Dockside Health & Rehab Center

Based on interview, clinical record review and facility documentation review the facility staff failed to review and revise the care plans for 1 Residents (#26) in a survey sample of 41 Residents. The findings included: For Resident #26 the facility staff failed to review and revise the care plan to include changes in behavior and the need for 1:1 monitoring. On 10/12/21 at approximately 11:45 AM, Resident #26 was observed in his bed fully dressed asleep. A staff member was sitting in a chair with an over bed table in front of her at the entrance to the room. The staff member identified herself as CNA E and was interviewed at that time. CNA E stated that Resident #26 was placed on 1:1 because of behaviors he had exhibited the previous evening. She stated that he has been hitting staff. When asked has he ever hit other Residents she stated that he did and has been placed on 1:1 in the past for that behavior. On 10/12/21 at 12:20 PM an interview was conducted with the RN Supervisor who stated that Resident #26 has a BIMS (Brief Interview of Mental Status) score of 4 indicating severe…

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

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide oxygen therapy consistent with infection control measures for 2 Residents, Resident #70 and Resident #6, in a survey sample of 41 Residents. The findings included: 1. For Resident #70, facility staff failed to change the oxygen tubing weekly as ordered. During initial tour on 10/12/21 at approximately 11:30 AM, Surveyor D observed Resident #70 with oxygen being administered via nasal cannula at 1 liter per minute as ordered by the physician. There was no date on the oxygen tubing. Surveyor D conducted an interview with RN C at the bedside of Resident #70. RN C confirmed the observation stating, No, I do not see any date on the [oxygen] tubing, typically it is changed weekly on night shift. When asked about the importance of changing the oxygen tubing weekly, RN C stated, It needs to be changed weekly to prevent the spread of infections. Review of Resident #70's clinical record revealed a physician's order that read, Change any O2 [oxygen] tubing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review, facility documentation and clinical record review the facility staff failed to ensure adequate pain management for 1 of 41 sampled residents (Resident #178). The findings included: For Resident #178 the facility staff did not administer pain medication although it was available in the stat box. A review of the clinical record revealed that Resident #178 was admitted to the facility on [DATE] at 8 PM, after having been hospitalized and had surgery for necrotizing fasciitis (also known as flesh eating bacteria) to her inner thigh. Among Resident # 178's discharge summary were orders for the following medications: Gabapentin 600 mg 1 tablet three times a day for neuropathic pain. A review of the MAR revealed the resident missed nine doses of gabapentin. Oxycodone 10 mg tablet immediate release one tablet every six hours as needed for pain. This pain medication was not administered until 8/14/21. A review of the progress notes revealed the nurses documented Gabapentin 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 interview, clinical record review and facility documentation the facility staff failed to ensure availability of medications for 1 Resident (#24) in a survey sample of 41 Residents. The findings include: For Resident #24, the facility staff failed to provide medications as ordered by the Physician. On 10/12/21 at 05:01 PM, Resident #24 stated, I have pain all over my body, I'm eat up with arthritis, they only give me Tylenol. On 10/13/21, a review of Resident #24's clinical record was conducted. This review revealed the following nursing notes: 9/21/21- Gabapentin Capsule 400 MG, Awaiting medication from pharmacy. 10/4/21- Famotidine Tablet 20 MG, unavailable to administer, reordered. 10/12/21-Gabapentin Capsule 400 MG, Awaiting arrival. 10/12/21-Vitamin D3 Tablet, on order. According to the September and October 2021 MAR (Medication Administration Record), the medications were not administered to Resident #24 as listed above. Review of Omnicell (on-site emergency medication stock) contents list revealed the following: Gabapentin Capsule 400 MG -Quantity: 5 in inventory On…

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

Based on interview, observation, clinical record review and facility documentation the facility staff has failed to ensure routine and emergency dental care for 1 Residents (# 16) in a survey sample of 41 Residents. The findings included: For Resident #16 the facility staff failed to ensure Residents received routine and emergency dental care. On 10/13/21 a review of the clinical record revealed that Resident #16 had order that read: Warm compress to affected area (toothache/pain) as needed every four hours as needed for toothache/pain times 20 minutes start date 9/23/2020 at 1 PM. This order was still active, over a year later, and was signed off as administered as recently as 10/11/2021 at 10:26 AM. Resident #16 had another orders that read: X-ray left jaw/mandible for edema one time a day for one day start date 10/14/21 at 12:30 PM. Pending confirmation clindamycin HCl capsule 300 mg two capsules by mouth four times a day for left side dental infection start date 10/14/21. Pending confirmation please make a follow up appointment with dental for left side tooth infection one time…

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

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain an accurate clinical record for one Resident (Resident #65) in a sample size of 41 Residents. For Resident #65, there was conflicting information regarding blood glucose values on 10/06/2021. The findings included: On 10/25/2021 at approximately 10:00 A.M., Resident #65's clinical record was reviewed. A physician's order dated 09/11/2020 documented, Obtain blood sugars ac & hs [before meals and at bedtime]. The Medication Administration Record for October 2021 was reviewed. The blood sugar values for 10/06/2021 documented the following: 0630 [blank] 1130 245 1630 232 2030 301 On 10/25/2021 at 1:00 P.M., the Director of Nursing (DON) was notified of findings. At 3:00 P.M., this surveyor and the DON observed Resident #65's glucometer. The Director of Nursing stated that there are dates but no times listed in the blood sugar history. The blood sugar values listed in the glucometer for 10/06/2021 were 245, 232, 305, and 324. The DON also provided a clinical record…

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

Based on observation, clinical record review, facility document review, staff interview, Resident interview, and family interview, the facility staff failed to provide a qualified Activity Professional for 62 days as of the end of survey. The findings included; The Administrator was interviewed in the conference room on 2-13-2020 at 3:30 p.m., and stated they had no qualified Activity Professional in the facility. The previous Activity professional's last day was 12-13-19. The Administrator informed surveyors that the previous activity professional's assistant was conducting activities. On 2-13-2020 at 4:00 p.m., the Administrator and Director of nursing were made aware of the findings. No further information was presented by the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, facility documentation, clinical record review the facility staff failed to ensure the Pharmacy drug regimen review were addressed for 1 Resident (Resident #19) in a survey sample of 29 Residents. This happened on multiple occasions. The findings included: For Resident # 19 the facility staff failed to address the Pharmacy recommendations. This happened on multiple occasions. Resident #19 a [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Atrial fibrillation, heart failure, hypertension, diabetes, Alzheimer's Dementia, anxiety disorder, depression and psychotic disorder. Resident #19's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/19/19 coded the Resident as having a BIMS ( Brief Interview of Mental Status) score of 00 indicating severe cognitive impairment. Resident is non ambulatory and requires total care with all aspects of ADL. During the review of Pharmacy recommendations it was discovered that the facility…

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

Based on staff interview and facility documentation review, the facility staff failed to conduct 2 of 4 quarterly meetings that included the Medical Director. The Findings included: On 2/13/20 at approximately 12:30 P.M., an interview was conducted with the Administrator (Employee A) in her office. The Quality Assurance Program was reviewed. The Administrator was unable to provide documentation (Attendance Sheets) that the Medical Director attended two out of 4 required quarterly meetings. The Medical Director's signature was documented for the following meetings: 2/4/19, 3/14/19, 12/30/19. The Administrator stated that there had been a turnover of Medical Directors. (i.e. There have been 3 different Medical Directors during the past year.) No further information was received.

Based on Staff interview and facility documentation review, the facility staff failed to complete a skilled nursing facility (SNF) Advanced Beneficiary Notice of Medicare non-coverage (ABN/NOMNC) for one Resident, (Resident #182), in a sample of 3 residents. The findings included: For Resident #182, no SNF/ABN NOMNC was provided prior to discharge from skilled services. On 2-13-2020, a review of the facility's ABN/NOMNC forms issued during the last six months was conducted. Three discharged residents were chosen for review. Resident #182 was admitted to skilled nursing care in the facility on 1-3-2020, and discharged on 1-15-2020. The last Medicare covered day for the Resident was 1-15-2020. The Resident's benefit days had not been exhausted, however, the Resident had reached a plateau, and it was felt that he no longer required skilled nursing care and that level of care was discontinued without the Resident receiving notice of the change in time to appeal the decision. The Resident was called via telephone after discharge to notify him of his loss of coverage as no form was signed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and clinical record review the facility staff failed to provide a clean, comfortable and homelike environment for 1 Resident (#54) in a survey sample of 29 Residents. The findings included: For Resident #33 the facility staff failed to provide sheets that were clean and without holes. Resident # 33 a [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to hemiplegia and hemiparesis following a stroke affecting right side, vascular dementia, major depressive disorder, hypertension and history of stroke. Resident # 33's most recent MDS ( Minimum Data Set) with an ARD (Assessment Reference Date) of 12/4/20 coded as a Quarterly codes Resident #33 as having a BIMS (Brief Interview of Mental Status) score of 4 indicating severe cognitive impairment. The Resident is also coded as being Always incontinent for bowel and bladder. On 2/11/20 at approximately 6:30 PM observed Resident #33 sitting on bed in room. The bed covers were pulled down 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 observation, clinical record review, staff interview, and Resident Representative interview, the facility staff interfered and prevented the free communication, as a direct request from a family member, to speak with state surveyors for one family member for a survey sample of 29 residents. The findings included; On 2-13-2020 surveyors observed 3 staff members stationed at the end of the Administrative office hallway. The hallway contained only offices for the directors, the Administrator, and a conference room where surveyors were located, which was across from the administrator's office. Those staff members were Admin (E), Admin (G), and Admin (H). Each of the three corporate staff members were observed standing by the hallway entrance individually or together at all times from 9:30 a.m., until 11:40 a.m. At 11:45 a.m., two surveyors exited the hallway, and saw all three at the nursing station talking. The surveyors were approached by a family member who asked are you from the state?, the surveyors responded yes, and family member stated I am so glad, I have been here…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed, for 3 residents of 29 residents (Resident #36, Resident #332, Resident #25) to implement or develop the comprehensive care plan. The Findings included: 1. For Resident #36, the facility staff failed to implement the Bowel and Bladder care plan. Resident #36 was an [AGE] year old. Resident #36's diagnoses included Generalized Muscle Weakness, and incontinence of bowel and bladder. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 12/4/19 was reviewed. Resident #8 had a Brief Interview of Mental Status score of 8, indicating moderately impaired cognition. Resident #8 was coded as requiring the physical assistance of one person for transfers for toileting and hygiene. Resident #8 was also coded as always being incontinent of bowel and bladder. On 2/12/20, a review was conducted 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 Observation, clinical record review, staff interview, and facility document review, the facility staff failed to review and revise a nutritional care plan for one Resident (Resident #60) in a survey sample of 29 Residents. The findings included; Resident #60's care plan did not reflect severe weight loss, Registered Dietician (RD) recommendations, and that the resident dependant upon staff to eat. Resident #60 was admitted to the facility initially on 4-28-17. Diagnoses included; Depression, blindness left eye, history of falling, Parkinson's disease, and high cholesterol. The most recent Minimum Data Set assessment was a significant change assessment with an assessment reference date of 12-27-19. Resident #60 was coded with a Brief Interview of Mental Status score of 13 indicating mild cognitive impairment. The Resident required limited assistance with activities of daily living (ADL's), to include set up and supervision for eating. The only exceptions were toileting, hygiene, and bathing, which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide services that meet professional standards of quality care for 1 residents (Resident #332) in a sample size of 29 residents. The findings included: 1. For Resident #332, the facility staff failed to create an Activities of Daily Living (including meal consumption) flowsheet since her admission on [DATE]. Resident #332, a [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses included but not limited to schizophrenia, dementia, and type 2 diabetes mellitus. Due to the new admission status, a Minimum Data Set assessment was not completed. On 02/11/2020 at approximately 7:10 PM, in the course of a nutrition investigation for Resident #332, an interview with Licensed Practical Nurse D (LPN D) was conducted. When asked about the documentation for intake and output, LPN D stated that the Certified Nursing Assistants (CNA's) document on the ADL [Activities of Daily…

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, clinical record review, facility document review, staff interview, Resident interview, and family interview, the facility staff failed to provide meaningful activities from 12-13-19 until the time of survey for one Resident (Resident #81) in a survey sample of 29 residents. The findings included; Resident #81 was admitted to the facility on [DATE]. Diagnoses included; Angina, atrial fibrillation, osteoarthritis of the knee, chronic kidney disease, chronic congestive heart failure, recurrent depression, recurrent falls, and insomnia. Resident #81's most recent Minimum Data Set Assessment was a full admission assessment with an assessment reference date of 11-30-19. She was coded with no cognitive impairment. She required only assistance with meal preparation and tray set up and was otherwise independent with all activities of daily living (ADLs). The Resident had difficulty with walking, and so in her room used a walker, and outside of her room, used a wheel chair for ambulation. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Resident interview, staff interview, clinical record review and facility documentation review, the facility failed to provide services and care for 1 Resident (Resident # 72) in a survey sample of 29 Residents. The findings include: Resident #72's right eye was red, swollen, and draining. The staff did not assess the eye, nor notify the physician of a possible eye infection until surveyors brought it to their attention after 2 days of observations. Resident #72 was admitted to the facility on [DATE]. Diagnoses included: Diabetes, malnutrition, functional quadriplegia, peripheral vascular disease, recurrent pain, recurrent depression, and skin wounds. On 2-11-2020 at 6:30 p.m., during initial tour of the building an interview was attempted with Resident #72. The Resident was also noted to have a swollen and red right eye, draining clear fluid. When asked if the eye was painful the Resident shook his head yes. The Resident's most recent (Minimum Data Set) MDS was reviewed. The MDS was a full admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and clinical record review the facility staff failed to provide podiatry services for 1 Resident (#54) in a survey sample of 29 Residents. The findings included: For Resident #33 the facility staff failed to provide podiatry services. Resident # 33 a [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to hemiplegia and hemiparesis following a stroke affecting right side, vascular dementia, major depressive disorder, hypertension and history of stroke. Resident # 33's most recent MDS ( Minimum Data Set) with an ARD (Assessment Reference Date) of 12/4/20 coded as a Quarterly codes Resident #33 as having a BIMS (Brief Interview of Mental Status) score of 4 indicating severe cognitive impairment. The Resident is also coded as being Always incontinent for bowel and bladder. On 2/11/20 at approximately 6:30 PM, this surveyor observed Resident #33 sitting on bed in room. Resident #33 was dressed in her clothes and had no shoes on her feet. Her toe…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure an accident hazard free environment for one resident (Resident #332) in a survey sample of 29 residents. The findings included; For Resident #332, the facility staff failed to provide pillows to assist with positioning in bed to prevent a potential accident of falling out of bed. Resident #332, a [AGE] year old male/female, was admitted to the facility on [DATE]. Diagnoses included but not limited to schizophrenia, dementia, and type 2 diabetes mellitus. Due to the new admission status, a Minimum Data Set assessment was not completed. On 02/12/2020 at 8:48 AM, Resident #332 was observed lying in her bed with the head of the bed elevated approximately 45 degrees and leaning to the left side of the bed, laterally bent at the waist. This surveyor looked for a certified nursing assistant to alert staff Resident #332 was leaning in her bed. This surveyor and Certified Nursing Assistants E…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility documentation and clinical record review the facility staff failed to provide sufficient support to maintain ideal body weight and prevent weight loss for 3 Residents (#54 #60 and #9) in a survey sample of 29 Residents. The findings included; 1. For Resident # 54 the facility staff failed to weigh the resident weekly. Resident #54 a [AGE] year old woman who was admitted to the facility on [DATE] with diagnoses of but not limited to COPD, dementia, dysphagia, COPD, disorientation, anxiety, and major depressive disorder. Resident #54. Resident #54's most recent MDS ( Minimum Data Set) with an ARD (Assessment Reference Date) 12/24/19 coded the Resident as having a BIMS (Brief Interview of Mental Status) of 1 indicating severe cognitive impairment. On 2/12/20 during clinical record review it was discovered that Resident #54 had lost 12.9% of her total body weight in 6 months. The review showed the Resident continued on monthly weights even with though there was significant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility documentation and clinical record review the facility staff failed to provide oxygen within the accepted standards of practice for 1 Resident (#78) in a survey sample of 29 Residents. The findings included: For Resident #78 the facility staff failed to change oxygen tubing weekly as outlined in care plan and per facility policy. Resident #78 a [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to schizophrenia, liver cell carcinoma, dysphagia, asthma, viral hepatitis and anxiety disorder. Resident #78's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/17/20 coded as a quarterly assessment codes Resident #78 as having a BIMS (Brief Interview of Mental Status) score of 15 indicating no cognitive impairment. Resident #78 is independent with all ADLs (activities of daily living) and is continent of bowel and bladder. On 2/11/20 at approximately 7:00 PM the Resident was observed in bed, oxygen concentrator…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure nurse aide competency in skills necessary to care for residents' needs for one resident (Resident #332) in a sample size of 29 residents. The findings included: For Resident #332, the nurse aides failed to operate the mechanical lift to obtain a weight according to manufacturer's instructions on 02/12/2020. They did not correctly zero the lift scale. Resident #332, a [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses included but not limited to schizophrenia, dementia, and type 2 diabetes mellitus. Due to the new admission status, a Minimum Data Set assessment was not completed. On 02/12/2020 at 11:00 AM, an interview with CNA C was conducted. CNA C verified she was responsible for obtaining monthly weights on residents. When asked to observe CNA C obtain a weight on Resident #332, CNA C stated yes and she would have to go get the mechanical lift to obtain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, facility documentation, clinical record review the facility staff failed to ensure Residents are free from unnecessary medications for 1 Resident (#19) in a survey sample of 29 Residents. The findings included; For Resident #19 the facility staff failed to ensure that the Resident had did not have PRN Lorazepam orders for longer than 14 days. Resident #19 a [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Atrial fibrillation, heart failure, hypertension, diabetes, Alzheimer's Dementia, anxiety disorder, depression and psychotic disorder. Resident #19's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/19/19 coded the Resident as having a BIMS ( Brief Interview of Mental Status) score of 00 indicating severe cognitive impairment. Resident is non ambulatory and requires total care with all aspects of ADL. On 2/13/120 at approximately 6:00 PM a review of the clinical record revealed that Resident # 19 had orders that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Resident interview, staff interview, clinical record review and facility documentation review, the facility failed to provide dental evaluations and care for 1 Resident (Resident # 72) in a survey sample of 29 Residents. The findings include: Resident #72's dentures did not fit, and would not stay in his mouth, preventing him to talk and eat properly. Resident #72 was admitted to the facility on [DATE]. Diagnoses included: Diabetes, malnutrition, functional quadriplegia, peripheral vascular disease, recurrent pain, recurrent depression, and skin wounds. On 2-11-2020 at 6:30 p.m., during initial tour of the building an interview was attempted with Resident #72. The Resident attempted to talk with the surveyor, however, the upper plate of his dentures kept falling down, and the bottom plate was so loose it jutted out of his mouth every time he tried to speak, and he was unable to communicate. When asked if he had been to the dentist he shook his head to indicate No. When asked if he wanted his dentures…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed, for 2 residents (Resident #9 and Resident # 54) out of 29 sampled residents to provide emergency and routine dental services. The Findings included: 1. For Resident #9, the facility staff failed to provide emergency dental services after her bottom dentures were broken and unusable. Resident #9 was a [AGE] year old. Resident #9's diagnoses included Gastro-Esophageal Reflux Disease, and Heart Failure. The Quarterly Minimum Data Set, dated [DATE] was reviewed. Resident #9 was coded as having a Brief Interview of Mental Status Score of 13, indicating no cognitive impairment. Resident #9 was also coded as requiring setup assistance for eating. On 2/12/20 at 10:30 A.M., an interview was conducted with Resident #9 in her room. She complained that her meat was often not cut up. She said that she could feed herself is the meal 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 2. For Resident # 50 the facility staff failed to ensure she accurate orders for advance directives. Resident # 50 a [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to hypertension, anxiety disorder, depressive disorder, history of stroke, arthritis, and lumbar radiculopathy (pain is often caused by nerve compressing causing pain to radiate from back to the lower extremity). Resident #50's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of [DATE] a quarterly assessment coded the Resident as having a BIMS (Brief Interview of Mental Status) score of 15 indicating no cognitive impairment. On [DATE] during clinical record review it was noted that Resident #50 has current physician orders dated for February 2020 signed by physician on [DATE] that read: Full Code However the Resident care plan read, Resident has advanced directives: Resident is DNR. Date initiated: [DATE] Revised [DATE] On [DATE], an interview was conducted with LPN B who was asked…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility documentation review, the facility failed to maintain equipment for one resident (Resident #25) in a sample size of 29 residents. The findings included: For Resident #25 the facility staff failed to provide the missing part to the Bi-Pap Machine they provided for 1 week. Therefore the Resident was unable to use her Bi-pap. Resident #25, a [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to acute and chronic respiratory failure with hypoxia, pneumonia, heart failure, anxiety disorder, Atrial fibrillation, and chronic obstructive pulmonary disorder. Resident #25's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Dater) of 12/01/19 coded as an OBRA Assessment. Resident #25's MDS coded the Resident as having a BIMS (Brief Interview of Mental Status) score of 15 indicating the Resident has no cognitive impairment. Resident #25 is independent in all ADL (Activities of Daily Living)…

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.