Birchwood Park Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility failed to maintain a qualified Social Worker in a 220 bed facility resulting in a Substandard Level of Care impacting resident care to all residents including 1 Resident (Resident #226) in a survey sample of 74 Residents. The findings included: For Resident #226, who refused a transfer to the locked memory care unit (for Residents with dementia and behaviors), the facility staff failed to honor the Resident's request. The staff moved him against his will, and did not afford him the services of a Social worker to plan care and discharge, per his wishes. Resident #226 was admitted to the facility on [DATE] with diagnoses including: End stage renal disease with hemodialysis, history of stroke, anemia, chronic congestive heart failure, hypertension, and diabetes type 2. The Resident did not have a diagnosis of dementia and was his own responsible party and by facility agreement cognitively…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to implement an infection prevention and control program to include environmental concerns for 4 of 4 nursing units to include the entire locked memory care unit and the direct care of four Residents (Resident #226, #117, #105, and #87) in a survey sample of 74 Residents. The findings included: 1. For Resident #226, the entire memory care unit was dirty, in disrepair, had bodily fluids on surfaces, and there were no paper towels nor soap to wash staff hands in any resident room. 2. For Resident #117, the entire memory care unit was dirty, in disrepair, had bodily fluids on surfaces, and there were no paper towels nor soap to wash staff hands in any resident room. 1. Resident #226 was admitted to the facility on [DATE] with diagnoses including: End stage renal disease with hemodialysis, history of stroke, anemia, chronic congestive heart failure, hypertension, and diabetes…

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, observation, and facility documentation the facility staff failed to promptly act upon the grievances and recommendations of regularly attending Resident council members. The findings included: The facility staff failed to promptly address the concerns brought forth by the Resident council group members. On 12/11/24 at 3 p.m. a Resident Council meeting was held with the Resident Council President and 6 other members who regularly attended. During the meeting it was discussed that the facility fails to act, in a timely manner, on suggestions, or concerns brought forth by the Resident Council. On 12/12/24 a review of the Resident council minutes revealed that several issues were repeatedly brought up in Resident council. Excerpts from the Resident council minutes revealed the following: On 8/14/24, 9/26/24, and 10/24/24 - Resident council minutes reflected complaints of needing more linens, (towels, sheets), long turnaround time for getting laundry back from housekeeping, and personal items missing from laundry, as well as bathrooms needing to be cleaner (unclean…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review and staff interview, the facility staff failed to ensure a Pre-admission Screening and Resident Review (PASARR) was completed prior to admission or shortly thereafter for 4 Residents (Residents #49, #24, #47, and #80) in a sample of 74 residents. The findings include: 1. For Resident #49, facility staff failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed correctly prior to admission or shortely thereafter. Resident #49 was admitted on [DATE] with diagnoses including: Major depressive disorder with psychotic symptoms, anxiety disorder, and Post Traumatic Stress Disorder (PTSD). Physicians orders for medications were reviewed and revealed psychotropic medications actively being administered for anxiety, and ongoing behavior monitoring. On 12-10-24, an observation was conducted of Resident #49. The Resident was sitting in her room and refused to respond to the surveyor who had entered the room and addressed her in a greeting while…

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 care plan for 4 Residents (Residents #117, #379, #91 and #39) in a survey sample of 74 Residents. The findings included: 1. For Resident #117, the facility staff failed to derive and implement a comprehensive care plan for prevention of significant weight loss and dehydration, Pressure sores, Hospice, and provision of ADL (Activities of Daily Living) care. Resident #117 was originally admitted to the facility on [DATE], and was hospitalized 10 days later on 9-15-24 for a colonic hemorrhage caused by a Stercoral ulcer (impacted hard stool at the anus and distal rectum) which pierced the bowel wall, after having had no bowel movements. The ulcer/perforation of the bowel wall resulted in blood loss requiring 2 blood transfusions according to hospital records. The Resident was again sent out to the hospital on [DATE] through 10-15-24 for a severe urinary…

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 review and revise a care plan for two (2) Residents (#'s 78 and 105) in a survey sample of 74 Residents. The findings included: 1. For Resident #78 the facility staff failed to review and revise care plan to include add each actual fall and update or add new interventions. On 12/11/24 a review of the clinical record revealed that Resident #78 was admitted to the facility on [DATE] with diagnoses that included but were not limited to cognitive communication deficit, dysphagia, muscle weakness, dementia, severe without behavioral disturbance, psychotic mood disturbance and anxiety, abnormalities of gait and mobility, hypertension, hx (history) of renal cancer, and hx of repeated falls. Resident #78 had a BIMS (Brief Interview of Mental Status) score of 13/15 on admission indicating mild cognitive impairment. On 2/13/24 (one month prior to falls) Resident #78 BIMS was assessed at 5/15 indicating severe…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to provide Activity of Daily Living (ADL) care to four (4) dependant Residents (Resident #226, #117, #18, and #48) in a survey sample of 74 Residents. The findings included: 1. For Resident #226, the Resident was dirty and unkempt. 2. For Resident #117, the Resident was dirty, unclothed, and unkempt. 1. Resident #226 was admitted to the facility on [DATE] with diagnoses including: End stage renal disease with hemodialysis, history of stroke, anemia, chronic congestive heart failure, hypertension, and diabetes type 2. The Resident did not have a diagnosis of dementia and was his own responsible party and by facility agreement cognitively intact and able to make his own decisions. The Resident had a room mate, Resident #117. 2. Resident #117 was admitted to the facility on [DATE] with diagnoses including: Dementia without behavioral disturbance, hypertension, major recurrent…

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

Based on a resident interview, staff interview, and clinical record review, the facility staff failed to have ongoing records of communication between the facility and the dialysis center for one (1) of 74 residents (Resident 13), in the survey sample. The findings included: Resident #13 was originally admitted to the facility 6/25/24. The current diagnoses included end stage renal disease requiring dialysis. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/2/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #13's cognitive abilities for daily decision making were intact An interview was conducted with the Resident #13 on 12/10/24 at 3:55 PM. Resident #13 stated she receives dialysis services outside the facility on a Monday, Wednesday and Friday schedule. The resident stated she was waiting for the staff to add a low air loss mattress to her bed because she was experiencing back pain. The resident stated the back pain started when the dialysis…

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 and clinical record review the facility staff failed to ensure medications were acquired and available to meet the needs of one (1) of 74 residents in the survey sample, Resident #327. The findings included: For Resident # 327, the facility staff failed to ensure several medications were available for administration as ordered by the physician. Resident # 327 was a [AGE] year old admitted to the facility on [DATE], with diagnoses that included but were not limited to: Asthma, emphysema, Pulmonary Fibrosis, Seizure disorder, Chronic anxiety and depression, Hypothyroidism and Gastroesophageal reflux disease, historyof Pulmonary Embolism, orthostatic hypotension and chronic hypoxic respiratory failure-on oxygen at 4 liters per minute via nasal cannula, Congestive Heart Failure. Cerebral Vascular Accident. The most recent MDS (Minimum Data Set) assessment was coded as an admission assessment with an ARD (Assessment Reference Date) of 8/1/2023. The BIMS (brief interview for mental…

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, clinical record review, and facility document review, the facility staff failed to ensure pharmacy recommendations were obtained and acted upon for five Residents (Residents #117, #226, #51, #33 and #78), in the survey sample of 74 Residents. The findings included: 1. For Resident #117, the pharmacist recommendations were either not obtained, or not acted upon, and none were in the clinical record in 2 of the preceding 3 months of survey (September, and October 2024). Resident #117's clinical record was reviewed and for the last 3 months prior to survey (September through November), as December had not yet been completed, The Registered Pharmacist (RPH) Monthly Medication Regimen Reviews (MMR) were reviewed. Resident #117 was receiving anticoagulants, blood pressure medication, psychotropic medication, anti seizure medication, diuretics, pain medication, heart medication, was on a fluid restriction, and had a history of kidney disease, congestive heart failure, bleeding, and dehydration. On 12-16-24 the Director of Nursing (DON) was interviewed…

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 label with expiration date and store medications appropriately for 3 Residents ( Resident #8, #74 and #103) and for the facility stock multi use vial medications, in a survey sample of 74 residents, and the facility failed to ensure that narcotic medications no longer in use by residents were properly locked away, accounted for and disposed of in a timely manner. The findings included: 1. For Resident #8, the facility had failed to correctly label / store 2 bottles of Ativan (Lorazepam an anti-anxiety medication). On [DATE] at approximately 3 p.m. while inspecting the medication room it was discovered that 2 bottles of liquid Ativan prescribed for Resident 8, had been opened and used however neither bottle had an open date on them. The bottles were open and available for use and clearly labeled to discard after 90 days. LPN #3 was asked how would you know if the bottle was expired. LPN #3 stated you…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, the facility staff failed to ensure resources necessary to provide for the needs of the residents who resided on the Memory unit were available. The findings included: On 12/10 through 12/13/24 observations were made from the conference room of the windows of residents who resided on the Memory Unit. Most windows were with broken window blinds which were unsightly and allowed residents and staff to be viewed. 12/12/24 and 12/13/24 observations were made of supplies (soap, paper towels, window coverings, damaged and missing tile or molding) to create a clean and homelike environment for all of the residents who resided on the unit. On 12/12/24 at 11:21 AM observations were made of multiple resident room floors (62, 64, 65, 66, 68, 69 and 71). The floors were discolored, with spills, dirt/debris, and some had molding pulling away from the walls. Multiple rooms (62, 65,66, 68, and 71) were with no blinds or window coverings or severely damaged window blinds. Several…

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 facility documentation the facility failed to maintain a training program for all new and existing staff based on the facility's assessment. The findings included: The facility failed to maintain a training program for all new and existing staff. Review of the Staff Education, SNF Clinic and Healthcare Academy training transcripts revealed that not all facility staff had completed all the required training. On 12/19/24 at approximately 6:30 PM, a final interview was conducted with the Administrator, Director of Nursing and the Staff Development Coordinator. They were made aware of the concerns. No additional information was provided.

Based on staff interview, and facility documentation, the facility failed to ensure that all direct care staff complete mandatory Effective Communication training. The findings included: The facility failed to ensure that all direct care staff complete mandatory Effective Communication training. Review of the Staff Education, SNF Clinic and Healthcare Academy training transcripts revealed that not all direct care staff has documented completion of mandatory Effective Communication training. On 12/18/2024 at approximately 2:40 p.m., an interview was conducted with the Staff Development Coordinator (SDC) who was asked about, direct care staff having completed mandatory Effective Communication training, she stated that training and education is recorded by SNF Clinic and Healthcare Academy, and that files are correct and up to date. On 12/19/24 at approximately 6:30 PM, during the end of day meeting the Administrator, Director of Nursing and Staff Development Coordinator were made aware of the concerns. No further information was provided.

Based on staff interview, and facility documentation, the facility failed to ensure that all staff members are educated in the rights of the residents and responsibilities of the facility. The findings included: The facility failed to ensure that staff members are educated in the rights of the residents and responsibilities of the facility. Review of the Staff Education, SNF Clinic and Healthcare Academy training transcripts, it was revealed that not all staff reviewed had completed the Resident Rights Training. On 12/18/24 at approximately 2:40 p.m., an interview was conducted with the Staff Development Coordinator (SDC) who was asked about, staff Residents Rights mandatory training, she stated that training and education, is recorded by SNF Clinic and Healthcare Academy and that the files are correct and up to date. On 12/19/24 at approximately 6:30 PM, during the end of day meeting the Administrator, Director of Nursing and Staff Development Coordinator were made aware of the concerns. No further information was provided.

Based on staff interview and facility documents the facility staff failed to ensure that all staff members were educated regarding the Quality Assurance and Performance Improvement The findings included: Review of the Staff Education, SNF Clinic and Healthcare Academy training transcripts revealed that not all facility staff had completed all the required training for Quality Assurance and Performance Improvement. On 12/19/24 at approximately 6:30 PM, a final interview was conducted with Administrator, Director of Nursing and the Staff Development Coordinator, they were made aware of the concerns. No additional information was provided.

Based on review of facility documents and staff interview the facility staff failed to ensure that all staff members were educated on Compliance and Ethics. The findings included: Review of the Staff Education, SNF Clinic and Healthcare Academy training transcripts revealed that not all facility staff had completed all the required training for Compliance and Ethics. On 12/19/24 at approximately 6:30 PM, a final interview was conducted with Administrator, Director of Nursing and the Staff Development Coordinator, they were made aware of the concerns. No additional information was provided.

Based on review of facility documents and staff interview the facility staff failed to ensure that all Certified Nurse's Aides (CNA) completed the mandatory twelve (12) hours of education each year. The findings included: Review of the Staff Education, SNF Clinic and Healthcare Academy training transcripts revealed that not all CNAs had completed the mandatory twelve (12) hours of education each year which addressed each CNA's areas of weakness as determined in nurse aides' performance reviews the facility assessment and the special needs of residents as determined by the facility staff. On 12/17/24 at 12:00 PM, an interview was conducted with the Staff Development Coordinator (SDC) regarding CNAs mandatory training. The SDC stated that training and education for most CNAs have been completed, but states that some of the transcripts were lost when the facility switched from Healthcare Academy to SNF Clinic for training transcripts, but that there was an ongoing plan for all CNAs to become compliant with mandatory training. On 12/19/24 at approximately 6:30 PM, a final 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, and facility documentation, the facility failed to ensure that all staff members had completed mandatory Behavioral Health Training. The findings included: The facility failed to ensure that all staff members had completed the mandatory Behavioral Health Training. Review of the Staff Education, SNF Clinic and Healthcare Academy training transcripts revealed that all staff had not completed the mandatory Behavioral Health Training. On 12/18/24 at 2:40 p.m. an interview was conducted with the Staff Development Coordinator (SDC) who was asked about staff training regarding, the mandatory Behavioral Health Training. She stated that the training and education is recorded by SNF Clinic and Healthcare Academy and that the files are correct up to date. On 12/19/24 at approximately 6:30 PM, during the end of day meeting the Administrator, Director of Nursing and Staff Development Coordinator were made aware of the concerns. No further information was provided.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure there was a self-administration of medication assessment prior to leaving medications at the bedside for one (1) of 74 residents (Resident #91) in survey sample. Findings included: For Resident # 91, the facility staff failed to ensure there was a self-administration of medication assessment prior to leaving medications at the bedside. Resident # 91 was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Cerebral Infarction, Hypertension, Anxiety Disorder, Hemiplegia and Vascular Dementia. The most recent Minimum Data Set (MDS) was an Annual Assessment with an Assessment Reference Date (ARD) of 11/3/2024. Resident # 91's BIMS (Brief Interview for Mental Status) Score was a 14 out of 15, indicating no cognitive impairment. Resident # 91 required assistance with Activities of Daily Living. Review of the clinical record was conducted on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to afford a resident the ability to refuse a transfer affecting one (1) resident (Resident #226) in a survey sample of 74 Residents. The findings included: For Resident #226, who refused a transfer to the locked memory care unit for Residents with dementia and behaviors, the facility staff failed to honor the Resident's request. The staff moved him against his will, for staff convenience. Resident #226 was admitted to the facility on [DATE] with diagnoses including: End stage renal disease with hemodialysis, history of stroke, anemia, chronic congestive heart failure, hypertension, and diabetes type 2. The Resident did not have a diagnosis of dementia and was his own responsible party and by facility agreement cognitively intact and able to make his own decisions. Three MDS (minimum data set) federal assessments were reviewed since the resident's admission through the time…

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 a resident personal funds review, the resident interview, staff interview and facility document review, the facility staff failed to ensure that one (1) resident out of 74 residents in the survey sample, Resident #24, was afforded the right to receive quarterly statements. The findings included; Resident #24 was originally admitted to the facility 11/17/22 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included Schizoaffective Disorder, Bipolar type. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 09/19/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #24 was moderatly impaired for the cognitive abilities for daily decision making. The care plan dated 11/24/23 read that Resident #24 has impaired thought processes as evidenced by delusions secondary to schizoaffective/bipolar disorder. The goal for the resident was for the resident will 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 staff interview, clinical record review, the facility staff failed to ensure the physician was notified of pertinent information regarding two (2) residents (Resident # 327 and # 326) in a survey sample of 74 residents. Findings included: 1. For Resident # 327, the facility staff failed to notify the Physician that medications were not available and not administered as ordered. Resident # 327 was a [AGE] year old admitted to the facility on [DATE], with diagnoses that included but were not limited to: Asthma, emphysema, Pulmonary Fibrosis, Seizure disorder, Chronic anxiety and depression, Hypothyroidism and Gastroesophageal reflux disease, history of Pulmonary Embolism, orthostatic hypotension and chronic hypoxic respiratory failure-on oxygen at 4 liters per minute via nasal cannula, Congestive Heart Failure. Cerebral Vascular Accident. The most recent MDS (Minimum Data Set) assessment was coded as an admission assessment with an ARD (Assessment Reference Date) of [DATE]. The BIMS (brief interview for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, the facility staff failed to maintain the confidentiality of medical records for two residents (Residents #'s 39, 74) in a survey sample of 74 residents. Findings included: 1. For Resident # 39, the facility staff failed to honor the resident's right to privacy and maintain confidentiality of medical records when the screen for documentation of Activities of Daily Living was left open for others to easily view on 12/10/2024. Resident # 39 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, Chronic Obstructive Pulmonary Disease, Emphysema, Primary Hypertension, Anxiety, Depression, Gastrpesophageal Reflux Disease, Barrett's Esophagus, Dysphagia and Insomnia. The most recent Minimum Data Set (MDS) was a Quarterly Assessment Quarterly with an Assessment Reference Date (ARD) of 11/17/2024. Resident # 161's BIMS (Brief Interview for Mental Status) Score was a 15 out of 15, indicating no cognitive impairment. Review 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 resident interview and staff interview, the facility staff prohibited and discouraged a resident from communicating with the state surveyor for one (1) of 74 residents (Resident #226), in the survey sample. The findings included: Resident #226 was originally admitted to the facility 6/6/2024 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included end stage renal disease requiring hemodialysis, dementia and atrial fib. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/13/2024 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #226's cognitive abilities for daily decision making were moderately impaired. On 12/12/24 at approximately 12:20 PM an interview was conducted with Resident 226. Resident #226 stated he did not know why he had to continue to live on the Memory Care unit. The resident pointed out that no one who resided on the unit wore…

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 report an accident hazard which resulted in bodily harm, to the State Survey and Certification Agency for one (1) or 74 residents, (Resident #56) in the survey summary. The findings included: Resident #56 was originally admitted to the facility 08/22/19 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Unsteadiness on feet and Impulsiveness, Burn of first degree of left forearm, initial encounter. Burn of unspecified degree of single right finger (nail) except thumb, initial encounter. Unspecified dementia without behavioral disturbance. Unsteadiness on feet. Impulsiveness. The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/01/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #56 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review, staff interviews and facility document reviews, the facility staff failed to notify the Office of the State Long-Term Care Ombudsman in writing of discharges for one (1) resident (Resident #32) in the sample of 74 residents. The findings included: Resident #32 was originally admitted to the facility 11/17/22 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Peripheral Vascular Disease, unspecified. The significant change, annual quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 06/29/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 7 out of a possible 15. This indicated Resident #32 cognitive abilities for daily decision making were severely impaired. According to the Admission/Discharge Report Resident #32 was discharged to the hospital on 6/10/24. The Discharge MDS assessment was dated for 06/10/24 - discharged assessment - return anticipated. The Re-entry…

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 complete a Comprehensive 14 day full admission assessment and submit it to CMS (Centers for Medicare and Medicaid Services) in a timely manner for one (1) Resident (Residents #117) in a survey sample of 74 Residents. The findings included: For Resident #117, the facility staff did not complete and submit a Comprehensive admission MDS assessment timely. Resident #117 was originally admitted to the facility on [DATE]. Resident #117 had a medical diagnosis history including; Congestive heart failure with diuretic use, unspecified dementia without behaviors, hypertension, depression, anxiety, dysphagia, gastro-esophageal reflux disease, and cardiac disease. Resident #117's most recent Minimum Data Set (MDS) assessment was a Significant change assessment with an assessment reference date of 11-28-24. Resident #117 had a Brief Interview of Mental Status score of 99 indicating severe cognitive impairment. He…

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

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 complete a correct Significant Change full MDS assessment for two (2) Residents (Residents #117 & #105) in a survey sample of 74 Residents. The findings included: 1. For Resident #117, the facility staff did not complete and submit a correct Significant Change MDS assessment, with significant weight loss identified. Resident #117 was originally admitted to the facility on [DATE]. Resident #117 had a medical diagnosis history including; Congestive heart failure with diuretic use, unspecified dementia without behaviors, hypertension, depression, anxiety, dysphagia, gastro-esophageal reflux disease, and cardiac disease. Resident #117's most recent Minimum Data Set (MDS) assessment was a Significant change assessment with an assessment reference date of 11-28-24. Resident #117 had a Brief Interview of Mental Status score of 99 indicating severe cognitive impairment. He was dependant on staff for eating,…

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 facility documentation review, the facility staff failed to follow the professional standards of quality for four (4)residents (Resident #'s 326, 91, 128 and 48) in survey sample of 74 residents. Findings included: 1. For Resident # 326, the facility staff failed to ensure wound care was provided as ordered by the physician. Resident # 326 was a [AGE] year old admitted to the facility on [DATE], with diagnoses that included but were not limited to: Calciphylaxis a rare serious disease that involves build up of calcium in small blood vessels of fat tissue and skin. People with the disease usually have kidney failure or receive dialysis. The most recent MDS (Minimum Data Set) assessment was coded as an admission assessment with an ARD (Assessment Reference Date) of [DATE]. The BIMS (brief interview for mental status) was coded as 15 out of possible 15 indicating no cognitive impairment. The assessment also coded Resident # 326 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, staff interview, facility documentation review, and clinical record review the facility staff failed to prevent a significant weight loss and dehydration for one (1) Resident (Residents #117) in a survey sample of 74 Residents. The findings included: For Resident #117, the facility staff did not provide meals consistently, and did not provide hydration consistently, resulting in significant weight loss and dehydration. Resident #117 was originally admitted to the facility on [DATE], and was hospitalized 10 days later on 9-15-24 for a colonic hemorrhage caused by a Stercoral ulcer (impacted hard stool at the anus and distal rectum) which pierced the bowel wall, after having had no bowel movements. The ulcer/perforation of the bowel wall resulted in blood loss requiring 2 blood transfusions according to hospital records. The Resident was again sent out to the hospital on [DATE] through 10-15-24 for a severe urinary tract infection causing sepsis and septic shock, and acute kidney injury which…

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 ensure Residents are free from significant medication errors for three (3) Residents (378, 109, and 327) in a survey sample of 74 Residents. The findings included: 1. For Resident # 378 the facility staff failed to ensure Vancomycin (an anti-biotic used to treat infection) was administered as prescribed by physician, delaying treatment by 4 days for C-Diff (Clostridium difficile a bacteria that causes watery diarrhea, abdominal pain and cramping, fever, nausea, and dehydration). On 12/12/24 a review of the clinical record revealed that Resident #378's admission order for Vancomycin read: 2/15/24 Vancomycin HCl Oral Capsule 125 MG (Vancomycin HCl) Give 5 ml via PEG-Tube one time a day for C. Diff for 6 Days -Start Date- 02/16/2024 1200 The following progress notes were entered regarding the Vancomycin administration or lack thereof: 2/16/24 1:36 p.m. - Vancomycin HCl Oral Capsule 125 MG Give 5 ml via…

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 audiology services. The findings included: On 12/18/24 at 1:20 PM an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that the facility does not have written agreements for dental services and audiology services. The ADON also stated that if a resident requires dental services, the facility will make an appointment with a dentist the resident requests or recommends. On 12/19/24 at approximately 6:25 p.m., a final interview was conducted with the Regional [NAME] President of Operations, Administrator, Regional Nursing Consultant, Regional MDS Consultant, Director of Nursing, Assistant Director of Nursing, and Owner. 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 staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain accurate and readily accessible medical records for one (1) resident (Resident # 327) in a sample size of 74 residents. The findings included: For Resident # 327, the Social Worker did not document social services notes in the clinical record regarding details of a grievance that was filed on [DATE]. Resident # 327 was a [AGE] year old admitted to the facility on [DATE], with diagnoses that included but were not limited to: Asthma, emphysema, Pulmonary Fibrosis, Seizure disorder, Chronic anxiety and depression, Hypothyroidism and Gastroesophageal reflux disease, history of Pulmonary Embolism, orthostatic hypotension and chronic hypoxic respiratory failure-on oxygen at 4 liters per minute via nasal cannula, Congestive Heart Failure. Cerebral Vascular Accident. The most recent MDS (Minimum Data Set) assessment was coded as an admission assessment with an ARD (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 Observation, staff interview, clinical record review, and facility document review the facility staff failed to provide services for two Residents receiving hospice care (Resident #117, and #78) in a survey sample of 74 Residents. The findings included; 1. For Resident #117, The facility staff failed to provide the following federally required areas for a Resident receiving hospice care; Provision of MDS assessments timely, and accurate. Provision of timely ADL care. Provision of a comprehensive care plan for services. Provision of medication regimen reviews. Provision of social work. Provision of a hospice communication process. Provision of nutritional support. Resident #117 was originally admitted to the facility on [DATE], and was hospitalized 10 days later on 9-15-24 for a colonic hemorrhage caused by a Stercoral ulcer (impacted hard stool at the anus and distal rectum) which pierced the bowel wall, after having had no bowel movements. The ulcer/perforation of the bowel wall resulted in blood loss…

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 and staff interviews, the facility staff failed to administer the influenza vaccine for 1 of 5 residents reviewed for immunization (Resident #34), in a survey sample of 74 Residents. The findings included: Resident #34 was originally admitted to the facility 4/1/16. The current diagnoses included; Alzheimer's Disease with early onset, hyperlipidemia, depression, dysphagia, and muscle weakness. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/8/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 00 out of a possible 15. This indicated Resident #34's cognitive abilities for daily decision making were severely impaired. The facility's policy on Influenza Vaccination with a revision date of 10/15/2024 was reviewed. The policy stated influenza vaccinations will be routinely offered annually from October 1st through March 31st unless such immunization is medically contraindicated, the individual has already been immunized during this time period or refuses to receive 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 clinical record review and staff interviews, the facility staff failed to administer the Covid-19 vaccine for 1 of 5 residents reviewed for immunization (Resident #34), in a survey sample of 74 Residents. The findings included: Resident #34 was originally admitted to the facility 4/1/16. The current diagnoses included; Alzheimer's Disease with early onset, hyperlipidemia, depression, dysphagia, and muscle weakness. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/8/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 00 out of a possible 15. This indicated Resident #34's cognitive abilities for daily decision making were severely impaired. The facility's policy and procedures on Influenza, Pneumococcal and Covid-19 Disease Prevention with a date of May 2022 was reviewed. The policy and procedures stated the resident's medical record includes: Documentation that the resident either received the influenza, pneumococcal and Covid-19 immunization or did not receive it due to medical…

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, clinical record review and facility documentation the facility staff failed to ensure functional, and sanitary environment for the residents, staff and the public. The findings included: For the facility, the facility staff failed to ensure all 3 dryers were operational to ensure Residents had clean personal laundry as well as staff having adequate linens to care for the Resident population. On 12/11/2024 at 3pm a Resident Council meeting was held and in the meeting several Residents mentioned the delay in getting laundry back in a timely manner and the shortage of linens was also mentioned. Excerpts from the Resident council minutes revealed the following: On 8/14/24, 9/26/24, and 10/24/24 - Resident council minutes reflected complaints of needing more linens, (towels, sheets), long turnaround time for getting laundry back from housekeeping, and personal items missing from laundry, as well as unclean bathrooms and shower rooms. On 12/11/24 - Linen carts were observed low of linens such as washcloths and towels as well as sheets. On 12/12/24 at…

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

Based a clinical record review and staff interview the facility staff failed to accurately code the Minimum Data Set (MDS) assessment and trackings for 1 of 29 residents (Resident #123), in the survey sample. The findings included: Resident #123 was originally admitted to the facility 6/10/2022 and was last readmitted to the facility 11/10/2024 after an acute care hospital stay. The current diagnoses included a stroke with hemiparesis, dysphagia requiring enteral feedings. The quarterly MDS assessment with an assessment reference date (ARD) of 3/28/2025 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #14's cognitive abilities for daily decision making were intact. An interview was conducted with the Business Office Manager (BOM) on 4/1/25 at approximately 1:38 PM. The BOM revealed the resident had resided in the facility since 6/10/2022 except for short stays in the acute care hospital. A review of the resident's MDS assessment with an ARD of 3/28/25 was coded at A1900 that the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review and facility documentation the facility staff failed to ensure that Residents are treated resident with respect and dignity for 1 Resident (#111) in a survey sample of 29 Residents. The findings included: For Resident #111 the facility staff failed to ensure that Resident #111 was treated with respect and dignity during ADL incontinence care. Resident #111 was admitted to the facility on [DATE]. Diagnoses for Resident #111 included but are not limited to fracture of right femur, aftercare following joint replacement surgery, benign prostatic hyperplasia, major depressive disorder, hx of fall, diabetes type 2, chronic kidney disease, hyperparathyroidism, and dysphagia. Resident #111 ' s Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 3/30/25 coded Resident #111 with a BIMS (Brief Interview of Mental Status) score of 15/15 indicating no cognitive impairment. On 4/1/25 a review of the clinical record revealed the following progress notes:…

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, clinical record review and facility documentation the facility staff failed to ensure Residents were transported to outside medical appointments, for two (2) Residents (#'s 378 and 381) in a survey sample of 74 Residents. The findings included: 1. For Resident #378 the facility staff failed to ensure transportation to outside medical appointments causing the Resident to miss three (3) appointments. On 12/11/24 a review of the clinical record revealed that Resident #378 was admitted to the facility on [DATE] with diagnoses that included but were not limited to encephalopathy, type 2 diabetes, UTI (urinary tract infection), surgical amputation of left lower leg, peripheral vascular disease, dysphagia, acquired absence of right lower leg, g-tube dependance due to malnutrition, depression, hypertension, urinary retention, benign prostatic hyperplasia with lower urinary tract symptoms and obstructive sleep apnea Resident #378's discharge instructions included follow up with the surgeon on 3/5/24.…

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, clinical record review and facility documentation the facility staff failed to implement the abuse policy for reporting allegations of abuse for 1 Resident (#111) in a survey sample of 29 Residents. The findings included: For Resident #111 the facility staff failed to follow abuse reporting guidelines set forth in the State Operations Manual and the facility abuse policy. Resident #111 was admitted to the facility on [DATE]. Diagnoses for Resident #111 included but are not limited to fracture of right femur, aftercare following joint replacement surgery, benign prostatic hyperplasia, major depressive disorder, hx of fall, diabetes type 2, chronic kidney disease, hyperparathyroidism, and dysphagia. Resident #111 ' s Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 3/30/25 coded Resident #111 with a BIMS (Brief Interview of Mental Status) score of 15/15 indicating no cognitive impairment. On 4/1/25 a review of the clinical record revealed the following progress…

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, clinical record review and facility documentation the facility staff failed to ensure allegations of abuse and neglect are thoroughly investigated for 1 Resident (#111) in a survey sample of 29 Residents. The findings included: For Resident #111 the facility failed to thoroughly investigate allegations of abuse. Resident #111 was admitted to the facility on [DATE]. Diagnoses for Resident #111 included but are not limited to fracture of right femur, aftercare following joint replacement surgery, benign prostatic hyperplasia, major depressive disorder, hx of fall, diabetes type 2, chronic kidney disease, hyperparathyroidism, and dysphagia. Resident #111 ' s Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 3/30/25 coded Resident #111 with a BIMS (Brief Interview of Mental Status) score of 15/15 indicating no cognitive impairment. On 4/1/25 a review of the clinical record revealed the following progress notes: 3/20/25 11:46 a.m.: More than 2 episodes of Loose BM's.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a clinical record review and staff interview the facility staff failed to provide a resident with as much discharge information as possible at the time of discharge for one (1) of 74 residents (Resident #278), in the survey sample. The findings include: Resident #278 was admitted to the facility on [DATE] after a hospital stay and left the facility against medical advice on 11/9/22. The resident's diagnoses included end-stage renal disease with dialysis, diabetes, and infected left hip hardware. The 5-Day Medicare Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/9/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #278's cognitive abilities for daily decision making were intact. The resident required supervision after set-up with most of his activities of daily living. A review of the nurse's notes revealed on 11/8/22 at 4:57 PM the nurse received a call from the Resident #278's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review and facility documentation, the facility staff failed to develop and implement a baseline care plan that includes the instructions needed to provide immediate and effective and person-centered care of the resident, for 1 Resident (#1) in a survey sample of 5 Residents. The findings included: For Resident #1, the facility failed to address the issue of wandering and food seeking for a Resident who is a high aspiration risk with a g-tube and NPO (Nothing by Mouth) order. On 4/11/24 a review of the clinical record revealed that Resident #1 was admitted to the facility on [DATE] with diagnoses that included but were not limited to unspecified fracture of left femur, gastrostomy tube placement, Type 2 diabetes, anemia (unspecified), unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, dysphagia high aspiration risk, hypotension with history of falls. A review of the baseline care plan revealed that on Page 3 Section G 8 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, clinical record review, and facility documentation, the facility staff failed to provide nutrition in a form designed to meet the individual needs of the Resident, for 1 Resident (#1) in a survey sample of 5 Residents. The findings included: The facility staff failed to implement NPO (Nothing by Mouth) orders for Resident #1. The resident was given a regular meal tray which he consumed, resulting in being sent out via rescue squad on 2/22/24 to the hospital. The resident was admitted with respiratory failure related to aspiration of food. On 4/11/24 a review of the clinical record revealed that Resident #1 was admitted to the facility on [DATE] with diagnoses that included but were not limited to unspecified fracture of left femur, gastrostomy tube placement, Type 2 diabetes, anemia (unspecified), unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, dysphagia high aspiration risk, hypotension with history of falls. The Resident has no BIMS (Brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinical record review, and facility documentation review, the facility staff failed to consistently assess, track, monitor, and treat a stage II pressure ulcer timely for 1 of 5 residents (Resident #5) in the survey sample. The findings included: Resident #5 was admitted to the nursing facility on [DATE]. Resident #5 was discharged to home on [DATE], she expired at the hospital on [DATE]. Diagnosis for Resident #5 included but was not limited to Multiple Myeloma (cancer), End Stage Renal Disease (ESRD) required dialysis in house 5 x week, and protein-calorie malnutrition. The most recent Minimum Data Set (MDS - an assessment protocol) an admission Assessment (14-day) with an Assessment Reference Date (ARD) of [DATE] coded Resident #5's Brief Interview for Mental Status (BIMS) scored a 00 indicating short- and long-term memory problems and severe cognitive impairment - never/rarely made decisions. Resident #5 was coded as having total dependence on one with bathing, extensive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, and staff interview, the facility staff failed to have a governing body of persons to ensure policies regarding the management and operations of the facility during COVID-19 outbreak. The findings included: The facility staff failed to conduct and document a facility wide assessment to determine what resources were necessary to assist in the prevention of the spread of COVID -19. The facility staff failed to use outside resources including the Local Health Department during a Major COVID-19 outbreak in the facility. During interaction with the Administrator and Infection Preventionist from [DATE] through [DATE] resulted in the facility's inability to provide COVID-19 cumulative data (total of COVID-19 positive residents/staff, number of residents/staff hospitalized COVID-19 related, number of resident/staff deaths, current number of quarantined resident/staff and number of affected residents/staff that were vaccinated since the outbreak began and currently) for the facility. A 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility staff failed to conduct and document a facility wide assessment to determine what resources were necessary to assist in the prevention of the spread of COVID -19. The findings included: The facility staff failed to use outside resources including the Local Health Department during a Major COVID-19 outbreak in the facility. The level of Community Transmission was noted to be high (Red). Upon entering the facility the Director of Nursing stated the facility was experiencing a major COVID outbreak. During the entrance conference the Administrator was asked how many COVID -19 positive residents and staff did the facility have. The Administrator stated there were 36 residents in the facility with COVID-19. On [DATE] the survey team was present with the 802 Resident matrix that coded three residents with COVID in the Infections section. On [DATE] the Infection Preventionist presented to the survey team with a list of residents on the 802 Resident matrix that totaled 21 residents with COVID -19. On [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility staff failed to utilize outside resource to assist in the prevention of the spread of COVID -19 which resulted in hospitalizations and deaths. The findings included: The facility staff failed to use outside resources including the Local Health Department during a Major COVID-19 outbreak in the facility. The outbreak started on 08/28/21 according to the facility's records. During entrance to the facility on [DATE] signage on the front door at the visitor's entrance read face mask required at all times. The signage lacked clear information/alerts to visitors. Review of other visitor entrances (kitchen, construction unit and the laundry door connecting with Unit 1 revealed no signage). Upon entering the facility, staff members stated screening was a self-performed task. After multiple days of reviewing the screening logs the team was unable to account for many on duty staff. Multiple attempts between 09/21/21 and 09/23/21 were made with the infection Preventionist to review the facility's COVID-19…

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

Based on deficiencies determined during this survey the QAA (Quality Assessment and Assurance) and Quality Assurance and Performance Improvement (QAPI) committee failed to develop and implement corrective plans of action and monitoring to ensure the necessary systems were in place and correct identified quality deficiencies during a major outbreak of SARS-CoV-2 in the facility beginning 08/28/2021. Immediate Jeopardy to the resident health and safety was identified on 09/23/21 in the area of Infection Control at (F-880 and F886) at a scope and severely level 4 Widespread (L) which constituted Substandard Quality of Care. The findings included: On 9/23/21 at 8:37 p.m., the facility Administrator, Director of Nursing and three Corporate Consultants were informed of the above Immediate Jeopardy concerns at F-880; Infection Prevention and Control Program secondary to an outbreak of SARS-CoV-2 infections within the facility. On the same day and at the same time, the Administrator, Director of Nursing and three Corporate Consultants were also informed of the above Immediate Jeopardy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interview, the facility staff failed to maintain an effective pest control program. The findings included: Roaches and fly's were observed through the facility on all days of the survey and on all units. These units included: The closed unit 4, Rehab Unit, locked units 3 and 5, as well as Unit 1 COVID-19. Roaches were observed in the front corridor bathrooms, as well as the wall ways. A brownish waste like matter was observed oozing from the roaches leaving a trail like substance on the floor. A house keeper was observed walking around with a spray container daily, spraying various areas of the facility. During an interview on 09/22/21 at 10:00 A.M. with the house keeper he stated, his job was to spray the building daily to help control the roaches. A customer service report of a pest control firm dated 4/13/21 indicated: Treated rooms, 9, 11, 13, 15, 17, 21, 23, 25, 26, 28, 29, and 30 for roaches. Rats noted during service bait station 1-8. A pest Sighting Log…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinical record review and facility documentation review the facility staff failed to send a copy of the Resident's Care Plan for 3 out of 42 residents (Resident #33, Resident #42 and Resident #21) after being transferred to the hospital. The findings included: 1. The facility staff failed to ensure Resident #33's Plan of Care Summary to include her care plan goals was sent upon or shortly after transfer/discharge to the hospital on [DATE]. Resident #33 was originally admitted to the facility on [DATE]. Diagnosis for Resident #33 included but not limited to Anxiety disorder. Resident #33's Minimum Data Set (MDS-an assessment protocol) a significant change MDS with an Assessment Reference Date of 07/28/21 coded Resident #33 with short and long-term memory problems and cognitive skills severely impaired-never/rarely made decisions. The Discharge MDS assessments was dated for 07/15/21 - discharged with return anticipated. A nurse's note entered on 07/15/21 at approximately 8:02 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 staff interview, facility documentation review and clinical record review the facility staff failed send a copy of the Bed-Hold Policy upon discharge/transfer for 4 of 42 resident's (Resident #33, Resident #42, Resident #21 and Resident #92) after being transferred to the hospital. The findings included: 1. The facility staff failed to ensure that Resident #33 or his resident's representative was provided a copy of the bed hold policy upon discharge/transfer to the hospital on [DATE]. Resident #33 was originally admitted to the facility on [DATE]. Diagnosis for Resident #33 included but not limited to Anxiety disorder. Resident #33's Minimum Data Set (MDS-an assessment protocol) a significant change MDS with an Assessment Reference Date of 07/28/21 coded Resident #33 with short and long-term memory problems and cognitive skills severely impaired-never/rarely made decisions. The Discharge MDS assessments was dated for 07/15/21 - discharged with return anticipated. A nurse's note entered on 07/15/21 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility document review and staff interviews the facility staff failed to revise a care plan to include an indwelling foley catheter upon re-admission for 1 or 42 residents in the survey sample, Resident #21. The findings included: The facility staff failed to revise Resident #21's care plan upon re-admission to the facility on 9/1/21 for 21 days to include an indwelling foley catheter. Resident #21 was re-admitted to the facility on [DATE] with diagnoses to include but not limited to Urinary Tract Infection, and Stage 3 Chronic Kidney Disease. Resident #21's most recent comprehensive Minimum Data Set (MDS) was a Significant Change with an Assessment Reference Date (ARD) of 5/21/21. Resident #21's Brief Interview for Mental Status (BIMS) was coded as a 02, indicating severe cognitive impairment and the inability to perform daily decision making. Under Section H - Bladder and Bowel H0100 Appliances; A. Indwelling catheter (including suprapubic catheter and nephrostomy tube),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility document review and staff interviews the facility staff failed to obtain physician orders upon re-admission for an indwelling foley catheter for 1 or 42 residents in the survey sample, Resident #21. The findings included: The facility staff failed to obtain physician orders for an indwelling foley catheter for Resident #21 for 21 days upon re-admission to the facility on 9/1/21. Resident #21 was re-admitted to the facility on [DATE] with diagnoses to include but not limited to Urinary Tract Infection, and Stage 3 Chronic Kidney Disease. Resident #21's most recent comprehensive Minimum Data Set (MDS) was a Significant Change with an Assessment Reference Date (ARD) of 5/21/21. Resident #21's Brief Interview for Mental Status (BIMS) was coded as a 02, indicating severe cognitive impairment and the inability to perform daily decision making. Under Section H - Bladder and Bowel H0100 Appliances; A. Indwelling catheter (including suprapubic catheter and nephrostomy tube),…

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 information, the facility staff failed to staff a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The findings included: During review of the facility's staffing for RN coverage in a 60-day lookback revealed the facility did not provide 8 consecutive hours of RN coverage on the following days: 08/07/21, 08/08/21, 08/21/21, 08/22/21 and 09/18/21. On 09/29/21 at approximately 10:30 a.m., a phone interview was conducted with the Administrator, Regional Director of Clinical Services, MDS Coordinator and Infection Preventionist/Staff Development Coordinator who were informed that the facility did not have 8 consecutive hours of RN coverage on the days mentioned above. The administration team did not have any further questions or present any information about the findings. An interview was conducted with the Administrator on 09/30/21 at approximately 2:27 p.m., who stated, I expect RN coverage 8 hours a day, 7 days a week. The Administrator, Interim Director of Nursing, Chief Operating Officer, Regional Director of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on information gleamed during the Antibiotic Stewardship task, staff interview, and clinical record review, the facility's staff failed to have a system to ensure that an antibiotic was prescribed based on laboratory results and/or clinical signs and symptoms of true infections when prescribing an antibiotic for 1 of 42 residents (Resident #75), in the survey sample. The findings included: Resident #75 was originally admitted to the facility 1/3/19 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Alzheimer's disease. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/27/21 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired daily decision making abilities. In section G (Physical functioning) the resident was coded as requiring total care of two people with transfers, personal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, and clinical record review, the facility staff failed to provide documentation in the resident's clinical record of the immunization and the administration or the refusal of or medical contraindications to vaccines for 3 of 42 residents (Resident #50, 24 and 5 ), in the survey sample. The findings included: 1. Resident #50 was originally admitted to the facility 8/7/21 and was discharged to an acute care hospital 9/3/21, returning to the facility on 9/8/21. The current diagnoses included; SARS-CoV-2 infection, urinary tract infection, diabetes, high blood pressure and strokes. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/15/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 7 out of a possible 15. This indicated Resident #50's cognitive abilities for daily decision making were severely impaired. The resident did not answer questions when asked. Review of Resident #50'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 resident interview, clinical record review, and review of facility documents, the facility staff failed to provide cumulative updates for residents, their representatives, and families at least weekly or by 5 p.m. the next calendar day following the subsequent occurrence of either: each time a confirmed infection of COVID-19 is identified, or whenever three or more residents or staff with new onset of respiratory symptoms occur within 72 hours of each other. The findings included: During an interview with the Infection Preventionist (IP) on 9/22/21 at 10:10 a.m., she stated the SARS-CoV-2 outbreak began 8/28/21 when an alert and oriented resident tested positive after a Rapid test. The resident was confirmed positive on 8/31/21 after the Polymerase Chain Reaction (PCR) test results were received. The IP stated on 8/30/21 all residents in the facility except the first resident who tested positive were tested with the rapid antigen test for the SARS-CoV-2 infection and the test results revealed multiple positive cases. The IP stated as a result of the rapid test, PCR test…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and staff interviews, the facility staff failed to ensure resident rooms who were identified as COVID-19 positive (Resident #16, #27 and #53) were cleaned and sanitized. The findings included: During the survey on 09/21/21-through 09/30/21 observations were made on Unit II. Resident #16, #27 and #53 were identified as being COVID-19 positive during this time period. 1. Resident #53 was admitted to the facility on [DATE] with diagnoses which included hemiplegia, insomnia, type 2 diabetes, major depression, convulsions, hypothyroidism, cerebral infarction, cognitive impairment and contracture of left hand. In the area of Cognitive Patterns Basis Interview for Mental Status this resident was coded as a 15. A Care Plan dated 09/25/21 indicated: Focus- COVID-19 active diagnosis. Resident #53 was identified as able to move around using a wheelchair. Resident #53 was observed on 09/20/21 at 7:53 P.M. and 09/21/20 at 9:43 A.M. seated in a wheelchair in room [ROOM NUMBER] door way.…

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 staff failed to notify the physician and/or responsible party of missed COVID-19 vaccination for Resident #24 and failed to notify the resident's representative of weight loss for Resident #22 in a survey sample of 42 residents. The findings included: 1. Resident #24 was originally admitted to the nursing facility on 07/15/21. Diagnosis included but not limited to Chronic Obstructive Pulmonary Disease (COPD). The most recent Minimum Data Set (MDS - an assessment protocol) an annual assessment with an Assessment Reference Date (ARD) of 09/14/21 coded Resident #24 with a 14 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. The MDS coded Resident #24 total dependence of two with transfer and total dependence of one with dressing, bathing and personal hygiene and extensive assistance of two with bed mobility and toilet use and supervision with limited assistance…

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

Based on clinical record review, staff interview and facility documentation, the facility staff failed to ensure Medicare Beneficiary Notices in accordance with applicable Federal regulations, were issued to 2 of 2 residents (Resident #5 and Resident #80) in the survey sample. The findings included: 1. The facility staff failed to issue an Advanced Beneficiary Notice (ABN) letter to Resident #5 who was discharged from skilled services with Medicare days remaining. Resident #5 was admitted to the nursing facility on 07/16/20. Diagnosis for Resident #5 included but not limited to Muscle Weakness. Resident #5's Minimum Data Set (MDS) a Medicare/5 day assessment with an Assessment Reference Date (ARD) date of 09/06/21 coded Resident #5 a 13 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicated no cognitive impairment. Review of the SNF Beneficiary Notification provided by the facility was noted that Resident #5 was not issued the SNF ABN (Skilled Nursing Facility-Advanced Beneficiary Notice). The resident had received a NOMNC (Notice of Medicare…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interviews, clinical record review, the facility's staff failed to ensure personal privacy of a resident's physical body during personal care for 1 of 42 residents (Resident #90), in the survey sample. The findings included: Resident #90 was originally admitted to the facility 5/14/19 and readmitted [DATE] after an acute care hospital stay, returning to the facility 9/9/21. The current diagnoses included; SARS-CoV-2 infection and Multiple Sclerosis. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/16/21 coded the resident as not completing the Brief Interview for Mental Status (BIMS). The staff interview was coded for intact long and short term memory as well as modified independence with daily decision making. In section G (Physical functioning) the resident was coded as requiring total care of one person with bathing, extensive assistance of one person with bed mobility, transfers, dressing, toileting, and personal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility documentation review, and in the course of a complaint investigation, the facility staff failed to provide reasonable care for the protection of residents' property from loss for 2 of 42 residents (Resident #7 and #22) in the survey sample. The findings included: 1. Resident #7 was originally admitted to the facility on [DATE]. Diagnoses for Resident #7 included but not limited to COVID-19 and Cognitive Communication Deficit. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/18/21 coded Resident #7 as not having the ability to complete the Brief Interview for Mental Status (BIMS). A review of the complaint/grievance report dated 2/06/20 filed by POA (Power of Attorney) Reads: Resident is missing significant amount of personal items: Clothes, burgundy/beige comforter, white watch and a gold bracelet. Sister sews name on garments. Resolution reads items returned on 2/21/20. A review of complaint document/grievance dated 1/01/21 filed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review, staff interviews and facility document reviews, the facility staff failed to notify the Office of the State Long-Term Care Ombudsman in writing of discharges for two residents (Resident #22, #21) in the sample of 42 residents. The findings included: 1. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #22's transfer to the local hospital on [DATE]. Resident #22 was originally admitted to the facility on [DATE] and was re-admitted on [DATE]. Diagnosis for Resident #22 include but not limited to Unspecified Intracapsular Fracture of the Left Femur, Sequela. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 07/17/21 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). On 7/10/20, according to the facility's documentation, a change in condition was reported concerning resident's skin color. An X-ray was ordered and showed an acute left hip fracture.…

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

Based on a closed record review, staff interviews, and a complaint investigation, the facility staff failed to re-admit one resident Resident # 92 in the survey sample of 42 residents after they were hospitalized . The findings included: Resident #92 had an original admission date of 08/19/15. Diagnoses included schizophrenia, anxiety, traumatic brain injury, benign prostatic hyperplasia, dementia, mood disorder, seizures, hypertension,muscle weakness, dysphagia. This resident was assessed on a quarterly Minimum Data Set (MDS) in the area of Cognitive Patterns as 15 on the BIMS assessment. This resident was assessed as requiring one person physical assist in the area of Activities of Daily Living (ADL's) in the area of transfer, dressing, personal hygiene and toileting. A Care plan dated 01/15/20 indicated: Focus- No plans to discharge. Goal- Participate in care decisions for long term stay. Interventions- Monitor for signs and symptoms of anxiety, distress, withdrawal or depression relating to not return to previous home environment. A Nursing Note dated 02:35 on 08/10/20…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility document review and staff interviews the facility staff failed to initiate a Level II Preadmission Screening and Annual Resident Review (PASARR) after a positive Level I PASARR screening was completed for 2 of 42 residents in the survey sample, Resident #21 and Resident #71. The findings included: 1. The facility staff failed to initiate a Level II PASARR for Resident #21 after a positive Level I PASARR screening was completed on 4/19/2017 Resident #21 was originally admitted to the facility on [DATE] with diagnoses to include but not limited to Dementia, Paranoid Schizophrenia, and Psychosis. Resident #21's most recent Minimum Data Set (MDS) was a Quarterly with an Assessment Reference Date (ARD) of 9/7/21. Resident #21's Brief Interview for Mental Status (BIMS) was coded as a 00, indicating severe cognitive impairment and the inability to perform daily decision making. Resident #21's last comprehensive MDS was a Significant Change with an ARD of 5/21/21. Under Section…

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 in the course of a complaint investigation, the facility staff failed to monitor daily weights per physician's orders for 1 of 42 residents (Resident #22) in the survey sample. The findings included; Resident #22 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Diagnosis for Resident #22 included but not limited Unspecified Dementia with Behavioral Disturbance and Major Depressive Disorder. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 07/17/21 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). In section G(Physical functioning) the resident was coded as extensive assistance of one person with bed mobility, dressing and locomotion on and off the unit. Requiring extensive assistance of two persons transfers. Requiring supervision set-up help with eating and requiring totals dependence of one person with toileting,…

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 in the course of a complaint investigation, the facility staff failed to maintain assistive devices to include hearing aids and dentures for 1 of 42 residents (Resident #22) in the survey sample. Resident #22 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Diagnosis for Resident #22 included but not limited Unspecified Dementia with Behavioral Disturbance and Major Depressive Disorder. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 07/17/21 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). In section G(Physical functioning) the resident was coded as extensive assistance of one person with bed mobility, dressing and locomotion on and off the unit. Requiring extensive assistance of two persons transfers. Requiring supervision set-up help with eating and requiring totals dependence of one person with toileting, personal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility staff failed to provide physician services for two residents in the survey sample (Residents #28 and #83) of 42 residents. The findings included: 1. Resident #83 was admitted to the facility on [DATE] with diagnoses which included atherosclerotic heart disease, benign prostatic hyperplasia, transient cerebral ischemic attack, dysphagia, muscle weakness and dementia. A 9/2/21 Quarterly Minimum Data Set (MDS) indicated this resident was not able to be coded in the Cognitive Pattern area for Brief Interview for Mental status. This resident required extensive assistance in all areas of Activities of Daily Living. A review of a Care Plan dated 08/02/21 indicated: Focus- Resident is on antibiotic therapy due to infection. Goal- Resident will be free of any discomfort or adverse side effects of antibiotic therapy. Interventions- Administer Antibiotic medication as ordered by physician. Monitor/document side effects and effectiveness Q-shift. Focus- Resident has…

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 extended survey task, staff interview and documentation review the facility staff failed to ensure 3 out of 3 Certified Nursing Assistant (CNA) received their required 12 hours of mandatory annual competencies and 1 out of 3 CNA's completed her mandatory Dementia training. The findings included: On 09/22/21 at approximately 8:58 a.m., the surveyor requested evidence that CNA #7, CNA #11 and CNA #12 received their required 12 hours of mandatory annual competencies to include abuse and dementia training. The admission Coordinator presented the list of Yearly Competency Training completed on 08/17/21. The training showed zero (0) hours. The competency training consisted of the following training: -Shower/Tub Bath -Nail Grooming -Oral Care -Elastic Stocking (Ted Hose) -Height & Weight -Vital Signs -Sit to Stand Lift / bedside to wheel chair -Positioning -SWAT-Full Body Lift (bed to wheel chair) -Catheter care -Perineal Care Male and Female -Heimlich maneuver -Hand washing -Intake/output -Personal protective equipment (PPE) On 09/29/21 at approximately 1:16 p.m., an phone…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a clinical record review, staff interviews, facility document review and during the course of a complaint investigation the facility staff failed to ensure a complete and accurate clinical record for 2 of 42 residents in the survey sample, Resident #8 and Resident #93. The findings included: 1. The facility staff failed to ensure Resident #8's clinical record documentation was complete to include a fall, nursing fall assessment, physician notification and physician order follow-up during the 11-7 shift on 10/23/20. Resident #8 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses to include but not limited to Right Femur Fracture and Dementia. Resident #8's most recent Minimum Data Set (MDS) was a quarterly with an Assessment Reference Date (ARD) of 9/22/21. Resident #8's Brief Interview for Mental Status (BIMS) was not attempted because the resident was coded as rarely or never understood. Resident #8 was also coded as having long and short term memory recall. 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 clinical record review, staff interviews and review of facility documentation, the facility staff failed to implement the advance directive policy by not sending a resident's advance directive to the receiving hospital, and/or provide acknowledgement that allowed an opportunity to formulate an advance directive for 3 of 57 residents (#82, #63 and #109) in the survey sample. The findings included: 1. Resident #82 was admitted to the nursing facility on 2/5/18 with diagnoses that included Alzheimer's disease, bipolar disorder and paranoid schizophrenia. The most recent Minimum Data Set (MDS) assessment was an annual dated 1/15/20 and coded the resident with short and long term memory and moderately impaired in the cognitive skills for daily decision making. A copy of the resident's Advance Directive was not sent with the resident when he was transferred to the local hospital on 6/2/19, 12/26/19 and 1/5/20. The Acute Care Transfer Document form for each of the resident's aforementioned transfers 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.

Based on observations and staff interviews, the facility staff failed to ensure a homelike environment on 3 units. The findings included: During the survey, the baseboard on Units III, IV and V were observed to be missing. The base boards were missing throughout the entire units. During an interview with the Maintenance Director on 03/04/20 at 11:00 a.m. he stated, the facility staff had removed the baseboard last year and had not replaced it. The Administrator was made aware of the findings on 03/04/20 at 3:15 P.M. The Administrator stated the new owners were going to renovate the facility. When asked for a capital improvement plan she was not able to provide one, nor was she able to give a date and time for the improvements. No further information was provided by the facility staff.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to send the comprehensive care plan goals upon transfer to the hospital for 4 out of 57 residents in the survey sample, Residents #119, #53, #82, and #21. The findings included: 1. Resident #119 was admitted to the facility on [DATE] with diagnoses that included but were not limited to cognitive communication deficit, unspecified mood disorder, and dementia with other diseases with behavioral disturbance. Resident #119's most recent MDS (minimum data set) assessment was a 14 day scheduled assessment with an ARD (assessment reference date) of 1/27/20. Resident #119 was coded as being severely impaired in cognitive function on the staff interview for mental status exam. Review of Resident #119's clinical record revealed that he was transferred to the hospital on 2/1/2020 for behaviors. The following was documented: Resident extremely agitated this shift, as exhibited by constantly walking in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and facility documentation review, the facility staff failed to issue a bedhold notice to the resident or resident representative at time of transfer to the hospital for 3 of 57 Residents (#89, #82 and #21) in the survey sample. The findings include: 1. The facility staff failed to ensure Resident #89 or Resident Representative (RR) was issued a written notice of the bed hold reserve policy upon transfer to the local hospital on 1/14/20. Resident #89 was admitted to the nursing facility on 7/12/18 with diagnoses that included non-Alzheimer's disease dementia and generalized muscle weakness. The resident was readmitted on [DATE] with diagnoses that included dysphagia, meniere's disease and urinary tract infection (UTI). The most recent Minimum Data Set (MDS) assessment dated [DATE] was a significant change is status and coded the resident with moderate difficulty in hearing, usually has the ability to express ideas and wants and usually comprehends most…

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 information obtained during the Sufficient and Competent Nurse Staffing task, the facility staff failed to staff a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week potentially affecting all residents in the facility. The findings included: During the nursing staff review for July 4, 2019 through March 1, 2020 the facility staff was unable to provide nurse staffing documentation for July 4, 2019 through October 6, 2019. Nurse staffing for October 12, 2019 through March 1, 2010 revealed there were not RN presence in the facility for at least 8 consecutive hours on 10/5/19, 10/19/19, 10/20/19, 10/31/19, 11/3/19, 11/9/19, 11/10/19, 11/16/19, 11/17/19, 11/28/19, 11/29/19, 11/30/19, 12/1/19, 12/7/19, 12/8/19, 12/15/19, 12/21/19, 12/22/19, 12/23/19, 12/24/19, 12/25/19, 12/26/19, 12/28/19, 12/31/19, 1/1//20, 1/11/20, 1/18/20, 1/19/20, 1/25/20, 1/26/20, 2/1/20, 2/2/20, 2/8/20, and 2/28/20. On 3/5/20 at approximately 3:50 p.m., the Staffing Coordinator was interviewed. The staffing coordinator stated she wasn't employed by the facility…

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, clinical record review, and facility documentation review, the facility staff failed to provide an accurate record of controlled medications for 4 of 57 residents (Residents #22, #37, #168 and #418), in a survey sample. The findings included: 1. The facility staff failed to ensure an accurate account of controlled medication for Resident #22. Resident #22 was admitted to the nursing facility on 05/23/19. Diagnoses for Resident #22 included but not limited to Cognitive Decline. On 3/02/20 at approximately 11:52 a.m., an inventory of controlled medication was conducted on the medication cart on Unit 1 with Licensed Practical Nurse (LPN) #2. The Medication Monitoring/Control Record was compared to the actual medication count with the following discrepancy: Resident #22's, Ativan 1 mg count per record=23, actual count=22. On 03/02/20 at approximately 11:55 a.m., an interview was conducted with LPN #2 who stated, I did not give Resident #22 her morning Ativan. She (LPN) said I retrieved the medication cart keys from Registered Nurse (RN)#1 this…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinical record review and facility documentation review the facility staff failed to ensure monthly medication reviews were readily available for review for 3 residents (Residents #21, #61, #71) and to ensure the physician reviewed pharmacy recommendations for 1 resident (Resident #112) of 57 residents in the survey sample. The findings included: On 03/05/2020 the following policy was reviewed regarding medication reviews: ORGANIZATIONAL ASPECTS IA2: CONSULTANT PHARMACIST SERVICES PROVIDER REQUIREMENTS POLICIES AND PROCEDURES-Pharmacy Services for Nursing Facilities 2006 American Society of Consultant Pharmacists and MED-PAS, INC (Revised January 2018) (Pharmacy Name) RX August 2019 Policy-Regular and Reliable consultant pharmacist services are provided to residents. A written agreement with a consultant pharmacist stipulates financial arrangements, at fair market price, and the terms of the services provided. Review of the procedures revealed and is documented in part, as follows: F.…

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

Based on general observations of the nursing facility and staff interview, the facility failed to ensure medications were labeled in accordance with currently accepted professional principles and stored according to manufacture guidelines in 3 out of 5 medication carts The findings included: 1. The facility staff failed to ensure one Lantus (insulin) vial was dated once open for Resident #109. Resident #109 was originally admitted to the nursing facility on 04/20/15. Diagnosis for Resident #109 included but not limited to Type 2 Diabetes. On 3/02/20 at approximately 11:37 a.m., the medication cart on Unit 4 was inspected with Licensed Practical Nurse (LPN) #1. During the inspection of the insulins stored inside the medication cart, one Lantus vial was open with no open date. An interview was conducted with LPN #1 who stated, The Lantus insulin vial belongs to Resident #109 but does not have an open date; the insulin should have been dated once open. The Lantus insulin was removed from the medication cart by the nurse. Review of Resident #109's February 2020 Physician Order Sheet…

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

Based on observations, staff interviews and facility document review the facility staff failed to store and prepare food in accordance with professional standards for food service safety. The findings included: On 3/2/20 at approximately 11:30 A.M. during the initial kitchen tour, the following observations were made: Dry Storage Room: 1-25 pound bag of parboiled rice not sealed, open to air with no date. 1-10 pound bag of macaroni noodles not sealed, open to air. 1 bag of bowtie pasta not sealed, open to air. Reach in Refrigerator #2: 1 gallon ziplock bag with a drink and a protein bar in it, which was immediately removed by the dietary aide that the food bag belonged to, stating it belonged to staff. 1 -2 pound package of smoked turkey breast sandwich meat not sealed, open to air. 1 open bag of boiled eggs with fluid leaking over other food contents in metal container. Main kitchen area: 1-50 pound bag of potato starch on back kitchen table not sealed, open to air, not dated and a large scoop sitting on top of the bag. 1-2 pound bag of light brown cane sugar not sealed and open 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 observations, staff interviews and facility document review the facility staff failed to maintain an effective pest control program. The findings included: 1. On 3/2/20 at approximately 1130 A.M. during the initial kitchen tour the following observations were made: Drain flies were observed flying around the steam table, the trash can and the handwashing sink. Three drains were inspected in the dishwashing area. All three drains were noted to have copious amounts of thick black grease build up. One drain was noted to have 3 fruit flies inside of it. On 3/2/20 at 11:50 A.M. an interview was conducted with the Dietary Aide regarding fruit flies. The Dietary Aide stated, They are mainly in the dishwasher area. The Dietary Manager was informed of all the above findings. On 3/2/20 at approximately 12:15 P.M. the Dietary Manager was asked about his expectations for the storage of food and pests in the kitchen. The Dietary Manager stated, When something is opened it should sealed so it is not open to air 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 staff interview, clinical record review and facility documentation, the facility staff failed to ensure Medicare Beneficiary Notices in accordance with applicable Federal regulations, were issued to 2 of 3 residents (Resident #3 and #87) in the survey sample. The findings included: 1. The facility staff failed to issue a Notice of Medicare Non-Coverage (NOMNC) letter to Resident #3 who was discharged from skilled services with Medicare days remaining. Resident #3 was admitted to the nursing facility on 11/11/19. Diagnoses for Resident #3 included but not limited to Muscle Weakness. Resident #3's Minimum Data Set (MDS) a significant change assessment with an Assessment Reference Date (ARD) date of 11/18/19 coded Resident #3 with an 02 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognitive skills for daily decision-making. On review of the Beneficiary Notification Checklists provided by the facility to surveyor, it was noted that Resident #3 was not listed for having been issued the Notice of Medicare Non-Coverage…

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 document review, the facility staff failed to implement their Abuse Investigation and Reporting Policy after a witnessed allegation of abuse/mistreatment for 1 of 57 Residents in the survey sample, Resident #64. The findings included: Resident #64 was admitted to the facility on [DATE] with diagnoses to include but not limited to Schizophrenia, Major Depressive Disorder, Bipolar Disorder and Dementia. Resident #64's most recent comprehensive Minimum Data Set (MDS) was an annual assessment with an Assessment Reference Date (ARD) of 1/7/2020. The Brief Interview for Mental Status (BIMS) for Resident #64 was coded as having short and long term memory recall problems and severely impaired for cognition and daily decision making. On 3/3/20 at approximately 12:15 P.M. a test tray food cart was followed onto Unit 5, the secured unit. At the first doorway of the dining area of the secure unit CNA (Certified Nursing Assistant) #2 was observed behind Resident #64's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and facility document review the facility staff failed to report an allegation of abuse/mistreatment to the State Survey Agency and Adult Protective Services within the required time frame for 1 of 57 Residents in the survey sample, Resident #64. The findings included: Resident #64 was admitted to the facility on [DATE] with diagnoses to include but mot limited to Schizophrenia, Major Depressive Disorder, Bipolar Disorder and Dementia. Resident #64's most recent comprehensive Minimum Data Set (MDS) is an annual assessment with an Assessment Reference Date (ARD) of 1/7/2020. The Brief Interview for Mental Status (BIMS) for Resident #64 was coded as having short and long term memory recall problems and severely impaired for cognition and daily decision making. On 3/3/20 at approximately 12:15 P.M. a test tray food cart was followed onto Unit 5 the secured unit. At the first doorway of the dining area of the secure unit CNA (Certified Nursing Assistant) #2 was observed behind…

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 document review the facility staff failed to thoroughly investigate a witnessed allegation of abuse/mistreatment for 1 of 57 Residents in the survey sample, Resident #64. The findings included: Resident #64 was admitted to the facility on [DATE] with diagnoses to include but mot limited to Schizophrenia, Major Depressive Disorder, Bipolar Disorder and Dementia. Resident #64's most recent comprehensive Minimum Data Set (MDS) is an Annual Assessment with an Assessment Reference Date (ARD) of 1/7/2020. The Brief Interview for Mental Status (BIMS) for Resident #64 was coded as having short and long term memory recall problems and severely impaired for cognition and daily decision making. On 3/3/20 at approximately 12:15 P.M. a test tray food cart was followed onto Unit 5 the secured unit. At the first doorway of the dining area of the secure unit CNA (Certified Nursing Assistant) #2 was observed behind Resident #64's wheelchair pushing him with full force under 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 and clinical record review, the facility staff failed to ensure a discharge assessment (MDS) was submitted for 2 of 57 residents (Residents #91 and Resident #1), in the survey sample. The findings included: 1. The facility staff failed to complete a discharge MDS assessment for Resident #91. Resident #91 was admitted to the nursing facility on 01/22/20. Resident #91 was discharged from the facility to home on [DATE]. Diagnoses for Resident #91 included but not limited to Muscle Weakness. Resident #91's last Minimum Data Set (MDS), an admission Assessment with an Assessment Reference Date of 01/27/20 coded Resident #91's Brief Interview for Mental Status (BIMS) scoring a 09 out of a possible 15 indicating moderately impaired cognitive skills for daily decision-making. Review of Resident #91's clinical note dated 02/07/20 read in part: Resident discharged from facility at 3:00 p.m. An interview was conducted with Licensed Practical Nurse (LPN) #2 (Assistant MDS Coordinator) on 03/03/20 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, the facility staff failed to accurately code the Minimum Data Set (MDS) assessment for 1 of 57 residents (Resident #76), in the survey sample. The findings included; Resident #76 was originally admitted to the facility 11/7/19 and has never been discharged from the facility. The current diagnoses included dementia and coronary artery disease. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/19/20 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 6 out of 15. This indicated the resident was with severely impaired daily decision making abilities. In section O0100k2of the 12/12/18 MDS assessment, the resident was coded for hospice care while a resident. Review of the physician order summary revealed no physician's order for hospice care, nor did the active care plan [NAME] hospice services. On 3/2/20 at approximately 11:00 a.m., Licensed Practical Nurse (LPN) #3 was asked which…

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 documentation review, the facility staff failed to develop a person centered care plan to include depression and anxiety for 1 of 57 residents in the survey sample, Resident #100. The findings included: Resident #100 was admitted to the facility on [DATE]. Diagnoses for Resident #100 included but are were limited to, Major Depressive Disorder and Anxiety Disorder Due to Known Physiological Condition. Resident #100's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 02/04/2020 coded Resident #100 with short-term memory problems, long-term memory problems, and with severely impaired cognitive skills for daily decision making. Review of Resident #100's clinical record on 03/04/2020 revealed the following: The Medication Administration Record (MAR) for the period of 03/01/2020 - 03/31/2020 revealed the following: Paroxetine (used for the treatment of depression) Tab 40 MG (Milligram) Give 1 tablet orally one time a day related…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review staff interview and review of facility documentation, the facility staff failed to revise the care plan for 1 of 57 residents (Resident #96) in the survey sample. The findings include: Resident #96 was admitted to the nursing facility on 7/12/18 with diagnoses that included non-Alzheimer's disease dementia and generalized muscle weakness. The resident was readmitted on [DATE] with diagnoses that included *dysphagia, *meniere's disease and urinary tract infection (UTI). The most recent Minimum Data Set (MDS) assessment dated [DATE] was a significant change is status and coded Resident #96 was coded on this assessment as having short and long term memory and never/rarely made decisions. Resident #96 was coded to need assistance with personal care. This assessment indicated the resident had no significant weight loss or gain. Significant weight loss is a loss of 5% or more in the last month or a loss of 10% in the last 6 months. Significant weight gain is a gain of 5% or more in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility staff failed to provide supervision for one resident (Resident #167) in the survey sample of 57 to prevent an elopement. The findings included: Resident #167 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus, Alzheimer's Disease, cardiovascular accident (CVA), dementia, Asthma, violent behavior, and dysphagia. Resident #167 eloped from the facility on 12/23/19. A Quarterly Minimum Data Set (MDS) dated [DATE] assessed this resident in the area of Cognitive Patterns -Brief Interview for Mental Status as a 7 which indicated severe cognitive impairment. In the area of Behaviors this resident was assessed as having behaviors for rejecting care. As well as other behavioral symptoms including pacing. In the area of Activities of Daily Living (ADL) this resident was assessed as requiring limited assistance with one person physical assist with transfer, dressing, and eating. A care plan revision dated 12/21/19 indicated: Focus- 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 family interview, medical record review, staff interviews and facility document review the facility staff failed to ensure 1 of 57 Residents in the survey sample, Resident #77, was free from unnecessary medications. The findings included: Resident #77 was admitted to the facility on [DATE] with diagnoses to include but not limited to Dementia, History of Falling and Schizoaffective Disorder. The most recent Minimum Data Set (MDS) was an Annual Assessment with an Assessment Reference Date (ARD) of 1/14/20. The Brief Interview for Mental Status (BIMS) was a 9 out of a possible 15 indicating the resident has moderate cognitive impairment. Under Section O Special Treatments, Procedures and Programs 00250 Influenza Vaccine A. Did the resident receive the influenza vaccine in the facility Resident #77 was coded as 1-Yes. On 3/3/20 at 12:20 P.M. a phone interview was conducted with Resident #77's daughter who was also the Resident's Responsible Party (RP) and Power of Attorney (POA). During the interview 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 documentation review the facility staff failed to indicate the duration for an as needed psychotropic medication for 1 resident (Resident #100) and failed to perform a gradual dose reduction for 1 resident (Resident #20) of 57 residents in the survey sample. The findings included: Resident #100 was admitted to the facility on [DATE]. Diagnosis for Resident #100 included but are not limited to, Major Depressive Disorder and Anxiety Disorder Due to Known Physiological Condition. Resident #100's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 02/04/2020 coded Resident #100 with short - term memory problems, long - term memory problems, and with severely impaired cognitive skills for daily decision making. On 03/04/2020 at approximately 10:00 a.m., review of Consultant Pharmacist recommendation revealed the following: The resident is on a PRN psychotropic drug: ALPRAZOLAM Tablet 0.5 MG (Milligram) Give 1 tablet by mouth…

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 interviews and review of facility documentation, the facility staff failed to prepare food by methods that conserves nutritive value and provide and present food that is palatable and attractive for 1 of 57 residents (Resident #89) in the survey sample. The findings include: Resident #89 was admitted to the nursing facility on 7/12/18 with diagnoses that included non-Alzheimer's disease dementia and generalized muscle weakness. The resident was readmitted on [DATE] with diagnoses that included *dysphagia (difficulty swallowing), *meniere's disease and urinary tract infection (UTI). The most recent Minimum Data Set (MDS) assessment dated [DATE] was a significant change is status and coded the resident with moderate difficulty in hearing, usually has the ability to express ideas and wants and usually comprehends most conversation. Resident #89 was coded on this assessment as having short and long term memory and never/rarely made decisions. She was not coded 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 staff interview, clinical record review, review of facility documentation, and in the course of a complaint investigation, the facility failed to maintain complete and accurately documented medical records for 2 out of 57 resident records reviewed, Resident #53 and Resident #77. The findings included: 1. Resident #53 was initially admitted to the facility on [DATE] with diagnoses including, but not limited to, dysphagia, repeated falls, other Escherichia coli, urinary tract infection and metabolic encephalopathy. Resident #53's most recent MDS (Minimum Data Set) assessment was a Quarterly Review Assessment with an ARD (Assessment Review Date) of 12/30/2019. Resident #53's BIMS (Brief Interview for Mental Status) score was recorded as unobtainable. A review of the medical record for Resident #53 revealed a note documented on 12/24/2020 at 11:00 p.m., stating, Resident #53 remained in bed after returning from the ER. Further review of facility progress notes failed to provide dates and a description 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 family interview, medical record review, staff interviews and facility document review the facility staff failed to follow the informed consent for the administration of the influenza vaccine for 1 of 57 Residents in the survey sample, Resident #77. The findings included: Resident #77 was admitted to the facility on [DATE] with diagnoses to include but not limited to Dementia, History of Falling and Schizoaffective Disorder. The most recent Minimum Data Set (MDS) was an Annual Assessment with an Assessment Reference Date (ARD) of 1/14/20. The Brief Interview for Mental Status (BIMS) was a 9 out of a possible 15 indicating the resident has moderate cognitive impairment. Under Section O Special Treatments, Procedures and Programs 00250 Influenza Vaccine A. Did the resident receive the influenza vaccine in the facility Resident #77 was coded as 1-Yes. On 3/3/20 at 12:20 P.M. a phone interview was conducted with Resident #77's daughter who was also the Resident's Responsible Party (RP) and Power of Attorney…

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.