Shalom Gardens Health & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff interview and facility document review, the facility staff failed to acquire medications for 2 of 28 residents (R#2 and R#291) in the survey sample. The findngs include: 1. For Resident # 2, the facility staff failed to ensure medications were available for administration as ordered by the physician. Resident # 2 was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Fracture of Left Fibula, Edema, Alzheimer's Disease, Gastroesophageal Reflux Disease, Anxiety and Hypertension. Resident #2's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 05/17/2024 was a quarterly assessment. The MDS coded Resident # 2 with a BIMS (Brief Interview for Mental Status) score of 2 out of 15, indicating severe cognitive impairment. The MDS coded Resident # 2 as requiring extensive to total staff assistance with Activities of Daily Living. Review of the clinical record was conducted on 6/26/2024 to 6/28/2024.…

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

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide care and services in accordance with professional standards for one resident, Resident #1, in a survey sample of three (3) residents. The findings included: For Resident #1, facility staff failed to administer a nutritional supplement as ordered by the Nurse Practitioner on 02/22/2022. On 09/13/2023, Resident #1's clinical record was reviewed and revealed a prescribed order, Supplement: ProSource ZAC daily via PEG, Once a Day; 12:00 p.m., start date 02/22/2022. Resident #1 received the first dose on 02/23/2022. On 09/13/2023 at approximately 4:15 p.m., a group interview was conducted with the Director of Nursing (DON) and the ordering Nurse Practitioner (NP). The NP stated, During the IDT [Interdisciplinary Team] meeting on the morning of February 22nd, we discussed resuming [name redacted, Resident #1's] protein supplement following her readmission from the hospital the previous day [02/21/2022]. I gave the verbal order during the morning meeting to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interview, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to prevent abuse involving 4 Residents (Resident #30, #17, #2, #71) in a sample size of 33 Residents. The Findings included: 1. For Resident #30, the facility staff failed to protect her from 3 episodes of Resident-to-Resident altercations by another female Resident (Resident #2) on 07/20/2021. For Resident #17, the facility staff failed to prevent another female Resident (Resident #2) from rummaging through her closet and taking her purple top and floral sweater on 07/20/2021. Resident #30, a 95- year old female, was admitted to the facility on [DATE]. Diagnoses included but were not limited to dementia and major depressive disorder. Resident #30's most recent Minimum Data Set with an Assessment Reference Date of 04/21/2021 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 9 out 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, resident interview, group interview and staff interview, the facility staff failed to act promptly to resolve grievances discussed in the group interviews. For 6 of 6 residents in the Resident Council group, the facility staff failed to resolve the issues/concerns discussed in Resident Council. The Findings included: Review of the Resident Council meeting minutes from March 2021 through July 2021, revealed documentation of the same concerns during several of the months. There was no documentation of the facility administration's response to the concerns expressed during the meetings. 4/28/2021 Meeting agenda- New Business included statement Nursing: DON (Director of Nursing) and Administrator will remind nursing to introduce them self (sic) at the beginning of each shift. 5/19/2021- Meeting Minutes-Old Business Aides still not introducing themselves when they come on shift (residents would like to know who their aides are for the morning and night. Under New Business, the statement was included When residents need something, they are having to go and find the…

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

Based on observation, staff interview and group interview, the facility staff failed to ensure the results of the most recent surveys of the facility were readily accessible to residents and family representatives. For 6 of 6 attendees of the group interview, the facility staff failed to ensure the residents knew where to find the survey results form the previous surveys. The Findings included: The following written statement was submitted by Surveyor E regarding observations and an interview with the receptionist. On 7/21/21 at 10:40 AM, I (Surveyor E) went to the front lobby and reception area and didn ' t see any notice indicating where survey results were posted. I then went to the nursing station at unit 1 and looked around as well as looked on the bulletin board. I still didn ' t see any notice regarding the posting of survey results. I asked _____ (name redacted), the ADON (Assistant Director of Nursing) where they were kept and she said 'at the front desk.' I returned to the receptionist and behind her, against the wall on the counter was a sign that read last 3 years survey…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility documentation review and clinical record review, the facility staff failed to complete a SNF ABN (Skilled Nursing Facility Advance Beneficiary Notice) for 1 Residents (Resident #66) in a survey sample of 33 Residents. For Resident #66, the facility staff failed to provide a SNF ABN notice prior to skilled care services, paid by Medicare, ended. Resident #66 was not afforded the opportunity to continue skilled care services and have Medicare make a determination about coverage of such services, as known as a demand bill. The Findings included: Resident #66, was admitted to the facility on [DATE], with a readmission date of 3/5/21. Resident #66's diagnoses included but were not limited to: status post fall and hip fracture with repair. Resident #66's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 5/18/21 was coded as a quarterly assessment. Resident #66 was coded as cognitive skills for daily decision making being 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 interview, clinical record review, and facility documentation review the facility staff failed to implement the abuse policy for 2 Residents (#71and #2) in a survey sample of 33 Residents. 1. For Resident #71 the facility staff failed to obtain prevent physical abuse of by a CNA contracted employee, and also failed to obtain the Virginia State Police criminal background check prior to allowing the staff to work with the Resident. Resident #71, a [AGE] year old woman admitted to the facility on [DATE] with diagnoses including diabetes type II, dementia with behavioral disturbance, chronic kidney disease, and pancreatitis. Resident #71's most recent MDS (Minimum Data Set) assessment coded Resident #71 as having a BIMS (Brief Interview of Mental Status) score of 4 indicating severe cognitive impairment. She was coded as requiring extensive assistance with all aspects of ADL (Activities of Daily Living) care. The Resident required the use of a sit to stand lift for transfers and a wheel chair for mobility.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, clinical record review and facility documentation and in the course of an investigation the facility staff failed to develop and implement a baseline care plan for 1 Resident (#340) in a survey sample of 33 Residents. The findings included For Resident #340 the facility staff failed to develop and implement a baseline care plan that includes the instructions needed to provide person centered care to the Resident. Resident #340 was admitted to the facility on [DATE]. Diagnoses for Resident #340 included but were not limited to Rhabdomyolysis, acute respiratory failure, acute kidney failure, altered mental status, history of bladder cancer and BPH (Benign Prostatic Hypertrophy), history of UTI, and Atrial Fibrillation. Resident #340's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 1/26/21 coded Resident #340 with a BIMS (Brief Interview of Mental Status) score of 14 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #340 as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interview, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to develop and implement the care plan for 2 residents (Resident #2 and Resident #71) in a sample size of 33 Residents. The Findings included: 1. For Resident #2, the facility staff failed to implement the care plan. Specifically, the facility staff failed to: a) Ensure adequate distance between resident and others to ensure safety of residents. This resulted in taking clothing from Resident #17 and 3 episodes of Resident-to-Resident altercations with Resident #30 on 07/20/2021. (b) Supervise wandering on units, resulting in Resident #2 walking with a fork, a stapler, and wandering into the unit manager's office on 07/21/2021. Resident #2, a [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses included but were not limited to unspecified dementia with behavioral disturbance. Resident #2's most recent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, Resident interview, staff interview, facility documentation review and clinical record review, the facility failed to provide ADL assistance to maintain personal hygiene for 2 Residents (Resident #190, #71) in a survey sample of 33 Residents. For Resident #190, the facility staff failed to provide personal hygiene assistance for shaving; he was dependent on staff for assistance. The Findings included: Resident #190 was admitted to the facility on [DATE], following hospitalization for a surgical wound infection. Resident #190 came to the facility requiring skilled services for therapy and IV (intravenous) antibiotic therapy treatment. Resident #190's diagnosis included but were not limited to: MRSA( methicillin susceptible staphylococcus aureus) infection, cellulitis of left lower limb, difficulty walking, displaced intertrochanteric fracture of left femur, chronic atrial fibrillation, and hypertension. Resident #190 had not been in the facility long enough for an MDS (minimum data set)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review, the facility staff failed to supervise one Resident (Resident #2) in a sample size of 33 Residents. Specifically, Resident #2 was observed walking with a fork, a stapler, and entering into the unit manager's office with access to items including but not limited to thumb tacks and scissors resulting in a potential accident hazard. The Findings included: Resident #2, a [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses included but were not limited to unspecified dementia with behavioral disturbance. Resident #2's most recent Minimum Data Set with an Assessment Reference Date of 03/08/2021 was coded as a quarterly assessment. Cognitive Skills for Daily Decision-Making were coded as severely impaired. Behavioral symptoms were coded as 0 meaning behaviors not exhibited during the 7-day lookback period. On 07/21/2021 at 8:10 A.M., Resident #2 was observed walking into the dining room on Unit 4 and standing next to a table…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review and facility documentation, the facility staff failed to ensure residents are free from unnecessary psychotropic drugs for 1 Resident (#71) in a survey sample of 33 Residents. The Findings included: For Resident #71 the facility staff failed to attempt the required GDR's for the 3 psychotropic medications and failed to accurately document appropriate diagnoses for the medications. Resident #71, a [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to diabetes type II, dementia with behavioral disturbance, chronic kidney disease, and Pancreatitis. Resident #71's most recent MDS (Minimum Data Set) assessment coded Resident #71 as having a BIMS (Brief Interview of Mental Status) score of 4 indicating severe cognitive impairment. She was coded as requiring extensive assistance with all aspects of ADL care. The Resident required the use of a sit to stand lift for transfers and a wheel chair for mobility. On 7/21/20 a review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility documentation review, the facility staff failed to label and store medication according to accepted professional principles for one Resident (Resident #10) out of a sample size of 33 Residents. The Findings included: For Resident #10, his multi-dose bottle of lorazepam suspension was opened and undated in the med room [ROOM NUMBER] fridge. Resident #10, a [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses included but were not limited to Parkinson's disease. On [DATE] at 10:55 A.M., this surveyor and Licensed Practical Nurse B (LPN B) entered the med room on Unit 2. When asked about the acceptable temperature range for the fridge, LPN B stated it should be between 40-45 degrees and added as long as it is not in the red zone. The temperature log for the small fridge could not be located. Upon opening the small med fridge, LPN B and this surveyor observed the temperature gauge inside the fridge to be 52 degrees Fahrenheit. LPN B stated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, Resident interview, staff interview, facility documentation review and clinical record review, the facility failed to provide beverages consistent with Resident needs and preferences for 1 Resident (Resident #190) in a survey sample of 33 Residents. For Resident #190, the facility staff failed to provide liquids/beverages in a consistency as ordered by the physician and requested by the Resident. The Findings included: Resident #190 was admitted to the facility on [DATE], following hospitalization for a surgical wound infection. Resident #190 came to the facility requiring skilled services for therapy and IV (intravenous) antibiotic therapy treatment. Resident #190's diagnosis included but were not limited to: MRSA( methicillin susceptible staphylococcus aureus) infection, cellulitis of left lower limb, difficulty walking, displaced intertrochanteric fracture of left femur, chronic atrial fibrillation, and hypertension. Resident #190 had not been in the facility long enough for an MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to assess and determine that residents are safe and appropriate to self administer medications for 4 residents (Resident #87, 21, 11, and 26) in a survey sample of 45 residents. 1. For Resident #87, the facility failed to assess that the resident was safe to self administer medications that she had access to her room. 2. For Resident #21 the facility failed to assess that the resident was safe to self administer medications that he had immediate access to. 3. For Resident #11 the facility failed to assess that she was safe to self administer medications that she had immediate access to. 4. For Resident #26 the facility failed to assess that he was safe to self administer medications that he had immediate access to. The findings included: 1. For Resident #87, the facility failed to assess that the resident was safe to self administer medications that she had access to her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, and staff interview, the facility staff did not allow a private Resident council meeting with state agency surveyors for 7 Resident attendees. Staff entered the Private group council meeting, while in progress, to interrupt the proceedings on 4 occasions during the hour long meeting. This staff intrusion in a confidential meeting, made Residents feel uncomfortable, and fearful of retaliation, should they share complaints with surveyors. The findings included; A Resident council private session with state agency surveyors commenced on 3-13-19 at 11:00 a.m. In attendance were 7 members of the resident population. The Resident council President was not in attendance, however, was interviewed prior to the meeting, and previous minutes from meetings were reviewed. Approximately 20 minutes into the session, and during Resident disclosure of grievances, a private duty sitter for a Resident entered the room, and was told this was a private meeting and please to place signs on the door to restrict access to all staff while the private meeting was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed for 8 residents (Resident #29, #87, #21, #345, #11, #26, #62, #27) in a sample of 45 residents to prevent accident hazards. 1. For Resident #29, the facility staff failed to recline a specialized High-Back Reclining wheelchair for fall prevention. 2. For Resident #87, the facility failed to ensure the environment is free of accident hazards by allowing resident access to medications, sharps and trip hazards. 3. For Resident #21 the facility failed to provide a safe environment by allowing resident access to medications, sharps and trip hazards. 4. For Resident #345 the facility failed to provide a safe environment by allowing resident access to medications, a disposable razor, and trip hazards. 5. For Resident #11 the facility failed to provide a safe and accident free environment by allowing resident access to medications, sharps and trip hazards. 6. For Resident #26 the facility failed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, family interview, staff interviews and facility documentation review, the facility staff failed to provide meals at regular times for five residents (Residents # 46, # 62, # 40, # 48, # 34 and # 86) in the survey sample of 45 residents. 1. For Resident # 46, breakfast was not served until 10:05 AM on 3/12/2019. 2. For Resident # 62, breakfast was not served until 9:46 AM on 3/13/19 3. For Resident # 40, breakfast was not served until 9:48 AM on 3/13/19. 4. For Resident # 48, breakfast was not served until 9:58 AM on 3/13/19. 5. For Resident # 34, breakfast was not served until 10:08 AM on 3/13/19. 6. For Resident # 86, breakfast was not served until 9:42 AM on 3/13/2019. Findings included: On 3/12/2019, the following observations were made concerning breakfast being served in the Second Floor Dining Room Unit 2. 3/12/2019 at 10:00 AM, Observed CNA J sitting at table with two residents helping them finish the last of their meal. 3/12/2019 at 10:05 AM, observed CNA…

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

Based on facility records and staff interview the facility failed to ensure the minimum staff were part of the facility quality assessment and assurance committee. The facility failed to ensure the director of nursing services and medical director attended the quality assurance meetings. The findings included: Review of the facility quality assurance meeting held on 1/16/19 sign in sheet, showed that the Director of Nursing failed to attend the meeting. During interview with interim Director of Nursing on 3/14/19 at approximately 3:40pm regarding the absence of the director of nursing, the interim Director of Nursing (DON) acknowledged the DON had not been present for at least 50% of the meeting. She stated, She must have forgot to sign in, I know she was there because we were half way through the meeting when she came in. Quality Assurance meeting held 9/25/18 sign in sheet showed that the Medical Director did not attend the meeting. The facility Administrator was made aware of the findings on 3/14/19 at approximately 3:45pm. No further documents were provided.

Based on observation, staff interview, facility documentation review, and in the course of a complaint investigation, the facility staff failed to provide Linens, Oxygen, and Activities of Daily Living (ADL) care supplies in a manner to prevent the spread of infection, in the general environment, laundry, in the unit 2 clean utility room, on medication carts in unit 1, and in the shower room of unit 2. In addition, the facility failed to develop and implement a water management plan for Legionella. Dust and mildew were on ventilation areas. Clean Linens were left uncovered, and handled improperly. Used and dirty oxygen tanks were commingled with clean unused oxygen tanks. Dirty ADL carts were brought into the clean utility room from the shower room, containing used and dirty resident care items. Medication carts were unsanitary, and dirty. Clean items were stored together in the room, with dirty items, and commingled. Staff did not practice accepted infection control standards. The findings included: The observations of 3-12-19 through 3-14-19 included the following (8) areas: 1.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation the facility staff failed to ensure the Resident right to dignified existence for 1 Resident (#76) in a survey sample of 45 Residents. For Resident #76, the facility staff pulled the resident backwards down the hallway in his Broda Chair. The findings include: Resident # 76, a [AGE] year-old man admitted to the facility on [DATE] with diagnoses of but not limited to Unspecified Dementia with behavioral disturbances, Diabetes Type 2, Lewy Body Dementia and Insomnia. Resident #76 resides on the memory care unit of the facility due to his advanced Dementia. Resident #76's last (Minimum Data Set) MDS (screening tool) was an annual with an (Assessment Reference Date) of 1/11/19, which coded the Resident as having a (Brief Interview of Mental Status) BIMS score of 99 which indicates severe cognitive impairment / unable to complete assessment. He was also coded as being a two-person physical assist with bed mobility,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, family interviews, resident interviews and clinical record review, the facility staff failed to ensure reasonable accommodation of resident needs and preferences for one Resident (Resident # 36 and # 86) in a survey sample of 45 residents. 1. For Resident # 86, the facility staff failed to get the resident up early for breakfast as desired. Findings included: 1. For Resident # 86, the facility staff failed to get the resident up early for breakfast as desired. Resident # 86, a [AGE] year old female was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Chronic Obstructive Pulmonary Disease, Acute and chronic respiratory failure with hypercapnia, Heart Failure, Hypertension, anemia, Abdominal Aortic Aneurysm, and Osteoporosis. Resident # 86's most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 2/22/2019. The MDS coded Resident # 86 with a BIMS (Brief Interview for Mental Status) score of 13…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation, the facility staff failed to ensure a resident's right to self-determination for 1 Resident (#75) in a survey sample of 45 Residents For Resident #75 the Physical Therapy staff faxed over a letter to his surgeon without first allowing the Resident to view it or have input in the content. The Resident is his own Responsible Party. The findings include: Resident # 75 a [AGE] year-old man admitted to the facility on [DATE] with diagnoses of but not limited to (Peripheral Vascular Disease) PVD, Orthopedic Surgical aftercare for (Below Knee Amputation) BKA of Left lower leg. Most recent (Minimum Data Set) MDS (an assessment tool) with an (Assessment Reference Date) ARD of 2/27/19 codes Resident as having a (Brief Interview of Mental Status) BIMS of 15 indicating No Cognitive Impairment. On 3/12/19, during an initial tour, Resident # 75 asked to have the door closed to discuss some issues he was not happy with. He stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to ensure resident privacy and confidentiality of his or her personal medical records for one resident in a survey sample of 45 residents. For Resident #62, the facility staff failed to ensure the confidentiality of medical records by leaving resident information visible on the computer in the hallway while other residents, staff and visitors were in the hallway. The findings included: Resident #62, a [AGE] year old female, was admitted to the facility on [DATE]. Her diagnosis included but were not limited to: presence of right artificial hip joint, mood disorder, mild cognitive impairment, anxiety disorder, suicidal ideation's, primary insomnia, repeated falls, and overactive bladder. Resident #62's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of [DATE] was coded as a quarterly assessment. Resident #62 was coded as having a BIMS (Brief Interview for Memory Status) score of 13 indicating cognitively…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation review, the facility staff failed to implement the abuse policy for 3 resident (Resident #3, # 27, and # 85) of 45 residents in the survey sample and they failed to ensure the abuse policy was accurate. 1. For Resident #3, the facility did not implement the abuse policy after discovery of an injury of unknown origin described as an unwitnessed fall with injury. 2. The abuse policy did not clearly state that injuries of unknown origin will be reported to the State Agency and thoroughly investigated. The policy did not state the final report of the investigation would be provided to the State Agency within 5 business days. 3. For Resident #27, the facility failed to implement their abuse protocol policy for an injury of unknown origin. 4. For Resident #85, the facility failed to implement their abuse protocol policy for an injury of unknown origin. The findings included: 1. For Resident #3, the facility did not implement 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 2. For Resident #27, the facility failed to report an injury of unknown origin and failed to report investigation results. Resident #27, an [AGE] year old male, was admitted to the facility on [DATE]. His diagnosis included but were not limited to: aphasia, nontraumatic intracerebral hemorrhage, facial weakness, dysphagia, hypothyroidism, hyperlipidemia, compression of brain and hypertension . Resident #27's most recent MDS (Minimum Data Set) (an assessment tool) with an ARD (assessment reference date) of 1/3/19 was coded as a quarterly assessment. Resident #27 was coded as having a BIMS (Brief interview for mental status) score of 3, indicating severe cognitive impairment. He was also coded as requiring extensive assistance of one staff member for transfers, locomotion on and off unit, dressing, toileting and personal hygiene. He requires supervision with setup assistance for eating. It states that he doesn't have any physical or verbal behavioral symptoms or any other behaviors directed toward others. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility documentation review, the facility staff failed for 3 residents (Resident #3, # 27 and # 85) of 45 residents in the survey sample to investigate an injury of unknown origin. 1. For Resident #3, the facility staff failed to investigate an incident of the resident being found on the floor with an injury of her left eye as an injury of unknown origin. The incident was documented as an unwitnessed fall. 2. For Resident #27, the facility failed to protect the resident, conduct an investigation of an injury of unknown origin and did not provide corrective action for an injury of unknown origin. 3. For Resident #85, the facility failed to protect the resident, conduct an investigation of an injury of unknown origin and did not provide corrective action for an injury of unknown origin. The findings included: 1. For Resident #3, the facility staff failed to investigate an incident of the resident being found on the floor with an injury of her left eye as an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility documentation review, the facility staff failed for 1 residents (Resident #33) of 45 sampled residents to ensure that necessary discharge documentation was completed and sent to the receiving facility. The facility staff failed to ensure that physician documentation, care plan goals, etc. were completed and sent to the receiving facility. The Findings included: Resident # 145 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #145's diagnoses included Heart Failure, Hypertension, Diabetes Mellitus, Dementia, and Depression. The Minimum Data Set, which was an admission Assessment, with an Assessment Reference Date of 10/26/18 was reviewed. Resident #145 was coded as having a Brief Interview of Mental Status score of 8, indication severe cognitive impairment. On 3/14/19, a review was conducted of Resident #145's clinical record, revealing the following nurse's note: 11/13/18. Skilled rehab for weakness. Alert and oriented x 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure a Quarterly Minimum Data Set was completed at least every 92 days for two residents (Resident # # 2 and # 3) in a survey sample of 45 residents. 1. For Resident #2, the facility staff failed to complete a (Minimum Data Set) MDS since the Significant Change MDS with and (Assessment Reference Date) ARD of 11/6/18. There are 128 days between 11/6/18 and 3/14/18 (the end of survey). 2. For Resident #3, the facility staff failed to complete a Minimum Data Set (MDS) since the admission MDS with an Assessment Reference Date (ARD) of 11/12/2018. There are 122 days between 11/12/2018 and 03/14/2019 (the end of survey). The findings include: 1. For Resident #2, the facility staff failed to complete a (Minimum Data Set) MDS since the Significant Change MDS with and (Assessment Reference Date) ARD of 11/6/18. There are 128 days between 11/6/18 and 3/14/18 (the end of survey). Resident #2 an [AGE] year-old…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation review, the facility staff failed for 2 residents (Resident #29 and #76) of 45 sampled residents to develop and implement a comprehensive care plan. 1. For Resident #29, the facility staff failed to develop and implement a comprehensive care plan to include a specialized High-Back Reclining wheelchair for fall prevention. 2. For Resident # 76 the facility failed to address transporting Resident in Broda Chair. The Findings included: 1. Resident #29 was a [AGE] year old who had been admitted to the facility on [DATE]. Resident #29's diagnoses included Dementia, Parkinson's Disease, Urinary Tract Infection, Hypertension and Neurogenic Bladder. The Minimum Data Set, which was a Significant Change Assessment with an Assessment Reference Date of 1/7/19 was reviewed. It coded Resident #29 as having a Brief Interview of Mental Status score of 5, indicating severe cognitive impairment. In addition, Resident #29 was coded as having…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and resident record review the facility failed to review and revise the careplan for one resident in a sample of 45 residents. 1. For Resident #62, the facility staff failed to review and update the careplan to remove the 15 minute checks/observations after being cleared by psychiatric services to no longer be suicidal. The Findings include: Resident #62, a [AGE] year old female, was admitted to the facility on [DATE]. Her diagnosis included but were not limited to: presence of right artificial hip joint, mood disorder, mild cognitive impairment, anxiety disorder, suicidal ideation, primary insomnia, repeated falls, and overactive bladder. Resident #62's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 2/13/19 was coded as a quarterly assessment. Resident #62 was coded as having a BIMS (Brief Interview for Memory Status) score of 13, indicating cognitively intact. She was also coded as requiring limited assistance with assistance of one 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, Resident interview, facility documentation review, and clinical record review, the facility staff failed to follow professional standards of practice for medication and treatment administration for 1 Resident (Residents #75) in a survey sample of 45 Residents. For Resident #75 facility staff failed to administer medications and change dressing to the Left Stump as ordered by the physician. The findings include: Resident # 75, a [AGE] year-old man admitted to the facility on [DATE] with diagnoses of but not limited to (Peripheral Vascular Disease) PVD, Orthopedic Surgical aftercare for (Below Knee Amputation) BKA of Left lower leg. Most recent (Minimum Data Set) MDS (an assessment tool) with an (Assessment Reference Date) ARD of 2/27/19 codes Resident as having a (Brief Interview of Mental Status) BIMS of 15 indicating No Cognitive Impairment. On 3/12/19 at 10:00 AM, during an initial tour the Resident removed his sock covering his stump to the left leg and a dressing was observed to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility documentation the facility staff failed to provide appropriate treatment to prevent urinary tract infection for 1 Resident in a survey sample of 45 Residents. For Resident #48 the facility staff failed to ensure proper catheter care by allowing the catheter tubing to drag on the floor while transporting Resident in a wheelchair and while sitting in the hall. The findings include: Resident # 48, a [AGE] year-old woman was admitted to the facility on [DATE] with diagnoses of but not limited to Dementia, abnormal weight loss, history of stroke, history of pneumonia, anxiety disorder, and urinary retention related to Neurogenic Bladder. Most recent (Minimum Data Set) MDS (an assessment tool) was an annual with an (Assessment Reference Date) ARD of 1/16/19 codes Resident as being unable to assess using the (Brief Interview of Mental Status) BIMS tool. The Resident is coded as not being understood and unable to screen indicating severe…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, family interview, clinical record review and facility documentation review, the facility staff failed to administer oxygen in a manner to prevent the spread of infection for two Residents (Residents #70 and # 86) in a survey sample of 45 Residents. 1. For Resident #70, the nebulizer tubing was not dated. 2. For Resident # 86, there were two different dates on the oxygen humidifier bottle. The finding include: 1. For Resident #70, the nebulizer tubing was not dated. Resident #70, a [AGE] year old woman who was admitted to the facility on [DATE] with diagnoses of but not limited to Hemiparesis following stroke affecting right (dominant) side, anemia, history of heart attack, long term use of inhaled steroids, osteo arthritis and dementia without behavioral disturbance. On 3/12/19, upon initial tour, it was observed that Resident #70 had a nebulizer in her room with tubing that was not dated. On 3/12/19 at 11:50 AM, an interview with the DON was conducted and she 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 facility documentation review and staff interview the facility failed to provide regular in-service education based on the outcome of performance reviews at least every 12 months for one employee in a survey sample of 6 employees. The facility failed to ensure CNA F was provided a minimum of 12 hours of in-service training annually. The findings include: Employee records were reviewed with the HR Director on 3/14/19 at 2:19pm. Those records indicated that CNA F, with a hire date of 8/17/11, had attended several training's in December 2018. She stated they usually last 15-20 minutes each. A total of 1.25 hours of inservice hours were recorded for CNA F for 2018. There was no evidence of receiving the required 12 hours of in-service training, based on performance reviews for 2017 or 2018. Interview with Employee K, HR Generalist on 3/14/19 at approximately 2:50pm indicated she had no further information she could afford to the survey team. The Administrator was made aware of the findings during the end of day meeting on 3/14/19. No additional information was provided.

Based on observation, staff interview and facility documentation review the facility staff failed to store and serve food in accordance with professional standards for food service safety. 1. Facility staff failed to ensure an air gap was in place between the ice machine drainage pipe and floor drain for the ice machine in the main kitchen. 2. Nursing staff CNA (Certified Nursing Assistant) D was observed entering the kitchen without a hair net on Unit 2. The findings included: 1. Facility staff failed to ensure an air gap was in place between the ice machine drainage pipe and floor drain for the ice machine in the main kitchen. A tour of the main kitchen took place on 3/12/19 at 8:10 a.m. with the Dietary Manager. Upon inspection of the ice machine, it was observed that one of the two drainage pipes from the ice machine was flush against the floor drain cover plate. There was no air gap in place to allow for back flow from the drain. After looking at the drainage pipe, the Dietary Manager stated that both pipes should be elevated off the drain. She stated that it looked like 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.