Nassawadox Rehabilitation And Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and facility document review the facility staff failed to notify the Office of the State Long-Term Care Ombudsman of 3 hospital discharges and 1 hospital transfer for 3 of 55 residents in the survey sample, Resident #58, Resident #70 and Resident #36. The findings included: 1. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #58's hospital transfer on 4/3/22. Resident #58 was admitted to the facility on [DATE] with diagnoses to include but not limited to Paranoid Schizophrenia, Bipolar Disorder and Dementia. Resident #58's most recent Minimum Data Set(MDS) was a Quarterly/Medicare 5 Day assessment with an Assessment Reference Date (ARD) of 4/12/22. The Brief Interview for Mental Status was coded as a 15 out of a possible 15 indicating the resident was cognitively intact and capable of daily decision making. Resident #58's Progress Notes were reviewed and are documented in part, as follows: .4/3/2022 20:01(8:01 p.m.)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a family interview, staff interview, and review of the clinical record review, the facility staff failed to develop and implement a person-centered comprehensive care plan to address rejection of care for 1 of 55 residents (Resident #48) in the survey sample. The findings included: Resident #48 was originally admitted to the facility 12/30/21 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; metastatic squamous cell carcinoma and encephalopathy. The significant change annual quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/2/2022 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #48's cognitive abilities for daily decision making were intact. A review of the Wound Care Nurse Practitioner's (WCNP) progress notes dated 5/3/22, 5/10/22 and 5/17/22 revealed wound care had been consulted for an ustageable pressure ulcer to the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interviews, staff interviews, clinical record review and facility documentation review, the facility staff failed to invite 2 of 55 residents, (Resident #75 and #60) in the survey sample to attend their person centered care plan meeting. The findings included: 1. Resident #75 was originally admitted to the facility on [DATE]. Diagnosis for Resident #75 included but not limited to End Stage Renal Disease (ESRD). The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 04/24/22 coded the resident with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. An interview was conducted with Resident #75 on 05/11/22 at approximately 4:49 p.m., who stated I do not recall ever being invited to attend a care plan meeting nor did I receive a letter to attend. On 05/12/22, an interview was conducted with the Social Worker (SW) at approximately 4:52 p.m., who stated, Resident #75 should have had her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interviews, and clinical record review, the facility staff failed to provide 1 of 55 residents (Resident #84) in the survey sample with as much information as possible to encourage a smooth transition from the facility to his private home after voicing a desire to be discharged . The findings included: Resident #84 was originally admitted to the facility 4/27/22 and discharged from the facility 5/10/22. The current diagnoses included; sepsis, diabetes, chronic kidney disease, atrial flutter and heart failure, skin tear to the left lower leg/cellulitis. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/2/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #84's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring total care of one person with bathing,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff interviews and facility document review the facility staff failed to ensure that 4 of 55 residents (Resident #85, #66, #13, and #69) in the survey sample who were unable to carry out grooming activities of daily living (ADL) were provided showers and nail care. The findings included: 1. The facility staff failed to ensure Resident #85 who was unable to carry out activities of daily living was offered and received a scheduled twice-weekly shower to maintain good personal hygiene during the last 4 months and failed to ensure that fingernail care was provided. Resident #85 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to included but not limited to Contractures of both knees and lower legs, Parkinson's Disease and Alzheimer's Disease. Resident #85's most recent Minimum Data Set (MDS) was a Significant Change Assessment with an Assessment Reference (ARD) of 4/28/22. The Brief Interview for Mental Status (BIMS) was unable…

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 interviews and facility documentation, the facility staff failed to provide necessary toenail care for 1 of 55 residents (Resident #13, a totally dependent resident for activities of daily living), in the survey sample. The findings include: Resident #13 was originally admitted to the facility 2/20/2014, was discharged to an acute care hospital 11/17/21 and returned 11/19/21. The current diagnoses; traumatic brain injury (TBI) and a seizure disorder. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/13/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #13's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring total care of one person with personal hygiene and bathing. On 5/18/22 at approximately 12:50 p.m., Resident #13 was observed in bed. His hair was long and stringy and his toe nails were approximately 2.5 inches beyond the tip of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and clinical record review, the facility staff failed to ensure a resident didn't experience a reduction in range of motion of bilateral knees and failed to provide necessary services to prevent further decrease in range of motion for 1 of 55 residents (Resident #190), in the survey sample. The findings included: Resident #190 was originally admitted to the facility 2/23/2017 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Alzheimer's dementia, diabetes and a left jaw swelling. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/7/22 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems and severely impaired daily decision making abilities. In section G (Physical functioning) the resident was coded as requiring total care of one person with bed mobility, transfers,…

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.

The facility staff failed to assure dietary recommendations made by the Registered Dietitian (RD) were implemented for 1 out of 55 resident (Resident #291) in the survey sample. The findings included: Resident #291's admission Assessment (14-day) with an ARD of 03/19/22 coded Resident #291 Brief Interview for Mental Status (BIMS) scored a 99 indicating short and long term memory problems and with severe cognitive impairment - never/rarely made decisions. Resident #291 was coded total dependence of two with toilet use, bed mobility and bathing, total dependence of one with dressing, personal hygiene and eating and for Activities of Daily Living (ADL). Resident #291 was coded as having no mood, rejection of care or behavioral problems. Resident #291's admission Assessment (14-day) with an ARD of 03/19/22 under section (K) Swallowing/Nutritional Status coded the resident for loss of liquids from mouth when eating or drinking while holding food in mouth/cheeks or residual food in mouth after meals. Resident #291 weight at 132 pounds. The MDS was not coded for weight loss. Resident…

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

Based on observation, staff interviews, clinical record review and facility documentation review, the facility staff failed to provide 1 of 55 residents (Resident #288) in the survey sample with respiratory care in accordance with professional standards of practice. The findings included: The facility staff failed to ensure Resident #288's had an oxygen order prior to administering oxygen. Resident #288 was originally admitted to the nursing facility on 09/19/19. Resident #288's diagnosis included but not limited to acute respiratory failure with hypoxia. Resident #288's Minimum Data Set (an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of 03/14/22 coded the resident's Brief Interview for Mental Status (BIMS) score 12 of a possible 15 with moderate impairment for daily decision-making. In section G (Physical functioning) the MDS coded Resident #288 requiring total dependence of two with transfer, total dependent of one with dressing, toilet use, personal hygiene and bathing, extensive assistance of one with bed mobility and supervision with…

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

Based on observations, staff interview, and clinical record reviews, the facility staff failed to have a pharmaceutical system which assured timely receiving and accurate dispensing and destruction of medications for 2 of 55 residents (Resident #13 and 14), in the survey sample. The findings included: 1. The facility staff failed to procure the anticonvulsive medication, Vimpat timely to prevent Resident #13 from missing dosages. and to ensure the medication is administered as ordered by the Practitioner. Resident #13 was originally admitted to the facility 2/20/2014, was discharged to an acute care hospital 11/17/21 and returned 11/19/21. The current diagnoses; traumatic brain injury (TBI) and a seizure disorder. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/13/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #13's cognitive abilities for daily decision making were intact. In section I (Active Diagnosis) the resident was coded at I5400 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.

Based on clinical record review, staff interviews, and review of facility documents, the facility staff failed to assure the Licensed Pharmacist recommendation were reviewed and responded to by the Physician and/or Practitioner for 1 of 55 residents (Resident #37), in the survey sample. The findings included: The facility staff failed to assure Resident #37's gradual dose reduction recommendation offered by the licensed pharmacist were acted upon by the Physician and/or Practitioner. Resident #37 was originally admitted to the facility 5/14/2021 resident had never been discharged from the facility. The current diagnoses included; dementia and Schizophrenia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/9/22 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired for daily decision making. A review of the Physician's Order Summary (POS) revealed an order dated 7/22/21 for Fluvoxamine Maleate ER…

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 the medication pass and pour observations, clinical record review, staff interviews and resident interview, the facility staff failed to ensure they were free of medication errors rates of five percent (%) or greater. During the medication passes totaling 25 observed opportunities for errors, two medication errors were made which resulted in a medication rate of 8%. The residents involved in the medications errors were Resident #55 and #28. The findings include: 1. Resident #55 was originally admitted to the facility 5/29/21 and had never been discharged from the facility. The current diagnoses included; dry eye syndrome. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/6/2022, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #55's cognitive abilities for daily decision making were intact. On 5/10/22 at 4:48 p.m., Licensed Practical Nurse (LPN) #4 pulled one oral medication and looked through the medication cart for Resident #55's Artificial…

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 interviews, and clinical record review, the facility staff failed to assure a resident was free of significant medication errors for 1 of 55 resident (Resident #13), in the survey sample. The findings included: Resident #13 was originally admitted to the facility 2/20/14, was discharged to an acute care hospital 11/17/21 and returned 11/19/21. The current diagnoses; traumatic brain injury (TBI) and a seizure disorder. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/13/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #13's cognitive abilities for daily decision making were intact. In section I (Active Diagnosis) the resident was coded at I5400 for a seizure disorder or epilepsy. The Physician's Order Summary (POS) revealed an order dated 11/19/2021 for Vimpat Tablet 200 milligrams, Give 1 tablet by two times a day for seizures. On 5/18/22 at approximately 11:15 a.m., a review of controlled medications was conducted for Resident #13.…

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 a review of facility documents the facility's staff failed to ensure accurate documentation in one of 55 resident (Resident #66), clinical records. The findings included: Resident #66 was originally admitted to the facility 10/16/15 from an acute care facility and discharged on 4/11/22 to an acute care facility and returned to the Long Term Care Facility on 4/13/22. The current diagnoses included; Pneumonia and COPD (Chronic Obstructive Pulmonary Disease). The Significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 04/18/2022 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #66 cognitive abilities for daily decision making were intact. In sectionG(Physical functioning) the resident was coded as requiring extensive assistance of one person with bed mobility and dressing. Requiring total dependence of one person with toilet use, personal hygiene and bathing. Requires set-up help only with eating. The 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 resident interview, staff interview, clinical record review, and review of facility documents, the facility staff failed to assure the Hospice Agency provided the facility staff with the coordinated plan of care to identify which services the Hospice Agency would provide, when the services would be provided, the communication process, and when or why the nursing facility staff should notify the Hospice Agency for 1 of 1 resident receiving Hospice services (Resident #36). The findings included: Resident #36 was originally admitted to the facility on [DATE] and was discharged to the hospital return anticipated on 2/3/2022. The resident's diagnosis included cirrhosis of the liver with ascites and a right inguinal hernia. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/21/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #36's cognitive abilities for daily…

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, review of facility documents and during the course of a complaint investigation, the facility's staff failed to provide and or coordinate services for 1 of 55 residents (Resident #338, a closed record resident) a requested COVID-19 vaccine. The findings included: Resident #338 was originally admitted to the facility on [DATE] after an acute care hospital stay and expired in the facility on [DATE]. The current diagnoses included; COVID19. The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired for daily decision making. In sectionG(Physical functioning) the resident was coded as requiring limited assistance of one person with bed mobility, walking in the room and walking in the corridor. Requiring extensive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews, and facility document review, the facility staff failed to send the comprehensive care plan goals upon transfer to the hospital for 3 of 56 residents in the survey sample (Residents #101, #61, and #128). The findings included: 1. Resident #101 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses to include but not limited to Functional Quadriplegia and End Stage Renal Disease. Resident #101's most recent Minimum Data Set (MDS) is a Quarterly with an Assessment Date (ARD) of 6/20/19. The Brief Interview for Mental Status (BIMS) was a 15 out of a possible 15 which indicated that Resident #101 is cognitively intact and capable of daily decision making. Resident #101's Detail Discharge Report was review and is documented in part, as follows: 1/18/19 Discharge to Hospital. 3/25/19 Discharge to Hospital. 5/7/19 Discharge to Hospital. 7/18/19 Discharge to Hospital. 7/21/19 Discharge to Hospital. 7/26/19 Discharge to Hospital. 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 3. Resident #129 was originally admitted to the facility for skilled services on 7/5/19 following a fall at home resulting in a left hip fracture and then readmitted on [DATE] after a hospitalization with diagnosis of Foley related sepsis Urinary Tract Infection (UTI), other diagnoses included neurogenic bladder (a dysfunction of the bladder) and dementia. The current MDS (Minimum Data Set) a 14 day with an assessment reference date of 7/19/19 coded the resident as having long and short term memory deficits and severely impaired cognitive skills for daily decision making. The clinical record face sheet evidenced the resident was not his own responsible party. The resident representative was listed as a son. The resident was sent out to the emergency room and admitted to the hospital for a change in condition on 7/28/19. The resident was re-admitted to the facility on [DATE]. There was no evidence in the clinical record that the written notice which describes the bed-hold policy was provided to the resident…

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

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 facility staff failed to revise the care plan for three of 56 residents in the survey sample, Resident #80, #134, and #121. The findings included: 1. Facility staff failed to revise the care plan when it was determined her left pinky blister was caused from trauma rather than a burn on 7/2/19; and failed to revise the care plan when the blister had healed on 7/11/19. Resident #80 was admitted to the facility on [DATE] with diagnoses that included but were not limited to, Parkinson's disease, convulsions, and Schizophrenia. Resident #80's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 4/2/19. Resident #80 was coded as being intact in cognitive function scoring 15 out of possible 15 on the BIMS (Brief Interview of Mental Status) exam. Review of Resident #80's clinical record revealed that Resident #80 obtained a blister on 6/30/19. The following…

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 1 of 56 residents in the survey sample was free from unnecessary psychotropic drugs, Resident #121. The facility staff failed to implement non-pharmacological approaches prior to administration of the anti-anxiety drug Ativan and failed to obtain a stop date for as needed (PRN) Ativan. The findings include: Resident #121 was admitted to the facility on [DATE] with diagnoses to include but not limited to, unspecified dementia without behavioral disturbance, major depressive disorder, recurrent with severe psychiatric symptoms. The current MDS (Minimum Data Set) a quarterly with an assessment reference date of 7/10/19 coded the resident as having long and short term memory deficits and severely impaired daily decision making skills. Under behaviors the resident was assessed as not exhibiting any physical or verbal behaviors or potential indicators for psychosis. And that the resident was not exhibiting…

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

Based on observation, staff interview, and facility document review, it was determined that facility staff failed to store and prepare food in a sanitary manner in the facility kitchen. The findings included: On 8/4/19 at 12:40 p.m., observation of the facility kitchen was conducted. On 8/4/19 at 1:10 p.m., an open container of ham was found in the reach-in refrigerator. The open date labeled on the container of ham documented 7/22/19. A second date on the container of ham documented 7/26/19. On 8/4/19 at 1:10 p.m., a pitcher that was half way full of tomato juice was also observed in the reach in refrigerator. 7/27/19 was the date labeled on the pitcher. On 8/4/19 at 1:11 p.m., an interview was conducted with OSM (other staff member) #7, the cook. When asked about the second date labeled on the ham, OSM #7 stated that the 7/26/19 date was the use by date and that the ham should have been thrown away. OSM #7 then stated that the ham was either old or staff labeled the wrong dates on the container. OSM #7 then threw the container away. When asked about the tomato juice, OSM #7 stated…

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

Based on observation, staff interview and facility document review, it was determined that facility staff failed to maintain the facility dumpster in a manner to prevent pests for one of two facility dumpsters. The findings included: On 8/4/19 at 1:15 p.m., observation of the facility dumpster was conducted with OSM #7, the cook. One of two facility dumpsters had the doors open to the front and back of the dumpster. The dumpster was over full with trash. When asked who was responsible for maintaining the facility dumpster; ensuring it was shut and free from surrounding debris, OSM #7 stated that everyone (all staff) should make sure the dumpsters are shut and the surrounding area was clean, but that it was ultimately dietary's responsibility. When asked why the dumpster should be shut, OSM #7 stated to prevent pests from getting into the trash especially the feral cats that have been spotted in the area. OSM #7 confirmed that the dumpster was not shut. On 8/8/19 at 3:18 p.m., ASM (administrative staff member) #1, the Administrator, and ASM #2, the ADON (Assistant Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, clinical record review and facility document review the facility staff failed to provide draping to prevent exposure of body parts and maintain dignity during the provision of care for 1 of 56 residents in the survey sample, Resident #124. The findings include: Resident #124 was admitted to the facility on [DATE] with diagnoses to include but not limited to, stroke and diabetes. The current MDS (Minimum Data Set) an annual with an assessment reference date of 7/1/19 assessed the resident as having long and short term memory deficits. The resident required extensive assistance of two staff for bed mobility and was dependent for transfers. Under section M. Skin Conditions the resident was coded as having a stage IV pressure injury (defined in the MDS as-full thickness tissue loss with exposed bone, tendon, or muscle. Slough, eschar may be present on some parts of the wound bed). On 8/7/19 at 12:33 p.m., an observation of the sacral dressing change was conducted. The facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review the facility staff failed to ensure medical equipment was maintained in good repair for 1 of 56 residents in the survey sample, Resident #78. Resident #78's mobility chair was observed to have areas that were ripped, torn and a piece of the foam arm rest was missing. The findings include: Resident #78 was admitted to the facility on [DATE] with diagnoses to include but not limited to, seizures, traumatic brain injury, and spastic hemiplegia (Spastic hemiplegia is a neuromuscular condition of spasticity that results in the muscles on one side of the body being in a constant state of contraction) affecting the right side. The current MDS (Minimum Data Set) a quarterly with an assessment reference date of 6/11/19 coded the resident as scoring a 12 out of a 15 on the BIMS (Brief Interview for Mental Status), indicating the resident had moderately impaired cognition. The resident required extensive assistance of two staff for bed mobility and…

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

Based on staff interview and facility record review, it was determined that the facility failed to develop and implement an abuse policy to include conducting a reference screening for one (1) prospective employee out of 25 records reviewed. Review of personnel records obtained from facility revealed that no verification of reference screenings was conducted for a current employee, Certified Nursing Assistant (CNA) #9. The findings included: On 8/8/2019 at approximately 1:20 p.m., the Human Resource (HR) Director was asked to provide evidence of reference screenings for CNA #9. The HR Director stated, I don't have one for her and I was not working here then. Facility policy on Abuse Prevention Program documented in part, the following: .2. Conduct employee background checks and will not knowingly employ or otherwise engage any individual who has: a. Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; b. Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation,…

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 record review, staff interviews and facility document review the facility staff failed to ensure that a Quarterly Review Assessment was submitted no less than once every three months for 3 of 56 residents in the survey sample, (Residents #2, #3 and #4). The findings included: 1. Resident #2 was admitted on [DATE] with diagnoses to include but not limited to Type II Diabetes Mellitus and Cerebrovascular Disease. Upon completing the Resident Assessment Task is was noted that Resident #2 was triggered for a Minimum Data Set (an assessment tool) that was greater than 120 days late. Resident #2's most recent Minimum Data Set (MDS) was a Quarterly with an Assessment Reference Date (ARD) of 6/25/19. The Brief Interview for Mental Status was a 10 out of a possible 15 indicating that Resident #2 was moderately cognitively impaired but capable of some daily decision making. Under Section Z Assessment Administration: Signature of RN (Registered Nurse) Assessment Coordinator Verifying Assessment Completion…

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 an MDS (Minimum Data Set-an assessment tool) was accurate for 1 of 56 residents in the survey sample, Resident #121. Section E. Behaviors was not accurate for the quarterly MDS with an assessment reference date of 7/10/19. The findings include: Resident #121 was admitted to the facility on [DATE] with diagnoses to include but not limited to, unspecified dementia without behavioral disturbance, major depressive disorder, recurrent with severe psychiatric symptoms. The current MDS (Minimum Data Set) a quarterly with an assessment reference date of 7/10/19 coded the resident as having long and short term memory deficits and severely impaired daily decision making skills. Under behaviors Section E. 0200 A. the resident was coded as not exhibiting any physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing). Resident #121 required extensive assistance of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review and clinical record review, it was determined that facility staff failed to implement the physician's recommendations for treatment to a non-intact blister; failed to document when the non-intact blister had healed in the clinical record; and continued to treat the non-intact blister when it was already healed for one of 56 resident in the survey sample, Resident #80. The findings included: Resident #80 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Parkinson's disease, convulsions, and Schizophrenia. Resident #80's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 4/2/19. Resident #80 was coded as being intact in cognitive function scoring 15 out of possible 15 on the BIMS (Brief Interview of Mental Status) exam. Review of Resident #80's clinical record revealed that Resident #80 obtained a blister on 6/30/19. The following nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility document review the facility staff failed to provide the necessary care and treatment to prevent and promote healing of a pressure injury for 1 of 56 residents in the survey sample, Resident #124. The findings include: Resident #124 was admitted to the facility on [DATE] with diagnoses to include but not limited to, stroke and diabetes. The current MDS (Minimum Data Set) an annual with an assessment reference date of 7/1/19 assessed the resident as having long and short term memory deficits. The resident required extensive assistance of two staff for bed mobility and dependent for transfers. Under section M. Skin Conditions the resident was coded as at risk for developing pressure ulcers/injuries and having a stage IV pressure injury (defined in the MDS as a full thickness tissue loss with exposed bone, tendon, or muscle. Slough, eschar may be present on some parts of the wound bed). On 8/7/19 at 12:33 p.m., an observation of the sacral…

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 interviews, clinical record review and facility document review the facility staff failed to provide a physician ordered safety device (a lidded cup) to promote safety for 1 of 56 residents in the survey sample, Resident #8. The findings include: Resident #8 was admitted to the facility on [DATE] with diagnoses to include but not limited to, legal blindness and history of major depressive disorder, recurrent, severe with psychotic symptoms. The current MDS (Minimum Data Set) a quarterly with an assessment reference date of 7/8/19 coded the resident as scoring a 6 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating the resident had severely impaired cognition. The resident was coded as requiring limited assistance with one person physical assist with eating, and transfers, and extensive assistance with one person physical assist with bed mobility, personal hygiene and dressing. The resident had limited range of motion to both upper and lower extremities.…

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 facility staff failed to ensure one of 56 residents (Resident #128) in the survey sample was free from unnecessary medication; specifically excess units of insulin. The findings included: Resident #128 was admitted to the facility on [DATE], with the most recent readmission on [DATE]. The resident was on hospice care as of 8/4/2019. The latest diagnoses included, but not limited to, type 2 diabetes mellitus with diabetic neuropathy, and pseudocyst of pancreas, and morbid obesity. Resident #128's most recent MDS (minimum data set) assessment was a 14 day scheduled assessment with an ARD (assessment reference date) of 7/9/19. Resident #128 was coded as being intact in cognitive function scoring 15 out of possible 15 on the BIMS (brief interview for mental status) exam. A review of Resident #128's comprehensive care plan dated 8/1/2019 revealed, in part, the following documentation: Problem / Need. Risk 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, facility document review and clinical record review, it was determined that facility staff failed to ensure one of 56 residents was free from a significant medication error, Resident #128. The findings included: Resident #128 was admitted to the facility on [DATE], with the most recent readmission on [DATE]. The Resident was placed on hospice care as of 8/4/2019. The diagnoses included, but not limited to, type 2 diabetes mellitus with diabetic neuropathy, pseudocyst of pancreas, and morbid obesity. Resident #128's most recent MDS (minimum data set) assessment was a 14 day scheduled assessment with an ARD (assessment reference date) of 7/9/19. Resident #128 was coded as being intact in cognitive function scoring 15 out of possible 15 on the BIMS (brief interview for mental status) exam. A review of Resident #128's comprehensive care plan dated 8/1/2019 revealed, in part, the following documentation: Problem / Need. Risk for hyper/hypoglycemia (high/low blood sugar) r/t (related to)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews the facility staff failed to maintain infection prevention for 2 of 56 residents in the survey sample. For Resident #12 the facility staff failed to perform wound care in a manner to prevent infection; and for Resident #129 the facility staff failed to maintain Foley catheter tubing and bag in a manner in accordance with infection control standards and practices. The findings included: 1. Resident #12 was originally admitted to the facility 08/19/10 and readmitted on [DATE]. Resident #12's diagnoses included Diabetes Mellitus without complications and Essential Hypertension. The Quarterly Revision Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 04/16/19 coded the resident as having short term and long term memory problems. In section G (Physical functioning) the resident was coded as needing limited physical assistance bed mobility, limited assistance with transfers, supervision with locomotion, limited assistance with dressing, limited…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff and family interview and facility policy review, the facility staff failed to inform Resident Representatives of a change in condition for 1 out of 29 residents (Resident #3) in the survey sample. The facility staff failed to inform Resident #3's Resident Representative of a change in condition. The findings include: Resident #3 was admitted to the nursing facility on 8/1/11 and readmitted on [DATE] with diagnoses that included high blood pressure, Type II diabetes mellitus, metabolic encephalopathy, dementia and dysphagia (swallowing problems). The most recent Minimum Data Set (MDS) was a quarterly dated 8/25/17 and coded the resident with short and long term memory problems and severely impaired in the skills necessary for daily decision making. Resident #3 was totally dependent on two staff for all activities of daily living (ADL). The resident was assessed with swallowing problems and on a mechanically altered diet. The person centered care plan dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interviews, facility documentation review and clinical record review the facility staff failed to update a care plan give a resident the opportunity to participate in her care plan meeting for 2 of 29 residents (Resident #2 and #14) in the survey sample. 1. The facility staff failed to revise Resident #2's comprehensive care plan to include a fall that occurred on 09/04/17 and 09/14/17. 2. The facility staff failed to give Resident #14 the opportunity to participate in her care plan meeting. The findings included: 1. Resident #2 was admitted to the nursing facility on 03/05/12. Diagnosis for Resident #2 included but not limited to dementia with behavioral disturbances (1). The current Minimum Data Set (MDS) a significant change assessment with an Assessment Reference Date (ARD) of 10/13/17 coded the resident with short and long term memory problems and with severe cognitive impairment - never/rarely made decisions. In addition, the MDS coded Resident #2 with total dependence 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.

Based on observation, resident interview staff interviews, facility documentation and clinical record review, the facility staff failed to follow physician orders for 1 out 29 Residents in the survey sample, (Resident #22). The facility staff failed to follow the physician orders for the administration of Zofran and MS Contin for (Resident #22). Resident #22 was originally admitted to the facility 09/08/16. Diagnosis included but not limited to Cancer, (1) and anemia (2). The current Minimum Data Set (MDS) an admission assessment with an Assessment Reference Date (ARD) of 09/15/16 coded the resident with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. In addition, the MDS coded Resident #22 requiring total dependence of one with dressing, hygiene, bathing and toilet use, extensive assistance of one with bed mobility and limited assistance of one with eating for Activities of Daily Living care. Resident #22's comprehensive care plan documented resident with a stage IV breast cancer - Resident #22 is at risk 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 observation, resident interview, staff interview, facility documentation review, clinical record review the facility staff failed to follow wound care standard procedures to prevent the potential complications for two Residents (Resident #8 and Resident #11) in the survey sample size of 29. 1. The faciliy staff failed to ensure potential complications were avoided during wound care for Resident #8. 2. The facility staff failed to ensure potential complications were avoided during wound care for Resident #11. The findings included: 1. Resident #11 was admitted to the facility on [DATE]. Diagnoses for Resident #11 included but are not limited to Cerebrovascular Accident* (1), Non-Alzheimer's Dementia* (2), and Krauosis Vulvae* (3). Resident #11's Quarterly Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 7/18/17 coded Resident #11 with short and long term memory problems with moderate memory impairment. During an observation on 11/8/17 at approximately 9:45 a.m., of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility documentation review, clinical record review the facility staff failed to ensure safety measures to prevent a potential accident of cutting a Resident's skin, were utilized when cutting off a soiled dressing using pointed tipped scissors and not bandage scissors for 1 Resident, (Resident #11) in the survey sample size of 29. The findings included: Resident #11 was admitted to the facility on [DATE]. Diagnoses for Resident #11 included but are not limited to Cerebrovascular Accident* (1), Non-Alzheimer's Dementia* (2), and Krauosis Vulvae* (3). Resident #11's Quarterly Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 7/18/17 coded Resident #11 with short and long term memory problems with moderate memory impairment. During an observation on 11/8/17 at approximately 9:45 a.m., of Resident #11's wound care for an Unavoidable Atypical Unstageable Facility Acquired on 7/24/17, Pressure Ulcer* (4). Resident #11 was lying…

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, staff interviews and revised of the facility documentation the facility staff failed to maintain an infection control program to provide a safe, sanitary environment to prevent the development and transmissions of disease and infection for 2 of 29 residents (Resident #8 and 11) in the survey sample. 1. The facility staff failed to implement appropriate hand hygiene during a sacral wound care dressing change for Resident #8. 2. The facility staff failed to implement appropriate hand hygiene during a right ankle care dressing change for Resident #11. The findings included: 1. Resident #8 was admitted originally admitted to the facility on [DATE]. Diagnosis for Resident #8 included but are not limited to Type 2 Diabetes (1), and a stage IV (2) sacral wound pressure ulcer (3). Resident #8 Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/27/17 coded the resident with a 09 of a total possible score of 15 on the 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.