Autumn Care Of Mechanicsville

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to implement the comprehensive care plan for three of 35 residents in the survey sample, Residents #120, #2, and #61. The findings include: 1. For Resident #120 (R120), the facility staff failed to implement the resident's comprehensive care plan for obtaining weights. R120's comprehensive care plan dated 10/22/24 documented, Resident requires Enteral tube feeding and is at risk for dehydration, aspiration .Monitor weight per orders. A physician's order dated 1/29/25 documented, Obtain weight daily. Further review of R120's clinical record failed to reveal the resident's weight was obtained on 2/5/25, 2/14/25, 2/16/25, 2/17/25, 2/18/25, 2/19/25, and 2/22/25. On 2/25/25 at 3:46 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 stated the purpose of the care plan is to follow doctors' orders and nursing staff implement residents' care plans by looking at the care plans. On 2/26/25 at 10:14 a.m., an interview was conducted 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 observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to review and revise the comprehensive care plan for two of 35 residents in the survey sample, Residents #79, and #75. The findings include: 1.a. For Resident #79 (R79), the facility staff failed to review and revise the resident's comprehensive care plan for adaptive eating equipment. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/10/24, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. A review of R79's clinical record revealed a physician's order dated 9/10/24 that documented, Provide 2 handled cup with lid + straw and red foam to knife and fork for all meals as tolerated. R79's comprehensive care plan edited on 2/13/25 failed to revealed documentation regarding a two handled cup with a lid and straw, or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, clinical record review, staff interview and facility document review, it was determined the facility staff failed to clarify a physician order for one of 35 residents in the survey sample, Resident #16. The findings include: For Resident #16 (R16), the facility staff failed to clarify a physician order regarding tracheostomy (1) change every two months. On the most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 12/28/2024, the resident scored a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact for making daily decisions. The assessment documented R16 receiving tracheostomy care at the facility. On 2/24/25 at 2:53 p.m., an observation was made of R16 in their room. At that time an interview was conducted with R16 who stated that they had a tracheostomy. R16 was observed with a bandana around their neck and proceeded to remove it to show a tracheostomy…

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, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide foot care for one of 35 residents in the sample R20. The findings include: The facility failed to evidence provision of foot care for R20. R20 was observed in bed on 2/24/25 at 2:30 PM with thick toenails on both large toes and toenails approximately one-half inch in length. R20 was admitted to the facility on [DATE] with diagnosis that included but were not limited to CHF (congestive heart failure), prosthetic heart valve, DM (diabetes mellitus) and osteoarthritis. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 115/25, coded the resident as scoring a 05 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring…

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 implement interventions to prevent worsening of a contracture of 35 residents in the survey sample, Resident #75 (R75). The findings include: For Resident #75 (R75), the facility staff failed to provide an orthotic device to the resident's right hand. On the following dates and times, R75 was observed. At each of these observations, the resident had a visible contracture of her right hand: 2/24/25 at 2:20 p.m., 2/25/24 at 9:05 a.m. and 1:18 p.m. At the 2/24/25 observation at 2:20 p.m., the resident was seated in the facility common area. In the resident's room, a carrot orthotic device was visible on the resident's bedside table. On 2/25/25 at 1:18 p.m., R75 stated she had been seen by the occupational therapy staff, and they had given her a carrot to hold to help the contracture. She stated she did not know where the carrot orthotic device was, and that the staff do 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.

Based on observation, resident interview, clinical record review, staff interview and facility document review it was determined that the facility staff failed to provide respiratory care and services consistent with professional standards of practice for two of 35 residents, Resident #61 and Resident #2. The findings include: 1. For Resident #61 (R61), the facility staff failed to administer oxygen at the prescribed rate. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/22/25, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. Section O documented R61 receiving oxygen at the facility. On 2/25/25 at 8:22 a.m., an observation was made of R61 in their room. R61 was observed in bed wearing an oxygen cannula attached to an oxygen concentrator. The oxygen was observed to be set at a rate of 3.5 l/min (liters per minute). At that time an interview was conducted with R61 who stated that they wore oxygen all 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, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide assistive devices for eating for one of 35 residents in the survey sample, Resident #75 (R75). The findings include: For Resident #75 (R75), the facility staff failed to provide built up eating utensils for the resident to use during meals. On the following dates and times, R75 was observed eating a meal. At each of these observations, the resident was attempting to use regular utensils to feed herself. At all observations, she abandoned using the utensils, and used her fingers to feed herself: 2/24/25 at 2:20 p.m., 2/25/24 at 9:05 a.m. and 1:18 p.m. On 2/25/25 at 1:18 p.m., R75 stated she had been seen by the occupational therapy staff, and they had given her eating utensils that were built up on the ends so she could more easily manipulate them. She stated she had lost the utensils, and it was her fault that she didn't have any adaptive utensils to use. She…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide the resident representative and/or the State LTC Ombudsman with written notification of hospital transfers for four of 51 in the survey sample; Residents #68, #147, #61, and #163, The findings include: 1. The facility staff failed to provide the resident representative and the ombudsman with written notice of a hospital transfer when the resident was sent to the hospital on 8/18/22 for Resident #68. On the 10/14/22 quarterly MDS (Minimum Data Set), Resident #68 was coded as being severely cognitively impaired in ability to make daily life decisions. A review of the clinical record revealed a nurse's note dated 8/18/22, that documented, CNA (Certified Nursing Assistant) .found pt (patient) on floor and called nurse. nurse observe pt laying on left hip on floor next to bed, pt was wearing gripper socks. left hip has protrusion and blanchable redness. pt state [they] was trying…

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

Based on observation, staff interview, and facility document review it was determined facility staff failed to prepare food in the facility kitchen in a sanitary manner in one of one facility kitchens. The findings include: On 11/30/2022 at approximately 9:50 a.m., an observation of the facility's dish room revealed OSM (other staff member) #8, dietary staff member, removing clean, wet cups, bowls and plate covers that had just come out of the automatic dishwasher and drying them with a towel and stacking them on drying racks. On 11/30/2022 at approximately 1:45 p.m. an interview was conducted with OSM #6, dietary manager. When asked about hand drying the plate covers OSM # 6 stated that it was their understanding that it was okay to hand dry the dishes as long as staff were wearing gloves. After reviewing the facility's policy Dish Machine Use Policy OSM # 6 stated that they were not aware that the dishes were not to be dried with a towel and needed to air dry. The facility's policy Dish Machine Use Policy documented in part, 11. Allow the dishes to air dry on the dish racks or…

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

Based on observation, staff interview and facility document review, the facility staff failed to maintain one of three dumpsters in a sanitary manner. The dumpster used for cardboard, was observed with debris, including several pieces of cardboard, plastic bags, used face masks and trash lying on the ground on the right and back side of the dumpster. The findings include: On 11/29/2022 at approximately 11:40 a.m., an observation of the facility's dumpsters was conducted with OSM (other staff member) #1, director of maintenance and OSM #2, maintenance helper. The observation revealed that the facility had one dumpster specifically for cardboard surrounded by a wooden fence. Observation of the area around the dumpster revealed several pieces of cardboard, plastic bags, used face masks and trash were found lying on the ground on the right and back side of the dumpster. When asked who was responsible for maintaining the immediate area around the dumpsters in a clean and sanitary manner and how often it was checked and cleaned OSM #1 stated that it was the maintenance department that was…

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

Based on resident interview, clinical record review, staff interview, and facility document review it was determined the facility staff failed to evidence notification of facility COVID-19 activity to residents and/or their responsible party (RP) and families for five of five residents reviewed, Residents #24, #68, #85, #132 and #48. The findings include: The facility staff failed to evidence notification by 5:00 p.m. the next calendar day following a single confirmed infection of COVID-19 (1) to sampled residents (Residents #24, #68, #85, #132 and #48) and/or their responsible party and families. On 11/29/2022 at 10:40 a.m., during entrance meeting with RN (registered nurse) #3, the infection preventionist and ASM (administrative staff member) #1, the administrator, RN #3 stated that residents/RP's and families were notified of new cases of COVID-19 in the facility by staff members after a case was identified and a progress note was entered into each residents medical record regarding the update regarding the facility status. On 11/29/2022 at approximately 1:00 p.m., ASM #1…

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

Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to assess one of 51 residents in the survey sample for self-administration of medication, Resident #48. The findings include: For Resident #48 (R48), the facility staff failed to assess for self-administration of medication. A bottle of docusate sodium (1) was observed unsecured at the bedside in R48's room. On the most recent MDS (minimum data set), a five-day admission assessment with an ARD (assessment reference date) of 10/13/2022, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 11/29/2022 at 2:46 p.m., an observation of R48's room was conducted with R48 present. A bottle of docusate sodium softgels were observed sitting on top of the nightstand to the left of R48's bed. On 11/30/2022 at 9:36 a.m., an interview was conducted with R48 in their room. The bottle of docusate sodium was on top of the nightstand to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to complete and accurate MDS (minimum data set) assessment for three of 51 residents in the survey sample, Residents #115, #132 and #106. The findings include: 1. For Resident #115 (R115), the facility staff failed to complete Sections B - Hearing, Speech and Vision, Section C - Cognition, and Section D - Mood on the Quarterly assessment dated [DATE]. On the most recent MDS assessment, a quarterly assessment, with an assessment reference date (ARD) of 9/27/2022, the resident was coded in Section B - Hearing, Speech and Vision, as being understood and understanding when spoken to. Sections C and D had dashes in all the boxes indicating it was not completed. On the quarterly MDS assessment, with an ARD of 9/7/2022, the resident was coded in Section B as being understood and understanding when spoken to. Section C had dashes in all the boxes. In Section C0600,…

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, clinical record review, it was determined that the facility staff failed to implement the comprehensive care plan for one of 51 residents in the survey sample, Resident #113 (R113). The findings include: For (R113), the facility staff failed to implement the comprehensive care plan for the placement of two fall mats next to (R113's) bed. (R113) was admitted to the facility with a diagnosis that included but was not limited to: muscle weakness and a history of falling. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 09/26/2022, the (R113) was coded as having both short- and long-term memory difficulties and was coded as being severely cognitively impaired for making daily decisions. On 11/29/22 at approximately 3:13 p.m., (R113) was observed lying in bed with one fall mat on floor next to the left side of (R113's) bed. On 12/01/22 at approximately 7:10 a.m., (R113) was observed lying in bed with one fall mat on floor next to the left side of (R113's) bed. The physician's…

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

Based on observations, staff interview, clinical record review, it was determined that the facility staff failed to implement interventions to reduce the risk of fall related injury, for one of 51 residents in the survey sample, Resident # 113 (R113). The findings include: For (R113), the facility staff failed to place fall mats on the right and left side of bed while (R113) was lying in bed. (R113) was admitted to the facility with a diagnosis that included but was not limited to: muscle weakness and a history of falling. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 09/26/2022, the (R113) was coded as having both short and long term memory difficulties and was coded as being severely cognitively impaired for making daily decisions. On 11/29/22 at approximately 3:13 p.m., an observation of (R113) revealed they were lying in bed and one fall mat on floor next to the bed on (R113's) left side. On 12/01/22 at approximately 7:10 a.m., an observation of (R113) revealed they were lying in bed and one fall mat on…

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

Based on observation, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to provide care and services for an indwelling urinary catheter, for one of 51 residents in the survey sample, Residents #24 (R24). The findings include: For (R24), the facility staff failed to keep the indwelling urinary catheter (1) tubing off the floor. (R24) was admitted to the facility with diagnoses that included but were not limited to: benign prostatic hyperplasia (2). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 09/13/2022, (R24) scored 15 out of 15 on the BIMS (brief interview for mental status), indicating (R24) was cognitively intact for making daily decisions. Sect H Bladder and Bowel code (R24) as having an indwelling catheter. On 11/29/22 at approximately 1:26 p.m., an observation of (R24) revealed they were sitting in their wheelchair in their room with the catheter tubing under the wheelchair; a portion of the catheter tubing was resting on the floor. On 11/29/22 at…

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

Based on observation, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to provide respiratory care and services consistent with professional standards of practice, for one of 51 residents in the survey sample, Residents #24 (R24). The findings include: For (R24), the facility staff failed to store a CPAP (continuous positive airway pressure) (1) mask in a sanitary manner. (R24) was admitted to the facility with diagnoses that included but were not limited to: chronic obstructive pulmonary disease (COPD) (2). On the most recent comprehensive MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 06/13/2022, (R24) scored 15 out of 15 on the BIMS (brief interview for mental status), indicating (R24) was cognitively intact for making daily decisions. Section O Special Treatments, Procedures and Programs coded (R24) for CPAP while a resident. On 11/29/22 at approximately 1:26 p.m., an observation of (R24's) CPAP mask revealed it was placed on top of their bedside table and uncovered. 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 staff interview, clinical record review and facility document review, it was determined the facility staff failed to conduct performance evaluations for two of five CNA's (certified nursing assistants) reviewed. The findings include: During the Sufficient and Competent Staffing facility task review on 11/30/22 at 2:30 PM there was no evidence of performance evaluations for two of five CNA's (certified nursing assistants) reviewed. On 11/30/22 at approximately 11:00 AM, ASM (administrative staff member) #1, the administrator, was provided with the list of five CNA's highlighted with request for evidence of performance reviews. At 2:00 PM, ASM #1, the administrator, provided the employee files requested which revealed the following: 1. CNA #2 with a date of hire of 9/25/17, revealed the last performance evaluation dated 10/23/21. There were no performance evaluation within the last 12 months. 2. CNA #3 with a date of hire of 3/1/16, revealed the last performance evaluation dated 8/15/21. There were no performance evaluation within the last 12 months. On 11/30/22 at 3:00 PM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement the comprehensive care plan for four of 52 residents in the survey sample, Residents #107, #86, #12 and #61. The findings include: 1.a. The facility staff failed to implement Resident #107's comprehensive care plan for pain medication administration. Resident #107 was admitted to the facility on [DATE]. Resident #107's diagnoses included but were not limited to heart disease, high blood pressure and a history of a hip fracture. Resident #107's significant change in status minimum data set assessment with an assessment reference date of 5/17/21, coded the resident's cognition as severely impaired. Review of Resident #107's clinical record revealed the following physician's orders: -5/10/21- oxycodone 5 mg (milligrams) - Give 0.5 tablet by mouth every 6 hours as needed for pain for 7 days. Give for pain 1-5. -5/10/21- oxycodone 5 mg - Give 1 tablet by mouth every…

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, it was determined that the facility staff failed to provide respiratory care and services consistent with professional standards of practice, and the comprehensive person-centered care plan for three of 52 residents in the survey sample, (Residents #86, #12 and #61). The facility staff failed to administer oxygen at the physician ordered rate to Resident #86 and Resident #12, and failed to maintain Resident #12's oxygen concentrator in a sanitary manner. The Facility staff failed to provide Resident # 61's oxygen continuously according to the physician's orders and keep the nasal cannula off the floor. The findings include: 1. Resident #86 was admitted to the facility on [DATE] with the diagnoses of but not limited to neuropathic bladder, diabetes, depression, high blood pressure, and quadriplegia. The most recent MDS (Minimum Data Set) assessment a quarterly assessment with an ARD (Assessment Reference Date) of 5/6/21,…

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, it was determined that the facility staff failed to implement a complete pain management program for one of 52 residents in the survey sample, Resident #107. The facility staff failed to administer the correct dosage of prn (as needed) oxycodone (1) per physician's order, based on Resident #107's pain rating on 5/14/21. The findings include: Resident #107 was admitted to the facility on [DATE]. Resident #107's diagnoses included but were not limited to heart disease, high blood pressure and a history of a hip fracture. Resident #107's significant change in status minimum data set assessment with an assessment reference date of 5/17/21, coded the resident's cognition as severely impaired. Review of Resident #107's clinical record revealed the following physician's orders: -5/10/21- oxycodone 5 mg (milligrams) - Give 0.5 tablet by mouth every 6 hours as needed for pain for 7 days. Give for pain 1-5. -5/10/21- oxycodone 5 mg - Give 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure one of 52 residents in the survey sample, (Resident #107), was free from unnecessary medication. The facility staff failed to attempt non-pharmacological interventions prior to administering prn (as needed) oxycodone to Resident #107 on 5/12/21. The findings include: Resident #107 was admitted to the facility on [DATE]. Resident #107's diagnoses included but were not limited to heart disease, high blood pressure and a history of a hip fracture. Resident #107's significant change in status minimum data set assessment with an assessment reference date of 5/17/21, coded the resident's cognition as severely impaired. Review of Resident #107's clinical record revealed a physician's order dated 5/10/21 for oxycodone 5 mg (milligrams) - Give 0.5 tablet by mouth every 6 hours as needed for pain for 7 days. Give for pain 1-5. Resident #107's comprehensive care plan revised on 5/11/21…

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 observation, staff interview, facility document review, clinical record review, and during the course of a complaint investigation, it was determined the facility staff failed to provide a complete and accurate medical record for two of 52 residents in the survey sample, (Resident #479 and Resident #40). The facility staff failed to provide a complete and accurate medical record of progress notes for Resident #479's Foley catheter being pulled out, reinserted and scratches on the residents fingers while the resident was admitted to the facility for respite care 2/17/21 through 2/22/21, and staff failed to maintain a complete and accurate clinical record documenting activities of daily living tasks completed for Resident #40. The findings include: 1. Resident #479was admitted to the facility on [DATE]. Resident #479's diagnoses included but were not limited to: congestive heart failure (abnormal condition characterized by circulatory congestion and retention of salt and water by the kidneys) (1), chronic…

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.