Evergreen Health And Rehabilitation Center

Based on observation, staff interview, and facility document review, the facility staff failed to maintain a sanitary environment in one of one kitchen. The findings include: The facility staff failed to maintain a clean main kitchen meat slicer, floors, microwave, and wet nesting of mugs. On 1/08/24 at 12:22. p.m., an observation was made of the main facility kitchen. The food slicer had food particles on the slicer. The microwave was visibly dirty with food particles. The floors had food particles and were greasy. The food trays and cups for residents were stacked on each other on a tray and had water droplets in between them. Cups had water droplets in them as well. On 1/08/24 at 12:23 p.m., OSM (other staff member) #11, the dietary manager stated that the cups were drying and ready for service and that they did not have enough drying racks to properly dry the residents' cups and trays. He stated that the floor has been an issue for some time, that the floor needs a power wash, and that it was not clean and needed to be cleaned this week. OSM #11 stated that the meat slicer did…

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

Based on staff interview and facility document review, it was determined the facility staff failed to have a written dialysis agreement for one of one dialysis residents in the survey sample, Resident #99. The findings include: The facility failed to evidence a written dialysis agreement for Resident #99 with one dialysis center. A review of the physician's order dated 9/21/23, included: Dialysis on Monday, Wednesday, and Friday. Pick up at 6am. During the entrance conference to the facility on 1/8/24, a request was made for the dialysis contracts or agreements to be provided. On 1/9/24 at 4:00 PM, ASM (administrative staff member) #2, the director of nursing stated, We do not have a dialysis contract for this company who has this resident. We have called them and are waiting for them to send it. The administrator thought she had it but she does not. On 1/10/24 at 12:45 PM, ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing and ASM #4, the regional director of clinical operations was made aware of the findings. According to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, the facility staff failed to implement the COVID-19 vaccination policy for four of five resident immunization reviews, Residents #95, #10, #98, and #12. The findings include: The facility policy titled, COVID-19 Vaccination for Residents documented, 3) Residents will be encouraged to accept COVID-19 vaccinations in accordance with CDC (Centers for Disease Control) guidance. CDC recommends the 2023-2024 updated COVID-19 vaccines: Pfizer-BioNTech, Moderna, or Novavax, to protect against serious illness from COVID-19. This information was obtained from the website: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html For Residents #95, #10, #98, #12 and CNA (certified nursing assistant) #4, the facility staff failed to offer/provide the 2023/2024 COVID-19 vaccination. Resident #95 (R95) was admitted to the facility on [DATE]. A review of R95's clinical record revealed the most recent COVID-19 vaccination…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to assess one of 42 residents in the survey sample for safe self-administration of medications, Resident #134. The findings include: For Resident #134 (R134), the facility staff failed to assess the resident for self-administration of an Albuterol inhaler (1) that was left at the resident's bedside for as needed use. On the most recent MDS (minimum data set) assessment, an admission assessment with an ARD (assessment reference date) of 11/15/2023, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating that they were cognitively intact for making daily decisions. On 1/8/2024 at 3:11 p.m., an observation was made of R134 in their room. R134 was observed sitting in bed with the overbed table to their right side. An Albuterol inhaler was observed on top of the overbed table. At that time an interview was…

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

Based on staff interview and clinical record review, it was determined the facility staff failed to notify the physician or nurse practitioner, when medications were not available for administration for two of 42 residents in the survey sample, Resident #110 and #95. The findings include: 1. For Resident #110, the facility staff failed to notify the physician/nurse practitioner when the Tramadol (used to treat pain) was not available for administration. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/10/2023, the resident scored a 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired for making daily decisions. The physician order dated, 12/21/2023, documented, Tramadol Oral Tablet 50 MG (milligrams); Give 1 tablet by mouth every 8 hours for wrist pain for 14 days. The MAR (medication administration record) for December 2023 documented the above order. On the following dates and times there was a 9 documented in the box for administration of the…

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

Based on staff interview and clinical record review, it was determined that the facility staff failed to provide notice of Medicare non-coverage for one of three beneficiary protection notification resident reviews, Resident #413. The findings include: For Resident #413 (R413), the facility failed to provide the resident and/or the resident's representative with an ABN (Advance Beneficiary Notice of Non-coverage) waiver of liability when a change in coverage occurred. R413's last covered day of Medicare part A services was 10/3/2023. R413 was admitted to the facility with diagnoses that included but were not limited to acute CVA (cerebrovascular accident). On 1/10/2024 at 10:50 a.m., an interview was conducted with OSM (other staff member) #2, social services assistant. OSM #2 stated that as soon as they were notified that a resident was being cut from skilled services they reached out to the resident and/or the responsible party to notify them and provide the notice of non-coverage. She stated that they had them sign the notice and documented it in the clinical record and typically…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that bed hold notification was provided when three out of 42 residents in the survey sample were transferred to the hospital, Residents #96, Resident #99, and Resident #125. The findings include: 1. The facility staff failed to evidence provision of bed hold notification at the time of discharge for Resident #96. Resident #96 was transferred to the hospital on 9/9/23. A review of the progress note dated 9/9/23 at 2:19 PM revealed, Sent to ER (emergency room) due to critical value WBC (white blood cell count) . A review of the progress note dated 9/9/23 at 6:48 PM, revealed, Resident admitted to hospital . There was no evidence that written bed hold information was provided for Resident #96. On 1/9/24 at 1:30 PM, an interview was conducted with LPN (licensed practical nurse) #1. When asked who provides the bed hold, LPN #1 stated, We send a bed hold paper but I do not know…

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

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to accurately code an MDS (minimum data set) assessment for one of 42 residents in the survey sample, Resident #75. The findings include: For Resident #75, the facility staff incorrectly coded the resident, on the MDS, as receiving insulin during the look back period. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/8/2023, the resident scored a 0 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired for making daily decisions. In Section N - Medications, the resident was coded as receiving two insulin injections in the past seven days. Review of the physician orders dated 9/25/2023, documented, Trulicity Subcutaneous Solution Pen Injector 3 MG/0.5 ML (milligrams per milliliter); inject 3 mg subcutaneously in the afternoon every seven days related to type 2 diabetes. Review of the MAR (medication administration record) for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interview, staff interviews, and facility document review, it was determined the facility staff failed to implement the comprehensive care plan for one of 42 residents in the survey sample, Resident #99. The findings include: For Resident #99, the facility staff failed to implement the comprehensive care plan interventions for nutritional risk. Resident #99 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: ESRD (end stage renal disease). A review of the comprehensive care plan dated 9/21/23 included, FOCUS: The resident has nutritional problem at nutritional risk related to ESRD, DM. Resident has ESRD and receives dialysis on Monday, Wednesday, and Friday. INTERVENTIONS: Provide, serve diet as ordered. renal, 1500 ml fluid rest [restriction] Monitor intake and record every meal. Provide supplements as ordered. Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis on Monday, Wednesday, and Friday. A…

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

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to follow professional standards of practice for the administration of medications, for one of 42 residents in the survey sample, Residents #110. The findings include: For Resident #110, the facility staff failed to administer Tramadol (used for pain) per the physician orders. The physician order dated, 12/21/2023, documented, Tramadol Oral Tablet 50 MG (milligrams); Give 1 tablet by mouth every 8 hours for wrist pain for 14 days. The MAR (medication administration record) for December 2023 documented the above order. On the following dates and times there was a 9 documented in the box for administration of the medication. A 9 indicated, Other/See progress notes. 12/23/2023 at 7:00 a.m.; 12/23/2023 at 11:00 p.m.; 12/24/2023 at 7:00 a.m.; 12/24/2023 at 3:00 p.m.; 12/25/2023 at 3:00 p.m. and 11:00 p.m.; 12/26/2023 at 7:00 a.m. and 11:00 p.m.; 12/27/2023 at 7:00 a.m.; 12/28/2023 at 7:00 a.m., and 12/30/2023 at 3:00 p.m. A 5 was documented on 1/25/2023 at 7:00 a.m.…

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

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide foot care to one of 42 residents in the survey sample, Resident #7. The findings include: For Resident #7 (R7), the facility staff failed to trim the resident's toenails. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 11/9/23, R7 was coded as requiring substantial/maximum assistance with personal hygiene. R7 was admitted to the facility with a diagnosis of vascular insufficiency. On 1/8/24 at 2:16 p.m., R7 was observed sitting up in bed. Both of the resident's feet were uncovered. The toenails on both feet were long, extending more than one centimeter over the end of the toes. Both great toes were thick and hard. A review of the list of resident's on R7's unit who were to be seen on the next visit by the podiatrist did not contain R7's name. On 1/8/24 at 2:43 p.m., LPN (licensed practical nurse) #5 accompanied the surveyor to observe R7's toenails. LPN #5 stated if a resident does not…

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

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services for hand contractures for one of 42 residents in the survey sample, Resident #2. The findings include: For Resident #2 (R2), the facility staff failed to provide evidence of assessment of R2's hand contractures, or of implementing interventions to prevent worsening of the contractures. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/28/23, R2 was coded as having functional limitation on both sides in both upper and lower extremities. R2 was admitted to the facility with a diagnosis of cerebral palsy. On the following dates and times, R2 was observed lying in bed; and at all of these observations, both of R2's hands were severely contracted: 1/8/24 at 2:05 p.m. and 4:14 p.m.; and 1/8/24 at 3:09 p.m. A review of R2's clinical record, including the resident's comprehensive care plan, revealed no evidence of assessments of R2's hand contractures, or of interventions attempted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interviews, staff interview, clinical record review, and facility document review it was determined that the facility staff failed to provide respiratory care and services consistent with professional standards of practice for three of 42 residents, Resident #134, #398, and #21. The findings include: 1. For Resident #134 (R134), the facility staff failed to store a nebulizer mask (1) in a sanitary manner when not in use, and obtain a physician order for an Albuterol inhaler (2) left at the bedside for as needed use. On the most recent MDS (minimum data set) assessment, an admission assessment with an ARD (assessment reference date) of 11/15/2023, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating that they were cognitively intact for making daily decisions. On 1/8/2024 at 3:11 p.m., an observation was made of R134 in their room, sitting in bed with the overbed table to their right side. An Albuterol inhaler was observed on top…

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

Based on staff interview, facility document review and employee record review, the facility staff failed to provide mandatory training for five of five CNA (certified nursing assistant) records reviewed, CNAs #8, #9, #10, #11, and #12. The findings include: For CNAs #8, #9, #10, #11, and #12, the facility staff failed to provide mandatory dementia training. The Sufficient and Competent Staffing facility task review revealed no evidence of mandatory training for CNAs #8, #9, #10, #11, and #12. On 1/10/24 at 10:55 a.m., RN (registered nurse) #1, the staff educator, was interviewed. She stated that they were switching education systems. She also stated, Dementia care should be in the training. It is mandatory. She also stated that she is new to long term care. On 1/10/24 at approximately 1:50 p.m., ASM#4, the regional director of clinical operations, was informed of these concerns. He stated, We will look for that. On 1/10/24 at 12:42 p.m., ASM (administrative staff member) #1, the administrator, #2 the director of nursing, #4 the regional director of clinical operations, and #5 the…

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

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to provide pharmacy services for one of 42 residents in the survey sample, Resident #95. The findings include: For Resident #95, the facility staff failed to administer Debrox (a medication to soften ear wax) per the physician order. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 10/6/2023, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is not cognitively impaired for making daily decisions. The physician order dated, 1/4/2024, documented, Debrox Solution 6.5% (carbamide peroxide) instill 5 drops in both ears two times a day, flush ears upon completion of treatment for 4 days. The nurse practitioner note dated, 1/4/2024 documented in part, Chief complaint: impacted ear wax .Plan: Order Debrox. The MAR (medication administration record) for January 2024 documented the above order. The MAR documented the following: 1/4/2024 at…

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

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to administer medications at an error rate less than 5% to one of five residents in the medication administration observation, Resident #140. This resulted in a total of two medication errors in a total of 36 administration opportunities, and a calculated medication error rate of 5.56%. The findings include: For Resident #140 (R140), the facility staff failed to administer the correct dosages of iron and Vitamin C during the medication administration observation on 1/9/24. On 1/9/24 at 8:18 a.m., LPN (licensed practical nurse) #6 was observed as she prepared to administer medications to R140. LPN #6 poured one tablet of Vitamin C 500 mg (milligrams) and one tablet of Iron 325 mg into the resident's medication cup. The resident was observed to swallow all medications in the cup. A review of R140's physician's orders revealed the following order, dated 12/31/23: Iron-Vitamin C Oral Tablet 100-250 MG (Iron-Vitamin C). Give 1 tablet by mouth one time a day for anemia.…

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

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain a complete and accurate clinical record for one of 42 residents in the survey sample, Resident #75. The findings include: For Resident #75, the facility staff failed to maintain a complete and accurate clinical record, as evidenced by two other resident's information in the documents section of the clinical record, Residents #58 and Resident #53. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/8/2023, the resident scored a 0 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired for making daily decisions. Review of the documentation in the clinical record, revealed a document, dated 6/21/2023, from the insurance company, documenting the reason for care at the facility for continued insurance coverage, for Resident #75, Resident #58 and Resident #53. An interview was conducted with RN (registered nurse) #4, the MDS…

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

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to store food in a sanitary manner in 1 of 1 facility kitchens. The findings include: On 4/12/22 at approximately 12:15 PM, the kitchen tour was conducted with OSM #7 (Other Staff Member) the Dietary Manager. The reach-in fridge was identified to contain a pan of bacon and sausage, a pan of beef patties, a pan of ground beef, a pan of tomato soup, and a pan of creamed corn, all which were not labeled and dated. This reach-in fridge also contained a pan of pancakes and toast and a pan of scrambled eggs, neither which were properly covered. Both pans had plastic wrap over them, which was pulled back on one side, exposing the food items to the environment of the reach-in fridge. A walk-in fridge contained a box of lettuce that were bagged. A bag was open with lettuce sticking out, exposing the lettuce to the environment in the walk-in fridge. On 4/12/22 at approximately 12:30, OSM #7 stated that these items should be covered, labeled and dated. The facility policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, the facility staff failed to evidence discussion of an advance directive for six of 45 residents in the survey sample, Resident #110, #47, #50, #111, #61 and #58 The findings include: 1. The facility staff failed to evidence documentation of a discussion regarding advance directives for Resident #110 (R110). On the most recent MDS (minimum data set) a quarterly assessment, with an ARD (assessment reference date) of [DATE], the BIMS (brief interview for mental status) was not coded correctly. On the prior MDS assessment, an admission assessment, with an ARD of [DATE], the resident scored a 13 out of 15 on the BIMS score indicating the resident not cognitively impaired for making daily decisions. Further review of the clinical record failed to evidence any documentation regarding a discussion regarding an advance directive. The comprehensive care plan dated [DATE], documented in part, Resident has established Do not resuscitate (DNR)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that all required information was provided to the hospital staff when five out of 45 residents in the survey sample were transferred to the hospital; Residents #94, #59, #124, #95 and #10. The findings include: 1. The facility staff failed to provide evidence that all required information was provided to the hospital staff when Resident #94 was transferred to the hospital on 2/16/22. Per the facility's Transfer Check List which includes the following documents: eINTERACT (interventions to reduce acute care transfers) V5 care form, face sheet, DNR (do not resuscitate)/advanced directives, notice of transfer or discharge form, bed hold form, recent history, MAR/TAR (medication administration record/treatment administration record), care plan, immunization report, pertinent labs, pertinent tests/diagnostics, provider progress notes/assessments and belongings. No evidence 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence written documentation to the Resident or RP (responsible party) and ombudsman upon transfer to the hospital for five out of 45 residents in the survey sample; Residents #94, #59, #124, #95 and #10. The findings include: 1. The facility staff failed notify the RP and the ombudsman when Resident #94 was transferred to the hospital on 2/16/22. Resident #94 was admitted to the facility on [DATE] with diagnosis included but were not limited to: metabolic encephalopathy, chronic obstructive pulmonary disease and duodenal ulcer. Resident #94's most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 3/14/22, coded the resident as scoring 03 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. The resident was coded as requiring extensive assistance in bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence a bed hold was provided to four out of 45 residents in the survey sample who were transferred to the hospital; Residents #94, #59, #124 and #95. The findings include: 1. The facility staff failed to provide evidence that bed hold information provided to Resident #94 when Resident #94 was transferred to the hospital on 2/16/22. Resident #94 was admitted to the facility on [DATE] with diagnosis included but were not limited to: metabolic encephalopathy, chronic obstructive pulmonary disease and duodenal ulcer. Resident #94's most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 3/14/22, coded the resident as scoring 03 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. The resident was coded as requiring extensive assistance in bed mobility,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to review and revise the comprehensive care plan for 3 of 45 residents in the survey sample; Residents #57, #16, and #54. The findings include: 1. Facility staff failed to review and revise the comprehensive care plan after a fall on 1/8/22, for Resident #57. On the most recent MDS (Minimum Data Set), a 5-day assessment, with an ARD (Assessment Reference Date) of 2/9/22, Resident #57 scored a 8 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely cognitively impaired for making daily decisions. The resident was coded as being dependent on staff for activities of daily living (ADL). A review of the clinical record revealed the following: • A nurse's note dated 1/8/22 that documented, 1420 (2:40 PM)-at this time resident's roommate was yelling out 'HELP and resident's alarms sounding, staff ran to room when approached doorway staff…

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

Based on staff interview and facility document review, it was determined that the facility staff failed to complete an annual CNA (certified nursing aide) performance review for five of five CNA record reviews. The facility staff failed to complete an annual performance review for CNA #2, CNA #3, CNA #4, CNA #5 and CNA #6. The findings include: CNA #2 was hired on 3/30/21. A review of CNA #2's record failed to reveal any performance reviews. CNA #3 was hired on 3/18/19. A review of CNA #3's record failed to reveal any performance reviews. CNA #4 was hired on 5/6/13. A review of CNA #4's record revealed the last performance review was completed on 10/1/18. CNA #5 was hired on 11/27/09. A review of CNA #5's record revealed the last performance review was completed on 9/20/18. CNA #6 was hired on 8/1/99. A review of CNA #6's record revealed the last performance review was completed on 9/5/18. On 4/13/22 at 1:58 p.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated performance reviews should be done annually. ASM #2 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 Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide skilled nursing facility advance beneficiary notice of non-coverage (SNFABN) to one of three beneficiary protection notification resident reviews, Resident #106. Resident #106's (R106) last covered day of Medicare part A services was 11/7/21. The facility staff failed to provide the SNFABN to Resident #106 (and/or the resident's representative). The findings include: R106 was admitted to the facility on [DATE] with diagnoses that included but were not limited to cellulitis. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/17/22, the resident scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident is not impaired for making daily decisions. A review of a list of residents who were discharged from Medicare Part A skilled services within the last six months revealed R106 was…

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

Based on staff interview and clinical record review, it was determined that the facility staff failed to maintain a complete MDS (minimum data set) for 2 of 45 residents in the survey sample, Resident #31 and Resident #110. The findings include: 1. The facility staff failed to complete the BIMS (brief interview for mental status) assessment for Resident #31's (R31) quarterly MDS assessment with an ARD (assessment reference date) of 1/24/2022. Section B of R31's quarterly MDS assessment with an ARD of 1/24/2022 coded the resident as being understood. Section C0100 documented the BIMS assessment should be conducted. All of the questions related to the BIMS assessment (C0200 through C0400) and the BIMS summary score were coded as not assessed. On 4/13/2022 at 1:07 p.m., an interview was conducted with OSM (other staff member) #4, the director of social services. OSM #4 stated that the BIMS assessment should be attempted on all residents. OSM #4 stated that R31's BIMS should be coded as a 15, being cognitively intact. OSM #4 reviewed the quarterly MDS with the ARD of 1/24/2022 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, facility document review and clinical record review, it was determined the facility staff failed to implement the comprehensive care plan for one of 45 residents in the survey sample, #57. The findings include: The facility staff failed to follow the comprehensive care plan to have fall mats on both sides of the bed for Resident #57. On the most recent MDS (Minimum Data Set), a 5-day assessment, with an ARD (Assessment Reference Date) of 2/9/22, Resident #57 scored a 8 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely cognitively impaired for making daily decisions. The resident was coded as being dependent on staff for activities of daily living (ADL). On 4/12/22 at 12:55 PM, and on 4/13/22 at 4:00 PM, Resident #57 was observed in bed. There was a fall mat on the door side of the bed (resident's left side.) There was no fall mat on the other side of the bed. A review of the comprehensive care plan revealed one dated 11/17/21 for Resident is at risk for falls related to weakness and unsteady gait.…

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 interviews, staff interviews, clinical record reviews and facility document reviews it was determined that the facility staff failed to ensure 2 of 45 residents were free of safety hazards, Resident #56 and Resident #36. Resident #56 and #36's bed rails were observed to be visibly loose creating a potential safety hazard. The findings include: 1. The facility staff failed to ensure Resident #56's (R56) bed rail was not loose, creating a potential safety hazard. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/8/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident is cognitively intact for making daily decisions. Section G documented R56 requiring extensive assistance from two or more staff members for bed mobility. On 4/12/2022 at 4:10 p.m., an observation was made of R56 in their room. R56 was observed in bed with bilateral upper bed rails on the bed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interviews, staff interviews, clinical record reviews and facility document review it was determined that the facility staff failed to administer oxygen as ordered to two of 45 residents in the survey sample, Resident #93 and #117. The findings include: 1. The facility staff failed to administer oxygen as ordered and in a sanitary manner to Resident #93 (R93). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/13/2022, the resident scored 11 out of 15 on the BIMS (brief interview for mental status) assessment indicating the resident is moderately impaired for making daily decisions. R93 was coded as using oxygen while a resident at the facility. An observation on 4/12/2022 at 1:22 p.m., revealed R93 in bed. An oxygen nasal cannula was observed lying in the floor to the left side of R93's bed. The oxygen concentrator was observed to be on with the oxygen set at 2 lpm (liters per minute). When asked about the oxygen, R93…

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 interviews, staff interviews, clinical record reviews and facility document review it was determined that the facility staff failed to assess 2 of 45 residents in the survey sample for the use of bed rails, Resident #93 and #54. The findings include: 1. The facility staff failed to evidence an assessment for the use of bed rails for Resident #93 (R93). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/13/2022, the resident scored 11 out of 15 on the BIMS (brief interview for mental status) assessment indicating the resident is moderately impaired for making daily decisions. R93 was coded as requiring extensive assistance of two or more staff members for bed mobility. An observation on 4/12/2022 at 1:22 p.m., revealed R93 in bed with bilateral mid bed rails up on the bed. When asked about the bed rails, R93 stated that they use them to turn in bed. Additional observations on 4/12/2022 at 2:45 p.m., 4:18 p.m. and 4/13/2022 at 8:05 a.m. revealed the same observation as stated above. Review of…

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

Based on clinical record reviews, facility document review and staff interview it was determined that the facility failed to maintain a complete and accurate clinical record for one of 45 residents in the survey sample, Resident #31 (R31). The findings include: The facility staff failed to maintain a complete and accurate clinical record documenting insulin administration for R31. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (Assessment Reference Date) of 1/24/2022, the BIMS (brief interview for mental status) assessment was not completed. On the previous quarterly assessment with an ARD of 12/30/2021 the resident scored 15 out of 15 on the BIMS assessment, indicating the resident is not cognitively impaired for making daily decisions. The physician orders for R31 documented in part, - 11/27/2020 Insulin Aspart FlexPen Solution Pen-Injector 100 Unit/ML (milliliter), Inject subcutaneously before meals related to Type 2 Diabetes Mellitus with Diabetic Neuropathy Unspecified. The eMAR (electronic medication administration record) dated…

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

Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to follow infection control practices for one of six residents in the medication administration observation, Resident #16. The findings include: The facility staff failed to wear gloves when administering two insulin injections to Resident #16 (R16). On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 1/20/2022, the resident scored a 3 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is severely cognitively impaired for making daily decisions. The physician orders dated, 3/2/2022, documented, Levemir solution (a long acting insulin used to treat people with type 1 and 2 diabetes) (1) 100 UNIT/ML (milliliter); inject 46 units subcutaneously in the morning for DM (diabetes mellitus). The physician order dated 3/3/2022, documented, Novolog (a short acting insulin used to treat people with type 1 and 2 diabetes)(2) FlexPen Solution Pen-injector…

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

Based on staff interview and facility document review, it was determined that the facility staff failed to ensure CNAs (certified nursing aides) completed required annual in-service training for two of five CNA record reviews. The facility staff failed to ensure CNA #4 and CNA #6 completed annual dementia training. The findings include: CNA #4 was hired on 5/6/13. A review of CNA #4's record failed to reveal evidence that the CNA had completed dementia training. CNA #6 was hired on 8/1/99. A review of CNA #6's record failed to reveal evidence that the CNA had completed dementia training. On 4/13/22 at 3:13 p.m., an interview was conducted with RN (registered nurse) #4 (the staff educator). RN #4 stated dementia training should be completed annually and due to a change in facility ownership and COVID-19, she was behind on making sure CNAs were doing required trainings. On 4/13/22 at 5:02 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Nurse Aide In-Service Training…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility documentation and clinical review, it was determined that the facility staff failed to provide respiratory care services consistent with professional standards of practice, and the comprehensive person-centered care plan for three of 47 residents in the survey sample; Residents #117, #32 and #58. 1. The facility staff failed to ensure a physician's order was in place prior to the administration of oxygen to Resident #117. 2. The facility staff failed to store a nebulizer mask and incentive spirometer (1) in a sanitary manner. 3. The facility staff failed to administer oxygen to Resident #58 per the physician prescribed rate of two liters per minute. The findings include: 1. The facility staff failed to ensure a physician's order was in place prior to the administration of oxygen to Resident #117. Resident #117 was admitted to the facility on [DATE]. Resident #117's diagnoses included but were not limited to: heart failure, Alzheimer's disease and muscle weakness.…

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

Based on staff interview and employee record review it was determined that the facility staff failed to ensure that five of 5 CNA records reviewed received the required 12 hours of annual training's, to include the required training's for Abuse and Dementia Care. The findings include: On 4/25/19, a review was conducted of the annual training's of five CNA's (Certified Nursing Assistants). This review revealed the following missing data: 1. CNA #2 had no evidence of 12 hours of annual training, and no evidence of annual dementia care training. 2. CNA #8 had no evidence of 12 hours of annual training, and no evidence of annual dementia care training. 3. CNA #9 had no evidence of 12 hours of annual training, and no evidence of annual abuse training, and no evidence of annual dementia care training. 4. CNA #10 had no evidence of 12 hours of annual training, and no evidence of annual abuse training. 5. CNA #11 had no evidence of 12 hours of annual training, and no evidence of annual abuse training. On 4/25/19 11:29 AM, in an interview with ASM #2 (Administrative Staff Member, 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, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure that two of five residents in the medication administration observation (Residents #75 and #47) were free of a medication error rate of five percent or less. There were 3 errors out of 25 opportunities and the medication error rate was 12%. 1. The facility staff failed to obtain Resident #75's blood pressure prior to administering a blood pressure medication. The determination as to administer or hold the medication was dependent on the resident's blood pressure, per the physician's order. 2. The facility staff failed to prepare Resident #47's medications appropriately during medication administration observation by crushing iron enteric-coated tablet and isosorbide mononitrate extended release tablet. The findings include: 1. The facility staff failed to obtain Resident #75's blood pressure prior to administering a blood pressure medication. The determination as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and facility document review, it was determined that the facility staff failed to label and store medications according to professional standards in three of seven facility medication carts; (the wing one back hall medication cart, wing two front hall medication cart and wing four medication cart), and in one of four medication refrigerators (the wing 100 medication refrigerator). The facility staff failed to label medication in the wing one back hall medication cart and wing four-medication cart and failed to discard expired medication in the wing one back hall medication cart, wing one medication refrigerator and wing two front hall medication cart. The findings include: On [DATE] at 1:09 p.m., observation of the wing-one back hall, medication cart was conducted. The following was observed: -One open vial of Lantus (1) with an open date of [DATE]. A label on the vial documented Discard After 28 Days. - One open vial of Levemir (2) with no label to include the resident'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 observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide a dignified dining experience for two of 47 residents in the survey sample, Residents #53 and #97. 1. The facility staff failed to serve lunch to Resident #94 in a dignified manner. Another resident seated at the same table as Resident #53 was served a meal and Resident #53 was not served a meal until 27 minutes later. 2. The facility staff stood next to Resident # 97 while assisting them with eating during lunch. The findings include: 1. The facility staff failed to serve lunch to Resident #94 in a dignified manner. Another resident seated at the same table as Resident #53 was served a meal and Resident #53 was not served a meal until 27 minutes later. Resident #53 was admitted to the facility on [DATE]. Resident #53's diagnoses included but were not limited to difficulty swallowing, heart failure and diabetes. Resident #53's 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 that the facility staff failed to notify the physician of a possible need to alter treatment for one of 47 residents in the survey sample, Resident #81. The facility staff failed to notify the physician when Crestor (Rosuvastin) (1) 10 MG (milligram) was not available for administration to Resident #81 on 01/04/19, 01/07/19, and 01/08/19. The findings include: Resident #81 was admitted to the facility on [DATE] with a most recent readmission on [DATE]. Resident #81's diagnoses included but were not limited to hyperlipidemia (2), hypertension (2), and heart failure (3). Resident #81's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 05/02/18, coded the resident as scoring a 15 on the brief interview for mental status (BIMS) of score of 0-15, 15 being cognitively intact for daily decision-making. Section G coded Resident #81 as requiring limited assistance of one…

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 provide the receiving facility, the required documentation upon transfer for three of 47 residents in the survey sample, Residents # 15, # 73, and #114. 1. The facility staff failed to provide the receiving hospital the comprehensive care plan goals upon Resident # 15's transfer to the hospital on 1/1/19 and 1/13/19. 2. The facility staff failed to provide the required documentation to the hospital for a facility initiated hospital transfer of Resident #73 on 2/27/19. 3. The facility staff failed to evidence the comprehensive care plan goals were provided to the receiving facility when Resident #114 was transferred to the hospital on 3/14/19 and 319/19. The findings include: 1. The facility staff failed to provide the receiving hospital the comprehensive care plan goals upon Resident # 15's transfer to the hospital on 1/1/19 and 1/13/19. Resident #15 was admitted to the facility 5/6/05…

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 provide written notification of transfer to the resident and/or resident representative and failed to notify the ombudsman of transfers to the hospital for three of 47 residents in the survey sample, Residents #15, #73 and #114. 1. The facility staff failed to provide written documentation to the resident and/or resident representative for the transfer of Resident #15 to the hospital on 1/13/19. 2. The facility staff failed to provide Resident #73 or the resident's representative (RR) with written documentation of a facility initiated transfer dated 2/27/19. 3. The facility staff failed to provide evidence that the required written notification was provided to Resident #114 and or the representative and ombudsman regarding the reasons for the transfer to the hospital on 3/14/19 and 3/19/19. The findings include: 1. The facility staff failed to provide written documentation to the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, it was determined that the facility staff failed to maintain a complete and accurate MDS (minimum data set) assessment for one of 47 residents in the survey sample, Resident #58. The facility staff failed to attempt the BIMS (Brief Interview for Mental Status) interview for Resident #58's quarterly MDS assessment with an ARD (assessment reference date) of 3/4/19. The findings include: Resident #58 was admitted to the facility on [DATE]. Resident #58's diagnoses included but were not limited to pneumonia, difficulty swallowing and muscle weakness. Section B of Resident #58's most recent MDS, a quarterly assessment with an ARD of 3/4/19, documented the resident was understood. Section C of the MDS documented, C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted? 0. No (resident is rarely/never understood). The staff assessment for mental status was completed, and coded Resident #58's cognitive skills for daily decision-making as severely…

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, resident interview, facility documentation review, and clinical record review, the facility staff failed to develop and/or implement the comprehensive care plan for two of 47 residents in the survey sample (Resident #21, #32). 1. The facility staff failed to develop a comprehensive care plan for Resident #21's indwelling urinary catheter (1). 2. The facility staff failed to implement the comprehensive care plan for non-pharmacological interventions prior to the administration of as needed pain medication to Resident #32. Findings include: 1. Resident #21 was admitted to the facility on [DATE], with a most recent readmission on [DATE], with diagnoses that included but were not limited to: MS (multiple sclerosis) (2), non-pressure chronic ulcer (3) of the skin, and pain. The most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 01/31/19, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility document review, it was determined the facility staff failed to review and revise the comprehensive care plan for two of 47 residents in the survey sample; Resident #114 and Resident #58. 1. The facility staff failed to review and revise Resident #114's comprehensive care plan to address the administration of the antipsychotic medication Seroquel. 2. The facility staff failed to review and revise Resident #58's care plan for oxygen administration. The findings include: 1. The facility staff failed to review and revise Resident #114's comprehensive care plan to address the administration of the antipsychotic medication Seroquel. Resident #114 was admitted to the facility on [DATE] with the diagnoses of but not limited to left femur fracture (1), anxiety, osteoporosis (2), high blood pressure, dementia with behavioral disturbance, and right femur fracture. The most recent MDS (Minimum Data Set), a 14-day Medicare assessment, with an ARD…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, resident interview, facility document review, and clinical record review, it was determined the facility staff failed to ensure pain management services, consistent with professional standards of practice, and the comprehensive person-centered care plan for two of 47 residents in the survey sample, Residents #108 and #32. 1. The facility staff failed to clarify Resident #108's medication orders for two as needed pain medications to determine when each medication should be administered to the resident based on pain level parameters to ensure effective consistent pain management. 2. The facility staff failed to implement non-pharmacological interventions prior to the administration of as needed pain medication to Resident #32 The findings include: 1. The facility staff failed to clarify Resident #108's medication orders for two pain medications. Resident #108 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: chronic pain syndrome, lung cancer,…

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 ensure medications were available for one of 47 residents in the survey sample, Resident #81. The facility staff failed to ensure the physician prescribed medication Crestor Tablet 10 MG (Rosuvastatin calcium) (1) was available for administration to Resident #81 as ordered. The findings include: Resident #81 was admitted to the facility on [DATE] with a most recent readmission on [DATE]. Resident #81's diagnoses included but were not limited to hyperlipidemia (2), hypertension (2), and heart failure (3). Resident #81's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 05/02/18, coded the resident as scoring a 15 on the brief interview for mental status (BIMS) of score of 0-15, 15 being cognitively intact for daily decision-making. Review of Resident #81's clinical record revealed physician's orders dated 05/03/18, 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 Based on observation, staff interview, clinical record review, and facility document review, it was determined the facility staff failed to ensure one of 47 residents in the survey sample, was free of unnecessary psychotropic medications; Resident #114. Resident #114 was administered Seroquel (1), an antipsychotic medication without adequate indications and diagnosis for the administration of the medication. The findings include: Resident #114 was admitted to the facility on [DATE] with the diagnoses of but not limited to left femur fracture (2), anxiety, osteoporosis (3), high blood pressure, dementia with behavioral disturbance, and right femur fracture. The most recent MDS (Minimum Data Set), a 14-day Medicare assessment, with an ARD (Assessment reference date) of 3/6/19, coded the resident as scoring a 3 on the BIMS (Brief Interview for Mental Status) score, indicating the Resident has severe cognitive impairment for daily decision making. The resident was coded as requiring limited assistance for eating;…

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

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to store food in accordance with professional standards for food service safety. The facility staff failed to ensure the margarine in the refrigerator was not open to air. The findings included: Observation was made of the kitchen on 4/23/19 at 11:40 a.m. accompanied by other staff member (OSM) # 1, the dietary manager. Observation was made of the refrigerator. There was a cardboard box containing seven sleeves of single serve pats of margarine. There was also loose pats of margarine in the box. The lid of the cardboard box had been cut off the box, thus exposing the margarine to air. When asked if the margarine was stored properly, OSM #1 stated, No, it needs to be covered. OSM #1 removed the margarine from the refrigerator. The facility policy, Refrigerated Storage Practice documented in part, 1. All cooked food or other products removed from original containers must be enclosed in clean, sanitized, covered containers and identified. ASM (administrative staff…

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 maintain a complete and accurate clinical record for two of ten residents in the survey sample, Residents #102 and #105. 1. The facility staff failed to document non-pharmacological interventions that were provided to Resident #102 prior to as needed acetaminophen administration on 5/30/19 and failed to accurately document Resident #102's pain level on that same date. 2. The facility staff failed to document accurately Resident #105's pain level on 6/3/19. The findings include: 1. The facility staff failed to document non-pharmacological interventions that were provided to Resident #102 prior to as needed acetaminophen (1) administration on 5/30/19 and failed to accurate document Resident #102's pain level on that same date. Resident #102 was admitted to the facility on [DATE]. Resident #102's diagnoses included but were not limited to pneumonia, diabetes and muscle weakness.…

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.