Bayside Health & Rehabilitation Center

Based on staff interviews, and facility documentation, the facility staff failed to ensure that licensed nursing staff completed the required competencies necessary to care for residents' needs. The findings included: The facility failed to maintain the required nursing staff competencies necessary to care for residents. A review of the Training Transcripts for 19 licensed staff members revealed that nine (9) of the 19 licensed nursing staff members did not complete the required training courses. On 6/11/24 at 1:40 p.m., an interview was conducted with the Human Resource (HR) Director who was asked about the licensed nursing staff competency training courses. The HR Director was not able to present evidence that the nine (9) licensed nursing staff had completed the required competency training courses. On 6/13/24, during the end-of-day meeting, the Administrator was made aware of the concerns. No further information was provided before the survey's exit.

Based on staff interviews, and facility documentation, the facility failed to ensure that a Registered Nurse worked at least 8 consecutive hours within 24 hours, 7 days a week. The findings included: The facility failed to ensure that a Registered Nurse (RN) worked at least 8 consecutive hours within 24 hours, 7 days a week. A review of the as worked schedules for 5/11/24-5/13/24, 5/24/24-5/31/24, and 6/4/24-6/24/24, indicated there was no documentation that a Registered Nurse worked for 8 consecutive hours a day, 7 days a week. On 6/11/24 at 1:40 p.m., an interview was conducted with the Human Resources (HR) Director who was asked about nursing staff RN coverage. The HR Director said that she was aware that an RN was required at least 8 consecutive hours, 7 days a week. The HR Director stated that the facility has been short-staffed and was currently supplementing staff with agency staff. On 6/13/24, during the end-of-day meeting, the Administrator was made aware of the above concerns. No further information was provided prior to the survey's exit.

Based on staff interviews, and facility documentation, the facility failed to ensure that the nurses' aides had performance reviews every 12 months and at least 12 hours of regular in-service education included on the aide's performance review. The findings included: The facility failed to conduct nurse aide performance reviews every 12 months and at least 12 hours of in-service education included on the aide's annual performance review per their hire date. A review of the training transcripts and staff education files revealed that not all nurse aides completed the mandatory in-services education. On 6/11/24 at 1:40 p.m., an interview was conducted with the Human Resources (HR) Director who was asked about the nurse aides' in-service education and stated that the employee files that included performance reviews and in-service records were correct and up to date. She had no additional records to provide for the nurse aides who did not have annual performance reviews with the required training hours. On 6/13/24, during the end-of-day meeting, the Administrator was made aware 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 Staff interview, clinical record review, and facility document review, the facility failed to provide medications as ordered by a physician for two (2) Residents (Resident #49, and #45) in a survey sample of 62 residents. The findings included: 1. For Resident #49, Facility staff failed to Administer Lovenox (anticoagulant) and Keflex (antibiotic) medication. Resident #49, was admitted to the facility on [DATE], and discharged to the emergency room with an infected wound on 4-19-24. The Resident returned on 4-24-24. Diagnoses included; After care following hip fracture, alzheimers disease, stage 4 sacral pressure sore, hypertension, hypothyroid, stroke, malnutrition, aphasia, dysphagia, and aspiration pneumonia. Resident #49 was a bed bound patient with severe cognitive impairment. Resident #49 was documented as being totally dependant on staff for all activities of daily living such as hygiene, transferring, and bed mobility. The Resident was incontinent of bowel and bladder. The Resident's 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 staff interviews, clinical record review, and review of facility documents, the facility staff failed to ensure pharmacist reported irregularities to the attending physician, the facility's medical director and the director of nursing, and were acted upon for four (4) of 62 residents (Resident #11, #172, #4 and #25), in the survey sample. The findings included: 1. The facility staff failed to ensure the physician and/or designee received the recommendations from the pharmacy review dated 4/20/24 for Resident #11. Resident #11 was originally admitted to the facility 4/18/24 after an acute care hospital stay. The current diagnoses included type 2 diabetes mellitus, acute bronchitis, hyperlipidemia, depression, muscle weakness, and unspecified dementia. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/24/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 6 out of a possible 15. This indicated Resident #11's cognitive…

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 review of facility documents, the facility staff failed to keep identified systems functioning properly, and to implement necessary action plans to assure the quality of life for the residents using the Quality Assurance and Performance Improvement (QAPI) committee; including to identify deficiencies in the area of Qualifications of an Activity Professional as well as repeated deficiencies, and to have the Director of Nursing (DON) and/or a designee participate in the 7/23/24 QAPI meeting. The findings include: On 8/7/24 at 4:10 PM a QA&A (Quality Assessment and Assurance) interview was conducted with the Administrator regarding the QAPI meeting that took place on 7/23/24. The Administrator stated that during the QAPI meeting all of the deficient citations from the Plan of Corrections survey ending 6/13/24 were discussed. The Administrator also stated that all of the audits were discussed related to the Plan of Corrections. During this interview the Administrator stated that the facility currently does not have a qualified professional directing the…

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

Based on staff interviews, and facility documentation, the facility failed to determine training needs based on its facility assessment and maintain a training program for all new and existing staff. The findings included: The facility failed to maintain a training program for all new and existing staff. A review of the staff Training Transcripts, and Staff Education files revealed that none of the 19 staff transcripts reviewed had completed all the mandatory training. On 6/11/24 at 1:40 p.m., an interview was conducted with the Human Resources (HR) Director who was asked about the staff development and training program. She stated that the education and training files are up to date. On 6/13/2024, during the end-of-day meeting, the Administrator was made aware of the above concerns. No further information was provided before the survey exit.

Based on staff interviews, and facility documentation, the facility failed to ensure that all direct care staff completed mandatory Effective Communication training. The findings included: The facility failed to ensure that all direct care staff completed mandatory Effective Communication training. A review of the staff's Training Transcripts and Staff Education files revealed that not all direct care staff had documented completion of mandatory Effective Communication training. On 6/11/24 at 1:40 p.m., an interview was conducted with the Human Resource (HR) Director who was asked about direct care staff having completed mandatory Effective Communication training. She stated that training and education were recorded in their computer-based training platform and that the files for each facility employee were correct and up to date. On 6/13/24, during the end-of-day meeting, the Administrator was made aware of the above concerns. No further information was provided before survey exit.

Based on staff interviews, and facility documentation, the facility failed to ensure that all employees are educated on resident rights and responsibilities of the facility. The findings included: The facility failed to ensure that staff members were educated on resident rights and responsibilities of the facility. A review of the staff's Training Transcripts and Staff Education files revealed that not all direct care staff had documented completion of Resident Rights training and the responsibilities of the facility. On 6/11/24 at 1:40 p.m., an interview was conducted with the Human Resources (HR) Director who was asked about direct care staff having completed mandatory Resident Rights training. She stated that training and education were recorded in their computer-based training platform and that the files for each facility employee were correct and up to date. On 6/13/24, during the end-of-day meeting, the Administrator was made aware of the above concerns. No further information was provided before the survey exit.

Based on staff interviews, and facility documentation, the facility failed to ensure that staff members had completed the mandatory Abuse, Neglect, and Exploitation training. The findings included: The facility failed to ensure that staff members had completed the mandatory Abuse, Neglect, and Exploitation training. A review of the staff's Training Transcripts and Staff Education files revealed that not all direct care staff had documented completion of mandatory Abuse, Neglect, and Exploitation training. On 6/11/24 at 1:40 p.m., an interview was conducted with the Human Resources (HR) Director. She was asked about staff education regarding Abuse, Neglect, and Exploitation training. She stated that training and education were recorded in their computer-based training platform and that the files for each facility employee were correct and up to date. On 6/13/24, during the end-of-day meeting, the Administrator was made aware of the above concerns. No further information was provided before the survey exit.

Based on staff interviews, facility documentation review, the facility staff failed to ensure all staff received mandatory infection control training. The findings include: Review of the staff training records indicated the following facility staff did not have mandatory infection control training: The Director of Nursing (DON), CNA #8, Others #9, Others #10, Others #11, Others #12, Others #13, and Others #14. The above findings were shared with the Administrator, Corporate Nurse #1, and Corporate Nurse #2 on 6/13/2024 at approximately 11:45 AM. No further information was provided prior to the conclusion of the survey.

Based on facility staff interviews, and facility documentation, the facility failed to ensure that all staff members had completed the mandatory Ethics and Compliance Training. The findings included: The facility failed to ensure that all staff members had completed the mandatory Ethics and Compliance Training. A review of the staff's Training Transcripts and Staff Education files revealed that 19 direct care staff had not documented completion of mandatory Ethics and Compliance Training. On 6/11/24 at 1:40 p.m., an interview was conducted with the Human Resources (HR) Director who was asked about staff training regarding, Ethics and Compliance Training. She stated that the training and education were recorded in their computer-based training platform and that the files for each facility employee were correct and up to date. On 6/13/24, during the end-of-day meeting, the Administrator was made aware of the concerns. No further information was provided before the survey exit.

Based on facility staff interviews, and facility documentation, the facility failed to ensure that the nurse aides had a minimum of 12 hours of in-service training including dementia, abuse prevention and facility assessments, and special needs of the residents in a year. The findings included: The facility failed to ensure that nurse aides have a minimum of 12 hours of in-service training within 12 months to meet the needs of the residents. A review of the staff's Training Transcripts and Staff Education files revealed that not all nurse aides completed the mandatory 12 hours of in-service education and training. On 6/11/24 at 1:40 p.m., an interview was conducted with the Human Resources (HR) Director who was asked about nurse aides' in-services and education. She stated that training and education are recorded in their computer-based platform and that the files are correct and up to date. On 6/13/2024, during the end-of-day meeting, the Administrator was made aware of the above concerns. No further information was provided before the survey exit.

Based on facility staff interview, and facility documentation, the facility failed to ensure that all staff members had completed the mandatory Behavioral Health Training. The findings included: The facility failed to ensure that all staff members had completed the mandatory Behavioral Health Training. A review of the staff Training Transcripts, and the Staff Education files for 19 staff members revealed that six (6) of the staff reviewed had not completed the mandatory Behavioral Health Training. On 6/11/24 at 1:40 p.m., an interview was conducted with the Human Resources (HR) Director who was asked about staff training regarding, the mandatory Behavioral Health Training. She stated that the training and education are recorded in their computer-based platform and that the files are correct and up to date. On 6/13/24, during the end-of-day meeting, the Administrator was made aware of the concerns. No further information was provided before the survey exit.

Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to ensure one Resident (Resident # 5) in a survey sample of 62 residents was clinically appropriate to self-administer medications. The findings included: 1. For Resident # 5, the facility staff allowed prescription eye drops to be kept at the bedside without an order and self administration assessment. On 6/5/2024 at 9:30 a.m., a plastic prescription bag with an affixed label that stated Bremonidine 0.2 % eye gtts (drops) was noted on Resident # 5's overbed table. The eye drops had been opened and still had medication remaining. Resident # 5 stated she kept the eye drops at her bedside because the staff members kept losing her eye drops. Resident # 5 stated that she was diagnosed with glaucoma and she was very concerned about not getting the eye drops on time. Resident # 5 stated she would give the eye drops to the nurses when it was time to administer them. On 6/5/2024 at 10:05 a.m., the bag with the eye drops was still on the overbed table. On 6/5/2024 at 10:20 a.m.,…

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 ensure one resident (Resident # 5) in the survey sample of 62 residents had the right to make choices about aspects of life in the facility. The Findings included: 1. For Resident # 5, the facility staff often failed to provide more coffee as requested. Resident # 5 was admitted to the facility on [DATE] with diagnoses including but not limited to: Type 2 Diabetes, Chronic Kidney Disease, Glaucoma, hypertension, Osteomyelitis and depression. Resident # 5's MDS review included the MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 4/22/2024 which was a quarterly assessment. The MDS coded Resident # 5 as requiring extensive assistance from one to two staff members with bed mobility, dressing, toileting, hygiene, and bathing. The Resident was also coded as 14 of 15 possible points on a brief interview for mental status (BIMS), indicating no cognitive impairment. The 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 interview and clinical record review, the facility staff failed to inform and provide written information to formulate an advance directive for 2 of 62 residents (Residents #3 and #21) in the survey sample. The findings included: 1. Resident #3 was originally admitted to the facility 5/2/24 after an acute hospital stay. The current diagnoses included metabolic encephalopathy, difficulty in walking, type 2 diabetes mellitus, muscle weakness, and chronic obstructive pulmonary disease. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/4/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #3's cognitive abilities for daily decision making were intact. A review of Resident #3's clinical records didn't reveal a written Advance Directive which would have included what to do if the resident becomes incapacitated, a designated health care surrogate, medical/surgical…

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

Based on staff interviews and clinical record review, the facility staff failed to ensure a resident was free from misappropriation of personal property for 1 of 62 residents (Resident #173), in the survey sample. The findings included: Resident #173 was originally admitted to the facility 6/3/24 after an acute care hospital stay. The resident's diagnoses included alcohol abuse and glaucoma. The resident had not been admitted to the facility long enough for the Minimum Data Set (MDS) to be completed therefore the following information was obtained from the Admission/readmission Nursing Collection Tool dated 6/3/24. The tool revealed at number 1. Cognitive state, that the resident was oriented to person and place. An interview was conducted with the resident on 6/10/24 at approximately 1:40 P.M. Resident #173 stated he had not received his eye drops since admission to the facility. The resident further stated that his sister administered his ophthalmic drops when he was home. The resident also stated he had not experienced blurred vision, burning, itching, or a feeling as if…

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 review and revise the care plan for 5 Residents (Residents #45, #359, #36, #161, and #50) in a survey sample of 62 Residents. The findings include: 1. For Resident #45, the facility staff failed to revise the care plan to include Eliquis anticoagulant therapy and assessment after a bilateral lung pulmonary embolus (blood clot) diagnosis in the hospital. Resident #45, was initially admitted to the facility on [DATE], with diagnoses including; Hypothyroidism, ileus, Atrial fibrillation, weakness, falls, gluten intolerance, and obesity. The Resident was discharged on 3-19-24 back to the emergency room for fever, body ache and change in level of consciousness. The Resident was readmitted on [DATE] after the inpatient hospitalization for bilateral pulmonary embolus (lung blood clots), bilateral pneumonia with sepsis, metabolic encephalopathy, and protein calorie malnutrition. Resident #45's most recent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to ensure a complete list of orders were sent to the Home Health Agency upon resident's discharge for 1 of 62 residents (Resident #167), in the survey sample. The findings included: Resident #167 was originally admitted to the facility 10/02/21 and discharged on 10/22/21 after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; End stage Renal Disease The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/08/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #167 cognitive abilities for daily decision making were intact. In sectionGG(Functional Abilities Goal) the resident was coded as Independent with eating, Requires partial/moderate assistance with toileting hygiene 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, interview, clinical record review and facility documentation, the facility staff failed to provide ADL (Activities of Daily Living) care 7 Residents (#'s 13, 161, 258, 7, 171, 5 and 165 ) in a survey sample of 62 Residents. The findings included: 1. For Resident #13 the facility staff failed to provide incontinence care in a timely manner leaving Resident #13 in brief that was visibly soiled. 6/4/24 at 11:30 AM, Resident #13 was laying in soiled brief notable urine and feces odor in room. Sheets soiled with brownish yellow stain on left side of the bed. Resident #13 asked if the staff have been in to provide incontinence care and she stated that they had not been in since they collected the breakfast trays and had not provided incontinence care since before breakfast. 6/4/24 at 12:00 AM , Resident feces odor remained in room has still not been changed. On 6/4/24 at 1:00 PM, Corporate Employee #1 stated that the facility does not have a policy on ADL Care, she stated they use Mosby'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 interview, clinical record review and facility documentation the facility staff failed to ensure residents who use psychotropics receive gradual dose reduction and are free from unnecessary psychotropic medications for one (1) resident (Resident #13) in a survey sample of 62 Residents. The findings include: The resident was admitted with diagnoses that included muscle weakness, scoliosis, hypotension, history of falls, anxiety disorder unspecified, insomnia, osteoporosis, atrial fibrillation, major depressive disorder, hypertension, psychophysiological insomnia, hx of transient ischemic attack, and protein calorie malnutrition. On the morning of 6/10/24 a review of the clinical record revealed the following orders for psychotropic medications for Resident #13: Duloxetine HCL (trade name Cymbalta, an anti-depressant) oral cap. Delayed release, 60 mg Give 1 cap by mouth one time a day order date 9/16/23. Zolpidem Tartrate (trade name Ambien, a hypnotic) tab. 5 mg. Give 1 tablet by mouth at bedtime for insomnia. Take 5mg (1 tab) at bedtime nightly. 2/27/24 Buspirone HCL (trade…

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 prevent significant medication errors for five (5) Residents (Residents #45, #49, #23, #166 and #358) in a survey sample of 62 residents. The findings included: 1. For Resident #45, the facility staff failed to administer Eliquis anticoagulant medication after a bilateral lung pulmonary embolus (blood clot) diagnosis in the hospital with a specialist doctor's ordered dose Resident #45, was initially admitted to the facility on [DATE], with diagnoses including; Hypothyroidism, ileus, Artial fibrillation, weakness, falls, gluten intolerance, and obesity. The Resident was discharged on 3-19-24 back to the emergency room for fever, body ache and change in level of consciousness. The Resident was readmitted on [DATE] after the inpatient hospitalization for bilateral pulmonary embolus (lung blood clots), bilateral pneumonia with sepsis, metabolic encephalopathy, and protein calorie malnutrition. 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 observations, resident interview, staff interview and clinical record review, the facility staff failed to ensure medications were stored properly in the refrigerator and on the medication carts. The findings included: 1. On 6/10/24 at approximately 12:40 PM the medication storage task was completed with Licensed Practical Nurse (LPN) #2. In the refrigerator in the medication room along with medication to be administered was an opened vial of purified protein derivative (PPD), which was absent of the date it was opened. There were also four single dose COVID-19 vaccines with expiration dates of April 2024. 2. Also on 6/10/24 at approximately 1:07 PM the medication cart that serviced Hall #3 was inspected with LPN #6. In the medication cart were three opened bottles of Latanoprost ophthalmic drops for Resident #50. The oldest bottle was dated 4/23/24, another 5/11/24 and 5/24/24. LPN #6 left the cart and Registered Nurse (RN) #2 completed the inspection. RN #2 stated that Latanoprost ophthalmic drops…

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 and clinical record review, the facility staff failed to ensure one Resident (Resident # 5) received routine and emergency dental care. The Findings included: For Resident # 5, the facility staff failed to schedule routine and emergency dental care appointments. Resident # 5 was admitted to the facility on [DATE] with diagnoses including but not limited to: Type 2 Diabetes, Chronic Kidney Disease, Glaucoma, hypertension, Osteomyelitis and depression. Resident # 5's MDS review included the MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 4/22/2024 which was a quarterly assessment. The MDS coded Resident # 5 as requiring extensive assistance from one to two staff members with bed mobility, dressing, toileting, hygiene, and bathing. The Resident was also coded as 14 of 15 possible points on a brief interview for mental status (BIMS), indicating no cognitive impairment. The Resident was coded as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Observation, facility document review, clinical record review, staff interview, and Resident interview the facility staff failed to follow the menu and preferences of one (1) Resident (Resident #45) in the survey sample of 62 residents. For Resident #45 the tray ticket, and menu, were not followed for the breakfast and lunch meals on 6-4-24, 6-5-24, and 6-6-24. The findings included; Resident #45, was admitted to the facility on [DATE], with diagnoses including; Hypothyroidism, ileus, Artial fibrillation, weakness, falls, gluten intolerance, and obesity. The Resident was discharged on 3-19-24 back to the emergency room for fever, body ache and change in level of consciousness. The Resident was readmitted on [DATE] after the inpatient hospitalization for bilateral pulmonary embolus (lung blood clots), bilateral pneumonia with sepsis, metabolic encephalopathy, and protein calorie malnutrition. Resident #45's most recent MDS (minimum data set) coded the Resident as having moderate cognitive impairment. 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, facility document review, clinical record review, staff interview, and Resident interview, the facility staff failed to follow therapeutic diets for one Resident (Resident #45) in the survey sample of 62 residents. The findings include: For Resident #45 the meals served to the Resident on 6-4-24, 6-5-24, and 6-6-24, were not gluten free. Resident #45, was admitted to the facility on [DATE], with diagnoses including; Hypothyroidism, ileus, Artial fibrillation, weakness, falls, gluten intolerance, and obesity. The Resident was discharged on 3-19-24 back to the emergency room for fever, body ache and change in level of consciousness. The Resident was readmitted on [DATE] after the inpatient hospitalization for bilateral pulmonary embolus (lung blood clots), bilateral pneumonia with sepsis, metabolic encephalopathy, and protein calorie malnutrition. Resident #45's most recent MDS (minimum data set) coded the Resident as having moderate cognitive impairment. The Resident was also coded as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interviews, and staff interviews, the facility staff failed to ensure residents which desires a snack at bedtime received a bedtime snack for three of 62 residents (Resident #21, 2, and 37), in the survey sample. The findings included: 1. Resident #21 was originally admitted to the facility on [DATE] after an acute hospital stay. The admission diagnoses included hemiplegia and hemiparesis, muscle weakness, type 2 diabetes with hyperglycemia, and depression. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/9/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #21's cognitive abilities for daily decision making were intact. During the Resident Council Meeting on 6/5/24 at 11:00 AM Resident #21 stated that snacks were not provided to residents at bedtime. Resident #21 also stated that she would like a snack at bedtime if the facility offered a snack to…

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

Based on observation, interview, and facility documentation the facility staff failed to store, prepare, and distribute food in accordance with professional standards for food safety for the facility. The findings included: For the facility in general, the facility staff failed wear beard guard while in kitchen, and also failed to properly store teriyaki sauce. On 6/4/24 at 11:45 -Other Employee 15 observed without beard guard in kitchen. Employee 15 was asked was he supposed to have on a beard guard, and he stated that he was supposed to. When asked why he was not wearing it he stated that he forgot. On 6/5/24 at 9:00 AM - Other Employee 15 again was observed without beard guard in kitchen. When asked a second time, the mployee stated that he forgot. On 6/5/24 at 9:05 AM - Interview with the Dietary Manager who stated it is our policy that all staff wear the appropriate hair net and beard guards while inside the kitchen area. At the end of the day the dietary manager brought the policy for Staff Attire excerpts are as follows: Policy Statement: It is the center policy that all…

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

Based on staff interviews, the facility staff failed to obtain agreements for dental services and optometry services. The findings included: On 6/12/24 at 10:55 AM an interview was conducted with the Corporate Nurse Consultant and the Administrator. The Corporate Nurse Consultant and the Administrator stated that the facility did not have agreements for outside resources regarding dental services and optometry services. On 6/13/24 at 11:45 AM an interview was conducted with the Corporate Nurse Consultant and the Administrator. The Corporate Nurse Consultant stated that there was no local dentist to accommodate any residents who required stretcher transport. The Corporate Nurse Consultant also stated that if a resident requires glasses the facility will send the resident to the VA (Veterans Administration) Hospital. On 6/13/24 at approximately 2:28 p.m., a final interview was conducted with the Administrator, and two Corporate Nursing Consultant's. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns…

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

Based on staff interviews, the facility staff failed to obtain a transfer agreement with a hospital to transfer residents from the facility to a hospital when deemed medically appropriate. The findings included: On 6/12/24 at 11:05 AM an interview was conducted with the Corporate Nurse Consultant and the Regional [NAME] President of Operations. The Corporate Nurse Consultant and the Regional [NAME] President of Operations stated that the facility does not have a transfer agreement with a hospital to transfer residents from the facility to a hospital when deemed medically appropriate. The Regional [NAME] President of Operations also stated that no hospital will sign a contract with the facility. On 6/13/24 at approximately 2:28 p.m., a final interview was conducted with the Administrator, and two Corporate Nursing Consultant's. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review and facility documentation the facility staff failed to develop and implement a comprehensive person-centered care plan for 2 (#'s 172 and 165) residents in a survey sample of 62 residents. The findings included: 1. For Resident # 172 the facility staff failed to provide a comprehensive care plan for wounds. Resident #1 was admitted to the facility on [DATE] with diagnoses that included but were not limited to diabetes, hypertension, on anticoagulant therapy, sustained injuries to left foot and leg in car accident. discharged from hospital with multiple wounds requiring sutures to the left leg as well as a lymphatic wound. On 5/1/24 the admitting nurse made the following entry: 5/1/24 at 12:00 AM - Skilled Nursing Focus: pt here for pt and ot he has a wound to the left leg no wound orders present at the moment. On 5/1/24 at 1:05 PM the wound specialist was in to see the Resident and he assessed all 4 wounds and identified 3 of them as lacerations that were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility staff failed to perform physician ordered pain assessments, topical and oral medications for 1 of 62 residents (Resident 166), in the survey sample. The findings included: Resident #166 was admitted to the facility with diagnoses that included but were not limited to Fracture of scapula, right shoulder, Osteoporosis, aortic valve disorder, history of falls, malignant neoplasm of upper lobe right bronchus, hypertension, bilateral osteoarthritis of knees, history of venous thrombosis, dementia without dementia without behaviors, and abnormality of gait. Resident #166 admitting orders included the following: Pain Assessment using 0-10 scale or non-verbal scoring tool every shift for Monitor -Order Date- 01/04/2024 - D/C (Discontinued) Date-02/20/2024. Acetaminophen Oral Tablet 500 MG Give 2 tablet by mouth three times a day for Pain -Order Date- 01/04/2024 -D/C Date-01/29/2024. Lidocaine…

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

Based on staff interviews and facility documentation, the facility staff failed to give 2 out of 5 residents in the survey sample (Resident #4 and Resident #12) the opportunity to receive the pneumococcal vaccination. The findings included: 1. Resident #4 was admitted to the nursing facility on 09/30/20. Diagnosis for Resident #4 included but not limited to Hypertension and Cerebral Infarction. The most recent Minimum Data Set (MDS) a quarterly assessment with an Assessment Reference Date (ARD) of 01/04/21 coded Resident #4 with a 14 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 #4 under section O Special Treatments and Programs (O0300) section (A) asked if the residents Pneumococcal vaccination was up to date; was coded No. In addition, the MDS under section (B) asked if Pneumococcal vaccine not received, state reason; was coded Not offered. Review of Resident #4's immunization record did not display the pneumococcal vaccine was either offered or declined. A phone interview was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff and resident interviews, and facility document review, it was determined that the facility staff failed to ensure 4 out of 21 residents (#131, #19, #8 and #1) in the survey sample had an opportunity to formulate and Advance Directive. The findings include: 1. Resident #131 was admitted to the nursing facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), acute cystitis with hematuria (blood), muscle weakness and repeated falls. The admission Minimum Data Set (MDS) assessment dated [DATE] coded the resident with a score of 14 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident had intact cognitive skills for daily decision making. On [DATE] at 1:00 p.m., during an interview with Resident #131, she stated she did not have an Advance Directive and had not been approached by any facility personnel about developing one. She stated she did not have a living will and wanted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, it was determined that facility staff failed to ensure a safe Hoyer lift transfer which resulted in a fall for one out of 21 sampled residents; Resident #1. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included but were not limited to debility, cardio-respiratory conditions, anemia, heart failure, high blood pressure, and diabetes. Resident #1's most recent MDS (minimum data assessment) was an annual assessment with an ARD (assessment reference date) of 11/7/20. Resident #1 was coded as being intact in cognitive function scoring 13 out of 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #1's clinical record revealed that she had experienced a fall on 12/19/20. The following nursing note was documented: Patient was being Hoyer lifted from bed to WC (wheelchair). When lowering to WC patient was on the edge and unable to get back in the chair. Went to readjust…

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

Based on observation, staff interview and facility document review, it was determined that facility staff failed to obtain a physician's order for the use of oxygen for one of 21 residents in the survey sample; Resident #279. The findings included: Resident #279 was admitted to facility on 2/10/21 with diagnoses that included but were not limited to COVID-19, sepsis, and acute respiratory failure. Resident #279's most recent MDS (minimum data set) assessment was an entry assessment with an ARD (assessment reference date) of 2/10/21. Resident #279 did not have a completed MDS assessment. On 2/17/21 at 12:18 p.m., an observation was made of Resident #279. She was sitting up in her wheelchair wearing a nasal cannula that was hooked up to an oxygen (02) concentrator. The 02 concentrator was turned on and at 2 liters of oxygen. On 2/18/21 at 11:15 a.m., a second observation was conducted of Resident #279. She was lying in bed with her nasal cannula in place. When asked how many liters she was receiving, Resident #279 stated that she has always been on 2 liters of oxygen. Review 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 facility document review and staff interviews the facility staff failed to ensure the services of a registered nurse for at least 8 consecutive hours on Saturday 1/30/21 and Sunday 1/31/21. The findings included: The facility's as worked schedules from January 18, 2021 through February 17, 2021 were reviewed for RN (registered nurse) coverage for at least 8 consecutive hours a day, 7 days a week. On Saturday 1/30/21 and Sunday 1/31/21 there was no RN coverage identified on the facility's as worked schedules. On 2/18/21 at 1:30 P.M. a phone interview was conducted with the facility's Scheduler. The Scheduler was asked about RN coverage for Saturday 1/30/21 and Sunday 1/31/21. The Scheduler stated, I don't see where there was an RN for that weekend. The Director of Nursing is the RN coverage during the week. On 2/18/21 at 2:30 P.M. a phone interview was conducted with the facility's Administrator regarding RN coverage on Saturday 1/30/21 and Sunday 1/31/21. The Administrator stated, There was no RN coverage for that weekend. The Unit Manager was out with COVID, our 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 information obtained during the Resident Council Meeting, observations and interviews, the facility staff failed to display advocacy agencies addresses, and telephone numbers in a manner the residents could utilize. The findings included: A resident council meeting was held in the resident dining hall on 10/03/2018 from 10:00 AM to 10:35 AM. Six residents attended the meeting. The residents were not aware of how to obtain or utilize the Long-Term Care Ombudsman's contact information or other advocacy agencies. They were also unaware of the role of the Long-Term Care Ombudsman. On 10/03/18 at approximately 3:20 PM an interview was conducted with the Activity Director regarding the residents in the Resident Council Meeting stating that they were not aware of who the Ombudsman was and the role of the Ombudsman. The Activity Directory stated that she would educated the residents to the facility posting and on the role of the Ombudsman. The Activity Director stated that the advocacy agencies addresses and phone numbers were displayed on the wall in the hallway. The advocacy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, facility documentation review and clinical record review the facility staff failed send a copy of the Bed-Hold Policy for 3 of 23 resident's (Resident #2, #30 and #38) in the survey sample. 1. The facility staff failed to provide the resident (Resident #2) and/or resident's representative with a written copy of the bed hold policy upon transfer to the hospital. 2. The facility staff failed to provide the resident (Resident #30) and/or resident's representative with a written copy of the bed hold policy upon transfer to the hospital. 3. The facility staff failed to provide the resident (Resident #38) and/or resident's representative with a written copy of the bed hold policy upon transfer to the hospital. The findings included: 1. Resident #2 was originally admitted to the facility 9/18/18, was discharged return anticipated from the facility to an acute care hospital 9/23/18 due to an acute illness. The resident returned to the facility 9/25/18. The current diagnoses included; a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and clinical record review the facility staff failed to ensure 1 of 23 residents (Resident #17) in the survey sample who were unable to carry out activities of daily living (ADL) receives the necessary services to maintain fingernail care. The facility staff failed to ensure that fingernail care was provided to Resident #17. The findings included: Resident #17 was re-admitted to the facility on [DATE]. Diagnosis for Resident #17 included but not limited to *Cerebrovascular Accident (CVA-stroke) with left *hemiplegia. *CVA is a medical emergency. Strokes happen when blood flow to your brain stops. Within minutes, brain cells begin to die (https://medlineplus.gov/stroke.html). *Hemiplegia is the loss of muscle function on one side of the body (https://medlineplus.gov/druginfo/meds/a682514.html). The current Minimum Data Set (MDS) a quarterly assessment with an Assessment Reference Date (ARD) of 08/20/18 coded Resident #17 with a 13 out of a possible score of 15 on the Brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, clinical record review and facility documentation, the facility staff failed to follow physician orders for 1 of 23 (Resident #27) in the survey. The facility staff failed to follow physician orders for a wound care dressing change to Resident #27's right elbow with a diagnosis of *Methicillin Resistant Staphylococcus Aureus (MRSA) infection. *MRSA is an infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections (https://www.mayoclinic.org/diseases-conditions/mrsa/symptoms-causes/syc). The findings included: Resident #27 was admitted to the facility on [DATE]. Diagnosis for Resident #27 included but not limited to Methicillin Resistant Staphylococcus Aureus (MRSA) infection. Resident #27 Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 09/11/18 coded Resident #27's Brief Interview for Mental Status (BIMS) scored of 05 out of a possible score of 15 indicating…

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 review of the resident's medical chart, staff interview, and review of the facility's policy the facility staff failed to assure each resident's medication regimen was reviewed monthly for 1 of 23 residents (Resident #3), in the survey sample. The facility staff failed to review Resident #3's medication regimen during the month of April 2018. The findings included: Resident #3 was originally admitted to the facility 2/26/14 and has never been discharged from the facility. The current diagnoses included; an anxiety disorder, depression and arthritis. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/26/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #3 cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring set-up assistance of 1 person with bed mobility, transfers, locomotion, dressing, eating, toileting, personal hygiene and bathing. Resident #3 Physician's order…

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 one medication cart was stored in a secured location, accessible to designated staff only. The facility staff failed to ensure medication cart containing medication in the hallway was locked when not in direct site of the nurse. The findings included: On 10/03/18 at approximately 6:20 p.m., the medication cart on the back hall was observed to be unlocked when not in direct view of the nurse. The surveyor waited at the medication cart for approximately 4 minutes before the License Practical Nurse (LPN) #4 returned to her med cart. The surveyor asked, Should your medication cart be locked when not in direct view of the nurse she replied, Yes, I should have checked to make sure my cart was locked before I walked away. On the same day at approximately 6:30 p.m., an interview was conducted with Unit Manager (UM) who stated, The nurse should have made sure her medication cart was locked before she walked away. The facility administration was informed of the finding during a…

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

Based on observation, staff interviews and facility document review the facility staff failed to store food in accordance with professional standards for food service safety. The food service staff failed to ensure foods stored in refrigerated units were labeled and dated appropriately when open; and failed to store employee lunch in an area designated for staff use only. The findings included: On 10/02/18 at 7:55 a.m., during the initial inspection of the kitchen with the dietary cook, the following was observed: 1. Inside the walk in refrigerator was a container of raw chicken; not labeled and dated. 2. Inside the walk in freezer was a bag of mixed vegetables, bag of cinnamon rolls and bag of pulled chicken, all items were open; not labeled and dated. 3. Inside the reach in refrigerator were pre-made salads for the residents along with an employee lunch box. On 10/02/18 at approximately 8:00 a.m., the surveyor asked the dietary cook, Should the raw chicken, mixed vegetables, cinnamon rolls and bag of pulled chicken be labeled and dated he replied, Yes the dietary cook immediately…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and facility documentation review, the facility staff failed to ensure a complete and accurate clinical record for 1 of 23 residents (Resident #27) in the survey sample. The facility staff failed to ensure Resident #27's Treatment Administration Record (TAR) was accurate for the right elbow surgical wound dressing change. The findings included: Resident #27 was admitted to the facility on [DATE]. Diagnosis for Resident #27 included but not limited to Methicillin Resistant Staphylococcus Aureus (MRSA) infection. Resident #27's Minimum Data Set (MDS - an assessment protocol) with an Assessment Reference Date of 09/11/18 coded Resident #27's Brief Interview for Mental Status (BIMS) scored of 05 out of a possible score of 15 indicating severe cognitive impairment. In addition, the MDS coded Resident #27 total dependence of one with bathing, extensive assistance of two with bed mobility, transfer, toilet use and personal hygiene, 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 observations and staff interviews the facility staff failed to maintain effective infection control practices during the provision of care for 2 of 23 residents (Residents #39 and 27), in the survey sample. 1. The facility staff failed to perform hand hygiene during wound care for Resident #39. 2. The facility staff failed to disinfect Resident #27's personal over bed table before after being used to perform a wound care dressing change that was being treated for *Methicillin Resistant Staphylococcus Aureus (MRSA) infection. The findings included: 1. Resident #39 was originally admitted to the facility 7/25/18 and has never been discharged from the facility. The current diagnoses included; a stage 4 pressure ulcer of the sacrum and an unstageable pressure ulcer of the left heel. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/1/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated…

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.