Life Care Center Of New Market

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interview, and facility document review, the facility staff failed to develop a care plan for side rail use for 1 of 35 residents in the survey sample; Resident #50. The findings include: Resident #50 was admitted to the facility on [DATE] with the diagnoses of but not limited to dementia, depression, osteoporosis, and COVID-19. The most recent MDS (Minimum Data Set) was a significant change assessment with an ARD (Assessment Reference Date) of 11/23/21. The resident was coded as being severely cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing and extensive assistance for all other areas of activities of daily living. On 1/4/22 at 3:35 PM, Resident #50 was observed in bed asleep, with the head of the bed elevated, and the half length side rails up bilaterally. A review of the clinical record revealed an Evaluation For Use of Bed Rails form dated 2/1/21 that documented, Bed rail(s) are…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow a physician's order to administer a medication for one of 35 residents in the survey sample, Resident #35. The facility staff failed to follow a physician's order to limit a resident's Tylenol dosage to 3000 mgs (millligrams) in a 24 hour period on 10/27/21, 10/29/21, 10/31/21, 11/1/21, 11/9/21, and 12/5/21. The findings include: Resident #35 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses including arthritis, diabetes, bilateral below the knee amputations, and peripheral vascular disease. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/15/21, the resident was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). A review of Resident #35's clinical record revealed the following order, dated 7/16/21:…

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.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility failed to store respiratory treatment equipment in a sanitary manner for one of 35 residents in the survey sample, Resident #90. On two separate occasions, Resident #90's CPAP (continuous positive airway pressure) (1) mask was observed uncovered, and lying in contact with his pillows. The findings include: Resident #90 was admitted to the facility on 9//24/18 with diagnoses including a traumatic brain injury, a stroke, and diabetes. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/27/21, the resident was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). On 1/4/22 at 2:56 p.m. and 1/5/22 at 10:22 a.m. Resident #90's CPAP mask was observed uncovered, and in direct contact with his bed pillows. Resident #90 was sitting up in the wheelchair in his room. He stated the staff always cleans the CPAP mask and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, the facility staff failed to prevent a resident from receiving unnecessary pain medication for one of 35 residents in the survey sample, Resident #35. The facility staff failed to follow a physician's order to limit a resident's Tylenol dosage to 3000 mgs in a 24 hour period on 10/27/21, 10/29/21, 10/31/21, 11/1/21, 11/9/21, and 12/5/21. The findings include: Resident #35 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses including arthritis, diabetes, bilateral below the knee amputations, and peripheral vascular disease. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/15/21, the resident was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). A review of Resident #35's clinical record revealed the following order, dated 7/16/21: Tylenol…

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, resident interview, facility document review and clinical record review, it was determined that the facility staff failed to meet Advance Directive requirements for Thirteen of 47 residents in the survey sample, Residents #71, #52, #64, #27, #82, #88, #85, #49, #15, #8, #21, #50, #43. The facility staff failed to evidence resident advance directives or information for developing an advanced directive was periodically reviewed with the resident and/or Resident Representative (RR) to residents wished change anything or maintain the advanced directive as written and or formulate an advanced directive for Residents #71, #52, #64, #27, #82, #88, #85, #49, #15, #8, #21, #50, #43. The findings include: 1. The facility staff failed to evidence Resident #71's advance directives dated [DATE], was periodically reviewed with the resident and/or Resident Representative (RR) to determine if she wanted to change anything or maintain the advanced directive as written. Resident #71 was admitted to the…

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

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 that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan for three of 47 residents in the survey sample, Resident #20, Resident #44 and Resident. On 10/11/19, a wound care specialist treated Resident #20. The facility did not act on the specialist's recommendations until 10/14/19, even though a facility staff member was in possession of the wound specialist's report/recommendation on the afternoon of 10/11/19. Staff also failed to monitor Resident #20's fluid intake as ordered by the physician on multiple shifts during September 2019 and October 2019 and the staff failed to look at Resident #44's abdominal binder every 30 minutes and failed to loosen the abdominal binder every two hours per physician orders. The findings include: 1. a. Resident #20 was admitted to the facility on [DATE], and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to treat one out of 47 residents in the survey sample, Resident #12, with dignity and respect. The findings include: Resident #12 was admitted to the facility on [DATE]. Diagnoses include but not limited to, high blood pressure, heart disease, edema, atrial fibrillation, congestive heart failure, and diabetes. The annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/11/19 coded the resident as being severely impaired in ability to make daily life decisions, scoring a 3 out of a possible 15 on the BIMS (Brief Interview for Mental Status) exam. The resident was coded as requiring total care for bathing; extensive assistance for transfers, dressing, toileting and hygiene; and was coded as independent for eating. A nurse's notes dated 10/12/19 at 3:46 AM that documented, Resident came out of activities this evening and was sitting in her doorway moaning and pointing…

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, it was determined that the facility staff failed maintain a comfortable and homelike environment for one of 47 residents in the survey sample, Resident # 85. The facility staff failed to maintain Resident # 85's over-the-bed-table was in good repair. The findings include: Resident # 85 was admitted to the facility on [DATE] and a readmission of 04/08/2019 with diagnoses that included but were not limited to chronic obstructive pulmonary disease [1], chronic kidney disease [2] and anxiety [3]. Resident # 85's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/02/19, coded Resident # 85 as scoring a nine on the brief interview for mental status (BIMS) of a score of 0 - 15, nine - being moderately impaired of cognition for making daily decisions. On 10/22/19 at approximately 12:45 p.m., and 2:45 p.m., Resident # 85's over-the-bed-table was observed. The edges were chipped and peeling, the trim…

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 the abuse policy for immediately reporting an allegation of abuse to the state agency for one of 47 residents in the survey sample, Resident #33. The facility staff failed to report an allegation of abuse from Resident #33 to the state agency immediately and or within the required two hours after learning of the allegation. The findings include: A review of the facility policy, Protection of Residents; Reducing the Threat of Abuse and Neglect, revealed, in part, the following: Reporting and Response .All associates are mandated to immediately report suspected resident abuse and/or neglect to their immediate supervisor and/or facility representative. All alleged or suspected violations involving mistreatment, abuse, neglect, injuries of unknown origin .will be immediately reported to the administrator and/or director of nursing .Facilities must ensure that all alleged…

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 report an allegation of abuse to the state agency in a timely manner for one of 47 residents in the survey sample, Resident #33. The facility staff failed to immediately report an allegation of abuse from Resident #33 to the state agency after learning of the allegation. The findings include: Resident #33 was admitted to the facility on [DATE] with diagnoses including, but not limited to recent right great toe removal, diabetes, and heart failure. He was discharged on 10/18/19. On the most recent MDS (minimum data set), an admission assessment with an assessment reference date of 817/19, Resident #33 was coded as being moderately impaired for making daily decisions, having scored nine out of 15 on the BIMS (brief interview for mental status). A review of a Facility Reported Incident (FRI) report related to Resident #33 revealed, in part, the following: Report date: 10/8/18 .Incident…

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 evidence the required information was provided to the receiving hospital on transfer for one of 47 residents in the survey sample, Residents #36. The facility staff failed to evidence what, if any, paperwork and information was provided to the receiving facility upon Resident #36's transfer to the hospital on 8/10/19. The findings include: Resident #36 was admitted to the facility on [DATE]. readmitted on [DATE], with the diagnoses of but not limited to atrial fibrillation, chronic kidney disease, anxiety disorder, spinal stenosis, and intervertebral disc degeneration of the lumbar region. The significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/20/19 coded the resident as being cognitively intact in ability to make daily life decisions. A review of the clinical record revealed a nurse's note dated 8/10/19 that documented, Resident complained of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to evidence that written notification of a hospital transfer was provided to the Resident Representative and/or Ombudsman, for three out of 47 residents in the survey sample, Residents #36, #31, and #99. The facility staff failed to evidence that written notification of a hospital transfer was provided to Resident #36 and/or Resident Representative and the Ombudsman, for a hospital transfer on 8/10/19. The facility staff failed to evidence written notification of discharge was provided to the ombudsman and the resident or resident's representative for a facility-initiated transfer to the hospital of Resident #31on 10/11/2019 and Resident #99 on 8/7/19. The findings include: 1. Resident #36 was admitted to the facility on [DATE]. readmitted on [DATE], with the diagnoses of but not limited to atrial fibrillation, chronic kidney disease, anxiety disorder, spinal stenosis, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and facility document review it was determined facility staff failed to evidence that written bed hold notice was provided to the resident or resident's representative for a facility-initiated transfer for two of 47 residents in the survey sample, Resident #31 and Resident #99. The facility staff failed to evidence that written bed hold notice was provided to Resident #31 or the resident's representative for a facility-initiated transfer of the resident on 10/11/2019 and to Resident #99 or the resident's representative when the resident was discharged to the hospital on 8/7/19. The findings include: 1. Resident #31 was admitted to the facility on [DATE]. readmitted on [DATE] with diagnoses that included but were not limited to chronic respiratory failure (1) and traumatic brain injury (2). Resident #31's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 08/09/19, coded Resident #31 in a persistent vegetative state/no discernible…

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 that the facility staff failed to develop and implement the comprehensive plan of care for three of 47 residents in the survey sample, Residents #44, #20, and #50. The findings include: 1. The facility staff failed to implement Resident #44's comprehensive care plan to look at and loosen a physical restraint per physician orders every 30 minutes. Resident #44 was admitted to the facility on [DATE]. readmitted on [DATE] with diagnoses including, but not limited to history of a stroke, obstructive uropathy (1) and dementia with behaviors (2). On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of 9/3/19, Resident #44 was coded as being severely cognitively impaired for making daily decisions, having scored five out of 15 on the BIMS (brief interview for mental status). He was coded as having an indwelling catheter in his bladder, and as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview and facility document review it was determined facility staff failed to accurately revise the care plan for two of 47 residents in the survey sample, Resident #31. The facility staff failed to review and revise the comprehensive care plan upon readmission to the facility for Resident #31 to address the discontinuation of oxygen and for #23 to address the use of a spirometer. The findings include: 1. The facility staff failed to revise the comprehensive care plan for Resident #31 after a readmission on [DATE] to address the discontinuation of oxygen. Resident #31was admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses that included but were not limited to chronic respiratory failure (1) and traumatic brain injury (2). Resident #31's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 08/09/19, coded Resident #31 in a persistent vegetative state/no discernible consciousness. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, resident interview and facility document review it was determined facility staff failed to follow professional standards of care for transcribing orders from the discharge after visit instructions received from the hospital for one of 47 residents in the survey sample, Resident #23. The facility staff failed to transcribe the order for hourly incentive spirometer use while awake for Resident #23 as documented on the After Visit Summary received from [Name of Hospital]. The findings include: Resident #23 was admitted to the facility on [DATE] with a readmission on [DATE], with diagnoses that included but were not limited to sepsis (1), and orthopedic (2) aftercare. Resident #23's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 08/03/19, coded Resident #23 as scoring a 14 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 14- being cognitively intact for making daily decisions. On 10/22/19 at approximately 2:30…

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 facility document review, it was determined that facility staff failed to provide care and services for an indwelling catheter to prevent urinary tract infections for one of 40 residents in the survey sample, Residents # 49. The facility staff failed to maintain Resident # 49 catheter tubing off the floor while he was sitting in his wheelchair. The findings include: Resident # 49 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Parkinson's disease [1], obstructive and reflux uropathy [2] and anxiety [3]. Resident # 49's most recent MDS (minimum data set), an quarterly assessment with an ARD (assessment reference date) of 09/06/19, coded Resident # 49 as scoring a four on the brief interview for mental status (BIMS) of a score of 0 - 15, four - being severely impaired of cognition for making daily decisions. Resident # 49 was coded as requiring extensive assistance of one staff member for all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, resident interview and facility document review it was determined facility staff failed to provide respiratory services consistent with professional standards of practice, the comprehensive person-centered plan for one of 47 residents in the survey sample, Resident #23. The facility staff failed to provide the incentive spirometer (1) treatments every hour while awake as ordered on the After Visit Summary from the hospital upon readmission to the facility for Resident #23. The finding include: Resident #23 was admitted to the facility on [DATE] with a readmission on [DATE], with diagnoses that included but were not limited to sepsis (2), and orthopedic (3) aftercare. Resident #23's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 08/03/19, coded Resident #23 as scoring a 14 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 14- being cognitively intact for making daily decisions. The document Discharge…

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 the facility staff failed to store controlled substances per regulations in one of two observed medication storage rooms, the willow medication storage room. The facility staff failed to store controlled substances in a separately locked, permanently affixed compartment. The findings include: On 10/23/19 at 10:45 a.m., observation of a medication refrigerator in the willow unit medication storage room was conducted, accompanied by LPN (licensed practical nurse) #2. LPN #2 unlocked the medication refrigerator. The following was observed inside the medication refrigerator: - Two bottles of lorazepam intensol (1) solution inside of a separately locked compartment that was unlocked. - Three bottles of lorazepam intelsol solution on a shelf on top of the separately locked compartment. - The separately locked compartment was attached/under the refrigerator shelf that could be completely removed from the refrigerator. Other medications such as insulin were also stored in the refrigerator. On 10/23/19…

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

Based on observation, staff interview, and facility document review it was determined facility staff failed to serve and store food in a sanitary manner. The facility staff failed to document an opened date on dry goods in the kitchen and discard thickened tea past its use by date in the stand-up refrigerator. The findings include: On 10/22/19 at approximately 12:30 p.m., an observation of the facility's kitchen was conducted with OSM (other staff member) #7, the dietary manager. Observation of the dry food storage area revealed an opened 16-ounce bag of miniature marshmallows approximately one-half full. Observation of the bag failed to evidence an opened or use by date. OSM #7 stated that the bag should have been dated when opened. OSM #7 removed the bag from the dry storage area. Further observation of the kitchen area revealed a double door stand up refrigerator, which contained a 46-ounce carton, labeled honey like consistency thickened sweetened tea. Further observation of the carton revealed a date of 7/3/19 written in black marker and a yellow stick-on note attached to the…

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

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 maintain an accurate clinical record for two of 47 residents in the survey sample, Residents #67 and #12. Resident #67's Level 1 (initial) PASRR (Preadmission Screening and Resident Review) screening was coded incorrectly at the time of Resident #67's admission on [DATE]. The facility staff failed to ensure that Resident #12's clinical record did not contain documents that belonged to another resident. The findings include: 1. Resident #67 was admitted to the facility on [DATE]; diagnoses include, but are not limited to, Parkinson's disease (1) and schizophrenia (2). On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of 9/20/19, Resident #67 was coded as being mildly cognitively impaired for making daily decisions, having scored 13 out of 15 on the BIMS (brief interview for mental status). On the admission MDS, with an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. The facility staff failed to implement infection control practices for storage of the incentive spirometer (1) Resident #23. Resident #23 was admitted to the facility on [DATE] with a readmission on [DATE], with diagnoses that included but were not limited to sepsis (2), and orthopedic (3) aftercare. Resident #23's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 08/03/19, coded Resident #23 as scoring a 14 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 14- being cognitively intact for making daily decisions. On 10/22/19 at approximately 2:30 p.m., an observation was made of Resident #23's room. Resident #23 was observed to be sitting beside the bed in a wheelchair, with the bedside table in front of her. An uncovered incentive spirometer was observed on the bedside table in front of Resident #23. The incentive spirometer was located between a foam cup with a lid and straw and a box of tissues. At this time, an interview 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.