Shore Health & Rehab Center

Based on observation and staff interview the facility staff failed to properly thaw and store chicken and the facility staff failed to appropriately label and date refrigerated and un-refrigerated food items. The findings include: On 7/23/24 at approximately 12:30 PM observations were made of: loaves of bread with no expiration dates on the bread rack, opened milk with no used by date in the walk-in refrigerator and open slice cheddar cheese in a plastic bag with no label or date. On 7/24/24 at approximately 12:30 PM an observation was made of the chicken legs that were thawed to be used by 7/23/24, were refrozen in the facility's freezer in clear plastic bags dated 8/31/24. An interview was conducted with Others #8 (dietary staff) on 7/24/2024 at approximately 2:30 PM. Others #8 shared that everything gets dated on the day of delivery with the delivery date. She shared when an item is opened and not completely used, the open and discard date should be written on the item. Others #8 indicated that once chicken is thawed and stored in the walk-in refrigerator, it should not be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff and resident interviews, the facility staff failed to provide personal hygiene to include full body showers and or whirlpools with hair washing for 4 of 41 residents (#64, #52, #19 and #53) in the survey sample. The findings include: 1. Resident #64 was not receiving personal hygiene to include showers and hair shampoos since 12/25/20. Resident #64 was admitted to the facility on [DATE] with diagnoses that included stroke with right sided weakness, tremors and swallowing problems, Bell's Palsy, lymphedema, high blood pressure and type 2 diabetes and neuropathy. The most recent Minimum Data Set (MDS) assessment was an Annual dated 1/25/21 and coded Resident #64 with a 15 out of a possible score of 15 which indicated the resident was intact with the skills needed for daily decision making. The MDS assessed the resident to not reject care. The resident was assessed totally dependent on one staff for dressing, personal hygiene and bathing. Resident #64 required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a complaint investigation, observations, staff and resident interviews and facility documentation, the facility staff failed to accurately assess and provide effective pressure relief while in sitting in a wheelchair to prevent pressure ulcers for 1 of 41 residents (Resident #64) in the survey sample. The findings include: Resident #64 was admitted to the facility on [DATE] with diagnoses that included stroke with right sided weakness, tremors and swallowing problems, Bell's Palsy, lymphedema, high blood pressure and type 2 diabetes and neuropathy. The most recent Minimum Data Set (MDS) assessment was an Annual dated 1/25/21 and coded Resident #64 with a 15 out of a possible score of 15 which indicated the resident was intact with the skills needed for daily decision making. The MDS assessed the resident to not reject care. The resident was assessed totally dependent on one staff for dressing, personal hygiene and bathing. Resident #64 required extensive assistance of one staff for bed mobility,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews and facility documentation review the facility staff failed to remove expired medication from 1 of 6 medication carts (A-Wing). The findings included: On [DATE] at 9:02 a.m., during a medication pass observation outside of room [ROOM NUMBER]-B on A Wing, Licensed Practical Nurse (LPN) #1 was observed pouring 2 tablets in medication cup from a bottle labeled Sodium Bicarbonate 5 gr (Grain) - 325 mg. (Milligram). Per inspection of the bottle it was observed that 03/22 was written in black ink on the bottle cap. When asked what 03/22 indicated, LPN #1 stated, This is when we opened it. Per further inspection of bottle an expiration date of 06/20 and Lot number 182027 was observed. When asked what do you check for when preparing to give medications, LPN #1 stated, Check the name, correct dose and expiration date. When asked what is the expiration date on the bottle, LPN #1 stated, 06/20. When asked if the medication was expired, LPN #1 stated, Yes. LPN #1 removed the Sodium…

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

Based on resident interview, family interview, staff interviews, and clinical record review, the facility's staff failed to act on replacing missing dentures after they were know not to be in the resident's possession for 1 of 41 residents (Resident 4), in the survey sample. The findings included: Resident #4 was originally admitted to the facility 11/5/2017 and had never been discharged . The resident has never been discharged from the facility. The current diagnoses included; dementia, a-fib, and breast cancer. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/10/20 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as moderately impaired for daily decision making. In section G (Physical functioning) the resident was coded as requiring extensive assistance of one person with bathing and dressing, limited assistance of one person, with bed mobility, transfers, and personal hygiene, supervision with one person…

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

Based on observation, staff interview, and facility document review, it was determined that facility staff failed to follow infection control practices while picking up meal trays from quarantine rooms on the C-Wing. The findings included: On 3/10/21 at 1:45 p.m., observations were made of CNA (Certified Nursing Assistant) #1 collecting meal trays from C-Wing, hallway (C-17 through C-22); the quarantine unit. All rooms on the quarantine unit had signage in front of each room documenting the following: Droplet-Contact Precautions Perform hand hygiene, Wear mask before entering the room, Gown before entering the room, Gloves before entering the room, eye protection before entering the room. At 1:50 p.m., CNA #1 was observed entering room C-20 wearing an N95 mask and face shield. CNA #1 failed to don a gown and gloves prior to entering the room. At 1:51 p.m., CNA #1 left room C-20, placed the meal tray on the cart and entered room C-22 without sanitizing her hands. CNA #1 also failed to don a gown and gloves prior to entering room C-22. CNA #1 was then observed leaving room C-22…

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 and staff interview, it was determined that the facility staff failed to maintain an effective pest control system potentially affecting all residents in the facility. The findings included: During the Kitchen Inspection on 10/16/19 at 11:45 AM 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 10/16/19 at 2:50 PM 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…

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

Based on information obtained during the Resident Council Meeting, observations and interviews, the facility staff failed to display advocacy agencies addresses, and telephone numbers in a manner the residents could utilize which could potentially affect resident's who utilize wheelchairs. The findings included: A resident council meeting was held in the resident dining hall on 10/17/2019 at approximately, 11:00 AM. Seven residents attended the meeting. The residents were not aware of how to obtain or utilize the Long-Term Care Ombudsman's contact information or other advocacy agencies. They also had trouble reading the signage on the wall in the hallway. On 10/17/19 at approximately 4:30 PM an interview was conducted with the Activity Director regarding the residents in the Resident Council Meeting stating they didn't know where to find the Ombudsman contact information. The Activity Director stated that she had previously educated the residents to the facility posting and the Ombudsman information. On 10/17/19 at approximately, 4:34 PM the Activity Director was asked if she 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 staff interviews, facility documentation review and clinical record review the facility staff failed send a copy of the Bed-Hold Policy upon discharge/transfer for 4 of 47 resident's (Resident #10, #47, #59 and #93) after being transferred to the local hospital. The findings included: 1. The facility staff failed to ensure that Resident #10 was provided a written copy of the facility's bed-hold and reserve bed payment policy upon transfer/discharge to the hospital on [DATE]. Resident #10 was originally admitted to the facility on [DATE]. Diagnosis for Resident #10 included but not limited to, Ileus. The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 07/09/19 coded the resident with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The Discharge MDS assessments was dated for 06/10/19 - discharged with return anticipated. According to the facility's documentation on 06/10/19, 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 observations and staff interview, the facility staff failed to ensure a two compartment deep fryer was clean and properly sanitized potentially affecting residents in the survey sample. The findings included: During the kitchen inspection on 10/17/19 at 11:20 AM, an inspection of the two compartment deep fryer revealed a heavy concentration of burnt food build up. The build-up had a two inch circumference around the deep fryer tray. The cooking oil in the deep fryer was noted to be of a dark brown color. During an interview with the Food Service Manager on 10/17/19 at 12:10 AM she stated, The deep fryer is cleaned two times a week. When asked how the build up of burnt food occurred, she stated, She did not know. A review of the Facility policy for cleaning kitchen equipment indicated: Kitchen equipment should be cleaned weekly and as needed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinical record review and facility documentation review the facility staff failed to send a copy of the Resident's Care Plans to include their goals for 3 of 47 residents in the survey sample (Residents #10, #47 and #93) after being transferred and admitted to the hospital. The findings included: 1. The facility staff failed to ensure that Resident #10's Plan of Care Summary to include his care plan goals was sent upon transfer/discharge to the hospital on [DATE]. Resident #10 was originally admitted to the facility on [DATE]. Diagnosis for Resident #10 included but not limited to Ileus. The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 07/09/19 coded the resident with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The Discharge MDS assessments was dated for 06/10/19 - discharged with return anticipated. On 06/10/19, according to the facility's documentation,…

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 47 residents (Resident #10 and #93) in the survey sample. The findings included: 1. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #10's transfer and admission to the hospital on 6/10/19. Resident #10 was originally admitted to the facility on [DATE]. Diagnosis for Resident #10 included but not limited to Ileus. The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 07/09/19 coded the resident with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The Discharge MDS assessments was dated for 06/10/19 - discharged with return anticipated. According to the facility's documentation, on 06/10/19 Resident #10 departed facility with local transport 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. The facility staff failed to ensure Resident #88's, MDS with an Assessment Reference Date (ARD) of 06/15/19 was coded correctly under Section N (Medications) for the use of insulin and injections. Resident #88 was admitted to the facility on [DATE]. Diagnosis for Resident #88 included but not limited to Type II Diabetes Mellitus. The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 06/15/19 coded the Resident #88 with a 12 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. Further review of Resident #88's quarterly MDS with an ARD of 06/15/19 was coded 0 for receiving injections and insulin. The section N on the MDS under medications received read as follows: Indicate the number of DAYS the resident receiving the medication during the last 7 days, enter 0 if medication was not received by the resident during the last 7 days. Resident #88's comprehensive care plan with a revision date of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interviews, and clinical record review, the facility staff failed to coordinate a recommendation dated 2/8/2018, for a Pre-admission Screening and Resident Review (PASARR) level II determination for 1 of 47 residents (Resident #26), in the survey sample. The findings included: Resident #26 was originally admitted to the facility 2/8/18 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included paranoia schizophrenia. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 7/16/19, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #26's cognitive abilities for daily decision making are intact. In sectionD (Mood) the resident was coded as having a little energy 2-6 days per week and in section E (Behaviors) no behaviors were coded. Review the current physician orders for Resident #26 revealed an order dated 8/21/19, 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.

Based on observations, clinical record review and staff interviews, the facility's staff failed to develop a baseline care plan within 48 hours to include use of heels float boots for 1 of 47 residents in the survey sample (Resident #207). The findings included: Resident #207 was originally admitted to the facility 9/30/19 and had never been discharged from the facility. The current diagnoses include chronic ulcers of the foot and lower leg, protein-calorie malnutrition, severe anemia and paranoid schizophrenia. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/30/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 10 out of a possible 15. This indicates Resident #207's cognitive abilities for daily decision making were moderately impaired. In sectionG(Physical functioning) the resident was coded as requiring supervision after set-up with eating, extensive assistance of 1 person with bed mobility, toileting, and personal hygiene, total care of 1 with bathing and total care of 2 with transfers.…

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, resident interview, staff interview, and clinical record review the facility's staff failed to obtain physician's orders for 2 of 47 residents in the survey sample, Resident #206 and #207. The findings included: 1. The facility staff failed to obtain a physician's order for the use of a *C-PAP (Continuous Positive Airway Pressure) machine for Resident #206. Resident #206 was originally admitted to the facility 10/9/19 and had never been discharged from the facility. The current diagnoses include pacemaker insertion, pneumonia and sleep apnea. The admission Minimum Data Set (MDS) assessment had not been completed therefore information was gleamed from the Nurse's admission assessment dated [DATE]. The assessment was coded for intact memory. An interview was conducted with Resident #206 on 10/16/19, at approximately 12:40 p.m. Resident #206 stated his family brought the C-PAP machine from home to the facility for his use and he was applying the mask nightly at bedtime. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, resident interview and clinical record review the facility staff failed to ensure 1 of 47 residents in the survey sample, Resident #86, was provided ADL (Activities of Daily Living) care to include removal of facial hair. The findings included: Resident #86 was admitted to the facility on [DATE]. Diagnoses included but were not limited to, Vascular Dementia without Behavioral Disturbance and Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side. Resident #86's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 09/12/2019 coded Resident #86 with a BIMS (Brief Interview for Mental Status) score of 08 indicating moderate cognitive impairment. In addition, the Minimum Data Set coded Resident #86 as requiring extensive assistance of 1 for bed mobility and dressing, total dependence with assistance of 1 for personal hygiene, bathing and toilet use and total dependence with assistance of 2 for transfer. During the tour…

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, resident interview, staff interview, and clinical record review the facility staff failed to provide necessary respiratory care and services for 1 of 47 residents (Resident #206), in the survey sample for *Continuous Positive Airway Pressure (C-PAP). The findings included: Resident #206 was originally admitted to the facility 10/9/19 and had never been discharged from the facility. The current diagnoses include pacemaker insertion, pneumonia and sleep apnea. The admission Minimum Data Set (MDS) assessment had not been completed therefore information was obtained from the Nurse's admission assessment dated [DATE]. The assessment was coded for intact memory. An interview was conducted with Resident #206 on 10/16/19, at approximately 12:40 p.m. Resident #206 stated his family brought the C-PAP machine from home to the facility for his use and he was applying the mask nightly at bedtime. Review of Resident #206's physician order summary did not reveal an order for use of a C-PAP. Review of the…

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

Based on information obtained during the Sufficient and Competent Nurse Staffing task, the facility staff failed to staff a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week which could potentially affect all residents. The facility staff failed to staff a RN for at least 8 consecutive hours a day on 12/23/18 and 1/1/19. The findings included: During the nursing staff review for December 3, 2018 through October 13, 2019 the facility staff was unable to verify RN presence in the facility for at least 8 consecutive hours on 12/23/18 and 1/1/19. On 1/9/19 at approximately 5:00 p.m., the Corporate Consultant stated they were unable to present any information verifying a RN was present in the facility for 8 consecutive hours. The above findings were shared with the Administrator, Director of Nursing and the Corporate Consultant on 10/18/19 at approximately 4:10 p.m., the Director of Nursing stated the RN called out and she wasn't notified, for if she had known she would have come in.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and staff interview, the facility staff failed to dispose of medications in a timely manner. The findings included: On [DATE] at approximately 1:00 PM an inspection was conducted in the medication room located on the A wing, cart #1. An expired, opened bottle of Humalog Insulin with an opened date of [DATE] written was observed. Licensed Practical Nurse #2 was asked how many days is the insulin good for after it's opened? She stated, It's good for thirty days. The resident is no longer receiving this. On [DATE] at approximately, 5:24 PM an interview was conducted with Registered Nurse (RN) #3 On the A-unit. She was asked how many days is a bottle of Humalog Insulin good for once it's opened? She stated, I'm gonna contact pharmacy. RN #3 stated that the pharmacist said it's good for 28 days. She was asked if you see insulin beyond 28 days what should you do? She stated, I would discard it and re-order. On [DATE] at approximately, 3:00 PM a pre-exit interview was conducted with the Director…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews and facility documentation review the facility staff failed to ensure house stock Artificial Tears eye drops was labeled to identify the specific resident for whom it was prescribed for 1 of 47 resident's in the survey sample (Resident #158); and failed to remove expired biological's from the Storage Room on B-Unit. The findings included: 1. On [DATE] at approximately 5:00 p.m., the First Hall medication cart on B-Unit was inspected with Licensed Practical Nurse (LPN) # 6. An opened box of Artificial Tears eye drops was observed in the medication cart and it was marked with the date [DATE]. LPN #6 was asked, What does the date [DATE] indicate? LPN #6 stated, That's the date it was opened. The Surveyor observed the (initials) had been written on the box with a black ink marker. The Surveyor asked LPN #6, Whose eye drops are those? LPN #6 stated that they were Resident #158's eye drops. The Surveyor asked LPN #6, The initials on the box are (Initials), the initials of 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 staff interview and clinical record review, the facility staff failed to follow physician orders to obtain a *Hemoglobin A1C once every three months for 1 of 47 residents in the survey sample, Resident #27. The findings included: Resident #27 was admitted to the nursing facility on 10/09/2018. Diagnosis included but not limited to Diabetes Mellitus without complications and Chronic Kidney Disease. The current Minimum Data Set (MDS) a quarterly revision MDS with an Assessment Reference Date (ARD) of 07/17/19 coded the resident with a 15 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS). This indicated Resident #27's cognitive abilities for daily decision making were intact. Section I, Metabolic, 12900 of the MDS indicates that Resident has Diabetes Mellitus. On 10/16/19 at approximately, 2:40 PM during the initial tour, Resident #27 stated, I'm supposed to get my A1C checked every month but haven't had it done since February. Review of the clinical record included the Physicians order summary which read: A1C in the morning every three months…

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 ensure infection control practices were followed during wound care for 1 of 47 resident's in the survey sample, Resident #87. The findings included: Resident #87 was admitted to the facility on [DATE]. Diagnoses included but were not limited to, Endocarditis, Valve unspecified and Venous Insufficiency. Resident #87's Quarterly Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of 09/14/2019 was coded with a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #87 as requiring extensive assistance of 1 for bed mobility, dressing, toilet use, personal hygiene and total dependence of 1 with transfer and bathing. On 10/17/2019 at 11:20 a.m., the Surveyor was at Resident #87's bedside to observe Registered Nurse (RN) #1 provide wound care. Resident #87 has pressure ulcers on her left and right buttocks.…

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.