The Laurels Of University Park

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure a PASARR was completed accurately for one of 39 residents in the survey sample; Resident #20. The findings include: For Resident #20, the facility staff failed to ensure the PASARR (Pre admission Screening and Resident Review) was completed accurately to determine if the resident did or did not have a mental condition requiring additional services. A review of the clinical record for Resident #20 revealed a PASARR form, dated 7/20/22. This form documented the following: 2. DOES THE INDIVIDUAL HAVE A CURRENT SERIOUS MENTAL ILLNESS (MI)? Yes No (Check Yes only if each item below are all Yes. If No, do not refer for evaluation of active treatment needs for MI (mental illness) Diagnosis.) a. Is this major mental disorder diagnosable under DSM (Diagnostic and Statistical Manual of Mental Disorders) (e.g., schizophrenia, mood, paranoid, panic, or other serious anxiety disorder; somatoform disorder; personality disorder; other psychotic disorder; 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 and facility document review, it was determined that the facility staff failed to provide ADL care of a dependent resident to one of 39 residents in the survey sample; Resident #136. The findings include: For Resident #136, the facility staff failed to evidence that ADL care was provided. Resident #136 was admitted to the facility on [DATE] and discharged on 1/25/24. A review of the ADL (Activities of Daily Living) record for December 2023 and January 2024 revealed that the resident was to have showers on Mondays and Thursdays. In December 2023 there were seven opportunities for a shower. There were four showers documented. One occasion contained documentation that the resident was unavailable. On two occasions, no shower was documented. In January 2024 there were seven opportunities for a shower. There were four showers documented. On three occasions, no shower was documented. The facility's ADL logs did not include a line item for documenting any bathing outside…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to provide care and services for the treatment of pressure injuries for one of 39 residents in the survey sample, Resident #189. The findings include: For Resident #189, the facility staff failed to evidence, the treatments for pressure injuries (1), were completed per the physician orders. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 11/4/2022, the resident scored a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section M - Skin Conditions, the resident was coded as having two stage three pressure injuries (2). Sacral Wound The physician order dated, 10/15/2022, documented, Cleanse sacral wound with ns (normal saline) and apply hydrofera blue (3) and secure with island border dsg (dressing) QD (every day; every…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to provide monitoring for fluid restriction and intake for three of 39 residents, Resident #17, Resident #18 and Resident #35. The findings include: 1.The facility failed to provide monitoring for fluid restriction and intake for Resident #17. Resident #17 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CHF (congestive heart failure) and DM (diabetes mellitus). A review of the comprehensive care plan dated 4/18/24, which revealed, FOCUS: Resident is at nutritional and/or dehydration risk related to: edema, CHF and DM. Requires therapeutic diet and mechanically altered diet with fluid restriction. INTERVENTIONS: Provide diet as ordered. Fluid Restriction: 1800cc. A review of the physician's orders dated 3/28/24, revealed, Fluid Restriction diet Chopped Meat texture, Regular consistency, 1800ml per day 720 ml nursing/ 1080 ml…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to provide dialysis care and services for one of 39 residents in the survey sample, Resident #35. The findings include: The facility failed to provide evidence of monitoring for bruit and thrill for Resident #35. Resident #35 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ESRD (end stage renal disease) and diabetes. A review of the comprehensive care plan dated 3/20/24, which revealed, FOCUS: Resident is at risk for complications related to dialysis due to: End Stage Renal Disease. INTERVENTIONS: Observe signs/symptoms of the following: Bleeding, Bruising, Hemorrhage, presence of aneurysm, Bacteremia & septic shock. Document and report abnormal findings to the physician. A review of the physician's orders dated 4/23/24, revealed, Hemodialysis Tuesday, Thursday, Saturday. Observe dialysis catheter for bleeding,…

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

Based on observation, staff interview, and facility document review, it was determined the facility staff failed to maintain infection control practices during the medication administration observation for one of three nurses observed. The findings include: Observation was made on 4/22/2024 at 11:32 a.m. of RN (registered nurse) #1 administering medications on the 200 hallway. RN #1 was observed popping two medications out of the medication bubble pack and dropping the pills into her hand. She then put the pills into the medication cup and administered the medications to the resident. An interview was conducted with RN #1 on 4/22/2024 at 11:55 a.m. The above observation was shared with RN #1. She stated she guessed she had done that. When asked should the nurse touch a resident's medications with her hands, RN #1 stated, no. When asked why, RN #1 stated because of sanitary reasons, germs. The facility policy, Medication administration, documented in part, 1 . If medications come into contact with the bare hands of the nurse/med(medication) tech (technician), or with the med cart,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement a complete immunization program for one of five residents reviewed for immunizations, Resident #5. The findings include: For Resident #5 (R5) the facility staff failed to provide education for and offer the most recent influenza vaccination. R5 was admitted to the facility on [DATE]. A review of R5's clinical record revealed no evidence that she was educated about or offered the most recent influenza vaccine. On 4/24/24 at 12:34 p.m., ASM (administrative staff member) #2, the director of nursing was interviewed. She stated the assistant director of nursing, who no longer works at the facility, was responsible for making sure all residents were offered the influenza vaccine when it became available in the fall of 2023. She stated residents should have been given a form with the risks and benefits of receiving the vaccine, and provided an opportunity to accept or decline its administration. She…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement a complete immunization program for one of five residents reviewed for immunizations, Resident #5. The findings include: For Resident #5 (R5) the facility staff failed to provide education for and offer the most recent COVID vaccination. R5 was admitted to the facility on [DATE]. A review of R5's clinical record revealed no evidence that she was educated about or offered the most recent COVID vaccine. On 4/24/24 at 12:34 p.m., ASM (administrative staff member) #2, the director of nursing was interviewed. She stated the assistant director of nursing, who no longer works at the facility, was responsible for making sure all residents were offered the most recent COVID vaccine when it became available. She stated residents should have been given a form with the risks and benefits of receiving the vaccine, and provided an opportunity to accept or decline its administration. She stated she could not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to evidence that residents and/or their RR (resident representative) were provided with written information and provided the opportunity to formulate advance directives at the time of admission and/or conduct a periodic review with the residents and/or their RRs if they wish to formulate one, or, if applicable, make changes to their existing advance directives or maintain them as written for 5 of 59 residents in the survey sample, Residents #90, #78, #114, #16, and #58. The findings include: 1. The facility staff failed to provide Resident #90 (R90) or the RR written information and the opportunity to formulate advance directives (1) upon admission, and failed to conduct a periodic review of advance directives in 2021 and 2022. R90 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 2/14/22, 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 7. The facility staff failed to implement the comprehensive care plan for dialysis care for Resident #76. Resident #76 was admitted to the facility on [DATE]. Resident #76's diagnoses included, but were not limited to, ESRD (end stage renal disease) and dementia. Resident #76's most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 3/19/22, coded the resident as scoring 9 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of Resident #76's comprehensive care plan revised 9/9/21, revealed the following, NEED: Resident is at risk for complications related to needs for dialysis due to: End Stage Renal Disease. dialysis cath replaced 1/6/21. Hemodialysis Tuesday, Thursday, Saturday. INTERVENTIONS: Observe for signs/symptoms of infection to access site: Redness, Swelling, warmth or drainage/bleeding and other signs of infection: fever, generalized malaise, complaints of abdominal…

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 document review and in the course of a complaint investigation it was determined that the facility staff failed to review and/or revise the comprehensive care plan for 4 of 59 residents in the survey sample, Resident #114, #87, #25, #336. The findings include: 1. The facility staff failed revise Resident #114's comprehensive care plan for (A) the use of a splint to the right upper arm and (B) the use of fall mats. On the most recent MDS, a quarterly assessment with an ARD of 5/23/2022, the resident scored 3 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. Section J1800 documented R114 not having any falls since admission/entry or reentry or prior assessment. A. On 6/13/2022 at 1:59 p.m., an observation was made of R114 in their room. R114 was observed lying in bed with a t-shirt on and asleep. R114 was observed not wearing a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to follow professional standards of practice for 2 of 3 residents in the Medication Administration observation task, Residents #14 and #96; and for 2 of 59 residents in the survey sample; Residents #87 and #113. The findings include: 1. For Resident #14, the facility staff failed to follow professional standards of practice when LPN #5 signed out for medication as given that was not administered. Resident #14 was admitted to the facility on [DATE]. On the annual MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 3/11/22, Resident #14 scored a 15 out of a possible 15 on the BIMS (brief interview for mental status) indicating the resident was cognitively intact in ability to make daily life decisions. On 6/14/22 at 8:17 AM, LPN #5 (Licensed Practical Nurse) was observed to prepare and administer the following medications 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, resident interview, staff interview, facility document review and in the course of a complaint investigation, the facility staff failed to provide ADL (activities of daily living) care for 3 of 59 residents in the survey sample, Residents #40, #10 and #87. The findings include: 1.a. The facility staff failed to trim Resident #40's (R40) fingernails. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/6/22, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. Section G coded R40 as being totally dependent on one staff with personal hygiene. On 6/14/22 at 3:10 p.m., an observation of R40's fingernails was conducted with LPN (licensed practical nurse) #8. R40's fingers were contracted and bent in towards the resident's palms; however, LPN #8 was able to move the resident's fingers out from the palms for the observation. R40's right thumb nail was approximately one forth inch long. All nails on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review, clinical record review and in the course of a complaint investigation, the facility staff failed to maintain residents' highest level of well-being for 4 of 59 residents in the survey sample, Residents #19, #15, #436, #701. The findings include: 1. The facility staff failed to schedule a mammogram per Resident #19's (R19) plan of care. On the most recent MDS (minimum data set), a five day Medicare assessment with an ARD (assessment reference date) of 4/18/22, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. On 6/13/22 at 1:21 p.m., an interview was conducted with R19. R19 stated that about a year ago, the resident's sister was diagnosed with breast cancer and the resident had not had a mammogram in approximately 15 years so R19 requested to have a mammogram scheduled at that time. R19 stated she spoke to two nurse…

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

Based on resident interview, staff interview clinical record review and in the course of a complaint investigation, the facility staff failed to provide condom catheter care and services per professional standards for one of 59 residents in the survey sample, Resident #40. The facility staff failed to change Resident #40's (R40) condom catheter every other day. The findings include: URINARY INCONTINENCE DEVICES: The systems for men most often consist of a pouch or condom-like device. This device is securely placed around the penis. This is often called a condom catheter. A drainage tube is attached at the tip of the device to remove urine. This tube empties into a storage bag, which can be emptied directly into the toilet. Condom catheters are most effective when applied to a clean, dry penis. You may need to trim the hair around the pubic area for better grip of the device. You must change the device at least every other day to protect the skin and prevent urinary tract infections. This information was obtained from the website: https://medlineplus.gov/ency/article/003974.htm 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 resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement a complete pain management program for one of 59 residents in the survey sample, Resident #58 (R58). The findings include: Facility staff failed to conduct complete pain assessments and attempt non-pharmacological interventions prior to the administration of a PRN [as needed] pain medication, tramadol (1). (R58) was admitted to the facility with a diagnosis that included by not limited to: rheumatoid arthritis. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 04/17/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section J0300 Pain Presence coded (R58) as having frequent pain in the past 5 (five) days. Section J0600 Pain Intensity coded (R58) as having a pain level of five out of ten with tem being the worse pain. The physician's order for (R58)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, resident interview, clinical record review, and facility document review, it was determined the facility staff failed to provide dialysis care and services for two of 59 residents in the survey sample, Resident #76 and Resident #116. The findings include: 1. For Resident #76, the facility failed to provide communication to the dialysis facility for 10 of 14 visits in March 2022, 11 of 13 visits in April 2022, 13 of 13 visits in May 2022 and 4 of 5 visits in June 2022 and failed to monitor the catheter site for signs of infection and bleeding. Resident #76 was admitted to the facility on [DATE]. Resident #76's diagnoses included but were not limited to: ESRD (end stage renal disease) and dementia. Resident #76's most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 3/19/22, coded the resident as scoring 9 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility document review it was determined facility staff failed to store food in one of one kitchens in accordance with professional standards for food service safety. The findings include: The facility failed to properly store plastic scoops in the dry good area, properly store opened, available for use frozen foods in the walk in freezer, and discard milk past it's expiration date in the walk in refrigerator. On 6/13/2022 at 10:44 a.m., an observation was made of the facility kitchen with OSM (other staff member) #11, the dietary aide. Observation of the dry goods area revealed three 18 quart plastic bins. One of the plastic bins was labeled Salt and was approximately 1/2 full. A blue plastic scoop was located inside the bin resting on top of the salt. Another plastic bin labeled Powdered milk was observed to be approximately 3/4 full. A plastic gallon sized zipper closure bag was observed laying on top of the lid to the bin with a plastic scoop sitting on top of the…

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

Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to honor a resident and/or a resident family's choices for one of 59 residents in the survey sample, Resident #103 (R103). The findings include: On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 05/13/2022, the resident scored 3 out of 15 on the BIMS (brief interview for mental status) assessment, which indicated the resident was severely impaired for making daily decisions. Section G documented R103 being totally dependent on two or more staff members for transfers and totally dependent of one person for dressing. On 6/13/2022 at approximately 12:15 p.m., an observation was made of R103 in their room. R103 was observed in bed wearing a hospital gown. R103 was observed to have their eyes open and respond by nodding yes or no to questions. R103 did not respond verbally. A handwritten note was observed to be written in a black marker on the bulletin board beside R103's bed…

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

Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to maintain the call bell in a position accessible to the resident for one of 59 residents in the survey sample, Resident #114 (R114). The findings include: On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/23/2022, the resident scored 3 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident is severely impaired for making daily decisions. Section G documented R114 having functional limitations in range of motion to both upper and lower extremities. The comprehensive care plan for R114 dated 2/25/2022 documented in part, [R114] is at risk for fall related injury and falls R/T (related to): new admit, confusion, psychoactive medication. Date Initiated: 02/25/2022. Revision on: 02/26/2022. Under Interventions it documented in part, .Put the resident's call light within reach and encourage him to use it for assistance as needed. Date Initiated:…

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 clinical record review, the facility staff failed to maintain a clean, comfortable, homelike environment for one of 59 residents in the survey sample, Resident #134. The facility staff failed to maintain Resident #134's (R134) bathroom in a clean and homelike manner. The findings include: On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/27/22, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. On 6/13/22 at 12:51 p.m., R134 was observed lying in bed. During an interview with R134, the resident stated the bathroom was dirty and the facility staff do not clean the floor in the bathroom. At that time, an observation of R134's bathroom was conducted. Small brown particles were observed on the floor in the right corner behind the toilet and in the corners under the sink; hair was observed around the trash can. On 6/14/22 at 3:05 p.m., another observation…

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

Based on staff interview, facility document review and in the course of a complaint investigation, the facility staff failed to implement the facility abuse policy for 4 of 11 employee record reviews. The facility staff failed to conduct certification and nursing license verifications upon hire for two CNAs)certified nursing assistant) #3 and #4, and two LPNs (licensed practical nurse) #10 and #11. The findings include: The facility abuse prohibition policy was reviewed and documented, A. Screening Employees and Guests/Residents: 1. The facility will screen potential new employees for a history of abuse, neglect, exploitation, misappropriation of property or mistreatment by a court of law .2. Without exception, all potential licensed and certified candidates must have their status confirmed with the appropriate boards to verify license/certification and to determine if any action has been taken against the license or certification. CNA #3 was hired on 8/25/21. CNA #4 was hired on 8/4/21. LPN #10 was hired on 8/18/21. LPN #11 was hired on 8/18/21. On 6/15/22 at 11:04 a.m., a review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review it was determined that the facility staff failed to evidence that all required documentation was provided to the receiving facility for a hospital transfer for 1 of 59 residents in the survey sample; Resident #128. The findings include: Resident #128 was transferred to the hospital on 5/17/22. There was no evidence that the comprehensive care plan goals, medication list, relevant progress notes or labs were provided to the hospital. Resident #128 was admitted to the facility on [DATE]. On the most recent MDS (Minimum Data Set), a quarterly assessment with an ARD (Assessment Reference Date) of 5/30/22, the resident scored an 11 out of a possible 15 on the BIMS (Brief Interview for Mental Status) indicating the resident was moderately impaired cognitively in ability to make daily life decisions. The resident was coded as requiring extensive assistance for eating and total care for all other areas of activities of daily living. A review of the clinical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review it was determined that the facility staff failed to evidence that written notification of a hospital transfer was provided to the resident and/or responsible party for a hospital transfer for one of 59 residents in the survey sample; Resident #128. The findings include: Resident #128 was transferred to the hospital on 5/17/22. There was no evidence that written notification of a hospital transfer was provided to the resident and/or responsible party. Resident #128 was admitted to the facility on [DATE]. On the most recent MDS (Minimum Data Set), a quarterly assessment with an ARD (Assessment Reference Date) of 5/30/22, the resident scored an 11 out of a possible 15 on the BIMS (Brief Interview for Mental Status) indicating the resident was moderately impaired cognitively in ability to make daily life decisions. The resident was coded as requiring extensive assistance for eating and total care for all other areas of activities of daily living. 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 staff interview and clinical record review it was determined that the facility staff failed to evidence that written bed hold notice was provided to the resident and/or responsible party for a hospital transfer for 2 of 59 residents in the survey sample; Residents #128 and #76 The findings include: 1. Resident #128 was transferred to the hospital on 5/17/22. There was no evidence that written bed hold notice was provided to the resident and/or responsible party. Resident #128 was admitted to the facility on [DATE]. On the most recent MDS (Minimum Data Set), a quarterly assessment with an ARD (Assessment Reference Date) of 5/30/22, the resident scored an 11 out of a possible 15 on the BIMS (Brief Interview for Mental Status) indicating the resident was moderately impaired cognitively in ability to make daily life decisions. A review of the clinical record revealed a nurse's note dated 5/17/22 that documented, Nurse practitioner in facility observed resident not at [their] baseline, observed right facial…

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 in the course of a complaint investigation, it was determined that the facility staff failed to accurately code the MDS (minimum data set) resident assessment for 3 of 59 residents in the survey sample, Resident #46, #114 and #701. The findings include: 1. The facility staff failed to accurately code Resident #46's (R46) quarterly MDS with an ARD (assessment reference date) of 6/4/2022 for falls sustained at the facility since the previous assessment. On the most recent MDS, a quarterly assessment with an ARD of 6/4/2022, the resident scored 3 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident is severely impaired for making daily decisions. Section J1800 documented R46 not having any falls since admission/entry or reentry or prior assessment. Review of the clinical record revealed a list of R46's MDS assessments. The list revealed the prior assessment was an End of PPS Part A Stay with an ARD of 4/21/2022 and a…

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

Based on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate level I PASRR (preadmission screening and resident review) to determine if a level 2 PASRR was required for one of 59 residents in the survey sample, Resident #19. The facility staff failed to entirely complete section 2 of Resident #19's (R19) PASRR and inaccurately documented the resident as not having a serious mental illness. The findings include: On the most recent MDS (minimum data set), a five day Medicare assessment with an ARD (assessment reference date) of 4/18/22, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), which indicated the resident was not cognitively impaired for making daily decisions. R19's diagnoses included bipolar disorder (1), borderline personality disorder (2) and dissociative identity disorder (3). R19's level 1 PASRR, completed on 9/14/21 documented, 2. DOES THE INDIVIDUAL HAVE A CURRENT SERIOUS MENTAL ILLNESS (MI)? No was circled. 2.a. Is this major mental disorder diagnosable under DSM (Diagnostic and…

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

Based on observation, resident interview, staff interview, clinical record review, facility document review and in the course of a complaint investigation it was determined that the facility staff failed to provide care and services to promote healing of a pressure ulcer for one of 59 residents in the survey sample, Resident #87. The findings include: The facility staff failed to evidence a treatment to the Stage 4 pressure ulcer between 1/7/2022-1/9/2022 and 1/11/2022-1/17/2022 for Resident #87 (R87). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/12/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was not cognitively impaired for making daily decisions. Section M documented R87 having 1 Stage 4 pressure ulcer and 1 Stage 3 pressure ulcer. On 6/14/2022 at 8:25 a.m., an interview was conducted with R87 in their room. R87 stated that the nurses had been in earlier that morning to change their wound dressing and had gotten better about doing 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, clinical record review, and facility document review, it was determined that facility staff failed to provide respiratory care and services for 3 of 59 residents in the survey sample, Residents #289, #94 and #61. The findings include: 1. The facility staff failed to store Resident # 289's (R289) nasal cannula (1) in a sanitary manner. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 06/05/2022, the resident scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. Section O Special Treatments, Procedures and Programs coded (R289) for Oxygen Therapy while a resident. On 06/13/22 at approximately 1:09 p.m., an observation of (R289's) nasal cannula was observed hanging over the partially open drawer of the bedside dresser uncovered. On 06/14/22 at approximately 3:10 p.m., an observation of (R289's) nasal cannula was observed hanging…

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 employee record review, it was determined the facility staff failed to complete annual performance/competency reviews for two of five CNA (certified nursing assistant), CNA #7 and CNA #8. The findings include: Five CNA employee records were reviewed for their annual performance/competency reviews. On 6/13/2022 at approximately 5:00 p.m. a request was made for the annual performance/competency reviews completed on CNA #7 and CNA #8. CNA #7 was hired on 9/2/2020 and CNA #8 was hired on 3/17/2021. A second request for the annual performance/competency reviews was made on 6/15/2022 at approximately 10:30 a.m. At the end of the day meeting on 6/15/2022 at 2:34 p.m. A third request was made for the performance/competency reviews for CNA #7 and CNA #8. At that time ASM (administrative staff member) #1, the administrator, stated the facility did not have the annual performance/competency reviews for CNA #7 and CNA #8. An interview was conducted on 6/15/2022 at 2:45 p.m. with ASM #4, the regional director of operations. When asked the process for CNAs to get…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure a medication error rate of less than 5%. The facility medication error rate was 10.71%, having made 3 identified medication errors out of 28 opportunities. The errors were for 2 of 3 residents in the Medication Administration task; Residents #14 and #96. The findings include: 1. For Resident #14, the facility staff failed to ensure the resident was free of medication errors. Resident #14 was admitted to the facility on [DATE]. On the annual MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 3/11/22, Resident #14 scored a 15 out of a possible 15 on the BIMS (brief interview for mental status) indicating the resident was cognitively intact in ability to make daily life decisions. A review of the facility policy, Medication Administration was conducted. This policy documented, Medications are administered in accordance…

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 document review, it was determined that the facility staff failed to ensure medication was stored in a safe and secure manner on one of 3 facility nursing units; the [NAME] unit. The findings include: During medication administration on the [NAME] unit, LPN #5 left a bottle of Folic Acid on top of the medication cart while in Resident #96's room, with the cart out of line of sight. Resident #96 was admitted to the facility on [DATE]. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/11/22, Resident #96 scored a 13 out of a possible 15 on the BIMS (brief interview for mental status) indicating the resident was cognitively intact in ability to make daily life decisions. On 6/14/22 at 8:28 AM, LPN #5 (Licensed Practical Nurse) was observed preparing medications on the [NAME] unit. A CNA (Certified Nursing Assistant) came and reported to LPN #5 that Resident #96 was asking for their inhaler. LPN #5 then began to prepare…

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 employee record review, it was determined the facility staff failed to ensure two of five CNAs had their annual training in dementia and abuse, CNA #7 and CNA #8. The findings include: Five CNA employee records were reviewed for documentation of their annual training in abuse and dementia. On 6/13/2022 at approximately 5:00 p.m. a request was made for the annual training in abuse and dementia for CNA #7 and CNA #8. CNA #7 was hired on 9/2/2020 and CNA #8 was hired on 3/17/2021. A second request for documentation for the annual training in abuse and dementia for CNA #7 and CNA #8 was made on 6/15/2022 at approximately 10:30 a.m. At the end of the day meeting on 6/15/2022 at 2:34 p.m. A third request was made for the documentation of annual abuse and dementia training for CNA #7 and CNA #8. At this time ASM (administrative staff member) #1, the administrator, stated the facility did not have evidence of annual training in abuse and dementia for CNA #7 and CNA #8. An interview was conducted with LPN (licensed practical nurse) #8, the assistant director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 6. Resident #57 was admitted to the facility with diagnoses that included but were not limited to metabolic encephalopathy (1), dementia (2) and osteoarthritis (3). Resident #57's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/15/2021, coded Resident #57 as scoring a 3 (three) on the staff assessment for mental status (BIMS) with a score of 0 - 15, 3- being severely impaired for making daily decisions. Section G coded Resident #57 as requiring extensive assistance of two or more staff for bed mobility, transfers and dressing. On 5/10/2021 at approximately 11:50 a.m., Resident #57 was observed in bed with bilateral upper bed rails in place on the bed. The bed rails were observed up and Resident #57 was observed grasping the bed rail when turning to the side in bed. An interview was attempted with Resident #57, however Resident #57 failed to answer questions appropriately. Additional observations of Resident #57 on 5/10/2021 at approximately 4:15 p.m. 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 5. Resident #71 was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of but not limited to acute respiratory failure, gastrostomy, below knee amputation (right), end stage renal disease, chronic obstructive pulmonary disease, deep vein thrombosis, dialysis, chronic kidney disease, dysphagia, aphasia, diabetes, depression, dementia, osteomyelitis, and COVID-19. The 5-day MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 4/28/21 coded the resident as severely cognitively intact in ability to make daily life decisions. The resident was coded as requiring total care for bathing and toileting; extensive assistance for transfers, dressing, eating, and hygiene; and was incontinent of bowel and bladder. A review of the clinical record revealed a nurse's note dated 4/16/21 at 3:32 PM documented, resident tolerated her medications this morning; about 15 minutes later, CNA (Certified Nursing Assistant) notified nurse that resident was c/o (complaining of) trouble breathing;…

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 interviews, staff interviews, clinical record reviews and facility document reviews it was determined that the facility staff failed to implement bed rail requirements for four of 38 residents in the survey sample, Residents #57, #132, #58 and #64. The facility staff failed to perform a physical device assessment, obtain a physician's order, obtain a consent for bed rails and evidence documentation of the use of bed rails on the comprehensive care plan for Resident #57, and Resident #58, and failed to obtain a consent prior to the use of bed rails for Resident #132, and failed to evidence an assessment for the use of bed rails [also referred to as side rails] for Resident # 64. The findings include: 1. Resident #57 was admitted to the facility with diagnoses that included but were not limited to metabolic encephalopathy (1), dementia (2) and osteoarthritis (3). Resident #57's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of…

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

Based on resident interview, staff interview, clinical record review, and facility document review it was determined the facility staff failed to ensure the drug regimens for three of 38 residents in the survey sample, (Residents #15, #58 and # 63), were free from unnecessary medications. The facility staff failed to implement and attempt non-pharmacological interventions per the physician's orders and plan of care prior to administering as needed (prn) pain medications to Resident #15, Resident #58 and Resident #63 on multiple dates during April and May 2001. The findings include: 1. Resident # 15 was admitted to the facility with diagnoses that include but not limited to: spinal stenosis [2]. Resident # 15's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 02/05/2021, coded Resident # 15 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Section J0300, J0400 and J0600 Pain Assessment Interview coded Resident # 15 as not having pain in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to evidence that the required information was provided to the receiving provider upon transfer to the hospital for two of 38 residents in the survey sample, Residents #71 and #333. The facility failed to evidence the comprehensive care plan goals were provided to the hospital for Resident #71's hospital transfer on 4/16/21, and for Resident #333's hospital on 3/9/21. The findings include: 1. Resident #71 was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of but not limited to acute respiratory failure, gastrostomy, below knee amputation (right), end stage renal disease, chronic obstructive pulmonary disease, deep vein thrombosis, dialysis, chronic kidney disease, dysphagia, aphasia, diabetes, depression, dementia, osteomyelitis, and COVID-19. The 5-day MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 4/28/21 coded the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to evidence that the Ombudsman was notified of a hospital transfer for three of 38 residents in the survey sample, Residents #71, #333, and #138. The facility staff failed to evidence that notification of the transfer was provided to the ombudsman for Resident #71, transferred to the hospital on 4/16/21, Resident #33, transferred to the hospital on 3/9/21 and Resident #138, transferred to the hospital on 2/24/21. The findings include: 1. Resident #71 was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of but not limited to acute respiratory failure, gastrostomy, below knee amputation (right), end stage renal disease, chronic obstructive pulmonary disease, deep vein thrombosis, dialysis, chronic kidney disease, dysphagia, aphasia, diabetes, depression, dementia, osteomyelitis, and COVID-19. The 5-day MDS (Minimum Data Set) assessment, with an ARD…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to evidence that a written bed hold notice was provided to the resident and/or responsible party upon a hospital transfer for 2 of 38 residents in the survey sample; Residents #71 and #333. The facility staff failed to evidence that a written bed hold notice was provided to the resident and/or responsible party upon a hospital transfer for Resident #71 on 4/16/21, and for Resident #333 on 3/9/21. The findings include: 1. Resident #71 was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of but not limited to acute respiratory failure, gastrostomy, below knee amputation (right), end stage renal disease, chronic obstructive pulmonary disease, deep vein thrombosis, dialysis, chronic kidney disease, dysphagia, aphasia, diabetes, depression, dementia, osteomyelitis, and COVID-19. The 5-day MDS (Minimum Data Set) assessment, with an ARD (Assessment Reference…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interview and facility document review, it was determined that the facility staff failed to code the annual MDS [minimum data set], with an ARD [assessment reference date] of 03/16/2021, for the use of oxygen for one of 38 residents in the survey sample, Resident # 58. The findings include: Resident # 58 was admitted to the facility with diagnoses that included but were not limited to: acute and chronic respiratory failure [1] and chronic obstructive pulmonary disease [2]. Resident # 58's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 03/16/2021, coded Resident # 58 as scoring an 14 on the brief interview for mental status (BIMS) of a score of 0 - 15, 14 - being cognitively intact for making daily decisions. Under section O0100 Special Treatments, Procedures and Programs it documented in part, C. Oxygen therapy. 2. While a Resident. Further review of this section revealed the box under 2. While a Resident,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, facility staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to implement a resident's initial baseline care plan for one of 38 residents reviewed, Resident #337. The facility staff failed to administer oxygen at the physician-prescribed rate, according to Resident #337's baseline care plan. The findings include: Resident #337 was admitted to the facility on [DATE] with diagnoses including COPD (1) and lung cancer. She had not been a resident of the facility long enough to have a completed MDS (minimum data set) assessment. On the Resident #337's admission nursing assessment dated [DATE], she was coded as being oriented to person, place, and time, and as receiving oxygen at the rate of two liters per minute. On 5/11/21 at 9:53 a.m., Resident #337 was observed sitting up in bed. Her eyes were closed. Oxygen was being delivered to her from a concentrator through a nasal cannula. The middle of the ball on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review it was determined that the facility staff failed to revise the comprehensive care plan for one of 38 residents in the survey sample, Resident #57. Resident #57's comprehensive care plan was not revised to address a significant weight loss. The findings include: Resident #57 was admitted to the facility with diagnoses that included but were not limited to metabolic encephalopathy (1), dementia (2) and osteoarthritis (3). Resident #57's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/15/2021, coded Resident #57 as scoring a 3 (three) on the staff assessment for mental status (BIMS) with a score of 0 - 15, 3- being severely impaired for making daily decisions. Section G coded Resident #57, as requiring extensive assistance of two or more staff for bed mobility, transfers and dressing. Section K coded Resident #57 as having a swallowing disorder and receiving a mechanically altered…

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 and staff interview, and clinical record review, the facility staff failed to follow professional standards of practice for one of 32 residents in the survey sample, Resident #128. The facility staff failed to clarify two different dose orders for Tylenol which were both prescribed as needed for pain for Resident #128, to determine which and when each dose of the medication should be administered based on pain level parameters. The findings include: Resident #128 was admitted to the facility on [DATE] with diagnoses including, but not limited to, COPD (Chronic Obstructive Pulmonary Disease) (1) and heart failure. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/25/21, Resident #128 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). She was coded as experiencing occasional pain at a maximum level of eight out of ten 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 observation, staff interview, facility document review, clinical record review, and facility policy review, it was determined the facility staff failed to provide wound care in a manner to promote healing and prevent infection of a pressure wound for two of 38 residents in the survey sample, Residents # 64 and # 18. 1. The facility staff failed to administer a wound treatment in a manner to promote healing and prevent infection for Resident #64. The facility staff failed to wash their hands before and after glove use and failed to wash their hands for a minimum of 15-20 seconds during Resident # 64's wound care. 2. The facility staff failed to administer a wound treatment in a manner to promote healing and prevent infection for Resident #18. LPN (licensed practical nurse) #4, failed to disinfect scissors removed from their uniform pocket before cutting dressings applied directly to Resident #18's wound, failed to wash their hands before and after glove use and failed to ensure handwashing for a minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review, it was determined that facility staff failed to provide appropriate treatment and services for the care of a Foley catheter to prevent infection for one of 38 residents in the survey sample, Residents # 18. Separate observations revealed Resident #18's Foley catheter tubing directly on the floor. The findings include: Resident # 18 was admitted to the facility with diagnoses that included but were not limited to: neuromuscular dysfunction of the bladder [1] and multiple sclerosis [2]. Resident # 18's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 02/12/2021, coded Resident # 18 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Resident # 18 was coded as requiring extensive assistance of one staff member for activities of daily living. Section H Bladder and Bowel coded Resident # 18 as having 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 observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to ensure the appropriate treatment and services to prevent complications of enteral feeding per the physicians orders for one of 38 residents in the survey sample, Resident #115. The facility staff failed to administer water flushes, and failed to record the total intake for the resident daily, per the physician's order. The findings include: Resident #115 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (1), dementia (2), and history of a stroke requiring the placement of a feeding tube (3). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/13/21, Resident #115 was coded as being severely cognitively impaired for making daily decisions, having scored three out of 15 on the BIMS (brief interview for mental status). She was coded as receiving greater than 51% of her total…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to provide dialysis services, consistent with professional standards of practice, the comprehensive person-centered care plan two of 38 residents, Resident #22 and Resident #439. The facility staff failed to evidence consistent assessments of Resident #22 and Resident #439's dialysis access sites per the comprehensive plan of care. Resident #22 had no documented assessment of the residents dialysis access site for a bruit and thrill on multiple dates in March, April and May, 2021. Resident #439 had no documented assessment of the residents dialysis access site for a bruit and thrill from 12/1/20 through 1/15/21, (47 days). The findings include: 1. Resident #22 was admitted to the facility on [DATE]. Resident #22's diagnoses included but were not limited to: ESRD [end stage renal disease] (inability of the kidneys to excrete wastes and…

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

Based on staff interview and facility document review, it was determined that the facility staff failed to complete the required annual performance review for two of five CNA (certified nursing assistant) records reviewed, CNAs #1 and #3. For CNA #1, no performance evaluation was completed between 3/7/20 and 3/7/21, and for CNA #3, no performance evaluation was completed between 6/11/19 and 6/11/20. The findings include: A review of performance evaluations was performed for CNA #1 and #3. On 5/11/21 at 9:45 a.m., ASM (administrative staff member) #1, the administrator, stated she had not located the annual performance review for CNA #1, but believed the review for CNA #3 was on her desk. On 5/11/21 at 4:45 p.m., ASM #1 was asked about the status of the performance reviews for both CNA #1 and CNA #3. She stated ASM #2, the director of nursing, was responsible for these reviews, and should be interviewed. On 5/12/21 at 10:58 a.m., ASM #2, the director of nursing, was interviewed about the missing performance reviews for CNAs #1 and #3. She stated the payroll department prints out a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to evidence a complete and accurate medical record for two of 38 residents in the survey sample, Resident #71 and Resident #333. The findings include: 1. For Resident #71, the facility staff failed to (A) ensure the comprehensive care plan goals for dialysis did not contain goals that were not appropriate for the type of dialysis access site the resident had in place; and (B) failed to ensure all medications and treatments were documented on the March 2021 and April 2021 Medication Administration Record (MAR). Resident #71 was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of but not limited to acute respiratory failure, gastrostomy, below knee amputation (right), end stage renal disease, chronic obstructive pulmonary disease, deep vein thrombosis, dialysis, chronic kidney disease, dysphagia, aphasia, diabetes, depression, dementia, osteomyelitis, 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, facility document review, and clinical record review, it was determined that the facility staff failed to follow infection control practices during wound care for two of 38 residents in the survey sample, Residents # 64 and # 18. 1. The facility staff failed to follow infection control practices by washing their hands before and after glove use and for a minimum of 20 seconds during Resident # 64's wound care. 2. The facility staff failed to disinfect scissors before use, wash their hands before and after glove use and failed to ensure handwashing for a minimum of 20 seconds during Resident # 18's wound care. The findings include: 1. Resident # 64 was admitted to the facility with diagnoses that included but were not limited to: heart disease, pressure ulcer and arthritis. Resident # 64's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 03/21/2021, coded Resident # 64 as scoring a 13 on the brief interview for mental…

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.