River View On The Appomattox Health & Rehab Center

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure the Resident's right to a dignified existence for 1 Resident (Resident #47) in a survey sample of 71 Residents. The findings included: For Resident #47, the facility staff failed to maintain dignity and assist Resident #47 with a meal on 3-1-23 resulting in Resident #47 sitting at a table with 2 other Residents observing them eat breakfast as she was unable to feed herself. On 3-1-23 at 8:00 A.M., Surveyor B observed Resident #47 sitting in a communal area on the nursing unit at a table with 3 other residents who were able to feed themselves. The residents were being served breakfast and eating while Resident #47 watched them eat with no meal in front of her. This dining observation was conducted from 8:30 A.M., until 9:35 A.M., when all of the food had been eaten by the other three residents, and Resident #47 had not been served nor assisted with a meal. No staff stayed in the room until 9:34 A.M. On 3-2-23, Resident #47's clinical record 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 interview, clinical record review, and facility documentation the facility staff failed to ensure the Residents right to participate in care planning for 2 Residents (#26 & # 82) in a survey sample of 71 Residents. The findings included: 1. For Resident # 26 the facility staff did not inform of and offer opportunity for RR (Resident Representative) to attend the care plan meetings since February 2022. On 2/28/22 at approximately 9:00 AM, an interview was conducted with Resident #26 who stated that he did not participate in care plan meetings. When asked why he did not participate, he stated he did not know when they were. A review of the clinical record revealed that Resident #26 was not his own RR due to his diagnoses. On 3/2/23 at 2:15 PM an interview was conducted with Employee G who stated that Resident #26 has not attended a care plan meeting in a while. When asked about his Representative attending the care plan meetings, she stated that the facility has been a little lax on getting invitations 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 observation, record review, staff interview, and facility policy review, the facility failed to maintain an effective housekeeping program to keep the floors free from debris and pests for one of 37 residents (Resident (R) 56) rooms observed in Initial Pool and six of six residents (R76, R104, R59, R67, R98, and R72) interviewed in the resident group meeting. Findings include: 1. Review of R56's undated Profile, found in the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with diagnoses including dementia, glaucoma, legal blindness, insomnia, and muscle weakness. Review of R56's significant change in status Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 02/18/23, located in the MDS tab of the EMR, revealed she scored two out of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. R56 had severely impaired vision and was sometimes able to understand others. She did not exhibit any…

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, the facility staff failed ensure freedom from neglect for 1 Resident (#16) in a survey sample of 71 Residents. The findings include: For Resident #16 the facility staff neglected to provide care which resulted in the Resident being left to sit in a Geri chair (medical style recliner) for a prolonged time, which exceeded 9 hours. As a result, Resident #16 developed a deep tissue injury. On 2/28/23 at approximately 9:00 AM, Resident #16 was observed to reside in room [number redacted] and was on droplet precautions as identified by signage on the door. Staff interviews confirmed that Resident #16 was under quarantine for COVID-19. On 2/28/23 at 10:12 AM, Resident #16 was noted to no longer be in room [number redacted] and the signage had been removed from the door alerting to droplet precautions. An interview was conducted with the unit manager/LPN D. The unit manager stated that Resident #16 was being moved back to the room he was in previously, due to his quarantine period had ended at mid-night. On 2/28/23 at approximately…

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

Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to develop a comprehensive dental care plan for one Resident (Resident #48) in a survey sample of 71 residents. The findings included; For Resident #48, the facility staff failed to include the problems, interventions and goals to address the Resident's ongoing dental care. Resident # 48's most resent MDS (Minimum Data Set) with an Assessment Reference Date of 2-2-23 was coded as a Quarterly assessment. The Brief Interview for Mental Status was coded as 12 out of possible 15 indicating very mild cognitive impairment. On 3-1-23 the Resident was interviewed by Surveyor B. The Resident complained of dental problems and stated he had seen the dentist, and was eating soft food, but wanted to start having regular dental care appointments. The Residents weight history was reviewed and in 6 months the Resident had experienced weight loss, however, not significant, and was stable for 5 months. Dental consult exam notes were reviewed and revealed a Dental doctors orders 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, interview, clinical record review, and facility documentation the facility staff failed to review and revise care plans to include changes in resident care for 2 Residents (#65 and #15) in a survey sample of 71 Residents. The findings included: 1. For Resident #65 the facility staff failed to revise the care plan after a verbal abuse allegation, to include LPN C not being assigned to Resident #65. On 3/2/23 at 12:15 PM Resident #65 was again observed in bed with her privacy curtain closed, an interview was conducted with Resident #65 who stated that on LPN C was rude to her. The Resident explained the incident and stated that the facility had stated that she would not have LPN C as her nurse anymore, however she continued to pull her medications and give them to another nurse to administer, causing Resident #65 to be concerned about her messing with her medications. Resident #65 also stated that when she got a roommate, LPN C was assigned to the roommate. On 3/3/23 a review of the facility investigation revealed the following excerpts: Based on an investigation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility documentation review, the facility staff failed to follow standards of nursing practice with regards to following physician orders for one Resident (Resident #16) in a survey sample of 71 Residents. The findings included: For Resident #16 the facility staff failed to provide daily treatment to a pressure wound as ordered by the physician for a period of 11 weeks. Review of the clinical record revealed that on 12/18/22, Resident #16 was seen by the wound care physician. This physician noted that Resident #16 had . a stage 3 pressure wound of the left arm for at least 1 day duration .Dressing Treatment Plan: Primary Dressing(s) Leptospermum honey apply once daily for 30 days; Alginate calcium apply once daily for 30 days Secondary Dressing(s) Gauze Island w/ bdr [with border] apply once daily for 30 days . However, review of the Treatment Administration Record revealed the order by the wound care physician was entered as Cleanse left antecubital space…

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

Based on staff interview and clinical record review, the facility failed to develop discharge plans for one Resident (Resident # 113) in a survey sample of 71 Residents. Findings included: Review of the clinical record was conducted on 3/2/2023. Review of the Progress Notes and care plans revealed no documentation of discharge plans for Resident # 113. Review of the Progress Notes revealed that Resident # 113 did not return to the facility after an outing with his wife. Review of the care plan revealed no documentation of discharge plans for Resident # 113. On 3/3/2023 at 12:24 p.m., an interview was conducted with the Social Services Director who stated # 113 did not return to the facility after going on leave with family. The Social Services Director stated that discharge plans should be developed for residents. During the end of day debriefing on 3/3/2023, the facility Administrator and Corporate Nurse Consultant were informed of there findings. No further information was provided.

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 provide services to maintain personal hygiene for 1 Resident (#98) in a survey sample of 71 Residents. The Findings included: For Resident #98, the Resident's fingernails were 1/2 inch long with brown hard debris under them. On 3-1-23 the Resident was interviewed, and complained that his nails were too long and stated no one would cut them for him. He stated that staff normally do it when he got bathed, but stated that bathing had not happened lately either. Resident #98 had an annual minimum data set assessment dated [DATE] which coded the Resident with a Brief Interview of Mental Status score of 15 indicating no cognitive impairment. The Resident was incontinent of bladder and bowel, and required one staff assistance for bathing. The document also denoted that the Resident had no aberrant behaviors and did not refuse care. On 3-3-23 Resident #98's activity of daily living care…

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 provide needed care and services that are resident centered, according to resident's preferences, goals for care that meet the resident's physical, mental, and psychosocial needs for 2 Resident (#26 & 104) in a survey sample of 71 Residents. The findings include: 1. For Resident #26 the facility staff failed to coordinate care to include a neurology consult for a Resident with epilepsy and traumatic brain injury with a ventriculoperitoneal shunt (a device that drains excess cerebrospinal fluid from the brain to the stomach). Resident #26 has diagnoses that include but are not limited to Diffuse Traumatic Brain injury, concussion, post-concussion syndrome, presence of cerebrospinal fluid drainage device (Ventriculoperitoneal shunt), epilepsy, post traumatic headache, cerebellar ataxia (poor muscle control causing spastic movements) from TBI (Traumatic brain injury) migraines and hypertension. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review and facility policy review, the facility failed to ensure two residents of two residents (Resident (R) 43 and R15) reviewed for podiatry services received services. Findings include: 1. Review of R43's undated admission Record located on his electronic medical record (EMR) revealed he was initially admitted to the facility on [DATE] with multiple diagnosis to include diabetes mellitus and hemiplegia. Review of R43's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 02/13/23 located in the MDS tab of the EMR, revealed R43 scored seven out of 15 on the Brief Interview for Mental Status (BIMS), which indicated R43 was severely cognitively impaired. R43 used wheelchair and was totally dependent for bathing with one staff assistance required and extensive assistance with one staff for personal hygiene. Review of R43's Physician's Orders dated 01/03/23 under Orders tab located on his EMR revealed resident had active orders for podiatrist screen…

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, record review, staff interviews, Food and Drug Administration's (FDA) guidance and facility policy review, the facility failed to demonstrate an indication for use and attempt alternatives prior to installing bed rails (siderails) for one of six residents (Resident (R) 464) reviewed for accidents. Findings include: Review of the FDA's Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, issued 03/10/06, indicated, For 20 years, FDA has received reports in which vulnerable patients have become entrapped in hospital beds while undergoing care and treatment in health care facilities . Patient entrapments may result in deaths and serious injuries . The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement . Long-term care facilities reported the majority of the entrapments. Review of R464's undated Profile, located in the Profile tab of the electronic…

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 complete a performance review of one Certified Nursing Assistant (CNA # 2) of 5 Certified Nursing Assistant's in the survey staff sample. Findings included: On 3/2/2023, a review of five staff inservice education was conducted. Review revealed one employee, CNA (Certified Nursing Assistant) # 2 was hired on 7/28/2020 and terminated on 11/5/2021. An annual performance review was due prior to the termination date of 11/5/2021. An interview was conducted with the Human Resources director who was asked to provide a copy of the annual performance review. During the end of day debriefing on 3/3/2023, the Administrator stated there was no performance review in the employee file for CNA # 2. The Administrator stated performance reviews should be completed annually. No further information was provided.

Based on interview, clinical record review, and facility documentation the facility staff failed to ensure Residents were free of unnecessary psychotropic medications for 2 Residents (#'s 15 &31) in a survey sample of 71 Residents. The findings included: 1. For Resident #15 the facility staff failed to ensure that as needed (PRN) orders for psychotropic drugs are limited to 14 days. On 3/1/23 during clinical record review it was discovered that Resident #15 had an order for PRN Lorazepam (an anti-anxiety medication). The clinical record revealed the following order. 2/9/23 Lorazepam Oral Concentrate 2 MG/ML (Lorazepam) Give 0.25 ml by mouth every 4 hours as needed for Anxiety or Restlessness -Start Date 02/09/2023 [ Note: there is no time frame of 14 days, or a stop date specified for this order] On 3/8/23 an interview was conducted with the acting DON who was asked about PRN anti-anxiety medications needing a stop date. The acting DON replied, there should be a stop date or documentation of the Resident requiring longer therapy and a duration of therapy. On 3/8/23 during the end of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to 1) provide influenza vaccines for 1 resident, Resident #465, out of 5 residents reviewed for influenza immunization and 2) facility staff failed to provide a pneumococcal vaccine for 1 resident, Residents #465, out of 5 residents reviewed for pneumococcal immunization. The findings included: 1. The facility staff failed to provide influenza immunization for Resident #465. On 2/28/23, clinical record review was performed and revealed that Resident #465, who was admitted to the facility on [DATE], had no documentation with regard to influenza immunization, to include the resident's current influenza vaccination status, offer to provide immunization against influenza infection, or documentation of resident refusal or medical contraindication. On 2/28/23 at approximately 3:30 PM, an interview was conducted with the Infection Preventionist (IP) who accessed the clinical record for Resident #465 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 clinical record review, staff interview, and facility documentation review, the facility staff failed to conduct COVID-19 testing in accordance with the Centers for Disease Control and Prevention (CDC) guidance for 2 residents, Resident #114 and Resident #116, in a sample of 5 Residents reviewed for COVID-19 testing. The findings included: 1. For Resident #114, facility staff failed to conduct COVID-19 testing on 2/13/23 and 2/15/23, following her admission to the facility on 2/13/23. The first COVID-19 test was administered on 2/17/23, four days post-admission. 2. For Resident #116, facility staff failed to conduct COVID-19 testing on 2/13/23 and 2/15/23, following her admission to the facility on 2/13/23. The first COVID-19 test was administered on 2/17/23, four days post-admission. On 2/28/23, a clinical record review was conducted and revealed no evidence of COVID-19 testing until 2/17/23, Day 4 post-admission, for both Resident #114 and Resident #116. The COVID-19 Community Transmissibility Level for the facility was HIGH for the week 2/13/23 through 2/26/23. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide COVID-19 immunization for 1 resident, Resident #465, in a survey sample of 5 residents reviewed for COVID-19 immunization. The findings included: The facility staff failed to provide evidence that Resident #465 was offered, educated, and provided/or declined COVID-19 vaccination. On 2/28/23, clinical record review was performed for Resident #465, admitted to the facility on [DATE]. Resident #465 had no documentation with regard to COVID-19 immunization, to include the resident's current COVID-19 vaccination status, offer to provide immunization against COVID-19 infection, or documentation of resident refusal or medical contraindication. On 2/28/23 at approximately 3:30 PM, an interview was conducted with the Infection Preventionist (IP). The IP verified the findings for Resident #465 and stated the COVID-19 immunization status should have been assessed at admission. A facility policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility failed to maintain an effective pest control program for one of 37 residents' (Resident (R) 56) rooms observed in Initial Pool. This failure had the potential to lead to further pest infestation in the facility. Findings include: Review of R56's undated Profile, found in the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with diagnoses including dementia, glaucoma, legal blindness, insomnia, and muscle weakness. Review of R56's significant change in status Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 02/18/23, located in the MDS tab of the EMR, revealed she scored two out of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. R56 had severely impaired vision and was sometimes able to understand others. She did not exhibit any behavioral symptoms. Review of R56's comprehensive Care Plan, located in the Care Plan tab…

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

Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to determine if it was safe for one Resident to self-administer nebulized respiratory medication (Resident #110 ) in a sample of 43 residents. The findings include: Resident #110's Diagnoses included; Chronic respiratory failure with hypoxia & hypercapnia, congestive heart failure, cardiac pacemaker, pulmonary heart disease, dementia without behavioral disturbance, and diabetes. On 2-5-2020 at 9:30 a.m., during morning interviews with residents, Resident #110 was visited and found to be in her room with a face mask covering her nose and mouth, receiving an aerosol medication. The medication was being administered through a nebulizer machine. The Resident was talking to the television, or her room mate, it is unknown which, and not inhaling the medication. As the surveyor entered, the Resident began immediately talking to the surveyor and not inhaling her medication. The medication nurse was found by the surveyor in another Resident room administering medications, and had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, facility documentation review, and the facility failed to prevent physical abuse by staff for one resident (Resident #169) in a survey sample of 43 residents. The Findings included: The facility staff pushed Resident #169's back while putting him to bed. Resident #169 was an [AGE] year old. Resident #169's diagnoses included Heart Failure, and Unspecified Dementia without Behavioral Disturbance Resident #169 was sometimes able to understand and be understood by others. Resident #169 expired at the facility on [DATE]. The Minimum Data Set, which was a Quarterly Assessment, with an Assessment Reference Date of [DATE] was reviewed. Resident #169 was coded as requiring the physical assistance of 2 persons for transfers, and utilized a wheelchair for mobility. On [DATE] a review was conducted of facility documentation, revealing a Facility Reported Incident dated [DATE]. An excerpt read, On [DATE] it was reported to me [Administrator - Administration 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 resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to implement a care plan for bowel management and incontinence care for 1 resident (Resident #23) in a survey sample of 43 residents. The Findings included: For Resident #23, the facility staff failed to provide toileting in a timely manner for bowel management and incontinence care. Resident #23 was a [AGE] year old. Resident #63's diagnoses included Cerebral Palsy, Congenital Malformations of Musculoskeletal System, Idiopathic Scoliosis, Osteoporosis, Age-Related Nuclear Cataract, Unspecified Eye, Depression and Anxiety. The Quarterly Minimum Data Set, dated [DATE] was reviewed. Resident #23 was coded as having a Brief Interview of Mental Status Score of 15, indicating intact cognition. Resident #23 was also coded as requiring the physical assistance of 2 persons for toileting. Resident #23 was also coded as having range of motion impairment on both of her upper and lower limbs.…

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 provide timely personal care after episodes of incontinence for 1 resident (Resident #23) in a survey sample of 43 residents. The Findings included: For Resident #23, the facility staff failed to provide personal cleaning in a timely manner after episodes of incontinence. Resident #23 was a [AGE] year old. Resident #63's diagnoses included Cerebral Palsy, Congenital Malformations of Musculoskeletal System, Idiopathic Scoliosis, Osteoporosis, Age-Related Nuclear Cataract, Unspecified Eye, Depression and Anxiety. The Quarterly Minimum Data Set, dated [DATE] was reviewed. Resident #23 was coded as having a Brief Interview of Mental Status Score of 15, indicating intact cognition. Resident #23 was also coded as requiring the physical assistance of 2 persons for toileting. Resident #23 was also coded as having range of motion impairment on both of her upper and lower limbs. 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, and clinical record review, the facility staff failed for one resident (Resident #80) of 43 residents to administer splints to the upper extremities and hands as ordered. The findings include: Resident # 80, a [AGE] year old, was admitted to the facility in 2016. Resident 80's diagnoses included but were not limited to : Gastrostomy, Dysphagia, Dementia, Chronic Obstructive Pulmonary Disease, Diabetes, Hypertension. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 1/5/2020. Resident # 80 was coded with a Brief Interview of Mental Status score of 00 indicating severe cognitive impairment and required total assistance of one staff person with activities of daily living including bed mobility except for transfers. The assessment coded Resident # 80 as requiring total assistance of two staff persons for transfers. Resident # 80 was also coded as always incontinent of bowel and bladder. The following observations…

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 adequate supervision to prevent elopement for 1 of 43 residents (Resident #168). The Findings included: Resident #168 eloped from the facility after a staff member (the Social Worker - Administration G) held the door open for him to exit the building to sit outside unattended near a driveway and parking lot. Resident #168 was a [AGE] year old who no longer resided at the facility at the time of the survey. Resident #168's diagnoses included Generalized Muscle Weakness, Lack of Coordination, and Cerebral Infarction. Resident #168's niece was his Responsible Party. He did not make independent decisions. The Discharge Minimum Data Set, dated [DATE] was reviewed. Resident #168 was coded as having a Brief Interview of Mental Status Score of 10, indicating moderately impaired cognition. Resident #168 utilized a wheelchair for mobility. On 2/5/20 a review was conducted of facility…

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 interview the facility staff failed to appropriately label and store medications and biologicals for 1 of 4 units The findings include: For Medication room on the 300 Hall the facility staff failed to lock the narcotic box inside of the medication refrigerator and inside of the refrigerator was an opened half used multi-use vial of Tubersol (a biological used to test for Tuberculosis) with no date opened or date to discard on label. On 2/5/2020 at 12:45 PM during Medication Storage Task, the medication room on the 300 hallway was inspected. Accompanying the Surveyor was LPN A. The medication room door was properly locked and the LPN used her keys to enter the room. The refrigerator was not locked but there was a narcotic box attached to the inside the refrigerator that had a lock on it. However, the narcotic box that was attached inside the refrigerator was left unlocked. The surveyor was able to open the narcotic box unassisted. Inside the Narcotic box was Marinol (gel capsule of THC the man-made form of the active substance in cannabis) and Lorazepam…

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 Council meeting, and two Resident interviews, the facility failed to ensure food was served at a palatable temperature for 2 of 43 residents (Resident #32 and #49). The findings included: On 2-4-2020 during the initial tour of the facility, Resident's #32, and #49 were interviewed. They were room mates, and both stated the only complaint they had regarding their care was that meals were served after they had become cold. Clinical records were reviewed for both Residents and they were both found to have a Brief Interview for Mental Status (BIMS) score of 15 points, out of a possible 15 points, indicating, no cognitive impairment. On 2-5-2020, the breakfast meal observation was conducted at 9:15 a.m. Residents #32, and #49 were observed and interviewed. Both Residents were in their rooms and both had eggs delivered to them while the surveyor was in the hallway just minutes before entering the room. Both Residents complained of cold food, and neither of them ate the meal. They stated that this had happened a lot lately, and getting the food reheated 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 Resident interview, facility documentation, and clinical record review the facility staff failed to ensure the resident received food that accommodates resident preferences, for 1 Resident (#32) in a survey sample of 43 Residents. The findings include: On 2-4-2020 during the initial tour of the facility, Resident's #32, and #49 were interviewed. They were room mates. Resident #32 stated that she would request soup at meal time, and the staff always told her there was no soup, even when her room mate received it. Resident #49 supported that statement. Resident #49 went on to say that her room mate loved all soups, and that just the day before she had received tomato soup and her room mate Resident #32 had requested the same, and staff told her there was no more soup. Both Residents stated this happened on almost every occasion, and Resident #32 stated that she could not understand how they would not let her have soup. The facility listed soups on their posted and reviewed menus frequently. Clinical records were reviewed for both Residents and they were both found to have 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, facility document review, clinical record review, and staff interview, the facility staff failed to implement an effective infection control program for two Residents (Resident #36, & #80) in a survey sample of 43 residents. The findings included: 1. For Resident #36 the facility failed to keep an enteral feeding pump clean, which was encrusted with a tan substance resembling dried enteral feeding liquid, and failed to remove and discard a visibly soiled clear plastic bag with brown watery liquid in it, and a tan smeared dried substance on the outside of the bag. On 2-5-2020 at 10:30 a.m. Resident #36 was observed, and his enteral feeding pump was observed on and infusing. The feeding pump was encrusted on the top and sides with a tan substance resembling dried enteral feeding liquid. Hanging from the pole, which the pump was affixed to, was a visibly soiled gallon sized clear plastic bag. The bag was hanging behind, and touching, the graduated bag containing the feeding formula. The clear…

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

Based on observation, staff interview and facility documentation review the facility staff failed follow professional standards for food service safety related to hand washing between changing gloves and touching face with gloved hands. The findings included: On 4/25/18 at 12:30 while observing tray line preparation Employee D changed gloves three times without washing hands after taking off soiled gloves, also on 4/2518 during tray line observation Employee E touched her face with gloved hands and did not wash hands and change gloves. On 4/26/18 during interview with Employee C (Dietary Manager) she stated that it was an expectation that when soiled gloves are removed hands are to be washed prior to donning clean gloves, she also stated that it was an expectation that employees not touch their faces with gloves on and if they do they need to change gloves and wash hands before continuing with food preparation. The Administrator provided a written copy of the hand washing policy that stated Frequent and thorough hand washing is a major importance in preventing the spread of germs.…

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 document review, clinical record review, and in the course of a complaint investigation, the facility staff failed to maintain peritoneal dialysis (PD) in a manner to prevent the spread of infection for 1 resident (Resident #308) in a survey sample of 28 residents. 1. For Resident #308, the facility staff contaminated the PD exchange during multiple steps on the 4-26-18 exchange observation. 2. The facility staff failed to ensure the ice machine on 2 of 2 units had an air gap to prevent backflow of contaminated water. The Findings included: Resident #308 was admitted previously to the facility on [DATE], after amputation surgery of her left foot. The Resident was discharged home from the facility on 3-14-18. The Resident was readmitted after further amputation surgeries on 4-19-18 with the diagnoses of, but not limited to; hypertension, heart disease, chronic kidney disease with peritoneal dialysis, bilateral below the knee amputations, insulin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility documentation review, clinical record review, and in the course of a complaint, the facility staff failed to notify the doctor of a serious weight gain for one Resident (Resident #308) of 28 residents in the survey sample. For Resident #308 the facility staff did not notify the doctor of weight gain as was ordered for a dialysis patient on more than one occasion. The findings included: Resident #308 was admitted previously to the facility on [DATE], after amputation surgery of her left foot. The Resident was discharged home from the facility on 3-14-18. The Resident was readmitted after further amputation surgeries on 4-19-18 with the diagnoses of, but not limited to; hypertension, heart disease, chronic kidney disease with peritoneal dialysis, bilateral below the knee amputations, insulin dependant diabetes, glaucoma, and asthma. The most recent Minimum Data Set (MDS) for this admission was a quarterly assessment with an Assessment Reference…

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, for 1 resident (Resident #31) of the survey sample of 23 residents, to ensure personal privacy. For Resident #31, the facility staff failed to knock on the door, announce themselves, and ask permission prior to entering the room. The Findings included: Resident #31 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #31's diagnoses included Diabetes Mellitus Type 2, Urinary Tract Infection, Peripheral Vascular Disease, Chronic Atrial Fibrillation, Overactive Bladder, and Gastro-Esophageal Reflux Disease. The Minimum Data Set, which was a Quarterly Assessment with a an Assessment Reference Date of 2/13/18, coded Resident #31 with a Brief Interview of Mental Status Score of 15, indication that he was cognitively intact. On 4/26/18 at 9:10 A.M., an interview was conducted with Resident #31 in his bedroom. He was sitting up in a Geri chair. His right leg was elevated, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and family interview, and facility and clinical documentation, the facility failed to maintain a clean and homelike environment. 1. For Resident #61, the room and bathroom needed cleaning and tiles replaced. 2. For Resident # 15, the facility staff failed to ensure that the room was free of a strong pervasive odor. The findings included: 1. On 4/24/18 at approximately 6:45 PM, during the initial tour, Resident #61's daughter was in the room. She expressed concerns over the cleanliness of the facility. She pointed out two smears of dark material on the bedside table, which she stated was food. She stated, It has been there for months and I refuse to clean it. She also pointed out in the corner of the room, near the TV, a crack in the wall which was stuffed with what looked like paper. In addition, the toilet area (around the commode) were dark, stained areas, possibly rust and mildew. On 04/27/18 at 10:46 AM, A walk through with the Maintenance Director was conducted. He was shown…

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 for 2 residents (Resident #4 and #262) in a survey sample of 28 residents to implement the abuse policy. An allegation of abuse was made by Resident #262 regarding Resident #4. The allegation was not reported to the Administration or to the State Agency. The findings included: Resident #4, a [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included colon cancer, hypertension, cerebrovascular disease, depression, reflux, dementia, and schizophrenia. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 1/11/18. Resident #4 was coded with a Brief Interview of Mental Status score of 4 indicating severe cognitive impairment and required extensive assistance with activities of daily living. Resident #4 was observed sitting in his wheel chair eating breakfast in his room on 4/25/18. He had no complaints at the time. 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, clinical record review and facility documentation review the facility staff failed for 2 residents (Resident #4 and #262) in a survey sample of 28 residents to report an allegation of abuse to facility administration or to the state agency. An allegation of abuse was made by Resident #262 regarding Resident #4. The allegation was not reported to the Administration or to the State Agency. The findings included: Resident #4, a [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included colon cancer, hypertension, cerebrovascular disease, depression, reflux, dementia, and schizophrenia. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 1/11/18. Resident #4 was coded with a Brief Interview of Mental Status score of 4 indicating severe cognitive impairment and required extensive assistance with activities of daily living. Resident #4 was observed sitting in his wheel chair eating breakfast in his 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #61's care plan did not contain information regarding his left sided neglect from a previous stroke affecting his communication. Resident #61 was admitted to the facility 3/16/16. Diagnoses included, but not limited to, dementia, stroke, diabetes and aphasia. Resident #61's most recent MDS (minimum data set) with an ARD (assessment reference date) of 3/13/18 was coded as an annual assessment. Resident #61 was coded as having a BIMS (brief interview of mental status) of 5 out of a possible 15 or severe cognitive impairment. Resident #61 was coded as requiring extensive to total assistance of one to two staff members to perform activities of daily living. On 4/24/18 at approximately:10 PM during the facility tour, the resident was observed in his bed with his daughter nearby. While speaking to the resident, the daughter stated, He has left side neglect from his stroke and will not recognize anyone from his left side, you have to come around to his right. This was done and the resident maintained eye…

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 review, and clinical record review, the facility staff failed to follow the professional standards of quality for medication and treatment administration for two Residents (Residents # 8 and # 407) in a survey sample of 28 Residents. 1. For Resident # 8, the facility staff failed to administer medications as ordered by the physician. 2. For Resident #407, Facility staff administered Oxygen without a Physician's order. Findings included: 1. For Resident # 8, the facility staff failed to administer medications as ordered by the physician. Resident # 8 was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of but not limited to: Hypertensive Heart Disease, Diabetes, End Stage Renal Disease, Hypotension, Anxiety, Bacteremia, Hyperkalemia, Pneumonia, Hyperlipidemia, and Dyspnea. The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of [DATE]. The MDS coded Resident # 8 with a BIMS (Brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, family interview, staff interview, and clinical record review the facility staff failed to provide Activity of Daily Living (ADL) assistance for 1 resident (Resident #258) of 28 residents in the survey sample. For Resident #258, facility staff failed to provide feeding assistance. The finding included: Resident #258, a [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included multiple myeloma, dysphagia, hypertension, anemia, and critical illness myopathy (muscle weakness). Resident #258 was new to the facility and did not have a Minimum Data Set completed. Her care plan documented that she was able to make basic care decisions and express care preferences. Resident #258's family was interviewed on 4/24/18 at 7:30 p.m. The family was concerned that the facility staff did not assist the resident during meal time. They stated they helped her when the visited. They stated that the resident had just come to the facility from the hospital where she had been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility documentation review and clinical record review, the facility staff failed to provide peritoneal dialysis services to maintain the highest practicable well being for one Resident (Resident #308) of 28 residents in the survey sample. Resident #308 did not receive peritoneal dialysis services to maintain her highest practicable wellbeing. The findings included: Resident #308 was admitted previously to the facility on [DATE], after amputation surgery of her left foot. The Resident was discharged home from the facility on 3-14-18. The Resident was readmitted after further amputation surgeries on 4-19-18 with the diagnoses of, but not limited to; hypertension, heart disease, chronic kidney disease with peritoneal dialysis, bilateral below the knee amputations, insulin dependant diabetes, glaucoma, and asthma. The most recent Minimum Data Set (MDS) for this admission was a quarterly assessment with an Assessment Reference Date (ARD) of 3-5-18, 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 observation, staff interview, facility document review, and clinical record review the facility staff failed to prevent a decrease in range of motion, for one resident (Resident #34) of 28 residents in the survey sample. Resident #34 was never observed wearing any protective hand device to prevent the formation of contractures, and loss of range of motion. The findings included: Resident #34 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Diagnoses included; multiple sclerosis, gastrostomy tube for feeding, failure to thrive, aphasia, depression, anxiety, and contractures. Resident #34's most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 2-20-18. Resident #34 was coded with a Brief Interview of Mental Status score of unable to complete due to severe cognitive impairment. The Resident was totally dependant on 1 to 2 staff members for all activities of daily living, such as bed mobility, toileting, bathing, and dressing.…

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 administer tube feeding per professional standards for 1 resident (Resident #34) in the survey sample of 28 residents. Facility staff failed to maintain Resident #34's head of bed elevated to prevent aspiration of tube feeding. The Findings included: Resident #34 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Diagnoses included; multiple sclerosis, gastrostomy tube for feeding, failure to thrive, aphasia, depression, anxiety, and contractures. Resident #34's most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 2-20-18. Resident #34 was coded with a Brief Interview of Mental Status score of unable to complete due to severe cognitive impairment. The Resident was totally dependant on 1 to 2 staff members for all activities of daily living, such as bed mobility, toileting, bathing, and dressing. Resident #34 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, clinical record review and facility documentation review, the facility staff failed for 1 resident (Resident #257) of 28 residents in the survey sample to provide respiratory care in the manner to prevent the spread of infection. For Resident #257, the tubing to the nebulizer machine was on the floor and a used sterile catheter used for bronchial suctioning was kept for reuse in an open plastic bag. The findings included: Resident #257 was admitted to the facility on [DATE]. Diagnoses included dysphagia, Pressure ulcer, Chronic Obstructive Pulmonary Disease, tracheostomy, feeding tube, catheter, and pulmonary fibrosis. As Resident #257 was new to the facility, a Minimum Data Set assessment had not been completed. Resident #257 had impaired communication and cognition. On 4/26/18 at 3:35 p.m., Resident #257 was observed lying in bed. The nebulizer machine was in the drawer of the bedside table. The tubing to the nebulizer machine was lying on the floor. There was a bedside…

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 provide pain management for 1 resident (Resident #258) of 28 residents in the survey sample. For Resident #258, facility staff failed to provide physician ordered fentanyl patch for pain management. The finding included: Resident #258, a [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included multiple myeloma (cancer), dysphagia, hypertension, anemia, and critical illness myopathy (muscle weakness). Resident #258 was new to the facility and did not have a Minimum Data Set completed. Her care plan documented that she was able to make basic care decisions and express care preferences. On 4/25/18 at 8:15 a.m., Resident #258 was observed in bed with her eyes closed. The skilled nursing note dated 4/24/18 read (Resident #258) is receiving skilled acre services for rehabilitation therapies scheduled at least 5 days/ week, daily assessment and management of pain, . Resident #258 had the following physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility documentation review, clinical record review, and in the course of a complaint, the facility staff failed to provide peritoneal dialysis services consistent with professional standards of practice, the comprehensive care plan, and the Resident's goals and preferences for one Resident (Resident #308) of 28 residents in the survey sample. Resident #308 did not receive peritoneal dialysis consistent with professional standards of practice. The findings included: Resident #308 was admitted previously to the facility on [DATE], after amputation surgery of her left foot. The Resident was discharged home from the facility on 3-14-18. The Resident was readmitted after further amputation surgeries on 4-19-18 with the diagnoses of, but not limited to; hypertension, heart disease, chronic kidney disease with peritoneal dialysis, bilateral below the knee amputations, insulin dependant diabetes, glaucoma, and asthma. The most recent Minimum Data Set (MDS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, Resident interview, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility failed to ensure competent nursing staff to provide peritoneal dialysis (PD) services for one Resident (Resident #308) in a survey sample of 28 residents. The Facility failed to provide competent nursing staff for Resident #308's peritoneal dialysis care needs. The findings included; Resident #308 was admitted previously to the facility on [DATE], after amputation surgery of her left foot. The Resident was discharged home from the facility on 3-14-18. The Resident was readmitted after further amputation surgeries on 4-19-18 with the diagnoses of, but not limited to; hypertension, heart disease, chronic kidney disease with peritoneal dialysis, bilateral below the knee amputations, insulin dependant diabetes, glaucoma, and asthma. The most recent Minimum Data Set (MDS) for this admission was a quarterly assessment with an Assessment Reference…

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 for 1 resident (Resident #258) of 28 residents in the survey sample that medication was available for administration. For Resident #258, physician ordered fentanyl patch was not administered because it had not been delivered by the pharmacy. The finding included: Resident #258, a [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included multiple myeloma (cancer), dysphagia, hypertension, anemia, and critical illness myopathy (muscle weakness). Resident #258 was new to the facility and did not have a Minimum Data Set completed. Her care plan documented that she was able to make basic care decisions and express care preferences. On 4/25/18 at 8:15 a.m., Resident #258 was observed in bed with her eyes closed. The skilled nursing note dated 4/24/18 read (Resident #258) is receiving skilled acre services for rehabilitation therapies scheduled at least 5 days/ week, daily assessment and management of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure one resident (Resident # 8) in a survey sample of 28 residents was free from significant medication errors. For Resident # 8, the facility staff failed to administer insulin as prescribed by the physician. Findings included: Resident # 8 was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of but not limited to: Hypertensive Heart Disease, Diabetes, End Stage Renal Disease, Hypotension, Anxiety , Bacteremia, Hyperkalemia, Pneumonia, Hyperlipidemia, and Dyspnea The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 4/17/2018. The MDS coded Resident # 8 with a BIMS (Brief Interview for Mental Status) of 15/15 indicating no cognitive impairment; the resident required extensive assistance of 1-2 staff persons with Activities of Daily Living except required supervision and set up for eating; and coded as frequently…

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.