Martinsville Health And Rehab

Based on staff interview, clinical record review, and facility document review, facility staff failed to develop a baseline care plan for (3) three of (38) thirty-eight sampled residents, Resident #4, Resident #64, and Resident #94. The findings included:1. For resident #4 the facility staff failed to complete a baseline care plan upon admission. Resident #4's diagnoses included but were not limited to, a history of stroke with hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness affecting one side of the body) as well as dysphagia (difficulty swallowing), type II diabetes, schizophrenia, bipolar disorder, anxiety disorder and epilepsy. The annual minimum data set (MDS) assessment with an assessment reference date of 12/16/25 assigned the resident a brief interview for mental status score of 10 out 15 indicating a moderate cognitive impairment. Resident #4 was initially admitted to the facility in April of 2024. The baseline care plan was initiated but only question #2 for primary language and question #4 for allergies had been answered. The rest of 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, clinical record review, and facility document review, the facility staff failed to develop and/or implement a person-centered, comprehensive, activity care plan for (1) one of (28) twenty-eight sampled residents, Resident #80. The findings included:For Resident #80 the facility staff failed to develop and implement a comprehensive person-centered activity care plan to include measurable objectives and timeframes to meet the resident's mental and psychosocial needs and include the resident's goals, desired outcomes, and preferences for activities. Resident #80's diagnosis list indicated diagnoses that included, but were not limited to, volume depletion, atherosclerotic heart disease, schizoaffective disorder, depression, bipolar disorder, suicidal ideations, schizoaffective disorder, acute or chronic malnutrition, and personal history of mental and behavioral disorders. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 1/10/26, assigned the resident a brief interview for mental status (BIMS) summary score of 4 out 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, clinical record review, and facility document review, the facility staff failed to ensure the comprehensive person-centered care plan was reviewed and revised by the interdisciplinary team, for (1) one of (28) twenty-eight sampled residents, Resident #9. The findings included:For Resident #9, the facility staff failed to reassess the effectiveness of the interventions and review and revise the resident's comprehensive person-centered activity care plan to meet the resident's needs. Resident #9's diagnosis list indicated diagnoses that included, but were not limited to, cerebrovascular disease, spastic hemiplegia affecting right dominant side, schizophrenia, depressive disorder, and cognitive communication disorder. The most recent annual minimum data set (MDS) with an assessment reference date (ARD) of 12/20/25, was coded for the resident being rarely/never understood with short and long-term memory problems, and moderate impairment in decision-making. A review of the current…

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 observations, staff interview, resident interview, clinical record review, and facility document review, facility staff failed to provide activities of daily living care for (2) two of (28) twenty-eight dependent residents, Resident #10 and Resident #64. The findings included:1.For Resident #10 the facility staff failed to provide showers or daily bed baths. Resident #10's clinical record listed diagnoses which included but not limited to hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side and contracture, left hand. Resident #10's most recent minimum data set with an assessment reference date of 11/21/25 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Section GG, functional abilities, coded the resident as needing partial/moderate assistance with showering/bathing. Resident #10's comprehensive care plan was reviewed and contained a plan for Potential for Self Care Deficit r/t (related to): Requires…

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 provide an ongoing, person-centered activity program to support resident choice, interests and physical, mental, and psychosocial well-being for (1) one of (28) twenty-eight sampled residents, Resident #80. The findings included:For Resident #80, the facility staff failed to provide an ongoing, person-centered, activity program to support resident choice, interests, and physical, mental, and psychosocial well-being. Resident #80's diagnosis list indicated diagnoses that included, but were not limited to, volume depletion, atherosclerotic heart disease, schizoaffective disorder, depression, bipolar disorder, suicidal ideations, schizoaffective disorder, acute or chronic malnutrition, and personal history of mental and behavioral disorders. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 1/10/26, assigned the resident a brief interview for mental status (BIMS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, clinical record review, and facility document review, the facility staff failed to provided ordered treatment for pressure ulcers for (1) one of (28) twenty-eight sampled residents, Resident #4. The findings included:Resident #4's diagnoses included but were not limited to, a history of stroke with hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness affecting one side of the body) as well as dysphagia (difficulty swallowing), type II diabetes, schizophrenia, bipolar disorder, anxiety disorder and epilepsy. The annual minimum data set (MDS) assessment with an assessment reference date of 12/16/25 assigned the resident a brief interview for mental status score of 10 out 15 indicating a moderate cognitive impairment. On 1/3/26 at 11:25 AM a progress note read, Stage 2 pressure injury noted to sacrum. Area was cleansed with normal saline, barrier cream and foam dressing applied. Resident repositioned every 2 hours and prn (as needed). Incontinent…

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, family interview, staff interview, clinical record review, and facility document review, facility staff failed to provide food that is prepared to conserve nutritive value, flavor, and appearance for (1) one of (28) twenty-eight sampled residents, Resident # 21. The findings included:For Resident #21 the facility staff failed to provide food that was palatable and attractive.Resident #21's clinical record listed diagnoses which included but not limited to dysphagia following cerebral infarction.Resident #21's most recent minimum data set with an assessment reference date of 11/16/25 assigned the resident a brief interview for mental status score of 9 out of 15 in section C, cognitive patterns. This indicates that the resident is moderately cognitively impaired.Resident #21's comprehensive care plan was reviewed and contained a plan for Potential for swallowing difficulty as related to: dysphagia. Interventions for this plan include diet as ordered.On 01/13/25 at 1 pm, surveyor spoke with Resident #21's mother. Resident #21's mother was visiting resident at this…

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 observations, staff interviews, clinical record reviews, and facility document review, the facility staff failed to follow an established infection control program for (3) three of (28) twenty-eight sampled residents, Resident #4, Resident #32, and Resident #73. The findings included: 1. For resident #4, the facility staff failed to ensure the foley catheter drainage bag was not resting on the floor. Resident #4's diagnoses included but were not limited to, a history of stroke with hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness affecting one side of the body) as well as dysphagia (difficulty swallowing), type II diabetes, schizophrenia, bipolar disorder, anxiety disorder and epilepsy. The annual minimum data set (MDS) assessment with an assessment reference date of 12/16/25 assigned the resident a brief interview for mental status score of 10 out 15 indicating a moderate cognitive impairment. On 1/14/26 at 11:38 AM, this surveyor entered resident #4's room with the infection preventionist (IP) to observe wound care. This surveyor noted 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, clinical record review, and facility document review, the facility staff failed to offer a pneumococcal vaccine in accordance with nationally recognized standards for (1) one of (5) five sampled residents, Resident #14. The findings included:The facility staff failed to offer the resident a pneumococcal conjugate vaccine 15 (PCV15), 20 (PCV20), or 21 (PCV21) after their admission to the facility.The Centers for Disease Control and Prevention (CDC) website updated 10/07/25 recommends for individuals greater than 50 years or older that have only previously received only PPSV23: 1 dose of PCV15 or 1 dose PCV20 or 1 dose PCV21 at least 1 year after the last PPSV23 dose.Resident #14's age was greater than 50 and their diagnoses included diabetes and dementia.Section C (cognitive patterns) of Resident #14's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 12/12/25 included a brief interview for mental status (BIMS) score of 13 out of a possible 15 points. Indicating this resident was cognitively intact.On 01/13/26 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 clinical record review the facility staff failed to ensue medications were available for administration for 1 of 13 residents, Resident #1. The findings included: For Resident #1 the facility staff failed to ensure the medication SPS Oral solution (Sodium Polystyrene Sulfonate [Kayexalate]) was available for administration. Resident #1's most recent minimum data set with an assessment reference date of 01/04/24 assigned the resident a brief interview for mental status score of 7 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #1's clinical record was reviewed and contained a physician's order summary which read in part, SPS Oral suspension 15 GM/60 ML (Sodium Polystyrene Sulfonate). Give 60 ml by mouth one time a day for hyperkalemia. Order Date: 01/03/2024. Start Date: 01/04/2024. Discontinue: 01/15/2024, Sodium Polystyrene Sulfonate Oral Suspension 15 GM/60 ML (Sodium Polystyrene Sulfonate). Give 30 ml by mouth one time only for supplement for 1 day. Order Date: 01/15/2024. Start…

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

Based on staff interview, clinical record review, and facility document review the facility staff failed to ensure 2 of 13 resident were free of significant medication errors, Resident #1 and Resident #1 and Resident #10. The findings included: 1. For Resident #1 the facility staff failed to administer the medications insulin glargine, metoprolol, and SPS Oral solution (sodium polystyrene sulfonate) per the physician's orders. Resident #1's most recent minimum data set with an assessment reference date of 01/04/24 assigned the resident a brief interview for mental status score of 7 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #1's comprehensive care plan was reviewed and contained a care plan for I am a diabetic and . has the diagnosis of hypertension . Interventions for these care plans included Diabetes medications as ordered by the physician and Medications as ordered by the physician. Resident #1's clinical record was reviewed and contained a physician's order summary for the month of January 2024 which…

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

Based on staff interview, clinical record review, and facility document review the facility staff failed to notify physician and/or responsible party of a change in condition for 3 of 13 residents, Resident #4, Resident #7, and Resident #2. The findings included: 1. For Resident #4 the facility staff failed to notify the physician and responsible party of a fall. Resident #4's face sheet listed diagnoses which included but not limited to COVID-19, weakness, dementia, and difficulty walking. Resident #4's most recent minimum data set with an assessment reference date of 09/07/22 coded the resident as having both short and long-term memory loss with severely impaired cognitive skills for daily decision making. Resident #4's clinical record was reviewed and contained nurse's progress notes which read in part, 09/07/2022 17:34 Note Text: Resident sustained an unwitnessed fall. Obtained a ST (skin tear) to right elbow and it is unclear whether or not he hit his head, there are no discolorations noted at present time. VS (vital signs): 117/86, 93, 18, 97.5 & 93 % on RA (room air). ROM…

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

Based on staff interview, clinical record review and facility document review, it was determined that the facility failed to implement facility policy and procedures regarding reporting and investigating a resident-to-resident altercation for 1 of 13 residents, Resident #2. The findings included: For Resident #2 the facility failed to implement facility policy in regard to reporting and investigating a resident-to-resident altercation occurring on 10/14/23. Resident #2's diagnosis list indicated diagnoses, which included, but was not limited to Unspecified Dementia/ Unspecified Severity/with other Behavioral Disturbance, AMS (altered mental status), Cognitive Communication Deficit, Generalized Anxiety Disorder and Unspecified Mood (Affective) Disorder. On a MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/25/23, R2 was coded as being severely cognitively impaired for making decisions, having scored zero out of 15 on the BIMS (brief interview for mental status). Resident #2's comprehensive care plan was reviewed and contained a care plan…

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

Based on staff interview, clinical record review, and facility document review, it was determined that the facility failed to report an incident of alleged resident-to-resident abuse for 1 of 13 residents in the survey sample, Resident #2. The findings included: For Resident #2, the facility failed to report a resident-to-resident altercation occurring on 10/14/23. Resident #2's diagnosis list indicated diagnoses, which included, but was not limited to Unspecified Dementia/ Unspecified Severity/with other Behavioral Disturbance, AMS (altered mental status), Cognitive Communication Deficit, Generalized Anxiety Disorder and Unspecified Mood (Affective) Disorder. On a MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/25/23, R2 was coded as being severely cognitively impaired for making decisions, having scored zero out of 15 on the BIMS (brief interview for mental status). A review of Resident #2's clinical record revealed a general progress note dated, 10/14/2023 14:15 (2:15 PM) General Note, Called to room via call bell. As this writer…

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

Based on staff interview, clinical record review, and facility document review, it was determined that the facility failed to investigate an incident of alleged resident-to-resident abuse for 1 of 13 residents in the survey sample, Resident #2. The findings included: For Resident #2 the facility failed to investigate an incident of alleged resident-to-resident abuse during a resident-to-resident altercation on 10/14/23. Resident #2's diagnosis list indicated diagnoses, which included, but was not limited to Unspecified Dementia/ Unspecified Severity/with other Behavioral Disturbance, AMS (altered mental status), Cognitive Communication Deficit, Generalized Anxiety Disorder and Unspecified Mood (Affective) Disorder. On a MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/25/23, R2 was coded as being severely cognitively impaired for making decisions, having scored zero out of 15 on the BIMS (brief interview for mental status). Resident #2's comprehensive care plan was reviewed and contained a care plan for, I sometimes have behaviors which…

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

Based on staff interview, clinical record review, and facility document review the facility staff failed to follow professional standards of practice for the administration of medications for 1 of 13 residents, Resident #1. The findings included: Resident #1's face sheet listed diagnoses which included but not limited to other cerebrovascular disease, vascular dementia, type 2 diabetes mellitus, and personal history of urinary tract infection. Resident #1's most recent minimum data set with an assessment reference date of 01/04/24 assigned the resident a brief interview for mental status score of 7 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #1's clinical record was reviewed and contained a physician's order summary which read in part, SPS Oral suspension 15 GM/60 ML (Sodium Polystyrene Sulfonate). Give 60 ml by mouth one time a day for hyperkalemia. Order Date: 01/03/2024. Start Date: 01/04/2024. Discontinue: 01/15/2024, Sodium Polystyrene Sulfonate Oral Suspension 15 GM/60 ML (Sodium Polystyrene…

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

Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to follow medical provider orders for 1 of 13 residents in the survey sample, Resident #9. The findings included: For Resident #9, the facility staff failed to obtain blood sugar readings as ordered by the provider. Resident #9's diagnosis list indicated diagnoses, which included, but not limited to Multiple Sclerosis, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, and Bipolar Disorder. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 1/17/24 coded the resident as being independent in cognitive skills for daily decision making. Resident #9's current physician orders included orders dated 1/23/24 to obtain fasting blood sugar in the morning every Monday, Wednesday, Friday and obtain blood sugar at 4:00 PM every Tuesday, Thursday, and Saturday. Surveyor reviewed Resident #9's clinical record and was unable to locate blood sugar results as ordered. The most recent blood sugar documented on the resident's Blood…

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 clinical record review, the facility staff failed to ensure the medication error rate was 5% or less during medication pass and pour observation on 6/13/2022. During medication pass and pour observation on 6/13/2022, the surveyor observed 25 opportunities for error. The surveyor observed 3 medication errors affecting 2 residents. The calculated error rate was 12% (3/25=.12 X 100%= 12%). Error observation detail: 1- For Resident #47, the antidepressant medication Wellbutrin was unavailable and the ordered dose of Adderall was not available. Resident #47 was admitted to the facility with diagnoses that included sequelae of cerebral infarction, encounter for surgical aftercare following surgery on the digestive system, dementia, major depressive disorder, fibromyalgia, rheumatoid arthritis, attention deficit hyperactivity disorder, dysphagia, hemiplegia and hemiparesis following cerebral infarction on right dominant side, and iron deficiency anemia. On the minimum data set assessment with assessment reference date 5/2/2022, the resident scored 10/15 on the…

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

Based on observation, staff interview, and facility document review, the facility staff failed to ensure food was stored under safe and sanitary conditions in 1 of 1 dry storage rooms and 2 of 3 nursing unit pantries, North Unit and South Unit. In the dry storage room, two (2) cans of tomato soup and three (3) cans of evaporated milk had exceed the best by dates. The [NAME] Unit pantry refrigerator contained an unlabeled container of cut watermelon, two (2) unlabeled fast food sub sandwiches, and an open, unlabeled package of precooked bacon. The South Unit pantry contained an open, unrefrigerated container of grated parmesan cheese. The findings included: On 6/12/22 at 2:00 pm, in the emergency food section of the dry storage room, surveyor observed a 51 ounce can of tomato soup with a printed best by date of 1/15/22 and a 51 ounce can of tomato soup with a printed best by date of 3/13/21. The dietary account manager was present and also observed the best by date printed on each can of tomato soup. On the other side of the dry storage room, surveyor observed three (3) 12 ounce cans…

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

Based on resident interview, staff interview and clinical record review, the facility staff failed to accurately complete an admission minimum data set (MDS) assessment for 1 of 23 Residents, Resident #91. The facility staff failed to code the MDS to indicate Resident #91 was receiving dialysis. The findings included: Section C (cognitive patterns) of Resident #91's admission MDS assessment with an assessment reference date (ARD) of 05/31/22 included a brief interview for mental status (BIMS) summary score of 14 out of a possible 15 points. Section O (special treatments/procedures/programs) had been coded to indicate the resident was not receiving dialysis. Resident #91's clinical record included the diagnoses end stage renal disease, dependence on renal dialysis, and acquired absence of kidney. Resident #91's physician orders included dialysis three times a week. The order date was documented as 05/30/22. Resident #91's comprehensive care plan included the focus area alteration in kidney function due to end stage renal disease evidenced by hemodialysis. During initial tour of 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, clinical record review, and facility document review, the facility staff failed to ensure a discharge summary was completed for 1 of 3 closed resident record reviews, Resident #97. The facility staff failed to complete a discharge summary when Resident #97 was discharged home. The findings included: This was a closed record review. Resident #97's diagnosis list indicated diagnoses, which included, but not limited to Respiratory Failure, Chronic Obstructive Pulmonary Disease, Heart Failure, Chronic Kidney Disease Stage 3, and Cerebrovascular Disease. The admission minimum data set (MDS) with an assessment reference date (ARD) of 3/17/22 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating Resident #97 was cognitively intact. The resident was coded as requiring extensive assistance with bed mobility, transfers, dressing, toileting, personal hygiene and being independent in eating. A discharge return not anticipated MDS with an ARD of 4/06/22 coded the resident as being discharged to the community on…

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

Based on observation, interviews, clinical record reviews, and facility document reviews, facility staff failed to ensure ordered medications were administered for 2 of 23 sampled current residents (#47, #70). 1- For Resident #47, the antidepressant medication Wellbutrin was unavailable and the ordered dose of Adderall was not available. Resident #47 was admitted to the facility with diagnoses that included sequelae of cerebral infarction, encounter for surgical aftercare following surgery on the digestive system, dementia, major depressive disorder, fibromyalgia, rheumatoid arthritis, attention deficit hyperactivity disorder, dysphagia, hemiplegia and hemiparesis following cerebral infarction on right dominant side, and iron deficiency anemia. On the minimum data set assessment with assessment reference date 5/2/2022, the resident scored 10/15 on the brief interview for mental status (indicating some cognitive impairment) and was assessed as without signs of delirium, psychosis, or behaviors affecting care. On 6/13/2022 at 10:21 AM during medication pass and pour observation,…

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, facility document review, and in the course of a complaint investigation, the facility staff failed to ensure medications were available for administration for 2 of 26 sampled residents, Resident #96 and Resident 47. Resident #96's eye drops, Amiodarone, and Spironolactone were not available for administration. Resident #47's Wellbutrin was not available for administration. The findings included: 1. This was a closed record review. Section C (cognitive patterns) of Resident #96's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 01/11/22 included a brief interview for mental status (BIMS) summary score of 15 out of a possible 15 points. Indicating Resident #96 was alert and orientated. Resident #96's clinical record included the diagnoses, congestive heart failure, diabetes, urinary retention, chronic kidney disease, and dementia. Resident #96's clinical record included the following orders. Ketorolac Tromethamine solution 1 drop in left eye two times a day order date 01/07/22. 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 interviews, clinical record reviews, and facility document review, the facility staff failed to ensure a medical provider ordered laboratory test was completed for 1 of 23 sampled current residents, Resident #44. For Resident #44, the facility staff failed to obtain a Basic Metabolic Panel (BMP) laboratory test. A potassium level is part of a BMP. The findings include: Resident #44's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 5/5/22, was dated as completed on 5/6/22. Resident #44 was assessed as usually able to make self understood and as usually able to understand others. Resident #44's Brief Interview of Mental Status (BIMS) summary score was documented as a zero (0) out of 15; this indicated severe cognitive impairment. Resident #44 was documented as requiring assistance with bed mobility, dressing, toilet use, and personal hygiene. Resident #44's diagnoses included, but were not limited to: anemia, heart disease, high blood pressure, and malnutrition. Resident #44's care plan included a current 'focus' for Risk for Cardiac Distress .…

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 a quality assurance program to meet the needs of the facility. The findings included: The facility staff failed to ensure an effective QA (quality assurance) program to meet the needs of the facility as evidenced by repeated deficiencies from the previous 6/4/18 survey in the areas of reasonable accommodations of needs/preferences, self determinstion, confidentiality of records, develop and implement comprehensive care plan, care plan timing and revision, services provided to meet professional standards, quality of care, dialysis, drug regimen review, resident records, free of accidendent hazzards/surpervision and infection control.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to provide the receiving provider all of the required documentation including a comprehensive care plan when a resident was transferred to the hospital for 4 of 30 residents in the survey sample (Resident #68, #39, #96 and #63). The findings included: 1. The facility staff failed to provide the receiving provider/facility of the required documentation including the comprehensive care plan when Resident #68 was sent to the ER (emergency room) on 10/6/19. Resident #68 was readmitted to the facility on [DATE] and discharged on 10/6/19 The resident had the following diagnoses of, but not limited to anemia, heart failure, high blood pressure, diabetes, dementia and depression. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/23/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #68 was also coded as requiring supervision 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 provide the resident or resident representative of the bed hold policy when 4 of 30 residents in the survey sample were discharged to the hospital (Resident #68, #39, #96 and #63). The findings included: 1. The facility staff failed to offer Resident #68 and the resident representative of the bed hold policy when the resident was discharged to the hospital on [DATE]. Resident #68 was readmitted to the facility on [DATE] and discharged on 10/6/19. The resident had the following diagnoses of, but not limited to anemia, heart failure, high blood pressure, diabetes, dementia and depression. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/23/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #68 was also coded as requiring supervision of 1 staff member for dressing, personal hygiene and limited assistance of 1 staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility staff failed to review and revise the comprehensive care plan for 6 of 30 residents in the survey sample (Resident #29, #39, #58, #78, #63 and #94). The findings included: 1. The facility staff failed to review and revise the comprehensive care plan for Resident #29. Resident #29 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to high blood pressure, anxiety disorder, manic depression and psychotic disorder. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of [DATE], the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #29 was also coded as requiring supervision of 1 staff member for dressing and personal hygiene and requiring physical help in part of the bathing activity from 1 staff member. During the clinical record review from [DATE] through [DATE], the surveyor noted the following documentation in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, Resident interview, staff interview, and clinical record review, the facility staff failed to provide one of 30 Residents in the survey sample with reasonable accommodation of needs, Resident # 63. The findings included The facility staff failed to ensure that the call bell was within reach for Resident # 63. Resident # 63 was a [AGE] year-old-female that was originally admitted to the facility on [DATE], and had a readmission date of 7/2/19. Diagnoses included but were not limited to, pain in bilateral hands, muscle weakness, vertigo, and paraplegia. The clinical record for Resident # 63 was reviewed on 10/10/19 at 9:46 am. The most recent MDS (minimum data set) assessment for Resident # 63 was a quarterly assessment with an ARD (assessment reference date) of 8/21/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 63 had a BIMS (brief interview for mental status) score of 15 out of 15, which indicated that Resident #63 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, clinical record review, Resident interview, staff interview, and facility document review, the facility staff failed to promote and facilitate resident self-determination for one of 30 residents in the survey sample, Resident # 47. The findings included The facility staff failed to allow Resident # 47 to eat meals in her preferred location, the facility dining room. Resident # 47 was admitted to the facility on [DATE]. Diagnoses included but were not limited to, anxiety disorder, traumatic brain injury and major depressive disorder. The clinical record for Resident # 47 was reviewed on 10/9/19 at 12:15 pm. The most recent MDS (minimum data set) assessment for Resident # 47 was a quarterly assessment with an ARD (assessment reference date) of 8/5/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 47 had a BIMS score of 15 out of 15, which indicated that Resident # 15 was cognitively intact. The current plan of care for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Resident interview, clinical record review, staff interview and during the course of a complaint investigation, it was determined that the facility staff failed to notify the physician of changes for two of 30 Residents in the survey sample, Resident #63 and Resident # 110. The findings included 1. The facility staff failed to notify the physician that Resident # 63 had vaginal bleeding for more than a month. Resident # 63 was originally admitted to the facility on [DATE], and had a readmission date of 7/2/19. Diagnoses included but were not limited to, anemia, abnormal uterine and vaginal bleeding, paraplegia, and muscle weakness. The clinical record for Resident # 63 was reviewed on 10/10/19 at 9:46 am. The most recent MDS (minimum data set) assessment for Resident # 63 was a quarterly assessment with an ARD (assessment reference date) of 8/21/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 63 had a BIMS (brief interview for mental…

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 during the course of a complaint investigation, the facility staff failed to protect the resident's property from loss or theft resulting in unavailability of pain medication and failing to maintain a clean air conditioning unit in the resident's room for 2 of 30 residents in the survey sample (Residents #103 and #112). 1. For Resident #103, facility staff failed to secure from loss or theft Resident #103 was admitted to the facility on [DATE]. Diagnoses included malignant carcinoid tumor of the rectum, major depression, low back pain, diabetes mellitus type 2 with ophthalmic complications, chronic pain, difficulty in walking, traumatic amputation of right lower leg, hypertension, anxiety, nicotine dependence, chronic obstructive pulmonary disease, and bipolar disorder. On the 14 day Minimum Data Set assessment with assessment reference date 9/23/19, the resident scored 15/15 on the brief interview for mental status and 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 clinical record review, staff interview, facility document review, and during the course of a complaint investigation it was determined that the facility staff failed to report allegations of abuse for two of 30 Residents in the survey sample, Resident # 314 and Resident # 97. The findings included 1. The facility staff failed to report an allegation of abuse for Resident # 314. Upon being informed of the allegation of abuse made by Resident # 314, the facility staff failed to report the allegation to the appropriate agencies within a timely manner. Resident # 314 was admitted to the facility on [DATE]. Diagnoses included but were not limited to muscle weakness, chronic pain, and hypertension. The clinical record for Resident # 314 was reviewed on 10/9/19 at 9:54 am. The surveyor observed a nurse's note that had been documented on 3/30/18 at 6:27 pm. The nurse's not was documented as, Resident alert with confusion noted, daughter reported to nurse that resident stated that he was beat up by two CNAs…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to investigate abuse allegations for one of 30 Residents in the survey sample, Resident # 314. The findings included The facility staff failed to investigate an allegation of abuse that had been reported for Resident # 314. Resident # 314 was admitted to the facility on [DATE]. Diagnoses included but were not limited to muscle weakness, chronic pain, and hypertension. The clinical record for Resident # 314 was reviewed on 10/9/19 at 9:54 am. The surveyor observed a nurse's note that had been documented on 3/30/18 at 6:27 pm. The nurse's not was documented as, Resident alert with confusion noted, daughter reported to nurse that resident stated that he was beat up by two CNAs (certified nursing assistants) that took their clothes off while changing his clothes, all this was done on the floor, daughter stated that she wants staff to be more tactful when caring for her dad, reported…

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 Ombudsman and/or resident upon discharge for 3 of 30 residents in the survey sample (Resident #68, #39, and #63). The findings included: 1. The facility staff failed to notify the Ombudsman of the discharge of Resident #68 when the resident was sent to the ER (emergency room) on 10/6/19. Resident #68 was readmitted to the facility on [DATE] and discharged on 10/6/19 The resident had the following diagnoses of, but not limited to anemia, heart failure, high blood pressure, diabetes, dementia and depression. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/23/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #68 was also coded as requiring supervision of 1 staff member for dressing, personal hygiene and limited assistance of 1 staff member for bathing. During the clinical record review on 10/15/19 through…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, the facility staff failed to periodically conduct a standardized reproducible assessment by completing an annual assessment for 1 of 30 residents in the survey sample (Resident # 8). Resident #8 was admitted to the facility on [DATE]. Diagnoses included diabetes mellitus with diabetic nephropathy, contracture of left wrist and hand, anemia, dysphagia, hemiplegia and hemiparesis following infarct, acquired absence or leg, essential hypertension, atherosclerosis with ulceration of left heel, symbolic dysfunctions, paraplegia, and other sequelae of cerebrovascular disease. On the quarterly Minimum Data Set (MDS) assessment with assessment reference date 6/10/19, the resident scored 10/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. Clinical record review on 10/10/19 at 9:07 AM revealed the Annual Minimum Data Set assessment due 9/10/19 had not been completed by 10/10/19. The surveyor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview the facility staff failed to ensure that two of 30 residents in the survey sample received the necessary services as outline in the Level II PASARR, Resident #9 and Resident #74. 1. The facility staff failed to ensure that Resident # 9 had restorative nursing and outpatient psychiatric services as recommended in her Level II PASARR (preadmission screening and record review). Resident # 9 was originally admitted to the facility on [DATE], and had a readmission date of 9/10/18. Diagnoses included but were not limited to, schizoaffective disorder, psychotic disorder, anxiety, and major depressive disorder. The clinical record for Resident # 9 was reviewed on 10/10/19 at 11:10 am. The most recent MDS (minimum data set) assessment was a significant change assessment with an ARD (assessment reference date) of 6/17/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 9 had a BIMS score (brief interview for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to complete a baseline care plan for 2 of 30 residents in the survey sample (Resident #68 and #39). The findings included: 1. The facility staff failed to complete the base line care plan when Resident #68 was readmitted to the nursing facility on 9/14/19. Resident #68 was readmitted to the facility on [DATE] after being discharged to the hospital on 9/11/19 for the resident coughing up blood. The resident had the following diagnoses of, but not limited to coronary artery disease, high blood pressure, stroke and depression. On the significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/31/19; the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 13 out of a possible score of 15. Resident #68 was also coded as being totally dependent on 1 staff member for dressing, personal hygiene and bathing. During the clinical record review on 10/15/19 through 10/18/19, the surveyor…

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, facility staff failed to develop and implement a comprehensive person-centered care plan for 3 of 30 Residents in the survey sample resulting in failure to provide specialized services or specialized rehabilitative services the nursing facility would provide as a result of PASARR recommendations (Resident #74) and to attain highest practicable well-being related to hospice care (Resident #108)and behavioral health (Resident #73). 1. For Resident #74, facility staff failed to incorporate the recommendations from the PASARR level II determination and the PASARR evaluation report into the resident's comprehensive care plan. Resident #74 was admitted to the facility on [DATE]. Diagnoses included catatonic schizophrenia, functional quadriplegia, epilepsy, gastrostomy, chronic pain, muscle weakness, dysphagia, convulsions, lack of falls, ischemia, Parkinson's disease, major depressive disorder, anxiety, and hypertension. On the Minimum Data Set assessment 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and facility document review, the facility staff failed to provide care consistent with professional standards of practice for two of 30 Residents in the survey sample, Resident # 47 and Resident # 96. The findings included 1. The facility staff failed to document the administration of Clonazepam on the medication administration record for Resident # 47. Resident # 47 was a [AGE] year-old-female that was admitted to the facility on [DATE]. Diagnoses included but were not limited to, anxiety, major depressive disorder, traumatic brain injury, and hypertension. The clinical record for Resident # 47 was reviewed on 10/9/19 at 2:27 pm. The most recent MDS (minimum data set) assessment for Resident # 47 was a quarterly assessment with an ARD (assessment reference date) of 8/5/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 47 had a BIMS score (brief interview for mental status) of 15 out of 15,…

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

Based on observation, clinical record review, staff interview, and during the course of a complaint investigation, the facility staff failed to provide ADL (activities of daily living) care of one of 30 residents in the survey sample, Resident # 88. The findings included The facility staff failed to ensure that Resident # 88's hair was washed. Diagnoses included but were not limited to, anxiety, dementia with behavioral disturbance, and schizophrenia. The clinical record for Resident # 88 was reviewed on 10/10/19 at 11:28 am. The most recent MDS (minimum data set) assessment for Resident # 88 was a quarterly assessment with an ARD (assessment reference date) of 9/10/19. Section B of the MDS assesses hearing speech and vision. In Section B0700, the facility staff documented that Resident # 88 was rarely or never understood. Section G of the MDS assesses functional status. In Section G0120, the facility staff documented that Resident # 88 was totally dependent with one person providing physical assistance for bathing. The current plan of care for Resident # 88 was reviewed and revised…

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 during the course of a complaint investigation, the facility staff failed to pain management was provided to residents who require such services resulting in unavailability of the pain medication oxycodone for administration according to physician orders for 1 of 30 residents in the survey sample (Resident #103). The findings included: Resident #103 was admitted to the facility on [DATE]. Diagnoses included malignant carcinoid tumor of the rectum, major depression, low back pain, diabetes mellitus type 2 with ophthalmic complications, chronic pain, difficulty in walking, traumatic amputation of right lower leg, hypertension, anxiety, nicotine dependence, chronic obstructive pulmonary disease, and bipolar disorder. On the 14 day Minimum Data Set assessment with assessment reference date 9/23/19, the resident scored 15/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based clinical record review and staff interview, the facility staff failed to ensure adequate and complete communication between the nursing facility and the dialysis facility for 1 of 30 residents in the survey sample (Resident #68). The findings included: The facility staff failed to ensure adequate and complete communication between the nursing facility and the dialysis facility for Resident #68. Resident #68 was readmitted to the facility on [DATE] and discharged on 10/6/19 The resident had the following diagnoses of, but not limited to anemia, heart failure, high blood pressure, diabetes, dementia and depression. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/23/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #68 was also coded as requiring supervision of 1 staff member for dressing, personal hygiene and limited assistance of 1 staff member for bathing. During the clinical record 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 clinical record review, and staff interview, the facility staff failed to assure that nursing staff had the appropriate competencies and skill sets to provide nursing and related services to assure resident safety for two of 30 residents in the survey sample, Resident #9 and Resident # 63. The findings included: The facility staff failed to produce documentation that nursing staff had the appropriate competencies related to safety with the Hoyer lift following falls from the Hoyer lift for Resident # 9 and Resident # 63. Resident # 9 was originally admitted to the facility on [DATE]. Resident # 9 had a facility readmission date of 9/10/18. Diagnoses included but were not limited to, schizoaffective disorder, psychotic disorder, anxiety, and major depressive disorder. The clinical record for Resident # 9 was reviewed on 10/10/19 at 11:10 am. The most recent MDS (minimum data set) assessment was a significant change assessment with an ARD (assessment reference date) of 6/17/19. Section C of the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review, and during the course of a complaint investigation, the facility staff failed to ensure that three of 30 residents in the survey sample received behavioral health care and services to maintain the highest practicable well-being, Resident # 9, Resident # 17, and Resident # 63. The findings included 1. The facility staff failed to ensure that Resident # 9 had a follow up visit with behavioral health services in a timely manner. Resident # 9 was originally admitted to the facility on [DATE], with a readmission date of 9/10/18. Diagnoses included but were not limited to, schizoaffective disorder, anxiety, and major depressive disorder. The clinical record for Resident # 9 was reviewed on 10/9/19 at 12:00 pm. The most recent MDS (minimum data set) assessment for Resident # 9 was a significant change assessment with an ARD (assessment reference date) of 6/17/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. The facility staff failed to ensure that the plan of care for Resident # 11 included resident centered dementia care to ensure the highest practicable well-being. Resident # 11 was originally admitted to the facility on [DATE], with a readmission date of 11/29/17. Diagnoses included but were not limited to, dementia, anxiety, psychosis, and delusional disorders. The clinical record for Resident # 11 was reviewed on 10/9/19 at 11:57 am. The most recent MDS assessment for Resident # 11 was a quarterly assessment with an ARD of 8/26/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 11 had a BIMS score (brief interview for mental status) of 15 out of 15, which indicated that Resident # 11 was cognitively intact. The most recent annual MDS assessment for Resident # 11 had an ARD of 3/20/19. According to the care area assessments in Section V0200, the facility staff documented that cognitive loss and dementia would be addressed in the plan of care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and facility document review the facility staff failed to ensure that medications were available for one of 30 Residents in the survey sample, Resident # 47. The findings included The facility staff failed to ensure that clonazepam was available for administration for Resident # 47. Resident # 47 was admitted to the facility on [DATE]. Diagnoses included but were not limited to, anxiety, major depressive disorder, traumatic brain injury, and hypertension. The clinical record for Resident # 47 was reviewed on 10/9/19 at 2:27 pm. The most recent MDS (minimum data set) assessment for Resident # 47 was a quarterly assessment with an ARD (assessment reference date) of 8/5/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 47 had a BIMS score (brief interview for mental status) of 15 out of 15, which indicated that Resident # 47 was cognitively intact. Resident # 47 had orders that included but was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, and staff interview, the facility staff failed to ensure that a pharmacy recommendation was acted upon in a timely manner for one of 30 Residents in the survey sample, Resident # 88. The findings included The facility staff failed to act upon a pharmacy recommendation in a timely manner for Resident # 88. Resident # 88 was admitted to the facility on [DATE]. Diagnoses included but were not limited to, anxiety, dementia with behavioral disturbance, and schizophrenia. The clinical record for Resident # 88 was reviewed on 10/10/19 at 11:28 am. The most recent MDS (minimum data set) assessment for Resident # 88 was a quarterly assessment with an ARD (assessment reference date) of 9/10/19. Section B of the MDS assesses hearing speech and vision. In Section B0700, the facility staff documented that Resident # 88 was rarely or never understood. On 10/10/19 at 11:23 am, the surveyor observed pharmacy recommendation in the clinical record For Resident # 17 dated 9/25/19. The pharmacy…

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

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure that psychotropic medications necessary to treat a specific condition as diagnosed and documented in the clinical record followed physician orders in regards to administering antipsychotic and psychotropic medications for 1 of 3 residents (Resident #113) and failed to monitor side effects of medications for 2 of 3 residents (Residents #106 and #110). The findings included: 1. For Resident #113, when the resident was re-admitted to the facility the nursing staff failed to enter the residents new orders into the computer system resulting in the resident receiving fluphenazine (anti-psychotic) and trazodone (anti-depressant) without a physicians order and being administered clonazepam at 5:00 and 9:00 p.m. when the order read every 6 hours. The resident had no adverse reactions to the medications. The clinical record was reviewed on 01/02-01/03/2020. The Residents face sheet included the diagnoses schizoaffective disorder depressive type, generalized anxiety, major…

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, staff interview and during the course of a complaint investigation, the facility staff failed to obtain labs as ordered for 2 of 30 residents in the survey sample (Resident #23 and #77). The findings included: 1. For resident #23 the facility staff failed to obtain a Valproic Acid Level as ordered for 8/15/18. Resident #23's face sheet listed an admission date of 1/23/15. The resident's diagnosis list indicated diagnoses, which included, but not limited to Bipolar Disorder, Generalized Anxiety Disorder, Major Depressive Disorder, Parkinson's Disease, Type 1 Diabetes, Peripheral Vascular Disease, and Chronic Kidney Disease Stage 3. The most recent quarterly MDS (minimum data set) with an ARD of 7/16/19 assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, cognitive patterns. Resident #23 was also coded as requiring extensive assistance of one staff member for dressing, personal hygiene and total dependence for bathing. Resident #23's medical record contained a physician's order dated 5/15/18 for 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 resident interview, staff interview, and clinical record review, the facility staff failed to obtain dental services to meet resident needs for one of 30 residents in the survey sample, Resident # 17. The findings included The facility staff failed to set up a dental appointment for Resident # 17 after she voiced that her dentures were ill fitting. Resident # 17 was originally admitted to the facility on [DATE], and had a readmission date of 12/4/10. Diagnoses included but were not limited to, dysphagia, gastro-esophageal reflux disease (GERD) and hypokalemia. The clinical record for Resident # 17 was reviewed on 10/9/19 at 11:49 am. The most recent MDS (minimum data set) assessment for Resident # 17 was a quarterly assessment with an ARD (assessment reference date) of 6/28/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 17 had a BIMS score (brief interview for mental status) of 13 out of 15, which indicated that Resident # 17 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 clinical record review, clinical record review, resident interview, staff interview, and during the course of a complaint investigation, it was determined that the facility staff failed to provide specialized rehabilitative services for one of 30 residents in the survey sample, Resident # 63. The findings included The facility staff failed to provide Resident # 63 with Prafos (pressure relief ankle foot orthosis) to avoid ankle contracture. Resident # 63 was originally admitted to the facility on [DATE], and had a readmission date of 7/2/19. Diagnoses included but were not limited to, anemia, Guillian Barre syndrome, paraplegia, and muscle weakness. The clinical record for Resident # 63 was reviewed on 10/10/19 at 9:46 am. The most recent MDS (minimum data set) assessment for Resident # 63 was a quarterly assessment with an ARD (assessment reference date) of 8/21/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 63 had a BIMS (brief…

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, facility staff failed to have a written order of a physician to provide Physical Therapy services for 1 of 30 residents in the survey sample (Resident #97). Resident #97 was admitted to the facility on [DATE]. Diagnoses included dementia with behavioral disturbance, contractures of hips and knees, repeated falls, attention and concentration deficits and spatial neglect following subarachnoid hemorrhage dysphagia, Alzheimer's disease, hypertension, major depression, and psychosis. On the quarterly Minimum Data Set assessment with assessment reference date 8/21/19, the resident was assessed with short and long term memory deficits and severely impaired cognitive skills for daily decision making and as without signs of delirium, psychosis, or behaviors affecting care. The resident was assessed as requiring extensive assistance of 2 or more persons for transfer, supervision for locomotion on the nursing unit in a wheelchair, and extensive assistance of one person…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility staff failed to ensure an accurate clinical record for two of 30 residents in the survey sample, Resident # 63 and Resident # 77. The findings included 1. The facility staff failed to document an open area to Resident # 63's right inner thigh on weekly skin sheets. Resident # 63 was originally admitted to the facility on [DATE], and had a readmission date of 7/2/19. Diagnoses included but were not limited to, anemia, abnormal uterine and vaginal bleeding, paraplegia, and muscle weakness. The clinical record for Resident # 63 was reviewed on 10/10/19 at 9:46 am. The most recent MDS (minimum data set) assessment for Resident # 63 was a quarterly assessment with an ARD (assessment reference date) of 8/21/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 63 had a BIMS (brief interview for mental status) score of 15 out of 15, which indicated that Resident #63 was cognitively intact.…

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

Based on observation, staff interview, and facility document review, the facility staff failed to follow infection control guidelines on one of three facility units. The findings included The facility staff failed to follow the infection control policy for handwashing. On 10/8/19 at 12:55pm, during initial tour the surveyor observed contact precaution signage on Resident # 88's door. The surveyor observed that CNA # 3 (certified nursing assistant) was in Resident # 88's room, with isolation gown and gloves on, as she provided feeding assistance to Resident # 88. On 10/8/19 at 1:05 pm, the surveyor observed CNA # 3 as she exited Resident # 88's room with Resident # 88's meal tray. The surveyor observed CNA # 3 as she carried the tray with her bare hands and placed the tray on the food cart. The surveyor observed that CNA # 3 did not wash or sanitize her hands. CNA # 3 entered room another Resident's room, handled items on her over bed table, and removed her meal tray from her room and placed it on the food cart. The surveyor asked CNA # 3 how facility staff was expected to handle…

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 maintain a pest free environment in the dining room as evidenced by two surveyors walked into dining room and observed a roach crawling across the floor. The findings included: On 1/3/2020 at approximately 12:15 pm, 2 surveyors walked into the dining room to speak to 3 un sampled residents. While the surveyors were walking in, 1 surveyor looked down and a brown colored roach was noted to be running from out of the bottom of the wall and going toward the center of the dining room. The three unsampled residents stated to the two surveyors, We are so glad that you got that roach. He comes out every day and tries to have lunch with us. The surveyors asked if they have only observed one roach in the dining room. The three residents stated, No there are usually three of them. The maintenance director was notified of the above documented findings at 12:25 pm by the 2 surveyors. The maintenance director stated, I didn't know the residents had been seeing them in here (referring to dining room). At 2 pm, the maintenance…

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.