Southampton Rehabilitation And Healthcare Center

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 maintain a safe environment for one dependent resident (Resident #4) in a survey sample of 6 residents. For Resident # 4, the facility staff failed to prevent a fall from the bed during incontinence care on 11/26/2023. Findings included: Resident #4 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, Epilepsy, Parkinsonism, and Essential Hypertension, The most recent Minimum Data Set (MDS) was an admission assessment with an Assessment Reference Date (ARD) of 11/9/2023. The MDS coded Resident # 4 with a BIMS (Brief Interview for Mental Status)score of 4/15 indicating severe cognitive impairment; the resident required assistance with activities of daily living and bathing and always incontinent of bowel and bladder. Review of the closed electronic clinical record was conducted on 11/4/2024 to 11/6/2024. Review of the Progress Notes revealed documentation of a Nursing note…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 meet professional standards of quality for three Residents (#3, #2, and #1) in a survey sample of 8 residents. Findings included: During tour of the facility on 2/22/2024, the nurses were asked the time of the next scheduled medication pass. The nurses stated 1:00 p.m., On the third floor, nurses were observed passing medications at 11:26 a.m. One nurse was observed standing at medication cart located at the nurses station. One nurse LPN (Licensed Practical Nurse)-F was observed pouring medications in medication cups and walking to a resident's room. The nurse returned to the nurses station, poured medications and walked to another resident's room. The nurse was observed repeating that with other residents. When asked if the medications she was administering was from the morning medication pass, LPN-F stated Yes. LPN-F stated she was handling something that happened earlier and was late passing 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, resident interview, staff interview, and facility documentation review, the facility staff failed to provide a clean and comfortable environment on two of three floors and in the dining room Findings included: On the second and third floors, the shower rooms were observed to be in need of cleaning, affecting residents on those floors who use the shower rooms. During the initial tour of the facility on 2/22/2024, the dining room wall near the entrance of the kitchen was observed to be very dirty with pronounced brown colored streaks extending from the floor to approximately 4 feet up the wall. Residents were observed sitting at tables in the dining room eating meals. The residents had clear view of the dirty wall. The wall was observed to still be dirty on 2/23/2024 and 2/26/2024 during rounds. Residents were observed participating in activities while in the dining room at various times during the survey. On 2/26/2024, tour of the physical environment revealed other areas of concern. On 2/26/2024 at 11 a.m., an interview was conducted with an alert resident in…

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

Based on staff interview and facility documentation review, the facility staff failed to implement the abuse policy for one resident (Resident #1) in a survey sample of 8 residents. Findings included: For Resident #1, the facility staff failed to implement their abuse policy as evidenced by failure to report an allegation of sexual abuse by a Certified Nursing Assistant (CNA)-B. According to the facility's documentation, Resident #1 reported an allegation of sexual abused to a Certified Nursing Assistant (CNA-C ) with whom he had a personal friendship. Resident #1 stated he told CNA-C not to say anything but he was upset because CNA-B had performed oral sex on him while he was sleepy after pain medication and being bathed. Review of the facility's investigation documents revealed that on 1/7/2024, Resident #1 confided in CNA-C that he had been sexually violated. When Resident #1 confided in another CNA (CNA-E) on 1/8/2024, CNA-E immediately reported to her supervisor who then reported to the Director of Nursing. It was then that the implementation of the abuse policy began. 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 interview, clinical record review, and facility documentation review, the facility staff failed to report an allegation of abuse within 2 hours of an allegation involving sexual abuse, for one resident (Resident #1) in a survey sample of 8 residents. The findings included: For Resident #1, a facility staff member, CNA (Certified Nursing Assistant )-C failed to identify and report an allegations of sexual abuse to the Administrator. Review of the facility's investigation documents revealed that on 1/7/2024, Resident #1 confided in CNA-C that he had been sexually violated. When Resident #1 confided in another CNA (CNA-E) on 1/8/2024, CNA-E immediately reported to her supervisor who then reported to the Director of Nursing. CNA-C did not report the allegation to the administrator. Interviews were conducted with the Administrator and the Director of Nursing. They were asked if the Certified Nursing Assistant should be able to identify and report abuse and neglect. The Administrator stated all the staff should be able to identify and report abuse and neglect. When asked if 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, facility documentation review, the facility staff failed to ensure an effectively functioning call bell system on two of three units affecting two residents (Residents #3 and #6) in a survey sample of 8 residents. Findings included: 1. For Resident #2, the call bell system did not work properly and the facility staff implemented the use of a cow bell system for notification of the need for assistance. On 2/23/2024, a cow bell was observed in Resident #2's room. An interview was conducted with Resident #2 who stated the cow bell had been in his room for a long time. Resident #2 stated the cow bell was really noisy and disturbed others. On 2/26/2024 at 10:10 a.m., an interview was conducted with the [NAME] President of Maintenance who stated he could provide the documents regarding maintenance because the Maintenance Director was off. The [NAME] President of Maintenance stated the facility utilized the electronic documentation of service requests in the computer system. Review of the facility's documentation of the tests of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, facility document review and clinical record review the facility staff failed to practice and maintain infection control measures to prevent the spread of infections to include Covid-19 while in an active Covid outbreak on 3 of 3 nursing units. The findings included: 1. For the facility in general, 3 employees failed to maintain infection control measures while working in the Resident rooms. Observations on 8/31/21: 830 AM all rooms on the second floor had signs posted on the doors that instructed to use 'Gown Gloves N95 and face shield' in room also there were signs instructing proper donning and doffing and handwashing. 8:45 AM - CNA C was in room [ROOM NUMBER] with no gloves, no gown, and no face shield, however she was wearing an N95 mask she exited the room without washing her hands but did use sanitizer in hall. 8:47 AM an interview was conducted with CNA C who stated I was only going in for a minute. I should have put on gown and gloves though. 12:40 PM 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 staff interviews the facility staff failed to have a designated individual to serve as the Infection Preventionist (IP) who had completed specialized training in infection prevention and control. This has the potential to affect all 106 Residents residing in the facility. The findings included: On 8/31/21, during an entrance conference with the facility Administrator, he identified the Assistant Director of Nursing (ADON) as the facilities designated Infection Preventionist. On 9/02/21 at 11:11 AM, Surveyor B met with Employee C, the ADON/Infection Preventionist. When surveyor B asked to see evidence of her training for the Infection Preventionist role, Employee C stated, I don't have any real training, I do know I've got to take those modules [referring to the Center for Disease Prevention and Control Infection Preventionist Training modules] but I haven't had any real training. On 9/2/21, during an end of day meeting with the facility Administrator, ADON and Corporate Nurse, they were made aware that Employee C doesn't have any specialized training in Infection Prevention…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews and facility documentation review, the facility staff failed to provide a qualified therapeutic recreation specialist or an Activities professional meeting the regulatory requirement to oversee the facility's Activity Program. The findings included: On 09/02/2021 at approximately 2:15 P.M., an interview with Employee D, the Community Life Director, was conducted. When asked about her training and qualifications as an Activities professional, the Community Life Director stated that she had her Bachelor's degree in Education and her Master's degree in Business. Employee D also stated that the facility trained her to be the Community Life Director. When asked about previous work experience, the Community Life Director stated that in her previous employment, she was a teacher. On 09/02/2021 at approximately 2:50 P.M., an interview with Employee G, Human Resources, was conducted. When asked about the employment status of the Community Life Director, Employee G indicated that the Community Life Director was initially hired in January 2020 as a part time…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation review and clinical record review, the facility staff failed to conduct COVID-19 testing of one Resident (Resident #112) who was symptomatic and failed to conduct routine COVID-19 testing of all unvaccinated staff, to prevent the spread of COVID-19 infections within the facility. The findings included: 1. For Resident #112, the facility staff failed to conduct COVID-19 testing immediately following the Resident presenting with symptoms. Review of the clinical record for Resident #112 revealed a progress note dated 8/4/21 at 6:45 AM, that read, .Stuffy nose with intermittent cough. Large amount of yellow mucus from mouth. Unable to cough out anything from mouth. Afebrile. The clinical record revealed no evidence of COVID-19 testing following the display of COVID symptoms, until 8/7/21, when the facility staff conducted facility wide outbreak testing. On 09/02/21 at 11:11 AM, Surveyor B met with Employee C, the Infection Preventionist. Employee C was asked to provide the line listing of Resident's and Staff who have had symptoms and/or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed for 1 resident (Resident #103) in the survey sample of 46 residents, to grant a written request for access to medical records. The Findings included: The facility staff failed to grant Resident #182's Responsible Party's request for a copy of medical records. Review of the Clinical record was conducted on 9/1/2021 and 9/2/2021. The Minimum Data Set, which was an admission Assessment with an Assessment Reference Date of 3/19/2021 was reviewed. Resident #182 was coded as having severely impaired cognition. Review of the record revealed Resident #182 had a Responsible party listed on the facesheet. Resident # 182 was hospitalized on [DATE] and did not return to the facility. The Responsible Party requested a copy of Resident # 182's medical record admission paperwork on 3/23/2020. On 09/03/2021, a review was conducted of facility documentation, revealing 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 observation, staff interview and facility documentation review, the facility staff failed to uphold one Resident's (Resident #49) personal privacy during care, in a survey sample of 41 Residents. This failure to uphold a Resident's privacy has the potential to violate the Resident's dignity and cause feelings of embarrassment. The findings included: On 9/1/21 at 4:06 PM, Surveyor B knocked on the room door of Resident #49. After hearing no response, Surveyor B opened the door and observed CNA B at the bedside providing care. Resident #49 was exposed and the privacy curtain was not pulled around Resident #49, leaving her exposed to her roommate as well as anyone entering the room. CNA B stated she was changing Resident #49's gown. CNA B was asked if she normally pulls the privacy curtain when providing care, CNA B stated, normally I do on this side [referring to between Resident #49 and her roommate], but there just isn't room. When asked why the privacy curtain would be used during care, CNA B stated, For her privacy. Resident #49 was not interviewable to ask how this…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation review, the facility staff failed to implement their abuse policy by failing to conduct a post investigation follow-up report after an allegation of abuse involving two Residents (Resident #27 and Resident #70) in a survey sample of 41 Residents. The findings included: On 9/2/21, during a clinical record review, Resident #27's electronic health record revealed a nursing progress note entry dated 7/24/21 at 19:26, which read, Resident was involved in an incident with another resident. All management, MD/NP [medical doctor/ nurse practitioner], and RP [responsible person/party] have been notified of all recent events, according to facilities policy and procedure guidelines. On 9/2/21, Surveyor B asked the facility staff to provide any FRI's (Facility Reported Incidents) involving Resident #27 for the year 2021. Upon receipt of 2 FRI's, Surveyor B observed that the Resident to Resident altercation between Resident #27 and #70 on 7/24/21, had no post-investigation follow-up report, to state the investigation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation review, the facility staff failed to report to the State Survey Agency the result(s) of an investigation within 5 working days, following an allegation of abuse involving two Residents (Resident #27 and Resident #70) in a survey sample of 41 Residents. The findings included: On 9/2/21, during a clinical record review, Resident #27's electronic health record revealed a nursing progress note entry dated 7/24/21 at 19:26, which read, Resident was involved in an incident with another resident. All management, MD/NP [medical doctor/ nurse practitioner], and RP [responsible person/party] have been notified of all recent events, according to facilities policy and procedure guidelines. On 9/2/21, Surveyor B asked the facility staff to provide any FRI's (Facility Reported Incidents) involving Resident #27 for the year 2021. Upon receipt of 2 FRI's, Surveyor B observed that the Resident to Resident altercation between Resident #27 and #70 on 7/24/21, had no post-investigation follow-up report, to indicate the results…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interview, and clinical record review, the facility staff failed to accurately complete MDS assessments for (3) Residents (#'s 51, 55, 57) in a survey sample of 40 residents. The findings included: 1. For Resident #51, the facility staff did not accurately complete the Quarterly MDS (Minimum Data Set) assessment dated [DATE] to reflect the status of the Resident. On 8/31/21 at approximately 9 AM an observation was made of Resident #51 lying in bed, the head of bed was elevated to a 45° angle and his tube feeding was infusing. The Resident did not answer to his name being called. The resident opened his eyes however they did not focus on surveyor, and gave no indication that he understood what the surveyor was saying. A review of the MDS revealed that the facility answered question C0100 Should BIMS be assessed? The answer was marked (1) yes For the MDS question C0500 BIMS Score a dash (-) was placed in the box instead of 99 (unable to access). For section G functional status the following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview, observation, clinical record review and facility documentation the facility staff failed to review and revise care plans for 1 Resident (#55) in a survey sample of 40 Residents. The Findings include: For Resident #55 the facility staff failed to review and revise the care plan to include an actual fall with major injury on 6/4/21. On 9/1/21 during clinical record review it was discovered that Resident #55's care plan read as follows: [Resident name redacted] is at risk for falls/potential for injury r/t confusion unaware of safety needs, psychotropic medication, pacemaker, a fib, Tachycardia and history of pain. Dementia history of falls Under interventions from most recent fall (6/4/21) when she broke her hip it listed; send to ER for evaluation and X-ray to hip as ordered. On 9/1/21 an interview was conducted with LPN B who was asked the purpose of a care plan, she stated It directs care of the resident. She was also asked who has access to the care plan, and she stated all nursing staff have access. LPN B was then asked to review Resident # 55's care plan 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 observations, resident interviews, staff interviews, and clinical record reviews, the facility staff failed to provide care and services according to professional standards of care for 1 resident (Resident #288) in a sample size of 46 residents. The findings included: 1. For Resident #288, the facility staff failed to provide wound treatment on 08/31/2021, 09/01/2021, and 09/02/2021 as ordered by the physician. On 09/01/2021 at 11:55 A.M., Resident #288 was interviewed. When asked if he had any wounds, Resident #288 indicated he had wounds on his right foot. When asked how he got the wounds, Resident #288 stated that his foot got all scratched up and it got worse and worse. Resident #288 moved the bed covers from his right foot to reveal the right foot with a dressing of kerlix and clear tape. The dressing was not dated or initialed. When asked if the dressing had been changed this day, Resident #288 stated it had not been changed today. Resident #288 indicated that the nurses haven't changed 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 interview, clinical record review the facility staff failed to provide timely ADL care to 1 dependent Resident (#15) in a survey sample of 40 Residents. For Resident #15 the facility staff failed to provide incontinent care in a timely manner resulting in Resident #15 sitting in a soiled brief for 2 hours. The findings included: On 8/31/21 at approximately 12:15 PM Resident # 15 and his roommate, Resident # 100 were observed in their room. The surveyor began talking to Resident number 100 about care provided at the facility and he stated Just ask my roommate he rang the bell at 10 o'clock to get changed and its 12:15 and they just changed him. At approximately 12:20pm, an interview was conducted with Resident # 15 who stated, I can't wait to get out of this place, and yes I did ring at 10 o'clock to get changed. The CNA came into the room told me I have to go get something I'll be right back. She left and came back at 12:00 PM. I just now got changed at 12 o'clock. At 1:00 PM an interview was conducted with CNA B who stated that she tries to get to everyone as fast as she…

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

Based on observation, interview, and clinical record review and in the course of an investigation the facility staff failed to provide appropriate foot care for 1 Resident (# 12) in a survey sample of 40 residents. The findings included: For Resident # 12 the facility staff failed to trim toenails or arrange for podiatry to do so for a Resident who is diabetic. On 8/31/21, an interview was conducted with resident #12 at approximately 10 AM. Resident # 12 was asked about the ADL care that he received from the facility and he stated he gets his showers but nobody ever cuts his toenails. When asked if he had seen the podiatrist he said, One time since I've been here. When asked if the surveyor could look at his feet, Resident #12 took off his shoes and the Surveyor observed that both feet had nails that were approximately 1/4 inch of an inch long. According to the admission MDS, Resident #12 was admitted in April 2018. During clinical record review, it was found that the resident had only one podiatry visit. The podiatrist saw the Resident on 3/16/21. Podiatry consult note dated…

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

Based on observation, interview, and facility documentation the facility staff failed to appropriately label and store medications for 2 Residents (#'s 40, 102) in a sample of 40 Residents and failed to remove expired medication from use for one medication cart and one medication room. The findings included: 1. For Resident # 40 the facility staff failed to date the Resident's eye drops when they were opened. On 9/1/21 at approximately 8:45 AM while inspecting the medication carts and medication rooms with LPN D, it was noted that there was a bottle of Latanoprost 0.005% eye drops belonging to Resident #40 that was not dated when opened. The pharmacy sticker on the bottle stated This medication is good for 45 days after opening. At that time, an interview was conducted with LPN D who stated that the sticker on the bottle was a reminder to nurses that the bottle should be dated when opened since it is only good for 45 days. She stated the importance of dating the eye drop bottle is that so you will not know when they are expired and do not keep using them. On 9/1/21 at approximately…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain an accurate clinical record for one resident (Resident #288) in a sample size of 46 residents. The findings included: For Resident #288, the nursing admission assessment documented a wound to the right heel when, in fact, Resident #288 had multiple wounds on the top and side of the right foot and no wound on the right heel. On 09/01/2021 at 11:55 A.M., Resident #288 was interviewed. When asked if he had any wounds, Resident #288 indicated he had wounds on his right foot. When asked how he got the wounds, Resident #288 stated that his foot got all scratched up and it got worse and worse. Resident #288 moved the bed covers from his right foot to reveal the right foot with a dressing of kerlix and clear tape. On 09/02/2021 at 7:05 P.M., this surveyor observed the wounds on Resident #288's right foot as Registered Nurse A (RN A) performed a wound treatment and dressing change. Resident #288 had 4 open wounds 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, facility staff interview, clinical record review, and facility documentation review, the facility staff failed for 6 residents (131, 71, 122, 104, 81, 65) of the survey sample of 46 residents, to ensure that they were free from unnecessary psychotropic medications. 1. For Resident #131, the facility staff failed to ensure that he was free of unnecessary psychotropic medication (Seroquel). 2. For Resident #71 the facility administered antipsychotic medication without proper diagnosis and without attempting at Gradual Dose Reduction. 3. For Resident #122 the facility failed to perform a gradual dose reduction (GDR) on psychotropic medications in spite of Pharmacy recommendations and hospital warning that it was dangerous to give Ambien and narcotic pain medicine. 4. Resident #104 did not have an appropriate diagnosis for the use of Geodon (antipsychotic) as well as having no documented behaviors for over a year. The pharmacist issued two recommendations for a GDR (12-12-17 and 6-7-18) but 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 and staff interview, the facility staff failed to ensure safe storage of medications. 1. Two medications were found to be expired, and open and available For Resident administration to Residents #52, and #133. 2. The facility staff failed to discard 2 bottles of expired medication (magnesium oxide) in 2 of 3 medication rooms (1st floor and 3rd floor medication rooms) 3. The facility staff failed to ensure the narcotic box was permanently affixed in 2 of 3 medication refrigerators (2nd and 1st floor medication rooms) In addition, the narcotic box in the 2nd floor medication refrigerator was not locked. The findings include: 1. Two medications were found to be expired, and open and available For Resident administration to Residents #52, and #133. On 10-3-18, at 10:00 a.m., during the medication pour and pass observation, with LPN (B) (licensed practical nurse (B), two pill form, bulk dose medications were noted to be expired. LPN (B) was asked during the medication pour and pass observation how medications are dated for expiration, and she responded we date them…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation review, the facility staff failed to ensure two residents (Resident #232 and 233) of 46 sampled residents was given a form CMS-10055 before discharge from skilled nursing. The findings include: Resident #232 was discharged from skilled nursing on 09/05/2018. A review of the record showed no form CMS-10055 was provided to the resident. Resident #233 was discharged from skilled nursing on 07/08/2018. A review of the record showed no form CMS-10055 was provided to the resident. On 10/04/2018 at 11:15 am, an interview was conducted with employee D who issues the forms to the residents who are discharging from skilled nursing. Employee D stated that she did not know she was supposed to use form CMS-10055 but instead was using form CMS-R-131 The facility was informed of the findings during a briefing on 10/03/2018.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview and clinical record review, the facility staff failed for 1 resident (Resident # 92) of the survey sample of 46 residents, to ensure that resident #92 was free from verbal abuse. For Resident #92, the facility staff failed to ensure that she was free of verbal abuse by facility staff on 2 occasions. The Findings included: Resident #92 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #92's diagnosis included Obesity, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Chronic Obstructive Pulmonary Disease, Low Back Pain, Major Depressive Disorder, Anxiety Disorder, Chronic Pain Syndrome, and Generalized Muscle Weakness. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 8/24/18, coded Resident #92 as having a Brief Mental Status Score of 15, indicating that she was independent in daily decision making ability. Resident #92 was coded as requiring the physical assistance of 2 persons 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, staff interview and facility documentation review the facility staff failed to screen employees for convictions of abuse, neglect, exploitation, misappropriation of property, or mistreatment. The facility staff failed to screen two employees prior to hire (Employee G, Employee B). The Findings included: On 10/3/18 at 11:45 A.M., an observation was completed of the facility kitchen. Employee G, and Employee B were working in the kitchen during lunch preparation and service. On 10/3/18 an interview was conducted with the Human Resources Manager (Employee J). The Human Resources Manager stated that the facility did not have any documentation on Employee G, or Employee B. She stated that they were sent by a food service agency. When asked if the facility had verified if they had been found guilty of abuse, neglect, or exploitation, the Human Services Manager stated that a background check had not been obtained by the facility prior to allowing them to work in the facility. They had worked in the facility for several months prior to the survey. On 10/3/18 a review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility record review, and staff interview, the facility staff failed to send a plan of care to the receiving hospital for one Resident (Resident #80) upon discharge to the hospital. For Resident #80, the facility staff failed to send a care plan to the emergency department with the Resident upon discharge. The findings included: Resident #80 was admitted to the facility on [DATE]. Diagnoses included; Stroke with left side weakness, encephalitis, depression, and dialysis. Resident #80's most recent Minimum Data Set (MDS), was a significant change assessment, with an assessment reference date of 8-22-18. The document coded the Resident as severely cognitively impaired. The document also coded Resident #80 as requiring total assistance from one to two staff members to complete all activities of daily living. The Resident was sent out to the hospital on 7-3-18 with seizure activity, according to the nursing progress notes, and Registered pharmacist's medication regimen review.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and facility documentation review, the facility staff failed to ensure an accurate assessment for 1 of 46 residents sampled (Resident #54). Specifically, the facility staff coded on the BIMS a 99 and also did the staff assessment when in fact the resident scored a 5 on the BIMS and the facility staff assessment should not have been completed. The findings included: Resident #54 was admitted [DATE] with diagnoses: anxiety, depression, diabetes, and stroke. Her most recent assessment was a Quarterly Minimum Data Set (MDS) dated [DATE]. This MDS had a score of 99 for the Brief Interview of Mental Status (BIMS), located in Section C. This interview generates an assessment of the resident's cognitive ability. Resident #54 provided responses to 3 of the 7 questions in the BIMS interview (repeating three words, correct year, and recall of one prior item spoken by the interviewer). She provided incorrect responses to the remaining 4 questions. These questions are in MDS fields C0200-C0400. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and facility documentation review, the facility staff failed to ensure an accurate PASARR assessment for 1 of 46 residents sampled (Resident #54). The findings included: Resident #54 was admitted [DATE] with diagnoses: anxiety, depression, diabetes, and stroke. Her most recent assessment was a Quarterly Minimum Data Set (MDS) dated [DATE]. This MDS showed a diagnosis of Anxiety, Depression, and Psychotic disorder in fields I5700, I5800, and I5950 respectively. Her prior assessments dated 5/9/2018, 2/6/2018, 11/8/2017, 8/10/2017, 5/10/2017, and 2/7/2017 did not have Psychotic disorder coded, but did list Anxiety and Depression. Her admission History and Physical, dated 1/30/2017, did not list schizophrenia, psychosis, or dementia as active diagnoses. Her PASARR Level I, done 1/30/2017, showed that the field asking Does the resident have a major mental disorder diagnosable under DSM-IV (e.g. schizophrenia, mood, paranoid, panic, or other serious anxiety disorder; somatoform disorder;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation and clinical record review, the facility staff failed to, for one Resident, Resident #104, in a survey sample of 46 residents, to ensure the care plan had targeted behaviors and non pharmacological interventions for the use of an antipsychotic medication. Resident #104's care plan had no targeted behaviors or non pharmacological interventions for the twice daily use of Geodon. The findings included: Resident #104 was admitted to the facility on [DATE]. Diagnoses included anemia, Alzheimer's dementia and psychosis. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 9-5-18. Resident #104 was coded as having short and long term memory impairments and was severely impaired in daily decision making. There were no behaviors coded for the last seven days of the ARD. On 10/2/18 at 1:01 PM, Resident #104 was observed eating in her room. She had a regular diet, eating well. On 10/03/18 at 10:38 AM, Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review the facility staff failed to ensure professional standards of nursing for medication administration were followed for 1 residents (#83) of 46 residents in the survey sample. 1. For Resident #83 the facility staff failed to administer calcium per physician order. The findings included: Resident #83, an [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included reflux, hypertension, hyperlipidemia, anemia, and depression. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 8/29/18. The resident was coded with a Brief Interview of Mental Status score of 11 indicating moderate cognitive impairment and required extensive assistance with activities of daily living. On 10/3/18 at 9:30 a.m., a medication pour and pass observation was conducted with Licensed Practical Nurse F (LPN F). LPN F was observed to prepare medications for Resident #83. LPN F was observed to administer 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 documentation review, the facility staff failed to develop a comprehensive, collaborative care plan with the hospice agency for 1 of 46 residents sampled (Resident #81). The findings included: Resident #81 was admitted [DATE] with diagnoses of: adult failure to thrive, schizophrenia, pressure ulcers, contractures, and dysphagia. She was admitted to hospice services on 8/21/2018. Resident #81 had an admission Minimum Data Set (MDS) on 8/14/2018 which did not show hospice services in field O0100k. On 8/22/18, the provider completed a significant change in status (SCSA) MDS, which did record hospice services. This SCSA assessment is required when a resident enrolls or dis-enrolls from hospice services. Per the RAI (Resident Assessment Instrument) Manual, v 1.14 (effective 10/1/2016), page 2-23: A SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers 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, staff interview, and clinical record review, the facility staff failed to administer oxygen per physician order. For Resident #108, the facility staff failed to administer the correct amount of oxygen per physician order. The Findings included: Resident #108 was admitted to the facility on [DATE]. Resident #108's diagnoses included Generalized Muscle Weakness, Unspecified Dementia without Behavioral Disturbance, Altered Mental Status, Hypertension, and Chronic obstructive Pulmonary Disease. The Minimum Data Set, which was an admission Assessment with an Assessment Reference Date of 9/20/18 coded Resident #108 as requiring the use of oxygen therapy. On 10/2/18 a tour was conducted of the facility. Resident #108's oxygen was being administered at 3 liters per minute. On 10/3/18 at 1:55 P.M., Resident #108's oxygen was being administered at 3 liters per minute. On 10/2/18 a review was conducted of Resident #108's clinical record, revealing a signed physician's order that read, 10/1/18. Oxygen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation and clinical record review, the facility failed to, for one Resident, Resident #104 in a survey sample of 46 residents, to ensure the resident received care and services for dementia care. Resident #104 has been taking Geodon 60 mg (milligrams) twice daily with no appropriate diagnosis or behaviors since her admission [DATE]). There are no care plan interventions to address behaviors or for the continued use of an antipsychotic. The findings included: Resident #104 was admitted to the facility on [DATE]. Diagnoses included anemia, Alzheimer's dementia and psychosis. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 9-5-18. Resident #104 was coded as having short and long term memory impairments and was severely impaired in daily decision making. There were no behaviors coded for the last seven days of the ARD. On 10/2/18 at 1:01 PM, Resident #104 was observed eating in her room. She had 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 observation, staff interview and facility record review, the facility staff failed to ensure that the Acting Dietary Manager was certified. The facility staff failed to ensure that the Acting Dietary Manager was Certified in Dietary Management. The facility did not have a Dietary Manager. The Findings included: On 10/3/18 at 11:45 A.M., an observation was completed of the facility kitchen. The Acting Dietary Manager (Employee A), was working in the kitchen during lunch preparation and service. She stated that her position was Assistant Dietary Manager and Executive Chef. Her hire date according to her employee file was 8/1/18. She stated since the former Dietary Manager quit, that she supervised the meal preparation, ordered food, and cooked food in the facility. She stated that she was not a Certified Dietary Manager, and that she planned to be trained for the certification the following week. On 10/3/18 a review was conducted of facility documentation, revealing a Employee A's Job Description that read, Assistant Manager & Executive Chef. Qualifications: Certified Dietary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 documentation review, the facility staff failed to provide Activities of Daily Living (ADL) care in a manner to prevent the spread of infection. A facility staff member carried a cloth bag from room to room, with no way to disinfect it. The Findings included: On 10-2-18 and 10-3-18 during multiple observations both days throughout the 7:00 a.m., to 3:00 p.m. shift, CNA (A) (certified nursing assistant A) was observed by 2 surveyors to be carrying a pink cotton cloth bag, (which resembled a ladies purse), in and out of Residents rooms. CNA (A) was observed laying it down on residents overbed tables when she entered each room. The bag contained shampoo, soap and other bathing supplies which were being used by CNA (A), and shared for all of the residents receiving ADL care from CNA (A). On 10-4-18 at 9:50 a.m., CNA (A) was interviewed, and stated the bag contained shampoo, soap and other bathing supplies which were being used by CNA (A) for all of the residents ADL care. She further stated I buy it myself, but I won't carry the bag,…

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