Berry Hill Nursing Home

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to accurately label three medications out of 41 opportunities during the medication pass and pour observations. 1. The medication Provera administered to Resident #11 (R11) during a medication pass observation was not labeled with a dosage. 2. Phenytoin sodium extended release 100 mg administered to Resident #8 (R8), and Atenolol/Chlorthalidone 50-25 mg administered to Resident #20 (R20) were not labeled with a dosage and had incomplete medication name. The findings include: 1. The medication Provera administered to Resident #11 (R11) during a medication pass observation was not labeled with a dosage. A medication pass observation was conducted on 8/21/24 at 7:58 a.m., with licensed practical nurse (LPN #1) administering medications to Resident #11. Among the medications administered was Provera. Observation of the multi-medication pill pack did not evidence a dosage for the Provera. LPN #1 also reviewed the pill packet and agreed there was no indication of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to provide dental services for two of twenty-one residents in the survey sample (Residents #5 and #21). The findings include: 1. Resident #5, with a physician's order for dental services, had not been referred or seen by a dentist. Resident #5 (R5) was admitted to the facility with diagnoses that included multiple sclerosis, hypertension, diabetes, depression, osteopenia, neurogenic bladder and cognitive communication deficit. The MDS dated [DATE] assessed R5 as cognitively intact. On 8/20/24 at 2:22 p.m., R5 was interviewed about quality of care in the facility. R5 was observed at this time with multiple missing teeth and visible teeth with broken edges and dark areas. R5 stated she had a tooth on the lower, right side that hurt when she chewed or put pressure on it. R5 stated she had taken medication for the tooth but had not seen a dentist. R5's clinical record documented the resident was seen 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 observation, staff interview, clinical record review and facility documentation review, the facility staff failed to provide a physician ordered therapeutic diet for one resident (Resident #35-R35) in a survey sample of 21 residents. The findings included: For R35, who had experienced significant weight loss, the physician ordered the resident to receive double portions at meals, which were not provided as ordered. On 8/20/24-8/21/24, a clinical record review was conducted of R35's chart. This review revealed that R35 had an active physician order that read, Regular diet, Pureed texture, Honey consistency double portions, EMP [enriched meal program]. A review of R35's weights was conducted and noted that on 7/3/24 R35 weighed 120.2 pounds. On 8/14/24, R35 weighed 113 pounds, which was a 7.2-pound weight loss in one month. According to R35's care plan with a revision date of 5/24/24, a focus area read, State of nourishment; less than body requirement characterized by weight loss . One of the associated interventions for this care plan focus area read, Diet is regular double…

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 provide an accurate clinical record for one of twenty-one residents in the survey sample (Resident #49). The findings include: Resident #49's plan of care listed the resident as a DNR (do not resuscitate) and the care plan interventions regarding advance directives documented a requirement for cardiopulmonary resuscitation. Resident #49 (R49) was admitted to the facility with diagnoses that included cancer, atrial fibrillation, deep vein thrombosis, hypertension and schizoaffective mood disorder. The minimum data set (MDS) dated [DATE] assessed R49 with severely impaired cognitive skills. R49's clinical record documented a current do not resuscitate (DNR) order. R49's plan of care (revised [DATE]) listed under the Focus column that the resident was on hospice and had a DNR order. Interventions to honor the resident's advance directives documented, CPR (cardio-pulmonary resuscitation): Full Code. On [DATE] at 2:00 p.m., 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 group interview, staff interview, and facility document review, the facility staff failed to ensure mail delivery to residents. Findings include: On 12/15/21 beginning at 3:00 p.m. a group interview was conducted with eleven cognitive residents (Residents # 18, 5, 24, 30, 22, 32, 36, 49, 31, 158, and 11). The group was asked about mail delivery in the facility, and if mail was received on Saturdays and also received unopened. The group responded No. Resident # 11 stated We haven't gotten any mail since the activity director left over a month ago. You know, it's close to Christmas, and we don't even know if we have gotten cards or anything. On 12/15/21 at approximately 4:30 p.m. the administrator was asked about the mail delivery, and for a policy. The administrator stated she would look for a policy, and was not aware residents were not having mail delivered. The policy for mail delivery in the facility stated Mail: Residents have the right to send and promptly receive mail that is unopened and have access to stationary, postage, and writing implements. Mail will 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, clinical record review, and facility document review, the facility staff failed to provide effective administration in a manner to maintain the highest practicable well-being of each resident. The facility staff failed to employ staff in the following key positions: activities director and infection control preventionist; and failed to have a restorative program in place. The findings include: An onsite survey was conducted from 12/14/2021 through 12/16/2021. During the survey deficient practice was identified in the areas of residents rights and activities including F550, F565, F576, F679, and F680 which were related to the facility not employing an activities director since 11/5/2021. The survey revealed deficient practice in the area of infection control including F880, F881, F882, F883, and F887 which were related to the facility not employing an infection control preventionist since 09/08/2021. The survey revealed deficient practice in the area of quality of care including F688, related to the facility not having a restorative program in place. 1. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to follow infection control policies for hand hygiene during a medication pass observation, failed to provide an ongoing program of infection surveillance, and failed to follow infection protocols for PPE (personal protective equipment) use for one of seventeen residents in the survey sample, Resident #34. The findings include: 1. A medication pass observation was conducted on 12/14/21 at 4:32 p.m. with licensed practical nurse (LPN #2) administering medications to three residents. LPN #2 prepared medications and administered them to Resident #15. Oral medications were administered in addition to nasal spray, Advair diskus aerosol inhaler, and eye drops. LPN #2 handled and disposed of the resident's medication and drinking cup after the resident touched the cups to her mouth. LPN #2 put on gloves prior to administering the eye drops. LPN #2 removed the gloves, left the room and discarded items in…

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

Based on staff interview and facility document review, the facility staff failed to implement an antibiotic stewardship program for the facility. The findings include: There was no staff person designated as the infection preventionist during the current survey. On 12/15/21 at 2:00 p.m., the administrator stated the facility had not had a designated/qualified infection preventionist since 9/8/21. The administrator stated the registered nurse staff development coordinator (RN #1) would assist with review of the infection control program. The infection control program was reviewed on 12/16/21 and revealed no evidence of an antibiotic stewardship program. Infection tracking information was missing for January 2021 and February 2021. Three infections were listed on a tracking sheet for March 2021 but there was nothing documented regarding antibiotic use. Infection data from April 2021 through November 2021 included no individual infection reports indicating the date, resident name, diagnoses/contributing factors, nature of infection, date of onset, infectious organism, treatments…

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 designate a qualified infection preventionist for the facility. The findings include: On 12/15/21 at 2:00 p.m., the administrator was interviewed about the facility's designated infection preventionist. The administrator stated they currently had no staff person qualified and/or trained to be the infection preventionist. The administrator stated the previous infection preventionist was out of leave during August 2021, resigned and did not work after 9/8/21. The administrator stated they had not had an infection preventionist since 9/8/21. On 12/15/21 at 2:52 p.m., the regional nurse consultant (administration staff #3) was interviewed about an infection preventionist for the facility. The nurse consultant stated the regional vice president was actively working to fill vacancies in the facility. On 12/16/21 at 10:16 a.m., the director of nursing (DON) was interviewed about an infection preventionist. The DON stated no person was currently assigned as the infection preventionist but the quality…

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, group interview, staff interview and clinical record review, the facility staff failed to promote resident rights by confining residents to their rooms and not allowing communal activities for three of 17 residents in the survey sample. For over two weeks residents in the facility, including Resident #36, #158 and #37 were not allowed out of their rooms and had communal dining and activities canceled. The findings include: 1. Resident #36 was admitted to facility on 11/18/16 with a re-admission on [DATE]. Diagnoses for Resident #36 included schizoaffective disorder, bipolar disorder, depression, hypertension, osteoporosis, anxiety, chronic kidney disease and peripheral neuropathy. The minimum data set (MDS) dated [DATE] assessed Resident #36 with moderately impaired cognitive skills. On 12/14/21 at 11:43 a.m., Resident #36 was interviewed about quality of life in the facility. Resident #36 stated, I'm tired of this room. Resident #36 stated she was no longer allowed out…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, family interview, and facility document review, the facility staff failed to allow visitors for one of 17 residents, Resident #38. Findings were: Resident #38 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: Arthropathy, dementia, prostatic hyperplasia, hypertension, syncope and collapse. His admission MDS (minimum data set) with an ARD (assessment reference date) of 11/10/2021 assessed him as severely impaired with a cognitive summary score of 07. Initial tour of the facility was conducted on 12/14/2021 at approximately 10:45 a.m. There were no visitors observed in the facility. All the residents were observed in their rooms. A meal observation was conducted on 12/14/2021 at approximately 12:30 p.m. on the 300 unit of the facility. All residents were observed dining in their rooms, no residents were observed in the dining room. One of the staff members who was passing out trays was asked why all the residents were eating in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on group interview and staff interview, the facility staff failed to respond to identified concerns of the residents in the facility. Facility staff stated they were not made aware of concerns. Findings include: On 12/15/21 at 8:18 a.m., accompanied by licensed practical nurse (LPN) #3, the residents' shower room was inspected. The shower stall had dried feces on the floor not far from the drain. The floor and protective molding around the base of the shower were covered with black grime. Black stains were scattered on the wall grout from the handrails down to the floor. LPN #3 was interviewed at this time about the dirty shower stall. LPN #3 stated the aides were supposed to clean the shower after each use. On 12/15/21 at 3:00 p.m. a meeting with the resident council was conducted with eleven cognitive residents in attendance (Residents # 18, 5, 24, 30, 22, 32, 36, 49, 31, 158, and 11). Council minutes were reviewed prior to the meeting, which identified recurring issues from August 2021 through October…

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, group interview and staff interview, the facility staff failed to provide a clean shower environment on one of one nursing units. The residents' shower room was dirty with feces and grime. The resident council documented complaints about the dirty shower room since August 2021. The findings include: Review of resident council meeting minutes dated 8/13/21 revealed residents complained that the shower room was filthy and not routinely cleaned after use. The minutes documented linens were left in the floor and thrown into cabinets. Council minutes dated 10/26/21 documented ongoing concerns that the shower room remained dirty with soiled linen and dirty floors. On 12/14/21 at 3:00 p.m., an interview was conducted with eleven cognitively intact residents that routinely participated in the resident council (Residents # 18, 5, 24, 30, 22, 32, 36, 49, 31, 158, and 11). Residents during the group meeting stated the shower room was dirty and had been so for months. The residents stated they had expressed concerns during council meetings and there had been no response or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, group interview, and staff interview, the facility staff failed to provide an ongoing activity program in the facility as identified by eleven cognitively intact residents (Residents # 18, 5, 24, 30, 22, 32, 36, 49, 31, 158, and 11) during the group interview; and also failed to ensure resident specific activities for two of 17 residents, # 36 and # 158. Findings include: 1. An interview with the Resident Council was conducted in the facility 12/15/21 beginning at 3:00 p.m. with 11 cognitive residents (Residents # 18, 5, 24, 30, 22, 32, 36, 49, 31, 158, and 11). The residents were asked if the group met monthly, and if facility staff helped to arrange those meetings. The resident council president, Resident # 158 stated The activity director left 11/5/21. There has been no group meetings, or any activities, since she left. I did bingo a couple of weeks after she left, but I don't want to do that .some of us have been wanting to go outside and sit, but that hasn't happened either. 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, group interview, and resident interview the facility staff failed to employ a qualified activity professional for the facility. Findings include: The survey team entered the facility 12/14/21 at 10:45 a.m. During the initial tour, several cognitive residents stated there were no activities in the facility and the activity director had left. A resident council interview was conducted 12/15/21 beginning at 3:00 p.m. with eleven cognitively intact residents (Residents # 18, 5, 24, 30, 22, 32, 36, 49, 31, 158, and 11). The resident group voiced several issues about no activities in the facility, and also stated that since the activity director had left November 5th, 2021, no activities were being provided. During an interview 12/15/21 beginning at 4:30 p.m. with the administrator and corporate nurse consultant, the administrator confirmed the resident's concerns. She stated Yes, the activity director resigned 11/5/21. We did hire a replacement, but after being here 2 hours, they left and did not return. We currently are advertising, but have not had much…

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 follow physician orders for one of 17 residents, Resident #38. Resident #38 did not have physician ordered compression stockings applied. Findings were: Resident #38 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: Arthropathy, dementia, prostatic hyperplasia, hypertension, syncope and collapse. His admission MDS (minimum data set) with an ARD (assessment reference date) of 11/10/2021 assessed him as severely impaired with a cognitive summary score of 07. The clinical record was reviewed on 12/15/2021 at approximately 9:30 a.m. The physician order section contained the following order: 11/03/2021 Measure and apply compression stockings-apply every morning and remove at bedtime. At approximately 10:15 a.m. on 12/15/2021, Resident #38 was observed sitting in a chair in his room. He was asked if he was wearing compression stockings on his legs. He pulled up his pants legs and stated,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review the facility staff failed to provide restorative nursing to one of 17 residents in the survey sample, Resident #34. Resident #34 was care planned to receive restorative care for ambulation and active range of motion exercises six to seven days per week. The facility did not have a restorative program in place. Findings were: Resident #34 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: dementia, urine retention, with foley catheter heart failure with pacemaker, and most recently with ESBL (extended spectrum beta-lactamase) in his urine requiring IV antibiotics for fourteen days (beginning 12/08/2021) with the implementation of contact precautions. Resident #34's most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 11/05/2021. He was assessed as cognitively intact with a summary score of 15. The care plan for Resident #34 was reviewed on 12/14/2021 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview and staff interview, the facility staff failed to develop and implement a policy regarding food storage for food brought or delivered for residents. Four expired half-pint containers of Pet whole milk were observed in Resident #18's refrigerator located in her room and one expired 25 ounce bottle of Ocean Spray Cran-Apple juice and one expired 4.5 ounce bag of organic coconut bite chucks were observed in the nourishment refrigerator on Unit #1. The findings include: Resident #18 originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included, multiple sclerosis, hypertension, depression, dysphasia, type 2 diabetes, right hand/elbow contracture and right side hemiplegia/hemiparesis. The most recent minimum data set (MDS) dated [DATE] assessed Resident #18 as cognitively intact for daily decision making with a score of 15 out of 15. On 12/15/2021 at 9:15 a.m., Resident #18 was interviewed regarding the quality of life and quality of 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 resident interview, staff interview, clinical record review and facility document review, the facility staff failed to ensure a complete and accurate record for one of 17 residents in the survey sample, Resident #4. Findings include: a. Resident #4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hypothyroidism, chronic pain, chronic obstructive pulmonary disease, psychotic disorder, neuromuscular bladder, acquired absence of left leg above knee, depression, anxiety, congestive heart failure, hyperlipidemia, and non-pressure chronic right calf ulcer. The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #15 as cognitively intact for daily decision making with a score of 15 out of 15. On 12/14/2021 Resident #4 was interviewed regarding her quality of life and quality of care since admission to the facility. Resident #4 stated she had resided at the facility for approximately two and half years and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, the facility staff failed to implement protocols and provide accurate documentation of influenza and pneumonoccocal immunizations for three of five residents reviewed for vaccination compliance, Resident #25, #26, and #48. Resident #25, not immunized for pneumonia prior to admission, had no evidence the pneumonoccocal vaccine was offered, administered and/or refused. Resident #26 had conflicting documentation of her pneumonoccocal immunization status. Resident #48 had incomplete documentation concerning the influenza vaccine and no evidence the pneumonoccocal was offered and/or refused. The findings include: During the review of five residents for compliance with the facility's immunization protocols, three residents were identified with issues related to the administration of pneumonoccocal vaccine and incomplete documentation concerning vaccines. Resident #25's clinical record documented an admission assessment dated [DATE] stating…

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 notify the physician that compression stockings were not available for one of 17 residents, Resident #38. Findings were: Resident #38 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: Arthropathy, dementia, prostatic hyperplasia, hypertension, syncope and collapse. His admission MDS (minimum data set) with an ARD (assessment reference date) of 11/10/2021 assessed him as severely impaired with a cognitive summary score of 07. The clinical record was reviewed on 12/15/2021 at approximately 9:30 a.m. The physician order section contained the following order: 11/03/2021 Measure and apply compression stockings-apply every morning and remove at bedtime. At approximately 10:15 a.m. on 12/15/2021, Resident #38 was observed sitting in a chair in his room. He was asked if he was wearing compression stockings on his legs. He pulled up his pants legs and stated, You want to see my socks? He was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, the facility staff failed to review and revise the comprehensive plan of care for one of seventeen residents in the survey sample, Resident #55. Resident #55's plan of care was not revised with individualized goals and interventions regarding recreational activities. The findings include: Resident #55 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, schizophrenia, hypertension, osteoarthritis, neuralgia, major depressive syndrome, hypothyroidism, dysphasia, dementia, history of COVID-19 and chronic pain syndrome. The minimum data set (MDS) dated [DATE] assessed Resident #55 with short and long-term memory problems and severely impaired cognitive skills. The annual MDS dated [DATE] documented the resident was unable to respond to activity preference interview questions. Staff assessed the resident's preferences as bed bath, family involvement and listening to music. Resident #55's clinical record documented 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 a medication pass observation, staff interview and clinical record review, the facility staff failed to ensure a medication error rate of less than 5 percent. Three medication errors were observed out of 34 opportunities resulting in an 8.8% error rate. The findings include: 1. A medication pass observation was conducted on 12/14/21 at 4:32 p.m. with licensed practical nurse (LPN #2) administering medications to Resident #15. Among the medications administered were Flonase nasal spray 50 micrograms and Advair 500/50 aerosol. LPN #2 handed the resident the bottle of Flonase spray and two sprays were applied to each nostril. There was no instruction from LPN #2 prior to or during the administration of the Flonase. LPN #2 activated the dose of Advair with the inhaler device and the resident inhaled the dose. The resident did not rinse her mouth after the administration of the Advair. There was no prompting or instruction from LPN #2 to rinse and spit after the Advair administration. Resident #15's clinical record documented a physician's order dated 9/22/21 for Advair Diskus…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, clinical record review and complaint investigation, the facility staff failed to ensure a safe bed environment for one of 20 residents in the sample (Resident #87) and failed to ensure two resident accessible restrooms had a call system for safety. The findings include: 1. Resident #87 was admitted to the facility on [DATE] and discharged from the facility on 6/5/19. Diagnoses for Resident #87 included cerebral palsy, schizophrenia, anxiety disorder, intellectual disabilities, autistic disorder and dysphagia. The minimum data set (MDS) dated [DATE] assessed Resident #87 as non-verbal with short and long-term memory problems and severely impaired cognitive skills. A facility reported incident form dated 6/4/19 documented, Resident's sister + guardian reported on 6/3/19 that when she visited the resident on 6/1/19, she found him with a belt around torso, close to his neck. She also found belt around his legs. Resident was in bed at the time. 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 facility documentation, the facility staff failed to ensure expired medications were not readily available for distribution on 2 medication carts on unit two. Two bottles of Major Aspirin EC (enteric coated) - Analgesic, 325 (milligrams), 100 tablets had an expiration date of 12/18 (December 2018). Findings include: On 01/07/2020 at 4:00 p.m., an inspection of the medication carts was conducted with the registered nurse (RN #1) on unit two. Two bottles of Major Aspirin EC- Analgesic, 325 mg, 100 tablets were observed with an expiration date of 12/18 (December 2018). RN #1 was interviewed regarding who was responsible for checking dates on the medication carts. RN #1 stated all nurses who worked the medication carts were responsible for checking the dates. On 01/07/2020 at 4:09 p.m., the director of nursing (DON) was asked for a policy on medication storage and expiration of medications. The DON stated the expectation was for each nurse who worked the medication cart to check the expiration dates. A review of the policy Medication Expiration…

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 employee a qualified dietary manager. The dietary manager working since 2017 without a full-time registered dietitian, had no education and/or certifications for safe food service management. The findings include: As part of the kitchen inspection tasks, the qualifications of the facility's dietary manager were requested from the administrator on 1/8/20. On 1/8/20 at 1:55 p.m., the administrator stated the dietary manager was not certified. The administrator stated the dietary manager was hired as the kitchen manager on 10/23/17 and took the class for dietary certification and a food safety class but did not pass either class. The administrator stated she started work at the facility permanently in October 2019 and the dietary manager was taking the certification class at that time. The administrator stated she did not realize the manager did not pass and had no certifications about food safety. On 1/8/20 at 2:10 p.m., the administrator was interviewed again about any further qualifications of the…

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

Based on observation, staff interview and facility document review, the facility staff failed to store and distribute food in a sanitary manner. The temperature of pureed beef stored/served from the kitchen's steam table was held at an unsafe temperature. The dishwasher was operated with wash/rinse temperatures below the manufacturer's recommended and/or minimum temperature and the sanitizer concentration above the recommended range. The findings include: a) On 1/7/20 at 12:00 p.m., the meal service from the main kitchen's steam table was observed, accompanied by the dietary manager (other staff #3). The dietary manager checked the temperature of each hot food item on the steam table. The temperature of the pureed beef was measured at 120 degrees (F). The dietary manager stated the temperature was low but did not remove the pureed beef from the steam table. On 1/7/20 at 12:30 p.m., the dietary manager was interviewed about the pureed beef held on the steam table at 120 degrees. The dietary manager stated she did not think there was enough left in the container so she did not remove…

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 proper operation of the facility's only dishwasher. The dishwasher wash/rinse temperatures were below the recommended range and the sanitizer concentration was higher than recommended. The findings include: On 1/7/20 at 12:33 p.m., accompanied by the dietary manager, the chemical low temperature dishwasher was observed for two wash/rinse cycles. The outer surfaces of the dishwasher were covered with heavy, white, scaly residue. The temperature gauge on the first run was observed at 104 degrees (F) and the second run was at 118 degrees (F). The dietary manager was interviewed at this time about the expected temperatures and stated the wash/rinse was supposed to be 140 degrees. The dietary manager also tested the chlorine sanitizer concentration with a test strip. The test strip was dark purple indicating 200 parts per million (ppm). The dietary manager stated the temperature gauge hardly moves when they wash dishes. The dietary manager stated their dishwasher vendor service was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate minimum data set (MDS) for one of 20 residents in the survey sample. Resident #73's significant change MDS dated [DATE] included no assessment regarding preferences for customary routines and activities. The findings include: Resident #73 was admitted to the facility on [DATE] with diagnoses that included metastatic prostate cancer, anemia, anxiety, high blood pressure, arthritis and history of pathological rib fractures. The MDS dated [DATE] assessed Resident #73 with severely impaired cognitive skills. Resident #73's clinical record documented a MDS assessment for a significant change in status dated 12/12/19. All categories in section F for assessment of the resident's preferred routines and activities were incomplete. The resident interview questions were marked with dashes and the staff assessment (section F0700) was blank. On 1/8/20 at 1:25 p.m., the registered nurse MDS coordinator (RN #3) was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and complaint investigation, the facility staff inaccurately completed a preadmission screening and resident review (PASARR) after admission for one of twenty residents in the survey sample. Resident #87's PASARR was completed five days after his admission and failed to include a diagnosis of a serious mental illness (schizophrenia). The findings include: Resident #87 was admitted to the facility on [DATE] and discharged from the facility on 6/5/19. Diagnoses for Resident #87 included cerebral palsy, schizophrenia, anxiety disorder, intellectual disabilities, autistic disorder and dysphagia. The minimum data set (MDS) dated [DATE] assessed Resident #87 as non-verbal with short and long-term memory problems and severely impaired cognitive skills. Resident #87's clinical record documented admission records indicating diagnoses of schizophrenia, anxiety disorder, intellectual disabilities and autism. These diagnoses were documented on the resident's face sheet and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to provide nail care for one of 20 residents in the survey sample. Resident #73 was observed with long, dirty, jagged finger and toenails. The findings include: Resident #73 was admitted to the facility on [DATE] with diagnoses that included metastatic prostate cancer, anemia, anxiety, high blood pressure, arthritis and history of pathological rib fractures. The MDS dated [DATE] assessed Resident #73 with severely impaired cognitive skills. This MDS documented the resident was totally dependent upon one person for hygiene. On 1/7/20 at 2:30 p.m., Resident #73 was observed in bed with his feet elevated on a pillow. The resident's fingernails were long and jagged. The left thumbnail had a V shaped cut in the center of the nail. A black substance was under the nails on the left hand. The resident's toenails were long and rough, extending beyond the end of his toes. On 1/8/20 at 9:00 a.m., Resident #73'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility failed for two of 20 residents in the survey sample, Residents # 33 and 83, to ensure the residents did not have a PRN (as needed) psychotropic medication ordered for greater then 14 days, and without a stop date specified. Both Resident # 33 and 83 had a PRN order for Ativan that did not have a stop date. The findings include: 1. Resident # 33 in the survey sample was admitted to the facility on [DATE] with diagnoses that included renal insufficiency, gastroesophageal reflux disease, hypertension, diabetes mellitus, hyperlipidemia, cerebrovascular accident, anxiety disorder, depression, bipolar disorder, and schizophrenia. According to the most recent Minimum Data Set (MDS), an Annual with an Assessment Reference Date (ARD) of 11/5/19, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 14 out of 15. Resident # 33 had a medication order, dated 11/20/19, for Ativan Injectable…

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.