Colonial Health & Rehab Center, LLC

Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility failed to report an allegation of abuse in a timely manner for one of 35 residents in the survey sample, Resident #21 (R21). The findings include: For R21, the facility staff failed to report an allegation of abuse that was reported to staff on 7/1/24 until 7/2/24. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/20/24, R21 scored 13 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. On 9/15/24 at 5:14 p.m., an interview was conducted with R21. R21 stated that they had recently filed a police report against another resident at the facility for threatening them. R21 stated that they had been in the hallway near the dining room and another resident [Name of Resident #64] had started arguing with them and threatened to kick her [expletive] and stab them. R21 stated that Resident #64 (R64) had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to evidence a written bed hold notice was provided to the resident and/or resident representative upon a hospital transfer for two of 35 residents in the survey sample; Residents #36 and #9. The findings include: 1. For Resident #36, the facility staff failed to evidence that a written bed hold notice was provided to the resident and/or representative upon a hospital transfer. A nurse's note dated 6/20/24 documented, Resident assessed by PA (physician's assistant) and NP (nurse practitioner) and new orders given and noted to send to (hospital) for further eval (evaluation) for possible TIA/CVA (stroke) due to symptoms. Resident noted with delayed reaction during conversation The resident was readmitted on [DATE]. Further review failed to reveal any evidence that a written bed hold notice was provided. On 9/17/24 at 2:31 PM, an interview was conducted with LPN #10 (Licensed Practical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure admission orders were put in place to provide immediate care for one of 35 residents in the survey sample, Resident #139. The findings include: For Resident #139(R139), the resident was admitted on [DATE] at 5:09 p.m. The admission orders were not entered into the computer until 3/22/24, 20 hours after the resident was admitted . Review of the clinical record, failed to evidence a nursing admission assessment for 3/21/24. The Discharge documents from the hospital documented the following orders: Tylenol 650 mg (milligrams)/20 ml (milliliters) soln (solution): 20.3 ml by po/g-tube (by mouth/gastrostomy tube) every 4 hours as needed for fever - pain. - entered into the medical record on 3/22/24 at 1:45 p.m. Amlodipine 5 mg tablets: instill 1 tab (tablet) into tube once a day. Indications: high blood pressure. Entered into the medical record on 3/22/24 at 1:41 p.m. Finasteride 5 mg…

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 interview, clinical record review and facility document review, it was determined the facility staff failed to provide an accurate MDS (minimum data set) assessment for two out of 35 residents in the survey sample, Resident #48 and Resident #58. The findings include: 1.The facility staff failed to complete an accurate MDS (minimum data set), a quarterly assessment for Resident #48. Resident #48 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ICH (intracranial hemorrhage), hemiplegia, hemiparesis and DM (diabetes mellitus). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 7/20/24, coded the resident as scoring a 07 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for bed mobility, transfer, hygiene…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of practice for one of 35 residents in the survey sample, Resident #5. The findings include: For Resident #5 (R5), the facility staff failed to obtain a physician's order prior to administering insulin (used to treat diabetes) to the resident on 5/12/24. R5 was readmitted to the facility on [DATE]. A review of R5's clinical record failed to reveal any physician's medication orders when the resident was re-admitted on [DATE]. A review of R5's MAR (medication administration record) for 5/11/24 and 5/12/24 failed to reveal any medication orders. A nurse's note dated 5/12/24 at 10:58 p.m. (recorded as a late entry on 5/13/24), documented, Received care of resident at 22:40 (10:40 p.m.) Resident had been released from the hospital a day before after falling face first on concrete. Resident states she is in a severe pain. This nurse looked at resident's MAR which was inadequately…

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, facility document review, and clinical record review it was determined the facility staff failed to provide ADL (activities of daily living) care for three of 35 residents in the survey sample, Residents #33, 46, and #42. The findings include: 1. For Resident #33 (R33), the facility staff failed to provide oral care. An interview was conducted with R33 on 9/15/24 at 5:29 p.m. The resident was in bed. R33 stated she has to ask for help in brushing her teeth. She stated she had asked someone to assist her this afternoon but no one has responded. A second interview was conducted with R33 on 9/16/24 at 8:47 a.m. She stated she was never offered to brush her teeth after this writer left on 9/15/24. On the most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 8/30/24, the resident scored a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services for a feeding tube for two of 35 residents in the survey sample, Residents #139 and #42. The findings include: 1. For Resident #139, the facility staff failed to administer tube feedings per the physician orders and as documented, let the resident eat a meal tray upon admission to the facility, the resident was to be NPO (nothing by mouth). Resident #139 (R139), the resident was admitted on [DATE] at 5:09 p.m. The hospital discharge orders documented in part, TF (tube feeding) - Jevity 1.5 KCAL/ML (calories per milliliter) Dose: 300 ml. Frequency: 4 times daily. Discharge Procedure Orders: NPO TF only (nothing by mouth tube feeding only). Entered into the medical record on 3/22/24 at 2:41 p.m. The MAR (medication administration record) for March 2024, documented the above order. The resident did not receive any tube feedings on 3/21/24 at 8:00 p.m., 3/22/24 at 8:00 a.m. and 12:00…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care and services for a midline for one of 35 residents, Residents #88. The findings include: Resident #88 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: respiratory failure, hypertension, diverticulitis and coronary artery disease. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 10/30/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as max assist for bed mobility, transfer, hygiene and set up for eating. Section O-Special Procedures: coded the resident for antibiotic, midline and isolation. A review of the comprehensive care plan dated 10/27/23 revealed, 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.

Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to complete an accurate bed rail assessment for two of 35 residents in the survey sample, Residents #137 and #138. The findings include: 1. For Resident #137(R137), the facility staff failed to accurately document the side rails on the assessment tool. R137 was observed on 9/15/24 at 4:53 p.m. in bed, with grab bars on both sides of the bed. The Enabler/Physical Restraint/Side Rail Review dated, 9/14/24 at 7:36 p.m. documented in part, Does resident currently use a device that could be considered a restraint (side rail, seat belt, lap buddy, trunk restraint, etc.)? A mark was made next to, no. An interview was conducted with LPN (licensed practical nurse) #1, on 9/18/24 at 9:42 a.m. When asked why a side rail assessment is completed, LPN #1 stated that they could be considered a restraint, so a side rail assessment is done to determine if they need them or want them for mobility. LPN #1 was asked if a grab bar or halo bar are considered side rails,…

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 document review, it was determined the facility staff failed to post daily staffing for one of four days reviewed. The findings include: During the Sufficient and Competent Staffing facility task review started on 9/15/24 and ending on 9/18/24, a review of the daily staffing evidenced the following: On 9/15/24 at 3:00 PM entered the facility for the survey. On the receptionist area in the main lobby the staff posting with a date of 9/13/24 on form. The daily staffing was posted correctly on 9/15/24 by 6:00 PM. On 9/18/24 at 8:50 AM, an interview was conducted with ASM (administrative staff member) #2, the director of nursing. When asked to describe the staff posting process, ASM #2 stated, we just hired a staffing coordinator last week, it will be her responsibility. When asked the process for the weekends, ASM #2 stated, it is the manager on call's responsibility to post the staffing. The manager on call came in both days this weekend, but to deal with emergency situations, so the posted staffing was not changed. 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.

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to act upon pharmacy recommendations in a timely manner for two of 35 residents in the survey sample, Residents #21 and #63. The findings include: 1. For Resident #21 (R21), the facility staff failed to act upon the pharmacy recommendations dated 5/6/24 that the physician approved and ordered lab studies to be completed on the next lab day. Review of the pharmacy consultation report for R21 dated 5/6/24 documented a recommendation to monitor labs (TSH- thyroid stimulating hormone) due to the use of the medication amiodarone on the next convenient lab day and every six months thereafter. The consultation report documented the physician review completed on 5/14/24 with the recommendations accepted and physician's order to check BMP, CBC, TSH (basic metabolic panel, complete blood count, TSH) next lab day. Review of the clinical record failed to evidence the laboratory tests completed or results of the BMP, CBC, or TSH. On 9/18/24 at approximately 10:00 a.m.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview and clinical record review, it was determined that the facility staff failed to prepare food in a form to meet the resident's needs for one of 35 residents, Resident #46. The findings include: Resident #46 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: dementia, hypertension, CKD (chronic kidney disease). The most recent MDS (minimum data set) assessment, a quarterly Medicare assessment, with an ARD (assessment reference date) of 7/24/24, coded the resident as scoring a 09 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring supervision for eating. MDS Section L-Dental codes the resident as missing/broken or loose teeth-yes. A review of the comprehensive care plan dated 3/14/24, which revealed, FOCUS: The resident has oral/dental health needs due to…

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

Based on observation, staff interview and facility document review, it was determined the facility staff failed to be in compliance with state laws and regulations in regard to maintaining emergency medical equipment on one of two units. The findings include: Observation was made of the Emergency Carts on both units on 9/16/24 at 3:18 p.m. Both carts had a locking device in place, the carts could not be opened without breaking the lock. The Emergency Cart Daily Checklist was reviewed on both carts. The Unit 2 March 2024 Emergency Cart Daily Checklist was reviewed. The cart was signed off as being checked on 3/1/24. From 3/2/24 through 3/31/24, the form was checked off by the same person with their signature on 3/2/24 and a line drawn down for the entire month, ending on 3/31/24. The nurse, the unit manager, that signed the Checklist was no longer employed at the facility and unavailable for interview. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 9/17/24 at 9:58 a.m. The above checklist was reviewed with ASM #2. When asked why the…

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

Based on staff interview, facility policy review and clinical record review, it was determined the facility staff failed to have a contract with a dialysis center where one of 35 residents in the survey sample was getting treatment from, Resident #33. The findings include: Resident #33 attended the dialysis center three times a week. There was no contract between the dialysis center and the facility. The physician orders dated, 8/15/24, documented, Resident to have dialysis on days: M-W-F (Mondays - Wednesdays - Fridays) Dialysis Center name: (name of dialysis center with address), Chair time: 2 p.m. Catheter Site: RUC (right upper chest), Dialysis Transport: (name of transport company with phone number) Bag meal/snack to go with resident to Dialysis. Once a day on Mon, Wed, Fri. A request was made for the contract with the dialysis center documented in the resident's clinical record, on 9/17/24 at 5:13 p.m. and then again on 9/18/24 at 3:00 p.m. No contract was provided prior to exit. The facility policy, Contract Administration and Management Policy, documented in part, A. A…

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

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain an accurate clinical record for one of 35 residents in the survey sample, Resident #18. The findings include: For Resident #18 (R18), the facility staff failed to accurate document the administration of a medication. The physician order dated, 3/19/24, documented, Micafungin recon (reconcentrated) soln (solution) (used to treat fungal infections) (1); Amount to Administer: 2 vials of 100 mg (milligram) intravenous. The March 2024 MAR (medication administration record) documented the above order. For the 9:00 a.m. dose on 3/21/24, the initials documented were those of ASM (administrative staff member) #2, the director of nursing. An interview was conducted with ASM #2 on 9/17/24 8:56 a.m. The above MAR was reviewed with ASM #2. When asked if she administered the medication above on 3/21/24, ASM #2 stated she did not. ASM #2 stated she had started to pass medications on the hallway as there was not a nurse to do so. She had logged into the computer and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and review of facility documents, the facility's staff failed to provide a Hospice Care Plan for 1 of 25 residents (Resident #106), in the survey sample. The findings included: Resident #106 was originally admitted to the facility 02/06/23 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Hemiplegia, Type 1 diabetes mellitus with diabetic neuropathy and Cerebral Vascular disease. The significant change, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/18/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 7 out of a possible 15. This indicated Resident #106 cognitive abilities for daily decision making were severely impaired. In Section O Special Treatments and Programs. K1= Coded resident as receiving Hospice Care. The Physician's Order Summary (POS) for October 2024 read: Hospice Evaluation and Treat, 10/03/24. The person-centered care plan dated…

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

Based on observation, staff interview and facility document review the facility staff failed to store food in accordance with professional standards for food service safety. The findings included: The food service staff failed to ensure foods stored in the freezer were labeled and dated when open. On 10/19/21 at 2:45 p.m., during the inspection of the kitchen with the Dietary Manager and Regional Dietitian, the following were observed: Inside the walk-in-freezer was a bag of French Toast, 1 bag of blueberries, 1 bag of strawberries, 1 bag of vegetable blend, 1 bag of broccoli and 1 bag green of peas were open; not labeled and dated. An interview was conducted with the Dietary Manager and the Regional Director on 10/19/21 at approximatley 3:15 p.m. The Dietary Manager stated, Most of our staff are new hires and we have a lot of coaching issues. He said the open bags of frozen food located inside the walk-in-freezer should have been labeled and dated once open. On the same day at approximately 1019/21 at approximately 3:35 p.m., the Dietary Manager provided an in-service document…

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

Based on observation, resident and staff interviews and clinical record review the facility staff failed to provide the accommodation needed for 1 of 41 residents (Resident #69) in the survey sample. The findings included: The facility staff to ensure Resident #24's call bell remained within reach. Resident #24 was admitted to the nursing facility on 05/11/21. Diagnosis for Resident #24 included but not limited Cerebral Infarction with hemiplegia (paralysis on one side of the body). The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 04/24/19 coded Resident #69 with a 13 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. In addition, the MDS coded Resident #69 total dependence of two with bathing, extensive assistance of two with bed mobility, dressing, toilet use and personal hygiene with Activities of Daily Living care. Resident #69's comprehensive care plan documented Resident #69 ask risk for falls, requires assist with transfers and have above left knee amputation.…

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 1 of 41 residents (Resident #63) had an accurate medical record for an advanced directive and failed to ensure 4 out of 41 residents (Resident #27, Resident #22, Resident #9 and Resident #32) in the survey sample were given the opportunity to formulate an advance directive. The findings included: 1. The facility staff failed to ensure Resident #63 had an accurate medical record for an advanced directive. Resident #63 was originally admitted to the nursing facility on 03/11/21. Diagnosis for Resident #63 included but not limited to Acute Upper Respiratory Infection. Resident #63's Minimum Data Set (MDS-an assessment protocol) a significant change assessment with an Assessment Reference Date (ARD) of 06/15/21 coded Resident #63 a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no impaired cognitive skills for daily decision-making. Resident #63'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 4. The facility staff failed to provide personal hygiene for Resident #25 who was dependent on the staff to wash her hair. Resident #25 was admitted to the nursing facility on 3/23/17 with diagnoses that included type II diabetes mellitus, stroke with right sided hemiplegia and hemiparesis and expressive aphasia, high blood pressure and non-Alzheimer's dementia. The resident's most recent Minimum Data Set (MDS) assessment was a quarterly and coded Resident #25 with clear speech, able to understand the staff and was understood by them. She was coded on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15, which indicated she was cognitively intact with the skills needed for daily decision-making. She was coded as having no problems with behavior and mood. The resident required extensive assistance of one staff for personal hygiene. She was impaired on one side, upper and lower, in range of motion. The wheelchair was her primary mode of transportation. The resident was…

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

Based on observation, clinical record review, staff and resident interviews, the facility staff failed to ensure dignity was maintained for 1 of 41 residents (Resident #25) in the survey sample to wear personal clothing, wash and cut hair. The findings included: Resident #25 was admitted to the nursing facility on 3/23/17 with diagnoses that included type II diabetes mellitus, stroke with right sided hemiplegia and hemiparesis and expressive aphasia, depression, high blood pressure and non-Alzheimer's dementia. The resident's most recent Minimum Data Set (MDS) assessment was a quarterly and coded Resident #25 with clear speech, able to understand the staff and was understood by them. She was coded on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15, which indicated she was cognitively intact with the skills needed for daily decision-making. She was coded as having no problems with behavior and mood. The resident required extensive assistance of one staff for personal hygiene. She was impaired on one side, upper and lower, in range 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, clinical record review, staff and resident interviews, the facility staff failed to honor choices for 1 of 41 residents (Resident #25) in the survey sample and assist to change out seasonal clothing from winter to spring and summer. The findings included: Resident #25 was admitted to the nursing facility on 3/23/17 with diagnoses that included type II diabetes mellitus, stroke with right sided hemiplegia and hemiparesis and expressive aphasia, high blood pressure and non-Alzheimer's dementia. The resident's most recent Minimum Data Set (MDS) assessment was a quarterly and coded Resident #25 with clear speech, able to understand the staff and was understood by them. She was coded on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15, which indicated she was cognitively intact with the skills needed for daily decision-making. She was coded as having no problems with behavior and mood. The resident required extensive assistance of one staff for bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinical record review and facility documentation review the facility staff failed to send a copy of the Resident's Care Plan to include their goals after being transferred and admitted to the hospital for one resident (Resident #27) in a survey sample of 41 residents. The findings included: Resident #27 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. The current diagnoses included; Essential Hypertension and Arthritis Due To Other Bacteria, Right Knee. The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 05/11/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #27 cognitive abilities for daily decision making were intact. A review of the clinical record on 7/07/21 revealed there were no advance directives in the clinical record on the above residents. A nursing note dated 3/30/2021(6:44 PM) Reads: Resident sent to ER 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 resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide evidence that one out of 41 residents was invited to attend a care plan meeting, Resident #35. The findings included: Resident #35 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to chronic heart failure, spinal stenosis, and chronic embolism and thrombosis of unspecified deep veins of lower extremity (bilateral). Resident #35's most recent MDS (Minimum Data Set Assessment) was a quarterly assessment with an ARD (assessment reference date) of 5/20/21. Resident #35 was coded as being intact in cognitive function scoring 15 out of possible 15 on the BIMS (Brief Interview for Mental Status exam). On 7/6/21 at 3:32 p.m., an interview was conducted with Resident #35. He could not recall receiving a recent invitation for a care plan meeting. Resident #35 stated that it had been awhile. Review of…

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

Based on observations, a complaint investigation, resident and staff interview and review of facility documentation, the facility staff failed to ensure 2 of 41 residents (Resident #25 and #49) were able to continue to maintain their ability to independently perform mouth care. The findings included: 1. The facility staff failed to provide Resident #25 her electric toothbrush that she independently uses to maintain good oral hygiene. Resident #25 was admitted to the nursing facility on 3/23/17 with diagnoses that included type II diabetes mellitus, stroke with right sided hemiplegia and hemiparesis and expressive aphasia, high blood pressure and non-Alzheimer's dementia. The resident's most recent Minimum Data Set (MDS) assessment was a quarterly and coded Resident #25 with clear speech, able to understand the staff and was understood by them. She was coded on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15, which indicated she was cognitively intact with the skills needed for daily decision-making. She was coded as having no problems…

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, facility document review and clinical record review, it was determined that the facility staff failed to assess and monitor two additional skin areas that were observed by the hospice aide during incontinence care on 7/7/21 to Resident #35's bilateral feet. The findings included: Resident #35 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to chronic heart failure, spinal stenosis, and chronic embolism and thrombosis of unspecified deep veins of lower extremity (bilateral). Resident #35's most recent MDS (Minimum Data Set Assessment) was a quarterly assessment with an ARD (assessment reference date) of 5/20/21. Resident #35 was coded as being intact in cognitive function scoring 15 out of possible 15 on the BIMS (Brief Interview for Mental Status exam). On 7/6/21 at 3:32 p.m., an interview was conducted with Resident #35. Resident #35 had mentioned to this writer that facility staff do not provide him…

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 reviews, staff and resident interviews, the facility staff failed to ensure 2 of 41 residents (Resident #49 and #37) were free of accident hazards. The sit-to-stand mechanical lift was not used in accordance to assessed need to prevent possible accidents for Resident #49, and that fall preventative measures, to include fall mats, were consistently in place to protect from potential fall injuries for Resident #37. The findings include: 1. Resident #49 was admitted to the nursing facility on 8/1/19 with diagnoses that included bipolar disorder, type 2 diabetes mellitus, depression, age related osteoporosis, restless leg syndrome and incomplete paraplegia. The most recent Minimum Data Set (MDS) was a quarterly dated 4/6/21 that coded Resident #49 on the Brief Interview for Mental Status (BIMS) with an 11 out of a possible score of 15 that indicated the resident was moderately impaired in the skills for daily decision-making. The resident was assessed to require 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.

Based on observation, resident and staff interviews, clinical record review, the facility staff failed to follow the physician order for the oxygen flow rate for 1 of 41 residents (Resident # 63) in the survey sample. The findings included: Resident #63 was originally admitted to the nursing facility on 03/11/21. Diagnosis for Resident #63 included but not limited to Acute Upper Respiratory Infection. Resident #63's Minimum Data Set (MDS-an assessment protocol) a significant change assessment with an Assessment Reference Date (ARD) of 06/15/21 coded Resident #63 a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no impaired cognitive skills for daily decision-making. In addition, under respiratory treatments was coded for the use of oxygen therapy. Resident #63's person centered care plan dated 06/10/21 had a focus which read; Resident #63 is on oxygen therapy. The goal read; will be free from signs and symptoms of hypoxia. One of the intervention included; administer oxygen as ordered. Review of Resident #63's Order Summary Report 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, resident interview and clinical record review it was determined that facility staff failed to obtain dental services for one of 41 residents, Resident #30. The findings included: Resident #30 was admitted to the facility on [DATE] with diagnoses that included but were not limited to heart failure, peripheral vascular disease, neurogenic bladder, dementia without behavioral disturbance and quadriplegia. Resident #30's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 1/18/21. Resident #30 was coded as being moderately impaired in cognitive function, scoring 08 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. On 7/6/21 at 2:58 p.m., an interview was conducted with Resident #30. Resident #30 was observed to have some natural teeth; with other missing. Resident #30 stated that his bottom front left tooth was painful, that it felt like his tooth was going into his gums. Resident #30 stated…

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 in the course of a complaint investigation, it was determined that facility staff failed to maintain a complete record for one of 41 residents in the survey sample; Resident #73. The findings included: Resident #73 was admitted to the facility on [DATE] with diagnoses that included but were not limited to heart failure, Alzheimer's disease, high blood pressure and age related osteoporosis. Resident #73's most recent comprehensive MDS (Minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 9/5/20. Resident #73 was coded as being severely impaired in cognitive function scoring 06 out of 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #73 was coded as requiring total dependence on one staff member with most ADLS (activities of daily living); and supervision only with meals. Review of Resident #73 clinical record revealed she was sent to the hospital on [DATE] at 8:30 a.m. for poor nutrition and not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinical record review and facility documentation review, the facility staff failed to send a copy of the comprehensive care plan to include the residents goals after being transferred to the hospital for 6 of 38 residents in the survey sample (Residents #55, #70, #67, #4, #45, & #12). The findings included: 1. Resident #55 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The current diagnoses included: Hypercalcemia and Alzheimer's disease. The quarterly Minimum Data Set (MDS) an admissions assessment with an assessment reference date (ARD) of 10/17/19, coded the resident with a 6 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating Cognitive skills for decision making shows resident as being severely impaired for daily decision making. On 11/04/19, according to the facility's documentation, Resident #55 departed the facility with transport to the local hospital. On 11/14/19 at approximately, 12:16 PM an interview was…

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

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 provide 4 of 38 residents in the survey sample, and/or the resident representative, a written bed hold notice when discharged to the hospital (Residents #4, #45, #12, #55). The findings included: The facility policy titled-Life Care-Bed Hold included: Policy Statement: It is the facility policy to inform the resident or resident representative of the durations of the bed-hold policy, if any, during which the resident is permitted to return and resume residence when admitted to an acute care facility or goes on therapeutic leave. .Resident or Resident Representative will be provided a 'Notice of Bed Hold Policy' letter at time of transfer; if not immediately possible, notification will be at first available opportunity. .Notice of bed hold policy will be provided with transfer documents. 1. Resident #4 was initially admitted to the facility on [DATE]. Resident #4's most recent discharge to 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 2. Facility staff failed to develop an ADL (activities of daily living) functional status care plan for Resident #45. Resident #45 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included, but were not limited to, unspecified dementia without behavioral disturbance, and cervical spinal cord injury. Resident #45's most recent MDS (Minimum Data Set) assessment was an annual assessment with an ARD (assessment reference date) of 9/30/19. Resident #45 was coded as being moderately impaired in cognitive function scoring 12 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #45 was coded as being totally dependent on one staff member with all ADLs (activities of daily living), except with meals. In Section V (Care Area Assessment ) (CAA) Summary, care area ADL Functional/Rehabilitation Potential was triggered on the assessment. A 1 was coded under Section B. Care Planning Decision indicating this care area would be care planned. Review of Resident #45'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 observations and staff interview the facility staff failed to provide a sanitary environment in the kitchen which could potentially affect most of the 35 current residents in the survey sample. The findings included: On 11/13/2019 at 11:30 a.m., while dietary staff were observed preparing lunch trays, under the metal sink which is located next to the steam table and tray line cob webs and dust was observed on the pipes. On 11/13/2019 at 1:05 p.m., the Surveyor observed cob webs and dust on the pipes under the metal sink in the kitchen. The Surveyor asked the Dietary Manager, What do you see? The Dietary Manager stated, I will get someone to clean the pipes. The Dietary Manager was asked if cob webs should be on the pipes under the sink? The Dietary Manager stated, No, I will get someone to clean the pipes now. The Dietary Manager stated that cleaning the pipes under the sink and counter was not on the cleaning schedule and would have to add it to the schedule. The Administrator and Director of Nursing was informed of the finding at the pre-exit meeting on 11/14/2019 at 4:25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and facility documentation, the facility staff failed to maintain a clean, sanitary and homelike environment for 2 of 38 residents (Resident #6 and #27) in the survey sample. The findings included: 1. For Resident #6, the wheel chair was observed with worn, torn and cracked armrest pads. Resident #6 was admitted to the facility on [DATE]. Diagnoses for Resident #6 included but not limited to, Dementia with behavioral disturbances. The current Minimum Data Set (MDS), quarterly assessment with an Assessment Reference Date (ARD) of 08/01/19 coded the resident with a 00 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. In addition, the MDS coded Resident #6 requiring total dependence of one hygiene and bathing, extensive assistance of two with bed mobility and transfer, extensive assistance of one with dressing and toilet use. The MDS was coded under section G 0600 (mobility devices) was coded for wheel chair…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined that facility staff failed to ensure one resident (Resident #14), was free from a sexual encounter initiated by another resident (Resident #44) that occurred on two occasions on 8/30/19. The findings included: Resident #14 was admitted to the facility on [DATE] with diagnoses that included but were not limited to dementia with behavioral disturbance and muscle weakness. Resident #14's most recent MDS assessment was a quarterly assessment with an ARD (assessment reference date) of 8/20/19. Resident #14 was coded as being severely impaired in cognitive function scoring 01 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #14 was coded in Section B as sometimes being understood by staff and sometimes understanding staff. Resident #14 was coded as requiring extensive assistance with one staff member with bed mobility, and dressing; and total dependence on staff with personal hygiene.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to implement abuse policies for 2 of 38 residents in the survey sample to ensure Resident #14 was free from a second sexual encounter by Resident #44 that occurred on 8/30/19; and failed to report an allegation of abuse to the facility administrator and to the appropriate state agencies in a timely manner. The findings included: Resident #14 was admitted to the facility on [DATE] with diagnoses that included but were not limited to dementia with behavioral disturbance and muscle weakness. Resident #14's most recent MDS assessment was a quarterly assessment with an ARD (assessment reference date) of 8/20/19. Resident #14 was coded as being severely impaired in cognitive function scoring 01 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #14 was coded in Section B as sometimes being understood by staff and sometimes understanding staff. Resident #14 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that facility staff failed to report an allegation of abuse that occurred between two residents of 38 sampled residents (Resident #44 and Resident #14) to the facility Administrator and to the appropriate State Agencies in a timely manner. The findings included: Resident #44 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Schizophrenia, major depressive disorder, anxiety disorder and dementia with Lewy Bodies (1). Resident #44's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 9/30/19. Resident #44 was coded as being intact in cognitive function scoring 15 out of 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #44 was coded as requiring limited assistance with one staff member with transfers, locomotion, dressing, and personal hygiene; and independent with bed mobility and meals. 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 clinical record review, staff interview and facility documentation, the facility staff failed to ensure that 1 of 38 residents (Resident #30) in the survey sample received a complete and accurate Minimum Data Set (MDS) assessment. Resident #30's quarterly MDS assessment with an Assessment Reference Date (ARD) of 09/09/19 was coded incorrectly under Section G (Functional Limitations of Range of Motion). The findings included: Resident #30 was originally admitted to the facility on [DATE]. Diagnoses for Resident #30 included but not limited to Cerebrovascular Accident (CVA-stroke) with left hemiparesis (weakness on one side of the body). The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 09/09/19 coded the Resident #30 with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. In addition, the MDS coded Resident #30 requiring total extensive assistance of one with transfer, dressing,…

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 revise the comprehensive care plan for 2 of 38 residents in the survey sample, Residents #40 and #14. The findings included: 1. The facility staff failed to revise Resident #40's care plan to include a DNR (do not resuscitate) order. Resident #40 was admitted to the facility on [DATE] with diagnoses that included but were not limited to, Chronic Kidney Disease, Stage 3 and Acute Diastolic (Congestive) Heart Failure. Resident #40's Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 09/24/2019 coded Resident #40 with a BIMS (Brief Interview of Mental Status) score of 08 indicating moderate cognitive impairment. In addition, the Minimum Data Set coded Resident #40 as requiring total dependence of 1 with transfer, dressing, toilet use, personal hygiene and bathing and total dependence of 2 with bed mobility. On 11/13/2019 Resident #40's Comprehensive Care Plan was reviewed and revealed the following:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that facility staff failed to provide fingernail care for a dependent resident for one of 38 residents in the survey sample, Resident #45. The findings included: Resident #45 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to unspecified dementia without behavioral disturbance, cervical spinal cord injury, and polyneuropathy (1). Resident #45's most recent MDS (minimum data set) assessment was an annual assessment with an ARD (assessment reference date) of 9/30/19. Resident #45 was coded as being moderately impaired in cognitive function scoring 12 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #45 was coded as being totally dependent on one staff member with all ADLs (activities of daily living), except with meals. On 11/13/19 at approximately 10:36 a.m., an interview was conducted…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that facility staff failed to provide podiatry services for one of 38 residents in the survey sample, Resident #45. The findings included: Resident #45 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to unspecified dementia without behavioral disturbance, cervical spinal cord injury, and polyneuropathy (1). Resident #45's most recent MDS (minimum data set) assessment was an annual assessment with an ARD (assessment reference date) of 9/30/19. Resident #45 was coded as being moderately impaired in cognitive function scoring 12 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #45 was coded as being totally dependent on one staff member with all ADLs (activities of daily living), except with meals. On 11/13/19 at approximately 10:36 a.m., an interview was conducted with Resident #45.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that facility staff failed to follow physician's orders and plan of care for the application of a hand splint for one of 38 residents in the survey sample, Resident #44. The findings included: Resident #44 was admitted to the facility on [DATE] with diagnoses that included but were not limited to post stroke, muscle weakness, Schizophrenia, major depressive disorder, and dementia with Lewy Bodies. Resident #44's most recent MDS (Minimum Data Set) assessment was a quarterly assessment with an ARD (assessment reference date) of 9/30/19. Resident #44 was coded as being intact in cognitive function scoring 15 out of 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #44 was coded as requiring limited assistance with one staff member with transfers, locomotion, dressing, and personal hygiene; and independent with bed mobility and meals. Resident #44 was coded is Section G0400. (Functional status) as having…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined that facility staff failed to ensure one of 38 sampled residents, Resident #47, was free from unnecessary psychotropic drugs. The findings included: Resident #47 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Dementia without behavioral disturbance, Alzheimer's disease with late onset, mental disorder and anxiety disorder. Resident #47's most recent MDS (Minimum Data Set) assessment was a quarterly assessment was an ARD (assessment reference date) of 10/8/19. Resident #47 was coded as being severely impaired in cognitive function scoring 09 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #47 was coded in Section D (Mood) as having a mood score of 00. Resident #47 was coded in Section E0200 (Behaviors) as having one episode of verbal behaviors. Resident #47 was coded in Section I (Active Diagnoses) as having Dementia. Resident #47 was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, facility document review, and clinical record review, it was determined that facility staff inaccurately documented that one of 38 residents (Resident #44), had a right hand roll/splint in use. The findings included: Resident #44 was admitted to the facility on [DATE] with diagnoses that included but were not limited to post stroke, muscle weakness, Schizophrenia, major depressive disorder, and dementia with Lewy Bodies. Resident #44's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 9/30/19. Resident #44 was coded as being intact in cognitive function scoring 15 out of 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #44 was coded as requiring limited assistance with one staff member with transfers, locomotion, dressing, and personal hygiene; and independent with bed mobility and meals. Resident #44 was coded is Section G0400. (Functional status) as having impairments to one side 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.

Based on observations and staff interview the facility staff failed to perform appropriate hand hygiene after removing dirty gloves for 1 of 38 residents in the survey sample (Resident #321). The findings included: On 11/13/2019 at 4:36 p.m., Licensed Practical Nurse (LPN) #6 was observed applying clean gloves and remove a glucometer and blood testing supplies from the medication cart. LPN #6 and the Surveyor entered Resident #321's room and LPN #6 obtained a blood sample from Resident #321 and checked the resident's blood sample with the glucometer. LPN #6 returned to the medication cart with the glucometer. LPN #6 removed her dirty gloves, performed hand hygiene with hand sanitizer and applied clean gloves. LPN #6 obtained germicidal wipes from the container and cleaned the glucometer. LPN #6 removed her dirty gloves and applied clean gloves. LPN #6 failed to perform hand hygiene after removing her dirty gloves. LPN #6 drew up insulin into a syringe and went back to Resident #321's bedside and administered the insulin to Resident #321. LPN #6 went back to the medication cart,…

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.