Old Southwest Health And Rehabilitation

Based on observation, staff interview, and clinical record review, the facility staff failed to maintain a clean, comfortable, homelike environment for 1 of 24 residents, Resident #118. The findings include: Resident #118's tube feeding pole was observed to have a dried brown substance on the bottom of the tube feeding pole. Resident #118's diagnoses included, but were not limited to, persistent vegetative state and cognitive communication deficit. Section B (hearing/speech/vision) of Resident #118's minimum data set (MDS) assessment with an assessment reference date (ARD) of 05/23/24 was coded to indicate Resident #118 was in a persistent vegetative state. Section K (swallowing/nutritional status) was coded to indicate this resident received nutrition via a feeding tube. On 07/10/24 at 11:00 a.m., the surveyor observed a brown dried substance on the bottom of this residents tube feeding pole. A second observation was made on 07/10/24 at approximately 2:35 p.m. the brown dried substance remained on the bottom of the tube feeding pole. On 07/11/24 at 4:30 p.m., during an end 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 staff interview and clinical record review, the facility staff failed to review and revise a comprehensive care plan (CCP) for 1 of 24 residents, Resident #115. The findings include: For Resident #115, the facility staff failed to review and revise the residents CCP to include their Do Not Resuscitate (DNR). Resident #115's diagnosis included adult failure to thrive. Section C (cognitive patterns) of Resident #115's significant change minimum data set (MDS) assessment with an assessment reference date (ARD) of 06/30/24 included a brief interview for mental status (BIMS) score of 6 out of a possible 15 points. Section O (special treatments and procedures) was coded to indicate this resident was receiving Hospice services. A review of Resident #115's clinical record revealed that the facility staff had not revised the CCP regarding the residents current code status. Under the focus area of Advance Directive, the facility staff documented this resident was a Full Code. Interventions included follow facility guidelines for full code. Resident #115's clinical record included the…

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

Based on staff interview, clinical record review, facility document review, and a medication pass and pour observation the facility staff failed to follow professional standards of practice for the administration of medications for 2 of 24 residents, Resident #123, and Resident #110. The findings included: For Resident #123 the facility staff signed a medication as being administered when the medication was unavailable for administration. Resident #123's clinical record listed diagnoses which included but not limited to unspecified asthma, uncomplicated. Resident #123's most recent minimum data set with an assessment reference date of 05/28/24 coded the resident as 3 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #123's comprehensive care plan was reviewed and contained a care plan for . is at risk for ineffective breathing d/t (due to) dx (diagnosis) of COPD (chronic obstructive pulmonary disease). Interventions for this care plan include give medications as ordered. Surveyor observed registered nurse (RN) #3…

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 clinical record review, the facility staff failed to ensure physician ordered equipment (splint) was in place to ensure the resident maintained and/or improved their highest level of range of motion (ROM) and mobility for 1 of 3 current residents in the survey sample. Resident #118. The findings include: The facility staff failed to apply a provider ordered splint to the residents right hand. Resident #118's diagnoses included, but were not limited to, persistent vegetative state, muscle weakness, and cognitive communication deficit. Section B (hearing/speech/vision) of Resident #118's minimum data set (MDS) assessment with an assessment reference date (ARD) of 05/23/24 was coded to indicate Resident #118 was in a persistent vegetative state. Section GG (functional abilities and goals) was coded to indicate this resident had limitations in ROM in the upper and lower extremities. Resident #118's comprehensive care plan included the focus area has limited physical mobility related to neurological deficits. Interventions included apply splint…

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, facility document review and during a medication pass and pour observation the facility staff failed to ensure medications were available for administration for 2 of 24 residents, Resident #123, #113 and failed to ensure the nursing staff correctly implemented the facility schedule control medication monitoring system for 5 of 5 medication carts. The findings included: 1. For Resident #123 the facility staff failed to ensure the medication Symbicort aerosol inhaler was available for administration. Resident #123's clinical record listed diagnoses which included but not limited to unspecified asthma, uncomplicated. Resident #123's most recent minimum data set with an assessment reference date of 05/28/24 assigned the resident a brief interview for mental status score of 3 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #123's comprehensive care plan was reviewed and contained a care plan for . is at risk for ineffective breathing d/t (due to) dx (diagnosis) of…

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

Based on staff interviews, medical record review and facility document review, the facility staff failed to act on pharmacy recommendations for one of three residents in the survey sample, resident # 101. The findings included: For resident # 101 (R101) the facility failed to act upon the pharmacy recommendations from May 27, 2024, and June 26, 2024. Progress notes in the clinical record indicated that medication regimen reviews had been done May 27,2024 and June 26,2024. This surveyor could not locate the Consultant Pharmacist Recommendation to Physician for either month in the record. On 7/11/2024 this surveyor asked the Director of Nursing (DON) for the pharmacy recommendations for May and June. They brought blank copies of each one. The recommendation for May read, Federal guidelines state psychopharmacological drugs should have an attempt at a gradual dose reduction (GDR) twice per year for the first year in two different quarters with 1 month between attempts, then annually thereafter, when used to manage behavior, stabilize mood, or treat psych disorder. This resident has…

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 ensure 1 of 24 residents was free from unnecessary medications, Resident #110. The findings included: For Resident #110 the facility staff administered the medication metoprolol without checking the residents blood pressure or pulse per the physician's order. Resident #110's clinical record listed diagnoses which included but not limited chronic diastolic (congestive) heart failure, and essential hypertension. Resident #110's most recent minimum data set with an assessment reference date of 06/07/24 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #110's comprehensive care plan was reviewed and contained care plans for . potential for altered cardiovascular status r/t (related to) hyperlipidemia, and CHF (congestive heart failure) with daily wts (weights) and . has potential fluid deficit/overload r/t (related to) diuretic use r/t CHF, HTN…

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

Based on staff interview, clinical record review and facility document review the facility staff failed to ensure 1 of 24 resident was free of significant medication error, Resident #110. The findings included: For Resident #110 the facility staff failed to administer the medication metoprolol per the physician's order. Resident #110's clinical record listed diagnoses which included but not limited chronic diastolic (congestive) heart failure, and essential hypertension. Resident #110's most recent minimum data set with an assessment reference date of 06/07/24 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #110's comprehensive care plan was reviewed and contained care plans for . potential for altered cardiovascular status r/t (related to) hyperlipidemia, and CHF (congestive heart failure) with daily wts (weights) and . has potential fluid deficit/overload r/t (related to) diuretic use r/t CHF, HTN (hypertension). Interventions for these care plan…

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 provide laboratory services to meet the needs of the resident for 1 of 4 sampled residents (Resident #122). The findings included: For Resident #122, the facility staff failed to obtain a urinalysis as ordered by the medical provider. The urinalysis was ordered to be obtained between 11/11/22 and 11/12/22; however, it was not obtained until 11/14/22. This was a closed record review. Resident #122's diagnosis list indicated diagnoses, which included, but not limited to Acute and Chronic Respiratory Failure, Obstructive and Reflux Uropathy, Acute Congestive Heart Failure, Dementia, and Chronic Cystitis. The minimum data set (MDS) with an assessment reference date (ARD) of 2/03/23 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 indicating the resident was severely cognitively impaired. A review of Resident #122's clinical record revealed a medical provider order dated 11/10/22 to obtain a urinalysis with culture and sensitivity (UA C&S) from 11/11/22 through…

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 clinical record review, the facility staff failed to ensure a medical provider was promptly notified of critical lab values for one (1) of four (4) residents sampled for laboratory review (Resident #114). The findings include: The facility staff failed to ensure Resident #114's critical laboratory results were promptly reported to a medical provider. Resident #114's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 5/2/24, was signed as completed on 5/19/24. Resident #114 was assessed as usually being able to make self understood and as sometimes being able to understand others. Resident #114's Brief Interview for Mental Status (BIMS) summary score was documented as a six (6) out of 15; this indicated severe cognitive impairment. Resident #114's clinical record included the results of a CBC with auto Differential laboratory test dated 6/1/24. (A Complete Blood Count (CBC) is a laboratory test that measures various components of a blood specimen.) These results indicated the Resident's [NAME] Blood Count (WBC) and Hemoglobin…

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 file laboratory results in the clinical record for 1 of 4 sampled residents (Resident #122). The findings included: For Resident #122, the facility staff failed to file the results of a urinalysis and thyroid-stimulating hormone (TSH) blood test in the resident's clinical record. This was a closed record review. Resident #122's diagnosis list indicated diagnoses, which included, but not limited to Acute and Chronic Respiratory Failure, Obstructive and Reflux Uropathy, Hypothyroidism, Acute Congestive Heart Failure, Dementia, and Chronic Cystitis. The minimum data set (MDS) with an assessment reference date (ARD) of 2/03/23 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 indicating the resident was severely cognitively impaired. A review of Resident #122's clinical record revealed a medical provider order dated 11/10/22 to obtain a urinalysis with culture and sensitivity (UA C&S) and an order dated 1/04/23 to obtain a TSH level. Surveyor was unable to locate…

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, facility document review, and clinical record reviews, the facility staff failed to maintain a complete and/or accurate clinical record for three (3) of 24 sampled current residents (Resident #114, Resident #110, and Resident #101). The findings include: 1. The facility staff failed to ensure Resident #114's weight was accurately documented in the resident's clinical record. Resident #114's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 5/2/24, was signed as completed on 5/19/24. Resident #114 was assessed as usually being able to make self understood and as sometimes being able to understand others. Resident #114's Brief Interview for Mental Status (BIMS) summary score was documented as a six (6) out of 15; this indicated severe cognitive impairment. The following information was found in a facility policy titled Weight Monitoring (with a reviewed/revised date of 12/1/22): Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual…

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, facility document review, and clinical record review, the facility staff failed to ensure one (1) of three (3) residents sampled for pneumococcal vaccination review were provided the pneumococcal vaccine (Resident #119). The findings include: The facility staff failed to provide Resident #119's pneumococcal vaccine. Resident #119's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 4/29/24, was signed as completed on 5/14/24. Resident #119 was assessed as able to make self understood and as able to understand others. Resident #119's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact and/or borderline cognition. Review of Resident #119's clinical record failed to provide evidence the resident was up to date on their pneumococcal vaccine. On 7/10/24 at 4:08 p.m., the facility's Assistant Director of Nursing (ADON) provided a copy of a nursing note, dated 4/26/24 at 3:16 p.m., which indicated consent had been obtained for the resident to receive the pneumococcal vaccine.…

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

Based on staff interview, clinical record review and facility document review the facility staff failed to ensure 2 of 3 residents was offered a 2023-2024 Covid-19 vaccine, Resident #109, and Resident #119. The findings included: 1. For Resident #109, the facility staff failed to offer a 2023-2024 Covid-19 vaccine. Resident #109's clinical record was reviewed, and surveyor could not locate any information that the resident has been offered and/or received an updated Covid-19 vaccine. Surveyor spoke with the assistant director of nursing/infection preventionist (ADON/IP) on 07/10/24 at 4:25 regarding Resident #109's Covid-19 vaccine status. ADON/IP stated, We are out of compliance with her Covid vaccine. Surveyor requested and was provided with a facility policy entitled Coronavirus Prevention and Response which read in part, 11. Vaccination Planning: a. Residents will be assessed for Covid 19 immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented in the medical record, including efforts 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.

Based on observation, staff interview and facility document review the facility staff failed to ensure licensed nursing staff have the competencies and skill sets necessary to provide care for the residents. The findings included: Surveyor observed registered nursing (RN) #3 on 07/10/24 at 11:15 am performing a blood sugar check for a resident via glucometer. RN #3 did not fully remove the glucometer from the plastic storage bag while checking the residents blood sugar, then returned the glucometer to the bag without cleaning or disinfecting the glucometer. Surveyor spoke with the assistant director of nursing (ADON), who is also the facility staff development coordinator, on 07/11/24 at 1:40 pm regarding RN #3. Surveyor asked ADON if RN #3 had received training on infection control and specifically on cleaning/disinfecting glucometer. ADON stated, We don't have nurse competencies. We don't have a program for that but will be starting one soon. I do have education/in-service training on infection control, glucometer cleaning and others. ADON provided surveyor with a copy of RN #3's…

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

Based on observation, resident interview, and staff interview, facility staff failed to ensure residents received services according to expressed preferences as evidenced by resident reports that the dining room is open only 1 meal per day, showers and bathing services are not provided per expectation, and staff is enforcing a curfew. During a Resident Council meeting on 3/27/2024, residents informed surveyors that the only meal served in the Dining Room was lunch. Breakfast and dinner were served in resident rooms. Residents stated that many would prefer to eat in the dining room for those meals. One resident stated that there were not enough chairs for ambulatory residents to eat in the dining room when they wanted to do so. During a summary meeting on 3/27/2024 surveyors informed a management group which included the director of nursing (DON) and a corporate regional director of clinical services (DCS) and regional director for operations, the surveyor asked if the dining room was only open for lunch. The DON stated that the dining room was only open for lunch when she started…

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, resident interview, clinical record review, and facility document review, facility staff failed to provide goods and services to residents that are necessary to avoid physical harm, pain, mental anguish or emotional distress as evidenced by discovery of multiple deficient care areas at a pattern level scope. During an on-site standard and complaint survey, surveyors discovered patterns of deficient practice in multiple care areas. In the area of Resident Rights, surveyors cited seven deficient practices. In the area of quality of life, surveyors found three deficient practices including a pattern of failure to provide ADL care (activity of daily life care) to dependent residents. In the area of Quality of Care, surveyors found three deficient practices including in pain management and a pattern of failure to provide quality of care. In the area of Nursing Services surveyors found a pattern scope of deficient practice in staffing and nurse aid training. In Pharmacy services, there were three citations including one harm level and two with…

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

Based on staff interview, employee record review, and facility document review, the facility staff failed to implement their policy regarding new hires for 5 of 5 new hires. New hire #1, 2, 3, 4, and 5. The findings included: The facility staff failed to follow their abuse and neglect policy regarding screening of new hires. On 03/26/24 at approximately 11:00 a.m., the surveyor completed the employee record reviews with the Regional Business Office Manager and Business Office Manager. New hire #1 was a Registered Nurse (RN), the facility staff provided the surveyor with a hire date of 05/30/23. The criminal background check was not completed until 09/19/23. The facility failed to provide the surveyor any evidence of a license verification or attempts to obtain reference checks. New hire #2 was a RN, the facility staff provided the surveyor with a hire date of 03/21/23. The criminal background check was not obtained until 09/19/23. New hire #3 was a RN, the facility staff failed to provide any evidence of attempts to obtain reference checks for this employee. New hire #4 was an…

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

Based on staff interviews, facility document review, and clinical record review, the facility staff failed to ensure that written transfer notices included the required information when provided to five (5) of five (5) residents reviewed for transfers (Resident #109, Resident #116, Resident #121, Resident #125, and Resident #126). The findings include: The transfer notice information documented at the time of Resident #109's, Resident #116's, Resident #121's, Resident #125's, and Resident #126's transfers to a local hospital failed to include the required information. This transfer notice information stated the reason for the transfer was that the facility could not manage the residents' care but did not detail the specific care issues the facility was unable to manage. This transfer notice information failed to provide information about the residents' appeal rights. This transfer notice information failed to include the name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman. The following information was found in a facility policy…

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, facility document review, and clinical record review, the facility staff failed to have written evidence of providing the bed hold policy to the resident and/or the resident representative when the resident was transferred for five (5) of five (5) residents reviewed for transfers (Resident #109, Resident #116, Resident #121, Resident #125, and Resident #126). The findings include: The facility staff was unable to provide written documentation to indicate the facility's bed hold policy was provided to the following residents at the time of their transfers to a local hospital: Resident #109, Resident #116, Resident #121, Resident #125, and Resident #126. The following information was found in a facility policy titled Transfer and Discharge (including AMA) (with a reviewed/revised date of 12/1/22): Emergency Transfers/Discharges - initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident . Provide a notice of the resident's bed hold policy to the resident and representative at the time of transfer, as possible, [sic]…

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, interviews, clinical record review, and facility document review, the facility staff failed to provide the necessary activities of daily living (ADL) care to maintain appropriate grooming/bathing for five (5) of 21 sampled residents (Resident #1, Resident #52, Resident #59, Resident #62, and Resident #66). The findings include: 1. The facility staff failed to provide appropriate bathing and/or showers for Resident #66. Resident #66's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 2/29/24, was signed as completed on 3/5/24. Resident #66 was assessed as being able to make self understood and as able to understand others. Resident #66's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact and/or borderline cognition. Resident #66 was assessed as being depended on others for bathing and personal hygiene. Resident #66 was assessed as requiring assistance with toileting hygiene and dressing. 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 resident interviews, staff interviews, clinical records review, and facility documents review, the facility staff failed to follow medical provider orders for 10 of 21 sampled residents (Resident #8, Resident #13, Resident #28, Resident #44, Resident #46, Resident #59, Resident #66, Resident #72, Resident #79, and Resident #235). 1. The facility staff failed to provide Resident #72's medication (Pancrelipase) as ordered by the medical provider. Resident #72's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/29/24, was signed as completed on 1/31/24. Resident #72 was assessed as being able to make self understood and as able to understand others. Resident #72's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact and/or borderline cognition. Resident #72 was assessed as being independent with eating, oral hygiene, toileting hygiene, dressing, personal hygiene, and bathing. Resident #72's clinical record included an order for three (3) capsules of Pancrelipase 24000 Unit to be given with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interviews, staff interviews, and facility document review, the facility staff failed to ensure water temperatures were maintained at a level to decrease the risk for injuries. The findings include: The facility staff failed to ensure water temperatures were maintained at a level that would decrease the risk for injuries. On 7/10/24 at 11:30 a.m., a surveyor checked the water in the sinks of resident room [ROOM NUMBER] and #309; the water in both rooms was hot to the point that the surveyor could not hold their hand under the stream for more that 2-3 seconds. On 7/10/24 at approximately 11:45, this surveyor checked the water temperature in the sink of room [ROOM NUMBER]. This surveyor was unable to hold their hand under the stream without feeling discomfort from the hot water. On 7/10/24 at 12:05 p.m., this surveyor checked facility water temperatures with the facility's Maintenance Director in three (3) resident rooms. Only one (1) of the (3) resident rooms had a water…

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 interviews, staff interviews, facility document review, and clinical record review, the facility staff failed to ensure sufficient nursing staff as evidenced by (a) on the morning of 3/25/24 there was a delay in medication administration for one (1) of four (4) resident medication carts and (b) on 3/26/24 some medications were not administered when a nurse allegedly left their shift early. The findings include: On the afternoon of 3/25/24, a resident reported to the surveyor that the morning medications had been administered late due to a nursing staff member showing up late for work. The Unit Manager (Licensed Practical Nurse (LPN) #7) confirmed that a staff member was late arriving to work on the morning of 3/25/24. On 3/25/24 at 5:20 p.m., the surveyor observed the DON and the Assistant DON while they were counting Medication Cart #4's controlled medications. During this observation, it was noted that multiple resident medications had been documented as being administered late during the morning of 3/25/24. On 3/25/24 at 5:48 p.m., the survey team met with the…

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

Based on staff interview and facility document review, the facility staff failed to complete a performance review of every nurse aide at least every 12 months and failed to provide regular in-service education based on the outcome of these reviews. The findings included: The facility administrative staff failed to complete performance reviews of every nurse aide at least every 12 months and failed to provide regular in-service education based on the outcomes of reviews/evaluations. On 03/26/24 at 1:00 p.m., the Assistant Director of Nursing (ADON) was given the names of Certified Nursing Assistants (C.N.A.'s) that would be reviewed for performance reviews/evaluations. The ADON was unable to provide performance review/evaluation for any of these employees. The ADON stated they had started a new process, and the previous process was a little broken. On 03/26/24 at 2:35 p.m., the Director of Nursing (DON) provided the surveyor with a copy of a policy titled, Evaluation Process. This policy read in part, It is the policy of our facility to review the work performance of employees with 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 resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure medications were available for administration for 4 of 21 residents. (Residents #11, #28) and failed to ensure the nursing staff correctly implemented the facility's scheduled/controlled medication monitoring system for 3 of 4 medication carts. The findings included: 1. For Resident #11, the facility staff failed to ensure the medications Prednisolone Ophthalmic Suspension and Suboxone were available for administration. Resident #11's diagnoses included, but were not limited to, chronic obstructive pulmonary disease, diabetes, hypertension, and systemic lupus. Section C (cognitive patterns) of Resident #11's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 01/05/24 included a Brief Interview for Mental Status (BIMS) summary score of 15 out of a possible 15 points. On 03/25/24, during initial tour of the facility Resident #11 stated they were not receiving their Prednisolone eye drops. Resident #11's clinical…

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, clinical record review, and facility document review, the facility staff failed to act on pharmacist recommendations for five (5) of five (5) residents selected for medication regimen view (Resident #11, Resident #32, Resident #36, Resident #57, and Resident #62). The findings included: 1. The facility staff failed to ensure Resident #36's medication regimen review (MRR) recommendations were addressed by a medical provider. Resident #36's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 2/18/24, was signed as completed on 2/26/24. Resident #36 was assessed as being able to make self understood and as able to understand others. Resident #36's Brief Interview for Mental Status (BIMS) summary score was documented as a 14 out of 15; this indicated intact and/or borderline cognition. Resident #36 was assessed as being dependent on others for toileting hygiene, bathing, dressing, and personal hygiene. Resident #36's MRR dated 11/27/23 included the following recommendation: Federal guidelines state antipsychotic drugs should have an…

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

Based on observation and staff interview, the facility staff failed to follow established infection control guidelines, the surveyor observed dirty linen in the floor for 1 of 21 residents, Resident #11. The findings included: The surveyor observed dirty linen in the floor of Resident #11's room. Resident #11's diagnoses included, but were not limited to, chronic obstructive pulmonary disease, diabetes, hypertension, systemic lupus, and functional Quadriplegia. Section C (cognitive patterns) of Resident #11's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 01/05/24 included a Brief Interview for Mental Status (BIMS) summary score of 15 out of a possible 15 points. On 03/28/24 at 8:25 a.m., the surveyor observed dirty linen in the floor of Resident #11's room. Certified Nursing Assistant (C.N.A.) #7 observed the surveyor in the resident room and stated, I'll get it. When asked how they usually took care of the linen this staff stated they usually use a bag. Resident #11 was not in the room at this time. On 03/28/24 at 3:20 p.m., during a meeting…

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

Based on staff interview, clinical record review, and facility document review, facility staff failed to ensure that each resident was offered Covid-19 vaccinations for 5 of 5 residents reviewed (Residents #1, #11, #25, #46, and #32). The surveyor reviewed infection control policies and records with the assistant director of nursing on 3/26/2024. The surveyor chose 5 current residents from the initial pool for review. Per clinical records, none of the records contained information about offering or receiving Covid-19 vaccination for the current (2023-2024) or vaccination information in the clinical record. Facility employees were unable to locate records that vaccines were offered to the 5 residents. The issue was reported to administrative staff during a summary meeting on 3/26/2024.

Based on staff interview and facility document review, the facility staff failed to maintain an effective training program for new and existing staff consistent with their expected roles. The findings included: The facility staff failed to provide evidence of staff trainings being offered and/or provided. On 3/28/24 at 4:06 PM, surveyor spoke with the Regional Director of Clinical Services (RDCS) who stated the company rolled out Healthcare Academy (an online training system) back in the fall but did not get it up and running. RDCS stated due to changes in leadership, the training system had not been fully implemented. RDCS stated previous training records were on paper and all the binders were missing. Surveyor spoke with the Regional Director of Operations on 3/29/24 at 10:57 AM who stated Healthcare Academy started approximately 3/01/24 and not all staff have been provided log-in information. On 3/29/24 at 12:05 PM, a surveyor spoke with Certified Nursing Assistant (CNA) #11 who stated they had been employed by the facility for about six to seven months. CNA #11 stated when they…

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, the facility staff failed to provide evidence of effective communication training for direct care staff. The findings included: The facility staff failed to provide evidence of effective communication training for direct care staff. On 3/29/24 at 9:05 AM, surveyor spoke with the Director of Nursing (DON) and requested evidence of the most recent effective communication staff training. The Assistant DON (ADON) returned to the surveyor at 9:23 AM and stated they had no evidence of staff trainings regarding effective communication. Surveyor spoke with the Regional Director of Operations on 3/29/24 at 10:57 AM who stated the on-line training system, Healthcare Academy, started approximately 3/01/24 and not all staff have been provided log-in information. Surveyor requested and received the facility policy titled Training Requirements which read in part It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual…

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, the facility staff failed to provide evidence of staff education on the rights of the resident for 4 of 4 staff members reviewed, Certified Nursing Assistant (CNA) #1, CNA #3, CNA #6, and Licensed Practical Nurse (LPN) #7. The findings included: The facility staff were unable to provide evidence of staff education regarding resident rights for three (3) CNAs and one (1) LPN. On 3/28/24 at 3:12 PM, surveyor spoke with the Assistant Director of Nursing (ADON) and requested evidence of staff education regarding resident rights for CNAs #1, #3, #6 and LPN #7. The ADON stated they did not think they had evidence of the education being provided and stated previous staff trainings were documented on paper and they could not find any of the previous records. On 3/28/24 at 4:06 PM, surveyor spoke with the Regional Director of Clinical Services (RDCS) who stated the company rolled out Healthcare Academy (an online training system) back in the fall but did not get it up and running. RDCS stated due to changes in leadership, the training…

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, the facility staff failed to provide evidence of staff education regarding activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, abuse prevention, procedures for reporting abuse, and dementia management for 4 of 4 staff members reviewed, Certified Nursing Assistant (CNA) #1, CNA #3, CNA #6, and Licensed Practical Nurse (LPN) #7. The findings included: The facility staff was unable to provide evidence of staff education regarding prevention, identification and procedures for reporting resident abuse and dementia management for three (3) CNAs and one (1) LPN. On 3/28/24 at 12:15 PM, surveyor spoke with the Assistant Director of Nursing (ADON) and requested evidence of staff education regarding resident abuse and dementia management for CNAs #1, #3, #6 and LPN #7. The ADON returned at 2:25 PM and stated they had no evidence of the requested staff members receiving the requested training. On 3/28/24 at 4:06 PM, surveyor spoke with the Regional Director of Clinical Services (RDCS) who…

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, the facility staff failed to provide evidence of staff training that outlines and informs staff of the elements and goals of the facility's Quality Assurance and Performance Improvement (QAPI) program for 4 of 4 staff members reviewed, Certified Nursing Assistant (CNA) #1, CNA #3, CNA #6, and Licensed Practical Nurse (LPN) #7. The findings included: The facility staff were unable to provide evidence of staff training regarding the facility's QAPI program for three (3) CNAs and one (1) LPN. On 3/28/24 at 12:15 PM, surveyor spoke with the Assistant Director of Nursing (ADON) and requested evidence of staff education regarding the facility's QAPI program for CNAs #1, #3, #6 and LPN #7. The ADON returned at 2:25 PM and stated they had no evidence of the requested staff members receiving training regarding the QAPI program. On 3/28/24 at 4:06 PM, surveyor spoke with the Regional Director of Clinical Services (RDCS) who stated the company rolled out Healthcare Academy (an online training system) back in the fall but did not get it up…

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, the facility staff failed to provide evidence of 12 hours of in-service training for nurse aides. The findings included: The facility staff failed to provide evidence of at least 12 hours of in-service training. During the task sufficient and competent nurse staffing the surveyor requested information regarding in-service training for Certified Nursing Assistant (C.N.A.) #1, #3, #4, #5 and #6. On 03/26/24 at 1:00 p.m., the Assistant Director of Nursing (ADON) stated the facility process regarding Education/Evaluations was a little broken and they had started a new process. On 03/26/24 at 1:50 p.m., the ADON stated they were unable to find any education for these employees. On 03/26/24 at 4:30 p.m., during an end of the day meeting with the Administrator, Director of Nursing (DON), Regional Director of Clinical Services (RDCS), and Regional Director of Operations these staff were made aware of the issue regarding the 12 hours of training for nurse aides. The RDCS stated they had recently rolled out training on Health Care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and facility document review, the facility staff failed to provide evidence of behavioral health training for staff. The findings included: The facility staff failed to provide evidence of behavioral health training for facility staff. On 3/29/24 at 9:05 AM, surveyor spoke with the Director of Nursing (DON) and requested evidence of the most recent staff behavioral health training. The Assistant DON (ADON) returned to the surveyor at 9:23 AM and stated they had no evidence of any staff trainings regarding behavioral health. Surveyor spoke with the Regional Director of Operations on 3/29/24 at 10:57 AM who stated the on-line training system, Healthcare Academy, started approximately 3/01/24 and not all staff have been provided log-in information. Surveyor reviewed the facility assessment dated [DATE] which indicated at the time of completion, the facility had a total of ten (10) residents with behavioral healthcare needs including trauma and/or PTSD (post-traumatic stress disorder). Upon…

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 treat 1 of 21 residents with dignity and respect, Resident #10. The findings included: The facility staff failed to treat Resident #10 with dignity and respect. Resident #10 was observed by the surveyor to ask 2 nurses if it was their day to attend an off campus program. Neither of these nurses answered or acknowledged this resident. Resident #10's diagnoses included but were not limited to, chronic obstructive pulmonary disease, diabetes, and hypertension. Section C (cognitive patterns) of Resident #10's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 03/08/24 included a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15 points. On the morning of 03/26/24, Resident #10 was observed by the surveyor to be up in their wheelchair at the nurses station. Two nurses were observed to be at this nurses station one was observed to be typing on the computer and the other was observed sitting in a chair with their head…

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

Based on resident interview and staff interview, facility staff failed to promote the resident's right right to make choices about aspects of his or her life in the facility that are significant to the resident as evidenced by the resident and staff reports that the resident's right to leave the building is restricted for 1 of 21 residents in the survey sample.(Resident #1). Resident #1 was admitted to the facility with diagnoses which include, but are not limited to, acute and chronic respiratory failure, dysphagia, quadriplegia, chronic decubitus ulcer, and more. The resident utilizes a mechanical chair to ambulate. On the most recent Minimum Data Set assessment, the resident scored 15/15 on the Brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. During initial tour on 03/26/24 at 03:04 PM, the resident reported he has been restricted from going out of the building. Resident #1 (R1) stated the reason given is there is no automatic handicap access door in the building and staff say R1 must be able to open the two…

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 representative interview, staff interview, clinical record review, and facility document review, the facility staff failed to notify the resident representative of a change in condition requiring treatment for 1 of 21 residents (Resident #13) and failed to notify the medical provider of unavailable medications for 1 of 21 residents (Resident #72). The findings included: 1. For Resident #13, the facility staff failed to notify the resident representative of a urinary tract infection requiring antibiotic medication. Resident #13's diagnosis list indicated diagnoses, which included, but not limited to Demyelinating Disease of Central Nervous System, Epilepsy, Bilateral Vitreous Degeneration, and Bipolar Disorder. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 3/06/24 coded the resident as rarely/never understood and rarely/never understands others. On 3/25/24 at approximately 2:00 PM, surveyor spoke with Resident #13's resident representative (RR) who stated the facility staff were good at notifying them when tests such as urine…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility staff failed to ensure a safe, clean, sanitary, and comfortable homelike environment for 2 of 21 current residents in the survey sample, Resident #14 and #52. The findings included: 1. For Resident #14, on two separate days of the survey, multiple areas of dried dark brown, spots and smears were observed on the wall next to the resident's bed. The corner of the resident's overbed table was broken on one corner leaving jagged and sharp edges. The overbed light was dim and flickering continuously. Resident #14's diagnosis list indicated diagnoses, which included, but not limited to Paranoid Schizophrenia, Heart Failure, Alzheimer's Disease, and Muscle Wasting and Atrophy. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 2/03/24 assigned the resident a brief interview for mental status (BIMS) summary score of 1 out of 15 indicating the resident was severely cognitively impaired. On 3/25/24 at 3:15 PM, surveyor observed Resident…

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

Based on staff interview, clinical record review, and facility document review, the facility staff failed to conduct a comprehensive assessment in accordance with the timeframe of not less than once every twelve (12) months for 1 of 21 residents in the current survey sample, Resident #57 (R57). The findings include: The facility staff failed to complete a Comprehensive Minimum Data Set (MDS) assessment within 12 months or three-hundred sixty-six (366) days of the previous comprehensive assessment. R57's diagnoses included, but were not limited to, hypertension, type two diabetes mellitus with hyperglycemia, unspecified dementia, chronic obstructive pulmonary disease (COPD), history of diabetic foot ulcer and chronic pain. A review of the clinical record revealed: The most recent quarterly MDS assessment with an Assessment Reference Date (ARD) of 02/14/24 included a Brief Interview for Mental Status (BIMS) summary score of 7 out of a possible 15 points, indicating severe cognitive impairment. R57's clinical record included an initial (admission) MDS assessment with an ARD of…

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

Based on staff interviews, clinical record review, and facility document review, the facility staff failed to accurately complete Minimum Data Set (MDS) assessments for one (1) of 21 sampled residents (Resident #62). The findings include: The facility staff failed to correctly assess Resident #62's extremities for functional limitation in range of motion for two (2) MDS assessments. Resident #62's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 3/2/24, was signed as completed on 3/18/24. Resident #62 was assessed as being in a persistent vegetative state and/or having no discernible consciousness. Resident #62 was assessed as being dependent on others for oral hygiene, toileting hygiene, dressing, personal hygiene, and bathing. Resident #62's MDS assessment with an ARD of 12/3/23 had the resident assessed as no impairment with upper extremity and lower extremity functional range of motion. Resident #62's MDS assessment with an ARD of 3/2/24 had the resident assessed as no impairment with upper extremity functional range of motion. The accuracy of these…

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, the facility staff failed to develop a comprehensive care plan for 3 of 21 residents, Resident #10, #79, and #52. The findings included: 1. For Resident #10, the facility staff failed to develop a comprehensive care plan (CCP) to include an out of facility Program of All-Inclusive Care for the Elderly (PACE) that the resident attended weekly. Resident #10's diagnoses included but were not limited to, chronic obstructive pulmonary disease, diabetes, and hypertension. Section C (cognitive patterns) of Resident #10's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 03/08/24 included a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15 points. Resident #10 attended the PACE program off the facility grounds weekly. During a review of Resident #10's clinical record the surveyor was unable to locate a care plan for the residents PACE program. On 03/27/24 at 9:30 a.m., the Regional Director of Clinical…

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

Based on observations, staff interviews, clinical record review, and facility document review, the facility staff failed to revise resident care plans and/or failed to include the resident in the care plan process for two (2) of 21 sampled residents (Resident #15 and Resident #62). The findings include: 1. The facility staff failed to review and revised Resident #62's comprehensive care plan to address a fall and to address the implementation of hand-splints. Resident #62's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 3/2/24, was signed as completed on 3/18/24. Resident #62 was assessed as being in a persistent vegetative state and/or having no discernible consciousness. Resident #62 was assessed as being dependent on others for oral hygiene, toileting hygiene, dressing, personal hygiene, and bathing. The following information was found in a facility policy titled Care Plan Revisions Upon Status Change (with a reviewed/revised date of 12/1/22): The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences 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, clinical record review, facility document review, and a medication pass and pour observation the facility staff failed to follow professional standards of practice for the administration of medications for 2 of 24 residents, Resident #123, and Resident #110. The findings included: For Resident #123 the facility staff signed a medication as being administered when the medication was unavailable for administration. Resident #123's clinical record listed diagnoses which included but not limited to unspecified asthma, uncomplicated. Resident #123's most recent minimum data set with an assessment reference date of 05/28/24 coded the resident as 3 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Resident #123's comprehensive care plan was reviewed and contained a care plan for . is at risk for ineffective breathing d/t (due to) dx (diagnosis) of COPD (chronic obstructive pulmonary disease). Interventions for this care plan include give medications as ordered. Surveyor observed registered nurse (RN) #3…

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 interviews, facility document review, and clinical record review, the facility staff failed to provide splints for one (1) of 21 sampled residents (Resident #62). The findings include: The facility staff failed to implement Resident #62's upper extremity splints as directed by the facility's therapy department. Resident #62's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 3/2/24, was signed as completed on 3/18/24. Resident #62 was assessed as being in a persistent vegetative state and/or having no discernible consciousness. Resident #62 was assessed as being dependent on others for oral hygiene, toileting hygiene, dressing, personal hygiene, and bathing. The following information was found in a facility policy titled Activities of Daily Living (ADLs) (with a reviewed/revised date of 12/1/22): The facility will provide a maintenance and restorative program to assist the resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment. The following information was found in an Occupation Therapy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, clinical record review, and facility document review, the facility staff failed to provide an ongoing program of activities designed to meet the interests, and the physical, mental, and psychosocial well-being for 1 of 21 current residents in the survey sample. Resident #52 (R52). The findings included: For R52, the facility staff failed to provide the resident with sensory stimulation activities. R52's diagnosis list indicated diagnoses that included, but not limited to, asphyxiation, chronic respiratory failure with hypoxia or hypercapnia, anoxic brain damage, functional quadriplegia, persistent vegetative state, contracture of muscle-multiple sites and cognitive communication deficit. The most recent minimum data set (MDS) dated [DATE], coded the resident as being in a persistent vegetative state. On 03/25/24 at 3:30 PM, surveyor observed R52 lying in bed, and the TV was not on in the room. On 03/25/24 at 3:40 PM, surveyor interviewed registered nurse #3 (RN#3) 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 interviews, facility document review, and clinical record review, the facility staff failed to provide care and/or treatment to address and/or prevent pressure wounds/area for one (1) of 21 sampled residents (Resident #62). The findings include: The facility staff failed to provide Resident #62's medical provider ordered wound treatments. The facility staff failed to consistently complete skin assessments related to Resident #62's wounds. Resident #62's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 3/2/24, was signed as completed on 3/18/24. Resident #62 was assessed as being in a persistent vegetative state and/or having no discernible consciousness. Resident #62 was assessed as being dependent on others for oral hygiene, toileting hygiene, dressing, personal hygiene, and bathing. The following information was found in a facility policy titled Skin Assessment (with a revised date of 12/1/22): - It is our policy to perform a full body skin assessment as part of our…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, clinical record review, and facility document review, the facility staff failed to provide services and/or treatment to prevent further decrease in range of motion, including the provision of equipment for limited range of motion for 1 of 21 current residents in the survey sample. Resident #52 (R52). The findings included: R52's diagnosis list included diagnoses that included, but were not limited to, asphyxiation, chronic respiratory failure with hypoxia or hypercapnia, anoxic brain damage, functional quadriplegia, persistent vegetative state, contracture of muscle-multiple sites and cognitive communication deficit. The most recent minimum data set (MDS) dated [DATE], coded the resident as being in a persistent vegetative state. On 03/25/24 at 3:30PM, surveyor observed R52 lying in bed and his right hand was visible and moderately contracted. At 3:40PM, surveyor interviewed registered nurse #3 (RN#3) and she agreed his hands were contracted and denied that he had an order…

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

Based on staff interview and clinical record review, facility staff failed to provide nutrition services to ensure the resident could maintain the highest practicable well-being for 1 of 21 residents in the survey sample (Resident #46). Resident #46 was admitted to the facility with diagnoses including, but not limited to, hypertension, gastroesophageal reflux, bacteremia, sepsis, gangrene of right foot, other disorders of the circulatory system, deep vein thrombosis, acquired absence of right leg above the knee, surgical aftercare. On the most recent Minimum Data Set assessment, the resident scored 12/15 on the Brief Interview for Mental Status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. Clinical record review on 3/27/2024 revealed weights upon return were 121.0 on 2/13 and 2/16, 124.8 on 2/16 and 2/23. Facility staff recorded exactly the same weight of 144.0 pounds on 3/1, 3/2, 3/3, 3/5. and 3/8. The weight on 3/8/2024 was the most recent in the clinical record. The surveyor interviewed the assistant director of nursing on 3/27/2024 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 resident interview, staff interview, clinical record review, and facility document review facility staff failed to ensure residents' pain was managed according to goals and preferences for 1 of 21 residents. Resident #77. The findings were: For Resident #77, facility staff failed to ensure the oxycodone prescription was available for treatment of pain between 3/13/24 through 3/22/24. Oxycodone tablets were available in the Cubex stock onsite. Resident #77 was admitted to the facility with a diagnosis of cauda equina syndrome which occurs when there is dysfunction of multiple lumbar and sacral nerve roots of the cauda equina (the collection of nerves at the end of the spinal cord). Other diagnoses included but were not limited to disruption of external surgical wound, and type 2 diabetes mellitus. On the minimum data set assessment with an assessment reference date of 01/11/24, the resident scored a 15 out of 15 on the brief interview for mental status in Section C (cognitive patterns). Section J (Health Conditions) coded Resident #77 frequently experienced pain which…

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 ensure 1 of 24 residents was free from unnecessary medications, Resident #110. The findings included: For Resident #110 the facility staff administered the medication metoprolol without checking the residents blood pressure or pulse per the physician's order. Resident #110's clinical record listed diagnoses which included but not limited chronic diastolic (congestive) heart failure, and essential hypertension. Resident #110's most recent minimum data set with an assessment reference date of 06/07/24 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #110's comprehensive care plan was reviewed and contained care plans for . potential for altered cardiovascular status r/t (related to) hyperlipidemia, and CHF (congestive heart failure) with daily wts (weights) and . has potential fluid deficit/overload r/t (related to) diuretic use r/t CHF, HTN…

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 the provider reviewed the residents laboratory results for 1 of 21 residents, Resident #79. The findings included: The provider had ordered the following laboratory tests on 03/07/24 thyroid-stimulating hormone (TSH), triiodothyronine (T3), and thyroxine (T4). The surveyor was unable to find any documentation to indicate these laboratory tests had been reviewed by the provider. Resident #79's diagnoses included, but were not limited to metabolic encephalopathy, persistent vegetative state, and cognitive communication deficit. Section B (hearing/speech/vision) of Resident #79's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 02/21/24 was coded to indicate Resident #79 was comatose. Resident #79's clinical record included the results of the following laboratory tests dated 03/08/24 TSH (high at 5.39), T3 (9.8), and T4 (low at 0.63). During the clinical record review, the surveyor was unable to find any information to indicate as of 03/26/24 the laboratory…

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 complete and/or accurate clinical records for three (3) of 21 sampled residents (Resident #46, Resident #59, and Resident #72). The findings included: 1. Resident #72's clinical documentation indicated the resident was provided a medication (Pancrelipase) during times when the medication was not available. Resident #72's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/29/24, was signed as completed on 1/31/24. Resident #72 was assessed as being able to make self understood and as able to understand others. Resident #72's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact and/or borderline cognition. Resident #72 was assessed as being independent with eating, oral hygiene, toileting hygiene, dressing, personal hygiene, and bathing. Resident #72's clinical record included an order for three (3) capsules of Pancrelipase 24000 Unit to be given with meals for pancreatitis. This order had a start 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 observations, resident interviews, staff interviews, clinical record reviews and facility document reviews, the facility staff failed to ensure a Quality Assurance and Performance Improvement (QAPI) Program to meet the needs of the facility and failed to monitor and revise as needed the plan of corrections for the standard recertification and abbreviated surveys dated 8/05/21 through 11/01/23, in order to maintain compliance as evidenced by repeated deficiencies in the areas of Resident Assessments, Quality of Care, Pharmacy Services, and Administration. The findings included: The area of Resident Assessments was previously cited with the 8/05/21 and 7/19/22 standard and the 4/28/22 abbreviated surveys due to inaccurate MDS (minimum data set) coding. This deficiency was cited again on the current standard survey dated 3/29/24 due to facility staff failing to accurately code an MDS assessment for 1 of 21 sampled residents. The area of Quality of care was previously cited with the 8/05/21 and 7/19/22 standard and the 2/10/22 and 10/12/23 abbreviated surveys for failure 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.

Based on staff interview, clinical record review, and facility document review, facility staff failed to ensure that each resident was offered the influenza and pneumococcal vaccinations for 3 of 5 residents reviewed (Residents #25, #46, and #32). The surveyor reviewed infection control policies and records with the assistant director of nursing on 3/26/2024. The surveyor chose 5 current residents from the initial pool for review. Per clinical records, 1 resident refused the influenza and pneumococcal vaccines. One resident received the influenza vaccine, and the other three residents had no vaccination information in the clinical record. Facility employees were unable to locate records that vaccines were offered to the three residents without records. The issue was reported to administrative staff during a summary meeting on 3/26/2024.

Based on staff interviews, clinical record review and facility document review, the facility staff failed to ensure that a resident and/or resident representative had an opportunity to develop an advanced directive for three of three residents sampled, resident #101, resident # 103, and resident # 104. The findings included: 1. For resident # 10 (R103), the facility staff failed to provide the resident representative with written information concerning the right to accept or refuse medical or surgical treatment and the option to formulate an advance directive. R103's diagnoses included but were not limited to anoxic brain damage and chronic respiratory failure due to asphyxiation. R103 was not interviewable, and the electronic record indicated there was a parent acting as their representative with a sibling also listed. A progress note written by the social worker with a date of 6/18/24 read, Tried to reach both RP's (responsible party) for the care plan that was unable to leave a message for contact # 1, and left a voice message for contact # 2, waiting on response. On 7/10/24 at…

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

Based on staff interview and clinical record review, the facility staff failed to provide laboratory services to meet the needs of the resident for 1 of 4 sampled residents (Resident #122). The findings included: For Resident #122, the facility staff failed to obtain a urinalysis as ordered by the medical provider. The urinalysis was ordered to be obtained between 11/11/22 and 11/12/22; however, it was not obtained until 11/14/22. This was a closed record review. Resident #122's diagnosis list indicated diagnoses, which included, but not limited to Acute and Chronic Respiratory Failure, Obstructive and Reflux Uropathy, Acute Congestive Heart Failure, Dementia, and Chronic Cystitis. The minimum data set (MDS) with an assessment reference date (ARD) of 2/03/23 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 indicating the resident was severely cognitively impaired. A review of Resident #122's clinical record revealed a medical provider order dated 11/10/22 to obtain a urinalysis with culture and sensitivity (UA C&S) from 11/11/22 through…

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 file laboratory results in the clinical record for 1 of 4 sampled residents (Resident #122). The findings included: For Resident #122, the facility staff failed to file the results of a urinalysis and thyroid-stimulating hormone (TSH) blood test in the resident's clinical record. This was a closed record review. Resident #122's diagnosis list indicated diagnoses, which included, but not limited to Acute and Chronic Respiratory Failure, Obstructive and Reflux Uropathy, Hypothyroidism, Acute Congestive Heart Failure, Dementia, and Chronic Cystitis. The minimum data set (MDS) with an assessment reference date (ARD) of 2/03/23 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 indicating the resident was severely cognitively impaired. A review of Resident #122's clinical record revealed a medical provider order dated 11/10/22 to obtain a urinalysis with culture and sensitivity (UA C&S) and an order dated 1/04/23 to obtain a TSH level. Surveyor was unable to locate…

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 the facility staff failed to properly label and store medications in 4 of 4 medications carts and for 1 of 33 resident's, Resident #30. The findings included: 1. The facility staff failed to ensure that opened insulin vials/pens were labeled with an opened on/discard by date, failed to discard insulin pens/vials 28 days after opening, and failed to correctly store unopened insulin vials/pens. On 10/30/23 at 10:55 am, surveyor observed the medication cart for unit 4 of the facility. Inside the medication cart, surveyor observed an insulin glargine pen dated with a use by date of 10/25/23, an insulin lispro pen with a use by date of 10/18/23, and an unopened insulin pen inside a plastic bag with a label reading, refrigerate until opened. On 10/30/23 at 11:10 am, surveyor observed the medication cart on unit 3 of the facility. Inside the medication cart, surveyor observed a basaglar insulin pen with a use by date of 10/23/23, a basaglar insulin pen with an illegible use by date, and an unopened…

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 a clean, comfort homelike environment for 3 of 33 Residents (#15, #23, and #24) and in 2 of 2 shower rooms. The findings included: Residents #15 and #23's room was observed to have debris scattered on the floor, a white substance that resembled milk and dried brown areas on the floor. The floor was sticky and there was debris in the windowsill. The wall behind Resident #24's bed had a brown substance splattered on the wall. The shower rooms were observed with debris present in floors and the shower room on the 100 hall had a musty odor. Resident #15's diagnoses included respiratory failure and chronic obstructive pulmonary disease. Section C (cognitive patterns) of Resident #15's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 08/29/23 included a brief interview for mental status (BIMS) summary score of 15 out of a possible 15 points. Resident #23's diagnoses included respiratory failure and diabetes. Section B (hearing/speech/vision) of Resident #23's quarterly MDS…

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

Based on observation and staff interview, the facility staff failed to ensure the facility was free of accident hazards in 2 of 2 shower rooms. The findings included: The shower rooms were observed to have missing tiles in the floor. On 10/31/23 at 8:23 a.m., the surveyor entered the shower room on 300 hall. The surveyor observed missing tiles under the shower chair. The Director of Environmental Service/Maintenance entered the shower room and stated they were going to have a complete renovation. On 10/31/23 at 8:34 a.m., the surveyor and Maintenance Assistant entered the shower room on 100 hall. This shower room was observed to have a musty smell and the surveyor observed missing tiles around the area where the shower chair was sitting. On 10/31/23 at 4:00 p.m., during an end of the day meeting with the Administrator and Regional Nurse Consultant the issues with the missing tiles in the shower rooms was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, staff interview, facility document review, clinical record review and during a medication pass and pour observation the facility staff failed to ensure that physician ordered medications were available for administration for 5 of 33 residents, Resident #1, Resident #10, Resident #31, Resident #32 and Resident #21. The findings included: 1. For Resident #1 the facility staff failed to ensure the medications Saccharomyces boulardii and Zyprexa Zydis were available for administration. Resident #1's face sheet listed diagnoses which included but not limited to anxiety, depression, and schizophrenia. Resident #1's most recent minimum data set with an assessment reference date of 08/03/23 assigned the resident a brief interview for mental status score of 12 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #1's comprehensive care plan was reviewed and contained a care plan for . has had episodes of delusions and hallucinations. Recent dosage reduction FAILED. Interventions for this care plan include…

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 develop a baseline care plan for 1 of 33 Residents, Resident #21. The findings included: The facility staff failed to develop a baseline care plan when the resident was admitted to the facility. This was a closed record review. Resident #21's diagnoses included, but were not limited to, bacteremia, pyogenic arthritis, diabetes, severe sepsis, and cutaneous abscess. Section C (cognitive patterns) of Resident #21's admission minimum data (MDS) assessment with an assessment reference date (ARD) of 09/25/23 included a brief interview for mental status (BIMS) summary score of 15 out of a possible 15 points. During a review of the clinical record the surveyor was unable to locate a baseline care plan. On 10/31/23 at 8:36 a.m., during an interview with the MDS nurse this nurse stated the baseline care plan was in progress but it was never completed. On 10/31/23 at 4:00 p.m., during an end of the day meeting with the Administrator and Regional Nurse Consultant the issue with the missing baseline care plan was…

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

Based on staff interview and clinical record review, the facility staff failed to develop and implement a comprehensive care plan (CCP) for 1 of 33 Residents, Resident #21. The findings included: The facility staff failed to develop and implement a CCP. This was a closed record review. Resident #21's diagnoses included, but were not limited to, bacteremia, pyogenic arthritis, diabetes, severe sepsis, and cutaneous abscess. Section C (cognitive patterns) of Resident #21's admission minimum data (MDS) assessment with an assessment reference date (ARD) of 09/25/23 included a brief interview for mental status (BIMS) summary score of 15 out of a possible 15 points. During a review of the clinical record the surveyor was unable to locate a CCP. On 10/31/23 at 8:36 a.m., during an interview with the MDS nurse this nurse stated there was not a CCP for Resident #21. On 10/31/23 at 4:00 p.m., during an end of the day meeting with the Administrator and Regional Nurse Consultant the issue regarding the missing CCP was reviewed. No further information regarding this issue was provided to the…

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

Based on observation, staff interview, and clinical record review, the facility staff failed to review and revise the residents care plan for 1 of 33 Residents, Resident #26. The findings included: The facility staff failed to review and revise Resident #26's care plan. Resident #26 was on contact isolation. Resident #26's diagnoses included, but were not limited to, severe sepsis, ventilator associated pneumonia, chronic respiratory failure, and diabetes. Section C (cognitive patterns) of Resident #26's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 10/14/23 included a brief interview for mental status (BIMS) summary score of 00 out of a possible 15 points. Resident #26's clinical record included a provider order dated 10/30/23 for contact isolation for candida auris fungemia. During a review of Resident #26's care plan the surveyor was unable to locate any information to indicate this resident was on contact isolation. There was no signage posted on the door to indicate this resident was on isolation. The surveyor did observe a cart 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, clinical record review, and during a medication pass and pour observation the facility staff failed to follow standards of practice in regards to medication administration for 2 of 33 residents, Resident #19, and Resident #33. The findings included: 1. For Resident #19 the facility staff documented vital signs, enteral feedings, and medications as administered when the resident was not in the facility. Resident #19's face sheet listed diagnoses which included but not limited to malignant neoplasm of right lung, malignant neoplasm of oropharynx, tracheostomy, and anxiety. Resident #19's most recent minimum data set with an assessment reference date of 09/17/23 assigned the resident a brief interview for mental status score of 13 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #19's clinical record was reviewed and contained a census report which indicated that the resident was discharged on 09/02/11…

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, the facility staff failed to provided pressure ulcer treatment for two of 33 residents in the survey sample, Resident # 18 and Resident # 25. The findings included: 1. For Resident # 18, the facility staff failed to perform wound care as ordered by the physician multiple days in the months of September 2023 and October 2023. Resident # 18's clinical record was reviewed and indicated that they have a diagnosis of quadriplegia. The most recent minimum data set (MDS) assessment with an assessment reference date of 8/18/23 indicated that resident is dependent on staff for most activities of daily living (ADL's) including bed mobility, transfers, and toileting. Resident is non-ambulatory, has contractures of both upper and lower extremities, and uses an electric wheelchair to self-propel on and off unit independently. The resident was coded as being at risk of developing pressure ulcers and as having pressure ulcers. The care plan for resident # 18 was reviewed and a problem statement that…

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

Based on observation, staff interview, and clinical record review, the facility staff failed to provide foot care for a dependent care resident for 1 of 33 Residents, Resident #23. The findings included: Resident #23's toenails were observed to be long, thick, and jagged. The residents feet were observed to be dry and flaky. Resident #23's diagnoses included, but were not limited to, diabetes and acute respiratory failure with hypoxia. Resident #23's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 09/02/23 was coded to indicate Resident #23 was in a persistent vegetative state/no discernible consciousness. Section G (functional status) was coded (4/2) for personal hygiene to indicate the resident was totally dependent on 1 staff for this task. Resident #23's comprehensive care plan included the focus areas activity of daily living self-care performance deficit and has diabetes mellitus. Interventions included but were not limited to, refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. On 10/31/23 at…

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

Based on observation, staff interview, clinical record review, and facility document review the facility staff failed to ensure 1 of 33 residents (Resident #23) tube feeding was set on the rate that was ordered by the provider. The findings included: Resident #23's tube feeding rate was set at the incorrect amount. The provider order read 50 ml/hour when the tube feeding was set to run at 65 ml/hour. Resident #23's diagnoses included respiratory failure and diabetes. Section B (hearing/speech/vision) of Resident #23's quarterly minimum data set (MDS) assessment with an ARD of 09/02/23 was coded to indicate this resident was in a persistent vegetative state. Section K (swallowing/nutrition) was coded to indicate this resident had a feeding tube. Resident #23's comprehensive care plan included the focus area all nutritional support is via tube feeding. Interventions included registered dietician to evaluate quarterly and as needed and make changes to tube feeding as needed. Resident #23's clinical record included the following order in reference to their tube feeding. Enteral…

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, clinical record review and a medication pass and pour observation the facility staff failed to ensure a medication error rate of less than 5 %. There were 6 errors in 34 opportunities for a medication error rate of 17.6 %. These errors affected Resident #30, Resident #32, and Resident #33. The findings included. 1. For Resident #30 the facility staff administered incorrect doses of docusate sodium and sertraline HCl and failed to administer the resident's insulin with meals as ordered by the physician. Resident #30's face sheet listed diagnoses which included but not limited to type II diabetes mellitus, depression, anxiety, and constipation. Resident #30's most recent minimum data set with an assessment reference date of 09/30/23 assigned the resident a brief interview for mental status score of 14 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Surveyor observed licensed practical nurse (LPN) #5 during a medication pass and pour on 10/31/23 at 7:30 am. Surveyor observed LPN #4…

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

Based on observation, staff interview, facility document review and clinical record review the facility staff failed to ensure 2 of 33 residents were free of significant medication errors, Resident #30, and Resident #21. The findings included: 1. For Resident #30 the facility staff failed to administered insulin within the physician ordered timeframe. Resident #30's face sheet listed diagnoses which included but not limited to type II diabetes mellitus, depression, anxiety, and constipation. Resident #30's most recent minimum data set with an assessment reference date of 09/30/23 assigned the resident a brief interview for mental status score of 14 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Surveyor observed licensed practical nurse (LPN) #5 during a medication pass and pour on 10/31/23 at 7:30 am. Surveyor observed LPN #4 check the resident's blood sugar. LPN #4 then returned to the medication cart and surveyor observed them prepare docusate 100 mg, one capsule and sertraline 25 mg, 1/2 tablet. LPN #4 then found a discrepancy…

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

Based on staff interview, clinical record review and facility document review the facility staff failed to maintain a complete and accurate clinical record for 2 of 33 residents, Resident #20, and Resident #21. The findings included: 1. For Resident #20 the facility staff documented that medications were administered when the resident was not in the facility. Resident #20's face sheet listed diagnoses which included but not limited to acute respiratory failure with hypoxia, gastrostomy status, hypertension, and anxiety. Resident #20 was admitted and discharged on the same day; therefore, no minimum data set was completed. Resident #20's electronic medication administration record (eMAR) for the month of September 2023 was reviewed and contained entries which read in part, Losartan Potassium Oral Tablet 50 mg (Losartan Potassium). Give 1 tablet via PEG [percutaneous endoscopic gastrostomy)-Tube one time a day related to essential (primary) hypertension, Sertraline HCl Oral Tablet 100 mg (Sertraline HCl). Give 1 tablet via PEG-Tube one time a day for depression, and Vitamin B-1 Tablet…

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

Based on observation, staff interview, facility document review, and clinical record review the facility staff failed to establish and follow an effective infection control program for 2 of 32 residents, Resident #12, and Resident #26. The findings included: For Resident #12 the facility staff failed to don proper personal protective equipment (PPE) upon entering the resident's room. Resident was on droplet precautions. Resident #12's face sheet listed diagnoses which included, but not limited to diabetes mellitus, anxiety, and depression. On 10/31/23 at 09:55 am, surveyor observed a Droplet Precautions sign located on Resident #12's door. This sign read in part, Everyone must: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry. Remove face protection before room exit. Surveyor observed an isolation cart located outside Resident #12's room, containing gowns, gloves, and masks. Surveyor did not observe any type of face/eye covering, however, an isolation cart located outside a nearby room…

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 former resident interview, staff interview, clinical record review and facility document review the facility failed to report incidents for 1 of 6 residents, Resident #1. The findings included: 1. For Resident #1 the facility staff failed to report an incident of neglect. Resident #1's face sheet listed diagnoses which included but not limited to hemiplegia, chronic obstructive pulmonary disease, hypertension and cognitive communication deficit. Resident #1's most recent minimum data set with an assessment reference date of 07/15/23 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Section G, functional status, coded the resident as independent in locomotion on and off the unit. Resident #1's comprehensive care plan was reviewed and contained care plans for .enjoys and prefers independent leisure in room such as computer, phone, and TV. He/She wheels around hallways and talks to staff. He/She enjoys going outside to garden, .has potential to be…

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

Based on staff interview, resident interview and clinical record review the facility staff failed to follow physician's orders for 1 of 6 residents, Resident #3. The findings included: For Resident #3 the facility staff failed to follow physician's orders for the monitoring of vital signs, specifically blood pressure. Resident #3's face sheet listed diagnoses which included but not limited to syncope and collapse, chronic obstructive pulmonary disease, orthostatic hypotension, and essential hypertension. Resident #3's most recent minimum data set with an assessment reference date of 07/19/23 assigned the resident a brief interview for mental status score of 14 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #3's comprehensive care plan was reviewed and contained a care plan for .has significant orthostatic hypotension r/t (related to) autonomic dysfunction, bilateral ICA (internal carotid artery) stenosis >75%. Interventions for this care plan include Monitor vital signs. Resident #3's clinical record was reviewed 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 staff interview and clinical record review, the facility staff failed to ensure the code status for 1 of 19 residents in the survey sample, Resident #39. For Resident #39, the clinical record contained conflicting documentation regarding the resident's code status. The findings included: Resident #39's diagnosis list indicated diagnoses, which included, but not limited to Acute and Chronic Respiratory Failure with Hypoxia, Congestive Heart Failure, Chronic Peripheral Venous Insufficiency, Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease Stage 3, Dysphagia, Gastro-esophageal Reflux Disease, Cerebral Infarction, Major Depressive Disorder, and Muscle Wasting and Atrophy. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of [DATE] assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #39's current physician's orders included an advanced…

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 interviews and facility document review, the facility staff failed to report the investigation results of an alleged episode of neglect to the appropriate agencies within 5 working days of the incident for one (1) of 19 sampled current residents, Resident #59. The facility staff self-reported an allegation of neglect involving Resident #59 to the state survey agency (SA); the facility staff failed to report the investigation results to the SA. The findings include: Resident #59's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 7/5/22, was signed as completed on 7/7/22. Resident #59 was assessed as able to make self understood and as able to understand others. Resident #59's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact or borderline cognition. Resident #59 was assessed as requiring assistance with bed mobility, transfers, dressing, and personal hygiene. Resident #59's diagnoses included, but were not limited to: anemia, high blood pressure, diabetes, anxiety, depression, 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 interviews, clinical record review, and facility document review, the facility staff failed to provide bed hold policy information to a resident or resident's representative for one (1) of 19 sampled current residents, Resident #13. Resident #13 had been admitted to a local hospital. The findings include: Resident #13's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 4/25/22, was signed as completed on 5/5/22. Resident #13 was assessed as sometimes able to make self understood and as sometimes able to understand others. Resident #13's Brief Interview for Mental Status (BIMS) summary score was documented as zero (0) out of 15; this indicated severe cognitive impairment. Resident #13 was assessed as being dependent on others for bed mobility, transfers, eating, toilet use, and personal hygiene. Resident #13's diagnoses included: anemia, high blood pressure, diabetes, dementia, and respiratory failure. Resident #13's clinical documentation was reviewed on 7/19/22. It was noted the resident had been discharged from the facility to a hospital 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 staff interview and clinical record review the facility staff failed to ensure the accuracy of MDS (minimum data set) assessments for 1 of 19 residents, Resident #42. For Resident #42, the facility staff failed to ensure the BIMS (brief interview for mental status) was completed The findings included: Resident #42's face sheet listed diagnoses which included but not limited to traumatic subdural hemorrhage with loss of consciousness, dysphagia, depression, convulsions, and cognitive communication deficit. Resident #42's most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 06/12/22 failed to assign the resident a brief interview for mental status (BIMS) score in section C, cognitive patterns. The quarterly MDS with an ARD of 03/12/22 assigned the resident a BIMS score of 4 out of 15 in section C. This indicates that the resident is severely cognitively impaired. Surveyor spoke with the MDS staff on 07/19/22 at 9:00 am. Surveyor asked MDS staff why the resident's BIMS score had not been assessed and MDS staff stated, I have no idea. MDS…

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

Based on staff interview and clinical record review, facility staff failed to conduct a level 1 PASARR (pre-admission screening and resident review) for 1 of 19 residents in the survey sample (Resident #55). Resident #55 was admitted to the facility with diagnoses including bipolar disorder, psychotic disorder, major depression, respiratory failure, coronary artery disease, heart failure, hypertension, malnutrition, hypertension, and anemia. On the minimum data set assessment with assessment reference date 7/6/2022, the resident scored 3/15 on the Brief Interview for Mental Status and was assessed as without delirium, psychosis, or behavior affecting care. On 7/18/22, the surveyor was unable to locate a PASARR in the resident's clinical record. The surveyor was offered a demographic form which did include the questions asked on a level 1 PASARR. The social worker stated to surveyors that the form was all the facility received from transferring facilities in North Carolina. There was also a brief discussion concerning the waiver of the requirement that the level 1 PASARR be conducted…

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 the facility staff failed to follow professional standards of practice for the documentation of medications for 1 of 19 Residents, Resident #47. For Resident #47 the facility staff initialed a nebulizer treatment as being administered as ordered, when the resident was not receiving the treatment. The findings included: Resident #47's face sheet listed diagnoses which included but not limited to myocardial infarction (heart attack), chronic obstructive pulmonary disease, and congestive heart failure. Resident #47's most recent quarterly minimum data set with an assessment reference date of 06/17/22 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #47's comprehensive care plan was reviewed and contained a care plan which read in part, .is at nutrition and/or hydration risk aeb (as evidenced by) dx (diagnosis) COPD (chronic obstructive pulmonary disease), severe…

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

Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure care and services were provided to address the needs for 5 of 19 residents in the survey sample, Residents #3, #16, #39, #47, and #164. For Residents #3 and #16, the facility staff failed to obtain weekly weights as ordered by the physician. For Resident #39, the facility staff failed to obtain a dermatology consult, gastroenterology consult, a chest CT (computed tomography) scan, and an upper GI (gastrointestinal) x-ray as ordered by the physician. For Resident #47, the facility staff failed to administer the medication Pulmicort as ordered by the physician. Pulmicort is an inhaled steroid used in the treatment of chronic obstructive pulmonary disease. For Resident #164, the facility staff failed to obtain a weight ordered by the dietician. The findings included: 1. Resident #3's diagnosis list indicated diagnoses, which included, but not limited to Demyelinating Disease of Central Nervous System, Epilepsy, Dysphagia, Bipolar Disorder, Generalized…

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 and resident interviews, and facility document review the facility staff failed to provide supervision to prevent potentially avoidable accidents for 1 of 19 residents. (Resident #5) For Resident #5 the facility staff failed to provide supervision while the resident was smoking. The findings were: Resident #5's admission record noted their diagnoses included, but were not limited to, congestive heart failure, chronic obstructive pulmonary disease, delusional disorders, non-ST elevation myocardial infarction (heart attack), and difficulty in walking. Resident #5's quarterly minimum data set with an assessment reference date of 04/25/2022 coded the resident's brief interview for mental status at a 14 out of 15 in Section C (cognitive patterns). Section G (functional status) read in part, for surface-to-surface transfers the resident was not steady, but able to stabilize without staff assistance. For functional limitation in range of motion, Resident #5 was coded as having no impairment in upper or lower extremities. During an interview with LPN#5 (licensed…

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, the facility staff failed to ensure a resident who is fed by enteral means receives the provider ordered tube feeding nutrition and hydration and failed to address a significant weight loss for 2 of 19 residents in the survey sample, Residents #3 and #164. For Resident #3, the facility staff failed to provide tube feeding formula and water as ordered on 7/18/22. For Resident #164, facility staff failed to address a documented significant weight loss. 1. Resident #3's diagnosis list indicated diagnoses, which included, but not limited to Demyelinating Disease of Central Nervous System, Epilepsy, Dysphagia, Bipolar Disorder, Generalized Anxiety Disorder, Essential Hypertension, and Pseudobulbar Affect. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 4/20/22 assigned the resident a brief interview for mental (BIMS) summary score of 0 out of 15 indicating the resident was severely cognitively impaired. Resident #3 was coded for the presence of 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, Resident interview, staff interview and facility document review the facility staff failed to maintain respiratory equipment for 1 of 19 residents, Resident #47. For Resident #47 the facility staff failed to store the resident's respiratory equipment to prevent contamination. The findings included: Resident #47's face sheet listed diagnoses which included but not limited to myocardial infarction (heart attack), chronic obstructive pulmonary disease, and congestive heart failure. Resident #47's most recent quarterly minimum data set with an assessment reference date of 06/17/22 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #47's clinical record was reviewed and contained a physician's order summary for the month of July 2022, which read in part Pulmicort suspension 0.5 mg/2 ml 0,5mg inhale orally two times a day for respiratory therapy rinse mouth after each use to avoid oral thrush. This order had a start date of 01/11/22. 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 observations, staff and resident interviews, clinical record reviews, facility document reviews, and during a medication pass and pour the facility staff failed to ensure medications were available for 3 of 19 residents. (Resident #25, Resident #32, and Resident #3) For Resident #25, facility staff failed to ensure Azelastine HCl Solution 0.05% eye drops (used to treat allergic eye inflammation) were available for administration. For Resident #32 the facility staff failed to ensure the medications Fentanyl and pantoprazole were available for administration. For Resident #3, the facility staff failed to ensure Clonazepam, a benzodiazepine used to control certain types of seizures and relieve panic attacks, was available for administration on seven (7) separate occasions. The findings were: 1. Resident #25's admission record contained a list of diagnoses which included but not limited to, Guillain-Barre Syndrome (immune system attacks the nerves), narcolepsy (chronic sleep disorder), asthma, encephalopathy (altered brain function), and anxiety disorder. The resident's annual…

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 interviews, facility document review, and clinical record review, it was determined the facility staff failed to ensure: (a) medical regimen reviews (MRRs) were completed and/or (b) medical regimen review (MRR) recommendations were addressed by a medical provider for three (3) of 19 sampled current residents, Resident #1, Resident #31, and Resident #59. The findings include: 1. The facility staff failed to ensure a medical provider addressed a MRR pharmacist recommendation for Resident #59. Resident #59's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 7/5/22, was signed as completed on 7/7/22. Resident #59 was assessed as able to make self understood and as able to understand others. Resident #59's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact or borderline cognition. Resident #59 was assessed as requiring assistance with bed mobility, transfers, dressing, and personal hygiene. Resident #59's diagnoses…

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

Based on observation, staff interview, and facility document review, the facility staff failed to safely store medications on 1 of 3 units (unit 1) and failed to secure a narcotic in 1 of 1-medication rooms. 1. The facility nursing staff failed to lock their medication cart when out of view and failed to secure a bottle of 325 mg Tylenol. 2. The facility staff failed to store liquid oxycodone, a Schedule II drug, in a separate and locked compartment within one (1) of one (1) medication storage units. The findings included: 1. 07/18/22 1:18 p.m., the surveyor observed an unattended medication cart positioned between two rooms on unit 1. The surveyor observed this medication cart to be unlocked. The surveyor also observed an open bottle of 1000 tablet-325 mg Tylenol on top of this cart. The surveyor observed residents in the hallway, a unit manager walked by this cart and spoke with the surveyor, and other various staff were observed in the hallway. Licensed Practical Nurse (LPN) #2 stated they were in the middle of a medication pass and they were in a resident's room, across 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 interviews, facility document review, and clinical record review, the facility staff failed to maintain complete and/or accurate clinical records for three (3) of 19 sampled current residents, Resident #32, Resident, #42, and Resident #59. For Resident #59, the facility staff failed to document the results of monthly medication regime reviews (MRRs) completed by a pharmacist. For Resident #32, the facility staff failed to document that medications were administered as ordered. For Resident #42, the facility staff failed to document that medications were administered as ordered. The findings include: 1. Resident #59's clinical record failed to include the results of monthly medication regime reviews (MRRs) completed by a pharmacist. Resident #59's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 7/5/22, was signed as completed on 7/7/22. Resident #59 was assessed as able to make self understood and as able to understand others. Resident #59's Brief Interview for Mental Status…

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 the facility staff failed to develop and implement a comprehensive care plan for 4 of 30 residents, Resident #32, Resident #10, Resident #31 and Resident #17. The findings included: 1. For Resident #32 the facility staff failed to develop a care plan for catheter use. Resident #32's face sheet listed diagnoses which included but not limited to hemiplegia, type II diabetes mellitus, acute kidney failure, aphasia, anxiety, depression, retention of urine, anemia, dysphagia and adult failure to thrive. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) 06/17/21 failed to assign the resident a BIMS (brief interview for mental status) score, in section C, cognitive patterns. The quarterly MDS with an ARD date of 03/31/21 assigned the resident a BIMS score of 8 out of 15 in section C. This indicates that the resident is moderately cognitively impaired. Surveyor observed Resident #32 on 08/01/21 at 10:10 am. Resident was resting in bed, catheter drainage tubing…

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

Based on observations, staff interviews, resident interview, and the review of documents, it was determined the facility staff failed review and revise comprehensive care plans for four (4) of 30 residents (Resident #10, Resident #13, Resident #14, and Resident #33). The findings include: 1. The facility staff failed to revise Resident #33's care plan to address a decline in mobility. Observations of Resident #33 during the survey revealed Resident #33 in either the bed or wheelchair. Resident #33 was never observed to be walking. Resident #33's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 6/17/21, was signed as completed on 6/24/21. Resident #33 was assessed as sometimes able to make self understood and as sometimes able to understand others. The resident was assessed as having problems with short-term and long-term memory. Resident #33 was assessed as requiring extensive assistance with bed mobility, transfers, dressing, and personal hygiene. Resident #33 was assessed as being dependent on staff for toilet use and bathing. Resident #33's diagnoses…

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, and clinical record review, the facility staff failed to ensure that residents who was unable to carry out (ADLs) activities of daily living received the necessary care and services to maintain personal hygiene and grooming for 10 of 30. Residents #35, #40, #52, #208, #10, #31, #5, #7, #33, and #34. The findings included: 1. For Resident #35, the facility staff failed to provide ADL care. Resident #35's toenails and fingernails were observed to be long and jagged. A dark debris was present under the residents fingernails. Resident #35's (EHR) electronic health record included the diagnoses, acute and chronic respiratory failure with hypercapnia, diabetes, dysphagia, and quadriplegia. Section C (cognitive patterns) of Resident #35's quarterly (MDS) minimum data set assessment with an (ARD) assessment reference date of 06/23/21 included a (BIMS) brief interview for mental status summary score of 9 out of 15. Section G (functional status) was coded 3/3 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 interviews, the review of documents, and in the course of a complaint investigation, it was determined the facility staff failed to ensure required care was provided to for 10 of 30 sampled residents (Resident #1, Resident #5, Resident #6, Resident #13, Resident #17, Resident #19, Resident #31, Resident #46, Resident #48, and Resident #52). The findings include: 1. The facility staff failed to ensure Resident #5 received ordered care to address an area noted to the resident's scalp. Resident #5's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 5/7/21, was signed as completed on 5/21/21. Resident #5 was assessed as rarely/never able to make self understood and as rarely/never able to understand others. Resident #5 was documented as having short-term and long-term memory problems. Resident #5 was assessed as being dependent on others for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. Resident #5's diagnoses included, but were not limited to: high blood pressure, seizure disorder, anxiety, depression, and central…

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, interviews, and the review of documents, it was determined the facility staff failed to ensure a properly working call system for parts of two (2) of two (2) open units. The findings include: On 8/3/21 at 8:28 a.m., the call light in the resident bathroom shared by room [ROOM NUMBER] and room [ROOM NUMBER] was noted to have been pulled but the light outside of the rooms in the hallway was not lit to indicate the bathroom call light had been activated. It was also noted that an alarm was not heard on either of the units to alert staff to the call light being activated. This observation was confirmed by the facility's Director of Maintenance (DoM) and Employee #31 (a respiratory therapist). Observations of the facility's call system identified the following additional concerns: 1. The call light in the resident bathroom shared by room [ROOM NUMBER] and room [ROOM NUMBER] was not working. 2. The call light for room [ROOM NUMBER] Bed B was not working. 3. The call light in the resident…

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

Based on staff interview, employee record review and facility document review the facility staff failed to implement facility abuse and neglect policy for 4 of 25 new hire employees, #16, #17, #18 and #19. The finding included: For new hire employee #16 the facility failed to obtain a criminal background check. For new hire #17, #18, and #19 the facility staff failed to obtain a sworn disclosure statement. Surveyor reviewed 25 new hire employee files on 08/03/21. For new hire #16, who is employed as the facility maintenance director, the surveyor could not locate a Virginia State Police criminal background check. For new hire #17, who is employed as a chef, the surveyor could not locate a sworn disclosure statement. For new hires #18 and #19, who are employed in dietary, the surveyor could not locate sworn disclosure statements. Surveyor spoke with the facility BOM (business office manager) on 08/03/21 regarding the missing information in the employees' files. BOM stated that employee #17, #18, and #18 were employed through a contract agency. No explanation was provided regarding…

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

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure an injury of unknown source was reported for 1 of 30 residents in the survey sample, Resident #31. The findings included: For Resident #31, the facility staff failed to report swelling and bruising to the right eye from an unidentified source. Resident #31's diagnosis list indicated diagnoses, which included, but not limited to Dementia in Other Diseases Classified Elsewhere without Behavioral Disturbance, Typical Atrial Flutter, Chronic Obstructive Pulmonary Disease Unspecified, Acute on Chronic Systolic (Congestive) Heart Failure, Primary Open-Angle Glaucoma Bilateral Severe Stage, and Unspecified Blepharitis Left Eye Upper and Lower Eyelids. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 6/17/21 coded the resident as being severely impaired with cognitive skills for daily decision making with short-term and long-term memory problems. Resident #31 was unable to complete the BIMS (brief interview for mental status)…

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

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure an injury of unknown source was investigated for 1 of 30 residents in the survey sample, Resident #31. The findings included: For Resident #31, the facility staff failed to investigate swelling and bruising to the right eye originating from an unidentified source. Resident #31's diagnosis list indicated diagnoses, which included, but not limited to Dementia in Other Diseases Classified Elsewhere without Behavioral Disturbance, Typical Atrial Flutter, Chronic Obstructive Pulmonary Disease Unspecified, Acute on Chronic Systolic (Congestive) Heart Failure, Primary Open-Angle Glaucoma Bilateral Severe Stage, and Unspecified Blepharitis Left Eye Upper and Lower Eyelids. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 6/17/21 coded the resident as being severely impaired with cognitive skills for daily decision making with short-term and long-term memory problems. Resident #31 was unable to complete the BIMS (brief interview 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 staff interview and clinical record review the facility staff failed to document basis for transfer in the residents clinical record for 1 of 30 residents, Resident #32. The findings included: For Resident #32 the facility staff failed to document information regarding the resident's transfer to the hospital. Resident #32's face sheet listed diagnoses which included but not limited to hemiplegia, type II diabetes mellitus, acute kidney failure, aphasia, anxiety, depression, retention of urine, anemia, dysphagia and adult failure to thrive. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) 06/17/21 failed to assign the resident a BIMS (brief interview for mental status) score, in section C, cognitive patterns. The quarterly MDS with an ARD date of 03/31/21 assigned the resident a BIMS score of 8 out of 15 in section C. This indicates that the resident is moderately cognitively impaired. Resident #32's clinical record was reviewed and contained a nurse's progress note dated 07/20/21 at 4:32 am, which read in part ED (emergency…

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 the facility staff failed to ensure the accuracy of MDS (minimum data set) assessments for 1 of 30 residents, Resident #32. The findings included: For Resident #32, the facility staff failed to ensure the BIMS (brief interview for mental status) was completed. Resident #32's face sheet listed diagnoses which included but not limited to hemiplegia, type II diabetes mellitus, acute kidney failure, aphasia, anxiety, depression, retention of urine, anemia, dysphagia and adult failure to thrive. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) 06/17/21 failed to assign the resident a BIMS score, in section C, cognitive patterns. The quarterly MDS with an ARD date of 03/31/21 assigned the resident a BIMS score of 8 out of 15 in section C. This indicates that the resident is moderately cognitively impaired. Surveyor spoke with the MDS coordinator on 08/02/21 at approximately 4:30 pm regarding the missing BIMS score. MDS coordinator stated that the facility SW (social worker) is responsible 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.

2. For Resident #16, the facility staff failed to refer the resident for a Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination. Resident #16's diagnosis list indicated diagnoses, which included, but not limited to Acute Respiratory Failure with Hypoxia, Bipolar Disorder Unspecified, Anxiety Disorder Unspecified, Mental Disorder not Otherwise Specified, and Unspecified Dementia with Behavioral Disturbance. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 5/28/21 assigned the resident a BIMS (brief interview for mental status) score of 3 out of 15 in section C, Cognitive Patterns. Resident #16's clinical record included a Level 1 PASARR dated 10/10/19 indicating the recommendation for a Level II evaluation and determination, MI (mental illness) was checked under section 5 Recommendation. Surveyor was unable to locate a Level II PASARR in Resident #16's clinical record and requested assistance in locating the Level II on 8/02/21. On 8/02/21 at 2:25 pm, the administrator stated they do not have a Level II…

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 the facility staff failed to provide catheter services for 3 of 30 residents, Resident #32, Resident #48 and Resident #14. The findings included: 1. For Resident #32 the facility staff failed to anchor the catheter tubing. Resident #32's face sheet listed diagnoses which included but not limited to hemiplegia, type II diabetes mellitus, acute kidney failure, aphasia, anxiety, depression, retention of urine, anemia, dysphagia and adult failure to thrive. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) 06/17/21 failed to assign the resident a BIMS (brief interview for mental status) score, in section C, cognitive patterns. The quarterly MDS with an ARD date of 03/31/21 assigned the resident a BIMS score of 8 out of 15 in section C. This indicates that the resident is moderately cognitively impaired. Resident #32's clinical record was reviewed on 08/01/21. It contained a physician's order summary for the month of August, which read in part Check placement…

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 ensure 1 of 30 residents received the necessary care and treatment in regards to a colostomy. Resident #30 The findings included: The facility staff failed to ensure Resident #30 had colostomy supplies. The clinical record included the diagnoses, quadriplegia, chronic pain syndrome, personality disorder, antisocial personality disorder, major depressive disorder, and insomnia. Section C (cognitive patterns) of Resident #30's significant change (MDS) minimum data set assessment with an (ARD) assessment reference date of 06/09/2021 included a (BIMS) brief interview for mental status summary score of 15 out of a possible 15 points. Section G (functional status) was coded to indicate the resident was totally dependent on two persons for bed mobility, transfers, dressing, toilet use, and personal hygiene. Section H (bladder and bowel) was coded to indicate the resident had a colostomy. Resident #30's comprehensive care plan included the focus…

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 interviews and the review of documents, it was determined the facility staff failed to address a weight loss for one (1) of 30 sampled residents (Resident #33). The findings include: The facility staff failed to address Resident #33's weight loss when the resident's weight dropped below the care planned goal to keep weight greater than 113 pounds. Resident #33's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 6/17/21, was signed as completed on 6/24/21. Resident #33 was assessed as sometimes able to make self understood and as sometimes able to understand others. The resident was assessed as having problems with short-term and long-term memory. Resident #33 was assessed as requiring extensive assistance with bed mobility, transfers, dressing, and personal hygiene. Resident #33 was assessed as being dependent on staff for toilet use and bathing. Resident #33's diagnoses included, but were not limited to: high blood pressure, Alzheimer's disease, dementia, depression, anxiety, and vision problems. Resident #33's clinical record included the…

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

Based on observation, staff interview, and clinical record review, the facility staff failed to follow physician orders in regards to tube feedings for 2 of 30 residents, Residents #40 and #32. The findings included: 1. For Resident #40, the facility staff failed to ensure the residents tube feeding was set at the prescribed physician ordered rate of 75cc/hour. Resident #40's (EHR) electronic health record included the diagnoses, chronic respiratory failure, diabetes, dysphagia, and epilepsy. Section C (cognitive patterns) of Resident #40's admission (MDS) minimum data set assessment with an (ARD) assessment reference date of 06/21/21 had been coded (0/1/1) to indicate the resident had problems with long term memory and had modified independence in cognitive skills for daily decision making. Section K (swallowing/nutritional status) was coded to indicate Resident #40 had a feeding tube. The Residents comprehensive care plan included the focus area requires tube feeding for 100% nutrition. The (EHR) electronic health record included a physician order to administer promote per peg via…

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 the facility staff failed to maintain respiratory equipment for 1 of 30 residents, Resident #19. The findings included: For Resident #19 the facility staff failed to store the resident's respiratory equipment in a manner to prevent contamination. Resident #19's face sheet listed diagnoses which included but not limited to acute and chronic respiratory failure, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, atrial fibrillation, gastroesophageal reflux disease and depression. Resident #19's most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 06/02/21 assigned the resident a BIMS (brief interview for mental status) score of 11 out of 15. This indicates that the resident is cognitively intact. Resident #19's clinical record was reviewed and contained a physician's order summary which read in part Ipratropium-Albuterol Solution 0.5-2/5 (3) MG/ML 1 application inhale orally every 4 hours as needed for sob/wheezing.…

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 interviews and the review of documents, it was determined the facility staff failed to provide a pain medication as ordered by the provider for one (1) of 30 sampled residents (Resident #34). The findings include: The facility staff failed to administer Resident #34's medication, to address pain, as ordered by the provider. Resident #34's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 5/21/21, was signed as completed on 6/11/21. Resident #34 was assessed as able to make self understood and as able to understand others. Resident #34's Brief Interview for Mental Status (BIMS) summary score was documented as 15 out of 15. Resident #34 was assessed as requiring assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #34's diagnoses included, but were not limited to: high blood pressure, seizures, anxiety, depression, and lung disease. During an interview on 8/1/21 at 11:00 a.m., Resident #34 reported that approximately a month ago, a medication (gabapentin) was not provided as ordered. Resident #34 reported…

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

Based on staff interview, clinical record review, and facility document review, the facility staff failed to coordinate care with the contracting dialysis center for 2 of 30 residents in the survey sample, Resident #46, and #49. The findings included: 1. For Resident #46, the facility staff failed to complete dialysis communication forms prior to dialysis treatments. Resident #46's diagnosis list indicated diagnoses, which included, but not limited to Acute Systolic (Congestive) Heart Failure, Chronic Obstructive Pulmonary Disease Unspecified, End Stage Renal Disease, Dependence on Renal Dialysis, Chronic Respiratory Failure with Hypoxia, Anemia in Chronic Kidney Disease, and Paranoid Schizophrenia. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 6/29/21 assigned the resident a BIMS (brief interview for mental status) score of 14 out of 15 in section C, Cognitive Patterns. A review of Resident #46's active physician's orders included an order dated 5/21/21 for outpatient hemodialysis on Tuesdays, Thursdays, and Saturdays. On 8/02/21,…

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

Based on staff interview, clinical record review and facility document review the facility staff failed to identify and report medication irregularities for 1 of 30 residents, Resident #13. The findings included: For Resident #13 the facility staff failed to identify multiple orders for the mediations aspirin and escitalopram on the physician's order summary and eMAR (electronic medication administration record). Resident #13's face sheet listed diagnoses which included but not limited to urinary tract infection, cerebral infarction, hemiplegia, and hemiparesis, dysphagia, hypertension, and acute and chronic respiratory failure. Resident #13's most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 06/24/21 assigned the resident a BIMS (brief interview for mental status) score of 15 of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #13's clinical record was reviewed and contained a physician's order summary, which read in part Aspirin Low Dose Tablet Chewable 81 mg (Aspirin). Give 1 tablet by…

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 in the course of a complaint investigation the facility staff failed to store and account for controlled medications for 1 of 30 residents, Resident #159. The findings included: For Resident #159 the facility staff failed to account for 36 hydrocodone tablets. Resident #159's face sheet listed diagnoses which included, but not limited to chronic kidney disease, anemia, anxiety, cirrhosis of liver, hypertension, and chronic viral hepatitis. Resident #159's admission MDS (minimum data set) with an ARD (assessment reference date) of 01/23/20 assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C cognitive patterns. This indicates that the resident was cognitively intact. Resident #159's comprehensive care plan was reviewed and contained a care plan for . (name omitted) has chronic pain due to bursitis and CTS (carpal tunnel syndrome). Resident #159's clinical record was reviewed and contained a physician's order summary for the months of January 2020 through March 2020, which read in part…

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

Based on staff interview and clinical record review, the facility staff failed to obtain a physician ordered laboratory test for 1 of 30 residents, Resident #40. The findings included: The facility failed to obtain the physician ordered laboratory test hemoccult of stools. Resident #40's (EHR) electronic health record included the diagnoses, chronic respiratory failure, diabetes, dysphagia, anemia, and epilepsy. Section C (cognitive patterns) of Resident #40's admission (MDS) minimum data set assessment with an (ARD) assessment reference date of 06/21/21 had been coded (0/1/1) to indicate the resident had problems with long term memory and had modified independence in cognitive skills for daily decision making. The clinical record included a physicians order for a hemoccult X3. A review of the (EMAR's) electronic medication administration records revealed that the facility nursing staff had signed the EMAR's with their initials beginning on 07/14/21 through 07/24/21. However, the surveyor was unable to find any results for the hemoccult test. 08/02/21 4:03 p.m., during a meeting…

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 interviews and the review of documents, it was determined the facility staff failed to maintain complete and accurate clinical records for three (3) of 30 sampled residents (Resident #6, Resident #34, and Resident #49). The findings include: 1. The facility staff failed to ensure the pharmacist completing Resident #6's monthly medication regimen review (MRR) documented in the resident's clinical records that no recommendations were made. Resident #6's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 5/7/21, was signed as being completed on 5/25/21. Resident #6 was assessed as usually able to make self understood and as usually able to understand others. Resident #6 was assessed as requiring assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #6's diagnoses included, but were not limited to: heart disease, high blood pressure, seizure disorder, depression, and diabetes. Review of Resident #6's clinical record included the phrase MRR Completed documented by a pharmacist for the following dates: 2/1/2021;…

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

Based on staff interview, clinical record review, and facility document review, the facility staff failed to offer the flu and pneumonia vaccine to 1 of 30 Residents, Resident #35. The findings included: For Resident #35, the facility staff failed to offer a flu and pneumonia vaccine upon admit to the facility. The Residents face sheet revealed that Resident #35 had been admitted to the facility 12/28/20 and included the diagnoses anxiety disorder, bipolar disorder, depressive disorder, and paranoid schizophrenia. Section C (cognitive patterns) of Resident #35's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 06/23/21 included a BIMS (brief interview for mental status) summary score of 9 out of a possible 15 points. Section O (special treatments, procedures, and programs) had been coded to indicate the resident had not received the influenza vaccine and was not offered the flu or pneumonia vaccine. 08/04/21 the [NAME] President of Clinical Services provided the surveyor with a copy of their pneumococcal vaccine and influenza vaccine policies.…

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.