Seven Hills Rehabilitation And Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure misappropriation of medications did not occur for one of nine residents, resident # 7 (R7). The findings included: On 5/14/24, licensed practical nurse #2 (LPN #2) was observed removed medications belonging to R7 from the facility med cart and gave them to certified nursing assistant #2, (CNA#2) for personal use. A review of the clinical record revealed that R7 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, dementia, cerebral infarction, major depressive disorder, chronic pain, generalized anxiety disorder, and hypertension. The most recent minimum data set (MDS) assessment was a quarterly assessment, dated 3/3/24, which assessed R7 as cognitively intact. On 6/11/24 at 8:38 AM, other staff #1 (OS#1), who was the director of rehabilitation, was interviewed. OS #1 stated that on 5/14/24 she was in the facility gym when she observed 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 facility documentation and staff interviews, the facility staff failed to review and update a facility-wide assessment to care for the resident population during day-to-day operations and emergencies, which had the potential to affect all 82 residents residing in the facility. The findings included: On 2/13/24, the facility administrator was asked to provide the survey team with the facility assessment. On 2/14/24, a three-ring binder was provided to the survey team which included the most recent facility assessment which indicated the following, Date of facility assessment: 5/12/22, Date reviewed with QAPI Committee: 5/26/2021 . It was noted that the facility name did not reflect the current name the facility was operating under, nor updates to reflect the current facility administration staff. On 2/14/24 at 9:40 a.m., an interview was conducted with the facility administrator. When asked what the facility assessment is and the purpose of it, the administrator said, It is done to look to overall view of the facility. When asked how often it is reviewed and by whom, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, the facility staff failed to review and revise the comprehensive care plan for three of seven residents in the survey sample (Residents #2, #3 and #6). The findings include: 1. a) Resident #2's plan of care was not revised following statements of self-harm and before/after two suicide attempts by the resident when the bed remote cord was found wrapped around the resident's neck. Resident #2 (R2) was admitted to the facility with diagnoses that included bipolar disorder, major depression disorder, affective mood disorder, borderline personality disorder, dementia with agitation, psychotic disturbance, generalized anxiety disorder, cognitive communication deficit, cerebral infarction, hypertension, diabetes, atrial fibrillation, ischemic heart disease, urinary tract infection, COPD (chronic obstructive pulmonary disease) and asthma. The minimum data set (MDS) dated [DATE] assessed R2 with severely impaired cognitive skills and as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, the facility staff failed to provide medically related social services in response to statements of self-harm for three of seven residents in the survey sample (Residents #2, #6 and #7). The findings include: 1. Facility staff failed to provide a social services assessment and initiate and/or advocate for interventions for suicide prevention and emotional support for Resident #2 following statements of self-harm and two suicide attempts involving the resident wrapping the bed remote cord around her neck. Resident #2 (R2) was admitted to the facility with diagnoses that included bipolar disorder, major depression disorder, affective mood disorder, borderline personality disorder, dementia with agitation, psychotic disturbance, generalized anxiety disorder, cognitive communication deficit, cerebral infarction, hypertension, diabetes, atrial fibrillation, ischemic heart disease, urinary tract infection, COPD (chronic obstructive…

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 and resident interviews, clinical record reviews and facility documentation reviews, the facility staff failed to provide effective administration regarding behavioral health services and smoking safety, resulting in the identification of two immediate jeopardy situations and substandard quality of care being identified, which had the potential to affect multiple residents on all 3 of the nursing units. The findings included: 1. The facility administration failed to administer the facility in an effective manner to address the behavioral health needs of 3 Residents who verbalized suicidal ideation, one of which had 2 attempts of suicide. On 2/12/24, during observations and clinical record reviews, the following was noted: 1A. On 12/26/23, Resident #2 (R2) reported to facility staff statements of suicidal ideation and was noted with increased verbal/physical behaviors. The facility staff failed to respond to the suicidal ideation and implemented no interventions to protect the resident…

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

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain an effective quality assurance program with regards to smoking safety, which had the potential to affect many residents on one of three nursing units. The findings included: The facility staff failed to maintain an effective quality assurance (QA) program to address smoking safety. On 7/21/23, the facility experienced a fire event that was related to unsecured smoking materials. This incident was investigated during a standard survey conducted 7/30/23 through 8/2/23, which resulted in immediate jeopardy being identified during that survey. As part of the facility's plan of correction, the facility stated, The smoking policy was revised to indicate that smoking material, including any incendiary device would be secured and supervised by facility staff. All smokers were educated to the process with particular attention to storage of smoking materials . The administrator/designee will conduct a random quality monitoring audit of 10 rooms per week to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to notify the physician and/or nurse practitioner of significant changes in condition for three of seven residents in the survey sample (Residents #2, #6 and #7). The findings include: 1. Resident #2's physician and/or nurse practitioner (NP) were not promptly notified regarding the resident's statements of self-harm, episodes of aggressive physical/verbal behaviors, or of Resident #2's first suicide attempt of wrapping a cord around her neck. Resident #2 (R2) was admitted to the facility with diagnoses that included bipolar disorder, major depression disorder, affective mood disorder, borderline personality disorder, dementia with agitation, psychotic disturbance, generalized anxiety disorder, cognitive communication deficit, cerebral infarction, hypertension, diabetes, atrial fibrillation, ischemic heart disease, urinary tract infection, COPD (chronic obstructive pulmonary disease) and asthma. The minimum data set (MDS) dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to follow physician orders for four of fifteen residents in the survey sample (Residents #101, #105, #107 and #108). The findings include: 1. Resident #107 (R107) was not administered medications hydrocodone-acetaminophen and ondansetron as ordered by the physician. Resident #107 was admitted to the facility with diagnoses that included dementia, seizures, atrial fibrillation, insomnia, protein-calorie malnutrition, anxiety, osteoporosis, breast cancer, chronic kidney disease, hypertension, spondylosis, cerebral infarction and COPD (chronic obstructive pulmonary disease). The minimum data set (MDS) dated [DATE] assessed R107 with severely impaired cognitive skills. R107's clinical record documented a physician's order dated 12/9/22 for hydrocodone-acetaminophen 5-325 mg (milligrams) three times per day for pain management and an order dated 12/21/22 for ondansetron 4 mg before meals for nausea prevention. R107's medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure medications were available for administration for two of fifteen residents in the survey sample (Residents #107 and #108). The findings include: 1. The medication ondansetron was not available for administration to Resident #107. Resident #107 (R107) was admitted to the facility with diagnoses that included dementia, seizures, atrial fibrillation, insomnia, protein-calorie malnutrition, anxiety, osteoporosis, breast cancer, chronic kidney disease, hypertension, spondylosis, cerebral infarction and COPD (chronic obstructive pulmonary disease). The minimum data set (MDS) dated [DATE] assessed R107 with severely impaired cognitive skills. R107's clinical record documented a physician's order dated 12/21/22 for ondansetron 4 mg (milligrams) before meals for nausea prevention. R107's medication administration record (MAR) documented ondansetron was not administered before breakfast on 9/24/23. A nursing…

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 laboratory services were obtained for one of 15 residents in the survey sample: Resident # 105. A urine specimen was not picked up by the contracted lab, and a Valproic acid (Depakote) level was not obtained as ordered by the physician. Findings include: Resident # 105 was admitted to the facility 2/2/23 with diagnoses which included, but were not limited to, acute and chronic respiratory failure, COPD, diabetes, and dialysis. The most recent MDS (minimum data set) was a quarterly review dated 8/21/23, which had Resident # 105 assessed as cognitively intact with a total summary score of 15/15. The clinical record was reviewed 9/26/23 beginning at 12:00 p.m. The physician order summary included orders for LAB: Valproic Acid one time only for Schizoaffective dx [diagnosis] for 1 day 9/21/23 U/A due to pain/burning with urination, lower abdominal pain, and milky consistency of urine. Start date 9/21/23. The MAR (medication administration record) was reviewed. There were staff initials beside the…

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

Based on staff interview, facility document review, and clinical record review, the facility staff failed to offer, educate, and document the status of pneumococcal immunizations for three of five residents reviewed during the infection control survey task (Residents #105, #109 and #111). The findings include: Immunizations were reviewed on 9/26/23 as part of the infection control survey task. During this review, the clinical records for Residents #105 (R105), #109 (R109) and #111 (R111) revealed no pneumococcal immunization status. There was no evidence that R105, R109 or R111 had been offered and/or educated about the pneumococcal vaccine. The clinical records for these residents documented no status, education, or offering of the pneumococcal vaccine. On 9/27/23 at 8:40 a.m., the director of nursing (DON) was interviewed about pneumococcal vaccination status for R105, R109, and R111. Reviewing the historical immunization records of these residents, the DON stated there was no record of their pneumococcal immunization status and it was not known if they had been offered the…

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

Based on staff interview, facility document review, and clinical record review, the facility staff failed to offer, educate, and document the status of COVID-19 immunizations for two of five residents reviewed during the infection control survey task (Residents #109 and #112) and failed to develop an infection control policy to address offering/provision of COVID-19 immunizations to all residents. The findings include: 1. Facility staff failed to offer, educate and document the status of COVID-19 immunizations for two of five residents reviewed during the infection control survey task (Residents #109 and #112). COVID-19 immunizations were reviewed on 9/26/23 as part of the infection control survey task. During this review, Resident 109's and 112's clinical records documented no status of COVID-19 immunization. There was no evidence the residents had received, refused, been educated about or offered the vaccine or boosters. On 9/27/23 at 8:40 a.m., the director of nursing (DON) was interviewed about COVID-19 vaccination status for R109 and R112. The DON reviewed immunization records…

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 complaint investigation, clinical record review, staff interview, and review of facility documents, the facility staff failed to report a fire in a resident bathroom on the Brookside Unit to the local fire department or the state survey and certification agency. A fire started in a trash can in a shared resident bathroom was believed to have been started by a resident. The findings were: On the morning of 8/22/2023, according to witness statements from six facility staff, a strong smell of smoke was detected on the area of room [ROOM NUMBER] on the Brookside Unit. Investigation by staff found a fire in a wastebasket located in the bathroom shared by room [ROOM NUMBER] and an adjoining resident room. The fire was extinguished by staff. There were no apparent injuries to residents or staff. At approximately 11:00 a.m. on 8/25/2023, the facility Administrator was asked if the fire was reported to the local fire department or the the state survey and certification agency. The Administrator responded, No, it…

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

Based on staff interview, facility document review and clinical record review, the facility staff failed to effectively manage and use resources to ensure resident safety following changes to the facility's smoking protocols. New smoking protocols transferred responsibility to secure smoking materials from staff to residents. Three days after implementing the policy, the facility experienced a centrally located fire resulting in evacuation and three residents (Residents #19, #23 and #239) sent to the hospital for assessment/treatment related to the fire. An unsecured lighter was associated with the start of the facility fire. Unsecured hazardous smoking materials, including lighters were found during the survey resulting in the identification of immediate jeopardy and substandard quality of care. The findings include: A facility reported incident form dated 7/21/23 documented the facility experienced a fire on 7/21/23 at approximately 7:45 p.m. This report to the state agency documented, At approximately 745 pm a resident came out into the hall and began yelling that it was flooding…

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 facility document review and staff interview, the facility staff failed to provide advanced notice of discontinued Medicare Part A services for two of three residents sampled (Residents #70 and #77). The findings include: Three residents were sampled as part of the skilled nursing facility beneficiary protection notification review. During this review, there was no evidence that an advanced notice was provided to Residents #70 (R70) and #77 (R77) regarding discontinued Medicare services. R70's Medicare Part A services started on 4/17/23 with the last date covered on 5/15/23. R77's Medicare Part A services started on 3/21/23 with the last dated covered on 4/10/23. The facility had no documentation that any type of notification was issued to R70 and R77 prior to the end of service and no explanation was documented as to why notices were not provided. On 7/31/23 at 3:08 p.m., the business office manager (other staff #5) was interviewed about any notices provided to R70 and R77. The business office manager stated she reviewed records and found no notices and/or explanation 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 and clinical record review, the facility staff failed to ensure complete and accurate minimum data set (MDS) assessments for four of forty residents in the survey sample (Residents #41, #48, #50 and #189). The findings include: 1. Resident #41 (R41) had no assessment of cognitive status for quarterly MDS assessments dated 4/25/23 and 6/25/23. Resident #41 was admitted with diagnoses that include schizophrenia, dementia, seizure disorder, hypertension, hyperlipidemia and respiratory failure. The MDS dated [DATE] assessed R41 with severely impaired cognitive skills. R41's clinical record documented quarterly MDS assessments dated 4/25/23 and 6/25/23. Section C. for assessment of cognitive patterns was blank with no responses to the BIMS (brief interview for mental status) or staff assessment of mental status. 2. Resident #48 (R48) had no assessment of cognitive status for the quarterly MDS assessment dated [DATE]. R48 was admitted to the facility with diagnoses that included anemia,…

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 interviews, record reviews, and facility policy reviews, the facility failed to complete a nursing assessment and/or incontinent care for one (Resident (R)90) of 41 sampled residents. Findings include: Review of the facility policy titled, Activities of Daily Living (ADLs), revised 12/01/22, revealed . A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . Nursing staff will record care as it is provided . and advise the charge nurse of any issues or concerns. Review of the facility's document titled, Eastern Required [User Defined Assessments] UDA Assessment Schedule, dated 07/23, revealed the following assessments should be conducted upon admission: admission/readmission screening, Morse Fall Scale, Braden Scale for predicting pressure sore risk, Gates Wandering Assessment, Base Line Care Plan, and Functional Abilities and Goals. Review of R90's undated admission Record located in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review, the facility staff failed to perform weekly skin assessments for pressure ulcer prevention for one of forty residents in the survey sample (Resident #55). The findings include: Resident #55 (R55) did not have weekly skin assessments as required in the plan of care for pressure ulcer prevention. R55 was admitted to the facility with diagnoses that included hypothyroidism, breast cancer, chronic kidney disease, macular degeneration, adult failure to thrive, dementia, dysphagia, insomnia, osteoporosis, anxiety, depression and COPD (chronic obstructive pulmonary disease). The minimum data set (MDS) dated [DATE] assessed R55 with severely impaired cognitive skills. R55's clinical record documented no skin assessments during the past three weeks. The last documented skin assessment was dated 7/5/23 indicating intact skin. R55's plan of care (revised 7/24/23) documented the resident was at risk of pressure ulcer development due to bowel/bladder…

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 interviews and the staffing pattern, the facility failed to ensure that there was a Registered Nurse (RN) on duty at least eight consecutive hours a day, seven days a week for five of the 30 days reviewed for staffing patterns, and two of the Payroll Based Data (PBJ) days reviewed. This failure had the potential to impact all residents present in the building. Findings include: Review of the staffing pattern for the 30 days prior to the start of survey on 07/30/23 revealed no Registered Nurse was in the building the entire day on 07/06/23, 07/09/23, 07/23/23, 07/27/23, and 07/31/23 respectively. Review of the facility's staffing schedule on 02/19/23, and 03/19/23 revealed no registered nurse on the schedule for those dates. During an interview on 08/02/23 at 3:21 PM, with Administrative Staff Member (ASM -Business office Manager)5 acknowledged there was no RN in the facility on all shifts on 02/19/23, 03/19/23, 07/06/23, 07/09/23, 07/23/23, 07/27/23, and 07/31/23.

Based on observations, interviews, and facility policy review, the facility failed to properly store food in a sanitary manner for 36 of 40 residents that received meals from the kitchen. This failure increased the risk for food borne illnesses. Findings include: Review of the facility's undated policy titled, Food Receiving and Storage revealed Foods shall be received and stored in a manner that complies with safe food handling practices .Dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by date) . All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date) .The freezer must keep frozen foods frozen solid. Wrappers of frozen foods must stay intact until thawing .Beverages must be dated when opened and discarded after twenty-four (24) hours .Other opened containers must be dated and sealed or covered during storage . During an observation and interview on 07/30/23 at 11:08 AM in the dry kitchen storage area, refrigerators, and freezer, the Lead [NAME] (LC) revealed: 1. Bag of egg noodles had 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 facility document review and staff interview, the facility staff failed to conduct quality assessment and assurance meetings at least quarterly. The findings include: Review of the facility's quality assessment and assurance program found no evidence of recent meetings that included the required staff and review of the facility's overall performance regarding quality management systems and process improvement projects. The last formal quarterly meeting was documented on 12/29/22. Additional meetings were due in March 2023 and June 2023 to meet the quarterly requirement. On 8/2/23 at 9:40 a.m., the interim administrator (administration staff #1), current administrator (administration staff #2) and regional director of clinical services (RDCS - administration staff #4) were interviewed about quality assessment (QA) and assurance committee meetings. The interim administrator, working since 7/17/23 stated she had not been involved in a formal QA meeting since she had been there. The interim administrator stated an ad hoc meeting was initiated on 7/25/23 in response to the fire…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide appropriate tuberculin testing per policy for four of forty residents (Residents #79, #68, #80, #90), failed to perform proper hand hygiene during care of one of forty residents (Resident #239), and failed to follow infection control protocols on one of four units (Brookside) regarding handling of linen. The findings include: 1. Facility staff failed to interpret/read a tuberculin (TB) test for Resident #79 (R79) as part of the infection control protocols for new admissions. Resident #79's immunization status was reviewed on 8/1/23 as part of the infection control/immunization survey task. R79's clinical record documented the resident was administered a tuberculin skin test on 6/21/23. As of 8/1/23, the result of the test was documented as pending. There was no documentation in the clinical that the test had been read and/or interpreted. On 8/1/233 at 4:00 p.m.,…

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, group interview, the facility failed to ensure an effective pest control program. Flies were observed in multiple areas of the facility. The Findings Include: Observations during initial tour of the facility on 7/30/23 included multiple sightings of flies throughout the facility, including residents' rooms and common areas. During a group interview meeting conducted on 7/31/23 at 1:37 PM, one of the concerns brought up by the group of residents were the flies throughout the facility. On 8/2/23, the facility's pest control logs were reviewed for the past 3 months. According to the contracted pest control company, a report dated 6/2/23 found improper food storage practices, along with food surfaces needing to be washed, and suggested that the facility remind employees to keep outside doors closed in the kitchen and to install a screen door with auto door closer. On 8/02/23 at 10:25 AM, the dietary manager (other staff, OS #6) was interviewed. OS #6 verbalized that the air conditioning system had been broken and staff had been propping the door…

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 facility document review and staff interview, the facility staff failed to track and show evidence that nurse aides received at least 12 hours of in-service training per year. The findings include: On 8/2/23 at 8:10 a.m., the training for nurse aides was reviewed with licensed practical nurse (LPN #1) responsible for staff development/education. LPN #1 had no tracking system or database indicating what annual training had been completed by certified nurse aides or when the training was due. LPN #1 was interviewed at this time about how the facility provided the required annual training for nurse aides. LPN #1 stated she had been in the education role since March 2023. LPN #1 stated there was no previous system for tracking the annual nurse aide training and she had not yet established a system. LPN #1 stated, Before me, it was not tracked effectively. LPN #1 stated all staff had been educated on abuse/neglect/resident rights multiple times in the past several months in response to incidents. LPN #1 stated incontinence care training was initiated if needed based upon…

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, interviews, and record review, the facility failed to ensure the maintenance of residents' dignity for two of two residents (Residents (R)239 and R240) with an indwelling urinary catheter by failing to provide a privacy cover for their urinary catheter drainage bags and one resident (R44) when the curtain and door were not closed during personal care out of a total sample of 41 residents. Findings include: Review of the facility's policy titled Promoting/Maintaining Resident Dignity, review/revised 12/1/22, revealed as follows: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality .1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights .12. Maintain resident privacy . 1. 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 record review, observations, interviews, and policy review, the facility failed to ensure safe positioning for one (Resident (R)140) of two residents reviewed for positioning in a total sample of 41 residents. This deficient practice had the potential to cause respiratory issues for residents who require assistance with positioning for meals. Findings include: Review of the Policy titled Accommodation of Needs, dated 12/01/22, documented: Based on individual needs and preferences, the facility will assist the resident in maintaining and/or achieving independent functioning, dignity, and wellbeing to the extent possible. Review of the admission Record, located in the Electronic Medical Record (EMR) under the Admission tab, revealed R140 was admitted to the facility on [DATE] with diagnoses that included dementia, torticollis (the neck twists to one side), dysphagia (difficulty swallowing), and anxiety. Review of the Care Plan, located in the EMR under the Care Plan tab and dated 01/28/21, related 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 record review, interviews, and facility policy review, the facility failed to notify the guardian of significant weight loss, of a significant event and/or potential for abuse for one (Resident (R)80) of two residents reviewed for notification of a pool of 41 residents. Specifically, the guardian was not notified of a fire in the building on 07/21/23 which required evacuation of residents in the building, and was not notified allegation of abuse involving R80. Findings include: Review of the facility policy titled, Notification of Changes, revised 03/10/23, revealed The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification . Review of the facility synopsis provided by the facility and dated 06/14/23, revealed that R80's arm and/or his Geri-chair was slapped by a nurse to get his attention on 06/14/23. The agency nurse…

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, interviews, document review, and facility policy review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for one unit (Brookside) of four units. Findings include: Observations conducted on the Brookside Unit revealed that rooms [ROOM NUMBERS] shared a bathroom area and rooms [ROOM NUMBERS] shared a bathroom area. There were three separate areas in each of the bathrooms: a room with two double sinks, a toilet room with no door behind the sink room, and a second toilet room with no door behind the first toilet room. 1. Observations conducted in the shared bathroom area for rooms [ROOM NUMBERS], on 07/30/23 at 11:29 AM and 12:50 PM, on 07/31/23 at 10:14 AM and 2:13 PM, and 08/01/23 at 12:54 PM, revealed the following: In the sink room, there were two wheelchairs in front of each sink, four basins that were not marked with a resident's name, one unmarked kidney basin with a new toothbrush and toothpaste,…

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 interviews, clinical record review, and facility document review, the facility failed to ensure that three of 41 residents of the survey sample (Resident (R) #1, R80, R189) were free from abuse. Findings include: Review of the facility's policy titled Abuse, Neglect, and Exploitation, revised on 10/01/21, revealed It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . Review of the facility's admission Agreement provided by the facility revealed, . Each resident has the following rights . 9. To be free from mental and physical abuse . 1. Resident #1 (R1) was subjected to verbal/physical/mental/emotional abuse by a facility nurse. Review of the facility synopsis provided by the facility and dated 06/14/23, revealed that Licensed Practical Nurse LPN10 had a verbal…

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 failed to prevent misappropriation of personal property for one of 40 residents in the survey sample. Resident #88's (R88) Klonopin (medication for anxiety) had been misplaced. The Findings Include: Diagnoses for Resident #88 included: Hypothyroidism, malnutrition, anxiety, and chronic pain. The most current MDS (minimum data set) was a 5 day assessment with an ARD (assessment reference date) of 4/16/23. Resident #88 was not cognitively assessed at the time of the 5 day assessment. A facility reported incident (FRI) for R88 dated 5/26/23 indicated a concern regarding misappropriation of personal property. On 7/31/23 R88's clinical record was reviewed. A physician's order documented Klonopin 1 MG [milligram] Give 1 tablet by mouth three times a day for anxiety. Review of R88's medication administration record (MAR) documented R 88 was receiving the medication as prescribed. Review of the facility's investigation indicated R88 had brought a bottle containing 79 pills of klonopin to the…

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

Based on staff interview, and facility document review, the facility failed to ensure an employee background check was completed for one of 20 employees reviewed. The Findings Include: During an employee record review conducted on 8/2/23 there was no documentation to indicate an employee hired on 4/28/23 had completed a required background check. On 8/1/23 at 4:00 PM the business manager (other staff, OS #5) was interviewed. OS #5 verbalized recently taking over the position and after going through employee records realized that the previous business manager had not been completing some of the required documentation on new employees and she (OS #5) had been trying to catch everything up to date. OS #5 went onto say that the employee in question works on an as needed basis and hasn't worked since the concern was identified but a form had been placed in the employees mailbox for her to sign so that the background check could be performed. A policy titled Abuse, Neglect and Exploitation read in part Background, reference, and credentials' checks shall be conducted on potential…

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 record review, interviews, and facility policy review, the facility failed to ensure three of three residents (Residents (R)1, R8, and R59) reviewed for care planning out of 41 sample residents were invited to participate in their quarterly care plan meetings. Findings include: Review of the facility's policy titled Care Planning- Resident and/or Resident Representative participation, revised 12/01/22, revealed The facility supports the resident's and/or resident's representative right to be informed of, and participate in, his or her care planning and treatment (implementation of care) . Review of the facility's policy titled Comprehensive Care Plans, revised 12/01/22, revealed It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive…

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, interview, record review, and policy review, the facility failed to ensure residents who were dependent on staff for Activities of Daily Living (ADL) assistance received services for three of four residents (Resident (R)50, R31, and R140 ) reviewed for shaving and/or fingernail care in a total sample of 41 residents. This failure placed residents at risk for diminished self-worth, self-esteem, feelings of embarrassment, and/or medical issues. Findings include: Review of the facility's policy titled Grooming a Resident's Facial Hair, dated 12/01/22, documented it is the practice of this facility to assist residents with grooming facial hair to help maintain proper hygiene. Review of the facility's policy titled Activities of Daily Living (ADL), dated 12/01/22, documented .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good grooming and personal and oral hygiene. 1. Review of the Face Sheet, located in the Electronic Medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and facility policy review, the facility failed to assess and monitor the nutritional status of one of five residents (Resident (R)80) reviewed for weight loss in a total sample of 41 residents. Findings include: Review of the facility's policy titled, Weight Monitoring, revised 12/01/22, revealed Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise . Interventions will be identified, implemented, monitored and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status .A significant change in weight is defined as: a. 5% change 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, interview, and record review, the facility failed to ensure the oxygen units for two of two residents (Resident (R)50 and R23) reviewed for respiratory care were clean and sanitary in a sample of 41 residents. This failed practice has the potential to cause respiratory and other infections for residents. Findings include: 1. Review of the Face Sheet, located in the Electronic Medical Record (EMR) under the Admissions tab, documented R50 was admitted to the facility on [DATE]. Review of the Physician Orders, located in the EMR under the Orders tab and dated 11/10/22, revealed an order for Oxygen Therapy - Oxygen at 2 liters per minute via nasal cannula. Review of R50's quarterly Minimum Data Set (MDS) located in the resident's EMR under the MDS tab with an Assessment Reference Date (ARD) of 03/22/23, revealed a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating R50 was cognitively intact and used oxygen. 2. Review of the Face Sheet, located in the EMR under the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure medications were available for administration for two of fifteen residents in the survey sample (Residents #107 and #108). The findings include: 1. The medication ondansetron was not available for administration to Resident #107. Resident #107 (R107) was admitted to the facility with diagnoses that included dementia, seizures, atrial fibrillation, insomnia, protein-calorie malnutrition, anxiety, osteoporosis, breast cancer, chronic kidney disease, hypertension, spondylosis, cerebral infarction and COPD (chronic obstructive pulmonary disease). The minimum data set (MDS) dated [DATE] assessed R107 with severely impaired cognitive skills. R107's clinical record documented a physician's order dated 12/21/22 for ondansetron 4 mg (milligrams) before meals for nausea prevention. R107's medication administration record (MAR) documented ondansetron was not administered before breakfast on 9/24/23. A nursing…

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 properly store liquid narcotics in one of two refrigerators and failed to ensure medications were labeled appropriately in one of two medication carts reviewed. Findings were: During a medication storage review conducted on 8/1/23 at 4:00 PM, the medication refrigerator serving Riverside and Twin Lakes unit was reviewed. A bottle of liquid Ativan was stored directly on the shelf of the refrigerator and not in the permanently affixed lock box inside the refrigerator. License practical nurse (LPN #4, assisting with the review) was asked about proper storage of a narcotic. LPN #4 verbalized that all narcotics are supposed to be inside of the lock box that is affixed to the refrigerator and locked. A medication cart on Twin Lakes unit was then reviewed and revealed the following: Two bottles of stool softeners 100 milligram (MG) tablets, 1 bottle of Melatonin 3 mg tablets, and 1 bottle of Famotidine 10 MG tablets, all opened and without an open date. Registered nurse (RN #2, assisting with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of facility policy, the facility failed to ensure a urinalysis (UA) and urine culture and sensitivity (C&S) tests were processed and reported to the provider for one of one (Resident (R)68) resident reviewed for urinary tract infections in a total sample size of 41. Specifically, R68's abnormal UA C&S results were not reported to the physician until 08/02/23, delaying the treatment for recurrent urinary tract infection. Findings include: Review of the facility's policy, Laboratory Services and Reporting, revised 12/01/22, documented the facility was to . provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law . The facility is responsible for the timeliness of the services .Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range. 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.

Based on staff interview, facility document review and clinical record review, the facility staff failed to offer, educate and document the status of pneumococcal and/or influenza immunizations for two of five residents reviewed during the infection control survey task (Residents #48 and #79). The findings include: Immunizations were reviewed on 8/1/23 as part of the infection control survey task. During this review, Resident #48's (R48's) clinical record documented no pneumococcal immunization status. There was no evidence the R48 had been offered and/or educated about the pneumococcal vaccine. Resident #79's (R79's) clinical record documented no status, education or offering of the pneumococcal or influenza vaccines. On 8/1/23 at 4:00 p.m., the licensed practical nurse infection preventionist (LPN #1) was interviewed about pneumococcal and influenza immunization requirements for R48 and R79. LPN #1 reviewed the clinical record and stated there was no documented status of R48's pneumococcal vaccine. LPN #1 stated there was nothing in the record indicating the resident had been…

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

Based on staff interview, facility document review, and clinical record review, the facility staff failed to offer and record the status of COVID-19 immunizations for one of five residents reviewed during the infection control survey task (Resident #79). The findings include: Immunizations were reviewed on 8/1/23 as part of the infection control survey task. During this review, Resident #79's (R79's) clinical record documented no status of COVID-19 immunizations. There was no evidence that R79 had received, refused, been educated about, or offered the vaccine or boosters. On 8/1/23 at 4:00 p.m., the licensed practical nurse infection preventionist (LPN #1) was interviewed about R79's COVID-19 immunizations. LPN #1 stated the resident was admitted in June 2023 and the COVID-19 immunization status should have been determined at admission. LPN #1 stated the status was not documented in the clinical record. LPN #1 stated she had just recently obtained access to an historical database to review immunization history but had not updated all records. The facility's policy titled 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 clinical record review and staff interview, the facility staff failed to ensure laboratory services were obtained for one of 15 residents in the survey sample: Resident # 105. A urine specimen was not picked up by the contracted lab, and a Valproic acid (Depakote) level was not obtained as ordered by the physician. Findings include: Resident # 105 was admitted to the facility 2/2/23 with diagnoses which included, but were not limited to, acute and chronic respiratory failure, COPD, diabetes, and dialysis. The most recent MDS (minimum data set) was a quarterly review dated 8/21/23, which had Resident # 105 assessed as cognitively intact with a total summary score of 15/15. The clinical record was reviewed 9/26/23 beginning at 12:00 p.m. The physician order summary included orders for LAB: Valproic Acid one time only for Schizoaffective dx [diagnosis] for 1 day 9/21/23 U/A due to pain/burning with urination, lower abdominal pain, and milky consistency of urine. Start date 9/21/23. The MAR (medication administration record) was reviewed. There were staff initials beside the…

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

Based on staff interview and facility document review, the facility staff failed to provide security of all resident personal funds deposited with the facility. The facility did not have a surety bond in an amount to cover resident fund balances. The facility's surety bond was for $55,000 and resident funds equaled $146,285. The findings include: On 11/30/21 at 4:24 p.m., the business office manager (other staff #8) was interviewed about resident fund accounts as part of the triggered personal fund survey task. The business office manager presented a balance sheet dated 11/30/21 listing the current balance of all resident deposited funds as $146,285.99. The surety bond was requested as part of the review. The business office manager presented a copy of the facility's surety bond (effective date 7/1/19) with the amount of coverage listed as $55,000. On 11/30/21 at 4:30 p.m., the business office manager was interviewed about the surety bond amount not covering resident funds. The business office manager stated she did not realize the surety bond amount was less than the residents'…

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

Based on staff interview and facility document review, the facility staff failed to ensure routine COVID-19 testing for unvaccinated staff was conducted based on level of community transmission rates, for two of four weeks in the month of November. Findings include: A review of the facility's infection control program was reviewed from 11/29/21 through 12/01/21. There were no current COVID-19 positive cases for residents or staff. On 11/30/21 the administrator presented the routine COVID-19 testing requirements for staff based on the facility's level of community transmission. The facility had a binder with the level of community transmission rates listed. For the month of November 2021 the following rates were recorded. 11/02/21 - 11.88 % (HIGH - twice weekly testing required) 11/09/21 - 9.55 % (SUBSTANTIAL - twice weekly testing required) 11/15/21 - 7.53 % (MODERATE - once weekly testing required) 11/22/21 - 9.84 % (SUBSTANTIAL - twice weekly testing required) On 12/1/21 at 8:50 AM, the facility's routine testing records for unvaccinated staff was reviewed. Routine testing 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 abuse prevention policies for reporting and thoroughly investigating an allegation of abuse for one of 23 residents in the survey sample, Resident #67. Allegations by Resident #67 of inappropriate sexual comments from another resident that made the resident uncomfortable were not reported or thoroughly investigated as required by the facility's abuse prevention policies. The findings include: Resident #67 was admitted to the facility on [DATE] and was discharged to the hospital on 11/17//21. Diagnoses for Resident #67 included viral hepatitis C, cirrhosis of liver, liver failure, affective mood disorder, renal failure, coronary artery disease, hypertension and hypothyroidism. The minimum data set (MDS) dated [DATE] assessed Resident #67 as cognitively intact. The facility's complaint/grievance logs were reviewed. The social services director documented a complaint/grievance form dated 6/17/21…

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 report to the state agency and adult protective services, an allegation of inappropriate sexual comments toward one of 23 residents in the survey sample. Allegations by Resident #67 of inappropriate sexual comments from another resident that made the resident uncomfortable were not reported to the state agency or local adult protective services. The findings include: Resident #67 was admitted to the facility on [DATE] and was discharged to the hospital on 11/17//21. Diagnoses for Resident #67 included viral hepatitis C, alcoholic cirrhosis of liver, liver failure, affective mood disorder, renal failure, coronary artery disease, hypertension and hypothyroidism. The minimum data set (MDS) dated [DATE] assessed Resident #67 as cognitively intact. While investigating complaint allegations regarding Resident #67, the facility's complaint/grievance logs were reviewed. The social services director documented 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, facility document review and clinical record review, the facility staff failed to thoroughly investigate allegations of potential verbal abuse for one of 23 residents in the survey sample. Allegations by Resident #67 of inappropriate sexual comments from another resident that made the resident uncomfortable were not thoroughly investigated. The findings include: Resident #67 was admitted to the facility on [DATE] and was discharged to the hospital on 11/17//21. Diagnoses for Resident #67 included viral hepatitis C, alcoholic cirrhosis of liver, liver failure, affective mood disorder, renal failure, coronary artery disease, hypertension and hypothyroidism. The minimum data set (MDS) dated [DATE] assessed Resident #67 as cognitively intact. While investigating complaint allegations regarding Resident #67, the facility's complaint/grievance logs were reviewed. The social services director documented a complaint/grievance form dated 6/17/21 stating, Resident [#67] reports that 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, resident interview, and clinical record review, the facility staff failed to ensure an accurate minimum data set (MDS) for one of 23 residents in the survey sample. Resident #49's 5-day and significant change MDS both documented an inaccurate assessment of bladder function. The findings include: Resident #49 originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hypertension, chronic kidney disease, vitamin d deficiency, depression, hypokalemia, after care for amputation, and urine retention. The most recent MDS dated [DATE] was a significant change and assessed Resident #49 as cognitively intact for daily decision making with a score of 15 out of 15. Under Section H - Bowels and Bladder, Resident #49 was assessed as having an indwelling catheter. A comparative review of the 5-day MDS dated [DATE] was completed. Under Section H - Bowels and Bladder, Resident #49 was assessed as having an indwelling catheter. On 11/29/2021 during the initial tour,…

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, and clinical record review, the facility staff failed to review and revise a comprehensive care plan for 2 of 23 residents in the survey sample, Resident #49 and Resident #47. Resident #49's care plans were not reviewed and revised for discontinuation of a foley catheter. Resident #47's care plans were not reviewed and revised for code status change. The findings include: 1. Resident #49 originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hypertension, chronic kidney disease, vitamin d deficiency, depression, hypokalemia, after care for amputation, and urine retention. The most recent MDS dated [DATE] was a significant change and assessed Resident #49 as cognitively intact for daily decision making with a score of 15 out of 15. Under Section H - Bowels and Bladder, Resident #49 was assessed as having an indwelling catheter. A comparative review of the 5-day MDS dated [DATE] was completed. Under Section H - Bowels and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to obtain a physician's order prior to use of a topical medication for one of 23 residents in the survey sample. Resident #72 had topical Nystatin powder applied to her skin without a physician's order for its use. The findings include: Resident #72 was admitted to the facility on [DATE] with a readmission on [DATE]. Diagnoses for Resident #72 included hypoxia, respiratory failure, morbid obesity, diabetes, urinary tract infection, obstructive sleep apnea, anxiety, urinary retention, depression and anemia. The minimum data set (MDS) dated [DATE] assessed Resident #72 as cognitively intact. On 11/30/21 at 9:30 a.m., Resident #72 was observed in bed. A bottle of Nystatin powder was observed on the resident's over-bed table. Resident #72 was interviewed at this time about the Nystatin powder. Resident #72 stated the aides or nurses sprinkled the powder on hot spots on her skin as needed. Resident #72…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility document review, the facility staff failed to ensure one of 23 residents in the survey sample, Resident #30, was provided care and treatment to promote healing and prevent infection of a pressure ulcer. Findings include: Resident #30 was admitted to the facility on [DATE], with the most recent readmission on [DATE]. Diagnoses for Resident #30 included, but were not limited to: anemia, CHF (congestive heart failure), high blood pressure, history of multiple strokes with hemiparesis/hemiplegia, cardiac arrhythmias, schizophrenia, and a stage 4 pressure ulcer. The most current MDS (minimum data set) was a quarterly assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 9, indicating the resident had moderate impairment in daily decision making skills. The resident was also assessed as requiring extensive assistance for all ADL's (activities of daily living). The resident was assessed as having a current stage 4…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide appropriate catheter care for two of 23 residents in the survey sample. Resident #72 had a urinary catheter in use with the tubing unsecured to prevent pulling/tugging at the insertion site. Resident #50's catheter bag was observed in the floor under the resident's bed. The findings include: 1. Resident #72 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #72 included hypoxia, respiratory failure, morbid obesity, diabetes, urinary tract infection, obstructive sleep apnea, anxiety, urinary retention, depression and anemia. The minimum data set (MDS) dated [DATE] assessed Resident #72 as cognitively intact. On 11/30/21 at 9:12 a.m., Resident #72 was observed in bed with a Foley urinary catheter in use. Resident #72 was interviewed at this time about catheter care provided by the facility. When asked about an anchor or 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 observation, resident interview, staff interview and facility document review, the facility staff failed to ensure oxygen equipment was maintained in sanitary manner for one of 23 residents, Resident #44. Findings include: Resident #44 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to: acute kidney failure, COPD (chronic obstructive pulmonary disease), heart failure, diabetes, HIV, history of pulmonary embolis, major depressive disorder and SIRS (systemic inflammatory response). The most current MDS (minimum data set) was an admission assessment dated [DATE]. This MDS assessed the resident as a 9 cognitively, indicating the resident had moderate impairment in daily decision making skills. On 11/29/21 at 12:23 PM, Resident #44's oxygen concentrator was observed in his room. The oxygen tubing was dated 11/22/21. The humidifier canister had approximately 1/8th of water remaining in the humidifier, and the humidifier canister was not dated. On 12/01/21 at approximately 7:45…

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 document review, the facility staff failed to properly store medications for two of 23 residents in the survey sample, Resident # 28 and #72. Findings include: 1. On 11/30/21 at 7:45 a.m., a medication pass and pour observation was conducted on the Riverside unit with LPN (licensed practical nurse) # 1. LPN # 1 was observed administering medications to Resident # 28. Upon entering the resident's room, a medication bag containing prescription nasal spray was on the overbed table. LPN # 1 asked the resident to hand her the bag. LPN # 1 was asked why the bag was there, and she stated I don't know, it could have been left there on night shift. LPN # 1 returned the nasal spay to the medication cart. On 11/30/21 at approximately 10:00 a.m. Resident # 28, who was assessed as cognitively intact, was asked about the nasal spray. She stated It's been there on that table since yesterday morning, I guess they just forgot. 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, clinical record review, and facility document review, the facility staff failed to ensure infection control practices were maintained during a dressing change for one of 23 residents (Resident #30), and during a medication pass and pour observation on one of two nursing units. Findings include: 1. Resident #30 was admitted to the facility on [DATE], with the most recent readmission on [DATE]. Diagnoses for Resident #30 included, but were not limited to: anemia, CHF (congestive heart failure), high blood pressure, history of multiple strokes with hemiparesis/hemiplegia, cardiac arrhythmias, schizophrenia, and a stage 4 pressure ulcer. The most current MDS (minimum data set) was a quarterly assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 9, indicating the resident had moderate impairment in daily decision making skills. The resident was also assessed as requiring extensive assistance for all ADL's (activities of daily living), no ambulation,…

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

Based on observation, clinical record review, and staff interview, the facility staff failed to obtain a physician order for the administration of supplemental oxygen for one of 31 residents in the survey sample: Resident # 102. Findings include: Resident # 102 was admitted to the facility 12/13/11 with a readmission date of 2/1/19. Diagnoses for Resident # 102 included, but was not limited to: hemiparesis and hemiplegia following a stroke, convulsions, COPD, high blood pressure, and dependence on supplemental oxygen. On 2/24/19 at 3:45 p.m. during initial tour of the facility Resident # 102 was observed sitting in her wheelchair in her room. There was a portable oxygen (02) tank on the back of the wheelchair that was empty; the resident had a nasal cannula hooked to it and the tubing in her nose. LPN (licensed practical nurse) # 1 was asked for assistance with the observation. LPN # 1 stated Yes, that tank is empty; when the CNA (certified nursing assistant) brought her back to the room she should have been switched over to the oxygen concentrator. LPN # 1 was asked if an 02…

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 obtain and administer pain medications as ordered by the physician for one of 31 residents in the survey sample. Resident #46, assessed with ongoing pain related to cancer, was not administered the pain medication Morphine Sulfate as ordered by the physician for five consecutive days. The findings include: Resident #46 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #46 included tonsil cancer, dysphagia with gastrostomy, gastroesophageal reflux disease (GERD), hypertension and cerebrovascular accident (stroke). The minimum data set (MDS) dated [DATE] assessed Resident #46 with moderately impaired cognitive skills. Resident #46's clinical record documented a nurse practitioner's progress note dated 1/10/19 stating, Hx [history] of malignant neoplasms of the tonsil, s/p [status post] chemo and radiation .I asked him on exam if he had pain states 'oh yes'; he does not get into specifics 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 resident interview, group interview, facility document review, and in the course of a complaint investigation, facility staff failed to answer call bells in a timely manner throughout the facility. Facility staff failed to answer call bells in a timely manner as evidenced by individual resident interviews, family interview, group resident interview, and as documented in past resident council meeting minutes. Findings included: Resident #97 was interviewed on 02/25/19 at 10:10 a.m. regarding call lights and the aides covering for one another during breaks. Resident #97 stated, They (CNAs) don't cover for each other. They will come in and say your aide is on break, turn off your light and leave. If you ring on third shift, no one comes. They need more CNAs. Resident #97's son was interviewed via phone on 02/25/19 at 10:20 a.m. He stated, Me and my sister [Name] get calls at night around midnight or so from Mom saying I am short of breath and no one is around. We will call at night and the phone rings 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 facility document review, the facility staff failed to treat one of 31 residents in the survey sample with respect and dignity. The facility administrator yelled and talked over Resident #455 during a conversation regarding the patient pay. The findings include: Resident #455 was admitted to the facility on [DATE] with diagnoses that included: muscle weakness, end stage renal disease requiring dialysis, fever, hypertension, unspecified abnormalities of gait and mobility, atrial fibrillation (AFIB) and systemic inflammatory response syndrome (SIRS). The Minimum Data Set, dated [DATE] assessed Resident #455 as cognitive intact for daily decision making with a score of 14. A facility reported incident (FRI) form dated [DATE] documented the following, Resident reported that while the Administrator was speaking along with the S.S. (social worker) and B.O.M. (business office manager) that the Administrator was condescending rude and he felt verbally abused, that she spoke in an angry…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility staff failed to ensure a safe, clean and homelike environment on two of four living units. On the Brookside unit, there was a damaged access cover in the hallway creating a trip hazard and a damaged over-bed table in room [ROOM NUMBER]. On the Pondside unit, water was leaking into the floor around the ice machine with resulting floor damage. The louvered air return panel on the Pondside unit was dirty with heavy lint accumulation. The findings include: On 2/24/19 at 3:45 p.m., a damaged access cover in the center of the hallway on the Brookside unit was observed. The circular panel was bent and partially raised from the floor creating a trip hazard. Residents and staff members were observed walking in the hallway in the area of this bent cover. Also on this unit, an over-bed table in room [ROOM NUMBER] was in disrepair. The corners/edges of the tables extended beyond the plastic trim with rough particle board visible. On 2/25/19 at 10:40 a.m., a damaged…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, the facility staff failed to implement written policies and procedures for the prevention of abuse, neglect and exploitation for one of 31 residents in the survey sample, Resident #42. The facility staff failed to investigate an injury of unknown origin, involving Resident #42. The resident was found with a knot and small laceration over his left eye, in addition to a broken front tooth. The facility failed to investigate, focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment occurred, the extent, and cause; and failed to provide a complete and thorough documentation of the investigation. Findings include: Resident #42 was admitted to the facility on [DATE]. Diagnoses for Resident #42 included, but were not limited to: syncope/collapse, high blood pressure, weakness, diabetes mellitus, seizures, history of chest pain, and major depressive disorder. The most current MDS (minimum data set) was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review, the facility staff failed to review and revise the comprehensive care plan for two of 31 residents in the survey sample, Resident #77 and #46. 1. Resident #77's care plan was not revised to reflect discontinuation of dialysis and shunt. 2. Resident #46's plan of care was not revised to include problems, goals and/or interventions regarding chronic nausea. The Findings Include: 1. Resident #77 was admitted to the facility on [DATE] with the most current readmission on [DATE]. Diagnoses for Resident #77 included: Depression, end stage renal disease, diabetes. The current MDS (minimum data set) was a 5 day assessment with an ARD (assessment reference date) of 2/1/19. Resident #77 was assessed as being cognitively intact with a score of 15 of 15. On 02/24/19 at 4:30 PM, Resident #77 was interviewed. When asked of any concerns regarding dialysis, Resident #77 verbalized that he no longer receives dialysis and it was his choice not to receive dialysis…

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 provide activities of daily living (ADL) care for two of 31 residents in the survey sample. Resident #98's teeth were not brushed/cleaned. Resident #104 was observed with long, dirty fingernails. 1. Resident #98, totally dependent upon staff for ADL care, was observed with unclean teeth. 2. The facility staff failed to ensure Resident #104 was provided ADL (activities of daily living) care to assist with nail care, and meal consumption. The findings include: 1. Resident #98 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #98 included hemiplegia/hemiparesis from cerebrovascular accident (stroke), intracranial injury, cataracts, hypertension, glaucoma, dysphagia, diabetes, seizures and history of aspiration pneumonitis. The minimum data set (MDS) dated [DATE] assessed Resident #98 with moderately impaired cognitive skills and as requiring the extensive…

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 medications were available for 2 of thirty-one in the survey sample, Resident #29 and Resident #104. 1. The facility staff failed to ensure medications were available for Resident #29 during a medication pass and pour observation, per the physician's order. 2. The facility staff failed to ensure the medications, Aricept and Vitamin D were available for administration for Resident # 104. Findings include: 1. On 02/25/19 at 8:31 AM, a medication pass and pour observation was conducted with LPN (Licensed Practical Nurse) #2. LPN #2 prepared medications for the second resident, Resident #29. LPN #2 stated that this resident gets 1000 mg of gabapentin and normally they (the pharmacy) will send an 800 mg (milligram) pill, but she (the resident) doesn't have any. LPN #2 stated that the resident usually gets one 800 mg pill, along with two 100 mg capsules to equal 1000 mg dose, as ordered by the physician. LPN #2 stated…

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, facility staff failed to act upon pharmacy recommendations for one of 31 residents in the survey sample, Resident #81. Facility staff failed to respond to a pharmacy request dated 02/01/2019 and 02/18/2019 for Resident #81. Findings included: Resident #81 was admitted to the facility on [DATE] with diagnoses including, but not limited to: Radiculopathy of the Lumbar Region, Dementia with Behaviors, Encephalopathy, Hypertension, and Osteoarthritis. The most recent MDS (minimum data set) was an admission assessment with an ARD (assessment reference date) of 02/02/2019. Resident #81 was assessed as severely impaired in her cognitive status with a total cognitive score of four out of 15. Resident #81's clinical record was reviewed on 02/26/2019 at approximately 9:00 a.m. During this review two pharmacy review notes were observed and included the following: 2/1/2019 23:13 [11:13 p.m.], Consulting Pharmacist .An admission/re-admission…

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

Based on medication administration observation, staff interview and clinical record review, facility staff failed to ensure a medication error rate of less than five percent in the facility. There were two medication administration errors out of 30 opportunities total, resulting in an overall medication error rate of 6.67 %. The Findings Include: During medication pass and pour observation conducted on 02/25/19 at 8:12 AM, Resident #37 was observed receving medications. The labels on two medications were observed. One label instructed Carvedilol (Coreg) 3.125 MG (millagrams) give two tablets twice a day (given for hypertension); the second instructed Allopurinol 100 MG give two tablets twice a day (given for hyperuricemia). Registered nurse (RN) #2 was observed putting one of each tablet into a dispense cup. Then RN #2 picked up the medication cup and began to enter Resident #37's room. At this time this surveyor stopped RN #2 and asked RN #2 to recheck the medication label for Coreg and Allopurinol. This surveyor pointed out that according to the medication labels Resident #37…

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 expired over the counter medications were not available for distribution on one of 4 medication carts. Four bulk over the counter (OTC) medications were expired and available for distribution on the Brookside medication cart. The Findings Include: On 02/25/19 at 2:14 PM, the Brookside medication cart was reviewed and evidenced the following expired medications: Vitamin C 1000 MG (Milligrams) expiration 12/2018, Antihistamine Allergy relief expiration 8/2018, Multivitamin expiration date 9/2018, and Vit B-12 500 MCG (Micrograms) expiration date 11/2018. License practical nurse (LPN) #3 was present during the observation and confirmed the medications were expired and available for distribution. When asked how nurses ensure that expired medications are not available for distribution, LPN #3 verbalized each nurse is responsible for checking for expired medications on a daily basis. On 02/25/19 at 5:12 PM, the above information was brought to the attention of the director of nursing (DON) and administrator…

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 clinical record for two of 31 residents in the survey sample. 1. Resident #46's clinical record failed to document a physician's order for hospice services. 2. Resident #78's clinical record inaccurately documented physician orders for contact precautions. The findings include: 1. Resident #46 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #46 included tonsil cancer, dysphagia with gastrostomy, gastroesophageal reflux disease (GERD), hypertension and cerebrovascular accident (stroke). The minimum data set (MDS) dated [DATE] assessed Resident #46 with moderately impaired cognitive skills. Resident #46's clinical record documented a change in payer source of 2/15/19 from Medicaid only to Medicaid plus hospice. The resident's clinical record documented no physician's order for hospice care. A social worker note dated 2/12/19 documented a discussion 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.