Signature Healthcare Of Norfolk

Based on observations and staff interview, the facility staff failed to maintain an effective pest control system/program potentially affecting all residents. The findings included: During the kitchen inspection on 10/22/19 at 10:31 A.M. house flies were observed in the kitchen area. Drain flies were observed in the mop room and dishwasher room. Fruit flies and house flies were observed in the conference room. House flies were observed in the dining room area. Flies were observed on all units. During an interview on 10/23/19 at 3:50 P.M. with the Maintenance Director he stated, the drain flies, fruit flies and house flies have been a concern and there is a need for pest control. The Maintenance Director stated The Pest Control company comes out to service the facility. The Maintenance Director stated the flies will be in the building like this until it turns cold out side. A review of the Pest Management policy indicated: Mission-We shall first seek to understand the unique needs of each customer, formulate effective solutions, and implement the actions in a timely professional…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff interviews and facility documentation review, the facility staff failed to ensure residents were able to formulate advance directives, obtain advance directives, and/or send them upon transfer to hospital; and have these documents maintained in the clinical record, readily accessible to the direct care staff for 16 of 63 residents in the survey sample (#64, #95, #128, 78, #11, #51, #50, #15, #90, #42, #88, #61, #72, #61, #139 and #124). The findings include: 1. Resident #64 did not have an advance directive readily available for direct care staff. Upon inquiry, an advance directive was located in a file drawer in the business office, not in the clinical record. Additionally, there was no evidence the resident's advance directive was sent with her when the resident was transferred to the local hospital on [DATE] or [DATE]. Resident #64 was admitted to the nursing facility on [DATE] with diagnoses that included generalized muscle weakness, bipolar disease and schizophrenia.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff interviews, clinical record review, facility documentation review and the facility's policy; the facility's staff failed to covey a copy of the resident's comprehensive care plan goals to the transferring facility for 10 of 63 residents (Resident #88, #112, #78, #64, #95, #128, #32, #11, #94, and #605) in the survey sample. The findings included: The facility's policy titled Discharge or Transfer Summary (Last Revision date: 06/28/19). Guidelines include but not limited to: -1. G: For the residents transferred to another provider the following will be documented and communicated to the receiver provider: Comprehensive Care Plan goals. 1. Resident #88 was originally admitted on [DATE] with a readmission date of 8/1/19. Resident #88's diagnoses included paraplegia, multiple sclerosis and anemia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/16/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) 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, staff interviews, facility documentation review and the facility's policy; the facility's staff failed to provide written information to the resident and/or resident representative explaining how a resident's bed is held while the resident is absent from the facility due to hospitalization for 9 of 63 residents (Resident #88, #112, #78, #64, #95, #128, #11, #94 and #605) in the survey sample. The findings included: 1. Resident #88 was originally admitted on [DATE] with a readmission date of 8/1/19. Resident #88's diagnoses included paraplegia, multiple sclerosis and anemia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/16/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #88's cognitive abilities for daily decision making are intact. Review of the clinical record reveal Resident #88 was discharged from the facility return anticipated to an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, family interview, facility documentation review and in the course of a complaint investigation, the facility staff failed to review and revise the person-centered care plan as their condition changed for 5 of 63 residents (Resident #88, #112, #11, #94 and #105) in the survey sample. The findings included: 1. Resident #88 was originally admitted on [DATE] with a readmission date of 8/1/19. Resident #88's diagnoses included paraplegia, multiple sclerosis and anemia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/16/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #88's cognitive abilities for daily decision making were intact. In sectionG(Physical functioning) the resident was coded as requiring total care with eating, personal hygiene and bathing, extensive assistance of two with bed mobility, extensive assistance of one with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident record review, staff interviews and facility document review the facility staff failed to ensure dialysis services to include ongoing communication with the dialysis center was in place for 1 of 63 residents in the survey sample, Resident #18. The findings included: Resident #18 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, End Stage Renal Disease and Schizoaffective Disorder Resident #18 attended dialysis on Tuesday, Thursday and Saturdays. The most recent Minimum Data Set (MDS) was a Quarterly with an Assessment Reference Date (ARD) of 8/1/19. Resident #18's Brief Interview for Mental Status (BIMS) was a 15 out of a possible 15 which indicates the resident is cognitively intact and capable of daily decision making. Under Section O Special Treatments, Procedures, and Programs Resident #18 was coded for Dialysis while a resident. On 10/22/19 at approximately 1:00 P.M. the resident was not observed in the facility and the staff stated she was at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews, resident interview and facility document review, the facility staff failed to ensure that the physician was notified of a positive urine culture in a timely manner for 1 of 63 residents in the survey sample, Resident #78. The findings included: Resident #78 was a [AGE] year old originally admitted to the facility on [DATE] with diagnoses to include but not limited to Urine Retention and Diabetes Mellitus. The most recent Minimum Data Set (MDS) was a Annual with an Assessment Reference Date (ARD) of 9/6/19. Resident #78's Brief Interview for Mental Status (BIMS) was a 13 out of a possible 15 which indicates the resident is cognitively intact and capable of daily decision making. Resident #78's Progress Notes were reviewed and are documented in part, as follows: 10/15/2019 15:46 (3:46 P.M.): urinalysis results received and placed in md (medical doctor) folder, greater than 100,000 gram negative rods, resident positive for uti (urinary tract infection), urine…

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 identified quality deficiencies determined during this survey the QAA (Quality Assessment and Assurance) committee failed to develop and implement an appropriate plan of action to correct repeat harm deficiencies in the area of Quality of Care-Pressure Injuries affecting 1 of 63 residents and potentially affecting all residents. The findings included: The facility was cited with harm in the area of Quality of Care for Pressure Injuries during the last survey ending 7/13/18. During the current survey, the facility was cited with a level 3 isolated (G) harm deficiency in the same area. The plan of correction for the last survey did not correct the deficient practice.

Based on staff interview the facility failed to ensure quarterly QAA (Quality Assessment and Assurance) meetings were conducted as required and required members were in attendance. The findings included: During the QAPI (Quality Assurance and Performance Improvement) review conducted on 10/24/19 at approximately 6:30 p.m., the Administrator was asked to provide evidence of quarterly QAA meetings to include the sign in sheets. The Administrator stated that he had identified that the facility QAA committee was lacking in participation from all department heads. He stated they have QAPI every month and revamped the QAPI process. The Administrator stated he did not have all the sign in sheets to show evidence of quarterly QAA committee attendance. The third quarter July 2019 QAPI meeting signature sheet did not have the Medical Director or his/her designee in attendance. No other information was provided to the survey team about the facility's QAPI quarterly meetings prior to exit.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interviews the facility staff failed to ensure privacy curtains were maintained in a sanitary condition in three resident rooms which included 6 of 169 beds. The findings included: On 10/22/19, 10/23/19 and 10/24/19 the privacy curtains in rooms 205, 206 and 208 were observed with visible stains; and food debris was noted on the curtains in room [ROOM NUMBER]. On 10/24/19 at approximately 10:00 a.m., an Environmental Services Staff (other staff #12) was asked how often are privacy curtains cleaned. He stated whenever the housekeeping staff let him know. He was asked to check the three rooms with the dirty curtains, he stated they need to be changed out. The Housekeeping Staff (other staff #11) who was responsible for cleaning the rooms on that hallway was interviewed. She was asked the process on how dirty privacy curtains get changed. She stated that if she finds any privacy curtains that need to be cleaned she writes them down and forwards the information. She was asked about 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 resident interview, staff interviews and facility documentation, the facility staff failed to ensure 1 of 63 residents (Resident #20) in the survey sample had a patient trust fund account. The findings included: The facility staff failed to ensure Resident #20 had a patient trust fund account. Resident #20 was originally admitted to the facility on [DATE]. Diagnosis for Resident #20 included but not limited to: Mild Intellectual disabilities. Resident #20's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/02/19 coded Resident #20's Brief Interview for Mental Status (BIMS) scored a 99 indicating short and long term memory problems and with severe cognitive impairment - never/rarely made decisions. An interview was conducted with Resident #20 on 10/22/19 at approximately 11:53 p.m. She said the facility would not put money in her account until her niece got involved. She said her niece was putting money into her account every month. An interview was conducted with the Business Office…

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 care equipment, a wheelchair and gel cushion, were maintained in a clean and sanitary condition, for 1 of 63 residents in the survey sample, Resident #51. The findings included: Resident #51 was admitted to the facility on [DATE] with a re-admit on 2/7/17 with diagnoses that included Parkinson's disease, major depression, and unspecified dementia without behavioral disturbances. The current MDS (Minimum Data Set) a quarterly with an assessment date of 8/16/19 coded the resident as scoring a 15 out of a possible 15 on the Brief Interview for Mental Status, indicating the resident's cognition was intact. The resident was identified as utilizing a wheelchair for mobility and was always incontinent of bowel and bladder. On 10/22/19 at 12:03 p.m., Resident #51 was observed in bed. She stated she did not sleep well last night and was not going to get up today. A strong smell of urine was in the room. An inspection to identify the origin 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 Facility Reported Incident, staff interview and the clinical record, facility staff failed to ensure that one of 63 residents was free from sexual abuse. The findings include: Resident # 90 was admitted to the facility on [DATE] with a readmission occurring on 11/15/2018 with the latest diagnosis including, but not limited to, spastic quadriplegic cerebral palsy, cervical spina bifida without hydrocephalus, unspecified convulsions conversion disorder with seizures or convulsions. Resident # 90's MDS (Minimum Data Set), Quarterly Review Assessment with an ARD (Assessment Review Date) of 9/18/2019 coded Resident #90 with a BIM (Brief Interview of Mental Status) as 14 out of a possible 15, cognitively intact with decisions of daily living. A review of Resident #90 Care Plan indicated limitations in ease of joining other residents in activities with a long term goal to express satisfaction with activity involvement; and, limited ability to maintain grooming/personal hygiene with a long term goal to be well…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews and facility document review, the facility staff failed to ensure that a Baseline Care Plan was developed for 1 of 63 resident's in the survey sample, Resident #155. The findings included: Resident #155 was a [AGE] year old admitted to the facility on [DATE] for a respite stay with diagnoses to include but not limited to Dementia and Chronic Obstructive Pulmonary Disease. Resident #155's Facility Face Sheet was reviewed and documented in part, as follows: admit date : [DATE] discharged : 5/20/2019 Resident #155's Electronic Medical Record was reviewed for the Baseline Care Plan and was not identified. On 10/24/19 12:06 P.M., an interview was conducted with the Social Worker as to if a baseline care plan was completed. The Social Worker stated, No I cannot find a baseline care plan, the admitting nurse should have done it on admission. I guess it wasn't done because she was a respite resident we don't normally do them for respite stays. On 10/24/19 at approximately 2:10…

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, resident interview and clinical record review, the facility staff failed to address Activities of Daily Living (ADLs) in the comprehensive care plan for 1 of 63 resident's in the survey sample, Resident #403. The findings included: Resident #403 was admitted to the facility on [DATE]. Diagnosis included but were not limited to, Dementia and Cerebral Infarction. Resident #403's Minimum Data Set (MDS) with an Assessment Reference Date of 09/13/2019 coded Resident #403 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 #403 as requiring limited assistance of 1 with transfer, extensive assistance of 1 with bed mobility, dressing and personal hygiene, and total dependence of 1 for toilet use and bathing. On 10/24/2019 at 10:45 a.m., Resident #403's comprehensive care plan was reviewed and did not include information communicating the resident'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 staff interviews, facility documentation review, and clinical record review, the facility staff failed to follow professional standards of nursing practices for 1 out of 63 residents (Resident #11) in the survey sample. The facility staff failed to obtain physician orders for a newly developed stage III sacral pressure ulcer for Resident #11. The findings included: Resident #11 was originally admitted to the facility on [DATE]. Diagnosis for Resident #11 included but not limited to *Pressure ulcer of other site, unspecified stage. The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 07/22/19, coded the resident with a 14 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. In addition, the MDS coded Resident #11 requiring total dependence of one with bathing, extensive assistance of one with bed mobility, transfer, dressing, toilet use and personal hygiene for Activities of Daily Living care.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews and facility document review, the facility staff failed to ensure that Discharge Planning was implemented for 1 of 63 resident's in the survey sample, Resident #155. The findings included: Resident #155 was a [AGE] year old admitted to the facility on [DATE] for a respite stay with diagnoses to include but not limited to, Dementia and Chronic Obstructive Pulmonary Disease. Resident #155's Facility Face Sheet was reviewed and is documented in part, as follows: admit date : [DATE] discharged : 5/20/2019 Resident #155's Electronic Medical Record was reviewed for Discharge Planning and there were none identified. On 10/24/19 at 12:06 P.M. an interview was conducted with the Social Worker regarding Resident #155's Discharge Planning. The Social Worker stated There was no discharge planning completed because she was respite and we knew she would be going back home and the PACE (Program of All-Inclusive Care for the Elderly) would be in place . On 10/24/19 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews and facility document review the facility staff failed to ensure that a Discharge Summary was completed at discharge for 1 of 63 resident's in the survey sample, Resident #155. The findings included: Resident #155 was a [AGE] year old admitted to the facility on [DATE] for a respite stay with diagnoses to include but not limited to, Dementia and Chronic Obstructive Pulmonary Disease. Resident #155's Facility Face Sheet was reviewed and is documented in part, as follows: admit date : [DATE] discharged : 5/20/2019 Resident #155's Electronic Medical Record was reviewed for the Discharge Summary but one was not identified. On 10/24/19 12:06 P.M. an interview was conducted with the Social Worker regarding Resident #155's Discharge Summary. The Social Worker stated, There is no discharge summary, we didn't do one. I guess it wasn't done because she was a respite resident. On 10/24/19 at approximately 2:10 P.M. an interview was conducted with the Director of Nursing…

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, family interview, clinical record review, facility document review and during the course of a complaint investigation the facility staff failed to ensure 1 of 16 residents in the survey sample was free from an avoidable fall from the bed during the provision of care, Resident #113. The findings included: Resident #113 was admitted to the facility on [DATE] with diagnoses to include stroke, contracture of left arm, and muscle weakness. The current MDS (Minimum Data Set) a quarterly with an assessment reference date of 9/10/19 coded the resident as scoring a 14 out of a possible 15 on the Brief Interview for Mental Status indicating the resident's cognition was intact. The resident required extensive assistance of 1 staff for bed mobility and personal hygiene and was totally dependent on two staff for transfers. The Comprehensive person centered plan of care identified the resident was a fall risk and had a history of a total of two falls in addition to the current fall 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 and clinical record review, the facility staff failed to follow the physician orders to obtain weekly weights for 1 of 63 residents in the survey sample, Resident #94. The findings included: Resident #94 was originally admitted to the facility on [DATE] with a re-admission date of 9/3/19 with diagnoses to include chronic obstructive pulmonary disease, type II diabetes, and schizophrenia. The current Minimum Data Set an annual with an assessment reference date of 9/17/19 coded the resident as scoring a 9 out of a possible 15 on the Brief Interview for Mental Status, indicating the resident's cognition was moderately impaired. The resident's weight was 109 pounds. The physician orders dated 9/3/19 directed the staff to obtain the resident's weight on admission and then weekly for four weeks following a hospitalization. The clinical record evidenced the resident's weight was obtained on 9/4/19 at 108.6 pounds, and 9/11/19 at 108.8 pounds, there were no other weekly weights obtained. 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, staff interview, clinical record review, and in the course of a complaint investigation, the facility staff failed to follow the physician order for the oxygen flow rate for 1 of 63 residents in the survey sample, Resident #94. The findings included: Resident #94 was originally admitted to the facility on [DATE] with a re-admission date of 9/3/19 with diagnoses to include chronic obstructive pulmonary disease (COPD). The current Minimum Data Set an annual with an assessment reference date of 9/17/19 coded the resident as scoring a 9 out of a possible 15 on the Brief Interview for Mental Status, indicating the resident's cognition was moderately impaired. The resident was coded as receiving oxygen therapy. The comprehensive person-centered plan of care dated 9/25/19 identified as a problem, that the resident requires oxygen therapy related to COPD. The goal was that the resident will not exhibit signs of hypoxia (low levels of oxygen). One of the approaches was to administer oxygen at 2…

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's staff failed to ensure the medication Procrit (a red blood cell producing drug) was available to be administered as ordered to 1 of 63 residents (Resident #88) in the survey sample. The findings included: Resident #88 was originally admitted to the facility on [DATE] and with a readmission date of 8/1/19. Resident #88's diagnoses included anemia, paraplegia, multiple sclerosis. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/16/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #88's cognitive abilities for daily decision making were intact. Review of the current physician order summary revealed Resident #88 had an order dated 9/20/19 for Procrit 10,000 units/milliliter injection once per week on Mondays between 7:15 a.m., and 11:00 a.m., for anemia. PROCRIT is indicated for 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 clinical record review, staff interviews, and facility documentation review the facility's staff failed to ensure 1 of 63 residents (Resident #88) in the survey sample was free from significant medication error. The findings included: Resident #88 was originally admitted on [DATE] with a readmission date of 8/1/19. Resident #88's diagnoses included anemia, paraplegia, multiple sclerosis. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/16/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #88's cognitive abilities for daily decision making were intact. Review of the current physician order summary revealed Resident #88 had an order dated 9/20/19 for Procrit (a red blood cell producing drug) 10,000 units/milliliter injection once per week on Mondays between 7:15 a.m., and 11:00 a.m., for anemia. PROCRIT is indicated for the treatment of anemia due to chronic kidney…

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 staff failed to ensure an accurate medical record for 1 of 63 residents (Resident #304) in the survey sample. The findings include: Resident #304 was a [AGE] year old admitted to the facility on [DATE] with diagnoses to include but not limited to Adrenomyeloneurpathy, Major Depressive Disorder and Anxiety Disorder. Jewish Family Services was Resident #304's court appointed Legal Guardian. Resident #304 expired in the facility on [DATE]. The most recent Minimum Data Set (MDS) was a Quarterly with an Assessment Reference Date (ARD) of [DATE]. Resident #18's Brief Interview for Mental Status (BIMS) was a 15 out of a possible 15 which indicates the resident is cognitively intact and capable of daily decision making. Resident #304's Progress Notes were reviewed and are documented in part, as follows: [DATE] 9:30 A.M.: Resident LOA (leave of absence) to urology appointment via stretcher. NAD (no apparent distress) noted.…

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 clinical record review, the facility staff failed to follow infection control practices during wound care for 1 of 63 residents, Resident #32. The Findings included: Resident #32 was originally admitted to the facility on [DATE]. Diagnoses for Resident #32 included but not limited to Pressure Ulcer of unspecified buttock stage 2 and Pressure Ulcer of Sacral Region. The current Minimum Data Set (MDS), an annual assessment with an Assessment Reference Date (ARD) of 08/02/19 coded the resident with a staff assessment for mental status because resident was unable to complete the interview. Staff assessment for mental status coded the resident as having short-term and long-term memory problems. On 10/23/19 at approximately 10:46 AM wound care observation was conducted. The wound care nurse Licensed Practical Nurse (LPN) #7 sanitized the resident's bedside table, allowed it to dry, placed a drape on the table, and added wound care items. After the completion of wound care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility staff failed to provide notice of Bed Hold and Reserve Bed Payment Policy for five Residents (Resident #6, #82, #89, #1, #108 ) in the survey sample. 1. The facility staff failed to provide notice of Bed Hold and Reserve Bed Payment Policy to Resident #6 upon discharge to the hospital. 2. The facility staff failed to provide notice of Bed Hold and Reserve Bed Payment Policy to Resident #82 upon discharge to the hospital. 3. The facility staff failed to provide notice of Bed Hold and Reserve bed Payment Policy to Resident #89 upon discharge to the hospital. 4. The facility staff failed to ensure that Resident #1 was made aware of the facility's bed-hold and reserve bed payment policy upon transfer/discharge to the hospital on 1/23/18 and 6/12/18. 5. The facility staff failed to provide notice of Bed Hold and Reserve Bed Payment Policy to Resident #108 upon discharge to the hospital. The findings included: 1. Resident #6 was readmitted to the facility 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 observation, staff interviews and facility documentation review the facility staff failed to ensure drugs and biological were secured and stored and discarded per professional guidelines. 1. The facility staff failed to discard 3 expired Culture Swab Collection and Transport System tubes that were located in the medication room on Unit 2. 2. The facility staff failed to discard an expired Lantus insulin located in the medication cart on Unit 2 (Long hall medication cart). 3. The facility staff failed to ensure a medication cart was locked when not in direct site of the nurse for 1 of 3 units (Unit 3). 4. The facility staff failed to assure medications were secure and inaccessible to Resident #139 who ingested anti-fungal ointment. 5. The facility staff failed to ensure that 3 medications supplied by the Resident #13's family were stored appropriately and not left at the resident's bedside. The findings include: 1. On [DATE] at approximately 8:15 a.m., the Medication Storage Room on Unit 3 was inspected…

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

Based on clinical record review, staff interviews and facility documentation review, the facility staff failed to ensure Medicare Beneficiary Notices in accordance with applicable Federal regulations, were issued to 2 of 38 residents (Resident #101 and 126) in the survey sample. 1. The facility staff failed to issue an Advanced Beneficiary Notice (ABN) letter to Resident #101 who was discharged from skilled services with Medicare days remaining. 2. The facility staff failed to issue an Advanced Beneficiary Notice (ABN) letter to Resident #126 who was discharged from skilled services with Medicare days remaining. The findings included: 1. Resident #101 was readmitted to the nursing facility on 02/13/18. Diagnosis for Resident #101 included but not limited to Chronic Kidney Disease - stage IV (kidney failure). Resident #101's Minimum Data Set (MDS) quarterly assessment with an Assessment Reference Date (ARD) date of 5/23/18 coded Resident #101 a 3 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident with severe cognitive…

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, facility documentation review and clinical record review the facility staff failed to accurately complete each required section of the MDS (Minimum Data Set) assessment for 2 out of 38 residents (Resident #126 & #135) in the survey sample. 1. The facility staff failed to complete the required section of Resident #126 quarterly MDS: section C-Brief Interview for Mental Status. 2. The facility staff failed to code Resident #135 for hospice care. The findings included: Resident #126 was admitted to the facility on [DATE]. Diagnoses for Resident #126 included but are not limited to Hypertension (high blood pressure). Resident #126 MDS with an Assessment Reference Date (ARD) of 4/25/18 coded the resident's Brief Interview for Mental Status (BIMS) score 11 of a possible 15 with moderate cognitive impairment. Review of the quarterly MDS with ARD of 06/13/18 noted it was marked with dashes under section C-Brief Interview for Mental Status. On 07/12/18 at 8:10 a.m., an interview was conducted…

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, observations, facility document review and staff interviews the facility failed to revise the Person Centered Care Plan's for 2 of 38 Resident's in the Survey Sample, Resident #34 and Resident #108. 1. The facility staff failed to revise Resident #34's Person Centered Care Plan in the area of Activities to include the resident's assessed activities of preference. 2. The facility staff failed to review effectiveness of interventions and review/revise Resident #108's person centered care plan after a fall resulting in a left hip fracture. The Findings Included: 1. Resident #34 is a [AGE] year old admitted to the facility 4/26/16 with diagnoses to include Depression and Dementia. The most recent Comprehensive Minimum Data Set (MDS) assessment was an Annual with an Assessment Reference Date (ARD) of 5/3/18. The Brief Interview for Mental Status (BIMS) for Resident #34 was attempted but unable to be completed by the Resident. Under Section C Cognitive Patterns Resident #34 was coded…

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