Maimonides Health Center Of Virginia Beach

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review and facility documentation the facility staff failed to develop and implement a person-centered care plan that is reviewed and revised for one (1) Resident (#1) in a survey sample of 20 Residents. The findings included: For Resident #1 the facility staff failed to review and revise the care plan after injuries, skin tear, pressure areas, and failed to have the required members of interdisciplinary team input on one care plan meeting. Resident #1 was admitted to the facility on [DATE]. Diagnoses for Resident #1 included but are not limited to dementia, severe protein calorie malnutrition, major depressive disorder, age related physical debility, restlessness, dysphagia, insomnia, osteoporosis, rheumatoid arthritis and pain. Resident #1's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 1/9/25 coded Resident #1 as unable to assess, indicating Resident #1 has severe cognitive impairment. In addition, the Minimum Data Set, coded Resident #1 as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review, and facility documentation, the facility staff failed to ensure adequate nutrition to prevent significant weight loss for 1 Resident (#1) in a survey sample of 20 Residents. The findings included: For Resident #1 the facility failed to obtain recognize signs of significant weight loss and consult with the Registered dietician for recommendations as ordered by physician on several occasions, resulting in 29 lb. weight loss from 12/31/24 - 2/11/25. Resident #1 was admitted to the facility on [DATE]. Diagnoses for Resident #1 included but are not limited to dementia, severe protein calorie malnutrition, major depressive disorder, age related physical debility, restlessness, dysphagia, insomnia, osteoporosis, rheumatoid arthritis and pain. Resident #1 ' s Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 1/9/25 coded Resident #1 as unable to assess, indicating Resident #1 has severe cognitive impairment. In addition, the Minimum Data Set, coded…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, and a clinical record review, the facility staff failed to ensure medications were administered in accordance to accepted professional standards for 1 of 20 residents (Resident #9), in the survey sample. The findings included: Resident #9 was originally admitted to the facility 7/27/2023 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included afib, diabetes and high blood pressure. The admission significant change annual quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/17/2025 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #9's cognitive abilities for daily decision making were intact. On 4/8/25 at approximately 10:54 AM, Resident #9 was observed in bed asleep. The resident did not answered when the door was knocked on. Upon entrance into the room to awaken the resident it was observed that 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 interview, clinical record review and facility documentation the facility staff failed to have a written agreement with hospice before hospice care is furnished for 1 Resident in a survey sample of 20 Residents. The findings included: For Resident #1 the facility staff failed to have a hospice contract before providing hospice services to the Resident and also failed to maintain hospice records within the clinical record. Resident #1 was admitted to the facility on [DATE]. Diagnoses for Resident #1 included but are not limited to dementia, severe protein calorie malnutrition, major depressive disorder, age related physical debility, restlessness, dysphagia, insomnia, osteoporosis, rheumatoid arthritis and pain. Resident #1's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of [DATE] coded Resident #1 as unable to assess, indicating Resident #1 has severe cognitive impairment. In addition, the Minimum Data Set, coded Resident #1 as requiring 4- total dependence, on staff, 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 and staff interviews, the facility staff failed to adhere to hand hygiene practices to help prevent the development infections for 1 of 20 residents (Resident #9), in the survey sample. The findings included: Resident #9 was originally admitted to the facility 7/27/2023 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included afib, diabetes and high blood pressure. The admission significant change annual quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/17/2025 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #9's cognitive abilities for daily decision making were intact. On 4/9/25 approximately at 11:24 AM, an observation of wound care to the resident's sacral pressure ulcer was conducted. Licensed Practical Nurse (LPN) #7 positioned the resident on his left side with help of Certified Nursing Assistant (CNA) #7. LPN #7 sprayed 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 family interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to respect and honor a resident's right to remain a full code for 1 of 7 residents in the survey sample, Resident #6. The findings included: For Resident #6, the facility staff entered an order for the resident to become a do not resuscitate/do not intubate (DNR/DNI) after the resident was admitted from the hospital as a full code and expressed wishes to remain a full code. On 7/11/24 at 3:35 PM the Administrator and The Director of Nursing were not able to find a signed DNR to support the order placed on 10/18/23-10/23/23 for Resident #6 being a DNR/DNI. Resident #6 was admitted to the facility on [DATE], status post right hip replacement from an acute care hospital. Diagnoses for Resident #6 included but are not limited to right hip replacement, hypertension, diabetes mellitus, and seizure disorder. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review, the facility's staff failed to ensure residents were free of significant medication errors for 2 of 7 residents in the survey sample, Resident #7 and Resident #6. The findings included: 1. Resident #7, a post kidney transplant resident was administered 8 days of the wrong medication, Cyclophosphamide, a chemotherapy drug, instead of the prescribed Cyclosporine, a drug used to prevent organ rejection in people who have received a kidney transplant, during his short term stay for rehabilitation. Resident #7 was originally admitted to the facility 4/08/24 after an acute care hospital stay. The current diagnoses included encounter for aftercare following kidney transplant and malignant neoplasm of unspecified kidney except renal pelvis. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 04/14/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 9 out of a possible 15.…

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

Based on clinical record review, staff interview and facility document review it was determined that the facility staff failed to ensure that the pharmacy provided one of 39 residents with the correct dosage of medication, Resident #15. The findings include: For Resident #15 (R15), the facility staff failed to ensure that the pharmacy provided 100 mg (milligram) of Gabapentin (1) as ordered. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 11/27/2022, the resident scored 12 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. The physician orders for R15 documented in part, Gabapentin 100 mg capsule, give 1 capsule (100 mg) by oral route every 12 hours. Schedule: Every day at 6:00 am; 6:00 pm; Original Order Date: 11/14/2022 . The progress notes for R15 documented in part, - 1/21/2023 6:01 a.m. Nursing. Note: During morning med pass, writer observed that gabapentin pills were incorrect dose. MD (medical doctor) order and sticker on…

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

Based on clinical record review, staff interview and facility document review it was determined that the facility staff failed to ensure that one of 39 residents was free from unnecessary psychotropic medications, Resident #21. The findings include: For Resident #21 (R21), the facility staff failed to implement physician approved pharmacy recommendations to reduce Paroxetine (1) in a timely manner resulting in the resident receiving 38 doses of 20 mg (milligrams) between 7/16/22 until 8/22/2022 instead of 10mg. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/30/2022, the resident scored nine out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. The assessment documented R21 receiving an antidepressant. A review of the monthly pharmacy medication regimen reviews for R21 documented a consultation report for R21 dated July 13, 2022 through July 14, 2022. The report documented in part, .Recommendation: Please consider Paroxetine 10…

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, observations, staff interview, clinical record review, and facility document review it was determined the facility staff failed to promote dignity for one of 39 residents in the survey sample, Resident #96. The findings include: For Resident #96 (R96), the facility staff failed to maintain a urinary catheter bag in a manner to prevent the contents from being seen from the hallway. On the most recent MDS (minimum data set) assessment, an admission assessment with an ARD (assessment reference date) of 11/19/2022, the resident scored eight out of 15 on the BIMS (brief interview for mental status) assessment, indicating that the resident was moderately impaired for making daily decisions. The assessment documented the resident having a urinary catheter. On 1/24/2023 at 2:25 p.m., an observation was made of R96 in their room. R96 was observed asleep in bed, a urinary catheter bag was observed attached to the bed frame on the right side of the bed facing the doorway. Approximately 300 ml (milliliter) of yellow urine was observed in the bag from the hallway. On…

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

Based on clinical record review and staff interview it was determined that the facility staff failed to maintain an accurate MDS (minimum data set) resident assessment for one of 39 residents in the survey sample, Resident #84. The findings include: For Resident #84 (R84), the facility staff failed to code the quarterly MDS assessment with an ARD (assessment reference date) of 12/28/2022 for a urinary catheter. On the most recent MDS assessment, a quarterly assessment, with an ARD (assessment reference date) of 12/28/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. Section H0100 failed to evidence documentation of use of an indwelling catheter. The physician orders for R84 documented in part, Indwelling catheter r/t (related to) urinary retention d/t (due to) BPH (benign prostatic hypertrophy). Original order date: 9/14/2022 . The comprehensive care plan for R84 documented in part, Catheter: Indwelling r/t BPH with obstruction, Foley cath (catheter) size: 16…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interview and facility document review it was determined that the facility staff failed to implement the comprehensive care plan for one of 39 residents, Resident #21. The findings include: For Resident #21 (R21), the facility staff failed to implement the comprehensive care plan for the use of floor mats as ordered. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/30/2022, the resident scored nine out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. Section G documented R21 being totally dependent on two or more staff for transfers and requiring extensive assistance from one staff member for toileting and personal hygiene. Section J documented R21 having one fall with no injury since the prior assessment. On 1/24/2023 at 1:33 p.m., an observation was made of R21 in their room. R21 was observed in bed with 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, clinical record review, staff interview and facility document review it was determined that the facility staff failed to implement fall interventions as ordered for one of 39 residents, Resident #21. The findings include: For Resident #21 (R21), the facility staff failed to implement fall mats as ordered. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/30/2022, the resident scored nine out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. Section G documented R21 being totally dependent on two or more staff for transfers and requiring extensive assistance from one staff member for toileting and personal hygiene. Section J documented R21 having one fall with no injury since the prior assessment. On 1/24/2023 at 1:33 p.m., an observation was made of R21 in their room. R21 was observed in bed with a fall mat in place on the floor 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.

Based on clinical record review, staff interview and facility document review it was determined that the facility staff failed to ensure that pharmacy recommendations were reviewed and implemented in a timely manner for one of 39 residents, Resident #21. The findings include: For Resident #21 (R21), the facility staff failed to implement physician approved pharmacy recommendations in a timely manner. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/30/2022, the resident scored nine out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. A review of the monthly pharmacy medication regimen reviews for R21 documented a consultation report for R21 dated July 13, 2022 through July 14, 2022. The report documented in part, .Recommendation: Please consider Paroxetine (1) 10 mg (milligram) QD (every day). Rationale for Recommendation: The manufacturer recommends dosing modification in individuals with kidney disease .Physician's Response: I…

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 staff failed to notify the Office of the State Long-Term Care Ombudsman in writing of resident discharges for 5 of 48 residents (Resident #11, #95, #107, #2, and #114) after being transferred to the hospital. The findings included: 1. Resident #11 was originally admitted to the facility on [DATE]. The resident was re-admitted to the facility on [DATE]. Diagnosis for Resident #11 included but not limited to Heart Failure Unspecified and Orthostatic Hypertension. Resident #11's current Minimum Data Set (MDS), a quarterly revision with an Assessment Reference Date (ARD) of 06/12/19 coded the resident with a 7 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The Discharge MDS assessment dated [DATE] - discharge return anticipated, resident re-admitted on [DATE]. The was no evidence that the Ombudsman was notified of the discharge. On 10/10/19 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 a facility document, clinical record reviews and staff interviews, the facility staff failed to encode and/or electronically transmit discharge Minimum Data Set (MDS) assessments to the Centers for Medicare/Medicaid System, for 9 of 48 residents in the survey sample, Resident #216, #217, #218, #219, #220, #221, #222, #223, & #224). The findings include: Review of the MDS 3.0 Missing Omnibus Budget Reconciliation Act (OBRA) Assessment report obtained by the facility's staff from the CMS website revealed no MDS OBRA assessments and/or MDS Discharge Assessment had been submitted for the following residents in greater than 92 days. Resident #216 was admitted to the facility 5/25/18, and was discharged from the facility with return not anticipated 7/3/18. The last assessment accepted into the MDS databank was dated 6/1/18. An interview was conducted with the MDS Coordinator on 10/10/19, at approximately 10 a.m., she stated the resident's discharge MDS was completed and transmitted to CMS 7/9/18, but CMS…

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

Based on observations and staff interviews, the facility staff failed to ensure that food was prepared, stored and served under sanitary conditions. During an inspection of the Facility kitchen occurring 10/08/2019 through 10/10/2019, it was found that the Facility staff: 1. Stored unlabeled, expired food in the refrigerator and freezer. 2. Kept and served food under the required temperature. The findings included: During an initial inspection of the facility kitchen on 10/8/2019 at approximately 11:37 a.m., a reading of pureed quiche showed a holding temperature of 111 degrees. Further observation yielded that the quiche was served on trays to be distributed to residents. During an interview with the Dietary Manager on 10/10/2019 at approximately 2:45 p.m., when asked about serving pureed quiche under required temperatures, his response was, According to our policy, the quiche was served just under the required temperature of 115 degrees. During an inspection of the facility dairy kitchen refrigerator on 10/8/2019 at approximately 11:40 a.m., it was noted that the label on an…

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

Based on observations and staff interviews, the facility staff failed to ensure that food storage, preparation, dining, and conference areas were free of visible signs of flies. The findings included: During an initial inspection of the kitchen and dining area on 10/8/2019 at approximately 11:37 a.m., flies were observed on covered dishes of peach cobbler and dining room tables. Additionally, flies were observed within the volunteer conference room. An interview was conducted on 10/10/2019 at approximately 2:26 p.m. with the Dietary Manager regarding observations of flies in the kitchen, dining area and volunteer conference room. The Dietary Manager responded, We have a fly deterrent system that uses ultra-violet lights to attract flies. We also have an air curtain at the back door to deter flies. The ultra-violet lights attract the flies and then glue sticks inside the light fixtures, kill them. Facility provided Pest Control Policy & Procedure: 1. Monitor access to the facility by pests and insects. 2. Deny pests food, water, and hiding/nesting places. 3. Wet towels and mop heads…

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

Based on observation, staff interviews and facility documentation review, the facility staff failed to certify an individual feeding residents participated in a state approved feeding assistant program. The findings included: During the initial tour of the dining room observation on the dementia care unit located on Sholom Hall a Unit Secretary was observed feeding residents on three occasions. On 10/08/19 at approximately 12:40 PM, the Unit Secretary (Other Staff #6) was observed feeding two residents in the dining area on Sholom Hall. On 10/09/19 at approximately 12:41 PM, the Unit Secretary (Other Staff #6) was observed feeding a resident in the dining area on Sholom Hall. Other Staff #6 was asked how long has she been assisting residents with feeding. She stated that she's been assisting residents for fours years. She voluntarily made a copy of a Certificate of Completion. The reading on the certificate stated that she had successfully completed the Assisted Oral Feedings in Adults dated August 01, 2015. The following interviews were conducted: On 10/10/19 at approximately 10:03…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility staff failed to conduct quarterly assessments for one resident (Resident #2) in the survey sample of 48 residents. The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses that included, but not limited to, previous stroke and history of progressive MS (multiple sclerosis), depression and neuropathic bladder. The Initial Minimum Data Set (MDS) dated [DATE], coded this resident in the area of Cognitive Patterns - Brief Interview Minimum Status (BIMS) score as a 9 which indicated moderate cognitive impairment. A Care Plan updated 04/16/19 indicated: Cognition- potential late effects of comorbidities, forgetfulness, potential effects of current medication regimen. - Intervention- Staff to anticipate needs. Limit/structure choices to avoid frustration. The clinical record was reviewed and the initial MDS was performed on 01/15/19, however there were no Quarterly MDS's for April or July 2019. During an interview on 10/09/19 with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, facility documentation review and clinical record review the facility staff failed to ensure a level I PASRR (Preadmission Screening and Resident Review) screening was completed prior to admission for 1 of 48 residents in the survey sample, Resident #95. The findings included: Resident #95 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include but not limited to, Anxiety Disorder, Major Depressive Disorder and Bipolar Disorder. The most recent Minimum Data Set (MDS) assessment was a quarterly dated 08/21/19 which coded the resident with having short-term and long-term memory problems and the resident's cognitive skills for decision making moderately impaired. In Section A1500-Preadmission Screening and Resident Review, it was not coded. On 10/10/19 at approximately 2:18 PM an interview was conducted with the Admissions Director (Other Staff #10). She was asked for a copy of Resident #95's Level 1 PASRR screening. She stated, We don't have…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, and facility documentation review, the facility staff failed to follow professional standards of quality for 1 (Resident #95) of 48 residents in the survey sample. The facility staff failed to follow physician orders by administering oxygen without a Physician's order. The findings include: Resident #95 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses for Resident #95 included but not limited to Anxiety Disorder, Major Depressive Disorder and Bipolar Disorder. The most recent Minimum Data Set (MDS) assessment was a quarterly dated 08/21/19 and coded the resident with having short-term and long-term memory problems and cognitive skills for decision making moderately impaired. Section O, Special Treatments and Programs, 0100C, Respiratory Treatments, on the MDS was not coded for Resident #95 receiving oxygen. A review of the MAR (Medication Administration Record) for the month of October, 2019 revealed no oxygen orders where included. 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, staff interviews and clinical record review the facility staff failed to ensure 1 of 48 residents (Resident #33) in the survey sample who were unable to carry out activities of daily living (ADL) received the necessary services to maintain fingernail care. The findings included: The facility staff failed to ensure that fingernail care was provided to Resident #33. Resident #33 was originally admitted to the facility on [DATE]. Diagnosis for Resident #33 included but not limited to Anxiety and Depression. The current Minimum Data Set (MDS), an annual assessment with an Assessment Reference Date (ARD) of 06/19/19, coded Resident #33 with a 05 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. In addition, the MDS coded Resident #33 requiring total dependence of one with bathing and limited assistance of one with hygiene. Resident #33's comprehensive care plan with a revision date of 11/04/19, under loss of ADL function,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, clinical record review,and in the course of a complaint investigation, the facility staff failed to ensure 1 of 48 residents (Resident #44) in the survey sample who were unable to carry out activities of daily living, received the necessary services for toenail care. The findings included: The facility staff failed to ensure that podiatry services was provided to Resident #44. Resident #44's Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date of 07/17/19 coded Resident #44's Brief Interview for Mental Status (BIMS) score of 00 out of a possible score of 15 indicating severe cognitive impairment. In addition, the MDS coded Resident #44 total dependence of two with transfer, toilet dependence of one with dressing, hygiene and bathing, extensive assistance of two with bed mobility and toilet use and extensive assistance of one with eating for Activities of Daily Living (ADL) care. Resident #44's comprehensive care plan with a revision date of…

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

Based on observations, resident interview, staff interview, and clinical record review the facility's staff failed to obtain a physician's order prior to applying bilateral arm/hand splints for 1 of 48 residents (Resident #60), in the survey sample. The findings included: Resident #60 was originally admitted to the facility 10/28/18 and has never been discharged from the facility. The current diagnoses included; polyosteoarthritis with stiffness of the elbows and pain to bilateral hands. The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/7/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 8 out of a possible 15. This indicated Resident #60 cognitive abilities for daily decision making were moderately impaired. In section G (physical functioning) the resident was coded as requiring extensive assistance of one person with bed mobility and personal hygiene, total care of two with transfers and toileting, and total care of two with locomotion, dressing, eating, and bathing. Resident #60 was observed in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews and facility documentation review the facility staff failed to ensure 1 of 8 medication carts ([NAME] Unit) was kept locked or under direct observation of authorized staff in an area where residents could access it; and failed to remove expired biological's from 1 of 3 Medication Storage Rooms (Sholom Unit). The findings included: 1. On [DATE] at 12:45 p.m., the Surveyor observed Licensed Practical Nurse (LPN) #4 prepare medications while standing in front of the medication cart in the hallway outside of room [ROOM NUMBER]. The LPN and Surveyor walked into room [ROOM NUMBER]; the medication cart was left unlocked. The LPN closed the door to room [ROOM NUMBER]. On [DATE] at approximately 1:00 p.m., an interview was conducted with LPN #4. The above observation was reviewed with LPN #4 and she was asked, Should you have left the medication cart unlocked and unsupervised when you went into room [ROOM NUMBER] and closed the door? LPN #4 stated, No, I should have locked the…

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

Based on observations, resident interview, staff interview, and clinical record review the facility's staff failed to provide a handled cup at meal times for 1 of 48 residents (Resident #60), in the survey sample. The findings included: Resident #60 was originally admitted to the facility 10/28/18 and has never been discharged from the facility. The current diagnoses included: polyosteoarthritis with stiffness of the elbows and pain to bilateral hands. The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/7/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 8 out of a possible 15. This indicated Resident #60 cognitive abilities for daily decision making were moderately impaired. In section G (Physical functioning) the resident was coded as requiring extensive assistance of one person with bed mobility and personal hygiene, total care of two with transfers and toileting, and total care of two with locomotion, dressing, eating, and bathing. Resident #60 was observed in her room having lunch 10/8/19 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.

Based on observations, staff interviews and facility documentation review the facility staff failed to have a water management plan for the facility; and failed to perform appropriate hand hygiene after removing dirty gloves for 1 of 48 residents in the survey sample (Resident #342). The findings included: 1. On 10/08/2019 at approximately 3:00 p.m., an interview was conducted with the Maintenance Director and he was asked for the facility's Legionella protocol. The Maintenance Director stated, We don't do any testing for Legionella. We do not have a problem with Legionella because we have a closed loop system, chiller system, and it is chemically treated. On 10/09/2019 at approximately 11:30 p.m., the facility risk assessment was reviewed and revealed the Probability of Water Contamination was scored as low. On 10/09/2019 at 12:55 p.m., an interview was conducted with the Maintenance Director and he was asked, Do you have a water management policy and procedure? The Maintenance Director stated, No, we do not. The Maintenance Director was asked, Do you have any water testing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and facility documentation, the facility staff failed to maintain a safe, clean, comfortable and sanitary environment and for 1 of 48 residents (Resident #43) in the survey sample. The finding included: The facility staff failed to ensure Resident #43's personal wheel chair was maintained in a sanitary condition. Resident #43 was originally admitted on [DATE]. Diagnoses for Resident #43 included but not limited to Glaucoma. The current Minimum Data Set (MDS) a quarterly assessment with an Assessment Reference Date (ARD) of 07/17/19 coded Resident #43 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 #43 requiring extensive assistance of one with transfers. The MDS was coded under section G 0600 for the use of a wheel chair for mobility devices. During the initial tour of the facility on 10/08/19 at approximately 12:10 p.m., Resident #43 was observed sitting up 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 interview, facility documentation review, the facility staff failed to store and prepare food in a sanitary manner. The findings included: On 4/17/18 at approximately 11:15 AM during the initial Kitchen tour, the Dietary Manager was asked the use by date on one 5 pound package of Mozzarella cheese in the walk-in refrigerator. The Dietary Manager looked for an expiration date on the cheese and she did not find one. The Dietary Manager stated she still had the box the cheese came in. The Dietary Manager was asked if all boxes that food product came in were saved and she stated, No. The Dietary Manager was asked if it was her expectation for her staff to go in search of boxes to find out the use by date and she stated, No. There was not posting observed in the walk in refrigerator of Use by dates. On 4/18/18 at approximately 10:50 AM, the Dietary Manager showed the box the cheese came in. The Dietary Manager again was asked if it was her expectation for dietary staff to go in hunt of boxes to determine a use by date. The Dietary Manager…

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 record review, the facility staff failed to obtain a written agreement with the dialysis center and failed to maintain communication with the dialysis center providing services for 1 of 27 residents in the survey sample (Resident #87). Findings included: Resident #87 was admitted to the facility on [DATE]. Diagnoses included, but were not limited too, hypertension, GERD (gastroesophageal reflux disease), syncope with collapse, unspecified systolic (congestive) heart failure, End Stage Renal Disease (ESRD), dependence on renal dialysis, and gout. Resident #87 had an admission Minimum Data Set (MDS) completed on [DATE]. The assessment indicated resident #87 has a BIMS (Brief Interview for Mental Status) assessment score of 10, indicating moderate cognitive impairment. Section O0100 J. indicated the resident received dialysis services. Resident #87's functional status was coded as limited assistance needed for self-performance and staff assistance of one staff member for 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident interview, and staff interviews, the facility staff failed to obtain a physician's order for self-administration of medications for 1 of 27 residents in the survey sample (Resident#63), and failed to ensure medications obtained from outside of the facility were properly labeled and stored. 1. The facility staff failed to obtain a physician's order for self-administration of Pepto-Bismol and Tylenol for Resident #63. 2. Facility staff failed to date multiple bottles of medication after opening on two of three medication carts inspected, and one medication room. 3. The facility staff failed to ensure 1 open multi-dose vial of Aplisol (tuberculin skin test serum) was dated correctly when opened. A review of the facility policy for: Bulk Medications, Dispensing of dated February 2017 notes: 4. Date and time each container when opened. The findings included: 1. Resident #63 was admitted to the facility on [DATE] with diagnoses that included but not limited to, Respiratory…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff interviews, and facility documentation review, the facility staff failed to maintain a sanitary environment for four residents in a survey sample of 27 Residents (#37, #11, #68, #67). 1. The facility staff failed to clean Oxygen concentrator filters for resident #37. 2. The facility staff failed to clean Oxygen concentrator filters for resident #11. 3. The facility staff failed to clean Oxygen concentrator filters for resident #68. 4. The facility staff failed to maintain Resident #67's wheelchair in a sanitary condition. The findings include: 1. Resident # 37 was originally admitted on [DATE] with a diagnosis of *Chronic Obstructive Pulmonary Disease. *Chronic obstructive pulmonary disease makes it hard for a resident to breath. Source: (https://medlineplus.gov/copd.html). The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) date of 1/3/2018. The Brief Interview for Mental Status (BIMS) was a 5 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 observations, clinical record review, staff interviews, and facility document review, the facility staff failed to revise person-centered comprehensive care plan for 1of 27 sample residents (Resident #12). The facility staff failed to revise Resident #12's person-centered comprehensive care plan to include Oxygen therapy. The finding include: Resident #12 was readmitted on [DATE] with diagnosis to include but not limited to Bipolar Disorder, Dementia, Hypothyroidism. The most recent Minimum Data Set (MDS) for Resident #12 was a quarterly with Assessment Reference Date (ARD) of 1/17/2018. The Brief Interview for Mental Status (BIMS) was a 6 out of a possible 15, which indicated that resident #12 has severe cognitive impairment. Resident #12's Physicians Order was reviewed on 4/18/2018. An order dated 3/22/2018 was written to administer Oxygen 2Liter/min via nasal cannula: Every day at 7:00 am -3:00 pm; 3:00 pm -11:00 pm; 11:00 pm - 7:00 am. The Person-Centered Comprehensive Care Plan initiated 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, resident observation, clinical record review, and facility documentation review, the facility staff failed ensure the clinical record was accurate for one (1) of 27 residents (Resident #88) in the survey sample. The facility staff failed to ensure the Resident's Medication Administration Record (MAR) for April 2018 was accurate for the removal of Resident #88's Lidocaine Patch. The findings included: Resident #88 was admitted to the facility on [DATE]. Diagnosis for Resident #88 included but not limited to *Pain (unspecified). *Pain is an unpleasant sensation that can range from mild, localized discomfort to agony (https://www.medicinenet.com). The current Minimum Data Set (MDS), a comprehensive assessment with an Assessment Reference Date (ARD) of 4/06/18 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. The resident required extensive assistance of one with toilet use, personal hygiene and…

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