Elizabeth Adam Crump Health And Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews and record review, the facility staff failed to ensure appropriate resident care and services were provided in accordance with accepted professional standards of care for 3 residents (Resident #4, #5 and #6) in a survey sample of 13 residents.Findings included:For Residents #4, #5 and #6, the facility staff failed to ensure residents' medications were administered by the physician's orders as evidenced by observing medications at the resident's bedside.For Residents #4, #5 and #6, the facility staff failed to ensure residents' medications were administered by the physician's orders as evidenced by observing medications at the resident's bedside.For Resident #4, she was admitted to the facility on [DATE] with diagnoses including but not limited to: major depressive disorder, hypertension, pain, generalized anxiety, presence of cardiac pacemaker, history of COVID, cardiomyopathy, retention of urine, combined systolic and diastolic congestive heart failure,…

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, interview, clinical record review and facility documentation, the facility staff failed to ensure residents receive care to prevent the development of pressure ulcers for 1 Resident (Resident #1) in a survey sample of 13 Residents.The findings included: Resident #1, the facility staff failed to provide assessments, ordered treatments and supplements for the prevention and development of new pressure injuries.For Resident #1, the facility staff failed to provide assessments, ordered treatments and supplements for the prevention and development of new pressure injuries.Resident #1 was admitted to the facility on [DATE] from home with diagnoses including but not limited to hypertension, unstageable pressure injury sacrum, moisture associated skin damage to right buttocks, atrial fibrillation gastro-esophageal reflux disease with esophagitis, ventral hernia without obstruction, vitamin D deficiency, lymphedema, pain, sequelae of unspecified cerebrovascular disease, morbid obesity, hemiplegia…

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, interview, and facility documentation the facility staff failed to ensure safe practice for infection prevention for one 5 staff memebers in the kitchen.For the facility, the facility staff failed to ensure that hair covering was worn by all staff entering the kitchen area.On 10/29/25 at approximately 12:15 PM LPN #1 was observed as she walked from hall past surveyor and went into the kitchen. There were no hairnets at this entrance. Surveyor was standing in doorway entrance awaiting staff to get hairnets. LPN #1 was observed going into the kitchen and walking out of the surveyors view to the other side of the kitchen. Surveyor spoke to dietary staff who alerted the dietary manager.LPN #1 walked to the other kitchen entrance where the hairnets are located exited to the hallway and then came to the surveyor and stated Oh! I had the hairnet in my hand and forgot to put it on.On 10/29/25 at approximately 12:25 p.m. an interview was conducted with the dietary Manager who stated anyone in the kitchen must have hair net.On 10/30/25 during the end of day meeting 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, interview, clinical record review and facility documentation the facility staff failed to ensure Residents care plans were reviewed and revised for 1 Resident (#2) in a survey sample of 5 Residents. The findings included: For Resident #2 the facility staff failed to review and revise the care plan after the Resident exited the through a window in his room while on 1:1 supervision for exit seeking behavior. Resident #2 was admitted to the facility on [DATE] with diagnoses that included but were not limited to dementia, mood disorder and hypertension, paranoid personality, and anxiety. Resident #2's BIMS (Brief Interview of Mental Status) score on admission was 4/15 indicating severe cognitive impairment. Resident #2's most Minimum Data Set with an ARD (Assessment Reference Date) of 9/4/24 scored Resident #2 as having a BIMS of 1/15. The clinical record that Resident #2 was placed on 1:1 supervision for exiting seeking behaviors 5/28/24. On 7/12/24 at approximately 7 p.m. Resident #2 was able…

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, interview, clinical record review and facility documentation the facility staff failed to ensure each Resident receives adequate supervision to prevent accidents, for 1 Resident (#2) in a survey sample of 5 Residents. The findings included: For Resident #2 the facility staff failed to ensure adequate supervision resulting in Resident #2 exiting through a window in his room while on 1:1 supervision. Resident #2 was admitted to the facility on [DATE] with diagnoses that included but were not limited to dementia, mood disorder and hypertension, paranoid personality, and anxiety. Resident #2's BIMS (Brief Interview of Mental Status) score on admission was 4/15 indicating severe cognitive impairment. Resident #2's most Minimum Data Set with an ARD (Assessment Reference Date) of 9/4/24 scored Resident #2 as having a BIMS of 1/15. The clinical record that Resident #2 was placed on 1:1 supervision for exiting seeking behaviors on 5/28/24. On 9/30/24 Resident #2 was observed walking briskly around…

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 interview, clinical record review and facility documentation the facility staff failed to ensure Residents were free of significant medication errors for 2 Residents (#'s 1 & 3) in a survey sample of 5 Residents. The findings included: 1. For Resident #1 the facility staff failed to ensure insulin (both long-acting and short-acting) were administered per physician orders. On 10/1/24 a review of the clinical record revealed that Resident #1 had 2 orders for insulin. Resident #1 had orders for a long-acting insulin given twice a day and a short-acting insulin given prior to meals. The long- acting insulin orders were as follows: Insulin Glargine Solostar Subcutaneous Solution Pen-injector 100 Unit/ml [units per milliliter] Inject 37 unit subcutaneously two times a day related to Type 2 diabetes. Order Date-08/14/2024 This long-acting insulin was ordered for 9:00 a.m. and 9:00 p.m. A review of the MAR (Medication Administration Record) revealed the order times and the administration times. The following is a list of times that this order was not following in August 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 interviews and review of facility documents, the facility staff failed to verify through the Department of Health Professions certification of five of five newly hired (October 12, 2023) Certified Nursing Assistant (CNA), (CNA #11 through #15), in the survey sample. The findings included: A review was conducted on 1/24/24 of CNA #11 because the individual had been identified as rude to a resident and it was stated that the facility's staff failed to verify the employee's certification through the Department of Health Professions prior to hiring the individual. A review of the facility's abuse policy titled Abuse Policies and Elder Justice Guidance with a revision date of January 2023 read No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and/or misappropriation of personal property against any resident. Violation of this standard will subject employees to disciplinary action, including dismissal, provided herein. Further review of CNAs hired at the same time as CNA #11 revealed that four other CNAs were…

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 observations, staff interviews, and review of the clinical record the facility staff failed to ensure a resident not assessed to be safe to self administer medications be allowed to have medications left on the over the table to be self administered when desired for 1 of 29 residents (Resident #8), in the survey sample. The findings included: Resident #8 was originally admitted to the facility 9/22/2022 and remained a resident of the facility during the survey. The resident's diagnoses included; Thoracic (T) T2-T6 spinal cord injury and paraplegia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/24/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #8's cognitive abilities for daily decision making was intact. On 1/23/24 at approximately 1:35 PM during the initial tour, Resident #8 was observed with a clear plastic cup with many pills in it on the over the bed table. Also on the over the bed table were many empty clear medication cups. 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 interviews, clinical record review, and review of facility documents, the facility staff failed to protect 1 of 3 residents (Resident #28), in the survey sample from staff abuse. The findings included: Resident #28 was verbally abused by Certified Nursing Assistant # 16. Resident #28 was originally admitted to the facility [DATE] and the resident died in the facility on [DATE]. The resident's diagnoses included stroke with hemiparesis and dementia with behavioral disturbances. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired for daily decision making. A review of the resident's progress notes revealed that the resident intermittently yelled out and the staff would attempt to determine the cause and provide interventions. The resident's care plan which…

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, facility document review, and clinical record review, it was determined that the facility staff failed to report an allegation of abuse within two (2) hours to the State survey and certification agency for 1 of 28 residents in the survey sample, Resident #1. The findings include: For Resident #1, the facility failed to report an allegation of abuse to the State survey and certification agency within 2 hours. Resident #1 was originally admitted to the facility on [DATE]. The current diagnoses included Morbid Obesity, Generalized Muscle Weakness, and Chronic Obstructive Pulmonary Disease. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/18/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #1 cognitive abilities for daily decision-making were independent. In the section GG (Functional Abilities and Goals), the resident was coded as Dependent for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to provide incontinent care for a dependent resident for one Resident (Resident #1) in a survey sample of 28 residents. The findings included: For Resident #1, the facility failed to provide incontinent care for an alert and oriented dependent resident for approximately four hours. Resident #1 was originally admitted to the facility on [DATE]. The current diagnoses included Diabetes Mellitus, Depression, Obstructive Sleep Apnea, Morbid Obesity, Lymphedema, Generalized Muscle Weakness, and Chronic Obstructive Pulmonary Disease. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/18/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #1 cognitive abilities for daily decision making were independent. In section GG (Functional Abilities and…

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

Based on observation, resident interview, staff interview, clinical record review, facility document review and in the course of a complaint investigation, it was determined the facility staff failed to promote dignity for four of 66 residents in the survey sample, Residents #135, #87, #122 and #85. The findings include: 1. The facility staff failed to promote dignity during dining for Resident #135 (R135). R135 was served their breakfast 21 minutes after their roommate was served their tray on 8/16/2022 and 23 minutes after their roommate at lunchtime on 8/16/2022. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/25/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident is cognitively intact for making daily decisions. Section G documented R135 requiring extensive assistance of one person for bed mobility and personal hygiene. Section G further documented R135 having range of motion impairments in both upper extremities and requiring physical assistance…

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 3. The facility staff failed maintain the wall behind the head of the bed in Resident 81's (R81's) room in good repair. (R81) was admitted to the facility with diagnoses that included but were not limited to: a stroke. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 06/24/2022, coded (R81) as scoring a 15 out of 15 on the brief interview for mental status (BIMS) which indicated (R81) was cognitively intact for making daily decisions. On 08/15/2022 at 2:48 p.m., an observation of (R81's) room revealed gouges, scrapes and missing paint on the wall behind the head of the bed covering an area approximately two feet high by three feet long. On 08/16/2022 at 9:22 a.m., an observation of (R81's) room revealed gouges, scrapes and missing paint on the wall behind the head of the bed covering an area approximately two feet high by three feet long. On 8/17/22 at 9:25 a.m., OSM (other staff member) #4, the maintenance director, was interviewed. When asked…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, facility document review, and during the course of a complaint investigation, it was determined the facility staff failed to provide evidence that all required information was provided to the hospital staff for ten out of 66 residents in the survey sample that were transferred to the hospital; Resident #'s 29, 103, 135, 242, 120, 81, 94, 96, 85 and 102. The findings include: 1. The facility staff failed to evidence provision of required resident information to a receiving facility at the time of discharge for Resident #29. Resident #29 was transferred to the hospital on 5/14/22 and 6/23/22. Resident #29 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: spinal stenosis, hypertension and diabetes mellitus. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 5/26/22, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, facility document review, and in the course of a complaint investigation, it was determined the facility staff failed to provide evidence of written RP (responsible party) and/or ombudsman notification was provided when ten out of 66 residents in the survey sample were transferred to the hospital; Residents #'s 29, 103, 135, 242, 120, 81, 94, 96, 85 and 102. The findings include: 1. The facility staff failed to provide evidence of written ombudsman notification when Resident #29 was transferred to the hospital on 5/14/22 and 6/23/22. Resident #29 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: spinal stenosis, hypertension and diabetes mellitus. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 5/26/22, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that bed hold notification was provided when eight out of 66 residents in the survey sample who were transferred to the hospital; Residents # 29, 103, 135, 242, 94, 96, 85 and 102. The findings include: 1. The facility staff failed to provide evidence of that a bed hold notification was provided when Resident #29 was transferred to the hospital. Resident #29 was transferred to the hospital on 5/14/22 and 6/23/22. Resident #29 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: spinal stenosis, hypertension and diabetes mellitus. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 5/26/22, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for seven out of 66 residents in the survey sample, Residents #289, #290, #36, #291, #85, #95, and #61. The findings include: 1. For R289, the facility staff failed to implement the care plan to treat pressure ulcers on multiple dates in September and October 2021. On the most recent MDS (minimum data set), an admission assessment with an ARD of 9/7/21, R289 was coded as being severely cognitively impaired for making daily decisions, having scored five out of 15 on the BIMS (brief interview for mental status). R289 was coded as having one stage pressure ulcer. A review of R289's clinical record revealed an Initial Pressure Injury assessment dated [DATE]. R289 was documented to have a stage 2 pressure injury on the right buttock measuring 5 X 1.5 X 0 centimeters. Further…

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, clinical record review, facility document review and in the course of a complaint investigation, it was determined the facility staff failed to provide ADL (activities of daily living) care to dependent residents for three of 66 residents in the survey sample, Residents #135, #189, and #122. The findings include: 1. The facility staff failed to trim Resident #135's (R135) fingernails. R135 was observed to have long, thick, uneven fingernails on 8/15/2022. R135 was admitted to the facility with diagnoses that included but were not limited to paraplegia (1) and contracture of muscle, multiple sites (2). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/25/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. Section G documented R135 requiring 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to provide care and services to promote the highest level of well being for eight of 66 residents in the survey sample, Residents #290, #36, #85, #135, #71, #11, #116, and #122. The findings include: 1. For Resident #290, (R290) the facility staff failed to follow the provider's order to provide wound treatments on multiple days in September 2021. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 1/20/22, R290 was coded as having no cognitive impairment, having scored 15 out of 15 on the BIMS. The resident was coded as having no unhealed pressure ulcers, and as having other open lesions other than ulcers. On the MDS directly preceding the complaint dates, R290 was coded as having no cognitive impairment for making daily decisions. The resident was coded as having 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 resident interview, staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to provide treatment for pressure ulcers for three of 66 residents in the survey sample, Residents #95 (R95), #289 (R289), and #291 (R291). The findings include: 1. For R95, the facility staff failed to treat pressure ulcers per physician's order on multiple dates in June, July, and August 2022. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 7/5/22, R95 was coded as being severely cognitively impaired for making daily decisions. R95 was coded as receiving hospice services during the look back period. R95 was coded as having one unhealed stage 4 pressure ulcer. A review of R95's clinical record revealed the resident was admitted to hospice services on 7/3/2020. A review of R95's clinical record revealed an Initial Pressure Injury assessment dated [DATE].…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to monitor and maintain residents nutritional status to prevent significant weight loss for 2 of 66 residents in the survey sample; Residents #22 and #96. The findings include: 1. The facility staff failed to monitor the resident's nutritional status by failing to obtain weights as ordered, and thus not being able to identify and address a significant weight loss in a timely manner for Resident #22. Resident #22 was admitted to the facility on [DATE]. The most recent MDS (Minimum Data Set), a quarterly assessment with an ARD (Assessment Reference Date) of 5/24/22, coded the resident as being severely cognitively impaired in ability to make daily life decisions. A review of the clinical record revealed a physician's order written on 9/24/21 for monthly weights. This order was discontinued on 2/8/22 when the resident entered hospice services. A review of the clinical record revealed 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, clinical record review, and facility document review, it was determined that the facility staff failed to evidence ongoing communication with the dialysis center for two of 66 residents in the survey sample, Resident #93 and Resident #75. The findings include: 1. The facility staff failed to evidence ongoing communication with the dialysis center for Resident #93 (R93). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 7/11/2022, 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. Section O documented R93 receiving dialysis while a resident at the facility. On 8/15/2022 at 11:36 a.m., an interview was conducted with R93 in their room. R93 stated that they go to dialysis on Tuesdays, Thursdays and Fridays at an outside dialysis center. R93 stated that a book was sent between the dialysis center…

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 5. The facility staff failed to provide sufficient staffing to meet resident needs. During the entrance conference on 8/15/22 at approximately 11:30 AM with ASM (administrative staff member) #1, the administrator, a request for as worked staffing schedules from 7/1/22-7/31/22 was made. When asked during the entrance conference if there were any staffing waivers, ASM #1 stated, No, there are no waivers. On 8/15/22 at 12:30 PM, a request was made for the as worked staffing sheets from 11/1/21-12/30/21 as part of a complaint survey for all residents. As worked staffing sheets were provided on 8/16/22 at approximately 2:15 PM by ASM #3, the regional director of clinical services. As a part of the sufficient staffing facility task and a complaint investigation the as worked staffing sheets for July 2022 and November-December 2021 sheets were reviewed. A review of the as worked nursing schedule for July 2022 revealed, 1-2 CNAs (certified nursing assistants) scheduled on all three shifts (Days/Evenings/Nights) for…

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

Based on resident interview, staff interview and facility document review, it was determined the facility staff failed to serve food at a palatable temperature on one of three units, Unit B. The findings include: During the initial phase of the survey process, interviews were conducted with residents. The residents stated that the food did not taste good and was cold when they got it. Observation was made on 8/16/2022 at 11:30 a.m. of the kitchen tray line. The following foods were at the following temperatures: Baked ziti - 182.6 degrees Green beans - 167.2 degrees Tomato sauce - 160.2 degrees Puree ziti - 164.3 degrees Puree vegetables - 165.2 degrees Puree bread - 164 degrees Mashed potatoes - 163 degrees Egg salad sandwich - 40 degrees Buttered ravioli - 168 - degrees The last cart of trays were sent to the floor on B wing at 12:37 p.m. There was an enclosed cart of trays and an open cart of trays. The test try was on the open cart of trays. At 1:14 p.m. the last tray was served and the resident was being assisted with their meal. The test tray was tested by two surveyors, OSM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility document review, it was determined the facility staff failed to prepare and serve food in a sanitary manner in one of one kitchens and in one of three unit nourishment rooms. The findings include: 1. Observation was made on 8/15/2022 at approximately 11:00 a.m. of the kitchen. The walk in freezer was observed. There were three large icicles found on top of three opened boxes of food. The two icicles were approximately, six inches in length and approximately an inch to an inch and a half in diameter. The third icicle was approximately three inches in length and approximately and inch to an inch and a half in diameter. The three boxes were sitting on a milk crate and were opened. The boxes contained [NAME], pie shells and biscuits. A second observation was made of the freezer on 8/16/2022 at 11:16 a.m. The icicles were gone but the boxes remained on top of the milk crate in the same place on the left upon entry into the freezer. OSM (other staff member) #1, the…

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

Based on staff interview, facility document review, clinical record review and in the course of a complaint investigation it was determined that the facility staff failed to maintain an accurate clinical record for two of 66 residents in the survey sample, Resident #397 (R397) and #396 (R396). The findings include: 1. The facility staff failed to document the percentage of food consumed at each meal for (R397). (R397) was admitted to the facility with a diagnoses that included by not limited to: dementia (1). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 02/02/2022, the resident scored 9 (nine) out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately impaired of cognition intact for making daily decisions. Review of the ADL (activities of daily living) sheet for (R397) dated February 2022 under the heading Nutrition - Amount Eaten failed to evidence the percentage of meals consumed by (R397). Blanks were noted on 02/04/2022 at 8:00 a.m., 12:00 p.m. and at 5:00 p.m., 02/13/2022…

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 the dish washing machine in operating condition in one of one kitchens. The findings include: Observation was made of the kitchen on 8/15/2022 at 11:15 a.m. The staff were putting dishes through the dish machine. The wash temperature gauge was observed for three cycles of dishes going through the machine. The gauge never moved. OSM (other staff member) #1 observed and stated it didn't move. OSM #7, the dietary district manager, observed and stated that the kitchen staff would have to use paper/Styrofoam for the lunch meal until it was fixed. The dish machine log for the past four weeks was observed. The temperature for the wash cycle was documented between 160 -162 degrees. Observation was made in the kitchen on 8/16/2022 at 11:15 a.m. The repair person was in the kitchen working on the dish machine. OSM #1 stated one of the boards (electrical) was fried. The facility policy, Equipment documented in part, All foodservice equipment will be clean, sanitary 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, facility document review and employee record review, it was determined that the facility staff failed to provide annual required training for five of five CNA (certified nursing assistant) record reviews. The facility staff failed to provide the required mandatory training for abuse, neglect and dementia training for five of five CNAs that were employed for greater than one year, CNA #1, #2, #3, #4 and #5. The findings include: During the Sufficient and Competent Staffing facility task review on 8/16/22 at 4:00 PM it revealed no evidence of mandatory training for five of five CNA's (certified nursing assistants) reviewed. 1. CNA #1 with a date of hire of 12/16/16, evidenced no dementia or abuse training. 2. CNA #2 with a date of hire of 12/16/16, evidenced no dementia or abuse training. 3. CNA #3 with a date of hire of 6/11/18, evidenced no dementia or abuse training. 4. CNA #4 with a date of hire of 8/2/19, evidenced no dementia or abuse training. 5. CNA #5 with a date of hire of 5/2/17, evidenced no dementia or abuse training. An interview was conducted…

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

Based on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to honor a resident's right to make choices about their day to day care and schedule for one of 66 residents in the survey sample, Resident #93. The findings include: The facility staff failed to assist Resident #93 (R93) out of the bed in a timely manner as requested by the resident. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 7/11/2022, 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. Section G documented R93 being totally dependent on two or more staff for transfers. On 8/15/2022 at 11:36 a.m., an interview was conducted with R93 in their room. R93 was observed lying in bed with a gown on. R93's call light was observed to be on. R93 stated that they had only seen the nurse that morning and had not seen the CNA. R93 stated that they had been calling to…

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

Based on staff interview, clinical record review, facility document review and in the course of a complaint investigation, it was determined that the facility staff failed implement their neglect policy for reporting and investigating an allegation of neglect for one of 66 residents in the survey sample, Resident #396 (R396). The findings include: The facility staff failed to implement their policy regarding reporting and investigation an allegation of neglect to protect (R396). (R396) was admitted to the facility with diagnoses that included but were not limited to: Alzheimer's disease (1), On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 01/18/2022, the resident scored 0 (zero) out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired of cognition for making daily decisions. A Facility Reported Incident (FRI) dated 01/31/2022 documented, Incident Date: 01/29/2022. Incident type: Allegation of neglect. Describe the incident, including location and action taken:…

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 report an allegation of abuse in a timely manner for one of 66 residents in the survey sample, Resident # 396 (R396). The findings include: The facility staff failed to timely notify the State Agency when (R396's) family member reported an allegation of neglect on 01/29/2022. (R396) was admitted to the facility with diagnoses that included but were not limited to: Alzheimer's disease (1), On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 01/18/2022, the resident scored 0 (zero) out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired of cognition for making daily decisions. A Facility Reported Incident (FRI) dated 01/31/2022 documented, Incident Date: 01/29/2022. Incident type: Allegation of neglect. Describe the incident, including location and action taken: (Family Member) of resident (R396) reported that her mother was going to die because…

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 maintain a complete MDS (minimum data set) assessment for 1 of 66 residents in the survey sample, Resident #87. The facility staff failed to complete sections C-Cognitive Patterns and D-Mood on R87's annual MDS with an ARD (assessment reference date) of 6/30/22. The findings include: On the most recent MDS, a quarterly assessment with an ARD of 8/3/22, the resident scored 11 out of 15 on the BIMS (brief interview for mental status), indicating the resident is moderately cognitively impaired for making daily decisions. A review of R87's annual MDS assessment with an ARD of 6/30/22 revealed the facility staff failed to complete sections C-Cognitive Patterns and D-Mood. On 8/17/22 at 12:25 p.m., an interview was conducted with RN (registered nurse) #3, the MDS coordinator. RN #3 stated R87's annual MDS was originally scheduled for an ARD of 7/8/22 but the resident began therapy so the date was moved to 6/30/22 to capture therapy. RN #3 stated the social worker is responsible for completing sections C 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 clinical record review and staff interview it was determined that the facility staff failed to follow up as recommended on a Level II PASRR (preadmission screening and resident review) for one of 66 residents in the survey sample, Residents #11. The findings include: The facility staff failed obtain the Level II PASRR on admission to the facility, and follow up on the recommendation for a targeted resident review for 120 days after the assessment to assess progress and identify additional supports as needed for Resident #11 (R11). R11 was admitted to the facility with diagnoses that included but were not limited to schizophrenia and depression. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 5/9/2022, the resident scored 3 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired for making daily decisions. Review of R11's clinical record evidenced a UAI (uniform assessment instrument) dated 3/24/2021 which included a Level I PASRR. The Level I PASRR dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence PASARR (preadmission screening and resident review) screenings were completed for two of 66 residents in the survey sample, Residents #127 and #87. The findings include: 1. The facility failed to ensure a PASARR was completed upon admission for Resident #127. Resident #127 was admitted to the facility on [DATE]. Resident #127's diagnoses included but were not limited to: CKD (chronic kidney disease). Resident #127's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 7/22/22, coded the resident as scoring 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of Resident #127's clinical record failed to reveal evidence of completion of a PASARR either prior to or on admission on [DATE]. On 8/16/22 a PASARR dated 8/15/22 for Resident #127 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to develop and implement an accurate baseline care plan for one of 66 residents in the survey sample, Resident #140; and failed to provide a baseline care plan to the resident and/or responsible party for one of 66 residents in the survey sample, Resident #396. The findings include: 1. For Resident #140 (R140), the facility staff failed to complete and implement an accurate baseline care plan regarding CPR. R140 was admitted to the facility on [DATE]. R140's admission assessment, dated [DATE], documented the resident's neurological status as alert and nonverbal. The resident expired in the facility on [DATE]. A review of R140's clinical record revealed the following, documented on a Doctor's Order Sheet: [DATE] Admit patient to [name of hospice company] under routine level of care for dementia. Patient is a full code. A review of R140's providers' orders throughout the four days of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to review and revise the comprehensive care plan for 3 out of 66 residents in the survey sample; Residents #22, #96, and #102. The findings include: 1. For Resident #22, the facility staff failed to review and revise the comprehensive care plan to include actual weight loss when the resident was identified as having lost 17.58% in approximately 20 weeks. On 09/23/2021, the resident weighed 91 lbs. On 02/15/2022, the resident weighed 75 pounds which is a -17.58 % loss in approximately 21 weeks. Resident #22 was admitted to the facility on [DATE]. The most recent MDS (Minimum Data Set), a quarterly assessment with an ARD (Assessment Reference Date) of 5/24/22, coded the resident as being severely cognitively impaired in ability to make daily life decisions. A review of the clinical record revealed a physician's order written on 9/24/21 for monthly weights. This order was…

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

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to ensure residents were free of accidents and hazard risks for 2 of 66 residents in the survey sample, Residents #87 and #120. 1. The facility staff failed to ensure a physician ordered fall mat was on the floor while Resident #87 (R87) was lying in bed. 2. The facility staff failed to check the placement and function of the wander guard according to the physician's orders for Resident #120. The findings include: 1. For R87, on the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/3/22, the resident scored 11 out of 15 on the BIMS (brief interview for mental status), indicating the resident is moderately cognitively impaired for making daily decisions. R87's comprehensive care plan dated 8/30/19 documented, Fall Mat beside bed. A review of R87's clinical record revealed a physician's order dated 11/27/19 for a fall mat while the resident is in bed. R87's kardex dated 3/1/22 documented, ASSISTIVE DEVICES: Fall…

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, clinical record review, and facility document review, it was determined that the facility staff failed to provide respiratory care and services per physician orders to three of 66 residents in the survey sample, Residents #93, #59 and #116. The findings include: 1. The facility staff failed to provide oxygen at the prescribed rate for Resident #93 (R93). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 7/11/2022, 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. Section O documented R93 receiving oxygen while a resident at the facility. On 8/15/2022 at 11:36 a.m., an interview was conducted with R93 in their room. R93 stated that they wore oxygen all the time. R93 was observed wearing an oxygen cannula attached to an oxygen concentrator. The flow meter was observed to be set between the 1.5…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to implement bed rail requirements for three out of 66 residents in the survey sample, Residents #127, 106 and 102. The findings include: 1. The facility staff failed to evidence review of the risks / benefits and failed to obtain informed consent for the use of bed rails for Resident #127. Resident #127 was admitted to the facility on [DATE]. Resident #127's diagnoses included but were not limited to: CKD (chronic kidney disease), hypertension and diverticulitis. Resident #127's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 7/22/22, coded the resident as scoring 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. MDS Section G- Functional Status: coded the resident as independent in bed mobility, transfers, walking, locomotion, dressing, eating, toilet use,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, facility document review, and in the course of a complaint investigation, it was determined the facility staff failed to provide routine dental services for one of 66 residents in the survey sample, Resident #189. The findings include: Resident #189 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: dementia and hemiplegia. The most recent MDS (minimum data set) assessment, a Medicare 5 day assessment, with an ARD (assessment reference date) of 3/27/21, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as being total dependent for transfers, dressing, locomotion, bathing; requiring extensive assistance for bed mobility/hygiene and supervision for eating. A review of the comprehensive care plan dated 7/10/14 documented in part, FOCUS: At risk for dental…

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, the facility staff failed to provide an alternative meal choice in a timely manner for one of 66 residents in the survey sample, Resident #87. On 8/15/22, Resident #87 (R87) refused lunch and requested peanut butter and jelly sandwiches. R87 did not receive the sandwiches until 5:03 p.m. The findings include: On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/3/22, the resident scored 11 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately cognitively impaired for making daily decisions. On 8/15/22 at 3:53 p.m., an interview was conducted with R87. R87 stated he did not want his lunch that day and had requested peanut butter and jelly sandwiches but did not receive them. On 8/15/22 at 3:56 p.m., R87's request for peanut butter and jelly sandwiches was reported to the resident's nurse. On 8/15/22 at 4:48 p.m., R87 did not have any peanut butter and jelly sandwiches. 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, facility document review and clinical record review, the facility staff failed to provide meals at regular times comparable to normal meal times for 2 of 66 residents in the survey sample, Residents #57 and #31. The facility staff failed to serve meals in a timely manner to Resident #57 (R57) and Resident #31 (R31) on 8/15/22. The findings include: On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/14/22, R57 scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. On 8/15/22 at 11:32 a.m., an interview was conducted with R57. R57 stated the resident had to ring the call bell and ask about breakfast because the resident had not received any food this morning. R57 stated the resident did not receive breakfast until 10:00 a.m. On the most recent MDS, an annual assessment with an ARD of 5/27/22, R31 scored 14 out of 15 on the BIMS (brief interview for mental status), indicating…

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

Based on staff interview, facility document review and employee record review, it was determined that the facility staff failed to evidence maintenance of required certification for two of five CNA (certified nursing assistant) record reviews. The facility staff failed to provide the evidence of required certification for two of five CNAs that were employed for greater than one year, CNA #2 and CNA #4. The findings include: During the Sufficient and Competent Staffing facility task review on 8/16/22 at 4:00 PM, it revealed that CNA #2's certification was pulled from the Virginia Department of Health Professions on 6/22/22 and had an expiration date of 9/30/22. CNA #2 was hired on 12/16/16. CNA #4's certification was pulled from the Virginia Department of Health Professions on 5/25/22 and had an expiration date of 4/30/23. CNA #4 was hired on 8/2/19. On 8/16/22 at 5:00 PM, ASM #3, the regional director of clinical services, stated the licenses are what was provided. On 8/17/22 at 11:15 AM, OSM #5, the human resources generalist, brought the files of CNA #2 and CNA #4. A review of the…

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

Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain a complete infection control program during the medication administration observation for Resident #20, and failed to implement infection control practices for the storage of a resident's Yankauer suction catheter for one of 66 residents in the survey sample, Resident #112 (R112). The findings include: 1. The facility staff failed to use hand hygiene after giving medications to a resident and before preparing and administering medication to a second resident. Observation was made on 8/16/2022 at 8:14 a.m. of LPN (licensed practical nurse) #3. LPN #3 prepared Resident #56's six oral medications and Timolol Maleate eye drops. LPN #3 administered the oral medications. She put on gloves and administered the prescribed eye drops. LPN #3 left the resident's room and discarded her gloves in the trash can attached to the medication cart, removed her keys from her pocket, moved the medication cart down to the next room without washing her hands…

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

Based on observation, staff interview, and facility document review, it was determined the facility staff failed to ensure one of one kitchens were free of ants. The findings include: Observation was made on 8/15/2022 at approximately 11:00 a.m. of the kitchen. The food storage room was observed. The locked storage area of the food storage room was observed. There were ants crawling across the bar across the mid-section of the steel mess door. When asked if he had observed them, OSM (other staff member) #1, the dietary manager, stated he had been working with the pest control company to get rid of them. All shelves were observed and the ants were not observed in any other areas other than the steel mess door. OSM (other staff member) #1, the dietary manager, stated the facility had had the pest control company in to take care of this. A second observation was made on 8/16/2022 at 11:16 a.m. Ants were again observed crawling across the bar across the mid-section of the steel mess door. There was no ant traps visible in the storage room where the ants were observed. The pest control…

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 develop and implement the comprehensive care plan for four of 52 residents in the survey sample, Residents #22, #47, #58 and #35. The findings include: 1. The facility staff failed to implement Resident #22's comprehensive care plan for checking the resident's skin under the resident's elbow splints every shift. Resident #22 was admitted to the facility on [DATE]. Resident #22's diagnoses included but were not limited to anoxic brain damage (1), contractures (2) of the right elbow, left elbow and right hand, and anxiety disorder. Resident #22's quarterly MDS (minimum data set) with an ARD (assessment reference date) of 1/1/21 coded the resident's cognitive skills for daily decision making as severely impaired. Section G coded Resident #22 as requiring total dependence of two or more staff with bed mobility and transfers. Review of Resident #22's clinical record revealed…

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

Based on observation, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to provide respiratory care consistent with professional standards of practice, the comprehensive person-centered care plan for three of 52 residents in the survey sample, Residents # 47, # 58 and #35. The facility staff failed to administer oxygen to Resident # 47, #58 and #35 at the prescribed flow rate according to the physician's orders. The findings include: 1. The facility staff failed to maintain Resident # 47's oxygen flow rate at three liters per minute according to the physician's orders. Resident # 47 was admitted to the facility with diagnoses that include but not limited to: chronic obstructive pulmonary disease [1]. Resident # 47 was admitted to the facility with diagnoses that include but not limited to: chronic obstructive pulmonary disease (COPD) [1]. Resident # 47's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 01/22/2021, coded Resident # 47 as scoring a 14 on the brief…

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

Based on resident interview, clinical record review, facility document review and staff interview, it was determined that the facility staff failed to evidence a complete and current communication plan with the dialysis (1) center for one of three residents receiving dialysis, Resident #57. The findings include: Resident #57 was admitted to the facility with diagnoses that included but were not limited to end stage renal disease (2) and diabetes mellitus (3). Resident #57's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/28/2021, coded Resident #57 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15- being cognitively intact for making daily decisions. On 3/17/2021 at approximately 9:35 a.m., an interview was conducted with Resident #57 in their room. Resident #57 stated that they go to the dialysis center on Tuesday, Thursday and Saturdays. Resident #57 stated that there was a book that was sent with them when they went to dialysis. The physician's orders for Resident #57 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 staff interview, facility document review and employee record review, it was determined the facility staff failed to complete annual performance reviews and competencies for six of 22 CNAs (certified nursing assistants) that were employed for greater than one year, CNA #3, CNA #4, CNA #5, CNA #6, CNA #7, and CNA #8. The findings include: A request was made on 3/16/2021 at 4:36 p.m. for the annual evaluations and a copy of the recent competencies completed for CNA #3, CNA #4, CNA #5, CNA #6, CNA #7, and CNA #8. CNA hire dates are as followed: CNA #3 - 12/16/2016 CNA #4 - 12/16/2016 CNA #5 - 12/16/2016 CNA #6 - 12/16/2016 CNA #7 - 12/16/2016 CNA #8 - 1/24/2019 ASM (administrative staff member) #1, the administrator, sent an email that documented, The HR (human resources) manager could not locate the annual evaluations and competencies for CNA #3, CNA #4, CNA #5, CNA #6, and CNA #8. An annual Performance Review Form was located on CNA #7. The Performance Review Form was dated 2/19/19. On 3/17/2021 at 2:01 p.m., the administrator was asked by email which staff was responsible…

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, clinical interview and facility document review it was determined facility staff failed to secure prescribed medications for one of 52 residents in the survey sample, (Resident #104) and failed to label and store drugs and biologicals in a safe and secure manner in two of six medication carts, (Wing A medication cart-one, Wing A medication cart-two), and failed to ensure expired medications and biologicals were not available for use, in two of six medication carts and one of three medication storage rooms, (Wing A medication cart-one, Wing A medication room and Wing B medication cart-one). The findings include: 1. The facility staff failed to secure a Ventolin (1) and a Breo (2) inhaler that were available for use on a folding table inside of Resident #104's room. Resident #104 was admitted to the facility with diagnoses that included but were not limited to malignant neoplasm of the lung (3) and chronic obstructive pulmonary disease (COPD) (4). Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility document review it was determined facility staff failed to ensure confidentiality and privacy of medical information for one of 52 residents in the survey sample, Resident #50. A facility staff member and a hospice nurse were heard and observed discussing Resident #50's medical information in the hallway, with Resident #78 present in the hallway. The findings include: On 3/17/2021 at approximately 10:00 a.m., observation on the hallway of the facility C unit revealed RN (registered nurse) #2 and the visiting hospice nurse. The visiting hospice nurse was heard asking RN #2 how Resident #50 was doing. RN #2 proceeded to discuss Resident #50's condition including pain management with the visiting hospice nurse for approximately two minutes. Resident #78 was observed in their electric wheelchair stopped in the hallway approximately four feet away. Resident #78 was admitted to the facility with diagnoses that included but were not limited to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to follow professional standards of practice for documentation of a resident assessment for one of 52 residents in the survey sample, Resident #118. The facility staff failed to document in the clinical record the assessment completed to determine and declare the death of Resident #118 on 3/3/2021. The findings include: Resident #118 was admitted to the facility on [DATE] with a recent readmission on [DATE] with diagnoses that included but were not limited to: high blood pressure, dementia (1), pain, depression and atrial fibrillation. (2) The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 3/1/2021, coded the resident as having both long and short term memory difficulties and was coded as being severely impaired to make daily cognitive decisions. Resident #118 was coded as requiring extensive assistance to being dependent upon one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide ADL (activities of daily living) care for one of 52 residents in the survey sample, Resident #75, who was coded as dependant on staff for personal hygiene. The facility staff failed to provide nail care to Resident #75. Resident #75 was observed with long nails and a jagged broken nail on the middle finger of the left hand. The findings include: The facility staff failed to provide ADL (activities of daily living) care, specifically nail care for a dependent resident, Resident #75. Resident #75 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: cerebro- vascular accident (hemorrhage or blockage of vessels to the brain leading to lack of oxygen) (1), paraplegia (paralysis of lower limbs with loss of sensory or motor function) (2) and post-traumatic stress disorder (mood disorder occurring after an event in which the person persistently…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure that residents receive treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan for one of 52 residents in the survey sample, Resident #77. The facility staff failed to follow the physician's order for thickened liquids during the medication administration for Resident #77. On 3/17/21 at approximately 9:05 a.m., Resident #77 was administered their medication with regular water. The findings include: Resident #77 was admitted to the facility with diagnoses that included but were not limited to dysphagia (1) and dementia (2). Resident #77's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 02/12/2021, coded Resident #77 as scoring a 10 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 10- being moderately impaired for making daily decisions. Section…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement professional standards of practice for the prevention of a pressure injury for one of 52 residents in the survey sample, Resident #22. The facility staff failed to frequently assess the skin under Resident #22's splints. On 12/15/20, the resident developed a pressure injury on the right arm. The findings include: Resident #22 was admitted to the facility on [DATE]. Resident #22's diagnoses included but were not limited to anoxic brain damage (1), contractures (2) of the right elbow, left elbow and right hand, and anxiety disorder. Resident #22's quarterly MDS (minimum data set) with an ARD (assessment reference date) of 1/1/21 coded the resident's cognitive skills for daily decision making as severely impaired. Section G coded Resident #22 as requiring total dependence of two or more staff with bed mobility and transfers. Section M coded the resident as having a stage 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 and clinical record review, it was determined that the facility staff failed to ensure the medication regimen was free from unnecessary medications for one of 52 residents in the survey sample, Resident # 35. The facility staff failed to attempt or implementation non-pharmacological interventions prior to the administration of as needed pain medication to Resident #35. The findings include: Resident # 35 was readmitted to the facility with diagnoses that included but were not limited to: cancer of the vulva [1] and pain. Resident # 35's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 01/14/2021, coded Resident # 35 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Section J0300, J0400 and J0600 Pain Assessment Interview coded Resident # 35 as having frequent pain at a level of 5 [five] on a pain scale of zero to ten, with ten being the worse pain. The current physician's order dated 01/09/2020…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain an accurate clinical record for three of 52 residents in the survey sample, Residents #22, #118 and #35. The findings include: 1. The facility staff failed to document the accurate stage of a pressure injury that Resident #22 developed on [DATE] Resident #22 was admitted to the facility on [DATE]. Resident #22's diagnoses included but were not limited to anoxic brain damage (1), contractures (2) of the right elbow, left elbow and right hand, and anxiety disorder. Resident #22's quarterly MDS (minimum data set) with an ARD (assessment reference date) of [DATE] coded the resident's cognitive skills for daily decision making as severely impaired. Section M coded the resident as having a stage 2 pressure injury (3). Review of Resident #22's clinical record revealed a nurse's note dated [DATE] that documented, Situation: open area under right under arm. Background: contracted,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to assess two of five residents in the immunization review, Residents # 75 and # 46. The findings include: 1. For Resident #75, the facility staff failed to offer and provide the resident the opportunity to receive or decline the influenza vaccine for this influenza season. Resident #75 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: stroke (1), paraplegia (2), and high blood pressure. The most recent MDS (minimum data set) assessment, with an assessment reference date of 2/10/2021, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was capable of making daily cognitive decisions. The resident was coded as requiring extensive assistance of one or more staff members for all of his activities of daily living. In Section O - Special Treatments, Procedures, and Programs, the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 10. The facility staff failed to evidence that Resident #163 and/or their Responsible Party (RP) was provided with written information and the opportunity to formulate advance directives at the time of admission and that periodic reviews were conducted with the resident and/or their RP to ascertain if they wished to formulate advance directives. Resident #163 was admitted to the facility on [DATE]; diagnoses included but are not limited to paranoid schizophrenia, insomnia, diabetes, and major depressive disorder. The most recent MDS (Minimum Data Set), a quarterly assessment, with an ARD (Assessment reference date) of 5/5/19, coded the resident as scoring a 15 out of 15 on the BIMS (Brief Interview for Mental Status) score, indicating the Resident had no cognitive impairment for daily decision making. A review of the clinical record failed to reveal any evidence of an Advance Directive being completed for Resident #163. Further review of the clinical record failed to reveal any evidence that written and verbal…

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 4. The facility staff failed to notify Resident #92's physician when the resident presented with a significant weight gain in March 2019. Resident #92 was admitted to the facility on [DATE]. Resident #92's diagnoses included but were not limited to diabetes, heart failure and anxiety disorder. Resident #92's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/5/19, coded the resident as being cognitively intact. Section K inaccurately coded Resident #92 as having a weight loss of five percent or more in the last month or weight loss of ten percent or more in the last six months. Review of Resident #92's clinical record revealed the following weights: 10/18/18- 147.4 pounds 3/18/19- 169.2 pounds (14.79 percent gain since 10/18/18) 4/1/19- 166 pounds (12.62 percent gain since 10/18/18) A nutritional assessment dated [DATE] and signed by a dining services employee documented a weight gain greater than five percent in 30 days, greater than seven and a half percent…

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 written notification to the resident/representative and/or ombudsman regarding transfers to the hospital for six of 71 residents in the survey sample, Residents #70, #140, #92, #50, #157, and #96. 1. Resident #70 was transferred to the hospital on 5/6/19. The facility staff failed to provide written notification of the transfer to Resident #70 and/or the resident's representative. 2. Resident #140 was transferred to the hospital on 4/16/19. The facility staff failed to provide written notification of the transfer to Resident #140 and/or the resident's representative. 3. Resident #92 was transferred to the hospital on 3/28/19. The facility staff failed to provide written notification of the transfer to Resident #92 and/or the resident's representative. 4. The facility staff failed to provide written notification to the resident and/or resident representative for Resident #50's transfer to the hospital…

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 6.a. The facility staff failed to implement Resident #144's comprehensive care plan for left gluteal fold (an area associated with the buttocks) wound care on 6/8/19. Resident #144 was admitted to the facility on [DATE]. Resident #144's diagnoses included but were not limited to heart failure, pain and diabetes. Resident #144's most recent MDS (minimum data set), a significant change in status assessment with an ARD (assessment reference date) of 4/29/19, coded the resident as being cognitively intact. Section G coded Resident #144 as requiring extensive assistance of two or more staff with bed mobility. Review of Resident #144's clinical record revealed an initial non-decubitus (pressure) skin injury record dated 5/9/19 that documented Resident #144 presented with a left gluteal fold abrasion. Resident #144's comprehensive care plan dated 5/9/19 documented, Altered skin integrity non pressure related to: Open Lesions to left gluteal fold related (sic) non compliance of off loading, reposition (sic) in bed, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure three of 71 residents in the survey sample, received care and services in accordance with professional standards and the comprehensive care plan for Residents #158, #96, #157 and #144. 1. The facility staff failed to administer medications, Lasix and Digoxin to Resident #158 per the physician orders. 2. The facility staff failed to administer medication, Digoxin, per the physician orders for Resident #96. 3. The facility staff failed to administer an antibiotic per the physician order for Resident # 157. 4. The facility staff failed to provide treatment per physician's order for Resident #144's left gluteal fold (an area associated with the buttocks) abrasion on 6/8/19. The findings include: 1. The facility staff failed to administer medications, Lasix and Digoxin to Resident #158 per the physician orders. Resident #158 was admitted to the facility on [DATE] with a readmission on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to provide respiratory services consistent with professional standards of practice, the comprehensive person-centered care plan for four of 71 residents in the survey sample, Resident #158, #157, #76 and #27. 1. The facility staff failed to administer oxygen per the physician order for Resident #158. 2. The facility staff failed to store oxygen tubing in a sanitary manner for Resident #157. 3. The facility staff failed to administer oxygen per the physician order for Resident # 76. 4. The facility staff failed to obtain a physician's order for Resident #27's use of an incentive spirometer (1) and failed to ensure the incentive spirometer (1) mouthpiece in a clean and sanitary manner. The findings include: 1. The facility staff failed to administer oxygen per the physician order for Resident #158. Resident #158 was admitted to the facility on [DATE] with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to provide pharmacy services for three of 71 residents in the survey sample, Residents # 158, #96 and #76. 1. The facility staff failed to provide the medication Apixaban for administration to Resident #158 as ordered by the physician. 2. The facility staff failed to provide the medications Potassium Chloride Solution, Keppra, Carvedilol, and Tramadol for administration to Resident #96 as ordered by the physician. 3. The facility staff failed to provide medication Tramadol for administration to Resident #76 as ordered by the physician. The findings include: 1. The facility staff failed to provide the medication Apixaban for administration to Resident #158 as ordered by the physician. Resident #158 was admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses that included but were not limited to: Stroke, COPD (chronic obstructive pulmonary disease - general term for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to maintain a clean, comfortable, homelike environment for three of 71 residents in the survey sample, Residents #135, #51 and #30. 1. The facility staff failed to maintain Resident #135's pillowcase in good repair. 2. The facility staff failed to maintain a pillow in Resident #51's former room in good repair. 3. The facility staff failed to maintain Resident # 30 bed pillows in good repair. The findings include: 1. Resident #135 was admitted to the facility on [DATE]. Resident #135's diagnoses included but were not limited to paralysis, difficulty swallowing and personal history of traumatic brain injury. Resident #135's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/28/19, coded the resident as being cognitively intact. Section G coded Resident #135 as being totally dependent for bed mobility 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, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to implement abuse policies for two of ten employee records (OSM [other staff member] #9 and OSM #10). The facility staff failed to implment the abuse policy to obtain reference checks at the time of hire for Other Staff Member (OSM) #10 and OSM #9. The findings include: The facility staff failed to implement abuse policies for the screening and hiring of new employees regarding obtaining reference checks for two of 10 employee records reviewed; Other Staff Member (OSM) #10 and OSM #9. On 6/13/19 at 9:43 AM, a review of 10 employee records was conducted. These were of employees hired between February 2019 and May 2019. The following concerns were identified; 1. There were no reference checks for OSM (Other Staff Member) #9 (a housekeeper) who was hired on 5/28/19. 2. There were no reference checks for OSM #10 (a housekeeper) who was hired on 2/6/19. On 6/14/19, at 10:24 AM, an interview with OSM #6, the Human…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to complete quarterly MDS (minimum data set) assessments for three of 71 residents in the survey sample, Residents #1, #2, and #3. 1. The facility staff failed to complete Resident #1's quarterly MDS assessment at least every 92 days. The last MDS assessment completed was the admission assessment with an assessment reference date of 1/18/19. 2. The facility staff failed to complete Resident # 2's quarterly MDS assessment at least every every 92 days. The resident's most recent completed MDS was a quarterly assessment with an ARD (assessment reference date) of 01/16/2019. 3. The facility staff failed to complete Resident # 3's quarterly MDS assessment at least every every 92 days. The resident's most recent completed MDS assessment was an admission assessment with an ARD of 02/01/19. The findings include: 1. The facility staff failed to complete Resident #1's quarterly MDS assessment 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 and clinical record review, it was determined that the facility staff failed to maintain a complete and accurate MDS (minimum data set) assessment for two of 71 residents in the survey sample, Resident #30 and # 92. 1. The facility staff failed to attempt the BIMS (Brief Interview for Mental Status) interview and the Mood interview for Resident #30's quarterly MDS assessment with an ARD (assessment reference date) of 3/12/19. 2. The facility staff failed to accurately code Resident #92's weight gain on a quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 4/5/19. Instead, the resident was coded as having a weight loss. The findings include: 1. Resident # 30 was admitted to the facility on [DATE] with diagnoses that included but were not limited to dementia (1), depressive disorder, (2), and anxiety (3). Section B of Resident #30's most recent MDS, a quarterly assessment with an ARD of 3/12/19, documented the resident was understood. Section C of the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, it was determined that the facility staff failed to develop a complete baseline care plan for one of 71 residents in the survey sample, Resident #27. The facility staff failed to address Resident #27's use of an incentive spirometer (1) on the resident's baseline care plan. The findings include: Resident #27 was admitted to the facility on [DATE], and was readmitted to the facility on [DATE]. Resident #27's diagnoses included but were not limited to asthma, chronic pain syndrome and anxiety disorder. Resident #27's most recent MDS (minimum data set), a significant change in status assessment with an ARD (assessment reference date) of 3/11/19, coded the resident as being cognitively intact. Section G coded Resident #27 as requiring supervision with bed mobility and transfers. Review of Resident #27's clinical record failed to reveal a physician's order for an incentive spirometer. Review of Resident #27's baseline care plan, implemented on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, resident representative interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide ADL (activities of daily living) care for one of 71 residents in the survey sample, Resident #29. On 5/26/19 during the day shift, the facility staff failed to assist Resident #29 out of bed. The findings include: Resident #29 was admitted to the facility on [DATE]. Resident #29's diagnoses included but were not limited to stroke, major depressive disorder and chronic pain. Resident #29's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 1/22/19 coded the resident as being cognitively intact. Section G coded Resident #29 as requiring extensive assistance of one staff with bed mobility. On 6/11/19 at 2:05 p.m., an interview was conducted with Resident #29 and his representative. During the interview, Resident #29's representative voiced concern that Resident #29 was not assisted out of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined the facility staff failed to provide the necessary treatment and services, consistent with professional standards of practice, to promote healing of pressure ulcer for two of 71 residents in the survey sample, Residents #217 and #144. 1. The facility staff failed to administer the prescribed physician ordered treatment to Resident #217's pressure injuries* on multiple dates in September 2018 and on 10/18/18. The October 2018 TAR documented the above order. On 10/8/18, for Resident #217. 2. The facility staff failed to provide treatment per physician's order for Resident #144's sacral pressure injury on 6/8/19. The findings include: 1. The facility staff failed to administer the prescribed physician ordered treatment to Resident #217's pressure injuries* on multiple dates in September 2018 and on 10/18/18. . *A pressure injury is localized damage to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility document review, it was determined the facility staff failed to implement assistive device interventions, per the plan of care to prevent accidents for one of 71 sampled residents, (Resident #50). Resident #50 was observed in bed with no fall mat down at the bedside and the bed was in an elevated position. The findings include: Resident #50 was admitted to the facility on [DATE] with a readmission on [DATE], with diagnoses that included but were not limited to: dementia, high blood pressure, and repeated falls. The most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 2/26/19, coded the resident as scoring a 9, indicating that the resident was moderately impaired to make daily cognitive decisions. The resident was coded in Section G - Functional Status, as requiring extensive assistance of one or more staff members for all of her activities of daily living. Observation was made of Resident #50 on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement bed rail requirements for three of 71 residents in the survey sample, Residents #144, #29 and #140. 1. The facility staff failed to assess Resident #144 for risk of entrapment, review risks and benefits and obtain informed consent prior to the installation of bed rails. 2. The facility staff failed to assess Resident #29 for risk of entrapment, review risks and benefits and obtain informed consent prior to the installation of bed rails. 3. The facility staff failed to assess Resident #140 for risk of entrapment, review risks and benefits and obtain informed consent prior to the installation of bed rails. The findings include: 1. The facility staff failed to assess Resident #144 for risk of entrapment, review risks and benefits and obtain informed consent prior to the installation of bed rails. Resident #144 was admitted to the facility on [DATE]. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, resident representative interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain sufficient nursing staff to care for a resident's needs for one of 71 residents in the survey sample, Resident #29. On 5/26/19 during the day shift, the facility staff failed to assist Resident #29 out of bed due to insufficient CNA (certified nursing assistant) staffing. The findings include: Resident #29 was admitted to the facility on [DATE]. Resident #29's diagnoses included but were not limited to stroke, major depressive disorder and chronic pain. Resident #29's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 1/22/19 coded the resident as being cognitively intact. Section G coded Resident #29 as requiring extensive assistance of one staff with bed mobility. On 6/11/19 at 2:05 p.m., an interview was conducted with Resident #29 and his representative. During the interview,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review it was determined the facility staff failed to report an irregularity to the physician during the MRR (Medication Regimen Review) for one of 71, sampled resident, Resident #158. The facility pharmacist at the last completed medication regimen review dated 6/7/19, failed to make a recommendation to the physician requesting a documented rational for the continued use of a PRN (as needed) anti-anxiety medication ordered on 4/29/`19 for Resident #158. The findings include: Resident #158 was admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses that included but were not limited to: Stroke, COPD (chronic obstructive pulmonary disease - general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis) (1) high blood pressure, atrial fibrillation (a condition characterized by rapid and random contraction of the atria of the heart causing irregular beats 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 staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure PRN (as needed) psychotropic medications were reviewed for continued use every 14 days for one of 71 residents in the survey sample, Resident #158. Resident #158 had a physician order for a PRN anti-anxiety medication that was prescribed on 4/29/19; there was no documentation in the clinical record by the physician for the continued use of this medication. Forty-five days had elapsed since the initial order. The findings include: Resident #158 was admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses that included but were not limited to: Stroke, COPD (chronic obstructive pulmonary disease - general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis) (1) high blood pressure, atrial fibrillation (a condition characterized by rapid and random contraction of the atria of the heart causing irregular…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure two of 71 residents in the survey sample were free of significant medication errors, Resident #96 and Resident #158. 1. The facility staff failed to administer Digoxin to Resident #96 as prescribed on 5/22/19 and 5/24/19. 2. The facility staff failed to administer Digoxin to Resident #158 as prescribed on two occasions and Lasix on two occasions. The findings include: 1. The facility staff failed to administer Digoxin to Resident #96 as prescribed on 5/22/19 and 5/24/19. Resident #96 was admitted to the facility on [DATE] with a recent readmission on [DATE], with diagnoses that included but were not limited to: anoxic brain damage (occurs when there is not enough oxygen getting to the brain. The brain needs a constant supply of oxygen and nutrients to function.) (1), depression, high blood pressure, and atrial fibrillation (a condition characterized by rapid and random contraction…

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 ensure a complete and accurate clinical record for one of 71 residents in the survey sample, Resident # 157. The facility staff failed to ensure another resident's information was not in the clinical record of Resident #157. The findings include: Resident # 157 was admitted to the facility on [DATE] with a recent readmission on [DATE], with diagnoses that included but were not limited to: dementia, depression fractured hip, and anxiety disorder. The most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 5/3/19, coded the resident as scoring a 3 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired to make daily cognitive decisions. Upon review of the clinical record, a document dated, 5/6/19, from a Vascular Surgery OP (out-patient) Visit was located in the clinical record. This document belonged to another…

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.