Rosedale Health & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, and facility document review, the facility staff failed to provide dignity and respect for two of 17 residents in the survey sample, Residents #4 and #9. The findings include: 1. For Resident #4 (R4), the facility staff failed to speak to the resident in a respectful and dignified manner. A grievance form regarding R4, dated 12/12/24 documented, Per sister, (name of RN [registered nurse] #4 [agency nurse]) was rude and abrasive (with) resident and sister after waiting for hours for someone. Per (name of sister), (name of RN #4) stated things like, 'I am busy too.' Per sister, not customer service appropriate. Initial Action: Date: 12/11/2024: Spoke (with) (name of RN #4). Per (name of RN #4) felt verbally abused by sister. However was abrasive with this unit manager as well. Follow Up Action: Date: 12/12/2024: RN to be DNR (do not return) from facility. Resident council meeting minutes dated 12/18/24, 1/22/25, 2/19/25, and 3/19/25 documented, Nursing: Customer service issues/staff…

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

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to meet room change requirements prior to a room change for one of 17 residents in the survey sample, Resident #3. The findings include: For Resident #3 (R3), the facility staff failed to provide a written notice of a room change and ensure the resident consented to the roommate assignment prior to the room change on 11/21/24. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/22/24, the resident scored 15 out of 15 on the (brief interview for mental status) assessment, indicating they were cognitively intact for making daily decisions. The assessment further documented no behaviors observed during the assessment period and active discharge planning occurring for the resident to return to the community. The admission record for R3 documented the resident as their own responsible party. The census list for R3 documented a room change on 11/21/24 from Unit one private room to Unit two semi-private…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to honor a resident's right to refuse a room change for one of 17 residents in the survey sample, Resident #3. The findings include: For Resident #3 (R3), the facility staff failed to honor a resident's right to refuse a room change on 11/21/24. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/22/24, the resident scored 15 out of 15 on the (brief interview for mental status) assessment, indicating they were cognitively intact for making daily decisions. The assessment further documented no behaviors observed during the assessment period and active discharge planning occurring for the resident to return to the community. The admission record for R3 documented the resident as their own responsible party. The census list for R3 documented an admission to Unit one to a private room with a room change on 11/21/24 to Unit two to a…

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

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to notify the physician/nurse practitioner and/or the responsible party of resident changes for two of 17 residents in the survey sample, Residents #6 and #1. The findings include: 1. For Resident #6 (R6), the facility staff failed to notify the responsible party and physician of refusal of care and a change in behavior on 7/26/24. On the most recent MDS (minimum data set) assessment, an admission assessment with an ARD (assessment reference date) of 7/28/24, the resident scored three out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. Section E documented physical and verbal behaviors directed towards others one to three days during the assessment period. The progress notes for R6 documented in part, - 7/24/2024 21:56 (9:56 p.m.) Note Text: resident arrived via stretcher from home, resident here for respite care. resident alert with some confusion. resident is a high…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff/resident interviews facility document review and clinical record review, it was determined the facility staff failed to provide a safe/clean and homelike environment for three of 17 residents, R9, R11 and R15. The findings include: 1. The facility staff failed to maintain a clean and homelike environment for Resident #9. Resident #9 (R9) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), CHF (congestive heart failure), seizures and chronic respiratory failure with hypoxia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/14/25, 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 1/18/25 revealed, FOCUS: The resident is at risk for weight loss, malnutrition or poor hydration status related to DM2, asthma,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff/resident interviews facility document review and clinical record review, it was determined the facility staff failed to develop the care plan for one of 17 residents in the survey sample, R9. The findings include: The facility staff failed to develop the comprehensive care plan for PICC (peripherally inserted central catheter) /midline care for R9. Resident #9 (R9) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), CHF (congestive heart failure), seizures and chronic respiratory failure with hypoxia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/14/25, 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 1/18/25 revealed, FOCUS: The resident is at risk for weight loss, malnutrition or poor hydration…

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

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide pharmacy services for one of 17 residents in the survey sample, Resident #4. The findings include: For Resident #4 (R4), the facility staff failed to obtain medications for administration. A review of R4's clinical record revealed physician's orders dated 12/3/24 for Verapamil 240 mg (milligrams)-one tablet by mouth at bedtime for high blood pressure and Prazosin 2 mg-one capsule by mouth at bedtime for HTN (hypertension [high blood pressure]). R4's December 2024 MAR (medication administration record) revealed the same physician's orders. Further review of R4's December 2024 MAR failed to reveal Verapamil and Prazosin was administered on 12/24/24 (as evidenced by blank spaces on the MAR). On 4/2/25 at 11:19 a.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated that if a medication is not available for administration, then nurses should check the Omnicell (a machine containing various medications). LPN #7 stated that if the medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, it was determined that the facility staff failed to evidence radiology services as ordered for one of 17 residents, R8. The findings include: Resident #8 (R8) was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), CVA (cerebrovascular accident) with hemiplegia, hemiparesis and vascular dementia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 12/5/24, coded the resident as scoring a 00 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. The resident was coded as being dependent for turning. A review of the comprehensive care plan dated 8/21/24 revealed, FOCUS: The resident has an ADL (activities of daily living) self-care performance deficit due to history of CVA, dementia. He is dependent on staff for all ADL needs. INTERVENTIONS: BED MOBILITY: The resident…

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

Based on staff interview, and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for one of 17 residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to document the resident's blood sugar reading on 12/13/24 at 3:59 a.m. A review of R1's clinical record revealed a physician's order dated 12/13/24 that documented, Recheck blood glucose at 0200 (2:00 a.m.) A review of R1's December 2024 medication administration record revealed the resident's blood sugar was re-checked on 12/13/24 at 3:59 a.m. Further review of R1's clinical record (including the December 2024 medication administration record, nurses' notes, and blood sugar summary) failed to reveal documentation of the numerical reading of the resident's blood sugar when it was re-checked on 12/13/24 at 3:59 a.m. On 4/2/25 at 3:23 p.m., an interview was conducted with LPN #9 (the nurse who signed off re-checking R1's blood sugar at 3:59 a.m.) LPN #9 stated that when a nurse checks a resident's blood sugar, the number should…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff/resident interviews, facility document review and clinical record review, it was determined the facility staff failed to implement the care plan for three of 5 residents in the survey sample, R1, R2 and R3. The findings include: 1. The facility staff failed to implement the comprehensive care plan for incontinence care for R1. R1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to ESRD (end stage renal disease), HIV (human immunodeficiency virus) cancer and malnutrition. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/11/25, 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 maximal assistance for mobility/transfers/bathing/dressing; dependent for toileting and supervision 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 resident/staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide ADL (activities of daily living) care for dependent residents for three of five residents, R1, R2 and R3. The findings include: 1.The facility staff failed to provide ADL (activities of daily living) specifically incontinence care for a dependent resident, R1. R1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to ESRD (end stage renal disease), HIV (human immunodeficiency virus) cancer and malnutrition. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/11/25, 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 maximal assistance for…

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

Based on observation, clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to implement the comprehensive care plan for five of 15 residents in the survey sample, Residents #8, #3, #4, #2 and #6. The findings include: 1. For Resident #8 (R8), the facility staff failed to implement the comprehensive care plan to maintain contact precautions for a diagnosis of C-diff (clostridium difficile) (1). On 7/30/24 at approximately 10:22 a.m., an observation was made of the facility. Observation of R8's room revealed a sign posted outside of the door with stop signs on the corners of the notice. The signage documented Contact Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff must also: Put on gloves before entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 that the facility staff failed to maintain transmission based precautions as ordered for three of 15 residents in the survey sample, Residents #5, #8, and #10. The findings include: 1. For Resident #5 (R5), the facility staff failed to maintain contact precautions for a diagnosis of C-diff (clostridium difficile) (1). On 7/30/24 at approximately 10:22 a.m., an observation was made of the facility. Observation of R5's room revealed a sign posted outside of the door with stop signs on the corners of the notice. The signage documented Contact Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff must also: Put on gloves before entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. A bin…

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

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide incontinence care for three of fifteen residents in the survey sample, Residents #2, #5 and #6. The findings include: 1. The facility staff failed to provide incontinence care for a dependent resident for Resident # 2. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/25/24, R2 was coded as being severely cognitively impaired for making daily decisions, having scored five out of 15 on the BIMS (brief interview for mental status). R2 was coded as being dependent for toileting hygiene. A review of R2's clinical record revealed a facility document, Documentation Survey Report V2 for March 2024 that includes documentation for ADL- Toilet Use, it revealed there were shifts where no incontinence care was provided. A review of R2's care plan, revealed in part: Encourage with BR (bathroom) as able and allowed to facilitate BM (bowel movement)/ resident may show increase movement in bed when…

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

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide care and services for a colostomy for one of 15 residents in the survey sample, Resident #4. The findings include: For Resident #4 (R4), the facility staff failed to provide colostomy (1) care during shifts on 3/8-3/11/24, 3/17/24, 3/26/24, 3/28/24, 3/29/24, 3/31/24, 4/12/24 and 5/3/24. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 5/23/24, the resident was assessed as having an ostomy. The physician orders for R4 documented in part, Colostomy Care as needed AND every shift On hold from 02/01/2024 23:13 to 02/03/2024 23:12. Order Date: 01/03/2024. Review of the eTARs (electronic treatment administration records) for R4 dated 3/1-3/31/24, 4/1- 4/30/24 and 5/1-5/31/24 failed to evidence colostomy care provided during shifts on 3/8-3/11/24, 3/17/24, 3/26/24, 3/28/24, 3/29/24, 3/31/24, 4/12/24 and 5/3/24. The comprehensive care plan for R4 documented in part, [Name of R4] has an…

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

Based on staff interview, clinical record review and facility document review, it was determined that staff failed to provide feeding assistance for one of 15 residents, Resident #2 (R2). The findings include: The facility staff failed to provide feeding assistance for Resident #2 on March 23, 2024. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/25/24, R2 was coded as being severely cognitively impaired for making daily decisions, having scored five out of 15 on the BIMS (brief interview for mental status). R2 was coded as being partial/moderate assistance for eating. A review of R2's clinical record revealed a facility document, Documentation Survey Report V2 for March 2024 that includes documentation for ADL- Eating and nutrition revealed resident did not receive feeding assistance or eat on March 23, 2024. A review of R2's physician orders dated 3/18/24 revealed, Mechanical Soft texture, Regular/Thin consistency, Diet: Mech Soft Liquids Thin for diet. A review of R2's care plan, revealed in part: Resident is at risk…

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

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide complete dialysis care and services for one of 15 residents in the survey sample, Resident #3. The findings include: For Resident #3 (R3), the facility staff failed to monitor the dialysis AV (arterio-venous) fistula (1) for function on 4/12-4/13/24, 5/30/24, 6/1-6-4/24 and 6/6/24. The physician orders for R3 documented in part, Assess Dialysis Fistula/Graft (left) for Thrill and Bruit Daily and signs and symptoms of infection. every shift. Order Date: 04/15/2024. Review of the eTARs (electronic treatment administration records) for R3 dated 4/1/24-4/30/24, 5/1/24-5/31/24 and 6/1/24-6/30/24 failed to evidence assessment of the dialysis fistula on 4/12-4/13/24, 5/30/24, 6/1-6-4/24 and 6/6/24. The comprehensive care plan for R3 documented in part, The resident has ESRD (end stage renal disease) (2) and receives {Hemo/Peritoneal} dialysis . Date Initiated: 06/06/2024. Revision on: 06/07/2024 . Under Interventions it documented in part,…

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

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to evidence neurological assessment and monitoring after an unwitnessed fall with head injury for one of six residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to evidence neurological check (1) monitoring after an unwitnessed fall with documentation of an injury to the forehead on 9/2/2023. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/28/2023, the resident scored 12 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. The assessment documented no falls during the assessment period. On 10/10/2023 at 11:57 a.m., an observation was made of R1 in their room. An interview was attempted with R1 but was not able to be conducted due to their cognition level. R1 was observed in bed with the bed in the lowest position and the call bell within…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure there was an RN (registered nurse) on duty for eight consecutive hours on 9/16/20223. The findings include: A review of the last 30 days as-worked schedule was conducted. There was no evidence that an RN was on duty for eight consecutive hours on 9/16/23. The Nursing Staffing Data for 9/16/2023 had blanks in the spaces for the number of RNs for each shift on 9/16/2023. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 9/20/2023 at 10:25 a.m. When asked the process for ensuring an RN is on duty for eight hours each day, ASM #2 stated the facility usually has RNs on duty as they have both full time and part time RNs. ASM #2 explained that on that day, they had two agency RNs scheduled and they canceled their shifts around 6:00 a.m. She stated she couldn't get coverage. When asked should there be an RN on duty for at least eight consecutive hours each day, ASM #2 stated, yes. A request was made for the policy regarding RN coverage.…

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

Based on staff interview, facility document review and clinical record review, the facility staff failed to notify the physician of a significant change in condition and/or a need to alter treatment in a timely manner for two of 40 residents in the survey sample, Residents #106 and #96. The findings include: 1. For Resident #106 (R106), the facility staff failed to notify the physician of a pressure injuries in a timely manner. A physical therapy evaluation dated 5/19/23 documented R106 presented with unstageable bilateral heel pressure areas (injuries) (1). Further review of R106's clinical record failed to reveal the physician was notified of the pressure injuries until 6/2/23. A physician note dated 6/2/23 documented, SKIN: (Name) indicated that patient has dark area on both heels. Wound care team to follow. Warm and dry. No induration, nodules, or discoloration . On 9/20/23 at 9:37 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated nurses should notify the physician and obtain treatment orders when a resident is admitted with pressure injuries…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to develop and/or implement the comprehensive care plan for eight of 40 residents in the survey sample, Residents #48, #108, #52, #219, #62, #76, #11, and #16. The findings include: 1. For Resident #48 (R48), the facility staff failed to develop a comprehensive care plan for the resident's laryngectomy tube (1). R48 was admitted to the facility on [DATE] with a diagnosis of the presence of an artificial larynx (a laryngectomy tube). A review of R48's comprehensive care plan initiated on 6/6/23 failed to reveal documentation regarding the resident's laryngectomy tube. On 9/20/23 at 8:34 a.m., R48 was observed sitting on the bed and the resident was observed to have a laryngectomy tube. At this time, an interview was conducted with R48. The resident was unable to verbally communicate but communicated via non-verbal gestures and by writing on a communication board. R48 was asked…

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

Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to monitor weights for two of 40 residents in the survey sample, Residents #53 and #16. The findings include: 1. For Resident #53 (R53), the facility staff failed to monitor weights between 6/9/2023-9/20/2023. On the most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 8/5/2023, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. The resident was coded as no or unknown for weight loss in the past 6 months. The nutritional at risk assessment for R53 dated 8/3/2023 documented in part, . Annual assessment for (age and sex) LTC (long term care) female w/hx (with history) of UTI (urinary tract infection), PNA (pneumonia), HTN (hypertension), anemia, GERD, hypothyroidism, paraplegia, depression, chronic pain, BPD (bipolar disorder), DVT (deep vein thrombosis). Ht (height)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide respiratory care and services for two of 40 residents in the survey sample, Residents #270 and #48. The findings include: 1. For Resident #270 (R270), the facility staff failed to obtain physician's orders for the care of the resident's laryngectomy tube (1), failed to assess R270 for self-care of the laryngectomy tube, and failed to provide oversight to ensure the resident's care of the laryngectomy tube. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/17/23, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. A review of R270's clinical record failed to reveal physician's orders for the care of the resident's laryngectomy tube. R270's comprehensive care plan revised on 9/1/23 failed to reveal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to provide dialysis care and services for two of 40 residents in the survey sample, Resident #119 and Resident #83. The findings include: 1. For Resident #119, the facility failed to provide a bagged lunch to take to the dialysis appointments for four of four days and to failed to communicate with the dialysis facility for three of four days. Resident #119 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ESRD (end stage renal disease), dialysis and acute pancreatitis. The most recent MDS (minimum data set) assessment, an uncompleted Medicare 5-day assessment, with an ARD (assessment reference date) of 9/16/23, coded the resident as scoring a 13 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-was incomplete. Section…

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

Based on staff interview, facility document review and clinical record review, the facility staff failed to provide pharmacy services for one of 40 residents in the survey sample, Resident #96. The findings include: For Resident #96 (R96), the facility staff failed to ensure the medication Nubeqa (1) was available for administration on multiple dates in August 2023. A review of R96's clinical record revealed a physician's order dated 8/24/23 for Nubeqa 300 mg (milligrams)- two tablets by mouth two times a day for prostate cancer. A review of R96's August 2023 MAR (medication administration record) revealed the same physician's order for Nubeqa. On 8/26/23 (a.m. and p.m. doses), 8/27/23 (a.m. and p.m. doses), 8/28/23 (p.m. dose), 8/29/23 (p.m. dose), 8/30/23 (p.m. dose) and 8/31/23 (a.m. dose), the MAR documented the code, 9=Other / See Nurse Notes Nurses' notes dated 8/26/23 documented, Will administer when med arrive from pharmacy and Medication out of stock, resident made aware, will continue to monitor. Nurses' notes dated 8/27/23 documented, Will administer when med arrive from…

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

Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure a resident was free from an unnecessary psychotropic medication for one of 40 residents in the survey sample, Resident #83. The findings include: For Resident #83 (R83), the facility staff failed to ensure the physician or nurse practitioner evaluated the resident for continued use of the as needed anti-anxiety medication diazepam (1). A review of R83's clinical record revealed a physician's order dated 8/4/23 for diazepam 5 mg (milligrams)- one tablet by mouth every eight hours as needed for 180 days for anxiety. A review of R83's August 2023 and September 2023 MARs (medication administration records) revealed the resident was administered as needed diazepam 28 times in August 2023 and 24 times in September 2023. Further review of R83's clinical record failed to reveal the physician or nurse practitioner documented a rationale for extended use and failed to reveal the physician or nurse practitioner evaluated the resident for continued use of the medication after the…

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

Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure a resident was free of a significant medication error for one of 40 residents in the survey sample, Resident #96. The findings include: For Resident #96 (R96), the facility staff failed to administer the medication Nubeqa (1), used to treat prostate cancer, on multiple dates in August 2023. A review of R96's clinical record revealed a physician's order dated 8/24/23 for Nubeqa 300 mg (milligrams)- two tablets by mouth two times a day for prostate cancer. A review of R96's August 2023 MAR (medication administration record) revealed the same physician's order for Nubeqa. On 8/26/23 (a.m. and p.m. doses), 8/27/23 (a.m. and p.m. doses), 8/28/23 (p.m. dose), 8/29/23 (p.m. dose), 8/30/23 (p.m. dose) and 8/31/23 (a.m. dose), the MAR documented the code, 9=Other / See Nurse Notes Nurses' notes dated 8/26/23 documented, Will administer when med arrive from pharmacy and Medication out of stock, resident made aware, will continue to monitor. Nurses' notes dated 8/27/23 documented,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain an accurate clinical record for one of 40 residents in the survey sample, Resident #108. The findings include: For Resident #108 (R108), the facility staff failed to accurately document the location of the resident's pressure injury on multiple weekly wound evaluations and the resident's care plan. R108 presented with a pressure injury on the sacrum (1)/buttock but the wound evaluations and care plan documented the pressure injury was on the right ischial/ischium (2). R108 was admitted to the facility on [DATE] with a diagnosis of a stage four pressure injury (3) on the sacral region. A weekly wound evaluation dated 6/2/23 documented R108's pressure injury was located on the right ischium. R108's comprehensive care plan dated 6/4/23 documented, I have actual impairment to skin integrity r/t (related to) right ischium . Weekly wound evaluations dated 6/9/23, 6/16/23, 6/23/23,…

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.

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 residents dignity for one of 40 residents in the survey sample, Resident #120. The findings include: The facility staff failed to ensure a resident's dignity for Resident #120 as his urinary catheter bag had no privacy covering during observations on 9/19/23 at 1:45 PM, 9/20/23 8:10 AM and 9/20/23 at 4:15 PM. Resident #120 was admitted to the facility on [DATE] with diagnoses that included but were not limited to, BPH (benign prostatic hypertrophy). A review of the baseline care plan dated 9/14/23, which revealed, FOCUS: The resident has Indwelling Catheter: history of BPH. INTERVENTIONS: The resident has 16 FR/10cc Position catheter bag and tubing below the level of the bladder and away from entrance room door. Dignity bag to cover drainage bag content. On 9/19/23 at 1:45 PM, 9/20/23 8:10 AM and 9/20/23 at 4:15 PM, Resident #120 was observed in their room and the uncovered 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 staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that written RP (responsible party) and ombudsman notification was provided when three of 40 residents in the survey sample were transferred to the hospital, Residents #49, Resident #33, and Resident #11. The findings include: 1. The facility staff failed to evidence provision of required written notification was provided to the RP (responsible party) and ombudsman at the time of discharge for Resident #49. Resident #49 was transferred to the hospital on 7/19/23. Resident #49 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: diabetes, congestive heart failure, COPD (chronic obstructive pulmonary disease) and acute respiratory failure. Resident # A review of Resident #49's eINTERACT (interventions to reduce acute care transfer) form dated 7/19/23 revealed, COPD, shortness of breath. Sent to hospital. An interview was conducted on…

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

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that bed hold notification was provided to the resident and/or responsible party (RP), when three out of 40 residents in the survey sample were transferred to the hospital; Residents #49, Resident #33, and Resident #11. The findings include: 1. For Resident #49, the facility staff failed to evidence provision of bed hold notification to the resident and/or the responsible party at the time of transfer to the hospital on 7/19/23. A review of Resident #49's eINTERACT (interventions to reduce acute care transfer) form dated 7/19/23 revealed, COPD, shortness of breath. Sent to hospital. A review of the clinical record revealed there was no evidence that written bed-hold notice was provided to the resident and/or RP when Resident #49 was transferred to the hospital on 7/19/23. An interview was conducted on 9/20/23 at 2:30 PM with LPN (licensed practical nurse) #2. When asked who provides bed hold notification upon transfer, LPN #2 stated, there is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interview, clinical record review, staff interview and facility document review, it was determined that the facility staff failed to maintain a complete and accurate MDS (minimum data set) assessment for three of 40 residents in the survey sample, Residents #62, #33 and #49. The findings include: 1. For Resident #62 (R62), the facility staff failed to code the annual MDS assessment for current tobacco use. On the most recent MDS assessment, an annual assessment, with an ARD (assessment reference date) of 6/20/2023, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were cognitively intact for making daily decisions. Section J documented no current tobacco use. On 9/19/2023 at 3:56 p.m., an interview was conducted with R62. R62 stated that they had smoked for years and had been smoking at the facility since admission. R62 stated that the facility stored their cigarettes and lighter in a box that they took at during 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 resident interview, staff interview, clinical record review and facility document review, it was determined the facility staff failed to develop and/or implement a baseline care plan for three of 40 residents in the survey sample, Residents #119, #120 and #96. 1. For Resident #119, the facility failed to implement the baseline care plan for pre and post dialysis weights. Resident #119 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ESRD (end stage renal disease) and dialysis. A review of the baseline care plan dated 9/9/23 revealed, FOCUS: The resident has ESRD and receives Hemodialysis on Tuesday/Thursday/Saturday (T-TH-SA). INTERVENTIONS: Pre-Post dialysis weights. Auscultation/palpation of the AV fistula (pulse, bruit and thrill) to assure adequate blood flow per protocols. A review of the physician's order dated 9/12/23 revealed, Dialysis every T-TH-SA. Obtain pre-dialysis vital signs, and weight - input weight from dialysis communication forms every…

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

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to review and revise the care plans for three of 40 residents in the survey sample, Residents #13, 108 and #83. The findings include: 1. For Resident #13 (R13), the facility staff failed to review and revise the comprehensive care plan after a resident to resident altercation on 8/21/2023. On the most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 6/24/2023, the resident scored 6 of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. Section E documented no behaviors other than rejection of care. The progress notes for R13 documented in part, - 8/21/2023 13:23 (1:23 p.m.) Note Text : Resident got into a physical altercation with another resident in resident's room. As a result this resident received a contusion to the right eye. Resident was medicated with Tylenol for pain. Resident alert and verbal. able to make…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow professional standards of practice for two of 40 residents in the survey sample, Residents #106 and #219. The findings include: 1.a. For Resident #106 (R106), the facility staff failed to obtain a physician's order for pressure injury treatments that were completed. A review of R106's clinical record revealed nurses' notes that documented the following: -5/22/23 It was reported by therapy that resident has large ulcers on heels. On arrival resident has unstageable ulcers (injuries) (1) on both heels and stage 1 (1) ulcer on both side of the foot and ankle. Wiped down with skin prep. -6/7/23 Resident was noted to have an unstageable ulcer (pressure injury) measuring 7 cm (centimeters) x 10 cm in circumference in the sacrum. 5 cm x 7 cm stage II (1) ulcer on the lateral aspect of the left upper thigh, fluid filled in the center and surrounding tissues red and irritated. 4 cm x 4.5 cm unstageable ulcer on both heels. Scattered bruises on the left lower leg 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 observation, resident interview, staff interview, clinical record review and facility document review, it was determined the facility staff failed to implement a safe smoking environment for three out of 40 residents in the survey sample, Residents #13, #62 and #101. The findings include: 1. For Resident #13 (R13), the facility staff failed to secure smoking materials observed carried by R13 during observations on 9/19/2023. On the most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 6/24/2023, the resident scored 6 of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. On 9/19/2023 at 2:30 p.m., an observation was made of R13 in the facility courtyard smoking. R13 was observed lighting their cigarette using a lighter that they removed from their pocket of the cargo shorts they were wearing and returning the lighter to the pocket. The supervising 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.

Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure a medication error rate of less than 5% for one of 40 residents in the survey sample; Resident #219. During the Medication Administration task, out of 29 opportunities, the facility failed to administer four medications, resulting in an error rate of 13.79%. The findings include: For Resident #219 the facility failed to administer four medications during the medication administration task. On 9/20/23 at 9:05 AM, the medication administration was conducted with LPN #10 (Licensed Practical Nurse), for Resident #219. Upon review of the physician's orders (below) and the Medication Administration Record (MAR) for September 2023 revealed that four medications were ordered but were not prepared and administered on observation. They were signed out as being administered. A review of the physician's orders revealed the following: (1) Aspirin an 81 mg (milligrams) tablet once daily. Order dated 9/8/23. (2) Valsartan an 80 mg tablet once daily.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, the facility staff failed to store medications safely in one of three medication carts. The findings include: On 12/13/23 at 9:19 a.m., an observation of the medication cart used during medication administration revealed one bottle each of Acetaminophen 500mg (milligrams), Multi-Vitamins, and Vitamin C 1000mg on the top of the medication cart, unsecured. There were no staff members within sight of the medication cart. On 12/13/23 at 9:25 a.m., LPN (licensed practical nurse) #3 was interviewed when she returned to the medication cart. She stated that she placed the medications on the cart because she was going to refill the cart after she came back to it. She stated she should not have left the medications unattended on the top of the cart. On 12/13/23 at 11:11 a.m., LPN#1 was interviewed. She stated that it is not okay for any types of medications to be on top of the medication cart, especially if the nurse is not around. She also stated, The medication cart is not supposed to be left unattended because patients can…

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

Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to obtain ordered laboratory testing for one of 40 residents in the survey sample, Resident #53. The findings include: For Resident #53 (R53), the facility staff failed to obtain a stool culture as ordered on 9/14/2023. On the most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 8/5/2023, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were cognitively intact for making daily decisions. On 9/19/2023 at 12:04 p.m., an interview was conducted with R53. R53 stated that they had been sick off and on for about 16 days with heartburn, nausea and abdominal pain. R53 stated that they had an x-ray done and had seen the doctor once and the nurse practitioner a couple of times. R53 stated that they were concerned that they were being brushed off because they still had times when they felt bad and didn't know what the next step…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility staff failed to have a written dialysis agreement for two of 40 residents in the survey sample, Resident #119 and #83. The findings include: 1. For Resident #119, the facility failed to evidence a written dialysis agreement with a dialysis center, . Resident #119 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ESRD (end stage renal disease), and dialysis. A review of the comprehensive care plan dated 9/9/23 which revealed, FOCUS: The resident has ESRD and receives Hemodialysis on Tuesday/Thursday/Saturday (T-TH-SA). INTERVENTIONS: Pre-Post dialysis weights. Auscultation/palpation of the AV fistula (pulse, bruit and thrill) to assure adequate blood flow per protocols. A review of the physician's order dated 9/12/23 revealed, Dialysis every T-TH-SA. During the entrance conference to the facility on 9/19/23, a request was made for the dialysis contracts or agreements. On 9/20/23 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 staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to follow infection control practices for two of 40 residents in the survey sample, Resident #49 and #120. The findings include: 1. Resident #49's bi-pap mask was observed on top of Resident #49's bed partially covered with a blanket and clothing, on 9/19/23 at 1:00 PM and 9/20/21 at 11:05 AM. Resident #49 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: diabetes, congestive heart failure, COPD (chronic obstructive pulmonary disease) and acute respiratory failure. A review of the comprehensive care plan dated 5/9/23 revealed, FOCUS: The resident has altered respiratory status/difficulty breathing and COPD. INTERVENTIONS: OXYGEN SETTINGS: Bi-pap at night- FIO2 30 %. A review of the physician orders dated 6/13/23 revealed, Bi-pap at night- FIO2 30% every evening and night shift for sob (shortness of breath). Bi-pap keep covered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain a complete antibiotic stewardship program. The facility failed to evidence documentation of antibiotic use monitoring for December 2022. The findings include: The facility staff could not evidence antibiotic use monitoring for the month of December 2022. The antibiotic stewardship program was reviewed. The last twelve months were reviewed. There was no evidence of any monitoring for December 2022. A request was made on 9/19/2023 at 4:32 p.m., to ASM (administrative staff member) #1, the administrator, for the December documentation. On 9/20/2023 at 10:21 a.m. ASM #1 and ASM #2, the director of nursing, stated the facility did not have the documentation for December 2022. ASM #2 stated she attempted to get the records from the previous pharmacy and since she didn't have clearance any longer with that pharmacy, she was unable to access the report. ASM #1 and ASM #2 were made aware of the above concern. The facility policy, Antibiotic Stewardship documented in part, Purpose:…

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

Based on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide education and offer the pneumococcal vaccination for one of five residents reviewed for immunizations; Resident #108. The findings include: For Resident #108 (R108), the facility staff failed to provide education and offer the pneumococcal vaccination. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 6/8/2023, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section O - Special Treatments, Procedures and Programs it was coded the resident's pneumococcal vaccination was not up to date and that the resident had been offered and declined the vaccination. The electronic clinical record documented under Immunization tab; it was documented Pneumovax 23 - consent refused. A request was made on 9/19/2023 at 4:30 p.m. for the documentation 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 observations, resident interview, staff interview, clinical record review, and facility document review, it was determined the facility staff failed to evidence bed inspections for one of 40 resident beds in the survey sample, Resident #52. The findings include: For Resident #52, the facility staff failed to perform bed rail inspections for the use of positioning/assist bars. A review of the comprehensive care plan dated 6/19/23, which revealed, FOCUS: The resident is at risk for falls related to limited mobility. INTERVENTIONS: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Resident #52 was observed resting in bed on 9/19/23 at 1:20 PM, 9/20/23 at 8:50 AM and 9/21/23 at 8:00 AM with bilateral one quarter rails raised on bed. A review of the facility's Side Rail Risk and Entrapment form dated 6/19/23 revealed Recommendations: Use both upper 1/4 rails for independent bed mobility. Reason for side rail use: to assist with bed positioning. An…

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

Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure an accessible call bell in the bathroom for one of 40 residents in the survey sample, Resident #76. The findings include: For Resident #76 (R76), the facility staff failed to ensure the call light was within reach in the bathroom. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 8/15/2023, the residents cognition status was not assessed. Section G documented R76 requiring supervision for walking in the room and corridor and extensive assistance of one person for toileting. The resident was assessed as being frequently incontinent. On 9/19/2023 at 12:34 p.m., an observation was made of R76's bathroom. R76 was observed sitting on the side of their bed with a walker in front of them. The wall beside R76's commode contained a call light panel with no pull cord attached. The call light was observed to not be accessible to the resident from the floor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 the facility staff failed to ensure skills competencies for six of six TNA's (temporary nursing assistants) reviewed, TNA #10, TNA #13, TNA #16, TNA #17, TNA #18, and TNA #19. For TNA #10, #13, #16, #17, #18, and #19, the facility failed to ensure each TNA possessed the skills and competencies to provide basic ADL (activities of daily living) care for residents. The findings include: On 3/28/2022 at 8:45 a.m., a request was made to ASM (administrative staff member) #1, the administrator and ASM #5, the former administrator for a list of all TNA's currently employed at the facility. On 3/28/2022 at approximately 10:30 a.m., ASM #5 provided a list of 9 TNA's with their assigned unit and date of hire. On 3/28/2022 at 12:11 p.m., a request was made to ASM #5 for evidence of training and skills competencies for TNA #13, TNA #16, TNA #17, TNA #18 and TNA #19. On 3/29/2022 at 1:41 p.m., a request was made to OSM (other staff member) #12, human resource director…

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

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide performance evaluations and mandatory training for five of five CNA's (certified nursing assistants) reviewed, CNAs #1, #6, #7, #8 and #9. The findings include: During the Sufficient and Competent Staffing facility task review on 3/29/22 at 1:38 PM revealed no evidence of performance evaluations and mandatory training for five of five CNA's (certified nursing assistants) reviewed. On 3/28/22 at 9:40 AM, the Facility Assessment was reviewed. The facility assessment addressed the resident population, care specifics, cultural and religious factors, services provided, staff competencies, physical environment, physical structures, equipment, information systems, patient transfer agreement, and all hazard risk assessment. The facility assessment had annual review dates of 1/28/21 and 2/24/22. On 3/29/22 at 1:38 PM, OSM (other staff member) #12, the Human Resources Director, brought in the five CNA employee records. A review of these five records revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain kitchen equipment in a sanitary manner for one of one microwave, one of one cook's refrigerators, and in one of one traditional ovens in the kitchen. On observation on 3/27/22, the microwave contained numerous pieces of food and debris, the two ovens contained grease and multiple food chunks and debris, and the cook's refrigerators contained evidence of multiple sticky liquid spills on the bottom shelf. The findings include: On 3/27/22 at 10:44 a.m., the kitchen was observed with OSM (other staff member) #2, the food services director. Both sides of the cook's refrigerator contained evidence of multiple liquid spills. Some of the liquid material was sticky. OSM #2 stated the refrigerator definitely needed to be wiped down. He stated the refrigerator should be cleaned each evening, and it appeared that this task was missed the previous evening. The microwave contained multiple pieces of food and debris on all four sides, the top, and the base. OSM #2…

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

Based on observation, resident interview, staff interview, facility document review, it was determined the facility staff failed to accommodate the needs of seven of 50 residents in the survey sample, Residents #86, #50, #60, #6, #43, #29, and #58. The finding include: 1. The facility staff failed to place Resident #86 (R86)'s call bell within their reach. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date (ARD) of 3/16/2022, the resident scored an 11 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately cognitively impaired for making daily decisions. An observation was made of R86 on 3/28/2023 at 2:02 p.m. R86 was lying in bed. The call bell was in the wheelchair, next to the bed, but behind the resident's reach. A second observation was made of R86 on 3/29/2022 a.m. R86 was lying in bed. The call bell was on the floor behind the wheelchair, not within the resident's reach. An interview was conducted with CNA (certified nursing assistant) #4 on 3/29/2022 at 10:29 a.m. When…

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

2. The facility staff failed to maintain a homelike environment for Resident #86 (R86). The wallpaper behind the bed was torn and ripped. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date (ARD) of 3/16/2022, the resident scored an 11 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately cognitively impaired for making daily decisions. Observation was made on 3/28/2022 at 2:02 p.m. of R86's room. The wall behind the bed had torn and ripped wallpaper. A second observation was made on 3/29/2022 at 8:47 a.m. The wall behind the bed had torn and ripped wallpaper. On 3/29/2022 at 9:50 a.m. an interview was conducted with OSM (other staff member) #4, the maintenance director at a sister facility. When asked how they are made aware of any maintenance repairs that are needed, OSM #4 stated they come over twice a week and make complete what needs to be done. OSM #4 stated the previous maintenance director was terminated a week ago. When asked the process for maintaining the facility, OSM…

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

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that all required information was provided to the hospital staff when five out of 50 residents in the survey sample were transferred to the hospital, Residents #452, #66, #67, #6, and #93. 1. The findings include: The facility staff failed to provide evidence that all required information was provided to the hospital staff when Resident #452 was transferred to the hospital on 3/20/22. Per the facility's Acute Care Documentation Checklist, the following documents should be sent to the receiving hospital when a resident is transferred there from the facility: INTERACT (interventions to reduce acute care transfers) care form, advanced directives, physician orders, facility's Transfer/Discharge Record, and the comprehensive care plan goals. No evidence of these documents being provided was revealed. Resident #452's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 2/7/22, coded the…

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

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence written documentation to the Resident and/or RP (responsible party) and ombudsman upon a facility initiated transfer for five out of 50 residents in the survey sample, Residents #452, #66, #67, #6, and #93. 1. The findings include: The facility staff failed to evidence written documentation to the Resident/RP and Ombudsman when Resident #452 was transferred to the hospital on 3/20/22. Resident #452's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 2/7/22, coded the resident as scoring 11 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the nursing progress note dated 3/20/22 at 7:04 PM, revealed the following, CNA (certified nursing assistant) notified nurse at 5:00 P.M. of the aforementioned resident complaining of chest pain and SOB (shortness of breath). Vitals blood pressure-154/86, pulse-70,…

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

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence a bed hold was provided at the time of discharge to four out of 50 residents in the survey sample, Residents #452, #66, #67 and #93. The findings include: 1. The facility staff failed to evidence a bed hold was provided when Resident #452 was transferred to the hospital on 3/20/22. Resident #452's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 2/7/22, coded the resident as scoring 11 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately cognitively impaired. A review of the nursing progress note dated 3/20/22 at 7:04 PM, revealed the following, CNA (certified nursing assistant) notified nurse at 5:00 P.M. of the aforementioned resident complaining of chest pain and SOB (shortness of breath). Vitals blood pressure-154/86, pulse-70, respirations-22, temperature-97.8, oxygen saturation-95% on room air. Resident appeared to be in respiratory distress.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide care and services in a manner to promote resident safety for four of 50 residents in the survey sample, Residents # 3, # 51, # 21 and # 47. The findings include: 1. Facility staff failed to re-evaluate (R3) for smoking. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 12/30/2021, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section J1300 Current Tobacco Use coded (R3) as using tobacco. On 03/28/22 at approximately 10:53 a.m., during an interview with (R3), they stated they smoked at the facility during each of the designated smoking times at 10:30 a.m., 2:30 p.m., 4:30 a.m., 8:00 p.m. On 03/28/2022 at approximately 2:45 p.m., an observation of the facility's gazebo area…

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

Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement a complete pain management program for one of 50 residents in the survey sample, Residents # 3 (R3). For Resident #3, the facility staff failed to conduct complete pain assessments and attempt non-pharmacological interventions prior to the administration of a prn [as needed] pain medication oxycodone-acetaminophen (1). The findings include: R3 was admitted to the facility with a diagnosis that included nerve pain and spinal stenosis. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 12/30/2021, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section J0300 Pain Presence coded R3 as having frequent pain in the past 5 (five) days. Section J0600 Pain Intensity coded R3 as having a pain level of seven out of ten, with ten being the worst pain. The physician's order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care and service for a complete dialysis [1] program for two of 50 residents in the survey sample, Residents # 73 and # 66. The findings include: 1a. The facility staff failed to provide dialysis communication forms for Resident #73's (R73's) and the dialysis center from 03/01/2022 through 03/26/2022. Resident # 73 was admitted to the facility with diagnoses that included end stage renal disease [2]. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 03/08/2022, 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 R73 for Dialysis while a resident. The physician's order for R73 documented in part, [Name of Dialysis Center and Phone Number] chair @ (at) 9:00…

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

Based on resident interview, staff interview, facility document review and clinical record review, it was determined that two of 50 residents in the survey sample were not invited to their care plan meetings/conference, Resident #50 and Resident #93. The findings include: 1. Resident #50 (R50) was not invited to their care plan meeting/conference. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/15/2022, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indication the resident is not cognitively impaired for making daily decisions. An interview was conducted with R50 on 3/28/22 at 11:17 a.m. When asked if she attended her care plan meetings, a gathering when the facility staff discuss the care of plan for the resident, R50 stated they were not aware of any meetings like this. When asked if R50 was invited to the meetings, R50 stated no, they were not. Review of the clinical record on 3/28/2022, failed to evidence documentation related to R50 being invited to their care…

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

Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care to promote dignity for one of 50 residents in the survey sample, Resident #43 (R43). Resident #43 was observed with visible dandruff flakes and crusty patches on the scalp, a noticeable body odor, dry and cracked areas on the lips with visible film in the corners of the mouth and white filmy substance on the fold area under their neck during an incontinence care observation on 3/29/2022. The findings include: On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/31/2022, the resident was assessed as being severely impaired for making daily decisions. Section G of the assessment documented R43 as being totally dependent on one staff member for dressing, eating, toileting and personal hygiene. The MDS assessment further documented R43 being always incontinent of bowel and bladder and receiving tube feeding. On 3/29/2022 at 10:23 a.m., an observation was made of TNA (temporary…

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

Based on resident interview and clinical record review, it was determined that the facility staff failed to facilitate a resident's right for self-determination and choice for 1 of 50 residents in the survey sample, Resident #47. The facility staff failed to honor Resident #47's (R47) preference for night time snacks in bed. The findings include: On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 2/11/22, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is not cognitively impaired for making daily decisions. R47's comprehensive care plan dated 2/7/22 documented, Honor food preferences . A physician's order for speech-language pathology dated 3/25/22 documented, Patient to be OOB (out of bed) for all regular textured meals. On 3/28/22 at 3:17 p.m., an interview was conducted with R47. R47 stated requests for snacks at night time have been verbalized but the staff will not provide snacks. R47 stated a couple of weeks ago, the speech therapist recommended the resident be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide the notice of the right to appeal discharge from Medicare Part A services for 1 of 50 residents in the survey sample; Resident #200. The findings include: Resident #200 was admitted on [DATE] and discharged on 2/1/22. Resident #200 was receiving skilled services that ended on 1/26/22. The resident was not provided with an Advance Beneficiary Notice (ABN) which document a resident's right to appeal the decision to discontinue skilled services. On the most recent MDS (Minimum Data Set), an Admission/5-Day assessment, with an ARD (Assessment Reference Date) of 1/12/22, Resident #200 was unable to complete the resident portion of the BIMS (Brief Interview for Mental Status exam) interview and was coded as being moderately impaired in ability to make daily life decisions on the staff interview regarding the resident's cognition. A review of the facility document, Notice 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 observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care to prevent neglect for one of 50 residents in the survey sample, Resident #43 (R43). Resident #43 was observed with visible dandruff flakes and crusty patches on the scalp, a noticeable body odor, dry and cracked areas on the lips with visible film in the corners of the mouth and white filmy substance on the fold area under their neck during an incontinence care observation on 3/29/2022. The findings include: On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/31/2022, the resident was assessed as being severely impaired for making daily decisions. Section G of the assessment documented R43 as being totally dependent on one staff member for dressing, eating, toileting and personal hygiene. The MDS assessment further documented R43 being always incontinent of bowel and bladder and receiving tube feeding. On 3/29/2022 at 10:15 a.m., a request was made to TNA (temporary 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 staff interview and clinical record review, it was determined that the facility staff failed to maintain a complete MDS (minimum data set) for 1 of 50 residents in the survey sample, Resident #51. The facility staff failed to complete the BIMS (brief interview for mental status) assessment for Resident #51's (R51) quarterly MDS assessment with an ARD (assessment reference date) of 2/16/2022. The findings include: Section B of R51's quarterly MDS assessment with an ARD of 2/16/2022 coded the resident as being understood. Section C0100 documented the BIMS assessment should be conducted. All of the questions related to the BIMS assessment (C0200 through C0400) and the BIMS summary score were coded with dashes, indicating the areas were not assessed. On 3/29/2022 at 8:00 a.m., an interview was conducted with ASM (administrative staff member) #2, interim director of nursing/MDS coordinator. ASM #2 stated that BIMS assessment was completed by social services, and if it was not completed by the ARD that dashes were entered in the area that were not completed. ASM #2 reviewed R51's…

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

Based on observations, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide respiratory therapy in a sanitary manner for one of 50 residents in the survey sample, Resident #59. The facility failed to store Resident #59's oxygen equipment in a sanitary manner. The findings include: Resident #59's most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 3/2/22, coded the resident as scoring 14 out of 15 on the BIMS (brief interview for mental status score), indicating the resident was not cognitively impaired. The resident was coded as requiring limited assistance in bed mobility, dressing, toileting, bathing and personal hygiene; supervision with transfers/locomotion and independence in eating. Resident #59 was observed with the nasal cannula oxygen tubing lying on the bed and the nebulizer face mask lying face down on bedside table on 3/28/22 at 9:00 AM, 3:55 PM and 3/29/22 at 12:15 PM. Resident #59's care plan dated 4/23/21 with no revision date, revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one of 50 residents in the survey sample received unnecessary psychotropic medications, Resident #6 (R6). For Resident #6, the facility staff failed to ensure a proper diagnosis for the use of Seroquel (Quetiapine Fumarate) (used to treat schizophrenia, Bipolar disorder and in addition to other medications to treat depression) (1); and failed to identify target behaviors for the Seroquel. The findings include: On the most recent MDS assessment, a quarterly assessment, with an ARD of 12/31/2021, the resident was coded as having both short and long term memory problems and was severely impaired to make daily decisions. In Section N - Medications, R6 was coded as receiving seven days of an antipsychotic during the look back period. The physician orders dated, 2/28/2022, documented, Quetiapine Fumarate Tablet 25 MG (milligrams), give 50 MG via G-Tube (gastrostomy tube - a tube placed through the abdomen into the stomach for feeding) (2), two times a day for antipsychotic. The physician order…

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

2. The facility staff failed to maintain a functioning toilet in Resident #47's (R47) room. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 2/11/22, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is not cognitively impaired for making daily decisions. On 3/28/22 at 3:17 p.m., an interview was conducted with R47. R47 stated the toilet in the room has been broken for the past month and won't flush. R47 stated this was verbalized to someone in the maintenance department but the toilet has not been fixed. R47 stated they did not use the toilet but the staff used the toilet to empty urine from the resident's urinary catheter bag. At this time, an observation of the toilet was conducted. There was toilet paper in the toilet and the toilet did not flush after the handle was pushed. On 3/29/22 at 7:20 a.m., another observation of the toilet was conducted. There was no toilet paper in the toilet and the toilet did not flush after the handle was pushed. On 3/29/22 at 9:54…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2. The facility staff failed to evidence Resident #11's comprehensive care plan goals were provided to the receiving facility, for the residents transfer to the hospital on 1/17/21, and failed to ensure that the physician wrote a note regarding the need for the 1/17/21 hospitalization for Resident #11. Resident #11 was admitted to the facility on [DATE] with the diagnoses of but not limited to multiple sclerosis, dysphagia, chronic obstructive pulmonary disease (COPD), dementia, depression, anxiety disorder, hypothyroidism, and high blood pressure. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 1/27/21. Resident #11 was coded as cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for all areas of activities of daily living, except for eating which coded Resident #11 as requiring extensive assistance. A review of the clinical record revealed a nurse's note dated 1/17/21 at 5:08 PM that documented…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 2. The facility staff failed to evidence that a written notification was provided to the resident and or resident representative upon Resident #11's transfer to the hospital on 1/17/21. Resident #11 was admitted to the facility on [DATE] with the diagnoses of but not limited to multiple sclerosis, dysphagia, chronic obstructive pulmonary disease (COPD), dementia, depression, anxiety disorder, hypothyroidism, and high blood pressure. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 1/27/21. The resident was coded as cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for all areas of activities of daily living, except for eating which coded the resident as requiring extensive assistance. A review of the clinical record revealed a nurse's note dated 1/17/21 at 5:08 PM that documented, Resident was found on floor by CNA (Certified Nursing Assistant) at 12:45PM when aide entered the room to pass 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 2. The facility staff failed to evidence that a written bed hold policy was provided to the Resident or Resident Representative for Resident #11's hospital transfer on 1/17/21. Resident #11 was admitted to the facility on [DATE], with the diagnoses of but not limited to multiple sclerosis, dysphagia, chronic obstructive pulmonary disease (COPD), dementia, depression, anxiety disorder, hypothyroidism, and high blood pressure. The most recent MDS (Minimum Data Set), a quarterly assessment with an ARD (Assessment Reference Date) of 1/27/21, coded the resident as cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for all areas of activities of daily living, except for eating which coded the resident as requiring extensive assistance. A review of the clinical record revealed a nurse's note dated 1/17/21 at 5:08 PM, documented in part: . On call NP (nurse practitioner) notified at 12:50PM and gave order to transfer resident to (name of hospital). Residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. The facility failed to develop a comprehensive care plan to include trach [tracheostomy] care and ROM (range of motion) for Resident #24. Resident #24 was admitted to the facility on [DATE]. Resident #24's diagnoses included but were not limited to: anoxic brain injury (irreversible damage to the brain caused by a lack of oxygen) (1), seizures (a sudden, involuntary and violent contraction of a group of muscles, sometimes with loss of consciousness) (2) and tracheostomy (a surgically created opening into the trachea, with a tube inserted to establish an airway) (3). Resident #24's most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 2/13/21, coded the resident as scoring 00 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. MDS Section G- Functional Status: coded the resident as dependent with bed mobility, transfers, dressing, eating, personal hygiene and bathing; walking 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 4. The facility staff failed to review and/or revise Resident #44's comprehensive care plan to address a worsened pressure ulcer (1). Resident #44 was admitted to the facility with diagnoses that included but were not limited to nontraumatic intracerebral hemorrhage (2) and tracheostomy (3). Resident #44's most recent MDS (minimum data set), a quarterly assessment with an ARD (Assessment Reference Date) of 3/12/21 coded Resident #44 as non-verbal and severely impaired of making daily decisions. Section G coded Resident #44 as totally dependent on two or more staff members for bed mobility, dressing and toileting and totally dependent on one staff member for eating and personal hygiene. Section M coded Resident #44 having one unstageable pressure ulcer. The comprehensive care plan for Resident #44 dated 12/03/2020 documented in part, At risk for alteration in skin integrity related to impaired mobility. Date Initiated: 12/03/2020. Revision on 12/15/2020. The care plan further documented Open area to sacrum. 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, it was determined that the facility staff failed to provide the necessary treatment and services, consistent with professional standards of practice, to prevent and promote healing of a pressure injury for two of 25 residents in the survey sample, Residents #25 and #44. 1. The facility staff failed to ensure ongoing assessments to include measurements, descriptions and the completion of a PUSH tool for the Resident #25's right lateral fifth toe pressure injury. Resident #25's clinical record revealed a PUSH tool (8) was completed for each of the resident's pressure injuries except for the right lateral foot, fifth toe pressure injury. In addition the facility staff failed to evidence any measurements or description of the right lateral foot, fifth toe pressure injury, from [DATE] through [DATE] and on [DATE]. 2. For Resident #44, the facility staff failed to ensure ongoing assessments to include measurements,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 failed to provide services related to a urinary catheter for one of 25 current residents in the survey sample, Resident #25. The facility failed to monitor and record urinary output amounts on multiple dates since the resident's admission on [DATE]. The facility failed to evidence Foley catheter care on multiple dates since the resident's admission on [DATE]. The findings include: Resident #25 was admitted to the facility on [DATE] with diagnoses including epilepsy, COPD (chronic obstructive pulmonary disease) (1), and diabetes (2). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 2/16/21, Resident #25 was coded as being moderately cognitively impaired for making daily decisions, having scored ten out of 15 on the BIMS (brief interview for mental status). Resident #25 was coded as being totally dependent on the assistance of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 6. The facility failed to provide oxygen at the physician prescribed flow rate for Resident #24 and failed to ensure tracheostomy care was provided as ordered by the physician on 4/12/21, 4/13/21 and 4/16/21 day shift and failed to ensure an ambu bag was present at Resident #24's bedside per the facility policy. Resident #24 was admitted to the facility on [DATE]. Resident #24's diagnoses included but were not limited to: anoxic brain injury (irreversible damage to the brain caused by a lack of oxygen) (1), seizures (a sudden, involuntary and violent contraction of a group of muscles, sometimes with loss of consciousness) (2) and tracheostomy (a surgically created opening into the trachea, with a tube inserted to establish an airway) (3). Resident #24's most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 2/13/21, coded the resident as scoring 00 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was 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 resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide dialysis services for two of 25 residents in the survey sample, (Residents #19 and #67). 1. The facility staff failed to ensure communication regarding Resident #19's care with the dialysis center, failed to assess the resident's dialysis access site per physician's order, failed to follow up on a fluid restriction recommendation from Resident #19's dialysis RD (registered dietician). 2. For Resident #67, the facility staff failed to obtain a physician's order for dialysis (1), failed to follow a physician's order for fluid restriction, failed to evidence documentation of assessment of her dialysis access site, and failed to maintain communication with the dialysis center. The findings include: 1.a. The facility staff failed to ensure communication regarding Resident #19's care with the dialysis center. Resident #19 was admitted to the facility on [DATE].…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility document review and staff interviews it was determined that the facility failed to maintain a complete and accurate clinical record for eight of 25 residents in the current resident sample, Residents #44, #67, #25, #11, #80, #19, #24 and #47. The findings include: 1. The facility staff failed to maintain a complete and accurate clinical record documenting treatments completed for Resident #44. Resident #44 was admitted to the facility with diagnoses that included but were not limited to nontraumatic intracerebral hemorrhage (1) and tracheostomy (2). Resident #44's most recent MDS (minimum data set), a quarterly assessment with an ARD (Assessment Reference Date) of [DATE] coded Resident #44 as being non-verbal and severely impaired of making daily decisions. Section G coded Resident #44 as being totally dependent on two or more staff members for bed mobility, dressing and toileting and totally dependant on one staff member for eating and personal hygiene. Section M 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 observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide privacy and dignity for a Foley catheter for one of 25 residents in the survey, Resident #80. On 4/21/21, Resident #80 was observed lying in bed with an uncovered Foley catheter bag visible from the hall. The facility staff failed to provide privacy and dignity for the Foley catheter bag. The findings include: Resident #80 was admitted to the facility on [DATE]. Resident #80's diagnoses included but were not limited to chronic kidney disease, diabetes and paralysis. Resident #80's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 4/6/21, coded the resident's cognition as severely impaired. Section H coded the resident as having a urinary catheter. On 4/21/21 at 9:01 a.m. and 3:26 p.m., observations, Resident #80's bed room door was half way open. The resident was lying in bed with an uncovered Foley catheter (1) bag attached…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain a clean environment for one of 25 current residents in the survey sample, (Resident #25). The facility staff failed to clean Resident #25's feeding tube pump. The findings include: Resident #25 was admitted to the facility on [DATE], with diagnoses including but not limited to: epilepsy, COPD (chronic obstructive pulmonary disease) (1), and diabetes (2). The most recent MDS (minimum data set) assessment, an admission assessment with an ARD (assessment reference date) of 2/16/21, coded Resident #25 as being moderately cognitively impaired for making daily decisions, having scored ten out of 15 on the BIMS (brief interview for mental status). He was coded as being totally dependent on the assistance of staff members for all activities of daily living (ADL). He was coded as receiving feedings by way of a PEG (percutaneous endoscopic gastrostomy) (3) tube. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, and facility document review, it was determined that the facility staff failed to orient a resident prior to transfer for one of 25 current residents reviewed, Resident #55. The facility staff failed to provide evidence that all required information including the resident notification and orientation prior to transfer was provided to Resident #55 upon transfer to the hospital on 4/12/21. The findings include: Resident #55 was admitted to the facility on [DATE]. Resident #55's diagnoses included but were not limited to: paraplegia (paralysis of the lower limbs) (1), diabetes mellitus (inability of insulin to function normally in the body) (2) and right below the knee amputation (surgical removal of part of the right leg below the knee) (3). Resident #55's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 3/17/20, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating 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 and facility document review, it was determined the facility staff failed to develop a baseline care plan for one of 25 current residents in the survey sample, Resident #24. The facility failed to develop a baseline care plan for Resident #24 to address the care required for the resident's tracheostomy and failed to address ROM (range of motion), which was triggered on the 2/6/21, admission assessment for the baseline care plan. The findings include: Resident #24 was admitted to the facility on [DATE]. Resident #24's diagnoses included but were not limited to: anoxic brain injury (irreversible damage to the brain caused by a lack of oxygen) (1), seizures (a sudden, involuntary and violent contraction of a group of muscles, sometimes with loss of consciousness) (2) and tracheostomy (a surgically created opening into the trachea, with a tube inserted to establish an airway) (3). Resident #24's most recent MDS (minimum data set) assessment, an admission assessment, with an 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 resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide ADL (activities of daily living) care for one of 25 residents in the survey sample, Resident #19. On three Sundays in March 2021, the facility staff failed to provide assistance with transfers, dressing or personal hygiene, to Resident #19, who was assessed as requiring extensive assistance of one staff with personal hygiene and dressing. The findings include: Resident #19 was admitted to the facility on [DATE]. Resident #19's diagnoses included but were not limited to end stage renal disease, diabetes and muscle weakness. Resident #19's admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 2/7/21, coded the resident as being cognitively intact. Section G coded Resident #19 as requiring extensive assistance of one staff with personal hygiene and dressing. Section G further documented transfers did not occur during the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide foot care and treatment, in accordance with professional standards of practice for one of 25 current residents in the survey sample, Resident #67. The facility staff failed to trim Resident #67's toenails to an optimal length to prevent infection or disease. The findings include: Resident #67 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses including ESRD (end stage renal disease) (1), diabetes (2), lymphedema (3), and bipolar disorder (4). On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 4/12/21, Resident #67 was coded as having no cognitive impairment for making daily decisions, having scored 12 out of 15 on the BIMS (brief interview for mental status). She was coded as requiring the extensive assistance of staff members for personal hygiene. Resident #67…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and facility document review, it was determined the facility staff failed to provide services to prevent a decrease in range of motion (ROM) for one of 25 current residents in the survey sample, Resident #24. The facility failed to provide ROM services after identification of weakness and impaired mobility on admission for Resident #24. The findings include: Resident #24 was admitted to the facility on [DATE]. Resident #24's diagnoses included but were not limited to: anoxic brain injury (irreversible damage to the brain caused by a lack of oxygen) (1), seizures (a sudden, involuntary and violent contraction of a group of muscles, sometimes with loss of consciousness) (2) and tracheostomy (a surgically created opening into the trachea, with a tube inserted to establish an airway) (3). Resident #24's most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 2/13/21, coded the resident as scoring 00 out of 15 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, facility document review and clinical record review, it was determined that the facility staff failed to address a significant weight gain for one of 25 residents in the survey sample, Resident #19. The facility staff failed to address Resident #19's monthly weight gain of 11.10 percent in March 2021. The findings include: Resident #19 was admitted to the facility on [DATE]. Resident #19's diagnoses included but were not limited to end stage renal disease, diabetes and muscle weakness. Resident #19's admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 2/7/21 coded the resident as being cognitively intact. Review of Resident #19's clinical record revealed a weight of 219 pounds on 2/2/21 and a weight of 243.3 pounds on 3/16/21 (totaling 11.10 percent gain). Further review of Resident #19's clinical record including nurses' notes, dietary notes and nutritional assessments failed to reveal the 11.10 percent gain on 3/16/21 was addressed. Resident #19's…

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

Based on staff interview and facility document review, it was determined that the facility staff failed to complete an annual CNA (certified nursing aide) performance review for one of five CNA record reviews. The facility staff failed to complete an annual performance review for CNA #5. The findings include: Review of CNA #5's record revealed the last performance review was completed for an appraisal period of March 2018 to March 2019. On 4/21/21 at 6:08 p.m., an interview was conducted with ASM (administrative staff member) #3 (the quality consultant). ASM #3 stated a list of CNAs who need a performance review is given to the director of nursing each month then the director of nursing either completes the performance reviews or has a unit manager or floor nurse complete the reviews. At this time, ASM #1 (the administrator), ASM #2 (the director of nursing) and ASM #3 were made aware of the above concern. An email sent from ASM #1 on 4/22/21 at 8:27 a.m. documented, (CNA #5) performance evaluation: She was on a leave of absence 7/1/2020-9/1/2020 and again 2/15/2021-3/15/2021. She…

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

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 that the facility staff failed to administer medication in a sanitary manner to prevent the spread of infection for one of 5 residents in the Medication Administration task, (Resident #28). During the medication observation RN #4 used her bare finger to tap at a Cardizem pill that was not easily dislodged from the packaging, her bare finger was in direct contact with the Cardizem pill that was partially protruding from the package. RN #4 dislodged the Cardizem pill from the package into the pill cup. RN #4 then administered The findings include: The facility staff failed to administer a medication, Cardizem (1), in a sanitary manner for Resident #28. Resident #28 was admitted to the facility on [DATE] with the diagnoses of but not limited to congestive heart failure, chronic obstructive pulmonary disease, dementia, high blood pressure, schizophrenia, atrial fibrillation and diabetes. 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.