Bayside Of Poquoson Health And Rehab

Based on staff interviews and review of facility documents, the facility staff failed to ensure that twelve hours of in-service education/training within twelve months was completed by five of five sampled Certified Nurse Aides (CNA) #7, 6, 3, 8 and 9. The findings included: A review of the five CNA training transcripts and education records revealed that they had not completed the mandatory 12- hours of in-service education/training including dementia management and resident abuse prevention training. An interview was conducted with CNA #7 on 8/28/24 at 10:05 AM. CNA #7 stated she did not recall if she had completed twelve hours of in-service training to include working with residents with dementia and resident abuse prevention training. An interview was also conducted with CNA #3 on 8/28/24 at 10:17 AM. CNA #3 stated she could not remember if she had received twelve hours of training within the last year. On 8/28/24 at 11:24 AM, an interview was conducted with the Director of Nursing (DON) regarding CNAs mandatory training. The DON stated that training and education were areas…

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 maintain a clean and sanitary food preparation area in accordance with professional standards for food service safety. The findings included; On 8-26-24 at approximately 6:40 PM, the kitchen area of the facility was inspected with the dining services manager. A metal drawer was observed under a long counter where food prep was conducted on the back wall of the kitchen. The drawer did not close under the counter, and was rusty, off of the track, and littered with food debris which could not be removed by simply wiping, as the debris was adhered with a sticky greasy substance. The inspection observations continued in the walk in freezer, dry storage room, and refrigerator. The dry storage food room contained canned goods, pasta, boxed goods, bagged cereals, and pantry storage of shelf stable items. Three large rolling bins of flour, sugar, and rice were observed open, which were dirty with a dried film on them and presumably a white food debris substance in the crevices of the sliding tops. The floor had food debris…

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 interview, the facility staff failed to implement an effective pest control program affecting dining services and as a result the facility as a whole. The findings included: For the Residents of the facility the facility staff failed to ensure the facility was free of pests to include mice. On 8-26-24 at approximately 6:40 PM, the kitchen area of the facility was inspected with the dining services manager. The inspection observations continued in the dry storage room of the kitchen which contained canned goods, pasta, boxed goods, bagged cereals, and general pantry storage of shelf stable items. Three large rolling bins of flour, sugar, and rice were observed open, which were dirty with a dried film on them and presumably a white food debris substance in the crevices of the sliding tops. The floor had food debris and a black sticky substances around the base boards and in the corners of the room. Mouse droppings (excrement) were on the floor of the room close to a mouse trap with a dead mouse in it. Behind the main door into the room was a Sticky trap which…

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 a resident's right to a dignified existence and self-determination for 1 Resident (#21) in a survey sample of 35 Residents. The findings included: For Resident #21, the facility staff failed to appropriately dress the resident, supply a top sheet and blanket and respond to his request to wear something other than an incontinent brief. Resident #21 was admitted to the facility on [DATE] with diagnoses that included but were not limited to dysphagia after stroke, Diabetes Type II, dialysis-dependent end-stage renal disease, hypertension, congestive heart failure, lack of coordination, major depressive disorder, muscle weakness (generalized) hemiplegia and hemiparesis following stroke affecting the right dominant side, contracture of the right hand and contracture of the right elbow. Resident #21's most recent MDS (Minimum Data Set), dated 7/7/24, coded Resident #21 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.

Based on observations and interviews, the facility staff failed to ensure the survey results book was readily accessible during the initial entrance of the facility. The findings included: On 8/26/24 at approximately 7:05 PM., during the facility entrance of the main lobby a sign was noticed on a table in the main lobby that read Survey Book is kept in the main lobby. No Survey Book was observed. 08/26/24 at approximately, 7:09 PM., an interview was conducted with the administrator concerning the survey book whereabout. The administrator pulled the survey book from a table in his office, saying that he had the survey book since Friday (8/23/24) because he was expecting us to come in at any time to survey the facility. The above findings were shared with the Administrator, The Director of Nursing (DON) and corporate staff on 8/28/24 at approximately 1:30 PM., during the final interview.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and clinical record review, the facility staff failed to provide a clean, comfortable, home-like environment for 3 of the 14 Resident rooms in Hall 100. The findings included: For the Residents who resided in rooms [ROOM NUMBERS], the facility staff failed to make repairs to the walls by the head of the bed, where there were gouges in the drywall from the bed impacting the wall. For the Residents in rooms [ROOM NUMBERS], the facility staff failed to provide linens that were in good repair and without holes or stains. On 8/26/24 at approximately 6:45 p.m. during the initial tour of the facility, the following observations were made: room [ROOM NUMBER] A & B - Deep gouges in the drywall by the head of the bed were observed and had not been repaired. room [ROOM NUMBER] A Bed - Resident asleep and the blanket was noted to have brownish colored stain at foot of bed room [ROOM NUMBER] A Bed - Small hole in bottom sheet and no top sheet on bed. room [ROOM NUMBER] A Bed - Large gouges 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, clinical record review and facility documentation review, the facility failed to review and revise the care plan for 2 Residents (Residents #2, and #21) in a survey sample of 35 Residents. The findings included: 1. For Resident #2, the the facility staff failed to document resident specific measurable goals, and failed to derive and implement a behavioral modification care plan for a Resident with documented brain injury and behaviors. Resident #2 was initially admitted to the facility on [DATE], and most recently readmitted on [DATE]. Diagnoses included; hypertension, seizure disorder, dementia, depression, pulmonary embolus, and traumatic brain injury with behaviors, stroke and convulsions/movement disorders/muscle weakness. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 7-17-24. He was coded with a Brief Interview of Mental Status score of 15 indicting no cognitive impairment. He required assistance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review, and review of facility documents, The facility staff failed to follow a physician's order to ensure two resident received physician ordered medications for two (2) of 35 residents (Resident #38, #21), in the survey sample. The findings included: 1. Resident #38 was originally admitted to the facility on [DATE] after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Essential (Primary) Hypertension. The quarterly revised Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 7/13/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #38 cognitive abilities for daily decision making were intact. In sectionGG(Functional Abilities and Goals) the resident was coded as being independent with eating, dependent with personal hygiene, showers/bathing, dressing, and toileting.…

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 interview, clinical record review and facility documentation the facility staff failed to provide necessary services to maintain good grooming and personal hygiene for 1 Resident in a survey sample of 35 Residents. The findings included: For Resident #21 the facility staff failed to provide 2 showers per week for Resident who is unable to provide self-care. Resident #21 was admitted to the facility on [DATE] with diagnoses that included but were not limited to dysphagia after stroke, Diabetes Type II, dialysis-dependent end-stage renal disease, hypertension, congestive heart failure, lack of coordination, major depressive disorder, muscle weakness (generalized) hemiplegia and hemiparesis following stroke affecting the right dominant side, contracture of the right hand and contracture of the right elbow. Resident #21's most recent MDS (Minimum Data Set), dated 7/7/24, coded Resident #21 as having a BIMS (Brief Interview of Mental Status) score of 15/15, indicating no cognitive impairment. On the morning…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed for two residents (Residents #2, and #49) to ensure pharmacy recommendations were obtained and acted upon, in the survey sample of 35 Residents. The findings included: 1. For Resident #2, the pharmacist recommendations were not obtained, nor acted upon, and not in the clinical record, in the preceding 8 months of 2024. Resident #2 was initially admitted to the facility on [DATE], and most recently readmitted on [DATE]. Diagnoses included; hypertension, seizure disorder, dementia, depression, pulmonary embolus, and traumatic brain injury with behaviors, stroke and convulsions/movement disorders/muscle weakness. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 7-17-24. He was coded with a Brief Interview of Mental Status score of 15 indicting no cognitive impairment. He required assistance with activities of daily living care. He 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 the interviews, clinical record review, and facility documentation, the facility staff failed to ensure they were free from unnecessary psychotropic medications for 1 Resident (#49) in a survey sample of 35 Residents. The findings included: For Resident # 49, the facility staff failed to ensure that the PRN (as needed) anti-anxiety drug Lorazepam was no more than 14 days duration without proper documentation. Resident # was admitted to the facility on [DATE] with diagnoses that included but were not limited to dementia, without behavioral disturbance, psychotic disturbance and anxiety, acute kidney failure, generalized anxiety disorder, unspecified dementia with severe agitation, Alzheimer's disease with late onset, prediabetes and history of falls. On 8/26/24, a review of the clinical record revealed that on 5/3/24, Resident # 49 received an order for Lorazepam (Ativan) 0.5 mg PO tabs, to be taken one tablet every 6 hours as needed for anxiety. There was no stop date for this order. A review of the MAR…

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 inspection of medications on one medication cart and the facility's Stat box, facility staff failed to ensure medications for resident administraton were not expired. The findings included: 1. A medication cart audit was conducted on 8/29/24 at approximately 11:57 AM., with Licensed Practical Nurse (LPN) #5. Stored inside the medication cart was 1 opened Humalog insulin pen with no open date, 1 opened Lantus insulin pen with no open date and 1 opened vial of mixed Humalog insulin with no resident name/identification. LPN #5 said that the dates should be written on the insulin pens because they expire in 28 days and that a name should be written on the vial. The above findings were shared during the Pre-exit with the Administrator, the Director of Nursing (DON) and corporate staff on 8/29/24 at approximately 1:30 PM. The DON said that drugs and biologicals should be labeled with a date and resident name. 2. For the facility, the facility staff failed to ensure that all medications available for use in the Stat box were not expired. On 8/27/24, a review of the stat box…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews and facility document review the facility failed to ensure that 5 of 34 residents in the survey sample were afforded the opportunity to formulate an Advance Directive upon admission, Residents' #5, #9, #19, #346, and #15. The findings included: 1. Resident #5 was admitted to the facility on [DATE] with diagnoses to included but not limited to Major Depressive Disorder, Dementia, Anxiety Disorder and Hypertension. The most recent Minimum Data Set (MDS) was an Annual with an Assessment Reference Date (ARD) of 2/10/21. The Brief Interview for Mental Status (BIMS) for Resident #5 was coded as a 15 out of a possible 15 which indicates the resident is cognitively intact and capable of daily decision making. Resident #5's electronic medical record was reviewed and there was no advance directive document located. Resident #5's current comprehensive care plan was review and is documented in part, as follows: Focus: Name (Resident #5) has an advance Directive as evidenced…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and facility documentation, the facility staff failed to ensure Medicare Beneficiary Notices in accordance with applicable Federal regulations, were issued to 3 of 34 residents (Resident #348, Resident #5 and Resident #9) in the survey sample. The findings included: 1. The facility staff failed to issue a NOMNC (Notice of Medicare Provider Non-Coverage), letter to Resident #348 who was discharged from skilled services with Medicare days remaining. Resident #348 was admitted to the nursing facility on 01/25/21. Diagnosis for Resident #348 included but not limited to Muscle weakness. Resident #348's Minimum Data Set (MDS) an OBRA admission Assessment with an Assessment Reference Date (ARD) date of 02/01/21 coded Resident #348 a 14 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident with no cognitive impairment. Review of the SNF Beneficiary Notification Review provided by the facility to surveyor, was noted that…

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 general observations, clinical record review, staff and resident interviews, the facility staff failed to ensure resident rooms were maintained clean comfortable and homelike for 3 resident rooms on the quarantine unit, room [ROOM NUMBER] (A&B), #204 (B) and #207 (A). The findings included: On 5/4/21 at 11:00 a.m., during the orientation tour, through 5/6/21 at 2:00 p.m., the biohazard receptacles were the over flowing trash and soiled linen in the resident's bathroom in room [ROOM NUMBER] and 207 as well as trash and other debris on the floors. Blood stains, trash, feces and other debris were identified on the floor in room [ROOM NUMBER]. Resident #147 who resided in room [ROOM NUMBER], unlike the residents in room [ROOM NUMBER] and 207 was able to express his discontent with the condition of his room. This resident was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus, chronic diabetic wounds of right and left foot with status post bilateral transmetatarsal amputations and skin…

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, clinical record review, staff interviews and review of facility documentation, the facility staff failed to ensure 4 of 34 residents (#152, #151, #30, #43) were free of the misappropriation of their narcotic medications, and ensure their standards and practices prevented reoccurrence. The findings include: 1. The facility staff failed to ensure Resident #152 was free of the misappropriation of her narcotic medication, *Oxycodone (Percocet). Resident #152 was admitted to the nursing facility on [DATE] for short-term rehabilitation. She had diagnoses that included UT not limited to intervertebral disc disorders with radiculopathy in the lumbar region. The resident was discharged on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 10 out of a possible score of 15 which indicated the resident was moderately impaired in the skills needed 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 resident and staff interviews, clinical record review and facility document review, the facility staff failed to ensure the baseline care plan summary was completed for 3 out of 34 residents (Resident #346, Resident #347 and Resident #147) in the survey sample. The findings included: 1. The facility staff failed to complete a newly admitted resident, (Resident #346), a baseline care plan summary. The summary must include the initial goals for the resident, a list of current medications, dietary instructions, services and treatments to be administered by the facility. The resident's Minimum Data Set (MDS) assessment was not due. Review of Resident #346's admission assessment dated [DATE] documented the residents was independent in decisions regarding task of daily life, indicating no cognitive impairment. The review of Resident #346's admission Order for May 2021, included but not limited to the following medications, dietary instructions and treatment: Medications include but not limited to: -Oxycodone…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interviews, clinical record review and facility documentation review, the facility staff failed to follow professional standards of nursing for 2 of 34 residents (Resident #346 and Resident #22) in the survey sample. The findings included: 1. The facility staff failed to follow a physician's orders for wound vac treatment of an abdominal surgical incision for Resident #346. Resident #346 was admitted to the facility on [DATE]. Diagnosis for Resident #346 included but not limited to surgical aftercare of an Exploratory Laparotomy. The resident's Minimum Data Set (MDS) assessment was not due. Review of Resident #346's admission assessment dated [DATE] documented the residents was independent in decisions regarding task of daily life, indicating no cognitive impairment. In addition, the admission Assessment was coded for having an abdominal surgical wound requiring surgical wound care (wound vac.) The admission Assessment under skin was coded for having an abdominal surgical wound…

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 interviews and facility documentation, the facility staff failed to staff a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The findings included: A review of the facility as-worked staffing documentation during a 30-day lookback revealed that there were no RN coverage within a 24-hour period on the following days in April 2021: 04/11/21, 04/24/21 and 04/25/21. On 05/10/21 at approximately 4:10 p.m., a phone interview was conducted with the Administrator and Director of Nursing (DON.) When asked about the facility not having 8 hours of RN coverage on 04/11/21, 04/24/21 and 04/25/21, they replied, We are not able to provide evidence that there was RN coverage on the days mentioned. A pre-exit conference was conducted with the Administrator, Director of Nursing (DON) and Cooperate Nurse on 05/10/21 at approximately 6:30 p.m. No further information was provided prior to exit.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff and resident interviews and facility documentation, the facility staff failed to assure the 5 agencies were sufficiently oriented to the facility's operational systems necessary to provide care and services. The findings include: The following examples demonstrated the agency staff's expression of the lack of orientation to the facility which directly affected the care and services rendered to the residents: 1. On 5/4/21 at 11:00 a.m., during the orientation tour, through 5/6/21 at 2:00 p.m., the biohazard receptacles were overflowing with trash and soiled linen in the resident's bathroom in room [ROOM NUMBER] and 207 on the quarantine unit. These rooms also had a foul odor upon entry. On 5/4/21 at 1:05 p.m., a foul order was apparent upon entering Resident #147's room, who resided on the quarantine unit, and it was discovered the biohazard (red bags) trash and linen receptacles in the bathroom were full, overflowing and soiled items of trash and linen piled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff interviews and review of facility documentation, the facility staff failed to ensure the system and disposition of all controlled drugs was in place and implemented to enable accurate reconciliation for 1 out of 34 residents (#146), as well as during the facility's physical inventory of their stored controlled medications at each shift change AND The facility staff failed to provide routine pharmacy services for Resident #20. The findings included: 1. Resident #146 was admitted on [DATE] to receive respite/palliative care. He was discharged home on 5/5/21. There was no completed Minimum Data Set (MDS) assessment due to the resident's short-stay. The History and Physical (H&P) dated 5/3/21 indicated that the resident was in the facility under the care of hospice for respite. He was alert and responsive. No Intravenous fluids to be given or laboratory specimens obtained. Resident #146 was ordered Morphine Sulfate 20 mg/ml, give 0.5 ml by mouth every 4 hours as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, the facility staff failed to ensure 2 of 34 residents (Resident #347 and Resident #147) in the survey sample were free of significant medication errors. The findings included: 1. The facility staff failed to follow physician orders to decrease Aspirin 325 mg to 81 mg. Resident #347's Minimum Data Set (MDS-an assessment protocol) a 5-day assessment with an Assessment Reference Date of 05/05/21 coded the resident with a 00 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. In addition, the MDS coded Resident #347 total dependent of two with bathing, personal hygiene and toilet use, extensive assistance of two with bed mobility, transfer and dressing and supervisor with one assist with eating. Resident #347's care plan dated 05/06/21 documented resident at risk for complications related to anticoagulant or antiplatelet medications due to Atrial Fibrillation. The goal:…

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 offer and provide Resident #147 with an alternative or substitute for his lunchmeal. Resident #147 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus, chronic diabetic wounds of right and left foot with status post bilateral transmetatarsal amputations and skin graft infections, end stage renal disease with dependence on renal dialysis. The 5-day Minimum Data Set (MDS) assessment was dated 4/30/21 and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15 which indicated the resident had the necessary cognitive skills for daily decision making. The resident had no problems understanding the staff and was understood. The resident was assessed without mood or behavioral problems. Resident #147 required extensive assistance from 2 staff for bed mobility and toilet use. He was not assessed to be able to ambulate (walk in and out of room). He had bilateral lower extremity impairment in range 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 record review and staff interview the facility staff failed to ensure the Quality assurance and performance (QAPI) program include monitoring, and measuring performance activities. The findings included: 1. The facility staff failed to maintain a QAPI plan for correcting quality deficiencies. During the survey conducted 05/04/21 through 05/12/21 indicated: In the area of (F-881) A review of the antibiotic Infection Control Surveillance Infection report log showed only the months of March, April, and May were available to view. During an interview on 05/10/21 at 6:00 PM with the Administrator, ADON and RDCS concerning Antibiotic Stewardship Program. They were asked if the ongoing review for antibiotic stewardship prior to the survey was complete. The ADON stated, We need to continue our reviews for February 2021. I don't see any other documentation from what was provided. The RDCS stated, They are working on it. April wasn't completed. In the area of (F-882) The facility staff failed to designate at least one qualified Infection Preventionist. Received Infection Prevention 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.

Based record review and staff interview the facility staff failed to implement corrective action and monitor to ensure the Quality assurance and performance (QAPI) program to ensure performance goals or targets are achieved. activities. The findings included: 1. The facility staff failed to maintain a QAPI plan for correcting quality deficiencies. During the survey conducted 05/04/21 through 05/12/21 indicated: In the area of (F-881) A review of the antibiotic Infection Control Surveillance Infection report log showed only the months of March, April, and May were available to view. During an interview on 05/10/21 at 6:00 PM with the Administrator, ADON and RDCS concerning Antibiotic Stewardship Program. They were asked if the ongoing review for antibiotic stewardship prior to the survey was complete. The ADON stated, We need to continue our reviews for February 2021. I don't see any other documentation from what was provided. The RDCS stated, They are working on it. April wasn't completed. In the area of (F-882) The facility staff failed to designate at least one qualified Infection…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, clinical record review, and review of facility documents, the facilitys staff failed to ensure infection control measures and practices were in place in the laundry room and 3 resident rooms on the quarantine unit (Room's 202, 204 and 207), in the survey sample. 1. The facility failed to ensure that all laundry was handled, stored, and processed in a safe and sanitary method. During the initial of the laundry on 5/4/21 at approximately 1:15 p.m., the following observations were made with the Housekeeping Supervisor present; Multiple Hoyer slings were observed on top of numerous pillows in the corner against the wall beside the washing machines. The Housekeeping supervisor stated they were slings which were no longer used therefore; they needed to be stored someplace and the pillows were there to be washed and returned to service. Many other Hoyer slings were hanging on the wall facing the washers and they made contact with the floor. The Housekeeping supervisor stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, facility document review staff interviews and family interview the facility staff failed to ensure one resident's daughter was called for a zoom care plan meeting after an invitation was sent for 1 of 34 residents in the survey sample, Resident #5. The findings included: Resident #5 was admitted to the facility on [DATE] with diagnoses to included but not limited to Major Depressive Disorder, Dementia, Anxiety Disorder and Hypertension. The most recent Minimum Data Set (MDS) was an Annual with an Assessment Reference Date (ARD) of 2/10/21. The Brief Interview for Mental Status (BIMS) for Resident #5 was coded as a 15 out of a possible 15 which indicates the resident is cognitively intact and capable of daily decision making. On 05/3/21 at 09:53 AM a phone interview was conducted with Resident #5. During the interview Resident #5 stated, My last care plan meeting my daughter received an invite but the facility never called her for the meeting. On 5/6/20 at 9:46 A.M. a phone…

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, a medical record view, staff interviews and family a interview the facility staff failed to follow-up with a resident's choice of an attending physician in March of 2020 to determine if the provider could meet the requirements for care for 1 of 34 residents in the survey sample, Resident #9. The finding included: Resident #9 was admitted to the facility on [DATE] with diagnoses to included but not limited to Major Depressive Disorder, Diabetes Mellitus, Anxiety Disorder and Hypertension. The most recent Minimum Data Set (MDS) was an Annual with an Assessment Reference Date (ARD) of 3/18/21. The Brief Interview for Mental Status (BIMS) for Resident #9 was coded as a 12 out of a possible 15 which indicates the resident is cognitively intact and capable of daily decision making. On 5/4/21 at 2:00 P.M. a phone interview was conducted with Resident #9's daughter who is also the Complainant. Resident #9's daughter stated, I took my mother to a primary care physician outside 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, clinical record review and facility document review, it was determined that the facility staff failed to ensure call bells were within resident reach for two of 34 residents in the survey sample, Resident #17 and #42. The findings included: 1. Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to type two diabetes without complications, obesity due to excess calories, atrial fibrillation, post COVID -19, and cognitive social or emotional deficit following unspecified cerebrovascular disease. Resident #17's most recent MDS (Minimum Data Set) assessment was an annual assessment with an ARD (Assessment reference date) of 12/31/20. Resident #17 was coded as being severely impaired in cognitive function scoring 05 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #17 was coded as requiring total dependence on two staff members with 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.

Based on staff interview, and facility document review, it was determined that facility staff failed to ensure that the state inspection results were easily accessible to all residents. The findings included: On 5/5/21 at 9:57 a.m., a group interview was conducted with five residents. The five residents interviewed were not aware of where the state inspection results were located. On 5/5/21 at 11:00 a.m., observation of the state inspection results were conducted. The state survey results was in a large three ring binder sitting in a wall mount affixed to the wall. There was no table or anywhere to place the binder once it was out of the wall mount. The wall mount was at a level where it would be difficult for some residents to reach if sitting in a wheelchair. The survey result book also felt heavy. On 5/6/21 at approximately 3:55 p.m., a Resident that was in group (Resident #5); was asked if she could reach the state survey results. Resident #5 was wheelchair bound and had all ROM (Range of Motion) of her upper extremities. Resident #5 stated that she wouldn't be able to quite…

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

Based on observation, resident interview, staff interview, and clinical record review, the facility's staff failed to ensure privacy during wound care for 1 of 34 residents (Resident #7), in the survey sample. The findings included: Resident #7 was originally admitted to the facility 10/21/20 and has never been discharged from the facility. The current diagnoses included; glaucoma, a seizure disorder, end stage renal disease requiring dialysis, diabetes and coronary artery disease. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/28/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #7's cognitive abilities for daily decision making was intact. In sectionG (Physical functioning) the resident was coded as requiring total care of two people with transfers, toileting, and bathing, total care of one with off unit locomotion, extensive assistance of two people with bed mobility and dressing, extensive assistance of one person with personal hygiene 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 observations, clinical record review, staff and resident interviews, the facility staff neglected to provide the necessary care and services for 1 of 34 residents (R#147) in the survey sample and failed to ensure a resident was free from abuse resulting in needless pain for 1 of 34 residents (Resident #36), in the survey sample. The findings included: 1. Resident #147 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus, chronic diabetic wounds of right and left foot with status post bilateral transmetatarsal amputations and skin graft infections, end stage renal disease with dependence on renal dialysis. The 5-day Minimum Data Set (MDS) assessment was dated 4/30/21 and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15 which indicated the resident had the necessary cognitive skills for daily decision making. The resident had no problems understanding the staff and was understood. The resident was assessed without…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to send all the necessary documentation; including care plan goals with the resident upon transfer to the hospital for 2 of 34 residents in the survey sample, Resident #17 and #346. The findings included: 1. Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to type two diabetes without complications, obesity due to excess calories, atrial fibrillation, post COVID -19, and cognitive social or emotional deficit following unspecified cerebrovascular disease. Resident #17's most recent MDS (Minimum Data Set) assessment was an annual assessment with an ARD (Assessment reference date) of 12/31/20. Resident #17 was coded as being severely impaired in cognitive function scoring 05 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #17's clinical record revealed that he was sent…

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 send a copy of the Bed-Hold Policy upon discharge/transfer for 1 of 34 resident's (Resident #346) after being transferred and admitted to the hospital. The findings included: The facility staff failed to ensure that Resident #346 or his resident's representative was provided a copy of the bed hold policy upon discharge/transfer to the hospital on [DATE]. Resident #346 was admitted to the facility on [DATE]. Diagnosis for Resident #346 included but not limited to Acute Renal Failure. The resident's Minimum Data Set (MDS) assessment was not due. Review of Resident #346's admission assessment dated [DATE] documented the residents was independent in decisions regarding task of daily life, indicating no cognitive impairment. The Discharge MDS assessments was dated for 05/08/21 - discharged with return anticipated. On 05/08/21 at approximately 1:28 p.m., according to the facility's documentation, Resident #346…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility staff failed to ensure a comprehensive care plan was developed within seven (7) days after completion of the comprehensive assessment for 1 of 34 residents in the survey sample, Resident 40. 1. For Resident #40, the facility staff failed to ensure resident had a comprehensive care plan developed within 7 days after completion of the comprehensive assessment. Resident #40 was admitted to the facility on [DATE]. Diagnosis included but were not limited to Vascular Dementia Without Behavioral Disturbance, Cerebrovascular Disease, Unspecified and Type 2 Diabetes Mellitus With Other Circulatory Complications. Resident #40's admission Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 04/05/2021 was coded with a BIMS (Brief Interview for Mental Status) score of 13 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #40 as requiring supervision of 1 with eating, extensive assistance of 2 for bed mobility, transfer and dressing, total…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interviews, clinical record review, and review of facility's documents, the facility staff failed to ensure 1 of 34 residents in the survey sample (Resident #346's) abdominal surgical wound had an alternate treatment until the primary treatment (a negative pressure wound vac) was available. 2. The resident's Minimum Data Set (MDS) assessment was not due. Review of Resident #346's admission assessment dated [DATE] documented the residents was independent in decisions regarding task of daily life, indicating no cognitive impairment. In addition, the admission Assessment was coded for having an abdominal surgical wound requiring surgical wound care (wound vac.) The admission Assessment under skin was coded for having an abdominal surgical wound - area measured 2.8 cm x 3.8 cm x 1.1 cm. Resident #346's record did not reveal a 48 hour baseline care or an interim care plan. Review of Resident's #346 discharge summary 05/03/21 read in part: Instructions for follow-up (Routine wound…

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 follow physician orders to provide foot care for 1 of 34 residents (R#147) in the survey sample. The findings included: Resident #147 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus, chronic diabetic wounds of right and left foot with status post bilateral transmetatarsal amputations and skin graft infections, end stage renal disease with dependence on hemodialysis. The 5-day Minimum Data Set (MDS) assessment was dated 4/30/21 and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15 which indicated the resident had the necessary cognitive skills for daily decision making. Resident #147 had no problems understanding the staff and was understood. Resident #147 was assessed without mood or behavioral problems. Resident #147 required extensive assistance from 2 staff for bed mobility and toilet use. Resident #147 was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a resident interview and staff interviews the facility staff failed to ensure 1 of 34 residents in the survey sample received appropriate sized incontinent products for 3 days, Resident #5. The findings included: Resident #5 was admitted to the facility on [DATE] with diagnoses to included but not limited to Major Depressive Disorder, Dementia, Anxiety Disorder and Hypertension. The most recent Minimum Data Set (MDS) was an Annual with an Assessment Reference Date (ARD) of 2/10/21. The Brief Interview for Mental Status (BIMS) for Resident #5 was coded as a 15 out of a possible 15 which indicates the resident is cognitively intact and capable of daily decision making. Under Section H Bladder and Bowel H0300 Urinary Continence and H0400 Bowel Incontinence Resident #5 was coded as a 2 Frequently Incontinent. Resident #5's current comprehensive care plan was reviewed and is documented in part, as follows: Focus: Name (Resident #5) has an alteration in elimination of bladder related to urinary urgency due 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 interviews, clinical record review and facility documentation, the facility staff failed to ensure 1 of 6 residents (Resident #346) in the survey sample had dialysis orders. The findings included: The facility staff failed to ensure dialysis order were obtained for Resident #346. Resident #346 was admitted to the facility on [DATE]. Diagnosis for Resident #346 included but are not limited to Acute Kidney Failure (on dialysis). The resident's Minimum Data Set (MDS) assessment was not due. Review of Resident #346's admission assessment dated [DATE] documented the residents was independent in decisions regarding task of daily life, indicating no cognitive impairment. In addition, the admission Assessment under special treatment was coded for dialysis. The facility did not provide a dialysis care plan. Review of Physician Progress note dated 05/06/21 read in part: Resident #346 has a right IJ temporal dialysis catheter placement as his renal function worsened and he was started on hemodialysis. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review the facility staff failed to ensure the physician reviewed pharmacy recommendations for 2 residents (Resident #4, #43) of 34 residents in the survey sample. The findings included: 1. Resident #4 was admitted to the facility on [DATE]. Diagnosis included but were not limited to, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side and Major Depressive Disorder. Resident #4's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 02/09/2021 was coded with a BIMS (Brief Interview for Mental Status) score of 08 indicating moderate cognitive impairment. The Minimum Data Set coded Resident #4 as requiring extensive assistance of 2 for bed mobility and dressing, total dependence of 1 for eating and total dependence of 2 for transfer, toilet use, personal hygiene and bathing. On 05/05/2021 at approximately 2:00 p.m., review of Resident #4's clinical record revealed the following: Pharmacy Review dated 02/07/2021…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review the facility staff failed to ensure that PRN (As Needed) orders for psychotropic medication was not ordered for longer than 14 days without a documented rationale for continued use for 1 resident (Resident #43) of 34 residents in the survey sample AND failed to implement Gradual Dose Reduction (GDR) interventions for the use of psychotropic medication as used by Resident #15. The findings included: 1. Resident #43, the facility staff failed to ensure PRN (As Needed) Xanax was not ordered for longer than 14 days, without a documented rationale for continued use. Resident #43 was initially admitted to the facility on [DATE]. Resident #43 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnosis included but were not limited to, Unspecified Fracture Of Left Femur and Depression. Resident #43's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 04/12/2021 was not coded with a BIMS (Brief Interview for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a complaint investigation, observations, resident interview and facility documentation, the facility staff failed to provide a separately locked, permanently affixed compartment for all controlled drugs to include those brought from resident homes on admission for 1 of 34 residents (Resident #146) in the survey sample. The findings included: Resident #146 was admitted on [DATE] to receive respite/palliative care. He was discharged home on 5/5/21. There was no completed Minimum Data Set (MDS) due to the resident's short-stay. The History and Physical (H&P) dated 5/3/21 indicated that the resident was in the facility under the care of hospice for respite. He was alert and responsive. No Intravenous fluids to be given or laboratory specimens obtained. Resident was ordered Morphine Sulfate 20 mg/ml, give 0.5 ml by mouth every 4 hours as needed for pain or shortness of breath. On 5/4/21 at 7:00 p.m. narcotic counts were observed by this surveyor (#2) for the facility's 2 medication carts, 100 and 200/300.…

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. Resident #147 was not able to chew and consume the meat served to him during the lunchmeal on 5/4/21. Resident #147 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus, chronic diabetic wounds of right and left foot with status post bilateral transmetatarsal amputations and skin graft infections, end stage renal disease with dependence on renal dialysis. The 5-day Minimum Data Set (MDS) assessment was dated 4/30/21 and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15 which indicated the resident had the necessary cognitive skills for daily decision making. The resident had no problems understanding the staff and was understood. The resident was assessed without mood or behavioral problems. Resident #147 required extensive assistance from 2 staff for bed mobility and toilet use. He was not assessed to be able to ambulate (walk in and out of room). He had bilateral lower extremity impairment in range of motion. 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, staff interview, and review of facility documents, the facility's staff failed to ensure on 5/10/21, the dishwasher temperature reached the appropriate wash temperature to sanitize the after breakfast dishes. The findings included: On 5/10/21 at approximately 9:50 a.m., observations of were made of the dishwashing machine during washing of the resident serving trays. After the first set of trays entered the cycle the dietary aide recorded the high wash temperature as 111 degrees and the high rinse temperature as 191 degrees. The trays were removed and placed on a rack which suspended each tray separately after-which another set of trays were put in the dishwasher, this time the high wash temperature only reached 109 degrees. On 5/1/21, at approximately 9:57 p.m., an interview was conducted with the Dietary Aide who stated the wash temperature requirement is 150 degrees and the rinse requirement temperature was 180 degrees. The Dietary Aide stated she would notify the District Dietary Manager that the dishwasher not reaching the recommended temperature and he…

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 a review of facility documents, the facility's staff failed to conduct an ongoing review for antibiotic stewardship for one person in a survey sample of 43 residents. The findings included: On 5/10/21 at approximately 12:45 PM., an appointment was made with the administrator concerning the Antibiotic Stewardship Program for 2:00 PM. On 5/10/21 A review of the antibiotic Infection Control Surveillance infection report log showed that only the months of March, April and May were available to view. The months of January and February were not available. No other supporting documents or forms were available to view per onsite surveyor. On 5/10/21 at approximately 3:25 PM a review of the Antibiotic Stewardship Program was conducted with the ADON (Acting Director of Nursing) and with the Regional Director of Clinical Services (RDCS). The Director of Clinical Services stated, If a staff recognize a person is suspicious for infection they go to the DON (Director of Nursing) for Skin infections, UTI's (Urinary Tract Infections) or fever of unknown origin we do 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 a review of facility documents, the facility staff failed to designate at least one qualified Infection Preventionist. The findings included: On 5/06/21 at approximately 9:15 AM an interview was conducted with the ADON (Acting Director of Nursing) Concerning the Infection Preventionist (IP). He stated, We had an Infection Control Nurse (RN #3) but she left abruptly on April 28th. I'm assuming the role. I registered for class on yesterday. I'm going to try to start the training this weekend. He was asked by the said surveyor if he could email the Infection Control Training certificate of the former Infection Control Preventionist as well as a copy of his registration for the Infection Control class. He stated, Okay. Received Infection Prevention and Control Certificates of Training on 5/07/21 for RN #3. The certificates show that out of fifteen modules only 14 were completed. Module #7 was not available. The following email was sent to the Administrator on 5/07/21 at approximately 9:38 AM after receiving RN #3's Infection Prevention Training…

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

Based on observations, staff interviews and facility documentation. The facility staff failed to implement COVID-19 testing to all staff. The findings include: The facility staff failed to test five nursing staff during their twice weekly COVID-19 testing. Therefore, increasing the chances of spreading COVID-19. A review of the as worked schedule and Employee COVID-19 consent forms reveal that the following nursing staff were not tested for COVID-19. LPN (License Practical Nurse) #15, CNA (Certified Nurses Aide) #1 and CNA #7 worked on 5/03/21 (Monday). LPN #3 worked on 5/05/21 (Wednesday). LPN #1 and LPN #7 worked on 5/06/21 (Thursday). LPN #15 and CNA #5 worked on 5/07/2. CNA #5 worked on 5/09/21. An interview was conducted on 5/06/21 at approximately 2:55 PM with CNA (Certified Nursing Assistant) #1 concerning the COVID-19 test. She stated, We get tested twice weekly. Monday and Thursday. I received my first COVID19 vaccine shot on yesterday. An interview was conducted with LPN (Licensed Practical Nurse) #15 on 5/10/21 at approximately 9:15 PM., Concerning the COVID-19 testing at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interview, the facility staff failed to ensure 1 of 35 Residents (#39) in the survey sample was seen by a physician or his/her designee at least every 60 days. Findings included: Resident #39 was originally admitted to the facility on [DATE]. Diagnosis included but were not limited to *Chronic Pulmonary Edema and *Depression. Resident #39's Minimum Data Set (MDS), a quarterly with an Assessment Reference Date (ARD) of 07/05/19 coded Resident #39 Brief Interview for Mental Status (BIMS) score of 11 out of a possible score of 15 indicating moderate cognitive impairment. In addition, the MDS coded Resident #39 total dependence of two with toilet use and transfer, total dependence of one with bathing, extensive assistance of one with bed mobility, dressing and personal hygiene for Activities of Daily Living care. Review of the clinical record revealed Physician's progress notes only for 09/18/18 and 6/20/19. An interview was conducted with the Director of Nursing…

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

Based on observations, staff interviews and facility documentation the facility staff failed to ensure that opened food products were properly dated, labeled, and stored in accordance with professional standards for food service safety. The findings included: On 08/14/2019 at 11:15 a.m., during the initial tour of the kitchen with the Dietary Manager an open carton of *Med Plus 2.0 Vanilla (a fortified nutritional shake) and an opened carton of Thickened Orange Juice was observed in the reach in refrigerator. They were not dated with an opened date or use by date. The Dietary Manager was asked, Should the staff date the cartons when they open them and date them with a use by date? The Dietary Manager stated, Yes, the staff should have dated them. They just forgot to date them. The Dietary Manager stated, I will throw them away. At approximately 11:25 a.m., walked into the walk in freezer accompanied by the Dietary Manager and noted a cardboard box sitting on the shelf. The Dietary Manager was asked, What is inside the cardboard box? The Dietary Manager took the box down off the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews and facility document review the facility staff failed to perform hand hygiene practices to provide a safe, sanitary environment and to help prevent the development and transmission of disease and infections; and failed for one of 35 residents, Resident #154's, Foley catheter tubing and bag in a manner in accordance with infection control standards and practices to help prevent associated urinary tract infections. The findings included: 1. On 08/15/2019 during a follow up visit in the kitchen, the following observations were made: At approximately 11:50 a.m., [NAME] #3 was observed washing her hands with soap and water for 5 seconds. At approximately 12:00 p.m., [NAME] #2 was observed washing his hands with soap and water for 5 seconds. At approximately 12:10 p.m., the Dietary Manager was observed washing his hands with soap and water for 5 seconds. On 08/15/2019 at 1:00 p.m. the surveyor reviewed hand washing observations with the Dietary Manager. The Dietary Manager 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 staff interview, facility document review and clinical record review, it was determined that facility staff failed for 1 of 35 residents in the survey sample, to ensure that the assessment accurately reflected Resident #22's status. The findings included: Resident #22 was admitted to the facility on [DATE]. Diagnosis included but were not limited to, Cognitive Communication Deficit and Type 2 Diabetes Mellitus. Resident #22's Quarterly Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of 06/10/2019 was coded with a BIMS (Brief Interview for Mental Status) score of 11 indicating moderate cognitive impairment. In addition, the Minimum Data Set coded Resident #22 as requiring extensive assistance of 1 with dressing and personal hygiene and extensive assistance of 2 with bed mobility, transfer and toilet use. On 08/15/2019 review of Resident #22's Quarterly MDS, Section P- Restraints, revealed that the resident was coded as using Bed Rails less than daily. On 08/15/2019…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility document review the facility staff failed to implement an approach listed in the residents Comprehensive Person-Centered Plan of Care for 2 of 35 residents in the survey sample (Resident # 154 & #10). The facility failed to implement an indwelling catheter securement device for Resident #154 and failed to administer medications for seizure disorder and Parkinson's Disease for Resident #10. The findings include: 1. Resident #154 was admitted to the facility on [DATE] with an indwelling Foley catheter for diagnoses of BPH (benign prostatic hyperplasia-an enlarged prostate gland that can cause urination difficulty) and UTI (urinary tract infection). The current MDS (Minimum Data Set) an admission with an assessment reference date of 7/22/19 coded the resident as having long and short term memory deficits and severely impaired daily decision making skills. The resident was coded as having an indwelling catheter (a plastic tube inserted into…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinical record review and facility documentation review, the facility staff failed to revise two of 35 residents (Resident #30 and #39) comprehensive person-centered care plans in the survey sample. The findings included: 1. The facility staff failed to revise Resident #30's comprehensive person-centered care plan to include the use of an indwelling Foley catheter. Resident #30 was originally admitted to the facility on [DATE]. Current diagnosis included but not limited to pressure ulcer of sacral region, stage IV. Resident #30's Minimum Data Set (MDS-an assessment protocol), a significant change MDS with an Assessment Reference Date of 06/21/19 coded the resident with a 13 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. In addition, the MDS coded Resident #30 as total dependence of two with bathing, extensive assistance of two with bed mobility, transfer, dressing, toilet use and personal hygiene for 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 record review and staff interview, the facility staff failed to provide one resident (Resident #10) in the survey sample of 35 residents, with physician ordered medications. The findings included: Resident #10 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, muscle weakness, Parkinson's Disease, Convulsions, shortness of breath and dysphagia. A review of the clinical records indicated Resident #10 was not provided physician ordered Keppra (a medication used for the treatment of seizure disorder) and Carbidopa-Levodopa (a medication used for the treatment of Parkinson's Disease symptoms). A Quarterly Minimum Data Set (MDS) dated [DATE] assessed this resident as having unclear speech and not able to make herself understood. This resident rarely understood and rarely understood others. This resident's vision was highly impaired. In the area of Activities of Daily Living this resident was assessed as requiring extensive assistance in the area of transfer, dressing, eating,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility document review the facility staff failed to ensure 1 of 35 residents in the survey sample received appropriate care and services to prevent complications from an indwelling Foley catheter, Resident # 154. The findings include: Resident #154 was admitted to the facility on [DATE] with an indwelling Foley catheter for diagnoses of BPH (benign prostatic hyperplasia-an enlarged prostate gland that can cause urination difficulty) and UTI (urinary tract infection). The current MDS (Minimum Data Set) an admission with an assessment reference date of 7/22/19 coded the resident as having both long and short term memory deficits and severely impaired daily decision making skills. The resident was coded as having an indwelling catheter (a plastic tube inserted into the bladder to drain urine). The Comprehensive Person-Centered Plan of Care dated 7/16/19 identified that the resident had a potential for Urinary Tract Infection due to the presence 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 observations, clinical record review and staff interview the facility staff failed to ensure 1 of 35 residents in the survey sample respiratory care equipment was maintained in a manner to ensure optimal functioning, Resident #49. The fixtures on both sides of the oxygen concentrator cabinet that hold the external air filters in place were missing. The findings include: Resident #49 had a re-admission date of 7/3/19 with diagnoses to include, but not limited to: chronic respiratory failure, sleep apnea and chronic obstructive pulmonary disease (COPD). The resident was coded as scoring a 15 out of a possible 15 on the Brief Interview for Mental Status indicating the resident's cognition was intact. The admission physician's orders dated 7/4/19 included an order to administer oxygen at 2 liters as needed for shortness of breath. The Comprehensive Person-Centered Plan of Care dated 7/4/19 identified the resident was at risk for sleep pattern disturbance. The goals listed were that the resident would not exhibit any sleep related behavioral symptoms and will express feelings 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 record review and staff interview the facility staff failed to provide pharmacy services to one resident (Resident #10) in the survey sample of 35 residents. Resident #10 was not provided physician ordered Keppra (a medication used for the treatment of seizure disorder) due to the medication not being available. The findings included: The facility staff failed to ensure medications were available in accordance with physician orders. Resident #10 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, muscle weakness, Parkinson's Disease, Convulsions, shortness of breath and dysphagia. A Quarterly Minimum Data Set (MDS) dated [DATE] assessed this resident as having unclear speech and not able to make herself understood. This resident rarely understood and rarely understood others. This residents vision was highly impaired. This resident was not assessed in the area of Brief Interview of Mental Status (BIMS). In the area of Activities of Daily Living this resident was assessed as…

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

Based on clinical record review, staff interview and facility documentation, the facility staff failed to ensure a PRN (as needed) psychotropic medication (Xanax-anxiety medication) was limited to 14 days for 1 out of 35 residents (Resident #27) in the survey sample who was receiving a PRN (as needed) psychotropic medication. The findings included: The physician did not do an evaluation of Resident #27 to extend the psychotropic medication past 14 days nor document the rational and duration in the resident's medical record. Resident #27 was originally admitted to the facility 02/28/19. Diagnosis for Resident #27 included but not limited to *Dementia without behavioral disturbances and Anxiety. Resident #27's MDS, a significant change with an Assessment Reference Date (ARD) of 06/18/19 coded resident with a BIMS score of 08 out of a possible 15 moderate cognitive impairment. In addition, the MDS with an ARD of 06/18/19, under section E (Behaviors), coded Resident #27 for exhibiting verbal behaviors directed towards others 1-3 days each week. Resident #27's comprehensive care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and facility documentation the facility staff failed to notify the physician and/or his designee of laboratory results for 1 of 35 resident (Resident #24) in the survey sample. The findings included: The facility staff failed to report to the physician Resident #24's abnormal lab results of a high Hemoglobin A1C (HgbA1C), resulting in a delay in medical treatment. Resident #24 was originally admitted to the facility on [DATE]. Diagnoses for Resident #24 included but not limited to, Type 2 Diabetes Mellitus (DM.) Resident #24's Minimum Data Set (MDS), quarterly assessment with an Assessment Reference Date of 06/12/19 coded the Brief Interview for Mental Status (BIMS) score an 03 out of a possible 15 indicating severe cognitive impairment. Resident is extensive assistance of one with bed mobility and bathing, limited assistance of one with dressing and personal hygiene and supervision with transfer and toilet use for Activities of Daily Living (ADL). Resident #24's…

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