Battlefield Park Healthcare Center

Based on resident interview, staff interview, and review of facility documents, the facility's staff failed to ensure residents packages were received unopened. The findings included: During the unit council meeting held in the facility on 9/18/24 at approximately 2:30 PM, three of the six residents that attended complained that their packages are always opened when received. These residents said that their mail is received unopened, but packages were always opened. The residents were frustrated and said it was an invasion of their privacy. An interview was conducted with the facility's Executive Director (ED) on 9/18/24 at approximately 4:15 PM. The ED stated that residents should received their mail and packages unopened and that she was unaware that resident's packages have been received open. The facility's policy titled Resident's Rights, undated reads, Residents have a right to have privacy in sending and receiving mail. On 9/19/24 at approximately 5:00 PM, the above findings were shared with the Executive Director (Administrator), Director of Nursing, Assistant Director 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, interview, and facility documentation the facility staff failed to ensure a clean, comfortable homelike environment for the Residents on the 100's hall and any Residents that receive food from the kitchen. The findings included: For the Residents on the e100's hall and those receiving food from the kitchen the following observations were made: 9/17/24 - 9/19/24 - during the 3 days of survey flies and gnats were noted in the conference room by all surveyors, dead bugs were noted in light fixtures throughout the building. 9/17/24 at 11:55 a.m. - floors in the hallway have stains near room [ROOM NUMBER] and 111. 9/17/24 at 12:05 p.m. - room [ROOM NUMBER] A area above bed has been repaired and spackled but not painted. 9/17/24 at 12:10 p.m. - room [ROOM NUMBER] B IV pole and floor have brownish substance dried on them appears to be tube feeding. 9/17/24 at 1:30 p.m. - Shower room was cluttered with 4 shower chairs a shower stretcher a weight scale, 2 vital signs machines, an IV pole. There were…

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, clinical record review and staff interview, the facility staff failed to ensure a Pre-admission Screening and Resident Review (PASARR) was completed prior to admission for 3 Residents(Residents #92, #104, & #84) in a sample of 42 residents. The Findings included: 1. Resident #92 was admitted on [DATE] with diagnoses including: Major depressive disorder with psychotic symptoms, anxiety disorder, and avoidant restrictive food intake disorder. Physicians orders for medications were reviewed and revealed several psychotropic medications actively being administered for agitation, frustration, yelling and ongoing behavior monitoring. Those medications are listed as follows; Trazadone/Desyrel - for depression Mirtazipine/Remeron - for clinical depression Buspar/buspirone - for depression Duloxetine/cymbalta - for major depressive/anxiety disorder It is notable to mention that Trazodone, Duloxetine, and Buspar are not recommended to be administered together as combined they may…

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 interviews, staff interviews, and review of the clinical record, the facility staff failed to provide appropriate care and services to manage indwelling catheters for 2 of 42 residents (Resident #67 and 81), in the survey sample. The findings included: 1. The facility staff failed to ensure that Resident # 67's indwelling catheter was anchored to prevent dislodgement and or trauma. Resident #67 was originally admitted to the facility 2/4/2022 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included quadriplegia, stage 4 pressure ulcers of the left groin and right gluteal fold and an obstructive uropathy. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/6/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #67's cognitive abilities for daily decision making were intact. The resident's active Physician Order Summary…

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, staff interviews, and clinical record review, the facility staff failed to coordinate mental health services for a resident with a diagnosis of depression, who was voicing feelings of increased depression for 1 of 42 residents (Resident #81), in the survey sample. The findings included: Resident #81 was originally admitted to the facility 04/15/22 and readmitted to the facility from an acute care hospital stay on 11/2/23. The current diagnoses included a depression disorder diagnosed, 10/16/2015. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/19/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #76's cognitive abilities for daily decision making were intact. In section D (Resident Mood Interview) the resident was assessed as feeling tired or having little energy 7 - 11 days, having trouble falling or staying asleep, or sleeping too much 12 -14 days and having little interest or pleasure in doing things 12…

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 facility documents, the facility staff failed to remove expired Covid 19 tests, an expired medication, and expired wound dressings stored in 2 of 2 medication storage rooms; failed to provide the date medications were opened and stored in 1 of 4 medication administration carts. The findings included: 1. On 9/18/24 at 3:10 PM an observation of the medication storage room on Wing 2 with LPN (D) revealed 11 boxes of BinaxNow Covid19 tests expired on 10/27/23. On 9/19/24 at 11:10 AM an interview was conducted with the Regional Nursing Consultant. The Regional Nursing Consultant stated that the BinaxNow Covid 19 tests are expired, and the facility is not able to use these tests. She also stated that these tests have been disposed of, so they are no longer able to be used. 2. On 9/18/24 at 3:48 PM an observation of the medication storage room on Wing 1 with Registered Nurse (RN) (B) revealed: in the refrigerator, there was 1 opened multi-dose vial of Insulin Lantus 100 units/ml with an open date of 7/12/24. A 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 observation, resident interview, and staff interview, the facility's staff failed to offer and provide snacks at bedtime. The findings included: There were no observations made during this survey from 9/17/24 to 9/19/24 of snacks being offered or provided to residents. During the unit council meeting held in the facility on 9/18/24 at approximately 2:30 PM, the six residents that attended complained that they do not get offered snacks and do not receive snacks on a regular basis. The residents stated that it is random and rare to receive snacks at bedtime. The residents also stated, when they do get snacks, they are full of sugar, such as fig bars and cakes. The residents further stated that they have witnessed the dietary staff bring snacks to the unit occasionally, and the nursing staff left them at the desk. The residents stated this allowed the residents who could get to the desk get a snack but the residents who could not, did not. An interview was conducted with the Dietary Manager (DM) on 9/19/24 at approximately 3:15 PM. The DM stated that he is aware snacks are 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.

Based on observation, staff Interview and facility documentation review, the facility staff failed to prepare and serve food in a safe and sanitary manner. The findings included: The facility staff failed to ensure the ice machine plumbing had an air gap to prevent the back flow of contaminated water, and failed to maintain a sanitary food storage and preparation area in accordance with professional standards for food service safety. On 9-17-24 at approximately 12:00 PM, the kitchen area of the facility was inspected with the dining services manager, and Regional food Services Director. In the main kitchen food preparation and cooking area a clean silverware tray was found on a rolling cart with a dish sponge on a stick commingled with the clean silverware. the sponge was wrapped in plastic wrap and when opened dead insects resembling small flies fell out, and some were still imbedded in it. On a separate cart covered in a brown liquid sticky substance, was noted bread clips, food crumbs and food debris, commingled with clean glasses which were stacked on the cart for use with 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 observation, interview, and facility documentation, the facility staff failed to maintain an effective pest control program so that the facility is free of pests and rodents. The findings included For the facility, the facility staff failed to follow the pest control company recommendations for reducing / eliminating pests from the facility. On 9/17/24 during the initial tour of the kitchen Surveyor C noted mouse droppings in the dry storage area, small flies in a dish washing sponge placed in a tray with Clean silverware 9/17/24 - 9/19/24 - during the 3 days of survey flies and gnats were noted in the conference room by all surveyors, dead bugs were noted in light fixtures throughout the building, and gnats and flies noted throughout the building in various Resident rooms. A review of the pest control book revealed the following excerpts from the service receipts: 4/19/24: Finding: Exit door doesn't close /seal properly ¼ inch or greater gap exists. Fire door in 100 wing facing sheds is rusted and potentially needs to be replaced. Exit door doesn't close /seal properly ¼…

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 review of the resident record, staff interviews and a review of facility documents, the facility staff failed to notify the Office of the State Long-Term Care Ombudsman in writing of a hospital discharges for 1 of 42 residents (Resident #67), in the survey. The findings included: Resident #67 was originally admitted to the facility 2/4/2022 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included quadriplegia, stage 4 pressure ulcers of the left groin and right gluteal fold and an obstructive uropathy. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/6/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #67's cognitive abilities for daily decision making were intact. A Nurse Practitioner's note dated 11/8/23 read that Resident #67 was observed unresponsive by a Certified Nursing Assistant (CNA). The note further read that the 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, interview, clinical record review and facility documentation the facility staff failed to develop and implement a comprehensive person-centered care plan for one Resident (#84) in a survey sample of 40 Residents. The findings included: For Resident #84 the facility failed to develop a comprehensive care plan that addressed the current contracture to left hand and measures to prevent further contracture. Resident #84 was admitted to the facility on [DATE] with diagnoses that included but were not limited to gastrostomy tube, epilepsy, history of venous thrombosis and embolism, dvt/pulmonary embolism, hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, aphasia (inability to speak) following cerebrovascular disease, and depression. Resident #84's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/21/24 coded the Resident as having a BIMS (Brief Interview of Mental Status) score of 99 - unable to evaluate as Resident 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 observation, interview, clinical record review and facility documentation the facility staff failed to ensure Residents who are unable to carry out activities of daily living receive the necessary services to maintain good grooming, and personal hygiene for three Residents (#'s 5, 38 and 60) in a survey sample of 40 Residents. The findings included: 1. For Resident #5 the facility staff failed to ensure she received adequate assistance for showering bathing and grooming. Resident #5 's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/27/24 coded Resident #5 as having a BIMS (Brief Interview of Mental Status) score of 5/15 indicating severe cognitive impairment. Resident #5 was coded as requiring partial or moderate assistance of 1 staff with bathing, dressing and grooming. Resident #5 had diagnoses that included but were not limited to type 2 Diabetes, COPD (Chronic Obstructive Pulmonary Disease), chronic kidney disease stage 4, hypertension, congestive heart failure,…

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, interview, clinical record review, and facility documentation, the facility staff failed to ensure Residents receive appropriate services, equipment, and assistance to maintain or improve mobility, for 1 Resident (#84) in a survey sample to 40 Residents. The findings included: For Resident # 84 the facility staff failed to address the contracture of left hand, failed to implement any measures to reduce consequences of contracture and reduce likelihood of worsening of contracture. Resident #84 was admitted to the facility on [DATE] with diagnoses that included but were not limited to gastrostomy tube, epilepsy, history of venous thrombosis and embolism, dvt/pulmonary embolism, hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, aphasia (inability to speak) following cerebrovascular disease, and depression. Resident #84's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/21/24 coded the Resident as having a BIMS (Brief…

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, interview, clinical record review and facility documentation the facility staff failed to ensure that Residents who are fed by enteral feeding received appropriate treatment and services and to prevent complications of enteral feeding for 2 Residents (#'s 12 & 84) in a survey sample of 40 Residents. The findings included: 1. For Resident #12 the facility staff failed to ensure 60 ml (milliliter) syringe used for peg tube maintenance were clean and changed daily, failed to ensure that tube feeding was correctly labeled and dated On 9/17/24 at 11:46 a.m. observation was made of Resident #12 in bed dressed in a hospital gown, she had empty bottle of tube feeding hanging undated, and an undated used 60 ml syringe hanging in the plastic wrap from the IV pole. The syringe had thick curdled tube feeding in the base of it, the pump was turned to the off position and the water flush bag was half empty but also undated. The tubing for the tube feeding had no date or time. A review of the clinical…

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, interview, clinical record review, and facility documentation the facility staff failed to ensure that a Resident who needs respiratory care is provided such care, consistent with professional standards of practice, for 1 Resident (#40) in a survey sample of 40 Residents. The findings included: For Resident #40 the facility staff failed to ensure that oxygen tubing was dated when first applied and that the Resident had an order for PRN use of oxygen. On 9/17/24 at approximately 11:45 a.m. Resident #40 was observed in bed dressed in a hospital gown, she was not using oxygen at this time. An oxygen concentrator was by her bedside, the tubing was connected to the concentrator and the end of the tubing with the nasal cannula was on the floor by the bed. The oxygen tubing was not in a plastic bag, and it was not dated. When Resident #40 was asked if she uses oxygen, she stated that she used it only when she became short of breath, and sometimes at night. On 9/17/24 at 12:15 p.m. the oxygen concentrator was again observed with the tubing laying on the floor undated…

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 interview, clinical record review and facility documentation the facility staff failed to ensure Residents were free from unnecessary medications to include duplicate drug therapy for 1 Resident (#5) in a survey sample of 40 Residents. The findings included: For Resident #5 the facility staff failed to ensure the Resident did not receive duplicate drug therapy of the antihistamines Loratadine (Claritin) and cetirizine (Zyrtec). On 9/18/24 during clinical record review it was noted that Resident #5 had the following orders: Cetirizine Oral Tablet 10 MG Give 1 tablet by mouth in the morning for seasonal allergies -Start Date- 05/24/2024 Loratadine Give 1 tablet by mouth in the morning for seasonal allergies -Start Date- 09/13/2024 [*Please note this Resident was being given both of these medications at the 9:00 a.m. med pass] A review of the orders revealed that one order was entered by the Medical Director and the other was entered by the NP (Nurse Practitioner). These medications are both second generation antihistamines and not usually prescribed together as they both are…

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 interview, clinical record review and facility documentation the facility staff failed to ensure Residents were free of significant medication errors for 1 Resident (# 84) in a survey sample of 40 Residents. The findings included: For Resident #84 the facility staff failed to ensure that Resident # 84's blood pressure was checked prior to administering Midodrine (a vasopressor medication that raises low blood pressure). Resident #84 has a BIMS (Brief Interview of Mental Status) score of 99 -unable to evaluate as Resident is nonverbal. Resident #84 has diagnosis of but not limited to intercranial injury, intraparenchymal hemorrhage, seizures, right hemiplegia, dvt/pulmonary embolism, dysphagia, peg tube and is under hospice care. A review of the clinical record revealed the following order: 6/6/24 -Midodrine HCl Oral Tablet 10 MG -Give 1 tablet via PEG-Tube every 8 hours as needed for hypotension sbp [systolic blood pressure] less than 100, for 14 Days. Hold for sbp.> [above]115 A review of the MAR (Medication Administration Record) revealed that the order was started on…

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

Based on observation and staff interview, the facility staff failed to dispose of garbage properly in one of three trash receptacles (dumpster near the small employee parking lot) outside the facility. On 8/16/2021 at 8:30 AM, the large garbage dumpster near the smaller staff parking lot on the right side of the facility was observed with several white trash bags and cardboard boxes visible at least twelve inches above the level of the top of the dumpster. There was no cover over the top of the dumpster. There was debris on the ground around the dumpster. The debris consisted of several pieces of paper, and gloves. On 8/16/2021 at 10:57 AM, further inspection of the dumpster revealed several rusted holes in the front and sides and several flies were seen on top of the bags of trash visible above the top of the dumpster. Inside the bags, containers of orange juice, other food items and blue pads were observed. There was a very foul odor emanating from the dumpster. There was an odor of urine and feces noted. On 8/17/2021 at 8:20 AM, the garbage dumpster again was observed with bags…

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 documentation review, the facility staff failed to implement their abuse policy regarding the screening of employees for 15 employees (Employee B, Employee D, Employee E, Employee F, Employee G, Employee H, RN A, RN B, LPN A, LPN B, LPN C, CNA A, CNA B, CNA C, and CNA E) in a sample of 25 employee records reviewed. The findings included: On 8/16/21, Surveyor C conducted a review of 25 employee files and revealed the following: 1. The facility staff failed to obtain a criminal background check within 30 days of hire for 8 Employees (Employee D, Employee E, Employee F, Employee G, Employee H, LPN A, LPN C, and CNA C). 2. The facility staff failed to perform professional license verification to ensure nursing employees held current licensure or certification and to determine if they had been subject to disciplinary action against their professional license as a result of abuse, neglect or mistreatment for 8 employees (Employee B, Employee E, Employee F, RN B, LPN A, LPN B, LPN C, and CNA C). 3. The facility staff failed to check references prior 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, facility documentation review and clinical record review, the facility staff failed to accurately code an MDS (minimum data set) assessment for four Residents (Residents #11 ,# 54, #11, #84, #33 ) in a survey sample of 40 Residents. Findings included: 1. For Resident # 11, the facility staff failed to assess the Resident's cognitive functioning in Section C: Cognitive Pattern in the Quarterly assessment dated [DATE]. Resident # 11 was a [AGE] year old admitted to the facility 12/22/2020. Resident # 11's diagnoses included but were not limited to: Diabetic Ketoacidosis, Diabetic ulcers bilateral feet, osteomyelitis and History of Diabetes (Non-compliant). The most recent MDS (Minimum Data Set) assessment was a Quarterly Assessment with an ARD (Assessment Reference Date) of 5/11/2021. Review of Section C:Cognitive Pattern revealed Resident # 11 did not have a Brief Interview for Memory score because the cognitive assessment had several sections documented as dashes and was not assessed.…

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 documentation review, and clinical record review, the facility staff failed for one resident (Resident #51 in the sample of 40 residents) to continue skilled care services following the issuance of a SNF ABN (skilled nursing facility advance beneficiary notice). Resident #51 did not choose to discontinue services. This failure prevented the Resident from excercising her right to continue to receive skilled care services, and have Medicare make the coverage determination or the Resident pay privately for the services. The findings included: Resident #51, was admitted to the facility on [DATE], with a readmission on [DATE]. Resident #51's diagnoses included but were not limited to: hypertension, renal insufficiency, dementia and Parkinson's disease. Resident #51's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 6/23/21, was coded as a quarterly assessment. Resident #51 was coded as her cognitive skills for daily decision making…

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 documentation review and clinical record review, the facility staff failed to obtain a PASARR (pre-admission screening) for 2 Residents (Resident #22 and Resident #207) in a sample of 40 Residents. This deficient practice has the potential to negatively impact both Residents, by failing to have a level I PASARR, the facility staff were not aware if the 2 Residents required a level II screening to determine if specialized services for the treatment of/for mental disorders and/or intellectual disabilities was warranted. 1. For Resident #22 the facility staff failed to obtain a PASARR, level I screening prior to admission. 2. For Resident #207 the facility staff failed to ensure a PASARR was completed prior to entry to the facility. The findings included: 1. For Resident #22 the facility staff failed to obtain a PASARR, level I screening prior to admission. Resident #22 was admitted to the facility on [DATE]. Diagnoses for Resident #22 included but were not limited to: unspecified…

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, interview, and clinical record review, the facility staff failed to provide incontinence care in a timely manner for 1 (Resident # 92) in a survey sample of 40 residents. The Findings included: For Resident #92, the facility staff failed to answer the call bell and provide incontinence care in a timely manner. Resident #92, was a [AGE] year old who was admitted to the facility on [DATE]. The diagnoses included history of a stroke, coronary artery disease, heart failure, hypertension, high cholesterol, hemiplegia or hemiparesis from stroke, seizure disorder, anxiety disorder, COPD, and depression. Resident # 92's most recent MDS (minimum data set) coded the resident as having a BIMS (brief interview of mental status) score of seven, indicating severe cognitive impairment. The resident was also coded as requiring the extensive physical assistance of two people for bed mobility. Resident #92 is coded as requiring total the dependence of 2 people for transfers, dressing, toilet use, personal…

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, interview, and facility documentation, the facility staff failed to provide services to prevent pressure ulcers, for 1 Resident (#36) in a survey sample of 40 Residents. The Findings included: For Resident #36 the facility staff failed to prevent a pressure area from developing from wearing tight shoes. Resident #36 was a [AGE] year-old who was admitted to the facility on [DATE]. Resident #36's diagnoses included stroke, high, cholesterol, difficulty walking, muscle weakness and long term current use of steroids. Resident #36's most recent MDS (minimum data set) with an ARD (assessment reference date) of 6/8/21, coded the Resident has having a BIMS (brief interview of mental status) score of 11 out of 15 indicating moderate cognitive impairment. Resident #36 was also coded as requiring the extensive physical assistance of two people for bed mobility, transfers, and toilet use. He is coded as requiring the extensive physical assistance of one person for dressing, personal hygiene, eating and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, facility documentation, and clinical record review, the facility staff failed for 1 Resident #207 to provide medially-related social services to attain or maintain highest practicable mental and psychosocial well-being. The findings included: For Resident #207, the facility staff failed to have her seen by the Social Worker in a timely manner when she was when she was asking to leave. Resident #207 failed to comply with isolation, and had a known diagnosis of schizoaffective disorder, She was her own responsible party. Resident #207, a [AGE] year-old, was admitted to the facility on [DATE] with diagnoses of but not limited to hemiplegia and hemiparesis following a CVA affecting the left non-dominant side, essential primary hypertension, type II diabetes with peripheral neuropathy, schizoaffective disorder, and depression. Resident #207 had only been in the facility for 3 days, therefore she did not have a completed MDS (Minimum Data Set). Per her admission assessment 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 observation, staff interview, resident interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to implement their abuse policy for 1 resident (Resident #38) in a survey sample of 42 Residents. The findings included: 1. For Resident #38, the facility staff failed to implement their abuse policy by not notifying the state agency timely after a serious injury, and failing to file an accurate 5 day follow up report to the state agency of the results of their internal investigation. Resident #38 was most recently admitted to the facility on [DATE]. Diagnoses included: hypertension, anemia, contractures of the right and left knees, dementia without behavioral disturbances, quadriplegia, peripheral vascular disease, gastrostomy tube for feeding, and high cholesterol. The closest Minimum Data Set (MDS) assessment to the time period associated with the event that injured Resident #38, was a significant change assessment with an…

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

Based on staff interview, and facility documentation review, the facility failed to provide annual nursing staff training based on their annual reviews for 5 out of 5 sampled Certified Nursing Assistants (CNA). The Findings included: The facility staff failed to provide annual training based on their annual performance reviews. On 9/17/19, a review was conducted of employee records. The facility Staff Coordinator (Employee J) was interviewed in her office. The employee records were computer-based. The Staff Coordinator utilized her computer to facilitate the review. The records did not contain documentation identifying the required training for the identified employees based on their annual review. In addition, according to the Relias System Course Completion History, the facility failed to implement required annual training for the following employees: Employee and Training Due Date (CNA O) 9/7/19 (CNA P) 9/14/19 (CNA A) 7/14/19 (CNA S) 7/20/19 (CNA T) 7/31/19 When asked about the importance of staff completing their training requirements, the Staff Coordinator stated, Deficits 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility record review, and clinical record review the facility staff failed to label and store medications and medical supplies within accepted professional principles in one of two medications rooms and on one of four medications carts. The findings included: 1. The facility staff failed to remove expired medical supplies from the medication storage room, to prevent the use of expired items. On [DATE] at approximately 10:40 AM an observation of the medication storage room on station 1 was performed with LPN E. Observation revealed in a locked cabinet the following items: * a dressing kit. Medline dressing change tray with an origination date of [DATE] on the prescription label. The label also stated discard after [DATE]. LPN E stated, I've never heard of these people, (referencing she didn't know the Residents whose name was on the prescription label). * MaxPlus- clear needless connector with an origination date of [DATE] on the prescription label and a discard 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.

Based on observation, staff interview, and facility documentation review, the facility staff failed to effectively wear a hair restraint during meal preparation, and failed to ensure that an unidentified green vegetable was labeled and dated in the refrigerator in one of one kitchens. The Findings included: The facility cook (Employee I) failed to effectively restrain his moustache. And; The facility staff failed to ensure that an unidentified green vegetable was labeled and dated in the refrigerator. On 9/15/19 at 1:00 P.M. a tour was conducted of the facility kitchen. The cook (Employee I) was not wearing his beard restraint over his moustache, which was approximately one-quarter inch long. When asked about the effectiveness of his hair restraint, the cook stated, I usually wear it this way, indicating that he usually did not restrain the hair on his upper lip. The kitchen Manager (Employee O) was present. He stated, I have told him many times to cover his moustache. The kitchen refrigerator contained a plastic bowl covered with cellophane. There was no label identifying the item,…

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 documentation review, the facility staff failed to obtain verification of licensure for 6 of 6 Registered Dieticians. The Findings included: On 9/16/19 a review was conducted of facility staff, including Registered Dieticians. The facility Staff Coordinator stated that she did not have any employee files on any of the Registered Dieticians who had worked in the facility during the past year. On 9/16/19 at approximately 10:50 A.M., an interview was conducted with the facility Administrator (Employee A). He stated that he did not know how many Registered Dieticians had been employed at the facility during the past year. employee information records on any of the Registered Dieticians who had worked at the facility during the past year. He stated that the facility utilized the services of an outside agency to provide Registered Dieticians. On 9/16/19 at 5:50 P.M., the Administrator stated that the employee files were just received via fax from the agency. He confirmed that the information on the Registered Dieticians had not been documented and on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility record review, and clinical record review the facility staff failed to handle linen and facility equipment in a manner to prevent the spread of infection for 2 Residents (Resident #104, Resident #31) in a survey sample of 42 Residents. The findings included: 1 For Resident #104 facility staff failed to handle soiled/blood tinged linen in a manner to prevent the spread of infection. Resident #104 was admitted to the facility on [DATE], with a most recent readmission on [DATE]. Resident #104's diagnoses included but were not limited to: unspecified convulsions, muscle weakness, chronic pain, and type 2 diabetes. Resident #104's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 9/5/19 was coded as an annual assessment. Resident #104 was coded as having had a BIMS (brief interview for mental status) score of 15, which indicated cognitively intact. The Resident was also coded as requiring extensive assistance of 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 observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed, for 1 resident (Resident #28), in the survey sample of 42 residents, to provide access to a dining room for his meals. The Findings included: For Resident #28, the facility staff failed to provide access to a dining room for his meals, confining him to his room. Resident #28 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #28's diagnoses included Diabetes Mellitus Type 2, Muscle Weakness, and Hypertension. The Minimum Data Set, which was an admission Assessment with an Assessment Reference Date of 4/22/19 was reviewed. Resident #28 was coded with a Brief Interview of Mental Status Score of 15, indicating no cognitive impairment. He was also coded as requiring set up assistance with meals, and being able to ambulate independently with his wheelchair. On 9/15/19 at 12:45 P.M. a tour was conducted of the facility. There were no residents in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, clinical record reviews, and facility documentation review, the facility staff failed to maintain dignity for 3 residents (Resident #31, Resident #87, Resident #70) in a sample size of 42 residents. The findings include: 1. For Resident #31, the facility staff observed he had food on his face, however, the facility staff failed to assist him clean his face promptly. In addition, the facility staff left Resident #31's pants down while in bed. Resident #31, a [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses included but not limited to dementia, dysphagia, and diabetes. Resident #31's most recent Minimum Data Set with an Assessment Reference Date of 07/15/2019 was coded as a quarterly assessment. Functional status for eating was coded as requiring a one-person physical assist and supervision (oversight, encouragement, or cueing) during meals. Personal hygiene was coded as total dependence on staff. On 09/16/2019 at approximately 5:05 PM, Certified…

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 assess, to determine if a Resident was safe to self administer medications, for one Resident (Resident #104) in a survey sample of 42 Residents. The findings included: Resident #104 was admitted to the facility on [DATE], with a most recent readmission on [DATE]. Resident #104's diagnoses included but were not limited to: unspecified convulsions, muscle weakness, chronic pain, and type 2 diabetes. Resident #104's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 9/5/19 was coded as an annual assessment. Resident #104 was coded as having had a BIMS (brief interview for mental status) score of 15, which indicated cognitively intact. The Resident was also coded as requiring extensive assistance of staff with dressing, eating, personal hygiene, bed mobility and toileting. For bathing, Resident #104 was totally dependent upon staff. During 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.

Based on observation, staff interview, Resident interview, the facility staff failed to provide reasonable accommodation of needs for 1 Resident (#30) in survey sample of 42 Residents. The findings included; For Resident #30 the facility staff failed to accommodate the residents's needs as evidenced by failure to provide an operational hospital bed. Resident #30's most recent re-admission to the facility was on 2/12/19. The Resident's diagnoses included but were not limited to: end stage renal disease and hyperlipidemia. Resident #30's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 7/17/19 was coded as a quarterly assessment. Resident #30 was not assessed for cognitive functioning on this assessment. Resident #30 was coded as being independent with dressing, eating and bathing. He was also coded as having had required supervision of one staff person for transfers, toileting and personal hygiene. On 9/15/19 at 12:50 PM, during an interview with Resident #30, the Resident stated this his bed did not work, and had not worked for 2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed for one Resident (Resident #28) in a survey sample of 42 residents, to facilitate a preference to interact with community members who live in the facility by sharing a community dining experience due to the dining room was closed for breakfast, lunch and dinner on the weekends The findings included; Resident #28 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #28's diagnoses included Diabetes Mellitus Type 2, Muscle Weakness, and Hypertension. The Minimum Data Set, which was an admission Assessment with an Assessment Reference Date of 4/22/19 was reviewed. Resident #28 was coded with a Brief Interview of Mental Status Score of 15, indicating no cognitive impairment. He was also coded as requiring set up assistance with meals, and being able to ambulate independently with his wheelchair. On 9/16/19 a review was conducted of Resident #28's clinical…

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 documentation the facility staff failed to ensure correct completion of the Advance Beneficiary Notice of Non-Coverage, for 1 Resident (#71) in a survey sample of 42 Residents. The findings include: The facility failed to ensure Resident #50 was given a choice and checked the one of three options box on the ABN form. On 9/17/19 at approximately 4:30 PM the business office manager was given the names of the client records for ABN notices to pull. She returned with Resident #50's ABN notice dated 6/7/19. Page 1 had Resident # 50's name and Effective Date Coverage of Your Current Skilled Nursing Facility Services Will End: 6/10/19. (Patient number was left blank) Page 2 read If you miss the deadline to request an immediate appeal you may have other appeal rights: If you have original Medicare call [NAME] listed on page 1. If you belong to a Medicare health plan call your plan at the number given below: (Space left blank) Additional information optional: Telephone Notification:…

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 and staff interview, the facility staff failed for 1 resident (resident #67) of 42 resident and for 2 of 61 resident rooms to provide a clean, comfortable, home-like environment. The findings include: For Resident #67 the facility staff failed to maintain a safe and homelike environment for a visually impaired resident, as evidenced by a broken cabinet with 2 drawer faces/covers missing. Resident #67 was admitted to the facility on [DATE]. The diagnoses for Resident #67 included but were not limited to: blindness, dementia, difficulty walking, and major depressive disorder. On 9/15/19 at approximately 12:40 PM, during an interview with Resident #67 it was observed that his bedside table had 2 drawers with the faces/covers missing. The drawer covers were observed propped beside the cabinet. Resident #67 is visually impaired but was asked how long it has been broken and he stated not too long. On 9/16/19 at 5:03 PM the maintenance director was asked if he was aware of or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, resident interview, clinical record review, facility documentation review, and in the course of a complaint investigation the facility staff failed to report allegations of abuse, and neglect, to the state agency timely for one resident (Residents #38) of 42 residents in the survey sample. The findings included: 1. For Resident #38, the facility staff failed to notify the state agency timely. Resident #38 was most recently admitted to the facility on [DATE]. Diagnoses included: hypertension, anemia, contractures of the right and left knees, dementia without behavioral disturbances, quadriplegia, peripheral vascular disease, gastrostomy tube for feeding, and high cholesterol. The closest Minimum Data Set (MDS) assessment to the time period associated with the event that injured Resident #38, was a significant change assessment with an assessment reference date (ARD) of 3-18-19. Resident #38 was coded with a Brief Interview of Mental Status score of 0 indicating severe…

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, clinical record review, and facility document review, the facility staff failed to complete a significant change MDS (minimum data set) assessment (SCSA) within 14 days of a significant change for one Resident (Resident #37) in a survey sample of the 42 Residents. The findings included; For Resident #37, the facility staff failed to complete a SCSA after significant weight loss, with pressure sore formation occurring from 7-3-19 to 9-2-19. Resident #37 was admitted to the facility on [DATE]. Diagnoses included: hypertension, anemia, arthritis, chronic kidney disease moderate, high cholesterol, heart disease, seizures, and a history of dysphagia. The most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an assessment reference date (ARD) of 9-9-19. This assessment had a seven day look back period to obtain data about the Resident's current clinical condition from 9-3-19 to 9-9-19. At this time the Resident's significant weight loss…

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 documentation review and clinical record review the facility staff failed to accurately code an MDS (minimum data set) assessment for two Residents (Resident #109, Resident #30) in a survey sample of 42 Residents. The findings included: 1. For Resident #109 the facility staff failed to assess the Resident's cognitive functioning. Resident #109 was admitted to the facility on [DATE] with a readmission date of 7/1/19. Resident #109's diagnoses included but were not limited to: Hypertension, diabetes mellitus with unspecified complications, end stage renal disease and altered mental status. Resident #109's most recent MDS assessment with an ARD (assessment reference date) of 6/25/19 was coded as an admission assessment. Resident #109 had not been assessed for cognitive skills and daily decision making on this assessment. The Resident was coded as being totally dependent upon staff for transfers, toilet use, personal hygiene and bathing. Review of Resident #109's MDS with an ARD 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 observations, resident interviews, staff interviews, clinical record reviews, and facility documentation review, the facility staff failed to implement the comprehensive care plan for one resident (Resident #78) in a sample size of 42 residents. The findings include: 1. For Resident #78, the facility staff failed to implement her care plan for dressing changes to her peripherally inserted central catheter (PICC) for intravenous access (IV). Resident #78, a [AGE] year old female, was admitted to the facility on [DATE] for IV (intravenous) antibiotic treatment and wound care following recent abdominal surgery. Her diagnoses included, but are not limited to sepsis. On 9/15/2019 at approximately 1:10 PM, Resident #78 was interviewed and stated that she was getting IV (intravenous) antibiotics and wound care for a couple of weeks and she would be returning home. A double lumen PICC line (peripherally inserted central catheter/line with two access ports) covered with a semipermeable dressing at the insertion…

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 follow professional standards for one Resident (Resident #122 ) in a survey of 22 Residents. The findings included: For Resident #122 the facility staff documented administration of medication which had been left at the bedside for the Resident to self administer, and was not taken. Resident #122 was admitted to the facility on [DATE], with a recent readmission date of 4/15/19. Resident #122's diagnoses included but were not limited to: encounter for surgical aftercare following surgery on the digestive system, muscle weakness, restlessness and agitation, bipolar disorder, schizophrenia and age-related cognitive decline. Resident #122's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 9/10/19 was coded as a quarterly assessment. Resident #122 was coded as having had a BIMS (brief interview for mental status) score of 12, which indicated…

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 documentation review, the facility staff failed to ensure a discharge summary was written after discharge on [DATE] for one resident (Resident #108) in a survey sample of 42 residents. The findings include: Resident #108 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses of but not limited to: Gastrostomy, contracture, history of traumatic brain injury, tracheostomy, pressure ulcer of sacral region, flaccid hemiplegia, Diabetes, Pneumonia and Hypertension. The most recent Minimum Data Set (MDS) Assessment was a Quarterly assessment with an Assessment Reference Date (ARD) of 6/15/2018. Under Section B 0100, the MDS coded Resident # 108 with being Comatose with Persistent vegetative state. The assessment also coded Resident # 108 as requiring total assistance of two staff persons with activities of daily living; and frequently incontinent of bowel and always incontinent of bladder. Review of the electronic clinical record and paper clinical record 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, Resident interview, staff interview, facility record review and clinical record review, the facility staff failed to ensure a resident received assistive devices for vision for one Resident (Resident #54) in a survey sample of 42 Residents. The findings included: Resident #54 was admitted to the facility on [DATE]. Diagnoses for Resident #54 included, but were not limited to: complete traumatic amputation at level between knee and ankle, right lower leg, peripheral vascular disease, and type 2 diabetes. Resident #54's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 7/16/19 was coded as a quarterly assessment. Resident #54 was coded as having had a BIMS (brief interview for mental status) score of 15, which indicated cognitively intact. Resident #54 was coded as having required extensive assistance of 2 staff persons for transfers, dressing, personal hygiene and toileting. During an interview with Resident #54 on 9/15/19, it was observed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to administer physician ordered enteral feeding and water flushes for one resident (#101) in a survey sample of 42 residents. The Findings included: For Resident #101, the facility staff failed to provide physician ordered PEG tube water flushes, and tube feeding. Resident #101 is a [AGE] year old who was admitted to the facility on [DATE]. Resident #101's diagnoses include Pancreatitis, Atrial Fibrillation, Muscle Weakness, and Major Depressive Disorder. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 9/5/19 was reviewed. Resident #101 was coded as having a Brief Interview of Mental Status Score of 15, indicating no cognitive impairment. Resident #101's signed physician order read: 8/1/19. Enteral Feed Order every shift Flush PEG tube with 30 ml H 2 O before and after each med pass. According to the Medication Administration…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Observation, staff interview, clinical record review, and facility record review, the facility staff failed to administer respiratory treatments as ordered by a physician for one Resident (Resident #13) in a survey sample of 42 residents. The findings included; For Resident # 13 the facility staff failed to remain with Resident during nebulizer treatment. Resident #13, an [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to hypertension, Dementia, abnormalities of heart beat, difficulty walking, Anxiety disorder, type 2 diabetes, GERD. Pacemaker, glaucoma, and arthritis. Resident #90's most recent MDS (Minimum Data Set) with and ARD (Assessment Reference Date) 6/28/19 coded as a Quarterly Assessment has Resident #90 listed as having a BIMS (Brief Interview of Mental Status) score of 12 indicating moderate impairment. Resident #13 is coded as requiring supervision and over site with 1 person physical assistance for bed mobility and dressing, transfers, meals,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility documentation the facility failed to ensure received behavioral health services for 1 Resident (#71) in a survey sample of 42 Residents. The findings included: For Resident # 71 the facility staff failed to ensure Resident received behavioral health services for increasing behavioral issues. Resident #71, a [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Cerebral Infarction (Stroke), Dysphagia, Cognitive Communication Deficit, Major Depressive Disorder, Anxiety Disorder, muscle weakness, Hemiplegia (one sided weakness) and Hemiparesis (one sided paralysis) following CVA, Congenital malformations unspecified. Resident is listed as her own Responsible Party (RP). Resident #71's most recent MDS (Minimum Data Set) with and ARD (Assessment Reference Date) of 8/21/19 coded Resident #71 as having a BIMS (Brief Interview of Mental Status) score of 12 indicating moderate cognitive impairment. 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 staff interview, clinical record review, facility document review, and in the course of a complaint investigation, the facility staff failed to ensure medications were available for administration for 1 resident (Resident #108) in a survey sample of 42 residents. The findings included; For Resident # 108, the facility staff failed to ensure medications were available for administration as ordered by the physician. Resident #108 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses of but not limited to: Gastrostomy, contracture, history of traumatic brain injury, tracheostomy, pressure ulcer of sacral region, flaccid hemiplegia, Diabetes, Pneumonia and Hypertension. The most recent Minimum Data Set (MDS) Assessment was a Quarterly assessment with an Assessment Reference Date (ARD) of 6/15/2018. Under Section B 0100, the MDS coded Resident # 108 with being Comatose with Persistent vegetative state. The assessment also coded Resident # 108 as requiring total assistance of two 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 observation, staff interview, clinical record review and facility documentation the facility failed to ensure Residents are free from unnecessary medications for 1 Resident (#71) in a survey sample of 42 Residents. The findings included: Resident #71, a [AGE] year old woman was admitted to the facility on [DATE] with diagnoses of but not limited to Cerebral Infarction (Stroke), Dysphagia, Cognitive Communication Deficit, Major Depressive Disorder, Anxiety Disorder, muscle weakness, Hemiplegia (one sided weakness) and Hemiparesis (one sided paralysis) following CVA, Congenital malformations unspecified. Resident is listed as her own Responsible Party (RP). Resident #71's most recent MDS (Minimum Data Set) with and ARD (Assessment Reference Date) of 8/21/19 coded Resident #71 as having a BIMS (Brief Interview of Mental Status) score of 12 indicating moderate cognitive impairment. She is coded as requiring extensive assistance with 2 person physical assistance needed for transfers and dressing. She is set…

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, and clinical record review, the facility staff failed to ensure resident's are free from significant medication error for 3 Residents (Resident #83, #109, and #72) in a survey sample of 42 Residents. The findings included: 1. The facility staff failed to ensure Resident #83 was free from significant medication error by ensuring the Resident did not receive expired insulin. Resident #83 was admitted to the facility on [DATE]. Diagnoses for Resident #83 included but were not limited to: cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and type 1 diabetes mellitus without complications. Resident #83's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 8/25/19 was coded as an annual assessment. Resident #83 was coded as having had moderately impaired daily decision making. Resident #83 was also coded 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, staff interview, resident interview, clinical record review, and facility documentation review, the facility staff failed to ensure meals were tailored to the preferences of 2 residents, (Residents #37, and #54) in a survey sample of 42 residents. The findings included; 1. For Resident #37, the facility staff failed to ensure the resident received his preferred diet, which the Resident complained about repeatedly and did not want to eat. Resident #37 was admitted to the facility on [DATE]. Diagnoses included: hypertension, anemia, arthritis, chronic kidney disease moderate, high cholesterol, heart disease, seizures, and a history of dysphagia. The most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an assessment reference date (ARD) of 9-9-19. Resident #37 was coded with a Brief Interview of Mental Status score of 11 indicating mild to no cognitive impairment and the Resident required extensive assistance, to complete dependence, on staff for all activities 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, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed for 1 resident (Resident #28) in the survey sample of 42 residents, to provide meals at scheduled mealtimes. The Findings included: For Resident #28, the facility failed to provide meals at scheduled mealtimes. Resident #28 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #28's diagnoses included Diabetes Mellitus Type 2, Muscle Weakness, and Hypertension. The Minimum Data Set, which was an admission Assessment with an Assessment Reference Date of 4/22/19 was reviewed. Resident #28 was coded with a Brief Interview of Mental Status Score of 15, indicating no cognitive impairment. He was also coded as requiring set up assistance with meals, and being able to ambulate independently with his wheelchair. On 9/15/19 at 1:40 P.M. an interview was conducted with Resident #28 in his room. His lunch had not been served. He stated that he had been waiting…

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 provide special eating utensils for one Resident (Resident #104) in a survey sample of 42 Residents. The findings included: Resident #104 was admitted to the facility on [DATE], with a most recent readmission on [DATE]. Resident #104's diagnoses included but were not limited to: unspecified convulsions, muscle weakness, chronic pain, and type 2 diabetes. Resident #104's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 9/5/19 was coded as an annual assessment. Resident #104 was coded as having had a BIMS (brief interview for mental status) score of 15, which indicated cognitively intact. The Resident was also coded as requiring extensive assistance of staff with dressing, eating, personal hygiene, bed mobility and toileting. For bathing, Resident #104 was totally dependent upon staff. On 9/16/19 at approximately 9:30 AM, Resident #104 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 clinical record review, and facility record review, the facility staff failed to ensure an accurate clinical record for one Resident (Resident #108) in a survey sample of 42 residents. The findings included; For Resident # 108, the facility staff did not ensure an accurate clinical record. Resident #108 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses of but not limited to: Gastrostomy, contracture, history of traumatic brain injury, tracheostomy, pressure ulcer of sacral region, flaccid hemiplegia, Diabetes, Pneumonia and Hypertension. The most recent Minimum Data Set (MDS) Assessment was a Quarterly assessment with an Assessment Reference Date (ARD) of 6/15/2018. Under Section B 0100, the MDS coded Resident # 108 with being Comatose with Persistent vegetative state. The assessment also coded Resident # 108 as requiring total assistance of two staff persons with activities of daily living; and frequently incontinent of bowel and always incontinent of bladder. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, Resident interview, staff interview, facility documentation review, and clinical record review the facility staff failed to provide a functioning call bell system for 2 Resident's (Resident #30 and Resident #87) in a survey sample of 42 Residents. The findings included: 1. For Resident #30, the facility staff failed to ensure an operating call bell. Resident #30's most recent re-admission to the facility was on 2/12/19. The Resident's diagnoses included but were not limited to: end stage renal disease and hyperlipidemia. Resident #30's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 7/17/19 was coded as a quarterly assessment. Resident #30 was not assessed for cognitive functioning on this assessment. Resident #30 was coded as being independent with dressing, eating and bathing. He was also coded as having had required supervision of one staff person for transfers, toileting and personal hygiene. On 9/15/19 at 12:50 PM, during an interview…

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.