Henrico Health & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff /resident interviews facility document review and clinical record review, it was determined the facility staff failed to provide respiratory care services for one of 38 residents, Resident #109 (R109). The findings include: The facility staff failed to provide respiratory therapy per physician orders for R109. R109 was admitted to the facility on [DATE] with diagnosis that included but were not limited to chronic respiratory failure, atrial fibrillation and CHF (congestive heart failure).The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 1/1/26, coded the resident as scoring an 11 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring moderate assistance for mobility/transfers/bathing/dressing and set-up for eating. A review of the comprehensive care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, the facility staff failed to document a clinical rationale for denial of a recommended dose reduction for one of thirty-eight residents in the survey sample (Resident #74).The findings include: Resident #74's physician failed to document a clinical rationale for a denied dose reduction of a psychoactive medication.Resident #74 (R74) was admitted to the facility with diagnoses that included atherosclerosis, diabetes, lung cancer, adult failure to thrive, protein-calorie malnutrition, chronic kidney disease, major depressive disorder, dementia, psychotic disturbance, mood disturbance, anxiety, and insomnia. The minimum data set (MDS) dated [DATE] assessed R74 with severely impaired cognitive skills.R74's clinical record documented a physician's order dated 4/9/25 for the antidepressant trazodone 50 milligrams (mg) given at each bedtime for treatment of insomnia. R74's medication administration record documented trazodone 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 and facility document review, the facility staff failed to ensure medications used in the facility were within expiration date for 1 of 2 medication storage rooms (South Unit).Findings include:The facility staff failed to ensure two medications were within expiration date in the medication room on the South Unit.On [DATE], an inspection of the Medication Room on South Unit was completed with LPN#1 revealing one bottle of Geri Dryl Allergy Relief Liquid with expiration date 4/2025 and one tube of Venelex Wound Dressing (a combination of [NAME] and castor oil used to treat wounds) with an expiration date 2/2025. When LPN#1 was given the 2 medications with expired dates, she stated these need to be discarded as they are expired.Review of the facility policy# 4.1, entitled Storage of Medications 8. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review, and facility documentation, the facility staff failed to report allegations of abuse or neglect for 1 Resident (#114) in a survey sample of 55 Residents.The findings included: For Resident #114, the facility staff failed to report the resident eloping from the facility on several occasions. Resident #114 was admitted to the facility on [DATE] with diagnoses that included but were not limited to pancreatic cancer, bile duct obstruction, palliative care, chronic bronchitis, muscle weakness, depression, general anxiety disorder, insomnia due to medical condition, psychotic disorder with hallucinations due to a known physiological condition (paranoid schizophrenia), and psychotic disorder with delusions due to a known physiological condition (paranoid schizophrenia).Resident #114's most recent BIMS (Brief Interview of Mental Status) scored the Resident at 15/15 indicating no cognitive impairment. Resident #114's clinical record included a document entitled Provider…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review and facility documentation, the facility staff failed to ensure residents were free from accidents and hazards for 3 Residents (#'s 114, 59, and 65) in a survey sample of 55 residents. The Findings included:1. For Resident #114 the facility staff failed to provide adequate supervision to prevent the residents from eloping from the facility.Resident #114 was admitted to the facility on [DATE] with diagnoses that included but were not limited to pancreatic cancer, bile duct obstruction, palliative care, chronic bronchitis, muscle weakness, depression, general anxiety disorder, insomnia due to medical condition, psychotic disorder with hallucinations due to a known physiological condition (paranoid schizophrenia), and psychotic disorder with delusions due to a known physiological condition (paranoid schizophrenia).Resident #114's most recent BIMS (Brief Interview of Mental Status) scored the Resident at 15/15 indicating no cognitive impairment. Resident #114'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.

Based on staff interviews and review of facility documents, the facility staff failed to ensure a violation involving abuse was reported to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services), within two hours of the violation occurring. The findings included: An interview was conducted on 5/7/25 at 2:50 PM with the Director of Nursing (DON). The DON stated that CNA #2 disclosed information on 4/2/25 during an interview regarding sexual allegations that occurred on 3/29/25. The DON stated that CNA #2 should have reported this to the Administrator, the Director of Nursing, or his immediate supervisor no later than two hours after the incidents occurred. An interview was conducted on 5/7/25 at 3:15 PM with Certified Nursing Assistant (CNA) #2. CNA #2 stated that on 3/29/25 a transporting driver approached him and stated that the receptionist was very inappropriate in a sexual manner with him. CNA #2 also stated that on this same day the receptionist got very close to him as well and started making funny noises…

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 review of facility documents, the facility staff failed to follow the professional standards of quality regarding two trained staff members assisting with mechanical lifts and transfers for 1 of 5 residents (Resident # 5 ), in survey sample. The findings included: Resident #5 was originally admitted to the facility 11/22/22. The current diagnoses included chronic kidney disease, type 2 diabetes mellitus with other diabetic kidney complication, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and muscle weakness. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/5/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 09 out of a possible 15. This indicated Resident #5's cognitive abilities for daily decision making were moderately impaired. An interview was conducted on 5/12/25 at 3:30 PM with Resident #5. Resident #5 stated that she was hit in the head by the Hoyer lift bar when a…

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

Based on resident interview, staff interviews, clinical record review, and review of facility documents, the facility staff failed to provide two-person assistance while transferring Resident #5, which resulted in the resident being struck in the head by the Hoyer lift sling bar for 1 of 5 residents in the survey sample. The findings included: Resident #5 was originally admitted to the facility 11/22/22. The current diagnoses included chronic kidney disease, type 2 diabetes mellitus with other diabetic kidney complication, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and muscle weakness. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/5/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 09 out of a possible 15. This indicated Resident #5's cognitive abilities for daily decision making were moderately impaired. An interview was conducted on 5/12/25 at 3:30 PM with Resident #5. Resident #5 stated that she was hit in the head by the Hoyer lift bar when a…

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

Based on Observations, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to schedule sufficient nursing staff to maintain the highest practicable well being of each resident. The findings included; During the course of the survey from 2-19-25 through 2-24-25 a complaint was investigated by the state agency. No date, nor date range was included for an allegation of insufficient nursing staff. The receipt of the complaint in the state agency occurred initially on 2-8-24. Residents placed in the survey sample were interviewed as well as nursing staff. They stated that staffing had been an issue at times over the past year, however, staffing had become more normalized within the last few months. Residents were observed to be dressed in clean clothing, no pervasive odors existed in the facility, and the general population of Residents were seen to be engaged in activities, therapies, and independent leisure activity outside on the front porch area, and in their own rooms. Residents clinical records were reviewed 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, clinical record review, and facility document review, the facility failed to ensure that one Resident (Resident #7), in a survey sample of 12 residents was informed, in advance, of the care to be provided and their rights upon admission. The findings include: For Resident #7, the facility staff failed to ensure that resident was informed, in advance, of the care to be provided and their rights upon admission and provide admission contract and rights on admission. Resident #7 was admitted to the facility on [DATE], and discharged on 10/14/2024, with diagnoses of, but not limited, Type 2 diabetes, kidney transplant status, end stage renal disease, pulmonary hypertension, nutritional anemia, and multiple fractures of ribs. The most recent MDS (minimum data set) was an admission assessment with an (ARD) assessment reference date of 09/03/2024 was reviewed and revealed Resident #7's (BIMS) Brief Interview for Mental Status was coded a score of 15 out a possible 15 indicating no cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, and staff interviews the facility staff failed to provide a comfortable, and homelike environment for 1 of 12 residents (Resident #5), in the survey sample. The findings included: Resident #5 was originally admitted to the facility 2/11/2025. The current diagnoses included wedge compression fracture of third lumbar vertebra, type 2 diabetes mellitus without complications, major depressive disorder, and muscle weakness. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/17/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #5's cognitive abilities for daily decision making were moderately impaired. On 2/18/25 during an observation tour for room [ROOM NUMBER], it was observed that the cove base was missing around the entire perimeter of the room as well as the perimeter of the bathroom. It was also observed that cold air was coming out of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, family interview and clinical record review, the facility's staff failed to remove/discontinue a Midline Intravenous Catheter before discharging a resident home therefore increasing the chance of complications, including infections, bleeding, and or dislodgement for 1 of 12 residents in the survey sample, Resident #12, a closed record sample. The findings included: Resident #12 was originally admitted to the facility 11/08/24 and discharged on 12/05/24 after an acute care hospital stay. The current diagnoses included: OTHER BACTERIAL INFECTIONS OF UNSPECIFIED SITE, FRACTURE OF UNSPECIFIED PART OF NECK OF RIGHT FEMUR, SUBSEQUENT ENCOUNTER FORCLOSED FRACTURE WITH ROUTINE HEALING. The admission, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/14/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 3 out of a possible 15. This indicated Resident #12 cognitive abilities for daily decision making were severely impaired.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, Resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to maintain the industry standards of diabetic management for one Resident (Resident #3) in a survey sample of 12 Residents. The findings included: For Resident #3, the facility staff failed to Assess and monitor the Resident, and update the plan of care for a morbidly obese immobile Diabetic Resident including removal of Diabetic medication management, removal of a therapeutic diet to decrease blood sugars, and removal of blood sugar checks, and resident weights. There was no assessment nor monitoring for a significant weight gain, while in the presence of worsening Respiratory illness, with continuous oxygen use, pneumonia, sleep apnea, and after hospitalization with an acute bout of congestive heart failure. Resident #3, was initially admitted to the facility on [DATE]. Diagnoses included; diabetes mellitus, acute congestive heart failure, morbid obesity due to excess…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of the facility, they failed to provide a sanitary environment for residents, staff and the public. The findings included: The facility staff failed to provide a sanitary environment for residents, staff and the public. During the initial tour of the facility on 9/3/2024 at 8:30 p.m., three grills were observed outside the door of the wing (unit) facing the left side of the parking lot. At 9:15 p.m., two surveyors looked near the area around the grills. Several large cockroaches were observed scurrying on the sidewalk and in the bushes near the door. The cockroaches were approximately 3 inches in length. When the lids to each grill were lifted, there were soiled aluminum foil sheets observed on each of the grill grates with noted food debris. The grills remained in the same location until 9/5/2024 around 4:00 p.m. in the afternoon, after the administrator was informed about the findings. On 09/04/2024, at approximately 10:00 AM, during a morning meeting, the surveyors were approached by a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility documentation, the facility staff failed to maintain an effective pest control program. The findings included: The facility staff failed to maintain an effective pest control program so that the facility is free of pests, to include mice, involving 2 of 2 units in the facility. During the initial tour of the facility on 9/3/2024 at 8:30 p.m., three grills were observed outside the door of the wing (unit) facing the left side of the parking lot. At 9:15 p.m., two surveyors looked near the area around the grills. Several large cockroaches were observed scurrying on the sidewalk and in the bushes near the door. The cockroaches were approximately 3 inches in length. When the lids to each grill were lifted, there were soiled aluminum foil sheets observed on each of the grill grates with noted food debris. The grills remained in the same location until 9/5/2024 around 4:00 p.m. in the afternoon, after the administrator was informed about the findings. On 09/04/2024, 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.

Based on interview, clinical record review and facility documentation the facility staff failed to review and revise care plan for 1 Resident in survey sample of 9 Residents. The findings included: For Resident #3 the facility staff failed to review and revise care plan after 9 incidents of elopement or attempted elopement between 5/23/24 and 8/23/24. A review of the clinical record revealed the following excerpts from the care plan: FOCUS: The resident is at risk for elopement related to exit seeking. GOAL: Resident will be monitored for exit attempts, constant staff observations for attempts Date Initiated: 02/01/2024 Revision on: 05/08/2024 The resident will not elope thru review period Date Initiated: 11/14/2023 Revision on: 05/14/2024 INTERVENTION: check function weekly Date Initiated: 11/14/2023, check placement every shift Date Initiated: 11/14/2023 Code orange when occur Date Initiated: 04/29/2024, elopement risk assessment as needed Date Initiated: 05/14/2024, Redirect from exit Date Initiated: 11/14/2023. On 9/5/24 at approximately 3 p.m. an interview was conducted with…

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

Based on staff interview, facility document review, and clinical record review, the facility staff failed to review and revise the comprehensive care plan for one of 13 residents in the survey sample, Resident #4. The findings include: For Resident #4 (R4), the facility staff failed to review and revise the resident's comprehensive care plan for a fall the resident sustained on 3/30/24. A review of R4's clinical record revealed a nurse's note dated 3/30/24 that documented the resident slid out of bed. A review of R4's comprehensive care plan dated 3/13/24 failed to reveal evidence that the care plan was reviewed and revised for the 3/30/24 fall (the care plan was not revised until after R4 sustained another fall on 4/19/24). On 5/8/24 at 10:37 a.m., an interview was conducted with RN (registered nurse) #3. RN #3 stated the care plan is a guideline for staff to be able to access and know what needs to be done for each resident. RN #3 stated the care plan should be reviewed and revised after each fall and this is usually done during the shift that a fall occurs, or the next day. 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.

Based on observation, staff interview, facility document review, it was determined the facility staff failed to provide adequate supervision and prevent accidents for three of 13 residents in the survey sample, Residents #10, 11 and #4. The findings include: 1. For Resident #10 (R10), the facility staff failed to provide supervision for smoking per the smoking assessment. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 4/15/2024, the resident scored a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section J - Health Conditions, the resident was coded as using tobacco products while a resident at the facility. In Section O - Special Treatments, Procedures and Programs, the resident was coded as using oxygen while a resident at the facility. Observation was made of R10 on 5/7/2024 at 3:24 p.m. outside on the front sidewalk to the right of the entrance. The resident was observed to be smoking a cigarette. An oxygen…

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

Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure a resident was free from an unnecessary medication for one of 13 residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to hold the medication Lasix (furosemide) (1) per the physician ordered parameter of a systolic blood pressure less than 110. A review of R1's clinical record revealed a physician's order dated 9/29/22 that documented, Check BP (blood pressure) Prior to Lasix administration one time a day for hypotension (low blood pressure) hold medication for SBP (systolic blood pressure) less than 110. This was scheduled on the MAR (medication administration record) to be done at 9:00 a.m. Further review of R1's clinical record revealed a physician's order dated 11/16/23 for furosemide 20 milligrams- three tablets by mouth two times a day for edema. A review of R1's February 2024 MAR and April 2024 MAR revealed the resident was administered furosemide on 2/15/24 at 9:00 a.m. although 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, clinical record review, and facility documentation review, the facility staff failed to provide care and services in accordance with professional standards for 1 resident, Resident #13, in a survey sample of 16 residents. The findings included: For Resident #13, facility staff failed to administer medications as ordered by the physician on 11/23/23. On 12/6/23, Resident #13's clinical record was reviewed and revealed physician orders and medication administration times as follows: -Glipizide Oral Tablet, 10mg, give 1 tablet by mouth two times a day--ordered on 11/23/23, documented as given on 11/24/23 -Synjardy Oral Tablet, 5-1000mg (Empagliflozin-Metformin HCl), give 1 tablet by mouth in the evening--ordered on 11/23/23, documented as given on 11/24/23 -Tamsulosin HCl Oral Capsule, 0.4mg, give 1 capsule by mouth one time a day--ordered on 11/23/23, documented as given on 11/24/23 On 12/6/23 at approximately 1:30 PM, an interview was conducted with the Director of Nursing…

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

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide oxygen therapy consistent with infection control practices for 1 resident, Resident #15, in a survey sample of 16 residents. The findings included: For Resident #15, facility staff failed to label and date the oxygen tubing, humidification bottle, and nebulizer mask with tubing in accordance with infection control standards of practice. On 12/6/23 at approximately 10:50 AM, Surveyor B observed an oxygen concentrator with a humidification bottle attached along with a nasal cannula in Resident #15's room. Resident #15 was not in her room. A facemask with a medication reservoir was attached to a nebulizer unit at her bedside. There were no labels or dates observed on any of the oxygen tubing or on the humidification bottle. The facemask attached to the nebulizer unit was not contained in a bag and was not labeled/dated. On 12/6/23, immediately following the observations, an interview was conducted in Resident #15's room, with LPN B [licensed practical…

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

Based on observation, resident interviews, staff interview, and facility documentation review, the facility staff failed to prepare the meal in accordance with the menu, which affected the residents residing on 2 of 2 nursing units. The findings included: On 09/25/2023 and 09/26/2023 during the initial tour, a significant number of residents, residing on both nursing units, expressed concern regarding the food to all surveyors. On 09/27/2023 during the morning, Surveyor F made observations of several residents' breakfast trays. The findings were as follows: For Resident #17, the meal ticket indicated she was to get scrambled eggs, slivered green onions, biscuit, grits, and sausage gravy. There was a notation at the bottom that the resident requested Hb Egg [hardboiled egg]. The meal tray consisted of 2 hardboiled eggs, 2 pieces of toast, and a bowl of oatmeal. During the above observation of Resident #17's meal tray, the resident said, I don't eat grits, but we never get what is on the ticket. Additional observations were made, which included but were not limited to Resident #65 and…

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

Based on observation, resident interview, staff interview, and facility documentation review, the facility staff failed to serve food that was palatable and hot to residents on 2 of 2 nursing units. Findings include: For residents residing on both nursing units, the facility staff failed to serve food in a manner to ensure the food was at a preferred temperature when it reached the residents. On 09/25/2023 - 09/26/2023 during the initial tour process, an abundance of residents on both nursing units expressed concerns about the food not being hot. On 09/28/2023, observation of breakfast tray distribution was conducted. For residents residing on the North wing, breakfast trays were not served until 10:00 a.m. It was noted that each cart of meal trays held approximately 25-30 meal trays. One entire cart, which served residents in rooms 1-12, were all served in Styrofoam containers, like a restaurant carryout container. Another cart, which served residents in rooms 13-24, approximately half of the trays were on regular dinnerware plates and the other half were in the same Styrofoam…

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 COVID-19 bivalent vaccines for 5 residents (Residents #43, #47, #1, #20, and #42) and 5 staff in a survey sample of 5 residents and 5 employees reviewed for COVID-19 immunizations. They also failed to provide education and obtain informed consent prior to administration of COVID-19 immunizations, for 4 of 5 Residents (Resident #43, #47, #20, and #42). The findings included: 1. The facility staff failed to offer/provide COVID-19 bivalent immunization, to include education of risks/benefits about COVID-19 immunization, for Residents #43, #47, #1, #20, and #42. On 09/26/2023, a clinical record review was conducted of the sampled residents reviewed for immunizations. The Surveyor was not able to view all the details regarding the administration of immunizations. There was no indication that any of the sampled residents had been educated on the benefit of or offered the COVID-19 bivalent immunization. 2. The facility staff failed to offer/provide COVID-19 bivalent…

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 safe, clean, comfortable, and homelike environment for residents residing on 2 of 2 units, and for Resident #363. The findings included: 1. For the facility, residents the staff failed to maintain clean shower rooms on 2 of 2 units and failed to control pests, such as bedbugs and roaches. On 09/26/2023 at 2:00 p.m. during the Resident Council meeting, the 6 residents (all the residents on that unit) present stated the shower rooms are filthy, who wants to shower in those rooms? Resident #42 stated she would rather sponge bathe daily than use the shower rooms and the other 5 participants agreed. Observations were made of the shower rooms on 09/26/2023. On 09/27/2023 and 09/29/2023, the shower rooms were not clean, and the shower stalls had orange and black stains. The shower chairs had brown stains and the floor needed repair in the North shower room. 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.

Based on observation, interview, facility documentation, and clinical record review, the facility staff failed to ensure the resident environment remains free of accident hazards for 1 of 2 units. The findings included: For the residents using the showers on the South Hall the facility, staff failed to ensure the shower room tiles were in good repair. On 09/26/2023 at 2:00 p.m. during the Resident Council meeting, it was brought up that the shower rooms were dirty, and Resident #42 added that the shower room has bugs and is dirty. Residents #68 and #18 added that in the shower cubical, the tiles are loose and coming up out of floor. When asked how long this was going on 6 of 6 residents in attendance agreed that it has been a few months (more than 2). When asked were staff aware of the issue, Resident #42 stated and the group agreed The staff have to be aware they are giving showers to residents in that room. On 09/26/2023 at 4:00 p.m., this surveyor accompanied the Maintenance Director to the shower rooms to observe the condition of the shower room. Upon entering the shower room,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to ensure residents maintain acceptable parameters of nutritional status for 3 residents (Residents #22, #53 and #19) in a survey sample of 48 residents. The findings included. 1. For Resident #22, the facility staff failed to ensure the resident did not sustain a significant weight loss. On 09/25/2023 at approximately 2:00 p.m., Resident #22 was interviewed and stated, The food is horrible, and they never give what is actually on the ticket. They don't care if I eat or not, I have lost weight being in here. A review of the clinical record revealed that on admission to the facility on [DATE], Resident #22 weighed 175 lbs. 3 months later on 08/09/2023, Resident # 22 weighed 154 lbs., which is a 12% weight loss (21 lbs.) in 3 months' time. A review of the care plan revealed the following: FOCUS: Resident is at risk for weight fluctuations related to recent hospitalization, BMI, pressure ulcers, Incomplete…

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

Based on interview, clinical record review, and facility documentation, the facility staff failed to provide snacks to residents who wish to eat outside of scheduled meal times. The findings included: For residents who wish to eat outside of regular mealtimes, the facility failed to ensure snacks were available on the units. On 09/26/2023 at approximately 2:00 p.m.,during the Resident Council meeting, 6 of 6 residents agreed that snacks are not available in the evenings. A review of the Resident Council minutes revealed that snacks being unavailable has been brought up in 4 of the last 6 meetings. On 09/28/2023 at 10:00 a.m., an interview was conducted with Employee K who stated that she sends snacks to the floor including cookies, pudding, applesauce, peanut butter crackers, juices, and milk. She stated that she does not know why there is not any left at bedtime. An interview was conducted with CNA G who stated there is hardly ever any snacks for residents. CNA G stated she has worked evenings and they did not have any when she worked. An observation was made of the pantry area 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.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to obtain consent and provide education prior to the administration of the flu vaccine for four residents (Residents #43, #47, #20, and #42) in a survey sample of 5 residents reviewed for immunizations. The findings included: For Residents #43, #47, #20 and #42, the facility staff failed to provide education regarding the risks and benefits of the immunization to be administered and failed to obtain consent prior to administration of the immunization. On 09/26/2023, a clinical record review was conducted of the sampled residents reviewed for immunizations. The Surveyor was not able to view all the details regarding the administration of immunizations. On 09/26/2023 at 4:00 p.m., Surveyor F met with the facility's Infection Preventionist (Employee C). During this meeting, Employee C accessed the clinical record of each of the residents and the following was noted: 1. Resident #43 was administered the influenza immunization on 10/17/2022. Consent for the immunization was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to maintain an effective pest control program so that the facility is free of pests involving 2 of 2 units in the facility. The findings included: For 2 of 2 units in the facility, roaches and/or bedbugs have been reported. On 09/29/2023 at approximately 1:15 p.m., Surveyor E entered Resident #19's room with CNA D, in the search for Resident #19's dentures which were missing. When the cabinet door and drawer were opened, cockroaches ran out (approximately 5-10 insects) all over the sides and top of the bedside cabinet. A review of the pest control log revealed that on 08/04/2023 rooms #32, #37 and #54 were treated for bed bugs; however, no follow-up treatment was done to ensure any eggs that have hatched were treated for, which is standard practice for bedbug treatment. On 09/28/2023, the resident in room [ROOM NUMBER] was complaining of itching and stated he had bed bugs. The facility did treat that…

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

Based on interview, clinical record review, and facility documentation, the facility staff failed to provide behavioral health training for all staff caring for the residents identified as having behavioral healthcare needs for 5 of 5 nursing staff members (Staff #6, Staff #21, Staff #22, Certified Nursing Assistant [CNA]-H and CNA-K) in the sample. The findings included: 1. For all residents identified as having behavioral healthcare needs, the facility failed to provide training to staff to care for such residents. A review of the facility assessment and CMS form 672 - Census and Condition Form revealed that there are 46 residents identified with behavioral healthcare needs. A review of the document entitled Facility Assessment, the facility is equipped to care for residents with behavioral healthcare needs, PTSD (Post-traumatic Stress Disorder), and substance abuse issues. On 09/25/2023 at approximately 1:00 p.m., an interview was conducted with Resident #22 who stated the facility, Does not know how to deal with us. I have PTSD and they don't know how to talk to me. When asked…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure the residents' right to participate in care planning for 1 resident, Resident #48, in a survey sample of 48 residents. The findings included: For Resident #48, the facility staff failed to provide the opportunity for her to participate in her own care planning. On 09/26/2023 at approximately 9:30 a.m., an interview was conducted with Resident #48, and she was asked if she participated in the planning of her care at the facility, to which Resident #48 replied, I have never been asked or invited to attend any meetings about my care here, I would like to be involved. On 09/28/2023 at approximately 11:30 a.m., a review of Resident #48's clinical record was performed and revealed the most recent Minimum Data Set (MDS), a quarterly review with an Assessment Reference Date (ARD) of 08/24/2023, coded Resident #48 with a Brief Interview of Mental Status (BIMS) score of 12 out of 15,…

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

Based on interview, clinical record review, and facility documentation the facility staff failed to ensure the resident's right to choose healthcare providers, for 1 resident, Resident #22, in a survey sample of 48 residents. The findings included: For Resident #22, the facility staff failed to schedule an appointment with the Pain Management Clinic as requested by the resident and ordered by the physician. On 09/25/2023 at approximately 3:00 p.m., Resident #22 requested to speak to this surveyor. Resident #22 had previously been interviewed about issues at the facility and wanted to add one more thing. The resident stated he had inquired with the Medical Director about pain medicine (Oxycodone) that he used to take and was discontinued, and wanting to restart that medication. Resident #22 stated the Medical Director told him it would be better if he would see a pain management clinic and wrote a referral to the pain management clinic in the chart. Resident #22 stated this happened months ago, and he still has not been told about an appointment. A review of the clinical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to act promptly upon the grievances arising from Resident Council. The findings included: Resident council continues to have complaints of the same nature with no improvement month after month. The facility has not effectively addressed the concerns of the residents regarding quality of food, timeliness of medication administration, timely incontinence care, poor staff attitudes, and cleanliness of the building. A review of the Resident Council minutes revealed the following: March 2023 - Residents complained that staff have bad attitudes, medication not given in a timely manner, CNAs not providing care to dependent residents routinely during the day and night. April 2023 - Staff are rude, staff are loud at night, staff are using cell phones while providing incontinent or ADL care, diets are not being followed, and the dietary staff are rude. May 2023 - Floors, bathrooms, and sinks are not cleaned…

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

Based on clinical record review, staff interview, and facility documentation review, the facility staff failed to notify the responsible party of a change in condition for 1 Resident, Resident #362, in a sample size of 48 Residents. The findings included: For Resident #362, facility staff failed to notify the responsible party/family of a change in his condition on 07/20/2023. On 10/02/2023 at approximately 3:00 p.m., Resident #362's clinical record was reviewed in its entirety with particular attention given to physician's orders, nursing assessments, and progress notes. A progress note dated 07/20/2023 at 7:34 p.m. documented, Resident's daughter [name redacted] upset upon arrival to visit her father, nurse informed her residents blood pressure was elevated approx. noon time today, Resident pcp notified of elevation and medicated as directed, family was not notified of change in condition, daughter request that resident be transferred to hospital for evaluation, pcp notified of request, resident was taken to the ER via EMS. On 10/02/2023 at 4:15 p.m., the Clinical Nurse Consultant…

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 issue appropriate notices when skilled services were ending for 1 resident (Resident #87) in a survey sample of 3 residents, which were all reviewed for such notices. The findings included: For Resident #87, the facility staff failed to issue an Advance Beneficiary Notice (ABN) when skilled services were ending. On 09/25/2023, the facility Administrator was asked to provide a listing of residents who were discharged from Medicare Part A services. From this listing, a sample was selected which included Resident #87. The notices issued to these residents were reviewed and revealed the following: For Resident #87, the facility staff failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) notice prior to skilled care services ending. Only a Notice of Medicare Non-Coverage (NOMNC) was issued. Resident #87 was under skilled care with Medicare Part A as the primary payer from 06/11/2023 - 07/02/2023. Upon skilled care ending, Resident #87 remained a…

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

Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility failed to report allegations of abuse by a staff member involving 2 residents (Residents #53 and #85) in a survey sample of 48 residents. The findings included: 1. For Resident #53, the facility staff failed to complete a timely and accurate report of an allegation of physical and sexual abuse by CNA C to the state survey agency, adult protective services, and law enforcement. On 09/26/2023, during a clinical record review of Resident #53's clinical chart, the following were noted: a. A progress note dated 08/10/2023 at 5:06 p.m. read, Patient sent to saint Mary's for evaluation r/t [related to] alleged assault, MD [medical doctor] made aware. Patient verbalized understanding the reason for transfer. b. Another progress note dated 08/10/2023 at 5:15 p.m., stated, Patient made a statement in regard to an assault that took place this morning, a statement was given from patient to myself dictated at 2:11 PM at the south unit nursing station. Phone call placed 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 resident interview, staff interview, clinical record review, and facility documentation review, the facility failed to conduct investigations of allegations of abuse by a staff member involving 2 residents (Residents #53 and #85) in a survey sample of 48 residents. The findings included: 1. For Resident #53, who reported an allegation of physical and sexual abuse by CNA C, the facility staff failed to conduct an investigation and take measures to prevent further abuse while an investigation was conducted. On 08/10/2023, Resident #53 reported an allegation of abuse to facility staff. On 09/26/2023, during a clinical record review of Resident #53's clinical chart the following was noted: a. A progress note dated 08/10/2023 at 5:06 p.m., read, Patient sent to saint Mary's for evaluation r/t [related to] alleged assault, MD [medical doctor] made aware. Patient verbalized understanding the reason for transfer. b. Another progress note dated 08/10/2023 at 5:15 p.m., stated, Patient made a statement in regard to an assault that took place this morning, a statement was given from…

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 complete a comprehensive assessment after significant change in a timely manner for one resident (Resident #19) in a survey sample of 48 residents. For Resident #19, the facility staff failed to perform a significant change in status assessment after 2 areas of decline in pressure ulcer formation after hospitalization, and significant weight loss prior to and after hospitalization within 14 days of knowing about the 2 declines. The findings included: For Resident #19, the facility staff did not intervene during the significant weight loss of a resident with known dysphagia following a stroke, insulin dependent Diabetes Mellitus, and 3 wounds. Resident #19 was admitted to the facility on [DATE], and most recently readmitted after hospitalization on 09/19/2023 with diagnoses including; encephalopathy, urinary tract infection, oral cadidiasis, and COVID-19. Resident #19 had a medical history including, stroke, diabetes, and acute…

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, family interview, staff interview, facility document review, and clinical record review, the facility staff failed to complete a 48-hour baseline care plan for one resident (Resident #19) in a survey sample of 48 residents. For Resident #19, the facility staff failed to develop and operationalize a 48-hour base line care plan after readmission and discontinuance of the resident's former care plan, which was canceled. The findings included: For Resident #19, the facility staff did not intervene during the significant weight loss of a resident with known dysphagia following a stroke, insulin dependent Diabetes Mellitus, and 3 wounds. Resident #19 was admitted to the facility on [DATE], and most recently readmitted after hospitalization on 09/19/2023 with diagnoses including, encephalopathy, urinary tract infection, oral cadidiasis, and COVID-19. The resident had a medical history including, stroke, diabetes, and acute gastrointestinal bleeding with resulting acute post hemorrhagic anemia 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, clinical record review, and facility documentation, the facility staff failed to review and revise care plans for 2 residents (Residents #21 and #53), in a survey sample of 48 residents. The findings included: 1. For Resident #21 the facility staff failed to review and revise the care plan to include interventions after a fall with fractured femur and surgical repair. On 09/25/2023 at approximately 2:30 p.m., Resident #21 was observed in her wheelchair in her room looking out of the window. She had bare feet. She stated she had a fall a while ago and now is in a wheelchair. She was not sure when the fall occurred or if it was at home or in the facility. A review of the clinical record revealed that Resident #21 had fallen in the facility on 04/03/2023 and was sent to the hospital on [DATE] with a diagnosis of fractured right hip. Upon return to the facility, the care plan was not updated to include a foley, surgical incision, PT/OT, limitations, nor any new fall interventions…

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 provide care and services in accordance with professional standards for 1 resident, Resident #362, in a survey sample of 48 residents. The findings included: For Resident #362, facility staff failed to administer medications as ordered by the physician on 07/17/2023 and 07/18/2023. On 09/28/2023, Resident #362's clinical record was reviewed and revealed physician orders and medication administration times as follows: *Aspirin EC-low dose tablet delayed release, 81mg, give 1 tablet by mouth one time a day--ordered on 7/18/23, documented as given on 7/19/23 *Ferrous Sulfate tablet 325 (65 Fe)mg, give 1 tablet by mouth one time a day--ordered on 7/18/23, documented as given on 7/19/23 *Finasteride tablet 5mg, give 1 tablet by mouth one time a day--ordered on 7/18/23, documented as given on 7/19/23 *Gabapentin Oral Capsule 300mg, give 1 capsule by mouth at bedtime--ordered on 7/17/23,…

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 provide Activities of Daily Living (ADL) assistance to residents residing on 1 of 2 nursing units. The findings included: 1. For Resident #19, who was dependent upon facility staff for eating, the facility staff failed to provide assistance with the meal to ensure the resident was fed a meal. Observations conducted on 09/29/2023 at 12:00 p.m., revealed Resident #19 in the communal dining room on the nursing unit. The resident was sitting at a table with 3 other residents with meal trays in front of them, and they were being assisted by one staff member to set up, and feed the residents at the table. Resident #19's tray was observed to have 1/2 inch cubed turkey meat, 1/2 inch chopped cubes of cabbage, mashed potatoes and gravy. The resident was not eating and CNA (Certified Nursing Assistant) D who was sitting with the residents stated she would be feeding 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.

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide respiratory care, consistent with professional standards of practice, for 2 residents (Residents #37 and #71) in a survey sample of 46 residents. The findings included: 1. For Resident #37, the facility staff failed change the nebulizer tubing three times per week as ordered and as per the facility's protocol. On 09/25/2023 during the initial tour of the building at approximately 12:50 p.m., there was an observation of a nebulizer machine on the bedside table and the tubing and mouthpiece were in a bag that was dated 09/07/2023. Review of the clinical record was conducted on 09/25/2023 and 09/26/2023. Review of Resident #37's physician's orders revealed the following: 07/23/2021 - Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3 ML (3 milligrams per 3 milliliters) 3 ml inhale orally every 4 hours as needed for SOB (Shortness of Breath) or wheezing via nebulizer. 11/10/2022 - Nebulizer tubing setup change M-W-F (Night Shift) every night shift every…

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

Based on interview, clinical record review, and facility documentation, the facility staff failed to provide medically related social services for 1 resident (Resident #22) in a survey sample of 48 residents. The findings included: For Resident #22, the Social Worker failed to assist the resident in obtaining his social security card and state identification card that was lost during his hospital admission prior to admission to the facility. On 09/25/2023 at approximately 3:00 p.m., Resident #22 was interviewed and stated he has not had his ID or Social Security card since he came to the facility. He stated it was lost during his hospital admission prior to entering the facility. When asked if he had made the staff aware of the need for assistance, he stated I made both of the Social Workers aware a few times but a lot of good that does they both quit on Friday. When asked when he told them, he stated, I have been asking since I got here. A review of the clinical record revealed there was no documentation at all from social services since arriving at the facility on 05/03/2022. 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.

Based on interview, clinical record review, and facility documentation, the facility staff failed to ensure medications were available for 1 resident (Resident #103) in a survey sample of 48 residents. The findings included: For Resident #103, the facility staff failed to ensure the resident had an adequate supply of Morphine 15mg for her pain control due to a wound. On 09/25/2023 at approximately 4:30 p.m., an interview was conducted with Resident #103 who stated the facility keeps running out of her pain medicine (Morphine 15 mg). When asked if she knew why this was happening, she stated she did not know but It happened again this morning. She stated the nurse got her an order for Tramadol, but she still has to wait to get that. A review of the clinical record read: 9/25/2023-4:13 pm Health Status - Note Text: Spoke with Resident this AM due to complaints that medication MS every four prn was not available. Spoke with nurse and pharmacy and medication requiring prior authorization. Physician will be in tomorrow to sign PA, in the meantime new order for Tramadol 50 mg every six…

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, resident interview, clinical record review, and facility documentation review, the facility staff failed to measure the success and track performance in their Quality Assurance and Process Improvement (QAPI) program for their abuse protocols resulting in Immediate Jeopardy involving abuse policy implementation for 2 residents (Residents #12 and #13) on 01/20/2023, and again on 09/27/2023 for 3 residents (Residents #53, #85, and #103) 8 months later. Immediate Jeopardy was found during a standard survey of the facility commencing on 09/25/2023 and conducted through 10/04/2023 when an abatement of the Immediate Jeopardy finding was achieved for the three new residents (Resident #53, #85, and #103), and the facility at large. The findings included; On 01/20/2023, Immediate Jeopardy (IJ) was identified at 3:55 p.m., at which time the facility Administrator and Director of Nursing were made aware. Following verification of the removal of immediacy, the facility abated IJ on 01/26/2023 at 4:07 p.m. The scope and severity was lowered to a level 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 record review, interviews, review of facility documents, and review of Centers for Medicare and Medicaid Services (CMS) memo QSO-20-29-NH, the facility failed to notify in a timely manner residents and resident representatives when a staff member tested positive for COVID-19. This failure had the potential to affect all 85 residents in the facility. Findings include: Review of the CMS Ref: QSO-20-29-NH Interim Final Rule Updating Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes, dated May 6, 2020, revealed The facility must inform residents, their representatives, and families of those residing in facilities by 5:00 PM the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. During an entrance conference on 09/07/21 at 9:10 AM, the Administrator indicated that during a routine weekly…

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

Based on observations, interview, and review of facility policies, the facility failed to store, prepare, and serve food under sanitary conditions. Specifically, air vents, portions of the ceiling, and electrical cords above food preparation tables and the steam table were found to be covered with dirt and dust. These failures had the potential to affect 78 of 82 residents living at the facility, who received food from the kitchen; there were four residents requiring tube feedings. Findings include: On 09/07/21 at 9:30 AM, an initial tour of the kitchen was conducted with the Dietary Manager (DM). Observations of the food preparation area in the kitchen revealed six electrical cords, hanging from the ceiling over the steam table and food preparation area, were noted to be covered with dirt and dust. The air conditioner vent and ceiling located over the reach in refrigerator were noted to be covered in dirt and dust. On 09/07/21 at 09:40 AM observations conducted in the walk-in refrigerator of the facility kitchen revealed the ceiling and all four walls to be covered in dust. 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.

Based on staff interview and facility documentation review, the facility staff failed to document the COVID-19 vaccination status for 27 out of 85 staff members. The findings included: The facility staff failed to obtain and document the COVID-19 vaccination status for 27 out of 85 staff members. On 10/27/21, a copy of the facility's documentation for the COVID-19 Immunization status staff members was requested and received from the Facility Administrator. Review of the document revealed that from a list of 85 staff members, the COVID-19 immunization status was unknown for 23 staff members as noted with blank spots in both the 1st vaccine and 2nd vaccine columns and 4 additional staff members that only had a first dose date recorded with a blank spot noted under 2nd vaccine column. On 10/27/21, an interview was conducted with the facility's Infection Preventionist who verified the list for staff members COVID-19 vaccine status was current and the immunization status was unknown for 23 staff members listed and incomplete for 4 members listed. The Infection Preventionist further…

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

Based on interview, record review, and policy review, the facility failed to ensure that each resident or the financial representative received a quarterly accounting of the personal funds for one of 27 sampled residents (Resident (R) 57). Findings include: Review of R57's undated admission Record, located in R57's electronic medical record (EMR) under the Profile tab, revealed a facility re-admission date of 08/06/20 with multiple medical diagnoses. Review of R57's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/12/21 revealed the facility assessed R57 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R57 was cognitively intact. On 09/08/21 at 3:11 PM an interview with R57 was conducted. R57 stated, I have not received any statements about my funds account. On 09/10/21 at 2:40 PM an interview with the Business Office Manager (BOM) was conducted. The BOM stated R57 has a resident fund account with $16.00 in it. There was a $20.00 deposit made on 06/11/21. Statements were sent out in July, there is no address…

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

Based on Resident interview, staff interview and facility documentation review, the facility staff failed uphold Resident Rights with regards to receiving mail unopened for 1 Resident (Resident #805) in a survey sample of 12 Residents. The findings included: On 10/26/21 at 2:00 PM, an interview was conducted with Resident #805. During this interview, Resident #805 stated that her wedding ring had been stolen. When asked if it was replaced, Resident #805 said No ma'am, I never got a penny for it. It was stolen in April when [previous facility Administrator name redacted] was here and I never got a cent. On 10/27/21 at 10:05 AM, during a follow-up interview with Resident #805, she reported she they lost the ring in April, I reported it to several nurses and said they had it locked in the med cart. The administrator said corporate was going to cut a check and send it, I never received anything. Then these people took over [referring to the change in facility ownership] and [the current Administrator name redacted] said the same thing, they were going to cut a check. That's all 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 interview and facility documentation review, the facility staff misappropriated a refund check for 1 Resident (Resident #805) in a survey sample of 12 Residents. The findings included: On 10/26/21 at 2:00 PM, an interview was conducted with Resident #805. During this interview, Resident #805 stated that her wedding ring had been stolen. When asked if it was replaced, Resident #805 said No ma'am, I never got a penny for it. It was stolen in April when [previous facility Administrator name redacted] was here and I never got a cent. On 10/27/21 at 10:05 AM, during a follow-up interview with Resident #805, she reported she they lost the ring in April, I reported it to several nurses and said they had it locked in the med cart. The administrator said corporate was going to cut a check and send it, I never received anything. Then these people took over [referring to the change in facility ownership] and the [current Administrator name redacted] said the same thing, they were going to cut a check. That's all they ever tell me. On 10/27/21, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of the facility policy, the facility failed to issue a written transfer notice to a resident and/or legal representative and to the state Ombudsman for one of two residents (Resident (R) 5) reviewed for hospitalizations. Findings include: Review of the facility policy titled, Notice of Discharge /Transfer, dated 01/06/20, revealed When the Center initiates a notice of transfer/discharge to a patient and/or responsible party, discharge planning will pursue timely and appropriate transfer/discharge notifications as well as discharge planning initiatives to ensure a safe and orderly discharge from the Center . Provide designated copies of the completed MFA Notice of Transfer/Discharge form to each of those specified on the form, which includes the Ombudsman . Scan a copy of the Notice of Transfer/Discharge into the patient's medical record in PCC [Point Click Care-electronic medical record] under the Misc. [Miscellaneous] tab. Once the document has been scanned into…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to provide the resident and/or the resident representative a written notice of the bed hold policy in one of two residents (Resident (R) 5) reviewed for hospitalizations. Findings include: The facility was unable to provide the requested bed hold policy by the end of the survey on 09/10/21. Review of R5's Face Sheet, found in the electronic medical record (EMR) under the Profile tab, revealed that R5 was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Review of R5's EMR Misc. [Miscellaneous] tab revealed a Nursing Note, dated 02/21/21, which indicated that R5 was sent to an acute care hospital and subsequently admitted . Review of R5's EMR lacked evidence to support that a written notice of bed hold was given to the resident and/or resident representative. During an interview on 09/03/21 at 11:30 AM, Discharge Planning Director (DPD) verified that there was no evidence that a written notice of bed hold…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Resident interview, staff interview, facility documentation review and clinical record review the facility staff failed to administer medications in accordance with physician orders and professional standards of practice for one Resident (Resident #806) in a survey sample of 12 Residents. The findings included: On 10/26/21 at 2:04 PM, an interview was conducted with Resident #806. During the interview RN B responded to Resident #806's call light. Resident #806 reported tightness in his chest and said they didn't give me my medicine last night, I think that may be the problem. I didn't get my gabapentin last night. I missed it once before and I got sick. On 10/26/21 at 2:14 PM, Surveyor C approached RN C at the nursing station. RN C and Surveyor C conducted a narcotic count of Resident #806's gabapentin and the count matched the quantity of pills present. A copy of the narcotic count sheet was obtained. On 10/26/21, a review of the electronic health record for Resident #806 was conducted. This review…

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