Kempsville Health & Rehab Center

Based on staff interview, clinical record review and facility document review the facility staff failed to develop a care plan for 1 of 37 residents (Resident #1) in the survey sample. The findings included: The facility staff failed to develop a person-centered care plan to include a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) with the use of oxygen therapy. Resident #1 was admitted to the nursing facility on 11/22/16. Resident #1's diagnosis included but not limited to Chronic Obstructive Pulmonary Disease. Resident #1's Minimum Data Set (an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of 10/05/21 coded the resident's Brief Interview for Mental Status (BIMS) score 15 of a possible 15 with no cognitive impairment for daily decision-making. In section G (Physical functioning) the MDS coded Resident #1 requiring total dependence of one with hygiene, bathing and toilet use, extensive assistance of two with bed mobility and extensive assistance of one with dressing for Activities of Daily Living (ADL) care. In section O (Special…

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

Based on staff interviews, clinical record review and facility documentation the facility staff failed to revise 1 of 37 residents (Resident #47) comprehensive personal centered care plan in the survey sample. The finding include: The facility staff failed to revise Resident #47's comprehensive person centered care plan to include parameters of antibiotics, monitoring for side effects of antibiotics. (Keflex and Levaquin). The current diagnoses included; Sepsis unspecified Organism and Urinary Tract Infection. The admission, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/14/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible. This indicated Resident #47 cognitive abilities for daily decision making were intact. The resident's MDS was coded for the usage of antibiotic medications. Section N on the MDS under medications reads as follows: Indicate the number of DAYS the resident receiving the medication during the last 7 days, the MDS was coded for receiving an antibiotics for 2 days In…

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

Based on observation, resident interview, staff interviews, and clinical record review, the facility staff failed to ensure a Resident dependent in activities of daily living received good grooming, personal hygiene and dressing care for 1 of 37 residents (Resident #281), in the survey sample. The findings included: Resident #281 was originally admitted to the facility 01/7/22 and had not been discharged . The current diagnoses included; new stroke with left side weakness, dysphasia and urinary retention. The Minimum Data Set (MDS) assessment had not been completed therefore; information was gained from Licensed Practical Nurse (LPN) #3 on 1/13/22 at approximately 10:30 a.m. LPN #3 stated the resident was alert and oriented to person, family, situation and place but required assistance to make daily decisions. LPN #3 also stated the resident required total care with all care including eating and she required use of an indwelling catheter. On 1/12/22 at approximately 10:15 a.m., Resident #281 was observed sitting across from the nursing station. The resident's head was lowered 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 resident interview, staff interviews and clinical record review, the facility staff failed to ensure a recommended referral from the Ophthalmologist for cataract extraction was provided for 1 of 37 residents (Resident #46) in the survey sample. The findings included: Resident #46 was originally admitted to the facility on [DATE]. Diagnosis for Resident #46 included but not limited to Cataract. Resident #46's Minimum Data Set (an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of 12/13/21 coded the resident's Brief Interview for Mental Status (BIMS) score 15 of a possible 15 with no cognitive impairment for daily decision-making. In section G (Physical functioning) the MDS coded Resident #46 requiring total dependence of one with bathing, limited assistance of one with dressing, hygiene, bed mobility and toilet use and supervision with one assist with transfer and eating for Activities of Daily Living (ADL) care. The care plan with a created on 01/13/22 identified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and facility documentation, the facility staff failed to obtain an order for use of an indwelling catheter including a valid medical justification for 1 of 37 Resident's (Resident #281), in the survey summary. The findings included: Resident #281 was originally admitted to the facility 01/7/22 and had not been discharged . The current diagnoses included; new stroke with left side weakness, dysphasia and urinary retention. The Minimum Data Set (MDS) assessment had not been completed therefore; information was gained from Licensed Practical Nurse (LPN) #3. LPN #3 stated the resident was alert and oriented to person, family, situation and place but required assistance to make daily decisions. LPN #3 also stated the resident required total care with all care including eating and she required use of an indwelling catheter. On 1/12/22 at approximately 10:15 a.m., Resident #281 was observed sitting across from the nursing station. The resident's head was lowered and 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 The facility staff failed to ensure one resident with a potential for weight loss received adequate protein, portion sizes, and preferences at each meal, and to obtain weights as a means of measuring weight management for Resident #15, failed to obtain weekly weights for Resident #47 and failed to record meal consumption for Resident #127. The findings included: 1. Resident #15 was originally admitted to the facility 03/29/2021 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Malnutrition, Cirrhosis, Heart failure and Anemia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARID) of 10/30/2021 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 10 out of a possible 15. This indicated Resident #15's cognitive abilities for daily decision making were moderately impaired. In section G (Physical functioning) the resident was coded as requiring total care of one with toileting and bathing, extensive…

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

Based on observation, resident interview, staff interviews, clinical record review, facility documentation review, the facility staff failed to provide 1 of 37 residents (Resident #1) in the survey sample with respiratory care in accordance with professional standards of practice. The findings included: The facility staff failed to ensure Resident #1's oxygen order contained a prescribed flow rate to be administered. Resident #1 was admitted to the nursing facility on 11/22/16. Resident #1's diagnosis included but not limited to Chronic Obstructive Pulmonary Disease (COPD). Resident #1's Minimum Data Set (an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of 10/05/21 coded the resident's Brief Interview for Mental Status (BIMS) score 15 of a possible 15 with no cognitive impairment for daily decision-making. In section G (Physical functioning) the MDS coded Resident #1 requiring total dependence of one with hygiene, bathing and toilet use, extensive assistance of two with bed mobility and extensive assistance of one with dressing for Activities of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and facility documentation review the facility staff failed to ensure medications were stored in a secured location, accessible to designated staff for 1 of 37 residents (Resident #46) in the survey sample. The findings included: The facility staff failed to ensure the ProAir HFA (Albuterol) inhaler was stored in a secured location, accessible to designated staff only. Resident #46 was originally admitted to the facility on [DATE]. Diagnosis for Resident #46 included but not limited to Chronic Obstructive Pulmonary Disease (COPD). Resident #46's Minimum Data Set (an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of 12/13/21 coded the resident's Brief Interview for Mental Status (BIMS) score 15 of a possible 15 with no cognitive impairment for daily decision-making. In section G (Physical functioning) the MDS coded Resident #46 requiring total dependence of one with bathing, limited assistance of one with dressing, hygiene, bed mobility…

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 record review, observation and staff interview the facility staff failed to obtain one visitor's temperature during the screening process and failed to screen one vendor. On 1/13/22 at approximately 3:50 PM a vendor was seen entering the facility through the rear entrance to drop off a package. He was let inside of the building, walked up to the nurse's station and was directed by the facility staff where to leave a package. No screening process was initiated. On 01/13/22 at approximately 3:53 PM an interview was conducted with CNA (Certified Nursing Assistant) #7 concerning the above. She stated, The delivery people usually come through the storage area. [NAME] Wing (Unit 100 and 200 unit). I didn't screen him because we normally don't. Usually around 5:00 PM the visitors come to the back of the building to be screened. Several Signs located on the outer door at the rear entrance of the building read: All visitors need to be screened before entering the facility. Another sign read: Screening is now done at the front desk! Please use front door till further notice! 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 observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to have an ongoing review of antibiotic stewardship and monitor the effectiveness of 1 resident, Resident #47's, antibiotic therapy out of a sample of 37 residents. The findings included: 1 A. The facility's staff failed to have evidence of an ongoing review of the Antibiotic Stewardship Program. On 01/13/22 at 10:34 AM an interview was conducted with the DON (Director of Nursing). She presented a binder to the said surveyor entitled McGreer Criteria for Long Term Care Surveillance updated 2012. On 01/13/22 at approximately 4:26 PM the DON was approached concerning antibiotic stewardship documents. The DON stated, I can't find them. On 01/14/22 at approximately 10:00 AM., Surveyor was given Antibiotic Use Tracking Sheets dated September 2021 from the DON. She stated, I do have the program. I just can't find it. On 1/18/22 at approximately 5:45 PM., the above findings…

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 and staff interviews the facility staff failed to protect resident from public view during wound care for 1 resident (Resident #21), of 36 residents in the survey sample. The facility staff failed to ensure privacy was maintained during a wound care dressing change for Resident #21. The findings included: Resident #21 was originally admitted to the facility on [DATE]. Diagnosis for Resident #21 included but are not limited to Type II Diabetes Mellitus. Resident #21's Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 05/04/19 coded the resident 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 #21 as requiring extensive assistance of two with personal hygiene, extensive assistance of one with bathing, toilet use, dressing and bed mobility for Activities of Daily Living care. Section M-skin condition was coded for pressure ulcer care. During a wound…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interview, staff interviews, clinical record review and facility documentation review the facility staff failed to ensure for 1 resident (Resident #44) out of 36 residents in the survey sample was free from physical restraint. The facility staff failed to ensure that Resident #44 was free of physical restraint. The findings included: Resident #44 was admitted to the facility on [DATE]. Diagnoses included but were not limited to, Alzheimer's Disease with Early Onset, Unspecified Dementia with Behavioral Disturbance and Osteoarthritis. Resident #44's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 05/24/2019 coded Resident #44 with short-term and long-term memory problems, and with severely impaired cognitive skills for daily decision making. In addition, the Minimum Data Set coded Resident #44 as requiring total dependence of 2 for bed mobility and transfer, and total dependence of 1 for dressing, eating, toilet use, personal hygiene and bathing. 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 interviews and clinical record reviews the facility staff failed to send comprehensive care plan goals for 2 residents (Resident #45, Resident #78) out of 36 residents in the survey sample when discharged to the hospital. 1. The facility staff failed to send comprehensive care plan goals for Resident #45 when discharged to the hospital on [DATE]. 2. For Resident #78, facility staff failed to evidence that the comprehensive care plan goals were sent with the resident upon transfer to the hospital on 9/1/18. The findings included: 1. Resident #45 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnoses included but were not limited to, Non Traumatic Intracranial Hemorrhage, unspecified and Hypertension. Resident #45's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 05/28/2019 was coded with a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment. In addition, the Minimum Data Set coded 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 resident record review, staff interviews and facility document review, the facility failed to notify the Office of the State Long-Term Care Ombudsman in writing of hospital discharges for 2 of 36 residents (Resident #83 and #45) in the survey sample. 1. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #83 discharge to the hospital on [DATE]. 2. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #45's discharge to the hospital on [DATE]. The findings included: 1. Resident #83 was admitted to the facility on [DATE]. Diagnosis for Resident #83 included but not limited to Cerebral Infarction. On 05/06/19, according to the facility's documentation, Resident #83 complained of chest pain. Resident #83 was transported to the local ER via Emergency Medical Services (EMS). Review of the May's 2019, faxed list to the ombudsman of all the resident's emergency transfers to the hospital was reviewed on 07/10/19 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 staff interview, facility document review, and clinical record review, it was determined that facility staff failed to provide written bed hold notification for 2 of 36 residents in the survey sample, Residents #78 and #45. 1. For Resident #78, facility staff failed to provide the Resident and/or Resident Representative a written bed hold notification upon transfer to the hospital on 9/1/18. 2. For Resident #45 the facility staff failed to provide the Resident and/or Resident Representative a written bed hold notice when discharged to the hospital on [DATE]. The findings include: 1. Resident #78 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to muscle weakness, anemia, high blood pressure, and heart failure. Resident #78's most recent MDS (minimum data set) assessment was a significant change assessment with an ARD (assessment reference date) of 6/28/19. Resident #78 was coded as being intact in cognitive function scoring 15 out of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, it was determined that facility staff failed to implement the comprehensive care plan for one of 36 residents in the survey sample, Resident #6. For Resident #6, facility staff failed to implement her plan of care and ensure a fall mat was in place to prevent injury from falls. The findings include: Resident #6 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Chronic Kidney Disease Stage 3, high blood pressure, type two diabetes, hypothyroidism and Bipolar disorder. Resident #6's most recent MDS (Minimum Data Set) assessment was a significant change assessment with an ARD (assessment reference date) of 4/22/19. Resident #6 was coded with no cognitive impairment; requiring extensive assistance from one staff member with toileting, personal hygiene and dressing; and extensive assist with two plus staff members with bed mobility and transfers. Review of Resident #6's current July…

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 interviews, clinical record review and facility documentation review the facility staff failed to invite 1 of 36 residents in the survey sample to attend his person centered care plan meeting (Resident #54) in the survey sample. The findings included: Resident #54 was admitted to the facility on [DATE]. Diagnoses for Resident #54 included but not limited to, Diabetes Mellitus and Chronic Obstructive Pulmonary Disease (COPD). The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 06/14/19, coded the resident with a 13 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. During the initial tour on 07/09/19 at approximately 1:09 p.m., an interview was conducted with Resident #54 who stated, I am not being invited to attend my care plan meetings nor did I receive a letter to attend a care plan meeting. An interview was conducted with the Social Worker (SW) on 07/10/19 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 resident interview, staff interviews, clinical record review and facility documentation review the facility staff failed to maintain professional standards for 1 resident (Resident #1) in the survey sample of 36 residents. The facility staff failed to communicate an ongoing assessment with the dialysis center for Resident #1 who attended outpatient dialysis three days per week on Monday, Wednesday and Friday; And, the facility staff failed to obtain weights on Resident #1 per the comprehensive care plan and physician's order. The findings included: Resident #1 was originally admitted to the facility on [DATE]. Diagnoses included, but not limited to, End Stage Renal Disease (ESRD) (Chronic irreversible kidney failure). The resident was receiving hemodialysis treatments three times a week every Monday, Wednesday and Friday at an outpatient dialysis center. The current Minimum Data Set (MDS) a Quarterly assessment with an Assessment Reference Date (ARD) of 01/24/19 coded the resident with a 13 out of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, the facility staff failed to conduct a thorough skin assessment of a pressure ulcer prior to it advancing to an unstageable pressure ulcer, and failed to evidence that a barrier cream was implemented per the plan of care, for one of 36 residents in the survey sample, Resident #6; and the facility staff failed to follow physician's orders for a wound care dressing for one of 36 residents, Resident #21. The findings include: 1. For Resident #6, the facility staff failed to conduct a thorough skin assessment and failed to provide evidence that an intervention was implemented once redness was documented as being observed on 4/10/19 to Resident #6's sacrum. Resident #6 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Chronic Kidney Disease Stage 3, high blood pressure, type two diabetes, hypothyroidism and Bipolar disorder. Resident #6's most recent MDS (minimum data set) assessment was a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility document review, it was determined that facility staff failed to implement interventions to reduce the potential for accidents/hazards for one of 36 residents in the survey sample, Resident #6. For Resident #6, facility staff failed to ensure her fall mat was placed on the floor while she was in bed per physician's order to prevent injuries. The findings include: Resident #6 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Chronic Kidney Disease Stage 3, high blood pressure, type two diabetes, hypothyroidism and Bipolar disorder. Resident #6's most recent MDS (minimum data set) assessment was a significant change assessment with an ARD (assessment reference date) of 4/22/19. Resident #6 was coded as requiring extensive assistance from one staff member with toileting, personal hygiene and dressing; and extensive assist with two plus staff member with bed mobility and transfers. Review of 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 resident interview, staff interviews, clinical record review and facility documentation review the facility staff failed to communicate an ongoing assessment for one resident (Resident #1) of 36 residents in the survey sample for monitoring of complications after dialysis treatment; and failed to check weights on Resident #1. The facility staff failed to communicate an ongoing assessment with the dialysis center for Resident #1 who attended outpatient dialysis three days per week on Monday, Wednesday and Friday. The facility staff failed to obtain weights on Resident #1 when she returned from dialysis on most days. The findings included: Resident #1 was originally admitted to the facility on [DATE]. Diagnoses included, but not limited to, End Stage Renal Disease (ESRD) (Chronic irreversible kidney failure). The resident was receiving hemodialysis treatments three times a week every Monday, Wednesday and Friday at an outpatient dialysis center. The current Minimum Data Set (MDS) a Quarterly assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a complaint investigation, staff interviews and facility documentation review, the facility staff failed for one (Resident #181) of 36 residents in the survey sample, to assist with transportation arrangements in order to attend an appointment with an outside physician. The findings included: The facility staff failed to ensure Resident #181 attended her scheduled physician appointment on 07/09/18. Resident #181 was admitted to the facility on [DATE]. Being the resident was no longer in the facility a closed record review was conducted. Diagnoses for Resident #181 included but not limited to Atherosclerotic Heart Disease, Cerebral Infarction (stroke) and Chronic COPD. The resident's Minimum Data Set (MDS) assessment was not due. Review of Resident #181's admission Evaluation coded Resident #181 as alert and oriented x 4. Under ADL/Mobility for level of functioning included the following: the assist of two with ambulation, toileting and transfers, assist of one with bed mobility, bathing and dressing 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, facility document review and clinical record review, it was determined that facility staff failed to maintain infection control practices for two of 36 residents in the survey sample (Residents #33 and #21); and facility staff failed to ensure annual review of the infection control policies. 1. For Resident #33, facility staff failed to maintain infection control practices during breakfast on 7/10/19. 2. The facility staff failed to ensure infection control measures were implemented during wound care to Resident #21's left heel pressure ulcer. 3. The facility staff failed to ensure the Infection Prevention & Control policy was reviewed annually. The findings include: 1. Resident #33 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to high blood pressure, heart failure, muscle weakness, and hypothyroidism. Resident #33's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD…

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.