Potomac Falls Health & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility staff failed to ensure the one resident (Resident #93's) Dialysis communication book was updated timely during Dialysis treatments in a survey sample of 43 residents. The findings included: Resident #93 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses which included displaced fracture of first cervical vertebra, osteoporosis without current pathological fracture, diabetes, hypothyroidism, stage 5 chronic kidney disease, dementia without behavioral disturbance, type III traumatic spondylolisthesis of seventh cervical vertebra and dependence of renal dialysis. Resident #93 was involved in an accident while being transported to her dialysis appointment on 11/19/21. Resident #93's dialysis communication book had not been updated since 11/19/21. An Annual Minimum Data Set (MDS) dated [DATE] assessed this resident in the area of Speech, Vision and Hearing as being able to understand others. In the area of Cognitive Patterns this resident was assessed in 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 interviews, and review of the facility's policy, the facility staff failed to store food under sanitary conditions. The finding included; On 12/01/21 at approximately 11:00 AM., during a follow up visit to the kitchen with OSM/CDM (Other Staff Member/Certified Dietary Manager) #5. An inspection of the dairy cooler was made. Located inside of the dairy cooler were multiple cartons of milk and spilled milk with a strong odor. The CDM stated, A staff member normally keep the cooler clean but due to the Thanksgiving holiday it was not cleaned. He usually cleans it once a week. On 12/02/21 at approximately 3:20 p.m., the above findings were shared with the Administrator, The Corporate Consultant, The Social Services Coordinator and The Corporate Clinical Services Specialist. An opportunity was offered to the facility's staff to present additional information but no additional information was provided.

Based on observation, staff interview and facility documentation review, the facility staff failed to maintain a complete and accurate clinical record for 1 of 45 residents (Resident #74) in the survey sample. The findings included: The facility staff failed to ensure Resident #74's Medication Administration Record (MAR) was accurate for the administration of a scheduled pain medication Pregabalin. Resident #74 was admitted to the nursing facility on 10/18/21. Diagnosis for Resident #74 included but not limited to Fibromyalgia and fracture of right fibula. Resident #74's Minimum Data Set (MDS - an assessment protocol) an annual assessment with an Assessment Reference Date of 10/23/21 coded Resident #74's Brief Interview for Mental Status (BIMS) scored a 13 out of a possible score of 15 indicating no cognitive skills for daily decision-making. Resident #74's person-centered care plan with a revision date 10/25/21 documented resident has pain or potential for pain due to recent fall with fracture and skin breakdown. The goal set for the resident by the staff is to maintain comfort…

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 review of facility documents, the facility's staff failed to have the call bell accessible and functional for resident's use. For 1 of 45 residents (Resident #47), in the survey sample. The Findings included; Resident #47 was originally admitted to the facility [DATE] and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Fracture of Upper and Lower End of the Right Fibula and Hypertensive Heart Disease with Heart Valve. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #47cognitive abilities for daily decision making were intact. In section G(Physical functioning) the resident was coded as requiring extensive assistance one person assistance with bed mobility, dressing eating, toilet use, personal hygiene and bathing.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, medical record review and facility documents the facility staff failed to provide for the accommodation of needs to maintain independence and to ensure the safety for 1 of 40 residents in the survey sample, Resident #154. For Resident #154, he facility staff failed to ensure the call bell was placed within reach. The findings included: Resident # 154 was a [AGE] year old admitted to the facility on [DATE] with diagnoses to include contusion of the lung, multiple fractures of ribs S/P fall, subsequent encounter for fracture with routine healing, Type 2 Diabetes Mellitus, Epilepsy, unsteadiness on feet, lack of coordination, muscle weakness, frontal lobe and executive deficit. The admission Minimum Data Set (MDS) had not been due/completed. Information was gathered from the Resident's baseline Care Plan. Focus: Name (Resident # 154) has an ADL (Activities of Daily Living) Demonstrates the need for ADL assistance r/t (related to) multiple rib fracture, s/p (status post)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, clinical record review and facility documentation review, the facility staff failed to notify one of 40 residents (Resident #19) of a change in roommate. The facility staff failed to inform Resident #19 in advance, of a roommate change of a resident that was transferred to his room from another unit in the facility. The findings included: Resident #19 was admitted to the nursing facility on 7/23/13 with diagnoses that included paraplegia. The most recent Minimum Data Set Assessment was an annual assessment dated [DATE] and coded the resident with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated no cognitive impairment. During an interview with Resident #19 on 10/10/18 at 10:40 a.m., he stated he had several roommates move in and out of his room and was never approached by anyone to let him know of the change in roommates. He stated the roommates were transferred into his room from another unit within 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 a complaint investigation, record review, family interviews, staff interviews, and facility document review the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) prior to discharge for 1 of 40 residents in the survey sample, Resident #148. The facility staff failed to issue a Medicare Notice of Non-Coverage prior to Resident #148's discharge that was facility planned on 8/8/17 however occurred on 8/9/17. The findings included: Resident #148 was admitted to the facility on [DATE] with diagnoses to include Left Femur Fracture, Atrial Fibrillation and Dementia. On the facility admission Record Resident #148's son was listed as her Responsibility Party and Guardian. The most recent comprehensive Minimum Data Set (MDS) assessment was an admission 5 Day with an Assessment Reference Date (ARD) of 7/23/17. The Brief Interview for Mental Status (BIMS) was a 3 out of a possible 15 which indicated that Resident #148 was not cognitively intact and incapable of daily decision making. The last…

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 record review, staff interviews and facility document review, the facility failed to notify the Office of the State Long-Term Care Ombudsman in writing of a hospital discharge for 1 of 40 residents (Resident #63) in the survey sample. 1. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #63's transfer to the emergency room (ER) from dialysis on 07/18/18. The finding included: Resident #63 was re-admitted to the facility on [DATE]. Diagnosis for Resident #63 included but not limited to *End Stage Renal Disease (ESRD). The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 08/29/18 coded the resident with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated no cognitive impairment. The Discharge MDS assessments was dated for 07/18/18, discharge return anticipated, re-admitted to the facility on [DATE]. On 07/18/18, according to the facility's documentation,…

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, staff interview, and facility documentation review, the facility staff failed to ensure one (Resident #146) of 40 residents in the survey sample had an accurate Minimum Data Set (MDS) assessment. Resident #146's discharge MDS, dated [DATE], was coded that she was discharged to the hospital rather than discharged home. The findings included: Resident #146 was a [AGE] year old admitted to the facility on [DATE] with diagnoses to include Chronic Kidney Disease and Congestive Heart Failure. The most recent MDS assessment was a Discharge with an Assessment Reference date of 8/28/18. Under Section A Type of Assessment Resident #146 was coded as 10/1 ( Discharge assessment-return not anticipated), planned. Under A 2100 Discharge Status Resident #146 was coded as 03 (discharge to acute hospital). Resident #146's progress note dated 8/28/18 at 11:26 A.M. was reviewed and is documented in part, as follows: pt. (patient) left the facility at 11:00 to home accompanied by her daughter. pt.…

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 a complaint investigation, record review, family interviews, staff interviews, and facility documentation review, the facility failed to develop a Comprehensive Care Plan to include discharge goals and interventions for 1 of 40 residents in the survey sample, Resident #148. The facility staff failed to develop a Comprehensive Care Plan to include discharge goals and interventions for Resident #148 The findings included: Resident #148 was admitted to the facility on [DATE] with diagnoses to include Left Femur Fracture, Atrial Fibrillation and Dementia. On the facility admission Record Resident #148's son was listed as her Responsibility Party and Guardian. The most recent comprehensive Minimum Data Set (MDS) assessment was an admission 5 Day with an Assessment Reference Date (ARD) of 7/23/17. The Brief Interview for Mental Status (BIMS) was a 3 out of a possible 15 which indicated that Resident #148 was not cognitively intact and incapable of daily decision making. The last Minimum Data Set (MDS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a complaint investigation, record review, family interviews, staff interviews, and facility document review the facility failed to involve the resident and resident representative in the final discharge plan for 1 of 40 residents in the survey sample, Resident #148. The facility staff failed to ensure that Resident #148's son was involved in the final discharge plan scheduled on 8/8/17. The findings included: Resident #148 was admitted to the facility on [DATE] with diagnoses to include Left Femur Fracture, Atrial Fibrillation and Dementia. On the facility admission Record Resident #148's son was listed as her Responsibility Party and Guardian. The most recent comprehensive Minimum Data Set (MDS) assessment was an admission 5 Day with an Assessment Reference Date (ARD) of 7/23/17. The Brief Interview for Mental Status (BIMS) was a 3 out of a possible 15 which indicated that Resident #148 was no cognitively intact and incapable of daily decision making. The last Minimum Data Set (MDS) assessment was a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interviews, staff interviews and clinical record review the facility staff failed to provide personal care to include showers for two resident in the survey sample of 40 (Resident #61 and 63) who were unable to independently carry out activities of daily living (ADL's). 1. The facility staff failed to ensure Resident #61 received showers according to resident plan and preference. 2. The facility staff failed to ensure Resident #63 received showers according to resident plan and preference. The findings include: 1. Resident #61 was originally re-admitted to the facility on [DATE]. Diagnosis for Resident #61 included but not limited to *Anxiety disorder and *Cardiomyopathy. Resident #61's Minimum Data Set (MDS - an assessment protocol) a quarterly assessment with an Assessment Reference Date of 08/24/18 coded Resident #61's Brief Interview for Mental Status (BIMS) scored a 15 out of a possible score of 15 indicating no cognitive impairment. In addition, the MDS coded Resident #61 total dependence…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review, and review of the facility's policy the facility staff failed to receives the appropriate care and services to prevent potential indwelling catheter complications for 1 of 40 residents (Resident #48), in the survey sample. The facility staff failed to anchor Resident #48's indwelling urinary catheter to prevent tension on the catheter and avoid potential kinking of the tubing. The findings included: Resident #48 was originally admitted to the facility 8/9/18 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; urinary retention with bilateral hydronephrosis (kidney swelling due to urine failing to drain properly). The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/16/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #48's cognitive abilities for daily decision…

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, staff interviews and facility documentation, the facility staff failed to ensure 2 of 40 residents (Resident #53 and #63) received the care and services consistent with the standards of practice and comprehensive person-centered care plan. 1. The facility staff failed to ensure hemodialysis care was provided for Resident #53 to include consistent and accurate assessments of *bruit and *thrill by the licensed nurses. 2. The facility staff failed to ensure hemodialysis care was provided to Resident #63 to include consistent assessments of bruit and thrill, as well as communication between the facility and dialysis center. The findings included: 1. Resident #53 was re-admitted to the nursing facility on 11/7/17 with a diagnosis that included end stage renal disease (ESRD) on hemodialysis. The most recent Minimum Data Set (MDS) assessment dated [DATE] was an annual and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 6 out of a possible…

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, staff interviews and facility documentation, the facility staff failed to ensure the licensed nursing staff were competent with the appropriate skills to provide assessments of Arterio-Venous (AV) dialysis shunts for 2 of 40 residents (#53 and #63) in the survey sample. 1. The facility staff failed to ensure the licensed nursing staff were competent in the provision of hemodialysis care for Resident #53 to include accurate assessments of *bruit and *thrill. 2. The facility staff failed to ensure the licensed nursing staff were competent in the provision of hemodialysis care for Resident #63 to include accurate assessments of bruit and thrill. The findings included: 1. Resident #53 was re-admitted to the nursing facility on 11/7/17 with a diagnosis that included end stage renal disease (ESRD) on hemodialysis. The most recent Minimum Data Set (MDS) assessment dated [DATE] was an annual and coded the resident on the Brief Interview for Mental Status (BIMS) with a score…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, clinical record review and review of facility documentation, the facility staff failed to ensure hand washing after removal of gloves during accuchecks (a fingerstick for blood glucose testing) for 2 of 40 residents (Resident #53 and #13) in the survey sample. 1. The facility staff failed to ensure hand washing after the removal of gloves during the accucheck procedure for Resident #53. 2. The facility staff failed to ensure hand washing after the removal of gloves during the accucheck procedure for Resident #13. The finding include: 1. Resident #53 was re-admitted to the nursing facility on 11/7/17 with a diagnosis that included diabetes. The most recent Minimum Data Set (MDS) assessment dated [DATE] was an annual and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 6 out of a possible score of 15 which indicated the resident was severely impaired in the skills needed for daily decision making. The resident was coded to be an insulin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and facility document review, the facility staff failed to store and prepare foods in a sanitary manner. The facility staff failed to ensure an open 25 pound bag of panko (bread crumbs) was stored in a sealed container to prevent physical contaminants from inadvertently entering the food, failed to ensure an open date and use by dated was placed on a 35 ounce open bag of toasted oats, and failed to ensure two deep fryer baskets were free from cross-contamination that were in contact with a trash can. The findings included: On 3/21/17 at 2:40 p.m. a Kitchen/Food Service tour was conducted with the Director of Dietary Services. During the kitchen tour the following observations were made: 1. In the Dry Storage Room an open unsealed 25 pound bag of panko (bread crumbs) with an opened of date of 2/14/17 and use by date of 5/14/17 with only a piece of loose plastic wrap lying over the opening of the bag was observed. 2. In the Dry Storage Room an opened 35 ounce bag of toasted…

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 The facility failed to provide medically related social services for 1 out of 15 residents as evidenced by the facility choosing not to follow the wishes of the legal power of attorney (POA) but following the wishes of the non-POA for her mother's diet. The findings included: Resident #115 was originally admitted to the facility 3/14/07 and readmitted [DATE] after an acute hospital stay. The current diagnoses included; dementia, legal blindness, diabetes, stroke with right hemiparesis, cardiovascular disease, osteoporosis, hypertension, glaucoma and macular degeneration. The clinical record also contained a document dated 1/16/17 and signed by a physician stated; given level of patient's impairment, in my opinion, she lacks capacity to manage her own medical and financial matters. Based on the preceding information the Durable Power of Attorney (POA), appointed 9/12/07 was initiated. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/31/17 coded the resident as…

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

Based on observation, resident interviews, staff interview, facility documentation review, the facility staff failed to maintain a clean comfortable homelike environment in 3 of 8 resident shower rooms. On 3/22/17 at approximately 10:00 to 11:00 a.m. during the General Observation tour of the facility the surveyor observed the following items: Soiled Shower rooms (3B, 2B, 2A) On 3/22/17 during the General Observation tour of the facility from 10:00 to 11:00 a.m. 3B Resident Shower Room was observed soiled. Used towels were observed lying in the shower room. The Shower room bench was observed with torn rough edges on the padded seat. On 3/22/17 during the General Observation tour of the facility from 10:00 to 11:00 a.m. 2B shower room was observed to be soiled. A used towel was observed lying in the shower room. The shower room bench was observed with torn rough edges. On 3/22/17 during the General Observation tour of the facility from 10:00 to 11:00 a.m. 2A shower room was observed to be soiled. A used brief was observed on the floor and a used glove was observed on the floor. Used…

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 interviews, and facility document review the facility staff failed to ensure that a single use wound care product was discarded after resident use for 1 of 47 residents in the survey sample, Resident #3, and failed to prevent the potential for the transmission of infection with the storage of clean supplies. 1. The facility staff failed to ensure that a single use Calcium Alginate Wound care product was discarded after wound care was completed on Resident #3. 2. The facility staff failed to ensure the storage of clean supplies in a manner to prevent the potential for transmission of infection. The findings included: 1. Resident #3 was a [AGE] year old admitted to the facility on [DATE] with diagnoses to include Multiple Sclerosis (1), Unstageable Pressure Ulcer (2), and Paraplegia (3). The most recent comprehensive Minimum Data Set (MDS) assessment was a Significant Change with an Assessment Reference Date (ARD) of 2/3/17. The Brief Interview for Mental Status (BIMS) was a 14 out of a…

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

Based on staff interviews and facility documentation review, the facility staff failed to ensure continuing competency of nursing aides with training hours no less than 12 hours a year. Specifically, the facility staff failed to ensure that five out of 46 CNAs (Certified Nursing Assistants) had completed at least 12 hours of training per year per hire anniversary date for each CNA. The findings included: On 3/23/17, the facility documentation was reviewed. A list of 46 CNAs with training hours per hire anniversary year was reviewed. Five out of 46 CNAs did not have at least 12 hours of training since their one year hire anniversary date. Also training transcripts were reviewed for all 46 CNAs. The training transcripts documented the course topic and the amount of hours completed for each CNA. The hours were totaled by two surveyors and five CNAs were below 12 hours within the year of the hire anniversary date. On 3/23/17 at approximately 4:15 p.m., a human resource staff member (Others #4) was interviewed. Others #4 explained that it was the responsibility of the Unit Managers 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 The facility staff failed to notify the physician and or designee and the Power of Attorney of a change in physical, mental, or psychosocial status for 1 of 15 residents in the survey sample, Resident #115. The facility staff failed to notify the physician and or designee and the Power of Attorney that Resident #115 was not receiving the dietary supplement (Pure Aloe Force) as ordered by the physician and the resident was refusing the anti-platelet medication Aggrenox. Aggrenox is used to reduce the risk of stroke in people who have had blood clots or a mini-stroke. The findings included: Resident #115 was originally admitted to the facility 3/14/07 and readmitted [DATE] after an acute hospital stay. The current diagnoses included: stroke with right hemiparesis, cardiovascular disease, hypertension, and dementia. The clinical record also contained a document dated 1/16/17 and signed by a physician which stated; given level of patient's impairment, in my opinion, she lacks capacity to manage her own medical 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 observations, resident, staff and group interviews, the facility staff failed to provide laundry services with reasonable accommodations for one resident, Resident #17, in the survey sample of 47 residents. the findings included: Resident #17 was admitted to the facility 7/1/15 with diagnoses which included hypertension, neurogenic bladder, diabetes mellitus, hyperlipidemia, anxiety disorder and depression. The facility staff failed to return Resident #17's laundry after 23 days. A Quarterly Minimum Data Set (MDS) assessed this resident as having adequate hearing, clear speech, makes self understood, able to understand and having adequate visions. This resident was assessed as having a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. This resident was assessed as having no behaviors. In the area of Activities of Daily Living (ADLs) this resident was assessed as requiring extensive assistance in the area of dressing. In the area of personal hygiene 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 observation, resident interview, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure the safe storage and transportation of oxygen cylinders. On 3/22/17 at approximately 10:10 a.m., during the General Observation Tour with the Assistant Administrator and the Director of Maintenance one full small oxygen cylinder was observed in the oxygen storage room, stored standing on boxes of supplies and not secured in a rack to prevent the cylinder from the potential of becoming airborne if it were to fall. The Oxygen Storage Room was observed not being directly beside or across from a resident room. During the observation of the oxygen cylinder, the Maintenance Director placed the one cylinder into the storage rack for oxygen cylinders. On 3/23/17 at approximately 12:55 p.m., a Physical Therapy Assistant #3 was observed walking out of the Rehabilitation gym carrying one empty small oxygen tank in her left hand…

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

Based on observation, staff interview, facility documentation review, the facility staff failed to ensure that all staff were trained in emergency procedures, specifically use of a fire extinguisher. On 3/22/17 at approximately 11:20 a.m. a Certified Nursing Assistant (CNA) was questioned on use of a fire extinguisher. The CNA #1 stated that to use a fire extinguisher she would take the extinguisher out of the wall unit, then squeeze the handle and aim at the bottom of the fire. When CNA #1 was asked what she would do if nothing came out of the nozzle when she squeezed the handle, she had no response. When CNA #1 was asked what she would do if she was not able to squeeze that handle, CNA had no response. The CNA and surveyor were standing in front of an extinguisher while questions were asked. Answers to PULL THE PIN were written on the extinguisher. CNA never was able to state, Pull the Pin to get the fire extinguisher to work. A copy of CNAs education completed on the computer system (type of training) was provided by the facility, and it did not document that Fire Safety had been…

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.