Waterside Health & Rehab Center

Based on observations, staff interview, and clinical record review, the facility staff failed to ensure staff reviewed the risks and benefits of bed rail use with the Resident and/or Resident Representative prior to installation, provide documentation that the facility staff attempted alternatives or that they obtained consent for the use of bed rails prior to use for 1 of 50 residents (Resident #27), in the survey sample. Findings include: Resident #27 was originally admitted to the facility 4/7/23 after an acute care hospital stay. The resident was discharged to a local hospital on 5/30/23 and returned to the facility on 6/8/23. The current diagnoses included chronic respiratory failure, status post a subdural hematoma, a seizure disorder and pressure ulcers. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/13/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 3 out of a possible 15. This indicated Resident #27's cognitive abilities for daily decision making were severely impaired. In section G…

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

Based on observations, resident interview, and staff interview, the facility staff failed to maintain an effective pest control program so that the facility was free of gnats which was voiced by 1 of 50 residents (Resident #273), in the survey sample. The findings included: Resident #273 was originally admitted to the facility 6/1/2023 after an acute care hospital stay. The resident discharged from the facility on 6/21/23. The diagnoses included; a urinary tract infection (UTI), status post a kidney transplant and kidney stones. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/7/2023 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #273's cognitive abilities for daily decision making were intact. On 6/20/23 at approximately 1:53 p.m. an interview was conducted with Resident #273 in her room. The resident was reclined in on her bed, talking about the events which brought her to the facility and the plan for her to be discharged home 6/21/23 at 3:00…

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 notify a representative of the Office of the State Long-Term Care Ombudsman of discharges to the hospital for 6 residents (Residents #63, #27, #71, #61, #37 and #62) of 43 residents in the survey sample. This deficiency is cited as Past Non-Compliance. The findings included: On 12/12/19 at approximately 3:13 PM an interview was conducted with the Corporate Nurse Consultant concerning the above. She stated, Ombudsman notification will fall under our past non compliance. A document was received shortly thereafter concerning discharge notices not being sent to the local state ombudsman by the previous director of social services for September or October. Corrective Action: The discharge notices will be sent to the ombudsman for those not previously sent. The Ombudsman was notified and he did confirm that he had not received notices for the past couple of months, but said that he is fine with us sending over a spread sheet monthly. How…

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

Based on observation, staff interviews, and review of the facility's policy, the facility staff failed to ensure food was stored under sanitary conditions. The finding included; On 12/10/19 at approximately 10:50 AM an initial tour of the kitchen was conducted with the Food Service Director (FSD). The following was observed during the tour: Located in the walk-in freezer-one opened and not sealed 5 lb. bag (1/2 full) of Chicken tenders with no opened date listed. Located in dry storage one opened bag of [NAME] Sugar (1/2 full) with no opened date. Located in the kitchen on the shelf was one bag of Red Raspberry Gelatin dessert mix. (1/4 mix left in bag) and one opened bag of [NAME] sauce with no opened date listed. Located in the reach in freezer was one opened, unsealed, and unlabeled bag of frozen vegetables with no opened date. Located in the reach in freezer was a 2 lb opened (sealed) brown bag of french fries with no opened date. The bag was not labeled with what the product was. One opened, 12 ounce bag of dry gravy mix (1/4 full) with no opened date. Policy: Storage 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 and staff interviews the facility staff failed to protect resident from public view during care for 1 resident (Resident #2), of 43 residents in the survey sample. The facility staff failed to ensure Resident #2's privacy was maintained during tracheostomy care. The findings included: Resident #2 was originally admitted to the facility on [DATE]. Diagnosis for Resident #2 included but are not limited to *Tracheostomy, Ventilator and Persistent Vegetative State. Resident #2's Minimum Data Set (MDS-an assessment protocol), a quarterly assessment with an Assessment Reference Date of 09/09/19, coded Resident #2 requiring total dependence of two with dressing, bed mobility, bathing, and toilet use, total dependence of one with hygiene and eating. On 12/12/19 at approximately 8:30 a.m., the Respiratory Therapist (RT) performed tracheostomy care with two surveyors present. While tracheostomy care was being provided on Resident #2's, the privacy curtain was not pulled nor was her door closed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to implement their abuse policies by failing to submit to the appropriate state agencies, a five day follow up investigation to a FRI (facility reported incident) that was reported on 1/7/19, for one of 43 residents in the survey sample, Resident #84. The findings included: Resident #84 was admitted to the facility on [DATE] with diagnoses that included but were not limited to hemiplegia (one sided paralysis) and aphasia (loss of ability to express speech) status post stroke, and type two diabetes. Resident #84 passed away on 10/15/19, therefore a closed record review was conducted. Resident #84's most recent comprehensive MDS (minimum data set) assessment was an significant change assessment with an ARD (assessment reference date) of 10/15/19. Resident #84 was coded as being severely impaired in cognitive function scoring 99 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, it was determined that facility staff failed to submit the results of an investigation within 5 working days of an allegation of neglect reported on 1/7/19 to the appropriate state agencies for one of 43 residents in the survey sample, Resident #84. The findings included: Resident #84 was admitted to the facility on [DATE] with diagnoses that included but were not limited to hemiplegia (one sided paralysis) and aphasia (loss of ability to express speech) status post stroke, and type two diabetes. Resident #84 passed away on 10/15/19 therefore, a closed record review was conducted. Resident #84's most recent comprehensive MDS (minimum data set) assessment was an significant change assessment with an ARD (assessment reference date) of 10/15/19. Resident #84 was coded as being severely impaired in cognitive function scoring 99 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #84 was coded as being…

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 send the required documentation to include care plan goals upon transfer to the hospital, for 3 of 43 residents in the survey sample, Residents # 61, #71, #63. The findings included: 1. Resident #61 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to spinal cord compression, dependence on ventilator, trachesostomy and gastronomy status (feeding tube). Resident #61's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 9/17/19. Resident #61 was coded as being severely impaired in cognitive function scoring 09 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #61 was coded as being dependent on staff for all ADLS (activities of daily living). Review of Resident #61's clinical record revealed that she had been transferred to the…

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

Based on clinical record review, staff interview and facility documentation the facility staff failed to ensure 1 of 43 residents (Resident #54) in the survey sample received a complete and accurate assessment. The findings included: The facility staff failed to ensure Resident #54's, MDS (Minimum Data Set) with an Assessment Reference Date (ARD) of 11/14/19 was coded correctly under Section N (Medications) for the use of Anti-depressant. Resident #54 was admitted to the facility 1/10/19. Diagnosis for Resident #54 included but not limited to Depression disorder. Resident #54's MDS, an annual assessment with an Assessment Reference Date (ARD) of 11/14/19 coded resident with a BIMS score of 15 out of a possible 15 indicating no cognitive impairment. Review of Resident #54's quarterly MDS with an ARD of 11/14/19 was coded 7 for receiving antianxiety medications and was coded 0 for days receiving antidepressant 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…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff interviews and facility documentation, the facility staff failed to develop a care plan for the prevention of pressure ulcers/injury for 1 of 43 residents (Resident #30) in the survey sample. The findings include: Resident #30 was admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease (PVD), right below the knee amputation (BKA), *unstageable left heel pressure ulcer, type 2 diabetes, stage 3 renal disease, stroke and Alzheimer's disease. Resident #30 was readmitted to the nursing facility on 10/15/19 with additional diagnoses that included post fall, urinary tract infection (UTI), generalized muscle weakness and gastro-esophageal reflux disease (GERD). *According to the NPUAP (National Pressure Ulcer Advisory Panel)/NPIAP (National Pressure Injury Advisory Panel) an unstageable pressure ulcer/injury is an obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed…

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, resident interview and clinical record review the facility staff failed to revise the comprehensive care plan to reflect the resident's current weight bearing status for 1 of 43 residents in the survey sample, Resident #49. The findings included: Resident #49 was admitted to the facility on [DATE]. Diagnoses included but were not limited to, Other Fracture of Right Lower Leg, Subsequent Encounter For Closed Fracture with Routine Healing and Other Fracture of Left Lower Leg, Subsequent Encounter For Closed Fracture with Routine Healing. Resident #49's Quarterly Minimum Data Set (MDS - an assessment protocol) with an Assessment Reference Date of 11/06/2019 coded Resident #49 with a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #49 as requiring limited assistance of 1 with bed mobility, transfer, walk in room, dressing and toilet use and independent with set up help only with 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, and clinical record review, it was determined that facility staff failed to provide fingernail care to a dependent resident for one of 43 residents in the survey sample, Resident #52. The findings included: Resident #52 was admitted to the facility on [DATE] with diagnoses that included but were not limited to post stroke, weakness following cerebrovascular disease (stroke) and diabetes type two. Resident #52's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 11/11/19. Resident #52 was coded as being moderately impaired in cognitive function scoring 13 out of 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #52 was coded in Section G Functional Status as having impairments to one side of his upper and lower extremities. On 12/10/19 at 11:24 a.m., an interview was conducted with Resident #52. Resident #52 had stated that he wanted his finger nails cut and that staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff interviews and facility documentation review, the facility staff failed to develop and implement preventative measures to prevent the formation of a new pressure ulcer to an at risk resident prior to identification at an advanced stage, for 1 or 43 residents (R#30) in the survey sample. Resident #30's sacral/coccyx pressure ulcer was first identified on 12/6/19 by the nursing staff as an unstageable pressure ulcer. The findings include: Resident #30 was admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease (PVD), right below the knee amputation (BKA), *unstageable left heel pressure ulcer, type 2 diabetes, stage 3 renal disease, stroke and Alzheimer's disease. Resident #30 was readmitted to the nursing facility on 10/15/19 with additional diagnoses that included post fall, urinary tract infection (UTI), generalized muscle weakness and gastro-esophageal reflux disease (GERD). The resident was a full code. She was not…

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 43 residents (Resident #35) 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 #35. Resident #35 was admitted to the facility on [DATE]. Diagnosis for Resident #35 included but not limited to Alzheimer's disease. The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 10/23/19 coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 06 out of a possible score of 15, which indicated severe cognitive impairment for daily decision-making. Resident #35 was coded total dependence of one with dressing, hygiene, bathing and toilet use, limited assistance of one with transfer and bed mobility with Activities of Daily Living (ADL) care. 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 and staff interview, the facility staff failed to a system in place to control, account for, and periodically reconcile, the controlled medication Ativan. The findings included: On 12/12/2019 at approximately 10:00 a.m., a tour of the medication storage room on North 3 Unit revealed a small refrigerator which contained an affixed small metal lock box on the bottom base of the refrigerator. LPN (Licensed Practical Nurse) #1 was asked to describe the purpose of the lock box located within the refrigerator. LPN#1 responded, I'm not going to open that lock box. I don't think there is anything in there. Surveyor asked LPN #1 to open the lock box, revealing six vials of Ativan in the box. LPN #1 was asked to show evidence of accounting for the medication and she stated, We don't have a system to count it. An interview was conducted with the Director of Nursing on 12/12/2019 at approximately 3:00 p.m. and when asked about the accounting of Ativan on North 3 unit, she replied, Those are for emergency usage. An interview was held with North 3 LPN #7, the Unit Manager 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 record review, staff interview and facility policy review, the facility staff failed to ensure 1 (Resident #335's) of 43 residents in the survey sample's medical records were readily accessible. The findings included: Resident #335 was admitted to the facility on [DATE] with diagnoses of pressure ulcer on the sacral region, unspecified stage and Multiple Sclerosis. Resident #335 was discharged on 11/29/18, therefore a closed record review was attempted. On 12/11/19 at approximately 1:45 PM, the Corporate Nurse Consultant was asked for Resident # 335's clinical record to include nurses notes, MDS (Minimum Data Set), and skin assessments. All requested medical records were received except the nurses notes. The Corporate Nurse Consultant explained that they could only access records from July 1, 2019 forward since the facility was bought out by another company. She stated the previous company did not give them access to the medical records prior to July 1st; the records had to be requested from the prior…

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 facility document review, the facility staff failed to maintain an active facility wide Infection Prevention and Control Program (IPCP) and failed to ensure infection control measures to prevent the potential transmission of infection while performing a blood glucose test on 1 resident of 61 residents in the survey sample (Resident #26) The finding's included; 1. On 6-25-18 at approximately 5:00 p.m., During the end of day debriefing, the Administrator was asked who surveyors should speak with, the next morning in regard to the facility infection control program. The Administrator stated the Director of Nursing (DON) who was no longer employed at the facility had previously been in charge of it, however, since she was no longer there, the new interim DON would be responsible. On 6-26-18 at 10:00 a.m., the Registered Nurse (RN-2) south unit manager and the Corporate Infection Preventionist (Other 3) RN came into the conference room and stated they would be in charge of infection…

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

Based on staff interview, and facility document review, the facility staff failed to maintain an active antibiotic stewardship program. The finding's include; On 6-25-18 at approximately 5:00 p.m., During the end of day debriefing, the Administrator was asked who surveyors should speak with, the next morning in regard to the facility infection control program. The Administrator stated the Director of Nursing (DON) who was no longer employed at the facility had previously been in charge of it, however, since she was no longer there, the new interim DON would be responsible. On 6-26-18 at 10:00 a.m., the Registered Nurse (RN-2) south unit manager and the Corporate Infection Preventionist (Other 3) RN came into the conference room and stated they would be in charge of infection control, not the DON. RN-2 and Other 3 were interviewed in the conference room by surveyors. RN-2 stated she was working in the new roles of south unit nursing manager, facility wound nurse, med and treatment nurse, and now infection control nurse coordinator. The Corporate Infection Preventionist RN was asked…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews and facility document review the facility staff failed to revise care plans for 5 of the 61 Resident's in the Survey Sample, Residents' #125, #28, #11, #5, and #72. 1. The facility staff failed to revise Resident #125's care plan on 5/21/18 to include the initial physician order for the antipsychotic medication Quetiapine 50 mg (milligram) tablet one time daily. 2. For Resident #28 care plan was not revised to include new wounds and pain from shingles. 3. For Resident #11 care plan has not been updated to accurately reflect Residents current communication abilities. 4. For Resident #5 care plan was not revised to include pain assessments or interventions. 5. For Resident #72 the facility staff failed to revise the care plan for wounds and treatments. The Findings Included: 1. Resident #125 was admitted to the facility on [DATE] with diagnoses to include . (1). Alcohol Abuse, (2). Anxiety Disorder and (3). Vascular Dementia. The most recent comprehensive Minimum…

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

Based on a complaint investigation, observations, clinical record review, staff and resident interview, the facility staff failed to ensure 1 of 61 residents (Resident #107) in the survey sample were seen by a physician, nurse practitioner or physician assistant every 60 days with 10 day grace period. Resident #107 was not seen every 60 days with 10 day grace period by the physician, nurse practitioner or physician assistant per mandate. Specifically, there was a 5 month gap between physician visits from 9/14/17 to 2/13/18. The findings include: Resident #107 was admitted to the nursing facility on 2/12/15 with diagnoses that included multiple sclerosis, contractures and neurogenic bladder. The most recent Minimum Data Set (MDS) assessment was a quarterly dated 5/25/18 and 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 the resident was cognitively intact for the skills in daily decision making. An interview was conducted with Resident #107 on 6/25/18 at 10:30 a.m. She stated she was not being seen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff and resident interview, and facility documentation review, the facility failed to ensure sufficient staff was in place to provide nursing and related services to maintain the highest practicable physical, mental and psychosocial well-being for 4 of 61 residents (Resident #124, #23, #118 and #5) in the survey sample. 1. Resident #124 was not provided timely incontinence care due to insufficient staffing on the 3 pm-11 p.m. shift on 6/25/18. She was left soiled and cold for 2.5 hours before she was able to receive incontinence care. 2. Resident #23 was not provided timely incontinence care due to insufficient staff on the 3 p.m.-11p.m. shift on 6/25/18. She was left up in her wheel chair soiled for 5.5 hours. The next shift (11 p.m.-7 a.m.) placed her in bed and provided incontinence care at 12:20 p.m. 3. The facility staff failed to assure there was sufficient staff to accompany Resident #118 to pre-planned Physical Therapy (PT) appointments on 6/7/18, 6/14/18,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure medications were available for administration for two Residents (Resident #72, & #5) of the 61 residents in the survey sample. 1. For Resident #72 the facility staff failed to administer Magnesium Citrate as requested and ordered on 6-14-18. 2. The facility failed to provide Resident #5, with twelve consecutive doses of a scheduled narcotic pain medication. The findings included; 1. Resident #72 was admitted to the facility on [DATE]. Diagnoses for Resident #72 included but were not limited to; Traumatic Brain Injury, constipation, and quadriplegia. Resident #72's most recent Minimum Data Set (an assessment protocol) was a quarterly assessment, with an Assessment Reference Date of 5-3-18. The MDS coded Resident #72 as alert, oriented to person, place, time and situation, with no cognitive impairment. The Minimum Data Set further coded Resident #72 as being totally…

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, family interview, staff interview, and clinical record review the facility staff failed to ensure 1 Resident (Resident #5) in a survey sample of 61 to be free of significant med error. For Resident # 5 facility staff failed to follow physicians order to administer Oxycodone 5 mg. (narcotic pain medication) as scheduled. The finding included: Resident #5 a 66 yr. old female was admitted on [DATE] with diagnoses of but not limited to anemia, CAD (coronary artery disease), hypertension (high blood pressure, CVA (stroke), depression and psychotic disorder. Resident # 5's most recent MDS (Minimum Data Set) dated 6/4/18 was coded as quarterly. She was coded as having a BIMS (Basic Interview of Mental Status) score of 15, indicating no cognitive impairment. She was coded as needing physical assistance of 1 staff member for activities of daily living. She was coded as being at risk for pressure ulcers however she was also coded as having no open areas or pressure ulcers. She is…

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, resident interview, facility documentation review, and in the course of a complaint investigation, the facility staff failed for 2 (Resident #176 and #118) of 61 residents in the survey sample to notify the physician and/or resident's family of a change of conditions 1. For Resident #176, the facility staff failed to notify the resident's family of a fall. 2. For Resident #118, the facility staff failed to notify the physician and/or designee of missed Physical Therapy (PT) appointments. The findings included: Resident # 176 was admitted to the facility on [DATE] with diagnoses of depression, insomnia, and bradycardia. Resident #176 had an unwitnessed fall on 2/27/18. An Initial Minimum Data Set (MDS) dated [DATE] assessed this resident in the area of Hearing, Speech, and Vision as having minimal hearing difficulty. In the area of Cognitive Patterns this resident was assessed as having a Brief Interview for Mental Status (BIMS) score of 9. Resident #176 was…

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

Based on observation, resident interview, staff interview, facility documentation review, the facility staff failed to ensure the Privacy of Residents related to leaving a team assignment face up on 1 medication cart of 10 med carts (Cart 2 Unit 2) The findings included: During a medication administration observation on 6/20/18 at approximately 11:11 AM, Registered Nurse #1 left her medication cart to retrieve a supply of insulin syringes and left her Patient Assignment face up on her medication cart. The Patient Assignment included medical information (diagnoses) on the Residents that anyone passing the medication cart may have seen. RN #1 on 6/20/18 at approximately 11:12 AM, when asked about the Resident Assignment being left face up, she stated, Oh that is a HIPPA (Health Insurance Portability and Accountability Act) issue. Other than the Surveyor remaining at the medication cart, no one saw the information. In addition, during medication pass, RN #1 was heard giving a medical update to a family member in the hall way where any resident or visitors in the Resident rooms could…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review, staff interviews and facility document review, the facility failed to notify the Office of the State Long-Term Care Ombudsman in writing of hospital discharges for 2 of 61 residents in the survey sample, Resident #42 and 91. 1. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #42's transferred and admitted to the hospital on [DATE]. 2. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #91 transferred and admitted to the hospital on [DATE]. The finding include: 1. Resident #42 was originally admitted to the facility on [DATE]. Diagnosis for Resident #42 included but not limited to *Chronic Respiratory Failure with *hypoxia -dependent on respiratory (*Ventilator). *Respiratory Failure is the inability of the cardiovascular and pulmonary systems to maintain adequate exchange of oxygen and carbon dioxide in the lungs (Mosby's Dictionary of Medicine, Nursing & Health Professions, 7th…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinical record review and facility documentation review the facility staff failed send or provide a copy of the Bed-Hold Policy for 1 resident (Resident #42) of 61 residents in the survey sample, after being transferred to the hospital on 5/19/18. The facility staff failed to provide the resident #42 or the resident's representative with a written copy of the bed hold policy. The finding include: Resident #42 was originally admitted to the facility on [DATE]. Diagnosis for Resident #42 included but not limited to Chronic Respiratory Failure with *hypoxia dependent on a ventilator-a machine that supports breathing (Source: http://www.nhlbi.nih.gov/health/health-topics/topics/vent). *Hypoxia is diminished availability of oxygen to the body tissues (Reference: http://medical-dictionary.thefreedictionary.com/hypoxia) The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 04/06/18 coded the resident with as comatose - persistent vegative…

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

Based on staff interview and clinical record review the facility staff failed to assure one resident (Resident #1) of 61 residents in the survey sample, was assessed at least quarterly utilizing the Minimum Data Set (MDS). For Resident #1, the facility staff failed to complete a quarterly MDS assessment within the required 92 days. The findings included: Resident #1 was admitted to the nursing facility 7/27/07. The diagnoses for Resident #1 included but not limited to Type II Diabetes. Resident #1's last Minimum Data Set (MDS) was a Comprehensive Assessment with an Assessment Reference Date of 01/29/18 coded Resident #1 Brief Interview for Mental Status (BIMS) scoring a 11 out of a possible 15 indicating moderate cognitive impairment. In addition the MDS coded Resident requiring supervision with one assist with bed mobility, transfer, dressing, toilet use and personal hygiene. An interview was conducted with MDS Coordinator on 6/26/18 at approximately 11:00 a.m., who stated, Resident #1 popped up on the Missing OBRA Assessment Report. She should have had 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.

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 accurately reflect, via the required Minimum Data Set (MDS) assessment, the resident's status for 1 of 61 residents (Resident #18) in the survey sample. The facility staff failed to accurately assess the resident's sacral pressure upon re-admission to the facility on [DATE]. The findings included: Resident #18 was originally admitted to the nursing facility on 11/9/17 with diagnoses that included right subdural hematoma, severe traumatic brain injury, closed facial fractures and mandible fracture, vegetative state, and enteral feedings via a gastrostomy tube (GT). The resident was seen in the Emergency Department (ED) on 11/10/17 and readmitted on [DATE] Resident #18 was readmitted to the nursing facility on 12/5/17 with an *unstageable sacral pressure ulcer. The facility staff failed to accurately assess and initiate an effective pressure ulcer treatment protocol, instead the ulcer was assessed as a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility documentation review, and clinical record review, the facility staff failed to develop and implement a comprehensive person centered care plan for two Residents (Residents #95, & #72) of the 61 residents in the survey sample. 1. Resident #95's care plan did not include person centered interventions for weight loss. 2. For Resident #72 the facility staff failed to care plan the Resident for constipation. Findings included: 1. Resident #95 was admitted to the facility on [DATE]. Current diagnoses included; Altered mental status, nutrition deficiency, vitamin D deficiency, and urinary tract infection. The current MDS (Minimum Data Set) was a significant change assessment with an ARD (assessment reference date) of 5-11-18. Staff assessment of mental status coded the Resident with severely impaired cognition. The Resident was coded as having no behaviors, and needing extensive to total assistance of 1-2 staff members for all activities of daily living. he Resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and closed record review the facility staff failed to meet professional standards of quality for 2 (Residents #477 and #95) of 61 residents in the survey sample. 1. The facility staff failed to meet professional standards of quality when an LPN (Licensed Professional Nurse) delegated the application of a hot compress to a CNA (certified nursing assistant) which resulted in second degree burns on Resident #477's hand. 2. The facility staff failed implement a physician's order to increase Pro-stat from once per day to three times per day for Resident #95; and provided the wrong diet to the Resident on 6-19-18 for the lunch meal. Findings included: 1. Resident #477 was admitted to the facility on [DATE] with diagnoses that include and were not limited to: Osteomyelitis of the vertebra (infection in the bones of neck), bilateral upper extremities paralysis, Type 2 diabetes, drug abuse, respiratory failure, viral hepatitis C, cystitis (urinary tract infection), urinary…

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 family and staff interview, the facility staff failed to provide one resident (Resident #103) with physician ordered oxygen in the survey sample of 61 residents. The findings included: Resident #103 was admitted to the facility on [DATE] with diagnoses which included hypertension, GERD, hemiplegia, Chronic Respiratory Failure, Tracheostomy, Gastrostomy Status, Pneumothorax, seizures, and CVA. The facility staff failed to provide physician ordered. A re-entry Minimum Data Set (MDS) dated [DATE] for Resident #103 indicated this resident is not able to communicate with speech. This resident is not able to make self understood or understand others. In the area of Cognitive Patterns for daily decision making this resident is assessed as being severely impaired. In the area of Activities of Daily Living (ADL) this resident is assessed as being totally dependent on staff. In the area of Special Treatments, Procedures, and Programs -Respiratory Treatment- this resident was assessed for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility documentation review, and clinical record review, the facility staff failed to meet the nutritional needs of one resident (Resident #95) of the 61 residents in the survey sample. For Resident #95, the facility staff failed to provide the ordered diet on 6-19-18, failed to provide the Pro-stat supplement as ordered, provide ongoing nutritional assessments, and failed to revise the care plan with feeding needs, during a significant weight loss. Findings included: Resident #95 was admitted to the facility on [DATE]. Current diagnoses included; Altered mental status, nutrition deficiency, vitamin D deficiency, and urinary tract infection. The current MDS (Minimum Data Set) was a significant change assessment with an ARD (assessment reference date) of 5-11-18. Staff assessment of mental status coded the Resident with severely impaired cognition. The Resident was coded as having no behaviors, and needing extensive to total assistance of 1-2 staff members for all…

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, family and staff interview the facility staff failed to provide one resident (Resident #103) with Respiratory care in accordance with professional standards of practice and the person centered care plan, in the survey sample of 61 residents. The findings included: Resident #103 was admitted to the facility on [DATE] with diagnoses which included hypertension, GERD, hemiplegia, Chronic Respiratory Failure, Tracheostomy, Gastrostomy Status, Pneumothorax, seizures, and CVA. The facility staff failed to provide Respiratory care and services in accordance with the residents care needs. A re-entry Minimum Data Set (MDS) dated [DATE] for Resident #103 indicated this resident is not able to communicate with speech. This resident is not able to make self understood or understand others. In the area of Cognitive Patterns for daily decision making this resident is assessed as being severely impaired. In the area of Activities of Daily Living (ADL) this resident is assessed as being totally dependent…

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 provide pain management for 1 resident (Resident # 5) in the survey sample of 61 Residents. For Resident # 5 facility staff failed to provide pain management according to physician's orders. The finding included: Resident #5 a 66 yr. old female was admitted on [DATE] with diagnoses of but not limited to anemia, CAD (coronary artery disease), hypertension (high blood pressure), CVA (stroke), and depression and psychotic disorder. Resident # 5's most recent MDS (Minimum Data Set) was coded as an annual an ARD (assessment reference date) of 6/4/18. She was coded as having a BIMS (Basic Interview of Mental Status) score of 15, indicating no cognitive impairment. She was coded as needing physical assistance of 1 staff member for activities of daily living as well as being always incontinent of bowel and bladder as well as being totally dependent on staff for bathing. She was coded as being at risk for pressure ulcers however she was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility staff failed to provide on communication with the dialysis facility for one resident (Resident #110) in the survey sample of 61 residents. The findings included: Resident #110 was admitted to the facility on [DATE] with diagnosis of colon cancer, failure to thrive, type two diabetes, depression, end stage renal disease and anemia. The facility staff failed to have ongoing communication with the dialysis facility regarding dialysis care and services. A Quarterly Minimum Data Set (MDS) dated [DATE] assessed this resident in the area of Hearing, Speech and Vision as having highly impaired Vision. In the area of Cognitive Patterns this resident was assessed as having a Brief Interview for Mental Status (BIMS) score of 15. In the areas of Activities of Daily Living (ADL) this resident was assessed as requiring limited assist of one person for bed mobility, not able to walk in room, eats with supervision of set-up and one person assist, requires extensive…

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 a information obtained during a complaint investigation, resident, staff and family interviews, and review of the clinical record, the facility staff failed to ensure residents who displays or has a history of a mental disorder and trauma receives the care and services necessary to reach and maintain the highest level of mental and psychosocial functioning for 1 of 61 residents (Resident #118), in the survey sample. The facility staff failed to acknowledge, assess, develop and implement a person centered plan for the underlying cause of displayed expressions of distress exhibited by Resident #118 on 6/5/18 and 6/12/18, and to ensure Resident #118 received appropriate, individualized treatment, services and assistance to meet her needs during community physical therapy appointments; which resulted in a decline in her psychosocial well-being. The findings included; Resident #118 was originally admitted to the facility 8/10/16. The admission diagnoses included Parkinson's disease, Major Depressive disorder, Unspecified Psychosis, an anxiety disorder, and an Adjustment disorder…

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 attempt gradual dose reductions of psychoactive medications for two residents (Resident #63 and 118) in the survey sample of 61 resident. 1. For Resident #63, the facility staff failed to attempt gradual dose reductions or document why gradual dose reductions are not indicated for ordered doses of Seroquel. 2. For Resident #118, the facility staff failed to attempt gradual dose reductions or document why gradual dose reductions were not indicated for ordered doses of Seroquel and Duloxetine; and to not prescribe as needed Xanax for greater than 14 days without documenting the rationale and duration of use in the medical record. The findings included: 1. Resident #63 was admitted to the facility on [DATE] with diagnoses of dementia without behavioral disturbance, epilepsy disorienting, anxiety and anemia. The facility staff failed to provide a Gradual Dose Reduction (GDR) for psychotropic medications for Resident #63. Resident #63 had…

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 Insulin was stored correctly with both an open and a correct expiration date on 1 of 10 medication carts (Unit 4 Cart 2, and failed to ensure one PPD (purified protein derivative-tuberculosis skin test) vial was stored correctly with both an open and expiration date on 1 of 3 medication storage rooms (South 1 Medication Storage Room) and failed to ensure one treatment cart was secure by LPN #7 after leaving her keys in the treatment cart lock when not in direct supervision of the nurse. The findings included: 1. On [DATE] at approximately 12:08 PM an observation was made of the Facility's Unit 4 Cart 2. A Humalog 100 ml (milliliter) opened vial was observed with an open date of [DATE] with an expiration date marked [DATE]. When RN #1 was asked what she thought was wrong with the labeling she stated, They marked it for 30 days instead of 28. The Clinical Manager…

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.