River Edge Rehabilitation And Nursing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of care for two of forty-one residents in the survey sample (Residents #2 and #20).The findings include:1. Nursing staff failed to document in the clinical record an unwitnessed fall for Resident #2, including immediate assessments, actions taken and circumstances of the fall. Resident #2 (R2) was admitted to the facility with diagnoses that included dementia, psychotic disturbance, mood disorder, anxiety, chronic kidney disease, gastroesophageal reflux disease, obesity, congestive heart failure, peripheral vascular disease and cognitive communication deficit. The minimum data set (MDS) dated [DATE] assessed R2 with severely impaired cognitive skills. R2's clinical record documented a nurse practitioner progress note dated 6/18/25 at 11:59 p.m. This note documented, .The patient sustained a fall yesterday [6/17/25], but no injuries were reported. Neuro checks initiated and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review and facility documentation review the staff failed to provide care and services related to dialysis for three residents, Resident # 24 (R24), #25 (R25) and #14 (R14) out of a survey sample of 41 residents.The findings included:1. There was no order for facility staff to monitor R24's dialysis fistula site in the left upper arm. On 8/7/25 at 8:40 a.m., an interview was conducted with R24. R24 was asked if his fistula site was monitored and he said, Dialysis checks it every Monday, Wednesday and Friday, but here no. Maybe once or so a nurse came in listen to it but don't see that nurse often here. On 8/7/25 at 9:00 a.m., an interview was conducted with a licensed practical nurse, LPN#5 (LPN5). LPN5 stated that the dialysis access site was to be monitored. She stated the bruit and thrill at the fistula site was to be checked. LPN5 stated that the dressing on the fistula site was to be removed every 24 hours and checked. She stated this treatment…

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 and clinical record review the facility staff failed to obtain an x-ray timely for one resident, Resident ##26 (R26) out of a survey sample of 41 residents.The findings included:There was an x-ray ordered stat (as soon as possible), and the facility did not follow up and the x-ray was not obtained timely.On 8/7/25 at 8:10 a.m., an interview was conducted with the nurse practitioner (NP). The NP stated if concern for a fracture we ordered the x-ray stat, and the expectation was for the x-ray to be obtained within eight hours. If the x-ray was longer than eight hours, we will send out to the emergency department and will send out sooner if the family wants the resident sent out for evaluation. NP also said, I will give more orders like frequent vitals, neuro checks and if pain is not controlled to send out.On 8/7/25 at 8:30 a.m., interview was conducted with a licensed practical nurse, LPN#7 (LPN7). LPN7 stated that R26 was in the dining room and fell. She stated that R26 was complaining about her left lower extremity and left hip area hurting. LPN7 stated…

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 notify the physician of a delay in the treatment of a UTI (urinary tract infection) for Resident #28. Findings were: Resident #28 was admitted to the facility with the following diagnoses including but not limited to: Diabetes mellitus, quadriplegia, contracture of the left hand, UTI, and chronic kidney disease. An annual MDS (minimum data set - a cms assessment tool), dated 09/02/2022, documented the BIMS (Brief Interview for Mental Status) score of 15 (out of 15), indicating intact cognitive function for daily decision making. The clinical record was reviewed on 11/01/2022 beginning at approximately 3:00 p.m, noting the progress notes with the following entries: 10/29/2022 22:20 (10:22 p.m.) Positive for UTI. Spoke with (Name); place PICC line begin ertapenem 1 GM (gram) q (every) 24 hours. 10/31/2022 (Note from nurse practitioner signed 10/31/2022 at 7:51 p.m.) .Infection and inflammatory reaction due to indwelling urethral catheter .urine culture came back with E. Coli 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, clinical record review and facility document review, the facility staff failed to develop a comprehensive care plan (CCP) for 4 of 21 residents in the survey sample (Resident #23, #78, #80, and #81). Resident #23 had no plan of care for anticoagulant (AC) medication and diabetic management, including insulin administration. Resident #78 had no plan of care developed/implemented for pain management. Resident #80 had no plan of care for anticoagulant (AC) medication. Resident #81 had no plan of care for anticoagulant (AC) medication. The findings include: 1. The facility staff failed to develop and implement a comprehensive care plan for anticoagulant therapy and diabetic management, including insulin therapy. Resident #23 was admitted to the facility with diagnoses that included COVID 19, hemiplegia/hemiparesis, chronic AFIB, DM2, cognitive communication deficit, and aphasia. The MDS (minimum data set -cms assessment tool) dated 09/05/22 was the 5 day admission assessment, which…

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. Facility staff failed to assist Resident #62 with wearing the physician ordered TED (thrombo-embolic deterrent) hose. On 11/02/2022 at approximately 9:30 a.m., Resident #62 was observed in her room. She was dressed for the day. No TED hose were observed. She was asked if she had white stockings that staff helped her put on in the mornings and took off in the evenings. She stated, No, I don't have that. She was asked if she had any stockings in her drawers. She opened her drawers and stated, No, I don't have any. CNA (certified nursing assistant) #1 was in the hallway. She confirmed that she was assigned to Resident #62. She was asked about the physician ordered TED hose. She stated, I didn't help her get dressed today, the nurse did. I don't know if she is supposed to be wearing TED hose or not. She was asked if she had reviewed Resident #62's kardex (daily care guide) prior to caring for her. She stated, I haven't looked at it recently .the nurses tell us what we are supposed to do .I think they put those 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 observation, staff interview, resident interview, clinical record review, and facility document review, the facility staff failed to provide timely treatment for an UTI (urinary tract infection) for one of twenty-one residents, Resident #28. The findings include: Resident #28 was admitted to the facility with the following diagnoses including but not limited to: Diabetes mellitus, quadriplegia, contracture of the left hand, UTI, and chronic kidney disease. An annual MDS (minimum data set -cms assessment tool) dated 09/02/2022 documented the BIMS (Brief Interview of Mental Status) score as 15 out of 15, indicating Resident #28 was cognitively intact for daily decision making. On 11/01/2022 beginning at approximately 3:00 p.m., a review of the clinical record included progress notes with the following entries: 10/29/2022 22:20 (10:22 p.m.) Positive for UTI. Spoke with [Name redacted]; place PICC line begin ertapenem 1 GM (gram) q (every) 24 hours. 10/31/2022 (Note from nurse practitioner signed 10/31/2022 at 7:51 p.m.) .Infection and inflammatory reaction due to indwelling…

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 and clinical record review, the facility staff failed to obtain physician orders to provide ongoing assessment and care for a colostomy for one of twenty residents in the survey sample. Resident #17 had no current physician orders for care the colostomy and no evidence of daily colostomy site assessments as documented in the comprehensive care plan. The findings include: Resident #17 was admitted to the facility with diagnoses that included inflammatory bowel disease with colostomy, asthma, history of cerebral infarction, diverticulosis, atrial fibrillation, hypothyroidism, depression, anxiety, hypertension and chronic respiratory failure. The MDS (minimum data set - CMS assessment tool) assessment dated [DATE] documented the BIMS (Brief Interview of Mental Status) as indicating intact cognition for daily decision making. On 11/1/22 at 12:06 p.m., when interviewed about quality of care in the facility, Resident #17 stated that she provided care for her colostomy 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.

Based on observation, resident interview, staff interview and facility document review, the facility staff failed to ensure a clean, comfortable and homelike environment in two resident rooms on a portion of B wing, specifically known as the B-Back hall. Findings include: On 11/01/22 at approximately 11:15 AM, Resident #34 was interviewed in his room, which had a bedside commode (used by Resident #34) sitting at the end of the bed. The bedside commode had a dry, smeared brown substance on the inside and around the sides of the bucket. The toilet seat also had a dry, brown substance that was smeared on it. When asked if staff clean the bedside commode, Resident #34 replied, Yes. Additional observations in the room included the following: The built in closet had paint chipped off with large scratches on the front and sides; the cabinet had some scraped, indented areas in the wood along the edges and sides; the resident's sink had a large brownish stain around the drain about 2-3 inches in diameter; the pipe under the sink had a flange ring detached from the wall and hanging on the…

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

Based on complaint investigation, clinical record review, and staff interview, the facility failed to ensure an accurate Minimum Data Set (MDS - a cms assessment tool) for one of 21 residents (Resident # 82) in the survey sample. Resident # 82, who was discharged to home, was incorrectly identified as being discharged to an acute care hospital on a Nursing Home Discharge Minimum Data Set. The findings include: Resident # 82 was admitted to the facility with diagnoses that included a left wrist fracture, cancer, hypertension, generalized muscle weakness, difficulty walking, right below the knee amputation, dysuria, bromhidrosis, frequency of micturition, and urinary urgency. According to a Nursing Home Discharge Minimum Data Set with an Assessment Reference Date of 8/19/2022, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. Under Section A (Identification Information), at Item A2100, Discharge Status, Resident # 82 was identified as being discharged to an acute hospital. Review of the Progress Notes in…

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

Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan for two of twenty residents in the survey sample (Resident #17 & #62). Resident #17's Comprehensive Care Plan (CCP) was not revised regarding the provision of colostomy care. Resident #62's plan of care was not updated to include the physician ordered intervention of therapeutic support hose (TED hose). The findings include: 1. The Comprehensive Care Plan for Resident #17 was not revised to address the provision of colostomy care by the resident. Resident #17 was admitted to the facility with diagnoses that included inflammatory bowel disease with colostomy, asthma, history of cerebral infarction, diverticulosis, atrial fibrillation, hypothyroidism, depression, anxiety, hypertension and chronic respiratory failure. The minimum data set (MDS - cms asssessment tool) dated 9/9/22 assessed Resident #17 as cognitively intact for daily decision making. On 11/1/22 at 12:06 p.m., Resident #17 was interviewed about quality of care 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 and staff interview the facility staff failed to ensure a safe room environment for one of 21 residents, Resident #62. Findings were: Resident #62 was admitted to the facility with hypertension, artherosclerotic heart disease, sick sinus syndrome, presence of cardiac pacemaker, diabetes mellitus, cognitive impairment, and a history of falls. A quarterly MDS (minimum data set - cms assedsment tool) with an ARD (assessment reference date) of 10/07/2022, assessed Resident #62 with a BIMS (Brief Interview for Mental Status) score of 5/15, indicating moderate cognitive impairment for daily decision making. Initial tour of the facility was conducted on 11/01/2022 at approximately 12:00 noon. Resident #62 was observed standing in the doorway of her room. An area of purple/blue discoloration was observed around her right eye. When asked what had happened to her eye, Resident #62 stated, I fall. When asked how she fell, Resident #62 stated, My mattress is slicky. Resident #62 then invited this surveyor into her room and stated, See my mattress? I was getting up and slid…

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, the facility staff failed to develop a comprehensive care plan for two of twenty residents in the survey sample, Residents #37 and #78. Resident #37 had no care plan developed regarding communication. Resident #78 had no plan of care for dehydration prevention. The findings include: 1. Resident #37 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #37 included end stage renal disease, atrial fibrillation, GERD (gastroesophageal reflux disease), hypertension, congestive heart failure, anxiety, depression, glaucoma, irritable bowel syndrome and restless leg syndrome. The minimum data set (MDS) dated [DATE] assessed Resident #37 with moderately impaired cognitive skills. On 4/6/21 at 10:54 a.m., Resident #37 was observed in the hall near her room talking with two staff members. Resident #37 was non-English speaking. On 4/6/21 at 11:20 a.m., a staff member was with Resident #37 in her room using a cell phone…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure a safe bed environment for one of 20 residents (Resident #60); and failed to ensure a medication cart was locked and secure in a resident care area on one of two nursing units (Unit 2). Findings include: 1. Resident #60 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, COPD (chronic obstructive pulmonary disease), affective mood disorder, cognitive communication deficit, hypertension, seizures, depression, heart failure and hyperlipidemia. The minimum data set (MDS) dated [DATE] assessed Resident #60 with severely impaired cognitive skills and as requiring the extensive help of two people for bed mobility and transfers. On 4/7/21 at 8:47 a.m., Resident #60's room and bed was inspected. U-shaped bed rails were in the up position on both sides of the bed near the head of the bed. Resident #60's clinical record documented the resident experienced…

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, the facility staff failed to assess one of twenty residents in the survey sample prior to the use of bed rails. Resident #64 had bed rails in use without a prior assessment for safety, attempted alternatives or informed consent regarding risks/benefits of the rails. The findings include: Resident #64 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction with left sided hemiplegia and hemiparesis, dysphagia, depression, aphasia, vascular dementia, dysarthria, lymphoma and history of COVID-19. The minimum data set (MDS) dated [DATE] assessed Resident #64 with moderately impaired cognitive skills and as requiring the extensive assistance of two people for bed mobility and total assistance of two people for transfers. On 4/6/21 at 3:00 p.m., Resident #64 was observed in bed with u-shaped bed rails up on both sides of the bed. The rails were located near the middle of the bed at the area of the resident's waist.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to ensure one of twenty residents was free from unnecessary medication. Resident #82 had a physician's order for the psychotropic medication lorazepam as needed (prn) for greater than 14 days without a documented rationale for the extended duration of the prescription. The findings include: Resident #82 was admitted to the facility on [DATE] with diagnoses that included anxiety, Alzheimer's, dementia with behavioral disturbance, lumbar disc degeneration, cognitive communication deficit, diabetes and major depressive disorder with psychosis. The minimum data set (MDS) dated [DATE] assessed Resident #82 with short and long-term memory problems and severely impaired cognitive skills. Resident #82's clinical record documented a physician's order dated 3/30/21 for lorazepam 0.5 milligrams (mg) with instructions to give 1 tablet every 8 hours as needed for agitation until 5/31/21. The clinical record documented no rationale for why the prn…

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 food in a sanitary manner in the main kitchen. Findings include: An initial tour of the main kitchen was conducted on 04/06/21 at 10:30 AM with the DM (dietary manager). The dry storage area was observed. Four packs of unopened, soft tortilla shells were observed with an expiration date of 02/11/21. The expiration date was on the original (manufacturer's) packaging. The DM stated that she would dispose of them and wasn't sure why they were still in the dry storage area. A policy was requested on food safety and storage. On 04/06/21 at approximately 2:00 PM, a policy was presented. The policy, Food receiving and storage documented, .non refrigerated foods .will be in a designated dry storage unit .rotated using first in - first out .foods shall be received and stored in manner that complies with safe food handling practices . A food storage chart was provided for reference on shelf life; this food chart did not have a reference for soft tortillas. The DON (director of nursing) 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.

Based on observation, staff interview and facility document review, the facility staff failed to ensure garbage and refuse were disposed of properly. Findings include: An initial tour of the main kitchen was conducted on 04/06/21 at 10:30 AM with the DM (dietary manager). On 04/06/21 at 11:00 AM, the garbage and refuse area and containers were observed. A sack of approximately 10 to 12 heads of cabbage were sitting outside of the dumpster on the ground. The DM was asked why it was on the ground and not in the dumpster. The DM stated that she did not know and opened the dumpster and picked up the sack with the cabbage heads and threw it into the dumpster. An empty milk carton was observed on the ground in front of the dumpster, as well a single latex glove. A policy was requested on garbage and refuse disposal and maintenance. On 04/06/21 at approximately 2:00 PM, a policy was presented. The policy, .Garbage and Rubbish Disposal documented, .All garbage and rubbish containing food wastes shall be kept in containers .Garbage and rubbish containing food wastes will be stored in a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for one of 20 residents in the survey sample, Resident #9. Resident #9's electronic health record failed to indicate the resident's correct code status. The findings include: Resident #9 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, end stage renal disease requiring dialysis, hyperlipidemia, hypothyroidism, muscle weakness and atrial fibrillation. The most recent minimum data set (MDS) dated [DATE] was an annual assessment and assessed Resident #9 as cognitively intact and independent for daily decision making with a score of 15 out of 15. Resident #9's electronic clinical record was reviewed on 04/06/2021. Observed on the resident information screen was the following: Code Status: Full Code Observed on the orders was the following: FULL CODE Active: 01/23/2020. Observed on the care plans was the following: [Resident #9] chooses to be a DNR (Do…

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 follow infection control protocols on one of two nursing units. A housekeeper failed to follow infection control protocols regarding personal protective equipment (PPE) on the A-wing quarantine unit. The findings include: On 4/6/21 at 12:32 p.m., a housekeeping employee (other staff #5) was observed exiting the quarantine unit through the zippered curtain. The housekeeper had on a mask, face shield, gown and gloves. The gown was not tied at the neck or waist, was loosely hanging and partially coming down as the housekeeper walked. The housekeeper went across the hall on the nursing unit and entered the dirty utility room located near the nursing station. The housekeeper immediately came out of the room wearing the same PPE and with a white wheeled cart re-entered the zippered quarantine unit. On 4/7/21 at 11:54 a.m., the registered nurse unit manager (RN #3) was interviewed about the quarantine unit. RN #3 stated the residents on the quarantine unit were on enhanced droplet precautions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to implement interventions to maintain bowel and bladder continence for one of 24 residents in the survey sample. Resident #11 had no interventions implemented for over 3 months in response to an assessed decline in bowel and bladder continence. The findings include: Resident #11 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #11 included anxiety, disc degeneration, Alzheimer's dementia, cataracts, cerebrovascular disease, osteoarthritis, history of breast cancer, dementia with behaviors, depression and diabetes. The minimum data set (MDS) dated [DATE] assessed Resident #11 with severely impaired cognitive skills. Resident #11's clinical record documented a decline in bowel and bladder function starting in February 2019. MDS assessments dated 10/2/18 and 12/26/18 documented Resident #11 was always continent of bowel and bladder function. A bowel and bladder evaluation tool dated 1/10/19…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to ensure one of 24 residents was free from unnecessary medications. Resident #11 had an as needed order for the anti-anxiety medication lorazepam (Ativan) renewed and in place beyond 14 days without a clinical justification and physician specified duration. Resident #11 was administered 37 doses of the as needed lorazepam from [DATE] through [DATE] without documented assessments indicating the need for the medicine or prior attempts at non-pharmaceutical interventions. The findings include: Resident #11 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #11 included anxiety, disc degeneration, Alzheimer's dementia, cataracts, cerebrovascular disease, osteoarthritis, history of breast cancer, dementia with behaviors, depression and diabetes. The minimum data set (MDS) dated [DATE] assessed Resident #11 with severely impaired cognitive skills and having wandering behaviors daily. Resident #11'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview and clinical record review, the facility staff failed to develop a comprehensive care plan for two of 24 residents in the survey sample. 1. Resident #11 had no plan of care developed regarding a decline in bowel and bladder function. 2. Resident #15 had no care plan developed regarding emotional support/grief following the death of a family member. The findings include: 1. Resident #11 had no plan of care developed regarding a decline in bowel and bladder function. Resident #11 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #11 included anxiety, disc degeneration, Alzheimer's dementia, cataracts, cerebrovascular disease, osteoarthritis, history of breast cancer, dementia with behaviors, depression and diabetes. The minimum data set (MDS) dated [DATE] assessed Resident #11 with severely impaired cognitive skills. Resident #11's clinical record documented a decline in bowel and bladder function starting in February 2019. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, document review and staff interview the facility failed to review and revise a comprehensive care plan for one of twenty-four residents. Resident #64's care plan was not revised regarding code status. The findings include: Resident #64 was admitted to the facility on [DATE] with diagnoses that included long-term use of anticoagulants, muscle weakness, dementia without behavioral disturbance, chronic a-fib, pain in right hip and lower back, hypertension, abnormal posture, and cognitive communication deficit. The most recent minimum data set (MDS) dated [DATE], was an annual assessment and assessed Resident #64 as severely cognitively impaired for daily decision making, having long and short term memory problems. Resident #64's clinical record was reviewed on 05/22/19 at 2:30 p.m. Observed on the physician orders was an order for a DNR (Do Not Resuscitate) dated 11/23/18. Additionally, observed was a completed DNR form dated 10/29/18 that was signed by the physician and 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 observation, staff interview and facility document review the facility staff failed to follow professional standards of practice for one of 24 residents in the survey sample: Resident # 16. Resident # 16 was not instructed to rinse his mouth after administration of an inhaled corticosteroid medication. Findings include: On 5/22/19 beginning at 7:45 a.m. a medication pass and pour observation was conducted with LPN (licensed practical nurse) # 1. Resident # 16 had wheeled himself to the medication cart and asked for his medications. One of the medications administered to Resident # 16 was Symbicort 160/4.5, an inhaled medication for asthma and COPD. LPN # 1 stated He gets two puffs; I give one puff, then his oral meds, then the other puff. The resident was not encouraged or instructed after each puff to rinse his mouth and spit. During reconciliation 5/22/19 at 8:45 a.m. of the medications administered to Resident # 16 was a current order for Symbicort 160/4.5 2 puffs twice a day. On 5/22/19 at 9:00 a.m. the administrator was asked for a policy for inhaled medications or 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, the facility staff failed to ensure a safe transfer for one of 24 residents in the survey sample. The legs of a mechanical lift were not locked prior to transferring Resident #49 from his bed to a wheelchair. The mechanical lift turned over during the transfer with Resident #49 experiencing a skin tear on his nose as a result of the incident. The findings include: Resident #49 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #49 included quadriplegia, heart failure, history of kidney transplant, neuromuscular dysfunction of bladder, diabetes, depression, high blood pressure, diabetic neuropathy and sleep apnea. The minimum data set (MDS) dated [DATE] assessed Resident #49 as cognitively intact and as totally dependent upon two people for mobility and transfers. Resident #49's clinical record documented a nursing note dated 1/15/19 stating, At approximately 11:30 a.m. this…

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 and clinical record review, the facility staff failed to perform a social service assessment and develop care interventions regarding grief/emotional support for one of 24 residents in the survey sample. Resident #15, with a recent death of a family member, had no assessment by social services to determine emotional care needs and grief support following the death. The findings include: Resident #15 was admitted to the facility on [DATE] with diagnoses that included cardiomyopathy, atrial fibrillation, hypothyroidism, major depressive disorder, anxiety, restless leg syndrome, high blood pressure and macular degeneration. The minimum data set (MDS) dated [DATE] assessed Resident #15 as cognitive intact and feeling down, depressed and/or hopeless on most days. On [DATE] at 12:09 p.m., Resident #15 was interviewed about quality of life and care in the facility. Resident #15 stated she was frequently sad and was still upset about the recent death of her son. Resident #15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility document review the facility staff failed to ensure medications were properly labeled on one of three medication carts: B-wing front hall. A vial of insulin was opened without an open date and available for administration. Findings include: On [DATE] at 4:30 p.m. the medication cart on B-wing was inspected with RN (registered nurse) # 1. An opened vial of insulin (Humalog) was observed in the medication cart. There was a label on the bottle which documented Discard 28 days after opening. The vial did not have a date indicating when it had been opened. RN # 1 stated Oh, you're right; there's no date . RN # 1 then picked up the vial and stated I'll fix that right now and began to write the current day's date on the vial. This surveyor stopped her asking how she could be sure when the vial was actually opened, and if it had already expired? RN # 1 then stated You have a point; I guess we should take it [to the med room] so we can get a new one. The DON (director…

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.