Beaufont Health And Rehabilitation Center

Based on staff interview, and clinical record review, the facility failed to provide care and services necessary to maintain good grooming for one resident (Resident # 6) in a survey sample of 50 residents. Findings included: For Resident # 6, the facility staff failed to provide grooming/nail care resulting in fingernails over 1/2 inch long on contracted hands. Resident # 6 was admitted to the facility in April 2024 with diagnoses that included but were not limited to: Dementia, contractures and sepsis. Resident #6's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 04/12/2024 was a quarterly assessment. The MDS coded Resident # 6 with a BIMS (Brief Interview for Mental Status) score of 10 out of 15, indicating moderate cognitive impairment. The MDS coded Resident # 6 as requiring extensive to total staff assistance with Activities of Daily Living. Resident # 6 was coded as incontinent of bowel and bladder. Review of the clinical record was conducted 5/7/2024-5/14/2024. Review of the ADL documentation report for April 2024 and May 2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility documentation review and clinical record review, the facility staff failed to provide treatment and services for pressure wounds for two Residents (Residents # 6 & # 87) in a survey sample of 50 Residents. 2. For Resident #87, the facility staff failed to administer wound care according to physician orders. The Findings Included: 1. For Resident #6, the facility staff failed to provide nail care to reduce the risk of development of new pressure wounds in the palms of the hands and failed to consistently provide treatments for pressure wound care per physician orders. Resident # 6 was admitted to the facility in April 2024 with diagnoses that included but were not limited to: Dementia, contractures and sepsis. Resident #6's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 04/12/2024 was a quarterly assessment. The MDS coded Resident # 6 with a BIMS (Brief Interview for Mental Status) score of 10 out of 15, indicating moderate…

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 documentation review, and clinical record review, the facility staff failed to provide respiratory care and services to maintain the highest practicable wellbeing for one resident, (Resident #40) in a survey sample of 50 residents, . The findings included: For Resident #40, the facility staff failed to assess and monitor the Resident's oxygen saturation and titrate oxygen administration to meet the needs of the Resident. Further, oxygen treatment orders were unclear, not followed, and not care planned for nursing staff guidance. Resident #40 was originally admitted to the facility on [DATE]. The Resident went out to the hospital on 3-19-24 with acute hypoxia, and returned on 4-10-24 to the facility with diagnoses including; Acute and chronic respiratory failure with hypoxia, muscle weakness, chronic obstructive pulmonary disease (COPD), acute pulmonary edema, morbid obesity, asthma, iron deficiency anemia, diabetes, and shortness of breath. Resident #40'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 in information obtained during the sufficient and competent nurse staffing task, the facility staff failed to staff a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week which could potentially affect all residents. The findings included; During the nursing staff review from June 2022 through May 2024. The facility staff was unable to verify RN coverage for at least 8 consecutive days on the following dates for eleven (11) days: 7/03/23, 7/04/23, 7/05/23, 7/08/23,7/16/23, 8/05/23, 8/06/23, 9/09/23, 9/10/23, 10/15/23, and 10/22/23. The above dates were verified by the scheduling coordinator on 5/14/24 at approximately 11:30 AM. On 5/14/24 at approximately 3:30 p.m., the above findings were reviewed with the Administrator, Director of Nursing and Regional Nurse Consultant. The administrator said that coverage should have been provided.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Staff interview, clinical record review, and facility document review, the facility failed to provide medications as ordered by a physician for one (Resident #179) in a survey sample of 50 residents. The findings included: 1. For Resident #179, Intravenous (IV) Antibiotics were unavailable during an acute post operative infection. Resident #179, was admitted to the facility on [DATE] at 6:30 PM, and discharged on 1-29-24 after 8:00 AM. Diagnoses included; After care following joint replacement surgery, infection due to right knee internal prosthetic, hypertension, hyperthyroidism, obesity, and gastroesophageal reflux disease (GERD). Resident #179's most recent MDS (minimum data set) with an ARD (assessment reference date) of 1-29-24 was coded as a discharge assessment. Resident #179 was coded as having no cognitive impairment. Resident #179 was also coded as requiring supervision or limited dependence on one staff member to perform activities of daily living, such as hygiene, transferring, and bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to prevent significant medication errors for one Resident (Residents #179) in a survey sample of 50 Residents. The findings included: For Resident #179, the facility staff failed to administer Intravenous (IV) antibiotics after an infection from a status post knee replacement with acute hospitalization follow up for the post operative infection. Resident #179, was admitted to the facility on [DATE] at 6:30 PM, and discharged on 1-29-24 after 8:00 AM. Diagnoses included; After care following joint replacement surgery, infection due to right knee internal prosthetic, hypertension, hyperthyroidism, obesity, and gastroesophageal reflux disease (GERD). Resident #179's most recent MDS (minimum data set) with an ARD (assessment reference date) of 1-29-24 was coded as a discharge assessment. Resident #179 was coded as having no cognitive impairment. Resident #179 was also coded as requiring supervision or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility documentation review, and clinical record review and in the course of a complaint investigation, the facility staff failed to provide multiple care and services in accordance with professional standards and according to physician orders for two Residents (Resident #259, #159) in a survey sample of 46 Residents. The findings included: 1a. For Resident #259 the facility staff failed to provide medications timely. On 5/22/22 and 5/23/22, a closed clinical record review was conducted. The physician orders and medication administration records (MAR's) were reviewed for Resident #259's entire stay at the facility, which was from November 2021, through February 2022. On 5/23/22, the facility staff provided Surveyor F with a listing of medication administration times for several specific days. Review of these documents revealed the following: * On 12/21/21, medications scheduled to be administered at 9 AM, were not administered until 4:10 PM. * On 1/8/22, medications scheduled to be…

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 failed to prevent significant medication errors regarding 4 medications for two Residents, (Resident #29 & #259) in a sample of 46 residents. The findings included; 1. For Resident #29, the Resident was given two doses of an anticoagulant significant drug, instead of the single dose ordered by the physician. Resident #29 was admitted to the facility on [DATE]. The Resident's diagnoses included atrial fibrillation, chronic ischemic heart disease, and valve replacement, requiring anticoagulant medication therapy. On Monday 5-23-22 at 8:00 a.m., during the Medication administration pour and pass observations with LPN (G), Resident #29's medications were observed while being prepared for administration, and was observed receiving those medications. The Resident was observed receiving 16 total medications to include the following medications of concern; Warfarin 5 milligrams (mg), and Warfarin 7.5 mg. both given…

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

Based on clinical record review, staff interview, and facility documentation review, the facility staff failed to conduct COVID-19 testing in accordance with the Centers for Disease Control and Prevention (CDC) guidance for 5 Residents, Residents #106, #69, #62, #104, and #310, in a sample of 8 Residents reviewed for new admission COVID-19 testing. The findings included: For Residents #106, #69, #62, #104, and #310, the facility staff failed to conduct COVID-19 testing upon their admission to the facility. On 5/23/22, a clinical record review was conducted and revealed no evidence of any COVID-19 testing for the previously referenced Residents. On 5/23/22 at approximately 2:30 PM, an interview was conducted with the facility Infection Preventionist (IP) who confirmed the facility conducts COVID-19 testing for all residents in accordance with CDC (Centers for Disease Control and Prevention) recommendations. The IP was asked about the facility's protocol for testing newly admitted residents for COVID-19 and she stated, all new admits are tested [for COVID-19] within 5-7 days 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.

Based on facility documentation review, and staff interview the facility staff failed to comply with the requirements of advanced directives for 4 out of 46 residents on 05/24/22. The findings included: For Residents #25, #66, #102, and #359 the facility failed to provide written information concerning the right to formulate an advanced directive. On 05/24/22, at approximately 1:30 p.m. a review of the electronic health record (EHR) for Residents #25, #66, #102, and #359 was conducted. The review noted that the record failed to contain Advanced Directives or written information about formulating an Advanced Directive. The facility's policy and procedures with an effective date 03/24/20 were reviewed. The policies read that documents of declaration for advance directives that are approved by state law (i.e. Living Wills, Durable Power of Attorney, appointments for anatomical gifts/organ donations) will be placed in the medical record as provided or legally designated agent/representative. On 05/24/22, at approximately 2:15 p.m., an interview with the Director of Nursing (DON was…

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

Based on Resident interview, family interview, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to prevent abuse for one Resident (Resident #71) in a sample size of 46 Residents. Specifically, a nurse aide left Resident #71 on the floor after a fall and closed the room door on 12/20/2021. The findings included: On 05/22/2022 at approximately 12:45 P.M., Resident #71 and a family member were interviewed by Surveyor E. When asked about any concerns, Resident #71 and the family indicated that Resident #71 had a fall recently and had to crawl out toward the room door to get help. The family member also stated that she was made aware the facility did an investigation and the staff member was terminated. On 05/23/2022 at approximately 9:30 A.M., the administrator was interviewed. When asked about any facility-reported incidents involving a staff member and [Resident #71], the administrator stated that the previous administrator did not conduct an investigation but when she herself learned…

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 Resident interview, family interview, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to report an allegation of abuse for one Resident (Resident #71) in a sample size of 46 Residents. The findings included: On 05/23/2022 at approximately 9:30 A.M., the administrator was interviewed. When asked about any facility-reported incidents involving a staff member and [Resident #71], the administrator stated that the previous administrator did not conduct an investigation but when she herself learned about the allegation of abuse [by adult protective services], she investigated it. The administrator also stated that there were inconsistencies in the Temporary Nurse Aide (TNA)'s story (TNA C) so she was terminated and no longer works at the facility. The administrator explained that TNA C denied working with [Resident #71] that day but the facility investigation revealed that TNA C did indeed work with Resident #71 that day. On 05/23/2022, Resident #71's clinical record was reviewed. A…

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

Based on observation, facility documentation review, and staff interview the facility staff failed to accurately code Resident #31's minimum data set at sections N0300 and N0350. The findings include: On 05/23/22, an electronic health record (EHR) review at approximately 2:00 p.m. of Resident #31's MDS was conducted. At sections N0300 (record the number of days that injections of any type were received during the last 7 days or since admission/entry or reentry if less than 7 days) and N0350 (record the number of days insulin injections were received during the last 7 days or since admission /entry if less than 7 days) were each coded as a 7. Subsequently, a record review of Resident #31's physician pharmacy orders in the EHR did not substantiate the MDS Coordinator's coding of 7 at N0300 and N0350. That is, there was no insulin order present in the EHR. On 05/23/22, at approximately 2:30 p.m., the MDS coordinator was interviewed. The MDS coordinator searched the referenced MDS at sections N0300 and N0350 in the EHR. As a result, the MDS coordinator verbally acknowledged both…

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, facility documentation review, and clinical record review and during the course of a complaint investigation, the facility staff failed to provide ADL assistance with regards to bathing/showering, for a Resident who was dependent upon staff to maintain personal hygiene, for one Resident (Resident #259) in a survey sample of 46 Residents. The findings included: On 5/22/22 and 5/23/22, a closed clinical record review was conducted. This review revealed Resident #259 scheduled shower days were, Wednesday and Saturdays. The clinical record revealed no evidence that Resident #259 was offered a shower on the following dates: 11/27/21, 12/15/21, 12/25/21, 12/29/21, 1/1/22, 1/15/22, 1/26/22, and 1/29/22. Review of Resident #259's MDS (minimum data set) (an assessment tool) coded the Resident as having required extensive assistance of on staff member for bathing. On 5/23/22, the facility staff provided the survey team with a shower schedule which did reveal Residents are scheduled for two baths/showers per week. On 5/23/22 at 1:46 PM, an interview was conducted…

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, clinical record review, and facility documentation review, the facility staff failed to provide an influenza vaccine for 1 resident out of 5 residents reviewed for influenza immunization. The findings included: The facility staff failed to provide influenza immunization for Resident #57. On 5/24/22, clinical record review was performed for Resident #57 and revealed the last documented influenza immunization occurred on 9/30/20. A physician's order dated 5/22/14 read, Flu Vaccine Annually as indicated. There was no documentation of the flu vaccine being offered, refused, contraindicated, or administered for 2021. An interview was conducted with the Director of Nursing who accessed the clinical records for Resident #57 and verified the findings. A facility policy on influenza immunization was requested and received. Review of the facility policy, effective date 2/6/20, entitled, Influenza & Pneumococcal Vaccinations, subheading Policy, read: Vaccination against influenza will be offered to Center patients and staff annually and subheading Procedure, item 1-c,…

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 employ staff with the skill sets to carry out the functions of the food and nutrition service. Facility failed to designate a person to serve as the director of food and nutrition services who is a certified dietary manager after one year of employment. The findings included: On 2/13/19 during a record review it was identified that Employee E was hired on 1/22/18. During interview with Employees D & E on 2/13/19 at 4:40 pm she stated I have not enrolled in a Certified Dietary Manager Course yet. During a staff interview with Employee D on 2/13/19, she provided the surveyor with a Serv Safe certificate and stated that the employee on the certificate, last day was yesterday, on 2/12/19. No other staff are Serv Safe Certified. The Administrator and Corporate Dietitian were notified of findings on 2/14/19.

Based on observation, staff interview and facility documentation review the facility staff failed to store and serve food in accordance with professional standards for food service safety. Facility staff failed to accurately monitor food temperatures, hold food at appropriate temperature, and reheat food to appropriate temperature. The findings included: On 2/12/19 at 8:35 AM, during observation of the walk-in freezer there were opened, uncovered, undated tortilla shells in freezer and hot dogs in freezer without an open date. During an interview the cook (employee H) stated if they were opened and undated, the items should be thrown away. During the observation of the walk-in cooler, grapes were noted in a zip lock bag (not in original packaging) without a date. The cook stated the date should have been written in the white writable area of the bag. Review of facility documentation of Freezer temperature logs revealed an employee had recorded freezer temperatures on 2/12/19 to be at 20 degrees Fahrenheit. The cook stated she recorded the temperature this morning and when asked, she…

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, facility records and staff interview the facility failed to maintain an effective pest control program. The facility had gnats flying throughout the kitchen and on clean dishes. The findings included: On 2/12/19 8:35am during the initial tour of the kitchen gnats were noted to be on cutting boards, gnats inside the open cover of clean food service cart with dishes and flying throughout the kitchen area. It was also observed to be multiple cups of vinegar sitting through the kitchen in hand washing areas, food prep areas and dish washing areas. An Interview with staff member E stated that the pest control representative comes regularly and due to the gnat problem he put out cups of vinegar. On 02/14/19 at 09:00 AM, observation of the kitchen gnats were observed on two cutting boards over the three compartment sink and on the serving utensils hanging over the 3 compartment sink. Multiple gnats were noted to be flying through the entire kitchen area and a bowl of food being prepared was on the food prep table uncovered. Review of facility records revealed that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, the facility staff failed to ensure a dignified experience for one resident (Resident # 308) in a survey sample of 38 residents. For Resident # 308, the facility staff was observed standing while feeding breakfast. Findings included: Resident #308, a [AGE] year old, was admitted to the facility on [DATE] for skilled nursing services. Diagnoses included but were not limited to: Epilepsy, dysphasia, hypertension, benign prostatic hyperplasia, Type 2 Diabetes. There was no Minimum Data Set assessment because it was too soon. In the admission assessment, Resident # 308 was assessed as having cognitive impairment and required assistance with activities of daily living to include eating. Resident # 308's physician orders signed 5/30/18 were reviewed. Included was an order dated 1/18/18 1:1 assist with meals. On 2/13/19 at 8:41 a.m., Resident #308 was observed in his room during the breakfast meal. The breakfast meal tray was on the over bed table…

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 staff interview, clinical record review, and facility documentation review, the facility staff failed for Resident #406 in a survey sample of 38 residents, to ensure the right to be informed of transportation arrangements. Resident #406's transportation to a medical office was not clarified to allow the responsible party (RP) to go with the resident. The findings included: Resident #406 was a resident of the facility but had no MDS (minimum data set-an assessment protocol) on the record. Review of the nurse's notes dated 11-15-17 revealed the resident had returned from the medical appointment on 11-15-17. There was no note as to the transfer time, date or how transferred in the medical record. On 2-13-19 at 3:45 PM, an interview was conducted with the discharge planner as the DON (director of nursing) or the unit manager named in the complaint no longer worked in the facility. The discharge planner remembered the event as she had talked with the unit manager when it happened. She stated that there was confusion as to whether the daughter was going to transport 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 staff interview and clinical record review, the facility failed to ensure her wishes for advance directives were recorded accurately for one resident (Resident #156) in a survey sample of 38 residents. Resident #156's advanced directives were not located on the electronic record or in the nurse's code book at the nurse's station. The findings included: Resident #156 was a resident of the facility. On 2-13-19 at 11:07 AM a review of the electronic clinical record revealed no orders for advanced directives. The NP (nurse practitioner) notes documented a no code status. Review of the care plan dated 2-5-19 documented Hospice orders for end of life care. On 2-14-19 at approximately 3:00 PM, the Corporate Nurse Consultant stated the nurse's use a book at the nurse's station to determine the resident's code status. On 2-14-19 at 3:31 PM An interview was conducted with LPN (licensed practical nurse- C), LPN C was asked how they determine someone's code status. LPN C stated, We look in the code book. However, the resident's code status was not listed in the book. On 2-14-19 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and resident and staff interview, the facility failed to ensure visual privacy for one resident, Resident #155, in a survey sample of 38 residents. Resident #155 was exposed during her bed bath. The findings included: Resident #155 was admitted to the facility on [DATE]. An MDS (minimum data set-an assessment protocol) had not been completed due to recent admission. The resident was alert and oriented to all spheres, she was noted to have contractures of all extremities, had a flat call alarm. The resident stated she had to have total care for her bath. During the initial interview, the resident voiced concerns her nether regions were not being cleaned sufficiently, especially around the catheter. On 2-13-19 at 9:25 AM, Resident #155's bathing was observed. The resident gown was removed, placed at the far end of the bed and during the entire bath, the resident was uncovered completely. There were four individuals in the room including two CNA's (certified nursing assistant), a Registered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility documentation review, and clinical record review, the facility staff failed to develop and implement a comprehensive person centered care plan for two Residents (Residents #93, and Resident #94, in a survey sample of 38 residents. 1. Resident #93 did not have a comprehensive care plan for activities and assistance with eating. 2. For Resident #94, the facility staff failed to develop an accurate, resident-centered care plan by including a leg brace intervention that was not ordered by the physician or recommended by occupational therapy. The findings included: 1. Resident #93 did not have a comprehensive care plan for activities and assistance with eating. Resident #93 was admitted to the facility on [DATE]. Diagnoses include dementia, chronic back pain requiring opioids, congestive heart failure and COPD (chronic obstructive pulmonary disease). Resident # 93's most recent quarterly Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of 1-25-19. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, resident interview and clinical record review, facility staff failed to provide Activity of Daily Living (ADL) assistance for 1 resident (Resident # 304) in a survey sample of 38 residents. For Resident #304, facility staff failed to provide morning care to include oral care prior to serving breakfast. The finding included: Review of the clinical record was conducted on 2/12/2019. Resident # 304, an [AGE] year old, was admitted to the facility on [DATE] for skilled services related to a right femur fracture. Diagnoses included Atrial Fibrillation, Hypertension, Coronary Artery Disease, History of Crohn's Disease, Irritable Bowel Syndrome and debility/weakness. There was no Minimum Data Set assessment done as it was not due at the time of survey. Review of the admission Nursing Assessment revealed Resident #304 was coded as having no cognitive impairment and required extensive assistance of one person assistance with activities of daily living to include eating. On 2/12/19…

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, record reviews, and facility documentation, the facility failed to assess and provide on-going resident-centered activities for one Resident (Resident #93) out of a sample of 38 residents. Resident #93 was observed to be in his room for 3 days without getting out of bed and with no meaningful activities provided. The findings included: Resident #93 was admitted to the facility on [DATE]. Diagnoses include dementia, chronic back pain requiring opioids, congestive heart failure and COPD (chronic obstructive pulmonary disease). Resident # 93's most recent quarterly Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of 1-25-19. Resident #93 did not have a Brief Interview of Mental Status (BIMS) score recorded but cognitive skills for daily decision-making were coded as moderately impaired. Resident #93 required extensive to total assistance of all ADL's (activities of daily living such as bed mobility) except for eating, in which she required supervision of one…

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, facility documentation and clinical record reviews, the facility staff failed to, for one Resident, Resident #93 of 38 residents in the survey sample, ensure interventions to prevent pressure ulcers were in place. Resident #93's orange service light was on through multiple observations and her heels were not elevated off the mattress. The findings included: Resident #93 was admitted to the facility on [DATE]. Diagnoses include dementia, chronic back pain requiring opioids, congestive heart failure and COPD (chronic obstructive pulmonary disease). Resident # 93's most recent quarterly Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of 1-25-19. Resident #93 did not have a Brief Interview of Mental Status (BIMS) score recorded but cognitive skills for daily decision-making were coded as moderately impaired. Resident #93 required extensive to total assistance of all ADL's (activities of daily living such as bed mobility) except for eating, in which she required…

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, family interview, staff interview, clinical record review, and facility documentation, the facility staff failed to provide intervention (wedge pillow) to prevent further decrease in range of motion for one Resident (Resident # 94) in a sample size of 38 residents. The findings include: Resident #94, a [AGE] year old female, was initially admitted to the facility on [DATE]. Diagnoses include but not limited to dementia, debility, depression, and anxiety. Resident #94's most recent Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of 12/27/2018 and was coded as an annual assessment. Resident #94 was not coded for a Brief Interview of Mental Status (BIMS) but cognitive skills for daily decision-making were coded as severely impaired. Functional status for dressing and personal hygiene was coded as requiring extensive assistance from staff. Functional limitation in range of motion in lower extremities was coded as impaired on both sides. On 02/12/19 at 01:24 PM, Resident #94 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview and clinical record review, the facility staff failed to, for one resident, Resident #155 in a survey sample of 38 residents, ensure the indwelling catheter was cleaned in a manner to prevent infection. Resident #155's catheter care was not performed appropriately (cleansed form back to front, bringing bacteria toward the catheter). The findings included: Resident #155 was admitted to the facility on [DATE]. An MDS (minimum data set-an assessment protocol) had not been completed due to recent admission. The resident had an indwelling catheter due to urinary retention. On 2-13-19 at 11:09 AM, an interview was conducted with the resident. Resident #155 was alert and oriented to all spheres, she was noted to have contractures of all extremities, had a flat call alarm. The resident stated she had to have total care for her bath. During the initial interview, the resident voiced concerns her nether regions were not being cleaned sufficiently, especially around the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility documentation review and clinical record review, the facility staff failed to provide a physician ordered nutritional supplement, and failed to implement interventions for further weight loss for one resident (Resident #93) of 38 residents in the survey sample. Resident #93 did not receive her supplements or whole milk, did not receive her substitute meal cut into bite sized pieces and did not receive supervision for her meals. The findings included: Resident #93 was admitted to the facility on [DATE]. Diagnoses include dementia, chronic back pain requiring opioids, congestive heart failure and COPD (chronic obstructive pulmonary disease). Resident # 93's most recent quarterly Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of 1-25-19. Resident #93 did not have a Brief Interview of Mental Status (BIMS) score recorded but cognitive skills for daily decision-making were coded as moderately impaired. Resident #93 required extensive to total assistance of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility and clinical record documentation, the facility staff failed to, for one resident, Resident #60, in a survey sample of 38 residents, provide respiratory care and services to maintain the highest practicable wellbeing. Resident #60's filter for the oxygen concentrator was dusty. The findings included: Resident #60 was admitted to the facility on [DATE]. Diagnoses include dementia, COPD (chronic obstructive pulmonary disease), anemia and coronary artery disease. Resident # 60's most recent quarterly Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of 1-4-19. Resident #60's Brief Interview of Mental Status (BIMS) score was 10 out of a possible 15, or mild cognitive impairment. Resident #60 required set up assistance of all ADL's (activities of daily living such as bed mobility). The resident was coded as using oxygen in the past 7 days. On 2-12-19 at 10:34 AM, during an observation, the resident was observed receiving 2 liters of oxygen by a nasal…

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 interview, the facility failed to ensure food was served at a palatable temperature for two Residents (Resident #304, #305) in a sample size of 38 residents. 1. For Resident # 304, the facility staff failed to provide a hot breakfast on 2/12/19 and 2/13/19. 2. For Resident #305, the pizza was cold. The findings included: 1. For Resident # 304, the facility staff failed to provide a hot breakfast on 2/12/19 and 2/13/19. Resident # 304, an [AGE] year old, was admitted to the facility on [DATE] for skilled services related to a right femur fracture. Diagnoses included Atrial Fibrillation, Hypertension, Coronary Artery Disease, History of Crohn's Disease, Irritable Bowel Syndrome and debility/weakness. There was no Minimum Data Set assessment done as it was not due at the time of survey. Review of the admission Nursing Assessment revealed Resident #304 was coded as cognitively intact, continent of bowel and bladder and required assistance with activities of daily living. He…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility documentation review, clinical record review, the facility staff failed to provide a therapeutic diet for 2 residents (Residents #93, and #91), in a survey sample of 38 residents. 1. Resident #93 did not receive her diet as ordered to include whole milk and minced foods. 2. Resident #91 did not receive minced green beans. Resident was observed to be coughing during her meal. The findings included: 1. Resident #93 did not receive her diet as ordered to include whole milk and minced foods. Resident #93 was admitted to the facility on [DATE]. Diagnoses include dementia, chronic back pain requiring opioids, congestive heart failure and COPD (chronic obstructive pulmonary disease). Resident # 93's most recent quarterly Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of 1-25-19. Resident #93 did not have a Brief Interview of Mental Status (BIMS) score recorded but cognitive skills for daily decision-making were coded as moderately impaired. Resident #93…

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.