Heritage Hall King George

Based on observation, Resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide an ongoing program to support residents in their choice of activities for one Resident (Resident #43) in a sample size of 38 Residents. For Resident #43, the facility staff failed to assist Resident #43 spend time outside in August 2022 as was her personal preference. The findings included: On 08/30/2022 at 8:30 A.M., Resident #43 was observed in her bed. When asked about concerns at the facility, Resident #43 stated she used to go outside sometimes but now she cannot go outside. When asked why, Resident #43 stated she didn't know why and would like to go outside again sometimes. On 08/31/2022, Resident #43's clinical record was reviewed. Resident #43's Minimum Data Set with an Assessment Reference Date of 07/07/2022 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 14 out of possible 15 indicative of intact cognition. An activity preference assessment was not completed with this quarterly…

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, clinical record review, and facility documentation review, the facility staff failed to provide care according to professional standards for one Resident (Resident #38) in a sample size of 38 Residents. For Resident #38, the facility staff failed to re-valuate for leg prosthetics after a fitting for shrinkers socks was completed. The findings included: On 08/30/2022 at 8:45 A.M., Resident #38 was observed dressed, sitting on his bed covers. Resident #38 had bilateral above the knee amputations. When asked if he had any concerns about the care he received at the facility, Resident #38 stated that he wanted his prosthetic legs. When asked if he knew where they were located, Resident #38 stated that he doesn't have prosthetic legs yet, but wants to get them. On 08/31/2022, Resident #38's clinical record was reviewed. Resident #38's Minimum Data Set with an Assessment Reference Date of 07/05/2022 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 15 out of possible 15 indicative of intact…

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 have an accurate system to track the immunization status of all facility employees affecting one employee (Staff #5) in a sample of 11 employees reviewed, and the facility staff permitted one staff member (Staff #5) who was not fully immunized to continue to work; the facility staff's vaccination rate was 99.5% The findings included: The facility staff failed to have an accurate system to track the COVID immunization status of one employee Staff #5 and permitted her to work after being eligible to receive the second dose, which she didn't receive timely. On 8/30/22, the facility staff provided the survey team with a copy of the staff vaccination matrix and a document titled, COVID-19 Vaccination Record Log for Staff, which included dates of vaccination. These two documents were reviewed and a sample of 11 employees were selected for review. The staff vaccination matrix revealed the following: Staff #5 was listed as being partially vaccinated. The COVID-19 vaccination record log for staff,…

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

Based on staff interview, facility documentation review and in the course of a complaint investigation, the facility staff failed to implement their abuse and neglect policy for 5 of 25 employees. (Employee D, Employee E, LPN C, CNA E and CNA F) The facility staff failed to implement their abuse and neglect policy by failing to pre-screen employees prior to hire by failing to obtain reference checks and verifying licenses/certification. The findings included: A review of employee records was conducted on 4/3/19. The facility failed to conduct license verification prior to hire for 2 of 25 employees, (employees LPN C and CNA E). During employee record review, LPN C was hired 3/5/19 and her nursing license was not verified until 3/8/19. This nurse did have findings against her license for a complaint of misconduct, which the facility was not aware of prior to her hire. During an interview with (Employee F), Human Resources Coordinator, on 4/4/19 at 9:37am, when asked if this is something the facility would want to know prior to hire, she replied, I would assume so, when I saw that I…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility documentation and clinical record review the facility failed ensure Residents had (Pre admission Screening And Resident Review) PASARR screening prior to admission for five residents, Residents (#7, #28, #97, #49, and #68) in a survey sample of 30 residents. 1. For Resident # 7 the facility staff failed to obtain a PASARR prior to admission to the facility. 2. For Resident # 28 the facility staff failed to obtain a PASARR prior to admission to the facility. 3. For Resident # 97 the facility staff failed to obtain a PASARR prior to admission to the facility. 4. For Resident # 49, the facility staff failed to obtain a PASARR screening prior to admission to the facility. 5. For Resident # 68, the facility staff failed to obtain a PASARR screening prior to admission to the facility. The findings include: 1. For Resident # 7 the facility staff failed to obtain a PASARR prior to admission to the facility. Resident # 7 is a [AGE] year old woman admitted to the facility on [DATE] with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility documentation the facility staff failed to ensure freedom from unnecessary psychotropic medications for 4 Residents (Resident #24, Resident # 86, #69, and #39) in a survey sample of 30 Residents. 1. For Resident #24 the facility doctor gave orders for Ativan 0.5 (Milligrams) MG every 6 hours (as needed) PRN for 90 days at a time. 2. For Resident #86 the facility staff gave anti-psychotic medication to a Dementia Resident without a proper diagnosis for use. 3. For Resident #69, the facility staff failed to ensure he was free from Seroquel (an antipsychotic) which is not indicated for use in residents with dementia. 4. For Resident #39, the facility staff failed to ensure she was free from Seroquel, an antipsychotic which is not indicated for use in residents with dementia. The findings include: 1. For Resident #24 the facility doctor gave orders for Ativan 0.5 (Milligrams) MG every 6 hours (as needed) PRN for 90 days at a time. Resident # 24 is an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, resident interviews and clinical record review, the facility staff failed to ensure reasonable accommodation of resident needs and preferences for two Residents (Resident # 49 and # 68) in a survey sample of 30 residents. 1. For Resident # 49, the facility staff failed to make sure the clock in his room was correct. 2. For Resident # 68, the facility staff failed to make sure the clock in her room was correct. Findings included: 1. For Resident # 49, the facility staff failed to make sure the clock in his room was correct. Resident # 49, a [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Alzheimer's Disease, Hypertension, Malignant Neoplasm of Prostate, Gastroesophageal Reflux Disease, Dementia, Osteoarthritis, and Anxiety. Resident # 49's most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 2/1/2019. The MDS coded Resident # 49 with a BIMS (Brief Interview for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility documentation, the facility staff failed to accurately convey Advanced Directives preferences to the staff responsible for resident's care for one resident (Resident #63) in a sample size of 30 residents. The findings included: Resident #63, a [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses include but not limited to Non-ST elevation (NSTEMI) myocardial infarction, heart failure, cerebral infarction, hypertension, diabetes, and hemiplegia. Resident #63's most recent Minimum Data Set had an Assessment Reference Date (ARD) of 02/18/2019 and was coded as a quarterly assessment. Resident #63 was coded with a Brief Interview of Mental Status (BIMS) score of 3 out of possible 15 indicative of severe cognitive impairment. Functional status for bed mobility, transfers, dressing, and personal hygiene were all coded as requiring extensive assistance from staff. Functional status for eating was coded as requiring…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and facility documentation review, the facility staff failed to notify resident/responsible party of termination of Medicare Part A benefits for one resident (Resident #77) in a sample of 3 residents. The findings included: Resident #77, a [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses included but not limited to diabetes, hypertension, and hyperlipidemia. Resident #77's most recent MDS (Minimum Data Set) assessment with an ARD (assessment reference date) of 02/22/2019 was coded as an annual assessment. The Brief Interview for Mental Status (BIMS) was coded as 9 out of possible 15 indicative of moderate cognitive impairment. Resident #77's Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) were reviewed. Neither form was signed. On 04/03/2019 at 3:00 PM, an interview with Employee N was conducted. When asked why there were no signatures on the forms, Employee N provided a copy of a page from 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, staff interview, and facility record review the facility staff failed to ensure one hospital bed was in good repair for one resident (Resident #71) in a survey sample of 30 residents. The facility staff failed to maintain a hospital bed in good repair for Resident #71. The findings included: Resident #71, a [AGE] year old, was admitted to the facility on [DATE]. Resident #71's diagnoses included but were not limited to: unspecified dementia with behavioral disturbance, hypothyroidism, essential hypertension, major depressive disorder, gastro-esophageal reflux disease without esophagitis, progressive bulbar palsy, and pseudobulbar affect. Resident #71's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 2/25/19, was coded as an Annual assessment. The resident was coded of having a BIMS (Brief Interview for Mental Status) score of 5, which indicated the resident's cognitive functioning was severely impaired. Resident #71 was coded as requiring…

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 notify the Ombudsman of a transfer to the hospital on 2 separate occasions for 1 resident (Resident #41) in a sample size of 30 residents. For Resident #41, the facility staff failed to notify the Ombudsman upon transfer to the hospital on [DATE] and 02/25/2019. The Findings included: Resident #41, a [AGE] year old male who was admitted to the facility on [DATE] with diagnoses to include but not limited to diabetes, heart failure, kidney failure requiring dialysis, and depression. Resident #41's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/13/2019 was coded as re-entry from an acute hospital. Resident #41 was coded with a Brief Interview of Mental Status (BIMS) score of 11 out of possible 15 indicating moderately impaired cognition. On 04/04/2019 at approximately 9:15 AM, Resident #41 was observed awake and resting quietly in bed. Resident #41 stated that he had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to provide notice of the facility Bed Hold Policy on 2 separate occasions for 1 resident (Resident #41) in a sample size of 30 residents. For Resident #41, the facility staff failed to provide notice of the facility Bed Hold Policy upon transfer to the hospital on [DATE] and 02/25/2019. The Findings included: Resident #41, a [AGE] year old male who was admitted to the facility on [DATE] with diagnoses to include but not limited to diabetes, heart failure, kidney failure requiring dialysis, and depression. Resident #41's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/13/2019 was coded as re-entry from an acute hospital. Resident #41 was coded with a Brief Interview of Mental Status (BIMS) score of 11 out of possible 15 indicating moderately impaired cognition. On 04/04/2019 at approximately 9:15 AM, Resident #41 was observed awake and resting quietly in bed. Resident #41…

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 conduct accurate assessment of resident's functional capacity for one resident (Resident #35) in a sample size of 30 residents. For Resident #35, the facility staff failed to accurately assess her visual functional capacity The findings included: Resident #35, 70-year female, was admitted to the facility on [DATE]. Diagnoses include but not limited to heart failure, hypertension, morbid obesity, and muscle weakness. Resident #35's most recent Minimum Data Set had an Assessment Reference Date (ARD) of 01/02/2019 and was coded as a significant change in status assessment. Resident #35 was coded with a Brief Interview of Mental Status (BIMS) score of 15 out of possible 15 indicative of intact cognition. Functional status for bed mobility, dressing, and personal hygiene were all coded as requiring extensive assistance from staff. Vision was coded as adequate - sees fine detail, including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility documentation review and clinical record review, the facility staff failed to ensure the assessment of the resident accurately reflected the resident's status for one resident (Resident #55) in a survey sample of 30 residents. For Resident #55, the facility staff failed to accurately code the MDS (Minimum Data Set) (an assessment tool). The findings included: Resident #55, a [AGE] year old, was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to: hypertension, Type 2 diabetes, and neuromuscular dysfunction of bladder. Resident #55's most recent MDS with an ARD (assessment reference date) of 2/8/19 was coded as an admission assessment. The resident was coded as having a BIMS (Brief Interview for Memory Status) score of 15, indicating the resident was cognitively intact. Functional status for transfers, dressing, toilet use and personal hygiene, was coded as Resident #55 required extensive assistance. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to complete a baseline care plan to provide behavioral health services for 1 resident (Resident #6) of the 30 residents in the survey sample. For Resident 6, the facility staff failed to develop a base line care plan for behavioral health services. The findings included: Resident #6, was admitted to the facility on [DATE]. Diagnoses included; depression, anxiety, heart disease, diabetes, high blood pressure, and chronic obstructive pulmonary disease (COPD). The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date (ARD) of 3-26-19. Resident #6 was coded with a Brief Interview of Mental Status (BIMS) score of 13 indicating little to no cognitive impairment and requiring assistance with physical activities of daily living. The full admission MDS assessment was also reviewed with an ARD date of 12-25-18 which revealed a BIMS score…

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 resident-centered care plan for 3 residents (Resident #63, #35, #6) in a sample size of 30 residents. The findings included: 1. For Resident #63, the facility staff failed to date interventions and goals on the care plan in order to establish time frames and measurable objectives. 2. For Resident #35, the facility staff failed to include vision services/needs on the care plan. 3. For Resident #6, the facility staff failed to develop a comprehensive care plan for the behavioral health services needs of depression and anxiety. The findings include: 1. For Resident #63, the facility staff failed to date interventions and goals on the care plan in order to establish time frames and measurable objectives. Resident #63, a [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses include but not limited to Non-ST elevation (NSTEMI) myocardial infarction, heart failure, cerebral infarction,…

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 interviews, clinical record reviews, and facility documentation, the facility staff failed to revise resident-centered care plans for 3 residents (Resident #63, Resident #49, Resident #68) in a sample size of 30 residents. 1. For Resident #63, the facility staff failed to revise the care plan to reflect current code status from Full Code to DNR 2. For Resident # 49, the facility staff failed to document the dates of problems and interventions listed on the careplan when revised. 3. For Resident # 68, the facility staff failed to document the dates of problems and interventions listed on the careplan when revised. The findings included: Resident #63, a [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses include but not limited to Non-ST elevation (NSTEMI) myocardial infarction, heart failure, cerebral infarction, hypertension, diabetes, and hemiplegia. Resident #63's most recent Minimum Data Set had an Assessment Reference Date (ARD) of 02/18/2019 and was coded as…

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 maintain professional standards when administering medications for 1 Resident (#97) in a survey sample of 30 Residents. For Resident #97 the facility staff failed to administer Heparin (an anti-coagulant) ,Daily, as ordered by the Physician. The findings include: Resident #97 is an [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Anemia, Hypertension, Dementia (Alzheimer's Type) History of Stroke, Anxiety and Depression. The most recent Minimum Data Set assessment was a PPI 5 Day assessment with an assessment reference date (ARD) of 3/12/19 Resident #97 was coded as having a (Brief Interview of Mental Status) BIMS score of 3, indicating severe cognitive impairment. Resident # 97 was coded as requiring 1 person physical assistance for all aspects of ADL's and a physical assist of 2 staff for transfers. On 4/5/19 during clinical record review it was noted that Resident #97 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 facility documentation review and clinical record review, the facility failed to complete a discharge summary that included a recapitulation of the resident's stay. For Resident #104, the facility staff failed to complete a discharge summary that accurately described the clinical status of the resident and a recapitulation of the resident's stay. The findings included: Resident #104, [AGE] year old, admitted to the facility on [DATE] and discharged on 1/10/19. The resident's diagnoses included but were not limited to, legal blindness, muscle weakness, encephalopathy, dysphagia, cognitive communication deficit and athscl [sic] heart disease. Resident #104's most recent MDS (Minimum Data Set) (an assessment tool) with an ARD (assessment reference date) of 1/1/19 was coded as a 60 day assessment. Resident #104 was coded as having a BIMS (brief interview for memory status) score of 4, indicating severe cognitive impairment. Functional status for Resident #104 was coded as being totally dependent on staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview and clinical record review, the facility staff failed to provide necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish for one resident (Resident #55) in a survey sample of 30 residents. The facility staff failed to provide care and assistance in ADL's (Activities of daily living) to maintain a resident's continence for Resident #55. The findings included: Resident #55, a [AGE] year old, was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to: hypertension, Type 2 diabetes, and neuromuscular dysfunction of bladder. Resident #55's most recent MDS with an ARD (assessment reference date) of 2/8/19 was coded as an admission assessment. The resident was coded as having a BIMS (Brief Interview for Memory Status) score of 15, indicating the resident was cognitively intact. Functional status for transfers, dressing, toilet use and personal hygiene, was coded as Resident #55 required extensive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, and in the course of a complaint investigation, the facility staff failed to provide needed care and services for one resident (Resident #45) in a sample size of 30 residents. 1. For Resident #45, the facility failed to identify, assess, and notify provider for a potential change in condition. It was documented in the clinical record Resident #45 weighed 226.4 pounds on 03/25/2019 and 199.6 pounds on 04/01/2019 (11.84% weight loss in 6 days). The findings include: Resident #45, a [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses included but not limited to atherosclerotic heart disease, diabetes, cerebral infarction, hypertension, atrial fibrillation, and dementia. Resident #45's most recent MDS (minimum data set) with an ARD (assessment reference date) of 01/25/2019 was coded as a quarterly review. The Brief Interview for Mental Status was coded as 9 out of possible 15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, Resident interview, staff interview, and clinical record review the facility staff failed to provide proper treatment and hearing assistive devices for 2 residents (Resident #57 and #35) in a sample size of 30 residents. 1. For Resident #57, the facility staff failed to provide proper treatment and assistive devices to maintain and/or enhance his hearing ability. 2. For Resident #35, the facility staff failed to assist with procurement of eye glasses as prescribed by optometrist. The Findings included: Resident #57, an [AGE] year old male who was admitted to the facility on [DATE] with diagnoses to include but not limited to diabetes, right leg amputation, high blood pressure, peripheral vascular disease, and depression. Resident #57's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/01/2019 was coded as an Annual assessment. Resident #57 was coded with a Brief Interview of Mental Status (BIMS) score of 14 out of possible 15 indicating no cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility documentation review and clinical record review, the facility staff failed to provide adequate supervision to prevent accidents for one resident (Resident #55) in a survey sample of 30 residents . For Resident #55 the facility staff failed to implement interventions and provide supervision to reduce fall risks and hazards following falls on 2/6/19 and 3/28/19. The findings included: Resident #55, was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to: hypertension, Type 2 diabetes, and neuromuscular dysfunction of bladder. Resident #55's most recent MDS with an ARD (assessment reference date) of 2/8/19 was coded as an admission assessment. The resident was coded as having a BIMS (Brief Interview for Memory Status) score of 15, indicating the resident was cognitively intact. Functional status for transfers, dressing, toilet use and personal hygiene, was coded as Resident #55 required extensive assistance of staff. Clinical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview,facility record review, and clinical record review, the facility staff failed to provide necessary care and services to ensure that a resident who was continent of bowel on admission receives services to maintain continence for one resident (Resident #55) in a survey sample of 30 residents. The facility staff were not assisting Resident #55 to have bowel movements in the toilet. The findings included: Resident #55, a [AGE] year old, was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to: hypertension, Type 2 diabetes, and neuromuscular dysfunction of bladder. Resident #55's most recent MDS with an ARD (assessment reference date) of 2/8/19 was coded as an admission assessment. The resident was coded as having a BIMS (Brief Interview for Memory Status) score of 15, indicating the resident was cognitively intact. Functional status for transfers, dressing, toilet use and personal hygiene, was coded as Resident #55 required…

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 failed to ensure certified nurse aides (CNA's) receive regular in-service education for 2 of 5 employees. (CNA F and CNA H) The facility staff failed to ensure CNA's receive 12 hours of in-service training annually for CNA F and CNA H. The findings included. On 4/4/19 a review of employee records was conducted and revealed that CNA F and CNA H had no recorded in-service training for 2018. An interview with Employee F on 4/4/19 at 10:14am she stated, they have no training on file. The Administrator and Director of Nursing were made aware of the findings on 4/4/19 at 5:30pm. No further information was provided.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to provide behavioral health services for 1 resident (Resident #6) of the 30 residents in the survey sample. Resident 6's clinical record documented that the Resident had anxiety and depression on admission. Continued behavioral health services assessment, care planning, physician evaluation, and non-pharmacologic nursing interventions, were not performed by facility staff. The findings included: Resident #6, was admitted to the facility on [DATE]. Diagnoses included; depression, anxiety, heart disease, diabetes, high blood pressure, and chronic obstructive pulmonary disease (COPD). The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date (ARD) of 3-26-19. Resident #6 was coded with a Brief Interview of Mental Status (BIMS) score of 13 indicating little to no cognitive impairment and requiring assistance with physical activities…

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 the facility failed to provide 2 doses of medication ordered daily for 1 Resident (Resident #7) in a survey sample of 30 Residents. The findings included: Resident # 7 is a [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Bipolar Disorder, Acute Kidney Failure, Repeated Falls, Pacemaker implant, Major Depressive Disorder, and Seizure Disorder On 4/3/19 during a clinical record review it was discovered that Resident #7 had missed 2 doses of a scheduled anti-anxiety medication Alprazolam (Generic Xanax) 0.25 MG daily. The medication was scheduled for 9:00 AM On 3/30/19 the (Medication Administration Record) MAR was marked N which indicates it has not been given. Under the comments it states Awaiting Pharmacy. On 3/31/19 the MAR was marked again with N indicating not given and under comments it states Received new script from Doctors Office. On 4/4/19 the DON was asked why the Resident missed 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and facility documentation the facility failed to ensure Resident is free from unnecessary meds for 1 Resident (#97) in a survey sample of 30 Residents. For Resident #97 the facility staff failed to follow Physicians Order for Heparin (an anti-coagulant) Flush to be administered daily, but instead, administered the Heparin Flush three times per day thus administering unnecessary amount of Heparin. The findings include Resident #97 is an [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Anemia, Hypertension, Dementia (Alzheimer's Type) History of Stroke, Anxiety and Depression. On 4/5/19 during clinical record review it was noted that Resident #97 had orders for Flushing Midline Catheter (Intravenous Line for medication administration.). The orders began on 3/17/18 at 2:30 PM. The orders read: Heparin flush 10 Units/ML [10 Units per Milliliter] Flush midline with Heparin [an Anti-Coagulant] & Normal Saline QD [Every Day] The order appears…

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 observation, the facility staff failed to serve food in accordance with professional standards for food service safety, for two residents (Resident #63, Resident #98) in a survey sample of 30 residents. 1. For Resident #63, the facility staff failed to serve food in a sanitary manner. 2. For Resident #98, the facility staff failed to serve food in a sanitary manner. The findings included: 1. For Resident #63, the facility staff failed to serve food in a sanitary manner. Resident #63, a [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included but were not limited to Non-ST elevation (NSTEMI) myocardial infarction, heart failure, cerebral infarction, hypertension, diabetes, and hemiplegia. Resident #63 ' s most recent Minimum Data Set had an Assessment Reference Date (ARD) of 02/18/2019 and was coded as a quarterly assessment. Resident #63 was coded with a Brief Interview of Mental Status (BIMS) score of 3 out of possible 15 indicative of severe cognitive impairment.…

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, the facility staff failed to maintain an accurate clinical record for one resident (Resident #63) in a sample size of 30 residents. The Resident #63's DNR status was inaccurate. The findings included: Resident #63, a [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses include but not limited to Non-ST elevation (NSTEMI) myocardial infarction, heart failure, cerebral infarction, hypertension, diabetes, and hemiplegia. Resident #63's most recent Minimum Data Set had an Assessment Reference Date (ARD) of 02/18/2019 and was coded as a quarterly assessment. Resident #63 was coded with a Brief Interview of Mental Status (BIMS) score of 3 out of possible 15 indicative of severe cognitive impairment. Functional status for bed mobility, transfers, dressing, and personal hygiene were all coded as requiring extensive assistance from staff. Functional status for eating was coded as requiring supervision 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.

Based on observation, staff interview, and facility documentation review, the facility staff failed to implement an effective infection control program. 1. The facility staff failed to assure that fingernails were cut to a short length on five direct care staff. The findings included: Licensed Practical Nurse (LPN) F, the Infection Control nurse was observed to have artificial multicolored nails about ½ in length on 12/6/2017 at 1:00 PM. Employee C, Medical Records, was observed pushing a resident in a wheel chair on 12/6/2017 at 2:30 PM. She was seen to have long natural, unpainted nails approximately ¾ in length. LPN A was noticed on 12/6/2017 at 2:45PM to have had long blue speckled artificial nails approximately 1 long. She was unable to type in a normal manner, having to use the pads of her fingers to touch the keyboard. RN B, Director of Nursing was seen to have artificial nails approximately 1/2 in length on 12/6/2017 at 4:45 PM. RN C, Assistant Director of Nursing was seen to have painted nails approximately 3/8 long. On 12/6/2017. LPN F, Infection Control nurse stated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, Resident interview, clinical record review, and facility documentation review, the facility staff failed to accommodate the needs of 2 Residents, (Resident #487, and #26) of the 22 Residents in the survey sample. 1. For Resident #487, the facility staff failed to have a call system in place. 2. For Resident #26, the facility staff failed to accommodate her preference to attend worship activity within the facility. The findings included: 1. Resident #487 was recently admitted to the facility, on 11-20-17, with diagnoses that included; Hypertension, heart failure, urine retention, pneumonia, dementia, anxiety, dysphagia, and major recurrent depression. On 12-4-17 at 12:30 p.m., an initial tour was conducted of the facility, and the Resident was observed, and interviewed. The Resident was sitting in a wheel chair, on the side of her bed at the foot end. The Resident was wrapped in a blanket that she was sitting on, in the chair, and the blanket extended from her neck to her…

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 and complete MDS (minimum data set) for one Resident (Resident #58) of 22 Residents in the survey sample. For Resident #58, the facility staff inaccurately coded the special treatments status at Section O for the MDS assessment with Transfusions were received while a Resident. The findings included: 1. Resident #58 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, pressure ulcer, kidney disorder, dysphagia, irritable bowel syndrome, contractures both ankles, anxiety, depression, manic depression, anemia, neurogenic bladder, diabetes, wound infection, and quadriplegia. Resident #58's most recent MDS (minimum data set) with an ARD (assessment reference date) of 11-2-17 was coded as a quarterly assessment. Resident #58 was coded as having a BIMS (brief interview of mental status) score of 15 out of a possible 15 points, revealing no cognitive impairment. Resident #58 was also coded as…

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 failed for one Resident, Resident 86, in a survey sample of 22 residents, to ensure a baseline care plan was initiated within 48 hours. Resident #86's initial care plan was initiated 8 days after his admission. The findings included: Resident #86 was admitted to the facility on [DATE]. Diagnoses included, but not limited to, stroke with hemiparesis, alcohol abuse. The resident has had no MDS (minimum data set) completed as he was a new admission. Care notes documented the resident required extensive to maximum assistance of two staff members. Resident # 86's initial care plan completed 8 days after admission. DON stated, Should be done 24 hours after admission. The only date on the document was the completion date. On 12/07/17 at 9:05 AM an interview was conducted with RN (registered nurse) A, the MDS coordinator, regarding interim care plans. She stated, The interim care plan form is included in the admission packet. The admit date is the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review the facility staff failed for 1 resident (Resident #52) of 22 residents in the survey sample to review and revise the care plan. For Resident #52, the care plan did not include interventions to prevent the development of the pressure ulcer to the right heel. The findings included: Resident #52, an [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included stroke, aphasia, dementia, atrial fibrillation, hypertension. The most recent minimum data set assessment was a quarterly assessment with an assessment reference date of 10/20/17. Resident #52 was coded with a Brief Interview of Mental Status score of 3 indicating severe cognitive impairment. He required assistance with his activities of daily living (ADL) and was coded to have 1 stage 3 wound. Resident #52 had a right heel wound measuring 3.0 x 2.5 x. 0.1 centimeters when first assessed by the wound care doctor on 9/20/17. Resident #52's care plan was dated 8/31/17. The problem…

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 1 resident (Resident #52) of 22 residents in the survey sample to prevent and assess a pressure ulcer to the right heel. For Resident #52, no interventions were in place to prevent the development of the pressure ulcer. Once the ulcer was identified, it was not correctly assessed by facility staff. The findings included: Resident #52, an [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included stroke, aphasia, dementia, atrial fibrillation, hypertension. The most recent minimum data set assessment was a quarterly assessment with an assessment reference date of 10/20/17. Resident #52 was coded with a Brief Interview of Mental Status score of 3 indicating severe cognitive impairment. He required assistance with his activities of daily living (ADL) and was coded to have 1 stage 3 wound. Resident #52 was first observed on 12/04/17 at 2:30 PM. Resident #52 was lying in bed with his feet flat on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, and clinical record review, the facility staff failed, for 1 resident (Resident #38) in the survey sample of 22 residents, to provide a safe form of transport within the facility. The facility staff failed to provide Resident #38 a safe form of transport, after her ankle was fractured in 2 places while being transported by staff in a standard wheelchair without leg rests/food petals. The Findings included: Resident #38 was [AGE] years old when admitted to the facility on [DATE]. Resident #38's diagnoses included Altered Mental Status, Encephalopathy, Heart Failure, Hypertension, and Diabetes Mellitus. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 10/12/17, coded Resident #38 as being able to understand and be understood by others. She was also coded as having fluctuating inattention and disorganized thinking. She was coded as requiring the extensive physical assistance of one staff person for locomotion, dressing 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, staff interview, facility documentation review and clinical record review, the facility staff failed to ensure that a urinary catheter drainage bag was maintained in a manner to prevent the spread of infection for one resident (Resident # 29) in a survey sample of 22 residents. For Resident # 29, the facility staff failed to ensure the urinary catheter bag was not resting the floor. Resident # 29 was observed to be sitting in a wheelchair in the dining room with his urinary drainage bag touching the floor. The findings included: Resident # 29 was a [AGE] year-old male who was admitted to the facility on [DATE], readmitted on [DATE] and 9/29/2017 with diagnoses of but not limited to: Hypertension, Diabetes, Acute Kidney Failure, Gastroesophageal Reflux Disease, Venous Insufficiency, Fluid Overload, Pulmonary Hypertension, Peripheral Vascular Disease, Neurogenic Bladder and Edema. The most recent Minimum Data Set (MDS) was a Significant Change Assessment with an Assessment Reference Date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, resident interview, and clinical record review, the facility staff failed to ensure a correct oxygen infusion rate for 2 Residents (Resident #487, and #41 ) of 22 residents in the survey sample. 1. Resident #487 failed to have 2 liters of oxygen infusing, and instead, had 4 liters of oxygen infusing. 2. For Resident # 41, the facility staff failed to ensure the oxygen tank was not empty on 12/5/2017. The findings included: 1. Resident #487 failed to have 2 liters of oxygen infusing, and instead had 4 liters of oxygen infusing. Resident #487 was recently admitted to the facility, on 11-20-17, with diagnoses that included; Hypertension, heart failure, urine retention, pneumonia, dementia, anxiety, dysphagia, and major recurrent depression. On 12-4-17 at 12:00 p.m., an initial tour was conducted of the facility, and the Resident was observed, and interviewed. The Resident was sitting in a wheel chair, on the side of her bed at the foot end. The Resident was wrapped in 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, and clinical record review, the facility staff failed, for 1 resident (Resident #38) in the survey sample of 22 residents, to provide appropriate equipment to maintain or improve mobility. The facility staff failed to provide Resident #38 with appropriate equipment to maintain or improve mobility, after her ankle was fractured in 2 places while being transported by staff in a standard wheelchair without leg rests/food petals. Prior to the fracture, Resident #38 was able to use her feet to ambulate independently with a wheelchair. The Findings included: Resident #38 was [AGE] years old when admitted to the facility on [DATE]. Resident #38's diagnoses included Altered Mental Status, Encephalopathy, Heart Failure, Hypertension, and Diabetes Mellitus. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 10/12/17, coded Resident #38 as being able to understand and be understood by others. She was also coded as having fluctuating…

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.