Lakeside Health & Rehabilitation

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 02/26/2024 at approximately 10:50 a.m. an inspection of the kitchen was conducted with OSM (other staff member) #1, dietary manager. 1. On 02/26/2024 at approximately 10:55 a.m., an observation of inside of the walk-in refrigerator during the initial tour of the facility kitchen revealed an open package of sliced cheese, resting on the second shelf from the top. 2. On 02/26/2024 at approximately 11:05 a.m., an observation of the facility's dry storage room revealed a scoop next to an empty plastic bag, laying on top of a flour bin. 3. On 02/26/2024 at approximately 11:45 a.m., an observation during the meal preparation in the facility's kitchen revealed OSM #14's beard was not covered. Further observation revealed OSM #13's hair was hanging out from underneath his ball cap while he was setting an and plating food from the steam table in the facility's kitchen. 4. 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 observation, resident interview, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to accommodate needs for one of 49 residents, Resident #145. The findings include: For Resident #145, the facility staff failed to maintain the call light in a position where she could access it. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/2/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring supervision for eating, extensive assistance for toileting, bathing and bed mobility. A review of the comprehensive care plan dated 10/27/23 revealed, FOCUS: The resident is at risk for falls related to a history of Falls, orthostatic hypotension, fall history, ESRD with hemodialysis, DM and anemia. INTERVENTIONS: Be sure the resident's call light is within reach 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, clinical record review, and facility document review, it was determined that the facility staff failed to maintain a complete and accurate MDS (minimum data set) assessment for two of 49 residents in the survey sample, Residents #120 and #42. The findings include: 1. For Resident #120 (R120), the facility staff failed to code the quarterly MDS assessment with an ARD (assessment reference date) of 2/15/2024 for dialysis. On the most recent MDS assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/15/2024, the resident scored nine out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. Section O failed to evidence documentation of dialysis services within the 14 day assessment period. The physician orders for R120 documented in part, Hemodialysis at (Name, phone number and address of dialysis center) on Monday Wednesday Friday. Pick up time 11am. Order Date: 11/25/2023 . The comprehensive care plan for R120 documented in part, The resident has…

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

Based on staff interview and clinical record review, it was determined that the facility staff failed to revise the comprehensive care plan for two of 49 residents in the survey sample, Residents #23 and #107. 1. For Resident #23 (R23), facility staff failed to revise the comprehensive care plan to identify the specific behaviors being monitored for the use of Zyprexa (1). R23 was admitted to the facility with diagnoses that included but were not limited to psychotic disturbances. On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/01/2024, R23 scored 7 (seven) out of 15 on the BIMS (brief interview for mental status), indicating R23 was severely impaired of cognition for making daily decisions. Section N Medications coded R23 as receiving antipsychotic medication. The physician's order for R23 documented in part, Zyprexa Oral Tablet 2.5 MG (milligrams) (Olanzapine) Give 0.5 tablet by mouth two times a day for bipolar disease related to vascular dementia, unspecified severity .Order Date: 2/12/24. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to follow professional standards of practice for one of 49 residents in the survey sample, Resident #166. The findings include: For Resident #166 (R166), the facility staff failed to administer medications timely and notify the physician when medications were administered past the scheduled timeframe. On the most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 1/11/2024, the resident scored an 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. On 2/26/2024 at 1:52 p.m., an interview was conducted with R166 who stated that they took pain medication and often their medications were given later than they were scheduled. R166 stated that this frustrated them and they never knew when they were able to get 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.

Based on observation, resident interview, staff interview, and facility document review, it was determined facility staff failed to provide treatment and services to maintain or improve mobility for one of 49 residents, Resident #66. The findings include: For Resident #66, the facility staff failed to provide the treatment of the left-hand splint for contracture. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 12/14/23, 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 MDS Section GG-functional abilities and goals coded the resident as being totally dependent for dressing, personal hygiene and bathing. A review of the comprehensive care plan dated 11/4/22 revealed, FOCUS: Alteration in musculoskeletal status r/t contracture of left hand. INTERVENTIONS: Assist the resident with the use of supportive devices (left hand splints) as recommended. A review of the physician orders dated 7/18/23…

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 observation, staff interview, facility document review and clinical record review, the facility staff failed to provide respiratory care consistent with professional standards, for two of 49 residents in the survey, Residents #180 and #60. The findings include: 1. For Resident #180 (R180), the facility staff failed to administer oxygen at the physician prescribed rate of two liters per minute. A review of R180's clinical record revealed a physician's order dated 2/09/24 for oxygen at 2 liters continuously via nasal cannula every shift. On 2/27/24 at 12:55 p.m., R180 was observed lying in bed receiving oxygen via nasal cannula at three-and-a-half liters per minute, as evidenced by the middle of the ball in the oxygen at three-and-a-half liter line. LPN #8 entered the room to help R180 and adjusted his oxygen to 3 liters a minute. On 2/27/24 at 3:58 p.m., R180 was observed lying in bed receiving oxygen via nasal cannula at three liters per minute, as evidenced by the middle of the ball in the oxygen concentrator flowmeter positioned on the three liter line. On 2/28/24 at 9:33…

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 two of 49 residents in the sample Resident #169 and Resident #159. The findings include: 1. For Resident #169, the facility failed to evidence provision of trauma informed care. Resident #169 was admitted to the facility on [DATE] with diagnoses that included but were not limited to sickle cell disease. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 12/26/23, 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 6/5/23 revealed, FOCUS: At risk for psychosocial well-being problem related to pain and weakness. INTERVENTIONS: Monitor/document residents' feelings relative to unhappiness, anger. A trauma informed care plan…

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 two of 49 residents in the sample Resident #169 and Resident #159. The findings include: 1. The facility failed to evidence provision of medically related social services for Resident #169. Resident #169 was admitted to the facility on [DATE] with diagnoses that included but were not limited to sickle cell disease. A review of the comprehensive care plan dated 6/5/23 revealed, FOCUS: At risk for psychosocial well-being problem related to pain and weakness. INTERVENTIONS: Monitor/document residents' feelings relative to unhappiness, anger. There was no trauma informed care plan initiated until 2/26/24 once survey began. A review of the facility's Trauma Informed Screen dated 6/5/23 revealed, Have you ever experienced a type of event that was unusually or especially frightening, horrible, or traumatic? Coded 'yes'.…

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 two of 49 residents in the survey sample were free from unnecessary antipsychotic medications, Residents #23 and Resident #107. 1. For Resident #23 (R23), facility staff failed to identify and monitor the specific behaviors for the use of Zyprexa (1). R23 was admitted to the facility with diagnoses that included but were not limited to psychotic disturbances. On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/01/2024, R23 scored 7 (seven) out of 15 on the BIMS (brief interview for mental status), indicating R23 was severely impaired of cognition for making daily decisions. Section N Medications coded R23 as receiving antipsychotic medication. The physician's order for R23 documented in part, Zyprexa Oral Tablet 2.5 MG (milligrams) (Olanzapine) Give 0.5 tablet by mouth two times a day for bipolar disease related to vascular dementia, unspecified severity .Order Date:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide dental services for one of 49 residents in the survey sample, Resident #102. The findings include: For Resident #102 (R102), the facility staff failed to assist the resident with obtaining a routine dental appointment. R102 was admitted to the facility on [DATE]. On R102's quarterly minimum data set assessment with an assessment reference date of 10/13/23, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 2/27/24 at 9:04 a.m., an interview was conducted with R102. The resident stated she has not seen a dentist since her admission, and she would like to have her gums examined and teeth cleaned. A review of R102's clinical record failed to reveal any dental examinations. On 2/27/24 at 2:54 p.m., an interview was conducted with OSM (other staff member) #3 (the director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility documentation review, clinical record reviews, and in the course of a complaint investigation, the facility staff failed to ensure the facility met the requirements/definitions of a Skilled Nursing Facility (SNF) or a Nursing Facility (NF). This determination has the potential to affect the entire certification of 194 facility beds. There were 83 of the 169 residents in the facility that were in locked units. These units either had locked doors (which required a code to open) on both ends or were located on the second floor (600 rooms) and the elevator and doors leading to the second floor required a code. Surveyor was provided code to unlock doors or elevator when asked for the code. A review of the 50 resident records of residents located on the second floor unit (600 rooms) revealed the following: 24 of 50 had no behavioral/elopement assessments and only 1 of 50 was assessed as exit seeking. A review of the Resident Council minutes 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 observation, staff interview, facility document review, and in the course of a complaint investigation, it was determined that the facility staff failed to serve meals in a palatable manner from 1 of 1 facility kitchens. The findings include: On 5/18/22 at 12:2 PM, an observation of the tray line was conducted. The following temperatures were observed, with temperatures obtained via a facility thermometer by OSM #6 (Other Staff Member) the Dietary Manager: -Green bean casserole 140 degrees -Potatoes 159 degrees -Breaded chicken 160 degrees -Mechanical chicken 130 degrees. OSM #6 put this back in the oven and rechecked at 12:17 PM at 145 degrees. -Hot dogs 155 degrees -Carrots 162 degrees -Chicken soup 180 degrees -Pureed green beans 130 degrees. OSM #6 put this back in the oven and rechecked at 12:17 PM at 140 degrees. -Pureed chicken 145 degrees at 12:17 PM (was not previously on the tray line.) On 5/18/22 at 1:43 PM a test tray was requested. On 5/18/22 at 1:55 PM the cart with the test tray arrived to the unit (400 hall). On 5/18/22 at 2:04 PM the test tray palatability…

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, prepare, and serve food in a safe manner in 1 of 1 facility kitchens. The findings include: On 5/17/22 at 12:19 PM, the kitchen tour was conducted with OSM #6 (Other Staff Member) the Dietary Manager. The following items were observed: -Serving trays were observed wet nesting and dietary staff were hand drying the trays with cloth towels for tray line. -In the walk-in refrigerator: pureed sausage, pureed eggs, and hash brown potatoes, were covered with foil or plastic wrap and one side of the foil or wrap was pulled back, exposing the food to the environment. -A pan of cooked cauliflower was covered but not labeled. -A pan of green beans covered in foil, was on the second shelf of a wire storage rack, with an off-whitish colored liquid dripped onto the foil cover which created a puddle on the foil covering the green beans. -A box of hot dogs with one package opened, that was only partially rewrapped, was stored on a wire rack shelf, over top of a shelf of…

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

Based on staff interview and facility document review, it was determined that the facility staff failed to hold quarterly meetings of the QAPI (quality assurance performance improvement) committee as required. The facility QAPI committee failed to meet in all four quarters of 2020 and 2021, and in the first quarter of 2022. The findings include: On 5/17/22 at 12:00 p.m., and entrance conference was conducted with ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing. At this time, evidence of QAPI committee meetings since the last survey were requested. On 5/17/22 at 4:36 p.m., ASM #1 provided QAPI policies and procedures, as well as the facility's QAPI plan. ASM #1 provided no evidence that the QAPI committee met during 2020, 2021, or during the first quarter of 2022. On 5/19/22 at 5:11 p.m., evidence of QAPI committee meetings during 2020, 2021, and the first quarter of 2022 were again requested from ASM #1. On 5/23/22 at 1:15 p.m., ASM #1 and ASM #2 were interviewed regarding required QAPI committee meetings. ASM #1 stated he had been 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 review of facility's documentation and staff interview, it was determined that the facility failed to promote and enhance each resident's right to a dignified existence by restricting the ability to move freely about the facility for 4 of 20 residents in the survey sample, Residents #109, #118, #119 and #105. There were 83 of the 169 resident in the facility that were in locked units. These units either had locked doors (which required a code to open) on both ends or were located on the second floor (600 rooms) and the elevator and doors leading to the second floor required a code. Surveyor was provided code to unlock doors or elevator when asked for the code. A review of the 50 resident records of residents located on the second floor unit (600 rooms) revealed the following: 24/50 had no behavioral/elopement assessment and only 1/50 being assessed as exit seeking. A review of the Resident Council minutes dated 4/19/22 revealed the following, New business-administration: Administrator invited 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 review of staff interview and facility documentation review, it was determined that the facility failed to promote and facilitate the resident's right to self-determination by restricting resident's choice in freely moving about the facility for 4 of 20 residents in the survey sample, Resident #109, #118, #119 and #105. There were 83 of the 169 resident in the facility that were in locked units. These units either had locked doors (which required a code to open) on both ends or were located on the second floor (600 rooms) and the elevator and doors leading to the second floor required a code. Surveyor was provided code to unlock doors or elevator when asked for the code. A review of the 50 resident records of residents located on the second floor unit (600 rooms) revealed the following: 24/50 had no behavioral/elopement assessment and only 1/50 being assessed as exit seeking. A review of the Resident Council minutes dated 4/19/22 revealed the following, New business-administration: Administrator invited…

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 evidence provision of required resident information to a receiving facility at the time of discharge for four of 52 residents in the survey sample, Residents #124, #106, #33, and #75. The findings include: 1. For Resident #124 (R124), the facility failed to evidence the provision of contact information of the practitioner responsible for care of the resident, resident representative information, advance directive information, instructions for ongoing care and comprehensive care plan goals to the receiving facility when R124 was discharged to the hospital on 3/27/22, 4/19/22, and 5/5/22 due to medical emergencies. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/13/22, R124 was coded as being severely cognitively intact for making daily decisions, having scored zero out of 15 on the BIMS (brief interview for mental status). A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide written notice to the RR (resident representative) and/or Office of the State Long-Term Care Ombudsman for resident discharges for five of 52 residents in the survey sample, Residents #124, #106, #33, #75, and #68. The findings include: 1. The facility staff failed to provide written notice to the RR and the ombudsman, for Resident #124 (R124) when the resident was discharged on 3/27/22, 4/19/22, and 5/5/22 due to medical emergencies. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/13/22, R124 was coded as being severely cognitively intact for making daily decisions, having scored zero out of 15 on the BIMS (brief interview for mental status). A review of R124's clinical record revealed the following progress notes: - 3/27/22 at 2:03 p.m.: Resident is non responsive to sternal rubs and hypotensive (low blood…

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 notice of the facility's bed hold policies at the time of discharge for five of 52 residents in the survey sample, Residents #124, #106, #33, #75, and #68. The findings include: 1. The facility staff failed to provide written notice of the facility's bed hold policies to Resident #124 (R124) when the resident was discharged due to medical emergencies on 3/27/22, 4/19/22, and 5/5/22. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/13/22, R124 was coded as being severely cognitively intact for making daily decisions, having scored zero out of 15 on the BIMS (brief interview for mental status). A review of R124's clinical record revealed the following progress notes: - 3/27/22 at 2:03 p.m.: Resident is non responsive to sternal rubs and hypotensive (low blood pressure). New order to send out to ER (emergency…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interviews, staff interviews and facility document review, it was determined the facility staff failed to develop and/or implement the comprehensive care plan for three of 52 residents in the survey sample, Residents #33, #16 and #63. The findings include: 1. The facility staff failed to implement the comprehensive care plan for smoking for Resident #33. The care plan was not updated to reflect smoking until after surveyor entrance and after surveyor observation of Resident #33 smoking on 5/17/22. Resident #33 was observed smoking on 5/17/22 at 4:00 PM and again on 5/19/22 at 1:00 PM. Staff provided cigarettes and lighter to resident from a locked box they brought with them. Resident #33 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: congestive heart failure, diabetes, dementia, pacemaker and obstructive sleep apnea. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility's documentation and staff interview, it was determined that the facility failed to promote and enhance each resident's quality of life by allowing residents to maintain the highest degree of practicability of well-being for 4 of 20 residents in the survey sample, Resident #109, #118, #119 and #105. There were 83 of the 169 resident in the facility that were in locked units. These units either had locked doors (which required a code to open) on both ends or were located on the second floor (600 rooms) and the elevator and doors leading to the second floor required a code. Surveyor was provided code to unlock doors or elevator when asked for the code. A review of the 50 resident records of residents located on the second floor unit (600 rooms) revealed the following: 24/50 had no behavioral/elopement assessment and only 1/50 being assessed as exit seeking. A review of the Resident Council minutes dated 4/19/22 revealed the following, New business-administration: Administrator invited 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 resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide care and service for a complete dialysis (1) program for two of 52 residents in the survey sample, Residents #16 (R16) and #149 (R149). The findings include: 1a. The facility staff failed to check (R16's) AV (arterial/venous) fistula (2) site for the thrill/bruit (3) according to the physician's orders. (R16) was admitted to the facility with diagnoses that included but were not limited to: end stage renal disease (4), dependent on renal dialysis. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 02/24/2022, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section O Special Treatments, Procedures and Programs coded (R16) for Dialysis while a resident. The physician's order summary for (R16)…

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 ensure one of 20 residents in the survey sample were free of a significant medication error, Resident #102 (R102). The findings include: On the most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 5/6/2022, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired to make daily decisions. The physician order dated, 3/3/2022, documented, Carvedilol Tablet - Coreg (used to treat high blood pressure and heart disease) (1) 3.125 MG (milligrams) - give 1 tablet by mouth every 12 hours every Tue (Tuesday), Thu (Thursday), Sat (Saturday), Sun (Sunday) for HTN (hypertension - high blood pressure) Hold for SBP (systolic blood pressure) < (less than) 120. The May 2022 MAR (medication administration record) documented the above order. On the following days and times, the medication was administered with the documented blood 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.

Based on observation, staff interview, and facility document review, it was determined the facility staff failed to maintain sufficient dietary staff to meet the needs of the residents at the lunch meal on 7/5/22 in one of one facility kitchens. There was insufficient staff from the dietary department working at lunch on 7/5/22, resulting in residents' receiving food which had not been prepared according to the therapeutic menu and recipe. The findings include: On 7/5/22 at 12:01 p.m., lunch service from the tray line in the kitchen was observed. At 12:27 p.m., the employee serving the lunch used a white scoop to serve turkey/rice mixture. The mixture was primarily rice, with small pieces of onion, mushroom, red and yellow pepper, and broccoli. Tiny bits of turkey could be seen in the rice mixture, as well. The turkey pieces were smaller in diameter than a thumbnail. The employee placed less than a full scoop onto each resident's Styrofoam tray. OSM (other staff member) #5, the temporary dietary manager, was asked how much volume a white scoop served. OSM #5 stated the white scoop…

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 employee record review, it was determined the facility staff failed to provide annual performance evaluations for five of five CNAs (certified nursing assistants) reviewed, CNA # 4, CNA #5, CNA #6, CNA #7, and CNA #8. The findings include: Five employee records were reviewed for the documentation of an annul performance review. The following documentation was presented: CNA #4 was hired on 7/16/2012. A Performance Appraisal was dated 10/16/2020. No further documents were provided. CNA #5 was hired on 2/15/2017. A Performance Appraisal was dated 5/30/2019. No further documents were provided. CNA #6 was hired 3/6/2019. There was no Performance Appraisal provided. CNA #7 was hired on 4/11/2007. A Performance Appraisal was dated 7/25/2019. No further documents were provided. CNA #8 was hired on 2/5/2020. There was no Performance Appraisal provided. An interview was conducted with OSM (other staff member) #2, the human resources director, on 5/19/2022 at 9:19 a.m. When asked the process for CNAs to get their annual performance…

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 clinical record review, the facility staff failed to provide accommodations of resident needs by failing to ensure the call bell [a device with a button that can be pushed to alert staff when assistance is needed] was within reach for one of 52 current residents in the survey sample, Resident #317 (R317). The findings include: The facility staff failed to keep (R317's) call bell within their reach. (R317) was admitted to the facility with a diagnosis that included by not limited to: muscle weakness. The most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 05/23/2022, was In progress at the time of the survey. (R317's) admission Assessment dated 05/16/2022 documented in part, Clinical Evaluation Neurological. Orientation. Further review revealed checks mark for Situation, Place, Person indicating (R317) was oriented to those areas stated above. On 05/17/22 at approximately 1:15 p.m., an observation of (R317) revealed they were lying in bed and the call bell was observed hanging over the drawer…

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, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to notify the provider of changes in status for two of 52 residents in the survey sample, Residents #802 and #63. The findings include: 1. For Resident #802 (R802), the facility staff failed to notify the provider of a delay in obtaining an X-ray for the resident's potentially fractured right hip. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/3/22, R802 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). R802 was coded as requiring the extensive assistance of two staff members for bed mobility and transfers. A review of the physician's orders for R802 revealed the following order, dated 4/8/22 at 11:27 p.m.: X-ray to right hip and right knee .for pain to right hip and knee. D/c (discontinue) order once performed. The order was entered by LPN #7. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and facility document review, it was determined during the beneficiary notification facility task, the facility staff failed to provide beneficiary notification for one of three residents, Resident #466. The findings include: During the facility task of beneficiary notification review on 5/18/22. The list of discharges for the last six months was provided on 5/18/22 at 7:30 AM. Resident #466 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: fracture of right femur, schizophrenia, bipolar disease and chronic obstructive pulmonary disease. Resident #466 was discharged on 11/30/21. The most recent MDS (minimum data set) assessment, a discharge return not anticipated assessment, with an ARD (assessment reference date) of 11/30/21, 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 social services progress note dated 11/30/21 at 2:38…

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 a clean, comfortable, homelike environment for two of 52 residents in the survey sample, Resident #135 and Resident #85; and in one of five pantries in the facility. The findings include: 1. The facility staff failed to maintain a clean privacy curtain in Resident #135's (R135) room. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/19/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident is not cognitively impaired for making daily decisions. On 5/17/2022 at approximately 2:15 p.m., an interview was conducted with R135 in their room. Observation of R135's room revealed a privacy curtain hanging between their bed and their roommate's bed. Visible stains were observed from the bottom border of the curtain approximately six inches up onto the curtain surface. R135 stated that the stains…

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

Based on observation, clinical record review, staff interview and facility document review it was determined facility staff failed to revise the care plan for one of 52 residents in the survey sample, Resident #61. The findings include: The facility staff failed to revise the care plan for elopement after 1:1 monitoring was no longer required for Resident #61 (R61). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/17/2022, the resident scored an 10 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident is moderately impaired for making daily decisions. Section E documented R61 having wandering behaviors 4 to 6 days during the assessment period. On 5/17/2022 at approximately 12:45 p.m., an observation was made of R61 in their room. R61 was observed dressed lying on top of his made bed reading a book. R61 was observed wearing a wandergaurd bracelet on the right wrist. R61 was observed to be in the room alone with no staff 1:1 supervision. Additional observations of R61 on 5/17/2022 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, resident interview and clinical record review, it was determined that the facility staff failed to provide foot care services for one of 52 residents in the survey sample, Resident #30. The facility staff failed to provide care and services for Resident #30's (R30) toenails. The findings include: R30 was admitted to the facility with diagnosis that included but were not limited to quadriplegia and atherosclerotic heart disease. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 3/2/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident is not cognitively impaired for making daily decisions. Section G documented R30 requiring extensive assistance of one person for personal hygiene and having functional limitations in range of motion to both upper and lower extremities. On 5/18/2022 at 10:00 a.m., an interview was conducted with R30. R30 was observed…

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, facility document review and clinical record review, it was determined the facility staff failed to evaluate smoking hazard and risk for one of 52 residents, Resident #33. The facility staff failed to evidence that they performed a safe smoking assessment for Resident #33. The findings include: Resident #33 was observed smoking on 5/17/22 at 4:00 PM and again on 5/19/22 at 1:00 PM. Staff provided cigarettes and lighter to residents from locked box they brought with them. Two staff were present with residents as they smoked. Resident #33 did not exhibit any unsafe smoking behavior. A list of smoking times revealed smoking times of 9:00 AM, 1:00 PM, 4:00 PM and 8:00 PM. Resident #33 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: congestive heart failure, diabetes, dementia, pacemaker and obstructive sleep apnea. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (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.

Based on staff interview, facility document review and employee record review, it was determined the facility staff failed to provide mandatory training on an annual basis for two of five CNAs (certified nursing assistants), CNA #5 and CNA #8. The findings include: The training records for five CNAs were reviewed. For CNA #5, the documentation, from the computerized training system, was blank. For CNA #8, the computerized training system documented only two trainings. There was no documentation for either CNA for training in abuse, infection control, dementia or emergency preparedness. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 5/18/2022 at 12:11 p.m. When asked who is responsible for education of the staff and their annual training requirements, ASM #2 stated it was a joint effort between the unit managers, the administrator, and the director of nursing. ASM #2 stated the human resources director is responsible for the [name of the computerized training system used]. An interview was conducted on 5/18/2022 at 12:15 p.m. with…

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

Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to follow the menu for one of 20 residents in the survey sample, Resident #116 (R116). The facility staff failed to serve R116 the recommended amount of turkey/rice stir fry on 7/5/22, and failed to prepare the turkey/rice stir fry according to the approved recipe. The findings include: On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 6/27/22, R116 was coded as being moderately impaired for making daily decisions, having scored nine out of 15 on the BIMS (brief interview for mental status). A review of R116's physician's orders revealed the following order dated 6/22/22: Regular diet, regular texture. On 7/5/22 at 12:01 p.m., lunch service from the tray line in the kitchen was observed. At 12:27 p.m., the employee serving the lunch used a white scoop to serve turkey/rice mixture. The mixture was primarily rice, with small pieces of onion, mushroom, red and yellow pepper, 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 interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to honor the resident's food preferences for two of 20 residents in the survey sample, Residents #115 and #102. The findings include: 1. The facility staff failed to provide Resident #115 (R115) double portions per the resident's preference at lunch on 7/5/22. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/13/22, R115 was coded as being moderately impaired for making daily decisions, having scored 10 out of 15 on the BIMS (brief interview for mental status). A review of R115's clinical record revealed the following order dated 9/30/21: Regular diet. Regular texture for nutrition, double entree portions per preference. On 7/5/22 at 12:01 p.m., lunch service from the tray line in the kitchen was observed. At 12:27 p.m., the employee serving the lunch used a white scoop to serve turkey/rice mixture. The mixture was primarily rice, with…

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

Based on staff interview and clinical record review, it was determined that during the immunization record review, that the facility staff failed to offer, obtain consent for, and/or provide education regarding the influenza and pneumococcal vaccines for two of five residents reviewed, Residents #83 (R83) and #132 (R132). The findings include: 1. The facility staff failed to offer, obtain consent for, and provide education regarding the influenza and pneumococcal vaccines for (R83). On the most recent MDS (minimum data set), an quarterly assessment with an ARD (assessment reference date) of 03/28/2022, the resident scored 9 (nine) out of 15 on the BIMS (brief interview for mental status), indicating the resident is moderately impaired for making daily decisions. Under Section O Special Treatments, Procedures and Programs (R83) was coded as not being offered the influenza vaccine and under O300 Is the Resident's Pneumococcal vaccine up to date? (R83) was coded No. A review of the (R83's) clinical record and EHR [electronic health record] failed to evidence a consent and education 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.

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 notify the physician and/or responsible party of a change in condition for four of 56 residents in the survey sample, Residents #93, #12, #26 and #17. 1. The facility staff failed to notify the physician and/or responsible party when Resident #93's insulin was not administered as ordered. 2. The facility staff failed to notify the physician when Resident # 12's insulin (1) was administered with blood sugars (1) below 100 (mg/dl [milligram/deciliter]). 3. The facility staff failed to notify the physician when Resident # 12's insulin was administered with blood sugars below 150. 4. The facility staff failed to ensure the physician was notified Resident #17's diabetic medications were held without an order, or not administered per the physicians orders. The findings include: 1. The facility staff failed to notify the physician and/or responsible…

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 comprehensive care plan for six of 56 residents in the survey sample, Residents #93, #26, #12, #17, #127, #72. 1. The facility staff failed to implement Resident #93's comprehensive care plan related to the the resident's diabetes. 2. The facility staff failed to implement the comprehensive care plan for the administration of insulin (1) for Resident # 26. 3. The facility staff failed to implement the comprehensive care plan for the administration of insulin (1) for Resident # 12. 4. The facility staff failed to implement Resident #17's comprehensive care plan for the administration of diabetic medications. 5. The facility staff failed to develop a comprehensive care plan to address Resident #127's oxygen use. 6. The facility staff failed to implement Resident #72's comprehensive care plan for the administration of oxygen. The findings include: 1. The facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review it was determined the facility staff failed to ensure one of 56 sampled residents, (Resident #89), received care and services in accordance with professional standards and the comprehensive care plan. The facility staff failed to ensure continuity of care and collaboration with hospice care services for Resident # 89. The findings include: Resident # 89 was admitted to the facility on [DATE] with diagnoses that included but were not limited to benign prostatic hyperplasia (1), Parkinson's disease (2), and hypertension (3). Resident # 89's most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 03/29/2019, coded Resident # 89 as scoring a 3 (three) on the staff assessment for mental status (BIMS) of a score of 0 - 15, 3 (three) - being severely impaired of cognition for making daily decisions. Resident # 89 was coded as requiring extensive assistance of one staff member…

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 ensure the medication regimen for two of 56 sampled residents, (Resident #26 and Resident #17) were free from unnecessary drugs. 1. The facility staff failed administered insulin to Resident # 26's when the resident's blood sugar was below the physician ordered parameter of 150 on multiple dates in February, March and April 2019. 2. The facility staff administered insulin to Resident #17 when the resident's blood sugar was below the physician prescribed parameter of 100, on three occasions in February 2019. The findings include: 1. Resident # 26 was admitted to the facility on [DATE] with diagnoses that included but were not limited to dementia (1), depressive disorder (2), dysphagia (3) and diabetes mellitus (4). Resident # 26's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/08/19, coded…

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 ensure three of 56 residents were free from significant medication errors, Residents # 93, #26 and #17. 1. The facility staff held Resident #93's prescribed insulin without a physician order on multiple occasions in April 2019. 2. The facility staff failed to hold the administration of insulin and administered insulin to Resident # 26's when the resident's blood sugar was below the physician ordered parameter of 150 on multiple dates in February, March and April 2019. 3. The facility staff administered insulin to Resident #17 when the residents blood sugar was below the physician prescribed parameter of 100, on three occasions in February 2019, and failed to administer insulin as ordered on multiple occasions in February, March and April 2019. The findings include: 1. The facility staff held Resident #93's insulin without a physician order 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 observation, staff interview and facility document review, it was determined that the facility staff failed to store and prepare food in accordance with professional standards of food service safety. 1. The facility staff failed to ensure food was discarded on before the expiration date. 2. The facility staff failed to ensure hair was covered in the food preparation area. The findings included: 1. The facility staff failed to ensure food was discarded on before the expiration date. On 4/30/19 at approximately 11:05 a.m., an observation was made of the dry storage room in the kitchen with OSM (other staff member) #4, the Food Service Manager. An observation was made of an opened bag of cereal with a hand written expiration sticker dated 3/23/19. On 4/30/19 at approximately 11:07 a.m., an observation was made of the reach in refrigerator in the kitchen with OSM #4, the Food Service Manager. Four cartons of fat free skim milk dated 4/23/19 was found to be past the expiration date. On 4/30/19 at approximately 11:10 a.m., an observation was made of the walk in refrigerator 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 staff interview and clinical record review, it was determined that the facility staff failed to provide comprehensive hospice services for one of 65 residents in the survey sample, Resident # 89. The facility staff failed to evidence consistent communication and collaboration for resident # 89's hospice care. The findings include: Resident # 89 was admitted to the facility on [DATE] with diagnoses that included but were not limited to benign prostatic hyperplasia (1), Parkinson's disease (2), and hypertension (3). Resident # 89's most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 03/29/2019, coded Resident # 89 as scoring a 3 (three) on the staff assessment for mental status (BIMS) of a score of 0 - 15, 3 (three) - being severely impaired of cognition for making daily decisions. Resident # 89 was coded as requiring extensive assistance of one staff member for activities of daily living. Section O Special Treatments, Procedures and Programs…

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 follow infection control practices for two of 56 residents in the survey sample, Residents # 65 and # 127 and during dining observations in two of two dining facility dining rooms, (main dining room and Arcadia dining room). 1. The facility staff failed to implement infection control practices during Resident # 65's wound care. 2. The facility staff failed to keep their thumbs off the food surface of dinner plates and refrain from touching resident's dinner rolls with bare hands while serving the resident's lunch in the main dining room. 3a. The facility staff failed to follow infection control practice for the care of Resident #127's respiratory equipment, Resident #127's nasal cannula was observed directly on the floor during separate observation. 3b. The facility staff failed to follow infection control practice for the care of Resident's #127 indwelling urinary…

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 facility staff failed to serve food in a manner to promote resident dignity for two of 56 residents in the survey sample, Residents # 118 and # 30. 1. On 04/30/19 at 12:00 p.m., during lunch service in the facility's main dining room the facility staff failed serve Resident # 118 her meal until after the two other residents seated at the table were served and were eating their meals. Resident # 118 waited fifteen minutes to be served her meal. 2. On 4/30/19 during the lunch service in the Arcadia dining room the facility staff failed to serve Resident #30 her meal until after the residents seated at her table had been served and were eating their meals, Resident #30 waited 12 minutes for her meal to be served. The findings include: 1. On 04/30/19 at 12:00 p.m., during lunch service in the facility's main dining room the facility staff failed serve Resident # 118 her meal until after the two other…

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 notice of Medicare non-coverage for two of 56 residents in the survey sample, Residents #354 and #355. 1. Resident #354's last covered day of Medicare Part A services was 11/7/18. The facility staff failed to notify Resident #354 (and/or the resident's representative) of the last covered day and the right to appeal. 2. Resident #355's last covered day of Medicare Part A services was 1/21/19. The facility staff failed to notify Resident #355 (and/or the resident's representative) of the last covered day and the right to appeal. The findings include: 1. Resident #354's last covered day of Medicare Part A services was 11/7/18. The facility staff failed to notify Resident #354 (and/or the resident's representative) of the last covered day and the right to appeal. Resident #354 was admitted to the facility on [DATE]. Resident #354's diagnoses included but were not limited 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, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide a homelike environment for one of 56 residents in the survey sample, Resident #58. Resident #58's room failed to provide a homelike environment as she only had a bed and over bed table. There was no other furniture on her side of the room. The findings include: Resident #58 was admitted to the facility 11/29/18 with diagnoses that included but were not limited to: cerebral palsy [A group of disorders that affect a person's ability to move and to maintain balance and posture (1)], intellectual disability [Refers to a group of disorders characterized by a limited mental capacity and difficulty with adaptive behaviors such as managing money, schedules and routines, or social interactions. Intellectual disability originates before the age of 18 and may result from physical causes, such as autism or cerebral palsy, or from nonphysical causes, such as lack of stimulation and adult responsiveness (2)] and high blood pressure. The most recent 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, facility document review, and clinical record review, it was determined that the facility staff failed to ensure the required documentation was provided to the receiving facility at the time of a transfer for one of 56 residents in the survey sample, Resident # 48. The facility staff failed to evidence that all required documentation and information was provided to the receiving provider for Resident # 48's facility-initiated transfer to the hospital on [DATE]. The findings include: Resident # 48 was admitted to the facility on [DATE] and a readmission on [DATE] with diagnoses that included but were not limited to heart failure (1), chronic obstructive pulmonary disease (2), and anemia (3). Resident # 48's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/22/2019, coded Resident # 48 as scoring a 14 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 14 - being cognitively intact for making daily decisions. 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 the required notifications of a transfer for one of 56 residents in the survey sample, Resident # 48. The facility staff failed to provide Resident # 48 and the Resident # 48's representative written notification and failed to notify the ombudsman of a facility-initiated transfer on 04/18/19 for Resident # 48. The findings include: Resident # 48 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to heart failure (1), chronic obstructive pulmonary disease (2), and anemia (3). Resident # 48's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/22/2019, coded Resident # 48 as scoring a 14 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 14 - being cognitively intact for making daily decisions. The nurse's Progress Notes, dated 04/18/2019 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.

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 a complete and accurate MDS (minimum data set) assessment for two of 56 residents in the survey sample, Resident #66 and Resident #65. 1. The facility staff failed to accurately code a BIMS (brief interview for mental status) assessment for Resident #66 on the quarterly MDS (minimum data set), assessment, with an ARD (assessment reference date) of 3/12/19. 2. The facility staff failed to ensure Resident # 65's MDS, a quarterly review assessment with an ARD (assessment reference date) of 03/12/19 was complete and accurate. Section C and section D of the assessment had columns marked with dashes [-] instead of numbers. The findings include: 1. Resident #66 was admitted to the facility on [DATE]. Diagnoses included but were not limited to: chronic diastolic heart failure (1), anemia, unsteadiness on feet and peripheral vascular disease (2). The most recent MDS (minimum data set), a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure one of 56 residents in the survey sample, (Resident #93) had a completed Level I PASARR (preadmission screening and resident review). The facility staff failed to have a Level I PASARR completed for Resident #93, to ensure the resident was evaluated and receiving care and services in the most integrated setting appropriate for the resident's needs. The findings include: Resident #93 was admitted to the facility on [DATE] with a recent readmission on [DATE], with diagnoses that included but were not limited to: dementia, psychosis [major mental disorder in which the person is usually detached from reality and has impaired perceptions, thinking, responses and interpersonal relationships (1)], diabetes and high blood pressure. The most recent MDS (minimum data set) assessment with an assessment reference date of 4/3/19, coded the resident as scoring a 1 on the BIMS (brief interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined that facility staff failed to review or revise the care plan for two of 56 residents in the survey sample, Resident # 18 and # 39. 1. The facility staff failed to update Resident # 89's comprehensive care with current diversionary interventions to alleviate Resident # 89's pain. 2. The facility staff failed to review and revise the comprehensive care plan to address Resident #18's AICD (automatic internal cardiac device). The findings include: 1. The facility staff failed to update Resident # 89's comprehensive care with current diversionary interventions to alleviate Resident # 89's pain. Resident # 89 was admitted to the facility on [DATE] with diagnoses that included but were not limited to benign prostatic hyperplasia (1), Parkinson's disease (2), and hypertension (3). Resident # 89's most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 03/29/2019, coded…

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 follow professional standards of practice for documentation in the clinical record anf the admoinistartion of medications for two of 56 residents in the survey sample, Resident #93 and Resident #12. 1. On 5/1/19, the facility staff documented Resident #93's Acute Transfer Document Checklist dated, 3/18/19, without indicating the date the documentation was completed on the form or that the documentation made was a late entry. 2. The facility staff failed to clarify Resident # 12's physician ordered parameters for Novolog insulin to determine when and if the insulin should be held based on the residents blood sugar of 100. The findings include: Resident #93 was admitted to the facility on [DATE] with a recent readmission on [DATE], with diagnoses that included but were not limited to: dementia, psychosis [major mental disorder in which the person is usually detached from reality and has…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility and clinical record review, it was determined that the facility staff failed to provide the necessary treatment and services, consistent with professional standards of practice, to promote healing, and prevent infection of a pressure injury for one of 56 residents in the survey sample, Resident 65. The facility staff failed to provide a clean barrier under Resident # 65's right heel and failed to prevent the heel from coming into contact with a contaminated area. The findings include: Resident # 65 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Alzheimer's disease (1), diabetes mellitus, (2), hypertension (3) and depressive disorder (4). Resident # 65's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 03/12/19, failed to coded Resident # 65 on the brief interview for mental status (BIMS). Resident # 65 was coded as being totally dependent of one staff member 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, it was determined that facility staff failed to provide appropriate treatment and services for a suprapubic catheter for one of 56 residents in the survey sample, Residents # 127. The facility staff failed to prevent Resident # 127's catheter collection bag and tubing from resting on the floor. The findings include: Resident #127 was admitted to the facility on [DATE], with diagnoses that included but were not limited to: hypertension (1), coronary artery diseases (CAD) (2), and dementia (3). The most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 04/15/19, coded the resident as scoring a 7 on the BIMS (brief interview for mental status) score of 0-15, 7 indicating severe cognitive impairment for daily decision-making. The resident was coded as being totally dependent upon two or more staff members for all of his activities of daily living. Section H Bladder and Bowel Resident # 127 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to provide respiratory care and services consistent with professional standards of practice for two of 56 residents in the survey sample, Resident #72 and Resident #127. 1. The facility staff failed to provide oxygen according to the physicians order for Resident #72. 2. The facility staff failed to ensure Resident # 127's nasal cannula was stored in a sanitary manner when not in use. The findings include: 1. The facility staff failed to provide oxygen according to the physicians order for Resident #72. Resident #72 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included but were not limited to: atrial fibrillation (1), chronic obstructive pulmonary disease (COPD) (2), anemia and weakness. The most recent MDS (minimum data set), a Medicare fourteen day assessment, with an ARD (assessment reference date) of 3/17/19 coded the resident as having a score…

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 that facility staff failed to provide pain management for one of 56 residents in the survey sample, Residents # 12. The facility staff failed to implement non-pharmacological interventions prior to administering as needed pain medication to Resident #32. The findings include: Resident # 12 was admitted to the facility on [DATE] with diagnoses that included but were not limited to malignant neoplasm of lung (1), depressive disorder (2), diabetes mellitus (3) gastroesophageal reflux disease (4), and convulsions (5). Resident # 12's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 01/28/19, coded Resident # 12 as scoring a 14 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 14- being cognitively intact for making daily decisions. Resident # 12 was coded as being independent and not requiring set up by staff members for activities of daily living.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility document review, it was determined the facility staff failed to ensure that expired laboratory supplies were not available for resident use in one of three medication supply rooms inspected. The facility staff failed to ensure that expired laboratory supplies were not available for resident use in the 600 Unit medication supply room. The findings include: On [DATE] at 1:32 PM an inspection was conducted of Unit #600's medication supply room. The inspection of Unit #600's medication supply room revealed that two Universal Viral Transport Media and Swabs (1), with an expiration date of 12/2018 were in the laboratory collection basket and available for resident use. On [DATE] at 1:45 PM an interview was conducted with LPN (Licensed Practical Nurse) #3. LPN #3 was asked about the process staff follows for the maintenance of the medication room. LPN #3 stated, The medical supply personnel clean the room nightly. When LPN #3 was asked about…

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 functional furniture for one of 56 residents in the survey sample, Resident #58. Resident #58's room failed to provide a nightstand for Resident #58. The findings include: Resident #58 was admitted to the facility 11/29/18 with diagnoses that included but were not limited to: cerebral palsy [A group of disorders that affect a person's ability to move and to maintain balance and posture (1)], intellectual disability [Refers to a group of disorders characterized by a limited mental capacity and difficulty with adaptive behaviors such as managing money, schedules and routines, or social interactions. Intellectual disability originates before the age of 18 and may result from physical causes, such as autism or cerebral palsy, or from nonphysical causes, such as lack of stimulation and adult responsiveness (2)] and high blood pressure. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date…

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