Lake Manassas Health & Rehabilitation Center

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to evidence a bed hold notice was provided when one of 40 residents were transferred to the hospital, Resident #25. The findings include: The nurse's note dated, 3/17/2023 at 9:24 a.m. documented, Patient was unresponsive to verbal and tactile stimuli. Blood pressure was 91/61, O2 (oxygen) was 54% on 4 L (liters), temp (temperature) was 97, heart rate was 81, blood sugar was 288. Patient was transferred to hospital via EMS (emergency medical services) at 0830 (8:30 a.m.). Emergency contact notified as well as (name of nurse practitioner). Further review of the clinical record failed to evidence that a bed hold notice was sent with the resident to the hospital. A request was made for evidence that the bed hold notice was sent with the resident upon transfer and none was provided prior to exit. An interview was conducted with RN (registered nurse) #3 on 4/17/2024 at 9:40 a.m. When asked what documents she sends to the hospital with the resident upon transfer, RN…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident/staff interviews, facility document review and clinical record review, it was determined the facility staff failed to develop/implement the care plan for three of 40 residents in the survey sample, Residents #72, #155 and #64. The findings include: 1.The facility staff failed to develop the comprehensive care plan for PTSD (Post Traumatic Stress Disorder) for Resident #72. Resident #72 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: PTSD (post-traumatic stress disorder), intestinal fistula, afib (atrial fibrillation) and CHF (congestive heart failure). The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 3/4/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section GG-functional status coded the resident as requiring maximal assistance for bathing,…

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 review and revise the comprehensive care plan for one of 40 residents in the survey sample; Resident #61. The findings include: 1. For Resident #61, the facility staff failed to review and revise the comprehensive care plan to include obtaining weights as ordered by the physician for a resident on a diuretic and fluid restriction with specific orders for daily weights and reporting changes to the physician. A review of the clinical record revealed a physician's order dated 3/20/24, documented, daily weight notify NP/MD (Nurse Practitioner / Medical Doctor) of more than 3 lbs (pounds) (of weight gain) in a day or 5lbs in a week for heart failure. A second physician's order, dated 3/20/24, documented, Fluid Restriction: 1500ml (milliliters) per day - Meals from kitchen = Breakfast 300ml; Lunch 420ml; Dinner 360ml. Nursing = Morning Meds 120ml; Afternoon Meds 120ml; Evening Meds 120ml; Night Shift 60ml. A third physician's order, dated 3/25/24, 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.

2. For Resident #156, the facility staff failed to administer a nasal spray and an iron supplement per the physician orders. A. The physician order dated,3/28/2024 documented, Ferretts Oral Tablet 325 MG (milligrams) (106 Fe [iron]) (Ferrous Fumarate) (used to treat anemia); Give 1 tablet by mouth in the morning for anemia. The April 2024 MAR (medication administration record) documented the above order. On the following dates for the 9:00 a.m. dose a 15 was documented: 4/2/2024 4/5/2024 4/5/2024 4/7/2024 4/8/2024 4/10/2024 A 15 indicated that No coverage was required. On 4/13/2024 through 4/16/2024, it was documented as administered. An interview was conducted with LPN (licensed practical nurse) #4 on 4/17/2024 at 1:10 p.m. The above order was reviewed with LPN #4. When asked why the medication had not given for all the days, LPN #4 stated the facility only had Ferrous Sulfate and it had to be ordered. (OSM - other staff member) #3, the central supply clerk had to order it and we had to wait for the shipment. An interview was conducted with OSM #3 on 4/17/2024 at 11:20 a.m. When…

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 the facility staff failed to provide showers in a timely manner for one of 40 residents in the survey sample, Resident #152. The findings include: For Resident #152, the facility staff failed to provide bathing for nine days after admission. On the MDS (minimum data set) assessment, an admission assessment, with the ARD (assessment reference date) of 3/2/2023, 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, the resident was coded as not having any baths during the lookback period. The ADL (activities of daily living) record for February 2023, documented on 2/28/2023, the day of admission, the bathing activity did not occur. The ADL record for March 2023, documented the showers were to be given on 3/2/2023 and on 3/6/2023. On both dates, it was documented that the activity did not occur. The first documented shower given to Resident #152 was on 3/9/2023, nine…

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 implement physician's orders for one of 40 residents in the survey sample; Resident #61. The findings include: 1. For Resident #61, the facility staff failed to implement physician's orders for (1) obtaining daily weights and (2) notify the nurse practitioner or physician of more than three pounds of weight gain in one day or five pounds in a week. A review of the clinical record revealed a physician's order dated 3/20/24, documented, daily weight notify NP/MD (Nurse Practitioner / Medical Doctor) of more than 3 lbs (pounds) (of weight gain) in a day or 5lbs in a week for heart failure. A second physician's order, dated 3/20/24, documented, Fluid Restriction: 1500ml (milliliters) per day - Meals from kitchen = Breakfast 300ml; Lunch 420ml; Dinner 360ml. Nursing = Morning Meds 120ml; Afternoon Meds 120ml; Evening Meds 120ml; Night Shift 60ml. A third physician's order, dated 3/25/24, for Furosemide (1) Oral Tablet 20 MG (milligrams) Give 40 mg by mouth…

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

Based on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to evidence documentation of current bed rail assessments and consents for three of 40 residents in the survey sample, Residents #4, #358 and #359. The findings include: 1. For Resident #4 (R4), the facility failed to evidence an assessment or consent for the use of bed rails. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 3/25/2024, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were cognitively intact to make daily decisions. The resident was coded as requiring partial/moderate assistance with rolling left and right and not having any limitation in range of motion to the upper extremities. On 4/15/2024 at approximately 3:26 p.m., an observation was made of R4 in bed with bilateral bar shaped bed rails in place. At this time an interview was conducted with R4 who stated they used the bed rails…

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 ensure one of 40 residents in the survey sample were free of unnecessary medications, Resident #156. The findings include: For Resident #156, the facility staff failed to hold a blood pressure medication when the blood pressure was below the physician ordered parameters. The physician order dated 4/10/2024, documented, Metoprolol Succinate ER (extended release) Oral Tablet Extended Release 24 hours 50 MG (milligrams); Give 1 tablet by mouth in the morning for HTN (high blood pressure)/Sick Sinus Syndrome. Hold for SBP (systolic blood pressure) < (less than) 130 or HR (heart rate) < 60. The April 2024 MAR (medication administration record) documented the above order. On 4/13/2024 the blood pressure was documented as 120/58. The medication was documented as having been administered. On 4/14/2024 the blood pressure was documented as 102/66. The medication was documented as having been administered. An interview was conducted with LPN (licensed practical nurse)…

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 the facility staff failed to have a written agreement for services provided for one of one resident receiving dialysis services, Resident #76. The findings include: The facility failed to have a written agreement with the dialysis center that was providing dialysis services to Resident #76. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 3/30/2024, the resident scored a nine out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired for making daily decisions. In Section B - Hearing, Speech and Vision, the resident was coded as having highly impaired vision. In Section O - Special Treatments, Procedures and Programs, the resident was coded as receiving hemodialysis (1). The resident was admitted to the facility on [DATE]. The physician order dated, 3/23/2024, documented, Hemodialysis (1) 3X/week (three times per week) MWF…

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 maintain a complete and accurate clinical record for two of 40 residents in the survey sample, Residents #10 and #155. The findings include: 1. For Resident #10, the facility staff failed to ensure a PASRR (preadmission screening and resident review) was dated and signed at the completion of the form. The clinical record was reviewed. A PASRR was scanned into the clinical record on 3/24/24. The form had no signature of person completing the form and no date of when the form was completed. An interview was conducted with OSM (other staff member) #4, the director of discharge planning and social services, on 4/17/2024 at approximately 9:15 a.m. The above noted PASARR was shown to OSM #4. When asked if a form, such as this, should be signed and dated, OSM #4 stated, yes it should be. She stated, it came from the hospital that way. OSM #4 was asked if this was an accurate clinical record, OSM #4 stated, no. Administrative staff member (ASM) #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 observation, staff interview and facility document review it was determined the facility staff failed to maintain infection control practices during the medication administration observation. The findings include: Observation was made on 4/16/2024 at 8:25 a.m. of LPN (licensed practical nurse) #4 administering medications. LPN #4 popped a Furosemide (diuretic) 20 mg (milligrams) tablet out of the bubble pack. The tablet landed on the medication cart, not in the cup. LPN #4 proceeded to pick up the pill with her bare hands and placed it in the medication cup. LPN #4 proceeded to administer the medication to the resident. An interview was conducted with LPN #4 on 4/17/2024 at 8:20 a.m. The observation above was reviewed with LPN #4. When asked if that was the process when a pill drops on the medication cart, LPN #4 stated, no, she should have thrown it away and popped a new one. When asked why she should do that, LPN #4 stated it's unsanitary to touch a pill. The facility policy, Administration Procedures for all Medications did not address when a pill lands on the medication…

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

Based on resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to develop a baseline care plan and/or provide a written summary of the baseline care plan for 4 of 47 residents in the survey sample, Residents #115, #138, #113 and #247. The findings include: 1. The facility staff failed to develop a baseline care plan for Resident #115 (R115) for pressure ulcers that were present on admission to the facility. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 6/23/2022 the resident scored 14 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident is cognitively intact for making daily decisions. Section M documented R115 having one Stage 3 pressure ulcer present upon admission to the facility and one unstageable-deep tissue injury present on admission to the facility. On 7/12/2022 at 2:30 p.m., an interview was conducted with R115 in their room. R115 stated that they had been in the facility for about 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 observation, resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide respiratory services for 4 of 47 residents in the survey sample, Residents #39, #8, #113 and #57. The findings include: 1. For Resident #39 (R39), the facility staff failed to administer oxygen at the physician prescribed rate and failed to store respiratory equipment in a sanitary manner. R39 has a diagnosis of chronic obstructive pulmonary disease (COPD). On the most recent MDS (minimum data set) assessment, the resident was coded as scoring 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 O - Special Treatments, Procedures and Programs, the resident was coded as using oxygen while a resident at the facility. Observation was made on 7/12/2022 at approximately 1:00 p.m. of R39 sitting up in their wheelchair. The resident had oxygen 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, facility document review, and clinical record review, it was determined the facility staff failed to evidence if a resident had or did not have an advance directive, or had a discussion with the resident and/or responsible party related to the resident's advance directive for two of 47 residents in the survey sample, Residents #14 and #29. The findings include: 1. The facility staff failed to evidence documentation that advance directive was discussed with Resident #14, the presence of an advance directive, or if the resident wished information regarding formulating an advance directive. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 4/13/2022, Resident #14 (R14) scored a 12 on the BIMS (brief interview for mental status) score, indicating the resident is moderately cognitively impaired for making daily decisions. Part of the admission paperwork dated 5/20/2019, documented in part, (Initial of corporation) Policies Covering the Implementation of Self-Determination Rights. documented 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, staff interview, facility document review and clinical record review, the facility staff failed to resolve a grievance for 1 of 47 residents in the survey sample, Resident #57. Resident #57 (R57) and/or the resident's family reported missing clothes to the facility staff in June 2022. The facility staff failed to resolve this grievance. The findings include: On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/29/22, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is not cognitively impaired for making daily decisions. On 7/12/22 at 1:19 p.m., an interview was conducted with R57. R57 stated it was hard finding personal belongings when the resident returns from the hospital. R57 stated approximately one month ago, it was difficult locating personal belongings upon the resident's readmission from the hospital. R57 stated the resident returned to a different room and some belongings including new shirts and pants were missing. R57 stated 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 provide the required documentation to the receiving facility at the time of a transfer for one of 47 residents in the survey sample, Resident #69 (R69). The findings include: The facility staff failed to evidence required documentation was provided for (R69) to the receiving facility for a facility-initiated transfer on 03/31/2022. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 05/24/2022, the resident scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. The facility's progress noted for (R69) dated 03/31/2022 documented, Resident is alert and very confused with hallucinations. Sent out to ER (emergency room) for low H&H (hemoglobin (1) and hematocrit (2)) and AMS (altered mental status) . On 7/13/2022 at 2:39 p.m., an interview was conducted with LPN…

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

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 the resident's representative of a facility initiated transfer for 2 of 47 residents in the survey sample, Residents #69 (R69) and #138 (R138), and failed to notify the ombudsman of a facility-initiated transfer for 1 of 47 residents in the survey sample, Resident #138 (R138). The findings included: 1. The facility staff failed to evidence written notification was provided for (R69) and (R69's) responsible party for a facility-initiated transfer on 03/31/2022. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 05/24/2022, the resident scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. The facility's progress noted for (R69) dated 03/31/2022 documented, Resident is alert and very confused with hallucinations. Sent out to ER (emergency room) for low…

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 facility staff failed to provide a bed hold policy to the resident or the resident's representative upon a transfer to the hospital for 2 of 47 residents in the survey sample, Residents # 69 (R69) and #127 (R127). The findings included: 1. For (R69), facility staff failed to provide a copy of the bed hold policy to the resident or resident representative at the time of transfer on 03/31/2022. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 05/24/2022, the resident scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. The facility's progress noted for (R69) dated 03/31/2022 documented, Resident is alert and very confused with hallucinations. Sent out to ER (emergency room) for low H&H (hemoglobin (1) and hematocrit (2)) and AMS (altered mental status) .…

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 correctly code an admission MDS (minimum data set) assessment for one of 47 residents in the survey sample, Resident #113 (R113). The findings include: Section N of the admission MDS with the ARD (assessment reference date) of 6/22/2022 coded R113 as receiving insulin injections during the assessment look back period, however there was no evidence of R113 receiving insulin. On the most recent MDS, an admission assessment with an ARD of 6/22/2022, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. The physician orders for R113 failed to evidence an order for insulin. The eMAR (electronic medication administration record) for R113 dated 6/1/2022-6/30/2022 failed to evidence insulin administration. On 7/13/2022 at 3:40 p.m., an interview was conducted with RN (registered nurse) #2, MDS coordinator. RN #2 stated that Section N of the MDS had a seven day look back period. RN #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 resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to develop a comprehensive care plan for one of 47 residents in the survey sample, Residents #115. The findings include: The facility staff failed to develop a comprehensive care plan for Resident #115 (R115) for pressure ulcers that were present on admission to the facility. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 6/23/2022 the resident scored 14 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident is cognitively intact for making daily decisions. Section M documented R115 having one Stage 3 pressure ulcer present upon admission to the facility and one unstageable-deep tissue injury present on admission to the facility. On 7/12/2022 at 2:30 p.m., an interview was conducted with R115 in their room. R115 stated that they had been in the facility for about a month. R115 stated that they had come to the facility for therapy 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 resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to review and/or revise the comprehensive care plan for 3 of 47 residents in the survey sample, Residents #113, #28 and #57. The findings include: 1. The facility staff failed to review and revise Resident #113's (R113) comprehensive care plan to include the use of a CPAP (continuous positive airway pressure machine) and incentive spirometer. On the most recent MDS, an admission assessment with an ARD of 6/22/2022, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. Section O did not document R113 using a CPAP during the assessment period. On 7/12/2022 at 2:14 p.m., an interview was conducted with R113 in their room. A CPAP machine was observed on the nightstand to the right of the residents bed with a mask lying on top of the machine uncovered. When asked about the CPAP machine and mask, R113 stated that they wore the mask at night…

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, clinical record review and in the course of a complaint investigation, the facility staff failed to provide ADL (activities of daily living) care for one of 47 residents in the survey sample, Resident #300. The facility staff failed to offer and provide bathing/showers to Resident #300 (R300) on multiple dates in November 2021 and December 2021. The findings include: On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 11/28/21, the resident scored 10 out of 15 on the BIMS (brief interview for mental status), indicating the resident is moderately cognitively impaired for making daily decisions. Section G coded R300 as being totally dependent on one staff with bathing. A review of R300's ADL records for the resident's stay from 11/22/21 through 12/22/21 only revealed documentation that the resident received bathing/shower on four days (11/30/21, 12/3/21, 12/10/21 and 12/17/21), per coding related to the legend on the ADL records (the legend coding documented): 1- Task…

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 during a complaint investigation, it was determined the facility staff failed to ensure one of 47 residents in the survey sample received dialysis services per the plan of care, (Resident #199). The findings include: Resident #199 (R199) was admitted to the facility on [DATE], with diagnoses that included but were not limited to: end stage renal disease requiring hemodialysis and depression. On the most recent MDS (minimum data set), around the time of the complaint, an annual assessment, with an assessment reference date of 1/5/2021, the resident was coded as scoring a 15 out of 15, indicating the resident was not cognitively impaired for making daily decisions. In Section D - Mood, the resident was coded as having little or no interest of doing things several days during the look back period and feeling down and depressed several days during the look back period. In Section O - Special Treatment, Procedures and Programs, R199 was coded as having dialysis…

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 act upon a pharmacy recommendation for one of 47 residents in the survey sample, Resident #75. The facility staff failed to act upon Resident #75's (R75) February 2022 pharmacy recommendation for thyroid and lipid levels. The findings include: On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 5/31/22, R75 scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident is not cognitively impaired for making daily decisions. A review of a consultant pharmacist recommendation to physician with a medication regimen review date of 2/27/22 documented a recommendation to add thyroid and lipid levels to R75's routine labs due to R75's use of thyroid and cholesterol medications. The physician/prescriber's response section of the form was blank. Further review of R75's clinical record failed from February 2022 through July 2022 failed to reveal documentation that the facility staff acted upon the above…

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 the facility staff failed to maintain a complete and accurate clinical record for one of 47 residents in the survey sample, Resident #28 (R28). The findings include: The facility staff failed to document in the clinical record fall interventions that were discussed in the at risk management meeting after two falls for R28. R28 had diagnoses that included but were not limited to: absence of left foot, absence of toes on right leg, and peripheral vascular disease. On the most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 5/7/2022, the resident scored a 10 out of 15 o the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired for making daily decisions. In Section G - Functional Status, the resident was coded as extensive assistance of one person for moving in the bed, transfers, walking in the room, and toileting. In Section J - Health Conditions R28 was coded as having had two or more falls during…

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

Based on staff interview, facility document review and clinical record review, the facility staff failed to provide education prior to administering the influenza immunization for one of 5 resident immunization reviews, Resident #55. The facility staff failed to provide education regarding the benefits and potential side effects of the influenza immunization prior to administering the immunization to Resident #55 (R55) on 11/19/21. The findings include: On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/27/22, 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. A review of R55's clinical record revealed a physician's order dated 11/19/21 for the influenza immunization. A review of R55's immunization record revealed the resident received the immunization on 11/19/21. Further review of R55's clinical record failed to reveal documentation that education regarding the benefits and potential side effects 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 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, and the comprehensive person-centered care plan, for six of 49 residents in the survey sample, Residents #322, #321, #118, #221, #47 and #72. The nebulizer masks for Residents #322, #321, Resident #118 and Resident #47 were observed uncovered on top of the residents' nebulizer machines or over the bed tables; and the incentive spirometer for Resident #321 and 221, were observed uncovered on the resident night stand and over bed table. Resident #72 was observed receiving oxygen at 3 LPM (liter per minute) instead of the 2 LPM ordered by the physician. The findings include: 1. Resident #322 was admitted to the facility on [DATE], with diagnoses that included but were not limited to chronic obstructive pulmonary disease (2), atrial fibrillation (3) and legal blindness. Resident…

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

Based on observation, staff interview, and facility document review, it was determined that the facility staff failed to serve food in a sanitary manner on one of four nursing units, the 400 unit. The facility staff failed to handle plates without putting thumbs on the food contact, surface area of the plate and the facility staff failed to cover facial hair during tray line service. The findings include: On 2/25/20 at 11:50 AM, the dining observation was made on the 400-unit dining room. OSM #3 (Other Staff Member) a dining associate, was in the unit dining room small kitchen area, plating food from the steam table for the residents. She was noted to be wearing gloves but was handling serving spoon handles, meal tickets, the surface of the steam table, and other items. She was observed handling plates with her thumb on top side of the rim, which was part of the food contact, surface area, with the same gloves on that she, had worn while touching multiple other items. OSM #3 was also observed picking up rolls with her hand and placing them on the plates, wearing the same gloves, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined, that the facility staff failed to implement infection control procedures to prevent infection for five of 49 residents in the survey sample, Residents #322, #321, #118, #221 and #47. The facility staff failed to implement infection control procedures for the storage of nebulizer masks when not in use for Residents #322, #321, Resident #118 and Resident #47 and failed to implement infection control procedures for the storage of Resident #321 and 221's incentive spirometers when not in use. The findings include: 1. Resident #322 was admitted to the facility on [DATE], with diagnoses that included but were not limited to chronic obstructive pulmonary disease (2), atrial fibrillation (3) and legal blindness. Resident #322's most recent MDS (minimum data set), was not due at the time of the survey. The facility's nursing admission assessment dated [DATE] coded Resident #322 as being…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review, it was determined that the facility staff failed to ensure one of 49 sampled residents, (Resident #275) needs for the use of a call bell were accommodated. The facility staff failed to place Resident #275's call bell within reach during observations on 2/25/2020 and 2/26/2020. The findings include: Resident #275 was admitted to the facility on [DATE] with diagnoses including, but not limited to pneumonia and difficulty swallowing. He had not been a resident of the facility long enough for an MDS (minimum data set) assessment to be completed. On the admission nursing assessment dated [DATE], he was documented as being oriented only to person. He was documented as moving all of his extremities well. On the following dates and times, Resident #275's call bell was observed looped around the left grab bar and hanging down near the floor, out of the resident's reach: 2/25/20 20 at 2:21 p.m. and 2/26/2020 at 8:36 a.m. On 2/26/20 at 8:36 a.m., 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 clinical record review, staff interview, facility document review, and review of a Facility Reported Incident (FRI), it was determined that the facility staff failed to ensure that one of 49 residents, Resident #7, was free from sexual abuse and coercion by another resident. The facility staff failed to ensure that Resident #7 was free from inappropriate touching and coercion by Resident #21 on 11/26/19. The findings include: Resident #7 was admitted to the facility on [DATE]; diagnoses include but are not limited to dementia with behaviors, high blood pressure, psychosis, anxiety disorder, schizoaffective disorder, depression, and diabetes. The annual MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 11/4/19 coded the resident as being severely impaired in ability to make daily life decisions. Resident #21 was admitted to the facility on [DATE]; diagnoses include but are not limited to diabetes, depression, hernia, chronic obstructive pulmonary disease, peripheral vascular…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review, it was determined that the facility staff failed to implement the baseline care plan for one of 49 residents in the survey sample, Resident #275. The facility staff failed to implement Resident #275's care plan to place the call bell within reach. During observations conducted on 2/25/2020 and 2/26/2020, Resident #275's call bell was looped around the left grab bar and hanging down near the floor, out of the resident's reach. The findings include: Resident #275 was admitted to the facility on [DATE] with diagnoses including, but not limited to pneumonia and difficulty swallowing. He had not been a resident of the facility long enough for an MDS (minimum data set) to be completed. On the admission nursing assessment dated [DATE], he was documented as being oriented only to person. He was documented as moving all of his extremities well. A review of Resident #275's care plan dated 2/23/2020 revealed, in part: Be sure the resident's call light is…

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 implement the comprehensive care plan for one of 49 residents in the survey sample, Residents # 72. The staff failed to implement Resident #72's comprehensive care plan to administer oxygen as ordered by the physician. The findings include: Resident # 72 was admitted to the facility with diagnoses that included but were not limited to: multiple sclerosis [1] and high blood pressure. Resident # 72's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 01/18/2020, coded Resident # 72 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. In Section O Special Treatment, Procedures and Programs, coded Resident # 72 was coded as receiving oxygen. The comprehensive care plan for Resident # 72 with a revision date of 10/15/2019 documented in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review, it was determined that the facility staff failed to provide care and services to maintain hydration status for one of 49 residents in the survey sample, Resident #275. The facility staff failed to offer fluids to or place fluids within Resident #275's reach during observations on 2/25/2020 and 2/26/2020. The findings include: Resident #275 was admitted to the facility on [DATE]; diagnoses include, but are not limited to pneumonia and difficulty swallowing. He had not been a resident of the facility long enough for an MDS (minimum data set) assessment to be completed. On the admission nursing assessment dated [DATE], he was documented as being oriented only to person. He was documented as moving all of his extremities well. The admission assessment contained no documentation of his needing assistance while eating/drinking. On 2/25/2020 at 2:21 p.m., Resident #275 was observed sitting up slightly in his bed. His lips and mouth appeared dry. No…

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

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 facility staff failed to provide a complete dialysis (1) communication plan for one of 49 residents in the survey sample, Resident #113. The facility staff failed to ensure the dialysis communication book fro Resident #113 was completed to ensure ongoing communication with the dialyisis center. The finding include: Resident #113 was admitted to the facility on [DATE] with a readmission on [DATE], with diagnoses that included but were not limited to chronic obstructive pulmonary disease (2), atrial fibrillation (3), and dependence on renal (kidney) dialysis. Resident #113's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 2/3/2020, coded Resident #113 as scoring a 1 (one) on the staff assessment for mental status (BIMS) of a score of 0 - 15, 1- being severely impaired for making daily decisions. Section O of the assessment documented Resident #113…

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 obtain a psychiatric per a physician's order after a resident to resident incident for one of 49 residents in the survey sample, Resident #21. Resident #21 was the aggressor in a resident-to-resident incident of inappropriate touching of another resident, Resident #7 on 11/26/19. The physician ordered a psychiatric consult for Resident #21, and the facility staff failed to obtain the consult as ordered. The findings include: Resident #21 was admitted to the facility on [DATE] with the diagnoses of but not limited to diabetes, depression, hernia, chronic obstructive pulmonary disease, peripheral vascular disease, and high blood pressure. The quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/22/19 coded the resident as being mildly impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing; extensive 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.