Forest Health & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to develop comprehensive care plans for eleven of 22 residents in the survey sample, Resident #'s 10, 17, 33, 39, 5, 12, 31, 18, 8, 301, and 11. Resident #10 had no care plan developed for activities of daily living, incontinence, falls, nutrition, pressure ulcer prevention, psychoactive medication use, pain management, dialysis, fluid intake restrictions or insomnia. Resident #17 had no care plan developed for activities of daily living, incontinence, falls, dehydration, dental problems, pressure ulcer prevention or psychotropic medication use. Resident #33 had no care plan developed to address communication, activities of daily living, incontinence, falls, nutrition, dehydration or psychoactive medication use. Resident #39 had no care plan developed to address hospice care. Resident #5 had no care plan developed for activities of daily living, communication, nutrition, falls, dehydration and pressure ulcers. Resident #12 had no care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility failed to develop a baseline care plan for skin integrity for for one of 37 Residents, Resident #198. The findings Include: Resident #198 was admitted to the facility on [DATE]. Diagnoses for Resident #198 included; Dementia, sepsis, kidney disease, and stage 2 pressure ulcer to buttocks. The most current MDS (minimum data set) was an entry assessment with an ARD (assessment reference date) of 02/15/21. Resident #198 was assessed with a cognitive score of 05 indicating cognitively impaired. On 2/24/21 Resident #198's medical record was reviewed and indicated that Resident #198 was newly admitted with a stage 2 pressure ulcer to right buttock. Review of Resident #198's baseline care plan dated 2/15/21 documented a check mark beside current skin integrity issues and indicating a stage 2 pressure ulcer on the right buttock, but did not indicate any goals or interventions for the care of Resident #198's pressure ulcer. On 02/24/21 at 01:46 PM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility staff failed to review and revise care plans for two of 22 residents in the survey sample, Resident #12 and Resident #35. Resident #12's care plan had not been reviewed or revised since 04/16/2020. Resident #35's care plan was not reviewed and revised for care and treatment of pressure ulcers. The findings include: 1. Resident #12 was admitted to the facility on [DATE] with diagnoses including heart failure, congestive heart failure, chronic kidney disease, hypertension, hyperlipidemia, and hemiparesis/hemiplegia. The most recent minimum data set (MDS) dated [DATE] was the annual/comprehensive assessment and assessed Resident #12 as cognitively intact for daily decision making with a score of 14 out of 15. Under Section G - Functional Status, Resident #12 was assessed as total dependent for transfers, toileting, dressing, bathing, and hygiene; extensive assistance for bed mobility and locomotion; and independent for eating. The MDS assessed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview and clinical record review, the facility staff failed to provide assistive devices for one of 22 residents in the survey sample, Resident #44, and failed to ensure a safe bed environment for one of 22 residents, Resident #35. Resident #44, who was identified as having a history of falls was observed without bilateral falls mats to each side of the bed. Resident #35's bed rails/grab bars were observed with a bent clip with a sharp edge. The findings include: 1. Resident #44 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included stroke, anemia, hypertension, renal insufficiency, type two diabetes, Non-Alzheimer's disease, and depression. The most recent minimum data set (MDS) dated [DATE] which was a 5-day assessment, assessed Resident #44 as severely impaired for daily decision making with a score of 6 out 15 with periods of fluctuating inattention and disorganized thinking. Under section G - Functional Status, Resident #44…

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, the facility staff failed to obtain informed consent and attempt alternatives prior to the use of bed rails for one of 22 residents in the survey sample. Resident #35, assessed with severe cognitive impairment, had bed rails in use without prior informed consent from her family or any attempted alternatives to the rails. The findings include: Resident #35 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, vascular dementia with behavioral disturbance, hypertension, glaucoma, osteoarthritis and COVID-19. The minimum data sets (MDS) dated [DATE], 12/5/20 and 1/30/21 assessed Resident #35 with short and long-term memory problems and severely impaired cognitive skills. On 2/23/21 at 11:12 a.m., Resident #35 was observed in bed with U-shaped side rails up on both sides of the bed near the head. The resident was observed in bed on 2/23/21 at 12:00 p.m. and at 12:40 p.m. with the side…

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

Based on observation, staff interview, and facility document review, the facility staff failed to ensure expired medications were not readily available for distribution on the East Wing. The findings include: On 02/23/2021 at 12:23 p.m. medication storage observations were conducted on the East Wing with RN #2 (registered nurse). An opened bottle of GERICARE 24 Hour Non-drowsy Allergy Relief Loratadine 10 mg (milligrams) tablets was observed with an expiration date of 01/2021 on the 200-300 East Wing medication cart. Additionally, an unopened bottle of the same medication with an expiration date of 08/2020 was observed in the medication storage room on the East Wing. RN #2 observed both bottles of expired medications. On 02/23/2021 at 12:45 p.m., RN #2 was interviewed regarding expired medication. RN #2 stated nursing should check the medication cart and storage room at least once or twice weekly to ensure medications are in date and any expired medications are destroyed. A review of the facility's medication storage policy documented the following: .5. Discontinued, outdated, or…

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

Based on observation, staff interview, and facility document review, it was determined that the facility failed to store and label food in a sanitary manner and failed to follow proper sanitizing procedures. The findings include: On 2/23/2021 at 10:35 a.m. while accompanied by kitchen staff (other staff #3), food items in the walk-in freezer were inspected and an unlabeled, undated, frozen container was found. When asked, OS #3 reported that it was sausage gravy. Food items in the walk-in refrigerator were inspected and a container of peas was found with no label or date. OS #3 was interviewed at the time of the observations and stated the containers should have been labeled and did not know why they were not. On 2/23/2021 at 10:45 a.m., OS #3 was observed conducting a test of the 3-compartment sink using a test strip. OS #3 stated the results were 100 ppm (parts per million). When asked what the results are supposed to be, OS #3 stated she did not know and that she usually just recorded the results on the test log. An inspection of the test strip container revealed an expiration…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate medical record for one of 22 residents in the survey sample, Resident #47B. No documentation was entered in Resident #47B's record regarding her death on [DATE]. Findings were: Resident #47B was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: Alzheimer's, dementia, respiratory failure, seizures, and anemia. A quarterly MDS (minimum data set) completed [DATE], assessed Resident #47B as severely impaired with a cognitive summary score of 00. The clinical record was reviewed on [DATE] at approximately 11:30 a.m. Resident #47B was discharged from the facility on [DATE]. A discharge MDS with an ARD (assessment reference date) of [DATE] coded Resident #47B's reason for discharge as Death in Facility. The progress note section was reviewed. The following entries for Resident #47B were observed: [DATE] 15:25 [3:25 p.m.] O2 SATS [oxygen saturation] WARNING: Value:…

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

Based on observation, staff interview and facility document review, the facility staff failed to follow infection control practices during a dining observation on one of two nursing units. A staff member failed to perform hand hygiene between residents during a meal observation on the [NAME] unit. The findings include: On 2/23/21 at 12:43 p.m., a dining observation was conducted on the [NAME] unit. Without prior hand hygiene, certified nurses' aide (CNA) #1 was observed assisting Resident #36 out of bed and into a chair. CNA #1 touched the resident's bed covers, the resident's arm, and chair during the transfer. CNA #1 proceeded to set-up the resident's meal tray using the resident's utensils. Without performing hand hygiene, CNA #1 went to the rack and touched several items on three meal trays looking for meal tickets. Without prior hand hygiene, CNA #1 served a lunch tray to Resident #20. CNA #1 used the resident's utensils to cut food items, butter bread and provide tray set-up. On 2/23/21 at 12:55 p.m., CNA #1 was interviewed about hand hygiene between residents during meal…

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. Resident # 29 was admitted to the facility on [DATE] with diagnoses that included multiple myeloma, osteoarthritis, gout, hypothyroidism, Vitamin D deficiency, benign prostatic hyperplasia, chronic kidney disease, and non-rheumatic aortic valve disorder. According to the most recent Minimum Data Set, a Medicare 90-Day, with an Assessment Reference Date of 1/28/19, the resident was assessed under Section C (Cognitive Patterns) as being cognitively impaired, with a Summary Score of 3 out of 15. Resident # 29 had the following wound care order, dated 3/30/19, Wound care to heel; Santyl - nickel thick into the wound bed and edges. Cover this with Dakins solution soaked gauze and wrap with Kling. Change everyday. Wear soft boot on L (Left) foot all times. May remove during bath. The order was also transcribed on the Treatment Administration Record (TAR) for March and April 2019. (NOTE: Santyl is a collagenase ointment used in the treatment of burns and skin ulcers. Ref. MedicineNet.com.) (NOTE: Dakins Solution is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to develop a comprehensive care plan for four of 21 residents in the survey sample. 1. Resident #9, assessed with two pressure ulcers, had no comprehensive care plan regarding pressure ulcers. 2. Resident #23 had no comprehensive care plan regarding cognitive impairment, impaired vision, activities of daily living, incontinence, falls, pressure ulcer prevention, use of psychotropic medication and pain. 3. Residents #41 had no plan of care available and/or developed regarding any care areas. 4. Resident #43 had no plan of care available and/or developed regarding any care areas. The findings include: 1. Resident #9 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #9 included altered mental status, congestive heart failure, end stage dementia, cerebrovascular accident (stroke) and atrial fibrillation. The MDS dated [DATE] assessed Resident #9 with moderately impaired cognitive skills. 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 2. Resident #2 was admitted to the facility on [DATE] with diagnoses that included: hypertension, osteoarthritis, hemiplegia of the right dominant side, muscle weakness, glaucoma, and hypothyroidism. The most recent minimum data set (MDS) dated [DATE] which was a quarterly assessment, assessed Resident #2 as being modernly impaired for daily decision making with a score of 12 out of 15. Resident #2's clinical record was reviewed on [DATE] at 9:30 a.m. A review of the nurses notes documented the following: [DATE] - Care plan conference mtg. held today. Resident in attendance. RP (responsible party) invited, but did not attend. Resident with no questions or concerns. Continue with current POC (plan of care). See care plan conference summary. On [DATE], a copy of the most recent MDS assessment and care plans were requested from the MDS Coordinator (RN #1). The requested items were provided at approximately 10:40 a.m. A review of the MDS assessment which was provided noted the assessment was dated [DATE]. A review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow physician's orders for two of 21 in the survey sample, Resident #60 and Resident #66. 1. The facility staff failed to accurately document Resident #60's fluid intake in every 24-hour as ordered by the physician. 2. Facility staff failed to apply physician ordered geri sleeves and TED hose to Resident # 66. The findings include: 1. Resident #60 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: ESRD (end stage renal disease) requiring HD (hemodialysis). Hemiplegia of the right dominant side, hypertension, peripheral vascular disease, seizure disorder, depression, gout, diabetes, and hyperparathyroidism. The most recent minimum data set (MDS) dated [DATE] assessed Resident #5 as being severely impaired for daily decision making with a score of 5 out of fifteen. Resident #60's clinical record was reviewed on 04/10/18. The current physician 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 observation and staff interview the facility staff failed to ensure essential equipment in the laundry area was in proper working order. A washer, identified during the survey conducted in the facility 5/29/18 through 5/31/18 as having broken and not replaced, was identified during the current survey to still not be replaced. A dryer, identified as not safe to use, also identified during the May 2018 survey, was again identified as unsafe to operate, and had not been repaired or replaced. Findings include: On 4/11/19 at 8:15 a.m. the laundry area was inspected with the housekeeping supervisor, identified as OS (other staff) # 2. An empty space between a small, household size washer, and a mush larger industrial size washer was observed. OS # 2 was asked about the space, and she stated Yes, they never replaced the other big washer that went out. It's been about a year or so that it went out. OS # 2 went on to say The one dryer that went out was never replaced; they've worked on it and it worked for a while but it's out for good now too. There was a handwritten notice on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, and staff interviews, the facility staff failed to maintain the dignity of one of 21 residents in the survey sample (Resident # 66). Resident # 66 was observed eating with a plastic spoon during two separate meal observations. The findings were: Resident # 66 was admitted to the facility on [DATE] with diagnoses that included depression, Alzheimer's disease, dementia without behavioral disturbances, Vitamin D and B deficiency, dysphagia, hypothyroidism, arthritis, chronic venous insufficiency, chronic lymphocytic leukemia, and idiopathic peripheral autonomic neuropathy. According to the most recent Minimum Data Set, a Quarterly review with an Assessment Reference Date of 3/1/19, the resident was assessed under Section C (Cognitive Patterns) as having short and long term memory problems with severely impaired daily decision making skills. Under Section G (Functional Status), Resident # 66 was assessed as needing supervision with set-up help only for eating. At 12:50…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to ensure one of 21 residents in the survey sample was assessed to self administer medications: Resident # 43. Resident # 43 was observed alone in her room with a nebulizer (aerosolized medication) treatment in place without staff. Findings include: Resident # 43 was admitted to the facility 1/22/19 with diagnoses to include, but not limited to: sepsis, acute bronchitis, COPD, Parkinson's disease, and muscle weakness. The most recent MDS (minimum data set) was the admission assessment dated [DATE] and had Resident # 43 as assessed as being cognitively intact with a total summary score of 15 out of 15. On 4/9/19 at 11:34 Resident # 43 was observed in her room with a mask applied to her face which was supplying medication. There were no staff present in the room, and the nurse medication cart was not in the hall. The resident was asked about the treatment, and she stated it took about 20-25 minutes to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #9 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #9 included altered mental status, congestive heart failure, end stage dementia, cerebrovascular accident (stroke) and atrial fibrillation. The MDS dated [DATE] assessed Resident #9 with moderately impaired cognitive skills. Resident #9's clinical record documented a quarterly MDS was completed on 6/29/18. There were no additional assessments completed until 12/21/18. There was no MDS completed in September 2018. On 4/10/19 at 1:50 p.m., the registered nurse (RN #1) MDS coordinator was interviewed about Resident #9's quarterly assessments. RN #1 reviewed the submitted MDS records and stated, I missed the one [MDS] due in September [2018]. RN #1 stated a quarterly MDS for Resident #9 was completed in June 2018 and the next MDS was not done until December 2018. This finding was reviewed with the administrator and director of nursing during a meeting on 4/10/19 at 4:15 p.m.Based on staff interview 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 and clinical record review, the facility staff failed to develop a baseline care plan for two of 21 residents in the survey sample. Residents #175 and #176 did not have a baseline care plan developed within 48 hours of their admission to the facility. The findings include: 1. Resident #175 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, history of deep vein thrombosis, hypothyroidism and anxiety. The admission nursing assessment dated [DATE] assessed Resident #175 as alert and oriented to time, place and person. Resident #175's clinical record documented no baseline care plan that stated initial goals, objectives and/or interventions to address the resident's immediate care needs. The admission nursing assessment dated [DATE] documented the resident required extensive and/or total assistance for activities of daily living (transfers, mobility, personal hygiene, eating assistance, dressing), was incontinent of bowel/bladder and had contractures of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, the facility staff failed to follow standards of professional practice for one of 21 residents in the survey sample. Nursing failed to provide a documented assessment of Resident #23 at the time of a fall. The findings include: Resident #23 was admitted to the facility on [DATE] with diagnoses that included legal blindness, dysphagia, diabetes, high blood pressure, macular degeneration, arthritis and insomnia. The minimum data set (MDS) dated [DATE] assessed Resident #23 with severely impaired cognitive skills. Resident #23's clinical record documented a neurological assessment flow sheet completed from 2/14/19 through 2/17/19. This form listed assessments of the resident's vital signs (blood pressure, temperature, pulse, respirations), level of consciousness, pupil response, motor function of hands/extremities and pain. Residents #23's clinical record including nursing notes documented no incidents, falls or any explanation for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to provide proper care and treatment of pressure ulcers for two of 21 residents in the survey sample. 1. A nurse failed to perform hand hygiene between glove changes during a dressing application to Resident #9's pressure sore. In addition, the nurse failed to date and/or initial the newly applied dressing. 2. A nurse failed to perform proper hand hygiene during a dressing change to Resident #23's pressure ulcer and failed date and/or initial the newly applied dressing. The facility staff also failed to follow physician's orders for a pressure relieving boot for Resident #23. The findings include: 1. Resident #9 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #9 included altered mental status, congestive heart failure, end stage dementia, cerebrovascular accident (stroke) and atrial fibrillation. The MDS dated [DATE] assessed Resident #9 with…

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

Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to ensure correct placement of a urinary catheter drainage bag for one of 21 residents in the survey sample, Resident # 42. Resident # 42 was observed in his wheelchair with the catheter drainage bag in the seat of the wheelchair without a privacy cover. Findings include: Resident # 42 was admitted to the facility 6/18/18 with diagnoses to include, but were not limited to: diabetes, urinary retention, depression, and high blood pressure. The most recent MDS (minimum data set) was a quarterly review dated 2/1/19 and had Resident # 42 assessed with moderate impairment in cognition with a total summary score of 10 out of 15. On 4/9/19 at 12:35 p.m. Resident # 42 observed in dining room with catheter drainage bag in seat of wheelchair beside him and not in a privacy bag. LPN (licensed practical nurse) # 3, who was the unit manager, was asked about the catheter bag placement. A physician order dated 8/31/18 directed Foley Cath Leg Bag when OOB (out of bed). LPN # 3 stated He…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, and clinical record review, the facility staff failed to develop a dementia care plan for two of 21 residents, Resident's #41 and #68. The findings include: 1. Resident #41 was admitted to the facility on [DATE]. Diagnoses for Resident #8 included: Alzheimer's disease, dementia with behaviors, chronic pain and depression.The most current MDS (minimum data set) was a quarterly with an ARD (assessment reference date) of 2/1/19. Resident #41 was assessed with a score of 0 indicating severely cognitively impaired. Review of Resident #41's medical record evidenced that resident #41 had a diagnoses of dementia with behaviors. A comprehensive MDS with an ARD of 8/20/18 section V indicated that Resident #41 would be care planned for cognitive loss for dementia, behavioral symptoms, and psychoactive drug use. Review of Resident #41's medical record showed no evidence that a care plan was developed for dementia concerns. On 04/10/19 at 1:45 PM, the MDS coordinator (registered nurse, RN #1) 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 observation, staff interview, and facility document review, the facility staff failed to ensure expired medications were not available for administration on one of two units: East unit. A vial of expired PPD (tuberculin skin test solution) was in the refrigerator and available for use. Findings include: The medication room on the East unit was inspected with RN (registered nurse) #3 on 4/10/19 at approximately 8:30 a.m. Two vials of PPD solution were in brown plastic bag in the refrigerator; one was open and dated 11/6/18. The date was verified with RN # 3 who stated That should be thrown out; it's only good for 30 days after opened/dated. Night shift is in charge of checking the refrigerator for any expired meds .not sure if it's evening or night shift but day shift does not do it. During a meeting with facility staff on 4/10/19 beginning at 4:10 p.m. the DON (director of nursing) was asked for a copy of the medication storage policy. On 4/11/19 at approximately 7:45 a.m. the policy Refrigerated Medications: Storage Instructions and Expiration Dates was reviewed. 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 clinical record review and staff interview, the facility staff failed to ensure a complete and accurate clinical record for one of 21 residents in the survey sample: Resident # 63. Resident # 63's clinical record had two other resident's information co-mingled in the record. Findings include: Resident # 63 was admitted to the facility 12/4/17 with diagnoses to include, but not limited to: shortness of breath, high blood pressure, and heart disease. The most recent MDS (minimum data set) was a significant change assessment. Resident # 63 was coded as having long term and short term memory problems, and severely impaired in daily decision making skills. On 4/10/19 at 9:50 a.m. during review of the clinical record, it was noted a medication order form for another resident filed in Resident # 63's record. Further review of the lab section of the record revealed yet another resident's lab results filed in Resident # 63's record. The medical records staff, who was identified as the staff responsible for filing paperwork, was present at the nursing station, and was asked about 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.