Woodmont Center

Based on observation, resident interview, and staff interview, the facility staff failed to provide accommodation of needs for one of ten residents in the survey sample, Resident #6 (R6). The findings include:For Resident #6 (R6), the facility staff failed to maintain the resident's call bell within reach. On 8/25/25 at 3:37 p.m., R6 was observed lying in bed. The resident stated staff answer the call bell, but this can only happen when the call bell is within reach. R6 further stated the call bell is not always within her reach. At this time, R6's call bell was observed on the floor, out of the resident's reach. On 8/25/25 at 3:41 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that when a resident is in bed, the call bell should be placed next to him or her or clipped on him or her, so the call bell is within the resident's reach. R6's call bell was observed with LPN #1. LPN #1 stated the call bell was not within R6's reach. On 8/26/25 at 4:08 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the interim director of…

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

Based on staff interview, clinical record review and facility document review, the facility staff failed to notify the responsible party as required for one of 10 current residents in the survey sample, Resident #8 (R8). The findings include:The findings include: For R8, facility staff failed to notify the responsible party (RP) that medication, Daptomycin (1), was not available for administration on 08/15/2025. R8 was admitted to the facility with diagnoses that included but were not limited to left foot infection. The admission MDS (minimum data set) was not due at the time of the survey. The facility's Clinical Admission assessment for R8 dated 08/14/2025 documented in part, Level of cognitive impairment: b. alert (some forgetfulness). The physician's order for R8 documented in part, Daptomycin Intravenous Solution Reconstituted 500 MG (milligram) (Daptomycin). Use 10 ml (milliliter) intravenously (into a vein) one time a day every other day for left foot gangreen [sic] (2) for 23 Days. Order Date Date:8/15/2025. The EMAR (electronic medication administration record) for R8 dated…

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

Based on observation, staff interview, facility document review, the facility staff failed to maintain a clean and comfortable environment for one of ten residents in the survey sample, Resident #4 The findings include: For Resident #4 (R4), the facility staff failed to maintain the resident's fall mats and floors in a clean and comfortable environment. Observation was made of R4's room on 8/25/25 at 4:02 p.m. The resident was in bed; there were fall mats on both sides of the bed. The fall mats had evidence of liquids having been spilled and the surveyor's shoes stuck to the fall mats. There were bits of paper on both sides of the bed. There were dirt and debris behind the bed and nightstand. On 8/26/25 at 10:59 a.m., an interview was conducted with OSM (other staff member) #5 (the director of environmental services). OSM #5 stated all resident rooms are cleaned every day. OSM #5 stated that in the morning, the cleaning consists of pulling the trash, cleaning surfaces, sweeping, moping, cleaning the bathroom, and replacing toiletries. OSM #5 stated that later in the day, 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, clinical record review, and facility document review, it was determined that the facility staff failed to evidence efforts to resolve a grievance for one of ten residents in the survey sample, Resident #1.The findings include: For Resident #1 (R1), the facility staff failed to evidence efforts to resolve a written grievance sent to the former administrator by R1's responsible party in November 2024. This is cited as past non-compliance with a date of compliance of 5/10/2025.A review of the facility grievances from 1/1/2024 to the present documented one grievance dated 4/13/2024 for care concerns. The grievances failed to evidence any concerns from November 2024.On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/9/2025 the resident was assessed as being severely impaired for making daily decisions. The resident was assessed as being dependent on staff for ADLs (activities of daily living).The resident demographic information documented a family member as the responsible party and health care…

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

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to submit an MDS (minimum data set) assessment in the required timeframe for one of ten residents in the survey sample, Resident #7.The findings include:For Resident #7 (R7), the facility staff failed to submit the admission MDS assessment within fourteen days of admission.Review of the facesheet for R7 documented an admission date of 8/9/2025.Review of the MDS assessments for R7 documented an admission assessment with an ARD (assessment reference date) of 8/15/25 in progress. The assessment failed to show a completion or submission date.On 8/26/2025 at 2:33 p.m., an interview was conducted with LPN (licensed practical nurse) #8, MDS coordinator. LPN #8 stated that the admission MDS was completed and submitted before the fourteenth day after admission. She stated that some of the MDS assessments had gotten behind due to staffing issues.According to the RAI (Resident Assessment Instrument) 3.0 User's Manual Version 1.19.1 October 2024, documented in part,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff/resident interview, clinical record review and facility document review, it was determined that the facility failed to provide an accurate MDS (minimum data set) assessment for one of nine residents in the survey sample, Resident 105 (R105).The findings include: R105 was admitted to the facility on [DATE] with diagnosis that included but were not limited to muscle wasting/atrophy, sacral pressure ulcer and atrial fibrillation. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 11/8/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring max assist for bathing/transfer/dressing/toileting and supervision for eating; Section H-Bladder and Bowel, H0100. Appliances- A. Indwelling catheter was coded as 'yes'. A review of 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 clinical record review, staff interview and facility document review, the facility staff failed to develop and implement a baseline care plan for two of 10 residents in the survey sample, Resident #2 (R2) and R7. The findings include:1. For R2, facility staff failed to develop a baseline care plan for oral hygiene. R2 was admitted to the facility with diagnoses that included but were not limited to muscle weakness. On the most recent MDS (minimum data set), a 5 (five)-Day assessment with an ARD (assessment reference date) of 02/12/2024, R2 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. The baseline care plan for R2 dated 02/09/2024 documented, “Focus: Resident has COVID 19 (coronavirus disease 2019) infection. Date Initiated: 02/09/2024. Created on: 02/09/2024.; Resident/Patient requires assistance/is dependent for mobility related to: Date Initiated: 02/09/2024. Created on: 02/09/2024.” On 08/27/2025 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 that the facility staff failed to provide care and services to promote healing of a pressure injury for two of 10 residents in the survey sample, Residents #1 and #7.The findings include:1. For Resident #1 (R1), the facility staff failed to provide pressure injury (1) treatment as ordered for dates in January and February 2025.On the most recent MDS, a quarterly assessment with an ARD (assessment reference date) of 1/9/2025, the resident was assessed as being severely impaired for making daily decisions. R1 was assessed as having one Stage II pressure injury and two unstageable pressure injuries.The physician orders for R1 documented in part,- Venelex External Ointment (Balsam Peru Castor Oil) Apply to sacrum topically every day and evening shift for wound to sacrum. Start Date: 11/22/2024.- Calcium Alginate-Silver External Pad 4 (Calcium Alginate-Silver) Apply to Left Gluteus topically every day shift for Wound.…

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 clinical record review, facility staff failed to provide care and services for an indwelling catheter for one of ten residents in the survey sample, Resident #8 (R8). The findings include:For R8, the facility staff failed to keep the catheter collection bag (1) off the floor. R8 was admitted to the facility with diagnoses that included but were not limited to urinary retention (2). The admission MDS (minimum data set) was not due at the time of the survey. The facility's Clinical Admission assessment for R8 dated 08/14/2025 documented in part, Level of cognitive impairment: b. alert (some forgetfulness). On 08/26/2025 at approximately 8:18 a.m. observation of R8's catheter collection bag revealed it was lying flat on the floor next to R8's bed. The physician's order for R8 documented, Indwelling catheter (3)16FR (French) with 10cc (cubic centimeter) balloon to bedside straight drainage for diagnosis/Hx (history) of urinary retention. Order Date Date:8/14/2025. The comprehensive care plan for R8 dated 08/19/2025 documented in part, Focus. Resident requires…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to maintain a complete and accurate medical record for one of ten residents in the survey sample, Resident #1.The findings include:For Resident #1 (R1), the facility staff failed to maintain an accurate medical record.Review of R1's clinical record documented a discharge date of [DATE].The progress notes for R1 documented in part,- [DATE] 07:40 Note : Significant change to reflect hospice closed due to resident death on 2/21.- [DATE] 20:15 (8:15 p.m.) Date of Service: 2025-03-12, Visit Type: Advanced care planning, Details: Chief complaint: ACP (advanced care planning) discussion w/ RP (responsible party), daughter in presence of DON (director of nursing) as res (resident) continues to decline. Res is seen for overall decline in condition and has been hospitalized 5 times this year for various issues of PVD (peripheral vascular disease), anemia, AMS (altered mental status), wound…

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 that the facility staff failed to store, prepare and serve food in a sanitary manner in one of one facility kitchens and two of two facility unit pantries. The findings include: On 1/23/23 at 10:45 AM the kitchen tour was conducted with OSM #1 (Other Staff Member), the dietary manager. The following items were identified: 1. In the dry storage area: trash was on the floor, a plastic cup was on the floor, the floor was sticky, a dry cereal bag was open and exposed. 2. In the refrigerator: A facility generic plastic storage container of fudge was observed and expired on 1/13/23. A block of cheese in a plastic bag, was not sealed. 3. Equipment: The large standing mixer was clean and ready for use, and covered by a plastic bag, however crumbs were in the mixer bowl. 4. In the 2 facility unit pantries: The refrigerators and freezers were dirty, with dripped, sticky food residue. On 1/24/23 at 8:24 AM, an interview was conducted with OSM #1. She stated that the dietary staff are going to clean the unit…

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

Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement the comprehensive care plan for 4 of 29 residents in the survey sample; Residents #47, #43, #4, and #51. The findings include: 1. For Resident #47, the facility staff failed to implement the comprehensive care plan to ensure that physician-ordered fall mat(s) were in place. A review of the physician's orders revealed one dated 5/11/22 for Floor mat while in bed. A review of the comprehensive care plan revealed one dated 3/7/22 for Resident has had actual fall and is at risk for further falls r/t (related to) cognitive loss, lack of safety awareness, Impaired mobility, impulsivity. This care plan included an intervention dated 3/7/22 for Fall mat(s) Indicate Number/side(s). Observations of Resident #47 on 1/23/23 at 12:29 PM and 2:04 PM and on 1/24/23 at 11:15 AM, all revealed Resident #47 in the bed. There were no fall mats down and no evidence of fall mats present in the room for Resident #47. On 1/24/23 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.

Based on staff interview, facility document review and clinical record review, the facility staff failed to review and revise the comprehensive care plan for three of 29 residents in the survey sample, Residents #49, #11 and #78. The findings include: 1. a. For Resident #49 (R49), the facility staff failed to review and revise the resident's comprehensive care plan after R49 inappropriate touched a female resident's breast. On the most recent MDS (minimum data set), a significant change in status assessment with an ARD (assessment reference date) of 12/5/22, the resident scored 10 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately cognitively impaired for making daily decisions. A nurse's note dated 9/25/22 documented a CNA (certified nursing assistant) observed R49 inappropriately touch a female resident's breast. R49's comprehensive care plan dated 11/11/19 failed to reveal documentation that the care plan was reviewed and revised regarding the event. On 1/24/23 at 3:36 p.m., 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 staff interview, facility document review and clinical record review, it was determined the facility staff failed to periodically review advance directives for two of 29 residents in the survey sample, Residents #51 (R51) and #2 (R2). The findings include: 1. For R51, the facility staff failed to review information for formulating an advance directive with the resident and/or responsible party. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/25/2022, the resident was coded being moderately impaired for making daily decisions. The physician order dated, 12/21/2022, documented, Full Code. The Social Services Assessment and Documentation dated, 11/02/2021, 2/2/2022, 4/29/2022, 5/13/2022, 7/17/2022, and 8/4/2022, documented the following: Patient/resident responsible for self - yes Power of Attorney - Financial - no Conservatorship - no Court-appointed Guardian - no Advance Directives (Living Will, Healthcare Power of Attorney or Healthcare Proxy) in place? - no Additional Conversation regarding advance care…

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

Based on staff interview, facility document review and clinical record review, the facility staff failed to notify the physician of a significant change in health for one of 29 residents in the survey sample, Resident #49. The findings include: For Resident #49 (R49), the facility staff failed to notify the resident's physician of a significant weight loss in December 2022. On the most recent MDS (minimum data set), a significant change in status assessment with an ARD (assessment reference date) of 12/5/22, the resident scored 10 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately cognitively impaired for making daily decisions. A review of R49's clinical record revealed the resident weighed 173.2 pounds on 11/5/22 and 163 pounds on 12/2/22 which indicated a 5.89% loss. An assessment signed by the former RD (registered dietitian) on 12/2/22 documented, Resident triggered for -5.8% weight loss x1 month. Per unit manager, last month resident was not getting out of bed or eating very much. Resident is now at baseline, getting out of 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 staff interview, facility document review and clinical record review, the facility staff failed to implement the facility abuse policy for reporting the final results of an allegation of abuse to the State Agency (SA) for one of 29 residents in the survey sample, Resident #11. The findings include: For Resident #11, the facility staff failed to implement the facility abuse policy for reporting the final results of an allegation of sexual abuse by another resident on 9/24/22. The facility abuse policy documented, 8.2 Report findings of all completed investigations within five (5) working days to the Department of Health . On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/7/22, the resident scored 5 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely cognitively impaired for making daily decisions. A nurse's note dated 9/24/22 documented a CNA (certified nursing assistant) observed a male resident inappropriately touching R11's body. An initial report regarding this event…

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 report the final results of an allegation of abuse to the State Agency (SA) within 5 working days, for one of 29 residents in the survey sample, Resident #11. The findings include: For Resident #11, the facility staff failed to report the final results of an allegation of sexual abuse by another resident on 9/24/22 to the State Agency. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/7/22, the resident scored 5 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely cognitively impaired for making daily decisions. A nurse's note dated 9/24/22 documented a CNA (certified nursing assistant) observed a male resident inappropriately touching R11's body. An initial report regarding this event was submitted to the SA on 9/24/22. The report documented a CNA observed a male resident touching R11's breast area. On 1/24/23 at 12:29 p.m., ASM (administrative staff member) #1 (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, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that bed hold notification was provided when two out of 29 residents in the survey sample were transferred to the hospital; Resident #18 and Resident #11. The findings include: 1. The facility staff failed to evidence provision of bed hold notification at the time of discharge for Resident #18. Resident #18 was transferred to the hospital on 9/29/22 and 11/12/22. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 12/1/22, coded the resident as scoring a 11 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. There was no evidence of bed hold documentation provided to the resident or the resident's responsible party (RP) when the resident was sent to the hospital on 9/29/22 or 11/12/22. On 1/24/23 at 2:30 PM, LPN (licensed practical nurse) #3, the unit manager, stated there were no bed holds for this…

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

Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to develop a baseline care plan for an indwelling urinary catheter (1) for one of 29 residents in the survey sample, Resident #245 (R245). The findings include: For (R245) the facility staff failed to develop a baseline care plan to address the care and service for an indwelling urinary catheter. (R245) was admitted to the facility with diagnoses included but were not limited to benign prostatic hyperplasia (2). The most recent MDS (minimum data set), an admission assessment was not due at the time of the survey. The facility's nurse's note for (R245) dated 12/27/2022 documented in part, .admitted from (Name of Hospital) .Resident has an indwelling foley catheter 20 fr (French). On 01/23/23 at approximately 1:52 p.m., an observation of (R245) revealed they that they were lying in bed and had an indwelling urinary catheter in place. 01/24/23 at approximately 8:31 a.m., an observation of (R245) revealed they that they were lying in bed and had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to obtain weights as ordered for one of 29 residents in the survey sample, Resident #11. The findings include: The facility staff failed to follow physician orders for a weights to be obtained on admission [DATE]), for Resident #11. Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to: pulmonary edema, congestive heart failure and dementia. A review of the comprehensive care plan with a revision date of 1/10/23, revealed, FOCUS: Resident exhibits or is at risk for cardiovascular symptoms or complications related to CVA (cerebrovascular disease), CAD (coronary artery disease), HTN (hypertension), MI (myocardial infarction). Needs stents for blocked artery. INTERVENTIONS: Monitor weight as ordered. A review of the physician orders dated 1/10/23, revealed, Weigh on admission, the next day, then on Mondays for 4 weeks,…

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 implement physician-ordered fall interventions per the plan of care for one of 29 residents in the survey sample; Resident #47. The findings include: For Resident #47, the facility staff failed to ensure fall mat(s) were in place per the physician's order. A review of the physician's orders revealed one dated 5/11/22 for Floor mat while in bed. Observations of Resident #47 on 1/23/23 at 12:29 PM and 2:04 PM and on 1/24/23 at 11:15 AM, all revealed Resident #47 in the bed. There were no fall mats down and no evidence of fall mats present in the room for Resident #47. A review of the comprehensive care plan revealed one dated 3/7/22 for Resident has had actual fall and is at risk for further falls r/t (related to) cognitive loss, lack of safety awareness, Impaired mobility, impulsivity. This care plan included an intervention dated 3/7/22 for Fall mat(s) Indicate Number/side(s). On 1/24/23 at 11:15 AM an interview was conducted with LPN #2…

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, clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide care and services for an indwelling urinary catheter (1) for one of 29 residents in the survey sample, Resident #245 (R245). The findings include: For (R245) the facility staff failed to the facility staff failed to keep the catheter collection bag (2) off the floor and failed to place the catheter collection bag below the level of the bladder. (R245) was admitted to the facility with diagnoses included but were not limited to benign prostatic hyperplasia (3). The most recent MDS (minimum data set), an admission assessment was not due at the time of the survey. The facility's nurse's note for (R245) dated 12/27/2022 documented in part, .admitted from (Name of Hospital) .Resident has an indwelling foley catheter 20 fr (French). On 01/23/23 at approximately 1:52 p.m., an observation of (R245's) catheter collection bag revealed that it was resting on the floor. On 01/24/23 at approximately 8:31 a.m., an observation revealed (R245) lying…

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 per physician's order, for one of 29 residents in the survey sample, Resident #4. The findings include: For Resident #4 (R4), the facility staff failed to administer oxygen at the physician prescribed rate of four liters per minute. On the most recent MDS (minimum data set), a significant change in status assessment with an ARD (assessment reference date) of 12/25/22, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. R4's comprehensive care plan dated 10/20/22 documented, Resident exhibits or is at risk for respiratory complications related to hx (history) of acute hypoxic respiratory failure. O2 (Oxygen) as ordered via nasal cannula . Further review of R4's clinical record revealed a physician's order dated 12/23/22 for continuous oxygen at four liters per minute via nasal cannula. On 1/23/23 at 11:38 a.m. and…

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

Based on observation, resident interview, facility document review and clinical record review, the facility staff failed to provide food to accommodate a resident's preferences for one of 29 residents in the survey sample, Resident #43. The findings include: For Resident #43 (R43), the facility staff failed to provide an egg salad sandwich as listed on the resident's meal ticket during lunch on 1/23/23. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/17/22, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. On 1/23/23 at 11:15 a.m., an interview was conducted with R43. R43 stated they are served items like red meat that they are not supposed to have due to a diagnosis of pancreatitis, and are not served the items listed on the meal ticket that is served with the meal tray. On 1/23/23 at 12:33 p.m., R43's meal tray was observed. The meal ticket documented an egg salad sandwich was to be on the tray; however,…

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 employee record review, it was determined that the facility staff failed to evidence maintenance of required certification for one of 25 employee record reviews. The facility staff failed to provide the evidence of required certification for one CNA (certified nursing assistant) that was hired within the last two years, CNA #2. The findings include: On 1/24/23 at 1:10 PM a review of nursing staff licenses and certifications was conducted an revealed that CNA #2 with a date of hire of 3/1/22 did not have their certification verified through the Department of Health Professions (DHP) until 1/23/23. OSM (other staff member) #2, the workforce manager stated there was no other certification pulled in her file until yesterday, when it was pulled [verified]. On 1/24/23 at 4:35 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the market clinical lead was made aware of the findings. According to the facility's Licensure and Certification of Personnel policy revised 7/1/22, revealed…

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

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure a complete and accurate clinical record for one of 29 residents in the survey sample; Resident #78. The findings include: For Resident #78, the facility staff failed to document the event details (where, how, why) of a fall on 12/14/22. A review of the clinical record revealed the following notes: 12/14/22: An SBAR (Situation, Background, Assessment, Recommendation) note documented that the resident had a fall. The form documented the resident had no pain and no changes in skin (for possible injuries) by checking off a box next to pain (no) and a box under skin next to no skin changes. However, there was no documentation that described the events of the fall (where, how, why). The section for Appearance: Summarize your observations and evaluation was left blank. In addition, the section Nursing Notes was left blank. On 1/24/23 at 2:15 PM, an interview was conducted with LPN #2 (Licensed Practical Nurse) She stated that a note should be documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide written notification to the resident and/or resident representative and ombudsman, upon transfer to the hospital for eight of 31 residents in the survey sample, (Resident #29, Resident #38, Resident #26, Resident #25, Resident #43, Resident #71, Resident #91 and Resident #81). The facility staff failed to evidence that a written notification was provided to the resident and or the resident representative and ombudsman upon hospital transfers for Resident #29, Resident #38, Resident #26, Resident #25, Resident #43, Resident #71, Resident #91 and Resident #81 The findings include: 1. The facility staff failed to provide Resident # 29 and Resident # 29's representative and the ombudsman written notification of a facility-initiated transfer on 04/05/2021 for Resident # 29. Resident #29 was admitted to the facility on [DATE]. Resident #29's diagnoses included but were not limited…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide a written bed hold notice prior to an or upon a facility initiated transfer for eight of 31 residents in the survey sample, Resident #29, Resident #38, Resident #26, Resident #25, Resident #43, Resident #71, Resident #91 and Resident #81. The findings include: 1. Resident #29 was admitted to the facility on [DATE]. Resident #29's diagnoses included but were not limited to: diabetes mellitus (inability of insulin to function normally in the body) (1), end stage renal disease (end stage of renal failure-inability of the kidneys to excrete wastes and function in the maintenance of electrolyte balance) (2) and chronic obstructive pulmonary disease (chronic, non-reversible lung disease) (3). Resident #29's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 6/4/21, coded the resident as scoring 07 out of 15 on the BIMS (brief…

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 the facility staff failed to implement bed rail requirements for four of 31 residents in the survey sample, Residents # 68, #252, #250 and # 92. The findings include: 1. The facility staff implemented bed rails for Resident #68 without a documented need and failed to obtain informed consent for the use of bed rails. Resident #68 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: fracture of hip, high blood pressure and diabetes. The most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 7/16/2021, coded Resident #68 as scoring a 12 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired to make daily cognitive decisions. In Section G the resident was coded for bed mobility as the activity did occur but only once or twice with the assistance of two or more staff…

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 that the facility staff failed to store food in a sanitary manner. The facility staff failed to discard two (five pound) plastic containers of low fat cottage cheese with a manufacturer's best if used by date of 7/31/21, failed to cover and label a metal pan of mixed vegetables with broccoli, cauliflower and carrots, and failed to ensure a scoop was not stored in a bin of flour. The findings include: On 8/16/21 at 10:35 a.m., a tour of the facility kitchen was conducted with OSM (other staff member) #1 (dietary manager. The following was observed: -In the walk in refrigerator: two (five pound) plastic containers of low fat cottage cheese with a manufacturer's best if used by date of 7/31/21. -In the walk in freezer: a metal pan of mixed vegetables with broccoli, cauliflower and carrots that was not covered or labeled. -In the dry storage room: a scoop sitting in flour within the flour bin. In regards to the cottage cheese, OSM #1 stated he follows manufacturers' best if used by dates and the…

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

Based on staff interview and facility document review, it was determined that the facility staff failed to maintain an effective Quality Assurance program. The findings include: On 08/17/2021 at approximately 8:00 a.m., a review of the facility's QAPI [quality assurance performance improving] Committee Meeting Sign-In Sheets dated October 2020 through December 2020, January 2021 through March 2021 and April 2021 through June 2021 were reviewed. The QAPI sign-in sheets listed above failed to evidence the signature of the facility's medical director. On 08/17/2021 at approximately 9:09 a.m., an interview was conducted with ASM [administrative staff member] # 1, center executive director regarding the missing signature of the medical director for the dates listed above. When asked how the members of the QAPI committee were notified of the meet times and dates, ASM # 1 stated they send out a Zoom invitation [allows you to send invites by email, contact or phone number] to all members. When asked about the missing signature of the medical director, ASM # 1 stated that the medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to implement the facility policies for advanced directives one of 31 residents in the survey sample, Resident #251. The facility staff failed to evidence documentation Resident #251 was provided an opportunity formulate an advance directive and failed to verify the residents wishes with the regards to the residents code status (full code [the decision if the resident would like to have cardiopulmonary resuscitation in the event their heart stops or they stop breathing), or DNR [do not resuscitate]) upon admission. The findings include: Resident #251 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: encephalopathy (any brain disease or disorder.) (1), alcohol use, alcoholic cirrhosis of the liver (chronic disease condition of the liver in which fibrous tissue and modules replace normal tissue, interfering with blood flow and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to develop a baseline care plan to address physician ordered antianxiety medication for one of 31 residents in the survey sample, Resident #252. The findings include: Resident #252 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: COPD (chronic obstructive pulmonary disease - general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis) (1), lung cancer, high blood pressure and diabetes. A MDS (minimum data set) assessment had not yet been completed prior to and during the time of survey. The Nursing Documentation dated 8/10/2021 at 9:17 p.m. documented in part, Reason for note: admission/readmission. Under question 3. Additional details about the note, the following was documented, Pt (patient) is A&O (alert and oriented) X4 (person, place time and situation). The form further documented,…

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, it was determined that the facility staff failed to implement the comprehensive care plan for three of 31 residents in the survey sample, Residents #81, #250 and #252. The facility staff failed to implement the comprehensive pain care plans for Residents #81, #250 and #252. The facility staff failed to assess the pain location, intensity and pain level rating and failed to attempt/ provide non-pharmacological pain interventions prior to administering physician prescribed as needed pain medications to Residents: #81, #250 and #252. The findings include: 1. Resident #81 was admitted to the facility on [DATE] with the most recent readmission on [DATE], with diagnoses that included but were not limited to: anemia (condition in which the hemoglobin content of the blood is below normal limits) (1), diabetes, high blood pressure, congestive heart failure (abnormal condition characterized by circulatory congestion and retention of salt and water by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to review and revise the comprehensive care plan for one of 31 residents in the survey sample, Residents #30 and #87. The facility staff failed to review and revise Resident #30's comprehensive care plan when the resident fell on 6/8/21, 7/17/21 and 8/3/21. The findings include: Resident #30 was admitted to the facility on [DATE]. Resident #30's diagnoses included but were not limited to high blood pressure, major depressive disorder and muscle weakness. Resident #30's quarterly minimum data set assessment with an assessment reference date of 6/2/21, coded the resident's cognitive skills for daily decision making as severely impaired. Review of Resident #30's clinical record revealed the resident sustained falls without injury on 6/8/21, 7/17/21 and 8/3/21. Interventions were implemented to prevent future falls. Review of Resident #30's comprehensive care plan initiated on 2/1/21 failed…

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, and during the course of a complaint investigation it was determined the facility staff failed to ensure the provision of care per professional standards for one of 31 residents in the survey sample, Resident #81. The facility staff failed obtain physician orders for treatment of Resident #81's left ankle pressure injury for prior to performing the treatment. The findings include: Resident #81 was admitted to the facility on [DATE] with the most recent readmission on [DATE], with diagnoses that included but were not limited to: anemia (1), diabetes, high blood pressure, congestive heart failure (2), COPD (chronic obstructive pulmonary disease) (3), and leukemia (4). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 8/7/2021, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was capable of making…

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, clinical record review, and in the course of a complaint investigation, it was determined the facility staff failed to provide treatment and services consistent with professional standards of practice, to promote healing, prevent infection of pressure injuries for one of 31 residents in the survey sample, Resident #81. A. The facility staff failed to administer treatment to Resident #81's pressure injuries in a manner to prevent infection, and performed dressing changes to a pressure injury without a physician order. B. The facility staff failed to administer treatments per the physician order for Resident #81. The findings include: A. Resident #81 was admitted to the facility on [DATE] with the most recent readmission on [DATE], with diagnoses that included but were not limited to: anemia (1), diabetes, high blood pressure, congestive heart failure (2), COPD (chronic obstructive pulmonary disease) (3), and leukemia (4). The most recent MDS…

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, facility document review and clinical record review, it was determined the facility staff failed to provide respiratory care consistent with professional standards for three of 31 residents, Resident #19, Resident #25 and Resident #252. The facility staff failed to store Resident #19 and Resident #25's nasal cannula oxygen tubing in a sanitary manner when not in use, Resident #19's and #25's nasal cannula oxygen tubing laying over the oxygen concentrators uncovered when not in use and the facility staff administered oxygen to Resident #252 without a physician's order. The findings include: 1. The facility staff failed to ensure Resident #19's nasal cannula tubing was stored in a sanitary manner when not in use. Resident #19 was admitted to the facility on [DATE]. Resident #19's diagnoses included but were not limited to: congestive heart failure (circulatory congestion characterized by circulatory congestion and retention of salt and water by the kidneys) (1),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review and clinical record review it was determined the facility staff failed to ensure implementation of a complete pain management program for three of 31 residents in the survey sample, Residents # 252, # 81, and # 250. The facility staff failed to assess the location of pain, pain level/intensity and failed to attempting/ offering non-pharmacological interventions prior to administering as needed narcotic pain medications to Resident #252, #81 and #250 on multiple dates in August 2021. The findings include: 1. Resident #252 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: COPD (chronic obstructive pulmonary disease - general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis) (1), lung cancer, high blood pressure and diabetes. There was no MDS (minimum data set) assessment completed during the time of survey. The Nursing Documentation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide dialysis services, consistent with professional standards of practice, the comprehensive person-centered care plan for two of 31 residents, Resident #29 and Resident #38. The facility staff failed to evidence of ongoing communication and collaboration with the dialysis facility for eight dialysis dates during May, June, and July 2021, for Resident #29 and for six dialysis dates during May and June 2021, for Resident #38. The findings include: 1. Resident #29 was admitted to the facility on [DATE]. Resident #29's diagnoses included but were not limited to: diabetes mellitus (inability of insulin to function normally in the body) (1), end stage renal disease (end stage of renal failure-inability of the kidneys to excrete wastes and function in the maintenance of electrolyte balance) (2) and chronic obstructive pulmonary disease (chronic, non-reversible lung disease) (3). 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure one of 31 residents was free of unnecessary psychotropic medications, Resident #252. There was no documentation as to why the medication Ativan was administered and no documentation any non-pharmacological interventions were attempted or provided prior to the administration of the medication to Resident #252. The findings include: Resident #252 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: COPD (chronic obstructive pulmonary disease - general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis) (1), lung cancer, high blood pressure and diabetes. A MDS (minimum data set) assessment had not yet been completed during the time of survey. The Nursing Documentation dated 8/10/2021 at 9:17 p.m. documented in part, Reason for note: admission/readmission. Under…

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

Based on observation and staff interview, it was determined that the facility staff failed to maintain the dumpster area in a sanitary manner. The facility staff failed to close the sliding doors on the facility's two dumpsters and maintain the area behind the dumpsters free of trash. The findings include: On 02/05/19 at 2:27 p.m., an observation of the facility's dumpsters was conducted with OSM (other staff member) # 7, dining services manager and OSM # 1, director of environmental services. The facility had two dumpsters located behind the facility on a concrete pad. Behind the dumpsters was a lawn area with small shrubs. Observation of both dumpsters revealed one sliding door located on the side was open on each dumpster. Further observation of the lawn area behind the two dumpsters revealed the following: approximately three old clear plastic trash bags, approximately four soda cans and bottles, a clear old plastic trash bag hanging from a branch in one of the shrubs. Approximately 24 plastic bowl covers, numerous pieces of paper, several Styrofoam cups, several plastic spoons…

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 that the facility staff failed to provide a dignified dining experience for fifteen of 55 residents in the survey sample; Residents #74, #13, #34, #62, #500, #36, #59, #49, #48, #55, #33, #24, #8, #40, and #61. 1. The facility staff failed to provide a dignified dining experience for Residents #74, #13, #34, #62, #500, #36, #59, #49, #48, #55, and #33. Residents were observed sitting at three tables in the small café dining room without food while another resident at the table was served their meal and eating. 2. The facility staff failed to provide a dignified dining experience for Resident #8 and Resident #24. The facility staff failed to address Resident #97's loud cursing at staff for approximately 29 minutes, during which time Resident #8 and #24 both expressed a dislike of Resident #97's cursing. 3. The facility staff failed to serve Resident #40 lunch on 2/5/19 at the same time her roommate…

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 develop and implement the comprehensive care plan for eight of 55 residents in the survey sample, Resident #50, #52, #97, #7, #99, #309, #71, and #29. 1. The facility staff failed to develop a comprehensive care plan regarding Resident #50's mail delivery. 2. The facility staff failed to implement the comprehensive care plan for the administration of oxygen for Resident #52. 3. The facility staff failed to develop a behavior care plan for Resident #97 to address the residents cursing. 4. The facility staff failed to follow Resident # 7's comprehensive care plan for the placement of the call bell. 5. The facility staff failed to develop a comprehensive care plan for Resident # 99's tube feeding and tracheostomy care. 6. The facility staff failed to develop a comprehensive care plan for Resident # 309's oxygen. 7. The facility staff failed to implement 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to review and/or revise the comprehensive care plan for six out of 55 residents in the survey sample; Residents #39, #31, #15, #35, #1, and #309. 1. The facility staff failed to evidence that Resident #39's comprehensive care plan was reviewed and/or revised after a fall on 11/8/18, 12/24/18, 1/1/19, 1/6/19, and 2/3/19. 2. The facility staff failed to evidence that Resident #31's comprehensive care plan was reviewed and/or revised after a fall on 1/18/19. 3. The facility staff failed to evidence that Resident #15's comprehensive care plan was reviewed and/or revised after a fall on 1/28/19. 4. The facility staff failed to evidence that Resident #35's comprehensive care plan was updated to include the resident's behaviors of going on leave of absences from the facility unsupervised, and his non-compliance with returning within the specified 4-hour window as ordered. 5. 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.

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 follow physician's orders and professional standards of practice for one of 55 residents in the survey sample, Residents #71. The facility staff failed to administer the medication Advair to Resident #71 per physician's order on multiple dates in November 2018 and January 2019. The findings include: The facility staff failed to administer the medication Advair (1) to Resident #71 per physician's order on multiple dates in November 2018 and January 2019. Resident #71 was admitted to the facility on [DATE]. Resident #71's diagnoses included but were not limited to chronic obstructive pulmonary disease (2), low back pain and anxiety disorder. Resident #71's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/8/19, coded the resident as being cognitively intact. Review of Resident #71's clinical record revealed 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 staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide care and services for the treatment of a pressure injury for one of 55 residents in the survey sample, Resident #29. The facility staff failed to provide Resident #29's pressure injury treatment as prescribed by the physician on multiple dates in October 2018 and November 2018. The findings include: Resident #29 was admitted to the facility on [DATE]. Resident #29's diagnoses included but were not limited to urinary tract infection, arthritis and abnormal posture. Resident #29's most recent MDS (minimum data set), a 30 day Medicare assessment with an ARD (assessment reference date) of 11/21/18, coded the resident's cognition as moderately impaired. Section G coded Resident #29 as requiring extensive assistance of one staff with bed mobility, toilet use and personal hygiene. Section M coded Resident #29 as having one stage three pressure injury (1) that was present upon…

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 that the facility staff failed to ensure that four of 55 residents in the survey sample (Resident #35, 31, #15 and #39) were provided a safe enviorment and adequate supervision to prevent potential accidents, injuries, or harm. 1. The facility staff failed to ensure Resident #35 was assessed to determine if the resident was able to go out into the community unsupervised safely, and allowed the resident to have unsupervised, unmonitored leaves of absences, alone, without a friend of family with him, putting him at risk of potential accidents, injuries. Resident #35 was documented as being excessively late returning to the facility at times and did not have a cell phone so the facility could contact him to check on his safety, and was documented as contacting the facility on 2 occasions in which he did not have a ride or money to return to the facility late at night. 2. Resident #31 sustained a fall 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, facility document review and clinical record review, it was determined that the facility staff failed to provide respiratory care and services according to physician's order for four of 55 residents in the survey sample, Residents #1, #51, #52 and #309. 1. The facility staff failed to administer oxygen to Resident #1 at two liters per minute, per physician's order. 2. The staff failed to discontinue Resident #51's oxygen per physician's order. 3. The facility staff failed to provide respiratory services according to the physicians order for Resident #52. 4. The facility staff failed to administer Resident # 309's oxygen according to the physician's orders. The findings include: 1. The facility staff failed to administer oxygen to Resident #1 at two liters per minute, per physician's order. Resident #1 was admitted to the facility on [DATE]. Resident #1's diagnoses included but were not limited to low back pain, bladder cancer and high blood pressure. Resident #1's most…

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

Based on staff interview and facility document review, it was determined the facility staff failed to conduct annual performance reviews for 10 of 23 CNAs (certified nursing assistants) who were employed for at least one year. The facility staff failed to complete annual performance reviews for CNA #1, CNA #2, CNA #3, CNA #4, CNA #5, CNA #6, CNA #7, CNA #8. CNA #9, and CNA #10. The findings include: On 2/6/19 at approximately 9:00a.m., a request for the annual performance reviews and associated training's for the CNAs was made to ASM (administrative staff member) #2, the nurse executive. On 2/6/19 at 5:30 p.m., a second request made for the annual performance reviews and associated training's for the CNAs to ASM #2, ASM #1, the executive director, and ASM #3, the clinical quality specialist. On 2/7/19 at 9:41 a.m., ASM #2 informed this surveyor that the facility could not find any performance reviews. When asked where they would be located, ASM #2 stated in the HR (human resources) files. ASM #2 stated, We searched the files last night and can't find anything. CNA #1 was hired on…

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

Based on observation, staff interview, and facility document review it was determined that the facility staff failed to store, prepare and serve food in a sanitary manner. 1. The facility staff failed to label containers of tartar sauce and sour cream with a use-by date. 2. The facility staff failed to maintain a mixer and meat slicer in a clean and sanitary manner. 3. The facility staff failed to keep used alcohol swabs off the food-preparation sheet pan and place clean soup bowls on a clean surface before serving. The findings include: 1. The facility staff failed to label containers of tartar sauce and sour cream with a use-by date. On 02/05/19 at 9:15 a.m., an observation of the kitchen was conducted with OSM (other staff member) # 7, dining services manager. Observation of the inside of the reach-in refrigerator revealed a tray with 12 small plastic containers with approximately two ounces of tartar sauce in each container and three plastic containers with approximately two ounces of sour cream in each one. Further observation of the tray of containers failed to evidence 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 staff interview, facility document review, and clinical record review and in the course of a complaint investigation, it was determined the facility staff failed to maintain a complete and accurate clinical record for four of 55 residents in the survey sample, Residents #312, # 35, #39 and #31. 1. The facility staff inaccurately documented Resident 312's comprehensive care plan with a diagnosis of dementia. 2. The facility staff failed to ensure an accurate clinical record for the administration of medications to Resident #35. The facility staff documented two medications were administered to Resident #35 at 8:00 p.m., on 8/30/18 and 10/3/18, when the clinical record documented the resident was out of the facility. 3. The facility staff failed to evidence that the clinical record documented the details of Resident #39's fall on 11/8/18, 12/24/18, 1/1/19, 1/6/19, and 2/3/19. 4. The facility staff failed to evidence that the clinical record documented the details of Resident #31's falls on 12/7/18 and…

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

Based on staff interview and facility document review, it was determined the facility staff failed to provide the required annual in-service training's for 10 CNAs (certified nursing assistants) who were employed for at least one year. The facility staff failed to provide the required annual 12 hours and/or dementia management training's for CNA #1, CNA #2, CNA #3, CNA #4, CNA #5, CNA #6, CNA #7, CNA #8, CNA #9, and CNA #10. The findings include: On 2/6/19 at approximately 9:00 a.m., a request was made to administrative staff member (ASM) #2, the nurse executive, for the training transcripts, for all CNAs who were employed at the facility for at least one year. For six of the above listed CNAs, an In-service Record was provided. The following was documented: CNA #2 - last training's completed - 1/5/18 CNA # 3 - last training's completed - 1/5/18 CNA # 1 - last training's completed - 1/8/18 CNA #6 - last training's completed - 1/5/18 CNA # 7 - last training's completed - 1/8/18 CNA # 9 - last training's completed - 1/8/18. There were no training records for CNA #4, CNA #5, CNA #8 and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, resident interview and clinical record review, it was determined that the facility staff failed to provide accommodation of resident needs for one of 55 residents in the survey sample, Resident # 7. The facility staff failed to ensure Resident #7's call bell (a device with a button that can be pushed to alert staff when assistance is needed), was within the resident's reach. The findings include: Resident # 7 was admitted to the facility on [DATE] with diagnoses that included but were not limited to lack of coordination, rheumatoid arthritis (1), Alzheimer's disease (2), gastroesophageal reflux disease (3) and hypertension (4). Resident # 7's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 10/20/18, coded Resident # 7 as scoring an eight on the brief interview for mental status (BIMS) of a score of 0 - 15, eight - being moderately impaired of cognition for making daily decisions. Resident # 7 was coded as requiring…

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 clarify a physician's order for code status for one of 55 residents in the survey sample, Resident #26. The facility staff failed to ensure Resident #26's current active physician's order form signed by the physician on 2/5/19 contained the resident's code status (whether or not to perform cardiopulmonary resuscitation in the event of cardiac arrest). The findings include: Resident #26 was admitted to the facility on [DATE]. Resident #26's diagnoses included but were not limited to fractured vertebra, acute kidney failure and urinary tract infection. Resident #26's most recent MDS (minimum data set), a 30 day Medicare assessment with an ARD (assessment reference date) of 11/25/18, coded the resident's cognition as severely impaired. Review of Resident #26's clinical record revealed a Virginia Department of Health Durable Do Not Resuscitate Order form dated 2/5/18. Resident #26's comprehensive care plan dated…

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

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 notify and consult with the physician regarding a possible need to alter treatment for two of 55 residents in the survey sample, Resident #71, and #35. 1. The facility staff failed to notify Resident #71's physician when the resident's medication Advair was not administered on multiple dates in November 2018 and January 2019. 2. The facility staff failed to evidence the physician was notified, consulted regarding, the need to administer prescribed medications to Resident #35 late, when the resident returned to the facility late, over an hour past the scheduled time for the 8:00 p.m., administration of two medications on 8/30/18 and 10/3/18. The findings include: 1. Resident #71 was admitted to the facility on [DATE]. Resident #71's diagnoses included but were not limited to chronic obstructive pulmonary disease (2), low back pain and anxiety disorder. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility policy review and clinical record review, it was determined the facility staff failed to ensure resident mail was received unopened for one of 55 residents in the survey sample, Resident #50. The facility staff failed to ensure Resident #50 received unopened mail. The findings include: Resident #50 was admitted to the facility on [DATE]. Diagnosis included but were not limited to: high blood pressure, depression, chronic obstructive pulmonary disease (1) and obstructive sleep apnea (2). The most recent MDS (minimum data set), an annual assessment, with an assessment reference date of 7/24/18, coded the resident as having a score of 15 of 15 on the BIMS (brief interview for mental status) indicating the resident was cognitively intact to make daily decisions. On 02/05/19 at approximately 11:09 a.m., an interview was conducted with Resident #50. Resident #50 was asked if he felt the facility offered him privacy. Resident #50 replied, For the most part. 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 staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement the facility abuse policy for three of 55 residents in the survey sample, Residents #3, #261 and #262. 1. The facility staff failed to implement the facility abuse policy for reporting Resident #3's allegation of abuse to the state agency within the required two-hour timeframe. 2. The facility staff failed to implement the facility abuse policy for reporting Resident #261's and Resident #262's allegations of abuse to the SA (state agency) within the required two-hour timeframe. On 9/23/18, Resident #261 reported an allegation of abuse to RN (registered nurse) #11. The allegation was not reported to the SA until 9/24/18. On 9/22/18, Resident #262 reported an allegation of abuse to CNA (certified nursing assistant) #9. The allegation was not reported to the SA until 9/24/18. Both allegations were submitted to the SA in one FRI (facility reported incident) on 9/24/18. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to report allegations of abuse to the SA (state agency) within a timely manner for three of 55 residents in the survey sample, Residents #3, #261 and #262. 1. The facility staff failed to report Resident #3's allegation of abuse to the SA within the two-hour timeframe. Resident #3's allegation of abuse was reported to staff on 1/17/19 and was not reported to the SA until 1/18/19. 2. The facility staff failed to report Resident #261's and Resident #262's allegations of abuse to the SA within the two-hour timeframe. Resident #261's allegation of abuse was reported to staff on 9/23/18 and was not reported to the SA until 9/24/18. Resident #262's allegation of abuse was reported to staff on 9/22/18 and was not reported to the SA until 9/24/18. Both allegations were submitted to the SA in one FRI (facility reported incident) on 9/24/18. The findings include: 1. The facility staff failed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to evidence that required documentation was sent with residents to the Hospital at the time of transfer, for three of 55 residents, Residents #208, #90, and #51. 1. The facility staff failed to evidence that Resident #208's comprehensive care plan goals were sent with the resident to the hospital at the time of the facility-initiated transfer on 05/25/2018. 2. The facility staff failed provide required documentation to a receiving provider for Resident #90's facility initiated hospital transfer dated 11/28/18 and 1/5/18. 3. The facility staff failed to provide evidence that all required information (including physician contact information, resident representative contact information, special instructions for ongoing care, advance directives and comprehensive care plan goals) was provided to the hospital staff when Resident #51 was transferred to the hospital on 1/24/19. The Findings Included: 1. 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 clinical record review, staff interview and review of facility documentation the facility staff failed to ensure professional standards for the administration of medications for one resident (Resident #35) in the survey sample of 55 residents. The facility staff failed to evidence the physician was notified, consulted and that orders were obtained to administer two medications late to Resident #35, when the resident returned to the facility late, over an hour past the scheduled time for administering two prescribed medications. The facility staff initialed/documented two 8:00 p.m., schedule medications as administered when the clinical record documented the resident was out of the facility on 8/30 and 10/3/18. The findings include: Resident #35 was admitted to the facility on [DATE] with the diagnoses of but not limited to hip fracture, atrial fibrillation, high blood pressure, falls, inguinal hernia, and cardiomyopathy. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility documentation review, facility staff failed to ensure one resident, Resident #61, was free of unnecessary psychotropic medications. Resident #61 had a PRN (as-needed) order for Lorazepam (1) more than 14 days old and with no stop date. The Findings Included: Resident #61 was admitted on [DATE]. Her diagnoses included Hyperlipidemia (high levels of fat/cholesterol in the blood), Anxiety, Alzheimer's disease (2), and Dementia. Resident #61's most recent Minimum Data Set (MDS) Assessment was a 14-Day Assessment with an Assessment Reference Date (ARD) of 01/01/2019. Resident #61 was scored as a 5 on the Brief Interview for Mental Status (BIMS), indicating severe impairment. Resident #61 was coded as requiring total assistance of two or more people for transfers and toileting; total assistance of one person for ambulation; extensive assistance of two or more people for dressing, and as requiring extensive assistance of one person for eating, bed mobility,…

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.