Norview Heights Rehabilitation And Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to monitor daily weights and Blood Sugar checks per physician's orders for 1 of 24 residents (Resident #15), in the survey sample. The findings included: Resident #15 was originally admitted to the facility on [DATE] and readmitted on [DATE] after an acute care hospital stay. The current diagnoses included; Type 2 Diabetes Mellitus without Complications, Moderate Protein Calorie Malnutrition and Dysphagia, Oropharyngeal Phase. The Quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/05/2021 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #15 cognitive abilities for daily decision making were intact. In section G(Physical functioning) the resident was coded as requiring limited assistance of two persons for bed mobility, transfers and dressing.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to monitor one resident after sustaining an injury after falling by obtaining neurological checks. For 1 of 24 residents (Resident #16), in the survey sample. The findings included: Resident #16 was originally admitted to the facility on [DATE] after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Cerebral Infarction Unspecified and Muscle weakness. The admissions Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/13/2021 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #16 cognitive abilities for daily decision making were intact. In section G(Physical functioning) the resident was coded as requiring extensive assistance of one person for bed mobility, transfers, dressing, eating…

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

Based on observation, staff interview, and clinical record review, the facility's staff failed to ensure appropriate care and services were provided to prevent/reduce trauma to the urethra and bladder, and other complications such as pressure ulcer development while utilizing an indwelling catheter for 1 of 32 residents (Resident #8), in the survey sample. The findings included: Resident #8 was originally admitted to the facility 8/29/20 and had never been discharged from the facility. The current diagnoses included; a neurogenic bladder, urinary retention with voiding trial failures. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/11/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #8's cognitive abilities for daily decision making were intact. In section H0100 the resident was coded for having an indwelling catheter. Resident #8 had a physician's order for an indwelling urinary Foley catheter to straight drainage 16 French with a 10 milliliter…

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 ensure ongoing communication and collaboration with the dialysis facility for one resident (Resident #6) in the survey sample of twenty four residents. The findings included: Resident #6 was admitted to the facility on [DATE] with diagnoses which included diabetes, end stage renal disease, failure to thrive, chronic kidney disease, congestive heart failure, hypertension, and a history of sepsis. The facility staff failed to ensure Resident #6 daily dialysis communication book was available. A Quarterly Minimum Data Set (MDS) dated [DATE] assessed this resident in the area of Cognitive Patterns (Brief Interview for Mental Status) BIMS as a 9. A Care Plan dated 10/26/21 indicated that this resident received dialysis services. Dialysis - AV fistula shunt- palpate gently over area with fingertips or palm of hand. Check complete dialysis communication log record on return from dialysis appointments for any reports. Collaborate with RD at dialysis center about weights, outcomes of…

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

Based on the facility's medication storage review of 1 medication cart and 1 medication room; the facility staff failed to ensure two opened containers of eye drops included the opened date. The findings included; On 10/26/21 at approximately 1:15 PM a medication cart audit was conducted with LPN (Licensed Practical Nurse) #1. Stored inside of the medication cart were two opened bottles of eye drops without open dates written on the bottles. (Latanoprost 0.095% expires 7/20/22 and Opthalmic Ultra eye drops expire 7/20/22). LPN #1 stated. They should put a date on them. On 10/26/21 at approximately 2:00 PM an interview was conducted with RN (Registered Nurse/Unit Manager) #1 concerning the above eye drops. She stated. When they open a bottle they should put a date on them. If no date they should discard and reorder the medications. On 10/28/21 at approximately 4:25 p.m., the above findings were shared with the Administrator and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and facility documentation review the facility staff failed to provide a safe, functional, sanitary, and comfortable environment for residents by not removing debris from two storage shed fires. The findings included; On 10/26/21 at approximately 1:15 PM an observation of the facility's dumpster area was conducted with the Food Service Director (FSD). Located near the dumpsters were the charred remains from two storage sheds. The first storage shed was completely burned to the ground and the second storage shed was partially burned. Located on the grounds were charred medical equipment, binders, scattered papers, Wheel chairs, several gallon jugs of water. An existing tree was located near the charred remains of the first shed with charred marks about 100 feet high upon it. There were two separate piles of wooden pallets near the charred remains. Some of the Charred debris was scattered beyond the parameters of the storage sheds near the sidewalk and building. The Food…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a complaint investigation, staff interview, facility documentation review, and clinical record review, the facility staff failed notify 1 of 38 residents in the survey sample, Resident #202, Responsible Party of changes in condition. The findings included: The facility staff failed to notify Resident #202's Responsible Party (RP) of facility acquired pressure ulcers. Resident #202 was originally admitted to the facility on [DATE]. Resident #202 was discharged to the hospital on [DATE]. Diagnoses for Resident #202 include but not limited to Disruption of wound and Vascular dementia without behavioral disturbance. Resident #202's Minimum Data Set (MDS-an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of 01/30/19 coded Resident #202's Brief Interview for Mental Status (BIMS) a 99 indicating short and long-term memory problems and cognitive skills severely impaired-never/rarely made decisions. In addition, the MDS coded Resident #202 total dependence of one with 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 Facility staff failed to ensure the required documentation was sent upon transfer to the hospital for seven of 38 residents in the survey sample, Resident #12, #20, #48, #40, #34, #200 & #11. The findings included: 1. Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to heart failure, high blood pressure, and dementia. Resident #12's most recent MDS (minimum data set assessment) was a quarterly assessment with an ARD (assessment reference date) of 8/12/19. Resident #12 was coded as being severely impaired in cognitive function scoring 99 out of a possible 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #12's nursing notes revealed that Resident #12 had been sent out to the hospital on 8/2/19. The following note in part was documented, .Resident exited facility apprx (approximately) 830am. Son, (Name of son) contacted and aware of patient change of condition. Resident was admitted to (Name of hospital) r/t…

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 interviews, clinical record review, and review of the facility's policy the facility staff failed to ensure residents received necessary activities of daily care to include; showers, shampoos, and finger nail care for 4 of 38 residents (Resident #149, #44, #5 and #48), in the survey sample. The findings included: 1. The facility's staff failed to ensure Resident #149 preferences for showers and shampoos were performed. Resident #149 was originally admitted to the facility 8/16/19 and had never been discharged from the facility. The current diagnoses included transient ischemia attack, generalized weakness, underweight and history of falling. The admission Minimum Data Set (MDS) assessment had not been completed therefore information was obtained from the nursing admission assessment dated [DATE]. The assessment stated the resident was alert and oriented to three spheres, she could understand written and spoken information and make her needs known. It also revealed…

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

Based on observations, staff interviews and facility document review the facility staff failed to ensure drugs were dated when opened in accordance with currently accepted professional principles on 2 out of 4 medication carts; and failed to remove 2 boxes of expired Influenza Vaccine from the refrigerator in the Medication Storage Room. The findings included: On 08/20/2019 at 11:00 a.m., the Blue medication cart on the 100 Hall was inspected with Licensed Practical Nurse (LPN) #5. Dorzolamide 2% eye drops was observed opened and did not have an open date on the product. LPN #5 was asked, Should the eye drops have been dated when they were opened? LPN #5 stated, Yes. LPN #5 was asked, Are the eye drops dated indicating when they were opened? LPN #5 stated, No. LPN #5 was asked, How long are the eye drops good for after opening? LPN #5 stated, 28 days. LPN #5 stated, I will get rid of them. The Surveyor inspected the Immunization refrigerator in the Medication Storage Room with LPN #5 and observed the following: a vial of Aplisol 50 5T Solution, marked House Stock, that had been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. The facility failed to implement appropriate infection control practices after utilizing a shared blood glucose meter. Blood glucose meters are devices that measure blood glucose levels. A medication administration pass observation was conducted with Licensed Practical Nurse (LPN) #5 on 8/20/19 at 4:30 p.m. The nurse obtained Resident #24's blood glucose using a shared glucometer. After obtaining the reading the nurse put the glucometer back into the medication cart without cleaning or sanitizing it first. After the medication pass the observation was shared with the nurse. LPN #5 stated, We do know to clean it after use. LPN #5 was not observed removing the glucometer to clean it after the issue was identified. The glucometer was not observed being used on another resident. Resident #24 was admitted to the facility on [DATE] with diagnoses to include, but not limited to, type 2 diabetes. The manufacturer's instructions for the blood glucose meter indicated the glucometer should be disinfected with approved…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility document review, it was determined that facility staff failed to ensure a clean, comfortable and homelike environment for two of 38 residents in the survey sample, Resident #5 and #11. The findings included: 1. Facility staff failed to ensure Resident #5's reclining chair was free from a large rip located directly where his head rests, prior to placing him in the chair. Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to cerebral palsy, severe intellectual disability, and high blood pressure. Resident #5's most recent MDS (minimum data set) assessment was quarterly assessment with an ARD (assessment reference date) of 8/7/19. Resident #5 was coded as being severely impaired in cognitive function on the Staff Assessment for Mental Status exam. On 8/20/19 at 11:16 a.m., Resident #5's reclining chair was out in the hallway with his name on the chair. The middle of…

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

Based on clinical record review and staff interviews the facility staff failed to encode a quarterly Minimum Data Set (MDS) assessment prior to 92 days after the previous Omnibus Budget Reconciliation Act (OBRA) MDS assessment for 1 of 38 residents (Resident #25), in the survey sample. The findings included: Resident #25 was originally admitted to the facility 4/4/19 and he had never been discharged from the facility. The current diagnoses included; Huntington's disease, a seizure disorder and dysphagia. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/11/19 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as moderately impaired abilities for daily decision making. In section G (Physical functioning) the resident was coded as requiring extensive assistance of two with bed mobility, transfers and eating, total care of one with locomotion, dressing, toileting, personal hygiene and bathing. On 8/21/19 a review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident interview, and staff interviews, the facility staff failed to ensure the baseline care plan included preferences for activities of daily living which included showers and shampoos for 1 of 38 residents in the survey sample, Resident #149. The findings included: Resident #149 was originally admitted to the facility 8/16/19 and had never been discharged from the facility. The current diagnoses included; transient ischemia attack, generalized weakness, underweight and history of falling. The admission Minimum Data Set (MDS) assessment had not been completed therefore information was obtained from the nursing admission assessment dated [DATE]. The assessment stated the resident was alert and oriented to three spheres, she could understand written and spoken information and make her needs known. It also revealed the resident required assistance with activities of daily living and she was incontinent of bowel and bladder. An interview was conducted with the resident on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to follow the comprehensive care plan for one of 38 residents in the survey sample, and improperly transferred Resident #12, which resulted in a fall with no injury. The findings included: Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to heart failure, high blood pressure, and dementia. Resident #12's most recent MDS (minimum data set assessment) was a quarterly assessment with an ARD (assessment reference date) of 8/12/19. Resident #12 was coded as being severely impaired in cognitive function scoring 99 out of a possible 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #12's nursing notes revealed that Resident #12 had fallen on 5/11/19. The following was documented: Called to resident's room and noted resident sitting on floor beside bed. CNA (certified nursing assistant) 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.

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 review and revise the care plan for 3 of 38 residents in the survey sample, Residents #12, #39 & #22. The findings include: 1. For Resident #12, facility staff failed to revise the comprehensive care plan to reflect his use for prn (as needed) oxygen. Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to heart failure, high blood pressure, and dementia. Resident #12's most recent MDS (minimum data set assessment) was a quarterly assessment with an ARD (assessment reference date) of 8/12/19. Resident #12 was coded as being severely impaired in cognitive function scoring 99 out of a possible 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #12's nursing notes revealed that Resident #12 had been sent out to the hospital on 8/2/19. The following note was documented in part,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a complaint investigation, staff interview, facility documentation review, and clinical record review, the facility staff failed adequately develop and implement a discharge plan for 1 of 38 residents (Resident #202) in the survey sample. The findings included: The facility staff failed assist Resident #202's Responsible Party with a requested discharge plan to home with home health care services. Resident #202 was originally admitted to the facility on [DATE] and discharged to the hospital on 3/21/19. Diagnoses for Resident #202 include but not limited to Disruption of wound, Vascular dementia without behavioral disturbance and Cerebrovascular Disease (stroke.) Resident #202's Minimum Data Set (MDS-an assessment protocol), a quarterly assessment with an Assessment Reference Date (ARD) of 01/30/19 coded Resident #202's Brief Interview for Mental Status (BIMS) a 99 indicating short and long-term memory problems and cognitive skills severely impaired-never/rarely made decisions. In addition, the MDS coded…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and clinical record review the facility staff failed to ensure 1 of 38 residents (Resident #7) in the survey sample who were unable to carry out activities of daily living, received the necessary services to maintain toenail care. The findings included: The facility staff failed to ensure that podiatry services was provided to Resident #7. Resident #7 was admitted to the facility on [DATE]. Diagnoses for Resident #7 included but not limited to Type II Diabetes Mellitus. The most recent Minimum Data Set (MDS) was an admission assessment (14-day) with an Assessment Reference Date (ARD) of 05/31/19. The MDS coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15, which indicated no cognitive impairment for daily decision-making. Resident #7 was coded extensive assistance of one with bed mobility, toilet use, transfer, dressing, personal hygiene and bathing for Activities of Daily Living (ADL). Resident #7'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 observation, staff interview, facility document review, and clinical record review, it was determined that facility staff failed to ensure an environment free from accidents and/or hazards for two of 38 residents in the survey sample, Resident #12 and #39. For Resident #12, facility staff conducted an improper transfer resulting in a fall with no injury and the facility staff failed to ensure the call light was in reach to promote safety and prevent avoidable accidents for Resident #39. The findings included: 1. Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to heart failure, high blood pressure, and dementia. Resident #12's most recent MDS (minimum data set assessment) was a quarterly assessment with an ARD (assessment reference date) of 8/12/19. Resident #12 was coded as being severely impaired in cognitive function scoring 99 out of a possible 15 on the BIMS (Brief Interview for Mental Status) exam. Review of 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 resident interview, staff interviews, and clinical record review the facility staff failed to investigate the cause and implement interventions to prevent dislodgement of a nephrostomy tube for of 1 of 38 residents in the survey sample (Resident #33). A nephrostomy tube is a catheter that's inserted through your skin and into your kidney. The tube helps to drain urine from your body. The drained urine is collected in a small bag located outside of your body (www.healthline.com) The findings included: Resident #33 was originally admitted to the facility 8/26/16 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Obesity, Parkinson's disease and use of a nephrostomy tube. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/15/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #33's cognitive abilities for daily decision making were intact.…

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 transcribe a complete order for oxygen for one of 38 residents in the survey sample, Resident #12. The findings included: Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to heart failure, high blood pressure, and dementia. Resident #12's most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (assessment reference date) of 8/12/19. Resident #12 was coded as being severely impaired in cognitive function scoring 99 out of a possible 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #12's nursing notes revealed that Resident #12 had been sent out to the hospital on 8/2/19 and returned to the facility on 8/6/19 with a diagnosis of pneumonia. The following nursing note was documented: Resident returned for hospital at 2345 (11:45) pm. orders verified with NP…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review the facility staff failed to provide pharmaceutical services to ensure insulin was available to meet the diabetic needs of 1 of 38 residents in the survey sample, Resident #24. The findings included: Resident #24 was admitted to the facility on [DATE] with diagnoses to include, but not limited to, type 2 diabetes. The current MDS a quarterly coded the resident as scoring a 15 out of a possible 15, indicating the resident's cognition was intact. The resident was coded as having received an insulin injection for 7 days of the 7 day look back assessment window. The Comprehensive Person-Centered Plan of Care dated 3/28/19 identified the resident was a diabetic. The goal was that the resident would maintain with adequate glucose levels and experience no signs and symptoms of low or high blood sugars through the next review date of 9/25/19. Two of the interventions listed to achieve the goals were to do finger sticks to check blood glucose levels, 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 clinical record review and staff interviews the facility staff failed to ensure that Resident #6 did not receive as needed Xanax for greater than 14 days without the physician and/or prescribing practitioner evaluating the resident for the appropriateness of continuous as needed use for 1 of 38 residents in the survey sample. The findings included: Resident #6 was originally admitted to the facility 1/23/14 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included bipolar disorder, dissociative identity disorder, a major depressive disorder and an anxiety disorder. The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/30/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #6's cognitive abilities for daily decision making were intact. The MDS assessment also revealed Resident #6 was without mood or behavior problems, required limited assistance…

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, the facility staff failed to store and prepare foods in a sanitary manner. The findings included: The initial tour of the Kitchen was conducted on 08/20/19 at approximately 10:43 a.m. with Other Staff #10 (Dietary Director) and with Other Staff #13. The following was observed: 1. Dialysis lunch bag was unlabeled (no date, not labeled). Food service staff, Other Staff #13 stated that she made the extra Dialysis lunch bag this morning. 2. Thick N Easy Dairy Beverage with a use by date of 08/19/19. 3. Coleslaw 10 lb container about 1/2 full, with a prepare date 8/15/19 use by date 8/22/19 however the date printed on container was use by 8/02/19. 4. 3 packs of hamburger buns (12 buns in each bag) exp. 8/01/19 was observed located in the dry storage area. On 08/22/19 at approximately, 10:00 AM an Interview was conducted with Other Staff #10, concerning the above expired and unlabeled food observed on the initial tour. He was asked what should have been done concerning the issues? He stated that the Dialysis meal…

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, the facility staff failed to ensure the facility garbage/refuse container door remained closed when not in use. The Facility Staff Failed to ensure the outside facility garbage/refuse container door was closed when it was not in use. The findings included: On 05/15/18 at approximately 11:18 AM, during the initial Kitchen tour, it was observed that the outside garbage/refuse container had one door open upon inspection with the Dietary Manager. On 5/15/18 at approximately 11:18 AM, the dietary Manager stated that he had just completed checking the garbage container doors. The Dietary Manager stated that in addition to Kitchen staff who dump garbage 3 times a day, the Housekeeping unit also empties garbage into the dumpster. In addition, the Dietary Manager stated that the facility policy is to keep the doors to the garbage can closed. The Facility Policy titled, Dispose of Garbage and Refuse with a date of 8/2017 documented the following: All garbage and refuse will be collected and disposed of in a safe 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 observation, resident interview, staff interview, facility documentation review, clinical record review, the facility failed to notify the State Long Term Care Ombudsman of transfers to the hospital for 5 of 18 Residents in the survey sample (Resident #36, #30, #8, #31, and #33). The findings included: 1. Resident #36 was admitted to the facility on [DATE]. Diagnoses for Resident #36 included but are not limited to Alzheimer's Disease. Resident #36's admission Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 11/4/16 coded Resident #36 with a BIMS (Brief Interview for Mental Status) score of 8 out of a possible 15 indicating a moderate cognitive impairment. Resident #36 was hospitalized on [DATE] after being found lying on the floor, on the right side of her bed by a CNA, the bed was in a high position per a 3/16/18 Late Entry 16:03 (4:03 PM) (nursing note). Review of Resident #36's clinical record revealed an emergency room note dated 3/15/18 that documented the 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 3. The facility staff failed to notify Resident #8 or his representative of the facilities bed hold policy when the resident was discharged to the hospital. Resident # 8 was re- admitted to the facility on [DATE] with diagnoses of seizures, cerebral palsy, chronic contractures, hypertension, severe intellectual disabilities and comfort measures. Resident #8 was sent out to the hospital emergency room on 1/16/18. A Quarterly Minimum Data Set (MDS) dated [DATE] assessed this resident in the area of Cognitive Pattern as having memory problems. In the area of Cognitive Skills for daily decision making as severely impaired. A revised Care Plan dated 12/6/17 indicated: Focus: Resident #8 has impaired cognition communication and/or impaired thought processes. Intervention- Introduce self frequently, add validation, visual cues, and gestures. Speak slowly and distinctly, maintain calm relaxed manner, observe body language for communicating needs. A nursing note dated 1/16/18 indicated: 'Resident #8 had a temperature 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 and facility, documentation review, clinical recorded review, the facility staff failed for one (Resident #33) of 18 residents in the survey sample, to ensure non-pharmacological interventions were attempted prior to administering a psychoactive medication. For Resident #33, the facility staff failed to ensure non-pharmacological interventions were attempted prior to the administration of a as needed psychoactive medication (*Xanax). *Xanax is used to treat anxiety and panic disorders (https://www.drugs.com). The findings included: The finding include: Resident #33 was originally admitted to the facility on [DATE]. Diagnosis included but not limited to *Anxiety Disorder. *Anxiety disorder is a mental condition in which you are frequently worried or anxious about many things. Even when there is no clear cause, you are still not able to control your anxiety (https://medlineplus.gov/ency/patientinstructions/000685.htm). The current Minimum Data Set (MDS) a quarterly assessment…

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

Based on clinical record review, staff interview and facility documentation the facility staff failed to ensure that 1 of 18 residents (Resident #16) in the survey sample received a complete and accurate assessment. The findings include: Resident #16 was admitted to the facility 10/18/17. Diagnosis for Resident #16 included but not limited to *Anxiety disorder. *Anxiety disorder is a mental condition in which you are frequently worried or anxious about many things. Even when there is no clear cause, you are still not able to control your anxiety (https://medlineplus.gov/ency/patientinstructions/000685.htm). Resident #16's MDS with an Assessment Reference Date (ARD) of 02/26/18 coded resident with a BIMS score of 15 out of a possible 15 indicating no cognitive impairment. Review of Resident #16's quarterly MDS with an ARD of 02/26/18 was coded 0 for receiving *antianxiety medications. The section N on the MDS under medications received read as follows: Indicate the number of DAYS the resident receiving the medication during the last 7 days, enter 0 if medication was not received by…

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 clinical record review the facility staff failed to ensure 1 of 18 residents (Resident #31) in the survey sample who were unable to carry out activities of daily living receives the necessary services to maintain toenail care. The facility staff failed to ensure that podiatry services was provided to Resident #31. The findings include: Resident #31 was originally admitted to the facility on [DATE]. Diagnosis for Resident #31 included but not limited to *Parkinson. *Parkinson is a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people (https://www.webmd.com). The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 04/02/18 coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15, which indicated no cognitive impairment for daily decision-making. 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.

Based on observation, resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure an oxygen concentrator filter was free of dust and debris for 1 resident of 18 in the survey sample (Resident #20) The following observations were made of the Resident in her room while oxygen was in use by nasal cannula at 2 liters per minute. 5/15/18 at approximately 12:10 PM during intial tour: oxygen concentrator filter dusty; 5/16/18 at approximately 3:30 PM observed oxygen concentrator filter dusty; 5/17/18 Observation at approximately 2:08 PM oxygen filter dusty. Interview with Unit Manager (UM) LPN #12 was conducted on 5/17/18 at approximately 2:10 PM. LPN #12 was asked to come look at filter in the Resident's room, with surveyor. After she observed the oxygen filter the surveyor asked her what she saw. The LPN #12 stated, It's full of dust. It's my 1st week- day 4 for me. The UM stated that she was uncertain whose responsibility it was to ensure the filters were cleaned. The DCS (Director of Clinical Services) stated on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interviews, clinical record review and facility documentation review the facility staff failed to communicate an ongoing assessment for one of 18 residents (Resident #33) for monitoring of complications before and after dialysis treatment. The facility staff failed to communicate an ongoing assessment with the dialysis center who attended an outpatient dialysis three days per week every Tuesday, Thursday and Saturday. The findings included: Resident #33 was originally admitted to the facility on [DATE]. Diagnosis included but not limited to *End Stage Renal Disease (ESRD) (Chronic irreversible kidney failure). The resident was receiving *hemodialysis treatments three times a week on Tuesdays, Thursdays and Fridays. *ESRD is the last stage of chronic kidney disease. When your kidneys fail, it means they have stopped working well enough for you to survive without dialysis or a kidney transplant (www.kidneyfund.org/kidney-disease/kidney-failure). *Hemodialysis-cleans blood by…

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 general observation of the nursing facility, staff interviews, the facility failed to ensure medications were labeled in accordance with currently accepted professional principles in 1 out of 3 facility medication carts. The facility staff failed to ensure two *Lantus (insulin) pens were dated when open and one unopened Lantus pen was dated when placed on the medication cart. *Lantus (insulin glargine) is a man-made form of a hormone that is produced in the body. Insulin is a hormone that works by lowering levels of glucose (sugar) in the blood. Insulin glargine is long-acting insulin that starts to work several hours after injection and keeps working evenly for 24 hours. Storing opened (in use) Lantus: Store the injection pen at room temperature (do not refrigerate) and use within 28 days (www.drugs.com/lantus.html). The finding include: On 5/16/18 at approximately 11:20 a.m., this surveyor inspected the split hall medication cart with License Practical Nurse (LPN) #16. Doing the inspection of the Lantus pens located inside the medication cart; two (2) Lantus pens where…

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, the facility staff failed to ensure accurate medical records for 1 Resident of 18 in the survey sample. (Resident #36). The Facility Staff Failed to ensure Resident #36's April and May 2018 Treatment Administration Record was complete and accurate. The findings included: Resident #36 was admitted to the facility on [DATE]. Diagnoses for Resident #36 included but are not limited to Alzheimer's disease and Cervical Fracture. Resident #36's admission Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 11/4/16 coded Resident #36 with a BIMS (Brief Interview for Mental Status) score of 8 out of a possible 15 indicating a moderate cognitive impairment. On 5/16/18 at approximately 2 PM, a Review of Resident #36's Treatment Administrator Record (TAR) for April and May 2018 showed the following omissions for signatures of the nurse. April 2018 TAR Check C-Collar for Protective foam…

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, the facility failed to ensure infection control measures for sanitizing the glucometer prior and after use to prevent the potential transmission of infection for 1 Resident of 18 (Resident #4) was performed. The findings included: Resident #4 was admitted to the facility on [DATE]. Diagnosis for Resident #4 include but are not limited to Diabetes Mellitus. Resident #4's admission Assessment with an Assessment Reference Date of 10/30/17 coded Resident #4 with a BIMS (Brief Interview for Mental Status) of 15 out of 15 indication no cognition impairment. Resident #4 required extensive assistance with Dressing, Bed Mobility, Transfers, Toilet Use, and Personal Hygiene. Resident #4's Physician Orders documented the following: 10/23/17 Humalog Solution 100 Unit/Milliliter Inject as per sliding scale: subcutaneously three times a day for blood sugar if 201-250 = 2 units 251-300 = 4 units 301-350 = 6 units…

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.