Old Dominion Rehabilitation And Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure alternative measures were attempted prior to the use of side rails, educated on the risks and benefits of side rail use, and failed to obtain a consent for the side rails for one of one Resident (Resident (R)63) out of 41 sampled residents. These failures placed the resident at risk of accidents and hazards related to side rail use.Findings include:Review of R63's Census tab located in the resident's electronic medical record (EMR) revealed R63 was readmitted to the facility on [DATE]. Review of R63's Diagnoses, located in the resident's EMR under the Medical Diagnosis tab revealed R63 had diagnoses which included cerebral infarction (stroke), vascular dementia without behavioral disturbance, and acquired absence of right leg above knee. Review of R63's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 02/04/26 and located in the resident's EMR under the MDS tab revealed 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, interview, record review, and review of facility policy, the facility failed to ensure a medication error rate below five percent. During medication administration three medication errors for three residents (Resident (R) 5, R10, and R62) were made of 27 opportunities resulting in a medication error rate of 11.11 percent. These failures had the potential to increase or decrease the effectiveness of these medications.Findings include: 1. Review of R5's undated admission Record located in the electronic medical record (EMR) under the Profile tab revealed R5 was admitted to the facility on [DATE] with a diagnosis of quadriplegia, dysphasia, and contracture of muscle.Review of R5's Physician's Orders, dated 09/29/25, located in the EMR under the Orders tab revealed orders for hydralazine Hydrochloride (HCL) tablet 100 milligrams (MG) give one tablet via gastrostomy tube (G-tube) every eight hours for hypertension, metoclopramide HCL solution 5 MG/5 milliliters (ML) give 15 ML via G-tube three…

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 document review, observation, interview, and facility policy review, the facility failed to ensure one Resident (Resident (R)23) of one observed out of a total of 41 sampled residents received the meal that was posted on the menu. The facility further failed to ensure the meal that was served to R23 was pureed. This had the potential for the resident not to have nutritional needs met. Findings include:During dining observation on 02/16/26 at 12:09 PM, lunch menu posted was as follows: -Rosemary pork chop-Shepherd's pie (vegetarian)-Hot dog on bun plus catsup, mustard-Cheeseburger on bun-Chicken tenders plus honey mustard-Grilled cheese sandwich Starch:-Baked sweet potato plus cinnamon butter-French friesVegetable:-Peas & carrots-Mixed vegetables-Onion rings Bread:-Dinner roll with margarine During a dining observation on 02/16/26 at 1:33 PM, R23's tray card noted he was to receive a pureed diet to consist of:-Rosemary pork chop-Mashed sweet potatoes-Creamed spinach-Dinner roll-Chocolate chip cookie cakeR23's puree meal was not observed to be the meal listed on is tray…

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, interview, and review of the test tray, the facility failed to ensure foods were served at palatable food temperatures for three of 96 residents (Resident (R) 8, R51, and R77) who received meals from the facility's kitchen. This had potential to dissatisfaction with meals and potential weight loss. Findings include:During an interview on 02/16/26 at 12:56 PM, R8 revealed that her meal tray is the first one on the third cart but last one to be served and it is always cold.During an interview on 02/16/26 at 3:03 PM, R8 revealed that her pork chop today was so tough the head nurse could not even cut it with the fork. Everything is always over cooked.During an interview on 02/17/26 at 8:41 AM, R51 said the facility food tastes like (expletive). R51 revealed hot food is not hot, it is cold and cold items like milk are not cold, they are warm.During an interview on 02/16/26 at 11:01 AM, R77 revealed he does not each much of the facility food because it does not smell good. R77 revealed he had requested a grilled cheese sandwich that was cold when he received it. R77…

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, and staff interview the facility staff failed to ensure resident rooms were maintained in a safe comfortable and homelike environment. The findings included: Observations made on 03/03/22 at 10:43 a.m. with the Administrator and Maintenance Director, indicated in room [ROOM NUMBER] bed -A a hole was observed in the wall at the head of the bed. The hole was estimated to be 8 inches wide and 14 inches long. The hole was observed to go through the wall. In room [ROOM NUMBER] bed -B, the wall was noted to have scrapes and paint chips. In room [ROOM NUMBER] the ceiling titles in front of the bathroom were observed to have water stains and black mold like substance. In room [ROOM NUMBER] bed A wall socket covering was noted to have exposed electrical outlets. The ceiling title was observed to be not affixed at the back exit door of the [NAME] Unit were rooms 52 through 58 are located. In room [ROOM NUMBER] the window blinds were observed to be bent, the walls were observed to have scraps 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 review of facility documents, staff interview and the facility's policy; the facility staff failed to implement their abuse policy regarding the screening of employees for 25 of 25 employee records reviewed. The findings included: On 3/1/22, a list of twenty-five employee names was provided to the Administrator to obtain information regarding their attestation/sworn statement, reference checks and obtaining a criminal background check and certification/licensure if applicable. Review of twenty-five employee records revealed the following; The facility staff failed to obtain a criminal background check within 30 days of hire for twenty-three Employees. The Criminal background check request for the twenty-three employees were obtained on 3/2/22 from the Central Criminal Records Exchange of the Virginia State Police. One of the employee criminal background check provided wasn't for an employee of the facility. It was for a person with a similar name. The facility staff failed to verify that the certification of four Certified Nursing Assistants was active and in good standing…

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, the facility staff failed to have ongoing communication, coordination and collaboration with the dialysis center regarding acute changes in the resident's status for 1 of 35 residents (Resident #64), in the survey sample. The findings included: Resident #64 was originally admitted to the facility 3/25/19 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; end-stage renal disease requiring dialysis and benign prostatic hyperplasia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/23/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #64's cognitive abilities for daily decision making were intact. Section O100J was coded for receiving dialysis services and at section G (Physical functioning) the resident was coded as requiring total care of two people with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review and staff interview the facility, the failed to ensure 3 of 35 residents, Residents (#30, #55 and #6) in the survey sample was seen by the pharmacist for Medication Regimen Review (MRR) on a monthly basis. The findings included: 1. The facility staff failed to review Resident #30's medication regimen for the month of 10/21 and 11/21. Resident #30 was admitted to the facility on [DATE]. Diagnosis for Resident #30 included but not limited to Dementia with behavioral disturbance and major depressive disorder. Resident #30's Minimum Data Set (MDS), a quarterly Assessment Reference Date (ARD) of 12/23/21 scored a 99 indicating short and long term memory problems and with severe cognitive impairment - never/rarely made decisions. The MDS coded Resident #30 requiring total dependence of two with transfer, total dependence of one with dressing, eating, toilet use, personal hygiene and bathing and extensive assistance of one with bed mobility for Activities of Daily Living…

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 ensure the recommendation for do a Gradual Dose Reduction (GDR) made on 01/20/22 by the facility's Nurses Practitioner (NP) for 1 of 35 resident (Resident #30) in the survey sample. Resident #30 received 41 extra doses of the unnecessary psychotropic medication Zyprexa 5 mg. The findings included: Resident #30 was admitted to the facility on [DATE]. Diagnosis for Resident #30 included but not limited to Dementia with behavioral disturbance. Resident #30's Minimum Data Set (MDS), a quarterly Assessment Reference Date (ARD) of 12/23/21 scored a 99 indicating short and long term memory problems and with severe cognitive impairment - never/rarely made decisions. The MDS coded Resident #30 requiring total dependence of two with transfer, total dependence of one with dressing, eating, toilet use, personal hygiene and bathing and extensive assistance of one with bed mobility for Activities of Daily Living (ADL)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to have laboratory reports filed in the resident's clinical record for 1 of 35 residents (Resident #64), in the survey sample. The findings included: Resident #64 was originally admitted to the facility 3/25/19 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; end-stage renal disease requiring dialysis and benign prostatic hyperplasia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/23/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #64's cognitive abilities for daily decision making were intact. Section O100J was coded for receiving dialysis services and at section G (Physical functioning) the resident was coded as requiring total care of two people with transfers, total care of one person with bathing and toileting,…

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 interviews, the facility staff failed to store utensils in a clean and sanitary manner. The findings included: On 03/01/22 from 11: 08 AM until 11:58 AM staff were observed with the refrigerator door open retrieving drinks, fruit cups, and sodas from within. The outside refrigerator temperature gauge indicated 43 degrees at the start of the meal tray preparation. The outside temperature gauge registered 56 degrees at (11: 58 AM). At around 12: 12 PM an estimated 14 plate tops fell to the floor in the dining room area from the kitchen serving line. A staff seated in the dining area placed the plates back on serving tray line. On 03/02/22 at 11:18 AM the Dietary Manager was observed to drop a serving spoon on the kitchen floor. The spoon was observed to remain on the floor for approximately 23 minutes. The Dietary Manager was observed to pick the spoon up and place it on the shelf were the bread used to make sandwich's were stored. During an interview on 3/3/22 at 9:02 AM with the Dietary Administrator he was informed of the observations. The Dietary…

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

Based on staff interview and facility document review, and it was determined that the facility staff failed to maintain an effective antibiotic stewardship program. The findings included: An interview was conducted with the Director of Nursing (DON) on 03/01/22 at approximately 10:52 a.m. When asked who is responsible for the Antibiotic Stewardship and Infection Prevention and Control Program (IPCP), the DON stated, I guess that would be me. When asked what is the process for tracking and trending infections, the DON stated I only monitor culture with sensitivity results. She stated, I don't have the time to track and monitor any other antibiotics. The DON said the last time antibiotic monitoring was done for the facility is by the previous Infection Preventionist (IP) and she left November 31, 2021. The surveyor requested the Infection Control Logs from June 2021 until November 2021. The DON said she was not been able to locate any of the Infection Control Logs for the last 6 months but did provide the phone number for the previous (IP). A phone interview was conducted with the…

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

Based on staff interviews, facility document and facility documentation, the facility staff failed to provide evidence of the facility's COVID-19 staff testing for an unvaccinated employee based on the level of community transmission according for the recommended frequency of twice a week. The findings included: An interview was conducted with the Director of Nursing (DON) on 03/01/22 at approximately 10:52 a.m. When asked who is responsible for ensuring the unvaccinated staff (housekeeper #1) was tested for COVID-19 based on the level of community transmission of twice a week, she stated, I guess that would be me. The DON was asked to provide the following: the community transmission level from 01/29/22 - 02/26/22 along with housekeeper #1's as-worked schedule and all her COVID-19 testing from 01/29/22 - 02/26/22. The DON stated, the housekeeper should have been tested twice a week since 01/29/22 until current but it wasn't done. On 03/02/22 at approximately 9:28 a.m., an interview was conducted with housekeeper #1 who stated, I'm have a religious exemption and I'm not vaccinated.…

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 staff interview, the facility's staff failed to ensure 1 resident was treated with dignity and respect while receiving wound care. For 1 of 35 Residents (Resident #22), in the survey sample. The findings included: Resident #22 was originally admitted to the facility on [DATE] after an acute care hospital stay and readmitted on [DATE]. The current diagnoses included; Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Pressure Ulcer of the Sacral Region. The quarterly-5 day, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/17/2021 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #22 cognitive abilities for daily decision making were intact. In sectionG(Physical functioning) the resident was coded as requiring extensive assistance of two persons with bed mobility. Extensive assistance of one person physical assist with dressing, eating…

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 and staff interview and during the course of a complaint investigation, the facility's staff failed to ensure privacy while providing wound care for 1 of 35 residents (Resident #31) in the survey sample. The findings included: Resident #31 was originally admitted to the facility 08/16/19 after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Infection and Inflammatory Reaction due to other internal joint prosthesis and Osteoarthritis, Right Knee. The quarterly revision, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/23/2021 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #31 cognitive abilities for daily decision making were intact. In sectionG(Physical functioning) the resident was coded as requiring extensive assistance of two persons with bed mobility, dressing and locomotion on the unit. Requires total dependence of two person with transfers.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a resident personal funds review, resident interview, staff interview and facility document review the facility staff failed to ensure that 1 resident out of 35 residents, (Resident #14) in the survey sample was afforded the right to manage their personal funds. The findings included; Resident #14 was originally admitted to the facility 08/28/2020 and readmitted [DATE] after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Acute Kidney Failure, Unspecified and Essential Hypertension. The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 02/16/2022 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #14 cognitive abilities for daily decision making were intact. On 03/01/22 at approximately 11:36 AM., during the initial tour Resident #14 was asked by the surveyor if she had any concerns. She stated, I get $30 a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a resident personal funds review, resident interview, staff interview and facility document review the facility staff failed to ensure that 1 resident out of 35 residents (Resident #14) in the survey sample was afforded the right to manage their personal funds. The findings included; Resident #14 was originally admitted to the facility 08/28/2020 and readmitted [DATE] after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Acute Kidney Failure, Unspecified and Essential Hypertension. The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 02/16/2022 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #14 cognitive abilities for daily decision making were intact. On 03/01/22 at approximately 11:36 AM., during the initial tour Resident #14 was asked by the surveyor if she had any concerns. She stated, I get $30 a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interviews, clinical record reviews and facility documentation review, the facility staff failed to ensure 2 of 35 residents in the survey sample, (Resident #55 and #3) were given the opportunity to formulate an advance directive. The findings included: The facility staff failed to ensure Resident #55 was given the opportunity to formulate an Advance Directive. Resident #55 was originally admitted to the nursing facility on [DATE]. Diagnosis for Resident #55 included but not limited to Chronic Obstructive Pulmonary Disease (COPD). The current Minimum Data Set (MDS) a quarterly assessment with an Assessment Reference Date (ARD) of [DATE] coded the resident with a 15 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. Review of the clinical record revealed that there was no advance directive for Resident #55. Review of Resident #55's Physician Order Sheet (POS) for [DATE] revealed the following order: Full Code…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review; the facility staff failed to ensure the physician and resident representative were informed the medication (Zyprexa) was not decreased from 5 mg to 2.5 mg as ordered for 1 of 35 residents (Resident #30), and the facility staff failed to notify the resident representative and physician of a change in condition in a timely manner for 1 of 35 residents (Resident #316), in the survey sample. The Findings Included: 1. The facility staff failed to notify the physician/Nurse Practitioner (NP) and Resident Representative (RR) that Resident #30's psychotropic medication (Zyprexa 5 mg) was not decreased to 2.5 mg as recommended by the (NP) on 01/20/22. Resident #30 received 41 extra doses of the psychotropic medication Zyprexa. Resident #30 was admitted to the facility on [DATE]. Diagnosis for Resident #30 included but not limited to Dementia with behavioral disturbance. Resident #30's Minimum Data Set (MDS), a quarterly Assessment Reference Date (ARD) of 12/23/21…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinical record review and facility documentation review the facility staff failed to ensure Comprehensive Care Plan Goals were sent upon transfer to the hospital for 1 out of 35 residents in the survey sample, Resident #3. The facility staff failed to ensure Resident #3's Comprehensive Care Plan Goals were sent upon transfer to the hospital on [DATE]. The findings included: Resident #3 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses to include but not limited to Left Hemiparesis, Bipolar Disorder and Muscle Weakness. Resident #3's most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 12/2/21. The Brief Interview for Mental Status (BIMS) was coded as 15 out of a possible 15, indicating the resident was cognitively intact and capable of daily decision making. Resident #3's Clinical Census was reviewed and revealed the resident was discharged on 11/25/21. Resident #3's Progress Notes were reviewed and 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 interviews, clinical record review and facility documentation review the facility staff failed to ensure a Bedhold notice was sent upon transfer to the hospital for 1 out of 35 residents in the survey sample, Resident #3. The facility staff failed to ensure Resident #3's Bedhold notice was sent upon transfer to the hospital on [DATE]. The findings included: Resident #3 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses to include but not limited to Left Hemiparesis, Bipolar Disorder and Muscle Weakness. Resident #3's most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 12/2/21. The Brief Interview for Mental Status (BIMS) was coded as 15 out of a possible 15, indicating the resident was cognitively intact and capable of daily decision making. Resident #3's Clinical Census was reviewed and revealed the resident was discharged on 11/25/21. Resident #3's Progress Notes were reviewed and are documented in part, as follows:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, and staff interviews the facility staff failed to ensure that a Level I Preadmission Screening and Resident Review (PASARR) was conducted prior to admission or within 30 days of admission to the nursing facility for 1 of 35 residents in the survey sample, Resident #3. The facility staff failed to ensure a Level I Preadmission Screening and Resident Review (PASARR) was conducted prior to admission or within 30 days of Resident #3's admission to the facility on 7/23/19. The finding included: Resident #3 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses to include but not limited to Left Hemiparesis, Bipolar Disorder and Muscle Weakness. Resident #3's most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 12/2/21. The Brief Interview for Mental Status (BIMS) was coded as 15 out of a possible 15, indicating the resident was cognitively intact and capable of daily decision making. Upon review of…

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

Based on observation, resident interview, staff interview and clinical record review the facility staff failed to include anticoagulation in the comprehensive care plan, for 1 of 35 resident (Resident #55), in the survey sample. The findings included: The facility staff failed to develop a care plan for Resident #55 who was receiving an anticoagulation medication (Xarelto). Resident #55 was originally admitted to the nursing facility on 09/18/19. Diagnosis for included but not limited to Atrial Fibrillation (A-Fib). The current Minimum Data Set (MDS) a quarterly assessment with an Assessment Reference Date (ARD) of 02/09/22 coded the resident with a 15 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. The residents MDS was coded for the usage of anticoagulant. The section N on the MDS under medications read as follows: Indicate the number of DAYS the resident receiving the medication during the last 7 days, the MDS was coded for receiving an anticoagulant for 7 days. The resident had a Physician order dated 09/02/20:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interviews, staff interviews, and clinical record review, the facility staff failed to review and revise the care plan after the resident's dentures were broken for 1 of 35 residents (Resident #65) in the survey sample. The findings included: Resident #65 was originally admitted on [DATE] and readmitted on [DATE] after an acute hospital stay. The current diagnoses include; chronic kidney Disease, osteoporosis, and diabetes. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) 2/9/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #65 cognitive abilities for daily decision making were intact. In section G (Physical Functioning), the resident was coded as requiring total care of two people with bed mobility, total care of one person with toileting, personal hygiene and bathing, and extensive assistance of one person with eating. At section L0200…

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 ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain grooming, and personal hygiene for 2 of 35 residents (Resident #31 and #14), in the survey sample. The findings included: 1.Resident #14 was originally admitted to the facility 08/28/2020 and readmitted [DATE] after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Acute Kidney Failure, Unspecified and Essential Hypertension. The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 02/16/2022 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #14 cognitive abilities for daily decision making were intact. In sectionG(Physical functioning) the resident was coded 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 observations, family interviews, staff interviews, and clinical record review, the facility staff failed to ensure a resident with limited range of motion of the left arm received application of the left arm splint as ordered to prevent further decrease in range of motion for 1 of 35 residents, (Resident #13), in the survey sample. The findings included: Resident #13 was originally admitted to the facility 7/15/19 and readmitted [DATE] after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; stroke with left hemiparesis, aphasia and dysphagia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/16/21 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as moderately impaired for daily decision making. In section G (Physical functioning) the resident was coded 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 clinical record reviews, staff and resident interviews and during the course of a complaint investigation, the facility staff failed to ensure 1 of 35 residents (Resident #316), in the survey sample was free of accident hazards. Activities of daily Living (ADL) assistance was not provided for a resident that was care planned to have the assistance of one person while bathing/showering which placed the resident at risk for falls. This is a closed record resident. The findings included: Resident #316 was admitted to the facility on [DATE] and discharged on 9/28/21 to an acute care facility. Diagnosis for Resident #316 included but not limited to COVID-19 and Difficulty in walking. Quarterly-5 day, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/01/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 10 out of a possible 15. This indicated Resident #316 cognitive abilities for daily decision making were moderately impaired. 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 observations, resident interview, staff interview, and clinical record review, the facility staff failed to address, assess and treat a resident's pain for 1 of 35 residents (Resident #6), in the survey sample. The findings included: Resident #6 was originally admitted to the facility 11/29/19 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; dementia and heart failure. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/10/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 5 out of a possible 15. This indicated Resident #6's cognitive abilities for daily decision making were severely impaired. In section G (Physical functioning) the resident was coded as requiring extensive assistance of one person with bed mobility, transfers, dressing, toileting, and bathing, limited assistance of one person with personal hygiene, and supervision after set-up with eating and locomotion. On…

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

Based on information obtained during the Sufficient and Competent Nurse Staffing task, the facility staff failed to staff a Registered Nurse (RN) for eight consecutive hours a day on 2/27/22, which could potentially affect all residents care. The findings included: During the nursing staff review for February 28, 2022 through March 3, 2022 the facility staff was unable to verify RN presence in the facility for at least 8 consecutive hours on 2/27/22 On 3/03/22 at approximately 4:38 p.m., the Staffing Coordinator (OSM/Other Staff Member #10) stated that she was unable to present any information verifying a RN was present in the facility for 8 consecutive hours on 2/27/22. She also stated that there should always be an RN on staff. The above findings were shared with the Administrator and Director of Nursing and the Corporate Consultant on 3/03/22 at approximately 9:00 p.m., No comments were made concerning the above issue.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff interviews, and facility document review the facility staff failed to ensure a medication was securely stored for 1 of 35 residents in the survey sample, Resident #53. The facility staff failed to securely store a respiratory inhaler that was observed at the bedside of Resident #53. The findings included: Resident #53 was admitted to the facility on [DATE] with diagnoses to include but not limited to Chronic Obstructive Pulmonary Disease and Pneumonia. Resident #53's most recent Minimum Data Set (MDS) was a 5 day/admission assessment with an Assessment Reference Date of 2/4/22. The Brief Interview for Mental Status (BIMS) was coded as a 15 out of a possible 15 indicating that Resident #53 was cognitively intact and capable of daily decision making. On 3/1/22 at 11:50 a.m. during a room visit with Resident #53 the following observation was made. On the residents nightstand there was one unlabeled Advair 250 mg(milligram) respiratory inhaler with 58 doses…

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, interviews, medical record review and facility document review the facility staff failed to ensure assistive devices for meal consumption was provided for 1 of 35 resident's in the survey sample, Resident #3. The facility staff failed to ensure Resident # 3's issued built up weighted rocker knife and foam built up fork for self feeding were provided on each meal tray. The findings included: Resident #3 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses to include but not limited to Left Hemiparesis, Bipolar Disorder and Muscle Weakness. Resident #3's most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 12/2/21. The Brief Interview for Mental Status (BIMS) was coded as 15 out of a possible 15, indicating the resident was cognitively intact and capable of daily decision making. Under Section G Functional Status, Resident #3 was coded as independent with no set up or physical help for eating. Resident #3's current…

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

Based on observations and staff interviews the facility staff failed to ensure garbage and refuse were disposed of properly. The findings included: Two outside trash dumpster's were observed open with over flowing trash and flies on 3/1/22 at 1:15 P.M. and on 3/2/22 at 12:45 P.M. During an interview with the Maintenance Director on 3/2/22 at 12:45 PM, he stated, the trash was supposed to have been picked up on Monday Feburary 28, 2022.

Based on observation, staff interview and facility documentation, the facility staff failed to designate at least one qualified staff member as the facility's Infection Preventionist (IP). The finding included: An interview was conducted with the Director of Nursing (DON) on 03/01/22 at approximately 10:52 a.m. When asked who is responsible for the Infection Prevention and Control Program (IPCP), the DON stated, I guess that would be me. The DON was asked to provide a copy of her completed specialized training in infection prevention and control, she replied, I have not completed the necessary training. The DON was asked if she had started the specialized training, she replied, No, I have not had time. The DON stated, We have not had an IP since the new (name of company) took over on 12/01/21. A briefing was held with the Administrator, Director of Nursing and Corporate support on 03/03/22 at approximately 3:00 p.m. When asked if the facility had an (IP), the Administrator replied, No. When asked if the facility should have an (IP), they stated, Yes. The surveyor asked, what is 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 resident interview, staff interviews and clinical record review, the facility staff failed to ensure 1 out of 35 resident (Resident #35) in the survey sample, was given the opportunity to either refuse or accept a COVID-19 vaccine. The findings included: Resident #45 was admitted to the nursing facility on 01/25/22. Diagnosis for Resident #45 included but not limited to Congestive Heart Failure and COVID-19. The most recent Minimum Data Set (MDS) an admission -5 day assessment with an Assessment Reference Date (ARD) of 01/28/22 coded Resident #45 with an 08 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. An interview was conducted with Resident #45 on 03/03/22 at approximately 10:30 a.m. The resident stated no one has spoken to me about receiving the COVID-19 vaccine. The resident further stated, I'm willing to get the vaccine but I need to be educated on the vaccine first. Resident #45 stated, I'm open to receiving the vaccine especially if my doctor tells me it okay to receive, I don't believe in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, group interview, staff interview and facility records, the facility staff failed to maintain hot water temperatures in resident rooms. The findings included: During the Resident Council Group meeting on 2/26/19 at 11:00 A.M. residents complained of hot water being cold. A random tour of Resident Rooms with the Maintenance Director on 2/26/19 at 12:17 P.M. found hot water temperatures to be as follows: room [ROOM NUMBER] temperature 70 degrees F. room [ROOM NUMBER] temperature 76 degrees F. room [ROOM NUMBER] temperature 72 degrees F. room [ROOM NUMBER] temperature 77 degrees F. room [ROOM NUMBER] temperature 84 degrees F. room [ROOM NUMBER] temperature 78 degrees F. room [ROOM NUMBER] temperature 93 degrees F. During an interview with the Maintenance Director on 2/26/19 at 12:47 P.M. he stated, The hot water has been not at peak temperature for about two weeks. We had a company out this morning to repair the valve, it is not working will need to call them back. A Routine Maintenance &…

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

Based on observations, resident interview, clinical record review, and staff interviews, the facility staff failed to provide needed hygienic care for a dependent resident for 1 of 43 residents (Residents #57), in the survey sample. The facility staff failed to provide necessary oral hygiene to remove adhered food and plaque from Resident #57's teeth; and the facility staff failed to provide basic hygienic care to Resident #57's feet to prevent severe dryness and flakiness. The findings included; Resident #57 was originally admitted to the facility 3/14/17 and was readmitted to the facility 6/5/18, after an acute care hospital stay. The current diagnoses included; stroke with hemiplegia, multiple decayed and carious teeth, and high blood pressure. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/4/19, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of 15. This indicated Resident #57's daily decision making abilities were moderately impaired. In section G (Physical functioning) 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 staff interview, resident interviews, clinical record review, and facility document review and in the course of a complaint investigation, the facility staff failed to ensure 1 of 43 residents in the survey sample, Resident #93, was free from a medication timing error. Resident #93 received his pain medication 60 or more minutes later than the prescribed time which interfered with the resident's pain control. The findings include: Resident #93 was admitted to the facility 03/10/2018. Diagnoses included but were not limited to: Aftercare following joint replacement surgery, presence of left artificial knee joint, muscle weakness (Generalized). The resident was no longer in the facility therefore a closed record review was conducted. Resident #93's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 03/17/2018 was coded with a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #93 as requiring limited assistance of 1 with bed mobility, dressing and limited…

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

Based on information revealed during the Infection Prevention and Control Program review and staff interview, the facility staff failed to have an current and active Infection Prevention and Control Program. The facility staff failed to sign the Infection Prevention and Control Program policy into effect, effective 1/1/2019, and establish an infection control program which investigates collected data to track trends, prevent the onset and the spread of infections or use the data to educate the staff. The findings included: The Infection Prevention and Control Program interview was conducted with the Director of Nursing, 2/28/19 at approximately 3:05 p.m. The Director of Nursing was unable to locate the reviewed and signed Infection Prevention and Control Program for 1/1/2019. During the surveillance plan the Director of Nursing identified five residents with facility acquired urinary tract infections in 1/2019 but she was unable to view the documentation and state the organisms each was growing, if the appropriate antibiotic therapy was administered, if the resident's involved 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 observation, staff interview, clinical record review, and facility documentation review, the facility staff failed for one (Resident #51) of 43 residents in the survey sample to determine if the resident was capable of self-administering medication. Resident #51 was not assessed or approved to self-administer eye drops. The findings included: Resident #51 was originally admitted to the facility 6/21/18 and has never been discharged . The current diagnoses included; dry eye syndrome. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/119/19, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 10 out of 15. This indicated Resident #51's daily decision making abilities was moderately impaired. In section G (Physical functioning) the resident was coded as requiring supervision of one person with personal hygiene and dressing and set-up assistance with bed mobility, transfers, in room walking, locomotion, eating, and toileting. The active physician orders dated 6/21/18, revealed an order for Refresh…

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 and facility document review the facility staff failed to ensure a Plan of Care Summary was sent upon transfer to the hospital for 3 of 43 Residents in the survey sample, Resident # 73, Resident #87 and Resident #57. 1. The facility staff failed to ensure that Resident #73's Plan of Care Summary was sent to the receiving facility upon transfer to the hospital on 1/16/19. 2. The facility staff failed to ensure that Resident #87's Plan of Care Summary was sent to the receiving facility upon transfer to the hospital on 2/25/19. 3. The facility staff failed to ensure that Resident #57's Plan of Care Summary was sent to the receiving facility upon transfer to the hospital on 5/31/18 The findings included: 1. Resident #73 is a [AGE] year old admitted to the facility originally on 5/23/18 and re-admitted on [DATE] with diagnoses to include but not limited to Left Radius Fracture and Chronic Kidney Disease Stage 3. The most recent comprehensive Minimum Data Set (MDS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and facility document review the facility staff failed to ensure a written notice of Bed-Hold Policy Notice was sent upon transfer to the hospital for 2 of 43 Residents in the survey sample, Resident # 73, and Resident #87. 1. The facility staff failed to ensure that Resident #73 received a written notice of Bed-Hold Policy Notice upon transfer to hospital on 1/16/19. 2. The facility staff failed to ensure that Resident #87 received a written notice of Bed-Hold Policy Notice upon transfer to hospital on 2/25/19. The findings included: 1. Resident #73, a [AGE] year old, admitted to the facility originally on 5/23/18 and re-admitted on [DATE] with diagnoses to include but not limited to Left Radius Fracture and Chronic Kidney Disease Stage 3. The most recent comprehensive Minimum Data Set (MDS) assessment was a 5 day with an Assessment Reference Date (ARD) of 1/28/19. Resident #73's Brief Interview for Mental Status (BIMS) was a 3 out of a possible 15 which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff interview and review of the facility's policy, the facility staff failed to accurately code the Minimum Data Set (MDS) assessment for 1 of 43 residents (Residents #57), in the survey sample. The facility staff failed to accurately code Resident #57's Annual Minimum Data Set assessment dated [DATE], in section L (Oral/Dental Status). The findings included; Resident #57 was originally admitted to the facility 3/14/17 and was readmitted to the facility 6/5/18, after an acute care hospital stay. The current diagnoses included; stroke with hemiplegia and high blood pressure. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/4/19, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of 15. That indicated Resident #57's daily decision making abilities were moderately impaired. In section G (Physical functioning) the resident was coded as requiring total care of two people with…

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

Based on clinical record review, staff interview and review of the facility's policy, the facility staff failed to assure that services provided met professional standards, for 1 of 43 residents (Residents #71), in the survey sample. The facility staff failed to transcribe Resident #71's antibiotic order on 2/1/19. The findings included: Resident #71 was admitted to the facility 10/24/18 and had never been discharged . The current diagnoses included; dementia with Lewy Body. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/18/19, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 3 out of 15. That indicated Resident #71's daily decision making abilities was severely impaired. In section G (Physical functioning) the resident was coded as requiring total care of two people with transfers, total care of one person with locomotion, bathing, personal hygiene, and toileting, extensive assistance of two people with bed mobility, and extensive assistance of one person with eating and dressing. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview and a review of clinical records, the facility staff failed to provide podiatry services for 3 residents out of a survey sample of 43 residents. (Resident # 47, # 28 & #57) The findings included: 1. Resident #47's toenails were long, thick and yellowish on both feet. 2. Resident #28's toenails were thick, long and yellowish on both feet. 3. The facility staff failed to ensure Resident #57 received podiatry care for overgrown and thick toe nails. The findings included: 1. Resident # 47 was originally admitted to the facility [DATE]. The current diagnoses included; Hypertension, Heart Failure and Anxiety disorder. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] coded the resident as completing the Brief Interview for Mental Status (BIMS) and scored a 4 which indicated severe cognitive impairment. In section G (Physical functioning) the resident was coded as requiring one person physical assistance with 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 observations, resident record review, resident interviews, staff interviews, and facility document review the facility staff failed to provide pharmaceutical services to include administering medications to 2 of 43 Resident's in the Survey Sample (Resident #67 and #51). 1. The facility staff failed to ensure that Resident #67's medications were consumed on 2/25/19 instead of being left on the bedside table unattended. 2. The facility staff failed to administer Resident #51 ophthalmic drops according to the prescriber's orders. The facility staff allowed Resident #51 to self-administer Refresh eye drops while contaminating the vial. The findings included: 1. Resident #67 is a [AGE] year old admitted to the facility on [DATE] with diagnoses to include but not limited to Dementia, Major Depressive Disorder and Glaucoma. The most recent Minimum Data Set (MDS) assessment is a Quarterly with an Assessment Reference Date (ARD) of 1/14/19. Resident #67's Brief Interview for Mental Status (BIMS) was a 15 out of…

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

Based on information obtained during a complaint investigation, a closed record review, and a staff interview, the facility staff failed to ensure a resident's drug regimen was free from unnecessary medications for 1 of 43 residents (Resident #92), in the survey sample. The facility staff administered three doses of Keflex (an antibiotic) to Resident #92, secondary to a medication transcription error. The findings included: Resident #92 was originally admitted to the facility 12/6/16, and was discharged from the nursing facility, return not anticipated on 8/6/18. Resident #92's diagnoses included; dementia, atrial fibrillation, heart failure, high blood pressure, kidney failure, and hypothyroidism. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/21/18, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 5 out of a possible 15. This indicated Resident #92's cognitive abilities for daily decision making were severely impaired. In section G (Physical functioning) the resident was coded 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.

Based on observations, resident interview, clinical record review, and staff interview, the facility staff failed to assure residents received needed dental services for 1 of 43 residents (Residents #57), in the survey sample. The facility staff failed to assist Resident #57 obtain needed dental services for decayed teeth and dental caries (cavities). The findings included; Resident #57 was originally admitted to the facility 3/14/17 and was readmitted to the facility 6/5/18, after an acute care hospital stay. The current diagnoses included; multiple decayed and carious teeth, stroke with hemiplegia and high blood pressure. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/4/19, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of 15. This indicated Resident #57's daily decision making abilities were moderately impaired. In section G (Physical functioning) the resident was coded as requiring total care of two people with transfers, total care of one person with bathing, extensive assistance of two…

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.