Lynchburg Health & Rehabilitation Center

Based on observation, staff interview, and resident interview, the facility failed to accommodate the resident's preference to dine in the dining room affecting multiple residents on three of three units. The findings included: The facility staff failed to have their main dining room available for the residents to have their meals. On 9/9/24, during the initial tour of the facility, the main dining room was observed to be used as a storage area and not being used for residents dining. On 9/10/24, at 2:00 p.m., during a resident council meeting conducted with eight residents, all of the residents in attendance were complaining about not having the dining room open for use during mealtimes. Resident # 6, Resident # 19, Resident # 109, Resident # 64, Resident # 69, Resident #65, Resident #58, and Resident #38 were complaining about how long the dining room had been closed off to the residents and that it was being used as a storage area. On 9/10/24 at 3:15 p.m, Resident #64 stated,It was nice when we all could get together and talk in the dining room at meals, but now it is just a…

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

Based on Resident interview, staff interview, and facility documentation review, the facility staff failed to provide Residents with quarterly statements of their trust account/bank accounts and failed to allow residents to readily access their trust funds, affecting all 140 residents with trust accounts. The findings included: On 9/10/24, an interview was conducted with Resident #14- R14. During the interview, R14 expressed that he doesn't get any kind of statement regarding his trust account. On 9/10/24 at 2 p.m., a group interview was conducted with eight residents (Resident # 6, Resident # 19, Resident # 109, Resident # 64, Resident # 69, Resident #65, Resident #58, and Resident #38).When asked about trust account statements, the residents reported that they did not receive any kind of statement regarding their trust fund accounts. These residents also verbalized concerns that they can only withdraw funds from their trust account for two hours, Monday through Friday, and no longer have weekend access. On 9/10/24 at approximately 4:28 p.m., observations noted a sign posted near…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan for four of thirty-three residents in the survey sample (Residents #49, #66, #30 and #131). The findings include: 1. Resident #131's plan of care of was not revised with interventions in place for trauma related care. Resident #131 (R131) was admitted to the facility with diagnoses that included urinary tract infection, major depressive disorder, post-traumatic stress disorder, diabetes, spinal stenosis, anxiety and anemia. The minimum data set (MDS) dated [DATE] assessed R131 as cognitively intact. R131's clinical record documented a trauma assessment 4/19/24 indicating the resident had history of physical abuse, verbal abuse and misappropriation of personal property by an ex-boyfriend. The trauma assessment documented no other source of trauma and identified the resident's trauma was related to fear that the ex-boyfriend would enter the facility and harm 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 observation, staff interview, clinical record review, and facility document review, the facility staff failed to follow physician orders for five of thirty-three residents in the survey sample (Residents #66, #159, #99, #149, and #92). The findings include: 1. Resident #66's heel protectors (bunny boots) were not applied as ordered. The findings include: Diagnoses for R66 included; Dementia, diabetes, osteoarthritis, and failure to thrive on hospice. The most current MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 8/8/24. R66 was assessed with a cognitive score of 00 indicating severe cognitive impairment. Review of R66's clinical record evidenced a physicians order dated 8/8/24 for Bunny boots bilaterally while in bed. The order indicated no documentation was needed. On 9/10/24 multiple observations were made between 8:30 a.m. and 10:30 a.m. of R66 lying in bed without bunny boots in place. The bunny boots were observed on the bed-side dresser. On…

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

Based on observation, staff interviews, resident interviews, clinical record reviews, and facility documentations the facility staff failed to provide trauma informed care for six residents, (Resident #30-R30, Resident #39-R39, Resident #105-R105, Resident #134-R134, Resident #149-R149 and Resident #367-R367) out of a survey sample of 33 residents. The findings included: 1. The facility staff failed to identify triggers related to trauma and did not provide interventions to address trauma-informed care on the care plans for R39, R105, R134 and R149. 1a. According to the clinical record R39 had diagnosis of psychotic disturbance, mood disturbance, and anxiety disorder. On 9/11/24 at 8:29 a.m. an interview was conducted with R39. R39 stated that she has increased anxiety with the way some staff speak to her at times. R39 stated, When the staff are rude with me or raise their voice, I become anxious. On 9/11/24, a clinical record review was conducted for R39. R39 had a trauma screen that was completed on 10/27/23, which identified trauma areas of physical abuse, homicide attempt, 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.

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide a therapeutic diet as ordered by the physician for four residents (Resident #139, #55, #9, and #30), in a survey sample of 33 residents. The findings included: 1. For Residents #139, 55, and 9, all who had therapeutic diets ordered, the facility kitchen failed to provide the appropriate diet. On 9/9/24 at 12:58 p.m., the lunch meal was observed in the restorative room on the west unit. It was noted that R139's meal ticket indicated she was to receive chopped meats. R139's meal tray included a whole/intact pork chop, which nursing staff had to cut up into bite size pieces, which was not a chopped consistency. R139 was observed to not eat the pork chop and verbalized several times, it's too tough. R24 and R9's meal ticket indicated they were to receive pureed foods. The meat on the tray was not a smooth consistency and appeared more like ground meat. Several staff members, to include LPN #6, LPN #3 and CNA #4 all agreed the pureed meat was not a pureed…

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 store, prepare and serve food in a sanitary manner from the main kitchen and on one of three units (West unit). The findings include: a) The walk-in refrigerator and freezer in the main kitchen had out-of-date and/or unsealed food items. Stainless prep pans were stored nested and wet. The bench mounted can opener was dirty with accumulated debris. Flies were observed in the kitchen during meal prep near the exit door beside the handwashing sink. On 9/9/24 at 10:41 a.m., accompanied by the dietary manager (other staff #2), the main kitchen was inspected during the initial tour of the facility. Stored in the walk-in refrigerator was a package of sliced turkey labeled with a use by date of 9/5/24. There was an opened 46-ounce carton of thickened cranberry cocktail with no label indicating when opened. A package of slice turkey, with no manufacturer's label was stored and available for use. There was no identification on the packaged turkey indicating a use by or expiration date. A box with…

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

Based on observation, staff interview, and facility document review, the facility staff failed to maintain effective pest control. The findings include: Flies were observed during the survey on the [NAME] unit dining/day room and in the main kitchen during food preparation. On 9/9/24 at 11:32 a.m., lunch preparation was observed in the main kitchen. Flies were observed in the kitchen near the handwashing sink located beside an exit door. Several flies were observed near the convection ovens. Kitchen staff members were observed exiting and re-entering through the exit door multiple times during meal preparation/service. An air curtain positioned over the exit door did not activate when the door was opened. The dietary manager was interviewed at this time about the flies and air curtain. The dietary manager stated the air curtain at the exit door did not come on automatically when the door was opened. The dietary manager stated she had to turn on the air curtain at the breaker box. The dietary manager stated she usually turned the air curtain on when the door stayed open for…

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

Based on observation and staff interview, the facility staff failed to distribute meals in a manner to maintain and enhance a residents dignity affecting several residents on one of three units. The findings included: The facility staff failed to distribute meal trays in a manner to uphold resident's dignity. On 9/9/24 at 12:58 p.m., the lunch meal was observed in the restorative room on the west wing. It was noted that R22 was sitting at a table with resident #9 (R9). R9 was served her meal and began eating. All the other residents in the dining room were served, including a tray sat between R22 and R9 for another resident who was not present in the dining room. CNA #4 was the only staff member remaining in the dining room after the trays had been served, and she was sitting to assist in feeding resident #55. The surveyor identified several concerns with regards to the consistency of pureed foods. LPN #6 was asked to verify that residents who were served pureed foods were not given a pureed consistency of food. LPN #6 then removed R9's tray to take it to the kitchen to be prepared…

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

Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure residents dignity was upheld for one resident, (Resident #99 - R99) in a survey sample of 33 residents. The findings included: 1. For R99, the facility failed to ensure the resident had adequate clothing and season approriate clothing to wear to ensure his dignity was maintained with regards to his personal appearance. On 9/09/24 at 12:45 p.m., R99 stopped the surveyor in the hallway. R99 was sitting outside his room in the hall and told the surveyor, Look what they dress us in, and pointed to his clothing. R99 was observed to be dressed in a flannel shirt and denim jeans which were cut off at the ankles and torn up the back of the calf. R99 reported he has lived at the facility for five years and had nice clothes when he came in, but they are all gone and, They give me clothes left over from other people, but they don't even fit. R99 went on to say he had a doctor's appointment outside of the facility and had to go, saying, This 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, facility documentation review, and clinical record review, the facility staff failed to issue an ABN (Advanced Beneficiary Notice) to one resident (Resident #107-R107) in a survey sample of three residents reviewed for such notices. The findings included: For R107, who remained a resident of the facility, the facility staff failed to issue an ABN, which would have afforded the resident the opportunity to decide if they wanted to continue to receive skilled services and assume the financial responsibility or have the fiscal intermediary make the coverage determination. On 9/9/24, a sample of three residents was selected for review of beneficiary notices. According to the listing provided by the facility, R107 had remained in the facility following skilled services ending. On 9/10/24, the facility staff provided the survey team with the beneficiary notices issued to each resident and noted R107 was not provided an ABN because .he was short-term and was supposed to discharge. On 9/10/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to provide a homelike environment and clean medical equipment for resident use, affecting two residents (Resident #99- R99 and Resident #55- R55) in a survey sample of 33 residents. The findings included: 1. For R99, the facility staff failed to provide the resident with a closet in good repair, as a door was missing. On 9/9/24 at 12:45 p.m., R99 was visited in his room. Observations of the resident's room were made, and it was noted that the closet was missing a door. R99 was asked about the closet and R99 reported it had been like that ever since he moved into that room. On 9/10/24 at 8:41 a.m., R99 was visited again in his room by the surveyor, and it was noted that the closet was still missing a door. On 9/10/24 at 8:43 a.m., an interview was conducted with the certified nursing assistant (CNA #3). CNA #3 was asked about R99's closet not having a door and she…

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 documentation review, the facility staff failed to report an allegation of abuse to the state survey agency and other officials as required for an incident involving two residents (Resident #14 - R14 and Resident #99 - R99) in a survey sample of 33 residents. The findings included: For R14 and R99, who had a physical altercation, resulting in injury to R14, the facility staff failed to have credible evidence that the incident of abuse and the investigation results were reported to the state survey agency and other officials. On 9/9/24 at 3:06 p.m., during an interview with R14, the resident reported that he had an incident with a prior roommate where the roommate was punching him and gave him a black eye. When asked what had happened to cause this, R14 said, He said the tv was too loud, but he never asked me to turn it down. On 9/10/24, the facility was asked to provide evidence of all events they had reported and addressed since January 2024. Review of the files revealed a one-page document that noted…

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

Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to develop a comprehensive resident-centered care plan for one resident (Resident #49-R49) in a survey sample of 33 residents. The findings included: For R49, who had bilateral hand contractures, the facility staff failed to develop a comprehensive resident centered care plan to identify the contractures and interventions. On 9/9/24 and 9/10/24, various observations were conducted of R49. R49 was noted on each observation to be non-verbal and had bilateral hand contractures. The resident was observed with no splint to the hands and no palm protectors. On 9/10/24 at 2:49 p.m., an interview was conducted with the therapy director (TD). The TD reported that R49 was on therapy caseload previously. The TD noted from 11/17/22-11/23/22, R49 was on occupational therapy caseload, and they were concerned about hand contractures. The therapy director noted that they had noted, Palm guards to right and left hands up to 4 hours and he was tolerating them 8 hours without 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.

Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to follow professional standards of practice for three of 33 residents in the survey sample. (Residents #268, #134, #49). The findings include: 1. Resident #268 (R268) pressure ulcer dressing was not dated or initialed by the facility staff. Diagnoses for R268 included; Pressure ulcer stage three, sepsis, diabetes, malignant neoplasm of rectum, and anemia. The most current MDS (minimum data set) was a five day assessment with an ARD (assessment reference date) of 9/2/24. R268 was assessed with a cognitive score of 15 indicating cognitively intact. Review of R268's clinical record documented an order dated 9/6/24 to Cleanse sacrum wound with wound cleanser, apply medical grade honey and cover with a bordered foam every day shift. Review of R268's treatment administration record (TAR) indicated that the order was being carried out. On 9/10/24 at 9:45 a.m. R268 was interviewed regarding dressing changes to sacrum. R268 said that the staff haven't been doing 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 2. For resident #92 (R92), the facility staff failed to provide activities to meet the psychosocial well-being of the resident and in accordance with resident preferences. On 9/9/24 at approximately 11:45 p.m., the surveyor was approached by a certified nursing assistant (CNA #3) who reported for the surveyor to not enter a room [which the CNA identified as R92's room]. CNA #3 reported the resident had behaviors and could be extremely combative. On 9/9/24 at approximately 12:30 p.m., R92 was observed in his room. It was noted that the room was dark, the curtains were pulled, no lights were on, and the resident was sitting in a wheelchair in the middle of the room. The room was noted to be empty with no personal possessions, no television, no radio, no books, magazines or other things for the resident to do to occupy his time. On 9/9/24 at approximately 2:30 p.m., facility activity staff were observed to deliver the resident a cup of Kool aide in his room. On 9/10/24 and 9/11/24, various observations were…

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

Based on staff interview, and clinical record review, the facility staff failed to implement interventions for care/treatment of pressure ulcer for one of 33 residents in the survey sample (Resident #268). The findings include: Resident #268 (R268) had no treatment orders implemented for a pressure ulcer until seven days after the ulcer was identified. Diagnoses for R268 included; Pressure ulcer stage three, sepsis, diabetes, malignant neoplasm of rectum, and anemia. The most current MDS (minimum data set) was a five day assessment with an ARD (assessment reference date) of 9/2/24. R268 was assessed with a cognitive score of 15 indicating cognitively intact. R268's weekly skin assessments were reviewed. Out of 5 skin assessments completed from 8/31/24 through 9/11/24, three skin assessments (8/31/24, 9/6/24, and 9/11/24) document R268 having a stage three sacral pressure ulcer, and two skin assessments dated 9/2/24 and 9/9/24 did not have any documentation of the pressure ulcer. The skin assessments did indicate that the wound was improving. A wound assessment report (from a wound…

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

Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to provide services to maintain good foot health of two residents (resident #49-R49 and resident #30-R30) in a survey sample of 33 residents. The findings included: 1. For R49 the facility failed to provide care and treatment to maintain good foot health as evidenced by the resident's toenails being approximately 3/4 of an inch long past the toes. On 9/10/24 at 3:01 p.m., the surveyor is accompanied to R49's room by a licensed practical nurse (LPN #3). During review of the resident LPN pulled back the sheets, exposing R49's feet. It was noted that R49 had not had foot/nail care performed in a long time as evidenced by the nails extending approximately 3/4 of an inch past the end of the toes. LPN #3 confirmed and agreed that R49 was in need of toenail care. Upon exit of the resident's room, LPN #3 was asked about nail care. LPN #3 said, we do reminders to the CNA's [certified nursing assistants] to trim nails and a podiatrist comes monthly. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review, the facility staff failed to implement interventions for a resident with contractures, to prevent the worsening of contractures for one resident (Resident #49-R49) in a survey sample of 33 residents. The findings included: On 9/9/24 at 3:28 p.m., R49 was observed in bed. R49 was noted to be non-verbal and had bilateral hand contractures. The resident was observed with no splint to the hands and no palm protectors. R49's fingernails were observed to be long. On 9/10/24 at 8:54 a.m., R49 was observed again, and no splint, palm guard or wash cloth was noted in the hands to prevent the worsening of the contractures. On 9/10/24 at 2:49 p.m., an interview was conducted with the therapy director (TD). The TD reported that R49 was on therapy caseload previously. The TD noted from 11/17/22-11/23/22, R49 was on occupational therapy caseload, and they were concerned about hand contractures. The therapy director noted that they had noted, Palm guards to…

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

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure suction was in place for respiratory care of a tracheostomy for one of 33 residents, Resident #159 (R159). The findings include: R159 did not have emergency suctioning device at bedside for the care of a tracheostomy. Diagnoses for R159 included; Displacement of esophageal anti-reflux device (tracheostomy), chronic obstructive pulmonary disease, esophageal obstruction, cellulitis of abdominal wall, feeding tube The most current MDS (minimum data set) was a quarterly assessment, with an ARD (assessment reference date) of 7/2/24, which assessed R159 with a cognitive score of 15 out of 15 indicating intact cognition. On 9/10/24 at 11:15 a.m., R159's room was observed for emergency suctioning due to R159 having a tracheostomy. There was no suctioning device observed. R159 was interviewed at this time and verbalized that there hadn't been any suctioning in the room and not having to use suctioning so far. When asked about the medical device inserted into the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review, and clinical record review, the facility failed to provide physician ordered dialysis services and failed to share/communicate care provided during a dialysis treatment for one of thirty-three residents (Resident #2). The findings include: Resident #2 (R2) was admitted to the facility with diagnoses that included end stage renal disease (ESRD), gastroesophageal reflux disease, protein-calorie malnutrition, obstructive uropathy, anxiety, anemia, and COVID-19. The minimum data set (MDS) dated [DATE] assessed R2 as cognitively intact. a) R2 missed two scheduled hemodialysis treatments due to lack of transportation to the dialysis center. R2's clinical record documented a physician's order dated 9/1/24 for hemodialysis three times per week with scheduled days listed as Tuesday, Thursday and Saturday. R2's clinical record documented R2 was diagnosed with COVID-19 on 8/26/24. The physician assessed R2 on 8/27/24, documented treatment of COVID-19…

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

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to attempt alternatives prior to implementing the use of bed rails for one resident (Resident #49-R49) in a survey sample of 33 residents. The findings included: For R49, who was in a persistent vegetative state and had a fall, the facility staff applied bed rails without attempting other alternatives and without assessing the risk of entrapment. On 9/9/24 and 9/10/24, R49 was visited in their room. R49 was noted to be non-verbal and did not respond to verbal stimuli. R49 was noted to be on an air mattress and had 1/8 length bed rails to both sides of the bed. On 9/10/24, a clinical record review was conducted. This review revealed R49 had diagnosis which included, but were not limited to, persistent vegetative state, obstructive hydrocephalus, cerebral palsy, and cerebral infarction due to unspecified intracranial injury with loss of consciousness of unspecified duration. According to a nursing note entry dated 7/26/24, R49 sustained a fall. The notes for that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to ensure a medication was available for administration for one of thirty-three residents in the survey sample (Resident #79). The findings include: Resident #79 (R79) was admitted to the facility with diagnoses that included atherosclerotic heart disease, generalized anxiety, depression, polyneuropathy, atrial fibrillation, chronic pain, mild cognitive impairment, hypertension, anemia, and migraine headache. The minimum data set (MDS) dated [DATE] assessed R79 as cognitively intact. On 9/9/24 at 12:38 p.m., R79 was interviewed about quality of care in the facility. R79 stated during this interview that she had recently missed doses of her anti-anxiety medication. R79's clinical record documented a physician's order dated 2/23/24 for the medication Xanax 0.5 mg (milligrams) to be administered twice per day for management of anxiety. R79's medication administration record documented 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, the facility staff failed to label an insulin pen when opened on one of three units (West unit). The findings include: On 9/11/24 at 3:53 p.m., accompanied by licensed practical nurse (LPN) #5, medications stored in cart #2 on the [NAME] unit were inspected. Stored in the medication cart was an opened Fiasp (insulin aspart) flextouch insulin pen labeled for a current resident. The insulin pen had no date written on the label indicating when the pen was opened. LPN #5 was interviewed at this time about the storage of opened insulin pens. LPN #5 stated all insulin pens were supposed to be dated when opened. The facility's policy titled Storage of Medications (revised 08/2024) documented, .When the manufacturer has specified a usable duration after opening (i.e. beyond use date), the nurse shall place a 'date opened' sticker on the medication and record the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days from opening, unless the manufacturer recommends another…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, resident interview, and clinical record the facility staff failed to provide food in accordance with the menu for one, (Resident #39, R39) out of 33 residents in the survey sample. The findings included: The facility staff failed to serve R39 the food that was on her menu ticket at lunch time. R39 was admitted to the facility on [DATE]. Diagnoses for R39 included but are not limited to unspecified protein-calorie malnutrition. R39's Minimum Data Set (an assessment protocol), with an Assessment Reference Date of 6/17/24, coded R39 with moderate cognitive impairment. On 9/9/24 the R39's meal ticket read in part, .Mechanical advanced/chopped baked pork chop - 4oz, mushroom gravy - 2 oz, mechanical advanced/chopped orange twist - 1 Ea, steamed summer squash - 1/2 cup, black eyed peas- 4 oz, dinner roll - 1 ind, and margarine - 1 pkt. On 9/9/24 at 12:37 p.m. an observation of the lunch time meal was conducted. During the observation, R39's meal tray was missing mushroom gravy 2…

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

Based on observation, resident interview, and staff interviews the facility staff failed to provide food preferences for one of 33 residents. Resident # 69 (R69) was not provided side salads as requested. The findings include: Diagnoses for R69 included; Diabetes, and obesity. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 7/2/24. R69 was assessed with a cognitive score of 15 indicating cognitively intact. During an interview conducted on 9/09/24 at 11:40 a.m. R69 verbalized concerns regarding food preferences saying we are no longer getting side salads like we used to. R69 went onto say the dietary manager is saying we no longer are providing salads as an option. R69 mentioned being a diabetic and prefers to have fresh fruits and vegetables. On 9/11/24 at 11:37 a.m. the dietary manager (other staff, OS #2) was interviewed. OS #2 said that corporate had recently changed to a different seasonal menu, and corporate office were no longer purchasing salad ingredients due to the change in the new menu. The kitchen…

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

Based on staff interview and clinical record review, the facility staff failed to provide a complete and accurate clinical record for three of thirty-three residents in the survey sample (Resident #268, #30 and #149). The findings include: 1. Resident 268's (R268) sacral wound was not properly identified on daily skilled progress notes and skin assessments. Diagnoses for R268 included; Pressure ulcer stage three, sepsis, diabetes, malignant neoplasm of rectum, and anemia. The most current MDS (minimum data set) was a five day assessment with an ARD (assessment reference date) of 9/2/24. R268 was assessed with a cognitive score of 15 indicating cognitively intact. Review of R268's daily skilled progress notes dated 8/31/24 through 9/7/24 documented no wounds. Another skilled progress note dated 9/7/24 indicated there was a sacral wound. On 9/8/24 two skilled notes were entered one of the notes indicating there was a wound the other indicting there were no wounds. A skilled progress note dated 9/9/24 again indicated there was not a wound. R268's weekly skin assessments were then…

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 interviews, clinical record review and facility documentation review the facility staff failed to provide a negative urinalysis prior to removing contact isolation for one resident, Resident #134 (R134) in a survey sample of 33 residents. The findings included: The facility staff failed to obtain a negative urine after completion of the antibiotic therapy for ESBL (Extended-spectrum beta-lactamases) before discontinuing contact isolation precautions. On 9/9/24 at 11:00 a.m. a tour of the facility south nursing unit was conducted. R134 had an enhanced barrier isolation sign on the outside of the room door. On 9/12/24 at 8:39 a.m. an interview was conducted with license practical nurse, LPN#2 (LPN2). LPN2 said she remembered R134 being on contact isolation precautions for ESBL (extended spectrum beta-lactamase) when she was admitted . LPN2 said that when R134 moved to the room she is in now, that she was on enhanced barrier precautions. LPN2 stated the protocol for ESBL is, they have to stay in room if incontinent, we have to recheck a urine after…

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

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure resident identifiable information was not released to the public for 41 of 42 residents in the survey sample, Residents 1- 41. The findings included: Residents 1 through 41 had personal health information given to the Registrar's office by facility staff that revealed their cognitive status. On 4/15/24 at 4:39 PM, during an interview with the facility administrator it was revealed that the facility had violated the Federal Standards for Privacy of Individually Identifiable Health Information. The administrator stated that on 1/10/24 the U.S. Department of Health and Human Services (HHS), Office for Civil Rights (OCR), had emailed her stating that they had received an allegation on 11/3/23 that the facility had violated the Federal Standards for Privacy of Individually Identifiable Health Information (45 C.F.R. Parts 160 and 164, Subparts A, C and E, (the Privacy and Security Rules), indicating that the facility provided a list of residents to the local Registrar's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to notify the physician in a timely manner of medication (Hydrocodone) not given per order, for one of thirteen residents, Resident #201. Findings were: Resident #201 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: COPD (chronic obstructive pulmonary disease), malignant neoplasm of the endometrium, vascular dementia and hypertension. The most recent MDS (minimum data set) was a quarterly review with an ARD (assessment reference date) of 06/23/2021. Resident #201 was assessed as moderately impaired with a cognitive summary score of 10. On 09/21/2021 the clinical record was reviewed. The physician order section contained the following: HYDROcodone-Acetaminophen Tablet 5-325 MG Give 1 tablet by mouth three times a day for Pain. The progress note section included the following documentation: 09/11/2021 20:44 [8:44 p.m.] HYDROcodone-Acetaminophen Tablet 5-325 MG Give 1 tablet by mouth…

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, staff interview, and facility document review, the facility staff failed to review and revise the comprehensive care plan for 5 of 38 Residents, (Resident #10, #23, #133, and #71). Resident #10's care plan was not reviewed and revised regarding hospice services, enhanced droplet precautions, and diabetes mellitus. Resident #23's care plan was not reviewed and revised regarding the resolution of pressure ulcers. Resident #133's care plan did not include hospice services. Resident #86's care plan was not reviewed and revised to include hospice admission and the use of geri-sleeves. Resident #71's care plan was not revised with problems, goals and interventions regarding pressure ulcers. Findings were: 1. Resident #10 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: COPD (chronic obstructive pulmonary disease), malignant neoplasm of the endometrium, vascular dementia and hypertension. The most recent MDS (minimum data set) was a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to ensure medications were available for two of 13 residents, Resident # 201 and Resident # 210. Resident #201 did not receive Hydrocodone three times per day as ordered by the physician because it was not available for administration. Resident # 210 was not administered Ofloxacin three times a day as ordered, and once a day as ordered. The findings were: 1. Resident #201 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: COPD (chronic obstructive pulmonary disease), malignant neoplasm of the endometrium, vascular dementia and hypertension. The most recent MDS (minimum data set) was a quarterly review with an ARD (assessment reference date) of 06/23/2021. Resident #201 was assessed as moderately impaired with a cognitive summary score of 10. On 09/21/2021 the clinical record was reviewed. The physician order section contained the following: HYDROcodone-Acetaminophen Tablet 5-325 MG Give…

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 store and prepare food in a sanitary manner in the main kitchen. The findings include: On 6/29/21 at 10:48 a.m., accompanied by the dietary manager (other staff #2), the kitchen and food storage areas were inspected. Stored in the walk-in refrigerator was a plastic container of potato salad. The potato salad was labeled with a prep date of 6/12/21 and use by date of 6/19/21. A plastic container of applesauce was also stored and labeled with prep date of 6/17/21 and use by date of 6/28/21. The dietary manager was interviewed at the time of the observation. The dietary manager stated the potato salad and applesauce should have been discarded prior to today. On 6/29/21 at 11:04 a.m., accompanied by the dietary manager, meal preparation was observed in the kitchen. A scoop was observed stored in bulk container of raw sugar, with the handle touching the sugar. The dietary manager stated at the time of the observation that the scoop was supposed to be stored separately and not positioned in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to ensure an accurate minimum data set (MDS) for one of 38 residents in the survey sample. An admission MDS for Resident #56 had an inaccurate assessment of the resident's dental issues. The findings include: Resident #56 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, atherosclerotic heart disease, hypertension, heart failure, benign prostatic hyperplasia, inguinal hernia, gastroesophageal reflux disease and localized edema. The MDS dated [DATE] assessed the resident with moderately impaired cognitive skills. On 6/29/21 at 2:52 p.m., Resident #56 was interviewed about quality of care in the facility. The resident was observed when talking with missing front teeth. Other visible teeth were broken, dark in color with several teeth black and decayed next to the gum tissue. The resident was interviewed about the condition of his teeth at this time. Resident #56…

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, complaint investigation, clinical record review, and staff interview, the facility staff failed for three of 38 residents in the survey sample (Residents # 80, 88 and 127), to provide routine foot care. Residents # 80, 88 and 127 had elongated toenails with clearly visible debris under the great toes on their left and right feet. The findings include: 1. Resident # 88 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses that included malignant neoplasm of endometrium, anemia, hypertension, renal insufficiency, diabetes mellitus, depression, generalized muscle weakness, difficulty walking, dysphagia, pulmonary hypertension, cerebral atherosclerosis, and gastroesophageal reflux disease. According to a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/21/2021, Resident # 88 was assessed under Section C (Cognitive Patterns) as being moderately cognitively impaired, with a Summary Score of 09 out of 15. Under Section G…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review, the facility staff failed to ensure one of ten residents was administered oxygen as ordered by the physician, Resident #106. Findings were: Resident #106 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: COPD (chronic obstructive pulmonary disease), malignant neoplasm of the endometrium, vascular dementia and hypertension. The most recent MDS (minimum data set) was a quarterly review with an ARD (assessment reference date) of 06/23/2021. Resident #106 was assessed as moderately impaired with a cognitive summary score of 10. During initial tour of the facility on 08/10/2021 at approximately 9:15 a.m., Resident #106 was observed lying in bed. She was wearing a nasal cannula with oxygen running at 2 liters/minute. The clinical record was reviewed at approximately 11:00 a.m. The physician orders included: Oxygen therapy-Oxygen at 1 liters per minute via nasal cannula every shift for SOB [shortness of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, document review, and staff interview, the facility staff failed to ensure expired vaccine was not available for administration on one of 3 units: East unit. A bag containing seven expired vials of Afluria, an influenza vaccine, was in a thermal container in the medication room refrigerator. Findings include: On [DATE] at approximately 10:15 a.m. an inspection of the medication room on the East unit was conducted with LPN (licensed practical nurse) # 6. A silver thermal bag was located in the bottom of the refrigerator and contained seven multi-dose boxes of Afluria. The boxes were marked with an expiration date of [DATE]. LPN # 6 stated I had no idea those were even in there. The package insert for the Afluria vaccine under 16.2 Storage and Handling directs Do not use AFLURIA QUADRIVALENT (sic) beyond the expiration date . The administrator, DON, and nurse consultant were made aware of the findings [DATE] at 1:15 p.m. during a meeting with facility staff. No further information was provided…

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, and staff interview the facility staff failed to honor food preferences for one of 38 residents in the survey sample: Resident # 18. Findings include: Resident # 18 was admitted to the facility 1/26/21 with diagnoses to include, but were not limited to: osteoporosis, muscle weakness, COPD, and Vitamin D deficiency. The most MDS (minimum data set) was a quarterly review dated 4/6/21 and had Resident # 18 assessed 13 out of 15 for cognition, indicating cognitively intact. On 6/30/21 at approximately 8:25 a.m. Residenty # 18 was observed with her breakfast tray on the overbed table. Resident # 18 was asked about her breakfast. She stated Not too good. I have scrambled eggs and oatmeal I am not going to eat, and look here: I have a biscuit but no butter or jelly or anything to put on it! Some of that sausage gravy would be nice to have to put on it . (Resident # 18's roommate had sausage gravy on her biscuit). The meal ticket for Resident # 18 was reviewed and revealed the resident should have also received a banana and bacon on her meal tray.…

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 ensure a complete and accurate clinical record for two of 38 residents (Resident #285 and Resident #71). Resident #285's clinical record contained another resident's Covid-19 vaccination record, and Resident #71 had an incomplete treatment record for pressure ulcer dressing changes. Findings include: 1. Resident #285 was admitted to the facility on [DATE]. Diagnoses for this resident included, but were not limited to: cerebral infarct (stroke/sub-dural hematoma), dysphagia, pneumonitis, muscle weakness, high blood pressure, peg tube placement, acute hypoxia and respiratory failure. The most current MDS (minimum data set) was an admission assessment (still in progress). This MDS was not complete. Resident #285 was assessed as alert and oriented to person and place on the nursing admission assessment dated [DATE]. On 06/29/21 at 2:59 PM, Resident #285's clinical records were reviewed. Another resident's [identified as Resident #286]…

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 policy review and clinical record review, the facility staff failed to follow infection control practices during meal tray distribution on one of three nursing units. Staff members on the South wing failed to don gowns and gloves when serving meal trays to residents on droplet precautions. The findings include: On 6/29/21 at 12:20 p.m., meal tray service on the South unit was observed. On 6/29/21 at 12:36 p.m., certified nurses' aide (CNA) #2 with a mask on and no other personal protective equipment (PPE), entered room (number), positioned the over-bed table and placed the meal tray for A-bed resident. CNA #1, without gown or gloves, also entered this room and set up the meal tray for B-bed resident. CNA #1 and #2 exited the room and applied hand sanitizer to their hands. On 6/29/21 at 12:38 p.m., CNA #2 entered room (number), moved the over-bed table and setup the meal tray for the B-bed resident. CNA #2 had no gown or gloves on when entering the room and providing meal setup. All residents in this section of the South wing including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, resident interview, and clinical record review, the facility staff failed to follow physician orders for 4 of 39 residents in the survey sample. A physician ordered knee brace for Resident # 86 was not applied per order; fluid restriction for Resident # 408 was not implemented as ordered; TED hose (compression stockings) were not applied as ordered for Resident # 143; and medications were not administered per physician's orders for Resident #355. Findings include: 1. Resident # 86 was admitted to the facility 8/3/17 with diagnoses to include, but not limited to: spinal stenosis, chronic pain, and chronic kidney disease. The most recent MDS (minimum data set) was a quarterly review dated 9/5/19 and had Resident # 86 with moderate impairment in cognition with a total summary score of 10 out of 15. On 9/15/19 at 2:00 p.m. Resident # 86 was observed in her room sitting in a wheel chair with splint boots on each foot. Resident #86 stated I also have another brace I usually have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, the facility staff failed to implement interventions for the prevention of pressure ulcers for one of 39 residents in the survey sample. Resident #121, with a recent history of pressure ulcers on both heels, did not have dressings, topical treatment and protective booties applied for 10 consecutive days as required by physician orders and the care plan for pressure ulcer prevention. The findings include: Resident #121 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #121 included bladder cancer, peptic ulcer, hypertension, adult failure to thrive, depression, congestive heart failure, dementia and diabetes. The minimum data set (MDS) dated [DATE] assessed Resident #121 with moderately impaired cognitive skills. Resident #121's clinical record documented the resident was assessed with pressure ulcers on both heels on 5/25/19. Skin assessment sheets documented the pressure ulcers as healed on 8/30/19. 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 clinical record review the facility staff failed to provide restorative nursing services for one of 39 residents in the survey sample, Resident # 86. Findings include: Resident # 86 was admitted to the facility 8/3/17 with diagnoses to include, but not limited to: spinal stenosis, chronic pain, and chronic kidney disease. The most recent MDS (minimum data set) was a quarterly review dated 9/5/19 and had Resident # 86 with moderate impairment in cognition with a total summary score of 10 out of 15. On 9/15/19 at 2:00 p.m. Resident # 86 was observed in her room sitting in a wheel chair. Resident # 86 was observed with splint boots to each foot. The boot on the left foot was not applied securely, and the right boot was sideways on the resident's foot. Resident # 86 stated Yes, they are quite a sight, aren't they? She went on to state the CNA (certified nursing assistant) applied the boots in the mornings after getting her out of bed. CNA # 3 was in the hallway across from the resident's room, and was asked to come and assist the resident to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, the facility staff failed to implement interventions for fall and injury prevention for one of 39 residents in the survey sample. Resident #112's fall mats were not implemented for over a month following an unwitnessed fall from his bed. The findings include: Resident #112 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #112 included respiratory failure, seizures, cerebrovascular disease, diabetes, COPD (chronic obstructive pulmonary disease), dysphagia, cognitive communication deficit, schizophrenia, glaucoma, mood disorder and high blood pressure. The minimum data set (MDS) dated [DATE] assessed Resident #112 with short and long-term memory problems and moderately impaired cognitive skills. The MDS listed the resident had highly impaired vision and required the extensive assistance of two people for bed mobility. On 9/15/19 at 5:20 p.m., Resident #112 was observed in bed. The resident's right foot 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 and staff interview, the facility staff failed to ensure a dignified dining experience on one of three dining areas. During breakfast in the East unit restorative dining room, facility staff stood over residents while feeding them and fed them without initiating any conversation. The findings include: On 9/16/19 from 7:50 a.m.to 8:15 a.m., breakfast service was observed in the East unit restorative dining room. On 9/16/19 at 7:50 a.m., certified nurses' aide (CNA) #3 offered Resident #34 a banana. CNA #3 handed a peeled banana to the resident. Resident #34 took one bite of the banana and placed it on a napkin on the table. The resident had no plate or dish in front of her. During this meal observation, certified nurses' aide (CNA) #1 was observed feeding Residents #9, #33 and #87 seated at the same table. CNA #1 was standing and went from resident to resident feeding them the breakfast food items/drink from their trays. CNA #1 gave Resident #33 a bite of food, then went to Resident #87 and fed him several bites. CNA #1 then went to Resident #9 and fed 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.

Based on resident interview, staff interview and clinical record review the facility staff failed to implement the care plan (CP) for Resident # 86 for restorative services, and failed to develop a comprehensive plan of care (CCP) for Resident # 408's fluid restriction. Findings include: 1. Resident # 86 was admitted to the facility 8/3/17 with diagnoses to include, but not limited to: spinal stenosis, chronic pain, and chronic kidney disease. The most recent MDS (minimum data set) was a quarterly review dated 9/5/19 and had Resident # 86 with moderate impairment in cognition with a total summary score of 10 out of 15. On 9/15/19 at 2:00 p.m. Resident # 86 was observed in her room sitting in a wheel chair. Resident # 86 was observed with splint boots to each foot. The boot on the left foot was not applied securely, and the right boot was sideways on the resident's foot. Resident # 86 stated Yes, they are quite a sight, aren't they? She went on to state the CNA (certified nursing assistant) applied the boots in the mornings after getting her out of bed. CNA # 3 was in the hallway…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan for two of 39 residents in the survey sample. Resident #112's care plan was not revised to include use of fall mats and an air mattress. Resident #69's care plan was not revised regarding a healed pressure ulcer. The findings include: 1. Resident #112 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #112 included respiratory failure, seizures, cerebrovascular disease, diabetes, COPD (chronic obstructive pulmonary disease), dysphagia, cognitive communication deficit, schizophrenia, glaucoma, mood disorder and high blood pressure. The minimum data set (MDS) dated [DATE] assessed Resident #112 with short and long-term memory problems and moderately impaired cognitive skills. On 9/15/19 at 5:20 p.m., Resident #112 was observed in bed. The resident's right foot was hanging off the side of the bed. The resident was on an air mattress…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and resident record review, the facility staff failed to follow physician orders for oxygen administration for 2 of 39 resdients in the survey sample, Residents #46 and #114. The Findings Include: 1. Resident #46 was admitted to the facility on [DATE]. Diagnoses for Resident #46 included: Congestive heart failure, diabetes, chronic obstructive pulmonary disease, and sleep apnea. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 7/17/19. Resident #46 was assessed as being cognitively intact. On 09/16/19 at 9:12 AM, Resident # 46 was interviewed. During the interview Resident #46 was asked if staff change out oxygen tubing and asked to observed oxygen concentrator. Resident #46 stated that staff do change the oxygen tubing. The oxygen concentrator was then observed and the rate of oxygen was set at 4 LPM (liters per minute). On 09/16/19 Resident #46's record was reviewed and included an active physician's order dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to assess one of 39 residents (Resident #112) for entrapment risks prior to use of bed rails with a specialty mattress. The findings include: Resident #112 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #112 included respiratory failure, seizures, cerebrovascular disease, diabetes, COPD (chronic obstructive pulmonary disease), dysphagia, cognitive communication deficit, schizophrenia, glaucoma, mood disorder and high blood pressure. The minimum data set (MDS) dated [DATE] assessed Resident #112 with short and long-term memory problems and moderately impaired cognitive skills. The MDS listed the resident had highly impaired vision and required the extensive assistance of two people for bed mobility. On 9/15/19 at 5:20 p.m., Resident #112 was observed in bed. The resident's right foot was hanging off the side of the bed. The resident was on an…

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

Based on observation, staff interview and facility document review, the facility staff failed to perform hand hygiene during meal assistance in one of three dining rooms (East unit restorative). The findings include: On 9/16/19, breakfast was observed in the East unit restorative dining room from 7:50 a.m. until 8:15 a.m. On 9/16/19 at 7:50 a.m., certified nurses' aide (CNA) #3 offered Resident #34 a banana. Without use of gloves, CNA #3 completely peeled the banana and directly touched the food with her bare hands before handing the banana to the resident. The resident took one bite of the banana and placed it on a napkin on the table. Certified nurses' aide (CNA) #1 was observed feeding Residents #9, #33 and #87, who were seated at the same table. CNA #1 was standing and went from resident to resident feeding them the breakfast food items/drink from their trays. CNA #1 gave Resident #33 a bite of food, then went to Resident #87 and fed him several bites. CNA #1 then went to Resident #9 and fed her several bites of food. CNA #1 proceeded to go from resident to resident feeding each…

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.