Cypress Pointe Rehabilitation And Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and a review of resident dietary tickets, the facility staff failed to serve portions of the planned menu for two (2) of 45 residents (Resident #32 and Resident #64) in the survey sample. the findings included: 1.The facility staff failed to ensure Resident #32's breakfast included boiled eggs and milk, instead of scrambled eggs and milk. Resident #32 was originally admitted to the facility 4/07/25 after an acute care hospital stay. The current diagnoses included: Hemiplegia and Hemiparesis following Cerebral Infarction Affecting the Left Non-Dominant Side and Contracture of Muscle, Left upper arm. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/17/26 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 8 out of a possible 15. This indicated that Resident #32's cognitive abilities for daily decision making were moderately impaired. In sectionG(Physical functioning), the resident was coded as requiring set up…

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

Based on information acquired while reviewing infections acquires in the facility and staff interviews the facility staff failed to have a qualified individual to perform the role of an Infection preventionist (IP). The findings included; On 7/3/24 at approximately 1:05 PM, an interview was conducted with the Registered Nurse identified as the IP. As the documentation was reviewed regarding urinary tract infections (UTI) for residents over a six month period two residents were identified with multiple UTIs. The IP stated staff education was provided without providing documentation of the curriculum. During the interview, the IP also stated that she had completed the training to become a qualified IP but, she did not have the certification because she had not completed the competency test. The IP stated based on information obtained from Human Resources the last qualified IP employed separated from the facility on 12/22/23 and currently she was wearing thehat as the current IP. On 7/8/24 at approximately 1:00 PM, a final interview was conducted with the Administrator, 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 resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to administer pain medication to a resident who experienced pain and requested pain medication for one (1) of eight (8) residents in the survey sample, Resident #7. The findings include: For Resident #7 the facility staff failed to give pain medication when requested. The resident went without pain medication for approximately 38 hours. Resident #7 was admitted to the facility on [DATE] with diagnoses included but are not limited to left leg pain, peripheral vascular disease (PVD), right below the knee amputation (BKA), left heel unstageable pressure ulcer, and a stage three (3) sacrum pressure ulcer. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/8/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible score of 15 which indicated Resident #7 was cognitively intact. Section J…

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 document administered controlled medication on the medication administration record (MAR) for one (1) of eight (8) residents in the survey sample, Resident #7. The findings include: For Resident #7 the facility staff failed to document 50 doses of oxycodone on the Medication Administration Record (MAR) that were signed out on the medication monitoring control records for December 2023 and January 2024. Resident #7 was admitted to the facility on [DATE] with diagnoses included but are not limited to left leg pain, peripheral vascular disease (PVD), right below the knee amputation (BKA), left heel unstageable pressure ulcer, and a stage three (3) sacrum pressure ulcer. Resident #7 care plan dated 12/21/2023 included a focus on the risk for alteration in comfort related to PVD, left second toe amputation, right BKA, and pressure ulcers. Review of Resident #7's medication monitoring control records 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.

Based on staff interview and facility document review, the facility staff failed to maintain a complete infection control surveillance program. The facility staff failed to maintain a complete surveillance system with enough data collection to properly track infections. The findings include: A review of the facility infection control surveillance program for January 2022 through June 2022 revealed the following: -Folders for January 2022 through April 2022 only contained a list of residents that were prescribed an antibiotic and information regarding the antibiotic prescription, lab tests results related to various infections for various residents and a color coded facility floor plan that tracked infections by categories of urinary infections, respiratory infections, gastrointestinal infections skin infections and other infections. -A folder for May 2022 only contained a log that tracked infection type, a list of residents that were prescribed an antibiotic and information regarding the antibiotic prescription. -No documentation for June 2022. On 8/3/22 at 4:14 p.m., an interview…

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 document review, the facility staff failed to conduct COVID-19 testing in a manner consistent with professional standards of practice. The facility staff failed to conduct complete COVID-19 testing during a facility outbreak that began on 6/10/22. The findings include: A review of facility documentation revealed the facility began COVID-19 outbreak status on 6/10/22 because a resident tested positive. A review of facility testing documentation revealed the following: On 6/10/22, all residents were tested and eight residents were positive for COVID-19. No staff were tested. On 6/13/22, only residents who were symptomatic or exposed were tested. Ten residents were positive. On 6/14/22, one staff member was tested and the results of the test were not documented. On 6/17/22, seven staff were tested and one was positive. On 6/20/22, eight staff were tested and all were negative. On 6/29/22, seven staff were tested and all were negative. On 7/1/22, one resident was symptomatic, tested and was positive. The resident's roommate was also tested and was…

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

Based on staff interview, facility document review, employee record review, and in the course of a complaint investigation, it was determined the facility staff failed to complete criminal background checks on 7 out of 25 employee records reviewed. The findings include: Twenty five employee records were reviewed. Seven of the twenty five employee records failed to evidence the completion of a criminal background check, OSM (other staff member) #14, central supply clerk; OSM #15, physical therapist; LPN (licensed practical nurse) #9; OSM #17, dietary aide; LPN #12; CNA (certified nursing assistant) #10; and OSM #6, the business office manager/human resources staff member. Two of the seven employees were still employed at the facility, LPN #9 and OSM #6. An interview was conducted with OSM #6 on 8/4/2022 at 7:58 a.m. When asked the process for a new hire, OSM #6 stated in the beginning after the new employee has their interview, we get their identification information, social security number, and vaccination card is submitted to us. Then we run the background check using their ID 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.

Based on staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined the facility staff failed to implement their policies for the investigation of an allegation of abuse for one of 43 residents in the survey sample, Resident #26; and failed to implement their policies for the investigation of an injury of unknown origin for one of 43 residents in the survey sample, Resident #5 (R5); and failed to implement their policies for the completion of criminal background checks for 7 of 25 employee record reviews. The findings include: 1. The facility staff failed to implement their policies for the investigation of an allegation of abuse, at the time the allegation was made by the resident, for Resident #26 (R26). On the most recent MDS (minimum data set) assessment, with an ARD of 5/30/2022, the resident scored a 15 out of 15 on the BIMS score, indicating the resident was not cognitively impaired for making daily decisions. Diagnoses included but were not limited to: schizophrenia and dementia The Facility Reported…

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.

2. The facility staff failed to develop a comprehensive care plan for treatment and care of (R36's) pressure ulcer. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 06/10/2022, the resident scored 0 (zero) out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired of cognition for making daily decisions. The physician's order for (R36) DATED 08/06/2022 documented in part, Sacral: Cleanse with wound cleanser, pat dry, apply hydrogel and foam dressing every other day, and prn. Review of the comprehensive care plan for (R36) dated 07/23/2022 failed to evidence documented for care and services for (R36's) sacral pressure ulcer. On 08/04/22 at approximately 11:24 a.m., an interview was conducted with LPN (licensed practical nurse) #5. When asked if there was a care plan that addressed (R36's) sacral pressure ulcer and the use of pressure reducing boots LPN #5 review (R36's) current comprehensive care plan and stated that there was no care plan for (R36's) pressure ulcer or the boots.…

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.

2. The facility failed to evidence coordination of hospice services with the hospice provider for Resident #6 (R6). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/29/22, R6 was coded as being moderately impaired for making daily decisions, having scored 12 out of 15 on the BIMS (brief interview for mental status). R6 was coded as receiving hospice services during the look-back period. A review of R6's clinical record revealed the following provider's order dated 4/22/22: Admit to [name of hospice company]. A review of R6's care plan dated 5/17/22 revealed, in part: Resident admitted to hospice services .Encourage support system of family and friends .Work with [hospice] nursing staff to provide maximum comfort for the resident. Further review of R6's clinical record failed to reveal a care plan, progress notes, or any other documentation by R6's hospice services provider. On 8/3/22 at 1:54 p.m., LPN (licensed practical nurse) #5, a unit manager, was asked to provide notes and/or other evidence of coordination with R6'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, resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to administer oxygen in a safe, sanitary manner for 4 of 43 residents in the survey sample, Residents #73, #69, #26, and #38. The findings include: 1. For Resident #73 (R73), the facility staff failed to obtain an order to administer oxygen, and failed to change the oxygen tubing in a timely manner. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of [DATE], R73 was coded as being moderately impaired for making daily decisions, having scored 11 out of 15 on the BIMS (brief interview for mental status). R73 was coded as having received oxygen at the facility during the look back period. R73's diagnoses included COPD (chronic obstructive pulmonary disease) and COVID-19. On the following dates and times, R73 was observed lying in bed, with oxygen being delivered at 3 lpm (liters per minute) via nasal…

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 facility document review it was determined facility staff failed to maintain a clean deli slicer and store dishware in a clean and sanitary manner in one of one kitchen; and failed to label and date resident food stored in the refrigerator in one of two nourishment rooms in accordance with professional standards for food service safety. The findings include: 1. The facility failed to maintain a clean blade on the deli slicer that was available for use; and failed to fully dry dishware in the kitchen prior to stacking. On 8/2/2022 at 11:57 a.m., an observation was made of the kitchen in the facility with OSM (other staff member) #2, the dietary manager. Observation of the deli slicer on the counter top in the kitchen revealed it covered with a plastic bag. OSM #2 stated that it was available for use and removed the bag. Observation of the blade on the deli slicer revealed debris that could be scraped off of the edge. When asked about the blade, OSM #2 stated that 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 resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide education and offer the COVID-19 immunization for 4 of 5 residents reviewed during the immunization record reviews, Residents #3 (R3), #73 (R73), #18 (R18) and #42 (R42). The facility staff failed to provide Residents R3, R73, R18 and R42 (or their representatives) education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine, or offer the vaccine. The findings include: 1. For R3, on the most recent MDS (minimum data set), a five day Medicare assessment with an ARD (assessment reference date) of 4/29/22, R3 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is not cognitively impaired for making daily decisions. A review of the immunization tab in R3's clinical record revealed the resident had received one dose of the Pfizer COVID-19 vaccine on 4/19/22. Further review of R3's clinical record failed to reveal evidence that R3 was provided education regarding 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 observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain an operational call bell system for four of 43 residents in the survey sample, Residents #29 (R29), #46 (R46), #60 (R60), and #36 (R36), The findings include: 1. The facility staff failed to ensure (R29's) call bell was operational on 08/02/2022. (R29) was admitted to the facility with diagnoses that included but were not limited to: muscle weakness. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 06/06/2022, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 08/02/22 at 1:11 p.m., an observation of (R29) revealed they were in their room sitting in a wheelchair. When asked to activate their call bell, (R29) pressed the call bell button and an observation revealed that the light in the hallway outside of (R29's) room did not light up. On 08/02/22…

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, employee record review and facility documentation review, it was determined that the facility staff failed to ensure that 5 of 5 certified nursing assistants (CNAs) during annual performance reviews received dementia training (CNAs #2, #3, #4, #5 and #6). The findings include: On 08/04/2022 at approximately 8:45 a.m., a review of the annual competency trainings for CNA (certified nursing assistant) #2 with a hire date of 05/13/2005, CNA #3 with a hire date of 07/22/2020, CNA #4 with a hire date of 07/05/2017, CNA #5 with a hire date of 07/06/2016 and CNA #6 with a hire date of 11/20/1990 was conducted. The review failed to evidence dementia training for CNA # 2 from 05/13/2021 through 05/13/2022, , CNA #3 from 07/22/2021 through 07/22/2022, CNA #4 from 07/05/2021 through 07/05/2022, CNA# 5 from 07/06/2021 through 07/06/2022 and CNA #6 from 11/20/2020 through 11/20/2021. On 08/04/22 at approximately 9:19 a.m., an interview was conducted with ASM (administrative staff member) #2 , director of nursing and ADON regarding the annual competency training for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and in the course of a complaint investigation, it was determined the facility staff failed to notify the physician and/or responsible party (RP) of missed medication and a change in condition for 2 of 43 residents in the survey sample, Resident #427 and #50. The findings include: 1. The facility failed to notify the RP of Resident #427's thrush and abrasion on buttocks. Resident #427 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: atrial fibrillation, stroke, hypertension, end stage renal disease and coronary artery disease. The most recent MDS (minimum data set) assessment, a 5 day Medicare assessment, with an ARD (assessment reference date) of 11/18/21, coded the resident as scoring a 00 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 G-functional status coded the resident as being totally dependent…

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, clinical record review, and in the course of a complaint allegation, it was determined the facility staff failed to report to the state agency an allegation of abuse for one of 43 residents in the survey sample, Resident #26 (R26); and failed to report an injury of unknown origin for one of 43 residents in the survey sample, Resident #5 (R5). The findings include: 1. The facility staff failed to file a report, of an allegation of abuse, to the State Agency as required after the resident made the statement of alleged abuse, for Resident #26 (R26) On the most recent MDS (minimum data set) assessment, with an ARD of 5/30/2022, the resident scored a 15 out of 15 on the BIMS score, indicating the resident was not cognitively impaired for making daily decisions. Diagnoses included but were not limited to: schizophrenia and dementia The Facility Reported Incident (FRI) dated, 11/4/2020, documented in part, Report date: 11/4/2020. Residents involved: Name of R26. Incident Type: Allegation of abuse/mistreat. Describe incident: (R26) report…

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 interivew, facility document review, clinical record review and in the course of a complaint investigation, it was detrmined the facility staff failed to investigate an injury of unknown origin for one of 43 residents in the survey sample, Resident #5 (R5). The findings include: On the most recent MDS assessment, a quarterly assessment, with an ARD of 5/4/2022, the resident scored a 0 out of 15 on the BIMS score, indicating the resident is severely cognitively impaired for making daily decisions. In Section G - Functional Status, the resident was coded as requiring extensive assistance to being totally dependent upon the staff for all of their activities of daily living. The Facility Reported Incident (FRI) dated, 11/4/2020, documented in part, Report date: 11/4/2020. Residents involved: (Name of R5). Incident Type: Allegation of abuse/mistreat; injury of unknown origin. Describe incident: (R5) injury of unknown origin. Resident unable to inform staff how bruise to her chest occurred .Resident was fully assessed by nursing staff and bruises were all properly…

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 the facility staff failed to provide evidence that all required information was provided to the hospital staff for 2 out of 43 residents in the survey sample that were transferred to the hospital; Residents #27 and #26. The findings include: 1. For Resident #27, the facility staff failed to evidence provision of required resident information to a receiving facility at the time of transfer to the hospital on 7/24/22. Resident #27 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: chronic respiratory failure, cerebrovascular accident and diabetes mellitus. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 5/29/22, coded the resident as scoring a 10 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…

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 the facility staff failed to provide evidence that written RP (responsible party) and/or ombudsman notification was provided for 3 of 43 residents who were transferred to the hospital, Residents #27, #26 and #29. The findings include: 1. The facility staff failed to evidence provision of written RP notification was provided for Resident #27. Resident #27 was transferred to the hospital on 7/24/22. Resident #27 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: chronic respiratory failure, cerebrovascular accident and diabetes mellitus. A closed record review was conducted. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 5/29/22, coded the resident as scoring a 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A 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 staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that bed hold notification was provided to one out of 43 residents in the survey sample who was transferred to the hospital; Residents #27. The findings include: The facility staff failed to evidence provision of bed hold notification for Resident #27. Resident #27 was transferred to the hospital on 7/24/22. Resident #27 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: chronic respiratory failure, cerebrovascular accident and diabetes mellitus. A closed record review was conducted. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 5/29/22, coded the resident as scoring a 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the facilities eINTERACT (Interventions To Reduce…

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 review and revise the comprehensive care plan for the use of oxygen for Resident #26 (R26). The findings include: On the most recent MDS (minimum data set) assessment, with an ARD of 5/30/2022, the resident scored a 15 out of 15 on the BIMS score, indicating the resident was not cognitively impaired for making daily decisions. The physician order dated, 6/2/2022, documented, Oxygen at 2 L (liters per minute) for nocturnal dyspnea. The comprehensive care plan, dated, 3/22/2022, failed to evidence any documentation related to the use of oxygen. Observation was made on 8/3/2022 at 8:04 a.m. of R26 resting on their bed. An oxygen concentrator was located across from the foot of the bed. The oxygen tubing was laying over the concentrator with the nasal prongs touching the floor. When asked if she uses the oxygen, R26 stated they have been having shortness of breath and used it last night. An interview was conducted with LPN (licensed practical nurse) #5 on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, facility documentation review and in the course of a complaint investigation, it was determined that the facility staff failed to develop, with the resident or the resident representative, a discharge plan for one of 43 residents in the survey sample, Resident #428. Resident #428's RP (responsible party), was not provided education on insulin administration or wound care. DME (durable medical equipment) was not at resident's home upon her discharge from the facility. The findings included: Resident #428 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: osteomyelitis, cardiomyopathy, atrial fibrillation, hypertension, diabetes mellitus and pneumonia. Resident #428 was discharged from the facility on 2/21/22. The most recent MDS (minimum data set) assessment, a 5 day Medicare assessment, with an ARD (assessment reference date) of 2/2/22, coded the resident as scoring a 03 out of 15 on 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 in the course of a complaint investigation, it was determined that the facility staff failed to implement interventions to keep a resident safe for one of 43 residents in the survey sample, Resident #34 (R34). R34's care plan called for anti-roll back system to be placed on R34's wheelchair. No anti roll devices were observed on multiple occasions during the survey while R34 was in the wheelchair. The findings include: On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/9/22, R34 was coded as being severely impaired for making daily decisions, having scored four out of 15 on the BIMS (brief interview for mental status). R34 was coded as requiring a wheelchair for moving around the room and the unit. On the following dates and times, R34 was observed sitting in a wheelchair: 8/2/22 at 12:47 p.m. and 1:59 p.m.; 8/3/22 at 8:00 a.m. At no time did R34's wheelchair have anti roll/tip devices on the back to prevent R34's wheelchair from rolling or tipping over…

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 that the facility staff failed to implement bed rail requirements for 3 of 43 residents in the survey sample, Residents #73, #4, and #23. The findings include: 1. The facility staff failed to assess Resident #73 (R73) for the necessity of bed rails, and failed to evidence education of the resident regarding risks and benefits of implementing bed rails. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/13/22, R73 was coded as being moderately impaired for making daily decisions, having scored 11 out of 15 on the BIMS (brief interview for mental status). On the following dates and times, R73 was observed lying in bed with the top quarter side rails up on both sides of the bed: 8/2/22 at 12:35 p.m. and 3:00 p.m.; 8/3/22 at 8:02 a.m. and 10:37 a.m. A review of R73's clinical record, including facility assessments, failed to reveal a bed rail assessment or any evidence the resident/RP (responsible party) received…

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, it was determined that the facility staff failed to store medications in a safe manner on 1 of 2 nursing units, [NAME] Garden Unit. 1. RN #1 left medications on top of a medication cart, unsupervised, on the [NAME] Garden unit. 2. LPN #2 left the medication cart unlocked during medication administration, while it was unsupervised, on the [NAME] Garden unit. The findings include: 1. RN #1 left medications on top of a medication cart, unsupervised, on the [NAME] Garden unit. Resident #42 was admitted to the facility on [DATE]. On the most recent MDS (Minimum Data Set), a quarterly assessment dated [DATE], the resident was coded as being cognitively intact in ability to make daily life decisions. Resident #19 was admitted to the facility on [DATE]. On the most recent MDS (Minimum Data Set), a quarterly assessment dated [DATE], Resident #19 was coded as being severely cognitively impaired in ability to make daily life…

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, clinical record review and in the course of a complaint investigation, the facility staff failed to obtain laboratory tests per physician's order for one of 43 residents in the survey sample, Resident #276. The facility staff failed to obtain multiple lab tests per Resident #276's (R276) nephrologist's (kidney doctor) orders. The findings include: On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/12/21, the resident scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. R276's diagnoses included acute renal failure and cystic kidney disease. A review of R276's clinical record revealed a note from the nephrologist (kidney doctor) dated 4/6/21 that documented, Follow-up in 6 months. H&H (hemoglobin and hematocrit), protein creatinine ratio, renal panel, vitamin D25, PTH. The note documented future lab orders for: 10/01/2021: SPOT URINE CREATININE (1). 10/01/2021: VITAMIN D 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.

Based on staff interview, facility document review, clinical record review and in the course of a complaint investigation, the facility staff failed to obtain a diagnostic test per physician's request for one of 43 residents in the survey sample, Resident #276. The facility staff failed to obtain a renal ultrasound (1) per Resident #276's (R276) nephrologist's (kidney doctor) request. The findings include: On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/12/21, the resident scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident is not cognitively impaired for making daily decisions. R276's diagnoses included acute renal failure and cystic kidney disease. A review of R276's clinical record revealed a note from the nephrologist (kidney doctor) dated 4/6/21 that documented, Follow-up in 6 months .Renal ultrasound prior to the next visit .Future Procedures: 4/12/20/21: RENAL ULTRASOUND . Further review of R276's clinical record failed to reveal any renal ultrasound results. On 8/4/22 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 observation, staff interview, facility document review, and clinical record review, it was determined that facility staff failed to follow professional standards of practice and document the amount of insulin actually given for three of 37 residents in the survey sample, Resident #42, #19 and #53. The findings included: For Resident #42, #19 and #53, Licensed Practical Nurse (LPN) #3 was identified as the nurse who inaccurately documented insulin administration. On 11/21/19 at 5:22 p.m., an interview was conducted with LPN #3. When asked if she had ever experienced glitches when documenting in the eMAR (electronic medication record), LPN #3 stated that she was a new nurse to the facility and has only been working at the facility for approximately 2.5 weeks. LPN #3 stated that she was still adjusting to the new computer system. LPN #3 stated that she requested an additional nine more days of training due to the computer system. LPN #3 stated at first when documenting blood sugars; she was entering in the…

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

Based on observation, staff interview, and facility document review, it was determined that facility staff failed to apply hair restraints before entering the food preparation area in the facility kitchen. On 11/19/19 at 6:20 PM during the initial tour of the kitchen there were no hair restraints available upon entrance into the kitchen and food prep area. On the floor before entering into the kitchen and food prep area was a yellow and black strip with unreadable lettering. There were staff observed throughout the survey crossing the unreadable yellow and black line on the floor entering the kitchen without hair restraints. In order to get a hairnet you had to enter the kitchen, turn right and go past the food prep area to open a drawer that housed the hair restraints. On 11/20/19 at approximately 11:15 AM a tour of the kitchen was made with the Dietary Director. She was asked how would someone entering the kitchen obtain a hairnet? She stated, They would stop at this line and someone would bring them a hairnet. She was then asked how would someone know to stop at this yellow line.…

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 provide written bed hold notification at the time of an acute transfer to the hospital for one of 37 residents in the survey sample, Resident #42. The findings included: Resident #42 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to Type 2 diabetes mellitus, and hemiplegia (left side paralysis following stroke). Resident #42's most recent MDS (minimum data set) assessment was an admission assessment with an ARD (assessment reference date) of 9/19/19. Resident #42 was coded as being intact in cognitive function scoring 15 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #42's clinical record revealed that she had been sent out to the hospital on 5/23/19. There was no evidence in the clinical record that written bed hold notification was sent with Resident #42 at the time 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 staff interview, facility document review, and clinical record review, it was determined that facility staff failed to transmit a discharge assessment within the required time frame for two of 37 residents in the survey sample, Residents #1 and #2. The findings included: 1. Resident #1 was admitted to the facility on [DATE] and discharged on 6/21/19 with diagnoses that included but were not limited to Hemiplegia (paralysis on left side). Resident #1's most recent MDS (Minimum Data Set) assessment was a discharge assessment with an ARD (assessment reference date) of 6/21/19. Resident #1 was coded as being severely impaired in cognitive function scoring 00 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #1's clinical record revealed that she was transferred to the hospital on 6/21/19 due to altered mental status. Resident #1 did not return to the facility. Further review of Section Z (assessment administration) of her discharge MDS assessment revealed that her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility documentation review and clinical record review the facility staff failed to develop a complete comprehensive care plan to include Diabetes Mellitus and that the resident was a smoker, for 1 of 37 residents in the survey sample, Resident #5. The findings included: 1a. Resident #5 was admitted to the facility on [DATE]. Resident #5 was discharged from the facility on 07/26/2019 and readmitted to the facility on [DATE]. Diagnoses included but were not limited to, Diabetes Mellitus and Hypertension. Resident #5's Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of 08/06/2019 was coded with a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment. On 11/21/2019 review of Resident #5's clinical record revealed the following: The Face Sheet listed Type 2 Diabetes Mellitus without complications under Additional Current Diagnosis. Review of Resident #5's Physician Orders revealed an order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, it was determined that facility staff failed to revise the care plan for one of 37 residents in the survey sample, Resident #4. The findings included: Resident #4 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Alzheimer's disease, Delusional disorders, lack of coordination. Resident #4's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 8/2/19. Resident #4 was coded as being severely impaired in cognitive function scoring 09 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #4's fall risk care plan dated 11/1/19 documented the following intervention: Wear clip alarms as ordered. On 11/19/19 through 11/20/19 several observations were made of Resident #4; she did not have a clip alarm in place. Review of Resident #4's November 2019 POS (physician order summary) revealed…

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 document review, and clinical record review, it was determined that facility staff failed to obtain orders for the use of a catheter for one of 37 residents in the survey sample, Resident #83. The findings included: Resident #83 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to Hydronephrosis with renal and ureteral obstruction. Resident #83's most recent MDS (Minimum Data Set) assessment was an admission assessment with an ARD (assessment reference date) of 10/28/19. Resident #83 was coded as being intact in cognitive function scoring 15 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #83 was coded in section H (Bowel and Bladder) as having an indwelling catheter. Review of Resident #83's elimination care plan dated 10/21/19 documented the following: Alteration in elimination Indwelling catheter and ileostomy related to: Dx (diagnosis) of Hydrourterinephrosis (1),…

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, the facility staff failed to ensure that 1 opened bottle of house stock calcium tablets 500 mcg (micrograms) with the expiration date of 09/2019 was discarded. The findings included: On [DATE] at approximately 10:15 AM, an inspection of the medication cart on the [NAME] unit was conducted with Licensed Practical Nurse (LPN) #1. An opened bottle of Calcium tablets was stored on a medication cart with an expiration of 09/19. LPN #1 was asked what should have been done with the expired bottle of medication; she stated, They should have discarded and replaced the medication. The Facility Policy titled, Storage of Medications Reads as follows: The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. The above findings were shared with the Administrator, the Acting Director of Nursing and the Corporate Nurse Consultant during the pre-exit…

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

Based on observation and staff interview the facility staff failed to ensure the garbage storage area was maintained in a sanitary condition. The findings included: On 11/21/19 at approximately 9:40 AM the garbage and refuse containers were observed with the Dietary Director. The ground area surrounding the two trash dumpsters were observed to have a small amount of scattered debris of glass fragments, cigarette butts, coffee filter grounds and two small trash bags located in front of the dumpsters on the ground. A cat was seen walking away from the dumpsters. The Dietary Director stated that the garbage disposal truck was here earlier and left debris on the ground. The Dietary Director was asked what should have been done concerning the debris left on the ground; she stated, We should keep the gate closed and check the dumpster after the garbage truck comes to pick up trash. The above findings was shared with the Administrator, the Acting Director of Nursing and the Corporate Nurse Consultant during the pre-exit meeting conducted on 11/22/19 at 12:30 PM. No further information 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 ensure an accurate clinical record for one of 37 residents in the survey sample, Resident #19. The findings included: Resident #19 was admitted to the facility on [DATE] with diagnoses that included but were not limited to type two diabetes mellitus. Resident #19's most recent MDS (Minimum Data Set) assessment was a quarterly assessment with an ARD (assessment reference date) of 8/21/19. Resident #19 was coded as moderately impaired in cognitive function scoring 13 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #19 was coded in section N (Medications) as receiving insulin injections. Review of Resident #19's November POS (physician order summary) revealed the following order for insulin: Novolog (1) 100 units/mL (milliliters) Flexpen AC/HS (before meals)/at bedtime) Novolog per sliding scale FBG (fasting blood sugar) less then 90 = 0U (units) 91-120 =…

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 document review and clinical record review, it was determined that facility staff failed to maintain infection control practices during the dining room observation for two of 37 residents, Resident #46 and #73; and failed to practice infection control measures while performing wound care for one of 37 residents, Resident #57. The findings included: 1. Resident #46 was admitted to the facility on [DATE] with diagnoses that included but were not limited to dysphagia (difficulty swallowing), and anomaly of jaw size. Resident #46's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 9/25/19. Resident #46 was coded as being severely impaired in cognitive function scoring 03 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #46 was coded in Section G (Functional Status) as requiring extensive assistance with one staff member with meals. 2. Resident #73 was admitted 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.