Riverside Lifelong H & R Warwick Forest

Based on clinical record review, staff interview and facility document review it was determined that the facility staff failed to ensure that pharmacy recommendations were reviewed and implemented in a timely manner for three of five residents reviewed for unnecessary medications, Resident #24, Resident #39 and Resident #41. The findings include: 1. For Resident #24 (R24), the facility staff failed to act on pharmacy medication regimen review recommendations in a timely manner. A review of the monthly pharmacy medication regimen reviews for R24 documented a consultation report for R24 dated 6/6/2023. The report documented in part, .Resident is currently on Olanzapine 20mg (milligram) daily. An A1c (Hemoglobin A1C blood test to measure average blood sugar over the past 3 months) was obtained 5/30/23, which resulted 9.3%. Currently, there are no orders for any antidiabetic medications. Recommendation(s): At this time, would it be appropriate to consider evaluation for potential initiation of an antidiabetic agent? The area for Physician/Prescriber response was observed to be blank. 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 staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to ensure that one of sixty residents in the survey sample, Resident #134, was free of unnecessary psychotropic medications. The findings include: 1. For Resident #134 the facility staff failed to evidence an appropriate diagnosis for the use of Trazodone (1), and failed to ensure consistent monitoring for the use of Trazodone and Risperdal (2), including behavior monitoring, effectiveness, side effects, and adverse reactions to an antipsychotic and an antidepressant medication. A review of the clinical record revealed a physician's order dated 9/13/23 for Trazodone Oral Tablet 50 MG, Give 0.5 mg by mouth at bedtime for per psych. A review of the clinical record revealed a physician's order dated 9/13/23 for Risperdal Oral Tablet 0.5 MG (milligrams) (Risperidone) Give 1 tablet by mouth at bedtime for psychotic disturbance. Further review failed to reveal any orders for staff monitoring for the use of Trazodone, including monitoring for signs and symptoms…

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 facility document review, it was determined that the facility staff failed to serve food in a palatable manner from one of one facility kitchens. The findings include: On 12/6/23 at 11:21 AM, tray line observation was conducted with OSM #9 (Other Staff Member) the Dietary Manager. The temperatures were taken of the tray line lunch meal. The following temperatures were obtained for the main meal: Meatballs was 179 degrees Noodles was 176 degrees Mixed vegetables was 183 degrees Florentine tomato soup was 167 degrees On 12/6/23 at 12:47 PM the cart with the test tray was taken to the [NAME] unit. Staff started serving trays at 12:53 PM. At 1:11 PM after all residents were served, temperatures for the test tray food items were obtained by OSM #9 as follows: Meatballs was 121 degrees. This was a 57 degree drop in temperature. Noodles was 113 degrees. This was a 63 degree drop in temperature. Mixed vegetables was 117 degrees. This was a 66 degree drop in temperature.…

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

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to store food in a sanitary manner in one of one facility kitchens. The findings include: On 12/5/23 at 11:10 AM a tour of the kitchen was conducted with OSM #9 (Other Staff Member) the Dietary Manager. In the walk-in refrigerator, a box of garlic bread was observed with the plastic bag open, exposing the bread to the elements of the refrigerator environment. OSM #9 stated that it should be sealed to protect it. The facility policy Food and Nutrition Services Infection Control, Food Safety and Sanitation Policy was reviewed. This policy documented, .J. Food will be stored in a manner to avoid deterioration in quality by drying out, freezer burning or change in color On 12/6/23 at 5:15 PM at the end-of-day meeting, ASM #1 (Administrative Staff Member) the Administrator and ASM #2 the Director of Nursing were made aware of the findings. No further information was provided by the end of the survey.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence bed inspections for four of 60 residents in the survey sample, Residents # 49, Resident #58, Resident #60 and Resident #8. The findings include: 1.The facility staff failed to perform bed rail inspections for the use of positioning / assist bars for Resident #49. Resident #49 was observed in bed with bilateral half bed rails on 12/6/23 at 7:30 AM and 12/7/23 at 8:00 AM. Resident #49 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: COPD (chronic obstructive pulmonary disease), cellulitis, ASCVD (atherosclerotic cardiovascular disease) and PVD (peripheral vascular disease). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/28/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating 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, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure reasonable accommodation of needs for one of 60 residents in the survey sample, Resident #19. The findings include: For Resident #19 (R19), the facility staff failed to ensure their roommates personal belongings did not hinder their ability to leave the room if they chose. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/14/2023, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. The assessment documented R19 being dependent on staff for bed to chair transfers, utilizing a manual wheelchair and dependent on staff to wheel at least 50 feet with two turns. On 12/5/2023 at 12:59 p.m., an interview was conducted with R19 in their room. R19 was observed in bed in their room on the right side of a semi-private room near the window. When asked…

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 review of facility's documentation and staff interview, it was determined that the facility failed to promote and facilitate the resident's right to self-determination by promoting resident's choice in transferring to wheelchair for one of 60 residents in the survey sample, Resident #154. The findings included: Resident #154 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: diabetes mellitus (DM), paraplegia and gangrene. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 9/19/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bed mobility, dressing and hygiene; supervision for eating and total dependence for transfers and bathing. A review of the comprehensive care plan dated 5/22/23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence of required resident information when a resident is transferred to the hospital, for one of 60 residents in the survey sample, Residents #49. The findings include: The facility staff failed to evidence provision of required resident information to a receiving facility at the time of discharge for Resident #49. Resident #49 was transferred to the hospital on [DATE] and 11/7/23. Resident #49 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: COPD (chronic obstructive pulmonary disease), cellulitis, ASCVD (atherosclerotic cardiovascular disease) and PVD (peripheral vascular disease). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/28/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide an accurate MDS (minimum data set) assessment for two out of 60 residents in the survey sample, Resident #192 and Resident #129. The findings include: 1.The facility staff failed to complete an accurate MDS (minimum data set), a discharge assessment for Resident #192. Resident #192 was sampled during the closed record review for transfer to hospital. Resident #192 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: COPD (chronic obstructive pulmonary disease), chronic bronchitis and acute kidney failure. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 10/8/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of Section A: Identification…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, the facility staff failed to develop a complete baseline care plan for one of 60 residents in the survey sample, Resident #347. The findings include: For Resident #347 (R347), the facility staff failed to develop a baseline care plan for dialysis care. R347 was admitted to the facility on [DATE]. A review of R347's clinical record revealed a physician's order for dialysis every Monday, Wednesday and Friday. R347's baseline care plan with an admission date of 11/25/23 only documented the resident was at risk for weight fluctuations due to dialysis; this was documented in the dietary section of the care plan. The care plan failed to document any information regarding R347's dialysis care. On 12/6/23 at approximately 3:30 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated the purpose of the baseline care plan is to show the plan of care for the patient while they are at the facility. LPN #5 stated…

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

Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined the facility staff failed to review and revise the care plans for three of 60 residents in the survey sample, Resident #24, Resident #120 and Resident #145. The findings include: 1. For Resident #24 (R24), the facility staff failed to review and revise the comprehensive care plan after a fall on 10/27/2023. On the most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 10/5/2023, the resident scored 3 of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. Section J documented no falls. Observations of R24 conducted during the dates of the survey revealed R24 in their wheelchair in the day area of the unit or participating in activities. The comprehensive care plan for R24 documented in part, (Name of R24) is High risk for falls r/t (related to) Gait/balance problems, Incontinence, Psychoactive drug use and history…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to meet professional standards for one of 60 residents, Resident #49. The findings include: The facility staff failed to meet professional standards by administering medications as ordered, specifically Fluoxetine CAP 40MG (milligram), for Resident #49. Resident #49 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: COPD (chronic obstructive pulmonary disease), cellulitis, ASCVD (atherosclerotic cardiovascular disease) and PVD (peripheral vascular disease). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/28/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bathing and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide ADL (activities of daily living) care to a dependent resident to one of 60 residents in the survey sample, Resident #2. The findings include: For Resident #2 (R2), the facility staff failed to provide incontinence care on the day shift (7:00 a.m. to 3:00 p.m.) of 3/13/2022. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 10/12/2023, R2 was assessed as scoring 14 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact. The assessment documented R2 requiring substantial/maximal assistance with toileting and being always incontinent of bowel and bladder. On the MDS assessment, a quarterly assessment with an ARD of 1/27/2022, R2 was assessed as requiring extensive assistance from two or more persons for toileting. Section H documented R2…

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

Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide care and services for a urinary catheter for one of 60 residents in the survey sample, Resident #23. The findings include: For Resident #23 (R23), the facility staff failed to obtain physician's orders and provide care per manufacturer's instructions for the resident's external urinary catheter. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/14/23, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 12/5/23 at 4:16 p.m., R23 was observed lying in bed. The resident's external urinary catheter canister was observed in a box on the floor beside the bed. R23 stated the staff changes the catheter wick every day and changes the canister, every so often. A review of R23's clinical record failed to reveal any physician's orders for R23's external urinary catheter. Further…

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

Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide respiratory care and services for one of 60 residents in the survey sample, Resident #344. The findings include: For Resident #344 (R344), the facility staff failed to store a nebulizer (1) mouthpiece in a sanitary manner. R344's admission minimum data set assessment was not complete. A clinical admission form dated 11/27/23 documented R344 was alert and oriented times three. A review of R344's clinical record revealed a physician's order dated 11/27/23 for ipratropium-albuterol inhalation solution (2) 0.5-2.5 three milligrams/three milliliters- three milligrams inhale orally four times a day for chronic obstructive pulmonary disease. On 12/5/23 at 12:23 p.m., R344 was observed sitting in a wheelchair in the bedroom. The resident's nebulizer mouthpiece was uncovered and sitting on the nebulizer machine. R344 stated the staff had never provided anything to cover the nebulizer mouthpiece. On 12/6/23 at 4:10 p.m., the nebulizer mouthpiece…

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, facility document review and clinical record review, the facility staff failed to implement a complete pain management program for one of 60 residents in the survey sample, Resident #23. The findings include: For Resident #23 (R23), the facility staff failed to treat the resident's reported right leg pain on 12/5/23. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/14/23, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. A review of R23's clinical record revealed a physician's order dated 3/15/23 for acetaminophen (Tylenol) 325 milligrams- give 650 milligrams by mouth every six hours as needed for pain. On 12/5/23 at 4:16 p.m., R23 was lying in bed. The resident stated her right leg was hurting and the facility staff had not done anything for her pain. A note signed by the nurse practitioner on 12/5/23 documented, Seen today in bed resting. She is alert and following…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide trauma informed care for one of 60 residents in the sample Resident #115. The findings include: Resident #115 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: PTSD (post-traumatic stress disorder), CVA (cerebrovascular accident) and hemiplegia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 10/24/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bathing, bed mobility, transfer, dressing, hygiene and eating. A review of Section I: Medical Diagnosis: I6100. Post Traumatic Stress Disorder (PTSD)-coded yes. A review of the comprehensive care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to implement bed rail requirements for three out of 60 residents in the survey sample, Residents # 49, Resident #58 and Resident #60. The findings include: 1.The facility staff failed to obtain informed consent for Resident #49. Resident #49 was observed in bed with bilateral half bed rails on 12/6/23 at 7:30 AM and 12/7/23 at 8:00 AM. Resident #49 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: COPD (chronic obstructive pulmonary disease), cellulitis, ASCVD (atherosclerotic cardiovascular disease) and PVD (peripheral vascular disease). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/28/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure sufficient CNA (certified nursing assistant) staffing to provide care and services for one of 60 residents in the survey sample, Resident #2. The findings include: For Resident #2 (R2), the facility staff failed to ensure sufficient CNA staffing on the day shift (7:00 a.m. to 3:00 p.m.) of 3/13/2022 to provide adequate incontinence care. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 10/12/2023, R2 was assessed as scoring 14 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact. On the MDS assessment, a quarterly assessment with an ARD of 1/27/2022, R2 was assessed as requiring extensive assistance from two or more persons for toileting. On 12/5/2023 at 3:44 p.m., an interview was conducted with R2. R2 stated that they had no concerns…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one of 60 residents in the sample, Resident #115. The findings include: The facility staff failed to assess and implement psychosocial interventions for Resident #115, who had an admitting diagnosis of PTSD (post traumatic stress disorder) and was coded on admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 4/30/23, Section I: Active Diagnosis: I6100: post-traumatic stress disorder- coded as present. Resident #115 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: PTSD (post-traumatic stress disorder), CVA (cerebrovascular accident) and hemiplegia. The most recent MDS (minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide medically related social services for one of 60 residents in the sample Resident #115. The findings include: For Resident #115, the facility staff failed to provide psychosocial follow up following the resident being admitted with a diagnosis of PTSD (post-traumatic stress disorder). Resident #115 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: PTSD (post-traumatic stress disorder), CVA (cerebrovascular accident) and hemiplegia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 10/24/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bathing,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide pharmacy services in a timely manner for one of 60 residents, Resident #49. The findings include: The facility staff failed to provide pharmacy services by administering medications as ordered, specifically ELIQUIS TAB 5MG (milligram), for Resident #49. Resident #49 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: COPD (chronic obstructive pulmonary disease), cellulitis, ASCVD (atherosclerotic cardiovascular disease) and PVD (peripheral vascular disease). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/28/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance 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 resident interview, staff interview, clinical record review and facility document review the facility staff failed to ensure 1 of 59 residents in the survey sample, Resident #122's choice to receive showers was honored. Resident #122 was dependent on staff for the provision of showers and had not received a shower from 12/6/19 through 2/19/20. The findings included: Resident #122 was admitted to the facility on [DATE] with diagnoses to include, but not limited to seizure disorder, paraplegia and spinal bifida (a congenital birth defect affecting the spinal canal-Taber's Cyclopedic Medical Dictionary, Edition 19). The current MDS (Minimum Data Set) a significant change with an Assessment Reference Date of 1/31/20 coded the resident as scoring a 15 out of a possible 15 on the Brief Interview for Mental Status, indicating the resident's cognition was intact. The resident was coded as requiring extensive assistance of one staff for bed mobility, dependent on two staff for transfers, and dependent on one…

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 record review and staff interviews, the facility staff failed to ensure eight residents (Residents #48, #135, #39, #46, #77, #138, #52, and #91, were given the opportunity to formulate an advance directive in the survey sample of 59 residents. The findings included: 1. The facility staff failed to ensure Resident #48 had the opportunity to formulate an advance directive. Resident #48 was admitted to the facility on [DATE] with diagnoses which included hypertension, GERD, history of UTI, hyperlipidemia, thyroid disorder, dementia, anxiety disorder and depression. During a review of the clinical record for Resident #48, no advance directive was included in the resident record. During an interview on [DATE] at 12:08 PM with the Director of Nursing , she stated, the resident does not have an advance directive. 2. The facility staff failed to ensure Resident #135 had the opportunity to formulate an advance directive. Resident #135 was re-admitted to the facility on [DATE] with diagnoses which included…

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 interviews, and facility documentation review; the facility's staff failed to covey a copy of the resident's comprehensive care plan goals to the receiving facility for 8 of 59 residents (Resident #80, #40, #125, #43, #63, #121, #3 and #77) in the survey sample. 1. The facility staff failed to convey the summary and goals of the comprehensive plan of care upon transfer/discharge to the local hospital for Resident #80. Resident #80 was admitted to the nursing facility on 10/28/11 with diagnoses that included high blood pressure, Alzheimer's Disease and diabetes mellitus. Resident #80's most recent Minimum Data Set (MDS) was a quarterly assessment and coded the resident with short and long term memory problems and severely impaired in the cognitive skills for daily decision making. There was no evidence provided that the facility staff conveyed the summary and goals of the comprehensive plan of care upon or after transfer/discharge to the local hospital's Emergency…

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 revise 5 (Resident #52, #175, #100, #122 and #165) comprehensive person-centered care plans of 59 residents in the survey sample. The findings included: 1. The facility staff failed to revise Resident #52's comprehensive person centered care plan to include a stage III right ankle pressure ulcer. Resident #52 was originally admitted to the facility on [DATE]. Current diagnoses for Resident #52 included but not limited to Stage III pressure ulcer to right ankle. Resident #52's Minimum Data Set (MDS-an assessment protocol) a quarterly assessment with an Assessment Reference Date of 11/21/19 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 skills for daily decision-making. During the review of Resident #52's current Physician Order Sheet (POS) for February 2020, a Stage III wound care order to the right lateral…

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 interviews the facility staff failed to maintain a clean, sanitary and homelike environment for 1 of 59 residents (Resident #109) in the survey sample. The findings included: Resident #109's, wheel chair observed with worn, torn and cracked armrest pads. Resident #109 was originally admitted to the facility on [DATE]. Diagnoses for Resident #109 included but not limited to Cognitive Communication Deficit. The current Minimum Data Set (MDS), quarterly assessment with an Assessment Reference Date (ARD) of 01/02/20 coded the resident with a 01 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. In addition, the MDS coded Resident #109 requiring total dependence of one bathing, extensive assistance of two with bed mobility, dressing, transfer and toilet use, extensive assistance of one with hygiene. The MDS was coded under section G 0600 (mobility devices) was coded for wheel chair usage. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined that facility staff failed to provide evidence that the written bed hold notification/policy was sent with three of 59 sampled residents, Residents #3, #77, and #63, upon transfer to the hospital. The findings included: 1. Resident #3 was originally admitted to the facility on [DATE]. Resident #3 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnosis included but were not limited to, Osteoporosis and Heart Disease. Resident #3's Minimum Data Set (MD'S - an assessment protocol) with an Assessment Reference date of 11/05/2019 coded Resident #3 with a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment. On 02/18/2020 evidence that written Bed Hold Notice was sent with Resident #3 upon discharge to the hospital on [DATE] was requested. On 02/18/2020 at approximately 6:00 p.m., the Administrator provided copy of Nursing Home to Hospital Transfer…

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 person-centered to include hospice services for 1 of 59 Residents in the Survey Sample, Resident #442. The findings included: Resident #442 was admitted to the facility on [DATE] with diagnoses to include but not limited to Alzheimer's Disease and Left Femur Fracture. Due to Resident #442's recent admission a Comprehensive Minimum Data Set (MDS) and a Comprehensive Care Plan have not been completed. Resident #442's admission Orders were reviewed and are documented in part, as follows: Order Date: 2/13/2020 Admit to Hospice Services Resident #442's Baseline Care plan dated 2/13/20 was reviewed and there was no entry to show that the resident would be receiving hospice services. Unit Manager LPN (Licensed Practical Nurse) #7 was asked if she saw any entry on Resident #442 Baseline Care Plan indicating the resident was receiving hospice services. LPN #7 stated, No I don't, we…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, and clinical record review; it was determined that facility staff failed to provide treatment and services to promote the healing of a pressure ulcer for two of 59 residents in the survey sample, Resident #189 and Resident #77. 1. For Resident #189, facility staff failed to thoroughly assess a healing stage 3 pressure ulcer* to her second right toe upon admission to the facility; and, failed to provide treatment in a timely manner. 2. For Resident #77, facility staff failed to apply physician ordered heel boots for the treatment and prevention of pressure ulcers. The findings included: 1. Resident #189 was admitted to the facility on [DATE] with diagnoses that included but were not limited to chronic kidney disease stage 4 requiring dialysis, idiopathic chronic gout, right ankle and foot with tophus (deposits), and open wound of right foot. Resident #189's most recent MDS (minimum data set) assessment was an admission assessment with an ARD…

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 medication pass observations, staff interviews, facility document review and clinical record review the facility staff failed to ensure they were free from a medication error rate of 5 % or greater. There were 28 observed medication opportunities with 2 errors (Resident #41 and #58), resulting in a 7.14% medication error rate. The findings include: 1. On 2/18/20 at 5:00 p.m., during the medication pass observation, for Resident #41, Licensed Practical Nurse (LPN) #11 administered 10 Units of *Humalog U-100 insulin (subcutaneously) before the evening meal. Resident #41 had physician's orders dated 9/28/19 to administer 9 Units of Humalog U-100 insulin prior to the evening meal. Resident #41's blood sugar reading was high at 253 mg/dL (milligrams/deciliter) prior to the administration of the insulin. After the observed error was brought to the attention of LPN #11, the LPN asked if the nursing facility needed different insulin syringes so you could see the lines more clearly. Additionally she said,…

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 facility document review, it was determined the facility staff failed to ensure one of six medication carts were free from expired medications; the second medication cart on [NAME] Unit. The findings included: On 2/21/20 at 11:49 a.m., inspection of the second medication cart on the [NAME] Unit was conducted with LPN (Licensed Practical Nurse) #4. One bottle of Multivitamin One a Day gummies was found with an open date of 4/30/19. The expiration date documented 1/26/2020. When asked how often the medication carts were checked for expired items, LPN #4 stated that she checked the cart whenever she worked. When asked if the multivitamins were expired, LPN #4 checked the bottle and confirmed they had just hit the expiration date. LPN #4 then stated that the multivitamins belonged to (Name of Resident #3) and that she was taken off the multivitamin awhile back. LPN #4 then dumped the contents of the multivitamin bottle into the sharps container. Resident #3 was admitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff and resident interviews, the facility staff failed to ensure a program of activities were in place for 1 of 51 residents (Resident #110) in the survey. Resident #110 was not provided one-to-one activities based on the comprehensive plan of care for five months. The findings include: Resident #110 was admitted to the nursing facility on 10/4/17 with diagnoses that included high blood pressure, stroke with swallowing problems and quadriplegia (paralysis of all four limbs), a feeding tube, and respiratory failure with a tracheostomy (surgically created hole through the front of your neck and into your windpipe) and oxygen therapy. The most recent Minimum Data Set (MDS) was a quarterly dated 6/27/18 and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 5 out of a possible score of 15 which indicated the resident was severely impaired in the cognitive skills for daily decision making. The resident was totally dependent on two staff…

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

Based on clinical record review, staff interviews and facility documentation, the facility staff failed to ensure Medicare Beneficiary Notices in accordance with applicable Federal regulations, were issued to 2 of 52 residents (Resident #102 and 152) in the survey sample. 1. The facility staff failed to issue an Advanced Beneficiary Notice (ABN) letter to Resident #102 who was discharged from skilled services with Medicare days remaining. 2. The facility staff failed to issue an Advanced Beneficiary Notice (ABN) letter to Resident #152 who was discharged from skilled services with Medicare days remaining. The findings included: 1. Resident #102 `was admitted to the nursing facility on 3/16/18. Diagnosis for Resident #102 included but not limited to Heart Failure. Resident #102 Minimum Data Set (MDS) a quarterly assessment with an Assessment Reference Date (ARD) date of 6/19/18 coded Resident #102 a 09 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident with moderate cognitive impairment. On review of the Beneficiary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review, staff interviews and facility document review, the facility failed to notify the Office of the State Long-Term Care Ombudsman in writing of hospital discharges for 2 of 52 residents in the survey sample, Resident #142 and #44. 1. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #142's transfer and admission to the hospital on 1/4/18. 2. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #44 being transferred and admitted to the hospital. The finding include: Resident #142 was originally admitted to the facility on [DATE]. Diagnosis for Resident #142 included but not limited to *Congestive Heart Failure (CHF). *Heart failure is a condition in which the heart cannot pump enough blood to meet the body's needs. Heart failure does not mean that your heart has stopped or is about to stop working. It means that your heart is not able to pump blood the way it should. It can affect one or both…

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 documentation, the facility staff failed to issue bed hold notices for 2 (Residents #133 and #142) of 52 residents in the survey sample. 1. The facility staff failed to ensure Resident #133 or resident representative was issued a written notice of the bed hold policy prior to transfer to the local hospital. 2. The facility staff failed to provide Resident #142 or resident's representative with a written or a copy of the bed hold policy. The findings include: 1. Resident #133 was admitted to the nursing facility on 6/22/18 with diagnoses that included Parkinson's disease and muscle weakness. The most recent Minimum Data Set (MDS) assessment was a 30 day scheduled assessment dated [DATE] and coded the resident on the Brief Interview for Mental Status (BIMS) with a 15 out of a possible score of 15, which indicated the resident was intact in the cognitive skills needed for daily decision making. Resident #133 was discharged to the local hospital 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 The facility staff failed to obtain PASARR level I assessments prior to admission for two residents (Resident #17 and #85) in the survey sample of 52. The findings included: 1. Resident #17 was admitted to the facility on [DATE] with diagnoses of celliulitis of right lower limb, dementia, delirium due to other condition, confusion, disorientation psychosis, major depressive disorder, and Psychotic disorder with delusions. The facility staff failed to assess Resident #17 prior to admission for a mental disorder and services-PASARR level I assessment. A Care Plan dated 4/30/18 indicated: Problem: Dementia due to arteriosclerosis with behavioral disturbance. and Psychotic disorder with delusions due to known physiological condition. Intervention provide resident with medications and Psychiatric follow-up. A Psychiatric Progress note dated 3/14/18 indicated: This is a follow-up visit for a history of severe dementia with psychosis. Notable behavior/information charted in a nursing note dated March 11, 2018 where she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, and clinical record review, the facility staff failed to ensure 1 out of 52 residents (Resident #37) in the survey sample who were unable to independently carry out activities of daily (ADL), received necessary services to maintain grooming. 1. The facility staff failed to ensure Resident #37 was provided ADL care to include removal of long facial hair to her lower lip and chin. Findings include: Resident #37 was admitted to the facility on [DATE]. Diagnosis for Resident #37 included but are not limited to *Dementia without behavioral disturbances. Resident #37 Minimum Data Set (MDS) a quarterly with an Assessment Reference Date (ARD) of 5/10/18 coded Resident #37 with a 15 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. In addition, the MDS coded Resident #37 requiring total dependence of two with bathing, extensive assistance of one with dressing, personal hygiene and toileting. Section, E (Behavior)…

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

Based on staff interview, clinical record review, and review of the Hospice policy; the facility staff failed to ensure the Hospice Agency provided a written agreement describing the provision of services for 1 of 52 residents (Resident #101), in the survey sample. The facility staff failed to ensure the Hospice Agency provided the facility staff with the coordinated plan of care for Resident #101, to identify which services the Hospice Agency would provide, when the services would be provided, the communication process, and when or why the nursing facility staff should notify the Hospice Agency. The findings included: Resident #101 was originally admitted to the facility 5/23/18 and has never been discharged from the facility. The current diagnoses included; protein calorie malnutrition The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/19/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 4 out of a possible 15. This indicated Resident #101's cognitive abilities for daily decision making…

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 interviews and facility documentation review the facility staff failed ensure 1 of 52 residents (Resident #151) in the survey sample's indwelling Foley catheter tubing remained off the floor. The facility staff failed to provide appropriate indwelling Foley catheter care. The findings included: Resident #151 was admitted to the facility on [DATE]. Diagnosis includes but limited to *Benign Prostatic Hyperplasia (BPH). *Benign Prostatic Hyperplasia (BPH) is a nonmalignant, non-inflammatory enlargement of the prostate, most common among men over [AGE] years of age (Mosby's Dictionary of Medicine, Nursing and Health Professions). The current Minimum Data Set (MDS) a comprehensive assessment with an Assessment Reference Date (ARD) of 02/1/17 coded the resident with a 11 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating cognitive impairment. In addition, the MDS coded Resident #151 with dependent of one with bathing, extensive assistance of one 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 information obtain during a complaint investigation, resident interview, staff interviews, and facility documentation review, the facility staff failed to ensure 1 of 52 residents was free from unnecessary drugs for (Resident #232), in the survey sample. The facility staff administered excess doses of Prednisone totaling of 50 mg everyday to Resident #232, from 12/17/17 through 12/20/17. The findings included: Resident #232 was originally admitted to the 11/3/17 and discharged from the facility 1/3/18. The admission diagnoses included; inflammatory and immune myopathy. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/10/17 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #232's cognitive abilities for daily decision making were intact. In section D (Mood) the resident was coded for feeling down on day, having trouble sleeping one day, feeling tired 7-11 days and feeling bad about himself one day. In section G (Physical functioning) 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 information obtain during a complaint investigation, resident interview, staff interviews, and facility documentation review, the facility staff failed to ensure 1 of 52 residents was free from significant medication error for (Resident #232), in the survey sample. The facility staff abruptly discontinued administration of Prednisone to Resident #232, against the prescriber's order and without tapering (a gradual dose reduction) a medication which can result in withdrawal syndrome. The findings included: Resident #232 was originally admitted to the 11/3/17 and discharged from the facility 1/3/18. The admission diagnoses included; inflammatory and immune myopathy. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/10/17 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #232's cognitive abilities for daily decision making were intact. In section D (Mood) the resident was coded for feeling down on day, having trouble sleeping one day, feeling…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and facility documentation review the facility staff failed to ensure medications were stored in a secured location for 1 (Resident #142) of 52 residents in the survey sample. The facility staff failed to ensure the following medications, Cortizone 10 liquid and Arctic Ice Analgesic gel were stored in a secured location. The medications were observed on Resident #142's overbed table. The finding include: Resident #142 was originally admitted to the facility on [DATE]. Diagnosis for Resident #142 included but not limited to *Congestive Heart Failure (CHF). *Heart failure is a condition in which the heart cannot pump enough blood to meet the body's needs. Heart failure does not mean that your heart has stopped or is about to stop working. It means that your heart is not able to pump blood the way it should. It can affect one or both sides of the heart (Mosby's Dictionary of Medicine, Nursing & Health Professions, 7th Edition). The current Minimum Data Set (MDS), a significant…

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

Based on staff interview, clinical record review, and review of the Hospice policy; the facility staff failed to ensure the Hospice Agency provided a written agreement describing the provision of services for 1 of 52 residents (Resident #101), in the survey sample. The facility staff failed to ensure the Hospice Agency provided the facility staff with the coordinated plan of care for Resident #101, to identify which services the Hospice Agency would provide, when the services would be provided, the communication process, and when or why the nursing facility staff should notify the Hospice Agency. The findings included: Resident #101 was originally admitted to the facility 5/23/18 and has never been discharged from the facility. The current diagnoses included; protein calorie malnutrition The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/19/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 4 out of a possible 15. This indicated Resident #101's cognitive abilities for daily decision making…

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.