Our Lady Of Hope Health Center

Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to assess one of 28 residents in the survey sample for self-administration of medication, Resident #41. The findings include: For Resident #41 (R41), two bottles of diabetic Tussin (1) liquid medication and two bottles of Systane (2) lubricant eye drops were observed at the bedside in R41's room unsecured. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 4/14/2023, the resident scored 11 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately impaired for making daily decisions. On 5/2/2023 at 10:14 a.m., an observation of R41's room was conducted. Two bottles of diabetic Tussin liquid medication were observed on a corner shelf storage rack, one four ounce bottle was observed to be unopened and one 8 ounce bottle was observed to be approximately three-quarters full. Two bottles of Systane lubricant eye drops were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility documentation review, it was determined that the facility failed to promote and facilitate the resident's right to self-determination by promoting resident's choice in desired bedtime for one of 28 residents in the survey sample, Resident #23. The findings included: For Resident #23, the facility staff failed to promote the resident's desired bedtime. Resident #23 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: right lower leg fracture, DM (diabetes mellitus) and depression. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 3/20/23, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring limited assistance for bed mobility, transfer, walking, locomotion,…

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

Based on staff interview and clinical record review, it was determined that the facility staff failed to maintain an accurate MDS (minimum data set) assessment for one of 28 residents in the survey sample, Resident #29. The findings include: For Resident #29 (R29), the facility staff failed to code the quarterly MDS assessment with an ARD (assessment reference date) of 2/27/2023 for hospice services received during the assessment period. Review of the clinical record for R29 revealed the most recent MDS assessment to be a quarterly MDS with an ARD of 2/27/2023. Section O of the assessment failed to document R29 receiving hospice services during the assessment period. The physician orders for R29 documented in part, Admit to [Name of hospice] for Alzheimer's disease. Order Date: 11/24/2022. The comprehensive care plan for R29 failed to evidence a care plan related to hospice services. On 5/2/2023 at 1:45 p.m., an interview was conducted with RN (registered nurse) #2, MDS coordinator. RN #2 stated that they used the RAI (resident assessment instrument) manual when completing the MDS…

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

Based on staff interview and clinical record review, it was determined that the facility staff failed to develop the comprehensive care plan for one of 28 residents in the survey sample, Resident #29. The findings include: For Resident #29 (R29), the facility staff failed to develop the comprehensive care plan to include hospice services. Review of the clinical record for R29 revealed the most recent MDS assessment to be a quarterly MDS with an ARD of 2/27/2023. Section O of the assessment failed to document R29 receiving hospice services during the assessment period. The physician orders for R29 documented in part, Admit to [Name of hospice] for Alzheimer's disease. Order Date: 11/24/2022. Review of the comprehensive care plan for R29 failed to evidence a care plan related to hospice services. The progress notes for R29 documented in part, 2/13/2023 3:21 p.m. Resident currently on hospice, denies pain or discomfort at this time. Will continue to monitor and treat per provider orders. The progress notes further documented, 2/27/2023 10:45 a.m. MDS Quarterly - (Name of R29) is a LTC…

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

Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to secure medications in resident rooms for two of 28 residents in the survey sample, Resident #41 and Resident #35. The findings include: 1. For Resident #41 (R41), the facility staff failed to secure two bottles of diabetic Tussin (1) liquid medication and two bottles of Systane (2) lubricant eye drops were observed at the bedside in R41's room unsecured. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 4/14/2023, the resident scored 11 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately impaired for making daily decisions. On 5/2/2023 at 10:14 a.m., an observation of R41's room was conducted. Two bottles of diabetic Tussin liquid medication were observed on a corner shelf storage rack, one four ounce bottle was observed to be unopened and one 8 ounce bottle was observed to be approximately three-quarters…

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

Based on observation, resident interview, clinical record review, facility document review and staff interview, it was determined facility staff failed to review the comprehensive care plan for one of 32 residents in the survey sample, Resident #28. On 11/14/21 Resident #28 sustained a fall. The residents comprehensive care plan was not reviewed or revised to address the residents 11/14/21 fall. The findings include: Resident #28 was admitted to the facility with diagnoses that included but were not limited to atrial fibrillation (1), pneumonia (2), and chronic respiratory failure with hypoxia (3). Resident #28's most recent MDS (minimum data set), a 5-day assessment with an ARD (assessment reference date) of 12/03/2021, coded Resident #28 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. Section J of the assessment documented Resident #28 having a fall in the month prior to entry and no falls since admission/entry or reentry. On 12/7/2021 at approximately 11:30 a.m., an observation was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, clinical record review, facility document review and staff interview, it was determined facility staff failed to store respiratory equipment in a sanitary manner for two of 32 residents in the survey sample, Resident #28 and Resident #62. The facility staff failed to store nebulizer equipment in a sanitary manner for Resident #28 and failed to store an incentive spirometer in a sanitary manner for Resident #62. The findings include: 1. The facility staff failed to store nebulizer (1) equipment in a sanitary manner for Resident #28. Resident #28 was admitted to the facility with diagnoses that included but were not limited to congestive heart failure (2) and chronic respiratory failure with hypoxia (3). Resident #28's most recent MDS (minimum data set), a 5-day assessment with an ARD (assessment reference date) of 12/03/2021, coded Resident #28 as scoring a 14 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 14- being cognitively intact for making…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that the facility staff failed to ensure that training records reviewed included all the required annual training for one of 5 CNA [certified nursing assistant] records reviewed, CNA #1. The findings include: On 12/8/21 a review of 5 CNA (Certified Nursing Assistant) training / education records were reviewed. CNA #1 was hired on 5/16/11 and her most recent completed anniversary year for training and education was 5/16/20 to 5/16/21. A review of CNA #1's training records for 5/16/20 to 5/16/21 failed to evidence that any abuse training was provided. On 12/08/21 at 2:19 PM, an interview was conducted with ASM #1 (Administrative Staff Member) the Executive Director. He stated that he looked everywhere and contacted the former Administrator and searched for any ad hoc abuse training. He stated that none was found. He stated that the facility does not have a training/education coordinator due to the facility being only a 75 bed facility. He stated that (ASM #2, the Director of Nursing)…

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

Based on observations, staff interview and facility document review, it was determined the facility staff failed to store, food in accordance with professional standards for food service safety. The facility staff failed to dispose of expired food during the facility task- kitchen observation on 12/7/21 at 9:45 AM. The findings include: On 12/7/21 at 9:45 AM, an observation was conducted in the main kitchen dry storage room with OSM (other staff member) #3, the director of dining services. A 32-ounce bag of walnut halves and pieces was torn open and uncovered, with plastic wrap at the bottom of the bag. On the spice rack, there was a 20-ounce grape jelly jar, one third full, the jelly was at room temperature and the label on the bottle documented refrigerate after opening. An interview was conducted on 12/7/21 at 10:00 AM with OSM (other staff member) #3, the director of dining services. When asked if the walnuts should be opened, OSM #3 stated, No, they should be closed. It looks like someone was snacking. When asked about the grape jelly and the length of time out of the…

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

Based on observation, staff interview, and facility document review, it was determined the facility staff failed to maintain the dumpster area in a clean and sanitary manner to prevent pests. Behind the three facility dumpsters, Styrofoam cups, three used gloves, one green and two blue were observed on the ground. Bits of trash were observed behind all three dumpsters The findings include: Observation was made of the three facility dumpsters was conducted on 2/27/2020 at 9:17 a.m., with OSM (other staff member) #3, the director of maintenance. Between two dumpsters, a puddle of spilled milk was observed on the ground. Behind the dumpsters, Styrofoam cups, three used gloves, one green and two blue were observed on the ground. There were bits of trash behind all three dumpsters. There were leaves and pine needles in the debris behind the dumpsters. When asked who is responsible for maintaining the area, OSM #3 stated ultimately, the grounds department. A copy of the policy for maintaining the dumpsters and dumpster area was requested. The facility policy titled, Dumpster Cleaning 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, family interview, facility document review, and clinical record review, it was determined the facility staff failed to implement the facility policies to meet the requirements for advanced directives for four of thirty-eight residents, (Residents #31, Resident #33, Resident #14 and Resident #45). The facility staff failed to evidence documentation of an annual review of the advanced directives and wishes with Resident #31 and/or the resident's responsible party (RP), Resident #33 and/or the residents RP, Resident #14 and /or the residents RP, and Resident #45 and/or the resident's responsible party. The findings include: 1. Resident #31 was admitted to the facility on [DATE]. Resident #31's diagnoses included but were not limited to: Alzheimer's disease (progressive loss of mental ability and function) (1), chronic kidney disease (decreased function of the kidneys) (2) and hydronephrosis (distension of the kidney, caused by accumulation of urine that cannot flow out…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review and revise the comprehensive care plan for five of thirty-eight residents in the survey sample, (Residents #17, #27, #55, #161, and #9). The facility staff failed to review and revise the comprehensive care plans for Resident #17, Resident # 27, Resident #55, Resident # 161 and Resident #9 to address and include the use of bed rails. The findings include: 1. Resident #17 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: acute respiratory failure [inability of the heart and lungs to maintain an adequate level of gas exchange.] (1), atherosclerotic heart disease, [plaque consisting of cholesterol and lipids form on inner arterial walls of the heart.] (2); and pneumonia [inflammation of the lungs usually by bacterial infection.] (3). Resident #17's most recent MDS (minimum data set) assessment, an admission assessment,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review, it was determined that the facility staff failed to implement bed rails requirements for eight of 38 residents in the survey, Residents #9, #14, #45, #161, #162, #17, #27, and #55. The facility staff failed to attempt appropriate alternatives prior to use, failed to assess for the risk of entrapment, failed to review risks and benefits and failed to obtained informed consent prior to the use of bed rails for Residents ##9, #14, #45, #161, #162, #17, #27, and #55. The findings include: 1. Resident #9 was admitted to the facility on [DATE], with diagnoses that included but were not limited to: fracture of her femur, high blood pressure, abnormalities of gait and mobility, and diabetes. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/3/19, coded the resident as scoring a 12 on the BIMS (brief interview for mental status) score, indicating she was moderately impaired…

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

Based on staff interview and facility document review, it was determined that the facility staff failed to complete annual CNA (certified nursing aide) performance reviews for seven of ten CNA employee records reviewed. The facility staff failed to complete annual performance reviews for CNA #1, CNA #2, CNA #3, CNA#4, CNA #5, CNA #6 and CNA #7. The findings include: The employee files of ten CNAs was completed and revealed the following: CNA #1 was hired on 10/11/05. Review of CNA #1's employee record revealed the last performance review was completed on 3/2/17. CNA #2 was hired on 6/13/17. Review of CNA #2's employee record revealed no performance review. CNA #3 was hired on 9/27/02. Review of CNA #3's employee record revealed no performance review. CNA #4 was hired on 5/16/11. Review of CNA #4's employee record revealed the last performance review was completed on 1/27/17. CNA #5 was hired on 8/22/18. Review of CNA #5's employee record revealed no performance review. CNA #6 was hired on 7/7/08. Review of CNA #6's employee record revealed the last performance review was completed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 inspect beds to identify areas of possible entrapment for eight of 38 residents, Residents #9, #14, #45, #161, #162, #17, #27, and #55. The findings include: 1. Resident #9 was admitted to the facility on [DATE], with diagnoses that included but were not limited to: fracture of her femur, high blood pressure, abnormalities of gait and mobility, and diabetes. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/3/19, coded the resident as scoring a 12 on the BIMS (brief interview for mental status) score, indicating she was moderately impaired to make daily cognitive decisions. In Section G - Functional Status, the resident was coded as requiring extensive assistance of one staff member for moving in the bed. On 2/25/2020, at 1:48 p.m., an observation and interview was conducted with Resident #9. The resident was in her bed 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 facility document review, it was determined the facility staff failed to implement their abuse policy for three of twenty-five employee record reviews, (CNA (certified nursing assistant) #8, LPN (licensed practical nurse) #5 and LPN #7). The facility failed to perform a timely criminal background check for CNA #8 and failed to obtain references for LPN #5 and LPN #7. The findings include: A review of twenty-five employee records revealed the following: - Review of the employee file for CNA #8 revealed a hire date of 4/17/19. Further review of the employee file failed to evidence documentation of a criminal background check for CNA #8. - Review of the employee file for LPN #5, revealed a hire date of 4/17/19. Further review of the employee file failed to reveal any reference checks at or before the date of hire. - Review of the employee file for LPN #7, revealed a hire date of 5/22/19. Further review of the employee file failed to reveal any reference checks at or before the date of hire. An interview was conducted on 2/27/20 at 8:07 AM with OSM (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 the facility staff failed to evidence transfer discharge requirements to the hospital for one of thirty-eight residents, Resident #31, when the resident was transferred to the hospital on 2/8/20. The findings include: Resident #31 was admitted to the facility on [DATE]. Resident #31's diagnoses included but were not limited to: Alzheimer's disease (progressive loss of mental ability and function) (1), chronic kidney disease (decreased function of the kidneys) (2) and hydronephrosis (distension of the kidney, caused by accumulation of urine that cannot flow out due to an obstruction) (3). Resident #31's most recent MDS (minimum data set) assessment, a quarterly admission assessment, with an assessment reference date of 1/15/20, coded the resident as scoring 3 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. The resident was coded as requiring…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide written notification upon transfer for one of thirty-eight residents in the survey sample, Resident #31. The facility staff failed to provide written notice of the reason for transfer to Resident #31 and or to the resident responsible party, when Resident #31 was transferred to the hospital on 2/8/2020. The findings include: Resident #31 was admitted to the facility on [DATE]. Resident #31's diagnoses included but were not limited to: Alzheimer's disease (progressive loss of mental ability and function) (1), chronic kidney disease (decreased function of the kidneys) (2) and hydronephrosis (distension of the kidney, caused by accumulation of urine that cannot flow out due to an obstruction) (3). Resident #31's most recent MDS (minimum data set) assessment, a quarterly admission assessment, with an assessment reference date of 1/15/2020, coded the resident as scoring 3 out of 15 on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to ensure a PASAAR (Pre-admission Screening and Resident Review) was completed prior to admission for two of 38 residents in the survey sample, (Residents #34 and #55). The facility staff failed to ensure a level I PASARR was completed for Resident #34 and Resident #55, to ensure the residents were evaluated and receiving care and services in the most integrated setting appropriate for the residents' needs. The findings include: Resident #34 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: anxiety disorder, Bipolar disorder (a mental disorder characterized by episodes of mania and depression) (1), and major depressive disorder. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 1/21/2020 coded the resident as scoring a 1 on her BIMS (brief interview for mental status) score, indicating…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to develop a complete baseline care plan for one of 38 residents in the survey sample, Resident #162. The facility staff failed to develop a baseline care plan to address Resident #162's use of bed rails. The findings include: Resident #162 was admitted to the facility on [DATE]. Resident #162's diagnoses included but were not limited to diabetes, constipation and pulmonary fibrosis (a lung disease). Resident #162's admission MDS (minimum data set) assessment had not been completed yet at the time of the survey. An admission observation report dated 2/21/20 documented Resident #162 was alert and oriented to person, place, time and situation. Resident #162's baseline care plan with an admission date of 2/21/20 documented a section titled, Required Safety/Enablers measures. There was an option for side rails (bed rails); however, this option was not checked. On 2/25/20 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, family interview, facility document review and clinical record review, it was determined that the facility staff failed to implement the comprehensive care plan for two of 38 residents in the survey sample, ((Residents #163 and #14). The facility staff failed to implement Resident #163's oxygen care plan and failed to implement the Resident # 14's comprehensive care plan for side rail protectors. During separate observations, Resident #14 was observed lying in bed with bilateral side rails up. One side rail was covered, the other rail was uncovered and the black side rail covering was observed on the floor under the resident's bed. The findings include: 1. Resident #163 was admitted to the facility on [DATE]. Resident #163's diagnoses included but were not limited to respiratory failure, acute kidney failure and muscle weakness. Resident #163's quarterly MDS (minimum data set) with an ARD (assessment reference date) of 11/20/19, coded Resident #163's cognition as severely…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide respiratory care and services for one of 38 residents in the survey sample, (Resident #163). The facility staff failed to administer oxygen to Resident #163 at the physician prescribed rate of three liters per minute. The findings include: Resident #163 was admitted to the facility on [DATE]. Resident #163's diagnoses included but were not limited to respiratory failure, acute kidney failure and muscle weakness. Resident #163's quarterly MDS (minimum data set) with an ARD (assessment reference date) of 11/20/19, coded Resident #163's cognition as severely impaired. Section G coded the resident as requiring extensive assistance of one staff with bed mobility and personal hygiene. Section O coded Resident #163 as receiving oxygen therapy. Review of Resident #163's clinical record revealed a physician's order dated 2/19/20 for oxygen at three…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 dialysis services, were provided consistent with professional standards of practice, and the comprehensive person-centered care plan, for one of 38 residents in the survey sample, Resident #55. The facility staff failed to evidence communication with the dialysis center and failed to have a contract with the dialysis center provider. The findings include: Resident #55 was admitted to the facility on [DATE]. Resident #55's diagnoses included but were not limited to: pneumonia [inflammation of the lungs usually caused by an infection.] (1), bipolar disorder [mental disorder characterized by mania and depression.] (2); schizophrenia [mental disorder characterized by gross distortions of reality, disturbances of thought, language and perception.] (3) Resident #55's most recent MDS (minimum data set) assessment, an admission assessment, with an 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.

Based on staff interview and facility document review, it was determined that the facility staff failed to ensure required annual in-service training's for CNAs (certified nursing aides) was completed for three of ten CNA records reviewed, (CNAs #3, #5 and #7). The facility staff failed to ensure CNAs #3, #5 and #7 completed the required annual 12 hours of training, including dementia management training and resident abuse prevention training. The findings include: Review of the employee records for ten CNAs revealed the following: CNA #3 was hired on 9/27/02. Review of CNA #3's employee record failed to reveal any completed trainings. CNA #5 was hired on 8/22/18. Review of CNA #5's employee record failed to reveal any completed trainings. CNA #7 was hired on 11/7/18. Review of CNA #7's employee record failed to reveal any completed trainings. On 2/26/20 at 5:55 p.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated the facility staff utilizes an online training company that determines the types of trainings that must be…

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