Portsmouth Health And Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview and staff interview, the facility's staff failed to ensure 1 of 21 residents (Resident #111) who was unable to carry out activities of daily living (ADL) received the necessary services to include nail care. The findings included: Resident #111 was originally admitted to the facility 07/22/20 and readmitted on [DATE] after an acute care hospital stay. The current diagnoses included Hypertension. The admission, significant change, annual quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 05/06/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 6 out of a possible 15. This indicated Resident #111 cognitive abilities for daily decision making were severely impaired. In sectionGG(Functional Abilities) the resident was coded as being dependent in oral hygiene, personal hygiene, toileting hygiene, showering and bathing. A review of a progress note dated 5/14/24 read that resident is dependent 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 and clinical record review the facility staff failed to ensure 1 resident (Resident #104), in the survey sample of 21 Residents who was unable to carry out activities of daily living receives the necessary services to maintain toenail care. The findings included: Resident #104 was originally admitted to the facility on [DATE]. Diagnosis for Resident #104 included but not limited to Diabetes Mellitus. The most recent Minimum Data Set (MDS) an annual with an Assessment Reference Date (ARD) of 2/23/24 coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 15 which indicated Resident #104 cognitive abilities for daily decision making were intact. In sectionGG(Functional Abilities) the resident was coded as requiring partial/moderate assistance with showering/bathing, dependent with putting on and taking off footwear, requiring substantial maximal assistance with personal hygiene. A review of a psychotherapy note dated on 2/13/24 read that Resident…

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

Based on observation, staff interview, clinical record review, and review of facility documents, the facility's staff failed to ensure a wander guard was placed on an at risk, wandering, exit seeking resident for monitoring for 1 of 21 residents (Resident #112), in the survey sample. The findings included: Resident #112 was originally admitted to the facility 6/18/21 after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Dementia. The annual, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 03/20/2024 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 5 out of a possible 15. This indicated Resident #112 cognitive abilities for daily decision making were severely impaired. In sectionG(Physical functioning) the resident was coded as requiring total care of one person with bed mobility, transfers, locomotion, dressing, eating, toileting, personal hygiene and bathing, extensive assistance of one person/ two people, limited assistance of one person,…

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

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's staff failed to answer call bells in a timely manner for 3 of 21 residents in the survey sample. Resident #106, Resident #108, and Resident #110. The findings included: 1. Resident #106 was admitted to the facility on [DATE]. The resident's diagnoses included: Paraplegia, Weakness, and Metabolic Encephalopathy. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/17/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 7 which indicated the resident was severely cognitively impaired. An observation was made on 5/21/2024 at approximately 1:55 PM, the resident's call bell activated. While waiting with the resident, at 2:11 PM, Others #7 Came in to answer the call bell. Resident #106 asked to be repositioned. Others #7 went to get nursing staff and returned at 2:17 PM with additional staff to reposition the…

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

Based on observation, staff interview, and policy review, the facility failed to ensure food was prepared and served in a sanitary manner. This involved failure to change gloves and/or wash hand between touching soiled dishes and touching clean dishes; failure to ensure sanitizing solution was at the proper level to sanitize food contact surfaces, pans, and serving utensils; failure to ensure food carts were cleaned and sanitized after transporting soiled dishes and before placing resident meal trays in them. This had the potential to affect all 67 residents in the facility who receive food from the dietary department. Findings include: Review of the resident matrix with a print date of 05/21/21 and the Resident Census and Condition of Residents (Form CMS-672) signed by the Minimum Data Set (MDS) nurse and dated 05/28/21 revealed seven of the facility's 74 residents received tube feedings. Therefore 67 residents receive food from the facility kitchen. 1. On 05/24/21 at 9:31 AM, Dietary Aide 1 (DA1) was observed wearing gloves while placing soiled plates on the dishwashing racks.…

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, interviews, and record reviews, the facility failed to have a functioning call system that relayed a call to a staff member or to a centralized staff work area. Findings include: On 05/24/21 at 11:14 AM, when asked about staff response to the call lights, resident (R) 42 stated the staff do not answer the call light because the call light was not working. R42 stated that when the button is pushed the light comes on but the light goes out when the button is no longer being pushed. The call light was checked by the surveyor and when pushed the light did not activate. R42's roommate's light was also checked and did not function. R42 stated the call light had not functioned in a long time. Review of R42's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/01/21 revealed R42 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating he was cognitively intact. Further review of this MDS revealed R42 required supervision with bed mobility,…

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

Based on observation, menu review, and staff interview, the facility failed to follow the menus during lunch service on 05/26/21. The facility failed to serve residents a full portion of the garlic and rosemary roasted red skin potatoes, the sauteed zucchini, and the baked macaroni and cheese and failed to follow the renal menu for one resident (Resident (R)1). This failure involved 20 of the 67 residents who receive food from the facility dietary department. Findings include: On 05/26/21 from 12:05 PM through 1:26 PM, [NAME] 2 was observed serving lunch from a steam table in the kitchen. Review of the menu revealed residents on regular diets and concentrated carbohydrate diets were supposed to receive a ½ cup (4 ounces) serving of sauteed zucchini and ½ cup (4 ounces) of garlic and rosemary roasted red skin potatoes, one Italian sausage, a dinner roll, and a lemon bar. Further review of the menu revealed residents on renal diets (residents with kidney disease) were supposed to receive a 3-ounce parsley pork chop, ½ cup of sauteed zucchini, ½ cup garlic mashed potatoes, a dinner…

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

Based on observation, interview, record review, review of policies and procedures, and review of medical device and product user information, the facility failed to ensure the nursing staff used a barrier between surfaces and cleaned and disinfected multi-use glucometers per the manufacturer's instructions when performing fingerstick blood glucose monitoring in three of three nurses observed. Findings include: Review of the Summary Report of Meeting for Infection Control, dated March 21, 2021, revealed an inservice on the procedure on how to disinfect multi-use glucometers. The inservice instructed the nursing staff to disinfect the multi-use glucometers after each use with an alcohol pad. Attendees included 10 facility Registered Nurses (RN) and/or Licensed Practical Nurses (LPN). Further review of the summary report revealed that the inservice did not include the use of EPA registered disinfecting wipes. On 05/28/21 at 8:18 AM, the Director of Nursing (DON) was asked to provide the facility policy for cleaning a glucose monitor and the actual hand booklet that came with the Assure…

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, policy review, and review of Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer pneumococcal vaccines to four out of five residents (Resident (R) 36, R27, R73, and R35) reviewed for pneumococcal immunizations out of a sample of 20 residents. Failure to provide pneumococcal vaccines increased the risk for pneumococcal pneumonia, a type of bacterial pneumonia, that is a common cause of hospitalization and death in the elderly. Findings include: Review of CDC pneumococcal guidelines revealed For adults 65 years or older who do not have an immunocompromising condition, cerebrospinal fluid leak, or cochlear implant and want to receive PPSV23 ONLY: Administer 1 dose of PPSV23. Anyone who received any doses of PPSV23 before age [AGE] should receive 1 final dose of the vaccine at age [AGE] or older. Administer this last dose at least 5 years after the prior PPSV23 dose. For adults 65 years or older who do not have an immunocompromising condition,…

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

Based on observation and staff interview, the facility failed to provide privacy related to hospice care for one resident (Resident (R)50) out of total sample of 20 residents. Signage was posted above the bed stating R50 was receiving hospice care, including bathing, on Monday, Wednesday, and Friday. Findings include: On 05/25/21 at 12:23 PM, observation revealed a sign above R50's bed stating Hospice Days are Monday, Wednesday, and Friday. Hospice aide will do bath on those days. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/19/20, revealed a Brief Interview for Mental Status (BIMS) score of eight out of 15 indicating moderately impaired cognitive status. Review of a quarterly MDS with an ARD of 04/28/21 revealed R50 was receiving hospice care. On 05/26/21 at 10:10 AM, interview with Unit Manager 2 revealed that she did not know that Hospice signage was above the resident's bed. Unit Manager 2 went into R50's room and removed the sign above R50's bed. Unit Manager # stated that the sign never should have been on the wall.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to complete a level II Preadmission Screen and Resident Review (PASARR) screening for three residents (Resident (R) 8, R51, and R33) reviewed out of 20 sampled residents. Level II PASARR screenings are required for individuals with serious mental disorders to determine the need for specialized services. Findings include: 1. Review of R8's undated Diagnosis tab in the electronic medical record (EMR) revealed diagnoses which included Major Depressive disorder, Unspecified psychosis not due to a substance or known physiological condition, and anxiety disorder. Review of a document titled Screening for Mental Illness, Mental Retardation/Intellectual Disability, or Related Conditions located in the miscellaneous tab of the EMR, signed and dated 02/26/19, revealed a recommendation for a referral for a secondary assessment/level II Preadmission Screen and Resident Review (PASARR). The medical record was reviewed in its entirety and was silent for a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure one resident's plan of care was revised for code status. This involved one resident (Resident (R) 54) of 20 sampled residents. Findings include: Review of R 54's Advance Directive, located in the paper chart and signed by his guardian and dated [DATE], revealed R54 was a full code status and was to receive cardiopulmonary resuscitation (CPR) if found without a pulse and/or not breathing. Review of R54's physician's Orders, located in the orders tab of the electronic medical record (EMR) revealed a physician's order, dated [DATE], for a full code. Review of R54's Care Plan, located in the care plan tab of the EMR and initiated on [DATE], stated R54 was a do not resuscitate (DNR) meaning CPR would not be initiated if found without a pulse and/or not breathing. Review of R54's previous Advance Directive, signed and dated [DATE], revealed R54's code status was do not resuscitate. The Advance Directive signed by his legal guardian on [DATE]…

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, interviews, record review, and review of facility policy, the facility failed to provide treatment to maintain and/or prevent decrease in range of motion (ROM), including the provision of equipment for limited range of mobility, for three out of three residents (Resident (R) 32, R45, and R69) reviewed for ROM/splints out of a sample of 20. Specifically, the facility failed to: 1. Provide an evaluation and treatment to R32's contracture of the right hand; 2. Provide care and services for R45's upper and lower extremities; and 3. Continue services for R69, including application of splints, after readmission to the facility. This failure has the potential to adversely affect the range of motion to each residents' contracted extremities. Findings include: Review of the facility's policy, provided by the facility as their ROM policy, titled Section 4, Range of Motion, training module from the 2017 Restorative Nursing Manual, documented range of motion rationale .to counteract negative effects…

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 record review and staff interview, the facility failed to ensure the attending physician reviewed recommendations, documented in the medical record that recommendations were reviewed, and documented rationale for not acting on the recommendations made by the pharmacist during monthly medication regimen reviews (MRR) for two of five residents (Resident (R) 49 and R54) reviewed for unnecessary medications. Findings include: Review of the undated policy titled Medication Monitoring - Medication Regimen Review and Reporting revealed it was the facility policy for pharmacy recommendations to be acted on in 30 days. On 05/27/21 at 4:30 PM, pharmacy recommendations with the physician responses were requested from the Director of Nursing (DON). On 05/28/21 at 10:30 AM, the Regional Clinical Director stated they were unable to find any responses to the pharmacist's MRRs for R49 and R54. Review of the pharmacy reports revealed the following: 1. Review of pharmacy reports for R54 revealed the following: A pharmacy MRR report titled PharMerica, dated 12/16/20, revealed the pharmacist…

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, pharmacy and nurse practitioner interview, and policy review, the facility failed to attempt a gradual dose reduction (GDR) for one of five residents (Resident (R)24) reviewed for unnecessary medications in a total sample of 20 residents. Findings include: Review of the Face Sheet, dated 05/05/17, revealed R24 was admitted to the facility on [DATE] and had current diagnoses which included dementia with behavioral disturbance, unspecified psychosis, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/05/21 revealed a Brief Interview for Mental Status (BIMS) of 11 out of 15 indicating moderate cognitive impairment. Further review of this MDS revealed no behaviors, no delusions, or hallucinations were documented for R24. During an interview on 05/27/21 at 11:21 AM, the Consultant Pharmacist revealed that a pharmacy recommendation was made for a gradual dose reduction (GDR) attempt for Seroquel (antipsychotic 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and policy review, the facility failed to ensure that all medicines and equipment in one of two medication storage rooms were not expired or opened. Findings include: Review of the policy Medication Storage, dated 2007, revealed . outdated, contaminated, discontinued or deteriorated medications and those in container that are cracked, soiled, or without secure closures are immediately removed from stock, and disposed of . On [DATE] at 4:24 PM, Unit 1 Medication Storage Room was inventoried. The following items were found to be outdated: Magnesium Citrate (laxative) 10 FL. Oz. with an expiration date of 2/2021. Sore Throat Spray 6 FL. Oz. with an expiration date of 2/2021. Vial 2 Bag DC 20mm. with an expiration date of [DATE]. A vial2bag device enables reconstitution and transfer of a drug between a vial and an IV bag. One opened oxygen connector was found opened in a drawer with no labeling or covering. One Kangaroo Pump container that was opened. On [DATE] at 4:50 PM, Unit…

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 and staff interviews, the facility staff failed to maintain a clean, sanitary and homelike environment. The facility staff failed to ensure the privacy curtains were in good repair, heating/air vents in all the rooms were without excessive dust and debris, and toilets were clean, sanitary and homelike. The findings included: The following observations were made with the Maintenance Director on 2/7/19, at approximately 12:30 p.m. room [ROOM NUMBER]'s privacy curtain was missing 7 hooks; therefore when the curtain was drawn it was unable to provide privacy. There was no privacy curtain in room [ROOM NUMBER]. All of the vents above the room entrance doors on unit 2 and rooms 6, 8, 9, 10, 11, 23, 26 and 28 were with thick dark brown dust and debris. The toilets in rooms 1 through 11 were with unsightly rust colored stains. The wall paper border on Wing 1 was peeling and in some areas torn. The facility's Environmental Services Operations Manual revised 6/2016 read; If cubicle curtains are off…

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 interviews, staff interviews and clinical record review the facility staff failed to provide personal care to include showers for two resident in the survey sample (Resident #30 and #363) who were unable to independently carry out activities of daily living (ADL's). 1. The facility staff failed to ensure Resident #30 was offered and received a scheduled twice-weekly shower to maintain good personal hygiene. 2. The facility failed to ensure that Resident #363 was provided ADL (Activities of Daily Living) Care to include shaving of his beard. The findings included: 1. Resident #30 was originally admitted on [DATE] with a readmission date of 12/7/18 and 01/09/19. Diagnosis for Resident #30 included but not limited to Legal Blindness. The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 11/16/18 coded the resident with a 12 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating moderate 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.

Based on observations, staff interview, and facility document review the facility staff failed to store and label food in accordance with food service safety guidelines. The findings included: On 2/4/19 at approximately 6:45 P.M. the Initial Kitchen Inspection was completed. In the Dry Storage Room the following observation was made: 1. Two 22 quart clear containers noted both half full one with corn flakes and one with rice krispies. There were blue lids lying on top of the containers but were not secured to the container. In the Reach in refrigerator the following observation was made: 1. One large package wrapped in clear plastic wrap was observed not labeled or dated. The package contained slices of bacon and ground sausage all mixed together. On 02/05/19 11:40 AM an interview was conducted with the Kitchen Account Manager regarding the package of bacon slices and ground sausage found in the walk-in refrigerator the previous night that was not labeled or dated and the 2 open containers of cereal in the dry storage room. The Kitchen Account Manager stated, The package of bacon…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews and clinical record review the facility staff failed for 1 of 41 residents in the survey sample (Resident #67) to deliver personal laundry in a timely manner, therefore violating his dignity and rights as an individual. A resident council meeting was held in the resident dining hall on 02/05/19 at 10:30 AM. Twelve residents attended the meeting. The residents chief complaint was that they were not receiving their personal laundry on time. Resident #67 stated that it took him a week before he received his laundry on several occasions. Some residents stated that although the laundry is done daily, they may not receive their personal laundry until a week later. The findings included: Resident #67 was admitted to the facility on [DATE] with diagnoses to include cerebrovascular disease, difficulty in walking, and cerebral infarction. The current MDS, an annual assessment with an assessment reference date of 09/10/18 coded Resident # 67 with a 12 out of 15 on the Brief 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 clinical record review, staff interviews and facility documentation, the facility staff failed to ensure Medicare Beneficiary Notices, were issued to 2 of 41 residents (Residents #411 and #412) in the survey sample. 1. Resident #411 was not issued a Notice of Medicare Provider Non-Coverage form (NOMNC). The NOMNC informs the beneficiary of his or her right to an expedited review of a services termination. 2. Resident #412 was not issued a Notice of Medicare Provider Non-Coverage form. The findings included: 1. Resident #411 was admitted to the nursing facility on 09/27/18. Resident #41 was discharged home on [DATE]. Resident diagnosis included but not limited to Congestive Heart Failure. The Minimum Data Set (MDS) 14-day assessment dated [DATE] coded the resident with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was intact in the skills needed for daily decision making. On review of the Beneficiary Notification Checklists provided by the…

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

Based on review of facility records of employees hired within the last two years, staff interviews, and review of the facility's policy the facility staff failed to implement their policy for screening new employees for abuse, neglect and mistreatment of others for 1 of 25 employees. The facility's staff failed to obtain a criminal history report within 30 days of hire for 1 employee, Employee #6. The findings included: Review of the Employee's #6, personnel file revealed the Criminal History Report was not completed until 09/5/18. Employee # 6, a Certified Nurses Assistant (CNA) was hired on 07/18/18. The criminal history report in the employee's file was dated 09/5/18 which indicated that Employee #6 had worked in the facility greater than 30 days before the criminal history report results were obtained. An interview was conducted with the Human Resources Director on 2/6/19, at approximately 5:45 p.m. The Human Resources Director stated the report was not obtained in a timely manner therefore all criminal history reports are requested before an employee is allowed to start work…

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, for two of 41 residents (Resident #30 and 105) in the survey sample, to send a copy of the Resident's Care Plan after being transferred and admitted to the hospital. 1. The facility staff failed to send Resident #30's care plan when discharged and admitted to the hospital on [DATE] and 12/20/18. 2. The facility failed to ensure that Resident #105's Plan of Care Summary was sent upon transfer to the hospital on [DATE] and 1/16/19. The findings included: 1. Resident #30 was originally admitted on [DATE] with a readmission date of 12/7/18 and 01/09/19. Diagnosis for Resident #30 included, but not limited to, End Stage Renal Disease. The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 11/16/18 coded the resident with a 12 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The Discharge MDS…

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 41 residents (Resident #30) in the survey sample. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #30's transfer to the local hospital on [DATE] and 12/20/18. The finding included: Resident #30 was originally admitted on [DATE] with readmission dates of 12/7/18 and 01/09/19. Diagnosis for Resident #30 included, but not limited, to End Stage Renal Disease. The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 11/16/18 coded the resident with a 12 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The Discharge MDS assessments was dated for 12/05/18 and 12/20/18-discharged with return anticipated. On 12/05/18, according to the facility's documentation,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinical record review and facility documentation review the facility staff failed send a copy of the Bed-Hold Policy for 2 residents (Resident #30 and #105) after being transferred to and admitted to the hospital. 1. The facility staff failed to ensure that Resident #30 was made aware of the facility's bed-hold and reserve bed payment policy upon transfer/discharge to the hospital on [DATE] and 12/20/18. 2. The facility failed to ensure that Resident #105 received a written notice of the Bed-Hold Policy upon transfer to the hospital on [DATE] and 1/16/19. The finding included: 1. Resident #30 was originally admitted to the facility on [DATE] with readmission dates of 12/7/18 and 01/09/19. Diagnosis for Resident #30 included, but not limited to, End Stage Renal Disease. The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 11/16/18 coded the resident with a 12 out of a possible score of 15 on the 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 observations, clinical record review, staff interviews and facility documentation, the facility staff failed to ensure a Level I PASRR (Preadmission Screening Resident Review) was conducted prior to admission or within 30 days of admission to the nursing facility for 2 of 41 residents (Residents #45 and #88) in the survey sample with diagnoses of either a mental disorder and or intellectual disability . 1. The facility staff failed to ensure Resident #45, who was identified with a mental illness, had a PASRR completed prior to admission. 2. The facility staff failed to ensure a Level 1 PASRR was completed prior to admission for Resident #88. The findings include: 1. Resident #45 was admitted to the nursing facility on 4/27/15 with diagnoses that included psychotic disorder and major depressive disorder. The most recent Minimum Data Set (MDS) was a annual assessment dated [DATE] and coded the resident with a 15 out of a possible score of 15 the Brief Interview for Mental Status (BIMS), which indicated…

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

Based on facility information obtained during the Sufficient and Competent Nurse Staffing task, and staff interview, the facility staff failed to staff a Registered Nurse for at least 8 consecutive hours a day, 7 days a week. The facility staff failed to staff a Registered Nurse (RN), for at least 8 consecutive hours on 1/16/19. The findings included: During the nursing staff review for January 1, 2019 through February 6, 2019 the facility staff was unable to verify RN presence in the facility for at least 8 consecutive hours therefore; further review was indicated on 1/16/19 an RN worked only 7.5 hours (8:56 a.m.- 4:58 p.m.). An interview was conducted with the Staffing Coordinator on 2/7/19, at approximately 5:15 p.m. The Staffing Coordinator stated she was told the Director of Nursing could assume the role of the RN when the scheduled RN didn't work a full 8 hour shift. The above information was shared with the Administrator, Director of Nursing and Regional Director and Chief Clinical Officer on 2/7/19, at approximately 5:40 p.m. The Chief Clinical Officer stated she was aware…

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 record review, and review of the facility's policy, the facility staff failed to consistently have 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: A QAPI/QAA interview was held on 02/07/19 at approximately 10:30 AM with the facility Administrator. He presented the following quarterly meeting dates from the facility QAPI plan: 04/27/18, 10/26/18, 02/01/19. The Administrator stated that no meeting was held in July of 2018. The data from the QAPI plan revealed signatures from all required members were present during the April 2018 meeting, including more than three other staff members. The meeting held on 10/26/18 listed only one member as being present. The February 2019 meeting did not have the required members present. The Administrator attached a post it note with the following signatures attached to the February 2019 meeting: The Acting Director of Nursing, The Medical Director and other member signatures. On 02/07/19 at 4:25…

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 and staff interview the facility staff failed to provide the contact information to the independent reviewer authorized by Medicare upon issuance of a Notice of Medicare Non-Coverage for 3 residents in the survey sample of 30, Residents #25, 26 and 27. The facility staff failed to provide in writing the name of the Quality Improvement Organization (QIO) and toll-free contact number to appeal and or ask questions when issued a Notice of Medicare Non-Coverage for Residents #25, 26 and 27. The findings included: 1. Resident #25 was admitted to the facility under Medicare part A, for skilled services on 2/6/17. The resident's diagnosis included chronic respiratory failure. A Notice of Medicare Non-Coverage (NOMNC) informing the resident that the effective date coverage of current services would end on 3/9/17 was issued and signed by the resident on 3/7/17. The Form CMS (Center for Medicare/Medicaid Services) 10123-NOMNC (approved 12/31//2011) did not include the QIO name or toll-free number to call for an appeal or questions. 2. Resident #26 was 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, resident group interview, staff interview, and facility document review, the facility staff failed to ensure residents had access to their personal funds 7 days a week. The findings included: On 7/11/17 at 3:30 pm, a group interview was conducted with 13 residents in attendance. During the group interview, the residents were asked if they had access to their personal funds. Residents with personal fund accounts stated that they have access to their funds. One resident stated that they were available 5 days a week, Monday through Friday, but closed on weekends. Another resident stated that they were able to access their personal funds between 10:00 am - 11:00 am and at 1:00 pm - 2:00 pm, Monday through Friday. He stated that if they need the money on weekends, they have to wait until Monday. During observation of the main lobby area with the Administrator on 7/12/17 at 9:00 am, there was no information posted for resident banking hours. No signage was observed in other areas of the facility that were accessible to the residents. On 7/12/17 at 9:15 am, 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 interview, the facility staff failed to assure prompt encoding and transmittal to Centers for Medicaid and Medicare (CMS) for 4 of 30 residents (Resident #21, #22, #23 and #30). 1. The facility staff failed to electronically transmit any Minimum Data Set (MDS) assessments after 2/17/17 to the National Data Base, the Centers for Medicare and Medicaid (CMS) for Resident #21 who was a current resident. 2. The facility staff failed to electronically transmit any Minimum Data Set (MDS) assessments after 1/2/17 to the National Data Base, the Centers for Medicare and Medicaid (CMS) for Resident #22 who was a current resident. 3. The facility staff failed to electronically transmit any Minimum Data Set (MDS) assessments after 1/18/17 to the National Data Base, the Centers for Medicare and Medicaid (CMS) for Resident #23 who was a current resident. 4. The facility staff failed to electronically transmit any Minimum Data Set (MDS) assessments after 2/21/17 to the National Data…

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, medical record review, facility documentation review, and staff interview the facility staff failed to ensure MD (Medical Doctor's) orders were followed for vascular wound care for 1 Resident (Resident #12) of 30 Residents in the survey sample. The findings included: Resident #12 was admitted to the facility on [DATE]. Diagnoses for Resident #12 included but are not limited to Peripheral Vascular Disease and open ulcers to Left leg. Resident #12's Quarterly Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 5/26/17 coded Resident #12 with a BIMS (Brief Interview for Mental Status) of 15 of 15 indicating no cognition impairment. In addition the MDS scored Resident #12 as requiring extensive assistance with two staff person assistance for transfers, bed mobility and toileting. Resident #12 was coded as being frequently incontinent of bowel functions. Resident #12's current Care Plan documented the following 5/22/17 focus area: Altered skin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interview, medical record review, facility documentation review, and staff interview the facility staff failed to ensure wound care was done to promote healing and to prevent infection of pressure ulcers for 2 Residents (Resident #1 and #6) of 30 Residents in the survey sample. The findings included: 1. Resident #1 was admitted to the facility on [DATE] with a readmission on [DATE] after hospitalization for a wound infection and urinary tract infection. Diagnoses for Resident #1 included but are not limited to Non-Alzheimer's Dementia, Malnutrition and Stage IV* Right Heel Pressure Ulcer. Resident #1's Quarterly Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 6/26/17 coded Resident #1 with a BIMS (Brief Interview for Mental Status) of 1 out of 15 indicating severe cognition impairment. In addition the MDS scored Resident #1 as requiring total dependence with 2 staff persons for Transfers. Resident #1 was coded as requiring total dependence with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility document review, the facility staff failed to ensure ongoing healthcare-associated infection (HAI) surveillance and failed to maintain appropriate infection prevention and control practices to prevent infections for 2 of 30 sampled residents, (Residents #1, #12 ), failed to implement appropriate hand hygiene practices, failed to ensure medical equipment and supplies were maintained in a clean and sanitary manner and failed to place soiled items in the appropriate storage space. 1. The facility staff failed to ensure surveillance for healthcare-associated infections were completed for October 2016, November 2016 and December 2016. 2. The facility staff failed to ensure infection control measures were followed to prevent the potential transmission of infection for Resident #1. 3. The facility staff failed to ensure infection control measures were followed to prevent the potential transmission of infection for Resident #12. 4. The facility…

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 and staff interviews, the facility staff failed to maintain a safe, clean, comfortable and sanitary environment. The findings included: During General Observation of the facility on 07/13/17 at 9:30 a.m., with the Maintenance Director, the facility staff failed to maintain a safe, clean, comfortable and sanitary environment. During observation of the exterior surrounding of the building, in the back of the building a wooden facial board located directly under the windows was observed with chipped paint and a hole was observed in the wooden siding measuring 2 inches x 8 inches. The outside screen to the window next to the activities room was torn. Outside the activities room and the back hall of the activities room, the wooden casing around the air-conditioning unit was observed with chipped paint and rotten boards. The Maintenance Director stated the chipped paint and rotten boards were probably the result of water damage or just from being old. On the right side of the building facing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, the facility staff failed to maintain a complete and accurate medical record for 3 of 30 residents in the survey sample, Resident #3, Resident #1, Resident #6. The findings included: 1. Resident #3 was admitted to the facility on [DATE] with a readmission date of 12/14/16. Diagnoses for Resident #3 included but not limited to, quadriplegia (1) and pressure ulcer (2). The most recent Minimum Data Set with an assessment reference date of 4/12/17, coded Resident #3 with a score of 13 out of possible 15 on the Brief Interview for Mental Status (BIMS), indicating an intact cognitive abilities for daily decision making. Resident #3 was assessed as at risk for pressure ulcer with a history of pressure ulcers. On 7/12/17, during the clinical record review, Resident #3's Treatment Administration Records (TAR) for May 2017, June 2017, and July 2017 were missing nursing documentation for treatments ordered. The nurses' initials that indicate…

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 and staff interviews the facility staff failed to promote care to maintain or enhance the dignity for 1 out of 30 residents (Resident #14) in the survey sample. The facility staff failed to provide Resident #14 with a clothing protector during lunch. The findings included: Resident #14 was admitted to the facility on [DATE]. Diagnosis for Resident #14 included but not limited to *GERD (gastroesophageal reflux disease) and *Morbid Obesity. Resident #14 is a new admission and does not currently have a completed MDS assessment. Resident #14's admission Data Collection Form revealed the following information under Cognitive/Communication/Mood & Behavior: no problems with short or long term memory loss. On 07/12/17 at approximately 12:25 p.m., during observation in the main dining room during lunch, Resident #14 was observed with a sheet covering her upper chest while eating her lunch. An interview was conducted with Resident #14 who stated, I would rather have a protector over my…

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 quarterly Minimum Data Set (MDS) assessments were completed no less than once every 3 months for 1 of 30 residents (Resident #20) in the survey sample. The findings include: Resident #20 was admitted on [DATE] with a diagnoses of stroke and diabetes mellitus. The most recent Minimum Data Set (MDS) assessment that was submitted to the National Data Base, Centers for Medicare and Medicaid was dated 1/23/17, a Significant Change in Status Assessment. This was the last assessment completed for the Resident per review of the MDS 3.0 Missing OBRA (Omnibus Budget Reconciliation Act) Assessment Report. During an interview with the MDS Coordinator on 7/11/17 at 4:30 p.m., it was brought to her attention the resident was listed on the 3.0 Missing OBRA assessment Report that identified the last assessment submitted to the National Data Base was dated 1/23/17. She stated she was not aware of this status and would have to investigate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review and facility document review, the facility staff failed to ensure resident assessments were accurate and/or complete for 3 of 30 sampled residents (Residents #16, Resident #10, and Resident #11). 1. The facility staff failed to accurately code Section O0100J (Dialysis (1)) under Special Treatments, Procedures, and Programs for Resident #16. 2. The facility staff failed to accurately code section C under Cognitive Pattern (Brief Interview for Mental Status - BIMS) and section J under Health Condition (Pain) for Resident #10. 3. The facility staff failed to accurately code section B under (Hearing, Speech and Vision) for Resident #11. The findings included: 1. Resident #16 was admitted to the facility on [DATE] and was readmitted on [DATE]. Diagnoses for Resident #26 included but not limited to, high blood pressure and end stage renal disease (2). The most recent MDS (Minimum Data Set) with an assessment reference date of 6/23/17, coded Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, the facility staff failed to develop a Comprehensive Resident-Centered Plan of Care based on the Care Area Assessments triggered by the MDS (Minimum Data Set) for 3 of 30 sampled residents (Residents #1, Resident #4 and Resident #6). 1. The facility staff failed to develop a Comprehensive Resident-Centered Care Plan for 6 out of 9 Care Area Assessments triggered by the MDS for Resident #4. 2. The facility staff failed to revise the Comprehensive Care Plan to show evidence for Care Plan Interventions for all CAAs (Care Area Assessments) triggered by the MDS (Minimum Data Set) for Resident #1. 3. The facility staff failed to revise the Comprehensive Care Plan to show evidence for Care Plan Interventions for all CAAs (Care Area Assessments) triggered by the MDS (Minimum Data Set) for Resident #6. The findings included: 1. Resident #4 was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. Diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility document review the facility staff failed to provide the appropriate care and services to prevent complications for the use of a Foley catheter for 1 of 30 residents in the survey sample, Resident #7. The facility staff failed to ensure the Foley catheter tubing was anchored and secured properly and failed to implement appropriate infection control practices during the change of the Foley catheter leg bag for Resident #7. The findings included: Resident #7 was admitted to the facility on [DATE]. The resident's current diagnoses included, but not limited to Alzheimer's and a stage 3 pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon, or muscle is not exposed). The current MDS (Minimum Data Set) a quarterly with an assessment reference date of 4/17/17 coded the resident as scoring a 00 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating the resident had severely impaired…

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, facility documentation review, staff interviews and clinical record review the facility staff failed to implement interventions to reduce a potential accident hazard for 1 Resident (Resident #1) of 30 residents in the survey sample. The findings included: Resident #1 was admitted to the facility on [DATE]. Diagnoses for Resident #1 included but are not limited to Non-Alzheimer's Dementia, Malnutrition and Stage IV Right Heel Pressure Ulcer. Resident #1's Minimum Data Set Quarterly assessment (MDS-an assessment protocol) with an Assessment Reference Date of 6/26/17 coded Resident #1 with a BIMS (Brief Interview for Mental Status) of 1 of 15 indicating severe cognition impairment. In addition the MDS scored Resident #1 as requiring total dependence with 2 staff persons for Transfers. Resident #1 was coded as requiring total dependence with one staff person assistance for Dressing, Hygiene, and Bathing. During an observation of wound care for Resident #1 on 7/12/17 at approximately 3:20 p.m.,…

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 reviews and staff interview the facility failed to ensure that its medication error rates were not 5% or greater. A medication administration observation pass was conducted to include 27 opportunities, with 2 medication errors resulting in a 7.40% error rate, involving 2 residents, Residents #18 and #19. 1. The nurse failed to shake the drug Megace (an appetite stimulant) that was in a liquid suspension form for Resident #18 prior to administration. 2. The nurse failed to administer a 20 mEq (milieu) potassium tablet before dinner as ordered for Resident #19. The findings included: 1. Resident #18 was admitted to the facility on [DATE] with diagnosis to include, but not limited to vascular dementia. The current MDS (Minimum Data Set) a quarterly with an assessment reference date of 6/16/17 coded the resident as scoring a 00 out of a possible 15 on the brief interview for mental status indicating the resident cognition was severely impaired. A physician telephone order dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, the facility staff failed to ensure 1 of 30 sampled residents (Resident #24) was free of significant medication error. The facility staff failed to administer Resident #24's medications according to the times ordered by the physician. The findings included: Resident #24 was admitted to the facility on [DATE] and was readmitted on [DATE]. Diagnoses for Resident #24 included but not limited to, high blood pressure and diabetes mellitus (1). The most recent Minimum Data Set with an assessment reference date of 5/31/17, assessed Resident #24 with a score of 14 out of possible 15 on the Brief Interview for Mental Status (BIMS), indicating Resident #24's cognitive abilities for daily decision making are intact. On 7/13/17, Resident #24's clinical record review was conducted. The Physician Order Review Report documented the following orders: a. Humalog Solution 100 unit/ml (milliliter). Inject 8 units subcutaneously (4) with meals related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review the facility staff failed to ensure medications were acquired to meet the needs of 1 of 30 residents in the survey sample, Resident #19. The facility staff failed to ensure Potassium Chloride 20 mEq (milliequivalent) was available for administration as ordered for Resident #19. The findings included: Resident #19 was admitted to the facility on [DATE] with diagnoses to include, but not limited to hypo-osmolality(1) and hyponatremia (low sodium). The current MDS (Minimum Data Set) a a quarterly with an assessment reference date of 4/11/17 coded the resident as scoring a 9 out of a possible 15 on the Brief Interview for Mental Status, indicating the resident had moderately impaired daily decision making skills. The physician order dated 5/19/17 instructed the staff to administer Potassium Chloride Crystals 20 mEq by mouth with meals related to hypo-osmolality and hyponatremia. The medication was scheduled to be administered at 8 am, 12 pm and 6 pm…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on general observations of the nursing facility, the facility failed to ensure medications (Purified Protein Derivative) PPD-Aplisol was stored in a secured location and to ensure a medication label of a resident's drug was accurate for 1 out of 30 residents (Resident #18) in the survey sample. 1. The facility staff failed to ensure medication medications (Purified Protein Derivative) PPD-Aplisol was stored in a secured location, on 1 out of 2 units, Unit 2. 2. The facility staff failed to ensure that the medication label in response to an order change was accurate for Resident #18's Megace suspension. The findings included: 1. On 7/13/17 at approximately 9:30 a.m., during general observations with the maintenance director, an open multi-dose vial of PPD (for tuberculosis testing) solution was observed sitting on top of the treatment cart on Unit 1 unattended. An interview was conducted with Licensed Practical Nurse (LPN) #3 on 07/13/17 at approximately 9:35 a.m., who stated I'm just getting to work but…

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.