Blue Ridge Rehabilitation And Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, clinical record reviews, and facility documentation reviews, the facility staff failed to provide activities of daily living (ADL) care to residents who required staff's assistance, for five residents (resident #12- R12, resident #22- R22, resident #57-R57, resident #40-R40, and resident #49-R49), in a survey sample of 31 residents. The findings included: 1. For R12, who was dependent upon facility staff for toileting assistance, the facility staff failed to respond timely to the resident's call light, which resulted in R12 urinating on the floor on one occasion. On 8/26/24 at 6:30 p.m., R12 was observed with her call bell on. R12 was sitting at her doorway waiting for staff to respond. When the certified nursing assistant (CNA) responded, at 6:48 p.m., the CNA noticed a wet spot on the room floor with a towel over it. R12 reported that she had not been able to hold it and had urinated on the floor. The CNA assisted R12 with being cleaned up and put in 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 follow physician orders for three of thirty-one residents in the survey sample (Residents #32, #57 and #77). The findings include: 1. For over two months, Resident #77 was not administered the nutritional supplement Pro-stat twice per day as ordered by the physician for treatment of protein-calorie malnutrition. Resident #77 (R77) was admitted to the facility with diagnoses that included congestive heart failure, protein-calorie malnutrition, seizures, dementia, chronic obstructive pulmonary disease, and obstructive uropathy. The minimum data set (MDS) dated [DATE] assessed R77 as cognitively intact. R77's clinical record documented a physician's order dated 2/8/24 for the nutritional supplement Pro-stat 30 milliliters twice per day for management of protein-calorie malnutrition. R77's medication administration record (MAR) documented Pro-stat was not administered as ordered on 3/28/24 through 4/4/24 and from 4/8/24 through…

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

Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure two residents (Resident #32-R32 and Resident #249) were free from significant medication errors/omissions, in a survey sample of 31 residents. The findings included: 1. For Resident #32 (R32), the facility staff failed to ensure the resident received antibiotic medication, as ordered by the physician. On 8/26/24 at 7:16 p.m., R32 was interviewed in his room. During the interview, R32 reported that he had osteomyelitis, a serious bone infection, and had been treated for c-diff (clostridioides difficile - an infection of the colon) but had missed a lot of his antibiotic doses .because they don't have the vanc [vancomycin] frequently. On 8/27/24, a clinical record review was conducted. This review revealed a physician order dated 7/20/24 that read, Vancomycin HCl Suspension 50MG/ML Give 2.5 ml by mouth in the morning every 2 day(s) for c diff for 8 Weeks. According to the medication administration record (MAR), R32 was not provided the vancomycin…

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 documentation review, the facility staff failed to maintain a complete and accurate clinical record for four residents (resident #79-R79, resident #57-R57, resident #32-R32 and resident #93-R93), in a survey sample of 31 residents. The findings included: 1. For Resident #79, the facility staff failed to maintain an accurate clinical record with regards to the changing of oxygen tubing and nebulizer tubing and mask. During initial tour on [DATE] at approximately 6:30 p.m., R79 was visited in her room. It was observed that R79 had a nebulizer on her bedside table. The nebulizer mask was sitting in the top drawer of the bedside table and was open to air. The nebulizer mask and tubing were dated [DATE], as the date it was changed. On [DATE] at 7:09 p.m., an interview was conducted with licensed practical nurse (LPN) #4. LPN #4 was asked about oxygen and nebulizer tubing and the frequency they were changed, LPN #4 said they…

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

Based on resident interview, staff interviews, clinical record review, and facility documentation review, the facility staff failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections, and failed to respond to a COVID outbreak in accordance with the guidance from the Centers for Disease Prevention and Control (CDC), which involved two residents (Resident #22 and Resident #57) but had the potential to affect numerous residents on 2 of 2 nursing units. The findings included: 1. The facility staff failed to provide care and adhere to infection control practices to include the use of personal protective equipment (PPE) to minimize the spread of multi-drug resistant organisms (MDROs), by implementing enhanced barrier precautions for Resident #22 (R22). On 8/26/24 at approximately 7 p.m., observations were conducted, and it was noted that R22's room had a sign on the door that indicated enhanced barrier precautions. There was a plastic storage hanger also on the door, but it was empty and…

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

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide education and offer the flu and pneumonia immunizations to 3 of 5 residents (Resident #80 - R80, Resident #42 -R42, and Resident #70 - R70) sampled for immunizations. The findings included: On 8/27/24, five residents were reviewed for compliance with immunization protocols, as part of the infection control task. During this review, the clinical record of each resident was reviewed. For R80 and R42, the clinical record documented no evidence that either resident had been educated about the vaccines or offered the flu and pneumonia vaccines since admission. There was no documentation for R80 or R42 regarding consent or refusal of the immunization. R70's clinical record had no evidence of being offered the flu vaccine, despite being admitted during the flu season. R70's clinical record revealed that she had received Prevnar 13, but there was no indication that the pneumococcal 23 vaccine was offered. The clincal record reviews revealed that each of the residents 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide education and offer the COVID-19 immunization to 4 of 5 residents (Resident #80 - R80, Resident #42 - R42, Resident #60 - R60 and Resident #70 - R70). The facility also failed to provide education to the employee regarding the spike vaccine booster for the 2023-2024 season for 1 of 1 staff sampled (Other Employee #8). The findings included: On 8/27/24, clinical record reviews were conducted of the five residents sampled for immunizations. The findings revealed no evidence of the residents being educated nor offered the COVID-19 2023-2024 spik vaccine. R80 had no immunization information noted, only a PPD tuberculin skin test. R42, had no immunization information noted. R60 and R70 had no information regarding COVID immunization listed. There was no information that the 2023-2024 Spike vaccine was offered, education provided, or that it was declined/refused. On 8/28/24 at 4:32 p.m., 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.

Based on observation, resident interview, staff interview, facility documentation review, and clinical record review the facility staff failed to ensure it was determined clinically appropriate to self-administer medications by the interdisciplinary team for one resident (Resident #79- R79) in a survey sample of 31 Residents. The findings included: For R79, who had Bengay cream, antifungal powder and tums at the bedside, the facility staff had not assessed the resident to determine if it was appropriate for the resident to self-administer medications, failed to obtain physician orders for the medications, and failed to remove the medications. On 8/26/24 at 6:19 p.m., R79 was visited in her room during the initial tour and on the over bed table a tube of Bengay ointment and a container of antifungal powder was observed. While talking to R79, the bedside tabletop drawer was open, and it was easily observed that a bottle of tums was inside. R79 was asked about the Bengay and reported she often has pain and reported the has arthritis. When asked about the Bengay cream, R79 reported she…

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 dignity when moving personal property for one of thirty-one residents in the survey sample (Resident #200). The findings include: Resident #200's personal property/items were moved to another room while the resident was out of the facility at an appointment. There was no advance notice of the room/property move and the resident was not given an opportunity to assist or accompany staff during transfer of personal items to a different room. Resident #200 (R200) was admitted to the facility with diagnoses that included congestive heart failure, hip fracture, neurogenic bladder, diabetes, anxiety and depression. The minimum data set (MDS) dated [DATE] assessed R200 as being cognitively intact. R200's closed clinical record documented a room change on 5/21/24. There was no documentation of a verbal or written notice provided to the resident prior to the 5/21/24 room change. A nursing note dated 5/21/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interviews, and facility documentation review, the facility staff failed to maintain adequate funds on-site so that two residents (resident #226 - R226 and resident #53 - R53) had access to their personal funds/trust accounts, which had the potential to affect 41 residents with a trust account. The findings included: 1. For R226, the facility failed to maintain sufficient funds and denied the resident's request to make withdrawals from his account. On 8/27/24 at approximately 8:15 a.m., R226 asked the surveyor to come into his room. R226 reported that he had failed to mention on the prior evening a concern with regards to him having access to his bank account. R226 went on to say that on multiple occasions he had attempted to get money out of his trust account for shopping but had been denied the ability to make withdrawals. R226 went on to say that he could get money previously but now he is told he must make a list of what he wants first or talk to the activities person or 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.

Based on staff interview and clinical record review, the facility failed to develop a care plan for one of thirty one residents. Resident #60 (R60) did not have a complete care plan developed for dialysis. The Findings Include: Diagnoses for R60 included: End stage renal disease receiving dialysis, congestive heart failure, pulmonary embolism, and hypertension. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 6/13/24. R60 was assessed with a cognitive score of 12 indicating cognitively intact. Review of R60's blood pressures (BP) from 7/25/24 through 8/24/24 indicated an average systolic pressure of 140's and diastolic pressure of 70's and also indicated recently (on 8/22/24 and 8/23/24) an increase in BP to 183/83 and 179/83. Review of physicians orders did not indicated blood pressure parameters for dialysis. The care plan was then reviewed and also did not indicate blood pressure parameters in the dialysis care plan or throughout the care plan in any other focus area. On 8/28/24 at 3:43 PM license practical nurse (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 resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to implement interventions in response to a resident's fall to prevent future falls and prevent accidents for one resident (resident #57-R57) in a survey sample of 31 residents. The findings included: For R57, who fell on 8/13/24, the facility staff failed to respond to the fall and implement interventions to prevent future accidents. On 8/26/24 at approximately 7:30 p.m., R57 was visited in his room. R57 reported he had recently fallen. When asked what the facility had done following the fall to prevent future falls, the resident said he didn't know. On 8/27/24, a clinical record review was conducted. This review revealed a nursing note entry dated 8/13/24, that read, Resident was informed that he needs to move to room [ROOM NUMBER]. CNA reports resident became anxious and agitated and called his wife. Afterwards this nurse was called to resident's room, resident was observed on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, the facility failed to ensure a device was implemented for a catheter for one of thirty one residents and failed to ensure a catheter bag was located to prevent infection for one of thirty one residents. 1. Resident 41 (R41) did not have catheter tube anchored to prevent dislodging. 2. Resident 77 (R77) catheter bag was touching the floor and had potential for infection. The Findings Include: 1. Diagnoses for R41 included; Benign prostatic hyperlasia, and obstructive uropathy requiring catheter. The most current MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 7/16/24. R41 was assessed with a cognitive score of 15 indicating cognitively intact. Review of R41's physician orders (on 8/27/24) revealed an order to check placement of catheter strap every shift. Original order date was 5/7/24. On 8/28/24 at 10:00 AM R41 was interviewed and was asked if there was a strap anchoring the catheter tube down 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 observation, resident interview, staff interview, and clinical record review, the facility failed to provide oxygen therapy consistent with infection control measure and professional standards of practice for one resident (Resident #79- R79) in a survey sample of 31 residents. Findings included: For Resident #79, the facility staff failed to change the oxygen tubing and nebulizer tubing and mask weekly. During initial tour on 8/26/24 at approximately 6:30 p.m., R79 was visited in her room. It was observed that R79 had a nebulizer on her bedside table. The nebulizer mask was sitting in the top drawer of the bedside table and was open to air. The nebulizer mask and tubing were dated 7/16/24, as the date it was changed. The oxygen tubing was not labeled with a date and the nasal cannula was on the floor. On 8/26/24 at 7:09 p.m., an interview was conducted with licensed practical nurse (LPN) #4. LPN #4 was asked about oxygen and nebulizer tubing and storage of them when not in use. LPN #4 said, we are to wrap it and put it in a bag and store it in the drawer, so it doesn't get…

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, record review, and facility menu review, the facility failed to coordinate services and provide meals and/or snacks for one of three sampled residents (Resident #32- R32) reviewed for dialysis and received dialysis treatments at an outside dialysis center. The findings include: 1. For R32 who received dialysis at an offsite location, the facility staff failed to provide meals or snacks for the resident when he would miss the lunch meal. Review of R32's Med Diag [medical diagnosis] tab in the resident's electronic medical record (EMR) revealed R32 was admitted to the facility with diagnoses which included end stage renal disease (ESRD), type 2 diabetes, and dependent on renal dialysis. Review of R32's Physician Orders, located under the Orders tab in the resident's EMR, revealed current orders for R7 to receive outpatient hemodialysis on Monday, Wednesday, and Friday and orders for a liberal renal diet, regular texture, thin consistency diet. Review of R32's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/12/24, located…

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 to label a medication per pharmacy standards on one of two units (B wing). The findings include: A Novolog prefilled insulin pen stored on a B wing medication cart had no pharmacy label indicating the drug name, resident's name, prescribed dose, strength or administration instructions. On 8/27/24 at 4:42 p.m., accompanied by licensed practical nurse (LPN #7), a B wing medication cart was inspected. Stored in the cart drawer was a Novolog prefilled insulin pen. There was no pharmacy label on the insulin pen. Resident #93's name was handwritten on the insulin pen along with the date opened. LPN #7 was interviewed about the Novolog insulin pen without a pharmacy label. LPN #7 stated she did not why the insulin pen had a handwritten name, and she did not know what happened to the bag or label typically provided by pharmacy. On 8/28/24 at 9:47 a.m., the director of nursing (DON) was interviewed about the Novolog insulin pen without a pharmacy label. The DON stated the insulin pen had been…

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 and clinical record review, the facility staff failed to provide a handled cup for one of thirty-one residents in the survey sample (Resident #28). The findings include: Resident #28 did not have a two-handled sippy cup provided as recommended by therapy and per her plan of care. Resident #28 (R28) was admitted to the facility with diagnoses that included atrial fibrillation, hypertension, arthritis, anxiety, depression, hypothyroidism and urinary tract infection. The minimum data set (MDS) dated [DATE] assessed R28 as cognitively intact. On 8/27/24 at 8:21 a.m., R28 was observed eating breakfast in her room. R28 stated at this time that she was supposed to have a sippy cup for her beverages because she had hand tremors. R28 stated she had the sippy cup a few times after it was first recommended but the cup had not been provided in several weeks. Tremors were observed on both of R28's hands and there was no sippy cup on the resident's breakfast tray. The…

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

Based on observation, staff interview, and facility documentation review, the facility staff failed to store, prepare, and serve food accordance with professional standards for food safety in the main kitchen and on one of two units (B Wing). The findings included: 1. Multiple open food products were not labled with an open date and expired meat product, sugar and flour was accessible for distribution. On 8/26/24 at 6:10 PM an initial kitchen tour was conducted with the dietary staff member (other staff, OS #1). The dry storage room yielded an opened syrup container, loaf of bread containing 4 slices, and open case of croissants with 9 croissants in the package did not have an opened date or use by date. The walk in refrigerator had an opened bag of mozzarella shredded cheese with no open date and an opened bag of cubed ham with a use by date of 8/12/24 was accessible for distribution. The main kitchen had bulk barrels of stored sugar and flour with a used by date of 6/28/24 and was accessible for distribution. OS #1 verbalized all opened food product are supposed to have an open…

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 review, staff interview, facility document review, and clinical record review the facility failed to review and revise the care plan for one of five residents in the survey sample (Resident #3). The findings include: Resident #3's (R3's) care plan was not revised following a surgical procedure which resulted in a change in medical condition. R3 was admitted with diagnoses that included diabetes, presence of cardiac pacemaker, major depressive disorder and heart disease. The most recent minimum data set (MDS) dated [DATE] assessed R3 as cognitively intact. On 1/3/24 at 2:00 PM R3 was interviewed regarding her pacemaker site. R3 stated she had recently had a procedure to her pacemaker on 12/14/23 to repair a lead. R3 displayed her surgical site near the left clavicle. There was a healing incision at the site with intact Steri-strips. R3's plan of care was revised on 11/24/23 and had not been updated since the 12/14/23 surgical procedure. The plan of care included no problems, goals…

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, the facility failed to follow professional standards of care for one of five residents in the survey sample (Resident #4). Facility staff failed to document an assessed skin impairment at Resident #4's pacemaker site and failed to provide ongoing assessment/monitoring of the impairment. The findings include: Resident #4 (R4) was admitted to the facility on [DATE] with diagnoses that included: atrial fibrillation, pleural effusion, chronic obstructive pulmonary disease, shock, malnutrition, covid, congestive heart failure, pacemaker, and hypertension. The most current MDS (minimum data set) was a discharge assessment dated [DATE], which assessed R4 with a cognitive score of 15 out of 15, indicating cognitively intact. R4's clinical record documented that the resident was admitted with a pacemaker. R4's care plan dated 8/30/23 listed interventions for the pacemaker that included: Monitor/document /report any signs/symptoms of infection…

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 facility document review, the facility staff failed to employee a qualified dietary manager. The facility's dietary manager had no certifications or education in food service management or food safety. The findings include: On 12/7/21 at 2:25 p.m., a follow-up inspection of the kitchen was conducted accompanied by the dietary manager (other staff #1). The dietary manager was interviewed at this time about his qualifications as the food services manager. The dietary manager initially stated he was not certified but had ServSafe training regarding food service/safety. A copy of the certification was requested. The dietary manager then stated that he used to have a food safety certificate but it had expired. The dietary manager stated he previously worked in the restaurant business but did not currently have a degree or any training certifications in food safety. The dietary manager stated he had been employed in the facility for approximately two months. The certifications for three dietiary employees were reviewed. The dietary employees had current…

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 review of facility personnel files, facility policy and procedures, and staff interview, the facility failed to implement the policy and procedure to ensure applicants for employment completed a Sworn Disclosure Statement disclosing .any criminal convictions or pending criminal charges Review of 25 personnel files revealed none of the 25 files reviewed contained a Sworn Disclosure Statement. The findings were: On 12/8/2021, 25 personnel files, selected from a list provided by the facility, were reviewed. The 25 files reviewed included 12 Certified Nursing Assistants, six Registered Nurses, three Licensed Practical Nurses, and four non-licensed personnel. There was no Sworn Disclosure Statement in 25 of the 25 files reviewed. During an interview at 2:00 p.m. on 12/8/2021, the facility Administrator provided a copy of the facility's Sworn Disclosure Statement form, a copy of an explanation of the facility's background check process, and a general information form, provided to applicants for employment. The Administrator indicated the Sworn Disclosure Statement form for the 25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review, and in the course of complaint investigation, the facility failed to ensure baths/showers were being provided as scheduled for three of 20 residents, Resident # 48, 7, and 13. The Findings Include: 1. Resident #48 was admitted to the facility on [DATE] with a readmission on [DATE]. Diagnoses for Resident #48 included: Diabetes, kidney disease, neuropathy, and dysphagia. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 11/5/21. Resident #48 was assessed with a cognitive score of 15 indicating cognitively intact. On 12/07/21 at 12:00 PM Resident #48 was interviewed. Resident #48 stated that she liked to take baths but had not been receiving baths as scheduled and had been told there was not enough staff to give baths. Resident #48's care plan, current MDS and bathing ADL's (activity of daily living) were reviewed and indicated Resident #48 needed set up and supervision for bathing. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, observation, staff interview and clinical record review, the facility staff failed to follow physician orders for four of 20 residents in the survey sample, Residents # 12, 68, 15, and 46. 1. Resident # 12 was not administered the correct probiotic as ordered by the physician. 2. Resident # 68 did not have weekly weights obtained per physician order. 3. Resident #15 was not administered the medications gabapentin and Eliquis as ordered by the physician. 4. Resident #46 did not have daily weights obtained as ordered by the physician. Findings include: 1. On 12/8/21 beginning at 8:00 a.m. a medication pass and pour observation was conducted with RN (registered nurse) # 1 on A wing. RN # 1 prepared Resident # 12's medications, which included Acidophilus (Lactobacillus) 303 mg 1 tablet. The medications administered were then reconciled with the physician orders. Resident # 12 did not have an order for Acidophilus; rather, he had an order for Saccharomyces boulardii (Florastor) 250 mg…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to assess and attempt non-drug interventions prior to the administration of opioid pain medication for one of 20 residents in the survey sample, Resident #15. Resident #15 was administered twenty-two doses of the pain medication hydromorphone (Dilaudid) without documented pain assessments or prior attempts or offers of non-drug interventions. The findings include: Resident #15 was admitted to the facility on [DATE] with diagnoses that included kidney cancer with metastasis, hypertension, congestive heart failure, atrial fibrillation, chronic embolism of femoral vein, esophagitis, anxiety, major depressive disorder with psychotic features, chronic lymphocytic leukemia and COPD (chronic obstructive pulmonary disease). The minimum data set (MDS) dated [DATE] assessed Resident #15 as cognitively intact and as experiencing pain almost constantly. Resident #15's clinical record documented a physician's order dated 6/21/21 for the medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review, and in the course of complaint investigation, the facility failed to ensure sufficient nursing staff were available to provide nursing care for three of 20 residents, Residents #48, #7, and #13; and failed to promptly respond to call bells for one of 20 residents, Resident #13. The Findings Include: Resident #48 was admitted to the facility on [DATE] with a readmission on [DATE]. Diagnoses for Resident #48 included: Diabetes, kidney disease, neuropathy, and dysphagia. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 11/5/21. Resident #48 was assessed with a cognitive score of 15 indicating cognitively intact. On 12/07/21 at 12:00 PM Resident #48 was interviewed. Resident #48 stated that she liked to take baths but had not been receiving baths as scheduled and had been told there was not enough staff to give baths. Resident #48's care plan, current MDS and bathing ADL's (activity 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 to ensure one of twenty residents was free from unnecessary medications, Resident #15. Resident #15 was administered multiple doses of the anti-anxiety medication lorazepam without a documented assessment of the need for the medication or of any prior attempts or offers of non-drug interventions. The findings include: Resident #15 was admitted to the facility on [DATE] with diagnoses that included kidney cancer with metastasis, hypertension, congestive heart failure, atrial fibrillation, chronic embolism of femoral vein, esophagitis, anxiety, major depressive disorder with psychotic features, chronic lymphocytic leukemia and COPD (chronic obstructive pulmonary disease). The minimum data set (MDS) dated [DATE] assessed Resident #15 as cognitively intact. Resident #15's clinical record documented a physician's order dated 8/19/21 for the anti-anxiety medication lorazepam 1 mg (milligram) with instructions to give 1.5 tablets every 4…

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, facility document review and staff interview, the facility staff failed to prepare, store and serve food in a sanitary manner in the main kitchen and on one of two nursing units. The findings include: 1. On 12/7/21 at 11:20 a.m., an initial tour of the kitchen was conducted. The cook (other staff #2) stated the dietary manager was not working and she was currently serving lunch from the steam table. On 12/7/21 at 11:25 a.m., the cook was requested to check the temperature of the food items currently stored on the steam table. The cook, using a digital thermometer, checked the temperature of ground turkey and then the pureed turkey. The cook then dipped the thermometer tip into a bucket of solution she identified as sanitizer. Without wiping the thermometer tip, the cook inserted the thermometer into a pan of green beans. The cook dipped the thermometer tip into the bucket of sanitizer solution and without wiping or drying the tip, inserted the thermometer into beef patties, then crab cakes and then into baked potatoes. The cook then dropped the thermometer 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, facility document review and clinical record review, the facility staff failed to coordinate services with a hospice provider for one of twenty residents in the survey sample, Resident #15. Resident #15, on hospice services since her admission on [DATE], had no hospice plan of care and no evidence of services provided for the resident by hospice personnel. The findings include: Resident #15 was admitted to the facility on [DATE] with diagnoses that included kidney cancer with metastasis, hypertension, congestive heart failure, atrial fibrillation, chronic embolism of femoral vein, esophagitis, anxiety, major depressive disorder with psychotic features, chronic lymphocytic leukemia and COPD (chronic obstructive pulmonary disease). The minimum data set (MDS) dated [DATE] assessed Resident #15 as cognitively intact. Resident #15's clinical record documented a physician's order dated 6/21/21 for hospice services due to terminal condition related to metastatic kidney cancer and leukemia.…

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 complaint investigation, clinical record review, resident interview, and review of facility documents, the facility failed to acknowledge the resident's personal choice for bathing, for one of 20 residents in the survey sample Resident # 13. Resident # 13, whose personal preference for bathing was a shower, received two showers between October 2, 2021 and December 1, 2021. The findings were: Resident # 13 in the survey sample was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, depression, morbid obesity, gastroesophageal reflux disease, lymphedema, slow transit constipation, and hypertrophic osteoarthropathy. According to the most recent Minimum Data Set (MDS), a Quarterly Review, with an Assessment Reference Date (ARD) of 9/23/2021, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. Under Section G (Functional Status), the resident was assessed as totally dependent with one person physical…

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 review and revise a comprehensive care plan for 1 of 20 residents in the survey sample, Resident #3. Resident #3's comprehensive care plans were not reviewed and revised for the discontinuation of anticoagulant use. The findings include: Resident #3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included legal blindness, atrial fibrillation, cerebral palsy, hypertension, dementia without behavioral disturbances, and generalized anxiety disorder. The most recent minimum data set (MDS) dated [DATE] was a quarterly and assessed Resident #3 as rarely/never understood for cognitive function and daily decision making. Under Section N - Medications, Anticoagulants was coded as 0 received. A comparative review of the significant change MDS dated [DATE] was completed. Under Section N - Medications, Anticoagulants was coded as 4 received. On 12/7/2021,…

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 facility document review, the facility staff failed to provide RN (registered nurse) coverage for two of fourteen days reviewed. Findings were: On 12/08/2021 at approximately 1:30 p.m., the as worked schedule for two weeks (11/21/2021-12/06/2021) was reviewed. On 11/21/2021, 12/04/2021 and 12/05/2021, there was no RN on the schedule. The administrator was interviewed at approximately 2:00 p.m., regarding the lack of RN coverage. She stated, That is correct. We had a nurse scheduled and she went out on FMLA (family medical leave) right before Thanksgiving. We tried to get it covered but I couldn't get anyone here .we have 6 agencies that we work with to try to get the shifts covered, no one would work it. I am working right now with someone who is interested in doing it. The above information was discussed during an end of the day meeting on 12/08/2021 with the DON (director of nursing), the administrator, and the corporate nurse consultant. On 12/09/2021 at approximately 8:00 a.m., the administrator came to the conference room. She stated, I never wrote…

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 ensure medications were available for administration for one of twenty residents in the survey sample, Resident #15. Doses of the medications gabapentin and apixaban (Eliquis) for Resident #15 were not provided from the pharmacy in a timely manner. The findings include: Resident #15 was admitted to the facility on [DATE] with diagnoses that included kidney cancer with metastasis, hypertension, congestive heart failure, atrial fibrillation, chronic embolism of femoral vein, esophagitis, anxiety, major depressive disorder with psychotic features, chronic lymphocytic leukemia and COPD (chronic obstructive pulmonary disease). The minimum data set (MDS) dated [DATE] assessed Resident #15 as cognitively intact. On 12/7/21 at 4:30 p.m., Resident #15 was interviewed about quality of life/care in the facility. Resident #15 stated during this interview that at times her medications were not available. The resident 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 observation, staff interview and facility document review, the facility staff failed to ensure Tuberculin PPD (purified protein derivative) solution was dated when opened, in one of two medication rooms. One multi-dose vial of PPD solution was observed opened, not dated and available for administration on the A wing. Findings were: On 12/08/2021 at approximately 2:30 p.m., the refrigerator on the A wing was inspected with LPN (licensed practical nurse) # 2. Observed in the refrigerator was an opened multi-dose vial of Tuberculin PPD solution. The vial was not dated. LPN #2 was asked when the vial had been opened. She stated, I don't know, I will throw it away. She was asked how long the vial should be kept after opening. She stated, Thirty days. At approximately 3;00 p.m., LPN #2 came to the conference room with a paper from the pharmacy titled Medication Storage List is not all-inclusive and subject to change. Information is from package inserts. The document listed medications, how to store them, and the expiration date. Per the document, PPD (Tubersol) should be stored…

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 facility document review, the facility staff failed to ensure qualified dietary staff in the main kitchen. The Dietary Manager (DM) failed to provide evidence of certification or a degree from an accredited institute of higher learning to qualify him as the director of food and nutrition services. Findings include: During an interview with the district dietary manager 3/7/19 at 12:00 p.m. she stated The dietary manager (DM) is a certified Chef; I don't have the information because it's at my house which is 2 hours away .what he has is at his house. I'll have to do a little research to see if a certified chef meets the requirements for the regulation you are referencing. He is going to begin the CDM (certified dietary manager) classes soon . The DM was interviewed 3/7/19 at 12:40 p.m. about his education status and if he had his certified chef certificate or any degree he may hold either at his home, or if the corporate entity for whom he worked had a copy of the information. The DM…

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 to procure, store, prepare, and serve food in a sanitary manner in the main kitchen. Items in the freezer were observed covered in ice due to a malfunctioning condenser, the freezer door did not seal with resulting ice crystals/frost on the items near the freezer door, scoops were stored with handles touching both the flour and sugar in the storage bins, and the can opener blade was covered with dry food debris. Findings were: Initial tour of the kitchen was conducted on 03/05/2019 with the DM (dietary manager). During the tour the DM stated, We are having a lot of maintenance issues with our freezer. The DM opened the door of the freezer, the floor of the freezer below the was covered in ice. There were frozen water droplets on the ceiling of the freezer. The fans of the condenser on the back wall of the freezer had small icicles hanging down. Stored on a rack below the condenser was a box of pizza dough, a large round container of ice cream, a box of frozen vegetables, and a large piece…

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 to ensure the walk-in freezer in the main kitchen was in safe operating condition. The freezer was observed with frozen water on the floor, on food stored under the condenser, and the freezer door did not seal properly. Findings were: Initial tour of the kitchen was conducted on 03/05/2019 with the DM (dietary manager). During the tour the DM stated, We are having a lot of maintenance issues with our freezer. The DM opened the door of the freezer, the floor of the freezer below the was covered in ice. There were frozen water droplets on the ceiling of the freezer. The fans of the condenser on the back wall of the freezer had small icicles hanging down. Stored on a rack below the condenser was a box of pizza dough, a large round container of ice cream, a box of frozen vegetables, and a large piece of beef. The aforementioned items all had frozen water across and around their sides. The DM was asked what had happened. He stated, The condenser is leaking .whenever it goes into the defrost…

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 interview, facility staff failed to ensure one of 24 residents bathing preferences, Resident #20. Facility staff failed to offer Resident #20 a tub/whirlpool bath weekly, stating the tub was broken. Findings included: Resident #20 was admitted to the facility on [DATE] with diagnoses including, but not limited to: Cerebrovascular Accident with left sided hemiplegia, Convulsions, Hypertension, and Psoriasis. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 12/11/18. Resident #20 was assessed as cognitively intact with a total cognitive score of 15 out of 15. Resident #20, the Resident Council President, was interviewed on 03/06/2019 at 1:30 p.m. During this interview Resident #20 stated, The small shower chair is broken. The large chair is too big for us small guys. We are afraid we will fall through the hole in the middle. The bath tub/whirlpool isn't working. I used to get in it at least once a 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 observation, resident interview, staff interview, and clinical record review, facility staff failed to implement an ongoing, individual centered activities program for one of 24 residents in the survey sample, Resident #39. Findings included: Resident #39 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to: Diabetes, End Stage Renal Disease requiring Hemodialysis, Hypertension, Epilepsy, Right BKA (below knee amputation), Left AKA (above knee amputation), Stage 4 Sacral Pressure Ulcer, and Cerebrovascular Disease. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 01/08/19. Resident #39 was assessed as cognitively intact with a total cognitive score of 13 out of 15. Resident #39 was interviewed on 03/06/19 at 8:15 a.m. Resident #39 was observed lying in bed with his tv on. Resident #39 stated, I have that wheelchair, but I never get out of this bed, except when I go to dialysis.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, family interview, clinical record review, and facility document review, the facility staff failed to provide a nourishing, well-balanced diet, that meets nutritional and special dietary needs; and failed to take into consideration dietary preference for two of 24 residents in the survey sample, Residents #55 and #95. 1. The facility staff failed to provide menu items and serving portions per resident choice for Resident # 55. 2. The facility staff failed to honor the dietary needs and preferences of Resident #95. The resident had a diagnoses of colitis and diverticulitis and was served corn and other food items that were communicated by the resident and documented by staff that the resident did not like or want, but the resident continued to receive the food items. Findings include: 1. Resident # 55 was admitted to the facility 1/11/19 for therapy following a fall at home resulting in a fractured hip. Other diagnoses for the resident included, but was not limited to:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. On 03/06/19 at 8:10 AM, the medication pass and pour observation was conducted with LPN (Licensed Practical Nurse) #1. LPN #1 prepared medications for Resident #44. While pulling the medications, the LPN stated that this resident took her medications whole in applesauce and then LPN #1 pulled one single packet of OcuSoft (eye lid scrub cloth) from the box, opened it and proceeded into the resident's room with the medications. LPN #1 attempted to administer the applesauce mixture with medications to the resident several times without success. LPN #1 then applied gloves and took the single OcuSoft cloth and began wiping the resident's eyes, the right eye, then the left and then the right again. LPN #1 then removed her gloves went to the sink and turned on the water. LPN #1 applied soap to her hands and washed her hands for approximately two seconds under the running water. LPN #1 then took her bare left hand, turned the water off, dried her hands and exited the room. LPN #1 then proceeded to the next resident.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility staff failed for one of 24 residents in the survey sample (Resident # 83), to offer a written bed-hold notice. Resident # 83, who was her own Responsible Party, was not offered a written bed-hold notice upon discharge to the hospital. The findings were: Resident # 83, was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses that included atrial fibrillation, congestive heart failure, hypertension, renal insufficiency, pneumonia, diabetes mellitus, osteoporosis, seizure disorder, chronic obstructive pulmonary disease, and respiratory failure. According to the most recent Minimum Data Set, a Significant Change with an Assessment Reference Date of 2/6/19, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 13 out of 15. According to the resident's Electronic Health Record (EHR), she was her own Responsible Party. On 1/22/19, Resident # 83 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, staff interview, and clinical record review, facility staff failed to develop a comprehensive care plan (CCP) for one of 24 residents in the survey sample, Resident #39. Facility staff failed to develop an activities care plan for Resident #39. Findings included: Resident #39 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to: Diabetes, End Stage Renal Disease requiring Hemodialysis, Hypertension, Epilepsy, Right BKA (below knee amputation), Left AKA (above knee amputation), Stage 4 Sacral Pressure Ulcer, and Cerebrovascular Disease. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 01/08/19. Resident #39 was assessed as cognitively intact with a total cognitive score of 13 out of 15. Resident #39 was interviewed on 03/06/19 at 8:15 a.m. Resident #39 was observed lying in bed with his tv on. Resident #39 stated, I have that wheelchair, but I…

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 for two of 24 residents in the survey sample (Residents # 35 and 83) to ensure PRN (as needed) psychotropic medications were not ordered for more than 14 days. 1. Resident # 35 had a PRN order for Lorazepam with out end date. 2. Resident # 85 had two PRN orders for Lorazepam; one for 29 days without a rationale for the extended use, and one with no end date. The findings include: 1. Resident # 83 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses that included atrial fibrillation, congestive heart failure, hypertension, renal insufficiency, pneumonia, diabetes mellitus, osteoporosis, seizure disorder, chronic obstructive pulmonary disease, and respiratory failure. According to the most recent Minimum Data Set (MDS), a Significant Change with an Assessment Reference Date (ARD) of 2/6/19, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary…

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 medication pass and pour observation, staff interview, and clinical record review, the facility staff failed to ensure a medication error rate of less than 5% (percent). The facility staff had a three medication errors out of 26 opportunities which resulted in a medication error rate of 11.54 percent (%). Findings include: 1. The facility staff failed to administer Resident #44 an Epoetin (Epogen) 10000 units/ml (milliliter) injection for a hemoglobin less than 11.0, per physician's orders; and failed to administer an OcuSoft Lid Scrub pad to each eye, per manufacturer's instructions (only one was used for both eyes). 2. The facility staff failed to administer insulin per physician's order for Resident #90. Findings include: 1. On 03/06/19 at 8:10 AM, the medication pass and pour observation was conducted with LPN (Licensed Practical Nurse) #1. LPN #1 prepared medications for Resident #44. While pulling the medications, the LPN stated that this resident took her medications whole in applesauce 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 resident interview, family interview, clinical record review, and facility document review, the facility staff failed to ensure one of 24 residents was provided routine and/or emergency dental services, Resident #95. Resident #95's lower denture was broken and the facility did not promptly assist the resident with dental services. The facility staff did not document any information regarding the damaged dentures and did not document any information regarding the resident's ability to adequately consume meals during this time. Findings include: Resident #95 was admitted to the facility on [DATE]. Diagnoses for this resident included, but were not limited to: DM (diabetes mellitus), history of wrist fracture, COPD (chronic obstructive pulmonary disease), anemia, gout, obesity, major depressive disorder, poly neuropathy, colitis, and diverticulitis. The most current full MDS (minimum data set) was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 15, indicating…

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