Grayson Health and Rehabilitation

Based on observations, staff interviews, clinical record review, and facility document review, the facility staff failed to complete a Significant Change Minimum Data (MDS) assessment for 1 of 23 sampled residents, Resident #160. The findings include: Resident #160's comprehensive minimum data set (MDS) assessment, with an assessment reference date of 2/23/22, was dated as completed on 3/1/22. Resident #160 was assessed as able to make self understood and as able to understand others. Resident #160's Brief Interview for Mental Status (BIMS) summary score was documented as an eight (8) out of 15; this indicated moderate cognitive impairment. Resident #160 was documented as requiring assistance with bed mobility, transfers, toilet use, and personal hygiene. Resident #160's diagnose included, but were not limited to: high blood pressure, thyroid disease, arthritis, and Alzheimer's disease. Resident #160 was assessed as not having unhealed pressure ulcers. Resident #160 was assessed as not having an indwelling urinary catheter. Resident #160's clinical documentation indicated, 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 document review, the facility staff failed to review and revise the comprehensive person-centered plan of care for 1 of 23 residents in the survey sample, Resident #29. Resident #29's comprehensive person-centered plan of care was not revised following discovery of the resident inappropriately touching another resident. The findings included: Resident #29's diagnosis list indicated diagnoses, which included, but not limited to Vascular Dementia, Chronic Obstructive Pulmonary Disease, Generalized Anxiety Disorder, Pulmonary Hypertension, and Peripheral Vascular Disease. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 2/07/22 assigned the resident a BIMS (brief interview for mental status) summary score of 0 out of 15 indicating the resident was severely cognitively impaired. A review of Resident #29's clinical record revealed a physician's progress note dated 11/30/21 stating in part On rounds 11-23-21 for eval (evaluation) of dementia and sexual behaviors. (He/she) recently 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.

Based on observation, staff interview, and clinical record review the facility staff failed to provide ADL (activities of daily living) care for a dependent resident for 1 of 23 residents, Residents #69. The facility staff failed to provide nail care. The findings included: Resident #69's diagnoses included, but were not limited to, chronic kidney disease, anxiety disorder, hypertension, anorexia, adult failure to thrive, and benign prostatic hyperplasia. Section C (cognitive patterns) of Resident #69's quarterly MDS assessment with an ARD (assessment reference date) of 02/15/22 included a BIMS (brief interview for mental status) summary score of 00. Section G (functional status) was coded 3/2 for personal hygiene to indicate the resident required extensive assistance of one person for this task. Resident #69's comprehensive care plan included the focus area-Has ADL self-care performance deficit related to diagnosis Alzheimer's dementia with behaviors, confusion. Interventions included, Check nail length and trim and clean on bath day and as necessary. 04/05/22 11:39 a.m., toenails…

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

Based on staff interview, clinical record review, and facility document review, the facility staff failed to follow physician's orders for 2 of 23 residents in the survey sample, Resident #7 and #110. For Resident #7, the facility staff failed to perform weekly skin assessments as ordered by the physician. For Resident #110, the facility staff failed to transcribe a physician's order from the hospital discharge summary for wound care. The findings included: 1. Resident #7's diagnosis list indicated diagnoses, which included, but not limited to Epilepsy, Alzheimer's Disease, Orthostatic Hypotension, Generalized Anxiety Disorder, Repeated Falls, Chronic Kidney Disease, and Essential Hypertension. The most recent admission MDS (minimum data set) with an ARD (assessment reference date) of 1/07/22 assigned the resident a BIMS (brief interview for mental status) summary score of 2 out of 15 indicating the resident was severely cognitively impaired. Resident #7 was coded as requiring extensive assistance with bed mobility, transfers, toilet use, and personal hygiene. The resident was coded…

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

Based on staff interview, clinical record review and facility document review the facility staff failed to follow up on monthly drug regimen reviews for 2 of 23 residents, Resident #72 and Resident #74. For Resident #72, the facility staff failed to follow up on pharmacist recommendations for the months of September 2021 and December 2021. For Resident #74, the facility staff failed to follow up on a pharmacist recommendation for the month of September 2021. The findings included: 1. Resident #72's face sheet included diagnoses which included but not limited to Alzheimer's disease, dementia, Type 2 diabetes mellitus, depression, hypertension, and gastroesophageal reflux disease. Resident #72's most recent annual MDS (minimum data set) with an ARD (assessment reference date) of 02/21/22 assigned the resident a BIMS (brief interview for mental status) score of 2 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #72's clinical record was reviewed and contained monthly MRR's (medication regimen review) dated 09/24/21…

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, facility document review, and during a medication pass and pour observation, the facility staff failed to ensure a medication error rate of less than 5% there were 3 errors in 30 opportunities for a medication error rate of 10%. These errors effected Residents #12 and #42. The findings included: 1. Section C (cognitive patterns) of Resident #12's annual MDS (minimum data set) assessment with an ARD (assessment reference date) 01/05/22 included a BIMS (brief interview for mental status) summary score of 3 out of a possible 15 points. The clinical record included the diagnoses Alzheimer's, dementia, glaucoma, and chronic kidney disease. 04/06/22 7:48 a.m., LPN (licensed practical nurse) #1 prepared Resident #12's morning medications to include Senna 8.6 mg 2 tablets. Resident #12's clinical record included a physicians order for Senna 8.6 mg give 1 tablet by mouth two times a day for constipation. 04/06/22 9:34 a.m., LPN #1 stated they administered Senna 2 tablets. LPN #1 reviewed the clinical record and stated the order read 1 tablet…

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, interviews, and facility document reviews, the facility staff failed to correctly implement contingency plans for staff who were not fully vaccinated for COVID-19. The findings include: Two (2) staff members (SMs), with COVID-19 vaccine exemptions, were reviewed as part of the COVID-19 immunization review (SM #21 and SM #22). On 4/6/22 at 9:30 a.m., SM #21 was observed to have a KN95 mask. SM #21 reported, as part of the facility's exemption contingency plan, they had to wear the mask when not eating or drinking. SM #21 also reported they had to have weekly COVID-19 test completed. On 4/6/22 at 9:40, SM #21 was asked about wearing a N95 mask verses a KN95 mask; SM #21 indicated their understand was the KN95 was okay to wear. On 4/6/22 at 9:35 a.m., SM #22 was observed to be wearing a KN95 mask. SM #22 reported, as part of the facility's exemption contingency plan, they had to wear the mask. SM #22 also reported they had to have weekly COVID-19 test completed. SM #22 was asked if the mask should be a N95 mask instead of a KN95; SM #22 indicated they believed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate DDNR (Durable Do Not Resuscitate) for 2 of 26 residents in the survey sample (Resident #99 and Resident #95). The findings included: 1. The facility staff failed to ensure a complete and accurate DDNR (Durable Do Not Resuscitate) for Resident #99. Resident #99 was admitted to the facility on [DATE] with the following diagnoses, but not limited to atrial fibrillation, high blood pressure, diabetes and dementia. On the 5 day admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/20/18, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 3 out of a possible score of 15. The resident was coded as requiring extensive assistance of 2 staff members for dressing and personal hygiene. Resident #99 was also coded as being totally dependent on 2 staff members for bathing. The surveyor conducted a clinical record review on Resident #99 on 1/30/19. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to ensure an accurate MDS (Minimum Data Set) for 1 of 26 residents in the survey sample (Resident #43). The findings included: The facility staff failed to code Resident #43's fall, which occurred on 1/13/18 on the MDS with an ARD (Assessment Reference Date) of 4/10/18. Resident #43 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to anemia, high blood pressure, dementia and respiratory failure. On the quarterly MDS with an ARD (Assessment Reference Date) of 11/26/18 which coded the resident as having a BIMS (Brief Interview for Mental Status) score of 10 out of a possible score of 15. Resident #43 was also coded as requiring extensive assistance of 2 staff members for dressing and personal hygiene and was totally dependent on 2 staff members for bathing. The surveyor performed a clinical review of Resident #44's record. During this review, the surveyor noted nursing documentation on 1/13/18,…

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 facility document review, staff interview and clinical record review, the facility staff failed to notify the MD (medical doctor) of a significant change for 1 of 26 residents in the survey sample (Resident #43). The findings included: The facility staff failed to notify the MD (medical doctor) of a significant change for Resident #43. Resident #43 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to anemia, high blood pressure, dementia and respiratory failure. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/26/18 which coded the resident as having a BIMS (Brief Interview for Mental Status) score of 10 out of a possible score of 15. Resident #43 was also coded as requiring extensive assistance of 2 staff members for dressing and personal hygiene and was totally dependent on 2 staff members for bathing. The surveyor performed a clinical review of Resident #43's record on 1/29/19 through 1/31/19. During this review, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review the facility staff failed to develop a comprehensive care plan for 1 of 26 Residents, Resident #47. Resident #47 was admitted to the facility on [DATE] with diagnoses including schizophrenia, diabetes mellitus, hypertension, gastroesophageal reflux disease, anxiety, and dementia. On the admission minimum data set assessment (MDS) with assessment reference date 12/6/18, the resident scored 11/15 on the brief interview for mental status and was assessed as without symptoms of delirium, psychosis, or behaviors affecting care or others. During an interview on 1/29/19, the resident indicated that she smoked cigarettes. The resident was on the list of smokers living in the facility. The surveyor observed the resident smoking outside with a group of residents. During clinical record review on 1/29/19, the surveyor noted a safe smoking assessment was conducted on 11/29/18. There was no conclusion concerning safety to smoke. That section was blank. Smoking 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 clinical record review and staff interview, the facility staff failed to review and revise the comprehensive care plan for 2 of 26 Residents in the survey sample, Resident # 25 and Resident # 86. The findings included 1. The facility staff failed to ensure that the comprehensive care plan for Resident # 25 included person centered non-pharmacological interventions associated with the use of Zyprexa and Abilify for Resident # 25. Resident # 25 was a [AGE] year-old-female who was admitted to the facility on [DATE]. Diagnoses included but were not limited to, schizophrenia, mood disorder, depression, and unspecified intellectual disabilities. The clinical record for Resident # 25 was reviewed on 1/29/19 at 3:00 pm. The most recent MDS (minimum data set) assessment was an annual assessment with an ARD (assessment reference date) of 11/14/18. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 25 had a BIMS (brief interview for mental status)…

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 follow professional standards of practice for 2 of 26 residents in the survey sample (Resident #13 and Resident #43). The findings included: 1. The facility staff failed to perform an assessment on Resident #13 when he returned to the facility from a hospital stay. Resident #13 was readmitted to the facility on [DATE]. On the annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/6/18, coded the resident as having a BIMS (Brief Interview for Mental Status) score of 12 out of possible score of 15. Resident #13 was also coded as requiring extensive assistance of 1 staff member for dressing and personal hygiene and totally dependent on 1 staff member for bathing. The surveyor performed a clinical record review on 01/31/19 at 10:45 am. During this review, it was noted that the facility staff failed to perform an assessment when the resident had returned to facility from the hospital.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, Resident interview, and staff interview, the facility staff failed to follow physician's orders for 2 of Residents in the survey sample, Resident # 40 and Resident # 86. The findings included: 1. The facility staff failed to follow physician's orders for Metolazone for Resident # 40. Resident # 40 was a [AGE] year-old-female who was originally admitted to the facility on [DATE] with a readmission date of 11/14/18. Diagnoses included but were not limited to, congestive heart failure, type 2 diabetes mellitus, atrial fibrillation, and chronic obstructive pulmonary disease. The clinical record for Resident # 40 was reviewed on 1/29/18 at 3:32 pm. The most recent MDS (minimum data set) assessment was a 14-day scheduled assessment with an ARD (assessment reference date) of 11/27/18. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 40 had a BIMS (brief interview for mental status) score of 15 out of 15, which indicated…

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. The facility staff failed to complete the smoking evaluation for Resident #99. Resident #99 was admitted to the facility on [DATE] with the following diagnoses, but not limited to atrial fibrillation, high blood pressure, diabetes and dementia. On the 5 day, admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/20/18, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 3 out of a possible score of 15. Resident #99 was coded as requiring extensive assistance of 2 staff members for dressing and personal hygiene. Resident #99 was also coded as being totally dependent on 2 staff members for bathing. The surveyor observed Resident #99 on 1/29/19 at 1:48 pm. The resident was outside smoking with a smoking apron over resident. One staff member was observed to be outside with the residents that were smoking. The surveyor conducted a clinical record review on Resident #99 on 1/30/19. During this review, it was noted by the surveyor that the Safe Smoking…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, Resident interview, staff interview, and clinical record review the facility staff failed to obtain physicians orders for the use of oxygen for 1 of 26 Residents, Resident # 40. The findings included The facility staff failed to obtain orders for oxygen for Resident # 40. Resident # 40 was a [AGE] year-old-female who was originally admitted to the facility on [DATE] with a readmission date of 11/14/18. Diagnoses included but were not limited to, congestive heart failure, type 2 diabetes mellitus, atrial fibrillation, and chronic obstructive pulmonary disease. The clinical record for Resident # 40 was reviewed on 1/29/18 at 3:32 pm. The most recent MDS (minimum data set) assessment was a 14-day scheduled assessment with an ARD (assessment reference date) of 11/27/18. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 40 had a BIMS (brief interview for mental status) score of 15 out of 15, which indicated that Resident # 40 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 staff interview, facility document review and clinical record review, the facility staff failed to ensure that a physician ordered medication was available for administration for 1 of 26 residents in the survey sample (Resident #44). The findings included: The facility staff failed to ensure a physician ordered medication, Hydrocodone, was available for administration for Resident #44. Resident #44 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to heart failure, high blood pressure, diabetes and anxiety disorder. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/27/18, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 4 out of a possible score of 15. Resident #44 was also coded as requiring extensive assistance from 2 staff members for dressing and being totally dependent on 2 staff members for personal hygiene and bathing. The surveyor performed a clinical record review on Resident #44 on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to monitor targeted behaviors for 1 of 26 residents in the survey sample. (Resident #44) The findings included: The facility staff failed to monitor targeted behaviors while Resident #44 was receiving Ativan for anxiety. Resident #44 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to heart failure, high blood pressure, diabetes and anxiety disorder. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/27/18, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 4 out of a possible score of 15. Resident #44 was also coded as requiring extensive assistance from 2 staff members for dressing and being totally dependent on 2 staff members for personal hygiene and bathing. The surveyor performed a clinical record review on Resident #44 on 1/31/19. During this review, the surveyor noted the resident had a physician order for 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure that 2 of 26 Residents were free of unnecessary psychotropic medications, Resident # 95 and Resident #25. The findings included 1. The facility staff failed to monitor behaviors associated with the use of psychotropic medications for Resident # 25. Resident # 95 was a [AGE] year-old-male who was admitted to the facility on [DATE]. Diagnoses included but were not limited to dementia, type 2 diabetes mellitus, chronic atrial fibrillation, and anxiety. The clinical record for Resident # 95 was reviewed on 1/29/19 at 1:26 pm. The most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 1/8/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 95 had a BIMS (brief interview for mental status) score of 3 out of 15, which indicated that Resident # 95's cognitive status was severely…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review the facility staff failed to ensure a complete and accurate clinical record for 1 of 26 residents in the survey sample (Resident #43). The findings included: The facility staff failed to document in the nursing notes when Resident #43 had returned from the ER (emergency room) on 5/20/18. Resident #43 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to anemia, high blood pressure, dementia and respiratory failure. On the quarterly MDS with an ARD (Assessment Reference Date) of 11/26/18 which coded the resident as having a BIMS (Brief Interview for Mental Status) score of 10 out of a possible score of 15. Resident #43 was also coded as requiring extensive assistance of 2 staff members for dressing and personal hygiene and was totally dependent on 2 staff members for bathing. The surveyor performed a clinical review of Resident #43's record on 1/29/19 through 1/31/19. During this review, the surveyor noted no 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility document review the facility staff failed to follow established infection control procedures for 2 of 26 Residents, #49 and #159. 1. For Resident #49 the facility staff failed to post signage outside of the Resident's room, and staff failed to don proper PPE (personal protective equipment) prior to assisting with Resident care. Resident #49 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included but not limited to anemia, atrial fibrillation, congestive heart failure, benign prostatic hyperplasia, diabetes mellitus, hypothyroidism, arthritis, Alzheimer's disease, dementia, anxiety, depression, schizophrenia, ataxia, dysphagia, and insomnia. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 12/04/18 coded the Resident as 3 out of 15 in section C, cognitive patterns. Section H, bowel and bladder, coded the Resident as being always incontinent of urine. This is an annual MDS. 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.