Skyview Springs Rehab And Nursing Center

Based on staff interview, facility document review and clinical record review, the facility staff failed to provide pharmacy services for one of 34 residents in the survey sample, Resident #35. The findings include: For Resident #35 (R35), the facility staff failed to ensure the medication Jardiance (1) was available for administration on 10/9/23 and 10/10/23. A review of R35's clinical record revealed a physician's order dated 3/13/23 for Jardiance 25 mg (milligrams) by mouth one time a day for type two diabetes mellitus. A review of R35's October 2023 MAR (medication administration record) revealed the same physician's order for Jardiance. On 10/9/23 and 10/10/23, the MAR documented the code, 9= Other/ See Progress Notes. Nurses' notes dated 10/9/23 and 10/10/23 documented the medication Jardiance was not administered and was on order. On 11/1/23 at 2:19 p.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated medications should be re-ordered from the pharmacy when there is a five-day supply of the medication left. LPN #4 stated that if a 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.

Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure a medication error rate of less than 5% for one of 34 residents in the survey sample; Resident #94. The facility had two medication errors out of 35 opportunities, resulting in a medication error rate of 5.71%. The findings include: For Resident #94, Humalog insulin was administered after breakfast instead of before breakfast, resulting in a medication error of not administering the medication at the right time as ordered by the physician. On 11/01/23 at 8:20 AM, the Medication Administration task was conducted with LPN #5 (Licensed Practical Nurse) for Resident #94. The following was observed: 1. Humalog (1) 10 units, scheduled, was administered after the resident had breakfast. 2. Humalog 2 units based on sliding scale, was administered after the resident had breakfast. A review of the clinical record revealed the following orders: 1. An order dated 7/27/23 for Humalog 10 units twice daily, before breakfast and lunch. 2. An order…

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 complete and accurate documentation for two of 34 residents in the survey sample, Residents #11 and #106. The findings include: 1. For Resident #11, the facility staff failed to evidence complete and accurate documentation for showers/bathing. A review of the comprehensive care plan dated 2/3/23, which revealed, FOCUS: Resident has an ADL (activities of daily living) self-care performance deficit related to weakness and right leg amputation. INTERVENTIONS: Provide supervision and cuing as needed with ADLs. Physical assist as needed with ADLs. A review of the ADL document in Resident #11's medical record, revealed documentation for showers was missing for 8/23/23 and 8/26/23. Shower documentation was also missing for 9/6/23, 9/30/23, 0/4/23, 10/7/23, 10/11/23, 10/18/23, 10/21/23, 10/25/23 and 10/28/23. An interview was conducted on 10/31/23 at 3:00 PM with Resident #11. Resident #11 stated, They do not give me showers consistently. I do not think they…

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

Based on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to promote self-determination to participate in activities and socialization with other resident for one of three residents in the survey sample, Resident #1. The findings include: Resident #1 (R1) only participated in an activity of choice 13 out of 28 days from 7/16/2023 through 8/14/2023. On the most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 7/22/2023, the resident was coded as scoring a nine out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired to make daily decisions. In Section G - Functional Status, the resident was coded as being either independent or requiring only supervision for all his activities of daily living. The resident was coded as being independent for locomotion on and off the unit. In Section F - Preferences for Customary Routine and Activities, the resident was coded as the following items…

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 4. The facility staff failed to implement the comprehensive care plan for bathing for Resident #52. Resident #52 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), a quarterly assessment, with an ARD (assessment reference date) of 12/30/2021, the resident scored an 8 of 15 on the BIMS (brief interview for mental status), indicating the resident is severely cognitively impaired for making daily decisions. In Section G - Functional Status, the resident was coded as not having had a shower or bath during the lookback period. The comprehensive care plan dated 11/29/2021 documented, in part, Focus: The resident has an ADL self-care performance deficit r/t (related to) Dementia, Limited Mobility .BATHING/SHOWERING - Provide sponge bath when a full bath or shower cannot be tolerated. There was no documentation in the care plan that the resident has refused baths/showers. An interview was conducted with the resident's family member on 2/6/2022 at 3:11p.m. When asked if she had any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement a complete pain management program by documenting the location of the resident's pain and implementing non-pharmacological interventions prior to the administration of prn (as needed) pain medications for two of 51 residents in the survey sample, Residents # 25 and # 88. The findings include: 1. The facility staff failed to document the location of the Resident #25's pain and implementing non-pharmacological interventions prior to the administration of Tramadol (1). Resident # 25 was admitted to the facility with a diagnosis that included by not limited to osteoarthritis. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/10/2021, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section…

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

Based on observation, resident interview, staff interview and clinical record review, it was determined that the facility staff failed to provide food at a palatable temperature during lunch service on 2/7/2022, with the potential to affect 53 of 54 residents on the North unit receiving a meal tray. The findings include: Review of the resident council minutes from a meeting held on 1/31/2022. The minutes stated: .1. Food- not being cooked/too tough. Cold food- Getting trays late. Resident requested hot . A resident comments/concerns form dated 1/31/22 included in the minutes documented in part, .Resident c/o (complains of) food being cold when they get it. 2. They want hot coffee. 3. Some of the food is too tough to eat. - The food is at temp (temperature) when it leaves the kitchen- we do not have any control of when it is delivered. The coffee is served at 160 (degrees) in an insulated mug. We will speak to DON (director of nursing). Tough food is most likely pork chops. We are working on that as we speak. Trying to find a way to tenderize them better. [Signature of OSM (other…

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

Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to act upon a reported grievance for missing personal items for one of 51 residents in the survey sample, Resident #21. The facility staff failed to promptly respond to a known grievance for missing clothing items for Resident #21. The findings include: On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/9/2021, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. On 2/6/2021 at 5:00 p.m., an interview was conducted with Resident #21. The resident stated that they had received several items of clothing from their son and his girlfriend for Christmas and had sent them to the laundry to be labeled which had not been returned. The resident stated that they were missing a sweatshirt, two pairs of sweatpants and a pajama set and they had spoken to [Name of 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.

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 implement facility initiated transfer requirements for 3 of 51 residents in the survey sample, Residents #96, #81 and #54. The facility staff failed to evidence a physician note regarding facility initiated hospital transfers for Residents #96 and #81 and failed to evidence required information provided to hospital staff for facility initiated transfers for Residents #81 and #54. The findings include: 1. Resident #96 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/18/21, the resident scored 3 out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely cognitively impaired for making daily decisions. Review of Resident #96's clinical record revealed the resident was transferred to the hospital on [DATE] for a fever and altered mental status. Further…

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, resident interview, facility document review and clinical record review, it was determined the facility staff failed to provide an accurate assessment for one of 51 residents, Resident #32. The facility staff failed to complete an accurate MDS (minimum data set), an annual assessment, for Resident #32. The findings include: During the entrance conference on 2/6/22, request was made for the facility to provide a list for smoking times and residents that smoke. There were five residents from the south wing and three residents from the north wing on the list provided 2/6/22 at 3:30 PM; Resident #32 was included on the list. On 2/7/22 at 3:00 PM, Resident #32 was observed to go to the outside smoking area. The smoking area for South wing residents was supervised by two staff, with five residents smoking. LPN (licensed practical nurse) #8 distributed cigarettes and then lit each resident's cigarette. The smoking area contained a smoke blanket and a fire extinguisher with inspection tag 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 family interview, facility document review, and clinical record review, it was determined the facility staff failed to provide ADL (activities of daily living) care for one of 51 residents in the survey sample, Resident #52. Resident #52, a dependent resident, was not provided baths. The findings include: Resident #52 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), a quarterly assessment, with an ARD (assessment reference date) of 12/30/2021, the resident scored an 8 of 15 on the BIMS (brief interview for mental status), indicating the resident is severely cognitively impaired for making daily decisions. In Section G - Functional Status, the resident was coded as not having had a shower or bath during the lookback period. The comprehensive care plan dated 11/29/2021 documented, in part, Focus: The resident has an ADL self-care performance deficit r/t (related to) Dementia, Limited Mobility .BATHING/SHOWERING - Provide sponge bath when a full bath or shower cannot be…

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 implement the physician ordered interventions for the prevention of pressure injuries for one of 51 residents in the survey sample, Resident # 11. The facility staff failed to place a donut pillow on the resident's left ankle. The findings include: Resident #11 was admitted to the facility 7/11/2015. On the most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 11/17/2021, the resident was coded as having short and long term memory problems and as being severely cognitively impaired for making daily decisions. In Section M - Skin Conditions, the resident was coded as having one stage III pressure injury. Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview and clinical record review, it was determined that the facility staff failed to implement interventions to prevent an accident for two of 51 residents in the survey sample, Residents # 10 and #32. The findings include: 1. The facility staff failed to provide two fall mats and place one fall mat on Resident # 10's right side of the bed. Resident # 10 was admitted to the facility with a diagnosis that included but was not limited to lack of coordination. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/16/2021, the resident scored 4 out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely impaired of cognition for making daily decisions. On 02/06/2022 at approximately 2:22 p.m., an observation of Resident # 10 revealed they were lying in bed with a fall mat on the floor to the resident's left side. On 02/07/2022 at approximately 9:52 a.m., an observation 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 it was determined that the facility staff failed to provide respiratory services as ordered, and in a sanitary manner, for three of 51 residents in the survey sample, Residents #74, #28, and #41. The findings include: 1. The facility staff failed to administer oxygen at the ordered flow rate to Resident #74. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/19/2022, the resident was coded as being severely impaired for making daily decisions. Section O documented the resident receiving oxygen while a resident at the facility. On 2/6/2022 at approximately 2:15 p.m., Resident #74 was observed in bed wearing an oxygen nasal cannula with a humidifier bottle dated 2/4/22; this equipment was attached to an oxygen concentrator. The oxygen flow rate on the concentrator was observed to be set at 1.5 lpm (liters per minute). Resident #74 was observed to be alert, awake and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to complete an assessment for the use of side rails and/or failed to have consent, after discussion of the risks and benefits for the use of the bed rails, for three of 51 residents in the survey sample, Residents #11, #40 and #28. The findings include: 1. The facility staff failed to obtain consent, after a discussion of the risks and benefits for the use of the bed rails, from the responsible party, for Resident #11. Resident #11 was admitted to the facility 7/11/2015. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/17/2021, the resident was coded as having short and long term memory problems and severely cognitively impaired for making daily decisions. In Section G - Functional Status, the resident was coded as requiring extensive assistance of two staff members for moving in the bed. Observation 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, facility document review and employee record review, it was determined that the facility staff failed to evidence documentation for one of four CNA (certified nursing assistant) employee records reviewed, CNA #3. For CNA #3, the facility staff failed to evidence documentation of an annual performance review. The findings include: A review was conducted of four CNA employee records for the documentation of an annual performance review. CNA #3 failed to have documented evidence of a performance review. A request was made for the above records on 2/7/2022 at the end of day meeting at approximately 4:45 p.m. On 2/8/2022 at approximately 9:00 a.m., OSM (other staff member) # 3, human resources, reviewed the requested documents with this surveyor and stated she'd return with answers after looking further. On 2/8/2022 at 11:00 a.m., OSM #3 presented a Critical Skills Checklist dated 7/8/2021. OSM #3 stated she could not find any other documentation of an annual performance review for CNA #3. The facility policy, Nurse Aide In-service Training, 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.

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 a complete and accurate clinical record for 1 of 51 residents in the survey sample, Resident #83. The facility staff failed to ensure that the PASRR (Pre-admission Screening and Resident Review) level 2 screening was available on the clinical record. The findings include: Resident #83 was admitted to the facility on [DATE] and had the diagnoses of but not limited to stroke, bipolar, and depression. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/25/22, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. The resident was coded as requiring extensive assistance for bathing and supervision for all other areas of activities of daily living. A review of the clinical record revealed a PASRR level 1 screening…

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 administer the pneumococcal immunization for one of five resident immunization record reviews, Resident 91. Resident #91's RR (resident representative) provided consent for the pneumococcal immunization on 12/29/21. The facility staff failed to evidence the immunization was administered to the resident. The findings include: Resident #91 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/27/22, the resident scored 5 out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely cognitively impaired for making daily decisions. Review of Resident #91's clinical record revealed a consent for the pneumococcal immunization form dated 12/29/21 that documented a check mark beside, I hereby GIVE the facility permission to administer a pneumonia VACCINATION,…

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 that the facility staff failed to track all employees' COVID-19 vaccination status, and failed to implement the facility policy for employee vaccination tracking for 6 of 100 employees sampled, OSM (other staff member) #10, #11, #12, #13, #14, and #15. The facility staff failed to implement their policy for COVID-19 employee vaccination status tracking, and failed to track COVID-19 vaccination status for OSM #10, #11, #12, #13, #14, and #15, all employees of [name of Hospice Company]. The findings include: The facility policy titled, COVID-19 (SARS-CoV-2) Vaccination Policy- Employee documented, 4. Procedures- [Name of facility company] requires all employees, and all volunteers and contractors working on-site, to be 'fully vaccinated' against COVID-19. Employees must provide proof of full vaccination status either by proof of vaccination via the Vaccination Attestation form .To establish they have received the COVID-19 vaccine, employees must [sic] one of the following: CDC (Centers for Disease Control)…

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 have an annual inspection of three resident beds of 52 beds in the survey sample, Resident #11, #40, and #28. The findings include: 1. For Resident #11, the facility staff failed to complete an annual bed inspection. Resident #11 was admitted to the facility 7/11/2015. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/17/2021, the resident was coded as having short and long term memory problems and severely cognitively impaired for making daily decisions. In Section G - Functional Status, the resident was coded as requiring extensive assistance of two staff members for moving in the bed. Observation was made of Resident #11 on 2/6/2022 at 2:10 p.m. The resident observed to be in her bed, with both side rails up. The physician orders dated, 5/29/2019, documented, 1/4 (quarter) side rails to aid with bed…

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 employee record review, it was determined the facility staff failed to ensure one of four CNA (certified nursing assistants) had required training, CNA #2. The facility failed to provide CNA #2 training in dementia care. The findings include: The employee education records of four CNAs were reviewed. It was noted that CNA #2 failed to have any documented dementia training. A request was made for CNA #2's dementia training records on 2/7/2022 at the end of day meeting at approximately 4:45 p.m. On 2/8/2022 at approximately 9:00 a.m. OSM (other staff member) # 3, human resources, reviewed the requested documents with this surveyor and stated she would return with further information. On 2/8/2022 at 11:00 a.m., OSM #3 stated she could not find the documentation of any dementia training for CNA #2. The facility policy Nurse Aide In-service Training documented, in part, 4. Annual in-services: e. include training that addresses the care of residents with cognitive impairment; and f. include training in dementia management, 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.

Based on staff interview and facility document review it was determined that the facility staff failed to ensure RN (Registered Nurse) coverage for at least 8 hours a day, every day. A review of the staffing schedules and postings revealed several dates where there was no RN on duty. The findings include: A review of the as-worked schedule for 30 days and the staff postings revealed there was no RN coverage on the following dates: 10/12/19 10/13/19 10/20/19 10/21/19- [Review of the staff posting for 10/21/19, documented 24 hours of RN coverage. This was not reflected on the as-worked schedule. No evidence was provided, that an RN was on duty this date.] 10/24/29 - [Review of the staff posting for 10/24/19, documented 16 hours of RN coverage. This was not reflected on the as-worked schedule. No evidence was provided, that an RN was on duty this date.] 10/25/19 10//25/19 11/9/19 11/10/19 A review of the staff posting revealed that there was no RN scheduled for the following dates: 10/12/19 - this was in agreement with the as-worked schedule. 10/13/19 - this was in agreement with 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, staff interview, and facility document review, it was determined that the facility staff failed to prepare and serve food in a sanitary manner. The findings include: On 11/13/19 from 11:42 AM to 12:40 PM, an observation was made of the tray line service. The following issues were observed: 1. OSM #10 (Other Staff Member, dietary staff) was preparing the plates for each tray. The tray line contained a wooden butcher-block surface area for setting items on. The wooden surface was noted to contain stains of various age appearance. She had the same pair of gloves on throughout the tray line service. She was noted to touch this stained wooden surface multiple times with her gloved hands. She was noted to place the tongs used to pick up fish and Salisbury steaks, directly on the wooden surface. OSM #10 was noted to handle plates, bowls, serving tongs and spoons, and touch various surfaces of the steam table / tray line equipment with the same gloves on that touched the stained butcher-block surface. She was observed to handling each plate as she prepared it with her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and employee record review, it was determined that the facility staff failed to meet the training requirements for eight of 15 CNA (Certified Nursing Assistant) employee records reviewed, (CNA #4, CNA #5, CNA #6, CNA #7, CNA #8, CNA #9, CNA #2 and CNA #100. The findings include: A review of education records was conducted for 15 facility CNA records. The following was identified: 1. CNA #4 did not complete the required 12 hours of training during her anniversary year of [DATE] to [DATE]. She completed 7.75 hours. 2. CNA #5 did not complete the required 12 hours of training during her anniversary year of [DATE] to [DATE]. She completed 10 hours. 3. CNA #6 did not complete the required 12 hours of training; did not complete dementia care training during her anniversary year from [DATE] to [DATE]. She completed 4.25 hours. 4. CNA #7 did not complete the required 12 hours of training; did not complete dementia care training during her anniversary year from [DATE]…

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

Based on resident interview, facility staff interview, and facility document review, it was determined that the facility staff failed to assist residents to exercise their right to vote. The facility staff failed to offer residents who could vote the opportunity to do so for the November 2019 election. The findings include: On 11/13/19 at 11:00 a.m., a group interview was conducted with 12 residents. Of these 12 residents, eight (Residents # 9, #45, #87, #13 and GRP [group resident] #31, #42, #3, and #48) were coded as cognitively intact with brief interview for mental status scores at 13-15. As a part of the group interview, the surveyor asked the residents if they were given the opportunity, or if they were assisted to vote in the recent elections. All eight cognitively intact residents stated they were not offered the chance to vote. On 11/13/19 at 3:11 p.m., OSM (other staff member) #17, the activities director, was interviewed. When asked who is responsible for arranging for facility residents to vote, OSM #17 stated, I am. But I did not do that this year. It completely slipped…

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 and facility staff interview, the facility staff failed to maintain a comfortable home-like environment in two of two common areas on the north wing, and in the main dining room. On 11/13/19, observations revealed temperatures in the north wing common areas were 61 degrees, and the temperature in the main dining room was 64 degrees. The findings include: On 11/13/19 at 8:58 a.m., the surveyor walked through the north wing of the facility. In both common areas at either end of the wing, the temperature felt cold. Two residents were observed in one of the common areas; both residents were wearing heavy sweaters and had their hands arms crossed tightly in front of them. On 11/13/19 at 9:04 a.m., OSM (other staff member) #7, the maintenance director, was asked to accompany the surveyor to the common areas and to take the temperatures. In the common area nearest the main entrance, the temperature registered 61 degrees. The common area at the opposite end of the unit also measured 61 degrees. OSM…

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 the facility staff failed to evidence documentation that the care plan goals were sent to the hospital upon transfer for 5 of 60 Residents in the survey sample, Residents #56, #19, #81, #82, and #105 The findings include: 1. On 10/8/19, Resident #56 was transferred to the hospital, there was no documented evidence that the comprehensive care plan goals were sent to the receiving facility. Resident #56 was admitted to the facility on [DATE], with a recent readmission on [DATE] with diagnoses that included but were not limited to: congestive heart failure (1), anxiety disorder, high blood pressure, gout (2), and dementia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 9/30/19, coded the resident as scoring a 14 on the BIMS (brief interview for mental status) score, indicating the resident was capable of making daily cognitive decisions. A nurse's 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure professional standards of quality for as needed pain medications for two of 60 residents in the survey sample, Resident #81 and #87. The facility staff failed to clarify two PRN (as needed) pain medication orders for Resident #81 to determine when each medication should be administered based on pain level parameters. The facility staff failed to clarify two PRN (as needed) pain medication orders for Resident #87 to determine when to administer each medication based on pain level parameters. The findings include: 1. Resident #81 was admitted to the facility with diagnoses that included but were not limited to: cancer of the lung, anxiety disorder, stroke, chronic pain syndrome, and high blood pressure. The most recent MDS (minimum data set) assessment, a Medicare 30 day assessment, with an assessment reference date of 11/7/19, coded the resident as scoring a 15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to assess a resident to administer their medications independently for one of 60 residents in the survey sample, Resident #87. Resident # 87 was observed administering her nebulizer treatments without supervision from a nurse on two occasions; review of the clinical record failed to evidence a self-administration of medication assessment for the resident. The findings include: Resident #87 was admitted to the facility on [DATE] with diagnoses that include but were not limited to: respiratory failure, chronic pain syndrome, COPD [general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis] (1) and anxiety disorder. The most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 10/24/19, coded the resident as scoring a 15 on the BIMS (brief interview for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility documentation review, facility staff failed to ensure two of 60 residents in the survey sample, Residents #72, and #82, were free from abuse. On 9/24/19, Resident #304 hit Resident #72 on the face with his open hand, causing a red area on Resident #72's face and pushed Resident #72, hitting his knee on the doorframe causing an abrasion. On 7/12/19, Resident #53 hit Resident #82 with her cane causing a bruises to her fifth digit of the right hand. The Findings Included: 1. Resident #72 was admitted to the facility on [DATE]. His diagnoses included diabetes, delusional disorders, and intellectual disability. Resident #72's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 10/15/2019. The Brief Interview for Mental Status (BIMS) scored Resident #72 at a 12, indicating mild impairment. Resident #72 was coded as requiring extensive assistance of one person for bed mobility, transfers, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to notify the ombudsman of a transfer to the hospital and evidence a notice was given to the resident and/or responsible party with the reason for the transfer for one of 60 residents in the survey sample, Resident #19. The findings include: Resident #19 was admitted to the facility on [DATE], with a recent readmission on [DATE] with diagnoses that included but were not limited to: anxiety disorder, dementia, seizures, and stroke. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 9/6/19, coded the resident as scoring a 9 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired to make daily cognitive decisions. The nurse's note dated, 10/16/19 at 8:34 a.m. documented, Resident found beside of bed on back. When attempted to move he complained of back and head pain, resident to be sent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, and facility document review, it was determined that the facility staff failed to accurately code the MDS (Minimum Data Set) assessment for smoking status for 2 of 60 residents in the survey sample; Residents #32 and #45. The facility staff coded the Resident #32 as not being a current tobacco user on the most recent comprehensive assessment dated [DATE] and the resident was observed smoking. The facility staff coded the Resident #45 as not being a current tobacco user on the most recent comprehensive assessment dated [DATE], when the resident stated during interview that (Resident #45) does go outside to smoke about twice a day with another resident. The findings include: 1. Resident #32 was admitted to the facility with the diagnoses including but not limited to, diabetes, nicotine dependence, angina, hemiplegia, mood disorder, depression, epilepsy, high blood pressure, cerebrovascular disease, and aphasia. The annual MDS (Minimum Data Set) assessment…

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 implement the comprehensive care plan for one Resident, Resident #25, in a sample of 60 Residents. The facility staff failed to implement the interventions for Resident #25's urinary catheter care plan. The Findings Included: Resident #25 was admitted to the facility on [DATE]. His diagnoses included anxiety disorder, depression, and urinary retention. Resident #25's most recent Minimum Data Set (MDS) assessment was a Significant Change Assessment with an Assessment Reference Date (ARD) of 09/04/2019. The Brief Interview for Mental Status (BIMS) scored Resident #25 at a 15, indicating no impairment. Resident #25 was coded as requiring extensive assistance of two or more people for all Activities of Daily Living (ADLs). On 11/12/2019 at 12:06p.m., an observation was made of Resident #25 in his room watching TV in his wheelchair. It was noted at that time that the urine drainage bag from…

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

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to review and/or revise the comprehensive care plan to address a fall for one of 60 residents in the survey sample; Resident #19. The findings include: Resident #19 was admitted to the facility with the diagnoses of but not limited to mental and behavioral disorders, sepsis, anxiety disorder, bladder neuromuscular dysfunction, vascular dementia, seizures, stroke, aphasia, and benign prostatic hyperplasia. The quarterly MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 9/6/19 coded the resident as being moderately impaired in ability to make daily life decisions. The resident was coded as extensive care for bathing, hygiene, toileting, and dressing; supervision for bed mobility; independent for eating and ambulation; had no upper or lower extremity impairment; was incontinent of bowel frequently and had an indwelling catheter for bladder. A review of the clinical record revealed a nurse's note dated 2/8/19 that documented, pt…

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 ensure respiratory care consistent with professional standards of practices for one of 60 residents in the survey sample, Resident # 86. The facility staff failed to ensure a full E-cylinder of oxygen for Resident #60 was properly stored and secured. The findings include: Resident #86 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: COPD [chronic obstructive pulmonary disease] (1), anxiety disorder, and GERD [gastroesphogeal refulx disease] (1). The most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 10/21/19, coded the resident as scoring a 14 on the BIMS (brief interview for mental status) score, indicating he was capable of making daily cognitive decisions. The resident was coded as requiring supervision to limited assistance for his activities of daily living. 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 staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure a complete and accurate medical record for one of 59 residents, Resident #48. The physician's progress notes failed to document discussion regarding alternative to smoking. The findings include: Resident #48 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Alzheimer's (progressive loss of mental ability and function often accompanied by personality changes and emotional instability (1), schizophrenia (mental disorder characterized by gross distortions of reality, withdrawal from social contacts, and disturbances of thought, language and perception) (2) and depressive disorder (dejected state of mind with feelings of sadness, discouragement, and hopelessness) (3). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 9/23/19, coded the resident as scoring a 15 out of 15 on the…

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