limited to: history of stroke, with hemiplegia, major depression, hypothyroidism, and dysphagia. The most current MDS was an annual assessment dated [DATE]. This MDS assessed the resident as having a cognitive score of 4, indicating the resident had severe impairment in daily decision making skills. The resident was also assessed as requiring supervision (oversight, encouragement or cueing) with one person physical assist for eating. On 08/06/19 at 1:13 PM, Resident #40 was observed in her room eating lunch. Resident #40 stated that she will ask for coffee and that staff bring her tea. She stated that she ate a piece…

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 staff failed to follow infection control practices in a resident room during a medication pass and pour observation. Findings include: On 8/6/19 beginning at 9:45 a.m. a medication pass and pour observation was conducted with RN (registered nurse) # 2. After administering medications to a resident, RN # 2 went to the sink in the resident's room, and proceeded to wash her hands. She briefly washed her hands, turned off water faucet with her bare hands, then dried hands with paper towel and discarded the paper towel in the trash. When asked about turning the water off with her bare hands after washing, RN # 2 stated Uh oh .yeah, you're supposed to turn it off with paper towel and wash 30 seconds .I didn't do that .I'm really nervous On 8/6/19 at approximately 10:15 a.m. the DON (director of nursing) was asked for a copy of the facility policy for handwashing. The policy Hand Hygiene included POLICY: Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection…

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.