Portside Health & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff/resident interviews facility document review and clinical record review, it was determined the facility staff failed to accommodate resident needs for one of 43 residents in the survey sample, R25. The findings include: For R25, the facility staff failed to maintain the call light in a position where they could access it. Resident #25 was admitted to the facility on [DATE] with diagnosis that included but were not limited to ESRD (end stage renal disease), Sepsis and bilateral osteoarthritis. The most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of 10/18/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring supervision for transfer/dressing/toileting and eating. A review of the comprehensive care plan dated 11/27/24 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. The facility staff failed to evidence provision of required written RP (responsible party) notification at the time of discharge for Resident #90. Resident #90 was transferred to the hospital on [DATE]. Resident #90 was admitted to the facility on [DATE] with diagnosis that included but were not limited to colon cancer, dementia, falls and femur fracture. The most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of 12/2/24, coded the resident as scoring a 02 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the comprehensive care plan dated 5/27/24 revealed, PROBLEM: Resident at risk for falling related to generalized weakness with dementia and history of colon cancer. APPROACH: Observe frequently and place in supervised area when out of bed. Encourage resident to assume a standing position slowly. Keep bed in lowest position with brakes locked. Always keep call light…

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 document review, it was determined that the facility staff failed to evidence bed hold notice provided for a facility-initiated transfer for one of 43 residents in the survey sample, Resident #9. The findings include: For Resident #9 (R9), the facility staff failed to evidence bed hold notice was provided to the responsible party for a facility-initiated transfer on 11/24/24. The progress notes for R9 documented in part, - 11/24/2024 09:00 Paramedics arrived and tended to resident while SN gave paramedics report. The resident continued to rapidly decline and resident was placed on a non-rebreather by paramedics. Facesheet, InterAct form, med list and DNR (do not resuscitate) form sent with resident which was emergently transported to [Name of hospital]. Report called to ER and to [Name of insurance company]. Message left with wife who is primary contact and legal representative. - 11/25/2024 0:31 (12:31 a.m.) This writer called [Name of hospital] for resident update. Per [Name of staff member] resident has been admitted…

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, clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide services to maintain or improve mobility for one of 43 residents in the survey sample, Resident #70. The findings include: For Resident #70 (R70), the facility staff failed to follow therapy recommendations for the use of a splinting device. On 12/9/24 at 8:16 p.m., an observation was made of R70 in bed. R70 was observed with limited range of motion (ROM) in the right hand. No splinting device was observed in use. Additional observation on 12/10/24 at 8:25 a.m. revealed R70 in bed with no splinting device and limited ROM in the right hand. The most recent OT (occupational therapy) evaluation and plan of treatment dated 8/14/24-9/11/24 documented treatments including but not limited to splinting and increasing finger flexion. The evaluation documented a right upper extremity contracture and impairment of the right hand. Under Recommendations it documented Splint/Orthotic Recommendations: It is recommended the patient wear an elbow…

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, facility document review and clinical record review, it was determined the facility staff failed to provide care and services for an indwelling catheter for one of 43 residents in the survey sample, Resident #89. The findings include: For Resident #89 (R89), the facility staff failed to evidence of providing catheter care. On 12/10/24 at 8:45 a.m. Resident was observed in bed, an indwelling catheter bag was noted hanging off the bedframe. the physician orders dated, 7/8/24, documented, Change foley (indwelling) catheter as needed. 18 fr (french) 10 cc (cubic centimeters). Special Instructions: Document catheter (french) and balloon (ml - milliliters) size inserted PRN (as needed). Further review of the physician orders failed to evidence an order for indwelling catheter care. Review of the MAR for October, November and December 2024, failed to evidence documentation of indwelling catheter care. Review of the comprehensive care plan dated, 7/11/24, documented in part, Problem: Urinary Incontinence: Incontinence d/t (due to) dx (diagnosis) of…

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

Based on observation, clinical record review, staff interview and facility document review, it was determined that the facility staff failed to obtain a physician's order for oxygen administration for one of 43 residents in the survey sample, Resident #9. The findings include: For Resident #9 (R9), the facility staff failed to obtain an order for the administration of oxygen (O2). The progress notes for R9 documented in part, - 11/23/2024 20:10 (8:10 p.m.) Resident in bed awake/alert and verbal. Resident has scattered rhonchi. Resident has O2 @ 2L/min (liters per minute) via NC (nasal cannula). IsoSource (enteral tube feeding) is not connected at this time per physician order. Staff will continue to monitor closely for any status change. - 12/07/2024 18:09 (6:09 p.m.) Resident completed ABT (antibiotic) for Pneumonia. No adverse reactions noted. Bed in low position, HOB (head of bed), and o2 running 2 L via nasal cannula. Will continue to monitor and report any changes in status. - 12/09/2024 20:20 (8:20 p.m.) During routine f/u (follow up) visit w/ MD [Name of physician], family…

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 the facility staff failed to provide trauma informed care for one of 43 residents in the sample Resident #176 (R176). The findings include: The facility failed to evidence provision of trauma informed care for Resident #176. R176 was admitted to the facility on [DATE] with diagnosis that included but were not limited to PTSD (post-traumatic stress disorder), CHF (congestive heart failure) and CVA (cerebrovascular accident). The most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of 12/3/24, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring moderate assistance for mobility/transfers and eating. Section I: PTSD yes. PTSD is listed on R176'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.

Based on clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to ensure timely physician visits for 1 of 43 residents in the survey sample, Resident #127. The findings include: For Resident #127 (R127), the facility staff failed to evidence a physician visit between 6/8/21 and 10/14/21. A review of the clinical record for physician visits documented a physician progress note for R127 dated 6/8/21 and the next dated 10/14/21, 127 days without a physician's visit. On 12/12/24 at 10:15 a.m., an interview was conducted with ASM (administrative staff member) #6, medical doctor who stated that long term care residents were seen every 60 days for recertification visits and she and the nurse practitioner alternated the visits. A request was made for a policy for physician visits however none was provided by the facility prior to exit. On 12/12/24 at approximately 2:09 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional vice president of operations, ASM #4, the regional director of clinical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff and resident interview and review of facility documents, it was determined that the facility staff failed to ensure 3 out of 42 residents (R#453, #457 and #456) in the survey sample had the opportunity to formulate an Advance Directive. The findings include: 1. Resident #453 was admitted to the nursing facility on 3/25/21 with diagnoses that included stroke, high blood pressure and atrial fibrillation. The resident was her own authorized representative. The admission Minimum Data Set (MDS) assessment dated [DATE] coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 12 out of a total score of 15 which indicated the resident was moderately impaired in the cognitive skills for daily decision making. The resident was assessed with the ability to express ideas and wants and was able to fully comprehend others. The resident was not coded to possess behavioral or mood symptoms. On 3/30/21 at 1:10 p.m., Resident #453 stated she did not have an Advance…

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

Based on observation, staff interview and facility document review, it was determined that facility staff failed to maintain hot foods at a temperature of 135 degrees or higher while holding on the steam table. The findings included: On 4/1/21 at 7:45 a.m., observation of the tray line was conducted. At 8:00 a.m., OSM (Other Staff Member) #3 was asked to provide the food temperatures before tray line had started. At the same time (8:00 a.m.) one cart had been sent out to the unit. At 8:10 a.m., OSM #3 was observed getting temperatures of the food on the steam table. When asked if the food temperature were taken prior to the start of tray line, OSM #3 stated that the cook had only documented two food items: The turkey sausage at 173.0 degrees Fahrenheit and the corn beef hash at 167.0 Fahrenheit. Observation was then conducted of OSM #3 taking temperatures of the rest of the food items on the steam table. The following low temperatures were recorded: Scrambled eggs- 131.0 degrees Fahrenheit Oatmeal- 123.1 degrees Fahrenheit The scrambled eggs were observed to be in a deep pan 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.

Based on observation, staff interview and facility document review, it was determined that facility staff failed to serve food at palatable temperatures. The findings included: On 4/1/21 at 7:45 a.m., observation of the tray line was conducted. All plate bottom warmers were observed being warmed up from an Aladdin (Brand Name) machine. Plates were then placed on top of the warmer, food placed on the plates and then covered with a lid. At 8:00 a.m., OSM (Other Staff Member) #3 was asked to provide the food temperatures before tray line had started. At the same time (8:00 a.m.) one cart had been sent out to the unit. At 8:10 a.m., OSM #3 was observed getting temperatures of the food on the steam table. When asked if the food temperature were taken prior to the start of tray line, OSM #3 stated that the cook had only documented two food items: The turkey sausage at 173.0 degrees Fahrenheit and the corn beef hash at 167.0 Fahrenheit. Observation was then conducted of OSM #3 taking temperatures of the rest of the food items on the steam table. The following temperatures were recorded 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 interviews, clinical record review and facility documentation review the facility staff failed to follow 2 physician orders for 1 of 42 residents in the survey sample, Resident #82. The findings included: 1. For Resident #82, the facility staff failed to follow physician order and discontinue medication. Facility staff failed to remove Scopolamine Patch. Resident #82 was originally admitted to the facility on [DATE]. Resident #82 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnosis included but were not limited to, Type 2 Diabetes Mellitus without complications, contracture, unspecified joint and Cerebral infarction due to unspecified occlusion or stenosis if unspecified cerebral artery. Resident #82's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 03/10/2021 was coded with short-term memory problems, long-term memory problems and with moderately impaired cognitive skills for daily decision making. In addition,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interviews, staff interviews, clinical record review, and a review of the facility's policy, the facility staff failed to ensure medically related social services to include resident's appointments and assessments were provided for 4 of 42 residents in the survey sample, Resident #57, #453, #457, and #456. The findings included: 1. The facility staff failed to ensure medically related social services needs were met; such as providing dental appointments in a timely manner for Resident #57. Resident #57 was originally admitted to the facility on [DATE] and readmitted on [DATE] after an acute care hospital stay. The current diagnoses included; Diabetes Mellitus due to underlying condition with Diabetes Mono-neuropathy and Essential Hypertension. A Quarterly revision, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 02/19/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interviews, staff interviews, clinical record review, and a review of the facility's policy, the facility staff failed to ensure one resident receive the services needed to meet their dental needs for 1 out of 40 residents (Resident #57), in the survey sample. The findings included: Resident #57 was originally admitted to the facility on [DATE] and readmitted on [DATE] after an acute care hospital stay. The current diagnoses included; Diabetes Mellitus due to underlying condition with Diabetes Mononeuropathy and Essential Hypertension. A Quarterly revision, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 02/19/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #57 cognitive abilities for daily decision making were intact. In Section G (Physical functioning) the resident was coded as requiring extensive assistance of one person with transfers, 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 observation and staff interview it was determined that facility staff failed to provide a dignified dining experience for five of 42 residents in the survey sample; Resident #33, #20, #2, #7 and #58 in the activity room on unit one. Facility staff failed to provide Resident #33 a dignified dining experience during dinner on 4/28/19; and failed to provide Residents #20, #2, #7 and #58 a dignified dining experience for lunch on 4/30/19 in the activity room on unit one. The findings include: On 4/28/19 at 5:39 p.m., observation of dining in the activity room was conducted. Four residents were observed sitting in the activity room waiting for their meals. On 4/28/19 at 5:46 p.m., three residents were served their meals. The fourth resident (Resident #33) did not have her tray at this time. On 4/28/19 at 5:50 p.m., an aide brought in a fifth resident into the activity room for his meal. On 4/29/18 at 5:55 p.m., Resident #33 still did not have her meal. Resident #33 appeared very agitated and stated, I am so hungry. On 4/28/19 at 5:59 p.m., the fifth resident was given his meal.…

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, facility staff failed to provide a homelike environment during the dining observation on two separate occasions on 4/28/19 and 4/30/19 in the activity room of unit one. Facility staff served resident meals on trays during the dining observation in the unit one activity room for dinner on 4/28/19 and for lunch on 4/30/19. The findings include: On 4/28/19 at 5:39 p.m., observation of dining in the activity room was conducted. Four residents were observed sitting in the activity room waiting for their meals. On 4/28/19 at 5:46 p.m., three residents were served their meals. Their meals were served on trays. On 4/28/19 at 5:50 p.m., an aide brought in a fifth resident into the activity room for his meal. On 4/28/19 at 5:59 p.m., the fifth resident was given his meal. His meal was served on a tray. On 4/28/19 at 6:04 p.m., the fourth received her meal. Her meal was removed from the tray. On 4/30/19 at 11:21 a.m., an interview was conducted with CNA (Certified Nursing Assistant) #2. When asked how to maintain a homelike environment in the dining…

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 for 3 of 42 residents (Resident #73, 32, and 70) after being transferred to the hospital. 1. The facility staff failed to ensure that Resident #73's Plan of Care Summary to include their care plan goals was sent upon transfer/discharge to the hospital on [DATE]. 2. For Resident #32, facility staff failed to evidence that all required documentation was sent with the resident upon transfer to the hospital for a facility-initiated transfer on 2/9/19. 3. For Resident #70, the facility staff failed to include in the transfer summary indication that the facility staff conveyed to the receiving providers the resident's comprehensive care plan goals at the time of discharge to the local hospital on 6/1/18, 6/3/18, 10/5/18 and 12/21/18 or as soon as possible to the actual time of transfer. The findings included: 1. Resident #73 was originally…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, facility documentation review and clinical record review the facility staff failed send a copy of the Bed-Hold Policy for 3 of 42 residents (Resident #73, 32 and 70) after being transferred to the hospital. 1. The facility staff failed to issue the resident/representative with a written copy of bed hold policy for Resident #73. Resident #73 went to his doctor's appointment and was transferred to the local hospital and admitted on [DATE]. 2. Facility staff failed to evidence that written bed hold notification was provided to the resident/responsible party at the time of a facility initiated transfer to the hospital on 2/9/19. 3. The facility staff failed to ensure Resident #70 or Resident Representative (RR) was issued a written notice of the bed hold reserve policy upon transfer to the local hospital on 6/1/18, 6/3/18, 10/5/18 and on 12/21/18. The findings included: 1. Resident #73 was originally admitted to the facility on [DATE]. The resident was re-admitted to the facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff interviews and facility documentation, the facility staff failed to ensure a Level II PASRR (Preadmission Screening and Resident Review) was conducted for 2 of 40 residents (Resident #18 and #32) in the survey sample with diagnoses of either a mental disorder and or intellectual disability. 1. The facility staff failed to ensure Resident #18, who was identified with a mental illness and had a Level I PASRR screening with recommendation for a Level II assessment, had the Level II conducted per standard protocol. 2. The facility staff failed to ensure a Level II PASRR was completed for Resident #32. The findings include: 1. Resident #18 was admitted to the nursing facility on 3/4/17 with diagnoses that included obsessive compulsive personality disorder and major depressive disorder. The most recent Minimum Data Set (MDS) assessment was a quarterly assessment dated [DATE] and coded the resident with a score of score of 13 out of a possible score of 15 the Brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined that facility staff failed to review and revise the care plan for five (5) of 42 residents in the survey sample, Resident # 71, #58, #32, #6 and #73. 1. For Resident #71, facility staff failed to revise the care plan when she was diagnosed with MRSA (Methicillin-resistant Staphylococcus aureus) in her sputum. 2. For Resident #58, facility staff failed to revise the care plan when she was diagnosed with pneumonia and receiving antibiotic therapy. 3. For Resident #32, facility staff failed to revise the care plan when a stage II pressure ulcer was found to her right hip; and a wound from trauma was found to her left lateral ankle on 4/2/19. 4. For Resident #6, the facility staff failed to revise the person centered care plan to include a Deep Tissue Injury (DTI), pressure ulcer to the right heel. 5. For Resident #73, the facility staff failed to revise the person centered care plan to include contact precaution and 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 resident interview, staff interviews and clinical record review the facility staff failed to provide personal care to include showers for one resident in the survey sample (Resident #62) who was unable to independently carry out activities of daily living (ADL's). The facility staff failed to ensure Resident #62 was offered and received scheduled twice-weekly showers to maintain good personal hygiene. The findings included: Resident #62 was admitted to the facility on [DATE]. Diagnosis for Resident #62 included but not limited to Difficulty waking and Muscle weakness. Resident #62's Minimum Data Set (an assessment protocol) with an Assessment Reference Date (ARD) of 04/01/19 coded the resident's Brief Interview for Mental Status (BIMS) score 15 of a possible 15 with no cognitive impairment. In addition, the MDS coded Resident #62 requiring extensive assistance of one with toilet use, limited assistance of one with transfer, dressing, hygiene, bed mobility and bathing with Activities of Daily Living…

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 communicate ongoing assessments for Resident #73 for the monitoring of complications after dialysis treatment. The facility staff failed to ensure ongoing communication and assessments with the dialysis center for Resident #73 who attended an outpatient dialysis three days per week every Tuesday, Thursday and Saturday. The findings included: Resident #73 was originally admitted to the facility on [DATE]. Diagnosis included but not limited to *End Stage Renal Disease (ESRD) (Chronic irreversible kidney failure). The resident was receiving *hemodialysis treatments three times a week every Tuesday, Thursday and Saturday. The current Minimum Data Set (MDS) a significant change assessment, with an Assessment Reference Date (ARD) of 04/9/19 coded the resident with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. 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, resident interview, staff interview, clinical record review, and review of the facility's policy the facility staff failed to acquire medications needed to meet each resident's needs for 1 of 42 residents (Resident #44), in the survey sample. The facility's staff failed to obtain Nystatin ointment (an antifungal) ordered for Resident #44 on 4/22/19. The findings included: Resident #44 was admitted to the nursing facility on 5/3/17, and re-admitted to the facility on [DATE], after an acute hospital stay. The current diagnoses included heart failure and asthma. Resident #44's annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/15/19, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #44's cognitive abilities for daily decision making were intact. The 3/15/19, MDS was coded for no mood or behavior problems. In section G (Physical functioning) the resident was coded 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 observation, staff interview, clinical record review and facility document review, it was determined that facility staff failed to follow infection control practices for three of 42 residents in the survey sample, Resident # 229, #71, and #58; and the facility staff failed to ensure they followed infection control practices to prevent the possible transmission of infection and disease on 2 of 2 facility nursing units. 1. For Resident #229, facility staff failed to wear the appropriate PPE (Personal Protective Equipment) while she was on contact precautions on 4/28/19 and had the wrong precaution sign on the resident's door. 2. For Resident #71, facility staff failed to wear the appropriate PPE while she was on droplet precautions on 4/29/19 and had the wrong precaution sign on the resident's door. 3. For Resident #58, facility staff failed to maintain oxygen equipment in a sanitary manner. 4. On Unit I, the facility staff facility staff failed to disinfect the glucose monitoring machine before and after…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility documentation review, clinical record review, the facility staff failed to notify pertinent individuals of a change in condition for 1 of 42 Residents (Resident #30), in a survey sample. The facility staff failed to notify the physician and Responsible Party of Resident #30's open areas on the right lower extremity. The findings included: Resident #30 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses for Resident #30 included but not limited to Diabetes Mellitus, Hypertension, and Cerebral Vascular Incident, dementia and Xerosis Cutis. Resident #30's Quarterly Minimum Data Set with an Assessment Reference Date (ARD) of 7/02/18 coded Resident #30 as having short term and long term memory problems. With cognitive skills indicating a severe cognitive impairment. In section G (Physical functioning) the resident was coded as being totally dependent with eating, locomotion, dressing, personal hygiene, bathing, 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 clinical record review, staff interviews and facility documentation, the facility staff failed to ensure Medicare Beneficiary Notices in accordance with applicable Federal regulations, were issued to 1 of 3 residents (Resident #68) in the survey sample. The facility staff failed to issue an Advanced Beneficiary Notice (ABN) letter to Resident #68. Resident #68 was discharged from skilled services who remained in the facility with Medicare days remaining. The findings included: Resident #68 was admitted to the nursing facility on 03/06/19 with a diagnosis included but not limited to Amyotrophic Lateral Sclerosis (ALS). The Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date (ARD) of 04/04/19 coded the resident with a 12 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), which indicated moderate cognitive impairment. On review of the Beneficiary Notification Checklists provided by the facility to surveyor, Resident #68 was not listed for having been issued the SNF ABN (Skilled Nursing Facility-Advanced Beneficiary…

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 during wound care and staff interviews the facility staff failed to assure privacy was maintained during the provision of care for 1 of 42 residents (Resident #67), in the survey sample. The facility staff failed to pull the privacy curtain to obscure Resident #67 from view while providing wound care and failed to wait for a response after knocking on the door before entering. The findings included: Resident #67 was originally admitted to the facility 03/10/16 and readmitted on [DATE]. The current diagnoses included; Multiple Sclerosis, Major Depressive Disorder, Diabetes Mellitus, Pressure Ulcers. The Minimum Data Set (MDS) Quarterly revision showed an assessment reference date (ARD) of 09/02/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15. This indicated Resident #67's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as being independent requiring set up help only 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.

Based on staff interviews, clinical record review and facility documentation the facility staff develop a comprehensive personal centered care plan for 1 of 42 residents (Resident #6) in the survey sample. The facility staff failed to develop a person-centered care plan to include the diagnosis of depression with the use of a psychoactive medication (*Zoloft). The findings included: Resident #6 was originally admitted to the nursing facility on 02/08/18. Diagnosis for Resident #6 included but was not limited to *Depressive Disorder. The current Minimum Data Set (MDS) was a significant change assessment with an Assessment Reference Date (ARD) of 01/17/19. The MDS coded the resident with short and long-term memory problems and cognitive skills severely impaired-never/rarely made decisions. The residents MDS was coded for the usage of antidepressant medication. Section N on the MDS under medications read as follows: Indicate the number of DAYS the resident receiving the medication during the last 7 days, the resident was coded for receiving an antidepressant for 7 days. The review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility documentation the facility staff failed for one (Resident #109) of 14 residents in the survey sample, to follow professional standards of care for medication administration. The facility staff failed to administer medication to Resident #109 per physician's order on 06/17/2019 and failed to document attempts to acquire the medication. The findings included: Resident #109 was admitted to the facility on [DATE]. Diagnoses included but were not limited to, Huntington's Disease (1) and Psychotic Disorder. Resident #109's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 05/27/2019 coded the resident with a BIMS (Brief Interview for Mental Status) score of 14 out of 15 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #109 as requiring no assistance with bed mobility, transfer and eating, supervision with eating and total dependence of 1 with bathing. On 06/19/2019, the NON-PRN…

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 there was Registered Nurse (RN) coverage for 8 hours, 7 days a week. The facility staff failed to ensure there was RN coverage for 8 hours on 3/2/19. The findings included: On 05/01/19 at approximately 2:30 PM, the facility's actual worked schedule was reviewed and revealed there was no RN coverage for 03/02/2019. On 05/01/19 at approximately 2:39 PM, an interview was conducted with the Operations Coordinator. She was asked to explain the RN weekend schedule. She stated that RN's (Registered Nurses) are hired for weekend coverage. If no one is here we ensure that we have RN coverage. She was asked if RN on call coverage suffices for RNs not being in the building? She replied no! She also stated that the Registered Nurse scheduled to come in on 03/02/19 on the 7:00 PM -7:00 AM shift called out, and there was not an on call Registered Nurse that could be reached by phone. On 05/01/19 at approximately 5:06 PM an interview was conducted with The Director of Nursing (DON) and 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 clinical record review and staff interviews the facility staff failed to ensure that the medication irregularities identified by the Pharmacist during the Drug Regimen Review were acted upon for 1 of 42 residents (Resident #47) in the survey sample. The facility staff failed to ensure medication irregularities identified by the Pharmacist during the Drug Regimen Review were acted upon for Resident #47. The findings included: Resident #47 was admitted to the facility on [DATE]. Diagnoses included but were not limited to, Heart Failure and Diabetes Mellitus. Resident #47's Minimum Data Set (MDS- an assessment protocol) with an Assessment Reference Date of 03/18/2019 was coded with a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #47 as requiring limited assistance of 1 with activities of daily living. Resident #47's Clinical Record was reviewed on 04/29/2019 and the Physician's Order Sheet revealed a medication…

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 inspection of 1 of 2 medication rooms (Unit II), the facility staff failed to ensure provision of a separately locked, permanently affixed compartment for the storage of controlled drugs or drugs subject to abuse. The findings include: On 4/29/19 at 11:15 a.m., the medication room on Unit II was inspected with the assistance of Licensed Practical Nurse (LPN) #8. Upon entry, the door to the medication room was locked. The refrigerator was not locked and a small 8 inch by 5 inch metal box sat on the bottom shelf that was lifted out and sat on the counter. The items in the box included three 30 milliliters (ml) boxes of 2 milligram (mg) per ml *Ativan/ Lorazepam. This LPN did not recognize that the drugs were not double locked and that the metal box was not affixed and could be easily removed from the medication room. A Registered Nurse (RN) #3 entered the room and stated, There were screws that secured the box in the refrigerator. I will take care of that right now! *Lorazepam belongs to a class of drugs known as benzodiazepines which is a schedule IV…

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, facility documentation review, the facility staff failed to ensure the Quality Assessment and Assurance (QAA) committee met at least quarterly and the required members attended. The facility staff failed to consistently have the required members at each quarterly Quality Assessment and Assurance Committee (QAA) meeting and failed to meet on a quarterly basis for one year. The findings included: On 05/01/19 at approximately 1:11 p.m., the Quality Assurance (QA) review was conducted with the Administrator. The surveyor requested the QAPI (QA Performance Improvement) meeting sign-in sheets for the last 4 quarters. The Administrator stated, I searched prior to this meeting for the QAPI sign-in-sheets but could only locate sign-in-sheets for 03/27/19 and 09/27/18. She stated, I'm not sure where the previous Administrator could have put the sign-in-sheets but they should be in the QA book. The Administrator started going through the QA book then stated, You can tell the meetings was held because the QA paperwork is here. The surveyor asked, Do you have 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.