Nans Pointe Rehabilitation And Nursing

Based on observations and staff interview, the facility staff failed to store and served food under sanitary conditions. The findings included: During the kitchen observations at 11:07 a.m. on 07/07/22 the left wall next to the eight burner stove and two door oven, was noted to copious amounts of burnt grease and food particles. Behind the stove was burned food particles and food crumbs. Food and debris was observed behind the standing two part oven. The wall next to the eight burner stove was observed to have a hole that measured an estimated 10 inches long and 3 inches wide. Rust was noted on the electrical sockets in front of the the eight burner stove. The wall behind the ice machine was observed to have an estimated 8 inch by 3 inch hole. The plaster was observed to be coming off. Trash and debris was observed behind the ice machine. The dish washing machine was observed to have a large 4 to 5 gallon clear plastic container catching water. The dish washer stated, the dish washer has been like that for several months. During an interview with the assistant maintenance worker, he…

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

Based on observation and staff interview the facility staff failed to maintain outside refuse area free of debris and trash. The findings included: During the outside observation of the trash dumpster area at 1:15 P.M. on 07/07/22, the area was observed to have trash and debris on the ground around the two dumpster area. The Dietary Manager stated, housekeeping and maintenance were responsible for maintaining the areas.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and staff interviews, and review of facility documents, the facility staff failed to ensure the facility's floors including resident rooms and common area were kept clean sanitary and homelike. The findings included: On 7/6/22 resident rooms [ROOM NUMBER] were observed with many stains and heavily soiled floors. On 7/11/22 the corridors were heavily soiled and paths of wetness throughout the resident care areas and evidence of wheels rolling through the wetness and tracking it throughout the building were obvious. An interview was conducted with the Director of Environmental Services on 7/11/22 at approximately 4:28 p.m. The Director of Environmental Services stated two staff member quit before the weekend of 7/9/22 - 7/10/22 therefore the manpower needed to provide facility services wasn't available and they are with needed equipment to keep the floors clean. The Director of Environmental Services stated the scrubber has been out of order for approximately a month and they have one buffer…

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 resident and staff interviews, facility document review, and clinical record review, the facility staff failed to follow professional standards of nursing practices for 3 out of 47 residents (Resident #68, #22 and #84) in the survey sample. The findings included: 1. The facility staff failed to follow physician orders for the administering of medication for Resident #68. Resident #68 was originally admitted to the facility on [DATE]. Diagnosis for Resident #68 included but are not limited to Bipolar disorder, major depression and anxiety. The most recent Minimum Data Set (MDS) a quarterly assessment with an Assessment Reference Date (ARD) of 05/31/22 coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 12 out of a possible score of 15, which indicated moderate cognitive impairment for daily decision-making. In section G (Physical functioning) the MDS coded Resident #68 requiring total dependence of one with bathing, extensive assistance of one with toilet use and personal…

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 interviews, and clinical record review, the facility staff failed to ensure a resident wasn't subjected to significant medication errors (omission of critical medications) for 2 of 47 residents (Resident #267 and #319), in the survey sample. The findings included: 1. Resident #267 was originally admitted to the facility 6/14/22 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; surgical interventions related to an abdominal wall infection, DVT, diabetes with neuropathic pain, and end-stage renal disease status post a renal transplant. The 5 Day Medicare Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/16/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #267's cognitive abilities for daily decision making were moderately impaired. In section G (Physical functioning) the resident was coded as requiring total…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and a review of the facility's contracts, it was determined that the facility staff failed to obtain a dialysis contract that would describe the care and services provided by the dialysis center for one resident (Resident #7) in the survey sample of 47 residents. The findings included: 1. Resident #7 was admitted to the facility on [DATE] with diagnoses which included congestive heart failure, peripheral vascular disease, COPD, hypertension, anxiety, depression, end stage renal disease, morbid obesity and GERD. During the entrance conference, one resident (Resident #7) was identified as receiving dialysis care and services outside of the facility. A 6/29/22 Quarterly Minimum Data Set (MDS) assessed this resident as a 14 in the area of Brief interview for mental status (BIMS). In the area of Activities of Daily Living (ADL's) this resident was assessed as requiring extensive assistance in the areas of transfer, dressing, toileting and personal hygiene. A Care Plan dated…

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 and staff interviews the facility staff failed to meet on a quarterly basis and as needed to identify issues with respect to which quality assessment and assurance activities are necessary. maintain a quality assessment and assurance committee consisting at a minimum of: (i) The director of nursing services; (ii) The Medical Director or his/her designee; (iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; The findings included; On [DATE] at approximately 5:01 PM during the initial tour an interview was conducted with the Acting administrator to set up an appointment to discuss the facility's QA/QAPI Plan. She stated, No QAPI meetings have been conducted in over a year. There was no mention of re-establishing QA/QAPI meeting when waivers for them expired [DATE] No documents were provided. On [DATE] at approximately 4:20 PM an interview was conducted with the Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review the facility staff failed to administer the pneumococcal immunization to 3 of 5 residents (Resident #5, 7 and 68) reviewed for the pneumococcal immunization protocol. The findings included: 1. Resident #5 was originally admitted to the facility 07/14/2021 and had never been discharged from the facility. The current diagnoses included a stroke and diabetes. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/24/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 8 out of a possible 15. This indicated Resident #5's cognitive abilities for daily were moderately impaired. Review of the clinical record for immunizations revealed on 10/7/21 Resident #5's representative gave consent for the resident to receive the pneumococcal immunization but it hadn't been administered by 7/12/22. An interview was conducted with the Infection Preventionist on 07/11/22 at approximately 10:30 a.m. The…

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

Based on staff interviews and review of facility documents, the facility staff failed to reduce the risk of COVID-19 transmission from unvaccinated staff by testing staff at least weekly for exempted staff regardless of whether the facility is located in a county with low to moderate community transmission, The findings included: A review was conducted of the twelve staff granted exemption from the COVID-19 vaccination. The review revealed the unvaccinated staff wasn't tested at least weekly for greater than 30 days. An interview was conducted with the Director of Nursing (DON) on 7/7/22 at approximately 1:20 p.m. The DON stated the testing was missed but they will begin testing. On 7/12/22 at approximately 8:00 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided and no further concerns were voiced.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and review of facility documents, the facility staff failed to maintain cleaning equipment in good operational condition to ensure the necessary equipment was available to keep the facility clean, sanitary and homelike. The findings included: On 7/6/22 resident rooms [ROOM NUMBER] were observed with many stains and heavily soiled floors. On 7/11/22 the corridors were heavily soiled and paths of wetness throughout the resident care areas and evidence of wheels rolling through the wetness and tracking it throughout the building were obvious. An interview was conducted with the Director of Environmental Services on 7/11/22 at approximately 4:28 p.m. The Director of Environmental Services stated two staff member quit before the weekend of 7/9/22 - 7/10/22 therefore the manpower needed to provide facility services wasn't available and they are with needed equipment to keep the floors clean. The Director of Environmental Services stated the scrubber has been out of order for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview the facility staff failed to maintain an effective pest control program. The findings included: During the kitchen observation at 11:07 a.m. on 07/07/22, live roaches (numerous) were observed on the wall at the beginning of the serving line were spices were observed stored. Live roaches were observed at the drain line behind the two door oven. Live roaches were observed coming in and out of the left side wall where an eight inch by three inch hole was observed. A pest control tech was observed removing a 4 by 4 tile block off of the wall at the floor drain line hole. Live roaches were observed coming in and out of the hole as well as from behind the tile block. A 7/5/22 pest control service report indicated: Found live cockroaches in kitchen. Inspected and treated. Kitchen- treated area food covered or removed. Rooms - treated- Rooms, 116, 117, 118, 119, 124, 125, dietitian office, hallway to dining room, kitchen dinning room. A 6/1/22 pest control service report…

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, a review of facility documents and during a complaint investigation, the facility's staff failed to notify family of significant weight loss for 1 of 47 residents (Resident #318), in the survey sample. The findings Included: The POS (Physician Order Summary) for May 2021 reads: Weigh Daily every day shift for Heart Failure Monitoring ALERT MD FOR WT GAIN OF 3LB IN ONE DAY, 5LB IN ONE WEEK, INCREASED EDEMA, SOB. Order date: 3/04/21. Start Date: 3/05/21. House Supplement in the morning 237 ml QD Order Date: 04/09/2022. Start Date: 04/10/2022. The Medication Administration Record (MAR) for May 2022 read: Furosemide Tablet 40 MG Give 1 tablet by mouth two times a day for CHF -Start Date 04/06/2021 1700 -D/C Date 05/23/2022 1204. All doses were administered. Resident #318 was originally admitted to the facility on [DATE] and discharged on 5/20/22 to an acute care facility. The current diagnoses included; CHRONIC COMBINED SYSTOLIC…

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

Based on a closed record review, staff interview and a complaint investigation, the facility staff failed to provide one resident (Resident #317 ) with an admissions package including admissions policies, transfer/discharge agreement and financial agreement in the survey sample of 47 residents. The findings included: Resident #317 was admitted to the facility from a hospital on 1/21/22 with diagnoses of muscle weakness, osteoporosis, hypertension and depression. Complainant alleges resident nor Authorized Representative were provided with an admission packet, including admission agreement and financial agreement. A review of the closed clinical record did not reveal an admission agreement was provided or signed by the resident or Authorized Representative. During an interview on 7/6/22 at 4:10 PM the Regional Admissions Director confirmed Resident #317 was not provided with an admission Agreement, Transfer/Discharge Agreement nor a Financial Agreement. An admission policy and procedure was requested but not provided during the survey. Compliant Deficiency

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and facility documentation, the facility staff failed to ensure that 1 of 47 residents (Resident #86) in the survey sample received a complete and accurate assessment Minimum Data Set (MDS). The findings included: 1. The facility staff failed to ensure Resident #86's, quarterly MDS assessment with an Assessment Reference Date (ARD) of 06/09/22 was coded correctly under section N0450 (Antipsychotic Medication Review.) Resident #86 was admitted to the facility on [DATE]. Diagnosis for Resident #86 included but not limited to dementia without behavioral disturbances. The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 06/09/22 coded the Resident #86 with a 01 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. A review of Resident #86's quarterly MDS with an ARD of 06/09/22 was coded for receiving antipsychotic medications. The section N on the 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 record review and staff interview, the facility staff failed to conduct a level I PASARR for one Resident (Resident #30) in the survey sample of 47 residents. The findings included: Resident #30 was admitted to the facility on [DATE] with diagnoses that included Anoxic brain damage, muscle weakness, history of prostate cancer, dementia, epilepsy, heart disease, diabetes, anxiety, insomnia PTSD and impaired safety awareness. The facility staff failed to conduct a level I PASARR. This resident was assessed as having scored an eight on the (BIMS) Brief Interview for Mental Status. A review of the clinical records indicated that Resident #30 did not have a level I PASARR screening. During an interview on on 07/07/22 at 3:15 p.m. the social service director stated Resident #30 had not been screened for a Level I PASARR.

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 47 residents (Resident #3) in the survey sample who were unable to carry out activities of daily living receives the necessary services to maintain fingernail care. The findings included: The facility staff failed to provide necessary fingernail care for Resident #3, a resident who was dependent on staff for activities of daily living (ADL). Resident #3 was admitted to the facility on [DATE]. Diagnosis for Resident #3 included but not limited to Dementia without behavioral disturbances. The most recent Minimum Data Set (MDS) a quarterly assessment with an Assessment Reference Date (ARD) of 06/24/22 coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 03 out of a possible score of 15, which indicated severe cognitive impairment for daily decision-making. The resident was not coded for rejection of care to include Activities of Daily Living (ADL). In section G (Physical…

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 interviews, clinical record review, facility documentation review, the facility staff failed to provide 1 of 47 residents (Resident #323) in the survey sample with respiratory care in accordance with professional standards of practice. The findings included: Resident #323 was admitted to the facility on [DATE]. Diagnosis for Resident #323 included but are not limited to acute and chronic respiratory failure with hypoxia. Resident #323's Minimum Data Set (an assessment protocol) an annual assessment with an Assessment Reference Date (ARD) of 06/06/22 coded the resident's Brief Interview for Mental Status (BIMS) score 12 of a possible 15 with moderate cognitive impairment for daily decision-making. In section O (Special Treatment and Programs) was coded for the use of oxygen therapy. During the initial tour on 07/05/22 at approximately 3:10 p.m., Resident #323 was observed lying in bed with oxygen on at 4 liters minute via nasal cannula. On 07/06/22 at approximately…

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 obtained during the Sufficient and Competent Nurse Staffing task, the facility staff failed to staff a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week which could potentially affect all residents. The facility staff failed to staff an RN for at least 8 consecutive hours for 7 days The findings included: During the nursing staff review for 1/09/22, 2/05/22 and 2/06/22 the facility staff was unable to verify RN presence in the facility for at least 8 consecutive hours on 2/27/22. On 7/12/22 at approximately 6:00 PM., an interview was conducted with ASM (Administrative Staff Member/Clinical Support). She said that the facility should have coverage for 8 hours everyday. The above findings were shared with the Administrator, the Assistant administrator at approximately 9:30 PM. No comments were made concerning the above issue.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interviews the facility staff failed to present its QAPI plan to the State Survey Agency and to ensure Good faith attempts by the committee to identify and correct quality deficiencies. The findings included; On [DATE] at approximately 5:01 PM during the initial tour an interview was conducted with the Acting administrator to set up an appointment to discuss the facility's QA/QAPI Plan. She stated, No QAPI meetings have been conducted in over a year. There was no mention of re-establishing QA/QAPI meeting when waivers for them expired on [DATE] During the course of the survey quality deficiencies were identified in the areas of medication procurement. 1. The DON stated the management team and the Medical Director were aware there were problems procuring medications timely and they had begun strategizing on back-up pharmacies but; it wasn't finalized. The DON also stated on the average it takes two days before a new admission's medications arrives to the facility which in 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 information obtain during the Infection Control task, staff interview, and facility documentation review, the facility staff failed to ensure 1 of 47 residents (Resident #268), didn't receive antibiotics therapy when clinical guidelines for prescribing an antibiotics was not met. The facility staff administered Macrobid 100 milligrams (mg) and Cipro 250 mg (antibiotic) to Resident #68, for a bacteria resistant to the drug. The findings included: Resident #268 was originally admitted to the facility [DATE] and died in the facility [DATE]. The resident's diagnoses included; a stroke with hemiparesis and aphasia. The admission 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 0 out of a possible 15. This indicated Resident #268's cognitive abilities for daily decision making were severely impaired. On [DATE] at 10:30 a.m., an Infection Control interview was conducted with 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 the facility staff failed to have a designated Infection Preventionist who had completed a specialized training in infection prevention and control oversee the COVID-19 infection program. The findings included: On 7/6/22 at approximately 10:40 a.m., an interview was conducted with the Infection Preventionist who had completed a specialized training in infection prevention and control to review the COVID-19 infection program. The Infection preventionist stated she oversaw all of the infection control program except the COVID-19 program because the previous Director of Nursing (DON) managed the program and now the new DON was managing the COVID-19 infection program. An interview was conducted with the DON on 7/7/22 at approximately 1:20 p.m. The DON stated she was the designated person to oversee the COVID-19 infection program but she hadn't completed specialized training in infection prevention and control. The DON further stated her role as the COVID-19 Infection Preventionist would cease and the plan was for the current in-house Infection Preventionist to…

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

Based on staff interviews clinical record review, and review of facility documents, the facility staff failed to inform residents, their representatives, and families of those residing in the facility by 5 p.m., the next calendar day or at least weekly following the occurrence of a single confirmed infection of COVID-19. The findings included: A review was conducted of the number of resident and staff COVID-19 cases over the last 4 weeks (6/7/22 - 7/6/22); it revealed Licensed Practical Nurse (LPN) #9 reported to work on 7/3/22 with a headache and expressed not feeling well. LPN #10 completed a Rapid COVID-19 test of LPN #9. The results identified LPN #9 as positive for a COVID-19 infection. LPN #10 stated the LPN #9 didn't enter the resident living area and was sent home after the positive results were confirmed. An interview was conducted with the Director of Nursing (DON) on 7/7/22 at approximately 1:20 p.m. The DON stated the facility staff began to inform resident representatives, and families of those residing in the facility of the COVID-19 positive staff member's case but…

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 and clinical record reviews the facility staff failed to issue written Bed Hold Notices to 3 Residents and/or Resident Representatives (Resident #17, Resident #121, Resident #106) out of 56 residents in the survey sample, when discharged to the hospital. 1. Resident #17 was discharged to the hospital on [DATE] and the facility staff failed to issue the Resident and/or Resident Representative a written Bed Hold Notice. 2. For Resident #121, the facility staff failed to issue a written Bed Hold Notice to the Resident and/or Resident Representative when discharged to the hospital on [DATE]. 3. The facility staff failed to ensure Resident #106 or Resident Representative (RR), who resided on [NAME] Hall, was issued a written notice of the bed hold reserve policy upon transfer to the local hospital on 2/12/19 and on 3/14/19. The findings included: 1. Resident #17 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnoses included but were not limited 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 observation, staff interview and facility record review, it was determined that facility staff failed to dispose of trash in a sanitary manner for one of one trash compactor and one of one recycle compactor. Facility staff failed to ensure one of one trash compactor and one of one recycle compactor were free from surrounding debris. The findings include: On 5/14/19 at 12:30 p.m., observation of the facility dumpster area was conducted with OSM (other staff member) #5, dietary aide and stock. It was observed that that facility had one trash and one recycle compacter. The trash compactor was observed to have the following debris on the ground around it: three gloves, plastic spoon and a plastic cup. The recycle compactor was observed to have the following debris on the ground around it: plastic bag, cookie wrapper, and a flattened box. At that time an interview was conducted with OSM #5 When asked who was responsible for maintaining the compactors in a sanitary manner, OSM #5 stated that it was his responsibility to check the compactors at least once a day. When asked if the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review, and review of the facility's policy the facility staff failed to create an environment to accommodate the needs for 1 of 56 residents (Resident #50), in the survey sample. The facility's staff failed to ensure a call bell system was in place that Resident #50 was capable of using to contact the staff. The findings included: Resident #50 was originally admitted to the facility 6/14/18, and readmitted [DATE], after an acute care hospital stay. The current diagnoses were quadriplegia, traumatic brain injury, hepatitis and cirrhosis. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/21/19, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 0 out of a possible 15. This indicated Resident #50's cognitive abilities for daily decision making were severely impaired. In section G (Physical functioning) the resident was coded as requiring extensive assistance…

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 and clinical record reviews the facility staff failed to send care plan summary goals for 4 residents (Resident #17, Resident #121, Resident #111, Resident #106 ) out of 56 residents in the survey sample when discharged to the hospital. 1. The facility staff failed to send Resident # 17's care plan summary goals when discharged to the hospital. 2. The facility staff failed to send care plan summary goals for Resident #121 when discharged to the hospital. 3. The facility staff failed to ensure that Resident #111's Plan of Care Summary to include their care plan goals was sent upon transfer/discharge to the hospital on [DATE]. 4. The facility staff failed to include in the transfer summary indication that the facility staff conveyed to the receiving providers the resident's comprehensive care plan goals at the time of discharge to the local hospital on 2/12/19 and 3/14/19 or as soon as possible to the actual time of transfer for Resident #106. The findings included: 1. Resident #17 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 clinical record review, staff interviews and facility documentation review, the facility staff failed to issue a Preadmission Screening and Resident Review (PASRR) for 1 out of 56 residents (Resident #88) in the survey sample. Resident #88 did not have the required Level I PASRR to assess for service that might be necessary based on diagnosis of a mental disorder. The findings included: Resident #88 was admitted to the nursing facility on 7/4/18 with diagnoses that included bipolar disorder and schizophrenia. There was no documentation in the clinical record that a Level I PASRR was completed. Resident #88's most recent Minimum Data Set (MDS) assessment dated [DATE] was a quarterly assessment which coded the resident with short and long term memory and severely impaired with the necessary skills for daily decision making. The resident's active diagnoses were coded in Section I: anxiety disorder, depression, manic depression (bipolar) and psychotic disorder, schizophrenia. On 5/16/19 at 3:15 p.m., an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to develop the comprehensive care plan for two of 56 residents in the survey sample, Resident #44 and #50. 1. For Resident #44, facility staff failed to develop a nutritional care plan to her comprehensive care plan dated 12/27/17. 2. The facility staff failed to develop a care plan to address Resident #50's inability to utilize a regular call light due to decreased range of motion of bilateral hands related to quadriplegia and traumatic brain injury. The findings include: 1. Resident #44 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Bipolar disorder, anxiety disorder, and mild cognitive impairment. Resident #44's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 3/3/19. Resident #44 was coded as being intact in cognitive function scoring 12 out of possible 15 on the BIMS (Brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview and facility document review, it was determined that facility staff failed to follow professional standards of practice for one of 56 residents in the surveys sample, Resident #7. For Resident #7, facility staff failed to obtain daily weights per physician's order and the comprehensive care plan. The findings include: Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to, atrial fibrillation, chronic kidney disease stage 3, high blood pressure, and type two diabetes. Resident #7's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 2/12/19. Resident #7 was coded as being cognitively intact in the ability to make daily decisions scoring 12 out of possible 15 on the BIMS (brief interview for mental status) exam. Review of Resident #7's clinical record revealed the following order: weight daily every day shift for heart failure,…

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, resident interview, clinical record review, it was determined that facility staff failed to provide respiratory treatment and services for one of 56 residents in the survey sample, Resident #13. For Resident #13 facility staff failed to administer oxygen per physician's order and comprehensive care plan. The findings include: Resident #13 was admitted to the facility on [DATE] and 1/11/18 with diagnoses that included but were not limited to heart failure, COPD (chronic obstructive pulmonary disease) and high blood pressure. Resident #13's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 4/23/19. Resident #13 was coded as being mildly impaired in cognitive function scoring 09 out of 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #13 was coded in Section O Special treatments, Procedures, and Programs as receiving oxygen therapy. Review of Resident #13's clinical record revealed 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 staff interview, facility document review, and clinical record review, it was determined that facility staff failed to ensure timely physician visits for one of 56 residents in the survey sample, Resident #44. For Resident #44, facility staff failed to ensure physician visits between the dates of: 5/25/18 through 9/19/18 (over 4 months) and 9/19/18 through 3/23/19 (6 months). The findings include: Resident #44 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Bipolar disorder, anxiety disorder, and mild cognitive impairment. Resident #44's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 3/3/19. Resident #44 was coded as 12 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam which indicated moderate cognitive impairment. Review of Resident #44's clinical record revealed that the nurse practitioner (NP) had visited Resident #44 on the following dates: 5/25/18 9/19/18 3/23/19…

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

Based on observation, staff interview, and facility document review, the facility staff failed to ensure Registered Nurse (RN) coverage for 8 hours, 7 days a week. The facility staff failed to ensure RN coverage for 8 hours on three days 11/10/18, 12/09/18 and 01/20/19. The findings included: On 05/14/19 at approximately 11:00 AM, the facility's actual worked schedule was reviewed with Other Staff #7 (Nursing Scheduler) and revealed there was no RN coverage for the following days: 11/10/18, 12/09/18 and 01/20/19. On 05/16/19 at approximately 9:45 AM, Other Staff #7 asked surveyor if she could re-check the above RN (Registered Nurse) non- coverage dates and staffing. Other Staff #7 later confirmed that there was no RN coverage for the above dates. She was asked what should have been done to ensure RN coverage? She stated that usually she would know ahead of time if an RN wouldn't be able to work. She also stated that if an RN staff member was calling out after hours they would call to the unit to inform the nurse supervisor that they wouldn't be coming in. The Nurse Supervisor, would…

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

Based on staff interview, clinical record review, and review of the facility's Infection Control policy, the facility staff failed to have an Infection Control and Prevention program which monitored all antibiotics administered by the facility staff. The facility's staff failed to have an antibiotic stewardship program which monitored newly and readmitted residents who were prescribed antibiotics in the hospital, to ensure indication of use was validated and the resident was prescribed an appropriate antibiotic. The findings included: The facility's infection control records for March 2019 were reviewed with the Assistant Director of Nursing (ADON) for three residents who were admitted to the facility receiving antibiotic therapy for urinary tract infections (UTI). The infection control records indicated one resident's laboratory data included a clean catch urinalysis with microscopic reflex culture and two residents laboratory data included a urinalysis only. The resident who had the clean catch urinalysis with microscopic reflex culture on 3/3/19 revealed a laboratory report…

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, facility documents, staff interviews and review of the facility's policy, the facility staff failed to accurately code Minimum Data Set (MDS) assessments for 9 of 35 residents, (Resident #17, and #27 through #34) in the survey sample. 1. The facility staff failed to accurately code Resident #17's Annual MDS assessment at A1500 and A1510. 2. The facility staff failed to accurately code Resident #27's Initial admission MDS assessment at A0600A and A0600B. 3. The facility staff failed to accurately code Resident #28's Initial admission MDS assessment at A0600A and A0600B. 4. The facility staff failed to accurately code Resident #29's Initial admission MDS assessment at A0800. 5. The facility staff failed to accurately code Resident #30's Initial admission MDS assessment at A0500 and A0600A. 6. The facility staff failed to accurately code Resident #31's Initial admission MDS assessment at A0800. 7. The facility staff failed to accurately code Resident #32's Initial admission 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 observation, staff interview, clinical record review and facility document review, the facility staff failed to ensure 1 of 35 residents in the survey sample, Resident #9, was free of significant medication error . The facility staff failed to administer the correct dosage of Eliquis (1) tablet for Resident #9. Eliquis tablet 5 mg (milligrams) two times a day was administered by the nurses for 5 1/2 days instead of Eliquis 10 mg two times a day, as ordered by the physician. The findings included: Resident #9 was admitted to the facility on [DATE]. Diagnoses for Resident #9 included but not limited to, muscle weakness, UTI (urinary tract infection), high blood pressure, depression, anxiety disorder, and post-surgical care. The most recent Minimum Data Set with an assessment reference date of 8/6/17, coded Resident #9 with a score of 15 out of possible 15 on the Brief Interview for Mental Status (BIMS), indicating Resident #9's cognitive abilities for daily decision making are intact. On 8/8/17 at…

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

Based on staff interview, family interview, clinical record review, facility document review and during the course of a complaint investigation the facility staff failed to ensure 2 of 35 residents in the survey sample were free from misappropriation of personnel property, Resident #35 and #26. 1. Registered Nurse #3 deliberately took an estimated 14 tablets of the medication Tramadol (1) from Resident #35's medication supply, without administering the medications. 2. Registered Nurse #3 deliberately took two tablets of the medication Tramadol from Resident #26's medication supply, without administering the medication. A Facility Reported Incident (FRI) sent to the State Survey Agency on 4/12/17 reported that an investigation of an allegation of misappropriation of resident's narcotic medication was underway for both Resident #35 and #26. The facility's investigation completed on 4/14/17 substantiated the allegation and the nurse was terminated. The findings included: 1. Resident #35 was admitted to the facility with an initial admission date of 8/3/15 and readmission date of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and review of the facility's policy the facility staff failed to ensure that an individual with intellectual disability, care and services incorporated the recommendations from the PASRR level II determination and to ensure further Community Service Board services were incorporated into the resident's assessments and care plan for 1 of 35 residents (Resident #17), in the survey sample. The findings included; Resident #17 was originally admitted to the facility 4/8/08 and readmitted [DATE] after an acute hospitalization. The current diagnoses included intellectual disability, cerebral palsy, and a seizure disorder. The Annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/1/17 coded the resident as not completing the Brief Interview for Mental Status (BIMS). The staff interview indicated the resident was with long and short term memory problems and severely impaired decision making abilities. Review of the 5/1/17 MDS assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review, and review of the facility's policy the facility staff failed to ensure 1 of 35 resident (Resident #8) in the survey sample received necessary equipment to aid in prevention of urinary incontinence episodes. The facility staff failed to provide Resident #8 with a bedpan for use when in bed. The findings included: Resident #8 was originally admitted to the facility 8/6/16 and readmitted [DATE]. The current diagnoses included; bilateral below the knee lower extremity amputations, hypertension and heart failure requiring diuretic therapy. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/20/17 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #8's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring extensive assistance of 1 person with 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 observation, resident interview, clinical record review and facility document review the facility staff failed to ensure topical (external) medications were properly stored for 1 of 35 residents in the survey sample, Resident #14. A container of ammonium lactate 1% medication cream and a bottle of Triamcinolone 1% medication cream were observed stored inside Resident #14's room. The findings included: Resident #14 was admitted to the facility on [DATE] following a hospitalization for a pulmonary (lung) embolism (a blockage in the pulmonary artery) and generalized weakness. The current MDS (Minimum Data Set) an admission with an assessment reference date of 8/1/17 coded the resident as scoring a 15 out of a possible 15 on the Brief Interview for Mental Status, indicating the resident's cognition was intact. On 8/8/17 an initial tour of the facility was conducted. Resident #14 was observed sitting on the side of the bed. Observed on the bedside drawer were two medication creams. One container of ammonium…

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.