Loudoun Rehabilitation And Nursing Center

Based on staff interview, facility document review, and clinical record review, the facility staff failed to report an allegation of resident exploitation to the State Agency (SA) for one of 31 residents in the survey sample, Resident #28. The findings include: For Resident #28 (R28), the facility staff failed to report an allegation of exploitation to the SA when staff members became aware on 10/11/23. A review of R28's progress notes revealed the following: 10/11/2023 .Social / Psychosocial Note .Social Work Note: The Director of Nursing let this writer know that [R28]'s daughter expressed concerns that her father is being exploited of his funds by a friend of his whom she does not know. This writer met with [R28] who denied all allegations. [R28] in fact, is alert and oriented X4 and denied these allegations. [R28] did share his wishes .to no longer have his daughter manage his bank account. This writer reached out to the Ombudsman who recommended SS (social services) to contact APS (adult protective services) and file a report. This writer contacted [name of county] Adult…

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

Based on staff interview, facility document review, and clinical record review, the facility staff failed to investigate an allegation of resident exploitation for one of 31 residents in the survey sample, Resident #28. The findings include: For Resident #28 (R28), the facility staff failed to investigate an allegation of exploitation when staff members became aware on 10/11/23. A review of R28's progress notes revealed the following: 10/11/2023 .Social / Psychosocial Note .Social Work Note: The Director of Nursing let this writer know that [R28]'s daughter expressed concerns that her father is being exploited of his funds by a friend of his whom she does not know. This writer met with [R28] who denied all allegations. [R28] in fact, is alert and oriented X4 and denied these allegations. [R28] did share his wishes .to no longer have his daughter manage his bank account. This writer reached out to the Ombudsman who recommended SS (social services) to contact APS (adult protective services) and file a report. This writer contacted [name of county] Adult Protective Services .today to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide a safe discharge for one of 31 residents in the survey sample, Resident #28. The findings include: For Resident #28 (R28), the facility staff failed to discharge the resident to a safe environment with a comprehensive discharge plan. A review of R28's clinical record revealed he was admitted to the facility with diagnoses including Parkinson's disease and alcoholism. Further review of the clinical record revealed multiple progress notes documenting the resident's continued alcohol abuse, including the following progress notes: 2/3/2024 16:16 (4:16 p.m.) Health Status Note .At around 1330 (1:30 p.m.) patient came back from outing. When patient returned this writer went in to take his vitals. Pt (patient) was noted aggressive, screaming, appeared red, slurring words. Pt was redirected. Noted smells of alcohol. Supervisor/NP (nurse practitioner) aware. 2/3/2024 22:45 (10:45 p.m.) Health Status Note…

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

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide required documentation for discharge for one of 31 residents in the survey sample, Resident #28. The findings include: For Resident #28 (R28), the facility staff failed to include the date of the planned discharge or the location of discharge for R28's discharge from the facility. A review of R28's clinical record revealed he was discharged from the facility on 5/4/24. A review of facility documents for R28 revealed a Notice of Transfer or discharge date d 2/8/24. This notice contained, in part, the following: To: [R28] The purpose of this letter is to inform you that after careful consideration, it is our plan to transfer or discharge you for the following reasons .[R28] failed, after reasonable and appropriate notice, to pay (or to have paid under Medicare or Medicaid) a stay at the nursing facility. Total amount due to the facility is $6251.60 and you and/or your representative were previously given notice of payment due on 1/22/2024. The notice contained…

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

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to implement the comprehensive care plan for one of 31 residents in the survey sample, Resident #2. The findings include: For Resident #2 (R2), the facility staff failed to implement the comprehensive care plan to A) provide showers on dates in August, September and October of 2024, B) provide incontinence care on dates in January and February of 2025 and C) monitor vital signs as ordered. On the most recent MDS (minimum data set) a quarterly assessment with an ARD (assessment reference date) of 2/8/25, the resident scored 0 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. The assessment documented R2 dependent on staff for showering/bathing and always incontinent of bowel and bladder. An annual assessment with an ARD of 6/12/24 documented R2 dependent on staff for showering/bathing and always incontinent of bowel and bladder. A) The comprehensive care plan for R2…

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

Based on staff interview and clinical record review, it was determined that the facility staff failed to revise the comprehensive care plan for one of 31 residents in the survey sample, Residents #1 (R1). For R1, facility staff failed to revise the comprehensive care plan for the discontinued use of a voice amplifier. R1 was admitted to the facility with diagnoses that included but were not limited to muscle weakness. On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 03/25/2024, R1 scored 11 out of 15 on the BIMS (brief interview for mental status), indicating R1 was moderately impaired of cognition for making daily decisions. The physician's order for R1 documented in part, SPECIAL EQUIPMENT: Voice amplifier and charger will be stored at bedside per resident request. Day Nurse will give to assigned CNA before breakfast, Eve Nurse will obtain from CNA HS. every day and evening shift Monitor every shift for appliance safety/ensure use. Evening shift to charge amplifier at night. Order Date 05/24/2024. Start…

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.

2. For R1, the facility staff failed to provide a scheduled bath. R1 was admitted with diagnoses that included but were not limited to hemiplegia (1). On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 03/25/2024, R1 scored 11 out of 15 on the BIMS (brief interview for mental status), indicating R1 was moderately impaired of cognition for making daily decisions. Section GG 0130 Self Care coded R1 as being dependent for showers or bathing self. The facility's POC (point of care) sheet for R1 dated May 2025 documented, in part, Shower Schedule: Wed/Sat Eve (Wednesday/Saturday Evening) shift. Review of the POC revealed a a blank on 05/07/2025 for showers. The comprehensive care plan for R1 with a revision date 01/25/2024 documented in part, Focus. Resident requires assistance with self care and mobility R/T (related to) right sided hemiplegia, parkinson's with ADL (activities of daily living) fluctuations according to disease process. Revision on: 01/25/2024. Under Interventions it documented in part,…

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

Based on staff interview and clinical record review, it was determined that the facility staff failed to provide incontinence care for two of 31 residents in the survey sample, Residents #13 (R13) and R19. The findings include: 1. For R13, the facility staff failed to perform incontinence care. R13 was admitted to the facility with diagnoses that included but were not limited to dementia (1). On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 03/14/2025, R13 scored 2 (two) out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely impaired of cognition for making daily decisions. Section H0300 Urinary Continence coded R13 as being always incontinent. On 05/13/2025 at 12:42 p.m. until 5:00 p.m. continuous observations were conducted of R13. During the four hour and 17 minutes of observation, R13 was not checked by a nurse or a CNA (certified nursing assistant) for incontinence care. On 05/13/2025 at approximately 5:05 p.m. an interview was conducted with CNA #3. When asked if he was assigned…

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.

2. For R1, the facility staff failed to store a nebulizer (1) mask in a sanitary manner. R1 was admitted to the facility with diagnoses that included but were not limited to pneumonia. On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 03/25/2024, R1 scored 11 out of 15 on the BIMS (brief interview for mental status), indicating R1 was moderately impaired of cognition for making daily decisions. On 05/14/2024 at approximately 2:00 p.m. an observation of R1's nebulizer mask revealed it was sitting on top of R1's bedside table uncovered. On 05/14/2024 at approximately 5:00 p.m. an observation of R1's nebulizer mask revealed it was sitting on top of R1's bedside table uncovered. On 05/15/2024 at approximately 9:40 a.m. an observation of R1's nebulizer mask revealed it was sitting on top of R1's bedside table uncovered. The physician's order for R1 documented, Ipratropium-Albuterol Solution (2) 0.5-2.5 MG (milligrams)/3ML (milliliters). 1 (one) vial (small container) inhale orally two times a day for Shortness of…

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

Based on staff interview and clinical record review, it was determined that the facility staff failed to maintain sufficient nursing staff to care for a resident's needs for one of 31 residents in the survey sample, Resident #1 (R1). The findings include: 1a. For R1, the facility staff failed to wash R1's hands before eating, stood while providing feeding assistance and serve the meal at the same time the roommate received their meal in the same room due to insufficient CNA (certified nursing assistant) staffing. R1 was admitted with diagnoses that included but were not limited to hemiplegia (1). On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 03/25/2024, R1 scored 11 out of 15 on the BIMS (brief interview for mental status), indicating R1 was moderately impaired of cognition for making daily decisions. Section GG 0130 Self Care coded R1 as being dependent for showers or bathing, Partial/moderate assistance with eating and Dependent for Personal hygiene: The ability to maintain personal hygiene, 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 staff interview, facility document review, and clinical record review, the facility staff failed to provide medically related social services for one of 31 residents in the survey sample, Resident #28. The findings include: For Resident #28 (R28), the facility social services staff failed to develop a safe discharge plan. A review of R28's clinical record revealed he was admitted to the facility with diagnoses including Parkinson's disease and alcoholism. Further review of the clinical record revealed multiple progress notes documenting the resident's continued alcohol abuse, including the following progress notes: 2/3/2024 16:16 (4:16 p.m.) Health Status Note .At around 1330 (1:30 p.m.) patient came back from outing. When patient returned this writer went in to take his vitals. Pt (patient) was noted aggressive, screaming, appeared red, slurring words. Pt was redirected. Noted smells of alcohol. Supervisor/NP (nurse practitioner) aware. 2/3/2024 22:45 (10:45 p.m.) Health Status Note .Resident went out…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, family interview, staff interview and facility document review, it was determined the facility staff failed to discard biologicals past their expiration date in one of two nursing unit storage closets and one of one central supply storage areas. The findings include: The facility failed to discard expired biologicals in the storage closet on the second-floor nursing unit and in the central supply storage area. On [DATE] at approximately 10:27 a.m., during an interview with a current resident family member, the family member voiced concerns regarding expired supplies since the new ownership had changed the medical supplier. On [DATE] at approximately 11:25 a.m., an observation was made of the Unit 2 storage closet. Observation revealed medical supplies located on shelving units against the walls on the left side of the room available for use. Ten IV (intravenous) start kits were observed on a shelf in a bin with an expiration date of [DATE]. Forty-eight 3x3 oil emulsion dressings were…

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 document review, it was determined the facility staff failed to serve pureed food in a form to meet the needs of residents in one of one kitchen. The findings include: On 5/12/25 during dinner service test trays were conducted. The test trays left the kitchen on 5/12/25 at 5:20 p.m. with the final food cart. The last resident tray was served at 5:32 p.m. The test tray was then tested for temperature by OSM (other staff member) #8, dietary manager. There were no concerns regarding the temperature of the food. Observation of the pureed test tray revealed snow peas served which had pod fibers present in the serving with the consistency not being smooth and appearing chopped. At that time, the test tray was tasted by OSM #29, the district manager for dietary services and two surveyors. Pod fibers were present in the food and not palatable. When asked about the pureed snow peas, OSM #29 stated that he saw what the problem was and OSM #8 stated that he did not think that snow peas could be pureed, and they should have substituted regular…

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

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to report a fire that occurred at the facility on 12/21/2024 to the state agency as required in 12VAC5-371-190. The findings include: The facility staff failed to report a fire on the interior patio of the facility on 12/21/24 which was caused by Resident #23 (R23) throwing a lit cigarette into the trash can. The fire caused damage to the glass on the patio door. The progress notes for R23 documented in part, - 12/21/2024 21:54 Note Text: Resident went to the patio to smoke even though he knows that the facility is a smoke free area. Resident put the lighter [sic] cigarette in the trash can and the trash can caught on fire. Fire extenguisher [sic] used to put the fire out. The glass door at the enterance [sic] of the patio is craked [sic] due to the heat from the fire. The resident admitted to putting the lighted cigarette in the trash can. Resident talked to about the dangers of smoking. 1 pack of cigarette [sic] and 2 lighters were taken from the resident…

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

Based on staff interview, facility document review, and clinical record review, the facility staff failed to maintain an accurate clinical record for one of 31 residents in the survey sample, Resident #28. The findings include: For Resident #28 (R28), the facility physician derroneously documented recommendation of an assessment which the facility staff are not trained to perform. A review of R28's clinical record revealed the following progress note: 4/12/2024 16:48 (4:48 p.m.) Medical Visit .Pt. asked to be seen by staff for recert (recertification) .Asked by staff to eval (evaluate) pt (patient) for q (each) 30/60 day follow up .Reason for admission: Diagnoses: Debility, Alcohol dependence .Parkinson's disease .Assessment/Plan: Worsening weakness, unsteady gait, unintentional weight loss, multiple falls Suspected due to chronic alcoholism .Alcohol use/withdrawal .As per the patient last drink was 1 week ago however the daughter at bedside disagrees. We will place on CIWA (Clinical Institute Withdrawal Assessment for Alcohol) (1) protocol .Rehab potential: fair. This note was…

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

Based on staff interview, and facility document review, the facility staff failed to ensure training regarding the facility QAPI (quality assurance and performance improvement) program was completed for two of five employee reviews. The findings include: For OSM (other staff member) #26 (a dietary aide), and OSM #27 (a housekeeper), the facility staff failed to ensure training regarding the facility QAPI program was completed. OSM #26 was hired on 4/3/23 and OSM #27 was hired on 4/6/23. The facility staff failed to provide evidence these two employees had completed training regarding the facility QAPI program. On 5/20/25 at 10:52 a.m., an interview was conducted RN #3 (the education coordinator). RN #3 stated QAPI education should be provided during orientation, but OSM #26 and OSM #27 are contracted employees and do not attend the facility orientation. On 5/20/25 at 11:26 a.m., another interview was conducted with RN #3. RN #3 stated the importance of QAPI training is so staff are aware the facility is constantly working on solving issues, but the issues need to be identified so…

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 document review, the facility staff failed to ensure CNAs (certified nursing assistants) completed required annual in-service trainings for two of five CNA reviews. The findings include: For CNA #10 and CNA #12, the facility staff failed to ensure the CNAs completed 12 hours of annual training. CNA #10 was hired on 11/1/23 and CNA #12 was hired on 10/23/23. A review of CNA #10 and CNA #12's record failed to reveal evidence that the two CNAs had completed 12 hours of annual training. On 5/20/25 at 10:52 a.m., an interview was conducted with RN (registered nurse) #3 (the education coordinator). RN #3 stated she assigns trainings in the computerized training software, tracks staff completion each quarter and submits a report of completion to the administrator and director of nursing. On 5/20/25 at 11:26 a.m., another interview was conducted with RN #3. RN #3 stated CNA #10 and CNA #12 did not complete 12 hours of annual training. RN #3 stated it is important for CNAs to complete 12 hours of annual training to keep up with their skills. RN #3…

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

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to review and revise the comprehensive care plan for one of two residents in the survey sample, Resident #1. The findings include: For Resident #1, the facility staff failed to review and revise the comprehensive care plan for the treatment of a urinary tract infection. The physician order dated 7/30/24 at 1:29 p.m. documented, Macrobid Oral Capsule 100 mg (milligrams); Give 100 mg by mouth one time only for UTI for 5 days 100 mg PO (by mouth) twice daily. Review of the comprehensive care plan dated, 1/4/24, failed to evidence revised documentation related to the treatment of a urinary tract infection on 7/30/24. On 12/4/24 at 11:59 a.m.an interview was conducted with RN (registered nurse) #1, When asked if a resident is being treated with antibiotics for a urinary tract infection, should that be addressed on the care plan RN #1 stated, yes. On 12/5/24 pm at 4:48 an interview was conducted with ASM (administrative staff member) #2, the director of nursing,asked…

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

Based on staff interview, resident interview, clinical record review and facility document review, the facility staff failed failed to maintain an effective infection control tracking system; failed to maintain an effective infection control program for five of 41 residents in the survey sample, Residents #49 #24, #15, #86, #76 ; and failed to store linens in a sanitary manner, for one of one linen carts. The findings include: 1. The facility staff failed to maintain complete infection control tracking. The March, May, June 2023 tracking logs documented the number of the following infections: UTI (urinary tract infections) Pneumonia Wound Gastrointestinal Clostridium Difficile Cellulitis Osteomyelitis Surgical Other infections. Attached to this tracking log were the list of antibiotics prescribed. There was no documentation of onset date of the infection, no diagnostic (x-ray or laboratory) results. No tracking of where the infections were in the facility. There was no infection tracking log for April 2023. What was presented was the vaccination status of residents, but no infection…

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 interview, resident interview, and facility document review, it was determined the facility staff failed to develop/implement the care plan for three of 41 residents in the survey sample; Resident #8, Resident #5 and Resident #63. The findings include: 1. For Resident #8, the facility staff failed to implement the comprehensive care plan for diet as ordered. Resident #8 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: dysphagia, oropharyngeal phase, and Parkinson's disease. The most recent MDS (minimum data set) assessment, a quarterly Medicare assessment, with an ARD (assessment reference date) of 11/6/23, coded the resident as scoring a 08 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring supervision for eating. MDS Section K0520. Nutritional Approaches: C. Mechanically altered diet -…

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 provide evidence of providing ADL (activities of daily living) care for one of 41 dependent residents, Resident #146. The findings include: For Resident #146, the facility staff failed to provide evidence of showers, bathing, and incontinence care. The most recent MDS (minimum data set) assessment, a significant change assessment, with an ARD (assessment reference date) of 6/25/23, coded the resident as scoring a 00 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section G-functional status coded the resident as being dependent for bed mobility, transfers, locomotion, dressing, eating, personal hygiene, toileting and bathing. A review of the comprehensive care plan dated 6/23/23 included: FOCUS: The resident has an ADL self-care performance deficit related to immobility and Advanced Dementia. Resident is incontinent of bowel and bladder related to immobility and advanced Dementia.…

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

Based on observation, staff interview, and facility document review, the facility staff failed to prepare, store, and serve food in a sanitary manner in one of one facility kitchens. The findings include: The initial kitchen tour and follow up observation on 11/28/23 revealed concerns with food storage, preparation, and service in a sanitary manner. On 11/28/23 at 7:52 a.m., initial observation of the kitchen occurred. All three compartments of the three compartment sink contained a moderate amount of loose debris and a small amount of grease residue. OSM (other staff member) #7, the dietary manger, stated: I agree. The sink could be cleaner. The plate warmer contained loose debris and a large amount of crumbs around the plate. Additionally, a buildup of grease/dirt was observed in the ledge surrounding the plate. OSM #7 stated the plate warmer needed to be cleaned. The standing food warmer contained a moderate amount of crumbs and loose black debris, as well as patches of grease build up. The handles were sticky. OSM #7 stated: It's not so great with cleanliness. The stove…

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

Based on observation, staff interview, facility document review, it was determined the facility staff failed to conduct regular bed inspections for four of 41 residents in the survey sample, Residents #63, #48, #9 and #7. The findings include: 1. For Resident #63, the facility staff failed to conduct regular bed inspections. Observation was made of Resident #63 on 11/28/2023 at approximately 9:00 a.m. Resident #63 was in bed with the bilateral side rails up in place. A copy of the bed inspections was requesting during the entrance conference on 11/28/2023 at 8:30 a.m. A book was presented on 11/28/2023 of the bed inspections. The last bed inspection was dated April 2022. A document dated 10/1/2022 through 9/30/2023 documented in part On-site repairs and preventative maintenance was performed. An interview was conducted with ASM (administrative staff member) #1, the administrator, on 11/30/2023 at 9:24 a.m. When asked if the bed inspections have been completed since April 2022, ASM #1 stated the facility did not have any bed inspections since April 2022. They had a company come in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to maintain dignity for three of 41 residents in the survey sample, Residents #246, #42, and #24. The findings include: 1. For Resident #246 (R246), the facility staff failed to cover the resident's lower body on 11/28/23. On 11/28/23 at 9:50 a.m., R246 was observed from the hallway lying in bed. The resident's lower body was completely uncovered. The resident was not wearing any clothing on his legs. The resident's incontinence brief was partially unfastened, and visible to anyone who looked in from hallway. Over the next 15 minutes, three staff members walked by or into the room. None of these staff members attempted to cover R246's exposed lower body. On 11/30/23 at 9:53 a.m., LPN (licensed practical nurse) #4 was interviewed. She stated walking by a resident who is exposed due to lack of covers is a no-no. She stated R246 should have been covered by staff when they walked…

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

Based on observation, resident interview, staff interview and facility document review, it was determined the facility staff failed to assess a resident for the self-administration of a medicated mouthwash for one of 41 residents in the survey sample, Resident #45. The findings include: For Resident #45 (R45), the facility staff failed to assess the resident for the self-administration of a medicated mouthwash. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 10/6/2023, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. Observation was made of R45 on 11/28/2023 at approximately 9:00 a.m. There was a bottle of Dexamethasone oral solution was noted on the bedside table. R45 stated her oncologist ordered this for her. She stated she takes it with her when she leaves the facility to go on outings. R45 stated she goes out almost daily with friends or goes to the senior center. The physician order dated,…

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

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 implement Advance Directive requirements for one of 41 residents in the survey sample, Resident #6. The findings include: For Resident #6 (R6), the facility staff failed to maintain the resident's advance medical directive on the clinical record. Review of R6's clinical record revealed a social services assessment dated [DATE] that documented R6 had advance directives and R6 assigned the resident's daughter as POA (power of attorney). Further review of R6's clinical record (including the electronic record and paper record) failed to reveal the advance directive and POA documents were on file. On 11/29/23 at 3:44 p.m., an interview was conducted with OSM (other staff member) #5 (the director of social services). OSM #5 stated the facility staff obtains advance directive and POA documents upon admission and uploads the documents into the electronic clinical record or gives the documents to the medical…

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

Based on staff interview, facility document review and clinical record review, the facility staff failed to issue a beneficiary notice of non-coverage for one of three beneficiary notice reviews, Resident #75. The findings include: For Resident #75 (R75), the facility staff failed to provide an advance beneficiary notice of non-coverage in a timely manner. A review of a list of residents discharged from a Medicare covered Part A stay with benefit days remaining revealed R75 was discharged from services on 9/23/23. A Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage documented, Medicare doesn't pay for everything, even some care that you or your health care provider think you need. The Skilled Nursing Facility (SNF) or its Utilization Review Committee believes that the care listed below does not meet Medicare coverage requirements. Beginning on 09/23/2023, you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs . The notice was signed by R75 on 11/29/23. On 12/1/23 at 8:44 a.m., an interview was conducted with…

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

Based on observation, staff interview, and facility document review, the facility staff failed to protect clinical information privacy for one of 41 residents in the survey sample, Resident #246. The findings include: For Resident #246 (R246), the facility staff failed to protect the resident's clinical information privacy by posting information related to the resident's medical diagnosis and feeding protocol on signs above his bed, visible to all visitors. On the following dates and times, R246 was observed in his room: 11/28/23 at 9:50 a.m. and 3:53 p.m.; 11/30/23 at 10:04 a.m. At each observation, two signs were posted on the wall above the head of the resident's bed. Each sign contained information about the resident's medical diagnosis of difficulty swallowing, and instructions regarding the altered texture of his food and liquids, and instructions regarding the resident's need for feeding assistance. On 11/30/23 at 9:53 a.m., LPN (licensed practical nurse) #4 was interviewed. When asked about the signs at the head of R246's bed, she stated the resident is unable to speak for…

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

Based on observation, staff interview, and facility document review, the facility staff failed to provide a clean, homelike environment for one of 41 residents in the survey sample, Resident #247. The findings include: For Resident #247 (R247), the facility staff failed to change the resident's soiled sheet and underpad. On 11/28/23 at 10:15 a.m. (first shift staff on duty) and 3:54 p.m. (second shift staff on duty), R247 was observed lying in his bed. On the left side, between his left shoulder to just below his left hand, dried red/black spots were visible on the sheet and the exposed underpad. On 11/28/23 at 3:54 p.m., LPN (licensed practical nurse) #2 observed R247's bed linens. She stated the linens looked to have blood stains on them. She stated: These need to be changed. I need to assess him because he is a bleeder. She stated the soiled linens did not create a clean, homelike environment for the resident. On 11/28/23 at 3:58 p.m., CNA (certified nursing assistant) #12 was interviewed. She stated if a resident has blood on the sheets, the sheets should be changed, and the…

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

Based on staff interview and facility document review, it was determined the facility staff failed to report a potential crime in a timely manner to the state agency. The findings include: There was threat to blow up this place up made by a resident's family member on 8/13/2023 and it was not reported to the state agency until 8/22/2023. The facility synopsis of the event was not dated where is stated, report date. At the bottom of the document it was dated, 8/13/2023, where the responsible party and law enforcement was notified. This form documented in part, The facility is reporting a bomb threat made by son of (resident's name). (Name of son) came into the facility intoxicated and when it was discovered his father's shirts were missing he made the comment, 'I should blow this place up. The family member was escorted from the facility and police called at which time the son was arrested. An interview was conducted with ASM (administrative staff member) #1, the administrator, on 11/30/2023 at 9:24 a.m. When asked if the facility had a bomb threat made against the facility, ASM #1…

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

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 provide evidence that required clinical information was provided to the receiving facility at the time of discharge for two of 41 residents in the survey sample, Residents #73 and #24. The findings include: 1. For Resident #73 (R73), the facility staff failed to provide evidence of sending clinical documents for the continuity of care (including care plan goals, advance directives, and current orders) to the receiving hospital when the resident was discharged on 10/19/23. A review of R73's clinical record revealed she was emergently transferred to a local hospital on [DATE]. Further review of her record failed to reveal evidence that any clinical information was sent to the receiving hospital when she was transferred. On 11/30/23 at 2:50 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional director of operations, were informed of these…

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

Based on staff interview and clinical record review, the facility staff failed to maintain a complete and accurate MDS (minimum data set) assessment for three of 41 residents in the survey sample, Residents #72, #78 and #80. The findings include: 1. For Resident #72 (R72), the facility staff failed to attempt the BIMS (Brief Interview for Mental Status) and mood interviews for the quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 11/1/23. Section B of R72's quarterly MDS with an ARD of 11/1/23 coded the resident as understood and as able to understand verbal content. A review of sections C and D revealed the BIMS and mood interviews were not attempted with the resident. On 11/29/23 at 4:02 p.m., an interview was conducted with RN (registered nurse) #1 (the MDS coordinator) and ASM (administrative staff member) #4 (the regional MDS coordinator). ASM #4 stated the BIMS and mood interviews are completed by the social services department and the interviews should be attempted with every resident because in that moment, the resident may be able to…

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

Based on observation, facility document review, clinical record review, and facility document review, the facility staff failed to develop a complete baseline care plan for one of 41 residents in the survey sample, Resident # 246. The findings include: For Resident #246 (R246), the facility staff failed to develop a baseline care plan for the resident's neck stabilizing collar. On the following dates and times, R246 was observed in his room wearing a neck stabilizing collar: 11/28/23 at 9:50 a.m. and 3:53 p.m. and 11/30/23 at 10:04 a.m. A review of R246's clinical record revealed the following order dated 11/8/23: Aspen (neck stabilizing) collar at all times every shift for support. Further review of R246's orders failed to reveal evidence of orders to check R246's skin or to clean the collar. A review of R246's baseline care plan dated 11/8/23 revealed no information at all related to R246's neck stabilizing collar. On 11/30/23 at 9:40 a.m., ASM (administrative staff member) #4, the regional MDS (minimum data set) coordinator, was interviewed. When asked if a resident's neck…

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

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to review and revise the care plan for one of 41 residents in the survey sample, Resident #45. The findings include: For Resident #45, the facility staff failed to review and revise the care plan for the use and self-administration of a medicated mouthwash. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 10/6/2023, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. Observation was made of R45 on 11/28/2023 at approximately 9:00 a.m. There was a bottle of Dexamethasone oral solution was noted on the bedside table. R45 stated her oncologist ordered this for her. She stated she takes it with her when she leaves the facility to go on outings. R45 stated she goes out almost daily with friends or goes to the senior center. The physician order dated, 11/10/2023 documented,…

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

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to follow professional standards of practice for the administration of medications and treatments for two of 41 residents in the survey sample, Residents #147 and #63. The findings include: 1. For Resident #147, the facility staff failed to administer a medication when it was available in the emergency medication supply. The physician order dated, 11/23/2023, documented, Pravastatin Sodium (1) Oral Tablet 40 MG (milligrams); Give 40 mg by mouth one time a day for hyperlipidemia. The MAR (medication administration record) documented the above order. On 11/24/2023, 11/25/2023, 11/26/2023 and 11/27/2023 a 13 was documented in the block for administration. A 13 indicated, Medication Not Available. Review of the nurse's notes for the dates above failed to evidence documentation for the reason the medication was not administered. Review of the Inventory On Hand list of medications available in the emergency box (CUBEX), documented, Pravastatin Sod (sodium) 10 MG…

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

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence of providing ADLs (activities of daily living) for two of 41 residents, Resident #42 and Resident #8. The findings include: 1. The facility staff failed to provide evidence of bathing and showers for Resident #42. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/6/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring supervision for bed, mobility, transfer, bathing, dressing, hygiene, eating and locomotion. A review of the comprehensive care plan dated 5/18/23 revealed, FOCUS: Resident has an ADL self-care performance deficit related to multiple health issues and difficulty in walking. INTERVENTIONS: BATHING /SHOWERING: Provide sponge bath when a full bath or shower cannot be tolerated. A review…

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

2. For Resident #246 (R246), the facility staff failed to provide evidence of skin checks and device cleaning for the resident's use of a neck stabilizing collar. On the following dates and times, R246 was observed in his room wearing a neck stabilizing collar: 11/28/23 at 9:50 a.m. and 3:53 p.m., and 11/30/23 at 10:04 a.m. A review of R246's clinical record revealed the following order dated 11/8/23: Aspen (neck stabilizing) collar at all times every shift for support. Further review of R246's orders failed to reveal evidence of orders to check R246's skin or to clean the collar. A review of R246's baseline care plan dated 11/8/23 revealed no information at all related to R246's neck stabilizing collar. On 11/30/23 at 9:53 a.m., LPN (licensed practical nurse) #4 was interviewed. She stated if a resident is wearing a neck stabilizing collar, the facility staff should take it off at least twice a day to clean the collar and to check the resident's skin underneath the collar. She stated the collar can rub the skin causing skin breakdown. She stated if the collar is dirty, bacteria can…

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 document review and clinical record review, the facility staff failed to implement a complete pain management program for one of 41 residents in the survey sample, Resident #197. The findings include: For Resident #197 (R197), the facility staff failed to administer the physician prescribed medication gabapentin (1) on 11/22/23. R197 was admitted to the facility on [DATE] with a fractured left upper leg. The MDS (minimum data set) assessment was not complete. A review of R197's clinical record revealed a BIMS (Brief Interview for Mental Status) assessment dated [DATE] that documented a score of 15 on a scale from 0 to 15, indicating the resident was cognitively intact. On 11/28/23 at 9:50 a.m., an interview was conducted with R197. The resident voiced concern about not getting pain medication in a timely manner during the first couple of days after admission to the facility. Further review of R197's clinical record revealed a physician's order dated 11/21/23…

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

Based on staff interview, facility document review, and clinical record review, the staff failed to provide trauma informed care for one of 41 resident in the survey sample, Resident #5. The findings include: For Resident #5, the facility staff failed to provide informed care for a resident with PTSD (post traumatic disorder) (1). On the most recent MDS (minimum data set) an annual assessment with an ARD (assessment reference date) of 9/28/23, R5 was coded as being moderately impaired for making daily decisions, having scored 10 out of 15 on the BIMS (brief interview for mental status). He was admitted to the facility with diagnoses including anxiety disorder, depression and PTSD. A review of the social service assessments dated 5/1/23 and 5/11/23 revealed no information related to PTSD. A review of the Trauma Screen assessments dated 7/24/23 and 7/25/23 revealed no information related to PTSD and were not fully completed. A review of care plan dated 5/11/23 revealed no information related to PTSD interventions and accommodations. On 11/29/23 at 3:45 p.m., OSM (Other Staff Member)…

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 document review, and clinical record review, the facility staff failed to provide medically related social services for one of 41 residents in the survey sample, Resident #5. The findings include: For Resident#5 (R5), who had a diagnosis of PTSD (post traumatic stress disorder) (1), the facility social worker failed to follow up on a recommendation for counseling services. There was no evidence of any kind of recommendation for counseling services. On the most recent MDS (minimum data set) an annual assessment with an ARD (assessment reference date) of 9/28/23, R5 was coded as being moderately impaired for making daily decisions, having scored 10 out of 15 on the BIMS (brief interview for mental status). He was admitted to the facility with diagnoses including anxiety disorder, depression and PTSD. A review of the social service assessments dated 5/1/23 and 5/11/23 revealed no information related to PTSD. A review of the Trauma Screen assessments dated 7/24/23 and 7/25/23 revealed no information related to PTSD and was not fully completed. A…

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

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure medications were available for administration for one of seven residents in the medication administration observation, Resident #198. The findings include: For Resident #198 (R198), the facility staff failed to reorder Aspirin and Multivitamins from the pharmacy in a timely manner, resulting in the resident missing a dose of both medications on 11/28/23. On 11/28/23 at 9:10 a.m., LPN (licensed practical nurse) #5 was observed preparing medications for administration to R198. LPN #5 handed two medication cards to the surveyor, and stated: These are not available. I will have to request a refill from the pharmacy. They will be here tomorrow. The two cards were for Aspirin 81 mgs (milligrams) and a Multivitamin. Neither card had any remaining medications. LPN #5 did not check for the availability of these two medications anywhere in the building, and did not administer Aspirin or a Multivitamin to R198. A review of R198's orders revealed an order for Aspirin…

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

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to administer medications at an error rate of less than five percent for one of seven residents in the medication administration observation, Resident #198. The findings include: For Resident #198 (R198), the facility failed to administer Aspirin and a Multivitamin as ordered by the physician during the medication administration observation on 11/28/23, resulting in two errors out of 34 total opportunities. The medication administration error rate was 5.88%. On 11/28/23 at 9:10 a.m., LPN (licensed practical nurse) #5 was observed preparing medications for administration to R198. LPN #5 handed two medication cards to the surveyor, and stated: These are not available. I will have to request a refill from the pharmacy. They will be here tomorrow. The two cards were for Aspirin 81 mgs (milligrams) and a Multivitamin. Neither card had any remaining medications. LPN #5 did not check for the availability of these two medications anywhere in the building, and did 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.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to offer a influenza vaccination and/or pneumococcal vaccination for two of five residents in the infection control task/review, Residents #48 and #72. The findings include: 1. For Resident #48, the facility staff failed to offer a pneumococcal vaccination. The clinical record was reviewed. Under the tab for immunizations, there was no documentation for a pneumococcal vaccination. Next to the pneumococcal vaccine it was documented, Consent Required. A request was made on 11/30/2023 at 5:00 p.m. for evidence of a pneumococcal vaccination administration or evidence that is was offered and declined. On 12/1/2023 at 8:45 a.m. ASM (administrative staff member) #2, the director of nursing, stated there was no documentation that it was given. The staff is pulling information from the state vaccination website. The staff need to verify if the resident needs it and if so, it will be offered. The facility policy, Pneumococcal Vaccine, documented in part, 1. Prior to or…

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

Based on observation, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to serve meals in a manner to promote resident dignity for two of 50 residents in the survey sample, Residents #32 and #95; and during the evening meal on 4/24/22 in two of two dining rooms. The findings include: 1. At dinner on 4/24/22, Resident #32 (R32) and Resident #95 (R95) had to wait 23 minutes for their meal to be served. While they waited at the table with Resident #34 (R34), R 34 was served her meal and finished eating her meal before R32 and R95 were ever served. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/5/22, R34 was coded as being moderately impaired for making daily decisions, having scored 12 out of 15 on the BIMS (brief interview for mental status). On the most recent MDS, a significant change assessment with an ARD of 2/24/22, R32 was coded as being severely cognitively impaired for making daily decisions, having scored two out of 15 on the BIMS. On the most…

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 document review, it was determined that the facility staff failed to store food in a sanitary manner in 1 of 1 facility kitchens. The findings include: On 4/24/22 at 2:40 PM an inspection of the kitchen was conducted with OSM #3 (Other Staff Member) the Assistant Dietary Manager. The following items were observed in the walk-in freezer: 1. A box of breaded chicken breast, a box of hamburger patties, a box of biscuits, were noted to be open and exposed to the environment. 2. Two whole pies on a sheet pan on a cart were noted to be uncovered, exposed to the environment. On 4/24/22 at 2:47 PM OSM #3 was asked about the exposed items in the freezer. They stated that everything should be sealed or covered. A review of the facility policy, Food and Supply Storage was conducted. This policy documented, Frozen Storage Store bulk materials in NSF approved containers that have tight fitting lids. Label both the bin and the lid. Use food grade plastic bags for food storage .Wrap food tightly to prevent cross contamination. On 4/25/22 5:40 PM…

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

Based on staff interview, clinical record review, and facility document review, it was determined the facility staff failed to provide a resident's comprehensive care plan goals to the receiving facility at the time of discharge for one of 50 residents in the survey sample, Resident #32. The facility failed to evidence that Resident #32's (R32's) care plan goals were sent to the hospital when the resident was discharged on 2/6/22. The findings include: On the most recent MDS, a significant change assessment with an ARD of 2/24/22, R32 was coded as being severely cognitively impaired for making daily decisions, having scored two out of 15 on the BIMS. A review of R32's clinical record revealed a rapid response assessment form dated 2/6/22. The form stated R32 had experienced a decrease in oxygenation due to COVID-19, and was transferred to the hospital via ambulance. The form contained a check list where staff had placed a check mark beside documents sent with the resident to the hospital. There was no check mark indicating comprehensive care plan goals had been sent to 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 observation, resident interview, staff interview, facility document review, and clinical record review, it was determined the facility failed to complete an accurate MDS (minimum data set) for four of 50 residents in the survey sample, Residents #108, #105, #23, and #83. The findings include: 1. For Resident #108 (R108) the facility inaccurately coded the discharge location on the 2/28/22 MDS. On the most recent MDS, an admission assessment with an ARD (assessment reference date) of 2/16/22, R108 was coded as being severely cognitively impaired for making daily decisions, having scored zero out of 15 on the BIMS (brief interview for mental status). A review of R108's clinical record revealed the following from the Discharge summary dated [DATE]: [R108] discharged home with all belongings. Family supportive of care. A review of the discharge MDS dated [DATE] revealed R108 was coded as having been discharged to the hospital. Box A2100, Discharge Status, was coded as a 3, indicating R108 was discharged to…

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

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to review and revise the comprehensive care plan for 1 of 50 residents in the survey sample, Resident #55. The facility staff failed to review and revise Resident #55's (R55) comprehensive care plan for the use of side rails. The findings include: On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/20/22, the resident scored 0 out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely cognitively impaired for making daily decisions. A review of R55's clinical record revealed a physician's order dated 3/16/22 for two upper side rails in bed. R55's comprehensive care plan dated 3/21/22 failed to document information regarding side rails. On 4/24/22 at 3:36 p.m. and 4/25/22 at 8:52 a.m., R55 was observed lying in bed with two upper side rails in the upright position. On 4/25/22 at 3:15 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated the purpose of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to follow professional standards of practice for 2 of 50 residents in the survey sample; Residents #317 and #98. The findings include: 1. The facility staff failed to transcribe and sign out for a medication as ordered and administered; and failed to ensure the medication that was administered was designated for the resident that received it. Resident #317 was admitted to the facility on [DATE] and discharged on 2/22/22. On the admission MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 2/1/22, Resident #317 scored 7 out of 15 on the BIMS (brief interview for mental status, indicating the resident was cognitively impaired for making daily decisions. The resident was coded as requiring extensive to total care for all areas of activities of daily living. A review of the clinical record revealed a nurse's note dated 2/15/22 that documented, .Sat in nurses station…

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, facility document review and clinical record review, the facility staff failed to ensure respiratory care and services were provided in a sanitary manner for 2 of 50 residents in the survey sample, Residents #209 and #59. The findings include: 1. The facility staff failed to store Resident #209's (R209) incentive spirometer in a sanitary manner. R209's diagnoses included but were not limited to pneumonia. On the most recent MDS (minimum data set), a 5 day Medicare assessment with an ARD (assessment reference date) of 4/19/22, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is not cognitively impaired for making daily decisions. A review of R209's clinical record revealed a physician's order dated 4/15/22 for an incentive spirometer. R209's comprehensive care plan dated 4/20/22 documented, Resident has potential for difficulty in breathing related to -Pna (pneumonia) -pulmonary masses. The care plan failed to document information regarding the storage of R209's…

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

Based on staff interview, facility document review and clinical record review it was determined that the facility staff failed to act in a timely manner on the pharmacy medication regimen review for one of 50 residents in the survey sample, Resident #47 (R47). R47's medication regimen review was completed on 1/13/2022 with recommendations for a gradual dose reduction of the antipsychotic medication which were not addressed by the facility physician until after 3/9/2022. The findings include: On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 3/8/2022, the resident scored a 2 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident is severely impaired for making daily decisions. Section N documented R47 receiving antidepressant and antipsychotic medications. Review of R47's clinical record contained a medication regimen review form which documented reviews completed on 4/14/21, 5/13/21, 6/9/21, 7/14/21, 8/11/21, 9/9/21, 10/13/21 and 12/8/21. On 4/26/2022 at 9:13 a.m., an interview was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide services to prevent a resident from receiving unnecessary psychoactive medications for two of 50 residents in the survey sample, Residents #91 and #23. The findings include: 1. For Resident #91 (R91), the facility staff failed to evaluate the use of, and document a reason for use beyond two weeks for, two psychoactive medications which were prescribed on a prn (as-needed) basis. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/7/22, R91 was coded as being severely cognitively impaired for making daily decisions, experiencing both short term and long term memory problems. R91 was coded as receiving an antipsychotic, antidepressant, and anti-anxiety medication on all seven days of the look back period. On 4/24/22 at 2:31 p.m., R91 was observed standing in the doorway between their bedroom and 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, clinical record review and facility document review, it was determined that the facility staff failed to ensure a complete and accurate clinical record for 1 of 50 residents in the survey sample; Resident #317. The findings include: Resident #317 was admitted to the facility on [DATE] and discharged on 2/22/22. On the admission MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 2/1/22, Resident #317 scored 7 out of 15 on the BIMS (brief interview for mental status, indicating the resident was cognitively impaired for making daily decisions. The resident was coded as requiring extensive to total care for all areas of activities of daily living. A. 2/15/22: A review of the clinical record revealed a nurse's note dated 2/15/22 that documented, .Sat in nurses station all shift. Not compliant with getting up by himself. This AM (morning) patient had a mental status change. MD (medical doctor) ordered Haldol (1) one time dose and not effective . This note did 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.

Based on staff interview and employee record review, it was determined that the facility staff failed to ensure that one of five CNA (certified nursing assistant) records reviewed received the required dementia training. The findings include: On 4/25/2022 at approximately 1:00 p.m., a review of the facility's CNA annual training was conducted. Review of five CNA training transcripts revealed one of five CNAs selected for review did not meet the required dementia training. Review of CNA #2's training transcript documented a hire date of 1/8/2007. Further review of the training transcript dated 1/1/2021 through 1/31/2022 failed to evidence dementia training during the review period. On 4/25/2022 at 2:44 p.m., an interview was conducted with RN (registered nurse) #2, education coordinator. RN #2 stated that they were new to the position but had a calendar they used with topics to assign to staff each month in the computer for them to complete. RN #2 stated that they also performed face to face inservices as needed. RN #2 reviewed the transcript provided for CNA #2 and stated that 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, facility document review and clinical record review, it was determined that the facility staff failed to ensure all required information was provided to the receiving health care institution for eight of 42 residents in the survey sample, Residents #63, #18, #43, #81, #79, #28, #48 and #23. 1. The facility staff failed to provide Resident #63's comprehensive care plan goals to hospital staff when the resident was transferred to the hospital on [DATE]. 2. The facility staff failed to ensure Resident #18's comprehensive care plan goals were sent with the resident to the hospital at the time of transfer on 3/4/19. 3. The facility staff failed to evidence that Resident # 43's comprehensive care plan goals were sent with the resident to the hospital for the transfer dated 3/5/19. 4. The facility staff failed to evidence that Resident #81's comprehensive care plan goals were provided to the receiving facility when the resident was transferred to the hospital on 2/19/19. 5. The facility 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 observation, staff interview and facility document review, it was determined the facility staff failed to serve food in a sanitary manner and failed to maintain infection control practices during the lunch meal in two of five dining areas, second floor multi-purpose room and the Dining Hall on the first floor. 1. OSM (other staff member) #1 (the dietary catering associate) touched her face with gloved hands multiple times while serving food to residents in the second floor multi-purpose room. OSM #1 failed to change gloves or wash her hands after touching her face, and continued to serve food. 2. During an observation of the lunch meal service on 3/20/19, in the Dining Hall on the first floor, the facility staff failed to wash or sanitize their hands after touching the food service utensils and the food service cart, and then touched the edge of resident's plate, while serving food in the dining hall. The findings include: 1. OSM (other staff member) #1 (the dietary catering associate) touched her face with gloved hands multiple times while serving food to residents in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility documentation review, and clinical record review the facility staff failed to serve food in a dignified manner for one of 42 residents in the survey sample; Resident #88. The facility staff failed to ensure Resident #88 was served the lunch meal in a home like manner on 3/20/19. LPN (Licensed Practical Nurse) #4 placed Resident #88's tray on the table without removing the plate, cups, and utensils from the tray. Resident #88 was observed eating his food from the tray, cafeteria style and not in a homelike manner. The findings include: Resident #88 was admitted to the facility on [DATE] with the diagnoses of but not limited to Cachexia, metabolic encephalopathy, and chronic pancreatitis. Resident #88's Minimum Data Set (MDS) was an admission assessment with an Assessment Reference Date (ARD) of 2/7/19. Resident #88 was coded as severely cognitively impaired in ability to make daily life decisions. The resident was coded as requiring extensive assistance for hygiene,…

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, it was determined that the facility staff failed to maintain confidentiality for one of 5 residents in the medication administration observation, Resident #83. The facility staff failed to ensure Resident #83's confidentiality by leaving medication packages that contained the resident's name, drug name and strength on top of the medication cart. The findings include: Resident #83 was admitted to the facility on [DATE]. Diagnoses for Resident #83 included but were not limited to Memory Loss, High Blood Pressure, and Depression. Resident #83's Minimum Data Set (quarterly assessment) with an Assessment Reference Date of 2/27/19 coded Resident #83 with no cognitive impairment. In addition, the Minimum Data Set (MDS) coded Resident #83 as requiring extensive assistance of one staff member with activities of daily living and supervision of one staff member with eating. On 3/20/19, at approximately 8:08 a.m., Resident #83 was observed during medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review and clinical record, it was determined the facility staff failed to review and revise the comprehensive care plan for two of 42 residents in the survey sample, Resident #48 and #17. 1. The facility staff failed to review and revise Resident #48's comprehensive care plan when the bed alarm was discontinued. 2.a. The facility staff failed to review and revise Resident #17's care plan when the medication Ativan was discontinued. 2.b. The facility staff failed to review and revise the comprehensive care plan to include the physician ordered feeding instructions for Resident #17. The findings include: 1. The facility staff failed to review and revise Resident #48's comprehensive care plan when the bed alarm was discontinued. Resident #48 was admitted to the facility on [DATE] with recent readmission on [DATE], with diagnoses that included but were not limited to: depression, high blood pressure, and Parkinson's Disease [a slowly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to follow professional standards of practice for one of five residents in the medication administration observation, Resident #407. LPN (Licensed practical nurse) #2 failed to administer medication labeled with Resident #407's name to the resident. Instead, LPN #2 borrowed medication labeled with Resident #408's name and administered the medication to Resident #407. The findings include: Resident #408 was admitted to the facility on [DATE]. Resident #408's diagnoses included but were not limited to high blood pressure, fractured ribs and malnutrition. Resident #408's admission MDS (minimum data set) was not complete. Resident #408's admission nursing assessment dated [DATE] documented the resident was alert and knew her own name. Review of Resident #408's clinical record revealed a physician's order dated 3/6/19 for hydralazine (1) 25 mg (milligrams)- one tablet by mouth 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, facility document review, and clinical record review, it was determined the facility staff failed to ensure one of 42 residents in the survey sample, received the care and services in accordance with professional standards and the comprehensive care plan for Resident #17. The facility staff failed to follow the physician ordered feeding instructions for Resident #17. During separate observations the facility staff were observed feeding Resident #17 without the resident being positioned at 90 degrees as ordered by the physician. The findings include: Resident #17 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: anoxic brain damage [damage to the brain after absence or abnormally low amount of oxygen in the blood (1)], quadriplegic [paralysis affecting all four limbs and the trunk of the body below the level of spinal cord injury (2)], and pneumonia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with 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 observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide respiratory care and services for two of 42 residents in the survey sample, Residents #21 and #28. 1.a. The facility staff failed to obtain a physician's order for an incentive spirometer that was observed in Resident #21's room and available for the resident's use. 1.b. The facility staff failed to store Resident #21's incentive spirometer mouthpiece in a clean and sanitary manner. 2. The facility staff failed to store oxygen tubing in a sanitary manner for Resident #28. The findings include: 1.a. The facility staff failed to obtain a physician's order for an incentive spirometer (1) that was observed in Resident #21's room and available for the resident's use. Resident #21 was admitted to the facility on [DATE]. Resident #21's diagnoses included but were not limited to heart failure, acute respiratory failure and depressive disorder. Resident #21's most recent…

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.