Brookside Rehab & Nursing Center

Based on clinical record review, staff interview and facility document review, it was determined the facility staff failed to provide ADL (activities of daily living) care to a dependent resident for one of 52 residents in the survey sample, Resident #362. The findings include: For Resident #362 (R362), the facility staff failed to evidence assistance with turning and repositioning on multiple dates in November 2023, December 2023 and January 2024. On the most recent MDS (minimum data set) a significant change assessment with an ARD (assessment reference date) of 1/15/2024, the resident was assessed as being dependent for rolling left and right and transfers. Review of the ADL documentation for R362 from 11/1/2023-11/30/2023 documented the resident requiring extensive to total assistance from one to two persons for bed mobility. It failed to evidence assistance with bed mobility provided on day shift 11/5/23, 11/6/23, 11/7/23, 11/18/23, 11/19/23, 11/26/23 and on evening shift on 11/5/23, 11/13/23, 11/18/23 and 11/23/23. It further failed to evidence assistance with bed mobility…

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

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services for the treatment of a pressure injury for three of 52 residents in the survey sample, Residents #87, #10, and #362. The findings include: 1. For Resident #87 (R87), the facility staff failed to provide physician ordered treatments to the resident's sacral pressure injury on 7/20/24, and 7/30/24. A review of R87's clinical record revealed a wound care physician note dated 7/15/24 that documented an area on R87's sacrum as an unstageable pressure injury (1) measuring 3.5 cm (centimeters) (length) by 2 cm (width) by 0.2 cm (depth). A physician's order dated 7/16/24 documented to cleanse the sacrum with wound cleanser, apply hydrogel and cover with a gauze island dressing every day. A review of R87's July 2024 TAR (treatment administration record) revealed the same 7/16/24 physician's treatment order. Further review of R87's July 2024 TAR failed to reveal treatment was administered on 7/20/24 and 7/30/24 (as evidenced by blank spaces on the TAR).…

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

Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure the physician responded to a pharmacy recommendation for three of five residents reviewed for unnecessary medications; Residents #74, #60 and #51. The findings include: 1. For Resident #74, the facility staff failed to ensure the physician acted on a pharmacy recommendation in a timely manner. A review of the clinical record revealed a Pharmacist Recommendations form dated 11/25/23, for Antipsychotic Reduction Therapy The resident has been taking RISPERDAL (1) 0.5 MG HS (milligrams at bedtime) since (5/2023) without a GDR (gradual dose reduction). Could we attempt a dose reduction at this time to perhaps 0.25 MG HS to verify this resident is on the lowest possible dose? If not, please indicate response below . Further review failed to reveal any evidence that the physician reviewed and signed this form, and chose to or not to reduce the medication dose related to this review. On 8/7/24 at 9:33 AM, ASM #4 (Administrative Staff Member) a Regional…

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

Based on observation, staff interview, and facility document review, it was determined the facility staff failed to serve pureed food in a palatable temperature. The findings include: Observation of the kitchen was made on 8/6/24 at 11:20 a.m. The temperature of the pureed food was as followed: Pureed Brussel sprouts - 160 degrees Mashed potatoes - 170 degrees Pureed orange chicken and rice - 161 degrees. The test tray left the kitchen at 12:06 p.m. sitting on top of the food cart. The last resident tray served was at 12:24 p.m. The test tray was then tested. The temperature of the pureed food was as followed: Pureed Brussel sprouts - 110 - a 50 degree drop in temperature. Mashed potatoes - 113.5 - a 56.5 degree drop in temperature. Pureed orange chicken and rice - 108.1 - a 52.9 degree drop in temperature. The test tray was tasted by OSM (other staff member) #7, the dietary manager, and OSM #8, the regional dietary manager and the surveyors. When asked how the chicken and rice tasted regarding its temperature, OSM #7 stated, mediocre. OSM #8 stated the meat was cooler to taste. The…

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

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to ensure a resident was safe to self-administer a medication for one of 52 residents in the survey sample, Resident #98. The findings include: For Resident #98 (R98), the facility staff failed to complete an assessment to determine if the resident was safe to self-administer a nebulizer medication. A review of R98's clinical record revealed a physician's order dated 6/14/24 for ipratropium-albuterol inhalation solution (1) 0.5-2.5 MG (milligram)/3ML (milliliters) three times a day for chronic obstructive pulmonary disease. Further review of R98's clinical record failed to reveal an assessment to determine it was safe for the resident to self-administer the medication. On 8/6/24 at 9:31 a.m., RN (registered nurse) #1 poured the ipratropium-albuterol solution into R98's nebulizer machine, turned on the machine, and handed the mouthpiece to R98. RN #1 exited the room while R98 continued to self-administer the medication. On 8/6/24 at 3:11 p.m., an interview was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure 3 of 52 residents in the survey sample were free from abuse; Residents #212, #98 and #96. The findings include: 1. For Resident #212, the facility staff failed to ensure the resident was free from abuse by a staff member (LPN #7) on 3/7/24. Resident #212 was admitted to the facility on [DATE] and discharged on 4/9/24. The admission MDS dated [DATE] coded Resident #212 as being cognitively intact in ability to make daily life decisions. A review of the clinical record revealed a nurse's note dated 3/7/24 at 7:50 AM that documented, writer observed resident and another staff member engaged in an argument. both parties threw insults and profanity at each other. after a few minutes resident was wheeled to his room and staff member walked down the hallway. A review of a facility synopsis of event form dated 3/7/24 and received by the state agency on 3/7/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement the facility abuse policy for three of 52 residents in the survey sample; Residents #212, #96 and #98. The findings include: 1. For Resident #212, the facility staff failed to implement the abuse policy to ensure the resident was free from abuse by a staff member (LPN #7) on 3/7/2 and failed to correctly identify the incident as abuse upon investigation in the facility's report to the required state agency. The facility policy, Abuse documented, Abuse - is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish Willful, as used in this definition of abuse, means the individual must have acted deliberately Prevention: a. The facility will not use verbal, mental, sexual or physical abuse .g. The organization will maintain protocols and procedures to identify, correct and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to report an allegation of abuse to the required state agency in a timely manner for one of 52 residents in the survey sample; Resident #212. The findings include: For Resident #212, the facility staff failed to report an allegation of abuse in a timely manner. On 3/7/24 at 7:50 AM, a nurse's note documented the incident of abuse. The facility did not report the incident to the required state agency until 3/7/24 at 5:19 PM. The facility policy, Abuse documented, Abuse - is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish Willful, as used in this definition of abuse, means the individual must have acted deliberately Prevention: a. The facility will not use verbal, mental, sexual or physical abuse .g. The organization will maintain protocols and procedures to identify, correct and intervene in…

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

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain an accurate MDS (minimum data set) assessment for three of 52 residents in the survey sample, Residents #3, #60 and #26. The findings include: 1. For Resident #3, the facility staff failed to code the resident as receiving hospice care services on the admission MDS. On the most recent MDS assessment, an admission assessment, with an assessment reference date of 7/24/24, the resident scored a three out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely, cognitively impaired for making daily decisions. In Section O - Special Treatments, Procedures and Programs, the resident was not coded as receiving hospice services. The physician orders documented, Admit to (Name of Hospice) effective 7/17/24, Dx (diagnosis) malignant neoplasm of unspecified part of left bronchus or lung (cancer). An interview was conducted on 8/6/24 at 4:51 p.m. with RN (registered nurse) #5, the MDS coordinator. The above admission MDS…

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

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to revise the comprehensive care plan for one of 52 residents in the survey sample, Resident #90. The findings include: For Resident #90 (R90), the facility staff failed to revise the comprehensive care plan to include ordered fluid restrictions or monitoring of fluid restrictions. On the most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 7/6/24, the resident scored 14 of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. Section O documented the resident receiving dialysis services while a resident at the facility. The physician orders for R90 documented in part, Order Date: 6/18/2024. Fluid restriction- 1000ml (milliliter) every shift for dialysis dependent 1,000 ml/day (720 ml from meals (B: 240 ml, L: 240 ml, D: 240 ml) and 280 ml between meals and with medications (140 ml per nursing shift). The progress…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interview and facility document review, it was determined the facility staff failed to follow professional standards of practice for one of 52 residents in the survey sample, Resident #4. The findings include: For Resident #4 (R4), the facility staff failed to clarify the physician's orders for two prescribed diet orders. On the most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 6/10/24, the resident scored a 9 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. The assessment documented R4 having no swallowing disorders, no weight loss and not receiving a mechanically altered diet. Observation of meal trays provided to R4 on 8/7/24 during breakfast and lunch revealed mechanical soft diets provided with staff observed assisting R4 to eat. The physician orders documented in part, - Order Date: 06/28/2024…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interview and facility document review it was determined that the facility staff failed to provide interventions for safety and supervision for two of 52 residents in the survey sample, Resident #4 and Resident #107. The findings include: 1. For Resident #4 (R4), the facility staff failed to implement fall mats. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 6/10/24, the resident scored nine out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. The resident was assessed as requiring substantial/maximal assistance with bed mobility and sitting on the side of the bed. Section J documented R4 having no falls since the previous assessment. On 8/5/24 at 12:33 p.m., an observation was made of R4 in their room. R4 was observed in bed with upper bed rails in place. No fall mat was observed. An interview was…

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

Based on resident interview, facility document review and clinical record review, it was determined the facility staff failed to provide care and services for an indwelling catheter for one of 52 residents in the survey sample, Resident #162. The findings include: For Resident #162 (R162) the facility staff failed to provide indwelling catheter care. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 8/5/24, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section H - Bladder and Bowel, the resident was coded as having had intermittent catheterization during the lookback period. An interview was conducted with R162 on 8/6/24 at 2:12 p.m. R162 stated that he had to have a catheter reinserted because he couldn't void on his own. He doesn't like having it. R162 stated that no one washes around the top of his penis where the catheter goes in. He further stated that the only time it has been cleaned…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide respiratory care and services for two of 52 residents in the survey sample, Residents #9 and #3. The findings include: 1. For Resident #9 (R9), the facility staff failed to administered oxygen at the physician prescribed rate and failed to administer the oxygen with a humidifying water. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 6/21/24, the resident scored a 15 out of 15, indicating the resident was not cognitively impaired for making daily decisions. In Section O - Special Treatment, Procedure & Programs, coded the resident as using oxygen during the look back period. Observation was made of R9 on 8/5/24 at 1:06 p.m. sitting in the dining room. The resident had her oxygen on and there was no humidification in use, the humidification bottle was sitting on top of the concentrator. A second…

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, clinical record review, staff interview and facility document review, it was determined that the facility staff failed to monitor fluid restrictions for a hemodialysis patient for one of 52 residents in the survey sample, Resident #90. The findings include: For Resident #90 (R90), the facility staff failed to evidence monitoring of ordered fluid restrictions. On the most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 7/6/24, the resident scored 14 of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. Section O documented the resident receiving dialysis (1) services while a resident at the facility. On 8/5/24 at 2:22 p.m., an interview was conducted with R90 in their room. R90 stated that they attended dialysis four days a week which had recently been increased due to increased fluid retention. R90 stated that they had been placed on a fluid restriction due to this. The physician orders for R90 documented in…

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

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to ensure that two of 52 residents in the survey sample were free of unnecessary medications, Resident #60 and Resident #81. The findings include: 1. For Resident #60 (R60), the facility staff failed to act upon pharmacy recommendations in a timely manner which resulted in the resident potentially receiving unnecessary medication. On 8/7/24 at 12:00 p.m., a request was made to ASM (administrative staff member) #3, the regional director of clinical operations for evidence of any pharmacy recommendations from the monthly medication regimen reviews with evidence of facility and physician response from 10/1/23 to the present. On 8/8/24 at 3:15 p.m., an interview was conducted with ASM #2, the director of nursing. ASM #2 stated that the pharmacist came in monthly to complete the monthly reviews and provided her with a list of residents that stated whether or not they gave any recommendations or not. She stated that for R60, the pharmacist had made…

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

Based on clinical record review, staff interview, and staff interview, it was determined that the facility staff failed to ensure that three of 52 residents in the survey sample were free from and/or monitored for the use of psychotropic medications, Residents #81, #87 and #94. The findings include: 1. For Resident #81 (R81), the facility staff failed to monitor the use of an antidepressant medication. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/10/24, the resident was assessed as taking an antidepressant medication while a resident at the facility. The physician orders for R81 documented in part, - Order Date: 07/13/2024 Lexapro Oral Tablet 10 MG (milligram) (Escitalopram Oxalate) Give 2 tablet by mouth one time a day for Depression/Anxiety Give 20mg (2 tablet) daily for anxiety/depression. - Order Date: 07/12/2024 Valproic Acid Oral Solution 250 MG/5ML (Valproate Sodium) Give 5 ml by mouth every 8 hours for MDD (major depressive disorder). Hold if lethargic. The physician/NP progress notes for R81 documented in…

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

Based on observation, staff interview, and facility document review, the facility staff failed to store medications in a locked compartment for one of six medications carts, a medication cart on the south unit. The findings include: 1. For one medication cart on the south unit, RN (registered nurse) #1 failed to lock the cart while he was in a resident room. On 8/6/24 at 8:57 a.m., RN #1 left the medication cart in the hall unlocked while administering medications in a resident room. The medication cart was not in RN #1's line of sight. On 8/6/24 at 3:11 p.m., an interview was conducted with RN #1. RN #1 stated nurses should lock the medication cart when it is not in their line of sight because someone may open the cart and mess up the medications. On 8/7/24 at 5:20 p.m., ASM (administrative staff member) #1 (the administrator), and ASM #2 (the director of nursing) were made aware of the above concern. The facility pharmacy policy titled, Storage of Medications documented, 2. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review and facility document, it was determined that the facility staff failed to accommodate needs for one of 45 residents in the survey sample, Resident #28. The findings include: The facility staff failed to accommodate Resident #28 (R28) with their bathing preference. R28 was admitted to the facility on [DATE] with diagnoses that included but were not limited to severe morbid obesity (1) and body mass index [BMI] 70 or greater, adult (2). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/23/2023, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) assessment, indicating that they were cognitively intact for making daily decisions. Section G coded R28 as requiring extensive assistance of two or more persons for transfers and totally dependent on one person for bathing. It documented R28 not steady, but able to stabilize without staff assistance when walking…

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, it was determined that the facility staff failed to provide care according to resident preference for one of 45 residents in the survey sample, Resident #28. The findings include: The facility staff failed to provide bathing according to resident requests and preferences for Resident #28 (R28). R28 was admitted to the facility on [DATE] with diagnoses that included but were not limited to severe morbid obesity (1) and body mass index [BMI] 70 or greater, adult (2). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/23/2023, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) assessment, indicating that they were cognitively intact for making daily decisions. Section G coded R28 as requiring extensive assistance of two or more persons for transfers and totally dependent on one person for bathing. It documented R28 not steady, but able…

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

Based on staff interview and facility document review, the facility staff failed to resolve resident concerns expressed at Resident Council meetings for two of three months of minutes reviewed, June and July 2023. The findings include: In both June and July 2023, residents raised concerns about breakfast food during the Resident Council meetings; the facility failed to respond to and resolve these concerns. A review of Resident Council meeting minutes from June 2023 revealed, in part: Resident Concerns/Issues .[resident] states when she receives her toast for breakfast, it is not toasted, it is a plain white piece of bread .[resident] stated when she receives her toast for breakfast, it is not toasted, it is a plain white piece of bread .[resident] does not receive any condiments with her toast or meals .[resident] states she wants to have scrambled or boiled eggs for breakfast twice a week .[resident] states when she receives her toast for breakfast, it is not toasted, it is a plain white piece of bread .Response and follow up: I emailed my regional director about the toaster isn't…

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

Based on observations, resident interviews, staff interviews, clinical record reviews and facility document reviews it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for six of 45 residents in the survey sample, Residents #28, #72, #10, #98, #25, and #87. The findings include: 1. For Resident #28 (R28), the facility staff failed to, implement the care plan for non-pharmacological interventions prior to as needed pain medications; develop the care plan for a diagnosis of diabetes; develop the care plan for the use of a diuretic medication; and develop the care plan for the use of an anticoagulant medication. Resident #28's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/23/2023, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. The assessment documented R28 having a diagnosis of Diabetes Mellitus, receiving as needed pain medication and not receiving…

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, clinical record review and facility document review, it was determined the facility staff failed to provide evidence of providing ADLs (activities of daily living) for two of 45 residents in the survey sample, Residents #72 and #303. The findings include: 1. For Resident #72 (R72), the facility staff failed to evidence a bath or shower was provided on 7/20/2023, 7/27/2023, 8/7/2023, 8/17/2023 or 8/28/2023. On the most recent MDS (minimum data set) a quarterly assessment with an ARD (assessment reference date) of 6/16/2023, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. The assessment documented R72 requiring supervision of one person for personal hygiene and being independent in bathing with assistance of one person. On 8/29/2023 at 12:32 p.m., an interview was conducted with R72. R72 stated that there were times when they did not get their showers when they were scheduled. R72 stated that they were supposed to get…

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

Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for dependent residents for three of 45 residents in the survey sample, Residents #6, #60, and #28. The findings include: 1. For Resident #6 (R6), the facility staff failed to provide showers/baths and personal hygiene on multiple dates in July and August 2023. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/3/23, R6 was coded as being cognitively intact for making daily decisions. She was coded as requiring the extensive assistance of staff for toileting and personal hygiene, and as being completely dependent on staff assistance for bathing. On 8/29/23 at 11:57 a.m., R6 was interviewed. She stated the staff has not been very good about getting me cleaned up in the mornings. She stated she does not always get a shower on her scheduled shower days. A review of R6's POC (point of care) records for July and August 2023 revealed no evidence of the…

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

Based on resident interview, staff interviews, clinical record reviews and facility document reviews it was determined that the facility staff failed to provide a complete pain management program for one of 45 residents in the survey sample, Resident #28. The findings include: For Resident #28 (R28), the facility staff failed to implement a complete pain management program including non-pharmacological interventions prior to administration of as needed pain medications. Resident #28's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/23/2023, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. The assessment documented R28 receiving as needed pain medication, not receiving non-medication interventions for pain and not having any pain. On 8/29/2023 at 12:33 p.m., an interview was conducted with R28. R28 stated that they took medications for pain. R28 stated that they asked the nurses for pain medication when they…

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

Based on staff interview, facility document review, and clinical record review, the facility staff failed to monitor weights as ordered for a resident receiving dialysis, for one of 45 residents in the survey sample, Resident #25. The findings include: For Resident #25 (R25), who was receiving dialysis, the facility staff failed to obtain weights per the provider's order. A review of R25's orders revealed the following orders: 7/28/23 Notify primary clinician for Weight gain of 2 or more pounds in 1 day or 5 pounds or more in 5 days. 7/29/23 Hemodialysis at [name of dialysis center] .MWF (Monday, Wednesday, Friday. A review of R25's weights revealed weights recorded on the following dates in August 2023: 8/2, 8/4, 8/10, 8/13, 8/18, 8/21, and 8/23. The clinical record revealed no other weights recorded for R25 in August 2023. A review of R25's care plan dated 6/26/23 revealed, in part: The resident has ESRD (end stage renal disease) and receives dialysis .Pre-Post dialysis weights. On 8/31/23 at 10:43 a.m., LPN (licensed practical nurse) #11 was interviewed. After reviewing R25'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 staff interview, clinical record review and facility document review, it was determined that the facility staff failed to evidence monitoring of psychotropic medication adverse effects and behavior monitoring for one of 45 residents in the survey sample, Resident #98. The findings include: For Resident #98 (R98), the facility staff failed to monitor for adverse effects and record targeted behavioral symptoms related to anti-psychotic medication use. On the most recent MDS (minimum data set) a significant change assessment with an ARD (assessment reference date) of 7/6/2023, the resident scored 5 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was severely impaired for making daily decisions. The assessment documented R98 receiving an antipsychotic medication 6 of the 7 days during the assessment period. The physician orders for R98 documented in part, - Risperidone Oral Tablet 2 MG (milligram) (Risperidone) Give 1 tablet by mouth one time a day for Anxiety. Order Date: 7/1/2023. The clinical record for R98 failed to evidence…

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 maintain the kitchen in a sanitary manner. The facility staff failed to date and dispose of opened food in one of one kitchen areas. The findings include: The facility staff failed to date and dispose of opened food identified during the facility task- kitchen observation. On 8/29/23 at 11:00 AM, an observation was conducted in the main kitchen. In the freezer, one bag of approximately 12 hamburger patties was torn open. There was no label on bag of date opened or expiration date. In the dry storage area, there was approximately three pounds of dried medium size noodles in a plastic bag that had been torn open. There was no label on bag indicating the date opened or when it expired. An interview was conducted on 8/29/23 at 11:20 AM with OSM (other staff member) #1, the dietary manager. When asked to review the opened bag of hamburger patties and noodles, OSM #1 stated, they should not have opened these bags like this, they should have a date and be secured with a…

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

Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to evidence that education and information regarding risks vs benefits of the influenza and/or pneumonia vaccines were provided to the resident and/or resident representative, prior to the vaccines being administered or refused, for four of five residents reviewed for immunizations; Residents #82, #93, #16, and #46. The findings include: The facility policy, Influenza Vaccination was reviewed. This policy documented, The facility will provide pertinent information about the significant risks and benefits of vaccines to staff and residents (or residents' legal representatives); for example, risk factors that have been identified for specific age groups or individuals with risk factors 2. Before offering influenza immunization, each resident or the resident's legal representative or employee will receive education regarding the benefits and potential side effects of the immunization .4. Consent for the administration of the influenza vaccination will be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to assess one of 45 residents in the survey sample for self-administration of medication, Resident #72. The findings include: For Resident #72 (R72), the facility staff failed to assess for self-administration of medication. During the medication administration observation task, R72 was observed to have a bottle of Fluticasone nasal spray (1) on the overbed table and self administered the medication when asked by LPN (licensed practical nurse) #7. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/16/2023, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 8/30/2023 at 8:05 a.m., an observation was made of LPN #7 preparing and administering medications to R72. LPN #7 prepared a medication cup of scheduled…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain a clean and homelike environment for three of 31 rooms on the north unit. The findings include: 1. The facility staff failed to maintain a clean and homelike environment for room [ROOM NUMBER]. Resident #23 was a resident in room [ROOM NUMBER]. Dried pureed food was found when the cubicle curtain was pulled for privacy during resident care. An interview was conducted on 8/31/23 at 10:11 AM, with OSM (other staff member) #8, housekeeping. When asked how rooms are cleaned, OSM #8 stated, they are cleaned every day. They sweep and mop, wipe all surfaces with peroxide multi surface cleaner, it takes 3 minutes to dry. OSM #8 stated, When the resident goes home, we clean the curtains. If the curtain is dirty while the resident is here, we change the curtain. We are to look at the curtain every day. We clean in hallways, common areas every day. An interview was conducted on 8/31/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, the facility failed to protect the resident's right to be free from physical abuse by another resident, for one of 45 residents in the survey sample, Residents #65. The findings include: The facility failed to protect Resident #65 from physical abuse from another resident, Resident #36 on 2/14/23 and 4/13/23. Resident #65 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: Alzheimer's Disease, diabetes mellitus and dementia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 5/23/23, coded the resident as scoring a 00 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the comprehensive care plan dated 12/17/22, which revealed, FOCUS: The resident has a behavior problem of pushing other residents in their wheelchairs, inviting another 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, clinical record review, and facility document review, it was determined that the facility staff failed to develop a baseline care plan for two of 45 residents in the survey sample; Residents #153 and #353. The findings include: The facility policy, Baseline Care Plans was reviewed. This policy documented, A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. 1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. 2. The Interdisciplinary Team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs 1. The facility staff failed to develop a baseline care plan for fall prevention with interventions, for Resident #153. Resident #153 was admitted to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to review and/or revise the care plan for three of 45 residents in the survey sample; Residents #153, #65, and #50. The findings include: The facility policy, Care Plan Goals and Objectives was reviewed. This policy documented, Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. 1. Care plan goals and objectives are defined as the desired outcome for a specific resident problem or opportunity 2. When goals and objectives are not achieved, the resident's clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established. Care plans will be modified accordingly 5. Goals and objectives are reviewed/revised: a. When there has been a significant change in the resident's condition; b. When the desired outcome has not been achieved . 1. 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 staff interviews, facility document review, and clinical record review, the facility staff failed to follow professional standards of care for three of 45 residents in the survey sample, Residents #6, #253, and #303. The findings include: 1. For Resident #6 (R6), the facility staff administered a medication to her to which the resident had a documented allergy. A review of R6's allergies listed on the electronic medical record revealed, in part: Allergies: Erythromycin (1). A review of R6's provider's orders revealed the following order, written 8/1/23: Azithromycin (2) Oral Tablet 250 MG (milligrams) .Give 1 tablet by mouth at bedtime for copd (chronic obstructive pulmonary disease) exacerbation for 5 Days. 2 tabs today, 1 tab days 2-5. A review of R6's August 2023 MAR (medication administration record) revealed R6 received Azithromycin as ordered on 8/1/23 and 8/2/23. A review of R6's progress notes revealed the following note dated 8/1/23: Order Note Text: The system has identified a possible drug…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to implement treatments and/or interventions to prevent and treat a pressure injury for three of 45 residents in the survey sample, Residents #7, #87, and #98. The findings include: 1. For Resident #7 (R7), the facility staff failed to elevate the resident's heels to prevent a pressure injury. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/30/23, R7 was coded as being moderately impaired for making daily decisions, having scored nine out of 15 on the BIMS (brief interview for mental status). She was coded as being at risk for a pressure injury, and as having no unhealed pressure injuries. On the following dates and times, R7 was observed lying in bed, with bed heels in direct contact with the mattress surface: 8/29/23 at 12:25 p.m. and 3:41 p.m.; 8/30/23 at 8:46 a.m. and 1:07 p.m. A review of R7's Braden Scale…

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

Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to implement interventions for resident safety related to falls for one of 45 residents in the survey sample; Resident #7. The findings include: For Resident #7 (R7), the facility staff failed to apply a physician-ordered helmet to the resident. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/30/23, R7 was coded as being moderately impaired for making daily decisions, having scored nine out of 15 on the BIMS (brief interview for mental status). She was coded as having had two falls without injuries during the look back period. On the following dates and times, R7 was observed lying in bed, without a helmet: 8/39/23 at 12:25 p.m. and 3:41 p.m.; 8/30/23 at 8:46 a.m. and 1:07 p.m. A review of R7's orders revealed the following order, dated 6/14/23: Foam helmet on at all times. Check placement and document refusal. A review of R7's care plan dated 1/18/23 and updated 6/14/23 revealed,…

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

Based on staff interview, clinical record review and facility document review it was determined that the facility staff failed to report non-compliance with fluid restrictions to the physician for one of 45 residents in the survey sample, Resident #10. The findings include: For Resident #10 (R10), the facility staff failed to report non-compliance with fluid restrictions to the physician. The physician orders for R10 documented in part, Fluid Restriction 2000cc per day: 600cc breakfast, 120cc morning medpass, 480cc lunch, 120cc afternoon medpass, 480cc dinner, 120cc evening meds, 80cc extra every shift related to Acute On Chronic Diastolic (Congestive) heart failure. Order Date: 09/02/2021. Review of the eTAR (electronic treatment administration record) dated 6/1/2023-6/30/2023 for R10 documented intake amounts totaled for each shift. The eTAR documented a total amount of 2700cc on 6/4/2023, 2340cc on 6/19/2023 and 2360cc on 6/28/2023. The eTAR failed to evidence notification of the physician of non-compliance with the 2000cc per day fluid restrictions. Review of the eTAR dated…

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

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to maintain respiratory equipment in a sanitary manner for two of 45 residents, Residents #6 and #253. The findings include: 1. For Resident #6 (R6), the facility staff failed to store the nebulizer mask in a sanitary manner. On the following dates and times, R6's nebulizer mask was observed to be uncovered and lying across the nebulizer machine: 8/29/23 at 11:57 a.m. and 3:36 p.m.; and 8/30/23 at 8:19 a.m. A review of R6's orders revealed the following order dated 8/10/23: Ipratropium-Albuterol Solution (1) 0.5-2.5 MG/3ML (milligrams per milliliter) 3 ml inhale orally three times a day for SOB (shortness of breath)/respiratory failure/COPD (chronic obstructive pulmonary disease. A review of R6's August 2023 MAR (medication administration record) revealed she had received the medication as ordered. On 8/31/23 at 10:43 a.m., LPN (licensed practical nurse) #11 was interviewed. She stated nebulizer equipment, and especially the nebulizer mask, should be washed after…

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, facility document review, and clinical record review, the facility staff failed to provide physician/provider supervision of a resident's condition for two of 45 residents in the survey sample, Residents #254 and #87. The findings include: 1. For Resident #254, the facility NP (nurse practitioner) failed to respond to notification about a resident who had received a skin tear, and failed to assess the resident following the skin tear. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 8/11/23, R254 was coded as being severely cognitively impaired for making daily decisions, having scored one out of 15 on the BIMS (brief interview for mental status). R254 was admitted to the facility with diagnoses including diabetes, dementia, and polyneuropathy (1). On 8/29/23 at 12:08 p.m., R254 was observed sitting in a wheelchair beside her bed. R254's daughter was seated beside the resident. R254's right leg…

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

Based on staff interviews, facility document review, and clinical record review, the facility staff failed to complete laboratory testing to prevent administration of an unnecessary medication for one of 45 residents in the survey sample, Resident #253. The findings include: For Resident #253 (R253), the facility staff failed obtain INR (international normalized ratio) (1) levels for Resident #253, as ordered by the physician. A review of R253's progress notes revealed, in part (all notes written by ASM (administrative staff member) #5, the nurse practitioner (NP)), unless otherwise noted: 8/14/23 Hx (history) of DVT (deep vein thrombosis) (2). Continue with Warfarin (3). Start INR. 8/17/23 Hx DVT. Stop Warfarin. Start INR Saturday. Start bridge to Xarelto (4) 10 [milligrams] when INR < 3. 8/19/23 Have pt (patient) check INR with her machine supplies. 8/21/23 Hx DVT .Stop warfarin. INR done on Saturday? not reported to NP or recorded in progress notes. 8/25/23 INR reported to be 1.3. This note was written by a nurse who was unavailable for interview at the time of the survey. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review and facility document , it was determined that the facility staff failed to maintain an accurate and complete facility assessment for care of one of 45 residents in the survey sample, Resident #28. The findings include: For Resident #28 (R28), the facility staff failed to maintain an accurate and complete facility assessment for care of bariatric residents greater than 500 lbs. R28 was admitted to the facility on [DATE] with diagnoses that included but were not limited to severe morbid obesity (1) and body mass index [BMI] 70 or greater, adult (2). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/23/2023, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) assessment, indicating that they were cognitively intact for making daily decisions. On 8/29/2023 at 12:33 p.m., an interview was conducted with R28. R28 stated that they had resided at the facility 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 staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide complete and accurate documentation for two of 45 residents, Resident #353 and #98. The findings include: 1. For Resident #353, the facility staff failed to evidence complete and accurate documentation for bladder and bowel elimination, bed mobility, and personal hygiene. Resident #353 was admitted to the facility on [DATE] with diagnoses that include but are not limited to: pacemaker, Afib (atrial fibrillation), DM (diabetes mellitus) and bipolar. Resident #353's most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an assessment reference date of 4/8/23, coded the resident as scoring 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. MDS Section G- Functional Status: coded the resident as total dependence with bathing, extensive assistance with bed mobility, transfers, locomotion,…

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

Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to evidence that education and information regarding the COVID-19 vaccine was provided to the resident and/or resident representative prior to the vaccine being refused, for one of five residents reviewed for immunizations; Resident #82. The findings include: The facility policy, COVID-19 Vaccination for Residents was reviewed. This policy documented, .2. Resident / resident representatives will be educated on: a) risks / benefits of COVID-19 vaccination. The education will be specific to vaccine being offered/administered and; b) current CDC guidelines for vaccination or residents for COVID-19 and; c) Symptoms, risks and benefits associated with the COVID-19 virus .5. Prior to administration of the COVID-19 vaccine, consent will be obtained from the resident / resident representative and will be documented in the resident's medical record For Resident #82, the facility staff failed to evidence that education and information regarding the COVID-19 vaccine…

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 and clinical record review, it was determined that the facility staff failed to provide food at a palatable temperature during lunch service on 02/16/2022, with the potential to affect 55 of 55 residents on the North unit receiving a meal tray. The vegetables, potatoes, and mechanical soft vegetables served at lunch and tested for palatability were below a palatable temperature. The findings include: Review of the resident council minutes from 11/30/2021 revealed in part, .Residents state their food is not hot when they receive their meals. Review of the resident council minutes from 12/01/2021 revealed in part, .Resident states his meals are not hot when he receives them in his room each shift .Resident states .food is not hot all meals .Resident states his breakfast is cold when received each morning . On the most recent MDS (minimum data set) for Resident # 23, a quarterly assessment with an ARD (assessment reference date) of 12/14/2021, the resident scored 15 out of 15 on the BIMS (brief interview for mental status),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review it was determined that the facility staff failed to notify the physician or resident representative of a change in condition or a possible need to alter treatment for two of 44 residents in the survey sample, Residents #45 and #11. The findings include: 1. The facility staff failed to notify Resident #45's physician (or nurse practitioner) when the physician prescribed medications Flomax (1), Metformin (2) and Buspar (3) were not administered on multiple dates in October 2021, November 2021, December 2021 and January 2022, and failed to notify the physician (or nurse practitioner) when the physician prescribed medication Levaquin (4) was not administered on 2/15/22. Resident #45 was admitted to the facility on [DATE]. Resident #45's diagnoses included but were not limited to diabetes and benign prostatic hyperplasia. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/9/22,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. The facility staff failed to provide the required documentation to the hospital for two transfers to the hospital for Resident #104. Resident #104 was admitted to the facility on [DATE], with two recent readmissions on 1/25/2022 and 1/31/2022. On the most recent MDS (minimum data set), a Medicare five day assessment, with an ARD (assessment reference date) of 2/3/2022, the resident scored a 3 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely cognitively impaired for making daily decisions. The nurses' note dated, 1/15/2022 at 9:37 p.m. documented, Resident decreased LOC (level of consciousness), no PO (by mouth) intake. 179/91 (blood pressure) heart rate 109, resp (respirations) 16, temp (temperature) 97.6. Spoke with wife/RP (responsible party) regarding change in condition and she requested he be sent to hospital. EMS (emergency medical services) transport resident to hospital. Sent with bed hold policy and current records. Report called to [name of hospital].…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for eight of 44 residents in the survey sample, Residents #43, #407, #18, #70, #73, #61, #45 and #307. The findings include: 1. The facility staff failed to develop a care plan for Resident #43's G-tube (gastrostomy tube) (1) and drainage bag. Resident # 43 was admitted to the facility with a diagnosis that included but not limited to ulcerative colitis. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 01/08/2022, the resident scored 12 out of 15 on the BIMS (brief interview for mental status), indicating the resident is moderately impaired of cognition for making daily decisions. On 02/15/22 at 12:01 p.m., an observation of Resident # 43 was observed lying in bed with G-tube connected to a drainage bag that was hung on side of their bed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to maintain the resident's highest level of well-being for five of 44 residents in the survey sample, Residents # 43, # 91, #11, # 45 and # 73. The findings include: 1. Facility staff failed to obtain a physician's order for the care and treatment of Resident # 43's G-tube (gastrostomy tube) (1) and drainage bag. Resident # 43 was admitted to the facility with a diagnosis that included but not limited to ulcerative colitis. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 01/08/2022, the resident scored 12 out of 15 on the BIMS (brief interview for mental status), indicating the resident is moderately impaired of cognition for making daily decisions. On 02/15/22 at 12:01 p.m., an observation of Resident # 43 was observed lying in bed with G-tube connected to a drainage bag that was hung on side…

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

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement a complete pain management program by documenting the location of the resident's pain and implementing non-pharmacological interventions prior to the administration of a prn (as needed) pain medications for two of 44 residents in the survey sample, Residents # 35 and # 77. The findings include: 1. The facility staff failed to document the location of the Resident #35's pain, and to implement non-pharmacological interventions prior to the administration of oxycodone (1). Resident # 35 was admitted to the facility with a diagnosis that included contractures. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 01/04/2022, the resident scored 5 (five) out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely impaired of cognition for making daily decisions. The resident was coded as frequently experiencing pain at a level of three out of 10 during the look…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide pharmacy services for one of 44 residents in the survey sample, Resident #45. The facility staff failed to acquire Resident #45's medication Buspar (1) for administration on multiple dates in October 2021, November 2021 and January 2022. The findings include: Resident #45 was admitted to the facility on [DATE]. Resident #45's diagnoses included but were not limited to diabetes and benign prostatic hyperplasia. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/9/22, the resident scored 11 out of 15 on the BIMS (brief interview for mental status), indicating the resident is moderately cognitively impaired for making daily decisions. Review of Resident #45's clinical record revealed a physician's order dated 5/14/21 for Buspar 5 mg (milligrams) by mouth three times a day for anxiety. Review of Resident #45's October…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to ensure residents were free of unnecessary psychoactive medications for 2 of 44 residents in the survey sample, Residents #70 and #61. The findings include: 1. For Resident #70, the facility failed to evidence documented appropriate diagnosis, target behaviors, behavior monitoring, monitoring of medication effectiveness, psychiatric evaluations as ordered/recommended, and care plan implementation as related to the use of psychoactive medications. Resident #70 was admitted to the facility on [DATE] with the diagnoses of but not limited to Alzheimer's disease, diabetes, high blood pressure, breast cancer, and anxiety disorder. On the most recent MDS (Minimum Data Set), a 5-day assessment with an ARD (Assessment Reference Date) of 1/18/22, the resident scored a 4 out of 15 on the BIMS (brief interview for mental status, indicating the resident was severely cognitively impaired 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 observation, staff interview, and facility document review it was determined facility staff failed to store and prepare food in a sanitary manner. The findings include; On 02/15/2022 at approximately 10:40 a.m., an observation of the facility's kitchen was conducted with OSM (other staff member) # 12, dietary manager with the following concerns: 1. The facility staff failed to ensure a food processor, ready for use, was cleaned and free from standing water. Observation of the food processor located in the facility's kitchen on a food preparation table was conducted with OSM # 12. When asked if the food processor was cleaned and ready for use, OSM # 12 stated, Yes. Observation of the inside of the food processor lid revealed it was wet, with standing water inside the bowl, and with a wet blade. After observing the food processor bowl OSM # 12 stated that the inside of the lid and blade were wet and that the bowl contained approximately one to two tablespoons of standing water. OSM # 12 immediately removed the food processor lid, blade and bowl and sent it to the dish washer…

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

Based on observation, staff interview, and facility document review, it was determined the facility staff failed to maintain a dignified dining experience in one of two dining rooms, the North Wing dining room. The facility staff failed to provide a dignified dining experience on the North Wing, not serving all residents at the same table at the same time. The findings include: Observation was made of the North Wing, the secured dementia unit, on 2/15/2022 at 12:02 p.m. The cart of trays arrived on the unit at 12:02 p.m. The staff started delivering trays to the dining room and resident rooms at the same time. Four residents were sitting at a table by the back wall. The first resident got their tray at 12:11 p.m. The second resident got their tray at 12:18 p.m. The third resident got their tray at 12:26 p.m. The fourth resident got their tray at 12:27 p.m., sixteen minutes after the first resident was served. A second table, where four residents were seated, was observed near the front of the dining room. The first resident at that table got their tray at 12:12 p.m. The second…

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, it was determined that the facility staff failed to provide skilled nursing facility advance beneficiary notice of non-coverage (SNFABN) to two of three beneficiary protection notification resident reviews, Resident #87 and Resident #357. The findings include: 1. Resident #87's last covered day of Medicare part A services was 8/14/21. The facility staff failed to provide the advance beneficiary notice to Resident #87 (and/or the resident's representative). Resident #87 was admitted to the facility on [DATE] with diagnoses that included but were not limited to COVID-19, multiple sclerosis and seizures. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/25/22, the resident scored 9 out of 15 on the BIMS (brief interview for mental status), indicating the resident is moderately impaired for making daily decisions. The progress notes for Resident #87 documented in part, 6/23/2021 10:04 (10:04 a.m.) MD…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to evidence written notification was provided to the responsible party and/or the ombudsman for a facility-initiated transfer for 2 of 44 residents in the survey sample, Resident #81 and Resident #104. The findings include: 1. The facility staff failed to evidence written notification of transfer was provided to Resident #81 and/or their representative for a facility-initiated transfer on 2/13/2022. On the most recent MDS (minimum data set), a 5-day assessment with an ARD (assessment reference date) of 1/22/2022, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. The progress notes for Resident #81 documented in part, 2/13/2022 17:57 (5:57 p.m.) Resident was sent to the hospital as advised by physician due to critical lab results, last vital signs taken 86/46 (blood pressure), HR…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to evidence bed hold notice was provided to the resident and/or the responsible party for a facility-initiated transfer for 2 of 44 residents in the survey sample, Residents #81and #60. The findings include: 1. The facility staff failed to evidence bed hold notice was provided to Resident #81 and/or their representative for a facility-initiated transfer on 2/13/2022. On the most recent MDS (minimum data set), a 5-day assessment with an ARD (assessment reference date) of 1/22/2022, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. The progress notes for Resident #81 documented in part, 2/13/2022 17:57 (5:57 p.m.) Resident was sent to the hospital as advised by physician due to critical lab results, last vital signs taken 86/46 (blood pressure), HR (heart rate) 89, O2 (oxygen) 92,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, it was determined that the facility staff failed to review and/or revise the comprehensive care plan for 2 of 44 residents in the survey sample, Residents #61 and #45. The findings include: 1. For Resident #61, the facility staff failed to review and revise the comprehensive care plan after a fall with injury on 1/2/22. Resident #61 was admitted to the facility on [DATE] and had the diagnoses of but not limited to Alzheimer's disease, depression, high blood pressure and history of falls. On the most recent MDS (Minimum Data Set), a significant change assessment with an ARD (Assessment Reference Date) of 1/10/22, the resident scored a 3 out of 15 on the BIMS (brief interview for mental status, indicating the resident was severely cognitively impaired for making daily decisions. A review of the clinical record revealed a nurse's note dated 1/2/22 that documented, This morning at approximately 07:20 am (7:20 AM) this nurse was called to room [number] by certified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide respiratory care and services in accordance with professional standards of practice for two of 44 residents in the survey sample, Residents # 11 and # 307. The findings include: 1. The facility staff failed to obtain a physician order for the use of oxygen, and failed to store the oxygen cannula and tubing in a sanitary manner for Resident #11. Resident #11 was admitted to the facility on [DATE] with a diagnosis of chronic respiratory failure and asthma. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 11/30/2021, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is not cognitively impaired for making daily decisions. Section O did not code the resident as having used oxygen. Observation was made of Resident #11 on 2/15/2022 at 11:45…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to provide communication to the dialysis facility for one of 44 residents, Resident #407. For Resident #407, the facility failed to provide communication to the dialysis facility for 23 to 25 visits. The findings include: Resident #407 was admitted to the facility on [DATE]. Resident #407's diagnoses included but were not limited to: end stage renal disease (end stage of renal failure-inability of the kidneys to excrete wastes and function in the maintenance of electrolyte balance) (1), congestive heart failure (abnormal congestion caused by circulatory congestion and retention salt and water by the kidneys) (2) and chronic respiratory failure (inability of the heart and lungs to maintain and adequate level of gas exchange) (3). Resident #407's most recent MDS (minimum data set) assessment, a five day assessment, with an assessment reference date of 12/31/21, coded 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 and facility document review, it was determined that the facility staff failed to conduct annual performance reviews for 2 of 3 CNAs (certified nursing assistants) whose records were reviewed, CNAs #4 and #6. The findings include: The facility staff failed to conduct a performance review for CNA #4, hired on 3/7/2017 and reviewed for performance evaluation completed between 3/1/2020-3/31/2021; and CNA #6, hired on 11/8/1993 and reviewed for performance evaluation completed between 11/1/2020-11/30/2021. On 2/16/22 at approximately 8:00 a.m., a list of CNAs who were employed at the facility for more than one year was provided by ASM (administrative staff member) #1, the administrator. On 2/16/22 at approximately 12:15 p.m., ASM #2, the director of nursing, was asked to provide the annual performance reviews for the CNAs selected from the facility list. Review of the annual performance reviews failed to reveal a completed review after 11/11/2020 for CNA #4 (hired 3/7/2017) and CNA #6 (hired on 11/8/1993). On 2/16/22 at 5:10 p.m., an interview was conducted 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 clinical record review, staff interview and facility document review, it was determined that the facility staff failed to ensure that 1 of 44 residents in the survey sample was free of unnecessary medications, Resident #359. On 7/27/2021, the facility staff administered Narcan nasal spray to Resident #359, rather than the physician-ordered and scheduled saline nasal spray. The findings include: Resident #359 was admitted to the facility with diagnoses that included but were not limited to chronic pain and low back pain. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/12/2021, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. Section J coded Resident #359 as having pain almost constantly. On 2/16/2022 at 2:45 p.m., an interview was conducted with OSM (other staff member) #13, the ombudsman. OSM #13 that they had received an anonymous report that Resident #359 had received Narcan by mistake from the nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure a resident was free of a significant medication error for one of 44 residents in the survey sample, Resident #45. On 2/9/22, the nurse practitioner prescribed Resident #45 the medication Levaquin (1) for seven days for a diagnosis of pneumonia. The facility staff failed to administer Levaquin to Resident #45 on 2/15/22. The findings include: Resident #45 was admitted to the facility on [DATE]. Resident #45's diagnoses included but were not limited to diabetes and benign prostatic hyperplasia. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/9/22, the resident scored 11 out of 15 on the BIMS (brief interview for mental status), indicating the resident is moderately cognitively impaired for making daily decisions. Review of Resident #45's clinical record revealed a note signed by the nurse practitioner on 2/9/22 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 2. The facility staff failed to document showers for Resident #53. The findings include: Resident #53 was admitted to the facility on [DATE]. Resident #53's diagnoses included but were not limited to: scoliosis (abnormal lateral or sideward curve to the spine) (1), pancreatitis (inflammation of the pancreas usually caused by alcohol or gallstones) (2) and obsessive compulsive disorder (uncontrollable need to repeat certain acts or rituals) (3). Resident #53's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 11/15/21, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is not cognitively impaired for making daily decisions. Section G coded the resident as requiring limited assistance for bathing. A review of Resident #53's comprehensive care plan dated 3/9/20, revealed in part, Resident has an ADL (activity of daily living) self-care performance deficit related to activity intolerance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, it was determined that the facility staff failed to follow infection control practices for 1 of 44 residents in the survey sample, Resident #207. Resident #207 was observed being assisted into the main dining room on the North unit for the lunch meal with other residents on 2/15/22 at 12:25 PM. Resident #207 was a newly admitted , unvaccinated resident who was on quarantine isolation for COVID-19 monitoring and observation. The main dining room on the North unit was filled with COVID-19 negative residents who were not on quarantine isolation. Resident #207's presence in this dining room placed other residents in the dining room at risk for contracting COVID-19. The findings include: Resident #207 was admitted to the facility on [DATE] with the diagnoses of but not limited to chronic obstructive pulmonary disease, Wernicke's encephalopathy, dysphagia, high blood pressure, and alcohol abuse. An MDS had not yet been completed at the time of the…

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

Based on staff interview and employee record review it was determined that the facility staff failed to ensure that 1 of 3 CNA (certified nursing assistant) records reviewed received the required annual training. The facility failed to provide evidence that CNA #5 received the required annual abuse training. The findings include: On 2/16/22 at approximately 4:00 p.m., a review of the facility's CNA annual training was conducted. Review of three CNA training transcripts revealed one of three CNAs selected for review did not complete annual abuse training for 2021. Review of CNA #5's training transcript documented a hire date of 6/29/09. The transcript documented Preventing, Recognizing, and Reporting Resident Abuse completed on 1/8/2010, 10/11/2012 and 3/15/2015. On 2/17/22 at 5:10 p.m., OSM (other staff member) #7, human resource manager, stated that they did not have any evidence of abuse training for CNA #5 except for a signature acknowledging receipt of the facility abuse policy and mandated reporter status dated 7/1/2021. On 2/17/22 at 7:30 a.m., an interview was conducted 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.