Dulles Health & Rehab Center

Based on staff interview, clinical record review, and facility document review, it was determined the facility staff failed to provide care and services for a gastrojejunostomy stoma site consistent with professional standards of practice for 1 of 54 residents in the survey sample, Resident #17. The findings include: For Resident #17 (R17), the facility staff failed to evidence care of a gastrojejunostomy (GJ) tube (1) stoma site.On the most recent MDS (minimum data set) assessment, annual assessment with a reference date of 2/5/2026, the resident was assessed as having a feeding tube and receives 51% or more of calories from enteral feeding.The physician's orders for R17 documented in part, tube feeding and water flushes but failed to evidence orders for GJ stoma site care.The discharge instructions for R17 dated 12/12/2025 documented in part, Discharge instructions for Gastrostomy/Gastrojejunostomy Tube . Cleanse the skin around the tube and under the skin disk daily with soap and water then dry thoroughly .The comprehensive care plan for R17 documented in part, R17 insertion site…

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

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to administer parenteral medications in a manner to prevent infection for one of five residents in the medication administration observation, Resident #2.The findings include:For Resident #2 (R2), the facility staff failed to administer an intravenous antibiotic in a sanitary manner on 3/23/26. On 3/23/26 at 8:13 a.m., RN (registered nurse) #1 was observed preparing and administering medications to R2. RN #1 placed all medications to be administered on a tray on the medication cart. She sanitized her hands and donned gloves. She closed two drawers on the medication cart, touched the surface of the medication cart, and pressed the lock on the medication cart. She took the tray of medications to the resident, who was sitting up in a chair. Without changing gloves, she administered oral medications, eye drops, and an injection to R2. Without changing gloves, she removed the cap to R2's central venous access, cleaned the access with alcohol, and connected the tubing for…

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

Based on observation, clinical record review and staff interview, the facility staff failed to provide respiratory care and services for one of 54 residents in the survey sample, Resident #161. The findings include:1a. For Resident #161 (R161), facility staff failed to administer oxygen according to the physician's order. R161 was admitted to the facility with diagnosis that included but not limited to respiratory failure (1) and chronic obstructive pulmonary disease (2). On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 03/03/2026, R161 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R161 was cognitively intact for making daily decisions. Section O Special Treatments, Procedures and Programs coded R161 as receiving Oxygen therapy. On 03/23/2026 at approximately 2:49 p.m. an observation revealed R161 receiving oxygen by nasal cannula (3). Observation of the oxygen concentrator (4) flow meter revealed a flow rate between two-and-a-half and three liters per minute. On 03/24/2026 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, staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide dialysis care and services for one of 54 residents in the survey sample, Resident #8.The findings include:The facility failed to provide evidence of communication with dialysis facility for Resident #8 (R8).R8 was admitted to the facility on [DATE] with diagnosis that included but were not limited to CVA (cerebrovascular accident), hemiplegia/hemiparesis, DM (diabetes mellitus) and ESRD (end stage renal disease).The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/19/26, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for locomotion/transfer/dressing/toileting and hygiene.A review of the…

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

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to store medications in a safe manner for one of 54 residents in the survey sample, Resident #132, and for one of ten medication carts. The findings include: For Resident #132 (R132), the facility staff failed to store the liquid medication cimetidine (a stomach acid reducing medication) in a safe manner. The medication was labeled with an expiration date of 3/15/26. A review of R132's clinical record revealed a physician's order dated 10/21/25 for cimetidine 300 milligrams/five milliliters-give 2.5 milliliters two times a day for gastroesophageal reflux disease. On 3/24/26 at 10:54 a.m., an observation of the Chesapeake unit medication refrigerator was conducted. R132's bottle of liquid cimetidine was labeled with an expiration date of 3/15/26. On 3/25/26 at 10:55 a.m., R132's bottle of liquid cimetidine was observed with LPN (Licensed Practical Nurse) #2. LPN #2 stated the nurses should check the medication refrigerator for expired medications every day. LPN #2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview and clinical record review, it was determined that the facility staff failed to honor dietary preferences for one of 54 residents in the survey sample, Resident #1.The findings include:The facility staff failed to honor dietary preferences by serving Resident #1 (R1) fish.R1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to DM (diabetes mellitus), CHF (congestive heart failure) and MI (myocardial infarction).The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/19/26, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for locomotion/transfer/dressing/toileting and dependent for bathing.A review of the comprehensive care plan dated…

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

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to maintain an accurate medical record for one of 54 residents in the survey sample, Resident #182. The findings include:For Resident #182 (R182), the facility staff failed to maintain an accurate medical record by failing to accurately document resident information in the skilled nursing notes on 3/22/26, 3/23/26 and 3/24/26. R182 was admitted to the facility with diagnoses that included but were not limited to cellulitis of the right and left lower limb (1), chronic lower extremity ulcers (2) and long-term use of anticoagulants (3). The nursing admission/readmission assessment for R182 dated 3/20/2026 documented cellulitis with wounds present on both lower extremities, open areas on both buttocks and the resident taking anticoagulant medication. A body audit for R182 dated 3/21/2026 documented in part, . Cellulitis wound to left posterior calf with necrotic tissue to wound bed, purulent drainage noted to site surrounding skin clustering. 11.5cm x 7.6cm x…

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

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement infection control practices for two of 54 residents in the survey sample, Residents #6, and #115, and for one of five residents in the medication administration observation, Resident #2. The findings include: For Resident #6 (R6), the facility staff failed to implement contact transmission-based precautions. (1) A review of R6's clinical record revealed a physician's order dated 3/23/26 for Contact Isolation for a diagnosis of CRE. (2) On 3/23/26 at 3:35 p.m., R6 was observed lying in bed and the resident's call light was ringing. A sign from the Centers for Disease Control was posted outside of R6's room door and documented, CONTACT PRECAUTIONS. EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit . On 3/23/26 at 3:37 p.m., CNA (Certified Nursing Assistant) #1…

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, clinical record review and facility documentation review, the facility staff failed to ensure the Resident's right to privacy for 1 Resident (Resident #3), in a survey sample of 4 Residents. The findings included: For Resident #3, the facility staff failed to ensure Resident #4, who was a Resident with dementia and wandering behaviors, did not wander into Resident #3's room at will. On 11/14/23 at 1:00 PM Resident #4 was observed in the hall self-propelling wheelchair down hall. She was observed to stop and stay in the doorway and look in the rooms. On 11/14/23 at 1:20 PM an interview was conducted with CNA B (certified nursing assistant-B) who stated they try to keep Residents that wander, out of other Residents rooms however it is not always possible. CNA B stated that Resident #4 has had to be redirected on many occasions out of Resident #3's room. CNA B stated that Resident #4 is easily redirected. On 11/15/23 at approximately 10:30 AM an interview was conducted with Resident #3 who was asked about issues with other Residents. Resident #3 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, interview, clinical record review and facility documentation review, the facility staff failed to ensure care plans were reviewed and revised to accurately reflect changes in care for 1 Resident (Resident #4) in a survey sample of 4 Residents. The findings included: For Resident #4 the facility staff failed to add the wandering risk assessment results, the addition of the wander guard, and interventions for wandering to the comprehensive care plan. On 11/14/23 at 1:00 PM Resident #4 was observed self-propelling the wheelchair down the hallway. She was observed to stop and stay in the doorway and look in the rooms. On 11/14/23 at 1:20 PM an interview was conducted with CNA B (certified nursing assistant-B) who stated they try to keep Residents that wander, out of other Residents rooms however it is not always possible. CNA B stated that Resident #4 has had to be redirected on many occasions out of Resident #3's room. CNA B stated that Resident #4 is easily redirected. On 11/15/23 at approximately 10:30 AM an interview was conducted with Resident #3 who stated 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.

Based on staff interview and facility documentation review, the facility staff failed to implement their abuse policy regarding the screening of employees for 12 employees (Employee D, Employee F, Employee G, CNA F, CNA G, LPN H, LPN J, LPN I, RN B, RN C, RN D and RN E) in a sample of 25 employee records reviewed. 1. The facility staff failed to obtain a criminal background check within 30 days of hire for 3 Employees (Employee D, Employee F and RN E). 2. The facility staff failed to perform professional license verification to ensure nursing employees held current licensure or certification and to determine if they had been subject to disciplinary action against their license as a result of abuse, neglect or mistreatment for 3 employees (LPN H, LPN J and RN D). 3. The facility staff failed to check references prior to hire for 9 employees (Employee D, Employee F, Employee G, CNA F, CNA G, RN B, RN C, RN E and LPN I). The findings included: On 8/3/21 during the afternoon, Surveyor E met with Employee A, the facility Administrator to review the above noted employee file findings.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, the facility staff failed to ensure necessary services for communication with one non English speaking Resident (Resident # 86) in a survey sample of 45 Residents. Findings included: For Resident # 86, the facility staff failed to ensure an effective means of communication for an a non English speaking resident. Resident # 86, a [AGE] year old female was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Dementia, Anemia, Anxiety Disorder, Insomnia, and Adjustment Disorder. Resident # 86's most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 6/16/2019. The MDS coded Resident # 86 with a BIMS (Brief Interview for Mental Status) score of 00 out of 15, indicating severe cognitive impairment. Resident # 86 was coded as requiring extensive to total assistance of one to two staff persons for ADLs (Activities of Daily Living). Resident # 86 was coded as always incontinent of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to properly label medications in 2 out of 6 medication carts. Specifically, there were vials of insulin and one bottle of ophthalmic solution observed opened and undated on 08/03/2021. The names of the Residents on the medication containers were identified and placed in the sample as Resident #3, Resident #106, Resident #19, and Resident #356. The findings included: Resident #3, a [AGE] year-old male, was admitted to the facility on [DATE]. Diagnoses included but were not limited to renal insufficiency and hypertension. Resident #3's most recent Minimum Data Set with an Assessment Reference Date of 04/26/2021 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 15 out of possible 15 indicative of intact cognition. Resident #106, a [AGE] year old female, was admitted to the facility 05/14/2019. Diagnoses included but were not limited to hypertension and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility documentation and clinical record review the facility staff failed to maintain infection control program to help prevent the development of communicable diseases and infections. For facility staff, 3 of the 5 CNA's working on the Chesapeake Unit did not don appropriate PPE prior to entering the room of a Resident on contact precautions. The findings included: Resident # 20, [AGE] year-old male admitted to the facility on five 721 diagnoses of but not limited to hypertension renal insufficiency diabetes wound infection septicemia hyper hypertension and stage renal disease dependent on dialysis. The resident's most recent MDS (minimum data set) with an ARD assessment reference date of 5/7/21 was reviewed. It coded the resident as having a BIMS (brief interview of mental status) score of 12 - indicating mild cognitive impairment. The resident was coded as requiring the extensive physical assistance of two persons for bed mobility, transfers, dressing, toilet use, and…

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

Based on Observation and Staff Interview, facility staff failed to maintain the kitchen areas in a manner to prevent the spread of infections. During tour of the kitchen, a powder scoop was stored inside a bin of thickener powder. The findings included: A tour of the kitchen was performed on 9/25/2018. At 1:15 p.m.,. a plastic bin labeled Thickener Powder In: 8/8/18 Out: 11/8/18 was observed with a scoop inside the bin, resting on the powder. Employee G, the Dietary Manager, was asked about the facility policy on storage of dry goods scoops. She replied, It should be stored on top of the bin, not inside. Employee G then asked another kitchen employee to take the scoop out of the bin, saying Its supposed to be on top. The Administrator and Director of Nursing were informed of the findings at the end of day meeting on 9/27/2018. No further information was provided.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility documentation, and clinical record review the facility denied 1 resident (Resident #199) in a survey sample of 33 residents the right to self administer medication. For Resident #199, on admission the facility assessed the resident as capable of having her inhaler medication at her bedside however; the facility did not allow her to keep it at the bedside. The findings include: Resident #199 was admitted to the facility on [DATE] with diagnoses of but not limited to Osteoporosis with current fractured vertebrae, weakness and asthma. Since Resident was a new admission, she did not yet have (Minimum Data Set) MDS completed. On 9/25/2018 at 1:30 PM during an interview with Resident #199 she stated that on the previous night she was feeling chest tightness and wanted her inhaler but it took so long for the nurse to get if for her and she had an asthma attack. On 9/25/2018 during a clinical record review there was no mention of asthma attack or…

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 and Resident interview, facility documentation and clinical record review the facility failed to allow accommodation of needs when obtaining weights for 1 Resident, (Resident #70) in a survey sample of 33 Residents. The facility failed to allow the Resident the right to choose the scale she prefers to obtain her weight. The finding include: Resident #70 a [AGE] year old female was admitted to the facility on [DATE] with diagnoses of but not limited to Chronic Respiratory Failure, Hypertension, Bilateral Arthritis of the Knees, Morbid obesity, sleep apnea, asthma and non pressure related ulcers. Resident #70 was coded in the MDS (minimum data set) as having a Brief Interview of Mental Status score of 15 indicating no cognitive impairment. On 9/25/2018 at 2:15 PM an interview was conducted with the Resident #70 and she stated she was unaware of how much she weighed because they haven't weighed her in a long time. She stated she knew she had lost a significant amount of weight and was…

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

Based on observation, resident interview, and staff interview, the facility staff did not allow a private Resident council meeting with state agency surveyors for 6 Resident attendees. Staff entered the Private group council meeting, while in progress, to remove Resident #100, and then interrupted it again to return Resident #100, approximately 10 minutes later. The findings included; A Resident council private session with state agency surveyors commenced on 9-26-18 at 11:00 a.m. In attendance were 6 members of the resident population to include the Resident council President. Approximately 20 minutes into the session, and during Resident disclosure of grievances, the Medication nurse from the 200 hall entered the private meeting. The nurse knocked on the door as she entered, with no hesitation for an answer, and the surveyor stated this is a private resident only meeting, you can not enter here now. The nurse proceeded to grab the handles of Resident #100's wheel chair. The nurse said nothing directly to Resident #100, and replied to the surveyor it's ok, I need this one for just…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility documentation review and clinical record review the facility staff failed to notify the physician of significant weight loss for one resident (Resident #81) of 33 residents in the survey sample. For Resident #81, the facility staff did not notify the doctor of the Resident's two significant weight losses in August and September of 2018. The findings included: Resident #81 was admitted to the facility on [DATE]. Diagnoses included; weakness, dysphagia, hypertension, chronic kidney disease, anemia, cognitive communication deficit, history of dehydration, and dementia. Resident #81's most recent Minimum Data Set (MDS) assessment was a 30 day assessment with an assessment reference date of 8-25-18. The Resident was coded with a Brief Interview of Mental Status score of 4 indicating severe cognitive impairment. The document coded Resident #81 as requiring extensive assistance from staff for eating, and was coded as having no abnormal behaviors. In the MDS document,…

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 & family interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to implement their abuse policies during an allegation of abuse for one Resident (Resident #149) in a survey sample of 33 Residents. Resident #149 reported an allegation of physical abuse by staff, to staff members, who did not institute the abuse policies and protocols of the facility, and mandated reporters. The findings included: Resident #149 was initially admitted to the facility on [DATE]. Diagnoses included acute reversible ischemia of large intestine, weakness, asthma, hypertension, osteoarthritis, and hypothyroidism. Resident #149's MDS (minimum data set) had not been completed, as she was a new admission. No cognitive impairment is documented in the care plan, or nursing progress notes. Resident #149 required the assistance of one staff member to perform her activities of daily living. The Resident was admitted for , and participating in physical therapy for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Resident & family interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to report, an allegation of abuse for two Residents (Resident #149, and #78) in a survey sample of 33 Residents. 1. Resident #149 reported an allegation of physical abuse by staff, to staff members, who did not report the allegation of abuse to the administrator or State Agency (SA). 2. The facility did not report a resident to resident abuse incident timely for Resident #78. The initial and final report were submitted 13 days later. The findings included: Resident #149 was initially admitted to the facility on [DATE]. Diagnoses included acute reversible ischemia of large intestine, weakness, asthma, hypertension, osteoarthritis, and hypothyroidism. Resident #149's MDS (minimum data set) had not been completed, as she was a new admission. No cognitive impairment is documented in the care plan, or nursing progress notes. Resident #149 required the assistance of one staff…

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 & family interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to protect, investigate, and further report, an allegation of abuse to the state agency (SA) for one Resident (Resident #149) in a survey sample of 33 Residents. Resident #149 reported an allegation of physical abuse by staff, to staff members, who did not protect the resident and investigate the allegation. The findings included: Resident #149 was initially admitted to the facility on [DATE]. Diagnoses included acute reversible ischemia of large intestine, weakness, asthma, hypertension, osteoarthritis, and hypothyroidism. Resident #149's MDS (minimum data set) had not been completed, as she was a new admission. No cognitive impairment is documented in the care plan, or nursing progress notes. Resident #149 required the assistance of one staff member to perform her activities of daily living. The Resident was admitted for , and participating in physical therapy for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to, for three residents (Resident #37, #73, #150), in a survey sample of 33 residents, to give notice before transfer. 1. Resident # 37 was transferred to the hospital without documentation of notice to the RP (responsible party) as well as the ombudsman. 2. Resident #73 was transferred to the hospital without documentation of notice to the RP (responsible party) as well as the ombudsman. 3. Resident #150 transferred to the hospital without documentation of notice to the RP (responsible party) as well as the ombudsman. The findings included: 1. Resident # 37 was transferred to the hospital without documentation of notice to the RP (responsible party) as well as the ombudsman. Resident #37 was admitted to the facility on [DATE]. Diagnoses included High blood pressure, hemiplegia and depression. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 7-19-18. Resident #37 was coded…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, the facility staff failed to, for one Resident (Resident #40) in a survey sample of 33 residents, to complete a SCSA (significant change in status assessment). Resident #40 developed a facility acquired pressure injury and weight loss during the quarterly assessment lookback, but was not coded for a SCSA. The findings included: Resident #40 was admitted to the facility on [DATE]. Diagnoses included, but not limited to diabetes, paraplegia, cauda equina syndrome and chronic kidney disease. Resident #40's Minimum Data Set (MDS, an assessment protocol) with an Assessment Reference Date of 7-19-18 coded Resident #40 with no cognitive impairment. The MDS was completed as a quarterly assessment. The resident required extensive to total care with ADL's (activities of daily living such as bed mobility and toileting) of one to two staff members. The resident had an indwelling urinary catheter and was incontinent of bowel. There were two pressure wounds…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, the facility staff failed to, for two Residents (Resident #40, #81) in a survey sample of 33 residents, to ensure an accurate RAI (resident assessment instrument) assessment was completed. 1. Resident #40 developed a facility acquired pressure injury on 7-1-10 and on the next quarterly assessment (7-19-18) the assessment coded the resident with an admitted unable to stage wound. 2. For Resident #81, the facility staff did not code weight correctly for a Resident with weight loss. The findings included: 1. Resident #40 developed a facility acquired pressure injury on 7-1-10 and on the next quarterly assessment (7-19-18) the assessment coded the resident with an admitted unable to stage wound. Resident #40 was admitted to the facility on [DATE]. Diagnoses included, but not limited to diabetes, paraplegia, cauda equina syndrome and chronic kidney disease. Resident #40's Minimum Data Set (MDS, an assessment protocol) with an Assessment Reference Date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility documentation and clinical record review the facility staff failed to obtain an accurate PASARR screening prior to or on admission for 1 Resident #115 in a survey sample of 33 Residents. For Resident #115 the facility failed to obtain an PASARR screening LEVEL II based on admission information. The findings include: Resident # 115 a [AGE] year old woman admitted to the facility on [DATE] diagnoses of but not limited to Acute kidney failure, Severe Anemia, Influenza, Depression and anxiety, Schizophrenia, medical non compliance. On 9/26/2018 a review of the clinical record revealed that Resident #115 was seen by primary care MD on 1/5/2018 and referred to the ER. Resident #115 refused to go to the ER and her home health RN was contacted by the physician and she was unable to get the Resident to go to the ER either. The discharge summary from hospital states that on 1/22/2018 the Resident went to the ER and was found to be severely anemic and in need of blood transfusion, 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 observation, staff interview, facility documentation review and clinical record review, the facility staff failed to complete a comprehensive care plan for significant weight loss for two residents (Resident #81, and #108) of 33 residents in the survey sample. 1. For Resident #81, the facility staff did not denote and provide a comprehensive care plan for 2 significant weight losses in August and September of 2018. 2. Resident #108 was administered Seroquel antipsychotic medication without a comprehensive care plan for measurable non-pharmacological interventions, and the care plan was not completed timely. The findings included: 1. For Resident #81, the facility staff did not denote and provide a comprehensive care plan for 2 significant weight losses in August and September of 2018. Resident #81 was admitted to the facility on [DATE]. Diagnoses included; weakness, dysphagia, hypertension, chronic kidney disease, anemia, cognitive communication deficit, history of dehydration, and dementia. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility documentation and clinical record review, the facility staff failed to ensure the highest practicable well being for 1 resident (Resident #46) in a survey sample of 33 residents. After readmission from the hospital, Resident #46 did not receive her ordered Pantoprazole for three days. The resident had a history of an esophageal ulcer. The findings included: Resident #46 was admitted to the facility on [DATE]. Diagnoses included, but not limited to diabetes, high blood pressure and esophageal ulcer. The resident was discharged to the hospital on 7-19-18 and was readmitted back to the facility on 7-23-18. Resident #46's Minimum Data Set (MDS, an assessment protocol) with an Assessment Reference Date of 7-28-18 coded Resident #46 with no cognitive impairment. The MDS was completed as a quarterly assessment. The resident required extensive to total care with ADL's (activities of daily living such as bed mobility and toileting) of one to two staff members. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility documentation and clinical record review, the facility staff failed to, for one resident (Resident #150), in a survey sample of 33 residents, was provided adequate supervision to prevent an elopement. Resident #150 had been observed exit seeking, but a Wanderguard was not placed until after the resident left the facility and was found across the street. The findings included: Resident #150 was admitted to the facility on [DATE]. Diagnoses included High blood pressure, dementia and chronic obstructive pulmonary disease (COPD). The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 9-11-18. Resident #150 was coded with a Brief Interview of Mental Status score of 10 out of a possible 15, or mild cognitive impairment and required limited to extensive assistance of one staff member with activities of daily living. On 9/27/18 at 2:24 PM Review of clinical record revealed a nurse's note dated 8-22-18 that the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility documentation review and clinical record review the facility staff failed to provide feeding assistance timely, and to prevent significant weight loss for one resident (Resident #81) of 33 residents in the survey sample. For Resident #81, the facility staff did not start to feed the Resident lunch until 1:30 p.m., after all other residents had eaten, and the unit kitchen had been cleaned. The staff also failed to intervene during two significant weight losses in August and September of 2018. The findings included: Resident #81 was admitted to the facility on [DATE]. Diagnoses included; weakness, dysphagia, hypertension, chronic kidney disease, anemia, cognitive communication deficit, history of dehydration, and dementia. Resident #81's most recent Minimum Data Set (MDS) assessment was a 30 day assessment with an assessment reference date of 8-25-18. The Resident was coded with a Brief Interview of Mental Status score of 4 indicating severe cognitive impairment. 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 facility record review, and clinical record review, facility pharmacy evaluations failed to recommend a gradual dose reduction, or discontinuance of a psychotropic medication without indications for use for one Resident, (Resident #108) in a survey sample of 33 residents. Resident #108 was administered Seroquel antipsychotic medication, without clinical justification and without using non-pharmacological interventions which the Pharmacist (RPH) failed to identify. The findings included: Resident #108 was admitted to the facility initially on 1-28-18, then discharged . She was readmitted on [DATE], and discharged home. Then finally readmitted on [DATE]. Primary Diagnoses included; Alzheimer's Dementia, weakness, cognitive communication deficit, hypertension, chronic kidney disease, type 2 diabetes with insulin administration, anemia, high cholesterol, Gastro-esophageal reflux disease, and peripheral vascular disease. Two Secondary diagnoses were made during the Resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview facility record review, and clinical record review, the facility staff failed to ensure the resident was free from un-necessary medications for one Residents, (Resident #108) in a survey sample of 33 residents. 1. Resident #108 was administered Seroquel antipsychotic medication without clinical justification. The findings included: Resident #108 was admitted to the facility initially on 1-28-18, then discharged . She was readmitted on [DATE], and discharged home. Then finally readmitted on [DATE]. Primary Diagnoses included; Alzheimer's Dementia, weakness, cognitive communication deficit, hypertension, chronic kidney disease, type 2 diabetes with insulin administration, anemia, high cholesterol, Gastro-esophageal reflux disease, and peripheral vascular disease. Two Secondary diagnoses were made during the Resident's stay at the facility which were not part of her medical record prior to admission to this facility. Those diagnoses were Major depressive Disorder, and 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.