Glenburnie Rehab & Nursing Center

Based on clinical record review and staff interview, the facility staff failed to develop a baseline care plan for one of 11 residents in the survey sample, Resident #103. The finding include:For R103, facility staff failed to develop a baseline care plan to address the use of a C-PAP (continuous positive airway pressure) machine (1). R103 was admitted to the facility with diagnosis that included but not limited to sleep apnea (2). The MDS (minimum data set) assessment was not due at the time of the survey. The facility's admission assessment for R103 dated 12/08/2025 documented in part, Cognitively intact. Oriented to person. Oriented to place. Oriented to situation.On 12/09/2025 at approximately 2:11 p.m. an observation of R103's room revealed a C-PAP machine and mask on R103's over-the-bed table.The facility's nurse's note for R103 dated 12/08/2025 at 8:50 p.m. documented in part, Use of CPAP/BiPAP (bilevel continuous positive airway pressure): Yes.The discharge summary from (Name of Hospital) documented in part, Details of Hospital Stay. Sleep - CPAP.Review of the baseline care…

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

Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement the care plan for one of eight residents in the survey sample, Resident #2.The findings include:For Resident #2 (R2), the facility staff failed to implement the resident's care plan regarding pressure injuries (1).A review of ASM (administrative staff member) #3's, the wound nurse practitioner's, progress note dated 9/18/25 revealed, in part: Date of Service: 9/16/25.Sacrum.Stage 2 (2) (present on admission).Treatment Recommendations: 1. Cleanse with wound cleanser. 2. Apply Manuka HD Super Lite (3) to base of the wound. 3. Secure with silicone bordered superabsorb. Change daily and PRN (as needed).Wound 6 Location: Right heel. Primary etiology: Pressure Ulcer/Injury. Stage/Severity: DTI (deep tissue injury) (4).Present on admission.Treatment Recommendations: 1. Cleanse with wound cleanser. 2. Apply Skin Prep to base of the wound. 3. Leave open to air. 4. Change daily and PRN.Recommend floating heels.air mattress.A review of R2's September 2025 TAR (treatment…

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 document review, and clinical record review, the facility staff failed to provide ADL (activities of daily living) care to a dependent resident for one of eight residents in the survey sample, Resident #1.The findings include:For Resident #1 (R1), the facility staff failed to bathe the resident on two days in October 2025.On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 10/15/25, the resident was coded as being completely dependent on facility staff for bathing/showering.A review of R1's October 2025 point of care records revealed no evidence that he received a shower or a bath on 10/12/25 and 10/13/25. This review revealed no evidence that the resident refused being bathed on either of these days.On 10/29/25 at 10:07 a.m., CNA (certified nursing assistant) #1 was interviewed. She stated she bathes every resident assigned to her each and every morning. She stated this is simply part of her job of taking care of the residents. She stated she wants to bathe every day and her residents…

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

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide incontinence care for one of eight residents in the survey sample, Resident #4.The findings include:For Resident #4 (R4) the facility staff failed to provide incontinence care on 10/28/25 from 10:07 a.m. through 5:30 p.m.On 10/28/25 a.m., R4 was observed without interruption from 10:07 a.m. until 5:30 p.m. During this time, R4 was sitting in her wheelchair. A staff member moved her from her room to the day room at 10:10 a.m. Following the move to the day room, the resident was moved by staff back and forth between the day room, activities room, and dining room. This observation was continuous with no interruptions. At no time did any staff member wheel the resident back to her room to provide incontinence care.On R4's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/9/25, she was coded as being severely cognitively impaired for making daily decisions, having scored only two out of 15 on the 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 resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to implement a complete pain program for one of eight residents in the survey sample, Resident #2.The findings include:For Resident #2 (R2), the facility staff failed to treat a resident's report of severe pain on [DATE].R2 was admitted to the facility on [DATE] with a history of fractures in the left hip, and right leg. On admission the resident was documented to have recent surgical wounds on both knees.On the following dates and times, R2 was observed in her room and was both alert and conversant: [DATE] at 1:54 p.m. and 4:19 p.m.; [DATE] a.m. at 9:03 a.m.; and [DATE] at 8:15 a.m. At each observation, the resident reported pain in her knees. She stated the staff usually treated her pain effectively, but that she had experienced severe pain once or twice that the medication did not help.A review of R2's progress notes revealed the following note dated [DATE] at 11:57 p.m.: Patient c/o…

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 document review, and clinical record review, the facility staff failed to provide 24 hour on-call physician services for one of eight residents in the survey sample, Resident #3.The findings include:For Resident #3 (R3), the facility staff failed to provide on-call physician services on 10/21/25 when a critical laboratory test result was communicated to the nursing staff.A review of R3's clinical record revealed the following progress note dated 10/21/25 at 1:10 a.m Critical lab called in from lab. Potassium 2.9 (1). Contacted on call physician to make aware. No call returned. 0145AM (1:45 a.m.) Contacted on call physician again, no returned call. 0658 (6:58 a.m.), no call returned, will have nurse follow-up with physician.On 10/29/25 at 7:54 a.m., ASM (administrative staff member) #4, the regional director of clinical operations, was interviewed. She stated the facility nurses should always be able to reach an on-call physician. She explained that if the nurses cannot reach an on-call physician in a reasonable amount of time, the medical director…

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 it was determined that the facility staff failed to maintain a complete and accurate record for two of 11 residents in the survey sample, Residents #101 and Resident #109. The findings include:1. For Resident #101 (R101), the facility staff failed to document the eMAR (electronic medication administration record) that the medication, Protonix (1), was administered. R101 was admitted to the facility with diagnosis that included but were not limited to gastro-esophageal reflux disease (2). On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/09/2025, R101 scored 2 (two) out of 15 on the BIMS (brief interview for mental status), indicating R101 was severely impaired of cognition for making daily decisions. The physician's order for R101 documented in part, Protonix Tablet Delayed Release 40 MG (milligrams) (Pantoprazole Sodium). Give 1 (one) tablet by mouth one time a day for gastritis Order Date:10/7/2025. 0630 and 1630 (6:30 a.m. and 4:30 p.m.) The facility's…

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

Based on staff interview and facility document review, the facility staff failed to implement an effective QAPI (quality assurance and performance improvement) program for one of one facility. The findings include: The facility staff failed to ensure their 3/28/25 QAPI plan regarding a fire incident was effective. The facility staff failed to ensure a resident who smoked utilized a lock box for her smoking materials and failed to ensure staff were knowledgeable regarding the education documented in the plan. An initial facility synopsis of events submitted to the SA (state agency) on 3/28/25 documented, Incident date: 3/28/2025. Residents involved: (R1) (R2). Resident [R1] lit a roll of toilet paper on fire in his bathroom. Staff extinguished the fire with water and dropped the paper roll in the toilet. Fire department alert [sic] and arrived to building. A QAPI plan dated 3/28/25 documented, PROBLEM: On 3/29/25 [sic] staff observed a fire in the bathroom of room (room number). F689. Immediate Response-what was done at the time. Both residents in the room were safely evacuated. 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 staff failed to evidence agreements for contractual services for one of one facility. The findings include: The facility staff failed to maintain agreements for services with the contracted podiatry company and contracted eye care company. A review of the facility contracts failed to reveal agreements for services with the contracted podiatry company and the contracted eye care company. On 4/22/25 at approximately 8:55 a.m., ASM (administrative staff member) #2 (the director of nursing) presented service agreements for a podiatry company and an eye care company. The agreements were dated 4/21/25 and were not signed by a facility representative. On 4/22/25 at 10:36 a.m., an interview was conducted with ASM #1 (the administrator). ASM #1 stated that when services are initiated with an outside company, she has the company sign an agreement and places the agreement in a contract binder. ASM #1 stated the facility began services with the podiatry company and eye care company before her employment at the facility. On…

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

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide timely physician visits for one of nine residents in the survey sample, Resident #5. The findings include: For Resident #5 (R5), the facility staff failed to provide physician visits every sixty days. A review of R5's clinical record revealed physician visits on 4/22/24 and 7/16/24. The review revealed no physician visits between these two dates. On 4/22/25 at 8:45 a.m., ASM (administrative staff member) #2, the director of nursing, was interviewed. She most residents need to be seen quarterly, with the exception of residents receiving skilled nursing services. She stated the facility's providers are diligent about timely visits. She stated R5 saw two outside providers between 4/22/24 and 7/16/24 but was not seen by a facility physician. On 4/22/25 at 10:36 a.m., ASM #1, the administrator, was informed of these concerns. A review of the facility policy, Physician Visits, revealed, in part: Each patient will be seen by a physician upon admission .Patients will then 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 4.The facility staff failed to meet professional standards by administering medications timely for R5. R5 was admitted to the facility on [DATE] with diagnosis that included but were not limited to acute myeloblastic leukemia in relapse, bone marrow transplant, CHF (congestive heart failure) and renal insufficiency. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 2/3/25, coded the resident 15 out of 15 on the BIMS (brief interview for mental status) score indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring max assist for bed mobility/transfers/bathing/dressing/toileting and supervision for eating. A review of the comprehensive care plan dated 2/7/25/24 revealed, FOCUS: GENERAL INFECTION: Resident is on long term medication due to AML (acute myeloblastic leukemia). INTERVENTIONS: Medications as ordered. Labs and diagnostics as ordered. A review…

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

Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to monitor/follow medication administration orders to prevent unnecessary medications for two of 13 residents in the survey sample, Residents #8 and #2. The findings include: 1. For Resident #8 (R8), the facility staff failed to monitor blood pressures prior to administration of Carvedilol as ordered. On 3/25/25 at 10:49 a.m., an observation was made of LPN (licensed practical nurse) #4 administering medications to R8 in their room. LPN #4 was observed preparing medications which included Carvedilol 12.5mg one tablet into a medication cup and was observed to administer the medication to R8. No blood pressure was obtained prior to administration of the medication. The physician orders for R8 documented in part, Carvedilol Tablet 12.5 MG Give 1 tablet by mouth two times a day for HTN (hypertension) Hold for SBP (systolic blood pressure) less than 110 and notify [Name of hospice]. Order Date: 02/26/2025. Review of the eMAR (electronic medication…

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

Based on observation, resident interview, staff interview and clinical record review, it was determined that facility staff failed to promote resident's dignity for one of 13 residents in the survey sample, Resident #10 (R10). The findings include: For R10, facility staff failed to maintain the room and bathroom in a dignified condition. On the MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 09/11/2024, R10 scored 8 (eight) out of 15 on the BIMS (brief interview for mental status), indicating R10 was moderately impaired of cognition intact for making daily decisions. On 03/25/2025 at approximately 12:55 p.m., an observation of R10's room revealed R10 was not in the room. Observation of R10's bathroom revealed approximately 14 holes in the linoleum flooring ranging in size from approximately one-and-a-half inches up to six inches in length and a half inch up to three inches in width. Observation of the flooring also revealed it curling away from the wall under the sink and behind the toilet and multiple cuts throughout the flooring. Further…

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 and clinical record review, it was determined that facility staff failed to maintain the resident's bathroom and room in a homelike environment for one of seven current residents in the survey sample, Resident #10 (R10). The findings include: For R10, facility staff failed to maintain the room and bathroom in a homelike environment. On the MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 09/11/2024, R10 scored 8 (eight) out of 15 on the BIMS (brief interview for mental status), indicating R10 was moderately impaired of cognition intact for making daily decisions. On 03/25/2025 at approximately 12:55 p.m., an observation of R10's room revealed R10 was not in the room. Observation of R10's bathroom revealed approximately 14 holes in the linoleum flooring ranging in size from approximately one-and-a-half inches up to six inches in length and a half inch up to three inches in width. Observation of the flooring also…

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/resident interviews, facility document review and clinical record review, it was determined the facility staff failed to implement the care plan for one of 13 residents in the survey sample, R5. The findings include: The facility staff failed to implement the comprehensive care plan for AML (acute myeloblastic leukemia) medication administration for R5. R5 was admitted to the facility on [DATE] with diagnosis that included but were not limited to acute myeloblastic leukemia in relapse, bone marrow transplant, CHF (congestive heart failure) and renal insufficiency. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 2/3/25, coded the resident 15 out of 15 on the BIMS (brief interview for mental status) score indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring max assist for 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.

Based on observation, resident interview, clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to review and/or revise the care plan for three of 13 residents in the survey sample, Residents #12, #7 and #2. The findings include: 1. For Resident #12 (R12), the facility staff failed to revise the comprehensive care plan to reflect hospice care. The physician orders for R12 documented in part, - Do Not Send to ER (emergency room) Call [Name of Hospice/phone number] every shift for Hospice per [Name of hospice physician/registered nurse]. Order Date: 03/06/2025. - Hospice Consult for End Stage Disease. Do not hospitalize. No labs. Order Date: 03/07/2025. - No Labs No Diagnostic Testing every shift for per [Name of hospice physician and registered nurse]. Order Date: 03/06/2025. The comprehensive care plan for R12 documented in part, The resident has an advance directive of DNR (do not resuscitate). Created on: 01/22/2025. Revision on: 01/29/2025. The care plan failed to reflect hospice care. On 3/25/25 at 4:01 p.m., an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care and services to promote a resident's highest level of well-being for two of 13 residents, R6 and R2. The findings include: 1. The facility failed to administer treatments as ordered, specifically blood glucose checks and insulin administration for R6. R6 was admitted to the facility on [DATE] with diagnosis that included but were not limited to muscular dystrophy, DM (diabetes mellitus) and CHF (congestive heart failure). The most recent MDS (minimum data set) assessment, a discharge assessment, with an ARD (assessment reference date) of 12/29/24, did not code the resident on the BIMS (brief interview for mental status) score. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for bed mobility/transfers/bathing/dressing/toileting and supervision for eating. A review of the comprehensive care plan dated 12/28/24 revealed, FOCUS:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide a safe environment by monitoring and implementing fall prevention measures for two of 13 residents, R6 and R7. The findings include: 1.During the abbreviated complaint survey 3/25/25 through 3/27/25 review of the facility event synopsis, the fall or R6 was reviewed. R6 was admitted to the facility on [DATE] with diagnosis that included but were not limited to muscular dystrophy, DM (diabetes mellitus) and CHF (congestive heart failure). The most recent MDS (minimum data set) assessment, a discharge assessment, with an ARD (assessment reference date) of 12/29/24, did not code the resident on the BIMS (brief interview for mental status) score. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for bed mobility/transfers/bathing/dressing/toileting and supervision for eating. A review of the facility's nursing admission /…

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 document review, it was determined that the facility staff failed to provide food in a form to meet resident needs for one of 13 residents in the survey sample, Resident #2. The findings include: For Resident #2 (R2), the facility staff failed to communicate a diet change order in a timely manner. The physician orders for R2 documented in part, - Regular diet Regular texture, Thin Liquids consistency. Order Date: 11/21/2024. - Regular diet Dysphagia Mechanically Altered texture, Thin Liquids consistency. Order Date: 11/25/24. The dietary communication form for R2 documented the diet change to the dysphagia mechanically altered texture. The communication form was dated 11/30/24. On 3/26/25 at 11:45 a.m., an interview was conducted with OSM (other staff member) #3, dietary manager. OSM #3 stated that the nurses communicated any diet change orders to them through the dietary communication forms. She stated that the nurse wrote out the communication form, brought it down to her and she entered it into the dietary management…

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 document review, and clinical record review, it was determined the facility staff failed to notify the physician and responsible party that a medication was not available for administration for one of ten residents in the survey sample, Resident #2. The findings include: For Resident #2, the facility staff failed to notify the physician and the responsible party when Flonase was not available for administration. The physician order dated, 12/17/24, documented, Flonase Allergy Relief Nasal Suspension 50 MCG/ACT (micrograms per activation) (Fluticasone Propionate) 2 sprays in each nostril one time a day for nasal. The January 2025 MAR (medication administration record) documented the above order. On 1/12/25 and 1/13/25 a 9 was documented in the space for administration. A 9 indicates Other/ See progress notes. On 1/14/25, the block for documenting the administration of the medication was blank. 1/12/25 at 3:15 p.m. The nurse's notes documented, Medication has been ordered. 1/13/25 at 3:15 p.m. The nurse's note documented, Medication has been ordered,…

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 document review, it was determined that the facility failed to protect two of ten residents in the survey sample from verbal abuse by a staff member, Residents #9 and #10. The findings include: For Resident #9 (R9) and Resident #10 (R10), the facility staff failed to ensure that they were free from verbal abuse from LPN (licensed practical nurse) #11 on 12/14/24. Review of a facility synopsis of events dated 12/14/24 documented in part, Residents involved: [Name of Resident #4, #9 and #10] .Supervisor reported employee [Name of LPN #11]. Supervisor stated that [Name of LPN #11] arrived to work and presented as belligerent and intoxicated. The nurse was observed screaming at the above residents, and when he was asked to leave the building, he mentioned that he had over medicated resident [Name of Resident #4] . Employee action initiated or taken: Employee was immediately removed from property and suspended pending investigation. The police was called to report the incident and for assistance with removing the employee from…

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

Based on staff interview, clinical record review and facility document review, it was determined that the facility failed to implement their abuse policy to protect two of ten residents in the survey sample from verbal abuse by a staff member, Residents #9 and #10. The findings include: For Resident #9 (R9) and Resident #10 (R10), the facility staff failed to implement their abuse policy to ensure that they were free from verbal abuse from LPN (licensed practical nurse) #11 on 12/14/24. Review of a facility synopsis of events dated 12/14/24 documented in part, Residents involved: [Name of Resident #4, #9, and #10] .Supervisor reported employee [Name of LPN #11]. Supervisor stated that [Name of LPN #11] arrived to work and presented as belligerent and intoxicated. The nurse was observed screaming at the above residents, and when he was asked to leave the building, he mentioned that he had over medicated resident [Name of Resident #4] . Employee action initiated or taken: Employee was immediately removed from property and suspended pending investigation. The police was called 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 clinical record review, staff interview and facility document review, it was determined that the facility staff failed to evidence a complete investigation into an elopement for one of 10 residents in the survey sample, Resident #5. The findings include: For Resident #5 (R5), the facility staff failed to evidence a complete and thorough investigation of an elopement on 9/30/24. Review of a facility synopsis of events dated 9/30/24 for R5 documented in part, .Resident exited facility without supervision. Resident has been returned to the facility at this time without injury . The investigation folder contained an investigation summary dated 9/30/24 which documented in part, .Investigation Findings: Resident had been walking throughout the facility without incident at various times during the day and evening. During rounding, staff identified that they were unable to locate [Name of R5]. Resident was located outside of the facility and returned. Social Services continue to follow residents as indicated.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to implement the baseline care plan for one of nine residents in the survey sample, Resident #104. The findings include: For Resident #104 (R104), the facility staff failed to implement the baseline care plan to administer medications as ordred. Olanzapine (1) 20mg (milligram) ordered on 3/7/25 was not available for administration until 3/10/25. The MDS (minimum data set) was not due at the time of the survey. The admission nursing assessment for R104 dated 3/7/25 documented the resident being cognitively impaired and oriented to person only. The baseline care plan for R104 documented in part, Psychoactive Medications: the resident is at risk for complications related to psychoactive medication use. Created on: 03/07/2025. Revision on: 03/11/2025. Under Interventions it documented in part, administer medications as ordered. Created on: 03/07/2025 . The physician orders for R104…

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

Based on clinical record review, staff interview and facility document review, it was determined that the facility failed to review and/or revise the comprehensive care plan for two of ten residents in the survey sample, Residents #9 and #10. The findings include: 1. For Resident #9 (R9), the facility staff failed to review and revise the care plan as needed after a verbal abuse incident on 12/14/24. Review of a facility synopsis of events dated 12/14/24 for R9 documented in part, Residents involved: [Name of Resident #4, #9 and #10] .Supervisor reported employee [Name of LPN #11]. Supervisor stated that [Name of LPN #11] arrived to work and presented as belligerent and intoxicated. The nurse was observed screaming at the above residents, and when he was asked to leave the building, he mentioned that he had over medicated resident [Name of Resident #4] . Employee action initiated or taken: Employee was immediately removed from property and suspended pending investigation. The police was called to report the incident and for assistance with removing the employee from the property .…

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, clinical record review and facility document review, it was determined that the facility staff failed to provide care and services to maintain a resident's highest level of well-being for one of 10 residents in the survey sample, Resident #4. The findings include: For Resident #4 (R4), the facility staff were made aware of a potential medication overdose on 12/14/24. The progress notes documented R4 being lethargic and responsive by sternal rub, however the nurse practitioner only gave telephone orders to continue to monitor the resident and the resident was taken to the emergency room via private vehicle at the family's discretion. On the most recent MDS (minimum data set), a five-day assessment with an ARD (assessment reference date) of 12/14/24, R4 scored 13 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were cognitively intact for making daily decisions. Review of a facility synopsis of events dated 12/14/24 documented in part, Residents involved: [Name of Resident #4, #9 and #10]…

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, and clinical record review, it was determined the facility staff failed to provide supervision to protect one of ten residents from a fire on 1/1/2025. The findings include: For Resident #1 (R1), the facility staff failed to put in interventions to prevent a fire. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date (ARD) of 11/20/24, the resident scored a four out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired for making daily decisions. On 1/15/25 at 10:05 a.m. An observation was made of (R1) He was sitting on the side of his bed, when asked if there had been a fire in his room recently, the resident stated, That wasn't me in that other room. The resident could not recall there being a fire in his room. On 1/15/25 at 10:15 a.m., An interview was conducted with Resident #2 (R2), R2 explained how he had been at the nurse's station…

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

Based on clinical record review, staff interview and facility document review, it was determined that the facility failed to provide medically related social services after a verbal abuse incident for one of 10 residents in the survey sample, Resident #10. The findings include: For Resident #10 (R10), the facility staff failed to evidence social service follow up after verbal abuse from LPN (licensed practical nurse) #11 on 12/14/24. Review of a facility synopsis of events dated 12/14/24 for R10 documented in part, Residents involved: [Name of Resident #4, #9 and #10] .Supervisor reported employee [Name of LPN #11]. Supervisor stated that [Name of LPN #11] arrived to work and presented as belligerent and intoxicated. The nurse was observed screaming at the above residents, and when he was asked to leave the building, he mentioned that he had over medicated resident [Name of Resident #4] . Employee action initiated or taken: Employee was immediately removed from property and suspended pending investigation. The police was called to report the incident and for assistance with removing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review it was determined the facility staff failed to ensure medications were available at the scheduled time of administration for one of ten residents in the survey sample, Resident #2. The findings include: For Resident #2, the facility staff failed to ensure, Flonase (used to treat allergies) was available for administration. The physician order dated, 12/17/24, documented, Flonase Allergy Relief Nasal Suspension 50 MCG/ACT (micrograms per activation) (Fluticasone Propionate) 2 sprays in each nostril one tine a day for nasal. The January 2025 MAR (medication administration record) documented the above order. On 1/12/25 and 1/13/25 a 9 was documented in the space for administration. A 9 indicates Other/ See progress notes. On 1/14/25, the block for documenting the administration of the medication was blank. The nurse's notes dated 1/12/25 at 3:15 p.m. documented, Medication has been ordered. The nurse's note dated 1/13/25 at 3:15 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.

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to ensure one of six residents in the survey sample was free of unnecessary medications, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to hold the Humalog insulin (1) as ordered when the resident's blood sugar was less than 150 twice in January 2024, three times in February 2024 and 16 times in March 2024. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 1/22/2024, the resident was assessed as having a diagnosis of Diabetes Mellitus and receiving insulin injections. The physician orders documented in part, Humalog KwikPen 100 UNIT/ML (milliliter) Solution peninjector Inject 4 unit subcutaneously before meals for DM2 (Type II Diabetes Mellitus) Hold for BS (blood sugar) less than 150. Order Date: 01/26/2024. Review of the eMAR (electronic medication administration record) for R1 dated 1/1/2024-1/31/2024 documented the Humalog insulin as documented in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility document review, the facility staff failed to maintain an operational resident call system for seven of 72 resident rooms. The findings include: For rooms 111A, 133A, 205B, 209B, 211B, 222B, and 230A, the facility staff failed to ensure the call system was properly functioning. On 5/13/24 at 1:11 p.m., an interview was conducted with OSM (other staff member) #1 (the director of maintenance). OSM #1 stated there were some call bells/lights in resident rooms that were not working, and he was waiting on parts to fix the call bells/lights. On 5/13/24 at approximately 1:30 p.m., observations of the resident call system were conducted with OSM #1 and OSM #2 (the maintenance assistant). The following was observed: -room [ROOM NUMBER]A- the call system pull station in the bathroom was missing from the wall. The call bell/light could not be rung. -room [ROOM NUMBER]A- the call bell/light by the bed did not activate when the button was pushed. -room [ROOM NUMBER]B- 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 facility document review, the facility staff failed to maintain a safe, functional, and sanitary, environment for one of one rehab restroom. The findings include: For the rehab restroom, the facility staff failed to repair a leak and replace a ceiling tile that contained a black substance. On 5/13/24 at 1:26 p.m., an observation of the rehab restroom was conducted. Approximately one fourth of an approximate 12-inch by 24-inch ceiling tile was covered with a black substance. On 5/14/24 at 12:57 p.m., an interview was conducted with OSM (other staff member) #9 (a rehab employee). OSM #9 stated the substance on the ceiling tile in the rehab restroom had been present for a while. OSM #9 stated the rehab staff initially thought the area was a water stain but approximately two or three months ago, the area became more obvious and looked [NAME] and moldier. OSM #9 stated that when the area worsened, the rehab staff made the decision to shut the bathroom down. OSM #9 stated 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, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to maintain the call bell in a position accessible to the resident for four of 50 residents in the survey sample, Resident #377, #55, #88, #79. The findings include: 1. For Resident #377 (R377), the facility staff failed to maintain the call light in a position where they could access it. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 1/9/2024, the resident scored 10 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. The assessment documented R377 not having any impairment in the upper extremities and requiring substantial/maximal assistance with toileting. On 1/22/2024 at 12:29 p.m., R377 was observed sitting in a wheelchair between the bed and the window in their private room. The call bell was observed to be hanging off of the bed frame on the right side of the 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.

Based on resident interview, observation, staff interview, and facility document review, the facility staff failed to provide a clean, comfortable, home like environment for five of 50 residents in the survey sample, Residents #47, #89, #38, #25, and #90. The findings include: 1. For Resident #47 (R47), the facility staff failed to maintain a home like environment on the wall beside and around her bed, in her bathroom, and on her overbed table. On 1/22/24 at 12:01 p.m. and 4:17 p.m., R47 was observed sitting up in her bed. At both observations, the wall extending from the area close to the head of her bed to the door of her room had multiple black marks the entire length of the wall. Behind the resident's bed, large indentations in the wall plaster were visible. In the resident's bathroom, a large indention in the wall plaster was visible near the toilet. The resident's overbed table contained a large amount of food particles and trash on the surface, and was greasy to touch in places. The molding around the overbed table was missing, and the plywood was exposed. In some areas the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interviews, staff interviews, clinical record reviews, and facility document review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for eight of 50 residents in the survey sample, Residents #36, #1, #25, #88, #83, #89, #47 and #117. The findings include: 1. For Resident #36 (R36), the facility staff failed to implement the comprehensive care plan for assisting with bathing/showers as needed. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/15/2023, the resident scored 11 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were moderately impaired for making daily decisions. The assessment documented no rejection of care and R36 requiring substantial/maximal assistance with shower/bathing and dependent for tub/shower transfers. On 1/22/2024 at 1:02 p.m., an interview was conducted with R36 in their room. R36 stated that they…

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

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services to prevent a decrease in range of motion (ROM) for two of 50 residents in the survey sample, Residents #89 and #100. The findings include: 1. For Resident #89 (R89), the facility staff failed to perform passive range of motion (PROM) exercises and apply a resting hand splint per physician order in November and December 2023, and in January 2024. On the following dates and times, R89 was observed lying in bed, with a contraction in his right hand. The resident's wrist was bent, and fingers on the resident's right hand were touching the resident's palm. There was no splint on the resident's right hand: 1/22/24 at 12:15 p.m. and 4:23 p.m.; 1/23/24 at 8:37 a.m. and 9:40 a.m. R89 was not interviewable. A review of R89's physician's orders revealed the following order dated 8/16/23: Nursing staff/caregiver to provide gentle stretch to Right Upper Extremity, assist patient to don/doff Right Resting Hand Splint daily with wearing schedule of 6-8…

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, observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services for an indwelling urinary catheter for two of 50 residents in the survey sample, Residents #89 and #83. The findings include: 1. For Resident #89 (R89) the facility staff failed to provide evidence of urinary catheter care from 12/6/23 through 1/22/24. On the following dates and times, R89 was observed lying in bed, with a Foley catheter draining urine into a collection bag hanging on the bed frame: 1/22/24 at 12:15 p.m. and 4:23 p.m.; 1/23/24 at 8:37 a.m. and 9:40 a.m. R89 was not interviewable. A review of R89's physician's orders revealed the following order dated 12/6/23: Foley [catheter] .related to benign neoplasm of bladder. The review of the orders failed to reveal evidence of an order for routine Foley catheter care. A review of R89's clinical record, including MARs (medication administration record), TARs (treatment administration record), and progress notes revealed no evidence of routine Foley catheter…

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

Based on observation, staff interview, and facility document review, it was determined facility staff failed to store and serve food in a sanitary manner in one of one facility kitchens. The findings include: On 01/22/2024 at approximately 10:55 a.m., an inspection of the facility's kitchen was conducted with OSM (other staff member) #3, dietary manager, with the following concerns identified: 1. On 01/22/2024 at approximately 10:55 a.m., an observation of the bottom shelf of a food preparation table, located in front of the reach-in refrigerator, revealed two sheet pans of chocolate cake uncovered. On 01/22/2024 at approximately 12:50 p.m., an interview was conducted with OSM #8, prep cook. When asked about the storage of the two sheet pans of chocolate cake OSM #8 stated that cakes should have been covered. On 01/22/2024 at approximately 12:50 p.m., an interview was conducted with OSM #3. After informed of the above observation OSM #3 stated that the sheet pans should have been place on a ladder rack and covered. 2. On 01/22/2024 at approximately 10:55 a.m., an observation of OSM…

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 document review, it was determined the facility staff failed to provide complete and accurate documentation for three of 50 residents in the survey sample, Resident #25, Resident #100 and Resident #119. The findings include: 1. For Resident #25, the facility staff failed to evidence complete and accurate documentation for incontinence care. Resident #25's most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 12/9/23, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as maximum assist for bed mobility and moderate assist for transfer, eating/hygiene. A review of Resident #25's comprehensive care plan dated 5/22/22 revealed, FOCUS: The resident has urinary incontinence related to impaired mobility. At risk for falls due to history of falls, impaired balance/poor coordination, medication side…

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 staff interview, the facility staff failed to administer a complete influenza and pneumonia vaccination program for five of five resident records reviewed, Residents #38, #5, #88, #89, and #61. The findings include: 1. For Resident #38 (R38), who received the influenza vaccine on 10/31/23, the facility staff failed to provide evidence of educating the resident on the risks and benefits prior to administering the vaccine. 2. For Resident #5 (R5), who received the influenza vaccine on 10/6/23, the facility staff failed to provide evidence of educating the resident on the risks and benefits prior to administering the vaccine. 3. For Resident #88 (R88), who was admitted to the facility on [DATE], the facility staff failed to provide evidence of offering the resident the pneumonia vaccine. 4. For Resident #89 (R89), the facility staff failed to provide evidence of offering both the flu and pneumonia vaccine since his admission to the facility on 7/5/22. 5. For…

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

Based on staff interview, clinical record review, and staff interview, the facility staff failed to meet COVID-19 vaccination requirements for five of five resident records reviewed, Residents #38, #5, #88, #89, and #61. The findings include: 1. For Resident #38 (R38), who received the COVID-19 vaccine on 7/22/22, the facility staff failed to provide evidence of educating the resident on the risks and benefits prior to administering the vaccine. 2. For Resident #5 (R5), who was documented as having refused the COVID-19 vaccine, the facility staff failed to provide evidence (including the date) of educating the resident on the risks and benefits of receiving the vaccine. 3. For Resident #88, who received the COVID-19 vaccine on 7/27/22, the facility staff failed to provide evidence of educating the resident on the risks and benefits prior to administering the vaccine. 4. For Resident #89 (R89), the facility staff failed to provide evidence of offering the COVID-19 vaccine since his admission to the facility on 7/5/22. 5. For Resident #61 (R61), who received the COVID-19 vaccine on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interview, staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence bed inspections for three of 50 residents in the survey sample, Residents #38, #25, and #109. The findings include: 1. For Resident #38, the facility staff failed to perform bed rail inspections for the use of positioning/assist bars. Resident #38 was observed in bed with bilateral half bed rails on 1/22/24 at 1:30 PM and 1/23/24 at 8:30 AM. A review of the comprehensive care plan dated 7/3/23 revealed, FOCUS: The resident requires assistance with ADLS (activities of daily living) related to chronic health conditions. INTERVENTIONS: .1/2 rails as per orders. A review of the facility's Bed Safety Audit Form revealed no bed inspections since 1/22/24. On 1/22/24 at approximately 10:00 AM, surveyor observed two maintenance staff performing bed inspections on the [NAME] Unit. An interview was conducted on 1/22/24 at 1:30 PM with Resident #38. When…

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

Based on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to assess one of 50 residents in the survey sample for safe self-administration of medications, Resident #103. The findings include: For Resident #103 (R103), the facility staff failed to assess the resident for self-administration of medications left at the bedside. On the most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 12/8/2023, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating that they were cognitively intact for making daily decisions. On 1/22/2024 at 1:16 p.m., an observation of R103's room was conducted. Observation of the nightstand located between R103's bed and their roommates bed revealed a 12 ounce bottle of liquid nighttime cold and flu medication approximately three-quarters full, and a 12 ounce bottle of liquid daytime cold and flu medication approximately three-quarter full. At that time, an…

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

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to notify the physician when medication was not administered as ordered for one of 50 residents in the survey sample, Resident #109 (R109). The findings include: For R109, the facility staff failed to notify the physician and the responsible party that the medication Methocarbamol (1) was not administered every twelve hours on 01/07/24, 01/08/2024, 01/10/2024 and on 01/17/2024. R109 was admitted with diagnoses that included but were not limited to muscle weakness. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 12/25/2023, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R109 was cognitively intact for making daily decisions. The physician's order for R109 documented in part, Methocarbamol Oral Tablet 500 MG (milligram) Methocarbamol. Give 1 (one) tablet by mouth every 12 hours for muscle spam Order Date: 12/19/2023. Start Date: 12/19/2023. The eMAR…

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

Based on staff interview and facility document review, the facility staff failed to implement the abuse policy for new employee screening for two of two employee records reviewed, CNAs (certified nursing assistants) #8 and #9. The findings include: 1. For CNA #8, the facility staff failed to obtain a criminal record check through the state police. A review of CNA #8's employee filed revealed a criminal background check completed 2/4/22. CNA #2, who was a contract employee through a healthcare worker staffing agency, began working in the facility on 4/4/22. Further review of the employee file failed to reveal a criminal background check processed by Virginia State Police. On 1/25/24 at 9:25 a.m., ASM (administrative staff member) #2, the regional vice president for operations, and ASM #4, the interim administrator, were interviewed. ASM #4 stated the facility does not currently have a human resources staff member. She stated the facility follows the same process for facility staff as they do for contract (agency) staff for criminal background checks at the time of hire. ASM #2…

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, clinical record review, and facility document review, it was determined the facility staff failed to provide an accurate MDS (minimum data set) assessment for two out of 50 residents in the survey sample, Resident #55 and Resident #5. The findings include: 1. The facility staff failed to complete an accurate MDS (minimum data set), a quarterly assessment for Resident #55. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 12/22/23, coded the resident as scoring a 05 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of Section O-Special Treatments, Procedures and Programs: K1. Hospice care-coded 'no'. A review of the comprehensive care plan dated 6/18/23 revealed, FOCUS: The resident is receiving hospice services and is not expected to improve in condition for diagnosis of advanced age. INTERVENTIONS: Hospice to provide bath or shower aid. Refer to hospice provider as needed. A review of the…

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

Based on clinical record review, staff interview, resident interview, and facility document review, it was determined that facility staff failed to review and revise the comprehensive care plan for three of 50 residents in the survey sample, Residents # 81, #1 and #94. The findings include: 1. For Resident #81 (R81) the facility staff failed to update comprehensive care plan for dialysis days. R81 was admitted to the facility with diagnosis that included but was not limited to: end stage renal disease. R81's most recent comprehensive MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 11/20/2023, coded (R81) as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Under O0110. Special Treatments, Procedures and Programs coded (R81) as receiving dialysis while a resident. The physician's order for R81 documented in part, Dialysis 3x's (three times) weekly. Monday, Wednesday, Friday. Order Date: 01/05/2024. The comprehensive care plan for R81 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.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to meet professional standards of care for two of 50 residents in the survey sample; Residents #117 and #109. The findings include: 1. For Resident #117, the facility staff failed to clarify orders with the physician for the use of a CPAP (1) device, to include specific settings. A review of the facility policy, Physician's Orders documented, admission Physician's Orders must be provided for every patient at the time of admission or readmission to activate a medical plan of care. Procedure: 1. Upon every patient's admission or readmission or re-entry to the Center, a licensed nurse will notify the physician requesting and/or verifying physician's orders b. admission orders should include: .9. Other orders as indicated by patient's condition with specific directions . A review of the clinical record for Resident #117 revealed 12 different physician progress notes that documented the resident was on CPAP (1). The dates were 3/24/23, 3/26/23, 3/29/23, 3/30/23, 3/31/23, 4/2/23,…

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, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide ADL (activities of daily living) care for dependent residents for three of 50 residents in the survey sample, Residents #36, #89 and #47. The findings include: 1. For Resident #36 (R36), the facility staff failed to evidence showers provided on scheduled shower dates reviewed. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/15/2023, the resident scored 11 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were moderately impaired for making daily decisions. The assessment documented no rejection of care and R36 requiring substantial/maximal assistance with shower/bathing and dependent for tub/shower transfers. On 1/22/2024 at 1:02 p.m., an interview was conducted with R36 in their room. R36 stated that they received baths and showers sometimes but not as much as they wanted them. R36 stated that they were not sure if there were…

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 facility document review, it was determined that the facility staff failed to maintain a safe environment for two of 50 residents in the survey sample, Resident #100 and #20. The findings include: 1. For Resident #100 (R100), the facility staff failed to store cleaning supplies outside of the residents room. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/4/2023, coded the resident as dependent on staff for transfers and non-ambulatory. On 1/23/2024 at 8:48 a.m., R100 was observed lying in bed. An overbed table was observed along the wall on the right side of R100's bed covered with a towel. A gallon container of Micro-kill disinfectant wipes (1) was observed sitting on top of the towel on the overbed table. The container was approximately three-quarters full. Additional observation of the Micro-kill disinfectant wipes on the overbed table in R100's room was made on 1/23/2024 at 1:44 p.m. On 1/23/2024 at 2:51 p.m., an interview was conducted with OSM…

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

Based on clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to monitor weights as ordered for one of 50 residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to obtain weights as ordered. On the most recent MDS (minimum data set), a 5-day assessment with an ARD (assessment reference date) of 12/29/2023, the resident scored six out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. The assessment documented no weight loss. The physician orders for R1 documented in part, 1/11/2024 15:55 (3:55 p.m.) Weekly Weight- Documented in POC every day shift every Wed (Wednesday) for 4 weeks . The progress notes for R1 documented in part, - 1/11/2024 15:59 (3:59 p.m.) Nutrition/Dietary Note. Note Text : Weight changes note/ high nutrition risk . Son reports increased need for feeding assistance with UTI (urinary tract infection) related delirium, has improved. Set up assist 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.

Based on clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to provide care and service for a complete dialysis (1) program for one of 50 residents in the survey sample, Residents #8. The findings include: For Resident #81 (R81) the facility staff failed to adequately complete dialysis communication forms on 01/07/2024, 01/17/2024 and on 01/22/2024. R81 was admitted to the facility with diagnosis that included but was not limited to: end stage renal disease. (R81's) most recent comprehensive MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 11/20/2023, coded (R81) as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Under O0110. Special Treatments, Procedures and Programs coded (R81) as receiving dialysis while a resident. The physician's order for R81 documented in part, Dialysis 3x's (three times) weekly. Monday, Wednesday, Friday. Order Date: 01/05/2024. Review of R81'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide trauma informed care for one of 50 residents in the sample Resident #88. The findings include: Resident #88 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: COPD (chronic obstructive pulmonary disease), DM (diabetes mellitus) and asthma. The PTSD (post-traumatic stress disorder) diagnosis was coded 8/30/23. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/18/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the comprehensive care plan dated 7/11/22 revealed, FOCUS: The resident is at risk for changes in mood related to anxiety. INTERVENTIONS: Observe for mental status/mood state changes when new medication is started 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 resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide medically related social services for one of 50 residents in the sample Resident #88. The findings include: For Resident #88, the facility staff failed to provide psychosocial follow up following the resident being diagnosed with PTSD (post-traumatic stress disorder) on 8/30/23. Resident #88 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: COPD (chronic obstructive pulmonary disease), DM (diabetes mellitus) and asthma. The PTSD (post-traumatic stress disorder) diagnosis was coded 8/30/23. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/18/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the comprehensive care plan 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, facility document review, and clinical record review, the facility staff failed to implement interventions to prevent administration of unnecessary psychoactive medications for one of 50 residents in the survey sample, Resident #42. The findings include: For Resident #42 (R42), the facility staff failed to attempt a gradual dose reduction for Sertraline (1), an antidepressant. R42 was admitted to the facility on [DATE] with diagnoses including major depression and generalized anxiety. A review of R42's clinical record revealed the following order dated 3/6/22: Sertraline HCl Tablet 100 MG (milligrams) Give 1 tablet by mouth one time a day for depression give 100mg and 25mg together 125 mg daily. A review of R42's MARs (medication administration records) for November and December 2023, and January 2024, revealed the resident had been receiving the Sertraline as ordered. A review of R42's clinical record failed to reveal evidence of a gradual dose reduction for Sertraline since August…

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 document review, it was determined that the facility staff failed to provide respiratory care and services for one of 50 residents in the survey sample; Resident #117. The findings include: For Resident #117, the facility staff failed to ensure a physician's order was in place prior to using a CPAP (1) device. A review of the facility policy, Respiratory / Oxygen Equipment documented, CPAP/BIPAP Set-Up Adult. 1. Validate CPAP/BIPAP orders for completeness: A. Specific name of treatment (CPAP or BIPAP). b. Inspiratory pressure setting and/or expiratory pressure setting if indicated. c. Duration and specific times of treatment. d. Oxygen flow rate as ordered A review of the clinical record for Resident #117 revealed 12 different physician progress notes that documented the resident was on CPAP. The dates were 3/24/23, 3/26/23, 3/29/23, 3/30/23, 3/31/23, 4/2/23, 4/3/34, 4/5/23, 4/7/23, 4/9/23, 4/11/23 and 4/12/23. A nurse's note dated 3/22/23 documented, .on C-PAP (which is at resident bedside) . A nurse's note dated 4/8/23…

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 document review and clinical record review, the facility staff failed to notify the physician and/or the RP (responsible party) of a need to alter treatment for four of 58 residents in the survey sample, Residents #114, #118, #112 and #6. The findings include: 1. For Resident #114 (R114), the facility staff failed to notify the physician when physician ordered medications were not administered to the resident on multiple dates in June 2022. A review of R114's clinical record revealed the following physician's orders: 6/9/22- omeprazole (1) 20 mg (milligrams)- 1 capsule by mouth one time a day for gastroesophageal reflux disease; 6/10/22-mupirocin ointment (2) 2%- apply to sacrum/buttocks rash two times a day for ten days (scheduled at 9:00 a.m. and 9:00 p.m.); 6/21/22-calcium with vitamin D 600 mg/200 units- 1 tablet by mouth one time a day for COVID; 6/21/22-melatonin 3 mg- 1 tablet by mouth at bedtime for COVID; 6/21/22-vitamin C 500 mg by mouth one time a day for COVID 6/21/22 (12:32 a.m.)-zinc sulfate 220 mg (milligrams)- 1 capsule by mouth 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 and staff interview, it was determined that facility staff failed to maintain resident's rooms in good repair, and in a clean and sanitary manner for three of 12 resident rooms observed. The findings include: 1a. For resident room [ROOM NUMBER], the facility staff failed to maintain the bathroom and the bedroom free of feces. On 02/05/2023 at approximately 2:30 p.m., and on 02/06/2023 at approximately 8:30 a.m., an observation of resident room [ROOM NUMBER]'s bathroom revealed loose feces in and on the toilet seat, down the front and side of the toilet bowl, on the floor trailing from the toilet to the bathroom door and extending out into the room. On 02/06/2023 at 9:04 a.m. an observation of resident room [ROOM NUMBER] revealed housekeeping staff OSM (other staff member) #2, housekeeper, standing in the doorway looking into the room and OSM #1, housekeeping manager, who was in the room, cleaning the bathroom. When asked what the dark substance was trailing from the bathroom out into 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 staff interview, facility document review, and clinical record review, it was determined the facility staff failed to provide evidence of the required transfer/discharge documents upon discharge/transfer for four of 58 resident in the survey sample, Residents #46, #116, #50, and #79. The findings include: 1. For Resident #46 (R46) the facility staff failed to evidence sending any documentation to the hospital for a transfer on 12/27/2022. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 12/28/2022, the resident scored a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is not cognitively impaired for making daily decisions. The nurse's note dated, 12/27/2022 at 7:00 p.m., documented in part, Writer called to residents room by cna (certified nursing assistant) after writer had given resident her 5pm medications upon entering room, writer observed resident with a nose bleed. Writer applied pressure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to give written notification to the resident and/or responsible party and failed to notify the Office of the State Long-Term Care Ombudsman upon transfer from the facility for four of 58 residents in the survey sample, Residents #46, #116, #50 and #79. The findings include: 1. For Resident #46 (R46) the facility staff failed to evidence where the resident and/or responsible party was given a written notification for the reason the resident was being transferred to the hospital and failed to notify the ombudsman of the transfer to the hospital that occurred on 12/27/2022. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 12/28/2022, the resident scored a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is not cognitively impaired for making daily decisions. The nurse's note 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, facility document review, and clinical record review, it was determined the facility staff failed to develop and/or implement the baseline care plan for four of 58 residents in the survey sample, Residents #117, #114, #112 and #365. The findings include: 1. For Resident #117 (R117), the facility staff failed to develop a baseline care plan to address the resident's activities of daily living and the care for a colostomy. On the most recent MDS (minimum data set) assessment, a Medicare five day assessment, with an assessment reference date of 1/29/2022, the resident scored a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section G - Functional Status, R117 was coded as requiring extensive assistance of one staff member for most of their ADLs (activities of daily living) except eating in which they only required supervision after set up assistance provided. In Section H - Bladder and…

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

Based on observation, resident and/or responsible party interviews, staff interview, clinical record review, and facility document review it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for three of 58 residents in the survey sample, Resident #6, #93, and #113. The findings include: 1. For Resident #6 (R6), the facility staff failed to implement the comprehensive care plan to provide incontinence care. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 11/11/2022, the resident scored 1 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. Section G documented R6 requiring extensive assistance from one person for toileting. On 2/5/2023 at 4:38 p.m., an interview was conducted with R6's responsible party (RP). R6's RP voiced concerns regarding the resident being left soiled for extended periods of time and often being found wet when they arrived to visit. R6's RP stated that when…

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 and/or responsible party interview, clinical record review, staff interview, and facility document review it was determined that the facility staff failed to provide ADL (activities of daily living) care to dependent residents for five of 58 residents in the survey sample, Resident #93, #6, #114 #128, and #113. The findings include: 1. For Resident #93 (R93), the facility staff failed to provide timely incontinence care. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/18/2023, the resident was assessed as being independent in making daily decisions. Section G documented R93 requiring extensive assistance from one staff member for toileting. On 2/5/2023 at 2:58 p.m., an interview was conducted with R93 in their room. R93 stated that they were incontinent of urine and wore a brief. R93 stated that they called on their call bell when they needed incontinence care and at times they had to wait an extended period of time because the staff were so busy. On 2/6/2023 at 8:26 a.m., a follow up…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, the facility staff failed to provide care and services to maintain residents' highest level of well-being for four of 58 residents in the survey sample, Residents #114, #22, #77 and #116. The findings include: 1. For Resident #114 (R114), the facility staff failed to administer multiple physician ordered medications in June 2022. These medications were available in the facility over-the-counter medication supply. A review of R114's clinical record revealed the following physician's orders: -6/9/22- omeprazole (1) 20 mg (milligrams)- 1 capsule by mouth one time a day for gastroesophageal reflux disease. -6/21/22-calcium with vitamin D 600 mg/200 units- 1 tablet by mouth one time a day for COVID. -6/21/22-melatonin 3 mg- 1 tablet by mouth at bedtime for COVID. -6/21/22-vitamin C 500 mg by mouth one time a day for COVID. A review of R114's June 2022 MAR (medication administration record) failed to reveal evidence that omeprazole 20 mg…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services for maintenance of a central venous access device for two of 58 residents in the survey sample, Residents #112 and #365. The findings include: 1. For Resident #112 (R112), the facility staff failed to evidence maintenance care for a PICC (peripherally inserted central catheter) (1), from the date of admission, 1/12/23, until 2/2/23. On R112's admission assessment dated [DATE], the resident was assessed to be cognitively intact, and oriented to person, place, time, and situation. On 2/5/23 at 2:54 p.m., R112 was observed to have a double lumen (two lines) PICC line inserted in the right arm. When asked about the care the staff gave the PICC line, R112 stated the staff did not always have the supplies to flush the line, and had only started putting heparin in the line recently. A review of R112's progress note revealed, in part: 2/1/2023 22:14…

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 employee record review it was determined that the facility staff failed to ensure CNAs (certified nursing assistants) received annual performance reviews for five of five CNA records reviewed. The findings include: On 02/07/2023 a record review was conducted of the annual performance reviews of five CNAs. This review failed to evidence annual performance reviews for the following CNAs: 1. CNA #1 - hire date 01/01/2020, no evidence of performance review between 01/01/2021 and 01/01/2022. 2. CNA #6 - hire date 01/01/2020, no evidence of performance review between 01/01/2021 and 01/01/2022. 3. CNA #8- hire date 01/01/2020, no evidence of performance review between 01/01/2021 and 01/01/2022. 4. CNA #9- hire date 01/01/2020, no evidence of performance review between 01/01/2021 and 01/01/2022. 5. CNA #10- hire date 01/20/2020, no evidence of performance review between 01/20/2021 and 01/20/2022. On 02/08/2023 at approximately 4:10 p.m. an interview was conducted with OSM (other staff member) #10, human resource director. When asked for the competency reviews…

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, responsible party interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to ensure that medications were available for administration for six of 58 residents in the survey sample, Residents #6, #77, #114, #112, #118, #365 and for one of six residents in the medication administration observation, Resident #416. The findings include: 1. For Resident #6, (R6), the facility staff failed to ensure Piperacillin-Tazobactam, an antibiotic, was acquired from the pharmacy for administration in a timely manner. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 11/11/2022, the resident scored one out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. On 2/5/2023 at 4:38 p.m., an interview was conducted with R6's responsible party (RP). The RP voiced concerns…

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 employee record review it was determined that the facility staff failed to ensure CNAs (certified nursing assistants) received annual retraining in the areas of dementia and abuse for four of five CNA records reviewed (CNAs #1, #6, #9, and #10). The findings include: On 02/07/2023 an employee record review was conducted for five CNAs. This review failed to evidence the annual required training for the following CNAs: 1. CNA #1 - hire date 01/01/2020, no evidence of dementia and abuse training between 01/01/2021 and 01/01/2022. 2. CNA #6 - hire date 01/01/2020, no evidence of abuse training between 01/01/2021 and 01/01/2022. 3. CNA #9- hire date 01/01/2020, no evidence of dementia and abuse training between 01/01/2021 and 01/01/2022. 4. CNA #10- hire date 01/20/2020, no evidence of dementia and abuse training between 01/20/2021 and 01/20/2022. On 02/07/2023 at approximately 4:10 p.m. an interview was conducted with OSM (other staff member) #10, human resource director. When asked for the evidence of dementia and abuse training for the CNAs listed above…

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

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services in a dignified manner for two of 58 residents in the survey sample, Residents #128 and #96. The findings include: 1. For Resident #128 (R128), the facility staff failed to change a resident's soiled sock, failed to provide personal privacy, and failed to help him to dress in street clothes. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 1/22/23, R128 was coded as being severely cognitively impaired for making daily decisions, having scored three out of 15 on the BIMS (brief interview for mental status). The resident was coded as requiring the extensive assistance of staff for personal hygiene, grooming, and dressing. On each of the following dates and times, R128 was dressed in a hospital gown, and was in a location visible to visitors and staff: 2/5/23 at 3:18 p.m., 3:40 p.m., and 5:12 p.m.; 2/6/23 at 8:16 a.m., 9:40 a.m., 2:56 p.m.; 2/7/23 at 12:10 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.

Based on staff interview and facility document review, the facility staff failed to respond to a resident council concern for one of one resident council meetings; the November 2022 meeting. The findings include: The facility staff failed to respond to the November 2022 resident council's concern regarding call bells not being answered in a timely manner. A review of the 11/28/22 resident council meeting notes revealed the following documentation, (Name of a resident) and various residents expressed a concern about the call bell response. They are not being answered in a timely manner. Grievance form will be written for the matter. A review of the November 2022 and December 2022 grievances failed to reveal a grievance regarding the resident council's call bell concern. On 2/6/23 at 3:15 p.m., ASM (administrative staff member) #1 (the administrator) was asked to provide evidence that the November 2022 resident council concern regarding call bells was addressed. No further documentation was provided. A review of the resident council meeting notes for 1/24/23 revealed further 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, resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide personal privacy for two of 58 residents in the survey sample, Residents #128 and #98 The findings include: 1. For Resident #128 (R128), the facility failed to cover exposed body parts visible from the hallway on 2/6/23. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 1/22/23, R128 was coded as being severely cognitively impaired for making daily decisions, having scored three out of 15 on the BIMS (brief interview for mental status). The resident was coded as requiring the extensive assistance of staff for personal hygiene, grooming, and dressing. On 2/6/23 from 8:16 a.m. until 9:40 a.m., R128 was dressed in a hospital gown, and sitting on the side of the bed facing away from the door. The resident's hospital gown was tied at the neck, and open from the neck down to the resident's buttocks. The resident's back was exposed to the view of anyone who…

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, staff interview and facility document review, the facility staff failed to evidence a response to a resident grievance for one of 58 residents in the survey sample, Resident #36. The findings include: For Resident #36 (R36), the facility staff failed to evidence a response to a grievance regarding missing clothes. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 1/2/23, the resident scored 11 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately cognitively impaired for making daily decisions. A complaint/grievance report for R36 dated 11/28/22 documented, Stated still has missing clothes from laundry. Stated does not want the facility to do clothes . The findings of investigation section documented, Check laundry for missing clothes with negative results. Notified admin (administrator) & staff that we won't wash clothes. The resolution section including if the grievance was resolved and if the complainant was satisfied was blank. On 2/7/23 at 9:22 a.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 staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that bed hold notification was provided when one out of 58 residents in the survey sample was transferred to the hospital; Residents #50. The findings include: The facility staff failed to evidence provision of bed hold notification at the time of discharge for Resident #50. Resident #50 was transferred to the hospital on 1/16/23. Resident #50 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: COPD (chronic obstructive pulmonary disease), dementia and anxiety disorder. The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 12/12/22, coded the resident as scoring a 01 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. There was no evidence of a bed hold sent with the resident to the hospital on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to complete an admission MDS (minimum data set) assessment within the required time frame for one of 58 residents in the survey sample, Resident #112. The findings include: For Resident #112 (R112), the facility staff failed to complete an admission MDS assessment. R112 was admitted to the facility on [DATE]. A review of R112's clinical record revealed an admission MDS assessment was not complete. On 2/7/23 at 3:11 p.m., an interview was conducted with LPN (licensed practical nurse) #5 (a MDS coordinator). LPN #5 reviewed R112's clinical record. LPN #5 stated R112 was admitted on [DATE] so the admission MDS assessment should have been completed by the 14th day after admission. LPN #5 stated it looked like the assessment was partially completed but there were sections that were outstanding. LPN #5 stated she references the CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) manual when completing 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 staff interview, clinical record review and facility document review, it was determined the facility staff failed to complete an accurate MDS (minimum data set) assessment for two out of 58 residents in the survey sample, Residents #48 and #51. The findings include: 1. The facility staff failed to complete an accurate MDS (minimum data set) annual assessment for Resident #48. Resident #48 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: diabetes mellitus, atrial fibrillation and depression. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/6/22, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired A review of the annual MDS dated [DATE], coded Section J-Health Conditions Tobacco Use-No. A review of the comprehensive care plan dated 5/17/22 and revised 1/2/23, revealed, FOCUS: Resident chooses…

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, clinical record review and facility document review, it was determined that the facility staff failed to review and/or revise the comprehensive care plan for one of 58 residents in the survey sample, Resident #101. The findings include: For Resident #101 (R101), the facility staff failed revise the comprehensive care plan for the use of bed rails. On the most recent MDS (minimum data set) assessment, an admission assessment with an ARD (admission reference date) of 11/29/2022, the resident was assessed as being severely impaired for making daily decisions. On 2/6/2023 at 9:00 a.m., R101 was observed in their room in bed. Bilateral upper bed rails were observed to be up and in place on the bed. Additional observations were made on 2/6/2023 at 4:15 p.m. and 2/7/2023 at 8:54 a.m. of R101 in bed with bilateral upper bed rails in place. The comprehensive care plan for R101 failed to evidence documentation of the use of bed rails. The physician orders for R101 documented in part, - B (bilateral) 1/4 bed rails to facilitate improving pt (patient)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to clarify physician orders and follow professional standards of practice for three of 58 residents in the survey sample, Residents #113, #463, and #365. The findings include: 1. For Resident #113 (R113), the facility staff failed to clarify two physician orders for the treatment of the same wound. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 9/18/2022, the resident scored an 11 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired for making daily decisions. In Section M - Skin Conditions, the resident was coded as having a stage four pressure injury (1). The physician order dated, 9/15/2022, documented, Dakin's (1/4 strength) Solution 0.125% (Sodium Hypochloride) Apply to right hip topically every day and evening shift for apply for wet to dry dressing on wound.…

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

Based on observation, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to provide care and services to promote healing for two of 58 residents in the survey sample, Residents #113 and #93. The findings include: 1. For Resident #113 (R113), the facility staff failed to administer treatments for a pressure injury per the physician orders. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 9/18/2022, the resident scored an 11 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired for making daily decisions. In Section M - Skin Conditions, the resident was coded as having a stage four pressure injury. (1) The physician order dated, 9/15/2022, documented, Dakin's (1/4 strength) Solution 0.125% (Sodium Hypochloride) Apply to right hip topically every day and evening shift for apply for wet to dry dressing on wound. The September 2022 TAR (treatment administration record) documented the above order. 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 staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide an environment free of hazards for two out of 58 residents in the survey sample, Residents #48 and #96. The findings include: 1. The facility staff failed to ensure Resident #48's smoking paraphernalia was secured when not in use. Resident #48 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: diabetes mellitus, atrial fibrillation and depression. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/6/22, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the comprehensive care plan dated 5/17/22 and revised 1/2/23, which revealed, FOCUS: Resident chooses to smoke -will smoke off facility grounds. Understands smokefree facility, declines smoking cessation and…

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

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care and services for a colostomy for one of 58 residents in the survey sample, Resident #117. The findings include: The facility staff failed to evidence the colostomy bag was cared for and emptied for Resident #117 (R117). On the most recent MDS (minimum data set) assessment, a Medicare five day assessment, with an assessment reference date of 1/29/2022, the resident scored a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section G - Functional Status, R117 was coded as requiring extensive assistance of one staff member for most of their ADLs (activities of daily living) except eating in which they only required supervision after set up assistance provided. In Section H - Bladder and Bowel, the resident was coded as having a colostomy. There was no care plan for the care of a colostomy. The physician order dated, 1/26/2022 read, Colostomy: change…

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 provide respiratory equipment per plan of care; and failed to store respiratory equipment in a sanitary manner for one of 58 residents in the survey sample, Resident #95. The findings include: The facility staff failed to ensure an ambu bag, tracheostomy (trach) care kits and an inner cannula were at the bedside of Resident #95 per the resident's care plan; and failed to store the resident's trach collar mask, used for nebulizer treatments, in a sanitary manner. Resident #95 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: trach, malignant neoplasm of pharynx, dysphagia and anemia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 12/28/22, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not…

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

Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement a pain management program for one of 58 residents in the survey sample, Resident #22. The findings include: For Resident #22 (R22), the facility staff failed to administer pain medication according to the physician orders and applicable pain scale, and failed to intervene after a pain reassessment on 2/3/23. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/18/23, R22 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). A review of R22's progress notes revealed the following: Effective Date: 2/3/2023 21:58 (9:58 p.m.) Type: Fall Note .Resident had no injuries from fall, but complaints of pain 10/10 in the neck and the head .Resident was assisted off the floor by nurse and nurse aide. VS (vital signs), neurological assessment assessed. Therapeutic care and medication administered for pain. This note was written by…

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, resident interview, clinical record review and facility document review, it was determined the facility staff failed to ensure ongoing communication with the dialysis facility for two of 58 residents in the survey sample, Resident #463 and #127. The findings include: 1. For Resident #463, the facility failed to ensure there was ongoing communication with the dialysis facility for 2 out of 4 visits in January-February 2023, on the dates of 1/30/23 and 2/6/23. Resident #463 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: ESRD (end stage renal disease). The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 1/30/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of Section O-Special Procedures coded dialysis-yes. A review of the comprehensive care plan 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 observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement side rail safety procedures for one of 58 residents in the survey sample, Resident #363. The findings include: For Resident #363 (R363), the facility staff to assess a resident for the use of side rails, educate the resident regarding the risks and benefits of using side rails, and obtain consent from the resident for the use of side rails. On 2/5/23 at 3:14 p.m. and 2/6/23 at 8:12 a.m., R363 was sitting up in bed with eyes closed. Quarter side rails were up on both sides of the resident's bed. A review of R363's admission assessment dated [DATE] revealed, in part: Does the resident need bed rails for positioning and/or rising from supine to sitting/standing position as mobility enabler? No. Bed rails are: Not indicated as a mobility enabler at this time. Are bed rails a resident/resident representative preference? No. Further review of R363's clinical record failed to reveal any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility documentation, and clinical record review, the facility physician failed to initiate orders for a medication in a timely manner for one of six residents in the medication administration observation, Resident #416. The findings include: For Resident #416, the facility physician failed to order Pancreaze (1) until 2/3/23. The resident was admitted to the facility on [DATE]. On R416's admission assessment dated [DATE], the resident was assessed to be cognitively intact, and oriented to person, place, time, and situation. A review of R416's diagnoses revealed the resident had part of the pancreas surgically removed prior to admission to the facility. On 2/4/23 at 9:02 a.m. during the medication administration observation, LPN (licensed practical nurse) #11 was observed preparing medications to administer to R416. LPN #11 stated: His Pancreaze is not in the cart. She stated she had been told there was a problem with the resident's insurance coverage,…

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 document review, it was determined that the facility staff failed to ensure timely physician visits for one of 58 residents in the survey sample; Resident #67. The findings include: For Resident #67, there were no physician visits for 125 days. A review of the clinical record for physicians visits for the last 6 months revealed physician visits dated 8/3/22, 8/5/22, 8/25/22 and 10/6/22. Up to the survey review on 2/7/23, there had been no further physicians visits identified in the clinical record, for a total of 125 days without a physician's visit. On 2/7/23 at 5:00 PM at the end-of-day meeting, ASM #1 (Administrative Staff Member) the Administrator ASM #2 the interim Director of Nursing, and ASM #3 the Regional Director of Clinical Services, were made aware of the findings and it was requested to see if there were any visit notes located anywhere else that had not been added to the electronic health record. On 2/8/23 at 9:20 AM an interview was conducted with ASM #4, the Nurse Practitioner. She stated that Resident #67…

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

Based on staff interview and facility document review, it was determined that the facility staff failed to ensure an RN (registered nurse) was on duty on one of 31 days reviewed. The findings include: The facility staff failed to ensure an RN was on duty at least eight consecutive hours on 01/05/2023. On 02/07/2023 at approximately 3:25 p.m., a review of the facility's As worked schedule dated 01/01/2023 through 01/31/2023 was conducted with CNA (certified nursing assistant) #4, staffing coordinator. The review revealed that on 01/05/2023, the facility failed to maintain registered nurse coverage for a 24-hour period. When asked about the lack of eight hours of RN coverage on 01/05/2023, CNA #4 stated it was an oversight in scheduling. On 02/08/2023 at approximately 10:30 a.m., ASM (administrative staff member) #1, administrator, was made aware of the above findings. No further information was provided prior to exit.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to evidence monthly drug regimen reviews were conducted by the pharmacist for one of 58 residents in the survey sample, Resident #42. The findings include: Resident #42 was admitted to the facility on [DATE]. Resident #42's diagnoses included but were not limited to Hepatitis A, high blood pressure, heart failure, depression, PTSD (post-traumatic stress disorder) and OCD (obsessive compulsive disorder). A review of the comprehensive care plan dated 2/2/17, revealed, FOCUS: At risk for adverse effects related to use of anti-depression medication/depression/PTSD, anti-anxiety. Use of antipsychotic medication. INTERVENTIONS: Evaluate effectiveness and side effects of medications for possible decrease/elimination of psychotropic drugs. Notify physician of decline in ADL ability or mood/behavior related to a dosage change. Provide patient education to risks and benefits of medications as needed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to administer medications in a manner free of medication errors less than five percent to two of six residents in the medication administration observation, Residents #56 and #416. There were two errors out of 33 opportunities, resulting in a medication error rate of 6.06%. The findings include: 1. The facility staff failed to instruct Resident #56 (R56) to rinse their mouth after the administration of Breo Ellipta dry powder inhaler (1). On 2/06/23 at 8:48 a.m., LPN (licensed practical nurse) #1 prepared medications to be administered to R56. LPN #11 took the Breo Ellipta powder inhaler to R56, prepared the correct amount of medication to be delivered by the inhaler, and had the resident inhale one puff of the medication. LPN #11 took the inhaler back from the resident, and returned to the medication cart without instructing the resident to rinse their…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility documentation, and clinical record review, the facility staff failed to prevent a significant medication error for one of six residents in the medication administration observation, Resident #416. The findings include: For Resident #416, the facility staff failed to administer Pancreaze (1) during the medication administration observation on 2/4/23. On R416's admission assessment dated [DATE], the resident was assessed to be cognitively intact, and oriented to person, place, time, and situation. A review of R416's diagnoses revealed the resident had part of the pancreas surgically removed prior to admission to the facility. On 2/4/23 at 9:02 a.m. during the medication administration observation, LPN (licensed practical nurse) #11 was observed preparing medications to administer to R416. LPN #11 stated: His Pancreaze is not in the cart. She stated she had been told there was a problem with the resident's insurance coverage, and the pharmacy would…

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

Based on staff interview and facility document review, it was determined the facility staff failed to have a written agreement for one of six contracted dialysis centers. The findings include: The facility failed to evidence a written agreement with one dialysis center where Resident #127 received dialysis services. During the entrance conference to the facility on 2/5/23, a request was made for the dialysis contracts or agreements to be provided. On 2/6/23, a review of the dialysis contracts evidenced no contract for the one dialysis company. On 2/6/23 at approximately 3:45 PM, ASM (administrative staff member) #1, the administrator stated, There are more contracts I am going through to get you that contract. On 2/7/23 at 5:15 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing, were made aware of the findings. ASM #1 stated, It is in a pile of contracts I have. On 2/8/23 at approximately 1:00 PM, ASM #1 stated, there is no contract for this dialysis center. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain an accurate clinical record for one of 58 residents in the survey sample, Resident #117 (R117). The findings include: For R117, the facility staff failed to accurately document the care for a colostomy. On the most recent MDS (minimum data set) assessment, a Medicare five-day assessment, with an assessment reference date of 1/29/2022, the resident was coded in Section H - Bladder and Bowel, as having a colostomy. The ADL (activities of daily living) documentation for January 2022, documented the bowel movements of a resident. Under Bowel Movements, the following was documented: 1/25/2022 - 3:00 p.m. to 11:00 p.m. shift (3-11)- M (medium), 1 - incontinent, 4 - total dependence on staff, 2 - one-person physical assist 1/26/2022 - 11:00 p.m. to 7:00 a.m. (11-7)- M, 3 -Continence not rated due to Ostomy, 2 - limited assistance, 2 - one-person physical assist 1/26/2022 - 7:00 p.m. to 3:00 p.m. (7-3) - 97 documented for all categories, according to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to maintain effective infection control practices for two of 58 residents in the survey sample, Resident #4 and #95. The findings include: 1. For Resident #4 (R4), the facility staff failed to wash or sanitize hands before administering medications to the resident. On 2/05/23 at 4:34 p.m., RN (registered nurse) #5 was observed as she came out of a resident's room after administering medications. RN #5 was wearing gloves. RN #5 approached the medication cart, removed the gloves, put on another pair of gloves, and prepared medications to be administered to R4. RN #5 delivered the medications to the resident, and the resident took the medications as instructed by RN #5. RN #5 did not wash or sanitize her hands after removing the old gloves or putting on new gloves just prior to preparing R4's medications. On 2/8/23 at 8:18 a.m., LPN (licensed practical nurse)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide the required transfer or discharge documentation for seven of 49 residents in the survey sample, Residents #101, #83, #114, #80, #15, #23 and #52. The facility staff failed to ensure that comprehensive care plan goals for Residents #101, #83, #114, #80, #15, #23 and #52, were provided and communicated to the receiving health care institution upon transfer to the hospital. The findings include: 1. The facility staff failed to provide evidence that all required information (comprehensive care plan goals) was provided to hospital staff when Resident #101 was transferred to the hospital on 6/15/21. Resident #101 was admitted to the facility on [DATE]. Resident #101's diagnoses included but were not limited to multiple sclerosis (1), seizures and high blood pressure. Resident #101's quarterly minimum data set assessment with an assessment reference date of 7/6/21, coded 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 staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide written notification of transfer to the resident and/or their representative for six of 49 residents in the survey sample, Residents #101, #83, #114, #15, #23 and #52. The findings include: 1. Resident #101 was transferred to the hospital on 6/15/21. The facility staff failed to provide written notification of the transfer to Resident #101's representative. Resident #101 was admitted to the facility on [DATE]. Resident #101's diagnoses included but were not limited to multiple sclerosis, seizures and high blood pressure. Resident #101's quarterly minimum data set assessment with an assessment reference date of 7/6/21, coded the resident's cognitive skills for daily decision making as severely impaired. Review of Resident #101's clinical record revealed the resident was transferred to the hospital on 6/15/21 because the resident was blue in the face, foaming out of the mouth…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide a notice of bed hold prior to and or upon transfer for six of 49 residents in the survey sample, # 83, #114, #80, #15, #23 and #52. The findings include: 1. The facility staff failed to provide Resident #83 and/or responsible party with a bed hold notification prior to and or upon a transfer to the hospital on 6/1/2021. Resident #83 was admitted to the facility on [DATE] with a readmission on [DATE], with diagnoses that included but were not limited to: urinary tract infection, stroke (abnormal condition in which hemorrhage or blockage of the blood vessels of the brain leads to oxygen lack and resulting symptoms - sudden loss of ability to move a body part [as an arm or parts of the face], or to speak, paralysis weakness or if severe, death) (1), and cancer of the colon. The most recent MDS (minimum data set) assessment, a Medicare five day assessment, with an assessment reference…

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 11. The facility staff failed to develop the comprehensive care plan to include and address Resident #59's AV (arterial-venous) shunt care and dialysis. Resident #59 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: diabetes mellitus (inability of insulin to function normally in the body) (1), ESRD [end stage renal disease] (inability of the kidneys to excrete wastes and function in the maintenance of electrolyte balance) (2), heart failure (inability of the heart to pump enough blood to maintain normal body requirements) (3) and cerebrovascular accident (abnormal condition in which a hemorrhage or blockage of the blood vessels of the brain leads to a lack of oxygen) (4). The most recent MDS (minimum data set) assessment, a Medicare 5 day assessment, with an ARD (assessment reference date) of 6/14/21, coded Resident #59 as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the 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 observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to review and/or revise the comprehensive care plan for four of 49 residents in the survey sample, Residents #105, #9, #114 and Resident # 82. The facility staff failed to review and/or revise Resident #105's comprehensive care plan for the use of bedrails, failed to review and revise Resident #9's comprehensive care plan to address an indwelling Foley catheter and failed to review and revise Resident #114's and Resident # 82's comprehensive care plans to address the use of antianxiety medication prescribed by the physician. The findings include: 1. The facility staff failed to review and/or revise Resident #105's comprehensive care plan for the use of bedrails. Resident #105 was admitted to the facility on [DATE]. Resident #105's diagnoses included but were not limited to history of a stroke, diabetes and high blood pressure. Resident #105's quarterly minimum data set…

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 document review and clinical record review, it was determined the facility staff failed to provide respiratory services per the physician orders and per the comprehensive care plan for three of 49 residents in the survey sample, Residents #172, #171 and #11. The findings include: 1. a. Resident #172 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: chronic obstructive pulmonary disease (COPD) (1), high blood pressure, diabetes and morbid obesity (overweight). The most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 6/22/2021, coded Resident #172 as scoring a 2 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired to make daily cognitive decisions. The resident was coded as requiring extensive assistance of one or more staff members for all of her activities of daily living except eating in which she was coded as requiring…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, clinical record review and in the course of a complaint investigation, it was determined the facility staff failed to provide care and services related to dialysis for six of 49 residents in the survey sample, Residents #64, #114, #173, #80, #59, and #52. The facility failed to ensure an ongoing communication process with the dialysis centers for Resident #64, #114, #173, #80, #59 and #52, and failed to have a physician order for Resident #173 to receive dialysis, failed to ensure Resident #80's dialysis AV [arteriovenous] shunt was assessed and checked for a Bruit and Thrill every shift according to the physician's orders. The findings include: 1. The facility staff failed to have a communication process with the dialysis center for Resident #64. Resident #64 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: end stage renal disease requiring hemodialysis (a procedure used in toxic conditions and renal [kidney]…

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 facility document review, it was determined the facility staff failed to ensure expired medication was disposed of and not available for use in one of two medication rooms, (the [NAME] unit medication room). Multiple expired IV (intravenous) medications were observed in the [NAME] unit medication room refrigerator available for resident administration. The findings include: Observation was made of the [NAME] unit medication room on [DATE] at 9:23 a.m. The following medications were located in the refrigerator in the medication room available for use: *2000 ml (milliliters) bag of TPN (total parental nutrition) solution - expired on [DATE] -the resident on the label had been discharged . *Six bags of 100 cc (cubic centimeter) of dextrose with Penicillin G (used to treat infections caused by bacteria) (1) 4 mg (milligrams) per 50 ml - expired on [DATE]. - Resident on the label was still in the facility. *Two bags of 100 cc of 0.9% Normal Saline with Meropenem (used 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.

Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain a resident's dignity by appropriately placing a resident's catheter collection bag in a discreet location one of 49 residents in the survey sample, Resident # 104. The facility staff placed Resident # 104's catheter collection bag on the front of the control arm of their power wheelchair. The findings include: Resident # 104 was admitted to the facility with diagnoses that included but were not limited to: Parkinson's disease [1] and multiple sclerosis [2]. Resident # 104's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 07/08/2021, coded Resident # 104 as scoring an 11 on the brief interview for mental status (BIMS) of a score of 0 - 15, 11 - being moderately impaired of cognition for making daily decisions. Resident # 104 was coded as requiring extensive assistance of one staff member for activities of daily living. Under section H Bladder and Bowel…

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

Based on observation, resident interview, staff interview and clinical record review, it was determined that the facility staff failed to ensure accommodation of resident needs maintain for two of 49 residents, Resident #45 and Resident #91. The facility staff failed to ensure the call bells for Resident #45 and 91 were positioned and maintained within reach. The findings include: 1. Resident #45 was admitted to the facility with diagnoses that included but were not limited to atrial fibrillation (1) and myocardial infarction (2). Resident #45's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 6/4/2021, coded Resident #45 as scoring a 6 on the brief interview for mental status (BIMS) scale, 6- being severely impaired for making daily decisions. Section G coded Resident #45 as requiring extensive assistance of one staff member for toilet use and personal hygiene. Section G further documented Resident #45 not having any impairment in the upper extremities. The comprehensive care plan for Resident #45 dated 5/28/2021 documented in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, it was determined that the facility staff failed to maintain a homelike environment in one of 126 resident rooms in the facility, (room [ROOM NUMBER]). The window sill in resident room [ROOM NUMBER] was observed with peeling paint and large chips of paint peeled up on the surface. The findings include: On 7/27/2021 at approximately 11:40 a.m., an observation was made of resident rooms in the facility. In resident room [ROOM NUMBER], observation revealed a window over the heating/air conditioning unit on the wall. The sill of the window was approximately 48 inches wide and 12 inches deep. A flower pot was on the window sill. One-quarter of the surface of the window sill, was observed with large chipped areas of peeling paint exposing the sheetrock underneath. Four additional areas approximately six inches in size were observed on the window sill with cracked and peeling paint. The paint chips were raised up from the surface of the window sill.…

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, it was determined that the facility staff failed to ensure the assessment accurately reflected the status of one of 49 sampled residents, (Resident #104). The facility staff failed to accurately code Resident # 104's bladder status on the admission assessment MDS (minimum data set) with an ARD (assessment reference date) of 07/08/2021. The findings include: Resident # 104 was admitted to the facility with diagnoses that included but were not limited to: Parkinson's disease [1] and multiple sclerosis [2]. Resident # 104's most recent MDS (minimum data set) assessment, an admission assessment with an ARD (assessment reference date) of 07/08/2021, coded Resident # 104 as scoring an 11 on the brief interview for mental status (BIMS) of a score of 0 - 15, 11 - being moderately impaired of cognition for making daily decisions. Resident # 18 was coded as requiring extensive assistance of one staff member for activities of daily living. Under section H Bladder and Bowel Resident # 104 was coded under H0100 as having an indwelling catheter…

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 document review, and clinical record review, it was determined that the facility staff failed to develop a baseline care plan for two of 49 residents in the survey sample, Residents #23 and #421. The facility staff failed to develop a baseline care plan for the use of an anti-anxiety medication and for the use of bed rails for Resident #23 and failed to develop a baseline care plan to address the physician ordered indwelling urinary catheter upon admission for Resident #421. The findings include: 1. Resident #23 was admitted to the facility on [DATE], discharged to home on 6/1/21 and readmitted to the facility on [DATE]. The resident had the diagnoses of but not limited to a stroke, quadriplegia, aphasia, diabetes, anxiety, high blood pressure, COVID-19, and contractures. The admission / 5-day MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/19/21 coded the resident as moderately impaired in ability to make daily life decisions. Resident #23 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 clinical record review, staff interview and review of facility documentation it was determined the facility staff failed to ensure professional standards for two of 49 residents in the survey sample, (Resident #421 and # 82). 1. The facility staff failed to clarify Resident #421's as needed pain medication order. The 7/19/21, physician order documented the maximum amount of acetaminophen for a 24 hour period should not exceed 3 grams (3000 mg). The 7/20/21, physician order documented to administer Acetaminophen tablet, 975 mg by mouth every 6 hours for pain (4 times a day for a total of 3900 milligram of Acetaminophen per 24-hour period). 2. The facility staff failed to clarify Resident #82's physician orders for two as needed pain medications to determine which and when to administer each as needed pain medication. The findings include: 1. Resident #421 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: left knee replacement (artificial joint replacement) (6),…

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

Based on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to the implement assistive device safety measures to ensure an environment free of accident hazards for one of 49 residents in the survey sample, Resident #40. The facility staff failed to implement Resident #40's fall mat on 7/26/21, 7/27/21, the morning of 7/28/21 and 7/29/21 per the comprehensive plan of care. The findings include: Resident #40 was admitted to the facility with diagnoses that included but were not limited to cerebral infarction (1) and hemiplegia (2). Resident #40's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/28/2021, coded Resident #40 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15- being cognitively intact for making daily decisions. Section G documented Resident #40 requiring extensive assistance from one staff member for transfers, walking in the room and toilet use. Section J documented Resident #40…

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

Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure the appropriate care and services for a urinary catheter for three of 49 residents in the survey sample, Residents #3, #9 and #104. 1. The facility staff failed to secure Resident #3's indwelling urinary catheter and failed place the urinary catheter collection bag below the level of the bladder. 2. The facility staff failed to maintain Resident #9's urinary catheter bag in a manner to prevent infection. The catheter bag was observed lying on the floor during the dates of the survey. 3. The facility staff failed to position Resident # 104's catheter collection bag below the level of their bladder to prevent backflow of urine and failed to obtain a physician's order for a catheter. The findings include: 1. Resident #3 was admitted to the facility with diagnoses that include but were not limited to metabolic encephalopathy (1) and hypertension (2). Resident #3's most recent MDS (minimum data set) assessment, a quarterly…

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 review of facility documentation the facility staff failed to ensure the medication regimen for two of 49 sampled residents (Resident #114, and Resident #27) was free of unnecessary medications. 1. The facility staff administered the narcotic pain medication Hydrocodone-Acetaminophen to Resident #114, for pain scale ratings below the physician ordered parameters of severe pain (8-10) and failed to attempt non-pharmacological interventions prior to administering the medication. 2. Resident #27 received Diclofenac Sodium Gel 1% (topical analgesic) medication ordered for moderate pain, when pain level was zero. The findings include: 1. Resident # 114 was admitted to the facility on [DATE] with a recent readmission on [DATE], with diagnoses that included but were not limited to: end stage renal disease requiring hemodialysis (a procedure used in toxic conditions and renal [kidney] failure, in which wastes and impurities are removed from the blood by a special…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure residents were free of unnecessary psychotropic medications for two of 49 residents in the survey sample, Residents #62 and #114. 1. The facility staff failed to monitor Resident #62 for targeted behaviors and side effects for the use of Seroquel (1). 2. The facility staff failed to offer non-pharmacological interventions prior to the administration of the as needed (PRN) Ativan an anti-anxiety medication, failed to document the reason for the administration of Ativan anti-anxiety medication, failed to have a stop date for the as needed Ativan anti-anxiety medication and the physician/nurse practitioner failed to document the monitoring for the use of an anti-anxiety medication for Resident #114. The findings include: 1. Resident #62 was admitted to the facility on [DATE]. Resident #62's diagnoses included but were not limited to obsessive compulsive disorder, major depressive…

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

Based on observation, resident interview, staff interview, and facility document review, it was determined that the facility staff failed to serve food at temperatures and flavor that was palatable for meal enjoyment. The findings include: During the survey process for individual resident interviews, surveyors reported that multiple residents with a BIMS of 15 (Brief Interview for Mental Status - which scores cognitive status from 0 to 15 with 0 being severely cognitively impaired and 15 being cognitively intact) complained of the food being cold and not good. On 7/28/21 at 11:40 AM, observation of the trayline was conducted. The temperatures were obtained with a facility thermometer by a dietary staff member. OSM #14 (Other Staff Member) the dietary manager, and OSM #16, a consultant for dietary services, were present. The temperatures were as follows: Riblet: Regular 170 degrees; Pureed 153 degrees. Corn: Regular 190 degrees. Cabbage: Regular 190 degrees; Pureed 161 degrees. Coleslaw: Regular 37.6 degrees. Mashed potatoes: 175 degrees. On 7/28/21 at 12:31 PM a test tray 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 observation, staff interview and facility document review, it was determined that the facility staff failed to store food in a sanitary manner. In the freezer an unsealed box of fish fillets was observed fish fillets in the box were exposed to the environment in the freezer and a bottle of opened thickened orange juice, half used, was not dated with an opened date or placed in the refrigerator after opening. The findings include: On 7/27/21 at 11:37 AM an inspection and observation of the kitchen was conducted. In the freezer an unsealed box of frozen fish fillets was observed. The fish fillets in the box were exposed to the environment in the freezer. In the pantry, a bottle of thickened orange juice had been opened, half used, and was not dated with an opened date or placed in the refrigerator after opening. On 7/27/21 at approximately 11:45 AM, OSM #14 (Other Staff Member) the dietary manager stated that the fillets should have been sealed and the orange juice should have been dated and refrigerated. On 7/28/21 at the end of the day at approximately 5:00 PM, 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 staff interview, clinical record review and facility document review, it was determined the facility staff failed to maintain a complete and accurate medical record for two of 49 residents in the survey sample, Resident #59 and Resident #101. The findings include: 1. The facility staff failed to document the assessment of Resident #59's the AV [arteriovenous] shunt for bruit and thrill every shift, on seven shifts in June 2021 and on eleven shifts in July 2021. Resident #59 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: diabetes mellitus (inability of insulin to function normally in the body) (1), ESRD [end stage renal disease] (inability of the kidneys to excrete wastes and function in the maintenance of electrolyte balance) (2), heart failure (inability of the heart to pump enough blood to maintain normal body requirements) (3) and cerebrovascular accident (abnormal condition in which a hemorrhage or blockage of the blood vessels of the brain leads to 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.