Bay Pointe Rehabilitation And Nursing

Based on observation, resident interview, staff interview, clinical record review and facility document review it was determined that the facility staff failed to provide ADL (activities of daily living) care to a dependent resident for one of 33 residents in the survey sample, Resident #68. The findings include: For Resident #68 (R68), the facility staff failed to trim their fingernails. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/3/2023, the resident scored 4 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired for making daily decisions. The assessment documented R68 requiring extensive assistance of one person for bathing and personal hygiene. On 8/22/2023 at 4:10 p.m., R68 was observed in bed asleep with their hands visible on top of the blanket. The fingernails on both hands were observed to be approximately one-quarter inch long. On 8/23/2023 at 8:36 a.m., an interview was conducted with R68. When asked if they performed nail care themselves, R68 stated 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.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to store respiratory equipment in a sanitary manner for two of 33 residents The findings include: 1. For Resident #6 (R6), the facility staff failed to store nebulizer equipment in a sanitary manner. On 8/22/23 at 1:58 p.m., and 8/23/23 at 9:09 a.m. and 12:52 p.m., R6's nebulizer tubing and mouthpiece were observed lying in direct contact with R6's nebulizer machine; there was no covering on the tubing or the mouthpiece. A review of R6's orders revealed the following order dated 5/18/23: Ipratropium-Albuterol Inhalation Solution 0.5-2.5 MG/3ML (milligrams/milliliter) (Ipratropium-Albuterol) 1 application inhale orally every 6 hours for SOB (shortness of breath). A review of R6's August 2023 MAR (medication administration record) revealed the resident received the medication as ordered. On 8/24/23 at 10:21 a.m., LPN (licensed practical nurse) #6, a unit manager, was interviewed. When asked where the tubing and mouthpiece for a nebulizer should be…

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 and staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to provide dialysis care and services for one of 33 residents in the survey sample, Resident #22. The findings include: The facility failed to provide a bagged lunch for Resident #22 to take with him to the dialysis appointment. Resident #22 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ESRD (end stage renal disease), dialysis, and diabetes mellitus. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 7/11/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. Section O- Special Procedures/Treatments: coded the resident dialysis-yes. A review of the comprehensive care plan dated 3/21.22, which revealed, FOCUS: The resident needs dialysis type…

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 document review, and clinical record review, it was determined that the facility staff failed to evidence documentation of a current bed rail assessment and consent, for one of 33 residents in the survey sample, Residents #109. The findings include: For Resident #109 (R109), the facility failed to evidence a consent for the use of bed rails and a bed rail assessment. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 7/26/2023, the resident scored 13 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were moderately impaired to make daily decisions. The resident was coded as being totally dependent on two or more persons for bed mobility and transfers. On 8/22/2023 at 1:51 p.m., an observation was made of R109 in bed with bilateral bar shaped bed rails in place in the up position on the upper portion of the bed. At this time an interview was…

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

Based on staff interview, facility document review and clinical record review, the facility staff failed to provide medically related social services for one of 33 residents in the survey sample, Resident #7. The findings include: For Resident #7, the facility staff failed to assess and monitor the resident's psychosocial well-being after a male resident fondled the resident's breast on 7/12/22. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/3/23, the resident scored 10 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately impaired for making daily decisions. A facility synopsis of events documented that on 7/12/22, an employee witnessed a male resident touching himself and fondling R7's breast. The residents were immediately separated, the male resident was placed on two-hour checks, and discharged on 7/14/22. The synopsis of events documented a skin check was completed for all residents (including R7), and R7 would be monitored for changes in behavior. A review of R7's…

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

Based on clinical record review, staff interview and facility document review it was determined that the facility staff failed to evidence monitoring of psychotropic medication for one of 33 residents in the survey sample, Resident #39. The findings include: For Resident #39 (R39), the facility staff failed to monitor behaviors and for adverse effects of an antianxiety and antidepressant medication. R39 was admitted to the facility with diagnoses that included but were not limited to bipolar disorder, major depressive disorder and alcohol dependence with alcohol-induced persisting dementia. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/9/2023, the resident scored 10 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately impaired for making daily decisions. The assessment documented R39 receiving an antidepressant seven of the seven days during the assessment period and an antianxiety medication seven of seven days during the assessment period. The physician orders for R39…

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

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to securely store a medication for one of 33 residents in the survey sample, Resident #52. The findings include: For Resident #52 (R52), the facility staff failed to store the resident's Midodrine (1) in a secure manner. On 8/24/23 at 8:35 a.m., the surveyor retrieved R52's dialysis communication notebook from an open shelf behind the nurses' desk. In the front of the notebook, a medication card containing 16 tablets of Midodrine was clipped inside the notebook by way of a three whole punch and three ring prongs. On 8/24/23 at 11:30 a.m., LPN (licensed practical nurse) #7 was interviewed. She stated that all medications should be locked inside the medication cart, or stored in the locked medication refrigerator in the medication room. She stated: We have to keep them locked up for resident safety. When shown R52's dialysis notebook with the Midodrine medication card clipped inside the notebook, LPN #7 shook her head and stated: Well that is inappropriate. She…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, the facility staff failed to maintain a current dialysis contract for two of 33 residents in the survey sample, Residents #52 and #22. The findings include: 1. For Resident #52 (R52) the facility staff failed to evidence a current dialysis contract. A review of R52's clinical record revealed the following order, dated 2/3/23: Outpatient Hemodialysis .Outside Center .Days Scheduled: Monday, Wednesday, Friday chair time 7:30am. A review of R52's MARs (medication administration records) from February through August 2023 revealed the resident had been receiving dialysis services as ordered. At the entrance conference on 8/22/23 at 12:25 p.m., ASM (administrative staff member) #1, the executive director, was asked to provide current contracts for the current companies from which residents were receiving dialysis services. On 8/24/23 at 2:28 p.m., ASM (administrative staff member) #1, the executive director was asked again to provide…

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, facility document review, and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for one of 33 residents in the survey sample, Resident #7. The findings include: For Resident #7 (R7), the facility staff failed to document an incident where a male resident touched the resident's breast on 7/12/22. A facility synopsis of events documented that on 7/12/22, an employee witnessed a male resident touching himself and fondling R7's breast. A review of R7's clinical record failed to reveal documentation regarding the 7/12/22 event. On 8/24/23 at 8:55 a.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated a progress note should definitely be made in the clinical record if a male resident touches a female resident's breast. LPN #2 stated this should be documented in both residents' clinical records. On 8/24/23 at 2:31 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled,…

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, interviews, and review of facility policies and procedures, the facility failed to ensure a safe and clean environment in 10 of 16 resident rooms on the second-floor east unit. This deficient practice affected 19 of 30 residents on the second-floor east unit. Findings include: Observations on 10/12/21 at 9:05 AM, revealed in resident room (RR)231 large scrapes on the wall, one foot off the floor measuring 2 feet wide high by 1 foot high. Interview with the Assistant Maintenance Director acting as Maintenance Director on 10/15/21 at 11:00 AM verified the condition of the wall. Observations on 10/12/21 at 9:10 AM, revealed in RR230 large scrapes on the wall one foot off the ground measuring 2 feet long by 1 foot high. Interview with the acting Maintenance Director on 10/15/21 at 11:00 AM verified the condition of the wall. Observations on 10/12/21 at 9:15 AM, revealed in RR226 large scrapes on the wall, one foot off the floor measuring 2 feet long by 1 foot high. Interview with the acting Maintenance Director on 10/15/21 at 11:00 AM verified the condition of 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 interviews, record reviews, and policy review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours of admission to the facility for five residents (Resident (R)286, R288, R290, R23, and R233) out of a total sample of 21 residents. Findings include: Review of facility policy titled, Baseline Care Plan, dated 10/01/21, revealed, The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care for the resident that meets professional standards of quality care . The baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. Initial goals based on admission orders. ii. Physician orders. iii. Dietary orders. iv. Therapy services. v. Social Services. vi. PASRR recommendation, if applicable. 2. The admitting nurse, or…

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

Based on observation, interview, and policy review, the facility failed to ensure that one resident's (Resident (R) 233) out of a sample of 21 residents electronic medical record (EMR) was kept from public view. Findings include: Review of the facility's undated policy titled Confidentiality directs that the facility complies with all the requirements of the Health Insurance Portability and Accountability Act (HIPPA) . All information regarding residents is confidential . a resident's personal or medical matters should never be discussed with other residents, visitors or anyone else . During an observation on 10/13/21 at 11:55 AM, the computer on Unit 1 East Hall was open on an unattended medication cart to R233's EMR. During this observation, multiple staff and two residents walked by the medication cart while R233's medical information was available for staff and residents to view. During an interview on 10/13/21 at 12:00 PM, Registered Nurse (RN) 2 acknowledged that the computer was open with R233's EMR on the screen when she left the medication cart to speak to a physician.…

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 review of the facility's policy, the facility failed to ensure one resident (Resident (R) 16) of 21 sampled residents was free from chemical restraints. On 07/16/21 R16 was administered Ativan (an antianxiety medication) via intramuscular (IM) injection for staff convenience. Findings include: Review of the facility's policy titled Resident Rights, dated 11/01/20, revealed . The resident has a right to be treated with respect and dignity, including a. The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms . Review of the facility's policy titled, Restraint Free Environment, revised 10/28/20, revealed Policy: Each resident shall attain and maintain his/her highest practical well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to complete an initial nursing assessment upon admission for one resident (Resident (R) 290) out of 21 sampled residents. Findings include: Review of the Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed that R290 was admitted on [DATE] for skilled care services for fracture of the left femur. Additional diagnoses included insomnia, pain, major depressive disorder, essential (primary) hypertension (high blood pressure), osteoporosis (condition where bones become weak and brittle) and atherosclerotic heart disease (a buildup of fats and cholesterol in the artery walls). Review of R290's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/08/21 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating that R290 was cognitively intact. Review of R290's Admission documents, located in the EMR under the Assessments tab, revealed that a nursing assessment was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, the facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for restorative nursing services for one resident (Resident (R) 76) in a total sample of 21 residents. Findings include: Review of the facility's policy titled Assessment Frequency/Timeliness, dated 11/01/20 and revised on 10/01/21, directs The purpose of this policy is to provide a system to complete standardized assessments in a timely manner, according to the current RAI [Resident Assessment Instrument] Manual . Review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual Chapter 3 MDS Items [O] documented that Reevaluation of special treatments and procedures the resident received or performed, or programs that the resident was involved in during the 14-day look-back period is important to ensure the continued appropriateness of the treatments, procedures, or programs . Review 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, interviews, record review, and policy review, the facility failed to ensure that one resident (Resident (R) 76) of three residents reviewed for activities out of a total sample of 21 residents was consistently provided activities that supported the physical, mental, and psychosocial needs of the resident. Findings include: Review of the facility's policy titled Activities, dated 11/01/20, revealed It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences of each resident. Facility-sponsored group and individual activities and independent activities will be designed to meet the interests of and support the physical, mental, and psychological well-being of each resident, as well as encourage both independence and interaction within the community . Special considerations will be made for developing meaningful activities for residents with dementia and/or special needs.…

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, record review, interview, and policy review, the facility failed to ensure that one resident (Resident (R) 76) of two residents reviewed for position and mobility out of a total sample of 21 residents received treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, facility staff failed to provide physician ordered passive (PROM) and splints and/or braces as recommended by therapy. Findings include: Review of the facility's policy titled Restorative Nursing Program, dated 11/01/20, revealed all residents will receive maintenance restorative nursing services . by certified nursing assistants . Residents, as identified during the comprehensive assessment process, will receive services from restorative aides when they are assesses to have a need for such services (level II services). These services may include a. Passive or active range of motion. b. Splint or brace assistance . Potential candidates for Level II restorative…

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, interviews, record review, and policy review, the facility failed to ensure that one resident (Resident (R) 15) out of five residents reviewed for accidents was transported in a wheelchair with legrests to prevent injury in a total sample of 21 residents. Findings include: Review of the facility's policy titled Accidents and Supervision, dated 11/01/20, directs The facility shall establish and utilize a systemic approach to address resident risk and environmental hazards to minimize the likelihood of accidents .The facility will provide adequate supervision to prevent accidents . based in the individual resident's assessed needs and identified hazards in the resident environment. Review of the R15's admission Record located in the electronic medical record (EMR) revealed R15 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/06/21 revealed a Brief Interview for Mental Status…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and review of the facility's policy, the facility failed to ensure one resident (Resident (R) 78) of seven residents reviewed for unnecessary medications had a stop date for a PRN (as needed) antianxiety medication used for seizures. Findings include: Review of the facility's policy titled, Unnecessary Drugs-Without Adequate Indication for Use, dated 11/01/20, revealed Policy: It is the facility's policy that each resident's drug regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being free from unnecessary drugs . 2. The attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication regimen . Each resident's drug regimen will be reviewed on an ongoing basis, taking into consideration the following elements: . b. Duration of use .4. When a drug is initiated or used to treat an emergency situation (i.e., acute onset or exacerbation 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.

Based on staff interview and employee record review the facility staff failed to verify licensure with the State licensing board prior to hire for 5 nurses and failed to verify certification of nursing assistants with the State nurse aide registry prior to hire for 3 nursing assistants. It was identified during an employee record review that the credentials of a total of 8 licensed and certified nursing staff were not verified prior to hire or verified at all. The findings included: Employee records were reviewed during the survey. The following issues were identified when reviewing employee records: 1. Employee #4 was hired as a Licensed Practical Nurse (LPN) on 3/6/18. The license was verified after hire on 3/9/18. 2. Employee #8 was hired as a Registered Nurse (RN) on 3/6/18. Her license was never verified. 3. Employee #9 was hired as a RN on 5/8/18. Her license was never verified. This employee was working during the survey. 4. Employee #10 was hired as a Certified Nursing Assistant (CNA) on 7/31/18. Her certification was verified after hire on 8/28/18. 5. Employee #13 was hired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Resident #41's bed remained in the high position during the days of survey. Resident #41 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, congestive heart failure, traumatic brain injury and seizure disorder. Resident #41's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 8-22-18. Resident #41 was coded with a Brief Interview of Mental Status score of 9 out of a possible 15 indicating moderate cognitive impairment. Resident #41 required extensive to total assistance of one to two staff members for bed mobility and bathing and toileting. On 10/24/18 at 9:06 AM Resident #41 was observed in bed: the bed was in high position. The resident had a suction machine at the bedside. On 10/25/18 at 10:27 AM Resident #41 was not in bed as he had been transferred to the hospital. The resident's bed remained in high position throughout the day on 10-24-18. 10/26/18 at 10:30 AM: An interview with LPN (licensed…

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 a dignified living experience for two residents (Resident #59 and Resident #41) in a survey sample of 33 residents. 1. Resident #59 was not offered a clothing protector during her meals and her clothing became stained with food. 2. Resident #41 had excessive drooling. There was no towel or clothing protector in place and his neck/shoulder was wet with mucus. 3. Residents in the dining room were called Grandma and Grandpa. The findings included: 1. Resident #59 was not offered a clothing protector during her meals and her clothing became stained with food. Resident #59 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, Alzheimer's dementia, high blood pressure and depression. Resident #59's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 9/4/18. Resident #59 was coded with a Brief Interview of Mental Status…

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 and clinical record review the facility staff failed to ensure 1 resident (Resident #28) of 33 residents in the survey sample were assessed to self administer medications. For Resident #28, Systane eye drops were observed on the bedside table. The findings included: Resident #28, an [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included anxiety, anemia, gout, diabetes, history of breast cancer, peripheral vascular disease, and heart disease. The most recent Minimum Data Set assessment was a 14 day assessment with an assessment reference date of 9/2/18. Resident #28 was coded with a Brief Interview of Mental Status score of 14 indicating no cognitive impairment and required extensive assistance with activities of daily living. On 10/23/18 at 12:00 p.m., an interview was conducted with Resident #28. At this time, the Systane eye drops were observed on the bedside table. Resident #28 was asked if she used the eye drops. She stated yes,…

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 documentation review, and clinical record review, the facility staff failed to ensure Advanced Beneficiary notices were provided prior to loss of benefits, for 3 residents (Resident #18, #146, and #147), in a survey sample of 33 residents. The facility staff failed to provide Residents #18, #146, and #147 with written notification prior to their loss of benefits. The Findings included: For Residents #18, 146, and 147, clinical records, admissions records, hospital records, and discharge records were reviewed. The review revealed Notice of Medicare Non-Coverage (NOMNC) documents. Two of the NOMNC documents were signed with the names of Resident #18, and #147's Power of attorneys (POA's). The signatures appeared on the documents as the following example; John [NAME] via [PHONE NUMBER] and were dated. The third NOMNC of Resident #146 only had the POA signature and a phone number. The word, via was not included. The handwriting and signatures, appeared identical in all three…

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

Based on observation, resident interview and clinical documentation, the facility failed to maintain a clean and homelike environment. Resident #59's room had a sustained strong urine odor. The findings included: On 10/23/18 at 2:54 PM, Resident #59 was resting in bed with the window open. The room still had a strong urine odor. On 10/24/18 at 8:37 AM, Resident #59 was in bed asleep, however there was a strong smell urine odor from the hallway. On 10/24/18 at 9:51 AM, An interview was conducted with the account manager-housekeeping (Other-F). He stated, We are trying to solve the problem. He stated that the room had been mopped and cleaned. The room continued to have a strong urine odor. On 10/24/18 at 4:22 PM, the facility Administrator and DON (director of nursing) were notified of above findings. On 10/25/18 at 8:56 AM, the resident's room has no odor. The housekeeping account manager was asked if the source of the odor had been found. He stated that they moved items in the room and found some diapers and linens, which were removed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to complete a discharge MDS ( Minimum data set) for one resident (Resident # 2 ) in a survey sample of 33 residents. For Resident # 2, the facility staff failed complete a Discharge MDS after discharge on [DATE]. Findings included: Resident # 2 was a [AGE] year old female admitted to the facility on [DATE] with the diagnoses of but not limited to: Hypertension, Respiratory Failure with Hypoxia, Congestive Heart Failure, Emphysema, Anxiety, Gastroesophageal Reflux Disease, Tachycardia, Alzheimer's Disease, Chronic Obstructive Pulmonary Disease. Review of the clinical record was conducted on 10/24/2018 at 4:00 PM. Review of the Nurses Notes dated 7/1/2018 at 3:51 PM revealed Resident # 2 was discharged with family to another state. The only MDS assessments in the clinical record were an admission assessment dated [DATE] and a 14 assessment dated [DATE]. Further review of the clinical record revealed no documentation of a MDS (Minimum…

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 Incorporate the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident ' s assessment, care planning, and transitions of care for one resident (Resident #12) in a sample of 33 residents. 1. For Resident #12, the facility staff failed to implement the PASARR II recomendations to meet the Resident's intellectual disability (ID) needs. The findings included: Resident #12, a [AGE] year old female, was admitted to the facility on [DATE] following a hospital admission for influenza with wheezing, cough, fever, and systemic inflammatory response syndrome. Note: The Resident's primary caregiver died of influenza/pneumonia the day before the Resident's hospital admission. Diagnoses for Resident #12 include athetoid cerebral palsy, moderate intellectual disability (ID), depression, anxiety, asthma, and anemia. Resident # 12's most recent quarterly Minimum…

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 facility documentation review, the facility staff failed to ensure the PASARR was completed prior to admission for three residents (Resident #74, #29, #85) in a sample of 33 residents. 1. For Resident #74, the facility staff failed to ensure a PASARR was completed prior to admission. 2. For Resident #29, the facility staff failed to ensure a PASARR was completed prior to admission. 3. For Resident #85, the facility staff failed to ensure a PASARR was completed prior to admission. The findings included: 1. For Resident #74, the facility staff failed to ensure a PASARR was completed prior to admission. Resident #74 was admitted to the facility on [DATE] and current diagnoses include major depressive disorder, post-traumatic stress disorder, and anxiety disorder. Resident #74's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/24/2018 was coded as a quarterly review. Resident #74 was coded with a Brief Interview of Mental Status score of 14 out of possible…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility documentation review, and clinical record review, the facility staff failed to develop and implement a comprehensive person centered care plan for three Residents (Residents #93, #53, #28) of 33 residents in the survey sample. 1. Resident #93's care plan did not include person centered interventions for weight loss. 2. Resident #53's care plan did not include person centered interventions for pressure sores. 3. For Resident #28, a discharge care plan was not included in the comprehensive care plan. The findings included; 1. Resident #93's care plan did not include person centered interventions for weight loss. Resident #93 was admitted to the facility on [DATE]. Diagnoses included; diabetes, heart disease, hypertension, stroke, gout, contractures, hypothyroidism, , depression, dementia, recurrent urinary tract infections (UTI's), hematuria, and anemia. Resident #93's most recent Minimum Data Set assessment was a 14 day re-entry assessment after hospitalization on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to follow professional practice standards for two residents (Residents #53) of the 33 residents in the survey sample. 1a) For Resident #53, the facility staff failed to administer physician ordered treatments. 1b) For Resident #53, the facility staff falsified medication and treatment administration records. 2. For Resident #96, an activities staff without a nursing background completed the baseline care plan The findings included: 1a) For Resident #53, the facility staff failed to administer physician ordered treatments. Resident #53 was admitted to the facility on [DATE]. Diagnoses for Resident #72 included but were not limited to; anemia, chronic kidney disease, pulmonary hypertension, and insulin dependant diabetes. Resident #53's most recent Minimum Data Set (an assessment protocol) was an admission assessment, with an Assessment Reference 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 observations, resident interview, staff interviews, and clinical record review, the facility staff failed to develop and implement an effective discharge planning process for two residents (Resident #12, #96) in a sample of 33 residents. 1. For Resident #12, the facility staff failed to implement a timely discharge plan to a facility equipped to meet the Resident's intellectual disability (ID) needs. 2. For Resident #96 the facility staff failed to develop a discharge plan. The findings included: Resident #12, a [AGE] year old female, was admitted to the facility on [DATE] following a hospital admission for influenza with wheezing, cough, fever, and systemic inflammatory response syndrome. Note: The Resident's primary caregiver died of influenza/pneumonia the day before the Resident's hospital admission. Diagnoses for Resident #12 include athetoid cerebral palsy, moderate intellectual disability (ID), depression, anxiety, asthma, and anemia. Resident # 12's most recent quarterly Minimum Data Set (MDS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interview, staff interviews, and clinical record review, the facility staff failed to provide activities appropriate for Resident's age and intellectual disability for one Resident (Resident #12) in a sample of 33 residents. The findings include: Resident #12, a [AGE] year old female, was admitted to the facility on [DATE] following a hospital admission for influenza with wheezing, cough, fever, and systemic inflammatory response syndrome. Diagnoses include athetoid cerebral palsy, moderate intellectual disability (ID), depression, anxiety, asthma, and anemia. Resident # 12's most recent quarterly Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of [DATE]. Resident # 12 did not have a Brief Interview of Mental Status (BIMS) conducted but cognitive skills for daily decision-making were coded as moderately impaired. Functional status for personal hygiene, dressing, mobility, and transfers were coded as extensive assistance for performance and support. Resident #12 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to provide treatments, failed to follow doctor's orders, and failed to complete a measurable comprehensive care plan for pressure ulcers for 1 Resident (Resident #53) in a survey sample of 33 residents. For Resident #53, the staff failed to treat 2 pressure ulcers on the Resident's left and right buttocks, failed to follow doctor's orders, and failed to appropriately care plan the Resident's needs. The findings included; Resident #53 was admitted to the facility on [DATE]. Diagnoses for Resident #72 included but were not limited to; anemia, chronic kidney disease, pulmonary hypertension, and insulin dependant diabetes. Resident #53's most recent Minimum Data Set (an assessment protocol) was an admission assessment, with an Assessment Reference Date of 9-15-18. The MDS coded Resident #53 as alert, oriented to person, place, time and situation,…

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 provide weight loss intervention, and to prevent further significant weight loss for one Residents (Resident #93) of the 33 residents in the survey sample. For Resident #93 the facility staff did not provide weight loss interventions for a Resident with diabetes, and wounds, and failed to intervene during a significant weight loss. The findings included: Resident #93 was admitted to the facility on [DATE]. Diagnoses included; diabetes, heart disease, hypertension, stroke, gout, contractures, hypothyroidism, , depression, dementia, recurrent urinary tract infections (UTI's), hematuria, and anemia. Resident #93's most recent Minimum Data Set assessment was a 14 day re-entry assessment after hospitalization on 9-21-18 for hematuria and UTI, with readmission on [DATE]. The assessment reference date was 10-9-18. The Resident was coded with a Brief Interview of Mental Status score of unable 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview and clinical record review, the facility staff failed to provide pain management for 1 resident (Resident #51) of 33 residents in the survey sample. Resident #51 did not have a standing X Ray as ordered by the pain management clinic. The findings included: Resident #51 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, high blood pressure, depression and diabetes. Resident #51's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 9/3/18. Resident #51 was coded with a Brief Interview of Mental Status score of 15 out of a possible 15 indicating no cognitive impairment. Resident #51 required supervision to limited assistance of one staff member for bed mobility and bathing and toileting. The resident was coded as having frequent pain of a 4 out of a possible 10. On 10/24/18 at 9:29 AM Resident #51 was observed in her room. She complained that her pain could get up…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interview, staff interview, and clinical record review, the facility staff failed to provide psychotherapy for grief, anxiety, and depression as recommended by the psychiatric nurse practitioner for one Resident (Resident #12) in a sample of 33 residents. The findings include: Resident #12, a [AGE] year old female, was admitted to the facility on [DATE] following a hospital admission for influenza with wheezing, cough, fever, and systemic inflammatory response syndrome. Diagnoses include athetoid cerebral palsy, moderate intellectual disability (ID), depression, anxiety, asthma, and anemia. Resident # 12's most recent quarterly Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of [DATE]. Resident # 12 did not have a Brief Interview of Mental Status (BIMS) conducted but cognitive skills for daily decision-making were coded as moderately impaired. Functional status for personal hygiene, dressing, mobility, and transfers were coded as extensive assistance for performance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to provide community living skills, day support and rehabilitation, self-help/personal care skills, a social skills development program, or transportation to specialized services as recommended on the PASARR II for one resident (Resident #12) in a sample of 33 residents. The findings include: Resident #12, a [AGE] year old female, was admitted to the facility on [DATE] following a hospital admission for influenza with wheezing, cough, fever, and systemic inflammatory response syndrome. The Resident's mother/primary caregiver died of influenza/pneumonia the day before the Resident's hospital admission. Diagnoses include athetoid cerebral palsy, moderate intellectual disability (ID), depression, anxiety, asthma, and anemia. Resident # 12's most recent quarterly Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of [DATE]. Resident # 12 did not have a Brief Interview of Mental Status (BIMS)…

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 documentation review the facility staff failed to ensure beverages were served according the plan of care for 1 resident (Resident #14) of 33 residents in the survey sample. Resident #14 was not served honey thickened beverages per the plan of care. The findings included: Resident #14, a [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included dysphagia, diabetes, stroke, failure to thrive, dementia with behaviors, and hypertension. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 7/30/18. He was coded with severe cognitive impairment and required extensive assistance with activities of daily living. On 10/24/18 at 8:35 am, Certified Nursing Assistant E (CNA E) had finished feeding Resident #14 his breakfast and taken him back to his room from the dining room. The meal tray was left on the table in the dining room. The tray included pureed foods, juice in a…

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

Based on observation and staff interview the facility staff failed to ensure an effective infection control program was implemented for 2 residents (Resident's #42 and #17) of 33 residents in the survey sample. 1. For Resident #42, the facility staff: a. touched medications with gloved hands after touching unclean surfaces b. laid the opened Spiriva handihaler on the medication cart with the inside of the inhaler touching the medication cart surface c. took the box of Spiriva capsules and Symbicort inhaler box into the resident room, laying them on the uncleaned bedside table and returning the boxes to the cart drawer. 2. For Resident #17, the facility staff prepared medications in a medication cup, put the medications in her pocket when providing care to another resident, and then administered the medications that had been stored in her pocket. The findings included: 1. For Resident #42, the facility staff: a. touched medications with gloved hands after touching unclean surfaces b. laid the opened Spiriva handihaler on the medication cart with the inside of the inhaler touching 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.