Autumn Care Of Suffolk

Based on staff interview, clinical record review, and facility document review the facility staff failed to obtain lab testing as ordered by the medical provider for 2 of 35 sampled residents. (Resident #51 and #357). The findings included: 1. For resident # 51 the facility failed to obtain a hemoglobin A1C (HgbA1c) ordered by the primary care provider. Resident # 51's diagnoses included type II diabetes mellitus. During a review of the clinical record on 9/12/24, an order to obtain a HgbA1c on 9/2/24 was noted. This surveyor was not able to locate results in the clinical record. The Medication Administration Record (MAR) was reviewed. The order was on the MAR and scheduled for 9/2/24, the order had not been signed off as done. On 09/12/24 04:04 PM this surveyor interviewed Registered Nurse (RN) # 2. They stated, the lab was not done. The physician has been notified and it is scheduled to be done tomorrow. They stated they did not know how the order was missed, I don't know, it was just missed. HgbA1c is a blood test that measures average blood sugar levels over the past two to…

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

Based on interviews, document review, and clinical record review facility staff failed to notify the medical provider and/or a responsible party for related to residents' medication regime for 2 of 35 sampled residents (Resident #100 & #206). 1. For Resident #100, facility staff failed to notify the physician when an anti-hypotensive medication was held. Resident #100 was admitted to the facility with diagnoses which included end stage renal disease with hemodialysis, diabetes mellitus, anemia, septicemia, peripheral vascular disease, deep vein thrombosis, orthostatic hypotension, and malnutrition. On the most recent Minimum Data Set assessment the resident scored 15/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. Clinical record review revealed an order for Midodrine 5 milligrams 3 tabs oral every 6 hours. A nursing medication note dated 9/10/2024 18:00 indicated Not Administered: Other Comment: held due to BP of 140/71. The surveyor was unable to locate hold parameters for the medication 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 staff interviews, clinical record review, and facility document review, the facility staff failed to ensure communication with hospice staff allowed for the timely implementation of resident orders for one (1) of 35 sampled residents (Resident #206). The findings include: The facility staff failed to ensure communication with hospice allowed for the prompt implementation of an order to discontinue Resident #206's oral morphine. Resident #206's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 7/25/23, was signed as completed on 7/27/23. Resident #206 was assessed as usually able to make self understood and as able to understand others. Resident #206 was assessed as having problems with both short-term memory and long-term memory. Resident #206 was assessed as being dependent on others for transfers, dressing, personal hygiene, and bathing. The following VERBAL ORDER was found in Resident #206's clinical record (dated 7/7/23 at 2:14 p.m.): Discontinue: effective 7/7/23 - morphine 20 mg/ml oral concentrate; Administer 0.25 milliliter(s) orally…

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 and staff interviews the facility staff failed to provide one resident (Resident #85) in the survey sample of 35 residents with a notice of transfer to the office of the state Long-Term Care Ombudsman. The findings included: Resident #85 was admitted to the facility on [DATE] with diagnoses which included anemia, coronary artery disease, heart failure, hypertension, diabetes, hyperlipdemia, manic depression, end stage renal disease, and bipolar disorder. The facility staff failed to provide a notice of transfer to the Office of the State Long-Term Care Ombudsman while being discharged to the hospital. A 3/3/21 Quarterly Minimum Data Set (MDS) assessed this resident in the area of Cognitive Patterns - Brief Interview for Mental Status as a (10). In the area of Daily Living this resident was coded as requiring minimum assist with supervision in the areas of dressing, toileting, and eating. Resident #85 was continent of bowel and bladder. A 3/18/21 Care Plan indicated: Resident #85 receives…

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 2. The facility staff failed to provide Resident #85 with a bed-hold policy prior to transferring to a hospital. Resident #85 was admitted to the facility on [DATE] with diagnoses which included anemia, coronary artery disease, heart failure, hypertension, diabetes, hyperlipdemia, manic depression, end stage renal disease, and bipolar disorder. The facility staff failed to provide Resident #85 with a bed-hold policy prior to transferring to a hospital. A 3/3/21 Quarterly Minimum Data Set (MDS) assessed this resident in the area of Cognitive Patterns - Brief Interview for Mental Status as a (10). In the area of Daily Living this resident was coded as requiring minimum assist with supervision in the areas of dressing, toileting, and eating. Resident #85 was continent of bowel and bladder. A 3/18/21 Care Plan indicated: Resident #85 receives dialysis and refuses to go to appointments on multiple occasions. Resident have behaviors of cursing, throwing items in room, also noted to make self vomit when not getting…

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 and staff interviews and clinical record review the facility staff failed to ensure 1 of 35 residents (Resident #24) in the survey sample who were unable to carry out activities of daily living (ADL) receives the necessary services. The findings included: The facility staff failed to ensure that Resident #24 had his hair washed and fingernail care was provided. Resident #24 was admitted to the facility on [DATE]. Diagnosis for Resident #24 included but not limited to contracture to the left and right upper arm. Resident #24's Minimum Data Set (MDS-an assessment protocol) a significant changes with an Assessment Reference Date of 04/06/21 coded Resident #24 total dependence of one with bathing, extensive assistance of two with bed mobility and transfer, extensive assistance of one with dressing, eating, toilet use and personal hygiene. Resident #24's comprehensive care plan with a revision date 01/19/20 documented the resident frequently refuses showers (agrees to bed baths) 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 information gleamed during a complaint investigation, resident, family and staff interviews, and clinical record review, the facility's staff failed to ensure a resident's emotional well being was managed to attain the highest practicable mental and psychosocial well-being for a resident with an anxiety disorder and a major depressive disorders for 1 of 35 residents (Resident #80), in the survey sample. The findings included: Resident #80 was originally admitted to the facility 11/19/20, and had never been discharged from the facility. Resident #80's diagnoses included; coronary artery disease, chronic diarrhea related to a hemicolectomy (surgical removal of part of the colon), a major depressive disorder and an anxiety disorder. The quarterly discharge Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/28/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #80's cognitive abilities 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 interviews, facility documentation review and clinical record review the facility staff failed to ensure 2 of 35 residents in the survey sample (Resident #67 and #16) received physician ordered medications. The findings included: 1. The facility staff failed to ensure Resident #67 received physician ordered medication (Maalox vixcous Lidocaine, Benadryl 1:1:1: max sign 10 ml) on 06/11, 06/12, 06/13, 06/14, 06/15, and 06/16/21. Resident #67 was admitted to the facility on [DATE]. Diagnoses included but were not limited to, Malignant Neoplasm of Larynx, unspecified, Dysphagia and Paroxysmal Atrial Fibrillation. Resident #67's admission Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 05/19/2021 was not coded with a BIMS (Brief Interview for Mental Status) score. In addition, the Minimum Data Set coded Resident #67 as requiring limited assistance of 1 with dressing and personal hygiene, extensive assistance of 1 with bed mobility and toilet use…

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 interviews the facility staff to ensure reasonable accommodation of need for 1 of 35 residents (Resident #24) in the survey sample. The findings included: The facility staff failed to ensure Resident #24 was assessed for the correct call light device. Resident #24 was admitted to the facility on [DATE]. Diagnosis for Resident #24 included but not limited to contracture to the left and right upper arm. Resident #24's Minimum Data Set (MDS-an assessment protocol) a significant changes with an Assessment Reference Date of 04/06/21 coded Resident #24's Brief Interview for Mental Status (BIMS) scored a 10 out of a possible score of 15 indicating moderate cognitive impairment. In addition, the MDS coded Resident #24 total dependence of one with bathing, extensive assistance of two with bed mobility and transfer, extensive assistance of one with dressing, eating, toilet use and personal hygiene. Resident #24's comprehensive care plan with a revision date 06/16/21…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility staff failed to assist one resident (Resident #85) in the survey sample of 35 residents to obtain his Federal Internal Revenue Service Stimulus funds. The findings included: Resident #85 was admitted to the facility on [DATE] with diagnoses which included anemia, coronary artery disease, heart failure, hypertension, diabetes, hyperlipdemia, manic depression, end stage renal disease, and bipolar disorder. The facility staff failed to assist Resident #85 in obtaining his Federal Internal Revenue Service Stimulus funds. A 3/3/21 Quarterly Minimum Data Set (MDS) assessed this resident in the area of Cognitive Patterns - Brief Interview for Mental Status as a (10). In the area of Daily Living this resident was coded as requiring minimum assist with supervision in the areas of dressing, toileting, and eating. Resident #85 was continent of bowel and bladder. A 3/18/21 Care Plan indicated: Resident #85 receives dialysis and refuses to go to appointments 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 medical record review, facility document review and staff interviews the facility staff failed to ensure that 2 of 35 residents in the survey sample were afforded the opportunity to formulate an Advance Directive upon admission, Residents' #63 and #84. The findings included: 1. Resident #63 was admitted to the facility on [DATE] with diagnoses to include but not limited to Heart Failure, Hypertension, and Pleural Effusion. The most recent comprehensive Minimum Data Set (MDS) was an admission 5 day with an Assessment Reference Date(ARD) of 5/5/21. The Brief Interview for Mental Status (BIMS) for Resident #63 was coded as a 9 out of a possible 15, which indicates the resident was moderately cognitively impaired but capable of some daily decision making. Resident #63's Physician Orders were reviewed and are documented in part, as follows: Order Summary: Full Code Order Date: 5/20/2021 A review of Resident #63's medical record evidenced no Advance Directive documentation. On 6/16/21 at 12:15 P.M. a phone…

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 family interview, facility document review and clinical record review, it was determined that facility staff failed to notify the responsible party of new order and a change in condition for one of 35 residents in the survey sample; Resident # 38. The findings included: Resident #38 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included but were not limited to Dysphagia (difficulty swallowing) post stroke, high blood pressure, chronic pain syndrome, multiple sclerosis, and dysfunction of the bladder. Resident #38's most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 4/24/21. Resident #38 was coded as being severely impaired in cognitive function on the Staff Assessment for Mental Status. Review of Resident #38's clinical record revealed that she was evaluated by the NP (Nurse Practitioner) on 6/14/21 at 12:35 p.m. The assessment documented the following: Pt (Patient) is a 63 y/o (year old) black female with a past…

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

Based on observation, resident interview and staff interviews the facility staff failed to provide reasonable care for the protection of residents' property from loss for 1 of 35 residents (Resident #53) in the survey sample. The findings included: Resident #53 was originally admitted to the facility 04/28/21 after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Aspiration Pneumonia and Lung Abscess. The admission, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 05/04/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of 15. This indicated Resident #53 cognitive abilities for daily decision making were moderately impaired. In section G(Physical functioning) the resident was coded as requiring extensive assistance of one person with bathing, dressing, toilet use and personal hygiene. Requiring supervision of one person physical assistance with eating, locomotion on and off the unit. A review of Resident's Care plan reveal the following:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, and clinical record review, it was determined that facility staff failed to report a suspected abuse allegation within the required time frame after the allegation was made for 1 of 35 residents in the survey sample, Resident #16. The findings included: Resident #16 was originally admitted to the facility on [DATE]. The resident has never been discharged from the facility. The current diagnoses included; Palliative Care and Pain Syndrome. The significant change, annual quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 03/24/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 6 out of a possible 15. This indicated Resident #16 cognitive abilities for daily decision making were severely impaired. In section G(Physical functioning) the resident was coded as requiring extensive assistance of two people with bed mobility and transfers. Requires extensive assistance of one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinical record review and facility documentation review the facility staff failed to send a copy of the Resident's Care Plan for two residents (Resident #76 and Resident #38) after being transferred to the hospital. The findings included: 1. The facility staff failed to send Resident #76's care plan to include their goals when discharged to the hospital on [DATE]. Resident #76 was originally admitted to the facility on [DATE]. Diagnosis for Resident #76 included but not limited to Dementia. Resident #76's Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 03/19/21 coded Resident #76 with short and long-term memory problems and cognitive skills severely impaired-never/rarely made decisions. The Discharge MDS assessments was dated for 03/13/21 - discharge return anticipated. Resident #76 was re-admitted to the nursing facility on 03/16/21. On 03/13/21, according to the facility's documentation, Resident #76 was observed lying on the floor beside the bed,…

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, facility document review, and clinical record review, it was determined that facility staff failed to provide evidence that one out of 35 sampled residents was invited to attend a care plan meeting on 5/18/21, Resident #54. The findings included: Resident #54 was admitted to the facility on [DATE] with diagnoses that included but were not limited to high blood pressure, atrial fibrillation, chronic kidney disease stage 3, adult failure to thrive, and personal history of mental and behavioral disorders. Resident #54's most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 5/7/21. Resident #54 was coded as being moderately impaired in cognitive function scoring 11 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. On 6/15/21 at 2:00 p.m., an interview was conducted with Resident #54. Resident #54 had stated that he wasn't sure why he was still in the facility and why (Name of Social Service Agency)…

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 interviews, facility documentation review and clinical record review the facility staff failed to ensure medication order was correctly transcribed for 1 resident (Resident #67) and the facility staff failed to follow physician orders for Neurontin (Gabapentin) for 1 resident (Resident #16) of 35 residents in the survey sample. Resident #16 should have received Neurontin 100 mg TID (Three Times a Day) but was given Neurontin 300 mg TID. The findings included: 1. Resident #67 was admitted to the facility on [DATE]. Diagnoses included but were not limited to, Malignant Neoplasm of Larynx, unspecified, Dysphagia and Paroxysmal Atrial Fibrillation. Resident #67's admission Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 05/19/2021 was not coded with a BIMS (Brief Interview for Mental Status) score. In addition, the Minimum Data Set coded Resident #67 as requiring limited assistance of 1 with dressing and personal hygiene, extensive assistance of 1…

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 medical record review, facility document review and staff interviews the facility staff failed to ensure that a physician order for daily weights was carried out for 1 of 35 residents in the survey sample, Residents' #63. The findings included: Resident #63 was admitted to the facility on [DATE] with diagnoses to include but not limited to Heart Failure, Hypertension, and Pleural Effusion. The most recent comprehensive Minimum Data Set (MDS) was an admission 5 day with an Assessment Reference Date(ARD) of 5/5/21. The Brief Interview for Mental Status (BIMS) for Resident #63 was coded as a 9 out of a possible 15, which indicates the resident was moderately cognitively impaired but capable of some daily decision making. Resident #63's Hospital Discharge summary dated [DATE] was reviewed and is documented in part, as follows: Discharge Orders: Diet: Cardiac Diet, daily weight. Resident #63's Physician Orders were reviewed and are documented in part, as follows: Order Summary: Weigh Resident Daily every day…

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 clinical record review the facility staff failed to ensure 1 of 35 residents (Resident #24) in the survey sample who were unable to carry out activities of daily living (ADL) receives the necessary services to maintain toenail care. The findings included: The facility staff failed to ensure that podiatry services was provided to Resident #24. Resident #24 was admitted to the facility on [DATE]. Diagnosis for Resident #24 included but not limited to Chronic Pain Syndrome. Resident #24's Minimum Data Set (MDS-an assessment protocol) a significant changes with an Assessment Reference Date of 04/06/21 coded Resident #24's Brief Interview for Mental Status (BIMS) scored a 10 out of a possible score of 15 indicating moderate cognitive impairment. In addition, the MDS coded Resident #24 total dependence of one with bathing, extensive assistance of two with bed mobility and transfer, extensive assistance of one with dressing, eating, toilet use and personal hygiene. Resident…

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

Based on information gleamed during a complaint investigation, observation, resident interview, staff interviews, and clinical record review, the facility's staff failed to ensure the resident was not left in fecal matter for extended periods of time for 1 of 35 residents (Resident #80) surveys, in the survey sample. The findings included: Resident #80 was originally admitted to the facility 11/19/20, and had never been discharged from the facility. Resident #80's diagnoses included; coronary artery disease, chronic diarrhea related to a hemicolectomy (surgical removal of part of the colon), a major depressive disorder and an anxiety disorder. The quarterly discharge Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/28/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #80's cognitive abilities for daily decision making were intact. Section D (Mood) stated the resident wasn't assessed and Section E (Behavior) for coded for no behaviors. Section G was coded for…

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

Based on facility documentation, the facility staff failed to staff a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The findings included: The request for the (RN) weekend coverage for a 60-day lookback was requested on 06/16/21 at 8:32 a.m., 06/17/21 at 8:05 a.m., and again on 06/17/21 at 1:27 p.m. The RN weekend coverage documents for a 60-day lookback was received on 06/21/21 at approximately 6:32 a.m. After reviewing the staffing documentation during a 60-day lookback indicated the following: 1.) On 05/22/21, RN #3 worked a total of 7.25 hours out of a scheduled 8 hour shift. 2.) On 05/23/21, RN #3 worked a total of 4.5 hours out of a scheduled 8 hours shift. A pre-exit conference was conducted with the [NAME] President of Operations and Regional Director of Clinical Services on 06/21/21 at approximately 9:30 a.m. When asked, What is the facility's expectation for RN weekend coverage, the Regional Director stated, To provide 8 hours of RN coverage on the weekends.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility documentation review and clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure the physician reviewed pharmacy recommendation for 1 of 35 residents in the survey sample, Resident #18. The findings included: Resident #18 was admitted to the facility on [DATE]. Resident #18 was discharged to the hospital on 4/22/2021 and readmitted to the facility on [DATE]. Diagnosis included but were not limited to, Unspecified Dementia with Behavioral Disturbances, Cognitive Communication Deficit and Major Depressive Disorder, Recurrent, Unspecified. Resident #18's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 03/26/2021 was coded with a BIMS (Brief Interview for Mental Status) score of 05 indicating severe cognitive impairment. In addition, the Minimum Data Set coded Resident #18 as requiring supervision with setup help only with eating, limited assistance of 1 with walk in room, walk in corridor, extensive…

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, it was determined that the facility staff failed to serve food at a palatable temperature. The findings included: On 6/15/21 at 11:25 a.m. tray line was observed with OSM #5 , the dietary cook. The main entree was pizza which was temped at 150 degrees Fahrenheit. The alternate entree was a salmon patty. This food item was not temped at tray line. There were no plate warmers observed being used during tray line. On 6/15/21 at 12:16 p.m., at the end of tray line; a test tray was requested. On 6/15/21 at 12:19 p.m., the last cart was brought to the last hallway (100 hall). On 6/15/21 at 12:39 p.m., the test tray was conducted with another surveyor and OSM #5, the dietary cook. The main entree pizza, dropped to a temperature of 92 degrees Fahrenheit. The alternate main entree, salmon patty dropped to a temperature of 86 degrees Fahrenheit. The above food items were not palatable due to temperature. There were no concerns with the additional food items on the test tray. On 6/15/21 at 12:40 p.m., an interview 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, facility document review, and clinical record review, it was determined that facility staff failed to maintain infection control practices during incontinence care observation for one of 35 sampled residents; Resident #37. The findings included: Resident #37 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to stroke, atrial fibrillation, anemia, contracture of the left hip, knee and ankle, and right hip, knee and ankle. Resident #37's most recent MDS (Minimum data Set) assessment was a quarterly assessment with an ARD (assessment reference date) of 4/21/21. Resident #37 was coded as being severely impaired in cognitive function scoring 01 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #37 was coded as requiring total dependence from two plus staff with bed mobility and toileting; and total dependence on one staff with transfers. Resident #37 was coded as being frequently…

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 a review of facility documents, the facility staff failed to designate at least one qualified Infection Preventionist. The findings included: On 6/15/21 at approximately 4:37 PM an email was sent to ASM #2 requesting proof of IP (Infection Preventionist) training. On 6/15/21 at 5:12 PM ASM #2 responded via email. I will work on this and get it to you soon. According to ASM #2 the DON (Director of Nursing) was also the IP, but left the facility abruptly on 6/17/21. She also stated that the ADON (Acting Director of Nursing) was seeking training in Infection Prevention. On 6/21/21 at approximately 5:31 PM., the above findings were shared with ASM (Administrative Staff Member/Regional Director of Clinical Services) #2 and with ASM #4 concerning the Infection Preventionist (IP) Training Completion Certificate. The ASM #2 stated, The former DON (Director of Nursing) may not give me a copy of her training certificate. She walked out the other night. I have a certificate. I received the training around 2019. I'm at the facility two or three days a…

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

Based on observation, staff interview, and facility document review, it was determined that the facility staff failed to maintain an effective pest control program for the facility kitchen. The findings included: On 6/15/21 at 11:00 a.m., observation of the facility kitchen was conducted. At 11:06 a.m. OSM (Other Staff Member) #8, the dietary aide was observed sweeping a pile of cockroaches; approximately 15 roaches. Some roaches were dead while others were living and on their backs moving their legs. When asked how many roaches were in her pile; OSM #8 stated that it was at least 15 of them. OSM #8 stated that she has always seen roaches in the kichen but never like this. OSM #8 stated that the roaches had been mostly found under the three compartment sink and she finally had the time to sweep them up. OSM #8 stated that they were under the sink since 5:30 a.m. that morning when she first arrived to her shift. On 6/15/21 at 11:09 a.m., OSM #9, the cook stated that maintenance had added two plugs (Pest Repellers) to the outlets on Monday 6/14/21. OSM #9 stated that he believed 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 resident record review, staff interviews and facility document review the facility staff failed to ensure that comprehensive care plan goals were sent upon transfer to the hospital for 4 of 59 Residents in the survey sample, Resident #89, #112, #74 and #101. The findings included: 1. Resident #89 was a [AGE] year old who was initially admitted to the facility on [DATE] with diagnoses to include but not limited to Congestive Heart Failure and Chronic Respiratory Failure. The most recent comprehensive Minimum Data Set (MDS) is an admission 5 Day with an Assessment Reference Date of 1/4/19. The Brief Interview for Mental Status (BIMS) indicates that Resident #89 has short and long term memory recall and is severely impaired in cognitive skills for daily decision making. The facility Discharge Report dated 1/1/19 through 5/31/19 for Resident #89 was reviewed and is documented in part, as follows: Hospital: 1/29/19 Hospital: 2/14/19 Hospital: 2/25/19 Hospital: 3/27/19 Hospital: 4/25/19 Hospital: 5/29/19 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 resident record review, staff interviews and facility document review the facility staff failed to ensure that the bed hold policy was provided to the resident or resident representative upon transfer to the hospital for 6 of 59 Residents in the survey sample, Resident #89, #112, #74, #1, #101 and #461. The findings included: 1. Resident #89 was a [AGE] year old who was initially admitted to the facility on [DATE] with diagnoses to include but not limited to Congestive Heart Failure and Chronic Respiratory Failure. The most recent comprehensive Minimum Data Set (MDS) is an admission 5 Day with an Assessment Reference Date of 1/4/19. The Brief Interview for Mental Status (BIMS) indicated that Resident #89 has short and long term memory recall and is severely impaired in cognitive skills for daily decision making. Resident #89 MDS history was reviewed and is documented in part, as follows: 1/29/19- Discharge Assessment-Return Anticipated, Unplanned. 2/4/19- Re-Entry from Acute Hospital. 2/14/19-Discharge…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinical record review and documentation review, it was determined that facility staff failed to complete and implement a baseline care plan within 48 hours of admission for three of 59 residents (Resident #27, #66 and #92) in the survey sample. The findings include: 1. Resident #27 was admitted to the nursing facility on 12/15/2018. Diagnoses included but not limited to, End Stage Renal Disease and Muscle Weakness. The current Minimum Data Set (MDS) a quarterly revision MDS with an Assessment Reference Date (ARD) of 05/07/19 coded the resident with a 14 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated that Resident #27's cognitive abilities for daily decision making were intact. A Review of the MDS (Minimum Data Set) Section A, A1600-Entry Date of 12/15/18. Section A, A1700 Reads: Type of Entry: Admission. A review of the Resident #27's Baseline care plan in the clinical record read the following: Most Recent admission: [DATE]. Date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interview, staff interview, facility documentation review and clinical record review it was determined that facility staff failed to revise the comprehensive care plan for 4 residents ( Resident #3, Resident #74, #83, #31) of 59 residents in the survey sample. The findings included: 1. Resident #3 was admitted to the facility on [DATE]. The resident was on Hospice. Diagnosis included but were not limited to, Chronic Pain Syndrome and Osteonecrosis Left Femur. The current Minimum Data Set (MDS an assessment protocol) was a significant change in status assessment with an Assessment Reference Date of 04/12/2019. The MDS coded the resident with a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #3 as requiring extensive assistance of 1 for eating, dressing, toilet use and personal hygiene, extensive assistance of 2 for bed mobility and total dependence of 1 for bathing. On 07/25/2019 Resident #3's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, family member interview, staff interviews, clinical record review and facility documentation review, the facility staff failed to provide foot nail care and/or podiatry services for four of 59 residents in the survey sample (Resident #27, #66, #43 and #12 ). The findings include: 1. Resident #27 was admitted to the nursing facility on 12/15/2018. Diagnoses included but not limited to End Stage Renal Disease and Diabetes Mellitus. The current Minimum Data Set (MDS) a quarterly revision MDS with an Assessment Reference Date (ARD) of 05/07/19 coded the resident with a 14 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS), which indicated Resident #27's cognitive abilities for daily decision making were intact. On 07/25/19 at approximately 12:44 PM an observation of Resident #27's feet was made with assistance from LPN (Licensed Practical Nurse) #9. The Resident's toenails on both feet were thick and yellow. Resident and Resident Representative (RP) was asked…

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, and in the course of a complaint investigation, the facility staff failed to ensure food was labeled and dated in the kitchen refrigerator. The findings included: During the initial tour of the Kitchen on 07/24/19 at approximately 11:00 a.m. the following were observed in the kitchen refrigerator: 1. One small container of beets- with initials DR (staff member initials). 2. Dietary staff lunch box found in refrigerator. 3. One 15 pound pork not labeled or dated. 4. One container of Moderately Thicken Sweet Tea exp. 1/15/20 was opened with no open date written on container. 5. One container of Mildly Thicken Sweet teas exp. 11/05/19. was opened with no date written on container. On 07/24/19 at 3:50 PM a brief interview was conducted with the Regional Dietitian, (Other Staff #3) and Dietary [NAME] (Other Staff #10) concerning the above findings. They were asked what should have been done. Other Staff #10, stated I should have labeled and put the dates on opened containers. On 07/26/19 at approximately,5:35 PM, 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 observation, staff interview, facility documentation and clinical record review, it was determined that facility staff failed to ensure annual review of the antibiotic stewardship and infection control policies; and failed to ensure staff wear the appropriate PPE (Personal Protective Equipment) for contact precautions for one of 59 residents in the survey sample, Resident #12. The findings included: 1. On 07/26/2019 at approximately 1:30 p.m., the Surveyor met with the Assistant Director of Nursing (ADON) to review the facility's Infection Prevention and Control Program. The Surveyor requested a copy of the Infection Prevention and Control Program Policy. On 07/26/2019 at approximately 5:00 p.m., the ADON provided a copy of the, Infection Control Policy dated with an effective date of May 2015 to the Surveyor. The Surveyor asked the ADON if she could provide a copy of the facility's Infection Prevention Control Program Policy which was provided and dated with an effective date of April 16, 2018. There…

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, clinical record review, documentation review, and complaint investigation, it was determined that facility staff failed to maintain an effective pest control program as evidenced by insects, including roaches and ants, in the kitchen, resident rooms and hallways. The findings Included: 1. The facility staff failed to store, prepare and serve food in an insect free environment. On 07/24/19, at approximately 11:00 AM during the initial inspection of the kitchen, the dietary staff were asked if they had roaches in the kitchen. Dietary Staff #10, stated Yes. No live cock roaches were seen in the kitchen by surveyor. On 07/25/19, day 2 of the kitchen inspection, at approximately 11:00 AM., while inspecting the dry storage area, seven (7) dead cockroaches were seen on the floor located underneath the shelving in the dry storage area. The Regional Dietician (Other Staff #13) was present. She confirmed that they were dead cockroaches. A review of the Sanitation/Inspection 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 and staff interviews the facility staff to ensure reasonable accommodation of need and preferences for the use of a bariatric shower bed for 1 of 59 residents (Resident #100) in the survey sample. The findings included: Resident #100 was originally admitted to the facility on [DATE]. Diagnosis for Resident #100 included but are not limited to *Morbid (severe) obesity. Resident #100's Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 07/11/19 coded the resident with a 13 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. In addition, the MDS coded Resident #100 total dependent of two with bathing and toileting, extensive assistance of two with bed mobility, dressing, toilet use and personal hygiene for Activities of Daily Living (ADL) care. An interview was conducted with Resident #100 on 7/24/19 at approximately 11:30 a.m. Resident #100 stated, I have not had a shower since…

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 facility document review, it was determined that facility staff failed to ensure a clean comfortable and homelike environment for 2 of 59 residents in the survey sample, Resident #12 and #56. The findings include: 1. Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to atrial fibrillation, COPD (chronic obstructive pulmonary disease). Resident #12's most recent MDS (Minimum Data Set) assessment was a quarterly assessment with an ARD (assessment reference date) of 4/26/19. Resident #12 was coded as being intact in cognitive function scoring 15 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. On 7/24/19 at 2:00 p.m., an interview was conducted with Resident #12. Resident #12 had stated that she was afraid of the roaches that were in her room. Resident #12 stated that she liked to leave her bathroom light on during the night to prevent the roaches from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, facility documentation review and clinical record review the facility staff failed to complete each required section of an MDS (Minimum Data Set) assessment for 1 out of 59 residents (Resident #41) in the survey sample. The findings included: The facility staff failed to complete the required section of Resident #41's quarterly MDS: section C-Brief Interview for Mental Status. Resident #41 was admitted to the facility on [DATE]. Diagnoses for Resident #41 included but are not limited to *Alzheimer's disease. Review of the most recent quarterly MDS with an ARD (Assessment Reference Date) of 05/31/19 revealed Section C (Cognitive Patterns) was not completed. Under (C0100) Section C, should the Brief Interview for Mental Status be conducted, the MDS was coded as Yes. Further review of section (C0100) showed evidence that Section (C0100) was not completed. Under Section C (C0600) asks if the staff assessment for mental status be conducted, the MDS was coded No. An interview was conducted…

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

Based on observations, staff interview, and facility documentation review, the facility staff failed to follow physician orders for blood sugar monitoring on 07/05/19 for 1 (Resident #27) of 59 residents in the survey sample. The findings include: Resident #27 was admitted to the nursing facility on 12/15//2018. Diagnosis included but not limited to Diabetes Mellitus and End Stage Renal Disease. The current Minimum Data Set (MDS) a quarterly revision MDS with an Assessment Reference Date (ARD) of 05/07/19 coded the resident with a 14 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS). This indicated Resident #27's cognitive abilities for daily decision making were intact. Section I, Metabolic,12900 of the MDS indicated that Resident #27 had Diabetes Mellitus. A review of the Medication Administration Record (MAR) for July 2019 was conducted. On 07/05/2019 at 1130 physicians order included: Novolin R solution 100 unit/ML (Insulin Regular Human) inject as per sliding scale however, no blood sugar reading was evidenced. An X was placed in the box for 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, staff interview, facility documentation, and clinical record review, it was determined that facility staff failed to maintain respiratory equipment in a sanitary manner for two of 59 residents in the survey sample (Residents #31 and #89); and failed to administer oxygen per physician's order for Resident #31. 1. Resident #31 was admitted to the facility on [DATE] with diagnoses that included but were not limited to pneumonia, muscle weakness, and Alzheimer's disease. Resident #31's most recent MDS (Minimum Data Set) assessment was a quarterly assessment with and ARD (assessment reference date) of 5/10/19. Resident #31 was coded as being intact in cognitive function scoring 15 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #31's clinical record revealed that he was diagnosed with pneumonia on 7/20/19. The following orders were documented: 1) 02 (oxygen) continuous via NC (nasal cannula) at 2 L (liters)/min (minute) every shift. 2) Levofloxacin…

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 record review, staff interviews and facility document review the facility staff failed to ensure an ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for 1 of 59 resident in the survey sample, Resident #73. The findings included: Resident #73 was a [AGE] year old admitted to the facility on [DATE] with diagnoses to include but not limited to End Stage Renal Disease and Type II Diabetes Mellitus. The most recent Minimum Data Set (MDS) is a Quarterly assessment with a Assessment Reference Date (ARD) of 6/21/19. The Brief Interview for Mental Status (BIMS) for Resident #73 was a 10 out of a possible 15 indicating the resident had mild cognitive impairment but was capable of some daily decision making. Under Section O Special Treatment, Procedures, and Programs Resident #73 was coded as receiving Dialysis Services. Resident #73's current Physician Orders were reviewed and are documented in part, as follows: May attend dialysis 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.