Three Rivers Health & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, Ombudsman interview, family interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to develop and implement a baseline care plan for cardiac treatment for two residents (Residents #2 and #1) in a survey sample of four (4) Residents. 1. For Resident #2, the facility did not develop nor implement a cardiac care plan for the primary admitting diagnosis of new onset atrial fibrillation, heart attack, with cardiac doctor oversight, and new cardiac medication therapy. 2. For Resident #1, the facility staff did not provide a baseline care plan for moisture associated skin damage (MASD), care for inguinal dialysis shunt placement site, and sutures in the neck and knee after hospitalization. The findings included: 1. Resident #2 was admitted to the facility on [DATE] from the hospital. Diagnoses included, new onset atrial fibrillation, aortic valve stenosis, aortic valve insufficiency, likely acute heart attack,…

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, Ombudsman interview, family interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to maintain the professional standards of nursing practice for two residents (Residents #2 and #1) in a survey sample of four (4) Residents. 1. For Resident #2, the facility staff discontinued all the resident's cardiac, antihypertensive, and blood thinning medications after 30 days for new onset atrial fibrillation. They also failed to notify the family and doctor of the discontinuance, did not obtain follow-up appointments with the resident's doctors as ordered by a physician, and did not develop nor implement a nursing care plan for cardiac treatment. 2. For Resident #1, the facility staff did not provide incontinence care timely resulting in moisture associated skin damage (MASD), and further failed to care for, and care plan for inguinal dialysis shunt placement site, MASD, and sutures in the neck and knee 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 staff interview, facility document review, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure incontinence and wound care was provided timely for 1 resident (Resident #1) of four (4) residents in the survey sample. For Resident #1, the facility staff did not provide incontinence care timely resulting in moisture associated skin damage (MASD), and further failed to care for inguinal dialysis shunt placement site, and sutures in the neck and knee after hospitalization. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses including, acute kidney failure, effusion left knee, diabetes type 2, acute embolism of left femoral vein, left knee pain, hypertension, hypothyroidism, venous insufficiency, stroke, and breast cancer. Resident #1's most recent Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 03/15/2023 was a 5-day admission assessment. The MDS coded Resident #1 as needing extensive to…

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

Based on staff interview and facility documentation review, the facility staff failed to implement their abuse policy regarding the screening of employees for 4 employees (CNA F, CNA G, LPN C, and RN B) in a sample of 25 employee records reviewed. CNA F, CNA LPN C faild to sign their sworn statements timely, or completely. RN B did not have reference checks. The findings included: On 7/28/21, a review of a sample of 25 of the facility's employee files was conducted by Surveyor E. The reviews revealed the following: 1. CNA F's hire date was confirmed as 8/10/20. CNA F signed a sworn statement on 1/23/2021. Therefore, CNA F had not sworn to not having any convictions or pending charges of barrier crimes from 8/10/20-1/23/21, prior to being permitted to provide direct care to Residents. In addition, on the sworn statement signed 1/23/21, CNA F failed to answer questions 2 and 3. These questions asked if he/she had Ever been convicted of a law violation(s) but excluding offenses committed before your eighteenth birthday that were finally adjudicated in a juvenile court or under a youth…

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 documentation review, the facility staff failed to store and prepare foods in accordance with professional standards in one out of one facility kitchens. Specifically, the facility staff failed to: 1) measure food temperatures for cold and steam table foods for lunch and dinner on 07/23/2021; and all 3 meals on 07/24/2021, 07/25/2021, and 07/26/2021 (11 out of 12 meals). 2) ensure the #4 walk-in refrigerator, #8 freezer, and #8 low-boy freezer were maintained at acceptable temperature ranges on 07/20/2021- 07/26/2021. 3) ensure dishwasher was reaching acceptable temperatures during the wash and rinse cycles in order to properly sanitize dishes on 07/10/2021, 07/13/2021, 07/21/2021, 07/22/2021, and 07/26/2021. The findings included: On 07/27/2021 at 7:55 A.M., Employee C, a cook, was interviewed in the kitchen. Employee C verified she has worked in the kitchen for 25 years. When asked about the temp logs, Employee C presented a log book and stated all the logs are in the one book. Employee C and this surveyor observed the logs 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 Resident and Staff interview, clinical record review and facility documentation the facility staff failed to treat Residents with respect and dignity for 1 Resident (#28) in a survey sample of 22 Residents. For Resident # 28 the facility staff undressed the Resident wrapped her in a sheet, put her in the shower chair and wheeled her down the hall to wait in line for a shower causing Resident to state it feels like punishment. The findings included: Resident number 28, an [AGE] year old woman admitted to the facility on [DATE], with diagnoses of but not limited to anemia, hypertension, hypothyroidism, Rheumatoid arthritis and major depressive disorder. Resident #28's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/7/21, coded the Resident as having a BIMS (Brief Interview of Mental Status) score of 10. Section G coded this resident as (3) extensive assistance with one person physical assist for bed mobility, (4) total dependence for transfers requiring two persons or more…

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

Based on observation, interview, facility record review the faculty staff failed to provide Residents with a written description of legal rights which includes the names and addresses and phone numbers of State Office of Licensure and Certification, LTC agencies and Ombudsman. The findings included: For the 10 of the 10 Residents attending Resident Council on 7/27/21 at 2:30 PM the facility staff have not verbally told them and have not given them in writing a list of the agencies with which they may file a formal complaint. On 7/27/21 during the Resident Council meeting 10 of the 10 Residents that attended, (including the Resident Council President), stated they did not know how to file a grievance, and they did not know they could file a formal complaint with the Ombudsman, and they did not know they could file a complaint with the State Office of Licensure and Certification. Only 1 Resident out of 10 Residents in attendance knew that the Survey Results were available in the lobby area. On 7/28/21 a review of the new admission packet revealed that there was a document in 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, clinical record review, and in the course of a complaint investigation, the facility staff failed to notify the responsible party of a change of condition for 1 Resident (Resident #13) in a sample size of 22 Residents. The findings included: 1) For Resident #13, the facility staff failed to notify the responsible party regarding: a) a procedure performed on Resident #13 by the podiatrist on 07/30/2020. b) the discovery of a right heel wound on 09/02/2020. Resident #13, a [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses for Resident #13 included but were not limited to diabetes mellitus, dementia, and aphasia. Resident #13's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 05/10/2021 was coded as an annual assessment. The Brief Interview for Mental Status was not assessed. On 07/28/2021 at approximately 5:30 P.M., in the course of a complaint investigation, documentation concerning an abscess around the time of July 2020 was requested.…

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 documentation review and clinical record review, the facility staff failed to complete a SNF ABN (Skilled Nursing Facility Advance Beneficiary Notice) for 1 Resident (Resident #27) in a survey sample of 3 Residents reviewed for Beneficiary Notifications. For Resident #27, the facility staff failed to provide a SNF ABN notice prior to skilled care services ending. As a result of this deficient practice Resident #27 was not afforded the opportunity to continue skilled care services and have Medicare make a determination about coverage of such services, known as a demand bill. The findings included: Resident #27, was admitted to the facility on [DATE], with a readmission date of 5/1/21. Resident #27's diagnoses included but were not limited to: Severe Hyperkalemia, Acute Kidney Injury Stage III, and UTI (urinary tract infection). Resident #27's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 5/6/21 was coded as an admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to develop a comprehensive care plan for one Resident (Resident #13) in a sample size of 22 Residents. For Resident #13, the facility staff failed to include: 1) focus, goals, and interventions addressing his pressure wounds 2) focus, goals, and interventions addressing his limited range of motion. The findings included: Resident #13, a [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses for Resident #13 included but are not limited to diabetes mellitus, dementia, aphasia, reduced mobility, and generalized muscle weakness. Resident #13's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 05/10/2021 was coded as an annual assessment. The Brief Interview for Mental Status was not assessed. On 07/27/2021 at 8:53 A.M., Resident #13 was observed in his bed. Resident #13 was positioned on his back with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review and facility documentation the facility staff failed to provide adequate care for 1 dependent (#28) in a survey sample of 22 Residents. The findings included: Resident number 28, an [AGE] year old woman admitted to the facility on [DATE], with diagnosis of but not limited to anemia, hypertension, hypothyroidism, Rheumatoid arthritis and major depressive disorder. Resident #28's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/7/21, coded the Resident as having a BIMS (Brief Interview of Mental Status) score of 10. Section G coded this resident as (3) extensive assistance with one person physical assist for bed mobility, (4) total dependence for transfers requiring two persons or more physical assistance and the use of mechanical lift, she is coded as (3) extensive assistance one person physical assistance for dressing, she is independent with set up help only for meals, she is coded as (4) total dependent for toileting, 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 observations, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to provide appropriate treatment and services for the prevention of further decrease in range of motion for one Resident (Resident #13) in a sample size of 22 Residents. For Resident #13, the facility staff failed to provide a left palm guard on 07/27/2021 and 07/28/2021 as ordered by the physician. The findings included: Resident #13, a [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses for Resident #13 included but are not limited to diabetes mellitus, dementia, aphasia, reduced mobility, and generalized muscle weakness. Resident #13's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 05/10/2021 was coded as an annual assessment. The Brief Interview for Mental Status was not assessed. On 07/27/2021 at 8:53 A.M., Resident #13 was observed in his bed. Resident #13 was positioned on his back with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, and clinical record review, the facility failed to provide oxygen therapy consistent with infection control measures and the plan of care for 2 Residents (Resident # 17 and # 19) in a survey sample of 22 Residents in the survey sample. Findings included: 1. For Resident # 17, the facility staff failed to change the oxygen tubing and humidifier bottle weekly as ordered. Resident # 17 was a [AGE] year-old who was admitted to the facility on [DATE] with diagnoses of but not limited to: Acute and Chronic Respiratory Failure, Hypoxia, Hypercapnia, Supraventricular tachycardia, Chronic Diastolic Heart Failure, Chronic Obstructive Pulmonary Disease, Bilateral Osteoarthritis of Knee and Hypertension. The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of /11/2017. The MDS coded Resident # 17 with a BIMS (Brief Interview for Mental Status) of 15/15 indicating no cognitive impairment; the resident required…

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

Based on observation, interview, and document review, the facility failed to post the nurse staffing timely and daily, resulting in the potential for inaccurate information to be presented to residents and visitors. Findings included: During an observation on 07/27/21 at 9:30 AM, there was no daily nursing staff report posted in the main lobby nor on any of the bulletin boards in the hallway or near the nurses station. On 07/29/21 at 9:55 AM, an interview was conducted with the Director of Nursing who stated the facility did have the nurse staffing hours posted. The Director of Nursing was asked to show Surveyor B where the staffing hours were posted. The Director of Nursing went to the nurses station, opened a drawer and retrieved a black notebook that held a daily schedule. When Surveyor B asked if the information was posted where the general public could view it, the Director of Nursing stated no. The Director of Nursing stated the facility used to have the posting of the nurse staffing hours on a bulletin board near the Solarium Room near the Nurses station. She stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed for 1 resident (Resident # 540) in the survey sample of 22 residents, to ensure medications were available for administration. For Resident # 54, the facility staff failed to provide medications as ordered by the Physician. The findings included: For Resident # 54, the facility staff failed to provide medications as ordered by the Physician. Resident #54 was admitted to the facility on [DATE]. Diagnoses for Resident # 54 included but were not limited to: CVA (cerebrovascular accident), Hypertension,, Diabetes, peripheral vascular disease, major depressive disorder and fracture of left humerus. Resident # 54's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 7/8/2021 coded Resident # 54 with a BIMS (brief interview of mental status) score of 15 out of 15 indicating no cognitive impairment. Activities of Daily Living care. Resident # 54 was coded as requiring extensive assistance of 2 person physical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review, and facility documentation the facility staff failed to ensure 1 Resident (Resident #6 ) in a survey sample of 22 Residents, was free of significant medication errors. For Resident #6, the facility staff failed to provide the Resident with 10 doses Sevelamer Carbonate between 6/10/21 and 7/22/21. The findings included: Resident #6, a [AGE] year old man admitted to the facility on [DATE] with diagnoses of but not limited to end stage renal disease, dialysis dependent, hypertension, progressive neuropathy, idiopathic gout, difficulty walking, and anemia in kidney disease. Resident #6's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 4/25/21 coded the Resident as having a BIMS (Brief Interview of Mental Status) score of 14 out of 15 indicating no cognitive impairment. The Resident was also coded as requiring limited assistance 1-2 persons with transfers, dressing and total assistance for bathing. He is coded as requiring set up and or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review and facility documentation the facility staff failed to ensure the Residents had access to services outside the facility for 1 Resident (#19) in a survey sample of 22 Residents. For Resident #19 the facility staff failed to ensure he had transportation to the wound clinic and subsequently had to reschedule 7 appointments. The findings included: Resident #19, a [AGE] year old man admitted to the facility on [DATE] with diagnoses of but not limited to COPD, oxygen dependent, major depressive disorder, chronic A-Fib, peripheral vascular disease, chronic respiratory failure, hypertension, intervertebral disc degeneration and neuromuscular dysfunction of bladder. Resident #19's most recent MDS (minimum data set ) with an ARD (assessment reference date) of 5/18/21, a quarterly review, coded the Resident as having a BIMS (Brief Interview of Mental Status) score of 13, indicating mild cognitive impairment. The MDS also coded the resident as requiring extensive…

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, group interview and staff interview and clinical record review, the facility staff failed to maintain a dignified existence for one resident (Resident # 33) in a survey sample of 27 residents. For Resident # 33, the facility staff failed to toilet her timely resulting in an incontinent episode. Findings included: Resident # 33 was a [AGE] year old female, was admitted to the facility on [DATE]. Her diagnoses included but were not limited to: Pneumonia, Diabetes Mellitus, Edema, Hypertension, Rheumatoid Arthritis, [NAME] -Chiari Syndrome without Spina Bifida, Spondylosis with Myelopathy, Cervical Region, Difficulty Walking, Spinal Stenosis, Abnormality of Gait, Degenerative Joint Disease and Unspecified Ptosis of Bilateral Eyelids. Resident 33's most recent MDS (minimum data set) with an ARD (assessment reference date) of 9/19/2018 was coded as a Quarterly assessment. She was coded as having a BIMS (Brief Interview for Memory Status) code of 15 indicating no cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and facility documentation review, the facility staff failed to provide notice to Resident #38's responsible party of a change in Medicare or Medicaid coverage in a survey sample of 27 residents. Findings: Resident #38 was admitted on [DATE]. A partial list of her diagnoses included: difficulty walking and Alzheimer's disease. Resident #38 received Medicare Part A skilled services to include physical and occupational therapy. She was discharged on 7/21/208, and readmitted on [DATE]. Her most recent comprehensive assessment was dated 8/7/2018, and showed that Resident #38 needed extensive staff assist with all self-care. The resident was listed as having significant cognitive impairment in the Brief Interview for Mental Status (BIMS) portion of the assessment. Due to the resident's cognitive impairment, her daughter executed a healthcare Power of Attorney, and was listed as the responsible party. The facility determined that Resident #38's Medicare Part A coverage would end on 8/9/2018.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and facility documentation review the facility failed to notify a receiving provider of the resident's comprehensive care plan goals for one of 27 sampled residents (Resident #20). Findings: Resident #20 was admitted to the facility on [DATE]. Partial listing of her diagnoses include: impaired gait, stroke, psychotic disorder with delusions, and dementia. On 10/7/2018 at 4:25 AM, Resident #20 was sent emergently to the hospital after a fall resulting in hip pain. The provider sent transfer paperwork with the resident which included an INTERACT (Interventions to reduce acute care transfers) tool. While this tool has a space to record care plan goals, none was listed. On 11/1/2018, at 10:10 AM, an interview was held with Employee F, the corporate Quality Control nurse. When asked if the resident's care plan goals were sent to the hospital, she replied No. No other information was provided prior to exit.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility documentation review and clinical record review the facility staff failed to provide an environment free from accident hazards for 2 residents (Resident #49 and #55) of 27 residents in the survey sample. 1. Resident #49 was not observed wearing a wander guard or gripper socks per physician order. 2. Resident #55's wheel chair breaks were not applied when transferred by the Certified Nursing Assistant (CNA) resulting in a fall. The findings included: 1. Resident #49 was not observed wearing a wander guard per physician order or gripper socks per the comprehensive care plan. Resident #49, an [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included hypertension, chronic obstructive pulmonary disease, depression, anxiety, and vascular dementia. The most recent Minimum Data Set assessment was a 14 day assessment with an assessment reference date of 9/20/18. Resident #49 was coded with a Brief Interview of Mental Status score of 9 indicating moderate…

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, group interview and staff interview and clinical record review, the facility staff failed to provide continence services for one resident (Resident # 33) in a survey sample of 27 residents. For Resident # 33, the facility staff failed to toilet her timely resulting in an incontinent episode. Findings included: Resident # 33 was a [AGE] year old female, was admitted to the facility on [DATE]. Her diagnoses included but were not limited to: Pneumonia, Diabetes Mellitus, Edema, Hypertension, Rheumatoid Arthritis, [NAME] -Chiari Syndrome without Spina Bifida, Spondylosis with Myelopathy, Cervical Region, Difficulty Walking, Spinal Stenosis, Abnormality of Gait, Degenerative Joint Disease and Unspecified Ptosis of Bilateral Eyelids. Resident 33's most recent MDS (minimum data set) with an ARD (assessment reference date) of 9/19/2018 was coded as a Quarterly assessment. She was coded as having a BIMS (Brief Interview for Memory Status) code of 15 indicating no cognitive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review the facility staff failed to ensure oxygen was available for 1 residents (Resident #55) of 27 residents in the survey sample. Resident #55 was observed seated in her wheelchair in the hallway wearing a nasal cannula for oxygen. The tubing was connected to a portable oxygen tank that was empty. The findings included: Resident #55, a [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, emphysema, reflux, epilepsy, and osteoarthritis. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 10/10/18. Resident #55 was coded with a Brief Interview of Mental Status score of 5 indicating severe cognitive impairment and required extensive assistance with activities of daily living. Resident #55 had a physician order dated 8/7/18 for oxygen 2 liters per minute via nasal cannula as needed. On 10/31/18 at 2:55 p.m., Resident #55 was observed…

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 ensure medication was available for administration for 1 residents (Resident #107) of 27 residents in the survey sample. For Resident #107, a Vitamin B-12 injection was unavailable during the medication pour and pass observation. The findings included: Resident #107, a [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included peripheral vascular disease, amputation, depression, vascular dementia, insomnia, epilepsy, stroke and hypertension. As Resident #107 was new to the facility, a Minimum Data Set assessment had not been completed. On 10/31/18 at 10:50 a.m., a medication pour and pass observation was conducted with Licensed Practical Nurse A (LPN A). While preparing medications for Resident #107, LPN A stated that the Vitamin B-12 was a new order and it was not available so she would hold the medication. Resident #107 took all of his other medications during the observation. Resident #107'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.