Marcella Post Acute

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 maintain documentation that an alleged violation of neglect was thoroughly investigated for one (1) of 42 sampled residents, Resident #63. The findings included:A facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program with a revision date of 04/2021, specified, Residents have the right to be free from.neglect. Under the heading, Policy Interpretation and Implementation Item #1 specified, Protect residents from.neglect.by anyone including.a. facility staff. Item #2 read, .Implement policies and protocols to prevent and identify.b. neglect of residents. Item #6 specified, Provide staff orientation and training/orientation programs that include topics such as.identification and reporting of abuse. Item #8 read, Identify and investigate all possible incidents of.neglect. Item #9 specified, Investigate and report any allegations within timeframes required by federal…

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 provide written notification regarding the reason(s) for transfer and/or discharge to the resident and/or the resident's representative(s) and failed to offer a bed hold for 1 of 42 residents, Resident #175.The findings include: Resident #175 was transferred to a higher level of care on 06/24/2024. The facility staff were unable to provide documentation showing written notification of the reason(s) for transfer and/or discharge was provided to the resident and/or resident representative. In addition, the facility staff could not provide evidence that a bed hold was offered. This was a closed record review.Resident #175's diagnoses included pneumonitis, atrial fibrillation, acute kidney failure, alcohol dependence, clostridium difficile, gastro-esophageal reflux disease, benign prostatic hyperplasia, hypotension, gout, diabetes, and protein-calorie malnutrition. Section C (cognitive patterns) of Resident #175's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) 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, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to provide activities of daily living care for 3 of 42 residents, Residents #55, #149 and #36. The findings include:1. For Resident #55, the facility staff failed to provide nail care. Resident #55 was observed to have fingernails that were excessively long and jagged. Resident #55's diagnoses included hemiplegia and hemiparesis following cerebral infarction, dysphagia, and diabetes. Section C (cognitive patterns) of Resident #55's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 02/16/2026 included a Brief Interview for Mental Status (BIMS) score of 3, indicating Resident #55 was severely impaired in cognitive skills for daily decision making. Section GG (functional status) was coded to indicate the resident was dependent on staff for personal hygiene. Section I (active diagnoses) documented a contracture of the left hand. Resident #55's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, policy review, and clinical record review, the facility staff failed to ensure each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized for one of five residents sampled for immunizations, resident #134.The findings included: A facility policy entitled, Pneumococcal Vaccine with a revision date of August 2025 read in part, 1. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has completed the current recommended vaccine series. An admission Record for resident #134 indicated the facility admitted the resident on 10/30/25. According to the admission Record resident #134 had a medical history that included the diagnoses of stroke, end stage renal disease, chronic obstructive pulmonary…

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 the resident's interview, observations, family interview, staff interviews, and clinical record review, the facility's staff failed to obtain emergency dental services for one resident (Resident 7), in the survey sample. The findings included: Resident #7 was not provided dental services who presented with a broken and severely painful left upper tooth for which the facility's staff could not provided documentation of extenuating circumstances that resulted in the delay of treatment by a dentist. Resident #7 was originally admitted to the facility 1/11/23 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included diabetes, high blood pressure and heart failure. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/4/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #7's cognitive abilities for daily decision making were moderately impaired. In…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interviews and staff interviews the facility staff failed to maintain a clean, comfortable, homelike environment for 2 of 7 residents (Resident #1 and Resident #2), in the survey sample. The findings included: 1. Resident #1 was originally admitted to the facility 5/25/24 after an acute care hospital stay. The admission diagnoses included; cardiogenic shock, chronic congestive heart failure, pulmonary hypertension, muscle weakness, and chronic obstructive pulmonary disease. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/30/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #1's cognitive abilities for daily decision making were intact. On 5/29/24 during an observation tour for room [ROOM NUMBER], it was observed that the air conditioning unit was not functioning. On 5/29/24 at 3:05 PM an interview was conducted with Resident #1. Resident #1 stated…

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, and clinical record review the facility staff failed to provide toileting hygiene/toileting assistance for 2 of 7 residents (Resident #6 and 5), in the survey sample. The findings included: 1. The facility's staff failed to provide toileting hygiene to Resident #6 when requested on 5/29/24 before and during the supper meal. Resident #6 was originally admitted to the facility 4/1/2017 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included dementia, high blood pressure and diabetes. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/5/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #6's cognitive abilities for daily decision making were moderately impaired. In section GG (Functional Abilities and Goals) the resident was coded as dependent for toileting hygiene. On 5/29/24 at 5:23 PM Resident #6 stated…

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 and staff interviews the facility staff failed to have an agreement with a dentist to provide emergency dental services for 1 of 7 residents (Resident #7), in the survey sample. The findings included: On 5/29/24 at 4:20 PM Resident #7 stated she had a broken tooth, and the pain was so severe it was causing pain in her eyes. Resident #7 stated the tooth broke off on Thursday 5/23/24 or Friday 5/24/24 and she reported it to a nurse on Saturday 5/25/24. The resident stated she was told that a dental appointment had been scheduled but she was not provided details. On 5/30/24 at 11:21 AM and interview was conducted with SW #1. SW #1 stated the resident required stretcher transport and an escort to the dentist office and there was no local dentist to accommodate any residents who required stretcher transport. SW #1 also stated the Medical Assistant (MA) attempted to make an appointment for Resident #7 on 5/29/24 at a dental school's clinic in another city but the MA was informed that a call would need to be made to the dental school's clinic on 6/1/24, 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 observation, record review, staff interview, resident interview, interview with the facility's Pest Control Company staff, and facility policy review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests. This affected three of three units, common areas, and the dining rooms in the facility, and had the potential to affect all 126 residents residing in the facility. Findings include: Observation in the dining room on 10/26/21 at 8:58 AM revealed four small white boxes on the floor in each corner of the room. The boxes were observed to have more than 10 dead bugs in each one of them. Some of the bugs were one and a half inches in length and were noted to be sticking out the end of the boxes. These four boxes were in the same room where the door was observed to be propped open with a rock. Interview with the Pest Control Company staff on 10/26/21 at 2:50 PM while he was in the building revealed he sprays for bugs in the building every two weeks. He…

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, review of maintenance records, and review of facility policy, the facility failed to ensure maintenance services to maintain clean and orderly environment for residents' rooms on three of three units in the facility. Findings include: The following observations were made during an environmental tour with the Maintenance Director (MD) on 10/29/21 that began at 10:11 AM and concluded at 11:00 AM: 1. In Room (RM) 109 the bathroom door was observed to have a large amount of white substance along the bottom on the inside of the door. The MD identified the substance as being material used to fill holes and was unaware aware of why there was no further repair such as painting the door. 2. In RM [ROOM NUMBER] the heating/air conditioning unit was attached only on the top corner and was hanging crooked off the wall. The base cove molding was observed to be coming away from wall and there was crumbling plaster underneath the heating/air conditioning unit. 3. In RM [ROOM NUMBER] the wall…

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 interview, record review and facility policy review, the facility failed to ensure the resident, his or her family, and/or the resident representative was provided information related to the benefits and risks to the residents for psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) for five of five residents reviewed for unnecessary medications (Resident (R) 17, 31, 55, 86, and 97). Findings include: 1. Review of R17's Face Sheet located in the Electronic Medical Record (EMR) under the Resident Info tab, revealed an admission date of 04/02/21 and included diagnoses of dementia with behavioral disturbance and anxiety disorder. Review of R17's Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 10/25/21 revealed a diagnosis of dementia and Brief Interview for Mental Status (BIMS) score of 05/15, indicating the resident was severely cognitively impaired. Review of R17's October 2021 Physician…

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, record review, interview, and facility policy review, the facility failed to ensure residents were treated with respect and dignity for three of 28 residents reviewed for respect and dignity (Resident (R) 36, R77, and R119). Findings include: 1. During dining observation on 10/26/21 at 12:27 PM, R77 was sitting at the table in the dining room and Certified Nursing Assistant (CNA) 2 walked over to the resident and fed her two spoonfuls of food, while standing at the table next to R77. During an interview on 10/26/21 at 12:34 PM, CNA2 confirmed she assisted R77 with eating while standing beside the resident. 2. Observations on 10/26/21 at 9:34 AM, 10/27/21 at 8:31 AM, and 10/27/21 at 2:14 PM revealed R119 lying in bed supine (on his back) with his urinary catheter bag hanging from the left side of his bed uncovered and exposed to the view of his roommate and others that may enter his room. During an observation on 10/27/21 at 8:31 AM, Nursing Assistant (NA)2 was standing to the right of R119,…

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, interview, record review, and policy review, the facility failed to provide documented evidence assistance with activities of daily living (ADLs) was given to three of four residents reviewed for ADLs (Residents (R)20, R32, and R95) out of a total sample of 28 residents. Specifically, there was no documented evidence residents received showers/tub baths in accordance with the bath schedule and their needs. All three residents resided on the [NAME] unit. Findings include: Review of the paper Tub or Shower Bath policy dated 03/01/15 revealed Residents should receive a tub or shower bath at least twice weekly. The purpose was To provide cleanliness and comfort to the resident. To assist the resident in bathing. To prevent body odors. To stimulate circulation and provide a mild form of exercise. To observe the resident's skin condition. To alleviate skin conditions. 1. Review of the Face Sheet undated, in the electronic medical record (EMR) under the admission tab, revealed R20 was admitted 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 interview, record review, and review of facility policy, the facility failed to provide services to ensure two (Residents (R)63 and R4) of four residents reviewed for limited of Motion (ROM) and mobility, maintained or improved function unless reduced ROM/mobility was unavoidable based on the resident's clinical condition. Findings include: 1. Review of the Face Sheet in the Electronic Health Record (EMR) for R4 revealed an admission date of 07/02/19 with a current diagnosis of arthritis. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/19/21 revealed a Brief Interview of Mental Status (BIMS) score of 14 indicating intact cognition. The MDS indicated R4 had functional limitation in ROM to her upper extremities to include her shoulder, elbow, wrist, and hand with impairment of both sides. Review of the Comprehensive Care Plan, located in the EMR under the Care Plan tab revealed R4 had the potential for health and safety concerns related to activities of daily living…

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, record review, interview, and review of facility policy, the facility failed to ensure one (Resident (R) 83) of four residents reviewed for nutrition maintained to the extent possible, acceptable parameters of nutritional status and did not experience a significant weight loss. Findings include: Review R83's Face Sheet located in the Electronic Medical Record (EMR) revealed he was admitted to the facility on [DATE] with a diagnosis of glaucoma, blindness of the right eye, low vision in left eye and Vitamin D deficiency. Review of the admission Minimum Data Set (MDS) in the EMR under the MDS tab with an assessment reference date (ARD) of 03/09/21 revealed R83 was able to understand and to be understood and his vision was noted to be highly impaired. R83's Brief Interview for Mental Status (BIMS) score was 15 indicating intact cognition. The MDS indicated R83 required supervision, oversite and cueing for meals by staff. Review of the current Nutrition Person Centered Comprehensive Care Plan…

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, record review, and review of the facility's policy, the facility failed to ensure a resident received timely pain medication for one of 28 sampled residents (Resident (R) 62). Findings include: Review of the facility's policy titled, Pain Management, revised 06/15/12, revealed pain should be assessed and documented at regular intervals to ensure residents receive optimal pain management. Assessments should include the onset, location, frequency, quality, and intensity of pain with the resident self-report as primary indicator of pain. Pain assessments should be ongoing, and if interventions are not effective, the treatment plan and plan of care should be revised accordingly. Pain should be coded at the most severe level when the assessment does not determine the exact frequency or intensity of pain. Review of R62's Face Sheet found in R62's Electronic Medical Record (EMR) under the Admission tab revealed the resident was admitted to the facility on [DATE] and had diagnoses 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, interview, record review, and policy review, the facility failed to attempt use of alternatives prior to installing bed rails, failed to obtain informed consent, and failed to ensure bed rails were maintained to ensure safety for one of one sampled resident (Resident (R)20) reviewed for bed rails out of a total sample of 28 residents. Findings include: Review of the Face Sheet undated, in the electronic medical record (EMR) under the admission tab, revealed R20 was admitted to the facility on [DATE]. Diagnoses included intellectual disability, epilepsy, aphasia (loss of ability to understand or express speech), and seizure disorder. R20 received all nutrition via a gastrostomy feeding tube. Review of the Annual Minimum Data Set (MDS), dated [DATE], in the EMR under the MDS tab, revealed the resident had no speech during the assessment period, she was rarely understood, and rarely understood others, and was highly impaired in vision. A Brief Interview for Mental Status test was not…

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, interview and review of facility policy, the facility failed to develop person-centered comprehensive care plans to meet resident preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs for dementia for two (Residents (R)31 and R55) of two residents reviewed with a diagnosis of dementia. Findings include: 1.Review of R31's Face Sheet located in the Electronic Medical Record (EMR) located under the Resident Info tab revealed R31 was admitted to the facility on [DATE] with a diagnosis of dementia. Review of R31's Minimum Data Set' (MDS) located in the EMR under the MDS tab with an assessment reference date of 08/16/21 revealed a diagnosis of dementia. Review of the Comprehensive Care Plan in the EMR located under Care Plan tab revealed there was no evidence of a person-centered comprehensive care plan to address the residents' preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs for dementia.…

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 review of facility policy, the facility failed to ensure metal boxes containing Schedule IV (controlled substances) medication located in the refrigerators in one of three medication rooms were secured in permanently affixed compartments. Findings include: The facility was identified to have three medications rooms. One medication room on each unit to include 100 Unit, 300 Unit and 400 Unit. Observation of the 100 Unit medication room on 10/29/21 at 8:25 AM with Licensed Practical Nurse (LPN)5 revealed the medication room door was locked and the refrigerator within the medication room was locked. There was an unlocked metal box in the refrigerator containing two unopened vials of Ativan 2 milligram (mg), an anti-anxiety Schedule IV medication. The box was able to be removed from the refrigerator as it was not permanently affixed. There was a chain attached to the inside of the refrigerator, but the chain was not attached to the metal box containing the Scheduled IV medications. LPN5 indicated the chain had been broken for a long time and she 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 clinical record review, staff interviews and facility document review, the facility staff failed to convey the summary and goals of the comprehensive plan of care upon transfer/discharge for 2 of 46 Residents in the survey sample, Resident #74 and #73. 1. The facility staff failed to include in the transfer summary the resident's comprehensive care plan goals at the time of discharge/emergency department, or as soon as possible to the actual time of transfer for Resident #74 on 12/31/17, 1/10/18, 1/29/18, 2/11/18, 2/26/18, 9/5/18 and 11/11/18. 2. The facility staff failed to ensure Resident #73's comprehensive care plan goals were included in the hospital transfer documentation when the resident was transferred to the hospital on 8/20/18 and 10/8/18. The findings include: 1. Resident #74 was originally to the nursing facility on 1/28/15 with a diagnoses that included Type 2 diabetes mellitus, high blood pressure, end stage renal disease (ESRD) on dialysis. The most recent Minimum Data Set (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 clinical record review, staff interviews, and facility document review the facility staff failed to notify the office of the State Long-Term Care Ombudsman in writing of applicable discharges for 2 of 46 residents in the survey sample (Resident #74 and #73). 1. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #74's discharges to the hospital/emergency room on [DATE], 1/10/18, 1/29/18, 2/11/18, 2/26/18, 9/5/18 and 11/11/18 . 2. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #73's transfer to the hospital on 8/20/18 and 10/8/18. The finding include: 1. Resident #74 was originally admitted to the nursing facility on 1/28/15 with diagnoses that included Type 2 diabetes mellitus, high blood pressure, end stage renal disease (ESRD) on dialysis. The most recent Minimum Data Set (MDS) assessment was a quarterly dated 10/25/18 and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, resident interviews and facility documentation, the facility staff failed to issue a written notice of the bed hold policy upon transfer to the local hospital for 2 of 46 residents (R #74 and #73) in the survey sample. 1. The facility staff failed to ensure Resident #74 was issued a written notice of the bed hold policy upon transfer to the local hospital/emergency department (ED) on 12/31/17, 1/10/18, 1/29/18, 2/11/18, 2/26/18, 9/5/18 and 11/11/18 . 2. The facility staff failed to provide Resident #73 or the resident representative with a written notice of the bed hold policy prior to transfer to the hospital on 8/20/18 and 10/8/18. The findings include: 1. Resident #74 was originally to the nursing facility on 1/28/15 with diagnoses that included Type 2 diabetes mellitus, high blood pressure, end stage renal disease (ESRD) on dialysis. The most recent Minimum Data Set (MDS) assessment was a quarterly dated 10/25/18 and coded the resident on the Brief 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 clinical record review, staff interview and facility documentation the facility staff failed to administer a significant medication (*Dimethyl Fumarate) as ordered for 1 out of 46 residents (Resident #387) in the survey sample. The facility staff failed to administer forty doses of the *Multiple Sclerosis (MS) medication Dimethyl Fumarate as ordered by the physician. The findings included: Resident #387 was admitted to the facility on [DATE] and discharged home on [DATE]. Diagnoses for Resident #387 included, but not limited to, Multiple Sclerosis. Resident #387's Minimum Data Set (an assessment protocol) with an Assessment Reference date (ARD) of 05/17/18 coded Resident #387 with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. Resident #387's comprehensive care plan effective on 05/21/18 documented Resident #387 with the potential for impaired quality of life related to new environment and change in health status. The goal: 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 observations, record review and staff interview, the facility staff failed to maintain an effective pest control program. The findings included: During the kitchen tour on 12/04/2018 at 11:37 A.M., roaches were observed in the kitchen area. Roaches and water bugs were observed in the kitchen area under the three-compartment sink area. The area was observed with water and food particles on the floor. A live roach was observed alongside the walk-in refrigerator next to the dry cooking pan racks. Dead roaches were observed in six overhead light covers. On 12/06/18 at 11:00 A.M., one dead roach was observed in the dry storage area under the food with bread and napkins. Dry corn flakes and cereal were observed on the floor. During a review of the Pest Control Log on 12/04/18 at 2: 33 P.M. the Pest Control Service Inspection Report noted date of service 11/14/18 in at 11:51 AM and time out 11/14/18 at 12:29 PM. The report indicated: applied Alpine Cockroach Gel-Area-Kitchen-target German Roaches. A Pest Control Long dated 11/28/18 Service Inspection Report indicated: date of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review the facility staff failed for 1 resident (Resident #65) of 46 residents in the survey sample to ensure an accurate annual resident assessment. The facility staff failed to ensure that the Annual Minimum Data Set (MDS-an assessment tool), was accurately coded to reflect Resident #65 Bladder and Bowel incontinence. The findings included: Resident #65 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, Diabetes Mellitus, Other sequelae of other Cerebrovascular Disease, and Anxiety Disorder. Resident #65's most recent MDS was an annual assessment with an Assessment Reference Date (ARD) of 10/12/18. The MDS coded Resident #65 with short-term memory problems, long-term memory problems, and with severely impaired cognitive skills for daily decision making. In addition, the Minimum Data Set coded Resident #65 requiring total dependence, on staff, for Activities of Daily Living care. The clinical record for Resident #65 was reviewed on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review the facility staff failed to provide personal care to include showers for one resident in the survey sample (Resident #387) who was unable to independently carry out activities of daily living (ADL's). The facility staff failed to ensure Resident #387 was offered and received a scheduled twice-weekly shower to maintain good personal hygiene. The findings included: Resident #387 was admitted to the facility on [DATE]. Diagnosis for Resident #387 included but not limited to *Multiple Sclerosis (MS). Resident #387's Minimum Data Set (an assessment protocol) with an Assessment Reference date (ARD) of 05/17/18 coded Resident #387 with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. In addition, the MDS coded Resident #387 requiring total dependence of one with bathing, extensive assistance of two and toilet use, extensive assistance of one with transfer, dressing, eating and personal hygiene.…

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 failed for 1 resident (Resident #65) of 46 residents in the survey sample to provide foot care and/or ensure that Podiatry services were provided. For Resident #65, who was a Diabetic, the facility staff failed to ensure toenail care was provided. Podiatry services had not been provided since 7/31/17. The findings included: Resident #65 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, Diabetes Mellitus, Other sequelae of other Cerebrovascular Disease, Anxiety Disorder. Resident #65's most recent Minimum Data Set (MDS-an assessment tool) with an Assessment Reference Date (ARD) of 10/12/18. The MDS coded Resident #65 with short-term memory problems, long-term memory problems, and with severely impaired cognitive skills for daily decision making. In addition, the Minimum Data Set coded Resident #65 as requiring total dependence, on staff, for Activities of Daily Living (ADL) care. On 12/04/18 at 12:24…

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 documentation review, the facility staff failed to ensure an opened refrigerated medication included the opened date in one of two medication rooms. The facility staff failed to date a multidose vial of influenza vaccine when opened. The findings include: On 12/06/18 the facility's medication storage review of 3 medication carts and 2 medication rooms was conducted. On 12/6/18 at approximately 12:12 PM, the medication refrigerator was inspected with Licensed Practical Nurse (LPN) #4. Stored inside the medication refrigerator was an opened multidose vial of *Influenza Vaccine with a manufacturer's expiration date of 05/20/2019. The date the multidose vial of influenza vaccine was opened was not written on the vial or the medication storage box. On 12/06/18 at approximately 3:20 PM, Licensed Practical Nurse # 3 was interviewed. She stated that if she observed a multidose vial of medication in the refrigerator not labeled with the opened date she would discard the medication. On 12/06/18 at approximately, 3:30 PM. Licensed Practical…

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 general observations, complaint investigation, staff and resident interviews and facility documentation, the facility staff failed to ensure furnishings were safe and clean to create homelike environment in the Family/Recreation Room. The findings included: During general observations, on 5/18/17 at approximately 2:30 p.m., Resident #27 asked two surveyors to examined the condition of the 7 sitting chairs. All the arms of the chairs were obviously discolored, worn and stains were observed on most chair cushions. The resident also showed the surveyors that the table, in the center of the room where they played board games, rocked back and forth. He directed the surveyors' attention toward the counters where all the trim was loose and if gently pulled came loose and exposed nails. The Assistant Administrator (AA) was shown the aforementioned resident concerns. She stated she was not aware of the resident concerns in the Family/Recreation room regarding, but that the trim on the counters would be repaired…

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 general observations, complaint investigation, staff interviews and facility documentation, the facility staff failed to ensure housekeeping and maintenance services were provided to maintain a sanitary and comfortable interior on two of three units ([NAME] and [NAME] Unit). The findings include: During general observations, on 5/18/17 at 11:45 a.m. escorted by the Assistant Administrator (AA), the following environmental conditions were identified on the [NAME] Unit: room [ROOM NUMBER]-Window ledge and track exhibited dark material that appeared to be dirt, dust, and dead ant carcasses. The toilet seat was loose and shifted side to side. The laminate on A bed's overbed table was coming off, exposing sharp edges. A Bed's bottom metal frame portion of the overbed table possessed large surface areas of rust. B Bed's bottom metal frame portion of the overbed table exhibited heavy accumulations of food deposits. room [ROOM NUMBER]-The strip in front of the sink was loose, held in place with nails that could…

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 interview, the facility staff failed to ensure that semi-private rooms on the [NAME] unit had ceiling suspended privacy curtains which allowed residents to completely withdraw from public viewing while occupying their bed. The findings include: During general observations rounds on 5/18/17 at approximately 12:05 p.m., the privacy curtains (the middle curtain which separates roommates) in rooms 301 through 308 and 322 through 331 were observed not be wide enough to promote total privacy for the residents. When the Director of Maintenance drew the middle curtain towards the head of the bed, the resident's lower body was viewable and when the privacy curtain was drawn towards the foot of the bed, one resident could see the other roommate's face. It was also observed there were multiple unused privacy curtain hooks on the privacy curtain track. The Director of Maintenance stated the above was an easy fix, a wider privacy curtain needed to be installed. On 5/18/17 at approximately 4:00…

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, the facility staff failed to provide privacy during a pressure wound dressing change for 1 of 27 residents in the survey sample, Resident #5. LPN #5 failed to close the door prior to providing treatment and dressing change to Resident #5's left heel. The findings included: Resident #5 was admitted to the facility on [DATE]. Diagnoses for Resident #5 included but not limited to diabetes mellitus and stroke. The most recent Minimum Data Set with an assessment reference date of 5/4/17, coded Resident #5 with a score of 12 out of possible 15 on the Brief Interview for Mental Status (BIMS), indicating cognitive abilities for daily decision making are intact. Resident #5 was coded as having a pressure ulcer. On 5/17/17 at 10:45 am, observed LPN #5 during a wound dressing change on Resident #5's pressure ulcer on his left heel. Resident #5 was in bed at the time and CNA #7 assisted LPN #5 during the procedure. Prior 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 interviews, clinical record review and during a complaint investigation the facility staff failed to make prompt efforts to resolve a grievance for 1 of 27 residents in the survey sample, Resident #23. The findings included: Resident #23 was admitted to the facility for skilled rehab services on 1/10/17 with diagnosis to include a fractured left upper arm. The admission MDS (Minimum Data Set) with an assessment reference date of 1/17/17 coded the resident as scoring a 15 out of a possible 15 on the Brief Interview for Mental Status, indicating the resident's cognition was intact. The resident required extensive assistance of two staff for bed mobility, transfers, extensive assistance of one staff for dressing, toileting, bathing and personal hygiene. The comprehensive person-centered care plan dated 1/26/17 identified the resident required limited assistance with all ADL's (Activities of Daily Living). The goal was that the resident will set realistic goals that can be achieved in small measurable steps, daily thru next review. Interventions to achieve the goal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure 2 of 27 residents, (Resident #3 and #22), received reasonable accommodation of needs. 1. Specifically, Resident #3's call bell was not in reach on two occasions: on 5/16/17 at approximately 12:30 p.m. during the initial tour and again on 5/16/17 at approximately 5:15 p.m. Also, during the initial tour observations another surveyor noted that a resident on another unit did not have her call bell within reach. 2. The facility staff failed to accommodate Resident #22 with a bedside commode or over the toilet raised seat to aid in elimination. The findings included: 1. Resident #3 was admitted to the facility on [DATE]. Diagnoses for Resident #3 included but are not limited to hemiplegia, atrial fibrillation, diabetes, and major depressive disorder. Resident #3's Minimum Data Set (an assessment protocol) with an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, clinical record review, and facility document review the facility staff failed to ensure MDS (Minimum Data Set) Assessments for 2 of 27 residents in the survey sample were accurate, Resident #4 and Resident #20. 1. The facility staff failed to ensure the Annual MDS with an Assessment Reference Date (ARD) of 4/8/17 under Section K Swallowing/Nutritional Status K0300 Weight Loss was accurately coded to include weight loss for Resident #4. 2. The facility staff failed to ensure the Quarterly MDS with an Assessment Reference Date (ARD) of 4/17/17 under Section O Special Treatments, Procedures, and Programs 00100 Other was accurately coded to include Dialysis for Resident #20. The findings included: 1. Resident #4 was a [AGE] year old admitted to the facility on [DATE] with diagnoses to include (1) Anxiety Disorder, (2) Bipolar Disorder and (3) Depression. The most recent MDS assessment was an Annual MDS with an assessment reference date (ARD) of 4/8/17. The Brief 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 clinical record review, staff interview and facility documentation the facility staff failed to ensure labs were obtained as ordered for 1 out of 27 residents (Resident #2) in the survey sample. The facility staff failed to ensure labs were obtained as ordered for the following labs: CBC (1), BMP (2) and Phenytoin (3) level for the month of April 2017. The findings included: Resident was originally admitted to the facility on [DATE]. Diagnosis for Resident #2 included but not limited to Cerebrovascular Disease (4), Hypertension (5) and Epilepsy (6). Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date of 02/07/17 coded the Brief Interview for Mental Status (BIMS) score an 11 out of a possible 15 indicating moderate cognitive impairment. Resident is extensive assistance of 2 with transfers, bowel and bladder, extensive assistance of 1 with dressing and eating and total dependent with hygiene and bathing. The clinical record revealed a physician order for Complete Blood Count (CBC),…

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, the facility staff failed to secure an indwelling urinary catheter (1) to prevent complications for 1 of 27 residents in the survey sample, Resident #15. The findings included: Resident #15 was admitted to the facility on [DATE] and was readmitted on [DATE]. Diagnoses for Resident #15 included but not limited to, hypertension, functional urinary incontinence, dysphagia (2) and gastrostomy tube (3). The most recent Minimum Data Set with an assessment reference date of 2/20/17, coded Resident #15 with a score of zero (0) out of possible 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Resident #15 was severely impaired in the skills needed for daily decision making. She was coded as not able to walk and dependent on staff for activities of daily living. Resident #15 was coded as having an indwelling urinary catheter. During the medication pass observation on 5/17/17 at 9:20 am, it…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, clinical record review and facility document review, the facility staff failed to ensure specialty care was provided consistent with professional standards of care for 2 of 27 residents (Resident #15 and #14) in the survey sample. 1. The facility staff failed to check placement of a gastrostomy feeding tube (1) prior to medication administration to prevent complications for Resident #15. 2. The facility staff failed to ensure Resident #14 received podiatry care for overgrown and thick toe nails. The findings included: 1. Resident #15 was admitted to the facility on [DATE] and was readmitted on [DATE]. Diagnoses for Resident #15 included but not limited to, hypertension, functional urinary incontinence, dysphagia (2), and gastrostomy tube. The most recent Minimum Data Set with an assessment reference date of 2/20/17, coded Resident #15 with a score of zero (0) out of possible 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility document review, the facility staff failed to practice good hand washing technique to prevent the spread of germs that cause infections for 1 of 27 residents in the survey sample, Resident #15. LPN #8 failed to wash her hands properly after touching a soiled towel used for tube feeding and medication administration for Resident #15 and after placing the soiled towel in the soiled linen containers. The findings included: Resident #15 was admitted to the facility on [DATE] and was readmitted on [DATE]. Diagnoses for Resident #15 included but not limited to, hypertension, functional urinary incontinence, dysphagia (1), and gastrostomy tube (2). The most recent Minimum Data Set with an assessment reference date of 2/20/17, coded Resident #15 with a score of zero (0) out of possible 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Resident #15 was severely impaired in the skills needed for 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and facility documentation, the facility failed to notify physician of labs results obtained on 12/22/16 for 1 out of 27 residents (Resident #2) in the survey sample. The facility staff failed to notify the physician of lab results drawn on 12/22/16 for Comprehensive Metabolic Panel (CMP (1)), Lipid Profile Complete (2), Phenytoin (3), Vitamin D 25-Hydroxy (4) and Hemoglobin A1C (5). The findings included: Resident was originally admitted to the facility on [DATE]. Diagnosis for Resident #2 included but not limited to Epilepsy (6), Type II Diabetes Mellitus (7), Vitamin D Deficiency (8) and Hyperlipidemia (9). Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date of 02/07/17 coded the Brief Interview for Mental Status (BIMS) score an 11 out of a possible 15 indicating moderate cognitive impairment. Resident is extensive assistance of 2 with transfers, bowel and bladder, extensive assistance of 1 with dressing and eating and total dependent with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and facility documentation, the facility staff failed to ensure the lab results were filed in the clinical record for 1 out of 27 residents (Resident #2) in the survey sample. The facility staff failed to ensure lab results for Comprehensive Metabolic Panel (CMP (1)), Lipid Profile Complete (2), Phenytoin (3), Vitamin D 25-Hydroxy (4) and Hemoglobin A1C (5) from 12/22/16 were filed in Resident #2's medical record. The findings included: Resident was originally admitted to the facility on [DATE]. Diagnosis for Resident #2 included but not limited to Epilepsy (6), Type II Diabetes Mellitus (7), Vitamin D Deficiency (8) and Hyperlipidemia (9). Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date of 02/07/17 coded the Brief Interview for Mental Status (BIMS) score an 11 out of a possible 15 indicating moderate cognitive impairment. Resident is extensive assistance of 2 with transfers, bowel and bladder, extensive assistance of 1 with dressing 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 clinical record review, staff interview and facility documentation, the facility staff failed to ensure the clinical records were complete and accurate for 1 out of 27 residents (Resident #2) in the survey sample. The facility staff failed to ensure the Medication Administration Record (MAR) were complete and accurate for April and May 2017. The findings included: Resident was originally admitted to the facility on [DATE]. Diagnosis for Resident #2 included but not limited to Epilepsy (1), Type II Diabetes Mellitus (2) and Gastro-esophageal reflux disease (GERD (3)). Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date of 02/07/17 coded the Brief Interview for Mental Status (BIMS) score an 11 out of a possible 15 indicating moderate cognitive impairment. Under section J (Health Conditions) was coded: received scheduled pain medication regimen. Resident #2 was coded with a diagnosis of diabetes with daily injections of insulin. Some of the interventions on the care plan is to obtain…

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.