Hampton Health & Rehab Center, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to ensure residents were free of significant medication errors for 1 of 9 closed record reviews. (Resident #279). The findings were: For Resident #279, facility staff failed to administer Insulin Lispro (1 Unit dial) Solution Pen-Injector 100 UNIT/ML according to hospital discharge orders. Resident #279's stay at the facility was approximately two (2) days. The admission record listed diagnoses which included but not limited to sepsis, and osteomyelitis, left ankle and foot. The acute care hospital discharge summary listed the active problem of type 2 diabetes mellitus with complication, with long-term current use of insulin. Resident #279's minimum data set (MDS) [NAME] Report listed the resident's cognition having ok short-term and long-term memory. The resident was able to recall the season, room location, staff names/faces, and that the resident was in a nursing home. The MDS [NAME] read the resident was independent with daily…

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

Based on staff interview, clinical record review, and facility document review, the facility staff failed to obtain a provider ordered laboratory test for 1 of 22 residents, Resident #20. The findings included: For resident # 20, the facility staff failed to obtain a Depakote level on 11/22/23 per physician's order. Resident # 20's diagnoses included but were not limited to unspecified dementia, bipolar disorder and depression. Resident # 20's minimum data set (MDS) assessment with an assessment reference date of 6/8/24 indicated that resident is severely cognitively impaired, they are rarely/never understood, rarely never understands others and decision making is severely impaired as well. During a review of resident # 20's Medication Regimen Reviews for the last year, a pharmacist Consultation Report with a date of 12/19/23, read in part, .has orders for labs but at the time of this review they were not available in the medical record. The missing lab values include: Depakote level every Wed related to bipolar disorder .Unless otherwise indicated, please ensure that ordered labs…

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

Based on observation and staff interview, the facility staff failed to store food in accordance with professional standards for food service safety in the facility kitchen. The findings included: The facility staff failed to discard seven (7) containers of unsweetened coconut milk that had exceeded the best by date of 5/13/24. On 9/04/24 at 9:30 AM, in the presence of the Dietary Manager (DM), the surveyor observed seven (7) 32-ounce containers of unsweetened coconut milk each with a best if used by date of 5/13/24 present in the dry storage area of the facility kitchen. The DM removed the containers of unsweetened coconut milk from the dry storage area. On 9/05/24 at 10:40 AM, the survey team met with the Administrator, Director of Nursing, and the Clinical Services Manager and discussed the concern of out-of-date coconut milk present in the facility kitchen. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/05/24.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinical record reviews, and facility document review, the facility staff failed to ensure a complete and/or accurate clinical record for 3 of 31 sampled residents, Resident #379, Resident #9, and Resident #62. The findings include: 1. For Resident #379, the facility staff failed to document the resident's allergy to the medication Hydrocodone in the clinical record. This was a closed record review. Resident #379's diagnosis list indicated diagnoses, which included, but not limited to End Stage Renal Disease, Edema, Depression, Dependence on Renal Dialysis, Type 2 (two) Diabetes Mellitus with Diabetic Neuropathy, Chronic Obstructive Pulmonary Disease, Weakness, and Retention of Urine. The minimum data set (MDS) with an assessment reference date (ARD) of 3/22/23 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 for cognitive abilities, indicating the resident was cognitively intact. A review of the clinical record revealed Resident #379 had…

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

Based on observation and staff interview, the facility staff failed to maintain infection prevention and control practices during medication administration for 1 of 2 nursing units, Unit #1. The findings included: For Unit #1, the licensed practical nurse (LPN) placed a resident's inhaler in their uniform pocket to transport into the resident's room prior to administration. On 9/05/24 at 8:43 AM, surveyor observed LPN #5 place a resident's Breo inhaler in the pocket of their uniform top to transport to the resident's room. LPN #5 removed the inhaler from their pocket and handed it to the resident for administration. When asked about placing the Breo inhaler in their pocket, LPN #5 stated they did not know if the resident would have tissues available in their room for use with their eye drops so they took theirs from the medication cart causing them to have extra items in their hands and they did not want to make two trips. On 9/05/24 at 10:40 AM, the survey team met with the Administrator, Director of Nursing, and Clinical Services Manager and discussed the concern of LPN #5 placing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, the facility staff failed to offer a pneumococcal vaccine in accordance with nationally recognized standards for 3 of 5 sampled residents reviewed for immunizations (Resident #42, #49, and #72). The findings included: 1. For Resident #42, the facility staff failed to offer the resident a pneumococcal conjugate vaccine 15 (PCV15) or a pneumococcal conjugate vaccine 20 (PCV20) following admission to the facility. Resident #42's diagnosis list indicated diagnoses, which included, but not limited to Type 2 Diabetes Mellitus, Parkinson's Disease, and Generalized Muscle Weakness. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/02/24 assigned the resident a brief interview for mental status (BIMS) summary score of 8 out of 15 indicating the resident was moderately cognitively impaired. Resident #42 was over the age of 65 years when admitted to the facility. Surveyor reviewed Resident #42's clinical record…

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

Based on staff interview, clinical record review, and facility document review, the facility staff failed to offer an updated 2023-2024 COVID-19 vaccine for 1 of 5 sampled residents (Resident #49), failed to provide evidence of education regarding the risks, benefits and potential side effects of the COVID-19 vaccine prior to the administration for 2 of 5 sampled residents (Resident #2 and #42), and failed to provide evidence of consent prior to the administration of a COVID-19 vaccine for 1 of 5 sampled residents (Resident #42). The findings included: 1. For Resident #49, the facility staff failed to offer the resident an updated 2023-2024 formula COVID-19 vaccine. Resident #49's diagnosis list indicated diagnoses, which included, but not limited to Type 2 Diabetes Mellitus, Aortic Valve Stenosis with Insufficiency, and Essential Hypertension. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/13/24 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. A review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff interview and review of facility documentation, the facility staff failed to ensure dignity was maintained for 3 residents (#409, #50, and #35). The facility staff failed to protect Resident #409 from body exposure to public view and provide his personal clothing. Resident #50 and #35 were not provided dignity covers for bedside drainage bags. The findings included: 1. Resident #409 was originally admitted to the nursing facility on 1/30/21 with diagnoses that included congestive heart failure, encephalopathy, cervical disc degeneration, and readmitted on [DATE] with an added diagnoses of TIAs (mini strokes), acute cystitis and kidney failure. The admission Minimum Data Set (MDS) assessment dated [DATE] coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 3 out of a possible score of 15 which indicated the resident was severely impaired in the necessary cognitive skills for daily decision making. Resident #409 required extensive…

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 notify the physician of missed medication for one of 15 sampled residents, Resident #212. The findings included: Resident #212 was admitted to the facility on [DATE] with diagnoses that included but were not limited to chronic heart failure, closed fracture of the right tibia with healing, pain in right knee, and high blood pressure. Resident #212's most recent comprehensive MDS (Minimum data set) assessment was an admission assessment with an ARD (assessment reference date) of 7/4/21. Resident #212 was coded as being cognitively intact in the ability to make daily decisions; scoring 13 out of 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #212 was coded in Section J0100. (Pain Management) as not receiving scheduled pain medications in the last 5 days from the ARD date (7/4/21). Resident #212 was coded as receiving prn (as needed) pain medications in the last 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 representative interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to ensure medications were procured for two of 15 residents in the survey sample; Resident #212 and #211. The findings included: 1. Resident #212 was admitted to the facility on [DATE] with diagnoses that included but were not limited to chronic heart failure, closed fracture of the right tibia with healing, pain in right knee, and high blood pressure. Resident #212's most recent comprehensive MDS (Minimum data set) assessment was an admission assessment with an ARD (assessment reference date) of 7/4/21. Resident #212 was coded as being cognitively intact in the ability to make daily decisions; scoring 13 out of 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #212 was coded in Section J0100. (Pain Management) as not receiving scheduled pain medications in the last 5 days from the ARD date (7/4/21). Resident #212 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 observation, resident interview, and staff interviews the facility's staff failed to afford the opportunity to get out of bed daily as desired for 1 of 36 residents (Resident #50), in the survey sample. The findings included: Resident #50 was originally admitted to the facility 12/3/14 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Multiple sclerosis, diabetes and depression. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/27/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #50's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring total care of two people with transfers, total care of one person with bed mobility, personal hygiene, bathing, transfers, dressing, and toileting, and supervision after set-up with eating. An interview 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 a medical record review, facility document review and staff interviews the facility The facility staff failed to ensure a Notice of Medicare Non-Coverage was given timely prior to the last covered skilled day of 12/17/20 for 1 of 36 residents in the survey sample, Resident #59. The findings included: Resident #59 is a [AGE] year old admitted to the facility on [DATE] with diagnoses to include but not limited to Diabetes Mellitus, End Stage Renal Disease and Hypertension. Resident #59's medical record indicated the resident was discharged home on [DATE] at 11:00 A.M. The most recent MDS (Minimum Data Set) for Resident #59 was a Discharge Assessment with a ARD (Assessment Reference Date) of 12/18/20. Resident #59's BIMS (Brief Interview for Mental Status) score was a 15 out of a possible 15 indicating the resident was cognitively intact and capable of daily decision making. Resident #59's Notice of Medicare Non-Coverage (NOMNC) document with Skilled Nursing Services ending on 12/17/20 was reviewed and is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interviews the facility's staff failed to maintain 1 of 36 residents (Resident #50), wheel chair in a clean and sanitary manner. The findings included: Resident #50 was originally admitted to the facility 12/3/14 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Multiple sclerosis, diabetes and depression. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/27/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #50's cognitive abilities for daily decision making were intact. On 3/17/21 at approximately 1:00 p.m., observation was made of Resident #50's wheel chair. A large amount of crumbs and other debris was observed on the side and beneath the seat cushion. An interview was conducted with Resident #50 on 3/17/21 at approximately 1:00 p.m. Resident #50 stated he wasn't aware of his wheel chair getting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide evidence that care plan goals were sent with one of 36 residents (Resident #15) upon transfer to the hospital on 1/7/21. The findings included: Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to stroke, high blood pressure, unspecified protein calorie malnutrition, and atrial fibrillation. Resident #15's most recent MDS (Minimum data set) assessment was a quarterly assessment with an ARD (Assessment Reference Date) of 1/23/21. Resident #15 was coded as being moderately impaired in cognitive function scoring 12 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #15's clinical record revealed that he was sent out to the hospital on 1/7/21 for a possible stroke. The following was documented in a nursing note dated 1/7/21: Resident at approximately 3pm 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 record review, staff interviews and complaint investigation, the facility staff failed to notify the Long Term Care Ombudsman of two residents (Resident #258 and #15) of transferring to the hospital in the survey sample of 36 residents. The findings included: 1. Resident #258 was admitted to the facility on [DATE]. This resident was diagnosed as having Tardue Dyskinesia, hypertension, anxiety, depression, Bipolar, Schizoaffective disorder, hyperlipidemia, and anemia. the ombudsman was not notified of Resident #258 transfer to the hospital. This resident was assessed being stand to pivot x 1 assist, alert and oriented times 1 to self. Resident noted to wander in other patient rooms and exit seeking. A wander guard placed on left ankle. A Nursing note dated 06/03/20 at 5:38 P.M. indicated: Resident noted cursing loudly, screaming, and speaking to self. Resident noted pulling pants down, while walking in hallway. A Nursing note dated 06/04/20 at 6:48 P.M. indicated: 'Police arrived, in contact with local…

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 record review, staff interviews and complaint investigation, the facility staff failed to provide two residents (Resident #258 and #15) with bed hold policy notice upon transfer to the hospital in the survey sample of 36 residents. The findings included: 1. Resident #258 was admitted to the facility on [DATE]. This resident was diagnosed as having Tardue Dyskinesia, hypertension, anxiety, depression, Bipolar, Schizoaffective disorder, hyperlipidemia, and anemia. Resident #258 was not provided with a bed hold policy notice upon transfer to the hospital. This resident was assessed being stand to pivot x 1 assist, alert and oriented times 1 to self. Resident noted to wander in other patient rooms and exit seeking. A wander guard placed on left ankle. A Nursing note dated 06/03/20 at 5:38 P.M. indicated: Resident noted cursing loudly, screaming, and speaking to self. Resident noted pulling pants down, while walking in hallway. A Nursing note dated 06/04/20 at 6:48 P.M. indicated: 'Police arrived, in contact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interview, staff interviews and clinical record review the facility staff failed to implement interventions, heel boots, in the comprehensive care plan for 1 of 36 Resident's in the survey sample, (Resident #6). The findings included: Resident #6 was originally admitted to the facility on [DATE]. The resident was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. The resident was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnosis included but were not limited to, Peripheral Vascular Disease and Moderate Protein-Calorie Malnutrition. Resident #6's admission Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of 12/16/2020 was coded with a BIMS (Brief Interview for Mental Status) score of 03 indicating severe cognitive impairment. In addition, the Minimum Data Set coded Resident #6 as requiring total dependence of 2 for bed mobility, dressing, toilet use, personal hygiene and bathing and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interviews and clinical record review the facility staff failed to failed to revise the care plan with a change in code status for one of 36 residents; (Resident #14) AND failed to ensure that the intervention, compression glove, was included in the comprehensive care plan for one of 36 residents, (Resident #27). The findings included: 1. Resident #14 was admitted to the facility on [DATE] with diagnoses that included but were not limited to atrial fibrillation, muscle wasting and atrophy, diverticulosis of the intestine, and vascular dementia without behavioral disturbance. Resident #14's most recent MDS (Minimum Data Assessment) was a quarterly assessment with an ARD (assessment reference date) of 1/7/21. Resident #14 was coded as being severely impaired in the ability to make daily decision on the Staff Assessment for Mental Status exam. Review of Resident #14's March 2020 POS (Physician Order Summary) revealed the following current order: Full Code. This order…

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 representative 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 follow professional standards of practice by signing off medications were administered to two of 15 residents; Residents #212 and #211 that were not available. The findings included: 1. Resident #212 was admitted to the facility on [DATE] with diagnoses that included but were not limited to chronic heart failure, closed fracture of the right tibia with healing, pain in right knee, and high blood pressure. Resident #212's most recent comprehensive MDS (Minimum data set) assessment was an admission assessment with an ARD (assessment reference date) of 7/4/21. Resident #212 was coded as being cognitively intact in the ability to make daily decisions; scoring 13 out of 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #212 was coded in Section J0100. (Pain Management) as not receiving scheduled pain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that facility staff failed to accurately obtain, assess and monitor weights per physician's order and plan of care for one resident, Resident #40 AND failed to ensure that 2 of 36 residents in the survey sample, (Resident #6, and #27) treatments were implemented. The findings included: 1. Resident #40 was admitted to the facility on [DATE] with diagnoses that included but were not limited to heart failure, peripheral vascular disease, and psychotic disorder. Resident #40's most recent MDS (Minimum Data Set) assessment was a quarterly assessment with an ARD (Assessment Reference Date) of 2/18/21. Resident #40 was coded as being severely impaired in cognitive function on the Staff Assessment for Mental Status Exam. Review of Resident #40's March 2020 POS (Physician Order Summary) revealed the following order: Weigh Resident Daily Notify MD (Medical Doctor) of 3 lb (pound) weight gain in one day/5 lb in one week.…

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, clinical record review and in the course of a complaint investigation, it was determined that facility staff failed to ensure pain relief measures were provided to one of 15 residents in the survey sample, Resident #212 who requested pain medication on 7/13/21 and 7/14/21. The findings included: Resident #212 was admitted to the facility on [DATE] with diagnoses that included but were not limited to chronic heart failure, closed fracture of the right tibia with healing, pain in right knee, and high blood pressure. Resident #212's most recent comprehensive MDS (Minimum data set) assessment was an admission assessment with an ARD (assessment reference date) of 7/4/21. Resident #212 was coded as being cognitively intact in the ability to make daily decisions; scoring 13 out of 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #212 was coded in Section J0100. (Pain Management) as not receiving scheduled pain medications in the last 5 days from the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review the facility staff failed to ensure that 1 of 36 residents (Resident #10) in the survey sample had an order for Dialysis. The findings included: Resident #10 was admitted to the facility on [DATE]. Resident #10 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnosis included but were not limited to, HTN (Hypertension) and End Stage Renal Disease. Resident #10's admission Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 12/18/2020 was coded with a BIMS (Brief Interview for Mental Status) score of 13 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #10 as requiring supervision with setup help only with eating, limited assistance of 1 with bed mobility, dressing, toilet use and personal hygiene, extensive assistance of 1 with transfer and physical help in part of bathing activity with assistance of 1. On 03/17/2021 review of Resident #10's Clinical Record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview the facility staff failed to acquire medications upon admissions for one resident (Resident #258) in the survey sample of 36 residents. The findings included: Resident #258 was admitted to the facility on [DATE]. This resident was diagnosed as having Tardue Dyskinesia, hypertension, anxiety, depression, Bipolar, Schizoaffective disorder, hyperlipidemia, and anemia. The facility staff failed to acquire medications upon admissions for Resident #258. This resident was assessed being stand to pivot x 1 assist, alert and oriented times 1 to self. Resident noted to wander in other patient rooms and exit seeking. A wander guard placed on left ankle. Resident #258 had a physician's order dated 06/03/20 for the following medications: Alendronate 35 milligrams (mg) tablet (1 tablet) oral one time weekly starting 06/03/20: Latanoprost 0.005% eye drops (1 drop) drops both eyes one time daily starting 06/03/20: Clonazepam 2 mg tablet (1 tablet) tablet oral two times daily…

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 the observation of 2 medication carts, 1 treatment cart and 1 medication room; the facility staff failed to dispose of expired medications and surgical supplies for two units. The facility staff failed to dispose of expired medications on Unit 1 and failed to discard two expired suture trays on unit 2. The findings include: On 3/17/21 at 11:09 AM an Inspection of Treatment Cart on Unit 2 was conducted with LPN (Licensed Practical Nurse) #4. Two suture removal Tray kits with an expiration date of 11/01/2020 was found during the inspection. LPN #4 replied, I should have discarded them. On 03/17/21 at 2:11 PM on unit 1 an inspection of medication cart #1 was conducted with LPN #3. Upon visual inspection a house stock bottle of acetaminophen 500 mg with an expiration date of 1/2021 was seen. It had an opened date of 3/08/21. Located in the same medication cart was 1 bottle of Humalog insulin with an open date of 2/10/21. LPN #3 stated, I meant to take it out this morning. It's over twenty eight days. I should have discarded the insulin and Tylenol. Numerous attempts were made…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that facility staff failed to maintain a complete and accurate clinical record for one of 36 residents in the survey sample, Resident #27. The findings included: 1. Resident #27 was admitted to the facility on [DATE]. Diagnosis included but were not limited to, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side and Type 2 Diabetes Mellitus. Resident #27's admission Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of 02/13/2021 was coded with a BIMS (Brief Interview for Mental Status) score of 13 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #27 as requiring total dependence of one person with bed mobility, transfer, dressing, toilet use, personal hygiene and bathing and supervision with setup help only for eating. On 03/17/2021 Resident #27's Clinical Record was reviewed and revealed the following: Review of…

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

Based on record review, staff interviews and facility documentation the facility staff failed to have the required minimal committee members attend QAA meetings and failed to meet on a quarterly basis. The findings included: On 3/18/21 at approximately 11:16 AM, a review of the facilities QA/QAPI Plan was conducted and findings were discussed with the Administrator, DON (Director of Nursing), The Regional Director of Operations and The Regional Director of Clinical Services. A review of the QAPI Plan signature page revealed that the Medical Director/designee did not attend the required amount of meetings on the following meeting dates: 2/18/20, 5/21/20 and 5/28/20. The QAPI Plan also revealed that the required quarterly meetings were not conducted. The meetings were conducted on the following dates: 2/18/20, 5/21/20, 5/28/20, 11/30/20 and 2/26/21. No quarterly meetings were conducted in August 2020. (This should have been the 3rd quarterly meeting). The VP (Vice President) of Regional Operations stated, We purchased the nursing home in November 2020. Policy: Quality Assurance 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.

The facility failed to comply with regulations requiring the participation of the medical director at quarterly QAA meetings. Findings: The facility failed to comply with regulations requiring the participation of the medical director at quarterly QAA meetings. The administrator and DON were interviewed regarding the QAA committee on 3/28/19 at 2:45 PM. The facility administrator was asked how often the QAA committee held meetings. She stated the committee meet for quarterly meetings. The administrator provided the quarterly sign-up sheet for the committee members. The medical director had not signed the sheets for 12/18/18 or 3/19/19. The surveyor asked if anyone was designated to take the medical director's place on the two dates in question. The administrator said, no one had been designated to take his place but they sent the committee minutes to him after each meeting. The facility had no additional information to offer prior to the survey team's exit.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, facility staff failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan for 1 of 21 residents in the survey sample (Resident #45). Resident #45 was admitted to the facility on [DATE]. Diagnoses included end stage renal disease with hemodialysis, diabetes mellitus, cardiopulmonary disease with oxygen dependence, hypertension, enteritis as a result of clostridium difficile infection, and chronic pain. On the admission minimum data set assessment with assessment reference date 2/23/19, the resident scored 15/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. During an interview, the resident reported receiving hemodialysis treatments 3 days per week., Clinical record review revealed a physician order fro hemodialysis treatments on Tuesday,…

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

Based on staff interview and clinical record review, the facility staff failed to ensure accurate MDS (minimum data set) assessments for 2 of 24 Residents, Resident #22 and #62. The findings included: 1. For Resident #22, the facility staff failed to code the Residents hospice status on the Residents significant change in status MDS assessment. The clinical record review revealed that Resident #22 had been admitted to the facility 08/22/18. Diagnoses included, but were not limited to, hypertension, dementia, Parkinson's disease, and malignant neoplasm of prostate. Section C (cognitive patterns) of the Resident significant change in status MDS assessment with an ARD (assessment reference date) of 02/08/19 included a BIMS (brief interview for mental status) summary score of 7 out of a possible 15 points. Section O (special treatments, procedures, programs) had NOT been coded to indicate the Resident was receiving hospice care. The clinical record included a care plan that indicated the Resident was receiving hospice care effective 02/01/19. On 03/27/19 at 10:13 a.m., MDS coordinator…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review the facility staff failed to implement the CCP (comprehensive care plan) for 1 of 24 Residents, Resident #53. The findings included: For Resident #53 the facility staff failed to implement a care plan for the use of bed rails. Resident #53 was admitted to the facility on [DATE]. Diagnoses included but not limited to atrial fibrillation, end stage renal disease, hyperlipidemia, arthritis, osteoporosis, pelvic fracture, Alzheimer's disease, seizure disorder, malnutrition, and dementia. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 03/12/19 coded the Resident as 10 out of 15 is section C, cognitive patterns. Section G, functional status coded the Resident as 3/3 in the areas of bed mobility and transfer, which is the equivalent of extensive assistance/ two person physical assist. This is an admission MDS. Resident #53's CCP (comprehensive care plan) was reviewed and contained a care plan for Bed Rails are used 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 The facility staff failed to provide adequate ADL (activities of daily living) services to 1 of 18 residents at the facility (Resident #113). Findings: The facility staff failed to provide adequate ADL (activities of daily living) services for Resident #113. The resident's clinical record was reviewed. Resident #113 was admitted to the facility for skilled care on 3/19/19. Her diagnoses included diverticulitis, arthritis, hypertension, and gastrointestinal hemorrhage (due to diverticulitis). The latest MDS assessment dated [DATE] coded the resident as cognitively unimpaired. Her ADL status was incomplete at the time of the survey. The resident 's initial CP (care plan), effective 3/20/19 coded the resident with significant ADL requirements. Due to weakness related to acute diverticulitis and post hemorrhagic anemia the resident required assistance with all self-care ADLs, bed mobility, transfers from bed to chair, and ambulation. The CP included interventions for staff assistance from physical and occupational…

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, the facility staff failed to ensure the highest practicable well-being for 3 of 24 Residents, Resident #6, #23, and #64. The findings included: 1. For Resident #6, the facility staff failed to ensure the Residents physician ordered pain medication was available and administered per the physicians order. The clinical record review revealed that Resident #6 had been admitted to the facility 02/15/15. Diagnoses included, but were not limited to, complex regional pain syndrome I, depressive disorder, sleep apnea, and deep vein thrombosis. Section C (cognitive patterns) of the Residents significant change in status MDS (minimum data set) assessment with an ARD (assessment reference date) of 12/31/18 included a BIMS (brief interview for mental status) summary score of 15 out of a possible 15 points. During an interview with Resident #6 on 03/28/19 at 10:40 a.m., the Resident verbalized to the surveyor that the facility had not applied her pain patch. Immediately after this interview, the surveyor approached LPN…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, family interview and clinical record review the facility staff failed to ensure an accident free environment for 1 of 24 Residents, Resident #53. The findings included: For Resident #53 the facility staff failed to follow physician's orders for fall mats at the bedside and failed to provide ¼ side rails per the physician's recommendation. Resident #53 was admitted to the facility on [DATE]. Diagnoses included but not limited to atrial fibrillation, end stage renal disease, hyperlipidemia, arthritis, osteoporosis, pelvic fracture, Alzheimer's disease, seizure disorder, malnutrition, and dementia. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 03/12/19 coded the Resident as 10 out of 15 is section C, cognitive patterns. Section G, functional status coded the Resident as 3/3 in the areas of bed mobility and transfer, which is the equivalent of extensive assistance/ two person physical assist. This is an admission MDS. Resident #53's CCP…

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 follow up on pharmacy recommendations for 2 of 24 Residents, Residents #8 and #23. The findings included: 1. For Resident #8, the facility staff failed to follow up on a pharmacy recommendation from April 2018 in regards to the Residents prn (as needed) tramadol. The clinical record review revealed that Resident #8 had been admitted to the facility 11/09/17. Diagnoses included, but were not limited to, heart failure, cardiomyopathy, difficulty in walking, chronic atrial fibrillation, dementia, and chronic obstructive pulmonary disease. Section C (cognitive patterns) of the Residents annual MDS (minimum data set) assessment with an ARD (assessment reference date) of 01/17/19 included a BIMS (brief interview for mental status) summary score of 12 out of a possible 15 points. The clinical record included a pharmacy recommendation dated 04/13/18 that read Recommendation: Seroquel, Tramadol, and Hydrocodone APAP have not be used in the last 45 days. Please consider discontinuing. A review of the March 2019…

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

Based on staff interview and clinical record review, the facility staff failed to ensure 1 of 24 Residents were free of unnecessary medications, Resident #22. The findings included: The Residents clinical record included a prn (as needed) order for the antipsychotic medication haldol. The clinical record did not include any information to indicate the physician had reviewed this order and/or provided a rationale for the continued use of this medication. The clinical record review revealed that Resident #22 had been admitted to the facility 08/22/18. Diagnoses included, but were not limited to, hypertension, dementia, Parkinson's disease, and malignant neoplasm of prostate. Section C (cognitive patterns) of the Resident significant change in status MDS assessment with an ARD (assessment reference date) of 02/08/19 included a BIMS (brief interview for mental status) summary score of 7 out of a possible 15 points. The Residents clinical record included orders for haldol oral concentrate as needed every 4 hours starting 02/05/19. The diagnosis was documented as restlessness 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, staff interview, and facility document review, the facility staff failed secure the narcotic box on unit 2 and on the back hall nursing cart on unit 1. The findings included: The narcotic box in the unit 2 medication room was not permanently affixed and the narcotic box on the back hall medication cart on unit 1 was unlocked. On 03/27/19 at 10:25 a.m., the surveyor and LPN (licensed practical nurse) #2 checked the unit 1 back hall medication cart. The narcotic box on this cart was found to be unlocked during this observation. This narcotic box included the following controlled medications oxycodone, lyrica, and lorazepam. There were 15 medication cards in this narcotic box. The medication cart was located in the hall LPN #2 was observed to be down the hall when the surveyor approached the medication cart. On 03/27/19 at 10:34 a.m., the surveyor and RN (registered nurse) #2 checked the medication room on unit 2. This medication room included a locked refrigerator inside this refrigerator the surveyor observed a narcotic box. The surveyor was able to remove this…

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

Based on staff interview and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for 1 of 24 Residents, Resident #23. The findings included: The facility staff failed to determine the Resident DNR (do not resuscitate) status. The clinical record review revealed that Resident #23 had been admitted to the facility 07/18/18. Diagnoses included, but were not limited to, stage III pressure ulcer to sacrum, dementia, degenerative disease of nervous system, essential tremor, spondylosis, and cerebrovascular disease. Section C (cognitive patterns) of the Residents significant change in status MDS (minimum data set) assessment with an ARD (assessment reference date) of 02/12/19 had been coded 1/1/2 to indicate the Resident had problems with long and short term memory and was moderately impaired in cognitive skills for daily decision making. The clinical record included a face sheet that listed the Resident as being a full code. Under the title of Advance Directive on the Residents comprehensive care plan the facility staff had documented that…

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.