South Roanoke Nursing And Rehabilitation

Based on observation, staff interview and clinical record review, the facility staff failed to provide respiratory services for 1 of 23 Residents, Resident #65. The findings included: For Resident #65 the facility staff failed to consistently provide and/or document oxygen usage per the physician's order and the hospice plan. Resident #65's face sheet listed diagnoses which included but not limited to malignant neoplasm of unspecified part of unspecified bronchus or lung, chronic obstructive pulmonary disease, emphysema, and respiratory failure. Resident #65's most recent minimum data set with an assessment reference date of 03/16/25 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 #65's comprehensive care plan was reviewed and contained a plan for The resident has COPD (chronic obstructive pulmonary disease) and is on 8 L/Min (liters per minute) via nasal cannula every shift for lung CA (cancer). He removes and reapplies his nasal cannula. Resident #65's…

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

Based on observations, interviews, and document reviews, the facility staff failed to store and/or prepare food in a sanitary manor in the main kitchen and failed to ensure a clean and sanitary food service area. The findings include: The initial tour of the kitchen/food service area was conducted on 3/22/22 at 9:53 a.m. Two (2) dietary staff members (SM) #26 and SM #27 participated in the tour. The following was observed: An open bag diced potatoes were observed in the reach-in freezer. The diced potatoes were uncovered. A bag of chicken flavored tofu was in contact with the diced potatoes. The refrigerator contained three (3) cups of orange juice and four (4) cups of grape juice that had been poured from a container into individual cups. These seven (7) cups of juice were not labeled with a date. Half a honeydew melon was found in a refrigerator. This melon was covered with plastic wrap but not labeled and dated. Three (3) trays of individual sized peanut butter pies were observed in a refrigerator. These trays of pies were not labeled and dated. A bowl of the peanut butter pie…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 a quality assurance and performance improvement (QAPI) plan for the facility. The findings were: The administrative team provided a policy titled, Quality Assurance and Performance Improvement; however, no evidence related to the development, implementation, or evaluation of corrective actions or performance improvement activities was provided. The Regional Director of Clinical Services (RDCS) and the facility's Administrator were interviewed on 03/24/2022 at 2:13 p.m. about the facility's QAPI plan. The RDCS said that although the current administrative team had searched everywhere, they were not able to provide any documentation to evidence their QAPI plan. No further information was provided prior to the exit conference.

Based on staff interview and facility document review, the facility staff failed to provide evidence they had developed and implemented appropriate plans of action to identify or correct quality deficiencies for the facility. The findings were: On 03/24/2022 at 2:13 p.m.,during review of the facility Quality Assessment and Perfomance Improvement Prgram, the Regional Director of Clinical Services (RDCS) and the facility's Administrator were interviewed. The RDCS said that although the current administrative team had searched everywhere, they were not able to provide any documentation to evidence their QAPI plans of action for quality deficiencies. No further information was provided prior to the exit conference.

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 quarterly quality assessment and assurance (QAA) committee meetings for the facility. The findings were: The Regional Director of Clinical Services (RDCS) and the Administrator were interviewed on 03/24/2022 at 2:13 p.m. The RDCS provided signature sheets for a QAA committee meeting dated [DATE]. The RDCS said that although the current administrative team had searched everywhere, they were not able to locate the signature sheets from other quarterly QAA committee meetings. Later the same day, the administrator provided a QAA meeting signature sheet dated January 23, 2020. No further information was provided prior to the exit conference.

Based on resident interview, staff interview, and clinical record review, the facility staff failed to provide the resident and/or their representative, a written summary of their baseline CP (care plan) for 2 of 20 residents, Residents #54 and #71. The findings included: 1. Resident #54's clinical record included the diagnoses stage 4 pressure ulcer of left buttock and left ankle, abdominal aortic aneurysm, and paraplegia. Section C (cognitive patterns) of Resident #54's admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 02/21/22 included a BIMS (brief interview for mental status) summary score of 15, indicating the resident was alert and orientated. On 03/23/22 at 3:32 p.m., MDS nurse #1 was interviewed and stated she was new to the facility as of December 2021. She stated the baseline CP was given to the residents within 48 hours of their admission, and thought the floor nurses provided the baseline CP to the residents. On 03/24/22 at 2:15 p.m., Resident #54 was interviewed and asked if they received a copy of their CP. Resident #54 stated 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, resident interview, and clinical record review, the facility staff failed to review and revise the care plan to reflect the resident's current status for one of 20 residents, Resident #180; and and failed to invite the resident to the care plan meeting for one of 20 residents in the survey sample, Resident #54. 1. Resident #180 was admitted to the facility with diagnoses including diabetes mellitus, congestive heart failure, generalized muscle weakness, end stage chronic renal insufficiency, and thrombocytopenia. On the minimum data set (MDS) assessment with assessment reference date 11/24/2021, the resident scored 11/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. Resident #180's clinical record included physician orders dated 2/24/2022 and 3/7/2022 to weigh the resident on Monday, Wednesday, and Friday, and notify the physician of weight gain over 5 pounds. On 03/23/22 at 3:11 PM, Resident #180's comprehensive care plan was reviewed with the MDS nurse. The care plan did not…

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

Based on observation, resident interview, and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for a dependent resident for 1 of 20 residents, Resident #36. The findings included: Resident #36's was admitted to the facility with diagnoses that included, but were not limited to, fibromyalgia and muscle weakness. Section C (cognitive patterns) of Resident #36's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 01/20/22 included a BIMS (brief interview for mental status) summary score of 15, indicating the resident was cognitively intact. Section G (functional status) was coded 2/2 in the area of personal hygiene indicating Resident #36 required limited assistance of one person to perform this task. Resident #36's comprehensive care plan included the problem area of ADL self-care performance deficit related to fibromyalgia/pain with little to no motivation. Approaches included to provide assistance with ADL tasks. On 03/22/22 at 3:11 p.m., Resident #36 was observed in their room and was observed 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, and clinical record review, the facility staff failed to follow physicians orders for 3 of 20 residents in the survey sample, Residents #9, #71, and #180. For Resident #9, the facility failed to administer the full course of the antibiotic cephalexin ordered by the physician. For Resident #71, the facility failed to follow physician's orders for the administration of the medication cephalexin. For Resident #180, facility staff failed to obtain weights as ordered. 1. Resident #9 was admitted to the facility with diagnoses including chronic respiratory failure with hypoxia, history of falls, muscle weakness, chronic obstructive pulmonary disease, dependence on oxygen, and essential hypertension. Clinical record review revealed Resident #9 returned from a hospitalization with orders including: 12/2/2021 cephalexin 500 mg tablet 1 tablet PO (by mouth) QID (4 times per day) X (times) 5 days diagnosis UTI (urinary tract infection). The total course would be 20 doses. The medication administration record (MAR) documented doses administered at 9:00 AM on 12/3,…

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 a physician ordered supplement was kept under direct observation by the nursing staff until consumed by the resident for 1 of 20 residents, Resident #54. The findings included: Resident #54's clinical record included the diagnoses stage 4 pressure ulcer of left buttock and left ankle, abdominal aortic aneurysm, and paraplegia. Section C (cognitive patterns) of Resident #54's admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 02/21/22 included a BIMS (brief interview for mental status) summary score of 15. Indicating the resident was alert and orientated. 03/23/22 9:51 a.m., Resident #54 was observed with a brown liquid substance in a medication cup on their over the bed table. LPN (licensed practical nurse) #1 was observed outside Resident #54's room and was not in direct line of sight of this physician ordered supplement. LPN #1 identified this substance as Proheal and stated they should not have left the Proheal in the residents' room. 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 observation, staff interview, and facility document review, the facility staff failed to perform hand hygiene during a medication pass and pour onservation on 1 of 2 resident care units, Wing 2. The findings included: On 3/23/22 at 8:15 am during a medication pass and pour observation, LPN (licensed practical nurse) #1 administered nasal spray to a resident while wearing gloves, exited the room, returned to the medication cart and placed the nasal spray back into a medicine bottle prior to removing gloves. LPN #1 then removed gloves and placed the medicine bottle into the medication cart and proceeded down the hall to another area without performing hand hygiene. On 3/24/22 at 11:54 am, surveyor informed the DON (director of nursing) of the observation of LPN #1 exiting a resident's room following nasal spray administration without removing gloves or performing hand hygiene. The DON acknowledged LPN #1 should have removed gloves and performed hand hygiene following the medication administration. The facility policy entitled Handwashing/Hand Hygiene documented in part: 2.…

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

Based on staff interview and clinical record review, the facility staff failed to determine flu and pneumonia status for 3 of 5 residents reviewed for vaccines, Resident's #8, #40, and #55. The facility staff was unable to provide evidence of consent or refusal in regards to the flu and/or pneumonia vaccines. The findings included: 1. Resident #8's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 12/15/21 included a BIMS (brief interview for mental status) summary score of 3 indicating severe cognitive impairment. Section O (special treatments/procedures/programs) was coded with a 1 indicating the resident had received the pneumonia vaccine. During clinical record review there was no consent for the pneumonia vaccine found nor any information to indicate when the resident received the vaccine. On 03/23/22 at 12:29 p.m., the DON (director of nursing) was asked for documentation in regards to Resident #8's pneumonia vaccine. On 03/23/22 at 5:45 p.m., during an end of the day meeting with the administrator, administrator in training, and DON 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, interviews, and document reviews, the facility staff failed to properly implement COVID-19 testing processes and/or procedures. The specimen collection was not obtained according to manufacturers instructions for one staff member (SM) #22; and the facility staff failed to conduct required COVID-19 testing on five separate occasions for for 1 of 2 staff members, SM #1. The findings include: 1. On 3/22/22 at 3:05 p.m., SM #21 was observed conducting a COVID-19 test on SM #22. SM #21 was observed inserting a swab into one of SM #22's nostrils. SM #21 rotated the swab 5 times prior to removing the swab and repeated the process in SM #22's other nostril. SM #21 was observed to have the swab inserted into each of SM #22 nostrils for less than 10 seconds per each nostril. SM #21 confirmed they rotated the swab 5 times in each nostril but reported they were not aware of a minimum time requirement for the COVID-19 specimen/sample collection. The following information was found in the manufacturer's instructions for use: Anterior Nasal (Nares) Swab .Only the swab…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 provide evidence of COVID-19 vaccination refusal for 1 of 5 residents, Resident #40. The findings included: Resident #40's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 01/25/22 included a BIMS (brief interview of mental status) summary score of 8 indicating moderate impairment in cognitive skills for daily decision-making. On 03/22/22, the facility provided a form titled, Resident Vaccination Status. Under the areas for type of vaccine and the date a resident would have received the vaccine, was transcribed the word Choice. During the clinical record review, there was no information located to indicate Resident #40 had been offered and/or refused the COVID-19 vaccine. On 03/23/22 at 12:29 p.m., the DON (director of nursing) was asked for documentation of Resident #40's COVID-19 vaccine. This documentation was not provided prior to survey exit. The current IP (infection preventionist) was new to the facility 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 observation, staff interview, and facility document review, the facility failed to implement policies and procedures for additional infection control precautions for staff who are not fully vaccinated for COVID-19, for 3 of 5 employees, Staff Members (SM) #1, #2, and #3. The facility staff also failed to ensure a process for tracking the COVID-19 vaccination status of staff for 1 of 7 sampled employees, SM #4. The findings included: 1. According to the COVID-19 employee vaccine tracking documentation provided by the facility on 3/22/22, SM #1 was partially vaccinated. SM #1 received their first administration of a multiple COVID-19 vaccine series on 3/03/22. SM #1's date of hire was 2/24/22. SM #1 worked in the facility four days (2/24/22, 2/25/22, 2/28/22, and 3/01/22) prior to receiving their first dose of a COVID-19 vaccine. On 3/23/22 at 4:20 pm, the HRS (human resource staff) #1 was interviewed regarding SM #1's work location and duties performed on 2/24/22, 2/25/22, 2/28/22, and 3/01/22. HRS #1 stated there was no way of knowing. At 4:22 pm, SM #1's department manager…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 prepare, store, and serve foods in a sanitary manner. The findings included: a. The facility staff failed to ensure that perishable food items were secured and appropriately labeled. b. The facility staff failed to ensure that perishable food items were discarded appropriately. c. The facility staff failed to ensure that facial hair was secured with a chin guard. d. The facility staff failed to ensure a clean and sanitary working environment in the facility kitchen. e. The facility staff failed to ensure that personal items were not in the facility kitchen. On 7/7/19 at 12:00 pm, the surveyor conducted an initial tour of the kitchen with dietary cook # 1. During the initial kitchen tour the surveyor observed and empty 16-ounce water bottle on the counter near the coffee maker and spices. The surveyor observed that there was a small amount of red liquid left in the bottle. The surveyor also observed a large amount of dried brown, yellow, and white debris on the stand beneath the tray…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 an effective infection control program for 1 of 24 Residents, Resident #18 and failed to follow their infection control program/plan for use of an SBAR (situation, background, assessment, recommendation) technique. The findings included: 1. For Resident #18, the facility staff dropped 2 medication capsules on the top of the medication cart, picked them up with their bare hands, and administered them to the Resident. The clinical record review revealed that Resident #18 had been admitted to the facility 04/15/19. Diagnoses included, but were not limited to, Parkinson's disease, hypertension, osteopenia, gait difficulties, and frequent falls. Section C (cognitive patterns) of the Residents admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 04/22/19 included a BIMS (brief interview for mental status) summary score of 13 out of a possible 15 points. On 07/08/19 at approximately 9:02 a.m., during a medication pass and pour…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, facility document review, and clinical record review, it was determined the facility staff failed to ensure Durable Do Not Resuscitate Order (DDNR) forms and/or the facility's advance directive processes were correctly implemented for 2 of 24 residents (Resident #336 and Resident #80). The findings include: 1. The facility staff failed to ensure provider/physician involvement in the implementation of DDNR forms as evidenced by finding thirty (30) DDNR forms that had been pre-signed by the facility's medical director (MD). These pre-signed DDNR forms did not include patient information. Eight (8) of the pre-signed forms included the medical director's name (printed) and the medical director's phone number. Resident #336 was admitted to the facility on [DATE]. Resident #336's diagnoses included, but were not limited to: Parkinson's disease, hyperlipidemia, arthritis, and thoracic compression fracture. Resident #336's initial minimum data set (MDS) assessment had not yet been completed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide notification of changes for 1 of 24 Residents in the survey sample, Resident # 30. The findings included: The facility staff failed to ensure that the physician was notified that Resident # 30 had falls. Resident #30 was a [AGE] year-old-female who was admitted to the facility on [DATE]. Diagnoses included but were not limited to, dementia, agitation, depression, and hypertension. The clinical record for Resident # 30 was reviewed on 7/7/19 at 1:59 pm. The most recent MDS (minimum data set) assessment for Resident # 30 was an admission assessment with an ARD (assessment reference date) of 5/6/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 30 had a BIMS (brief interview for mental status) score of 7 out of 15, which indicated that Resident # 30's cognitive status was severely impaired. The current plan of care for Resident # 30…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide the receiving provider with the appropriate information to include the basis for the transfer, contact information of the practitioner responsible for the care of the resident, resident representative information including contact information, Advanced Directive information, all special instructions or precautions for ongoing care, comprehensive care plan goals, and all other necessary information including a copy of the resident's discharge summary and the facility failed to document information provided to the receiving provider in the clinical record for 2 of 24 residents (Resident #34 and Resident #37). The findings included: 1. The facility staff failed to document what information was sent to the receiving provider when Resident #37 was transferred to the emergency room 5/24/19. The clinical record of Resident #37 was reviewed 7/7/19 through 7/9/19. Resident #37 was admitted to the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review the facility staff failed to provide notifications to the ombudsman and Resident's RP (responsible party) when a Resident was transferred for 2 of 24 Residents, Resident #34 and Resident #37. The findings included: 1. For Resident #34 the facility staff failed to notify the local state ombudsman that the Resident had been transferred to the hospital. Resident #34 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included but not limited to hypertension, diabetes mellitus, arthritis, dementia, chronic obstructive pulmonary disease, hip fracture and glaucoma. The admission MDS (minimum data set) with an ARD (assessment reference date) of 05/09/19 assigned the Resident a BIMS (brief interview for mental status) score of 15 out of 15. Resident #34's clinical record was reviewed on 07/09/19. It contained a nurse's progress note, which read in part 06/29/19 1:30 pm .called Resident's husband. She was sent to ER for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, the facility staff failed to provide to the resident and the resident representative at the time of transfer/discharge written notice that specifies the duration of the bed-hold policy for 2 of 24 residents (Resident #34 and Resident #37). The findings included: 1. The facility staff failed to provide Resident #37 and the resident representative written information about bed-hold when the resident was transferred to the hospital 5/24/19. The clinical record of Resident #37 was reviewed 7/7/19 through 7/9/19. Resident #37 was admitted to the facility 1/10/19 and readmitted [DATE] with diagnoses that included but not limited to pneumonia, urinary tract infection, gastroesophageal reflux disease (GERD), hypertension, hypothyroidism, peripheral neuropathy, anxiety, fibromyalgia, dementia, near syncope, first degree AV (atrioventricular), hyperlipidemia, and chronic kidney disease. Resident #37's quarterly MDS (minimum data set) with an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and during a medication pass and pour observation, the facility staff failed to follow physician orders for 1 of 24 Residents, Resident #49. The findings included: The facility staff failed to administer the Residents eye ointment as ordered by the physician. The order read to administer to the left eye when in fact the nurse administered the medication to both eyes. The record review revealed that Resident #49 had been admitted to the facility on [DATE]. Diagnoses included, but were not limited to, trichiasis left lower eyelid, dementia without behavioral disturbance, hypertension, dry eyes, bladder spams, depression, and insomnia. Section C (cognitive patterns) of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 05/23/19 included a BIMS (brief interview for mental status) summary score of 6 out of a possible 15 points. On 07/08/19 beginning at approximately 8:34 a.m., the surveyors observed RN (registered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review, the facility staff failed to ensure that 1 of 24 Residents in the survey sample received respiratory care consistent with professional standards of practice, Resident # 30. The findings included The facility staff failed to ensure that Resident # 30 received 3 liters of oxygen per physician's orders. Resident #30 was a [AGE] year-old-female who was admitted to the facility on [DATE]. Diagnoses included but were not limited to, dementia, agitation, depression, and hypertension. The clinical record for Resident # 30 was reviewed on 7/7/19 at 1:59 pm. The most recent MDS (minimum data set) assessment for Resident # 30 was an admission assessment with an ARD (assessment reference date) of 5/6/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 30 had a BIMS (brief interview for mental status) score of 7 out of 15, which indicated that Resident # 30's cognitive status was severely…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, facility document review, and during a medication pass and pour observation, the facility staff failed to ensure a medication was available for administration for 1 of 24 Residents, Resident #49. The findings included: The facility staff did not have the physician ordered medication refresh tears available for administration. This resulted in Resident #49 missing their scheduled dose at 9:00 a.m. The record review revealed that Resident #49 had been admitted to the facility on [DATE]. Diagnoses included, but were not limited to, trichiasis left lower eyelid, dementia without behavioral disturbance, hypertension, dry eyes, bladder spasms, depression, and insomnia. Section C (cognitive patterns) of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 05/23/19 included a BIMS (brief interview for mental status) summary score of 6 out of a possible 15 points. The Residents clinical record included a physicians order for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to ensure that 2 of 24 Residents in the survey sample were free of unnecessary psychotropic medications, Resident # 13 and Resident # 14. The findings included: 1. The facility staff failed to appropriately monitor Resident # 13 for behaviors, side effects, and effectiveness associated with the use of Risperidone. Resident # 13 was an [AGE] year-old-female who was admitted to the facility on [DATE]. Diagnoses included but were not limited to, Alzheimer's disease, dementia, hallucinations, and psychosis with behavioral disorder. The clinical record for Resident # 13 was reviewed on 7/7/19 at 2:20 pm. The most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 4/16/19. Section C of the MDS assesses cognitive patterns. In Section C1000, the facility staff documented that Resident # 13's cognitive status was moderately impaired. Section N of the MDS assesses medications. In…

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

Based on observation, staff interview, and facility document review, the facility staff failed to ensure a narcotic medication (lorazepam/ativan) with the potential for abuse was stored in a locked permanently affixed box on 1 of 2 wings, wing 2. The findings included: The medication refrigerator in the wing 2 medication room contained two-2 mg vials of lorazepam. This box was not permanency affixed and was able to be removed from the refrigerator. On 07/08/19 at approximately 2:00 p.m., the surveyor checked the medication refrigerator on wing 2. This refrigerator contained a plastic box with a plastic breakaway lock. Inside this box, the surveyor observed two-2 mg vials of lorazepam. The surveyor was able to pick this plastic box up and remove it from the refrigerator. The facility policy titled Storage of Medication read in part, The facility shall store all drugs and biological's in a safe, secure, and orderly manner . The administrative staff were notified of the issue regarding the lorazepam during a meeting with the survey team on 07/08/19 at approximately 3:10 p.m. Per the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review the facility staff failed to ensure a complete and accurate clinical record for 2 of 24 Residents, Resident #22 and Resident #30. The findings included: For Resident #22 the facility staff failed to ensure daily CNA (certified nursing assistant) flow sheets were completed. Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included but not limited to congestive heart failure, aphasia, dementia, anxiety, depression, and glaucoma. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 04/23/19 assigned the Resident a BIMS (brief interview for mental status) score of 4 out of 15 in section C, cognitive patterns. Resident #22's clinical record was reviewed on 07/09/19. It contained CNA flowsheets and Resident Care Rosters for the months of February, March, April, May, June and July of 2019. These forms contain information on food/fluid intake, toileting, bathing, ADL's (activities of daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interview, staff interviews, clinical record review, and facility document review the facility staff failed to follow their policy and procedure regarding the Residents smoking supplies for 1 (one) of 24 Residents, Resident #38. The findings: The facility's smoking policy indicated that Residents who desire to smoke may not keep smoking related materials (cigarettes, cigars, pipes, tobacco, lighter, lighter fluid, match etc.) on their person when not smoking or in their room. Resident #38 kept their cigarettes and lighter with them at all times. During an interview with Resident #38 on 07/08/19 at 12:20 p.m. the resident explained they kept their own cigarettes and own lighter in a bag they kept at their side at all times. Resident #38 showed the bag to two (2) surveyors by picking it up from where it was sitting beside the resident's leg in their wheelchair. Resident #38 stated they had permission to smoke without supervision. The surveyors also observed an oxygen concentrator…

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