Autumn Care Of Norfolk

Based on staff interview and review of facility documents, the facility staff failed to inform residents, their representatives, and families of those residing in the facility by 5 p.m., the next calendar day following the occurrence of confirmed infection of COVID-19 or include cumulative updates for residents, their representatives, and families at least weekly with mitigating actions implemented to prevent or reduce the risk of transmission. The findings included: A review of facility documents revealed on 11/25/22 a staff member tested positive for COVID-19 and by 12/1/22 twenty staff were positive for COVID-19. On 11/27/22 twenty-four residents tested positive for COVID-19 and by 12/1/22 a total of 32 residents tested positive for COVID-19. On 12/1/22 the facility's staff issued a letter titled Confirmed or Probable COVID-19 Cases. The letter read unfortunately, despite our efforts, like so many other communities, like ours we too have had additional staff and resident test positive for COVID-19. While this is not unexpected, it still saddens us, and our hearts go out to those…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to provide the required documentation at the time of a transfer to the hospital for three of 44 residents in the survey sample, Residents #13, #33, and #108. The findings include: 1. Resident #13 was admitted to the facility on [DATE] with diagnoses that included but were not limited to muscle weakness, heart failure, high blood pressure, repeated falls, and dementia. Resident #13's most recent MDS (minimum data set) assessment was a significant change assessment with an ARD (assessment reference date) of 6/19/19. Resident #13 was coded as being severely impaired in cognitive function scoring 99 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #13's clinical record revealed that he was sent out to the hospital on two occasions; 9/14/19 and 9/15/19. The following note was documented on 9/14/19: Resident had fall this shift. Neuro checks and vitals…

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 activities to support the physical, mental, and psychosocial well-being of two of 44 residents in the survey sample, Resident #96 and #31. The findings Include: 1. Resident #96 was admitted to the facility on [DATE] with diagnoses that included but were not limited to anoxic brain damage, gastronomy status (feeding tube), and post stroke. Resident #96's most recent comprehensive MDS (minimum data set) assessment with an admission assessment with an ARD (assessment reference date) of 5/22/19. Resident #96 was coded in Section B (Hearing, Speech , Vision) as being in a persistent vegetative state. Section F (Preferences for Customary Routine and Services) could not be filled out or completed due to the his vegetative state. On 9/10/19 through 9/12/19 several observations were made of Resident #96. He was lying in bed with television on. Resident #96 could not verbally…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interviews, clinical record review and facility documentation review the facility staff failed to failed to provide evidence a care plan meeting was held and/or invite 1 of 44 residents to attend their person centered care plan meeting (Resident #264) in the survey sample. The findings included: Resident #264 was admitted to the facility on [DATE]. Diagnosis for Resident #264 included but not limited to Acute Kidney Failure. Resident #264's Minimum Data Set (MDS-an assessment protocol), a 14-day assessment with an Assessment Reference Date of 08/19/19, coded Resident #264's Brief Interview for Mental Status (BIMS) score of 14 out of a possible score of 15 indicating no cognitive impairment. During the initial tour on 09/17/19 at approximately 11:41 a.m., an interview was conducted with Resident #264 who stated, No one has ever given me a letter or invited me to attend a care plan meeting. An interview was conducted with the Social Worker (SW) on 09/18/19 at approximately 11:24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview and facility documentation review, the facility staff failed to ensure resident rights were maintained for a facility initiated room change for 1 of 44 residents (Resident #264) in the survey sample. The findings included: Resident #264 was admitted to the facility on [DATE]. Diagnosis for Resident #264 included but not limited to Acute Kidney Failure. Resident #264's Minimum Data Set (MDS - an assessment protocol), a 14-day assessment with an Assessment Reference Date of 08/19/19 coded Resident #264's Brief Interview for Mental Status (BIMS) score of 14 out of a possible score of 15 indicating no cognitive impairment. In addition, the MDS coded Resident #264 total dependence of one with bathing, extensive assistance of two with transfer, extensive assistance of one with dressing, hygiene, bed mobility and toilet use for Activities of Daily Living. During the initial tour on 09/17/19 at approximately 11:41 a.m., Resident #264 voiced concerns that she was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interviews the facility staff failed to ensure 1 of 44 residents (Resident #74) mobility wheelchair was in good repair. Resident #74's wheelchair had a worn, torn and cracked left armrest pad. The findings included: Resident #74 was admitted to the facility on [DATE]. Diagnoses for Resident #74 included but not limited to, Metabolic Encephalopathy. The current Minimum Data Set (MDS), a 14-day assessment with an Assessment Reference Date (ARD) of 07/16/19 coded the resident with a 08 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. In addition, the MDS coded Resident #74 requiring extensive assistance of one with transfer, dressing, eating, hygiene, bathing, bed mobility and toilet use. The MDS also included extensive assistance of one on and off the unit. The MDS was coded under section G 0600 for wheelchair for mobility devices. During the initial tour of the facility on 09/17/19 at approximately 11:00 a.m.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to provide written bed hold notification at the time of a facility-initiated transfer for one of 44 residents in the survey sample, Resident #33. The findings included: Resident #33 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to, urinary tract infection, Parkinson's disease, occlusion of the bilateral carotid arteries, presence of cardiac pacemaker, type two diabetes and Bipolar disorder. Resident #33's most recent MDS (Minimum Data Set) assessment was a 14 day scheduled assessment with an ARD (assessment reference date) of 7/2/19. Resident #33 was coded as being cognitively intact scoring 15 out of possible 15 on the BIMS (Brief Interview For Mental Status) exam. Review of Resident #33's nursing notes revealed the resident had been transferred to the hospital on 6/7/19 and was admitted back to the facility on 6/18/19…

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

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 that the Minimum Data Set (MDS) assessment accurately reflected 2 residents (Resident #84, #116) of 44 residents in the survey sample. The findings included: 1. For Resident #84, the facility staff coded an inaccurate active diagnosis. Resident #84 was admitted to the facility on [DATE]. Diagnoses included but were not limited to, Viral Hepatitis and Diabetes Mellitus. Resident #84's Quarterly Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 08/10/2019 was coded with a BIMS (Brief Interview for Mental Status) score of 14 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #84 as requiring extensive assistance of 1 with bed mobility and dressing and total dependence of 1 with toilet use, personal hygiene and bathing. On 09/19/2019 review of Resident #84's diagnosis information in the clinical record revealed a diagnosis of Chronic Viral Hepatitis…

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 Facility staff failed to ensure the baseline care plan for one of 44 residents in the survey sample, Resident #214, included care for her fractured right shoulder and right femur. The findings include: Resident #214 was admitted to the facility on [DATE] with diagnoses that included but were not limited to, fracture of upper end of right humerus, type two diabetes mellitus, and dementia without behavioral disturbance. Resident #214 did not have a completed MDS (Minimum Data Set) assessment as it was not due. Review of Resident #214's September 2019 POS (physician order sheet) revealed the following orders written on 9/12/19: Continue use of sling to right arm. No range of motion to shoulder. Continue hand and wrist (physical therapy). RLE (right lower extremity) - partial weight bearing only. Review of a physical therapy note dated 9/13/19, documented the following: 74 yr (year) old was hospitalized after falling on steps after tripping on her clothes while trying to go down steps without rails to go do laundry.…

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, family interview, staff interview, facility document review, and clinical record review, it was determined that facility staff failed to develop an activity care plan for one of 44 residents in the survey sample, Resident #96. The findings include: Resident #96 was admitted to the facility on [DATE] with diagnoses that included but were not limited to, anoxic brain damage, gastronomy status (feeding tube), and post stroke. Resident #96's most recent comprehensive MDS (Minimum Data Set) assessment with an admission assessment with an ARD (assessment reference date) of 5/22/19. Resident #96 was coded in Section B (Hearing, Speech , Vision) as being in a persistent vegetative state. Section F (Preferences for Customary Routine and Services) could not be filled out or completed due to the his vegetative state. On 9/10/19 through 9/12/19 several observations were made of Resident #96. He was lying in bed with the television on. Resident #96 could not verbally respond when spoken to. Resident #96…

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 the comprehensive person centered care plan for 2 of 44 residents in the survey sample, Resident #68 and #13. The findings included: 1. The facility staff failed to revise Resident #68's comprehensive person centered care plan to remove the usage of an antidepressant medication. Resident #68 was admitted to the facility 11/17/15. Diagnoses for Resident #68 included but not limited to, Depression. Resident #68's MDS (Minimum Data Set), a significant change assessment with an Assessment Reference Date (ARD) of 07/22/19, coded Resident #68 with a BIMS (Brief Interview for Mental Status) score of 99 indicating short and long-term memory problems and with moderate cognitive impairment. Resident #68's person-centered comprehensive care plan with a revision date of 02/08/19 documented that Resident #68 uses antidepressant medication related to depression. The goal: will be free from discomfort or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview and facility documentation review, the facility staff failed to follow physician orders for 1 of 44 residents (Resident #65) in the survey sample. The facility staff failed to follow physician orders for the application and removal of Icy Hot Patches to bilateral knees. The findings included: Resident #65 was admitted to the facility on [DATE]. Diagnosis for Resident #65 included but not limited to Muscle Weakness. Resident #65 Minimum Data Set (MDS-an assessment protocol), a quarterly with an Assessment Reference Date of 07/23/19 coded Resident #65's Brief Interview for Mental Status (BIMS) score of 15 out of a possible score of 15 indicating no cognitive impairment. In addition, the MDS coded Resident #65 as total dependence of two with transfer, extensive assistance of two with bathing, bed mobility and toilet use, extensive assistance of one with dressing and hygiene. Resident #65's Comprehensive person-centered care plan with a revision date of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, and clinical record review, it was determined that facility staff failed to provide treatments per physician's order to promote the healing of a pressure ulcer for one of 44 residents in the survey sample, Resident #108. The findings include: Resident #108 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to enlarged prostate, retention of urine, and high blood pressure. Resident #108's most recent MDS (Minimum Data Set) was a five day scheduled assessment with an ARD (assessment reference date) of 8/27/19. Resident #108 was coded as being severely impaired in cognitive function scoring 99 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #108 was coded in Section M (skin conditions) as having one Stage 4 (1) and two unstageable pressure ulcers* (2). Review of Resident #108's weekly wound reports revealed that Resident #108 had a stage 4 pressure ulcer…

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, facility document review and closed record review, it was determined that facility staff failed to prevent elopement of a known resident who wanders for one of 44 residents in the survey sample, Resident #114. The findings included: Resident #114 was admitted to the facility on [DATE] and discharged to the community on 02/07/2019. He was readmitted to the facility on [DATE] and discharged to the hospital on [DATE]. Diagnoses included but were not limited to, Unspecified Dementia without Behavioral Disturbance and Post Traumatic Stress Disorder. Resident #114's admission Minimum Data Set (MD-an assessment protocol) with an Assessment Reference Date of 03/18/2019 was coded with short term memory problems and long term memory problems and with moderately impaired cognitive skills for daily decision making. In addition, the Minimum Data Set coded Resident #114 as requiring supervision of 1 person for transfer, walking in room, walking in corridor, locomotion on unit 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 observations, staff interview and clinical record review it was determined that facility staff failed to obtain an order for a indwelling catheter for one of 44 residents in the survey sample, Resident # 108. The findings included: Resident #108 was admitted to the facility on [DATE]. Diagnoses included but were not limited to, Obstructive Uropathy and Dementia. Resident #108's most recent Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 08/27/2019 coded Resident #108 with short term memory problems and long term memory problems and with severely impaired cognitive skills for daily decision making. In addition, the Minimum Data Set coded Resident #108 as requiring extensive assistance of 1 with dressing, eating and personal hygiene, extensive assistance of 2 with bed mobility and transfer, total dependence of 1 with bathing and total assistance of 2 with toilet use. On 09/19/ 2019 at approximately 11:00 a.m., Resident #108 was observed lying in bed with an indwelling…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to act upon pharmacy recommendations for one of 44 residents in the survey sample, Resident #17; and failed to include a timeframe in their policies and procedures for the monthly drug regimen review processes. The findings include: Resident #17 was admitted to the facility on [DATE] with diagnoses that included but were not limited to muscle weakness, cognitive communication deficit, high blood pressure, type two diabetes and major depressive disorder. Resident #17's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 6/22/19. Resident #17 was coded in section N (Medications) as receiving one anticoagulant (blood thinner) in the last seven days. Review of Resident #17's clinical record revealed the following pharmacy recommendation was made in January, February and March of 2019: (Name of Resident #17) receives apixaban…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview and facility documentation review, the facility staff failed to ensure a complete and accurate clinical record for 1 of 44 residents (Resident #65) in the survey sample. The findings included: The facility staff failed to ensure Resident #65's Treatment Administration Record (TAR) was accurate for the application of Icy Hot Patches to bilateral knees. Resident #65 was admitted to the facility on [DATE]. Diagnosis for Resident #65 included but not limited to, Muscle Weakness. Resident #65's Minimum Data Set (MDS-an assessment protocol), a quarterly assessment with an Assessment Reference Date of 07/23/19 coded Resident #65's Brief Interview for Mental Status (BIMS) score of 15 out of a possible score of 15 indicating no cognitive impairment. In addition, the MDS coded Resident #65 total dependence of two with transfer, extensive assistance of two with bathing, bed mobility and toilet use, extensive assistance of one with dressing and hygiene. 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 interviews, clinical record review and facility document review, the facility staff failed to provide the resident or residents representative education regarding the benefits and potential side effects of influenza immunization for 2 of 44 residents in the survey sample, Residents #54, #84. The findings included: 1. Resident #54 was admitted to the facility on [DATE]. Diagnoses included but were not limited to, Cerebral Palsy and Dementia. Resident #54's Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of 07/12/2019 was coded with a BIMS (Brief Interview for Mental Status) score of 14 indicating no cognitive impairment. In addition, Section O - Influenza Vaccine was coded as-the resident did not receive the influenza vaccine in this facility for this year's influenza season. The reason influenza vaccine not received-Offered and declined. On 09/19/2019 at approximately 12:00 p.m., the surveyor requested documentation evidencing that Resident #54 and/or 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, and staff interviews, the facility staff failed to maintain the residents environment in a clean, safe and comfortable manner. During the environment inspection on 2/6/18 through 2/14/18 the facility failed to ensure housekeeping and maintenance services were provided to maintain a sanitary, orderly and comfortable environment. The findings included: On the Two Hundred Unit: room [ROOM NUMBER] was observed to have a large cracked in the wall at bed A. The rubber base board was observed to be coming off at the right corner of the sink. room [ROOM NUMBER] was observed to have a very rusty over bed light fixture. The corner wall guard next to the sink was observed to be ill repaired. The wall next to the bathroom was observed to have peeling paint. On the Three Hundred Unit: room [ROOM NUMBER] was observed to have a hole in the wall that measured approximately one inch wide and 7 inches long at the window side of the room. room [ROOM NUMBER] was observed to have the dresser drawers coming…

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 review, the facility failed to revise comprehensive person centered care plans for 3 of 56 residents (Residents #87, #88 and #51 in the survey sample). 1. The facility staff failed to revise Resident #87's person centered care plan to include resident options with rehab services. 2. The facility staff failed to revise Resident #88's person centered care plan to include hospice services. 3. The facility staff failed to revise the care plan for Resident #51 to include the need for a CPAP unit. The findings included: 1. Resident #87 was originally admitted to the nursing facility on 01/10/2018. Diagnosis for included but not limited to *Enterocolitis due to *Clostridium Difficle (C-Diff). *Enterocolitis is an inflammation involving both the large and small intestines. *C-Diff is a bacterium that causes diarrhea (https://medlineplus.gov/clostridiumdifficileinfections.html). The current Minimum Data Set (MDS) with an Assessment Reference…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure adequate respiratory care for 3 of 56 residents in the survey sample (Residents #51, #7, and #84). 1. The facility staff failed to ensure a Continuous Positive Air Pressure (CPAP) device was on Resident #51 per Physician Orders, and failed to ensure Resident #51 had a filter in her nebulizer. 2. The facility staff failed to ensure a CPAP device was on Resident #7, failed to ensure the CPAP unit was cleaned per facility Policy and Procedure, and failed to ensure Resident's nebulizer filter was changed. 3. The facility staff failed to ensure CPAP device was on Resident #84. The findings included: 1. Resident #51 was admitted to the facility on [DATE]. Diagnoses for Resident #51 included but not limited to Heart Failure, Chronic Obstructive Pulmonary Disease and Diabetes. Resident #51's Quarterly 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.

Based on observation, staff interview, and facility documentation review, in the facility staff failed to ensure foods were stored and prepared in a sanitary manner. The findings included: During the initial kitchen tour on 2/6/18 at approximately 10:30 AM, the following were observed: 1 opened French dressing with dressing dripping down the sides with no open date 1 staff water stored in the main Kitchen Refrigerator 1 can opener with sticky black substance on the blade 1 spray bottle of bleach sitting in the main kitchen area on top of the handwashing sink trash can On 2/14/18 at approximately 11:15 AM, an observation was made of the steam table base. Food particles of 1 small orange square looking like a piece of carrot and some beige substances floating in the water under the steam trays. A Dietary Staff member # was asked when the steam tray table was cleaned and he stated, it was cleaned at the end of the day. When asked what the items were floating in the water he stated, the orange item was a carrot from the previous day's meal. Then asked, if it is a carrot from yesterdays…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to maintain an infection prevention and control program to provide safe and sanitary environment and to help prevent the development and transmission of communicable disease and infection for 3 of 56 residents in the survey sample (Residents #7, #105, and #365), and in the facility Dining Room. The facility also failed to maintain an effective infection control system to prevent nosocomial infections. 1. The facility staff failed to ensure infection control measures were implemented in Continuous Positive Airway Pressure (CPAP) care for Resident #7. 2. The facility staff failed to ensure infection control measures were implemented between feeding of Residents in the Dining Room. 3. The facility staff failed to maintain an effective Infection Control Program to prevent nosocomial infections (Nosocomial-originating or taking place in a hospital or other health care facility);…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and facility document review, the facility staff failed to assess a resident for self-administration of medications for 1 of 56 residents (Resident #42) in the survey sample. The facility staff failed to assess Resident #42 for self-administration of Saline Nasal Spray Solution. The findings included: Resident #42 was originally admitted to the facility on [DATE]. Diagnosis for Resident #42 included but are not limited to Atrial Fibrillation. The current Minimum Data Set (MDS) a quarter with an Assessment Reference Date (ARD) of 12/14/17 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. During medication pass and pour on 02/09/18 at approximately 5:06 p.m., a bottle of Saline nasal spray was located on the resident's nightstand. The surveyor asked the License Practical Nurse (LPN) #4 if the Saline Nasal Spray should be at resident's bedside, she replied, Yes, there's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 1 of 56 residents (Residents #22) in the survey sample. The findings included: Resident #22 was admitted to the nursing facility on 9/26/17 with diagnoses that included heart failure and generalized weakness. The Minimum Data Set (MDS) assessment dated [DATE] was a quarterly and coded the resident with a 13 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident had no problems in the skills needed for daily decision making. On review of the Beneficiary Notification Checklists provided by the facility it was noted that Resident #22 was not listed for having been issued the SNF ABN (Skilled Nursing Facility-Advanced Beneficiary Notice, form CMS-10055). The resident had received a NOMNC (Notice of Medicare Provider Non-Coverage- form CMS-10123), however no…

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 assure that 1 of 56 residents (Resident #105) in the survey sample received a complete and accurate assessment. The findings include: Resident #105 was admitted to the facility on [DATE]. Diagnosis for Resident #105 included but not limited to Major Depressive Disorder. Resident #105's MDS with an Assessment Reference Date of 01/24/18 coded the resident with a BIMS score of 11 out of a possible 15, indicating moderate cognitive impairment. In addition, the MDS coded Resident #105 requiring total dependence of two with transfers, dependence of one with dressing, eating and toilet use, extensive assistance of one with bed mobility, personal hygiene and bathing. In addition, under section J under (Health Conditions) asked the question, Should Pain Assessment be Conducted the MDS was coded yes; continued review of the MDS under section J was also marked with all dashes. An interview was conducted with 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 observation, resident interview, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure the baseline care plan summary was provided for 2 residents of 56 in the survey sample (Resident #313 and Resident #365). The findings included: Resident #313 was admitted to the facility on [DATE]. Diagnoses for Resident #313 included but are not limited to Asthma and Diabetes. Resident #313's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/2/18, coded Resident #313 with short and long term memory problems and with severely impaired cognitive skills for daily decision making. Resident #313 was totally dependent on two staff for bed mobility, transfers, dressing and personal hygiene. Resident #313 was coded with a wheel chair for mobility device. Resident #313 balance was assessed as not steady, only able to stabilize with staff assistance. The Administrator was asked how the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interviews, and review of the facility's documentation, the facility staff failed to ensure the necessary treatment was provided to prevent infection and promote healing for 1 of 56 residents (Resident #365) in the survey sample. The facility staff failed to ensure during wound care a standard to promote healing and prevent the spread of infection. The findings included: Resident #365 was admitted to the facility on [DATE]. Diagnosis for Resident #365 included but not limited to *Methicillin Resistant Staphylococcus Aureus Infection (MRSA) and *Unstageable sacral pressure ulcer wound. *MRSA is a bacterium that causes infections in different parts of the body. It is tougher to treat than most strains of staphylococcus aureus or staph - because it is resistant to some commonly used antibiotics. *Pressure Ulcer is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present…

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 appropriate care of a catheter for 1 of 56 residents (Resident #25) in the survey sample. Resident #25's suprapubic catheter bag was observed on the floor inside its protective cover. The findings included: Resident 25 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 12 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating cognitive impairment. In addition, the MDS coded Resident #10 with dependent of one with bathing, extensive assistance of two with bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to ensure 1 Resident (Resident #313) of 56 in the survey sample was assessed and given measures for pain control during the 4.25 hours she remained sitting in her wheel chair. The findings included: Resident #313 was admitted to the facility on [DATE]. Diagnoses for Resident #313 included but are not limited to Asthma, Adult Failure to Thrive and Diabetes. Resident #313's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 2/2/18 coded Resident #313 with short and long term memory problems and coded Resident #313 severely impaired cognitive skills for daily decision making. The Resident was unable to answer pain presence on the admission MDS. Staff assessment for pain included: non-verbal sounds and facial expressions. The Resident was scored a 2 for indicators of pain or possible pain, meaning pain/possible pain was observed 3 to 4 days in the last 5…

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

Based on observation, staff interviews, and facility documentation review, the facility staff failed to ensure one medication cart for 1 of 2 units (Unit 1) was stored in a secured location, accessible to designated staff only. The facility staff failed to ensure medication cart containing medication in the hallway was locked when not in direct sight of the nurse. The findings include: During the initial tour of the facility on 2/6/18 at approximately 9:10 a.m., the medication cart on the front hall was observed unlocked when not in direct view of the nurse. Residents were observed walking past the cart. On the same day at approximately 9:15 a.m., an interview was conducted with the Director of Nursing (DON) who stated, The nurse should have ensured the medication cart was secure before she left her cart. An interview was conducted with License Practical Nurse (LPN) #1 on 2/6/18 at approximately 9:20 a.m., who stated, I thought I had locked my medication cart; I went to get a name badge so the surveyors could identify me. The surveyor asked the unit manager if the medication cart…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility staff failed to ensure complete documentation for Medication Administration Records for 3 Residents out of 56 in the survey sample (Resident #58, Resident #67, and Resident #8). The findings included: 1. Resident #58 was readmitted to the facility on [DATE]. Diagnoses included but were not limited to Diabetes, Right Below the Knee Amputation, Non-Alzheimer's Disease and Seizure disorder. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/27/17 coded Resident #58 as scoring a 15 out of a possible 15 on the BIMS (Brief Interview for Mental Status), indicating no cognitive impairment. The Resident required supervision with 1 staff assistance for bed mobility, transfer, locomotion on and off the Unit, and personal hygiene. The Resident required Extensive Assistance with one staff for toilet use and bathing. The Comprehensive Person Centered Care Plan with a revision date of 4/20/17 identified the resident was at risk…

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, the facility staff failed to ensure the Medical Director attended and signed the quarterly Quality Assurance (QA) meetings. The findngs included: On 02/13/18 1:39 PM an interview was conducted with the Administrator regarding the facility's Quality Assessment and Assurance (QAA) program. The quarterly sign in sheets acknowledging committee members attendance were reviewed for 3/19/17, 5/11/17, 8/25/17, and 10/27/17. On the 10/27/17 QAA sign in sheet, it was identified that the Medical Director's signature was not present. There was no other staff identifed as a designee for the Medical Director on the sign in sheet. The facility policy titled, QAPI (Quality Assurance and Performance Improvement) effective 11/28/17 documented in part, as follows: 4). The facility will maintain a QAPI committee consisting at a minimum of: b) The Medical Director or his or her designee; 8). A separate sign-in sheet will be maintained with the date of the meeting and Committee member name, title, and signature to be provided, as requested, 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.