Poplar Hill Health And Rehab

Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to develop and/or implement the comprehensive care plan for four of 22 residents in the survey sample, Residents #38, #39, #242 and #35. The findings include: 1. For Resident #38, the facility staff failed to implement the comprehensive care plan for administering pain medications per the physician orders. The comprehensive care plan dated, 5/27/2023 documented in part, Focus: (R38) is at risk for acute pain due to her osteoarthritis, limited ROM (range of motion) to her neck and kidney stones. The Interventions documented in part, Pain patches to neck and knee per MD (medical doctor) order. Observation was made of RN (registered nurse) #3, administering medications on 8/1/2023 at 8:42 a.m. to R38. RN #3 prepared the medications. She pulled out two Aspercreme Pad Lido (lidocaine) 4% pads. One was for the resident's neck, and one was for the resident's left knee. RN #3 entered the room and administered the oral medications. She then placed one of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to provide dialysis care and services for one of 22 residents in the survey sample, Resident #35. The findings include: The facility failed to provide a bagged lunch for Resident #35 to take with him to the dialysis appointment or offer additional food prior to going to dialysis. Resident #35 was admitted with diagnoses that include but are not limited to: ESRD (end stage renal disease. Resident #35's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 6/7/23, coded the resident as scoring 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of MDS Section O-Special Procedures: coded the resident as dialysis-yes. A review of the comprehensive care plan dated 12/12/19 and revised on 6/30/23, revealed, FOCUS: Resident has end stage renal…

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

Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to administer medications per the physician order for one of 22 residents in the survey sample, Resident #38. The findings include: For Resident #38 (R38), the facility staff failed to remove a lidocaine patch per the physician orders. Observation was made of RN (registered nurse) #3, administering medications on 8/1/2023 at 8:42 a.m. to R38. RN #3 prepared the medications. She pulled out two Aspercreme Pad Lido (lidocaine) 4% pads. One was for the resident's neck, and one was for the resident's left knee. RN #3 entered the room and administered the oral medications. She then placed one of the Aspercreme Pads to the back of the resident's neck. She proceeded to the other side of the bed and pulled back the covers off the resident's left knee. The Aspercreme pad was still on the resident's left knee, dated 7/31/2023. RN #3 stated she could not just remove the patch and apply the new one as there was an order to remove it after 12 hours of being on.…

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

Based on observations, staff interview, clinical record review, it was determined that the facility staff failed to implement fall interventions for one of 22 residents in the survey sample, Resident #242. The findings include: For Resident #242 (R242), the facility staff failed to place a fall mat on the floor to the left side of the bed while he was lying in bed. R242 was admitted to the facility with a diagnosis that included but was not limited to convulsion (1). R242's admission MDS (minimum data set) was not due at the time of the survey. On 08/01/23 at approximately 1:30 p.m., R242 was observed lying in bed asleep. Further observation failed to evidence a fall mat on the floor next to the bed. On 08/01/23 at approximately 3:20 p.m., R242 was observed lying in bed asleep. Further observation failed to evidence a fall mat on the floor next to the bed. The physician's order for R242 documented in part, Fall mat in place to left side of bed when resident is in bed. Order Date: 07/31/2023. The comprehensive care plan for R242 documented in part, Focus. (R242) is at risk for falls…

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, the facility staff failed to provide services to attempt to restore bladder and bowel continence for one of 22 residents in the survey sample, Resident #25. The findings include: For Resident #25 (R25), the facility staff failed to provide evidence of attempting to restore her bladder and bowel function after admission to the facility. R25 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/26/23, R25 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). She was coded as being frequently incontinent of both bowel and bladder. On the admission MDS (8/28/22) and the quarterly assessments (11/21/22 and 2/21/23) since her admission, she was also coded as being frequently incontinent of bowel and bladder. On all of…

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

Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to store food in a sanitary manner in one of one kitchen areas. The findings include: The facility staff failed to date and/or dispose of opened food. On 7/31/23 at 9:15 AM, an observation was conducted in the main kitchen. In the freezer, one of two five-pound frozen hash browns packed in a plastic bag had been torn open. There was no label on the bag of the date it was opened or expiration date. An interview was conducted on 7/31/23 at 9:20 AM with OSM (other staff member) #1, the chef/dietary supervisor. When asked to review the opened hash brown bag, OSM #1 stated, They must have just opened this with breakfast service. It should not be open like this. I will remove it. The ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing was made aware of the finding on 8/1/23 at 4:15 PM. The facility's Infection Control Sanitation/Safety Guidelines policy dated 8/2013, revealed the following, Storage: The objective is to maintain…

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 implement the comprehensive care plan for four of 31 residents in the survey sample, Residents #51, #8, #5, and #6. The findings include: 1. The facility staff failed to offer non-pharmacological interventions and document the location of pain prior to the administration of pain medications per the comprehensive care plan for Resident #51. Resident #51 was admitted to the facility on [DATE] with diagnoses that included but not limited to: stroke (abnormal condition in which hemorrhage or blockage of the blood vessels of the brain leads to oxygen lack and resulting symptoms - sudden loss of ability to move a body part [as an arm or parts of the face], or to speak, paralysis weakness or if severe, death) (1), hemiplegia (paralysis affecting only one side of the body (2), Bipolar Disorder (a mental disorder characterized by episodes of mania and depression) (3), and chronic pain syndrome.…

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

Based on clinical record review and staff interview, it was determined that the facility staff failed to obtain daily weights according to the physician's orders for 1 of 31 residents in the survey sample, Resident # 5. The findings include: Resident # 5 was admitted to the facility with diagnoses that included but were not limited to: high blood pressure, heart failure and cancer of the liver. Resident # 5's most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 10/27/2021, coded Resident # 5 as scoring a four on the brief interview for mental status (BIMS), indication the resident is severely impaired of cognition for making daily decisions. The POS [physician's order sheet] for Resident # 5 documented in part, Daily weight every day for Heart Failure. If weight greater than 3LBS (three pounds) in 1 day and/or greater than 5LBS (five pounds) in 1 week - reweigh immediately notify MD (medical doctor) loss/gain. Date Order: 03/26/2021. Start Date: 03/27/2021. The comprehensive care plan for Resident # 5 with a revision date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to identify and monitor targeted behaviors for the use of psychotropic medications for two of 31 residents in the survey sample, Residents #40 and #6. The findings include: 1. The facility staff failed to identify and monitor targeted behaviors for the use of Seroquel (used to treat schizophrenia, bipolar disorder, and in combination with other medications to treat depression) (1) for Resident #40. Resident #40 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: anxiety disorder (state of mild to severe apprehension, often without specific cause, resulting in body changes such as quickened heartbeat and sweat.) (2), mood disorder (a mood disorder, feeling sad or irritable, affects a person's everyday emotional state.) (3), depression (a dejected state of mind with feelings of sadness, discouragement, and hopelessness, often accompanied by reduced…

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 written notice of hospital transfer for one of 31 residents in the survey sample, Resident #45. Resident #45 transferred to the hospital on [DATE]. The facility staff failed to provide written notice of the transfer to the resident representative or ombudsman. The findings include: Resident #45 was admitted to the facility on [DATE]. Resident #45's diagnoses included but were not limited to high blood pressure, heart disease and major depressive disorder. Resident #45's quarterly minimum data set assessment with an assessment reference date of 11/22/21 coded the resident's cognition as severely impaired. Review of Resident #45's clinical record revealed a nurse's note that documented the resident was transferred to the hospital on [DATE] for a left knee wound. Further review of Resident #45's clinical record failed to reveal evidence that written notice of the transfer 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 clinical record review, facility document review and staff interviews it was determined that the facility staff failed to evidence a bed hold notice was provided to 1 of 31 residents in the survey sample, Resident #254. Written bed hold notice was not provided to Resident #254 or their responsible party after admission to the hospital on [DATE]. The findings include: Resident #254 was admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses that included but were not limited to malignant neoplasm of bladder (1) and end stage renal disease (2). Resident #254's most recent MDS (minimum data set), an admission five-day assessment with an ARD (assessment reference date) of 10/22/2022, coded Resident #254 as scoring a 12 on the brief interview for mental status (BIMS) assessment, 12- being moderately impaired for making daily decisions. The progress notes for Resident #254 documented in part, - 11/9/2021 07:52 (7:52 a.m.) Note Text: resident appears shaky this morning. Vital signs…

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

Based on clinical record review and staff interview, it was determined that the facility staff failed to accurately code a Resident's MDS (minimum data set) assessment for 1 of 31 residents in the survey sample, Resident #8. For Resident #8, the facility staff failed to accurately code the 11/01/2021 MDS for hospice care. The findings include: Resident # 8 was admitted to the facility with diagnoses that included but were not limited to: high blood pressure, low iron and breast cancer. Resident # 8's most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 11/01/2021, coded Resident # 8 as scoring a 0 (zero) out of 15 on the brief interview for mental status (BIMS), with 0 indicating the resident is severely impaired of cognition for making daily decisions. Section O Special Treatments, Procedures and Programs failed to code Resident # 8 as receiving hospice. The POS (physician's order sheet) for Resident # 8 documented in part, Admit to LTC (long term care) for hospice service - [Name of Hospice Organization]. Date Order:…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and facility document review, it was determined that the facility staff failed to provide a written summary of the baseline care plan after a readmission to the facility for 1 of 31 residents in the survey sample, Resident #254. There is no evidence to support that Resident #254 and/or the responsible party were provided a written summary of the care plan after the readmission to the facility on [DATE]. The findings include: Resident #254 was admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses that included but were not limited to malignant neoplasm of bladder (1) and end stage renal disease (2). Resident #254's most recent MDS (minimum data set), an admission five-day assessment with an ARD (assessment reference date) of 10/22/2021, coded Resident #254 as scoring a 12 on the brief interview for mental status (BIMS) assessment, 12- being moderately impaired for making daily decisions. The progress notes for Resident #254 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.

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 review and revise the comprehensive care plan for one of 31 residents in the survey sample, Resident #45. The facility staff failed to review and revise Resident #45's comprehensive care plan for anticoagulant (blood thinning) medication use. The findings include: Resident #45 was admitted to the facility on [DATE]. Resident #45's diagnoses included but were not limited to high blood pressure, heart disease and major depressive disorder. Resident #45's quarterly minimum data set assessment with an assessment reference date of 11/22/21, coded the resident's cognition as severely impaired. Review of Resident #45's clinical record revealed a physician's order dated 8/10/21 for Xarelto (1) 20 mg (milligrams) - one tablet by mouth in the evening for a right lower extremity deep vein thrombosis (blood clot). Review of Resident #45's January 2022 medication administration record revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to follow professional standards of practice for the clarification of physician orders for pain medications for one of 31 residents in the survey sample, Resident #51. The findings include: Resident #51 was admitted to the facility on [DATE] with diagnoses that included but not limited to: stroke (abnormal condition in which hemorrhage or blockage of the blood vessels of the brain leads to oxygen lack and resulting symptoms - sudden loss of ability to move a body part [as an arm or parts of the face], or to speak, paralysis weakness or if severe, death) (1), hemiplegia (paralysis affecting only one side of the body (2), Bipolar Disorder (a mental disorder characterized by episodes of mania and depression) (3), and chronic pain syndrome. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 1/5/2022, coded the resident as scoring a 13…

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

Based on clinical record review and staff interview, it was determined that the facility staff failed to check the placement and function of the wander guard according to the physician's orders for 1 of 31 residents in the survey sample, Resident # 8. The findings include: Resident # 8 was admitted to the facility with diagnoses that included but were not limited to: high blood pressure, low iron and breast cancer. Resident # 8's most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 11/01/2021, coded Resident # 8 as scoring a 0 (zero) on the brief interview for mental status (BIMS), indicating the resident is severely impaired of cognition for making daily decisions. Section P Restraints and Alarms coded Resident # 8 for a wander guard Used daily. The POS (physician's order sheet) for Resident # 8 documented in part, Wanderguard to wheelchair check function & (and) placement every shift. Date Order: 08/06/2021. Start Date: 08/06/2021. The comprehensive care plan for Resident # 8 dated 08/03/2021 documented. FOCUS: [Resident…

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

Based on clinical record review and staff interview, it was determined that the facility staff failed to provide a therapeutic diet according to the physician's orders for 1 of 31 residents in the survey sample, Resident # 5. The facility staff failed to provide Resident # 5 with a NAS (No Added Salt) and NCS (no concentrated sugar) diet according to the physician ' s orders. The findings include: Resident # 5 was admitted to the facility with diagnoses that included but were not limited to: high blood pressure, heart failure and diabetes mellitus [1]. Resident # 5's most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 10/27/2021, coded Resident # 5 as scoring a four on the brief interview for mental status (BIMS) of a score of 0 - 15, four - being severely impaired of cognition for making daily decisions. The POS (physician's order sheet) for Resident # 5 documented in part, Accu checks [2] at bed time related to TYPE 2 (two) DIABETES MELLITUS WITH DIABETIC NEUROPATHY [3]. Date Order: 02/18/2021. Start Date: 02/18/2021.…

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 maintain a complete pain management program for one of 31 residents in the survey sample, Resident #51. The facility staff failed to document the location of pain and failed to off non-pharmacological interventions prior to the administration of pain medication. The findings include: Resident #51 was admitted to the facility on [DATE] with diagnoses that included but not limited to: stroke (abnormal condition in which hemorrhage or blockage of the blood vessels of the brain leads to oxygen lack and resulting symptoms - sudden loss of ability to move a body part [as an arm or parts of the face], or to speak, paralysis weakness or if severe, death) (1), hemiplegia (paralysis affecting only one side of the body) (2), Bipolar Disorder (a mental disorder characterized by episodes of mania and depression) (3), and chronic pain syndrome. The most recent MDS (minimum data set)…

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 ensure one of 31 residents in the survey sample was free of unnecessary pain medication, Resident #51. For Resident #51, the facility staff administered pain medication when the documented pain level was outside the parameters of the physician ordered pain medication. The findings include: Resident #51 was admitted to the facility on [DATE] with diagnoses that included but not limited to: stroke (abnormal condition in which hemorrhage or blockage of the blood vessels of the brain leads to oxygen lack and resulting symptoms - sudden loss of ability to move a body part [as an arm or parts of the face], or to speak, paralysis weakness or if severe, death) (1), hemiplegia (paralysis affecting only one side of the body) (2), Bipolar Disorder (a mental disorder characterized by episodes of mania and depression) (3), and chronic pain syndrome. The most recent MDS (minimum data set) assessment, 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, facility document review, and clinical record review, it was determined that the facility staff failed ensure the drug regimen for three of 40 residents in the survey sample, Residents # 63, # 30 and # 31, were free from unnecessary pain medications. The facility staff failed to implement non-pharmacological interventions prior to the administration of as needed pain medication, for Resident # 63 and #31 on multiple occasions in August, September and October 2019, and for Resident # 30 on multiple occasions in September 2019. The findings include: 1. The facility staff failed to implement non-pharmacological interventions prior to the administration of as needed pain medication, Tylenol [1] for Resident # 63 on multiple occasions in August, September and October 2019. Resident # 63 was admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses that included but were not limited to: chronic pain osteoarthritis [2] and high blood pressure. 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 observation, resident interview, staff interview, facility document review and clinical record review, it was determined that facility staff failed to serve food and provide catheter care in a manner to promote resident dignity for one of 40 residents in the survey sample, Residents # 175. On 10/17/19, a nursing student was observed standing while feeding Resident #175 her breakfast in bed. The findings include: Resident # 175 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: swallowing difficulties, low iron and high blood pressure. The most recent MDS (minimum data set) assessment for Resident # 175's was not due at the time of the survey. The facility's nursing admission assessment dated [DATE], coded Resident # 175 as Oriented to place times one. Resident # 57 was coded as requiring the assistance of one staff member for eating. The facility's baseline care plan for Resident # 175 dated 10/11/2019 documented, Cognitive status: Cognitively impaired. Under…

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 the necessary paperwork to the receiving facility for a facility initiated transfer for one of 40 residents, Resident #325. The facility staff failed to provide evidence that all required information was provided to the hospital staff when Resident #325 was transferred to the hospital on 9/5/19. The findings include: Resident #325 was admitted to the facility on [DATE] with diagnoses that include but are not limited to: congestive heart failure [circulatory congestion, retention of fluid in the lungs and edema of extremities. (1)], pleural effusion [accumulation of fluid in the space between the chest wall and the lungs. (2)] and atrial fibrillation [rapid and random contraction of the atria of the heart (3)]. The most recent MDS (minimum data set) assessment, a 14 day Medicare assessment, with an ARD (assessment reference date) of 9/24/19, coded the resident as scoring a 11…

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 implement the comprehensive care plan for two of 40 residents in the survey sample, Residents # 63 and # 31. The facility staff failed to implement the comprehensive care plan for Resident # 63 and Resident #31 for the use of non-pharmacological interventions prior to the administration of as needed pain medications. The findings include: 1. The facility staff failed to implement Resident # 63 comprehensive care plan for the use of non-pharmacological interventions prior to the administration of as needed Tylenol [1]. Resident # 63 was admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses that included but were not limited to: chronic pain osteoarthritis [2] and high blood pressure. Resident # 63's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 09/26/19, coded Resident # 63 as scoring a 12 on the brief…

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

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 facility staff failed to review or revise the comprehensive care plan for two of 40 residents in the survey sample, Resident # 41 and # 50. The facility staff failed to revise Resident # 41's comprehensive care plan to reflect the correct use of a seat cushion and not a back brace cushion for the resident, and failed to revise Resident # 50's comprehensive care plan to reflect the use of an indwelling catheter. The findings include: 1. Resident # 41 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: lower back pain, heart failure and chest pain. Resident # 41's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 09/04/2019, coded Resident # 41 as scoring an eight on the staff assessment for mental status (BIMS) of a score of 0 - 15, eight - being moderately impaired of cognition for making daily decisions. Resident # 41…

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 facility staff failed to provide respiratory care consistent with professional standards of practice, the comprehensive person-centered care plan for two of 40 residents in the survey sample, Residents # 27 and 31. The facility staff failed to store Resident # 27's C-PAP [Continuous Positive Airway Pressure] [1] mask in a sanitary manner and failed to administer Resident # 31's oxygen according to the physician's orders. The findings include: 1. Resident # 27 was admitted to the facility on [DATE] and a re-admission on [DATE] with diagnoses that included but were not limited to: obstructive sleep apnea [1], anxiety [2], and muscle weakness. Resident # 27's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 08/21/19, coded Resident # 27 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily…

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, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to ensure physician prescribed medication was obtained and provided for administration as ordered for one of 40 residents in the survey sample, Resident #8. The facility staff failed to ensure Resident #8's newly prescribed antibiotic medication was provided for administration on 1/2/19 at 9:00 PM as ordered by the physician. The antibiotic was not obtained and administered until 1/3/19 at 9:00 AM. The findings include: Resident #8 was admitted to the facility on [DATE] with the diagnoses of but not limited to Parkinson's disease, dementia, high blood pressure, psychosis, glaucoma, and left arm fracture. The quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/24/19 coded the resident as being severely impaired in ability to make daily life decisions. A review of the clinical record revealed a social worker note 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.

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 dispose of biologicals upon expiration date in one of two nourishment rooms. The facility staff failed to dispose of biologicals upon expiration date. Three bottles of expired tube feeding formula were observed available for resident use in the Dogwood/Willow nourishment room. The findings include: On [DATE] at 8:00 AM an inspection of nourishment rooms was conducted. Three bottles of expired tube feeding formula were found in one nourishment room, 1000 milliliter bottle of Osmolite expired [DATE], 1000 milliliter bottle of Jevity expired [DATE] and 500 milliliter bottle of Vital expired [DATE]. An interview was conducted with LPN (licensed practical nurse) #2, on [DATE] at 8:00 AM. LPN #2 stated, I was checking the tube feedings this morning and found they were expired, but I couldn't reach them to throw them out. All three bottles of expired tube feedings were located on the third shelf. When asked about…

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 facility staff failed to implement infection control practices to prevent the development and transmission of infections for one of 40 residents in the survey sample, Residents # 27. The facility staff failed to implement infection control practices for the storage of Resident # 27's C-PAP mask [Continuous Positive Airway Pressure] [1] when it was not in use. The findings include: Resident # 27 was admitted to the facility on [DATE] and a re-admission on [DATE] with diagnoses that included but were not limited to: obstructive sleep apnea [1], anxiety [2], and muscle weakness. Resident # 27's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 08/21/19, coded Resident # 27 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Review of the annual MDS with an ARD of 02/26/19 coded 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.