Fredericksburg Health And Rehab

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to store and serve food in a sanitary manner in one of one kitchen. The findings include: The facility staff failed to accurately label prepared food not stored in the original container, discard expired produce, store dry good scoops and thickener in a sanitary manner in the facility kitchen. On 10/24/2023 at 8:30 a.m., an observation was conducted of the kitchen of the facility with OSM (other staff member) #4, dietary manager. Observation of the walk-in refrigerator revealed a four-shelf wire cart with a 5.2-quart plastic container with a white plastic lid on the third shelf labeled Ranch dressing with a prepared date of 5/10/23 and a use by date of 5/10/24. The container was observed to contain a brown pudding like substance. OSM #4 identified the substance as chocolate pudding and stated that it was not labeled or dated accurately. She stated that the container should be labeled with the accurate contents, date it was prepared and a use by date of 3 days later.…

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 review of facility's documentation and staff interview, it was determined that the facility failed to convey personal funds in a timely manner for one of 39 residents in the sample, Resident #438. The findings included: Resident #438 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), diabetes mellitus (DM), bipolar and candidiasis. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of [DATE], coded the resident as scoring a 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring supervision for bed mobility, transfer, walking, locomotion, dressing, eating, hygiene and bathing. A review of the comprehensive care plan dated [DATE], which revealed, FOCUS: Long term care in a…

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

Based on observation, staff interview and clinical record review, it was determined that the facility staff failed to maintain a clean, comfortable and homelike environment for one of 39 residents in the survey sample; Resident #125. The findings include: On 10/24/23 at 10:32 AM, an observation was made of Resident #125's room. The base of the toilet around the area where the bolts hold the toilet to the floor had dark brown / black substance all over it. On 10/24/23 at 3:33 PM and 10/25/23 at 10:02 AM, there was no change to the above observation. On 10/26/23 at 9:34 AM, there was no change to the above observation. At this time, OSM #17 (Other Staff Member), a housekeeper, was asked about the substance on the toilet base. He said he would clean it now. He sprayed a cleaner on it and the substance immediately dispersed, indicating it was something that could easily be cleaned and was not a permanent stain. He stated it should have been cleaned before now. A policy was requested for clean/comfortable/homelike environment / housekeeping services. None was provided. On 10/26/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide an accurate MDS (minimum data set) assessment for one out of 39 residents in the survey sample, Residents #135. The findings include: The facility staff failed to complete an accurate MDS (minimum data set), a discharge assessment for Resident #135. Resident #135 was sampled during the closed record review for transfer to hospital. Resident #135 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: diabetes, congestive heart failure, hemiplegia and end stage renal disease. The most recent MDS (minimum data set) assessment, a discharge assessment, with an ARD (assessment reference date) of 8/2/23, coded the resident as scoring a 00 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of Section A: Identification Information: A 2100. Discharge Status: 03. Acute…

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 review and revise the care plan for one of 39 residents in the survey sample, Resident #79. The findings include: For Resident #79 (R79), the facility staff failed to review and revise the resident's care plan to reflect the removal of a Foley catheter (1) and the addition of compression stockings. On the following dates and times, R79 was observed lying in her bed: 10/24/23 at 9:54 a.m., 1:00 p.m., and 2:30 p.m.; and 10/25/23 at 9:44 a.m. At each of these observations, R79 did not have a Foley catheter, and the resident was not wearing compression stockings on her legs. A review of R79's clinical record revealed the following order dated 8/3/23: Apply Compression Stockings one time a day. Further review of R79's clinical record revealed she was admitted to the facility with a Foley catheter, but the catheter was discontinued on 8/11/23. A review of R79's care plan dated 8/3/23 failed to reveal any information related to the compression stockings. This review revealed, in part: I have a…

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

Based on resident interview, staff interview and clinical record review, the facility staff failed to follow professional standards of practice for one of 39 residents in the survey sample, Resident #89. The findings include: For Resident #89 (R 89), the facility staff failed to administer the medication sodium bicarbonate per physician's order on multiple dates in October 2023. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/17/23, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 10/24/23 at approximately 9:30 a.m., an interview was conducted with R 89. The resident voiced concern about not getting sodium bicarbonate. A review of R 89's clinical record revealed a physician's order dated 10/7/23 for sodium bicarbonate 650 mg (milligrams) by mouth two times a day for heartburn and indigestion. A review of R 89's October 2023 MAR (medication administration record) revealed the same physician's order for sodium…

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

Based on observation, staff interview, and clinical record review, the facility staff failed to follow a physician's order for one of 39 residents in the survey sample, Resident #79. The findings include: For Resident #79 (R79), the facility failed to apply compression stockings on the resident's legs as ordered by the physician. On the following dates and times, R79 was observed lying in her bed: 10/24/23 at 9:54 a.m., 1:00 p.m., and 2:30 p.m.; and 10/25/23 at 9:44 a.m. At each of these observations, the resident was not wearing compression stockings on her legs. A review of R79's clinical record revealed the following order dated 8/3/23: Apply Compression Stockings one time a day. A review of R79's care plan dated 8/3/23 failed to reveal any information related to the compression stockings. On 10/25/23 at 2:18 p.m., CNA (certified nursing assistant) #14 was interviewed. She stated if a resident has an order for compression stockings, the order appears on the resident's electronic medical record the CNA is able to see. She stated the CNAs are usually responsible for applying…

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 implement interventions to prevent a decline in mobility for two of 39 residents in the survey sample, Residents #79 and #6. The findings include: 1. For Resident #79 (R79), the facility staff failed to implement interventions to prevent further loss of mobility related to her contractures (1). R79 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 8/9/23, the resident was coded as requiring the extensive physical assistance of two staff members for bed mobility, and as having impairment on both left and right sides of both her upper and lower extremities. On the following dates and times, R79 was observed lying in her bed, with contractions in both arms and both legs: 10/24/23 at 9:54 a.m., 1:00 p.m., and 2:30 p.m.; and 10/25/23 at 9:44 a.m. On 10/25 at 2:30 p.m. and 10/25/23 at 9:44 a.m., there was a folded thin…

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 safe supervision for one of 39 residents in the sample, Resident #106. The findings include: For Resident #106 (R106), the facility staff failed to supervise him for safety when he independently walked into two commercial parking lots adjacent to the facility. R106 was admitted to the facility with a history of a traumatic brain injury. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/10/23, R106 was coded as being moderately impaired for making daily decisions, having scored 12 out of 15 on the BIMS (brief interview for mental status. He was coded as exhibiting no behaviors during the look back period, including wandering. He was coded as requiring supervision, and the physical assistance of one staff member for locomotion off the unit. He was coded as having no psychological diagnoses. On 10/24/23 at 12:20 p.m., R106 was observed putting his 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, staff interview, and clinical record review, the facility staff failed to provide respiratory services in a sanitary manner for one of 39 residents in the survey sample, Resident #138. The findings include: For Resident #138 (R 138), the facility staff failed to maintain and store nebulizer equipment in a sanitary manner. On the following dates and times, R 138 was observed in his room: 10/24/23 at 9:25 a.m. and 2:35 p.m.; and 10/25/23 at 9:40 a.m. At each observation, a nebulizer machine was positioned on the overbed table. The nebulizer tubing was dated 10/15/23, and the nebulizer mask was uncovered, and resting on top of a plastic bag on the overbed table. A review of R 138's orders revealed the following order dated 10/4/23: Budesonide Suspension 0.5 MG/2 ML (milligrams per milliliter) 1 vial inhale orally via nebulizer two times a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH (ACUTE) EXACERBATION. A review of R 138's October 2023 MAR (medication administration record)…

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

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to evidence communication with the dialysis center for each dialysis visit for one of 39 residents in the survey sample; Resident #61. The findings include: A review of the clinical record for Resident #61 revealed a physician's order dated 9/3/23 for dialysis services every Tuesday, Thursday, and Saturday. A review of the dialysis communication book revealed the following: One communication sheet that was completed but was not dated. There was no way to know what dialysis visit the data on the sheet pertained to. Three communication sheets were not completed by the facility but was completed by the dialysis center. The facility did not provide pertinent data to the dialysis center. One of those sheets was also not dated. There was no way to know what dialysis visit the data from the dialysis center pertained to. All total, there were 22 opportunities for dialysis communication as of the survey review 10/25/23. There were 22 sheets in the book, including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide trauma informed care for 1 of 39 residents in the sample Resident #130. The findings include: Resident #130 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: PTSD (post-traumatic stress disorder) and epilepsy. The most recent MDS (minimum data set) assessment, a quarterly Medicare assessment, with an ARD (assessment reference date) of 9/18/23, coded the resident as scoring a 05 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring supervision for eating and limited assistance for bed mobility, transfer, walking and locomotion; extensive assistance for dressing and hygiene. MDS Section I: Active diagnosis: I6100.Post Traumatic Stress Disorder coded as yes. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review, the facility staff failed to provide physician oversight of a resident's care for one of 39 residents in the survey sample, Resident #79 The findings include: For Resident #79 (R79), the facility staff failed provide physician (and/or nurse practitioner) supervision to assess a resident to prevent further loss of mobility related to her contractures (1). R79 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 8/9/23, the resident was coded as requiring the extensive physical assistance of two staff members for bed mobility, and as having impairment on both left and right sides of both her upper and lower extremities. On the following dates and times, R79 was observed lying in her bed, with contractions in both arms and both legs: 10/24/23 at 9:54 a.m., 1:00 p.m., and 2:30 p.m.; and 10/25/23 at 9:44 a.m. On 10/25 at 2:30 p.m. and 10/25/23 at 9:44…

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 medically related social services for two of 39 residents in the survey sample, Residents #106 and #130. The findings include: 1. For Resident #106 (R106), the facility social worker failed to provide for psychological and safety assessments for this resident, who left the facility independently and walked through commercial parking lots adjacent to the facility. R106 was admitted to the facility with a history of a traumatic brain injury. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/10/23, R106 was coded as being moderately impaired for making daily decisions, having scored 12 out of 15 on the BIMS (brief interview for mental status. He was coded as exhibiting no behaviors during the look back period, including wandering. He was coded as requiring supervision, and the physical assistance of one…

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 therapy services to prevent further decline in mobility for one of 39 residents in the survey sample, Resident #79. The findings include: For Resident #79 (R79), the facility staff failed to obtain a therapy evaluation to prevent further loss of mobility related to her contractures (1). R79 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 8/9/23, the resident was coded as requiring the extensive physical assistance of two staff members for bed mobility, and as having impairment on both left and right sides of both her upper and lower extremities. On the following dates and times, R79 was observed lying in her bed, with contractions in both arms and both legs: 10/24/23 at 9:54 a.m., 1:00 p.m., and 2:30 p.m.; and 10/25/23 at 9:44 a.m. On 10/25 at 2:30 p.m. and 10/25/23 at 9:44 a.m., there was a folded thin…

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

Based on staff interview, facility document review and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for a dependent resident, for one of four residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to provide the resident a scheduled shower or bath on 8/26/23. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/7/23, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. Section G coded R1 as requiring extensive assistance of one staff with bathing. A review of R1's ADL records for August 2023 revealed the resident was scheduled for bathing during the day shift every Wednesday, Saturday, and as needed. Further review of the ADL records revealed R1 received a shower on Wednesday 8/23/23 but failed to reveal R1 was provided a shower or bath on Saturday 8/26/23. The ADL records documented, N/A. On 8/28/23 at 2:33…

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, it was determined the facility staff failed to provide evidence that all required information was provided to the hospital staff when five out of 47 residents in the survey sample were transferred to the hospital; Residents #56, #94, #90, #16 and #116. The findings include: 1. The facility staff failed to evidence provision of required resident information to a receiving facility at the time of transfer for Resident #56. Resident #56 was transferred to the hospital on 7/4/22. Resident #56 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Alzheimer's disease, dementia and cerebral infarction. The most recent MDS (minimum data set) assessment, a 5 day Medicare assessment, with an ARD (assessment reference date) of 7/14/22, coded the resident as scoring a 05 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident 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 interview, clinical record review, facility document review and in the course of a complaint investigation, it was determined the facility staff failed to provide evidence of written RP (responsible party) and/or ombudsman notification when six out of 47 residents in the survey sample were transferred to the hospital; Residents #56, #94, #90, #34, #16 and #116. The findings include: 1. The facility staff failed to provide evidence of written RP notification when Resident #56 was transferred to the hospital on 7/4/22. Resident #56 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Alzheimer's disease, dementia and cerebral infarction. The most recent MDS (minimum data set) assessment, a 5 day Medicare assessment, with an ARD (assessment reference date) of 7/14/22, coded the resident as scoring a 05 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the nursing progress note…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that bed hold notification was provided when four out of 47 residents in the survey sample were transferred to the hospital; Residents #56, #94, #90 and #34. The findings include: 1. The facility staff failed to provide evidence of that a bed hold notification was provided when Resident #56 was transferred to the hospital on 7/4/22. Resident #56 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: Alzheimer's disease, dementia and cerebral infarction. The most recent MDS (minimum data set) assessment, a 5 day Medicare assessment, with an ARD (assessment reference date) of 7/14/22, coded the resident as scoring a 05 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the nursing progress note dated 7/4/22 at 9:00 AM, revealed, Situation: 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 it was determined the facility staff failed to have a repair person present in the kitchen wear protective hair guard; store food properly in the walk-in refrigerator; dry dishware in a sanitary manner; store a scoop used for dry goods properly; and store food in one of two nourishment room refrigerators in accordance with professional standards for food service safety. The findings include: 1. The facility failed to properly store food in the walk-in refrigerator, properly dry dishware, and properly store a scoop in dry goods in the main kitchen of the facility. On 8/29/2022 at 11:06 a.m., an observation was made of the facility kitchen with OSM (other staff member) #6, dietary manager in training. Observation of the kitchen revealed staff members actively preparing lunch for residents. A staff member was observed making repairs to the ice machine in the kitchen, OSM #6 identified the staff member as a maintenance vendor brought in to fix the ice machine. The staff member was observed wearing a facemask and a hair…

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

Based on staff interview and facility document review it was determined that the facility staff failed to evidence annual abuse, neglect and dementia training for five out of five CNAs (certified nursing assistants) reviewed who were employed for at least one year. The findings include: The facility staff failed to evidence annual abuse, neglect and dementia training for CNA #4, #5, #6, #7 and #8. On 8/29/2022 at approximately 3:10 p.m., a request was made to ASM (administrative staff member) #3, the regional director of clinical services for evidence of annual abuse, neglect and dementia training for CNA #4, CNA #5, CNA #6, CNA #7 and CNA #8. On 8/31/2022 at 10:28 a.m., an interview was conducted with OSM (other staff member) #9, human resource director. OSM #9 stated that they and the director of nursing were responsible for the CNA education. OSM #9 stated that they coordinated with the unit managers and assigned the education in the computer. OSM #9 stated that abuse, neglect and dementia were required annually and they notified the director of nursing when they were due for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to honor a resident's rights to visitation for 1 of 47 residents in the survey sample; Resident #701. The facility staff denied Resident #701 family visitation on Christmas Day 2021. The findings include: Resident #701 was admitted to the facility on [DATE] and discharged on 5/10/22. On the most recent MDS (Minimum Data Set) an annual assessment with an ARD (Assessment Reference Date) of 4/1/22, the resident was coded as being cognitively intact in ability to make daily life decisions, scoring a 15 out of 15 on the BIMS (Brief Interview for Mental Status). A review of the progress notes in the clinical record failed to reveal anything regarding visitation for Christmas Day 2021. A review of a Concern Form dated 12/25/21 documented, Documentation of concern: Resident's [family member] stated [they] was told [they] could not visit (the…

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

Based on resident interview, staff interview, clinical record review, facility document review and in the course of a complaint investigation, it was determined that the facility staff failed to protect two of 47 residents in the survey sample from abuse, Residents #32 (R32) and (R317). The findings include: 1. The facility staff failed to protect (R32) from a facility housekeeper pinching (R32's) right nipple. (R32) was admitted to the facility with diagnoses that included but were not limited to: stroke, bipolar disorder (1), hemiplegia (2) and depression. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 06/29/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. The Facility Reported Incident (FRI) dated 07/09/2022 documented, Incident Date: 07/09/2022. Incident type: Allegation of abuse/mistreat (mistreatment). Describe the incident, including location and action taken: Resident reported while asleep in 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review it was determined that the facility staff failed to maintain an accurate MDS (minimum data set) assessment for two of 47 residents in the survey sample, Resident #116 and Resident #31. The findings include: 1. For Resident #116 (R116), the facility staff failed to accurately code a discharge MDS (minimum data set) assessment. The discharge MDS (minimum data set) for R116 with the ARD (assessment reference date) of 7/15/2022 coded R116 as being discharged to the community, however the progress notes reflected that R116 was admitted to the hospital on [DATE]. On the most recent prior MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 6/28/2022, the resident scored 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. Review of the clinical record revealed a list of R116's MDS assessments. The list revealed that a discharge MDS was completed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to implement the care plan for one of 47 residents in the survey sample, Resident #30. The findings include: The facility staff failed to implement the comprehensive care plan for dialysis care for Resident #30. Resident #30 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: end stage renal disease, peripheral vascular disease and gangrene. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 6/25/22, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bed mobility, transfer, dressing, hygiene and bathing; limited assistance for locomotion and supervision 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, clinical record review and facility document review, it was determined facility staff failed to follow professional standards of practice during medication administration for one of five residents observed during the medication administration observation, Resident #83. The findings include: For Resident #83 (R83), the facility staff failed to follow medication administration standards of practice following the administration of a Symbicort inhaler (1). The facility staff did not have the resident rinse their mouth after administration of the inhaler. R83 was admitted to the facility with diagnoses that included but were not limited to chronic obstructive pulmonary disease (2). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (Assessment Reference Date) of 7/30/2022, the resident scored 5 out of 15 on the BIMS (brief interview for mental status) assessment indicating the resident was severely impaired for making daily decisions. On 8/30/2022 at…

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

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to provide respiratory care and services according to professional standards for one of 47 residents in the survey sample, Resident #316. The facility staff failed to obtain a physician's order for Resident #316's (R316) use of oxygen. The findings include: R316's admission MDS (minimum data set) assessment was not complete. R316's admission data collection form dated 8/18/22 documented the resident's ability to make decisions regarding daily tasks of life was moderately impaired. R316's baseline care plan with an implementation date of 8/19/22 documented R316 was to receive continuous oxygen at two liters per minute via a nasal cannula. A review of R316's active physician's orders as of 8/30/22 failed to reveal a physician's order for oxygen. On 8/29/22 at 3:52 p.m. and 8/30/22 at 8:20 a.m., R316 was observed lying in bed receiving oxygen via nasal cannula at a rate between two and a half and three liters. On 8/30/22 at 2:57 p.m., an interview was conducted with LPN…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, resident interview, clinical record review, and facility document review, it was determined the facility staff failed to provide dialysis care and services for one of 47 residents in the survey sample, Resident #30. The findings include: The facility failed to provide communication to the dialysis facility for 6 of 13 visits in May 2022, 4 of 13 visits in June 2022, 2 of 13 visits in July 2022 and 3 of 14 visits in August 2022, for a total of 15 of 53 visits with no communication. Resident #30 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: end stage renal disease, peripheral vascular disease and gangrene. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 6/25/22, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the…

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 employee record review it was determined that the facility staff failed to ensure that received annual performance reviews for 10 of 10 CNA [certified nursing assistant] records reviewed. The findings include: On 03/14/2021 a record review was conducted of the annual performance reviews of 10 CNAs. This review failed to evidence the annual performance reviews for the following CNAs: 1. CNA # 1, with a hire date of 12/16/2016, had no evidence of a performance review being completed between 12/16/2019 and 12/16/2020. 2. CNA # 4, with a hire date 01/25/2019, had no evidence of a performance review being completed between 01/25/2020 and 01/25/2021. 3. CNA # 5, with a hire date 12/16/2016, had no evidence of a performance review being completed between 12/16/2019 and 12/16/2020. 4. CNA # 6, with a hire date 12/05/2018, had no evidence of a performance review being completed between 12/05/2019 and 12/05/2020. 5. CNA # 7, with a hire date 12/16/2016, had no evidence of a performance review being completed between 12/16/2019 and 12/16/2020. 6. CNA # 8, with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to maintain the kitchen in a sanitary manner. The facility staff failed to store food in closed containers during the facility task- kitchen observation on 4/13/21 at 11:10 AM. The findings include: On 4/13/21 at 11:10 AM, an observation was conducted in the dry storage room of the main kitchen. A 16 ounce coffee creamer with the top opened to air was observed on the fourth shelf of the wire cart next to doorway. An interview was conducted on 4/13/21 at 11:15 AM, with OSM (other staff member) #6, the regional director of dietary services. When shown the opened top of the coffee creamer, OSM #6 stated, That should not be opened like that. In the main kitchen, on metal cart there were two spices / seasoning containers that were open to air: 1-gallon [NAME] cooking wine with no top and hole punched in seal and ground nutmeg 16 ounces with container top opened to air. An interview was conducted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, it was determined that the facility staff failed to serve lunch in a manner to promote resident dignity for one of 24 current residents in the survey sample, (Resident # 9). CNA [certified nursing assistant] # 3 was observed standing next to the bed while feeding Resident # 9 the lunch meal. The findings include: Resident # 9 was admitted to the facility with diagnoses that included but were not limited to: stroke and swallowing difficulties. Resident # 9's most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 01/17/2021, coded Resident # 9 as scoring a 3 [three] on the brief interview for mental status (BIMS) of a score of 0 - 15, 3 - being severely impaired of cognition for making daily decisions. Resident # 9 was coded as requiring extensive assistance of one staff member for eating. On 04/13/21, an observation of lunch meals being delivered to resident room revealed Resident # 9 received…

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 it was determined the facility staff failed to ensure services provided or arranged by the facility were in accordance with professional standards of quality for one of five residents in the medication administration observation, (Residents #52). The facility staff failed to administer a generic Symbacort inhaler per the manufacturer's instructions for Resident #52. The findings include: Resident #52 was admitted to the facility on [DATE] with diagnoses that included COPD (chronic obstructive pulmonary disease - general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis) (1), high blood pressure and GERD (gastroesophageal reflux disease - backflow of the contents of the stomach into the esophagus, usually caused by malfunction of the sphincter muscle between the two organs; symptoms include burning pain in the esophagus, commonly known as heartburn). (2) The most recent MDS (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to provide oxygen therapy in a sanitary manner for one of 24 residents, (Resident #46). Resident #46's nasal cannula oxygen tubing was observed wrapped around the oxygen tank with the nasal cannula portion on the floor. The findings include: The facility staff failed to provide oxygen therapy in a sanitary manner for Resident #46. On 4/13/21 at 12:24 PM during initial resident observation and on 4/13/21 at 1:07 PM, Resident #46's nasal cannula oxygen tubing was observed wrapped around the oxygen tank with the nasal cannula portion on the floor. Resident #46 was admitted to the facility on [DATE] with diagnoses that include but are not limited to: Chronic obstructive pulmonary disease (chronic, non-reversible lung disease) (1), dementia (progressive state of mental decline) (2) and COVID-19 (coronavirus pandemic 2019). (3) Resident #46's most recent MDS (minimum data set) assessment, an annual…

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, it was determined that the facility staff failed to post daily nurse staffing information. On 04/13/2021 the facility staff failed to post the daily nurse staffing information. The findings include: On 04/13/2021 observations in the facility's lobby at 10:45 a.m. and 3:55 p.m., on the [NAME] 1 Unit at 3:56 p.m., on the [NAME] 2 Unit at 4:00 p.m. and on the Memory Care Unit at 3:57 p.m., failed to evidence of the daily nurse staffing information. On 04/14/21 at 10:43 a.m., an interview was conducted with CNA (certified nursing assistant) # 2 (the person responsible for posting the daily nurse staffing information). CNA # 2 was asked the process for posting the nurse staffing information. CNA #2 stated they give the staffing for that day to the facility's receptionist every morning either before or after their morning meeting at approximately 9:00 a.m. On 04/14/21 at approximately 11:02 a.m. an interview was conducted with OSM [other staff member] # 8, the facility's receptionist. When asked about the posting of the daily nurse staffing, OSM #…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and facility document review, it was determined that the facility staff failed to label and store medications according to professional standards in one of three observed medication room refrigerators, (Wing 2 [NAME] medication refrigerator). The facility staff failed to label an open date on a opened multidose vial of Afluria Quadrivalent Influenza Vaccine and failed to label an open date on a opened multidose vial of Tuberculin Purified Protein Derivative, in the Wing 2 [NAME] medication refrigerator. The finding include: Observation was made of the [NAME] 2 medication room on [DATE] at 3:31 p.m. accompanied by LPN (licensed practical nurse) #3. A vial of Afluria Quadrivalent Influenza Vaccine (used for the prevention of influenza*) was found in the refrigerator. The vial had been opened. Observation of the vial and the box, it was contained in, failed to reveal any documentation of a date indicating when the vial was opened. When asked about the process staff follows for…

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

Based on observation, staff interview and clinical record review, it was determined that facility staff failed to serve for the lunch meal at a palatable temperature for one of 24 current residents in the survey sample, (Resident # 9). Resident # 9's lunch sat in their room for thirty-three minutes and was not reheated by staff before the meal was fed to the resident. OSM [other staff member] # 6, regional director for dietary services stated that the resident's (Resident #9's) food would have been cold. The findings include: Resident # 9 was admitted to the facility with diagnoses that included but were not limited to: stroke and swallowing difficulties. Resident # 9's most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 01/17/2021, coded Resident # 9 as scoring a 3 [three] on the brief interview for mental status (BIMS) of a score of 0 - 15, 3 - being severely impaired of cognition for making daily decisions. Resident # 9 was coded as requiring extensive assistance of one staff member for eating. On 04/13/21, an observation…

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, it was determined the facility staff failed to maintain infection control practice during the medication administration observation for one of five residents in the medication administration observation, (Resident # 57). During the medication pass observation LPN (licensed practical nurse) #8 dropped a pill on the top of her medication cart, picked the pill up with her bare hands placed it in the cup with the other medications and administered the pill to Resident 57. The findings include: Resident #57 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Alzheimer's disease (a progressive loss of mental ability and function, often accompanied by personality changes and emotional instability.) (1), depression and anxiety (state of mild to severe apprehension, often without specific cause, resulting in body changes such as quickened heartbeat and sweat.) (2). Observation was made on 4/14/2021 at 8:35 a.m.…

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.