Newport News Nursing & Rehab

Based on resident interview, staff interviews, clinical record review, and facility documentation review, the facility failed to provide proper notification of a resident room transfer for one of 46 residents (resident #13). The facility failed to give Resident #13 proper notification of room transfers 10 of 14 times and have documentation of notification of room transfers. The findings included:On 03/3/2026 at 2:00 PM, an interview with Resident #13 (R13) was conducted and R13 said, The facility moved me to this room from my previous room without notification. The staff put all of my belongings on the bed and wheeled me into this room. They wanted to fix up my previous room. On 3/6/2026 at approximately 11:35 AM a staff interview was conducted with the Director of Social Work (DSW) and the Assistant Social Worker (ASW). The DSW and ASW were asked to provide evidence that R13 was provided with notification prior to a room change on 8/12/2025. Neither could find documentation of notification to R13 for a room transfer. On 3/10/2026 at 9:00 AM, an interview was conducted with the DON…

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, and review of facility documents, the facility staff failed to prevent the employment of a person who has been convicted of a barrier crime, which disqualifyed the employee from employment in a nursing home for one of twenty-five employees reviewed (certified nursing assistant #3- CNA #3). The findings included: The facility staff permitted a Certified Nursing Assistant (CNA #3) to provide direct care to residents with unrestricted and unsupervised access despite the employee having a conviction for a barrier crime, which prohibits employment in a long-term care facility under regulatory requirements.On 3/6/26 at 11:55 AM, while completing a review of employee records it identified that Certified Nursing Assistant (CNA) #3's Commonwealth of Virginia Department of State Police criminal history and sex offender record read in part: 08/28/2023 Guilty - Felony 18.2 - 474.1 Jail: Delivery of Drugs to Prisoner.On 3/6/26 at 11:56 AM ,an interview was conducted with the Administrator in Training and the Human Resource Coordinator. The findings of CNA…

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 documentation review and clinical record review, the facility staff failed to accurately code an MDS (minimum data set) assessment for one Resident (Resident #113) in a survey sample of 46 Residents. The findings included:For Resident # 113, the facility staff failed to code a Stage 4 pressure ulcer on a discharge Minimum Data Set Assessment.Resident #113 was admitted to the facility on [DATE] with diagnoses that included but were not limited to pathological fracture of right femur, a history of malnutrition, B 12 deficiency, adult failure to thrive, need for assistance with personal care, difficulty in walking, lack of coordination and unsteadiness on feet. The most recent Minimum Data Set (MDS) assessment was an admission assessment with an Assessment Review Date of 5/20/2023. The MDS coded the BIMS (Brief Interview for Mental Status as 7 out of 15, indicating severe cognitive impairment. Resident # 113 required assistance with ADLs (Activities of Daily Living.) According to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan for three of forty-six residents in the survey sample (Residents #9, #72 and #113).The findings include:1. Resident #9's plan of care was not revised to include current interventions for pressure ulcer prevention. Resident #9 (R9) was admitted to the facility with diagnoses that included COPD (chronic obstructive pulmonary disease), sacral pressure ulcer, bipolar disorder, benign prostatic hyperplasia, orthostatic hypotension, schizotypal disorder, chronic kidney disease, ichthyosis, anemia, dementia, hip fracture, psychotic disturbance, mood disorder and protein-calorie malnutrition. The minimum data set (MDS) dated [DATE] assessed R9 with severely impaired cognitive skills. R9's clinical record documented that the resident had a sacral pressure ulcer that was healed as of 12/1/25. Current physician orders for prevention of pressure ulcers included pressure relief cushion…

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 interview and facility record reveiw the facility staff failed to provide services that meet professional standards of quailty for one resident (Resident #121-R121) in a survey sample of 22 residents.The findings included:For R121 the facility staff failed to ensure all medications were taken and consumed by the resident prior to leaving the room.R121 was admitted to the facility on [DATE] with diagnoses that included but were not limited to multiple sclerosis, opioid dependence, hypertensive heart disease and history of stroke. R121's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 4/9/26 coded R121 as having a BIMS (Brief Interview of Mental Status) score of 14 out of 15 indicating no cognitive impairment. R121's MDS also coded the resident as needing partial to moderate assistance with most ADL activities including transfers, toileting, bathing, dressing and grooming.On 4/47/26, a review of the clinical record revealed the following note: 4/25/26 10:30 am - Nurse went to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, and clinical record review, the facility staff failed to provide assistance with activities of daily living for one resident (Resident #117-R117) in a survey sample of The findings included.The facility staff failed to provide assistance to Resident #117, who required assistance with eating her breakfast until it had sat in front of the resident and gotten cold. Resident #117 was most recently readmitted to the facility on [DATE]. The Resident's diagnoses included; Cerebral palsy, left sided hemiplegia, Aphasia, stroke, malnutrition, dysphagia, contractures of upper extremities, lack of coordination, and dementia.The most recent MDS (Minimum Data Set federal assessment) was most recently completed as an annual assessment with an Assessment Reference Date (ARD) of 3-13-26. The assessment described the Resident with a Brief Interview for Mental Status (BIMS) score of unable to complete, indicating severe cognitive impairment. The Resident required extensive to fully…

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 documentation review, the facility staff failed to ensure care and services met professional standards of practice to meet the physical, mental and psychosocial needs of two residents (Resident # 115 and Resident #107) in a survey sample of 46 residents.Findings included:For Resident # 115, the facility staff failed to identify, recognize and assess risk factors for prescribing and administering medications to which the resident was documented as being allergic. There was a reported history of allergies to medications that were prescribed for Resident # 115 and did not ensure medications were administered as ordered. Resident #115 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: multiple myeloma, Diabetes with Diabetic chronic kidney disease, chronic obstructive pulmonary disease, atrial fibrillation, acute cystitis with hematuria, acute posthemorrhagic anemia, and hemorrhage of the anus and rectum. The most…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to provide respiratory care, consistent with professional standards of practice, for 2 Residents (Residents # 11 and # 68) in a survey sample of 46 Residents.The findings included:1.For Resident # 11, the facility staff failed to change oxygen tubing weekly. The tubing was dated 2/18/2026.Resident # 11 was admitted to the facility on [DATE] with the diagnoses of, but not limited to: congestive heart failure, hypertension, diabetes and renal disease.The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 12/22/2025. Resident # 11's BIMS (Brief Interview for Mental Status) Score was 14 out of 15, indicating no cognitive impairment.Review of the electronic clinical record was conducted on 3/3/2026 to 3/10/2026. During the initial tour of the facility on 3/3/2026, the date on the tubing on the oxygen concentrator was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinical record review, and facility documents, the facility staff failed to ensure dialysis communication logs were completed for one of 46 residents in a survey sample. The Findings Include: Resident #3 (R3) did not have dialysis communication logs completed. R3 diagnoses included, end stage renal disease with dialysis, diabetes, major depression, and kidney failure. The most recent MDS (minimum data set) was a quarterly 2/16/26 and indicated R3 was cognitively intact. Review of R3's physician orders indicated R3 goes to dialysis three days per week. Review of R3's facility/dialysis communication logs/assessments were reviewed and revealed only one dialysis assessment dated [DATE] had been completed.On 3/05/2026 at 10:08 a.m. license practical nurse (LPN #4) was interviewed. LPN #4 verbalized that R3 had recently been admitted to the hospital, and the hospital didn't send the communication book back with R3. It was pointed out that there was missing documentation of a communication…

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 documentation review, the facility staff failed for 1 resident (Resident #107) to provide significant medications during a loss of the electronic healthcare records (EHR) software system of the 40 Residents in the survey sample. The findings included:Resident #107 was admitted to the facility on [DATE], and discharged on 4-14-25 with diagnoses to include but not limited to; osteoarthritis, and left knee artificial joint replacement with instability, constipation, hypertension and macular degeneration. The Resident used a walker for ambulation.On 3-6-26 at approximately 11:00 A.m. the Resident was contacted and interviewed. The Resident stated she was placed in an adult brief because staff told her we can't come walk you to the bathroom every time. She further stated that she missed my pain meds for days, and stated I had to get out of there, it was horrible.The admission nursing assessment record revealed that the Resident was…

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

Based on observation, staff interview, and resident interview, the facility staff failed to provide food in accordance with the physician's order for one of 46 residents in the survey sample. The Findings Include: Resident #23 (R23) did not get yogurt as ordered by the physician. On 3/3/2026 at 3:00 p.m. R23 was interviewed regarding food. R23 verbalized food concerns not getting what is ordered and food being cold at times. R23 went on to say that she does a lot of her own grocery shopping and prefers it that way. Review of R23's diet order indicated a regular diet with regular liquids and is to be served two yogurts for breakfast. On 3/4/2026 at 8:30 a.m. R23's breakfast was observed. The breakfast consisted of hashbrown patty, biscuits, cereal, coffee and milk. R23 verbalized usually only eating cereal and would not be eating the hashbrown or biscuit. When asked about getting yogurt the R23 said that she used to get yogurt, but since the new company has taken over, she no longer receives yogurt but would like it. On 3/4/2026 at 8:35 a.m. certified nursing assistant (CNA #7)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, record reviews, and facility document review, the facility staff failed to follow established infection control practices in the storage of respiratory equipment and the administration of medications in a sanitary manner to prevent contamination for 3 residents in a survey sample of 46 residents. (Residents #18, 40, 21).Findings included:1.For Residents #18, the facility staff failed to store unused respiratory equipment in a sanitary manner to prevent contamination. Resident #18 was originally admitted on [DATE] and readmitted on [DATE] after a brief hospitalization for treatment of acute on chronic hypoxic respiratory failure and fluid overload secondary to congestive heart failure. Her diagnoses included but are not limited to chronic obstructive pulmonary disease with acute exacerbation, hypertensive heart disease with heart failure, obstructive sleep apnea, morbid obesity with alveolar hypoventilation, type 2 diabetes mellitus, cocaine abuse, and chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and review of facility documents, the facility staff failed to administer a medication per physician order for one of nine residents, (Resident #8) in the survey sample. The findings included: Resident #8 was admitted to the facility on [DATE] after an acute care hospital stay. The diagnoses included syncope, seizure disorder, diabetes mellitus (DM), alcohol dependence, and human immunodeficiency virus disease (HIV). The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/31/23, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #8 cognitive abilities for daily decision making were intact. In section I(active diagnosis) the resident was coded for seizure disorder. An interview was conducted with Licensed Practical Nurse (LPN) #1, on 11/6/24 at approximately 1:04 PM. LPN #1 stated that she was not able to give Resident #8 his Keppra…

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

Based on resident interview, staff interview, clinical record review, and review of facility documents, the facility staff failed to protect a resident from leaving the premises or a safe area without the facility's knowledge and supervision for 1 of 9 residents (Resident #4) in the survey sample. The findings included: Resident #4 was originally admitted to the facility 5/4/23. The resident's diagnoses included unspecified dementia, cognitive communication deficit, anxiety disorder, peripheral vascular disease, and type 2 diabetes mellitus. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/11/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring (-) out of a possible 15. An interview was conducted on 11/7/24 at 3:47 PM with the MDS Coordinator. The MDS Coordinator stated that the (-) means the Brief Interview for Mental Status (BIMS) was not completed. The MDS Coordinator also stated that this was due to the Social Services Department not completing the interview. The MDS Coordinator also voiced that…

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

Based on facility record review, the facility staffed failed to have an Administrator present for a quarterly quality assurance performance improvement (QAPI) meeting. The findings included: The facility's attendance sheet for the quarterly QAPI meeting dated 9/24/2024, was missing evidence of an Administrator being present. An interview was conducted with the Regional [NAME] President of Operations (RVPO) on 11/7/2024 at approximately 11:20 AM. The RVPO said that he had been functioning as the facility's Administrator since the previous administrator left a few weeks ago. The RVPO shared a copy of the facility's quarterly QAPI meeting sign in sheet for 9/24/24. After it was noted that there was no Administrator's signature, the RVOP was asked if he was sure this was a quarterly meeting and he responded, yes. The facility's policy titled Quality Assurance Performance Improvement Program effective on 11/30/2014, revised on 10/24/22, list the Executive Director (Administrator) as one of the four members who must be present on the QAPI committee. On 11/7/24 at approximately 3:15 PM,…

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

Based on observations, facility documentation, staff and resident interviews, the facility staff failed to ensure menus were followed. The findings included: During the dinner meal observation on 08/28/22 at 3:28 PM ( kitchen tour) the dinner - meal included: spaghetti and meat sauce, squash, dinner rolls, and chocolate pudding with whip topping for deserts. Alternate menu included- vegetable soup, deep fried fish which was served during the lunch menu as (lemon pepper fish fillet), and mashed potatoes. Beverages included ice tea, and milk. The week -4 master menu indicated: Dinner- chicken tenders, creamy gravy, french fries, tossed salad with dressing, biscuit, vanilla ice cream, milk and tea of choice. Alternate menu included: hamburger steak with grilled onions, brown gravy, buttered noodles and whole kernel corn. During the lunch meal observation at 11:18 a.m. on 8/30/22 the meal consisted of chicken thighs, noodles, green beans, loaf of bread slices (2) chocolate pudding for desert. The alternate menu included meat loaf which was served during the Monday's lunch menu, mash…

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, and staff interview the facility staff failed to store and serve food under sanitary conditions. The findings included: During the kitchen observations at 3:28 P.M. on 08/28/22 the ice machine was observed to be leaking water. Towels with brown stains were observed under the ice machine. An open package of Lance cheese crackers was observed on the counter under the micro wave oven. A hole was observed in the drain line of the three compartment sink. A large plastic pan measuring approximately 14 inches wide by 22 inches long was observed catching drained waste water. Ice build-up was observed on the kitchen floor leading from the walk-in freezer. Ice build-up was observed on the freezer door seals. Ice build-up was observed on the floor inside the freezer. The freezer door was observed to have a bend in the middle of the door seal. The base board at the hand washing sink was observed to have a four inch by six inch long hole with exposed plaster coming off. The wall at the two compartment sink was observed to have an estimated four feet long by four inch wide…

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 and clinical record review the facility staff failed to provide personal care to include showers for 2 of 38 residents (Resident #41 and #15) in the survey sample who was unable to independently carry out activities of daily living (ADL's). The findings included: 1. The facility staff failed to ensure Resident #41 received showers on a routine basis. Resident #41 was admitted to the facility on [DATE]. Diagnoses for Resident #41 included but not limited to obesity and Chronic Obstructive Pulmonary Disease (COPD). Resident #41's Minimum Data Set (MDS-an assessment protocol) a quarterly assessment with an Assessment Reference Date of 07/07/22 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. The MDS coded Resident #41 total dependent of one with bathing, extensive assistance of two with transfer, extensive assistance of one with toilet use, limited assistance of one with bed…

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 the facility staff failed to have on duty sufficient nursing staff to provide nursing services to include showers during the 3:00 p.m.-11:00 p.m. shift. The findings included: On 8/28/22 at 4:20 p.m. an interview was conducted with Certified Nursing Assistant (CNA) #6 regarding Resident showers. CNA #6 stated, Showers are not getting done on 3-11 because of us being short staffed. We have been working short and we having been trying to do all we can for the residents. On 8/28/22 at 5:00 p.m. an interview was conducted with CNA #7 regarding Resident showers. CNA #7 stated, I normally work 3-11 and showers are not getting done because of us being short staffed. On 8/31/22 at 2:40 p.m. an interview was conducted with CNA #8 regarding Resident showers. CNA #8 stated, I work over to help 3-11 because we are short staffed. By the time you make rounds, help with meals, and get the residents in bed there is no time for showers. An interview was conducted with Certified Nursing Assistant (CNA) #3 on 08/30/22 at approximately 5:06 p.m. The CNA stated when the…

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

Based on clinical record review, staff interview, and review of the facility's policy the facility staff failed to ensure a resident didn't receive an unnecessary psychotropic medication for 1 of 38 residents (Resident #26), in the survey sample. The facility's staff failed to ensure Resident #26 did not receive as needed Xanax for greater than 14 days without the physician and/or prescribing practitioner evaluating the resident for the appropriateness of continuous as needed use. The findings included: Resident #26 was originally admitted to the facility 11/18/2014 and the resident had never been discharged from the facility. The current diagnoses included; dementia, a-fib, and high blood pressure. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/20/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 0 out of a possible 15. This indicated Resident #26's cognitive abilities for daily decision making were severely impaired. In section G (Physical functioning) the resident was coded as requiring total…

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

Based on observation and staff interviews, the facility staff failed to ensure insulin pens were labeled in accordance with currently accepted professional principles in 3 out of 5 medication carts. The findings included: On 08/31/22 at approximately 11:28 a.m., the medication cart on Meadowland Unit (cart 2) was inspected with Registered Nurse (RN) #2. Stored inside the medication cart was four (4) Lantus (insulin) pens open but without a date when open. A pharmacy sticker was observed on all the insulin pens to discard 28 days after opening. On 08/31/22 at approximately 11:34 a.m., the medication cart on Rosewood Unit (cart 1) was inspected with RN #2. Stored inside the medication cart was a Lantus (insulin) pen with an open date of 06/24/22. A pharmacy sticker was observed on the insulin pen to discard 28 days after opening. The RN stated the insulin pen should have been removed from the medication cart 28 days after being open on 06/24/22. Further inspection of the medication cart revealed an open Lantus pen but without an open date. The RN stated once the insulin pens were…

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 and staff interview, the facility staff failed to maintain all mechanical equipment in safe operating condition. The findings included: During the kitchen observation at 3:28 P.M. on 8/28/22, the facility staff failed to ensure the following mechanical equipment in the kitchen was in safe operating condition: One of the steam table sections was not operating properly and was out of use. A Project Agreement proposal dated April 25, 2022 indicated: Walk in freezer has two defective defrost heaters. Inoperative defrost termination switch. Defective evaporator coil freezer. The freezer was observed to have ice on the walk in freezer floor as well as spillage out into the kitchen floor due to the above problems identified with the walk in freezer. The temperatures were within normal range. An inoperable kitchen equipment list provided by the dietary manager dated 08/10/22 indicated: Tray line bracket inoperable. Meat slicer inoperable. Two door stand-up refrigerator inoperable. During an interview on 08/28/22 at 3:40 P.M.,the dietary manager stated, she gave 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 interviews, clinical record review and facility document review, the facility staff failed to notify the physician of two (2) missed doses of a scheduled medication Coreg (Carvedilol) 6.25 milligrams (mg) per physician's orders for 1 out of 38 residents (Resident #24) in the survey sample. The findings included: Resident #24 was admitted to the facility on [DATE]. Diagnoses included but are not limited to Congestive Heart Failure (CHF) and Coronary artery disease (CAD). Resident #24's Minimum Data Set (MDS - an assessment protocol) a quarterly assessment with an Assessment Reference Date of 06/16/22 coded Resident #24's Brief Interview for Mental Status (BIMS) scored a 13 out of a possible score of 15 indicating no cognitive impairment. The MDS coded Resident #24 requiring limited assistance of one with bed mobility, transfer, dressing, transfer, personal hygiene and bathing and supervision with limited assistance of one with eating for Activities of Daily Living (ADL) care. The care plan with 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 observation, clinical record review, and staff interviews, the facility staff failed to report to the Office of Licensure and Certification an injury of unknown origin which resulted in an edematous, black and blue right foot for 1 of 38 residents (Resident #26), in the survey sample. The findings included: Resident #26 was originally admitted to the facility 11/18/2014 and the resident had never been discharged from the facility. The current diagnoses included; dementia, a-fib, and high blood pressure. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/20/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 0 out of a possible 15. This indicated Resident #26's cognitive abilities for daily decision making were severely impaired. In section G (Physical functioning) the resident was coded as requiring total physical assistance of one person with toileting, extensive physical assistance of two plus persons with bed mobility and transfers, extensive physical assistance of one person with dressing…

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 ensure a Baseline Care Plan was developed within 48 hours upon admission for 1 of 38 residents in the survey sample, Resident #91. The facility staff failed to ensure a Baseline Care Plan was developed within 48 hours for Resident #91 who was admitted on [DATE]. The findings included: Resident #91 was admitted to the facility on [DATE] with diagnoses to include but not limited to Subarachnoid Hemorrhage, Mild Cognitive Impairment and History of Falling. Resident #91's most recent Minimum Data Set was a 5 day with an Assessment Reference Date of 8/18/22. Resident #91's Brief Interview for Mental Status was coded as a 12 out of a possible 15 indicating the resident was cognitively intact and capable of daily decision making. On 08/29/22 at 1:52 p.m. during an initial tour interview Resident #91 was asked if the facility had reviewed his baseline care plan. Resident #91 stated that he did not remember getting…

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 documentation, the facility staff failed to develop a person-centered comprehensive care plan for 1 of 38 residents (Resident #36) in the survey sample. The findings included: Resident #36 was admitted to the facility on [DATE]. Diagnoses included but are not limited to Leiomyoma (cancer) of the uterus, End Stage Renal Dialysis (requiring dialysis), Cerebral Infarction and Atrial Fibrillation (A-FIB). The most recent Minimum Data Set (MDS) was an admission assessment with an Assessment Reference Date (ARD) of 07/04/22 coded the resident on the Brief Interview for Mental Status (BIMS) 15 out of a possible score of 15 indicating no cognitive impairment. Resident #36 was coded total dependence of two with bathing and dressing, extensive assistance of two with bed mobility, transfer, toilet use and personal hygiene and supervision with limited assistance of one with eating for Activities of Daily Living (ADL) care. Review of Resident #36's care plan on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interviews, clinical record review and facility documentation review the facility staff failed to invite 2 of 38 (Resident #60 and #40) residents in the survey sample to their person-centered care plan meeting. The findings included: 1.Resident #60 was originally admitted to the facility on [DATE] and readmitted [DATE] after an acute care hospital stay. The current diagnoses included: Type 2 Diabetes Mellitus without complications and chronic obstructive pulmonary disease with acute exacerbation. The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 07/28/2022 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 00 out of a possible 15. This indicated Resident #60 cognitive abilities for daily decision making were severely impaired. In sectionG(Physical functioning) the resident was coded as requiring limited assistance of one person with bed mobility, supervision set-up help only with dressing,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, and clinical record review, the facility staff failed to assure 1 of 38 residents (Resident #14) was assisted to properly apply and seal the (continuous positive airway pressure (CPAP), and to ensure 1 of 38 residents (Resident #33)'s oxygen concentrator filter was clean and free of debris. The findings included: Resident #14 was originally admitted to the facility 4/4/22 for rehabilitation and the resident had never been discharged from the facility. The current diagnoses included; scarring related to coronary artery disease with previous bypass surgery, chronic pain syndrome secondary to chronic obstructive pulmonary disease, Long COVID-19, and obstructive sleep apnea, requiring CPAP. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/7/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #14's cognitive abilities for daily decision…

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 record review, staff interviews and facility document review the facility staff failed to ensure dialysis services to include ongoing communication with the dialysis center was in place for 1 of 38 residents in the survey sample, Resident #21. The facility staff failed to ensure dialysis services to include ongoing communication with the dialysis center was in place on Resident #21's dialysis days. The findings included: Resident #21 was admitted to the facility on [DATE] with the diagnoses to include but not limited to End Stage Renal Disease and Dependence on Dialysis. Resident #21 attends dialysis on Mondays, Wednesdays and Fridays. The most recent Minimum Data Set (MDS) was a Quarterly with an Assessment Reference Date (ARD) of 6/17/22. Resident #21's Brief Interview for Mental Status (BIMS) was a 12 out of a possible 15 which indicates the resident is cognitively intact and capable of daily decision making. Under Section O Special Treatments, Procedures, and Programs 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 observations, staff interviews, and facility document review the facility staff failed to ensure that the Nursing Staffing Information was posted daily potentially affecting all residents. The findings included: On 8/28/22 upon entrance the posted Daily Staffing Information document was observed in the front lobby and was dated 8/26/22. On 8/28/22 at 3:48 p.m. an interview was conducted with the Weekend Receptionist regarding the posted Daily Staffing Information dated 8/26/22. The Weekend Receptionist stated that she is the person responsible for updating and posting the Daily Staffing Information, however no one had left her any to post for 8/27/22 or 8/28/22. The Weekend Receptionist informed the supervisor that there been a recent change in the staff scheduler and that was the reason the staffing sheets were not available for 8/27/22 and 8/28/22. The Facility was unable to provide a policy for posting of the Daily Staffing Information when requested. On 8/31/22 at 11:17 a.m. an interview was conducted with the Director of Nursing regarding the missing Daily Staffing…

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 of medication pass and pour, staff interviews, clinical record review, and facility documentation, the facility staff failed to ensure they were free of medication error rate of 5 percent (%) or greater. During the medication observation, there were twenty-five (25) opportunities for error, two (2) medication errors were observed which resulted in a medication error rate of 8%. The resident involved in the medication error rate was Resident #24. The findings included: Resident #24 was admitted to the facility on [DATE]. Diagnoses included but are not limited to Congestive Heart Failure (CHF) and Coronary artery disease (CAD). Resident #24's Minimum Data Set (MDS - an assessment protocol) a quarterly assessment with an Assessment Reference Date of 06/16/22 coded Resident #24's Brief Interview for Mental Status (BIMS) scored a 13 out of a possible score of 15 indicating no cognitive impairment. On 08/26/22 at approximately 4:20 p.m., a medication pass and pour observation was conducted with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinical record review and facility documentation, the facility staff failed to administer two (2) doses of a significant medication Coreg (Carvedilol) 6.25 milligrams (mg) as ordered by the physician for 1 out of 38 residents (Resident #24) in the survey sample. The findings included: Resident #24 was admitted to the facility on [DATE]. Diagnoses included but are not limited to Congestive Heart Failure (CHF) and Coronary artery disease (CAD). Resident #24's Minimum Data Set (MDS - an assessment protocol) a quarterly assessment with an Assessment Reference Date of 06/16/22 coded Resident #24's Brief Interview for Mental Status (BIMS) scored a 13 out of a possible score of 15 indicating no cognitive impairment. The care plan with a revision date of 02/03/21 identified Resident #24 has altered cardiovascular status related but not limited to CHF and high blood pressure. The goal set for the resident by the staff was that the resident will be free from complications of cardiac problems.…

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 review of facility documents, the facility's staff failed to have a consistent ongoing Infection prevention and control program to include antibiotic use protocols and a system to monitor antibiotic use. The findings included: A review the Antibiotic Stewardship education book was conducted on 8/30/22 at approximately 11:20 AM., Months were reviewed from January 2022-July 2022. The following areas were missing or incomplete: March: Missing [NAME] criteria. June: Incomplete [NAME] criteria, no line listing. July: No [NAME] criteria. On 8/30/22 at approximately 11:20 AM an interview was conducted with RN (Registered Nurse) #3 concerning the Antibiotic Stewardship Program. She said the [NAME] Criteria told you what the infection is and whether it met the criteria for surveillance, and it showed trends in antibiotics. Moving forward, I will finish the [NAME] criteria and line listings every month. In March 2009, members of the Society for Healthcare…

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 review of facility documents, the facility's staff failed to have an Infection Preventionist to work on a part-time basis and failed to complete specialized training in infection prevention and control. The findings included: On 8/29/22 at approximately 10:45 AM., an interview was conducted with RN #3 (Infection Preventionist/IP). She stated, I only work here prn/as needed. I only do the Antibiotic Stewardship portion. On 8/30/22 at approximately 12:05 PM an interview was conducted with the IP concerning her Infection Preventionist Certification. She stated that she completed her certification a few years ago but is not able to retrieve her certificate at this time. On 08/31/22 at approximately 4:30 PM., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, and clinical record review, the facility staff failed to provide documentation in the resident's clinical record of the influenza vaccine administration and or the pneumococcal vaccine or the refusal/declinations of vaccines for 2 of 38 residents (Resident #21 and Resident #74), in the survey sample. The findings included: 1.Resident #21 was originally admitted to the facility 08/13/2018 and readmitted on [DATE]. The current diagnoses included; DEPENDENCE ON RENAL DIALYSIS and TYPE 2 DIABETES MELLITUS WITH DIABETIC CHRONIC KIDNEY DISEASE. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 06/17/2022 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #21's cognitive abilities for daily decision making were moderately impaired. A review of Resident #21's clinical record revealed that he was offered the Influenza vaccine but declined on 10/23/2019. No recent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to inform three Residents of a COVID-19 Positive case on 8/24/22 and failed to inform 1 Resident of his COVID-19 test results. (Resident #11, Resident #60 Resident #76), in the survey sample. The findings included: 1. For Resident #11 the facility staff failed to notify her of a COVID-19 positive notification on 8/24/22. Resident #11 was originally admitted to the facility on [DATE]. The resident has never been discharged from the facility. The current diagnoses included; FIBROMYALGIA and MUSCLE WEAKNESS (GENERALIZED). The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 06/02/2022 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #11 cognitive abilities for daily decision making were intact. In sectionG(Physical functioning) the resident was coded…

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 review of facility documents, the facility staff failed to manage an effective pest control program for 1 of 38 residents (Resident #11), in the survey sample. The findings included: Resident #11 was originally admitted to the facility 11/15/2018. The resident has never been discharged from the facility. The current diagnoses included; FIBROMYALGIA and MUSCLE WEAKNESS (GENERALIZED). The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 06/02/2022 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #11 cognitive abilities for daily decision making were intact. In sectionG(Physical functioning) the resident was coded as requiring supervision one person assist with bed mobility, eating and dressing, supervision set-up help with transfers, toilet use, personal hygiene and bathing. On 08/30/22 at approximately 1:00 PM., during an…

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

Based on review of Facility documentation, the facility failed to provide the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. The findings included: A review of the facility as-worked staffing documentation revealed that on the date of 08/16/2019, there was no coverage provided by a RN (Registered Nurse) within a 24-hour time-frame. An interview with the Director of Nursing (DON) on 01/27/2020 at approximately 6:30 p.m. when asked about RN coverage for 8/16/2019 the DON responded, I agree that there was no RN coverage documented for 8/16/2019. These findings were reviewed with the facility Administrator during a meeting on 01/28/2020 at approximately 4:30 p.m. No further information was provided prior to exit.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview the facility failed to develop/complete a baseline care plan within 48 hours of a resident's admission for 4 of 43 residents in the survey sample, Residents # 61, #78, #348 and #351. The findings include: 1. Resident #61 was admitted to the facility on [DATE] with diagnoses to include but not limited to, end stage renal disease requiring hemodialysis three times a week. The admission MDS (Minimum Data Set) with an assessment reference date of 1/8/20 coded the resident a 15 out of a possible 15 on the Brief Interview for Mental Status indicating the residents cognition was intact. Review of the clinical record evidenced a Baseline Care Plan and Summary dated 1/2/20. The document was not completed as the Orders and Services failed to include dialysis services. The section for nurse and resident signatures and dates of those participating in the initial baseline care plan development were blank. On 1/27/20 at 5:15 p.m., the Director of Nursing was asked to review…

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

Based on observations, facility documentation review, and staff interviews, the facility kitchen staff failed to ensure that food was stored, labeled, and served under sanitary conditions. The findings included: During an initial inspection of the facility kitchen occurring on 01/26/2020 at approximately 11:21 a.m., the following was observed: 1. Partially covered Salisbury steak in the refrigerator. 2. No dates for 2 rolls of raw hamburger stored in the refrigerator. 3. No use by dates for milk stored and purposed for fluid restriction diets. 4. No use by dates for thickener stored in the refrigerator. 5. Undated, dried noodles in the storage room. During an interview on 01/26/2020 at approximately 12:00 p.m. with the Dietary Manager yielded, We just hired another cook, he has not been here that long. He should have known better. During an interview on 01/28/2020 at approximately 1:53 p.m. with the Dietary Manager, the Dietary Manager stated, Once staff open items, they are supposed to label and date items. I agree with you regarding the items discovered unlabeled and not covered.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview the facility failed to ensure 3 of 43 residents in the survey sample on admission had an advance directive or determined the residents wish to formulate an advance directive, Residents #61, #78 and #348. The findings included: 1. Resident #61 was admitted to the facility on [DATE] with diagnoses to include but not limited to end stage renal disease requiring hemodialysis three times a week. The admission MDS (Minimum Data Set) with an assessment reference date of 1/8/20 coded the resident with a score of 15 out of a possible 15 on the Brief Interview for Mental Status indicating the resident's cognition was intact. A review of the Advance Directives Discussion Document dated 1/2/20 was not completed. The section that allows for the resident to indicate whether they possess any of the following: Advance Directive, Health Care Agent, Conservator of Person, Living Will, or Durable Power of Attorney was blank. There was no documentation in the clinical record that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, facility document review and during the course of a complaint investigation, the facility staff failed to notify the physician and Resident Representative after an unwitnessed fall for 1 of 43 residents in the survey sample, Resident #350. The findings include: Resident #350 was admitted to the facility on [DATE] with diagnoses to include cerebrovascular disease, diabetes, unspecified abnormalities of gait, mobility, and muscle weakness. Approximately 48 hours later the resident was sent to the emergency room (ER) on 4/6/19 and admitted . The facility Admission/readmission Data Collection document dated 4/4/19 assessed the resident as arriving to the facility at 5:30 p.m., oriented to person, usually makes self understood, understands, pleasant and content, no obvious behaviors, required one person assist with bed mobility, transfers, ambulation with use of a walker. Section N3. Fall Risk identified the resident did not have a history of falls in the last 30 to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that facility staff failed to evidence that an Advanced Beneficiary Notice was issued to one of 43 residents in the survey sample, Resident #92. The findings included: Resident #92 was admitted to the facility on [DATE] with diagnoses that included but were not limited to, diabetes mellitus type one. Resident #92's most recent MDS (minimum data set) assessment was an admission MDS assessment with an ARD (assessment reference date) of 6/12/19. Resident #92 was coded as being intact in cognitive function scoring 15 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #92's census report revealed that she became long term care under Medicaid Pending on 6/25/19. Review of Resident #92's clinical record revealed a note from social services dated 6/25/19 that documented the following: SW (social work) spoke with daughter regarding skilled nursing services ending on 6/24/19. In…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews and facility document review the facility failed to notify the State Long-Term Care Ombudsman of a facility discharge for 1 of 43 residents in the survey sample, Resident #94. The findings included: Resident #94 was admitted tot he facility on 11/05/19 with diagnoses to include but not limited to, Acute Kidney Failure and Vascular Dementia. The most recent Minimum Data Set (MDS) was a Discharge Assessment-return not anticipated with an Assessment Reference Date (ARD) of 11/25/19. Under Section A0310 G. Type of discharge Resident #94 was coded as 1 (Planned). Under Section A2000 discharge date Resident #94 was coded as 11-25-2019. Under Section A2100 Discharge Status Resident #94 was coded 01 (Community). Resident #94's Discharge Plan and Instructions document dated 11/25/19 was reviewed and is documented in part, as follows: Summary of discharge: g. Date and time of discharge: [DATE] 12:00. h. Your Discharge Destination: 4. Other h1. Describe Other: Home with home…

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. The facility staff failed to revise the Comprehensive Care Plan for Resident #61 to include dialysis three times a week scheduled on Mondays, Wednesdays and Fridays. Resident # 61 was admitted to the facility on [DATE] with diagnoses to include but not limited to end stage renal disease requiring hemodialysis three times a week. The admission MDS (Minimum Data Set) with an assessment reference date of 1/8/20 coded the resident scored a 15 out of a possible 15 on the Brief Interview for Mental Status indicating the residents cognition was intact. Review of the Comprehensive Care Plan failed to evidence a revision of the comprehensive person-centered plan of care for the resident's hemodialysis treatments three times a week. On 1/27/20 at 10:00 a.m., Resident #61 was at the dialysis center receiving treatment. On 1/27/20 at 5:15 p.m., the Director of Nursing was asked if comprehensive care plan should have been revised to include a dialysis care plan, she stated, Yes, there should have been a care plan 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 documentation review and clinical record review the facility staff failed to meet professional standards of practice for transcribing physician orders for 1 of 43 residents in the survey sample, Resident #192. The findings included: Resident #192 was admitted to the facility on [DATE]. Diagnoses included but were not limited to, Malignant Neoplasm of Larynx, unspecified and Dysphagia following other Cerebrovascular Disease. Resident #192's admission Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of 01/15/2020 coded Resident #192 with a BIMS (Brief Interview for Mental Status) score of 12 indicating moderate cognitive impairment. On 01/27/2020 at approximately 3:30 p.m., review of Resident #192's clinical record revealed the following: Order Summary Report dated with Active Orders As Of: 01/27/2020 revealed an order for Respiratory: Suction as needed with an order date of 01/09/2020; and an order for Trach care as needed with an order date 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 observations, medical record review, staff interviews and facility document review the facility failed to ensure a verbal telephone order for the discontinuation of an indwelling Foley catheter was written and transcribed at the time of the order on 1/26/20, for 1 of 43 resident's in the survey sample, Resident #21. The findings included: Resident #21 was admitted to the facility on [DATE] with diagnoses to include but not limited to, Malignant Neoplasm of Parotid Gland and Benign Prostatic Hyperplasia. Resident #21's most recent comprehensive Minimum Data Set (MDS) was a Significant Change with an Assessment Reference (ARD) of 1/6/2020. The Brief Interview for Mental (BIMS) was a 14 out of a possible 15 which indicates that Resident #21 was cognitively intact and capable of daily decision making. Under Section H Bladder and Bowel Resident #21 was coded as having an indwelling (urinary) catheter. On 1/26/20 at 1:30 P.M. Resident #21 was observed in bed with no visible indwelling catheter. On 1/27/20 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility document review the facility staff failed to ensure 1 of 43 residents in the survey sample received the appropriate care and services for the management of a PICC line, Resident #348. A PICC line is a peripherally inserted central catheter, a form of intravenous access that can be used for a prolonged period of time (e.g., for extended antibiotic therapy). The findings include: Resident #348 was admitted to the facility on [DATE] with diagnoses to include but not limited to, sepsis due to methicillin resistant staphylococcus aureus. The admission MDS with an assessment reference date of 1/16/20 coded the resident as scoring a 15 out of a possible 15 on the Brief Interview for Mental Status indicating the residents cognition was intact. Section O. Special Treatments, Procedures, and Programs indicated the resident was receiving IV medications. The physician orders dated 1/10/20 were for PICC dressing change every Monday evening shift 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 observation and staff interview, the facility staff failed to ensure that the garbage disposal area was free from debris and refuse. The findings included: During an initial inspection of the facility's disposal dumpsters occurring on 01/26/2020 at approximately 12:30 p.m., debris to include paper and plastic soda bottles were discovered around the garbage disposal dumpsters. During an interview on 01/26/2020 at approximately 12:30 p.m. with the Dietary Manager, the Dietary Manager stated We are supposed to check the area daily. During an interview on 01/28/2020 at approximately 1:53 p.m. the Dietary Manager stated, Normally we check dumpsters everyday. I will meet with my cooks to direct them to keep dumpster area clean. Facility provided policy dated 08/2017 regarding Dispose of Garbage and Refuse: All garbage and refuse will be collected and disposed of in a safe and efficient manner. Procedures: 1. The Dining Services Director coordinates with the Director of Maintenance to ensure that the area surrounding the exterior dumpster area is maintained in a manner free 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 2. The facility staff failed to ensure the Treatment Administration Record (TAR) was accurate for Resident #348's PICC dressing change date. A PICC line is a peripherally inserted central catheter, a form of intravenous access that can be used for a prolonged period of time (e.g., for extended antibiotic therapy). Resident #348 was admitted to the facility on [DATE] with diagnoses to include but not limited to sepsis due to methicillin resistant staphylococcus aureus. The admission MDS with an assessment reference date of 1/16/20 coded the resident as scoring a 15 out of a possible 15 on the Brief Interview for Mental Status indicating the residents cognition was intact. Section O. Special Treatments, Procedures, and Programs indicated the resident was receiving IV medications. The physician orders dated 1/10/20 were for PICC dressing change every Monday evening shift and to discontinue PICC at the end of antibiotic therapy and Meropenem (an antibiotic) 2 grams IV every 8 hours until 2/3/20. On 1/26/20 during…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, clinical record review and facility documentation review the facility staff failed to ensure infection control practices were followed during wound care for 1 of 43 residents in the survey sample, Resident #57. The findings included: Resident #57 was admitted to the facility on [DATE]. Diagnoses included but were not limited to, Pressure Ulcer of Sacral Region, Stage 4, Chronic Kidney Disease and Heart Failure unspecified. Resident #57's Minimum Data Set (MDS assessment protocol) with as Assessment Reference Date of 12/19/2019 coded Resident #57 with short-term memory problems, long-term memory problems and with severely impaired cognitive skills for daily decision making. In addition, the Minimum Data Set coded Resident #57 as requiring extensive assistance of 1 for toilet use, extensive assistance of 2 for bed mobility, dressing and personal hygiene and total dependence of 1 for eating. On 01/28/2020 at 10:17 a.m., Registered Nurse (RN) #2 provided wound care to 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.