Gainesville Health And Rehab Center

Based on observation, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to provide respiratory care and services for one of 46 residents in the survey sample, Resident #11. The findings include: For Resident #11 (R11), the facility staff failed to maintain the physician ordered oxygen flow rate at two liters per minute. Resident #11 was admitted to the facility with diagnoses that included but were not limited to: congestive heart failure (1). On 02/27/2023 at approximately 12:39 p.m., an observation of (R11) revealed they were lying in bed receiving oxygen via nasal cannula. Observation of the flow meter on the oxygen concentrator revealed a flow rate between three-and-a-half and four liters per minute. On 02/27/2023 at approximately 3:52 p.m., an observation of (R11) revealed they were lying in bed receiving oxygen via nasal cannula. Observation of the flow meter on the oxygen concentrator revealed a flow rate between three-and-a-half and four liters per minute. On 02/28/2023 at approximately 8:54 a.m., an…

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

Based on resident interview, clinical record review, staff interview and facility document review it was determined that the facility staff failed to provide a complete pain management program including implementation of non-pharmacological interventions prior to the administration of as needed pain medications for one of 46 residents in the survey sample, Resident #58. The findings include: For Resident #58 (R58), the facility staff failed to evidence implementation of non-pharmacological interventions prior to administration of the as needed pain medication, Percocet (1). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/15/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. Section J documented R58 receiving as needed pain medications and not receiving non-medication interventions for pain. Section N documented R58 receiving Opioid medications 2 of the 7 days during the assessment period. 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, facility document review, and clinical record review, it was determined the facility staff failed to follow the assessment for the use of side rails for one of 46 residents in the survey sample, Resident #165. The findings include: For Resident #165 (R165), the facility staff had side rails up while the resident was in bed, however the bed/side rail evaluation indicated no bed rails were required. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/22/2022, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score indicating the resident was not cognitively impaired for making daily decisions. In Section G - Functional Status, R165 was coded as requiring extensive assistance of one staff member for moving in the bed and extensive assistance of two staff member for transfers. On 2/27/2023 at approximately 12:00 p.m. R165 was observed in their bed with both side rails up at that time. A second observation was made on 2/27/2023 at 3:12 p.m. R165 was in…

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

Based on resident interview, clinical record review, staff interview and facility document review, it was determined the facility staff failed to store medications in a secure manner for one of 46 residents in the survey sample, Resident #71. The findings include: The facility failed to secure medications for Resident #71 (R71). On 2/28/2023 at 8:36 a.m., three Midodrine 2.5 mg tablets (1) were observed unsecured in R71's dialysis communication book in the residents room in an open duffel bag. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 1/13/2023, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact for making daily decisions. Section O documented R71 receiving dialysis while a resident. The physician orders for R71 documented in part, - Midodrine HCl (hydrochloride) Tablet 10 MG (milligram) Give 1 tablet by mouth every day shift every Mon, Wed, Fri for Hypotension. Send 1 tab (tablet) with pt (patient) to dialysis every M,W,F.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for three of 31 residents in the survey sample, Resident's # 35, #10, and #32. The facility staff failed to develop Resident # 35's comprehensive care plan to address the care needs and diagnosis of epilepsy; failed to implement the comprehensive care plan for Resident # 10's physician ordered fluid restriction and failed to implement Resident #2's comprehensive care plan, for the use of non-pharmacological interventions prior to the administration of as needed pain medication. The findings include: 1. Resident # 35 was admitted to the facility with diagnoses included but were not limited to: epilepsy [1]. Resident # 35's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 07/10/2021, coded Resident # 35 as scoring an 11 on the brief interview for mental status (BIMS)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care plan for three of 31 residents in the survey sample, Residents #64, #297, and #63. 1. The facility staff failed to revise the comprehensive care plans for Residents #64 and #297 following a resident to resident incident between them on 5/8/21. 2. The facility staff failed to revise Resident #63's care plan when he began taking an antidepressant medication. The findings include: 1. Resident #64 was admitted to the facility on [DATE] with diagnoses including a femur fracture, bipolar disorder (1), epilepsy (2), alcohol abuse, and nicotine dependence. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 8/3/21, Resident #64 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). He was coded as having demonstrated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care and services to promote a safe environment for three of 31 residents in the survey sample, Residents #64, #297, and #35. 1. Resident #64 was repeatedly allowed to leave the facility unsupervised without being assessed for safety to do so, and without being educated by the facility regarding the risks of suffering a serious injury while out of the facility without supervision. On 5/8/21, Resident #64 rammed his wheelchair into Resident #297's wheelchair multiple times while Resident #297 was seated in her wheelchair. The facility failed to assess Resident #297 for injury, and failed to implement interventions to ensure a safe environment and the safety of Resident #297. The facility failed to perform urine and/or blood screening tests for alcohol and illegal drugs on Resident #64 on multiple occasions when the resident displayed symptoms of impairment,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 have a complete pain management program for two of 31 residents in the survey sample, Resident #32 and Resident #63. 1. The facility staff failed to offer non-pharmacological interventions prior to the administration of an as needed pain medication and failed to document the location of Resident #32's pain. 2. The facility staff failed to document the location of Resident #63's pain on multiple occasions in September 2021 when administering an as-needed pain medication to him. The findings include: 1. Resident #32 was admitted to the facility on [DATE] with a recent readmission on [DATE], with diagnoses that included but were not limited to: pneumonia (1), depression, asthma (2), and a pressure injury on the sacral area (3). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 7/9/2021, coded Resident #32 as scoring a 15 on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide care and service for a complete dialysis [1] program for two of 31 residents in the survey sample, Residents # 10 and Resident #33. The facility staff failed to ensure ongoing communication regarding Resident #10 and Resident #33's care with the residents' dialysis centers. The findings include: 1. Resident # 10 was admitted to the facility with diagnoses included but were not limited to: end stage kidney disease [2]. Resident # 10's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 06/13/2021, coded Resident # 10 as scoring a three [3] on the brief interview for mental status (BIMS) of a score of 0 - 15, three - being severely impaired of cognition for making daily decisions. Section O Special Treatments, Procedures and Programs coded Resident # 10 for Dialysis while a resident. The POS [physician's order sheet] for…

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

Based on observation, staff interview, resident interview and clinical record review, it was determined that the facility staff failed to provide accommodations of resident needs by ensuring the call bell [a device with a button that can be pushed to alert staff when assistance is needed] was within reach for one of 31 current residents in the survey sample, Resident # 70. The facility staff failed to maintain Resident # 70's call bell within reach for use. The findings include: Resident # 70 was admitted to the facility with diagnoses that included but were not limited to: hemiplegia [1] and muscle weakness, respiratory failure [2] and tracheostomy [3]. Resident #70's most recent MDS (minimum data set) assessment, a modification admission assessment with an ARD (assessment reference date) of 08/09/2021, coded Resident # 70 as scoring a 6 [six] on the brief interview for mental status (BIMS) of a score of 0 - 15, 6 - being severely impaired of cognition for making daily decisions Section G0400 Functional Limitation in Range of Motion coded Resident # 70 as Impairment on one side of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review it was determined the facility staff failed to issue a notice of discharge from Medicare services for three of 31 residents in the survey sample, Residents # 91, #145, #146. The findings include: 1. Resident #91's last covered Medicare Part A services was 8/8/2021. The facility staff failed to notify Resident #91 (and/or the resident's responsible representative) of the last covered day and the right to appeal. Resident #91 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: high blood pressure, COVID 19 pneumonia (an infection in one or both of the lungs. Many germs, such as bacteria, viruses, and fungi, can cause pneumonia) (1), and dementia (a progressive state of mental decline, especially memory function and judgement, often accompanied by disorientation. (2). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 9/8/2021, coded the…

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

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 ensure a witnessed allegation of abuse was reported immediately and or within 2 hours to the state agency for one of 31 residents in the survey sample, Resident #297. On 5/8/21, a staff member observed Resident #64 repeatedly slamming his wheelchair into Resident #297's wheelchair. The facility did not report this incident to the state agency. The findings include: Resident #297 no longer resides in the facility. She was admitted on [DATE] and discharged on 5/15/21. She was admitted with diagnoses including urinary tract infection, COPD (3), and anxiety disorder. On the most recent MDS, an admission assessment with an ARD of 4/26/21, she was coded as being severely cognitively impaired for making daily decisions, having scored seven out of 15 on the BIMS. She was coded as being completely dependent on facility staff for all ADLs, and as using a wheelchair for locomotion. Resident #64 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to ensure written notification of a hospital transfer was provided to the Ombudsman for one of 31 residents in the survey sample, Resident #58. The facility staff failed to provide notice to the ombudsman of Resident #58's transfer to the hospital on 8/22/21. The findings include: Resident #58 was admitted to the facility on [DATE] with the diagnoses of but not limited to myoclonus, epilepsy, nonpsychotic mental disorder, substance abuse, anxiety, and depression. The most recent MDS (Minimum Data Set) assessment, a quarterly assessment with an ARD (Assessment Reference Date) of 8/5/21 coded Resident #58 as cognitively intact to make daily life decisions. The resident was coded as requiring extensive assistance with all areas of activities of daily living. A review of the clinical record revealed a nurse's note dated 8/22/21 that documented, Resident was visiting with SO (significant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and facility document review, it was determined the facility staff failed to ensure physician ordered fluid restrictions were implemented and monitored per physicians orders for two of 31 residents in the survey sample, Resident # 10 and #33. The facility staff failed to ensure physician ordered fluid restrictions for Resident #10 and #33 were implemented and monitored to ensure the physician amount of fluids were provided. The findings include: 1. Resident # 10 was admitted to the facility with diagnoses included but were not limited to end stage kidney disease [2]. Resident # 10's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 06/13/2021, coded Resident # 10 as scoring a three [3] on the brief interview for mental status (BIMS) of a score of 0 - 15, three - being severely impaired of cognition for making daily decisions. Section O Special Treatments, Procedures and Programs coded Resident # 10 for Dialysis while a…

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

Based on staff interview and facility document review, it was determined that the facility staff failed to ensure that two of five CNA [certified nursing assistant] records reviewed had received required annual competencies, CNA #1 and #2. The facility failed to evidence completed competencies for CNA [certified nursing assistants] # 1 with a hire date of 06/26/2018 and CNA # 2 with a hire date of 05/16/2017. The findings include: Upon entrance on 09/14/21 at approximately 11:00 a.m., an Entrance Conference form was provided to ASM [administrative staff member] # 1, administrator. One document on this form was a request for a list of all current CNA [certified nursing assistant] staff who had been employed at the facility for longer than one year. The list provided contained seven CNA's that had been employed longer than a year and was still employed at the facility. A request was made for both CNA #1 and CNA #2's annual training and competency evaluations. On 09/16/21 at 9:56 a.m., during a meeting with ASM # 1, ASM # 2 and ASM # 3, a concern was expressed regarding the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide behavioral health services for one of 31 residents in the survey sample, Resident #64. The facility staff failed to evidence that behavioral health services were offered to Resident #64 between 5/14/21 and 8/15/21. The findings include: Resident #64 was admitted to the facility on [DATE] with diagnoses including a femur fracture, bipolar disorder (1), epilepsy (2), alcohol abuse, and nicotine dependence. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 8/3/21, Resident #64 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). He was coded as having demonstrated no mood disorder symptoms, no psychosis, no behaviors toward himself or others, no rejection of care, and no wandering. He was coded as being independent…

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

Based on observation, staff interview, and facility document review, it was determined the facility staff failed to ensure proper labeling and storage of drugs in one of three medication carts observed, medication cart on the Fairview unit. An unlabeled Ventolin inhaler without the box packaging was observed stored, available for resident use in the middle drawer of the Fairview unit. the findings include: Observation was made of the medication cart on the Fairview unit, middle hall on 9/16/2021 at 11:32 a.m. An inhaler, Ventolin HFA (1), was observed sitting in the middle drawer of the medication cart. There was no resident name, no pharmacy label, and nothing documented on the container. There was no empty box for the inhaler in the drawer. An interview was conducted with LPN (licensed practical nurse) #4 on 9/16/2021 at 11:32 a.m. When asked who the inhaler belonged to, LPN #4 stated the resident was no longer there. LPN #4 stated he grabbed it and threw away the box. He stated he didn't know how to discard the medication. An interview was conducted with RN (registered nurse) #4,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, facility document review, and in the course of a complaint investigation, it was determined that the facility staff failed to ensure food was served at temperatures palatable for meal enjoyment during the lunch meal on 9/15/21. The findings include: On 9/14/21 at 12:12 PM, an interview was conducted with Resident #38. She stated that the food was an issue. She did not give specifics. However, a complaint being investigated regarding Resident #38, dated 6/3/21, also alleged that the resident had reported that the food was so bad she won't eat it. A review of facility grievances revealed one dated 12/17/20 from Resident #38 that documented, Resident reports food is still horrible and has gotten worse Resident #38 was admitted to the facility on [DATE] with the diagnoses of but not limited to congestive heart failure, rheumatoid arthritis, diabetes, Hodgkin's lymphoma, Meniere's disease, adjustment disorder, anxiety, and depression. 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.

Based on observation, staff interview, and facility document review, it was determined that the facility staff failed to prepare and serve food in a sanitary manner. During observation of trayline services on 9/15/21, OSM #2 (Other Staff Member), a dietary aide picked up a sandwich off the floor and continued preparing meal trays without changing gloves and washing her hands. The findings include: On 9/15/21 at 11:20 AM, the trayline service was observed in the kitchen. OSM #2 (Other Staff Member), a dietary aide, was at the end of the trayline, adding final items to the trays, i.e. desserts, beverages, etc., before placing on the cart for delivery. During this observation, at 11:56 AM, OSM #2 was observed retrieving a sandwich from a nearby refrigerator for a tray. OSM #2 dropped the sandwich on the floor, picked it up off the floor, and placed it on a nearby stainless steel table, away from the food prep area. She then obtained another sandwich, placed it on the resident's tray. She continued with the trayline service of finishing off the trays with final items and carting them;…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility document review, it was determined that the facility staff failed to provide care and services in a manner to prevent the spread of infection on two of three hallways on the Fairview Unit, the warm hallway , and the combination hallway containing both warm and cold residents. Two CNAs (certified nursing assistants), CNA #6 and CNA #7 were observed distributing meal trays, setting up resident meal trays, and removing meal trays from resident rooms on the warm hallway and the combination hallway of the Fairview Unit during lunch on 9/14/21. They were not wearing gloves or gowns when coming into contact with personal items and linens in the warm rooms, were not wearing gloves when handling trays from the hot rooms, and were not consistently sanitizing their hands between residents. The findings include: On 9/14/21 at 11:15 a.m., an entrance conference was conducted with ASM (administrative staff member) #1, the administrator. When asked if any residents were on…

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

Based on staff interview, and employee record review, the facility staff failed to ensure six of eight CNA (certified nursing assistant) records reviewed, received the required twelve-hours, of annual training, (CNA [certified nursing assistant] # 1, 2, 3 4, 5 and 6); and failed to ensure that the training included the required dementia, abuse and neglect or infection control training for four of the eight CNA's reviewed, (CNA #1, 2, 3 and 6). The findings include: On 1/23/20 at 4:30 p.m., a review of the facility's CNA annual training was conducted by this surveyor. Review of eight CNA training transcripts revealed six of eight CNAs selected for review did not meet the required 12-hours of annual training. Further Review of eight CNA training transcripts revealed four of eight CNAs selected for review did not meet the required dementia, abuse and neglect or infection control training. 1. Review of CNA #1's training transcript documented a hire date of 8/4/2015. Further review of the training transcript dated 8/4/2018 through 8/4/2019 documented, 0 hours and failed to evidence…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and prepare food in a sanitary manner. In the dry storage area, a five-pound bag of pasta open and undated, and one-pound-eight-ounce package of dry drink mix was observed opened and undated. Food debris were observed on the inside of each of 18 dessert bowls that were stacked upside down on the second shelf of the dry dish rack in the facility, and OSM (other staff member) #5, a cook was observed with a uncovered mustache preparing resident food. The findings include: On 01/22/20 at 10:40 a.m., an observation of the facility's kitchen, was conducted with OSM [other staff member] # 1, dietary manager and revealed the following: Observation the kitchen's dry storage room revealed a five-pound bag of 'Bowtie' pasta with approximately half remaining in the bag, sitting in a box on the middle shelf. Observation of the bag failed to evidence an open date. After observing, the bag of pasta OSM # 1 stated that the bag did not have a date on it and it could not be…

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

Based on observation, staff interview and clinical record review, it was determined that facility staff failed to provide care in a manner to promote dignity for one of 40 residents in the survey sample, Residents # 29. The facility staff failed to ensure Resident #29's urinary catheter bag was place in a privacy bag. Observation of Resident #29's catheter collection bag revealed the bag was hanging on the lower part of the bed and was not in a privacy bag, and urine was visible in catheter bag from the hallway. The findings include: Resident # 29 was admitted to the facility with diagnoses that included but were not limited to: obstructive and reflux uropathy [1], low iron and swallowing difficulties. Resident # 29's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 11/19/19, coded Resident # 29 as scoring a three on the brief interview for mental status (BIMS) of a score of 0 - 15, three - being severely impaired of cognition intact for making daily decisions. Resident # 29 was coded as being dependent of one staff member for…

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

Based on staff interview and clinical record review, it was determined that the facility staff failed to meet advanced directive requirements for one of 40 residents in the survey sample, Resident # 99. The facility staff failed to obtain and place completed copy of Resident #99's advance directive in the clinical record. The findings include: Resident # 99 was admitted to the facility with diagnoses that included but were not limited to: high blood pressure, low iron and cerebral palsy [1]. Resident # 99's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 01/02/2020, coded Resident # 99 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. The comprehensive care plan for Resident # 99 with a revision date of 09/06/2018 documented, Focus: [Resident # 99] has a full code status. Revision on 09/06/2018. The Social Services Annual/Significant Change Assessment for Resident # 99 dated 11/30/2019 documented, B1b. If Advance Directive exist, has 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 ensure two of 40 residents in the survey sample, Residents # 65 and # 87, were free from abuse. On 10/04/20 9, Resident # 38 hit Resident # 65's right arm and Resident #87, was hit on the upper left arm by Resident #90 causing a pre-existing blood blister to open and bleed on 2/18/19. The findings include: 1. Resident # 65 was admitted to the facility with diagnoses that included but were not limited to: swallowing difficulties, ataxia [1] and epilepsy [2]. Resident # 65's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/11/19, coded Resident # 65 as scoring an 12 on the brief interview for mental status (BIMS) of a score of 0 - 15, 12 - being moderately impaired of cognition for making daily decisions. Resident # 65 was coded as requiring extensive assistance of one staff member for activities of daily living. 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 observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to develop or implement a comprehensive care plan for two of 40 residents in the survey sample, Resident #20 and #87. The facility staff failed to develop a comprehensive care plan, to include the use of an incentive spirometer (1) for Resident #20 and #87. The finding include: 1. Resident #20 was admitted to the facility on [DATE] with a readmission on [DATE], with diagnoses that included but were not limited to atrial fibrillation (2), obstructive sleep apnea (3) and congestive heart failure (4). Resident #20's most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 11/05/2019, coded Resident #20 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15- being cognitively intact for making daily decisions. On 1/22/20 at 10:55 a.m., an observation was made of 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 observation, staff interview, resident 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 40 residents in the survey sample, Resident # 82. The facility staff failed revise Resident #82's comprehensive care plan to address the resident's forgetfulness, of placing the nasal cannula [1] back on for continuous oxygen therapy according to the physician's order. The findings include: Resident # 82 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: chronic obstructive pulmonary disease [2]. Resident # 82's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/22/19, coded Resident # 82 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Section O Special Treatments, Procedures and Programs coded 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 observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to follow professional standards of practice for two of 40 residents in the survey sample; Residents #67 and #94. The facility staff failed to administer medications in accordance to professional standards for Resident #67. The facility staff crushed the resident's Aspirin EC (1) (enteric coated) Delayed Release 81 mg (milligrams) tablet; and crushed the resident's Potassium Chloride ER (2) (extended release) 10 meq (milliequivalent) tablet. The facility staff failed to clarify a physician's order for Resident #94's prn [as needed] pain medications to determine when and which as needed pain medication to administer based on pain level rating parameters. The findings include: 1. Resident #67 was admitted to the facility on [DATE] with the diagnoses of but not limited to chronic respiratory failure, high blood pressure, heart disease, heart failure, atrial fibrillation,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 podiatry (foot) services for one of 40 residents in the survey sample, Resident #3. The facility staff failed to ensure foot care was provided to Resident #3 a diabetic. The findings include: Resident #3 was admitted to the facility on [DATE] with diagnoses that included but were not limited to diabetes mellitus (1) with diabetic neuropathy (2), hemiplegia (3) and hemiparesis (4) following cerebral infarction (5). Resident #3's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 01/12/20, coded Resident #3 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Resident #3 was coded as requiring extensive assistance of one staff member for activities of daily living. Section M of the assessment coded Resident #3 as receiving the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined facility staff failed to provide respiratory services consistent with professional standards of practice, for two of 40 residents in the survey sample, Resident #20, and #99. The facility staff failed to obtain a physician order for the use of an incentive spirometer for Resident #20 and Resident #99 and failed to store incentive spirometers for both residents in a sanitary manner. The finding include: 1. Resident #20 was admitted to the facility on [DATE] with a readmission on [DATE], with diagnoses that included but were not limited to atrial fibrillation (2), obstructive sleep apnea (3) and congestive heart failure (4). Resident #20's most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 11/05/2019, coded Resident #20 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15- being cognitively…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined facility staff failed to provide a complete dialysis (1) communication plan for one of 40 residents in the survey sample, Resident #20. The finding include: Resident #20 was admitted to the facility on [DATE] with a readmission on [DATE], with diagnoses that included but were not limited to end stage renal disease (2) atrial fibrillation (3), obstructive sleep apnea (4) and congestive heart failure (5). Resident #20's most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 11/05/2019, coded Resident #20 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15- being cognitively intact for making daily decisions. Section O of the assessment documented Resident #20 receiving dialysis. On 1/22/20 at approximately 2:45 p.m., an interview was conducted with Resident #20. Resident #20 stated that he went…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure that one of 40 residents in the survey sample; Resident #67, was free of a medication error rate of less than 5%. The facility staff made two medication errors out of 25 opportunities, resulting in a medication error rate of 8%. The facility staff failed to administer medications correctly, resulting in medication errors for Resident #67. The facility staff crushed the resident's Aspirin EC (1) (enteric coated) Delayed Release 81 mg (milligrams) tablet; and crushed the resident's Potassium Chloride ER (2) (extended release) 10 meq (milliequivalent) tablet. The findings include: Resident #67 was admitted to the facility on [DATE]; diagnoses include but not limited to chronic respiratory failure, high blood pressure, heart disease, heart failure, atrial fibrillation, oxygen dependence, insomnia, anxiety disorder, adjustment disorder, depression, hypothyroidism,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure that one of 40 residents in the survey sample; Resident #67, was free of a significant medication error. The facility staff crushed the Resident #67's Potassium Chloride ER (2) (extended release) 10 meq (milliequivalent) tablet, resulting in a medication error that could cause adverse effects, including death. The findings include: Resident #67 was admitted to the facility on [DATE]; diagnoses include but not limited to chronic respiratory failure, high blood pressure, heart disease, heart failure, atrial fibrillation, oxygen dependence, insomnia, anxiety disorder, adjustment disorder, depression, hypothyroidism, diabetes, asthma, and obstructive sleep apnea. The quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/13/19 coded the resident as being cognitively intact in ability to make daily life decisions. The resident was coded as…

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

Based on staff interview and clinical record review, it was determined that the facility staff failed to obtain consent and/or provide education regarding the pneumococcal vaccine for one of five residents in the immunization record review, Residents # 89. The findings include: Resident # 89 was admitted to the facility with diagnoses that included but were not limited to high blood pressure, seasonal allergies and dementia [1]. Resident # 98's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 01/01/2020, coded Resident # 98 as scoring a three on the brief interview for mental status (BIMS) of a score of 0 - 15, three - being severely impaired of cognition for making daily decisions. Under Section O Special Treatments, Procedures and Programs Resident # 98 was coded as not being offered the pneumococcal vaccine. A review of the Resident # 98's clinical record and EHR [electronic health record] failed to evidence a consent to receive or any education for the pneumococcal vaccine. On 10/02/19 at 4:45 p.m., an interview was conducted…

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