Northern Cardinal Rehabilitation And Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review the facility staff failed to ensure 2 residents out of 57 (Resident #57 and 74) in the survey sample who was unable to carry out activities of daily living receives the necessary services to maintain fingernail care and showers. The findings included: 1. Resident #57 was admitted to the facility on [DATE]. Diagnosis included but not limited to Alzheimer's disease, dementia, cerebrovascular accident (CVA) with right sided hemiplegia and hemiparesis. The current Minimum Data Set (MDS) a quarterly assessment with an Assessment Reference Date (ARD) of 02/03/23 coded the resident with a 00 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. The MDS coded Resident #57 required total dependence of one with dressing and bathing, extensive assistance of one with bed mobility, transfer, toilet use and personal hygiene and supervision with eating for Activities of Daily Living (ADL) care.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to provide oxygen therapy as needed for one (Resident (R) 28) of two residents reviewed who required respiratory care received out of a total sample of 57 residents. Oxygen was not continuously delivered at the rate ordered by the physician and was removed by staff who were not qualified to perform this task. Findings include: Review of the facility's policy titled, Oxygen Administration, revised 12/01/22, revealed, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the residents' goals and preferences . 2. Personnel authorized to initiate oxygen therapy include physicians, RNs [Registered Nurse], LPNs,[Licensed Practical Nurse] and respiratory therapists. Review of R28's admission Record, located in the electronic medical record (EMR) under the Profile tab, indicated R28 was originally admitted to the facility 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 interview, record review, and facility policy review, the facility failed to ensure that medication irregularities identified by the consultant pharmacist were acted upon for two (Resident (R)35 and R80) of five residents reviewed for unnecessary medication use. The failure to ensure that the physician reviewed and responded to the pharmacist's recommendations placed the residents at risk for unnecessary medications and associated side effects. Findings include: Review of an undated document provided by the facility titled Addressing Pharmacy Recommendations revealed Step 1: Pharmacy recommendations are given to the prescriber/physician. The Director of Nursing (DON) or designee ensure that pharmacy recommendations are delivered to the prescriber/attending physician in a timely manner .Step 2: Nursing to follow through per prescriber's response. DON or designee ensures that recommendations signed by the prescriber are acted upon in the medical record .Step 3: Maintaining a record of addressed pharmacy…

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 resident and staff interview, clinical record review and facility document review, the facility staff failed to ensure 1 of 57 residents (Resident #312) in the survey sample were free of significant medication errors. The findings included: The facility staff failed to ensure the following significant medication Seroquel was administered as ordered to Resident #312. Diagnosis included but not limited to dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. A review of the Brief Interview for Mental Status (BIMS) admission assessment scored a 13 out of a possible 15 indicating moderate cognitive skills for daily decision-making. Resident #312's care plan created on 04/11/23 identified the resident uses anti-psychotropic medications. The goal set for the resident by the staff was that the resident will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction, or cognitive/behavioral impairment. Some of the interventions/approaches the staff…

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

Based on observation, staff interviews and facility documentation review the facility staff failed to ensure a bottle of medication (Aspirin 81 mg) was stored in a secured location, accessible to designated staff only. The findings included: On 04/12/23 at 11:25 a.m., a bottle of medication was observed on top of Medication Cart two (2) on the Chesapeake Unit. The nurse assigned to Cart 2 was not in view of the medication cart. The bottle of medication was observed for 4 minutes on top of the medication cart as residents, staff and visitors walked past. On the same day, the Assistant Director of Nursing (ADON) and Unit Manager arrived at the medication cart at 11:29 a.m. They were asked if the bottle of medication left on top of the cart unattended contained any medication. The ADON picked up the bottle of medication; shook the bottle and stated, Yes, there's medication inside the bottle. The ADON stated the medication was Aspirin 81 mg tablets. The ADON stated mediation should never be left on top of the medication when not in direct view. She stated the medication should have been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy reviews, the facility failed to ensure that three (Resident (R) 38, R62, and R414) of five residents reviewed for vaccine administration, were offered and/or received the pneumococcal series and/or influenza vaccination. Specifically, R38 was not educated or offered the pneumococcal series or influenza vaccination, R62 was not educated or offered the pneumococcal series, and R414 was not offered the influenza vaccination. Findings included: Review of the facility's Immunization Informed Consent Record, revised 2020, revealed a statement that said, I certify that I have received relevant Vaccine Information Statements (VIS) that provide current CDC [Center for Disease Control] information about the vaccine(s) I have elected to receive. I further certify that the benefits and potential side effects of such immunization(s) have been thoroughly explained to me and I do understand such information . Place the original signed and dated copy of this form 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 interview, record review, and review of facility policy, the facility failed to timely notify the families of two (Resident (R) 63 and R73) of 57 sampled residents by 5:00 PM the following day when the residents tested positive for COVID-19. Findings include: Review of the facility policy titled, Coronavirus Prevention and Response revised 07/18/22, stated, Notify physician, Director of Nursing, Infection Preventionist, and family. Review of the facility's document titled COVID-19 Action Plan revised 02/15/22. stated, Facility will notify and document Medical Director, attending physician, resident and family of positive COVID-19 case/s in the facility as well as emergency plans initiated. Notifications to be documented in PCC [Point Click Care electronic medical record] for residents . Communication plan is activated, and staff are assigned to contact family members at least weekly with updates. Review of the policy titled Notification of Changes with a revised date of 12/01/22 revealed it was the facility's policy to notify the family member/legal representative when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to provide required education and offer immunization to one (Resident (R) 414) of five residents reviewed for immunizations. Specifically, the facility failed to provide education and offer the COVID-19 vaccine to the resident. Findings include: Review of the facility's policy titled, Coronavirus Prevention and Response, revised 07/18/22, revealed, 11. Vaccination Planning a. All facility staff and residents will be encouraged to get vaccinated against SARS-CoV-2. Review of the facility's policy titled, COVID-19 Action Plan, revised 02/15/22, revealed, All residents are to be offered and provided a COVID-19 vaccination(s) as indicated. Any resident who refuses vaccination must have a declination form documented. Education regarding vaccinations must also be offered and recorded in the medical record. Review of R414's admission Record, located in the electronic medical record (EMR) under the Profile tab, indicated the resident 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 resident interviews, staff interviews, and clinical record review the facility staff failed to administer medications as ordered by the physician for 2 of 42 residents in the survey sample, Resident #3 and #25. The findings included: 1. The facility staff failed to administer medications at the correct time for Resident #3. Resident #3 was admitted to the facility on [DATE] with diagnoses to include, but not limited to, chronic obstructive pulmonary disease (COPD), restless leg syndrome, heart failure and high blood pressure. The current MDS (Minimum Data Set) an annual with an assessment reference date of 8/5/19, coded the resident as scoring a 15 out of a possible 15, indicating the resident's cognition was intact. On 10/1/19 during the initial tour of the facility, the resident was observed in bed and reading a letter. The resident was interviewed on the care and serviced provided by the facility . The resident stated that the staff often administer his medications late. He stated this occurred…

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 and facility document review, the facility staff failed to determine that it was safe for one of 42 residents in the survey sample to self-administer medications, Resident #7. The findings include: Resident #7 was admitted to the facility on [DATE] with diagnoses to include but not limited to, unspecified dementia, gastro-esophageal reflux disease (GERD), anxiety disorder, major depression and chronic pain syndrome. The current MDS (Minimum Data Set) a quarterly with an assessment reference date of 9/23/19, coded Resident #7 as scoring a 15 out of a possible 15, indicating the resident's cognition was intact. The resident required supervision for all activities of daily living. The pain assessment coded the resident as having experienced pain almost constantly making it difficult to sleep at night and limiting day-to-day activities with a pain level score of 10 out of a possible 10 (zero being no pain and ten as the worst pain you…

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 and facility document review the facility staff failed to revise the comprehensive person-centered care plan to include medication self-administration for one of 42 residents in the survey sample, Resident #7. The findings include: Resident #7 was admitted to the facility on [DATE] with diagnoses to include but not limited to, unspecified dementia, gastro-esophageal reflux disease (GERD), anxiety disorder, major depression and chronic pain syndrome. The current MDS (Minimum Data Set) a quarterly with an assessment reference date of 9/23/19 coded the resident as scoring a 15 out of a possible 15, indicating the resident's cognition was intact. The resident required supervision for all activities of daily living. The pain assessment coded the resident as having experienced pain almost constantly making it difficult to sleep at night and limiting day-to-day activities with a pain level score of 10 out of a possible 10 (zero being no…

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, clinical record review and facility documentation review the facility staff failed to meet professional standards for the administration of medications for 1 of 42 residents (Resident #25) in the survey sample. Resident #25 was administered her roommate's medications in error. The findings included: Resident #25 was admitted to the facility on [DATE] with diagnoses to include Type II Diabetes and Depressive Disorder. The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 07/29/19, coded the resident with a 12 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. During the Resident Council Meeting held on 10/02/19 at approximately 10:00 a.m., Resident #25 reported she was given her roommates medication. An interview was conducted with the Director of Nursing (DON) on 10/03/19 at approximately 10:05 a.m. The DON said she completed a Medication Error…

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 interviews and clinical record review the facility staff failed to ensure 3 residents (Resident #15, #57, #288) out of 42 residents in the survey sample, received the necessary services to maintain good personal hygiene. The findings included: 1. For Resident #15, the facility staff failed to provide fingernail care. Resident #15 was admitted to the facility on [DATE]. Diagnosis included but were not limited to, Functional Quadriplegia and Dementia. Resident #15's admission Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 07/16/2019 coded Resident #15 with a BIMS (Brief Interview for Mental Status) score of 02 indicating severely impaired cognitive skills for daily decision making. In addition, the Minimum Data Set coded Resident #15 as requiring limited assistance of 1 with eating, extensive assistance of 1 with toilet use, extensive assistance of 2 with personal hygiene, dressing, bed mobility and transfer and total dependence…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review the facility staff failed to ensure 1 of 42 residents in the survey sample received the appropriate treatment and services to prevent further decrease in range of motion, Resident #57. The facility staff failed to consistently apply the left comfy knee orthosis as ordered. The findings included: Resident #57 was admitted to the facility on [DATE] with diagnoses to include but not limited to, contracture of the left leg and functional quadriplegia (paralysis of all four extremities). The current MDS (Minimum Data Set) an annual assessment with an assessment reference date of 8/26/19 coded the resident as scoring a 2 out of a possible 15 on the brief interview for mental status (BIMS), indicating the resident had severely impaired cognition. The resident was dependent on staff for all activities of daily living (ADL) to include personal hygiene/grooming such as nail care and dressing. The resident had functional limitation of range of motion to both…

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, clinical record review and facility documentation review, the facility staff failed to ensure 1 out of 42 residents, Resident #25 was free from the use of unnecessary medications. Resident #25 was administered another resident's medications in error. The findings included: Resident #25 was admitted to the facility on [DATE] with diagnoses to include Type II Diabetes and Depressive Disorder. The current Minimum Data Set (MDS) a quarterly assessment with an Assessment Reference Date (ARD) of 07/29/19, coded the resident with a 12 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. During Resident Council Meeting held on 10/02/19 at approximately 10:00 a.m., Resident #25 reported she was given her roommates medication. An interview was conducted with the Director of Nursing (DON) on 10/03/19 at approximately 10:05 a.m. The DON said she completed a Medication Error Report on Resident #25; the nurse…

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 general observations of the nursing facility, the facility failed to ensure medications were labeled in accordance with currently accepted professional principles in 1 out of 5 medication carts. The findings included: The facility staff failed to ensure medication that was taken out of its original package was identified in a medication cup inside the medication cart. On 10/02/19 at 2:45 p.m., an inspection of the medication cart was made on the Nansemond Unit. The surveyor inspected the cart with Licensed Practical Nurse (LPN) #1. The LPN opened the medication cart and located inside the medication cart was a white plastic medication cup containing 6 pink pills. The LPN had written Aspirin 81 mg on the outside of the medication cup. The LPN stated, No one else is getting (Aspirin) on this shift. The LPN stated, I did not have any Aspirin on this cart so I borrowed from another cart and placed them in the medication cart. When asked if the Aspirin should be in its original container, LPN #1 replied, Yes, the aspirin should be in its original container when stored inside the…

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

Based on staff interview and documentation review the facility staff failed to ensure 2 out of 6 Certified Nursing Assistants (CNA) received their required annual dementia training. The findings included: On 10/03/19 at approximately 10:15 a.m., the surveyor requested evidence that Certified Nursing Assistant (CNA) #4 and CNA #5 received their annual mandatory training on dementia. On the same day at approximately 5:25 p.m., the Director of Nursing (DON) said the Staff Development Coordinator (SDC) had the facility's annual Skills Fair on July 15-16 2019. The DON said she reviewed the Program/Course Title from the Skills Fair but it did not include education on dementia. The DON stated, I'm not able to provide evidence that CNA #4 and CNA #5 received their yearly mandatory dementia training. The DON stated the Skills Fair should have consisted of all the mandatory training required by the CNA's. The DON presented a list of the training from the Skills Fair presented on 07/15-07/16/19, which consisted of the following training: -Point Click Care Documentation -Transfers -Activities…

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, resident interview, and staff interview, the facility failed to provide baseline care plan summaries to the resident or the resident's respresentative; and failed to document in the medical record that summaries were provided for 7 of 41 residents in the survey sample (Residents #25, #64, #213, #96, #103, #51, and #57). The findings included: 1. Resident #25 was admitted to the facility on [DATE]. Diagnoses for Resident #25 included but were not limited to COPD (Chronic Obstructive Pulmonary Disease. Resident #5's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of scored Resident #5 with a score of 15 out of a possible 15 BIMS (Brief Interview for Mental Status) indicating no cognitive impairment. The Resident required two staff person assistance with bed mobility and required one staff person assistance with transfers, locomotion on unit, dressing, toilet use and personal hygiene. The Comprehensive Person Centered Care Plan revised on [DATE] identified a focus…

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 an extended survey task, a review of the facility's competencies for the Certified Nursing Assistants (CNA) was completed. The facility staff failed to demonstrate the required 12 hours continual competencies were completed for 6 CNAs. The findings included: During an interview with the Staff Development Coordinator (SDC) on 3/19/18 at 10:45 a.m., she stated she and the Director of Nursing (DON) discovered problems existed with the transference of an old paper system of recording required educational competencies to the new electronic portal system. They stated they had not recognized the problem existed until the CNA competencies were requested by this surveyor. They further said, after several days of cross referencing and analysis of educational requirements, as well as interviews, they identified 6 CNA's that had not completed any of their mandatory annual competencies to equal 12 hours. All 6 had 0 hours. The SDC presented a list of the facilities required training that included the following mandatory annual competencies: -Client rights and promotion of independence…

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,clinical record review, facility document review, and staff interviews, the facility staff failed to ensure an effective infection control program to help prevent the development and transmission of communicable diseases and infections. 1. The facility staff failed to report and track infection control data for months. 2. The facility staff failed to ensure infection control measures were implemented during a glucometer check to prevent the potential of cross contamination. 3. The facility staff failed to ensure handwashing between feeding of residents in the dining room was implemented to prevent the potential of cross contamination. 4. Facility failed to ensure resident # 96 nebulizer was stored in a sanitary manner. 5. Facility failed to store respiratory equipment in a sanitary manner for resident #103. The findings included: 1. On 3/16/18 at approximately 2:00 p.m. the facility Infection Control Program was reviewed with the Infection Control Nurse RN (Registered Nurse) #5. The review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to invite 2 of 41 residents in the survey sample, to attend their person centered care plan meeting (Resident #10 and #75). The findings included: 1. Resident #10 was originally admitted to the facility on [DATE]. Diagnosis for Resident #10 included but not limited to Heart Failure and Diabetes Mellitus. The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 2/26/18 coded the resident with an 11 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. In addition, the MDS coded Resident #75 with total dependence of two with bathing, transfer, and personal hygiene, and total dependence of one with toilet, extensive assistance of two with bed mobility and dressing. During the initial tour on 3/12/18 at approximately 3:19 p.m., an interview was conducted with Resident #75 who…

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, resident interview, and facility documentation review, the facility staff failed notify the physician and resident representative of an abuse allegation with injury for one (1) of 41 residents (Resident #75) in the survey sample. The finding included: Resident #75 was admitted to the facility on [DATE]. Diagnosis for Resident #75 included but not limited to Type II Diabetes and Hypertension The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 2/9/18 coded the resident with a 15 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 #75 with extensive assistance of one transfers, bed mobility, dressing, toilet use, personal hygiene and bathing. The resident was coded to have verbal behaviors directed at others, and other behaviors directed at others, 4 to 6 days out of the 7-day assessment period. She was also coded for reject care 1 to 3 days…

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, the facility staff failed to ensure Medicare Beneficiary Notices were issued to 2 of 41 residents (Residents #75 and #94) in the survey sample. The findings included: 1. Resident #75 was admitted to the nursing facility on 1/11/18 with a diagnosis of congestive heart failure (CHF), neuropathy and difficulty walking. The Minimum Data Set (MDS) admission assessment dated [DATE] coded the resident with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was intact in the skills needed for daily decision making. On review of the Beneficiary Notification Checklists provided by the facility to surveyors it was noted that Resident #75 was not listed for having been issued the SNF ABN (Skilled Nursing Facility-Advanced Beneficiary Notice, form CMS-10055). The resident had received a NOMNC (Notice of Medicare Provider Non-Coverage- form CMS-10123), however no copies of the SNF…

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 and resident interview, and the investigation of a Facility Reported Incident (FRI), The facility staff failed to ensure privacy and confidentiality was maintained for two residents (Resident #34 and #163) in the survey sample of 41 residents. The findings included: 1. Resident #163 was admitted to the facility on [DATE] with diagnoses which included quadriparesis due to severe spinal canal stenosis with advanced cord compression at C2-3 and C3-4. This resident had diagnoses of Cervical spine DJD and neck pain, prerenal azotemia, type 2 diabetes, hypertension, thrombocytopenia. No Minimum Data Set information was available due to the resident's short stay in the facility. During the investigation of a FRI dated 2/14/18 Resident #163's roommate complained of staff treating him roughly. The roommate stated to the nursing staff, You are on camera. Resident #163 was discharged from the facility on 2/12/18. During an interview on 3/16/18 at 2:15 P.M. with the Director of Nursing (DON)…

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, resident interview, and review facility documentation, the facility staff failed to notify the State Survey Agency of an allegation of abuse in a timely manner for 2 of 41 residents (Resident #75 and 34) in survey sample. 1. The facility staff failed to report to the State Survey Agency an allegation of abuse involving Resident #75 within 24 hours of their knowledge of the incident. 2. 1. The facility staff failed to ensure the results of an investigation of alleged abuse involving Resident #34 was reported to the State Survey Agency within 5 days. The finding include: 1. Resident #75 was admitted to the facility on [DATE]. Diagnosis for Resident #75 included but not limited to Type II Diabetes and Hypertension. The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 2/9/18 coded the resident with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. In addition, the MDS coded…

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 reviews, and staff interviews the facility staff failed complete a thorough investigation of a Facility Reported Incident (FRI) for 1 resident (Resident #34) in the survey sample of 41 residents. The findings included: Resident #34 was admitted to the facility on [DATE]. This resident was admitted with diagnoses which included benign prostatic hyperplasia with lower urinary tract symptoms, Type 2 Diabetes Mellitus, dependence on renal dialysis, chronic obstructive pulmonary disease, severe protein - calorie malnutrition, acute embolism and thrombosis, chronic kidney disease, and cognitive communication deficit. An Initial Minimum Data Set (MDS) dated [DATE] assessed this resident in the area of Hearing, Speech and Vision as having no concerns. In the area of Cognitive Patterns this resident was assessed as having a Brief Interview for Mental Status (BIMS) as having a score of (13). In the area of Cognitive Patterns this resident was coded as having no concerns. In the area of Mood, this 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.

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 send a copy of the Bed-Hold Policy for 1 of 41 residents in the survey sample (Resident #109). The facility staff failed to provide Resident #109 or the resident's representative, with a written or a copy of the bed hold policy after being transferred to the hospital on 1/20/18. The finding include: Resident #109 was originally admitted to the facility on [DATE]. Diagnosis for Resident #10 included but not limited to Heart Failure and Seizures. The current Minimum Data Set (MDS), a comprehensive assessment with an Assessment Reference Date (ARD) of 02/26/18 coded the resident with a 02 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. In addition, the MDS coded Resident #109 with total dependence of with eating and bathing, extensive assistance of two with bed mobility and toilet use, extensive assistance of one with dressing 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 interviews, staff interviews, facility documentation review, and clinical record review, the facility staff failed to review and revise the comprehensive care plan for 1 of 41 residents in the survey sample (Residents #263 and #34). The facility failed to include painful thickened toenails on the care plan for Resident # 263. The findings included: Resident #263 was admitted to the facility on [DATE]. Diagnoses for Resident #263 included but are not limited to Chronic Pain Syndrome, Anxiety and Mycotic Toenails. Resident #263's Significant Change Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 1/22/18 scored Resident #263 with a BIMS (Brief Interview for Mental Status) score of 15 of a possible 15 indicating no cognitive impairment. The Resident was dependent on one staff person for dressing, toilet use, and hygiene needs. The Comprehensive Person Centered Care Plan last revised 1/29/18 did not include a focus area of thickened, long, painful…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to follow physician orders and to ensure insulin and glucometer checks were done per plan of care for 1 resident of 41 Residents in the survey sample (Resident #267). The findings included: Resident #267 was admitted to the facility on [DATE]. Diagnoses for Resident #267 included but are not limited to Diabetes Mellitus. Resident #261's admission Minimum Data Set (MDS) with an Assessment Reference Date of 3/28/17 scored Resident #267 with a BIMS score of 14 of a possible 15, indicating no cognitive impairment. Resident #267's Patient Centered Care Plan documented a 3/23/17 Focus Area of Diabetes. The Goal documented the resident would be free from signs and symptoms of hyperglycemia throughout the review date. One intervention documented was Sliding Scale Insulin as ordered. Resident #267's 3/21/17 Physician orders documented…

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 interviews, staff interviews, facility documentation review, and clinical record review, the facility staff failed to ensure Podiatry services were provided in a timely manner for 1 Resident of 41 Residents in the survey sample (Resident # 263). The findings included: Resident #263 was admitted to the facility on [DATE]. Diagnoses for Resident #263 included but are not limited to Chronic Pain Syndrome, Anxiety, and Mycotic Toenails. Resident #263's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date of 1/22/18 scored Resident #263 with a BIMS (Brief Interview for Mental Status) score of 15 of a possible 15 indicating no cognitive impairment. The Resident was dependent on one staff person for dressing, toilet use, and hygiene needs. The Comprehensive Person Centered Care Plan last revised 1/29/18 did not include a focus area of thickened, long, painful toenails. Resident #263's last documented Podiatrist visit was on 5/10/17. A Podiatry note dated 3/19/18…

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 interviews, staff interviews, facility documentation review, and clinical record review, the facility staff failed to ensure pain management with prescribed Fentanyl Patch after Hospice services were discontinued for 1 Resident of 41 residents in the Survey Sample (Resident # 263). The findings included: Resident #263 was admitted to the facility on [DATE]. Diagnoses for Resident #263 included but are not limited to Chronic Pain Syndrome, Anxiety and Mycotic Toenails. Resident #263's Significant Change Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 1/22/18 scored Resident #263 with a BIMS (Brief Interview for Mental Status) score of 15 of a possible 15 indicating no cognitive impairment. The Resident was dependent on one staff person for dressing, toilet use, and hygiene needs. The Comprehensive Person Centered Care Plan last revised 1/30/18 identified the Resident at risk for pain related to the diagnosis of Chronic Pain Syndrome, Anxiety, Chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, the facility staff failed to communicate ongoing assessments of condition and monitoring for complications before and after dialysis treatments for 1 of 41 residents in the survey sample (Resident #51). The Facility staff failed to communicate ongoing assessments for Resident #51 who attended outpatient dialysis three days per week on Tuesday, Thursday and Saturday. The findings include: Resident #51 was admitted to the nursing facility on 1/17/18 with diagnoses that included end stage renal disease (ESRD), high blood pressure and gastroesophageal reflux disease (GERD). The most recent Minimum Data Set (MDS) assessment dated [DATE] assessed the resident on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible 15, which indicated the resident was fully intact with cognitive skills for daily decision making. The resident was coded to receive outpatient dialysis treatments. Resident #51's physician orders contained 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 observation, staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure medications accepted from family or outside sources were reconciled by the facility for 1 of 41 residents in the survey sample (Resident #5). The findings included: Resident #5 was admitted to the facility on [DATE]. Diagnoses for Resident #5 included but are not limited to Parkinson's disease. Resident #5's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 2/19/18 scored Resident #5 with a BIMS score of 15 out of a possible 15, indicating no cognitive impairment. The Resident was dependent on staff for dressing, toilet use, personal hygiene, bed mobility and transfers. The Comprehensive Person Centered Care Plan last revised 10/23/17 identified the Resident used a Duopa Pump via PEG Tube for Parkinson's disease. The goal was to not have discomfort or complications related to Parkinson's disease through review date. One intervention included: Administer Duopa…

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, record review, and staff interview, the facility staff failed to ensure medical records were accurately documented for 1 of 41 residents in the survey sample (Resident #413). Facility staff failed to maintain accurate Treatment Administration Record (TAR). The findings included: Resident #413 was admitted to the facility on [DATE], diagnoses included but not limited to GI bleed, hyperlipidemia, hereditary hemochromatosis, essential hypertension, atherosclerotic heart disease, acute embolism and thrombosis of left lower extremity, metabolic encephalopathy, and chronic liver disease. This resident was admitted on [DATE] and discharged on [DATE] and did not have an MDS completed. A Care Plan dated [DATE] indicated: Focus - Diuretic therapy related to edema. Goal - Resident will be free of discomfort or adverse side effects of diuretic therapy through the next review date. Interventions - Administer Lasix as ordered, Administer medications as ordered, Monitor dose, Report pertinent lab results…

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.