Autumn Care Of Portsmouth

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to develop a care plan for three of four residents (Resident (R) 64, R30, and R5) that included targeted behaviors for the use of anxiety medication out of a total sample of 38 residents. This failure had the potential for residents to experience adverse effects of an anxiety medication which was not specifically monitored. Findings include:1. Review of R64's Face Sheet, located under the Resident tab in the electronic medical record (EMR) indicated R64 was readmitted to the facility on [DATE] with the diagnosis of multiple sclerosis and congested heart failure (CHF).Review of R64's quarterly Minimum Data Set (MDS), located under the Resident Assessment Instrument (RAI) tab in the EMR, with an Assessment Reference Date (ARD) of 01/18/26 indicated R64 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R64 had moderately impaired cognition.Review of R64's Care Plan, located under the RAI tab 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 record review and staff interviews, the facility failed to ensure timely review and revision of care plans for one resident (Resident (R) 42) of four reviewed for care plan revisions out of a total sample of 38 residents. The facility failed to ensure R42's care plan was updated to reflect the resident's current smoking status. Failure to ensure care plan accuracy had the potential for the residents who smoke to be at risks for accidents/hazards during smoke breaks by not reflecting accurate smoking assessments for all residents who smoke.Findings include:1. Review of R42's Face Sheet, under the Resident tab of the electronic medical record (EMR) revealed the resident was originally admitted to the facility on [DATE] with diagnoses that included B-cell lymphoma with intrapelvic lymph nodes, unspecified psychosis, glaucoma, dementia, and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 02/10/26 and located under the Resident Assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and review of facility policy, the facility failed to ensure staff maintained professional standards of practice by ensuring one resident (Resident (R) 122) was not administered crushed medications when there was not a clinical indication to do so. Findings include:Review of R122's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/21/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated no cognitive impairment. R122 discharged on 07/25/25. Review of R122's Care Plan, dated 05/01/25 and located in the residents' EMR under the Care Plan tab, revealed R122 was care planned for behavioral symptoms. 07/16/25 Resident pocketing medications and refusing to give to the nurse. Review of R122's Orders located under the Resident tab of the EMR, revealed a physician order, dated 02/10/25, for may crush medications unless contraindicated.Review of R122's Nurse's Note dated 07/21/25 at 8:13 AM and located in the EMR under…

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, record review, interviews, and policy review, the facility failed to administer oxygen in accordance with physician orders for two of four residents (Resident (R) 30 and R76) reviewed for oxygen therapy out of a total of 38 sampled residents. This failure had the potential for the residents not to receive the correct amount of oxygen causing hyperoxia (cells, tissues and organs are exposed to an excess supply of oxygen) or hypoxia (cells, tissues and organs are exposed to a decrease in oxygen). Findings include: 1. Review of R30's Face Sheet, located under the Resident tab in the electronic medical record (EMR) indicated R30 admitted to the facility on [DATE] with the diagnosis of chronic obstructive pulmonary disease (COPD) and congested heart failure (CHF). Review of R30's admission Minimum Data Set (MDS), located under the Resident Assessment Instrument (RAI) tab in the EMR, with an Assessment Reference Date (ARD) of 01/29/26 indicated R30 had a Brief Interview for Mental Status (BIMS)…

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, interview, and facility policy review, the facility failed to ensure that staff followed physician orders and weighed (Resident #4) prior to and after dialysis for one of one resident reviewed for dialysis, out of a sample of 38 residents. This had the potential to affect all residents who went out for dialysis treatment. Findings include:Review of R4's Face Sheet in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease with end stage renal disease and dependence on renal dialysis. Review of R4's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/03/26 EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated the resident was not cognitively impaired. R4 was documented as receiving hemodialysis. Review of R4's Care Plan dated 08/26/25 and located in the EMR under the Care Plan tab revealed…

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, clinical record reviews and facility documentation review, the facility staff failed to ensure 2 of 38 residents in the survey sample, (Resident #10 and #33) were given the opportunity to formulate an advance directive. The findings included: 1. The facility staff failed to ensure Resident #10 and or their Representative was given the opportunity to formulate an Advance Directive. Resident #10 was originally admitted to the nursing facility on 03/06/19. Diagnosis for Resident #10 included but not limited to Chronic Obstructive Pulmonary Disease (COPD). The current Minimum Data Set (MDS) a quarterly assessment with an Assessment Reference Date (ARD) of 04/14/22 coded the resident with a 02 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Review of the clinical record revealed that there was no Advance Directive for Resident #10. Review of Resident #10's Physician Order Sheet (POS) for April 2022 revealed the following order: Do Not Resuscitate (DNR) starting on 03/01/21. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on employee record review, facility document review and staff interviews the facility staff failed to implement their Abuse/Neglect Prevention Policy for screening of new employees. Criminal Background Checks were not obtained for 5 current employees 2 of which were agency staff within 30 days of their hire date and Sworn Statements were not obtained for 2 current agency staff employees upon hire. The findings included: On 4/13/22 twenty-five current employee records were reviewed. The employee record review revealed that 5 current employees 2 of which were agency staff did not have a Criminal Background Checks. There were also 2 current agency staff employees that had no Sworn Statements upon hire. On 4/13/22 at 1:00 p.m. an interview was conducted with the Director of Human Resources regarding the missing employee Criminal Background Checks and Sworn Statements. The Director of Human Resources stated, I know I ran them but I can't find them. I called the agency and spoke with the owner. The owner said…

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 closed record review, staff and family interviews, and a complaint investigation, the facility staff failed to thoroughly investigate an incident of an injury of unknown source for one resident (Resident #89) in the survey sample of 38 residents. The findings included: Resident #44 was admitted to the facility on [DATE] with diagnoses which included coronary artery disease, dementia, benign prostatic hyperplasia and COPD. Resident #89 was sent out to the hospital with a change of condition and being unresponsive to verbal and tactile stimuli. This resident was identified as having a large subdural hematoma of unknown source. A [DATE] Quarterly Minimum Data Set (MDS) assessed this resident in the area of Cognitive Pattern - Brief Interview for Mental Status (BIMS) as having a score of 15. This resident was assessed as requiring extensive assistance of one person in the areas of bed mobility, transfer, dressing and personal hygiene. A care plan dated [DATE] assess Resident #89 as- Focus: - Self care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinical record review and facility documentation review the facility staff failed to send a copy of the Resident's Care Plan to include their goals after being transferred and admitted to the hospital for one resident (Resident #35) in survey sample of 38 residents. The findings included: Resident #35 was admitted to the facility 9/26/1991 and readmitted to the facility on [DATE]. Diagnoses for Resident #35 include: Contracture, unspecified and Quadriplegia, unspecified. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 02/21/2022 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was not conducted. Resident's cognitive skills for decision making were coded as severely impaired for daily decision making. A review of the clinical record show that Resident #35 was admitted to the hospital from [DATE] through 2/15/22 due to a clogged Foley catheter. On 04/14/22 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 resident record review, staff interviews and facility document review, the facility failed to notify the Office of the State Long-Term Care Ombudsman in writing of hospital discharges for 1 of 38 residents (Resident #88, a closed record resident) in the survey sample. The findings included; Resident #88 was originally admitted to the facility on [DATE] and discharged on 2/23/2022 to an acute care facility. The current diagnoses included; Anemia and Coronary Artery Disease. The quarterly Revision Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 02/12/2022 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #88 cognitive abilities for daily decision making were intact. In section G(Physical functioning) the resident was coded as requiring extensive assistance of two persons with bed mobility. Requires total dependence of two person's physical assist with transfers. Requires total dependence…

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, clinical record review and facility documentation review, the facility staff failed to revise 1 of 38 residents (Resident #10) comprehensive personal-centered care plan in the survey sample. The findings included: The facility staff failed to revise Resident #10's comprehensive person centered care plan to include her current code status of Do Not Resuscitate (DNR). Resident #10 was originally admitted to the nursing facility on 03/06/19. Diagnosis for Resident #10 included but not limited to Chronic Obstructive Pulmonary Disease (COPD). The current Minimum Data Set (MDS) a quarterly assessment with an Assessment Reference Date (ARD) of 04/14/22 coded the resident with a 02 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Review of Resident #10's Physician Order Sheet (POS) for April 2022 revealed the following order: Do Not Resuscitate (DNR) starting on 03/01/21. Resident #10's person-centered comprehensive care plan created on 03/07/19 document the resident/Responsible Party has…

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 review of facility documents, the facility staff failed to obtain weights and labs necessary for management of acute on chronic hypoxic and hypercapnic respiratory failure due to CHF and COPD exacerbations for 1 of 38 residents (Resident #61), in the survey sample. The findings included: Resident #61 was originally admitted to the facility 1/5/21 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; obstructive sleep apnea (OSA)congestive Heart failure (CHF), chronic obstructive pulmonary disease (COPD) and post COVID-19. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) 3/18/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #61's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring 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.

Based on observation, staff interview, and facility document review, the facility staff failed to ensure a Registered Nurse (RN) coverage for 8 hours, 7 days a week. The facility staff failed to ensure RN coverage for 8 consecutive hours for 24 days. The findings included: On 04/14/22 at approximately 11:00 AM, the facility's actual worked schedule was reviewed with Other Staff #2 (Nursing Scheduler) and revealed there was no RN coverage for the following days: 1/01/22,1/02/22, 1/08/22, 1/15/22, 1/16/22, 1/22/22, 1/23/22, 1/30/22, 1/31/22, 2/05/22, 2/12/22, 2/13/22, 2/19/22, 2/20/22, 2/26/22, 2/27/22, 3/05/22, 3/06/22, 3/12/22, 3/13/22, 3/19/22, 3/19/22, 4/02/22, 4/03/22. 04/15/22 at approximately, 1:15 PM a pre-exit interview was conducted with The Director of Nursing (DON) and the facility Administrator concerning the above issue. The DON was asked what should have been done concerning the above issue. She stated, I have an RN (Registered Nurse) that provides weekend coverage. The ADON (Assistant Director of Nursing) stated she worked weekends since she started in October (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 record reviews and staff interviews, the facility staff failed to ensure drug regimen of each resident were reviewed monthly for two residents (Resident #44 and #56) in the survey sample of 38 residents. The findings included: 1. Resident #56 was admitted to the facility on [DATE] with diagnoses which included hypertension, depression, dementia, Parkinson's disease, hypothyroidism, coronary artery disease and psychosis. This resident did not have monthly drug regimen reviews provided by a pharmacist for irregularities. Resident #56 was coded on a Quarterly Minimum Data Set (MDS) dated [DATE] in the area of Cognitive Pattern for Basic Interview for Mental Status (BIMS) as a (06). In the area of medications this resident was coded as receiving Antipsycotic and Antidepressant medications on a routine basis. Resident #56 was noted to be receiving the following medications Seroquel, Klonopin, and Effexor on a routine basis. A review of Pharmacy Reviews did not include reviews for the months of October 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, clinical record review, review of facility documents and during the course of a complaint investigation, the facility's staff failed to accurately document in one residents medical record for 1 of 38 residents (Resident #35), in the survey sample. The findings included: Resident #35 was admitted to the facility 9/26/1991 and readmitted to the facility on [DATE]. Diagnoses for Resident #35 include: Contracture, unspecified and Quadriplegia, unspecified. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 02/21/2022 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was not conducted. Resident's cognitive skills for decision making were coded as severely impaired for daily decision making. In section G(Physical functioning) the resident was coded as requiring total dependence of one person with bed mobility, locomotion on and off units, dressing, eating, toilet use,…

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

Based on observations and staff interview it was determined that the facility staff failed to maintain an effective pest control system. The findings included: During the kitchen inspection on 10/01/19 at 11:45 A.M. house flies were observed in the kitchen area. Drain flies were observed in the mop room and dishwasher room. Fruit flies and house flies were observed in the conference room. House flies were observed in the dining room area. Flies were observed on all units. During an interview on 10/03/19 at 2:50 P.M. with the Maintenance Director she stated, the drain flies, fruit flies and house flies have been a concern and there is a need for pest control. The Maintenance Director stated The Pest Control company came out on 10/03/19 at 11:18 A.M. to service the facility. A copy of the work order was provided by the Maintenance Director. A review of the Pest Management policy indicated: Mission- We shall first seek to understand the unique needs of each customer, formulate effective solutions, and implement the actions in a timely professional manner. No further information 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 interviews, clinical record review and facility document review, the facility staff failed to provide the resident or resident's representative education regarding the benefits and potential side effects of influenza immunization for four of 39 residents in the survey sample, (Resident #33, #10, #96, #88). The findings include: 1. Resident #33 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to major depressive disorder, bipolar disorder, high blood pressure, and type two diabetes. Resident #33's most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 7/25/19. Resident #33 was coded as being moderately impaired in cognitive function scoring 11 out of 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #33's clinical record revealed that she received her last flu vaccine on 10/4/18. The following was documented in her clinical record: Immunization: Influenza:…

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 review, it was determined that the facility failed to replace personal property damaged by facility laundry for one resident out of 39 records reviewed. The findings included: Resident #32 was initially admitted to the facility on [DATE] with most recent admission occurring on 4/26/2019 with diagnoses of, but not limited to, chronic pain syndrome and epilepsy. Resident #32's most recent MDS (minimum data set) assessment was a quarterly review assessment with an ARD (assessment reference date) of 7/21/19. Resident #32 was coded as being intact in cognitive function scoring 15 out of possible 15 on the BIMS (brief interview for mental status) exam. The resident was assessed to have clear speech and no impairments in understanding others. Resident #32 was assessed at requiring extensive support with dressing and personal hygiene. An interview conducted on 10/2/2019 at approximately 12:37 p.m. with Resident #32 who reported two of her clothing items returned from…

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 interviews, the facility's staff failed to assure 1 of 39 residents (Resident #59), in the survey sample call bell was within reach at all times. The findings included: Resident #59 was originally admitted to the facility 2/5/18 and has never been discharged from the facility. The current diagnoses included, left sided hemiplegia (paralysis). The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/27/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #59 cognitive abilities for daily decision making were intact. In section G (physical functioning) the resident was coded as requiring extensive assistance of two people with transfers and toileting, extensive assistance of one person with bed mobility, dressing and personal hygiene and total care of one person bathing and locomotion. One 10/1/19 at approximately 12:30 p.m., the resident was observed seated in a wheelchair close to the foot of the bed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interview, the facility staff failed to ensure one of 39 residents in the survey sample, Resident #68, was free from physical restraints. The facility staff had tube socks in use to Resident #68's bilateral arms to prevent scratching of a wound. The findings included: Resident #68 was re-admitted to the facility on [DATE] with diagnoses that included, but not limited to, dementia, Type 2 Diabetes mellitus without complications, dementia, depression, sepsis, osteomyelitis of vertebra, sacral and sacrococcygeal region. A Quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #68 Brief Interview for Mental Status (BIMS) a score of 6 which indicated severe cognitive impairment. In the area of Functional Status this resident was assessed in the area of Activities of Daily Living (ADL'S) as requiring total dependence of two persons for bed mobility and toileting. Extensive assistance of one person physical assist for dressing and personal hygiene. In the area 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 staff interview, facility document review and clinical record review, it was determined that facility staff failed to send the required documentation upon transfer to the hospital for two of 39 residents in the survey sample, Resident #33 and #26. The findings include: 1. Resident #33 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to, major depressive disorder, bipolar disorder, high blood pressure, and type two diabetes. Resident #33's most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 7/25/19. Resident #33 was coded as being moderately impaired in cognitive function scoring 11 out of 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #33's clinical record revealed that Resident #33 was transferred to the hospital on 8/27/19. The following note was documented: 8/27/2019 14:36 (2:36 p.m.) SBAR S Situation: Change in condition, symptoms or signs I am calling…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review and clinical record review, it was determined that facility staff failed to send written bed hold notification upon transfer to the hospital for one of 39 residents in the survey sample, Resident #33. The findings include: Resident #33 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to major depressive disorder, bipolar disorder, high blood pressure, and type two diabetes. Resident #33's most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 7/25/19. Resident #33 was coded as being moderately impaired in cognitive function scoring 11 out of 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #33's clinical record revealed that Resident #33 was transferred to the hospital on 8/27/19 for a change in condition. There was no evidence in Resident #33's clinical record that written bed hold notification 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 to ensure an accurate MDS (minimum data set) assessment for two of 39 residents in the survey sample, Residents # 102 and #59. The findings include: Resident #102 was admitted to the facility on [DATE] with diagnoses that included but were not limited to, type 2 diabetes, atrial fibrillation, high blood pressure and muscle weakness. Resident #102's most recent MDS (minimum data set) assessment was a discharge, return not anticipated, assessment with an ARD (assessment reference date) of 8/2/19. Resident #102 was coded as being intact in cognitive function scoring 15 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Further review of Resident #102's MDS coded Resident #102 in Section A2100. Discharge Status, as being sent to the hospital. Review of Resident #102's August 2019 nursing notes revealed the following notes: 8/2/19 at 08:52 a.m.: (Name of Resident #102)…

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, record review and staff interview the facility staff failed to revise the comprehensive care plan for two of 39 residents in the survey sample, Resident #23 and Resident #68. The findings included: For Resident #23, the facility staff failed to include a focus, interventions, or goals for inappropriate sexual comments/requests made to staff. Resident #23 was admitted to the facility on [DATE] with diagnoses that included hypertension, contractures of left hip, sleep disorder, anxiety disorder, major depression and osteoporosis. An annual Minimum Data Set (MDS) dated [DATE] assessed this resident in the area of Cognitive Patterns as scoring a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated intact cognition. In the area of Mood this resident was assessed as feeling down, depressed or hopeless. In the area of Functional Status Activities of Daily Living (ADL's) this resident was assessed as requiring total dependence of two person physical assist in the area 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, resident interview, staff interviews, and clinical record review the facility staff failed to ensure 1 of 39 residents (Resident #21), in the survey sample received fingernail care prior to his fingernails becoming long with broken edges and a brownish substance beneath them. The findings included: Resident #21 was originally admitted to the facility 1/16/16 and had never been discharged from the facility. The current diagnoses included rheumatoid arthritis and severe deformity of bilateral feet. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 7/16/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #21's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring extensive assistance of 1 person with eating, total care of two people with bed mobility and toileting and total care of one person with transfers, locomotion, dressing, personal hygiene and bathing.…

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 interviews the facility staff failed to ensure 1 of 39 residents (Resident #21), in the survey sample received foot care prior to the toe nails advancing to painful, long and curvy nails. The findings included: Resident #21 was originally admitted to the facility 1/16/16, and had never been discharged from the facility. The current diagnoses included; rheumatoid arthritis and severe deformity of bilateral feet. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 7/16/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #21's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring extensive assistance of 1 person with eating, total care of two people with bed mobility and toileting and total care of one person with transfers, locomotion, dressing, personal hygiene and bathing. On 10/1/19 at approximately 11:45 a.m., Resident #21 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, family interview, staff interview, and clinical record review, the facility staff failed to ensure necessary respiratory care and services were provided for 2 of 39 residents in the survey sample (Residents #97 and #10). For Resident #97, the facility staff failed to ensure resident specific tracheostomy equipment was easily accessible in case of an emergency, failed to provide tracheostomy care without compromising the resident's respiration/airway and failed to administer oxygen (O2) as ordered. For Resident #10, the facility staff failed to administer oxygen as ordered. The findings included: 1. Resident #97 was originally admitted to the facility 9/6/19 and had never been discharged from the facility. The current diagnoses included sarcoidosis requiring a tracheostomy. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/13/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 0 out of a possible 15. This…

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, family interview and staff interviews the facility staff failed to ensure staff was competent in tracheostomy tube care for 1 of 39 residents (Resident #97), in the survey sample. The findings included: Resident #97 was originally admitted to the facility 9/6/19 and had never been discharged from the facility. The current diagnoses included sarcoidosis requiring a tracheostomy. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/13/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 0 out of a possible 15. This indicated Resident #97's cognitive abilities for daily decision making were severely impaired. In section G (Physical functioning) the resident was coded as requiring extensive assistance of 1 person with bed mobility and total care with locomotion, dressing, eating, toileting, personal hygiene and bathing. Observations were made of the resident's room on 10/2/19, at approximately 11:00 a.m., with Licensed Practical Nurse #1. An ambu bag was on the table near the foot 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 staff interview and facility documentation review, the facility staff failed to ensure there was Registered Nurse (RN) coverage for eight consecutive hours in a twenty-four hour period. The findings include: During review of the facility's staffing for Registered Nurse coverage, the facility failed to ensure there was an RN for at least 8 consecutive hours a day seven days a week on 12/1/18, 12/2/18, 12/16/18, and 12/22/18. On 10/4/19 at 9:49 a.m., an interview was conducted with the scheduler Other staff member (OSM) #4. When asked how long she had been creating the schedule, OSM #4 stated that she had been doing the schedule for four years. When asked if it was difficult to get RN coverage back in December of 2018, OSM #4 stated, On the weekends. Yes. OSM #4 stated that there should be an RN on shift for 8 hours in a 24 hour period. OSM #4 confirmed through review of the as worked nursing staffing schedule that there was no RN coverage 8 consecutive hours in the 24 hours on 12/1/18, 12/2/18, 12/16/18, and 12/22/18. On 10/4/19 at 10:46 a.m., during the pre-exit meeting,…

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 record review and staff interview the facility staff failed to ensure medications were available for administration for two residents (Resident #68 and Resident #96 ) in the survey sample of 39 residents. The findings included: 1. Resident #68 was re-admitted to the facility on [DATE] with diagnoses which included, but not limited to, sepsis, osteomyelitis of vertebra, sacral and sacrococcygeal region, Type 2 Diabetes mellitus without complications, dementia, and chronic obstructive pulmonary disease (COPD). A Quarterly Minimum Data Set (MDS) dated [DATE] assessed this resident in the area of Hearing, Speech, and Vision as having unclear speech. In the area of Cognitive Patterns this resident received a Brief Interview for Mental Status (BIMS) score of 6 which indicated severe cognitive impairment. In the area of Functional Status this resident was assessed in the area of Activities of Daily Living (ADL) as requiring total dependence of two persons for bed mobility and toileting. Extensive assistance 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 interview, staff interviews, clinical record review, the facility's staff failed to review food preference with the resident and provide like food alternatives for 1 of 39 residents (Resident #95), in the survey sample. The findings included: Resident #95 was originally admitted to the facility 9/12/19 and the resident has never been discharged from the facility. The current diagnoses included; stroke with left hemiparesis. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/18/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #95's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring extensive assistance of 1 person with locomotion, dressing, eating, toileting, and personal hygiene, extensive assistance of 2 people with bathing, bed mobility, and transfers. On 10/1/19 at…

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