Staunton Post Acute & Rehabilitation

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 promote a safe, drug free environment for one of eleven residents in the survey sample (Resident #1).The findings include:Facility staff failed to promptly implement interventions following reports of marijuana and a chemical smell in Resident #1's room on 1/13/25. During an emergency room visit for seizures, Resident #1 tested positive for marijuana and methamphetamine following suspected illicit drug use by the resident's roommate (Resident #5). Resident #1 (R1) was admitted to the facility with diagnoses that included traumatic hemorrhage of cerebrum, post-traumatic hydrocephalus, epilepsy, dementia, history of substance abuse, depression, hypertension, dry eye syndrome and cognitive communication deficit. The minimum data set (MDS) dated [DATE] assessed R1 as cognitively intact. R1's clinical record documented no drug/alcohol use since July 2021.Resident #5 (R5) was admitted to the facility with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for two of eleven residents in the survey sample (Residents #6 and #10).The findings include:1. Documented neurological checks following a fall with injury were not included in Resident #6's clinical record. Resident #6 (R6) was admitted to the facility with diagnoses that included dementia with behavioral disturbance, anxiety, depression, gastroesophageal reflux, insomnia, cataracts, and cognitive communication deficit. The minimum data set (MDS) dated [DATE] assessed R6 with severely impaired cognitive skills. R6's clinical record documented the resident had an unwitnessed fall on 3/4/25. A nursing note dated 3/4/25 documented the resident was found on the floor in her room. This note documented physical and neurological checks were completed. The resident was observed with a large hematoma on the forehead and bruising on the upper bridge of the nose with a small break in skin. This…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility's records, interviews, and policy review, the facility failed to maintain a legionella prevention program to protect residents from contracting water-borne pathogens as part of the facility's infection prevention and control program. This failure had the potential to affect all residents residing in the facility. Additionally, the facility failed to ensure staff follow infection prevention practices for hand hygiene during dining observation. This has the potential for facility wide spread of infection and/or contamination. Findings: 1. Review of the facility's policy revised July 2017 and titled Legionella Water Management Program revealed .Facility is committed to the prevention, detection and control of water-borne contaminants, including legionella . 1. As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team. 2.The water management team will consist of at least the following personnel: 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, facility document review, resident interview and staff interview, the facility staff failed to provide a clean, homelike environment on three of four living units. The findings include: The shower rooms on 2 new west, 2 west side, and 3 new west had black stains along caulking lines on/around the shower stall seats, black stains under the stall floor mats, missing drain covers, and deteriorated flooring at the thresholds to the stalls. On 6/12/23 at 4:22 p.m., accompanied by licensed practical nurse (LPN) #1, the shower room on 2 new west unit was inspected. There were three shower stalls. The caulked area around the seat base, back, and flooring was black on each of the three seats. The entrances to the shower stalls had deteriorated flooring and black stains around the safety strips. The shower stall floors had black stains under and around the floor mats and safety strips. LPN #1 stated at this time that certified nurses' aides (CNAs) disinfected the shower stalls after each resident and housekeeping was responsible for daily cleaning of the shower rooms. On…

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

Based on observation, facility document review, and staff interview, the facility staff failed to store, prepare and distribute food in a sanitary manner. The findings include: 1. Food preparation/service equipment and the overall kitchen environment were dirty. Undated, out of date, and unsealed food items were stored in the refrigerator and available for use. The dishwasher was dirty and operated by staff members not using hair restraints. Stainless steel serve pans were stored nested and wet. On 6/12/23 at 11:05 a.m., the initial tour of the main kitchen was conducted accompanied by the cook (other staff #2). Two dietary aides (other staff #14, #15) were observed operating the dishwasher with no hair restraints in use. The dishwasher had crumbs and food particles on the top surface of the machine along with streaks of a white/orange colored substance down the front of the dishwasher panels. There was an empty, broken spray bottle on top of the machine. The hand sink near the dishwashing area was dirty with brown stains in the sink bowl. The dry storage room had a five-gallon…

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

Based on observation and staff interview, the facility staff failed to ensure proper function of the freezer in the main kitchen. The findings include: On 6/12/23 at 11:30 a.m., accompanied by the cook (other staff #2), the walk-in freezer in the main kitchen was inspected. Upon opening the door, there was water and ice on the floor, at the threshold to the unit. Water was noted dripping along the top of the freezer door. There was frozen condensation visible on the entire ceiling of the freezer. The cook was interviewed at this time about the water/ice. The cook stated that the freezer had been worked on but not repaired and that the water/ice had been there for weeks. On 6/13/23 at 11:45 a.m., the maintenance director (other staff #4) was interviewed about the freezer with condensation/ice. The maintenance director stated that he thought the kitchen manager had contacted an outside vendor for repair. The maintenance director stated that he was not sure if the vendor worked on the freezer or the outcome of the repair. The maintenance director denied knowledge of a work 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 interview and record review, the facility failed to ensure Power of Attorney (POA) for healthcare document was located in the medical record for one sampled resident reviewed for advance directives (Resident (R)11). This failure had the potential for an unauthorized person to enter a Do Not Resuscitate (DNR) directive for the resident. Findings include: Review of R11's POA dated [DATE] revealed R11's daughter (F11) and another individual appointed as attorneys-in-fact by R11. The document revealed in part the power to act on R11's behalf as follows: .1.To demand, hold and generally deal with any monies, securities and other property which now or hereafter belongs to me, or in which I may have interest. 2. To sign any note, check, security or other instrument, negotiable or nonnegotiable, whether or not the check or other instrument is drawn to the order of my Attorney, for deposit, discount, collection or otherwise. 3. To write checks upon, or otherwise withdraw, all funds or account balances now or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility failed to ensure a significant change assessment was completed for one of 25 residents. Resident #61 did not have a significant change assessment completed, after a functional decline in ADL's (Activities of Daily Living). The Findings Include: Diagnoses for Resident #61 included: Dementia, schizophrenia, anxiety, Alzheimer's disease and malignant neoplasm. The most current MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 5/31/23. Resident #61 was assessed with short and long-term memory problems and as severely cognitively impaired. On 6/13/23, a comparison of Resident #61's quarterly MDS dated [DATE] and an annual MDS dated [DATE] indicated (in section G) Resident #61 had a decline in the following: Bed mobility from extensive with one person assist to total dependence with two person assist, dressing from extensive assist to total dependence one person assist, eating from extensive assist to total…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of facility policy, the facility failed to ensure the required Level II Preadmission Screening and Resident Review (PASRR) was completed for one of 24 residents (Resident (R) 4). Potentially, this impedes R4 from receiving the appropriate treatments/services for mental illness. Findings include: Review of facility's undated document titled ''Virginia Long-Term Services and Supports (LTSS) Screening, Preadmission Screening and Resident Review (PASRR) Policy'' reads in part, ''Level 2 Referral When a resident has a positive Level I screening, the facility will initiate the Level II screening request by faxing (do not e-mail PHI [protected health information]) the following materials to the state-designated authority (Ascend): Level 1 Screening (DMAS-95), indicating if the resident has a serious mental illness, intellectual disability, or related condition .'' Review of R4's ''admission Record'' revealed that R4 was admitted to the facility on [DATE] with diagnoses that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and review of facility policy, the facility failed to revise the comprehensive care plan to ensure accuracy for two of 21 residents (Resident (R) 89 and R54) reviewed for care plan revision. Specifically, the facility failed to revise R89's care plan to address weight loss and failed to revise R54's care plan to identify use of a catheter safety strap. Findings include: Review of the undated facility policy titled Care Planning - Comprehensive Person-Centered, revealed, A person centered comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing . needs shall be developed for each resident . comprehensive care plan means an interdisciplinary communication tool developed after completion of a comprehensive MDS [Minimum Data Set] . The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: when the desired outcome is not met, when goals, needs and preferences change . 1. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, record review, and review of facility policy, the facility failed to ensure one of one resident (Resident (R)54) reviewed for catheter care was wearing a securement device. This failure increased the potential for the catheter to become dislodged or cause injury. Findings include: Review of facility's undated policy titled ''Urinary Catheter Care'' read in part'' Changing Catheters: indwelling catheters will be changed in accordance with physician/ nurse practitioner's orders by a licensed nurse. Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.)'' During an observation on 06/14/23 at11:05 AM of R54's catheter care, it was noted R54's catheter was not secured to her upper thigh area. R54's catheter was draining yellow color urine with slight amount of sediment noted in the tubing. Review of R54's ''admission Record'' located in the resident's…

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

Based on observation, facility document review and staff interview, the facility staff failed to properly dispose of garbage/refuse. The findings include: On 6/12/23 at 11:30 a.m., accompanied by the cook (other staff #2), the garbage disposal area/dumpsters were observed. The doors on the two dumpsters were open with visible/exposed refuse in both containers. On the ground around and in front of the dumpsters were several blue gloves, a plastic drink bottle, an empty trash bag, and small trash items/debris. The cook stated that garbage was supposed to be placed inside the dumpsters and the doors kept closed. On 6/13/23 at 11:45 a.m., the regional dietary director (other staff #3), serving as interim kitchen manager, was informed about the open dumpsters with trash/debris on the ground. The regional dietary director had no comment about the dumpsters but stated that kitchen staff were responsible for daily cleaning and disposal of waste. The facility's policy titled Food Safety - Director of Dinging Services' Responsibilities (Chapter 4: Sanitation and Infection Control 4-3)…

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 staff interview and facility document review, the facility staff failed to ensure a registered nurse was onsite at the facility for 8 consecutive hours on 06/05/2022. Findings were: The facility as worked schedule for the week of the survey and the week prior to the survey. On 06/01/2022, 06/03/2022, and 06/05/2022, there was no RN (registered nurse) scheduled. CNA (certified nursing assistant) #1 who did staffing was interviewed on 06/08/2022 at 10:00 a.m. She stated, The MDS (minimum data set) nurses are RNs and they are here for at least 8 hours a day Monday through Friday, so they were here on June 1st and June 3rd .they aren't on the schedule but they are in the building and here if needed .June 5th was a Sunday so there was not an RN here that day. She was asked why no RN was scheduled. She stated, There are only three PRN (as needed) nurses who work here .two are on nights, one is on dayshift. They are required to work at least 20 hours per month, 1 weekend per month and one holiday per year. There are no full time RNs here right now .we are trying to hire some . 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 review of employee files, facility policy review, and staff interview, the facility failed to implement their policy for Abuse, neglect, and Exploitation. Six of 25 employee files reviewed did not contain either a criminal record check, a sworn statement, or references, The findings were: Twenty-five employee files were reviewed on 06/08/2022 beginning at approximately 3:30 p.m. The files were reviewed for sworn statements, criminal background checks, license verification, and references. Four of the files reviewed did not have a criminal background check completed, three of the files did not have sworn statements, and two of the files did not have reference checks. The six files included the following: 1. HR (human resources) Coordinator/Payroll: Hired 05/27/2021. No criminal record check. 2. LPN (Licensed practical nurse): Hired 03/09/2021. No criminal record check. 3. LPN/MDS (Minimum data set): Hired 12/01/2020. No sworn statement, no criminal record check, and no references. 4. NA (nursing assistant): Hired 10/13/2020. No reference checks. 5. Activities: Hired…

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 provide gastrostomy care as ordered for one of thirty-one residents in the survey sample, Resident #23. A physician's order to cleanse and apply a daily dressing to Resident #23's gastrostomy site was not implemented for over three months. The findings include: Resident #23 was admitted to the facility with diagnoses that included cerebral infarction, dysphagia with gastrostomy, chronic pulmonary embolism, severe protein-calorie malnutrition, history of COVID-19, dementia, anemia and diaphragmatic hernia. The minimum data set (MDS) dated [DATE] assessed Resident #23 with severely impaired cognitive skills. This MDS listed the resident received 51% or more of total caloric intake through a feeding tube. Resident #23's clinical record documented a physician's order dated 3/2/22 to cleanse the resident's PEG (percutaneous endoscopic gastrostomy) with wound cleanser and apply a drain sponge each day for care of the PEG…

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 complaint investigation, clinical record review, facility document review, and staff interview, the facility failed to ensure three of 31 residents in the survey sample, Residents # 169, 24, and 168 were free from abuse. Resident # 169 was physically abused and Residents # 24 and 168 were verbally abused by a facility staff member. The findings include: 1. Resident # 169 was admitted to the facility with diagnoses that included Non-Alzheimer's Dementia, dementia with behavioral disturbance, anxiety disorder, depression, hypothyroidism, Vitamin-D deficiency, dysphagia, and history of COVID-19. According to a Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/15/2022, the resident was unable to respond to questions and be assessed under Section C (Cognitive Patterns). Under Section G (Functional Status), the resident was assessed as totally dependent with one person physical assist for eating. Review of the Progress Notes in the resident's closed Electronic Health Record (EHR)…

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 develop a comprehensive care plan for one of thirty-one residents in the survey sample, Resident #23. Resident #23 had no care plan regarding care of a gastrostomy. The findings include: Resident #23 was admitted to the facility with diagnoses that included cerebral infarction, dysphagia with gastrostomy, chronic pulmonary embolism, severe protein-calorie malnutrition, history of COVID-19, dementia, anemia and diaphragmatic hernia. The minimum data set (MDS) dated [DATE] assessed Resident #23 with severely impaired cognitive skills. This MDS listed the resident received 51% or more of total caloric intake through a feeding tube. Resident #23's clinical record documented a physician's order dated 3/2/22 to cleanse the resident's PEG (percutaneous endoscopic gastrostomy) with wound cleanser each day along with a drain sponge. The record documented a physician's order dated 3/15/22 for bolus administration of Osmolite…

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 thirty-one residents in the survey sample, Resident #72. Notification was not made to the provider regarding weight gain for Resident #72 as ordered by the physician. The findings include: Resident #72 was admitted to the facility with diagnoses that included dementia, ventricular fibrillation, tachycardia, cervical disc disorder, COPD (chronic obstructive pulmonary disease), hypertension, chronic kidney disease, heart failure, atrial fibrillation, depression, anxiety, sleep apnea and benign prostatic hyperplasia. The minimum data set (MDS) dated [DATE] assessed Resident #72 with severely impaired cognitive skills. Resident #72's clinical record documented a physician's order dated 5/18/22 for daily weights (same scale before breakfast) with instructions to notify the nurse practitioner of weight gain greater than 2 pounds (lbs.) in one day or 5 lbs. in one week. Resident #72's clinical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review the facility staff failed to implement interventions to prevent weight loss for one of 31 residents in the survey sample, Resident #117. Findings include: Resident #117's diagnoses included, but were not limited to: cerebral infarction, Vitamin D deficiency, localized edema, pre-diabetes, vascular dementia, insomnia, and major depression. The most recent MDS (minimum data set) was a quarterly assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 3 indicating the resident had severe impairment in daily decision making skills. The resident was assessed as requiring supervision with one person physical assistance for eating. Resident #117's weight was documented as 163.0 pounds. The resident was also coded as having weight loss (not physician prescribed). On 06/07/22 at 12:48 PM, Resident #117 was observed eating in the dining room, feeding himself. The resident ate 100 % of his meal. When asked if the food was good and…

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

Based on observation, staff interview, and facility document review, the facility staff failed to ensure drugs and biological's were labeled appropriately on one of two nursing units. The facility failed to appropriately label a multi- dose vial of Tuberculin on unit 3 New West. Findings include: On 06/08/22 at 8:41 AM, the 3 New [NAME] unit medication storage refrigerator was observed with license practical nurse (LPN #3, unit manager). The refrigerator had one vial of tuberculin medication in it's original box. The vial of Tuberculin had been opened with approximately half of the medication remaining in the vial. Neither the vial of Tuberculin, nor the original box had an open date, indicating when the medication had been opened/accessed. LPN #3 stated the vial of Tuberculin should have an open date on it and should be discarded after 30 days of being opened, and since there was no open date it would be discarded. A policy titled, Storage and Expiration Dating of Medications documented, .Once any medication or biological package is opened .follow manufacturer/supplier guidelines…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility document review, facility staff failed to store drugs and biologicals appropriately on two of four units in the facility. Findings included: Medication storage on 2-New [NAME] was observed on [DATE] at 8:10 a.m. In the locked, medication refrigerator behind the nurse's desk was a blue, plastic box with a black handle, not permanently affixed. The box was closed with a green zip tie. Labeling on the box included, Lorazepam Box. LPN (licensed practical nurse) #2, the unit manager, was interviewed regarding the box and verified the box did contain Lorazepam. LPN #2 stated, It just showed up on our unit. They [pharmacy] said [physician name] just wanted it in the building in case we needed it. We have never opened it. In a locked cabinet behind the nurse's desk, where the stat medication boxes were stored, was a red, plastic box with a black handle, not permanently affixed. The box was closed with a green zip tie and a small combination lock. Enclosed in the box…

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 complete a valid Durable Do Not Resuscitate Order (DDNR) for one of 34 residents in the survey sample. No resident representative signed the state approved DDNR form for Resident #122. The findings include: Resident #122 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE]. Diagnoses for Resident #122 included end stage renal disease with hemodialysis, schizoaffective disorder, dementia, hypotension, dysphagia, anemia, neurocognitive disorder and gastroesophageal reflux disease. The minimum data set (MDS) dated [DATE] assessed Resident #122 as cognitively intact. Resident #122's clinical record documented a DDNR order form dated 1/16/20 indicating the resident was incapable of making an informed decision about providing, withholding, or withdrawing a specific medical treatment or course of medical treatment. This form also documented the patient had not executed a written…

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 CCP (comprehensive care plan) was reviewed and revised for two of 34 residents in the survey sample, Resident #66 and Resident #86. Findings include: Resident #86 was admitted to the facility on [DATE] with diagnoses that included diabetes II, muscle weakness, dementia without behavioral disturbance, depression, Alzheimer's disease, adult failure to thrive, hypertension and venous insufficiency. The most recent minimum data set (MDS) dated [DATE] was the annual assessment and assessed Resident #86 as severely impaired for daily decision making with a score of 7 out of 15. Resident #86's clinical record was reviewed on 02/10/20. Observed on the physician order sheet was the following order: 10/14/19: TX (treatment) - Compression Stockings for Bilateral Lower Extremities Ankle High. A review of Resident #86's care plans did not document the orders for the compression stockings. On 02/10/20 at 4:05 p.m., the MDS coordinator…

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 follow physician orders for the use of compression stockings for one of 34 in the survey sample, Resident #86. The findings include: Resident #86 was admitted to the facility on [DATE] with diagnoses that included diabetes II, muscle weakness, dementia without behavioral disturbance, depression, Alzheimer's disease, adult failure to thrive, hypertension and venous insufficiency. The most recent minimum data set (MDS) dated [DATE] was the annual assessment and assessed Resident #86 as severely impaired for daily decision making with a score of 7 out of 15. Resident #86's clinical record was reviewed on 02/10/20. Observed on the physician order sheet was the following order: 10/14/19: TX (treatment) - Compression Stockings for Bilateral Lower Extremities Ankle High. A review of Resident #86's treatment administration record (TAR) documented the application of the stockings dated 02/10/20. On 02/10/20 at 8:45 a.m.,…

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 proper treatment and assistive devices to maintain vision for one of 34 residents, Resident #66. Resident #66 was assessed and care planned for needing glasses, but the resident was not provided visual aids to assist and/or maintain vision. Findings include: Resident #66 was admitted to the facility on [DATE]. Diagnoses for this resident included, but were not limited to: dementia with behavioral disturbances, high blood pressure, Alzheimer's dementia, atrial fibrillation, depression and anxiety disorder. The most recent MDS (minimum data set) was a quarterly assessment dated [DATE]. This MDS assessed the resident as having short and long term memory impairment with severe impairment in daily decision making skills. This MDS also assessed the resident as having highly impaired vision, in addition to not having corrective lenses. A significant change assessment dated [DATE] was reviewed for comparison and 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 resident interview, staff interview, and clinical record review, the facility staff failed to provide supervision to prevent accidents for one of 34 residents, Resident #51. Kitchen staff opened a locked door giving Resident #51 access to the outside. The door locked behind her and she was unable to reenter the building. Findings were: Resident #51 was admitted to the facility on [DATE] with the following diagnoses, including, but not limited to: Cellulitis, Lupus, Chronic pain syndrome, hepatitis C, emphysema, and lung cancer. The admission MDS (minimum data set) with an ARD (assessment reference date) of 12/09/2019, assessed Resident #51 as cognitively intact with a summary score of 15. The clinical record was reviewed on 02/09/2020. The following information was observed in the nurse's notes section: 11/28/2019 6 A [6:00 a.m.] Resident rested will in bed .s/p [status post] fall this shift Pt [patient] reports she used her tight hand to break her fall. No skin break. Pt wrapped her need [sic-knee] per…

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 interventions were implemented to prevent weight loss for one of 34 residents in the survey sample, Resident #22. Resident #22 was not weighed for three months by facility staff. A weight was obtained on 02/11/20 and the resident had lost 5.45 % since the last weight completed in November 2019 (3 months). Findings include: Resident #22 was admitted to the facility on [DATE]. Diagnoses for this resident included, but were not limited to: dementia, anxiety disorder, depression, psoriasis, and hypothyroidism. The most recent MDS (minimum data set) was a quarterly assessment dated [DATE]. This MDS assessed the resident with short and long term memory impairment with severe impairment in daily decision making skills. The resident was assessed as requiring extensive assistance of one staff member for most all ADL's (activities of daily living), including consuming meals. The resident resident's height and weight on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, family interview, clinical record review, facility document review, and in the course of a complaint investigation, the facility staff failed to ensure that medication (Methadone) was available for administration for one of 34 residents, Resident #48. Findings were: Resident #48 was originally admitted to the facility on [DATE]. His current diagnoses included, but were not limited to: Dementia, Parkinson's Disease, Chronic Pain Syndrome, Cerebral Atherosclerosis, Hypothyroidism, and Depressive Disorder. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of [DATE], assessed Resident #48 as cognitively intact with a summary score of 14. The complainant was interviewed on [DATE] at approximately 10:55 a.m., she voiced concerns that the pharmacy had not delivered Resident #48's methadone. She stated, He gets it twice a day and he hasn't had it since yesterday morning. At approximately 11:15 a.m., LPN (licensed practical nurse) #11 was interviewed. She was asked if…

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 and pour observation, clinical record reviewed, staff interview and facility document review, the facility staff failed to ensure a medication error rate of less than 5% (five percent). The medication pass and pour observation consisted of 25 (twenty- five) medication opportunities with four medication errors, resulting in a medication error rate of 16% (sixteen percent). Findings include: On 02/09/20 at 04:19 PM, a medication pass and pour observation was conducted on Unit 3 NW (NorthWest) with LPN (Licensed Practical Nurse) #7. LPN #7 used hand sanitizer and began to prepare medications for Resident # 138. Medications prepared included the following: (1) Three Tegretol 100 mg (milligram) tablets for a total of 300 mg. (2) One calcium with vitamin D 600/400 mg tablet. (3) One ethosuximide 250 mg tablet. (4) One pravastatin 20 mg tablet. The medication pills were counted and verified with LPN #7; a total of six pills were counted. Resident #138 took the medications whole with water. LPN #7 cleansed his hands and exited the room. On 02/09/20 at 4:35 PM, LPN…

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, clinical record review, resident interview, staff interview, the facility staff failed, for two of 34 residents in the survey sample (Residents # 59 and 137), to provide routine and emergency dental services. Resident # 137 lost a natural tooth and was not provided with emergency dental services to treat the loss. Resident # 59 was not provided routine dental care for tooth decay and a broken partial plate. The findings include: 1. Resident # 137 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses that included coronary artery disease, deep vein thrombosis, heart failure, hypertension, cirrhosis, diabetes mellitus, gastroesophageal reflux disease, Non-Alzheimer's dementia, chronic obstructive pulmonary disease, and palliative care. According to an Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/22/2020, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15…

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, facility document review and staff interview, the facility staff failed to store food in a sanitary manner. Two large pans of plain cake were stored in the walk-refrigerator uncovered. The findings include: On 2/9/20 at 2:23 p.m., accompanied by a dietary employee (other staff #5), the food items in the walk-in refrigerator were inspected. Stored near the bottom of a portable food tray rack were two large pans of plain cake. The cakes were not covered or sealed to protect against contamination. The dietary employee was interviewed at the time of the observation about the uncovered cakes. The dietary worker stated she made the cakes yesterday (2/8/20) for use tomorrow (2/10/20). The dietary worker stated the cakes were usually covered with another pan to protect them from contamination. On 2/9/20 at 2:45 p.m., the dietary manager (other staff #6) was interviewed about the cakes stored in the refrigerator without a seal or cover. The dietary manager stated food items were supposed to be covered and dated when made. The facility's policy titled Food Storage: Cold…

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, clinical record review, resident interview, and staff interview, the facility staff failed, for one of 34 residents in the survey sample (Resident # 137), to maintain a complete and accurate clinical record. Facility staff failed to document Resident # 137's loss of a natural tooth in the clinical record. The findings were: Resident # 137 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses that included coronary artery disease, deep vein thrombosis, heart failure, hypertension, cirrhosis, diabetes mellitus, gastroesophageal reflux disease, Non-Alzheimer's dementia, anxiety disorder, depression, bipolar disorder, chronic obstructive pulmonary disease, and palliative care. According to an Annual Minimum Data Set with an Assessment Reference Date of 1/22/2020, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. At 2:30 p.m. on 2/9/2020, Resident #137 was interviewed. While…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, facility document review, staff interview and clinical record review, the facility staff failed to follow infection control practices during dressing changes for two of 34 residents in the survey sample (Residents #122 and #112). The findings include: 1. Resident #122 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE]. Diagnoses for Resident #122 included end stage renal disease with hemodialysis, schizoaffective disorder, dementia, hypotension, dysphagia, anemia, neurocognitive disorder and gastroesophageal reflux disease. The minimum data set (MDS) dated [DATE] assessed Resident #122 as cognitively intact. On 2/11/20 at 9:40 a.m., licensed practical nurse (LPN #14) was observed performing a dressing change to the pressure ulcer on Resident #122's left hand. LPN #14 placed a plastic bag with dressing supplies on Resident #122's bed covers. LPN removed supplies (gauze pads, bottle of Dakin's cleansing solution, scissors) from the bag and placed them directly…

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.