Virginia Beach Healthcare And Rehab Center

Based on observation, staff interview, facility documentation review, the facility staff failed to ensure the facility was administered effectively to maintain the highest practicable well being of each resident. The findings included: The facility had a multi-system failure to include deficient practices including environmental services, sanitary and a safe building and dining, infection control practices, medication storage and administration, and resident abuse. These issues affected the quality of life of the residents in the facility. During the survey, investigations revealed the facility had issues involving multiple systems. There were issues involving environmental services to include inadequate laundry services with only one working washing machine for several months. Residents were complaining of not having adequate linens for their beds, not being able to get clean gowns , not getting their personal clothing washed and returned in timely manner. Staff members were observed while performing duties and providing care. Some staff members were overheard apologizing to other…

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

Based on staff interview and facility documentation review, the facility staff failed to devise a facility-specific facility assessment The Findings included: On 10/9/2024 at 4:00 p.m., the facility Administrator was informed of the plan to review the Facility Assessment with the Administrator on 10/10/2024. A copy of the Facility Assessment was given to the surveyor. On 10/10/2024 upon arrival at the facility, the survey team was informed that the Administrator was no longer working at the facility as of the evening of 10/9/2024. The Regional [NAME] President of Operations was serving as the Acting Administrator. On 10/10/2024 at 11:15 a.m.,review of the facility assessment was conducted with the Regional Director of Operations (Acting Administrator). Review revealed the assessment was not tailored to the facility. The facility assessment was 22 pages in length. The assessment utilized a template but did not answer the questions as they related to the facility. Examples of non-compliance included: The facility assessment was dated 9/3/2024. There was no documentation 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 observation, Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure the facility maintained a safe, sanitary, and comfortable environment to prevent the transmission of communicable diseases, infections, Legionnaires', and other potentially transmissible waterborne pathogens, on 4 of 4 Resident living units and communal spaces. The findings included; The facility staff failed to ensure that the facility was free from dampness, and mold. Surveyors observed wet mold on floors, walls, ceiling tiles, ceiling insulation and pipes, shower grout, base boards, and shower curtains, and Resident rooms. Unsanitary areas also included shower rooms, laundry facilities, the main kitchen, insects on 4 of 4 units, ice machines were not kept clean and sanitary, and staff further failed to complete, and document preventative maintenance, water/water damage testing, and cleaning schedules. On 10-9-24 observation of the Resident hydration ice machine in the closet across from the dining room revealed standing water on 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, interview, and facility documentation the facility staff failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. The findings included: For the facility staff failed to ensure that the facility was free from damp mildew smell, wet ceiling tiles, unsanitary shower rooms, and ice machines were kept clean and sanitary and document preventative maintenance and cleaning schedules. On 10/11/24 observation of the ice machine in closet across from the dining room revealed standing water on the floor, a rubber mat with live roaches (5-6 of them) crawling around and under it, the ice machine drainage pipe was dripping on the floor not in the drain. Under the ice machine was black slimy substance and wet paper trash as well. The entire area smelled of dampness and mildew. The Administrator was coming down the hall and asked to view the area when asked if he thought it was safe and sanitary for Residents to consume ice made in that environment,…

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 obtained during the Resident Group interview, observations, staff interviews, and Resident Group meeting minutes, the facility staff failed to demonstrate their response, action and/or a rationale for not taking action to the Resident Group grievances. The findings included: On 10/7/24 at 2:00 PM a Resident Group meeting was held with the President, [NAME] President, four resident who attends the group meeting regularly and one who does not attend the regularly. It was a consensus of all attending the meeting that their grievances are not acted upon even when they had been voiced multiple times. The groups stated they had never received communication from the administrative staff regarding any of their grievances. The group's President stated that the Activity's Director (AD) assists with the meeting and she ensures the departments are aware of their grievances but she has her assistant act as a liaison between the residents and the staff. A review of six months of the Resident Group minutes revealed that the residents voiced the following concerns multiple…

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 interviews, clinical record reviews, and facility documentation review, the facility staff failed to prevent repeated willful abuse and neglect, failed to report the abuse to the state agency, failed to fully investigate the abuse, failed to protect the victims during the investigation, and further failed to implement their abuse and neglect policies for four known Residents (Residents #68, #20 and #521, ) in a survey sample size of 55 residents. The findings included: The facility failures described above resulted in the willful abuse of Residents #68, #20, and a third unknown Resident victim as perpetrated by Resident #521. Resident #68 (victim 1)was admitted to the facility on [DATE]. Diagnoses included but were not limited to: heart failure, hypertension, high cholesterol, malnutrition, peripheral venous insufficiency, hypothyroidism, rheumatoid arthritis, scoliosis, rhabdomyolysis, and foot pain. Resident #68's most recent Minimum Data Set with an Assessment Reference…

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 interviews, clinical record reviews, and facility documentation review, the facility staff failed to implement their abuse policies to prevent repeated willful abuse and neglect, in so doing, failed to report the abuse to the state agency, failed to fully investigate the abuse,and further failed to protect the victims during the investigation, for four known Residents (Residents #68, #20, #521, and #325) in a survey sample size of 55 residents. The findings included: The facility failures described above resulted in the willful abuse of Residents #68, #20, and a third unknown Resident victim as perpetrated by Resident #521. Resident #68 (victim 1)was admitted to the facility on [DATE]. Diagnoses included but were not limited to: heart failure, hypertension, high cholesterol, malnutrition, peripheral venous insufficiency, hypothyroidism, rheumatoid arthritis, scoliosis, rhabdomyolysis, and foot pain. Resident #68's most recent Minimum Data Set 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 staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to prevent repeated willful abuse and neglect, failed to report the abuse to the state agency, failed to fully investigate the abuse, failed to protect the victims during the investigation, and further failed to implement their abuse and neglect policies for four known Residents (Residents #68, #20, #521, and #325) in a survey sample size of 55 residents. The findings included: The facility failures described above resulted in the willful abuse of Residents #68, #20, and a third unknown Resident victim as perpetrated by Resident #521. Resident #68 (victim 1)was admitted to the facility on [DATE]. Diagnoses included but were not limited to: heart failure, hypertension, high cholesterol, malnutrition, peripheral venous insufficiency, hypothyroidism, rheumatoid arthritis, scoliosis, rhabdomyolysis, and foot pain. Resident #68's most recent Minimum Data Set with an 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 staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to prevent repeated willful abuse and neglect, failed to fully investigate the abuse, failed to report the abuse to the state agency, failed to protect the victims during the investigation, and further failed to implement their abuse and neglect policies for four known Residents (Residents #68, #20, #521, and #325) in a survey sample size of 55 residents. The findings included: The facility failures described above resulted in the willful abuse of Residents #68, #20, and a third unknown Resident victim as perpetrated by Resident #521. Resident #68 (victim 1)was admitted to the facility on [DATE]. Diagnoses included but were not limited to: heart failure, hypertension, high cholesterol, malnutrition, peripheral venous insufficiency, hypothyroidism, rheumatoid arthritis, scoliosis, rhabdomyolysis, and foot pain. Resident #68's most recent Minimum Data Set with an 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 Resident staff interview, facility documentation review, and clinical record review, the facility staff failed to provide a comprehensive care plan for care and services to maintain the highest practicable well being for two residents, (Resident #73, and #521) in a survey sample of 55 residents. The findings included: 1. Resident #73 had contractures with splints and palm guards required to prevent further contracture and maintain skin integrity. No care plan was ever devised for the palm guards and the splinting care plan was not individualized nor Resident centered. Resident #73, with contracted fingers of the left hand, experienced a pressure sore injury from his fingernails pressing into his palm. The pressure sore became infected resulting in cellulitis, which led to the identification of the pressure sore injury in the facility. The pressure sore and resulting infection caused the Resident to be sent out to the hospital for treatment with IV (intravenous) antibiotics for 10 days. The facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, Resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to follow the professional standards of nursing practice for 2 residents, (Residents #89, and #161) in a survey sample of 55 residents. The Findings Included: 1. For resident #89 the facility staff failed to apply a Cardiac Monitor, to the Resident for the required time frame to capture and diagnose the cause of repeated syncopal episodes from suspected heart arrythmias (irregular heart beats). Resident #89 was admitted to the facility on [DATE], and readmitted on [DATE], after a 6 day hospitalization. Diagnoses included; Chronic Kidney disease, sick sinus syndrome after syncope and collapse on 7-12-24, dementia, hypertension, malnutrition, stroke, and anemia. Resident #89's most recent Minimum Data set assessment was a quarterly assessment with an assessment reference date (ARD) of 8-1-24. Resident #89 was coded with a Brief Interview of Mental Status score of 3…

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 and clinical record review, the facility staff failed to ensure two Residents (Resident #89 and #68) received ADL (activities of daily living) care to include hygiene and showers in a survey sample of 55 residents. The findings included: 1. For Resident #89 her fingernails were long and dirty/encrusted with a brown substance, and the resident did not receive twice weekly showers. Resident #89 was admitted to the facility on [DATE], and readmitted on [DATE], after a 6 day hospitalization. Diagnoses included; Chronic Kidney disease, sick sinus syndrome after syncope and collapse on 7-12-24, dementia, hypertension, malnutrition, stroke, and anemia. Resident #89's most recent Minimum Data set assessment was a quarterly assessment with an assessment reference date (ARD) of 8-1-24. Resident #89 was coded with a Brief Interview of Mental Status score of 3 indicating severe cognitive impairment. Resident #89 required extensive to total assistance from one to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to identify and address necessary behavioral health services, and failed to devise and implement a comprehensive person centered care plan for identified responses to stressors for one Resident with non-Alzheimer's type dementia with a language barrier (Resident #521) in a survey sample of 55 Residents. The findings included: For Resident #521 the facility staff failed to obtain a physician ordered psychiatric consult timely, failed to conduct behavior monitoring, failed to provide a comprehensive care plan for emotion regulation, failed to identify stressors and responses such as language barrier and supervision, to those stressors, which resulted in aggressive behaviors aimed at and impacting other residents. The facility failures described above resulted in the willful abuse of Residents #68, #20, and a third unknown Resident victim as perpetrated by Resident #521. Resident #521 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 observations, resident interview, staff interview, clinical record review, and review of facility documents, the facility staff failed to ensure significant medication was administered for 5 of 55 residents (Resident #47, Resident #57, Resident #424, Resident #372 and #161), in the survey sample. The findings included: 1. Resident #47 was originally admitted to the facility 3/11/20. The resident's diagnoses included chronic obstructive pulmonary disease, essential hypertension, anemia, and constipation. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/22/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #47's cognitive abilities for daily decision making were intact. On 10/1/24 at 7:00 PM an interview was conducted with Resident #47. Resident #47 stated that there was no nurse on unit 3 from 3pm to 11pm and 11pm to 7am on 8/17/24. Resident #47 also stated that due to…

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

Based on observation and staff interview, the facility staff failed to remove expired medications and provide the date medications were opened on 2 of 4 facility units. The findings included: 1. On 10/9/24 at 12:55 PM an observation of the medication administration cart on Unit 3 with Licensed Practical Nurse (LPN) #1 revealed 1 opened multi-dose Humalog (insulin lispro) 100 units/ml KwikPen with an open date of 9/6/24. A review of the manufacturer's literature indicated to discard the insulin lispro Kwikpen 28 days after opening. An interview with LPN #1 was conducted on 10/9/24 at 12:57 PM. LPN #1 stated that the Humalog (insulin lispro) 100 units/ml KwikPen should not be on the medication cart due to the opening date being more than 28 days. 2. On 10/9/24 at 1:05 PM an observation of the medication administration cart on Unit 3 with Licensed Practical Nurse (LPN) #1 revealed 1 opened multi-dose Fiasp (insulin aspart) 100 units/ml injection pen with an open date of 7/31/24. A review of the manufacturer's literature indicated to discard the Fiasp (insulin aspart) 100 units/ml…

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

Based on observation, interview, clinical record review and facility documentation the facility staff failed to maintain an effective pest control program so that the facility is free of pests for the facility. The findings included: For the facility, the facility staff failed to ensure the environment was kept pest free, roaches both alive and dead were observed at the facility. On 10/7/24 during the kitchen inspection there were 2 dead roaches noted in the dry storage area and one in the kitchen near the 3-compartment sink. On 10/11/24 observation of the ice machine in closet across from the dining room revealed standing water on the floor, a rubber mat with live roaches (5-6 of them) crawling around and under it, the ice machine drainage pipe was dripping on the floor not in the drain. Under the ice machine was black slimy substance and wet paper trash as well. The entire area smelled of dampness and mildew. During the entire survey there were fruit flies as well as large flies noted on all units and in the common areas as well. A review of the pest control logs revealed 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 staff interview the facility failed to maintain a training program for all new and existing staff based on the facility's assessment. The findings included: The facility failed to maintain a training program for all new and existing staff. Review of the Staff Education and Relias training transcripts revealed that not all facility staff had completed all the required training. On 10/11/24 at approximately 8:15 PM, a final interview was conducted with the Administrator, Interim Administrator, Director of Nursing and two regional Nurse Consultants. They had no comments and voiced no concerns regarding the above information.

Based on review of facility documents and staff interview the facility staff failed to ensure that all staff members were educated on Resident's rights and facility responsibilities. The findings included: Review of the Staff Education and Relias training transcripts revealed that not all facility staff had completed all the required training for the rights of the resident and the responsibilities of a facility to properly care for its residents. On 10/11/24 at approximately 8:15 PM, a final interview was conducted with the Administrator, Interim Administrator, Director of Nursing and two regional Nurse Consultants. They had no comments and voiced no concerns regarding the above information.

Based on review of facility documents and staff interview the facility staff failed to ensure that all staff members were educated regarding the Quality Assurance and Performance Improvement The findings included: Review of the Staff Education and Relias training transcripts revealed that not all facility staff had completed all the required training for Quality Assurance and Performance Improvement. On 10/11/24 at approximately 8:15 PM, a final interview was conducted with the Administrator, Interim Administrator, Director of Nursing and two regional Nurse Consultants. They had no comments and voiced no concerns regarding the above information.

Based on review of facility documents and staff interview the facility staff failed to ensure that all staff members were educated on Compliance and Ethics. The findings included: Review of the Staff Education and Relias training transcripts revealed that not all facility staff had completed all the required training for Compliance and Ethics. On 10/11/24 at approximately 8:15 PM, a final interview was conducted with the Administrator, Interim Administrator, Director of Nursing and two regional Nurse Consultants. They had no comments and voiced no concerns regarding the above information.

Based on review of facility documents and staff interview the facility staff failed to ensure that all Certified Nurses Aides (CNA) completed the mandatory twelve (12) hours of education each year. The findings included: Review of the Staff Education and Relias training transcripts revealed that not all CNAs had completed the mandatory twelve (12) hours of education each year which addressed each CNA's areas of weakness as determined in nurse aides' performance reviews the facility assessment and the special needs of residents as determined by the facility staff. On 10/11/24 at approximately 8:15 PM, a final interview was conducted with the Administrator, Interim Administrator, Director of Nursing and two regional Nurse Consultants. They had no comments and voiced no concerns regarding the above information.

Based on review of facility documents and staff interview the facility staff failed to ensure that all staff members were educated on Behavioral health. The findings included: Review of the Staff Education and Relias training transcripts revealed that not all facility staff had completed all the required training for Behavioral health care and services. On 10/11/24 at approximately 8:15 PM, a final interview was conducted with the Administrator, Interim Administrator, Director of Nursing and two regional Nurse Consultants. They had no comments and voiced no concerns regarding the above information.

Based on interview, clinical record review and facility documentation the facility staff has failed to determine that Residents are clinically appropriate to self-self-administer medication for 1 Resident (#142) in a survey sample of 55 Residents. The findings included: For Resident #142 the facility staff allowed the Resident to self-administer the psychotropic medication, trazadone (an anti-depressant used to treat insomnia), without an assessment to determine if it was clinically appropriate for him to do so. On 10/7/24 at approximately 12:00 p.m. an interview was conducted with Resident #142 who stated that they used to let him keep his trazadone by his bedside and take it when he wants to. He stated that he now has to ask for it and it Takes an act of God to get it. When asked if he had any special lock box for it, he stated that he did not he used to keep it on his night table. On 10/8/24 a review of the clinical record revealed the following orders for trazadone: trazodone HCl Oral Tablet 100 MG Give 1.5 tablet by mouth at bedtime for insomnia MAY GIVE ANYHTIME BETWEEN 7PM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, Resident interview, staff interview and clinical record review, the facility staff failed to provide services in the facility with reasonable accommodation of resident needs and preferences, for 2 Residents (# 161 and # 107) in a survey sample of 55 Residents. The findings included: 1. For Resident # 161, the facility staff failed to ensure the clock on the bedroom wall was working. Resident # 161 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, Primary Osteoarthritis of the Knee, Septic Arthritis of the Knee, Heart Failure, and edema. The most recent Minimum Data Set (MDS) was an admission Assessment with an Assessment Reference Date (ARD) of 9/10/2024. Resident # 161's BIMS (Brief Interview for Mental Status) Score was a 14 out of 15, indicating no cognitive impairment. Review of the clinical record was conducted on 10/92024-10/11/2024. During rounds on 10/9/2024 at 1:15 p.m., Resident # 161 was observed lying in the bed and watching television. 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 a clinical record review and staff interview the facility staff failed to thoroughly and accurately complete the Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability (PASARR) for 2 of 55 residents (Resident #56 and #28), in the survey sample. The findings included: 1. The facility staff failed to code Resident #56's PASARR assessment for a current serious mental illness. Resident #56 was originally admitted to the facility 6/1/24 and readmitted [DATE] after an acute care hospital stay. The resident's current diagnoses included Post Traumatic Stress Disorder (PTSD), an anxiety disorder, ODC, personality hysterical and a major depressive disorder with recurrent, severe psychotic symptoms. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/2/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #56's cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on family interview, staff interviews, and clinical record review, the facility staff failed to have an ongoing discharge planning process which focused on the resident's/resident representative discharge goals for 1 of 31 residents (Resident #119), in the survey sample. The findings included: Resident #119 was originally admitted to the facility 2/17/23 and readmitted [DATE] after an acute care hospital stay. The resident's current diagnoses included intellectual disability, aphasia and a history of cancer of the colon which required a hemicolectomy and resulted in an ileostomy. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/3/24 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired daily decision making abilities. The resident was admitted on [DATE] to the nursing facility after surgery for colon cancer. 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, family interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to apply the correct size Ostomy appliance and failed to provide care to an ostomy according to the physician's order for 1 of 31 residents in the survey sample. The findings included: Resident #119 was originally admitted to the facility 02/17/23 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Ileostomy Status, Autistic Disorder and Malignant Neoplasm of Sigmoid Colon. The quarterly Revision Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/03/24 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired for daily decision making. In sectionGG(Functional Abilities Goal) the resident was coded as being independent with eating, Substantial/ maximal with toileting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility documentation review, and clinical record review the facility staff failed to prevent significant weight loss and malnutrition for one Resident (Resident #73) in a survey sample of 55 Residents. The findings included: Resident #73, suffered significant weight loss and malnutrition, increasing debility, and promoting an inability to heal from a new pressure sore injury which became infected leading to cellulitis and required hospitalization. Resident #73 was originally admitted to the facility on [DATE], was hospitalized on [DATE] for a pressure sore injury with infection and cellulitis and returned 10 days later on 6-1-24. Diagnoses included: Acute infection/cellulitis of upper left limb, stroke with left hemiplegia, dementia, contractures of left side limbs, dysphagia, epilepsy, hypertension, hypernatremia, and vitamin D deficiency. Resident #73's most recent Minimum Data Set assessment was a significant change assessment with an assessment reference date of…

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

Based on information obtained during the as worked nursing schedule nursing staff, the facility staff failed to staff a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week which could potentially affect all residents. The facility staff failed to staff a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The findings included; A review of the as worked schedule from 11/19/24 through 12/05/24. The facility staff was unable to verify 8 consecutive hours a day of RN coverage for at least 2 days on the following dates: 11/30/24 and 12/01/24. The above dates were verified by the Corporate Nurse Consultant (CNC) #2 on 12/03/24 at approximately 4:40 PM. The CNC #2 said there was no RN coverage, but there should have been coverage on 11/30/24 and 12/01/24. A final interview was conducted on 12/04/24 at approximately 5:45 PM., with the Corporate Nurse Consultant (CNC) #2. The CNC #2 said that RN coverage should have been provided on the above dates.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility record review, and clinical record review, the facility staff failed to provide specific and adequate treatment services for mental health and psychosocial concerns for one Resident with depression, and anxiety (Resident #126) in a survey sample of 30 Residents. Resident #126 did not receive adequate psychosocial, psychiatric, nor psychoactive medication care and services while in the facility after multiple falls, a hospitalization with fracture and head injury, and after return to the facility with behavioral issues complicated by new onset confusion. Further the facility failed to reinstitute long standing medication therapy for depression and anxiety after the hospitalization return. The findings included: Resident #126 was admitted to the facility on [DATE] and discharged back to the hospital on [DATE] for a fall with refracture of right hip, and head injury with acute subdural hematoma. He was readmitted on [DATE] after the 2-day hospital stay, and was transferred back to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interviews, staff interview, clinical record review, and facility document review, it was determined that the facility social worker failed to provide services for one resident (Resident #521) in the survey sample of 55 Residents The findings included; For Resident #521, the facility Social worker failed to provide medically related social services to meet the Resident's needs for a strictly Spanish speaking Resident who had signs of frustration, and aggression. Resident #521 abused 3 Residents in the facility and exhibited aggressive behaviors and signs of distress which were never assessed and care planned, and not evaluated by medical social work. For Resident #521 the facility staff failed to obtain a physician ordered psychiatric consult timely, failed to conduct behavior monitoring, failed to provide a comprehensive care plan for emotion regulation, failed to identify stressors and responses such as language barrier and supervision, to those stressors, which resulted in aggressive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, the facility staff failed to procure routine medications as ordered by the physician for 2 Residents (#142, #161) in the survey sample of 55 residents and establish a system of records of receipt and disposition of all controlled drugs. The findings included: 1. For Resident #142 the facility staff failed to sign off administration of all 9 a.m. medications on 9/1/24 as well as failing to document why the medications were not given. On 10/10/24 during clinical record review it was discovered that Resident #142 did not receive any of his 9 a.m. medications on 9/1/24. Those medications included vitamins, iron, aspirin (given for dx. of Atrial Fibrillation, a cardiac arrhythmia) and Namenda (a medication given to slow the progression of dementia). The record contained no skilled charting for 9/1/24 and none of the ordered vital signs for that shift. On 10/10/24 at approximately 2 p.m. an interview with the DON and the Clinical Nurse Consultant was conducted,…

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

Based on observation, interview, and facility documentation the facility staff failed to ensure food was prepared, in accordance with professional standards for food service safety for 1 of 4 kitchen staff. The findings included: The preparing the evening meal on 10/7/24 failed to ensure the beard guard was sufficient to cover his large amount of facial hair. On 10/7/24 at approximately 5:00 PM a staff member who identified himself as the cook (Other Employee #9) was observed preparing food with a beard guard that only halfway covered his facial hair. When asked about it he stated, It's the only one the facility provides, and it doesn't fit right. A review of the facility policy entitled Staff Attire read: Policy Statement: It the center policy that all Dining Services employees wear approved attire for the performance of their duties. Action Steps: 1. The Dining Services Director ensures that all staff members have their hair off their shoulders confined in a hair net or cap and facial hair properly restrained. On 10/7/24 at approximately 5:30 p.m. Corporate employee #1 went to…

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

Based on observation, interview, clinical record review and facility documentation the facility staff failed to Maintain all mechanical, electrical, and patient care equipment in safe operating condition The findings included: For the facility, the facility staff failed to ensure the dishwasher, and 2 washing machines were functional and available for use by staff. On 10/7/24 during the kitchen inspection the kitchen staff were noted to be using Styrofoam take out containers for food service during the lunch and dinner meals. When questioned Other Employee #9 stated the dishwasher has been broke for weeks now. He stated we have a new one it's just not hooked up yet. On 10/8/24 an interview was conducted with Other Employee #5 who stated that he wasn't exactly sure how long the dishwasher had been down. He was asked to research and provide a timeline. 8/6/24 - dishwasher was purchased (evidenced by email from corporate purchasing office to maintenance). 9/24/24 - dishwasher arrived at facility (as evidenced by email between maintenance and supplier). 10/10/24 - during the current…

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 family interview, a clinical record review and staff interviews, the facility staff failed to notify the resident's Emergency Contact of his transfers to the emergency room (ER) for 1 of 55 residents (Resident #473), in the survey sample. The findings included: Resident #473 was originally admitted to the facility 8/5/22 and he was discharged home on 8/24/22. The resident's diagnoses at the time of his admission were lumbar spinal stenosis with lower back pain radiating to his feet, lumbar spinal fusion and chronic musculoskeletal injuries from a motor vehicle accident. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/8/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #473's cognitive abilities for daily decision making were intact. On 10/9/24 at 11:25 AM, an interview was conducted with Family Member (FM) #1. FM #1 stated while her brother was a resident at the facility he was transferred to the hospital because they facility's staff did…

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 family interviews, clinical record review, and staff interviews, the facility staff failed to provide a resident with a discharge summary at the time of discharge for 1 of 55 residents (Resident #472), in the survey sample. The findings included: Resident #472 was originally admitted to the facility 8/7/24 and was discharged no return anticipated on 8/10/24 . The resident's diagnoses included diabetes, hypertension and recurrent urinary tract infections. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/10/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #472's cognitive abilities for daily decision making were intact. On 10/9/24 at 12:40 PM an interview was conducted with Family member (FM) #2. FM #2 stated that Resident #472 was transferred to the long term care facility on 8/7/24 after a hospital stay. FM #2 stated upon arrival to the facility she and her sister were very dissatisfied because of the odors, pest, the appearance of their…

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 provide the necessary supervision to prevent an elopement for two (2) out of 24 residents, Resident #217 and Resident # 223, in the survey sample. The findings included: 1. Resident #217 eloped from the facility on 1/21/25 at 11:03 PM., in the snow to the facility parking lot where employees and visitors parked their vehicles. This behavior could have put the resident at risk for death, hypothermia and or being hit by a moving vehicle. Resident # 217 was originally admitted to the facility 10/16/18 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Suicidal Ideations and Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. The admissions Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of coded the resident as completing the Brief…

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

Based on resident interview, staff interview, and review of facility documents, the facility staff failed to provide sufficient nursing staff to provide nursing and related services to meet the resident's needs for 2 of 55 residents (Resident #47, #472), in the survey sample. The findings included: 1. On 10/1/24 at 7:00 PM an interview was conducted with Resident #47. Resident #47 stated that there was no nurse on unit 3 from 3pm to 11pm and 11pm to 7am on 8/17/24. Resident #47 also stated that due to this, she did not receive her Gabapentin, Tylenol, or Lisinopril. On 10/2/24 at 12:15PM an interview was conducted with the two (2) Regional Nurse Consultants. The Regional Nurse Consultants stated that the expected staffing levels for all shifts is the following on all the nursing units: 2 Nurses for 7am - 3pm shift, 2 Nurses for 3pm - 11pm shift, and 1 Nurse for 11pm-7am shift. The Regional Nurse Consultants also stated that on 8/17/24 only 1 Nurse worked on Unit 3 from 3pm - 11pm and only 1 Nurse worked on Unit 4 from 3pm - 11pm. The Regional Nurse Consultants further stated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to provide requested medical records for 1 of 55 residents (Resident #171), in the survey sample. The findings included: Resident #171 was no longer a resident of the facility; therefore, a closed record review was conducted. Resident #171 was admitted to the facility on [DATE] and the resident was discharged home on [DATE]. The resident's diagnoses included acute respiratory failure with hypoxia, cystic fibrosis with pulmonary manifestations, muscle weakness, and chronic obstructive pulmonary disease. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/31/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #171's cognitive abilities for daily decision making were intact. On 10/8/24 at 10:45 AM an interview was conducted with the Regional Nursing Consultant. The Regional Nursing Consultant stated that due…

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 meet professional standards for one of five residents in the survey sample, Resident #4. The findings include: The facility staff failed to meet professional standards by administering medications as ordered for Resident #4. Resident #4 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: sepsis, dementia, cardiomyopathy, Parkinson's and COPD (chronic obstructive pulmonary disease). The most recent MDS (minimum data set) assessment, a significant change assessment, with an ARD (assessment reference date) of 10/27/23, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring total dependence for transfer, bathing, bed mobility, dressing, hygiene, toileting and moderate assist 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 observations, staff interviews, facility document review and clinical record review, it was determined the facility staff failed to provide evidence of ADL (activities of daily living) care for one of five residents in the survey sample, Resident #1. The findings include: The facility staff failed to provide evidence of ADL (specifically incontinence care and feeding assistance) care for Resident #1. Resident #1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CKD (chronic kidney disease), vascular dementia and stroke with hemiplegia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 4/22/24, coded the resident as scoring a 99 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was unable to complete the interview. A review of the MDS Section G-functional status coded the resident as requiring total dependence for transfer and bathing; extensive assistance…

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

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 meet provide catheter care for one of five residents in the survey sample, Resident #4. The findings include: The facility staff failed to provide urinary catheter care for Resident #4. Resident #4 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: sepsis, dementia, cardiomyopathy, Parkinson's and COPD (chronic obstructive pulmonary disease). The most recent MDS (minimum data set) assessment, a significant change assessment, with an ARD (assessment reference date) of 10/27/23, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring total dependence for transfer, bathing, bed mobility, dressing, hygiene, toileting and moderate assist for eating. A review of the comprehensive care…

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, resident interview, facility document review and clinical record review, it was determined the facility staff failed to provide feeding assistance to prevent weight loss for one of five residents in the survey sample, Resident #1. The findings include: The facility failed to provide feeding assistance to prevent weight loss for Resident #1. Resident #1 weighed 127 pounds on 1/13/23, 117.6 pounds on 5/6/23 and currently 99.3 on 5/1/24. Resident #1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CKD (chronic kidney disease), vascular dementia and stroke with hemiplegia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 4/22/24, coded the resident as scoring a 99 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was unable to complete the interview. A review of the MDS Section G-functional status coded the resident as requiring total…

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 and staff interview, resident observation, facility document review and clinical record review, it was determined that the facility staff failed to provide sufficient staffing to meet resident needs for two of five residents in the survey sample, Resident #1 and Resident #4. The findings include: 1.The facility staff failed to provide sufficient staffing to meet Resident #1's needs. During the course of the standard, licensure and complaint Medicare survey conducted 5/24/24-5/29/24, a request was made on 5/24/24 for the as worked staffing schedule for 3/1/24-5/24/24. When asked during the entrance conference if there were any staffing waivers, ASM (administrative staff member) #2, the director of nursing, stated, No, there are no waivers. Resident #1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CKD (chronic kidney disease), vascular dementia and stroke with hemiplegia. The most recent MDS (minimum data set) assessment, a quarterly assessment, 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.

Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to provide snacks at bedtime and meals in a timely manner. The findings include: Mealtimes provided by the facility indicated that breakfast was to be delivered to unit 2A at 8:10 AM and unit 2B at 8:40 AM; lunch was to be delivered to unit 2A at 12:15 PM and unit 2B at 1:05 PM. During the survey period of 5/24/24-5/29/24 meals were observed to be delivered on 5/24/24 unit 2B at 9:00 AM. On 5/28/24 on unit 2A breakfast was delivered at 8:30 AM unit 2 B at 8:55 AM and unit 2A lunch at 12:35 PM and unit 2B at 1:15 PM. 5/28/24 tour of the pantries on all units revealed the following: 1:10 PM observations of Unit 1 pantry: Lance PB cheese crackers 6 packs, 12 chocolate puddings, no applesauce, no graham crackers, no milk, no cheese. 1:15 PM observations of Unit 2 pantry: Lance PB cheese crackers 5 packs, Lance Toasted crackers 10 packs, no applesauce, no graham crackers, no milk, no cheese. 1:25 PM observations on Unit 3 pantry: Lance PB cheese crackers 3 packs, no…

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 review of facility's documentation and staff interview, it was determined that the facility failed to promote and enhance each resident's right to a dignified existence and being respected for one of five residents in the survey sample, Resident #1. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CKD (chronic kidney disease), vascular dementia and stroke with hemiplegia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 4/22/24, coded the resident as scoring a 99 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was unable to complete the interview. A review of the MDS Section G-functional status coded the resident as requiring total dependence for transfer and bathing; extensive assistance for bed mobility, dressing, hygiene, toileting and eating. A review of the comprehensive care plan dated 5/22/23 revealed, FOCUS:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and facility document review, it was determined the facility staff failed to respect the resident's and RP's (responsible party) right to participate in care planning for one of five residents in the survey sample, Resident #1. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CKD (chronic kidney disease), vascular dementia and stroke with hemiplegia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 4/22/24, coded the resident as scoring a 99 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was unable to complete the interview. A review of the MDS Section G-functional status coded the resident as requiring total dependence for transfer and bathing; extensive assistance for bed mobility, dressing, hygiene, toileting and eating. A review of the comprehensive care plan dated 5/22/23 revealed, FOCUS: 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 staff interview and facility document review, it was determined the facility staff failed to notify the RP (responsible party) of a change in condition for one of five residents in the survey sample, Resident #1. The findings include: The facility failed to notify the RP for Resident #1's weight loss. Resident #1 weighed 127 pounds on 1/13/23, 117.6 pounds on 5/6/23 and currently 99.3 on 5/1/24. No notification to family after 7/28/23. Resident #1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CKD (chronic kidney disease), vascular dementia and stroke with hemiplegia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 4/22/24, coded the resident as scoring a 99 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was unable to complete the interview. A review of the MDS Section G-functional status coded the resident as requiring total dependence 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 interviews, clinical record review, and facility documentation the facility staff failed to notify the physician of not of medications not being administered to 20 Residents (the entire Unit 3 B Assignment) in a survey sample of 28 Residents. The findings included: For the 20 Residents on assignment B in Unit 3, the facility staff failed to notify the physician that she did not give medications from 3 PM - 7 PM on 2/6/24. Those meds included insulin, cardiac medications, anti-convulsant medications, anti-coagulants, and controlled substances for pain. On 2/20/24 at 5:29 PM RN B (Registered Nurse B) was interviewed, and she stated that on 2/6/24 she Volunteered to work 3 PM-7 PM shift to fill in the gap on the schedule. When asked if she was passing medications and working the floor, she stated that she was. She was asked if she received an admission that night, she stated that she had but was busy passing medications, so she had not gotten to the admission. When asked which assignment she had she stated that she had the B assignment which encompassed 20 Residents. 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 interviews, clinical record review, and facility documentation, the facility staff failed to provide services that meet professional standards of care for 20 Residents in a survey sample of 28 Residents. The findings included: For all 20 Residents in Unit 3 nursing assignment B, the facility staff failed to administer medications as ordered by the physician. On 2/20/24 at 5:29 PM RN B (Registered Nurse B) was interviewed, and she stated that on 2/6/24 she Volunteered to work the 3 PM-7 PM shift to fill in the gap on the schedule. When asked if she was passing medications and working the floor, she stated that she was. When asked which assignment she had she stated that she had the B assignment which encompassed 20 Residents. On 2/20/24 Surveyor B conducted a review of the clinical record, and it was found that none of the Residents on Unit 3 assignment B had received medications or treatments from 3-7 PM on 2/6/24. Medications were either not given, or given late, when the 7 PM -11 PM nurse came in. 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 interviews, clinical record review, and facility documentation, the facility failed to ensure the necessary care and services are provided consistent with the resident's physical status and immediate needs upon admission to the facility for one (1) Resident (#1) in a survey sample of 28 Residents. The findings included: For Resident #1 the facility staff failed to perform an admission assessment, obtain vital signs, enter orders, administer oxygen, notify the physician to verify the orders, review the discharge summary from the hospital for the provision of immediate care resulting in the resident being found on the floor of his room unresponsive 2 hours after arrival at the facility. Resident #1 was transferred to the facility from an acute care hospital with diagnoses that include but are not limited to acute hypoxic respiratory failure secondary to influenza A, COPD (Chronic Obstructive Pulmonary Disease), history of prostate cancer, history of tongue cancer, and hypertension. 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 interview, record review, and facility policy, the facility failed to ensure advanced directives were offered and periodically reviewed; and Do Not Resuscitate (DNR) forms were completed and accurate for ten residents out of 34 sampled residents (Resident (R) 51, R11, R33, R114, R67, R85, R407, R412, R126, and R107). Findings include: The facility's Advance Directives Policy, titled MFA [Medical Facilities of America] Policies Governing the Implementation of Self-Determination Rights read, in pertinent part, 3. All Residents at the time of admission will be provided with this document entitled MFA Policies Governing the Implementation of Self-Determination Rights which summarizes the Health & Rehabilitation Center's policies and procedures regarding advanced directives . 8. The original or a Health & Rehabilitation Center verified copy of any advance directive that is appropriately signed and witnessed as permitted by Virginia state law will be filed by the Health & Rehabilitation Center with 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, interview, and facility policy review, the facility failed ensure food was stored safely for three of four unit refrigerators. This failure could possibly lead to cross contamination and food-borne illness for the residents on three units. Findings include: During an observation of Unit 2 refrigerator with the Dietary Manager on 12/29/21at 12:25 PM, the following items were unlabeled and undated in the refrigerator: two bags of food in plastic grocery bags, two containers of lean cuisine frozen meals, one slice of pizza in a Ziploc bag. Additionally, there was a bottle of French dressing with an expiration date of 11/03/21. During an observation of Unit 3 refrigerator with the Dietary Manager on 12/29/21at 12:30 PM, the following items were unlabeled and undated in the refrigerator: two opened bottles of water, one bottle of Frappuccino, a bag of apples, a bag of oranges, and a bottle of Gatorade. During an observation of Unit 1 refrigerator with the Dietary Manager on 12/29/21at 12:35 PM, the following items were unlabeled and undated in the refrigerator: blue…

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, record review, and review of facility policy, the facility failed to maintain a complete and accurate medical record for six of thirty-four sampled residents (Resident (R) 107, R126, R199, R402, 407, and 412). Specifically, the nursing staff failed to document the completion of physician orders on the resident's medication administration records (MAR). Findings Include: Review of facility policy titled Documentation Summary dated 11/01/19 indicated Licensed Nurses and CNAs [Certified Nurse Aides] will document all pertinent nursing assessments, care interventions, and follow up actions in the medical record. Review of facility policy titled Monitoring dated 11/01/19 indicated Licensed nurses will complete blood glucose monitoring as ordered by the physician .4. Blood glucose checks will be documented on the eMAR [Electronic Medication Administration Record]. 1. R107 was admitted to the facility on [DATE], according to the electronic medical record (EMR) under the Medical Diagnosis tab, 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 observation, record review, interview, review of facility policy, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases for six residents of nine residents (Resident (R) 403, R404, R405, R406, R407, and R408) reviewed for transmission-based precautions; three of seven residents (R37, R51, and R105) observed during the observation of medication administration; and three of seven residents (R3, R138, and R144) reviewed for catheter care. Specifically, enhanced droplet precautions were not followed for R403, R404, R405, R406, R407, and R408. Staff did not perform hand hygiene between R37, R51, and R105. Additionally, R3, R138, and R144's catheter bags were observed lying on the ground. Findings include: 1. Review of the CDC's Interim Infection Prevention and Control Recommendations to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and review of facility policy the facility failed to ensure dignity was maintained for one of thirty-four sample residents (Resident (R) 404)). Specifically, R404's foley catheter bag was uncovered and within view of individuals in the corridor. Findings include: Review of facility policy title Suprapubic Catheter Reinsertion dated 11/01/19 instructs staff to . 18. Hang bag below level of the bladder and place privacy bag over the drainage bag. Review of the admission note, in the Progress Notes tab of electronic medical record (EMR), dated 12/24/21, revealed R404's diagnoses included metabolic encephalopathy in the setting of hyponatremia and acute cystitis. Review of R404's physician's orders in the Orders tab of EMR revealed R404 was admitted on [DATE] with an order for a Suprapubic Foley Catheter. Review of the R404's admission Minimum Data Set (MDS) dated 12/30/21 revealed R404 required extensive assistance with bed mobility; one person physical assist 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 observation, interview, record review, and facility policy, the facility failed to ensure one of 34 sampled residents (Resident (R) 85) had a physician's order and was screened/assessed for the self-administration of medications prior to medications being stored at the bedside and self-administered. Findings include: Review of the facility policy Self-Administration Medication at Bedside, dated 11/01/19, revealed, .physician's order in patient's chart for self-administration . complete self-administration screen . self-administration must be reviewed by interdisciplinary team . medications . to be self-administered will be identified on MAR [medication administration record]. Review of R85's electronic medical record (EMR) under the Profile tab revealed R85 admitted to the facility on [DATE]. Review of R85's EMR under the Med Diag tab revealed, multiple diagnoses to include congestive heart failure. Review of R85's Orders tab in the EMR revealed .Muro 128 Ointment 5 % (Sodium Chloride (Hypertonic))…

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, record review, and facility policy review, the facility failed to ensure an accurate Level 1 pre-screening of the resident for a mental disorder (MD) or intellectual disability (ID) prior to admission to the facility was completed for two of three residents (Resident (R) 13 and R133) reviewed for Level 1 Pre-admission Screening and Resident Review (PASRR). Findings include: Review of the facility's policy titled, Discharge Planning Policies and Procedures dated 01/06/20, indicated, Prior to the arrival of a planned admission the Discharge Planner will collaborate with the Admissions Director to preview the transferring hospital's Level 1 PASRR (Level 1 Screening for Mental Illness, Intellectual Disability, or Related Conditions) and/or initiate completion of the Level 1 PASRR if not completed by the transferring hospital. 1. Review of R13's Face Sheet located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 08/11/04 and included, but was not limited…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours of admission to the facility for one resident of eight residents (Resident (R)404) reviewed for baseline care plans in a total sample of 34 residents. Findings include: Review of facility policy titled, Care Planning, dated 11/01/19, revealed, A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care, and the necessary health-related care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being of the patient. The computerized baseline Care Plan is initiated and activated within 48 hours. The Center will provide the patient and representative(s) with a summary of the baseline care plan that includes but is not limited to: . any services and treatments to be administered by 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 interview, record review, and review of facility policy, the facility failed to develop, assist, and follow through to completion with discharge plans for one of 34 sampled residents (Resident (R) 133) reviewed for discharge planning. The facility did not have a person-centered discharge plan for R133. Findings include: Review of the facility policy, titled Discharge Planning Policies and Procedures, dated 01/06/20 revealed, Discharge planning will review extended care (long-term care) patients for discharge planning needs and pursue placement . Communicate with patient. discharge plans . Discharge planning staff will proactively spearhead the discharge planning process and follow through to completion to ensure a discharge. Review of R133's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/06/21, revealed a Brief Interview for Mental Status (BIMS) score of nine out of 15, which indicated R133 had moderate cognitive impairment. Review of R133''s Profile tab in the electronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policy the facility failed to provide an individualized activity program for two of 34 sampled residents (Resident (R) 33 and R51). Findings include: Review of the facility's policy titled Activities Policies and Procedures dated January 2020 documented activities staff will monitor, evaluate and record patient's activities participation and response to activities. and .utilize the patient record to determine whether the patient's participation in activities and/or independent activities pursuits achieves the stated goals on the patient's plan of care. 1. Review of an admission Record located in R33's electronic medical record (EMR) under the Profile tab indicated she was admitted on [DATE] with diagnoses including major depressive disorder Review of a care plan dated 10/06/21 found in R33's EMR under the Care Plan tab indicated she would engage in independent leisure pursuits 2-4x's [times] weekly. The leisure activities listed included…

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 and record review the facility failed to ensure treatment and care in accordance with professional standards of practice was provided for two of 34 sampled residents (Resident (R) 51 and R47). Specifically, the staff failed to ensure R51 was transported to her cardiologist follow up appointment on two different occasions. In addition, the staff failed to follow physician's orders for R47. Findings include: 1. Review of an admission Record located in R51's electronic medical record (EMR) under the Profile tab indicated she was admitted on [DATE] with diagnoses including acute and chronic respiratory failure, type II diabetes, atrial fibrillation, and heart failure. Review of R51's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/17/21 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. Review of the Progress Notes found in R51's EMR under the Assessments tab indicated she missed a…

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

Based on interview, record review, and facility policy review, the facility failed provide treatment as ordered for prevention for pressure ulcer/skin injury for one of nine residents (Resident (R) 138) reviewed for pressure ulcers. Findings include: Review of the facility's policy titled, General Wound Care/Dressing Changes dated 11/01/19 indicated, Provide treatments as ordered. Review of R138's Face Sheet located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 11/17/15 and included, but was not limited to, the following diagnoses: quadriplegia and diabetes. Review of R138's Wound Evaluation located in the EMR under the Misc tab, dated 09/21/21, indicated an etiology of Moisture-Associated Skin Damage (MASD). Review of R138's Order Summary Report located in the EMR under the Orders tab, revealed the following orders: 09/22/21 Hibiclens Liquid 4 % - Apply to bilateral buttocks topically every day and evening shift for MASD cleanse with hibicleanse, pat dry, apply Silver Sulfadiazine (SSD), cover with Abdominal (ABD) pad; 09/22/21…

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

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure one of four residents (Resident (R) 67) reviewed for limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, staff did not apply R67's right hand splint per physician's orders to maintain range of motion. Findings include: Upon request of a policy regarding residents' splints, the facility provided a documented titled, Assisting with Activities of Daily Living, undated, that revealed, .Splints keep . wrist, thumbs, fingers . in normal position. Review of R67's electronic medical record (EMR), revealed R67 admitted to facility on 10/13/17. Review of the Med diag [Medical Diagnosis] tab in the EMR revealed multiple diagnoses to include hemiplegia (paralysis on one side of the body) and hemiparesis (loss of strength on one side of the body) following cerebral infarction (ischemic stroke, result of disrupted blood flow to the brain) affecting right dominate side. Review of…

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

Based on interview, record review, and facility policy review, the facility failed prevent accidents by failing to safely transfer a resident and perform neurological assessments for one of three residents reviewed for accidents (Resident (R) 42). Findings include: Review of the facility's policy titled, Falls Management Program dated 11/01/19 indicated, Evaluate, monitor, and document patient response for the first 24 hours (3 consecutive shifts) post fall, include a neurological assessment if the fall was unwitnessed and/or the patient hit his/her head. Review of R42's Face Sheet located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 5/30/13 and included, but was not limited to, the following diagnoses: epilepsy, flaccid hemiplegia affecting left nondominant side, and anoxic brain damage. Review of R42's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/17/21 indicated that R42 was to be transferred with a one-person assist. During an interview on 12/27/21 at 5:16 PM, R42 stated that she had a fall about a week ago…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policy, the facility failed to follow physician's orders to maintain the suprapubic urinary catheter for one resident of two residents (Resident (R) 404) reviewed for catheters. Specifically, the facility failed to ensure R404's suprapubic urinary catheter was flushed every shift and daily dressing change per physician's orders. Findings include: Review of facility policy titled Suprapubic Catheter Care dated 11/01/19 revealed It is the Center's policy to provide safe and proper care of a patient with a suprapubic catheter by evaluating elimination status, minimizing risk of bladder infection and maintaining skin integrity in accordance with the physician's order. Review of the admission note, in the Progress Notes tab of electronic medical record (EMR), dated 12/24/21, revealed R404's diagnoses included metabolic encephalopathy in the setting of hyponatremia and acute cystitis. Review of R404's physician's orders in the Orders tab of EMR…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for one of one resident (Resident (R) 58) reviewed for dialysis. The facility failed to ensure R58 had reliable transportation to and from dialysis and the facility did not demonstrate ongoing communication to the dialysis center and assessment of the resident prior to dialysis. Findings include: Review of R58's electronic medical record (EMR) under the Profile tab revealed R58 admitted to the facility on [DATE]. Review of R58's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/22/21, revealed R58 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating she was cognitively intact. The MDS revealed R58 had end stage renal disease and received dialysis. Review of R58's Med Diag tab in the EMR revealed multiple diagnoses to include end stage renal disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide alternatives to residents who did not like what was served and failed to provide alternatives of similar nutritive value when alternatives were provided for three of 34 sampled residents (Resident (R)131, R405, R412). Findings include: Review of facility policy titled Dining and Food Preferences dated October 2019 documented, It is the center policy that individual dining, food, and beverage preferences are identified for all residents/patients. Observation on 12/27/21 at 11:00 AM, revealed menu with alternative foods posted in main hallway. 1. R131 was admitted to the facility on [DATE], according to the electronic medical record (EMR) under the Medical Diagnosis tab. Record review of R131, revealed a Dietary Progress Note in EMR, under Progress Notes tab, dated 12/07/21 revealed R131 typically consumed 26%-100% of meals. Review of the EMR under Tasks tab revealed for month of December 2021 meal intake varied from 26%-100%.…

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, and facility document review, the facility staff failed to follow physician orders for 9 of 36 Residents, Residents #141, 170, 366, 467, 115, 20, 11, 126, and 38. The findings included: 1. For Resident #141, the facility failed to administer the Residents erythromycin ophthalmic ointment as ordered by the physician. The clinical record review revealed that Resident #141 had been admitted to the facility on [DATE] and had been readmitted on [DATE]. Diagnoses included, but were not limited to, cerebral infarction due to unspecified occlusion, cerebral edema, hydrocephalus, and respiratory failure. Section C (cognitive patterns) of the Residents admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 01/24/19 included a BIMS (brief interview mental status) summary score of 15 out of a possible 15 points. The Residents clinical record included a physicians order for erythromycin ointment 1 application in both eyes…

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 interview, the facility staff failed to ensure physician ordered medications were available for administration, failed to date opened medication, and failed to properly store medications for 5 of 36 Residents (#38, 11, 126, 20, and 7) and on 2 of 5 medication carts. The findings included: 1. For Resident #38, facility staff failed to ensure medications were available for administration. Resident #38 was admitted to the facility on [DATE] with diagnoses including paraplegia, muscle weakness, chronic pain, neurogenic bowel, hypertension, diabetes mellitus, anxiety, and depression. On the quarterly minimum data set assessment with assessment reference date 12/27/18, the resident scored 15/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. During an interview on 3/13/19 at 12:56 PM, the resident mentioned that during her stay, robaxin and gabapentin had both run out with no quick replacement. Record review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review the facility staff failed to ensure a complete DNR (do not resuscitate) form for 1 of 36 Residents, Resident #129. The findings included: For Resident #129 the facility staff failed to ensure a complete Virginia Department of Health DDNR (durable do not resuscitate) form. Resident # 129 was admitted to the facility on [DATE]. Diagnoses included but not limited to Alzheimer's disease, dementia, seizure disorder, anxiety, depression, and psychotic disorder. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 02/13/19 coded the Resident as 3 out of 15 in Section C, cognitive patterns. This is a quarterly MDS. Resident #129's clinical record was reviewed on 03/12/19. It contained a physician's order summary, which read in part Code status: DNR. The clinical record also contained a Virginia Department of Health DDNR form, which read as follows: I further certify (must check 1 or 2): [] 1. The Patient is CAPABLE of making an informed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to notify the physician of medication refusals for 3 of 36 residents in the survey sample (Resident #'s 126, 35 and 41). The findings included: 1. The facility staff failed to notify the physician of medication refusals for Resident #126. Resident #126 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to heart failure, high blood pressure, urinary tract infection, diabetes, manic depression, and chronic obstructive pulmonary disease. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/12/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #126 was also coded as requiring extensive assistance of 2 staff members for dressing, and 1 staff member for personal hygiene and being totally dependent on 1 staff member for bathing. The surveyor performed a clinical record review of Resident #126's…

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

Based on observation, staff interview, and facility document review, the facility staff failed to protect the private healthcare information of residents on 1 of 4 units in the nursing facility (Unit 2). The findings included: The facility staff failed to protect the private healthcare information of residents on Unit 2. On 3/12/19 at 9:05 am, this surveyor observed confidential and private healthcare information for resident room #'s 46 through 60B. This information was on top of the medication cart and anyone walking by could view the information. This medication cart belonged to LPN (Licensed Practical Nurse) #1. On 3/13/19 at 10:02 am, the surveyor observed private and confidential healthcare information for resident room #'s 31 through 45. This information was on top of the medication cart and anyone walking by could view the information. The medication cart belonged to LPN #2. The surveyor requested and received a copy of the facility's policy concerning Confidentiality on 3/13/19 at approximately 10:30 am from the director of nursing. This policy read in part, .Protect all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to review and revise the resident's comprehensive care plan for 1 of 36 residents in the survey sample (Resident #35). The findings included: The facility staff failed to review and review Resident #35's care plan in regards to his refusals of medications. Resident #35 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to high blood pressure, aphasia, stroke, anxiety disorder and depression. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/26/18, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 10 out of a possible score of 15. Resident #35 was also coded as requiring extensive assistance of one staff member for dressing, and personal hygiene and being totally dependent on 1 staff member for bathing. During the clinical record review of Resident #35 on 3/12/19 and 3/13/19, the surveyor noted the resident had refused the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to administer pain medications for 2 of 36 Residents, (Residents #38 and #41) 1. For Resident #38, facility staff failed to consistently administer pain medications per physician orders. Resident #38 was admitted to the facility on [DATE] with diagnoses including paraplegia, muscle weakness, chronic pain, neurogenic bowel, hypertension, diabetes mellitus, anxiety, and depression. On the quarterly minimum data set assessment with assessment reference date 12/27/18, the resident scored 15/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. During an interview on 3/13/19 at 12:56 PM, the resident mentioned that during her stay, robaxin and gabapentin had both run out with no quick replacement. Record review revealed that on 3/11 the Lidocaine patch was held (code 5=see note), without a nursing note to document the reason and on 1/10, Fentanyl and Lidocaine…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. The facility staff failed to coordinate care with dialysis for Resident #316. Resident #316 was admitted to the facility 3/7/19 with the following diagnoses of, but not limited to end stage renal disease. The resident did not have an admission MDS (Minimum Data Set) completed at the time of this survey. However, it was noted by the surveyor that the resident was .alert and oriented X4 . as documented in the nursing notes for 3/7/19 at 23:49 (11:49 pm). On 3/13/19, the surveyor could not find any documentation of communication between the facility and the dialysis center. The resident was noted to be receiving dialysis on Monday, Wednesday and Friday of every week. At 10:45 am on 3/13/19, the surveyor asked the director of nursing (DON) where to locate the documentation of communication between the facility and dialysis for Resident #316. The DON stated, We don't use the communication forms for dialysis and only chart exceptions if there are any noted. The surveyor notified the administrative team of the above…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review the facility staff failed to identify irregularities related to medications for 1 of 36 Residents, Resident #129. The findings included: For Resident #129, the pharmacist failed to identify prn (as needed) usage of psychotropic medications for longer than 14 days without being re-evaluated by a physician. Resident # 129 was admitted to the facility on [DATE]. Diagnoses included but not limited to Alzheimer's disease, dementia, seizure disorder, anxiety, depression, and psychotic disorder. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 02/13/19 coded the Resident as 3 out of 15 in Section C, cognitive patterns. This is a quarterly MDS. Resident #129's clinical record was reviewed on 03/13/19. It contained a signed physician's order summary, which read in part Ativan Tablet 1 mg (lorazepam). Give 1 tablet by mouth every 24 hours as needed for Psychosis related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOW PSYSIOLOGICAL…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review the facility staff failed to ensure 1 of 36 Residents was free of unnecessary psychotropic medications, Resident #129. The findings included: For Resident #129 the facility staff failed to ensure that the psychotropic medications Ativan and Haldol were not used unnecessarily. Resident # 129 was admitted to the facility on [DATE]. Diagnoses included but not limited to Alzheimer's disease, dementia, seizure disorder, anxiety, depression, and psychotic disorder. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 02/13/19 coded the Resident as 3 out of 15 in Section C, cognitive patterns. This is a quarterly MDS. Resident #129's clinical record was reviewed on 03/14/19. It contained a signed physician's order summary, which read in part Ativan Tablet 1 mg (lorazepam). Give 1 tablet by mouth every 24 hours as needed for Psychosis related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PSHYIOLOGICAL CONDITION (F29). Given 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 interview, clinical record review and facility document review the facility staff failed to ensure 3 of 36 Residents were free of significant medication errors, Resident #88, Resident #90, and Resident #7. The findings included: 1. For Resident #88 the facility staff held the medication Novolog without a physician's order. Resident #88 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included but not limited to hypertension, neurogenic bladder, diabetes mellitus, quadriplegia, and depression. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 01/29/19 coded the Resident as 15 of 15 in section C, cognitive patterns. This is a quarterly MDS. Resident #88's clinical record was reviewed on 03/13/19. It contained a signed physician's order summary, which read in part Novolog Solution 100 units/ml (Insulin Apart). Inject 20 units subcutaneously before meals for dmii (diabetes mellitus type 2). The Resident's eMAR (electronic medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review the facility staff failed to ensure a complete and accurate clinical record for 3 of 36 Residents, Resident #129, Resident #1 and Resident #11. The findings included: 1. For Resident #129 the facility staff failed to maintain a complete record. Resident #129 was admitted to the facility on [DATE]. Diagnoses included but not limited to Alzheimer's disease, dementia, seizure disorder, anxiety, depression, and psychotic disorder. The most recent MDS (minimum data set) with an ARD (assessment reference date) of [DATE] coded the Resident as 3 out of 15 in Section C, cognitive patterns. This is a quarterly MDS. Resident #129's clinical record was reviewed on [DATE]. It contained a signed physician's order summary, which read in part Antianxiety Medication-Monitor for Drowsiness, slurred speech, dizziness, nausea, aggressive/impulsive behavior. Document 'Y if monitored and not of the above observed. N if monitored and any of the above 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 observation, resident and staff interview, facility document review and clinical record review it was determined the facility staff failed to coordinate services with hospice to include a hospice plan of care for 1 of 36 residents (Resident #122.) Findings: Facility staff failed to obtain a care plan from Resident #122's hospice provider. The resident's clinical record was reviewed on 3/12/19 at 2:00 PM. Resident #122 was admitted on [DATE]. Her diagnoses included pulmonary fibrosis, hypertension, congestive heart failure, respiratory failure, anxiety and chronic obstructive pulmonary disease. The latest MDS (minimum data set) assessment indicated the resident was cognitively intact. She required facility staff assistance with all the ADLS (activities of daily living) with the exception of eating independent with staff set-up. Resident #122's CCP (comprehensive care plan) documented the resident was on hospice care, but did not detail the provision of services provided by hospice. There was no…

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 maintain a hazard free environment. The findings included: The doors to the room that accessed the back of the dryers were rusted which allowed for debris from the outside to collect in this room. On 03/14/19 at 8:19 a.m., the surveyor and the maintenance director checked the area behind the dryers. This area was accessed from the outside by outside doors. Upon opening the doors, the surveyor was able to observe a moderate amount of debris from the outside that had blown in under the doors and through rusted out areas on the doors. After exiting this room, the surveyor notified the administrator of the issue regarding the debris. On 03/14/19 at 9:36 a.m., the maintenance director stated he had spoken with the door company and obtained prices for new doors. The maintenance director also stated he had swept out the backside of the dryers. The administrative staff were notified of the above issue during a meeting with the survey team on 03/14/19 at 12:38 p.m. The administrator verbalized that the new doors had been…

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.