Galax Health And Rehab

Based on staff interview, clinical record review, facility document review, the facility staff failed to notify the MD and/or RP of significant changes in the resident's physical, mental or psychosocial status for 3 of 22 residents sampled. Resident # 19, 26, 64. The findings included: 1. For resident # 19, the facility staff failed to notify the physian and responsible party of a fall that occurred 10/6/23. This was a closed record review. Resident #19's diagnoses included but were not limited to, unspecified dementia, angina, cognitive communication deficit, moderate protein calorie malnutrition, Alzheimer's with late onset, adult failure to thrive, muscle weakness (generalized), essential hypertension, and paroxysmal atrial fibrillation. The most recent minimum data set (MDS) assessment assigned the resident a brief interview for mental status score (BIMS) of 3, indicating severe cognitive impairment. There was a progress note in the clinical record with an effective date of 10//6/23 at 2:34 AM that indicated resident fell at 2:25 AM. The resident was assessed for injury 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 documents received at the Office of Licensure and Certification (OLC), facility staff failed to ensure the right to secure and confidential medical records for 1 of 22 residents sampled (Resident #68). Resident #68 was admitted to the facility with diagnoses which included Alzheimer's dementia, hypertension, congestive heart failure, dysphagia, recurrent falls, and diabetes mellitus type 2 with neuropathy. On the Minimum Data Set assessment with Assessment Reference Date 10/6/23, the resident scored 9/15 on the brief interview for mental status, indicating impairment in daily decision-making skills, and was assessed as without signs of delirium, psychosis, or behaviors affecting care of self or others. On 11/15/2023, a complaint was received in OLC which included a screen shot of a resident's progress note in the electronic clinical record. The complainant wrote that the note was proof of an allegation of failure to report an incident (the progress note described an incident, but did not address the complainant's allegation). The complaint form including the progress note…

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

Based on staff interviews and facility document review the facility staff failed to provide the ongoing re-evaluation of the need for physical restraints for 1 of 22 sampled residents. Resident #33. The findings were: For Resident #33, the facility staff failed to reassess the risk for elopement/wandering prior to applying a Wander Guard monitor. The resident's admission Record listed their diagnoses to included, but were not limited to multiple sclerosis, dementia, Alzheimer's disease, Parkinson's disease with dyskinesia, and type 2 diabetes mellitus. On the quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 10/11/23, the resident scored a 10 out of 15 on the brief interview for mental status. Section P (Restraints and Alarms) read the resident had a wander/elopement alarm daily. Resident #33's clinical record was reviewed. One (1) Elopement Risk Assessment document was found, dated 04/03/23 and read the resident was not at risk for elopement. There were no other elopement risk assessments found. The Treatment Administration Record (TAR) for November…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to provide sufficient preparation and orientation to residents to ensure a safe and orderly discharge from the facility for 1 of 22 residents in the survey sample, Resident #86. The findings included: For Resident #86, the facility staff failed to provide the resident with discharge instructions or medication prescriptions prior to a planned discharge home. Resident #86's diagnosis list indicated diagnoses, which included, but not limited to Pressure Ulcer of Right Buttocks, Open Wound of Abdominal Wall, Ventral Hernia with Obstruction, Type 2 Diabetes Mellitus, and Muscle Weakness. The quarterly minimum data set (MDS) with an assessment reference date (ARD) of 10/23/23 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating Resident #86 was cognitively intact. The resident was coded as being dependent with personal hygiene and toileting…

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, the facility staff failed to review and revise the comprehensive care plan for 3 of 22 residents sampled. Resident # 26, # 64, and # 33. The findings included: 1. For resident # 26, the facility staff failed to update the comprehensive care plan after a fall with injury and after an injury of unknown origin. Resident # 26's diagnoses included but were not limited to, hypertension, Alzheimer's Disease, anxiety, depression, unspecified mood disorder, diabetes and chronic obstructive pulmonary disease. Resident # 26's most recent MDS assigned them a BIMS score of 4 indicating severe cognitive impairment. During a review of the clinical record, a progress note dated 9/8/23 at 1:01 PM read in part, Resident continues to complain of right shoulder and arm pain. New order given to sent to ED (emergency department) for x-ray of arm and shoulder. The note also indicated that the physician and the responsible party had been notified. On 9/8/23…

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

Based on observation, staff interview, clinical record review, and facility document review the facility staff failed to follow standards of professional practice for 2 of 22 residents, Resident's #242 and #24. The findings included: 1. For Resident #242, the facility nursing staff documented they had administered the medication Isosorbide when this medication had never been delivered to the facility from the pharmacy. This medication was not available in the facility STAT box. Resident #242's diagnoses included hypertension, congestive heart failure, and chronic kidney disease. There was no completed minimum data set (MDS) assessment for this Resident. Resident #242 was alert and orientated to self. Resident #242's clinical record included an order for the medication Isosorbide Mononitrate 10 mg 1 tablet three times a day for hypertension. The order date was documented as 11/08/23. A review of Resident #242's medication administration record (MAR) revealed that the nursing staff had documented they had administered this medication on 11/09/23 at 8:00 a.m. and 2:00 p.m., 11/10/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, facility document review, the facility staff failed to follow physician's orders for 3 of 22 residents, Resident #51, Resident #86, and Resident #242. The findings included: 1. For Resident #51 the facility staff failed to administer the medication Zoloft. Zoloft is a medication used to treat depression. Resident #51's face sheet listed diagnoses which included but not limited to Alzheimer's disease, anxiety, depression, and dementia. Resident #51's most recent minimum data set with an assessment reference date of 10/18/23 assigned the resident a brief interview for mental status score of 14 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #51's comprehensive care plan was reviewed and contained a care plan for I am taking an antidepressant medication. Interventions for this care plan include Medication as ordered by the physician. Resident #51's clinical record was reviewed and contained a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure a resident with pressure ulcers receives necessary treatment and services to promote healing for 1 of 22 residents in the survey sample, Resident #86. The findings included: For Resident #86, the facility staff failed to treat a stage 3 pressure ulcer to the sacrum as directed by the wound specialist from 11/03/23 through 11/10/23. Resident #86's diagnosis list indicated diagnoses, which included, but not limited to Pressure Ulcer of Right Buttocks, Open Wound of Abdominal Wall, Ventral Hernia with Obstruction, Type 2 Diabetes Mellitus, and Muscle Weakness. According to Resident #86's demographic face sheet, the resident was admitted to the facility on [DATE]. An admission Data Collection Form dated 11/02/23 documented the resident as being alert and independent in decisions regarding tasks of daily living. On 11/13/23 at 5:17 PM, surveyor spoke with Resident #86 who 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.

Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure each resident received assistance devices to prevent accidents for 1 of 22 residents in the survey sample, Resident #24. The findings included: For Resident #24, the facility staff failed to ensure placement of Dycem non-slip material in the resident's wheelchair seat as indicated on the resident's comprehensive person-centered care plan. Resident #24's diagnosis list indicated diagnoses, which included, but not limited to Iliotibial Band Syndrome of the Right Leg, Dementia, Major Depressive Disorder, Mood Disorder, Generalized Anxiety Disorder, Nightmare Disorder, Parkinson's Disease, Unsteadiness on Feet, and Muscle Weakness. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 9/15/23 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #24 was coded as requiring limited assistance with transfers,…

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, facility document review and during a medication pass and pour the facility staff failed to ensure medications were available for administration of 2 of 22 residents, Resident #3 and Resident #294. The findings included: 1. For Resident #3 the facility staff failed to ensure the medication Vitamin D was available for administration. Resident #3's face sheet listed diagnoses which included but not limited to Vitamin D deficiency, unspecified. Resident #3's most recent minimum data set with an assessment reference date of 10/24/23 assigned the resident a brief interview for mental status score of 5 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively intact. Surveyor observed licensed practical nurse (LPN) #6 during a medication pass and pour on 11/14/23 at 7:55 am. LPN #6 prepared Resident #3's medications but stated that the resident's Vitamin D was not available in the medication cart, and they would have to get it from the medication room. LPN #6 stated that Vitamin D 400 iu and…

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

Based on staff interview, clinical record review, and facility document review, the facility staff failed to act upon drug regimen review recommendations for 1 of 22 residents in the survey sample, Resident #24. The findings included: For Resident #24, the facility staff failed to carry out a physician approved drug regimen review recommendation for a movement test, such as AIMS or DISCUS, to be performed at least every six months. Resident #24's diagnosis list indicated diagnoses, which included, but not limited to Iliotibial Band Syndrome of the Right Leg, Dementia, Major Depressive Disorder, Mood Disorder, Generalized Anxiety Disorder, Nightmare Disorder, Parkinson's Disease, Unsteadiness on Feet, and Muscle Weakness. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 9/15/23 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #24 was coded as requiring limited assistance with transfers, dressing, and personal hygiene. The resident was coded…

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

Based on staff interview and clinical record review, the facility staff failed to ensure PRN (as needed) orders for psychotropic drugs were limited to 14 days for 1 of 22 residents in the survey sample, Resident #24. The findings included: For Resident #24, the facility staff failed to ensure the order for the medication Vistaril included a duration limited to 14 days. Vistaril is an antihistamine drug which may be used to relieve anxiety and tension. Resident #24's diagnosis list indicated diagnoses, which included, but not limited to Iliotibial Band Syndrome of the Right Leg, Dementia, Major Depressive Disorder, Mood Disorder, Generalized Anxiety Disorder, Nightmare Disorder, Parkinson's Disease, Unsteadiness on Feet, and Muscle Weakness. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 9/15/23 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #24's clinical record included a current physician's order dated 10/31/23 for Vistaril 50 mg…

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

Based on observation, staff interview, clinical record review and during a medication pass and pour the facility staff failed to ensure a medication error rate of less than 5%. There were 2 errors in 30 opportunities for a medication error rate of 6.67%. These errors affected Resident #3 and Resident #12. The findings included: On 11/14/23 at 7:50 am, surveyor observed licensed practical nurse (LPN) #6 during a medication pass and pour. LPN #6 prepared Resident #51's medications but stated that the Zoloft was not available in the medication cart. LPN #6 stated, I'll probably have to call the pharmacy about the Zoloft. Surveyor asked LPN #6 to let them know when the had the Zoloft for administration. Surveyor was never informed that the Zoloft was available or administered. Surveyor reconciled Resident #51's medications with the clinical record. Resident #51's clinical record contained a physician's order summary which read in part, Zoloft Tablet 50 mg (Sertraline HCl). Give 1 tablet by mouth one time a day for major depressive disorder, recurrent, unspecified. Surveyor observed…

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 facility document review and staff interview facility staff failed to ensure the IPCP program was reviewed annually. The surveyor was provided the Infection Control Program- Antibiotic Stewardship F881 policy and procedure with effective date 2/2017. The surveyor spoke with the regional vice president of operations (RVPO) about the need for an Infection Prevention and Control Program (IPCP) policy and for the policies to be reviewed and revised annually. The Antibiotic Stewardship Policy the RVPO had also was effective 2/2017 and had not been revised. RN#4, who became the acting ICP on 11/25/23, found a manual for Infection Control Program Version 4 revised October 2020. The October 2020 Version 4 represented the most recently revised infection control policies available in the facility. The surveyor repeated the concern with not reviewing and revising the Infection Contol Program manual annually during a summary meeting on 11/14/23 attended by the administrator, Director of Nursing and RVPO.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical review facility staff failed to ensure the pneumococcal immunization was offered to 1 of 5 residents reviewed for immunizations (Resident #82). Resident #82 was admitted to the facility with diagnoses which included cerebral infarction with hemiplegia and hemiparesis, diabetes mellitus type 2, atherosclerotic heart disease, and cardiopulmonary disease. On the most recent Minimum Data Set assessment with Assessment Reference date 10/4/23, the resident scored 11/14 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. The resident's clinical record was reviewed for offer, education, and receipt of required vaccinations. The record indicated the resident received influenza vaccine October 2023 and Covid 19 [NAME] in 2021 and a booster July 2023. There was no record of offering or receiving pneumococcal vaccine. The surveyor notified the Administrator and RVPO during a summary meeting on 11/15/23. 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.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to allow family visitation for 1 of 4 closed record reviews, Resident #92. The findings included: The facility staff failed to allow the family to stay with the Resident at the facility after the resident had a change in condition. Resident #92's diagnoses included but were not limited to, Alzheimer's, dementia, and muscle weakness. Section C (cognitive patterns) of Resident #92's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 08/16/23 included a brief interview for mental status (BIMS) summary score of 3 out of a possible 15 points. Resident #92's comprehensive care plan included the focus areas sometimes shows behavior symptoms, at risk for pressure ulcers, requires assistance with one or more staff for activity of daily living, and difficulty with independent feeding. Resident #92's clinical record included an order for Hospice effective 10/13/23. The facility staff provided the survey team with a copy of the Hospice documentation. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review the facility staff failed to ensure injuries of unknown origin were reported for 1 of 22 current residents sampled and one of 4 closed records sampled. Resident #19 and Resident #26. The findings included: 1. For resident # 19, the facility staff failed to report a right hip fracture that was identified on 10/13/23. This was a closed record review. Resident # 19's diagnoses included but were not limited to, unspecified dementia, cognitive communication deficit, generalized anxiety, Alzheimer's with late onset, insomnia, weakness, history of falling. Resident # 19's Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 10/20/23 assigned the resident a Brief Interview for Mental Status (BIMS) score of 3, indicating they were severely cognitively impaired. The resident was also coded as dependent for Activities of Daily Living (ADL's) and mobility. The clinical record was reviewed. A progress note dated 10/13/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, facility document review, facility staff failed to initiate a thorough investigation of an injury of unknown origin for 1 of 22 active residents sampled and 1 of 4 closed records. Resident # 19 and Resident # 26. The findings included: 1. For resident # 19 the facility staff failed to investigate a right hip fracture that was identified October 13, 2023. This was a closed record review. Resident # 19's diagnoses included but were not limited to, unspecified dementia, cognitive communication deficit, generalized anxiety, Alzheimer's with late onset, insomnia, weakness, history of falling. Resident # 19's Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 10/20/23 assigned the resident a Brief Interview for Mental Status (BIMS) score of 3, indicating they were severely cognitively impaired. The resident was also coded as dependent for Activities of Daily Living (ADL's) and mobility. The clinical record was reviewed. A progress note dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, resident interview and during the course of a complaint investigation, the facility staff failed to provide Activities of Daily Living care to one of 7 residents. Resident # 7. The findings included: For Resident # 7, the facility staff failed to provide scheduled bathing assistance in March 2023. Resident # 7's demographic sheet listed diagnoses that included but were not limited to; Type 2 diabetes mellitus, hypertension, chronic obstructive pulmonary disease, anxiety disorder, major depressive disorder, and unspecified mood disorder. The most recent Minimum Data Set (MDS) assessment with an assessment reference date of 7/12/23, assigned resident # 7 a brief interview for mental status score of 12 indicating moderate cognitive impairment. This surveyor interviewed resident #7 on 10/5/23 at 11:16 AM. When asked about the care provided by the facility staff, resident stated, I get good care here. When asked if they are assisted with bathing and showering, they…

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

Based on observation, staff interview, resident interview, and clinical record review, the facility staff failed to ensure that a resident who was unable to carry out ADL's (activities of daily living) received the necessary care and services to maintain personal hygiene for one of 17 residents, Resident #19. The facility staff failed to provide nail care for a dependent resident. Resident #19's fingernails were observed to be long and jagged, with debris observed underneath the nails. The findings included: Resident #19's diagnoses included, but were not limited to, diabetes, peripheral vascular disease, cerebral infarction, acute angle-closure glaucoma, and gout. Section C (cognitive patterns) of Resident #19's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 09/22/21 included a BIMS (brief interview for mental status) summary score of 10 out of 15, indicating the resident was moderately impaired of cognition. Section G (functional status) was coded 3/2 for personal hygiene indicating Resident #19 required extensive assistance of one person…

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 interviews and facility document review, it was determined the facility staff failed to properly implement processes to prevent and/or contain COVID-19 as evidence by two (2) of three (3) staff members, sampled for COVID-19 screening, not being consistently screened prior to starting their work shift (CNA (Certified Nurse Aide) #21 and CNA #22). The findings include: Review of the facility's staff screening documentation revealed CNA #21 and CNA #22 failed to consistently have evidence of being screened prior to starting their work shifts. The following information was found in a facility policy/procedure titled Active Screening Process for COVID-19 Visitors and Employees (with a revision date of 9/21/2020): Precautions and Screening Process . Limit visitor entry to front entrance ONLY to ensure all persons entering the building will be screened as directed. Visitors will be assisted to self-attest immediately upon entry for travel history to affected areas, contact with persons confirmed to have COVID-19 and symptoms of new onset of fever, sore throat, sneezing,…

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 interviews and facility document review, it was determined the facility staff failed to consistently implement processes to prevent and/or contain COVID-19 as evidence by two (2) of three (3) staff members (CNA (Certified Nurse Aide) #21 and CNA #22), who were sampled for COVID-19 screening, who had not been tested for COVID-19 as required by the facility's high community transmission level. The findings include: The facility staff failed to test CNA #21 and CNA #22, as required, for COVID-19. CNA #21 and CNA #22 were two (2) of the three (3) facility staff members who were not fully vaccinated. The third staff member, who was not fully vaccinated, had tested positive for COVID-19 during the previous 90 days therefore would not have required COVID-19 testing by the facility. The following information was found in a facility policy/procedure titled Facility COVID-19 Testing with a revision date of 9/2021: - Fully vaccinated refers to a person who is (greater than or equal to) 2 weeks following…

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

Based on observation and staff interviews, the facility staff failed to provide privacy in a manner that maintained or enhanced the dignity of the residents during a resident council meeting on 9/12/18. The findings included: During a resident council meeting held on 9/12/18 beginning at 10:00 a.m., the facility staff failed to respect the resident's dignity, privacy, and individuality. The facility staff entered the area where the resident council meeting was held numerous times disturbing the resident council meeting each time a staff member entered or exited the room. The group meeting was held in the facility's dining room and was attended by seven residents of the facility. Soon after the resident council meeting began, the surveyor and group observed a hospitality aide come in the dining room through the door at the back of the dining room carrying a tray and placed the tray in the kitchen window. The hospitality aide then left the dining room. The same hospitality aide came through the door at the back of the dining room carrying a second tray a second time. She left the tray…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, the facility staff failed to follow physician orders for medication administration for 1 of 28 residents (Resident #53). The findings included: The facility staff failed to follow physician orders for the administration of insulin. The licensed practical nurse (LPN #1) administered Humalog insulin after Resident #53 had eaten breakfast. The clinical record of Resident #53 was reviewed 9/11/18 through 9/13/18. Resident #53 was admitted to the facility 5/31/16 and readmitted [DATE] with diagnoses that included but not limited to diabetes mellitus with diabetic neuropathy, gross hematuria, chronic pain, bipolar disorder with hallucinations, Vitamin D deficiency, major depressive disorder, post-traumatic stress disorder, dementia with behavioral disturbances, hypercholesterolemia, hypertension, atrial fibrillation, diastolic heart failure, chronic obstructive pulmonary disease, and chronic kidney disease. Resident #53's quarterly minimum data set…

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 interviews and clinical record review it was determined the facility staff failed to provide 1 of 25 residents (Resident #43) with a diet as ordered by the physician. Findings: Facility staff failed to provide Resident #43 with a diet as ordered by the physician. The resident's clinical record was reviewed on 9/12/18 at 9:00 AM. The resident was admitted to the facility on [DATE]. Her diagnoses included dementia, heart failure and hypertension. The latest MDS (minimum data set) dated 7/27/18 coded the resident with slightly impaired cognitive ability. The resident was coded to eat meals independently with staff oversite. The resident's CCP (comprehensive care plan) documented the resident with involuntary weight loss. The staff interventions included, Magic cup supplement daily. The resident's physician's orders, signed and dated on 10/17/17, included the resident's dietary supplements for weight loss. The physician ordered a Magic cup one time each day at lunch for weight loss. 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, the facility staff failed to ensure that 1 of 25 residents in the survey sample was free of unnecessary psychotropic medication (Resident #24). The findings included: The facility staff failed to discontinue or re-evaluate the use of a prn (as needed), Xanax, for Resident #24. Resident #24 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to coronary artery disease, high blood pressure, End Stage Renal Disease, stroke and dementia. On the admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/16/18 coded the resident as having a BIMS (Brief Interview for Mental Status) score of 3 out of a possible score of 15. Resident #24 was also coded as requiring extensive assistance of 2 staff members for dressing and being totally dependent on 1 staff member for personal hygiene and bathing. The surveyor performed a review of Resident #24's clinical record on 9/13/18. During this review, the surveyor noted 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, staff interview, and facility document review, facility staff failed to ensure that milk in personal refrigerators had not expired for 2 of 27 residents in the survey sample (Residents #9 and 79). 1. For Resident #9, facility staff failed to discard expired milk stored in the personal refrigerator in the resident's room. Resident #9 was admitted to the facility on [DATE]. Diagnoses included alzheimer's disease, urinary tract infection, gastrointestinal hemorrhage, pain, hallucinations, dementia, hypertension, and anxiety. On the Quarterly Minimum Data Set Assessment with assessment reference date 6/26/18, the resident was assessed with short and long term memory impairment and without symptoms of delirium, or psychosis. The resident exhibited physical behavior symptoms toward others 1-3 of the 7 days prior to the assessment. During initial tour on 09/11/18 at 01:19 PM , the surveyor checked the contents of the resident's personal refrigerator. The milk in the refrigerator in the resident's…

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 during a medication administration observation the facility staff failed to follow established infection control guidelines in regards to hand hygiene on 1 of 2 units (unit A). The findings included: The facility nursing staff failed to complete hand hygiene during a medication administration observation. On 09/12/18 beginning at approximately 7:58 a.m. the surveyor observed LPN (licensed practical nurse) #1 prepare medications for administration. During this time surveyor did not observe LPN#1 wash hands or use hand sanitizer prior to preparing medications. After preparing the medications LPN #1 offered Resident #72 medications as Resident #72 was awaiting by medication cart. Resident #72 refused one of the prepared medications. LPN #1 put bare fingers in administration cup to get refused medication out and once again did not wash hands, use sanitizer or don gloves. LPN #1 continued with administration by donning gloves and administering eye drops to Resident #72. LPN#1 handed Resident #72 a tissue to wipe eyes, LPN#1 then…

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.