Winchester Health & Rehabilitation

Based on staff interview and facility document review, the facility staff failed to provide RN (registered nurse) coverage on three of 30 days reviewed. The findings include: A review of facility nursing schedules revealed there was no RN coverage on 3/11/23, 4/8/23 and 4/9/23. On 4/11/23 at 4:14 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated the facility is required to have eight hours of RN coverage each day, seven days a week, 365 days a year. ASM #2 stated there was only one other RN besides her, but she recently hired another RN. On 4/11/23 at 5:18 p.m., ASM #1, the administrator, and ASM #2 were made aware of the above concern. The facility policy titled, Department Duty Hours - Nursing Services documented, 7. Registered nurse hours will be eight consecutive hours per day; 7 days a week.

Based on resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to ensure that medications were available for administration for three of 32 residents in the survey sample, Residents #262, #14, and #37. The findings include: 1. For R262, the facility staff failed to ensure medications were available for administration on 12/28/2021. R262 was admitted to the facility with diagnoses that included but were not limited to chronic obstructive pulmonary disease (1), hypertension and congestive heart failure (2). The eMAR (electronic medication administration record) for R262 dated 12/1/2021-12/31/2021 documented in part, - Metoclopramide HCL Solution 5mg/ml (milligram per milliliter) Use 5mg intravenously three times a day for before meals. Start Date: 12/28/2021 0900 (9:00 a.m.). The eMAR documented a 9 in the administration area for 12/28/2021 at 9:00 a.m., 1:00 p.m. and 5:00 p.m. The eMAR chart codes documented in part, .9= Other/See Nurse Notes . - Diltiazem HCL tablet 30mg Give 1 tablet by mouth…

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

Based on staff interview, facility document review, and clinical record review, the facility staff failed to complete a monthly medication regimen review for three of 32 residents in the survey sample, Residents #25, #29, and #20. The findings include: 1. For Resident #25 (R25), the facility pharmacist did not complete a medication regimen review (MRR) in December 2022 or January 2023. A review of R25's clinical record failed to reveal evidence of an MRR in December 2022 and January 2023. On 4/11/23 at 5:07 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant, were informed of these concerns. ASM #1 stated: We just got a pharmacist. She stated the facility had undergone a change of ownership on 12/1/22, and lost their pharmacist. She stated the facility was without a pharmacist until February 2023. She stated she would check to make sure there were no MRRs for this resident in December 2022 and January 2023. On 4/12/23 at 9:24 a.m., ASM #1 stated: I couldn't find anything regarding a pharmacist…

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 evidence infection tracking for 9 of 12 months reviewed. The findings include: The facility staff failed to evidence infection tracking for 4/1/2022 through 12/31/2022. On 4/11/2023 at approximately 11:30 a.m., a request was made to ASM (administrative staff member) #2, the director of nursing/infection preventionist, for the facility infection tracking logs for the past 12 months. On 4/12/2023 at approximately 8:40 a.m., LPN (licensed practical nurse) #2 provided a binder with infection tracking from 1/1/2023 through the present. LPN #2 stated that they were looking for the rest of the logs in the previous director of nursing's office files. On 4/12/2023 at 10:10 a.m., ASM #2 stated that they did not have any other tracking logs to provide. ASM #2 stated that the logs they had were the ones they had completed since they started working at the facility a few months back. ASM #2 stated that they were notified of new infections in their morning meetings, in chart reviews, and lab…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, the facility staff failed to evidence clinical documentation was sent to the receiving facility at the time of resident discharge for three of 32 residents in the survey sample, Residents #23, #25, and #44. The findings include: 1. For Resident #23 (R23), the facility staff failed to evidence required information regarding the resident's clinical status, including a medication list and care plan goals, to the receiving facility when the resident was discharged to the hospital on 2/25/23. A review of R23's clinical record revealed the resident was discharged to the hospital on 2/25/23 and readmitted to the facility on [DATE]. Further review of the clinical record failed to reveal evidence that the facility provided the receiving hospital with a medication list or care plan goals at the time of the discharge. The resident's E-Interact form dated 2/25/23 did not evidence that the resident's medication list and care plan goals were sent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, the facility staff failed to evidence written notification to the resident representative (RR), the resident and/or the Office of the State Long-Term Care Ombudsman of a resident's discharge for three of 32 residents in the survey sample, Residents #23, #25, and #44. The findings include: 1. For Resident #23 (R23), the facility staff failed to evidence written notification to the RR, resident and ombudsman when the resident was discharged to the hospital on 2/25/23. A review of R23's clinical record revealed the resident was discharged to the hospital on 2/25/23 and readmitted to the facility on [DATE]. Further review of the clinical record failed to reveal evidence that the facility notified the RR, resident and ombudsman in writing of the discharge. On 4/11/23 at 3:55 p.m., LPN (licensed practical nurse) #2, the unit manager, was interviewed. She stated when a resident is discharged to the hospital, the nurses are not responsible…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, the facility staff failed to evidence that a bed hold notice was provided to the resident and/or resident representative at the time of transfer to the hospital, for two of 32 residents in the survey sample, Residents #23 and #25. The findings include: 1. For Resident #23 (R23), the facility staff failed to evidence bed hold notification was provided to the resident when the resident was discharged to the hospital on 2/25/23. A review of R23's clinical record revealed the resident was discharged to the hospital on 2/25/23 and readmitted to the facility on [DATE]. Further review of the clinical record failed to reveal evidence that the facility provided the required bed hold notification to the resident at the time of discharge. The resident's E-Interact form dated 2/25/23 did not evidence that the bed hold notification was issued to the resident. On 4/11/23 at 3:55 p.m., LPN (licensed practical nurse) #2, the unit manager, was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to provide a resident or the resident representative with a summary of the baseline care plan for one of 32 residents in the survey sample, Resident #210. The findings include: For Resident #210 (R210), the facility staff failed to provide the resident or the representative a summary of the baseline care plan. R210 was admitted to the facility on [DATE]. A review of R210's clinical record, including the baseline care plan dated 4/1/23 and progress notes for April 2023, failed to reveal the facility staff provided R210 or the resident's representative, a summary of the baseline care plan. On 4/11/23 at 4:28 p.m., an interview was conducted with OSM (other staff member) #1, the social services director. OSM #1 stated a care conference is held with residents and/or their representatives within 72 hours of admission. OSM #1 stated at the care conference, she offers residents and their families a summary of the baseline care plan. OSM #1…

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 clinical record review, the facility staff failed to review and revise the comprehensive care plan for two of 32 residents in the survey sample, Residents #34 and #44. The findings include: 1. For Resident #34 (R34), the facility staff failed to review and revise the resident's comprehensive care plan for bed rail use. A review of R34's clinical record revealed a side rail (bed rail) evaluation dated 11/17/22 that documented bilateral quarter side rails was recommended to assist with bed mobility. A review of R34's comprehensive care plan dated 12/7/22 failed to reveal documentation regarding bed rails. On 4/10/23 at 4:43 p.m., R34 was observed lying in bed with bilateral quarter bed rails in the upright position. On 4/11/23 at 3:12 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated the purpose of the care plan is, Where everybody can see them and go off with what's going on with the resident. LPN #2 stated residents' care plans should be reviewed and revised to include bed rails, So everybody can see what…

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, the facility staff failed to provide smoking supervision for one of 32 residents in the survey sample, Resident #33. The findings include: For Resident #33 (R33), on 4/10/23, the facility staff failed to provide a smoking apron per the resident's safe smoking assessment. R33 was admitted to the facility with diagnoses including Huntington Disease (1). On 4/10/23 at 2:18 p.m. and 3:53 p.m., R33 was sitting in a wheelchair outside on the smoking area patio. R33 had a lit cigarette in hand. R33 was not wearing a smoking apron at either observation. The resident was supervised per facility policy. A review of R33's safe smoking assessment dated [DATE] revealed, in part: 1. Is the resident a safe smoker? b. Safe to smoke with supervision. A review of R33's care plan dated 4/8/23 revealed, in part: .If resident is going to smoke cigarettes resident will need to utilize smoking apron. On 4/11/23 at 3:55 p.m., LPN (licensed…

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

Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide care and services for pain management in a timely manner for one of 32 residents in the survey sample; Resident #10. The findings include: For Resident #10, the facility staff failed to address the resident's complaint of pain on 4/10/23 at 4:10 PM. On the most recent MDS (Minimum Data Set), an admission / 5-Day MDS assessment, dated 3/15/23, Resident #10 was coded as being cognitively intact in ability to make daily life decisions. On 4/10/23 at 4:10 PM Resident #10 was observed and the resident requested something for pain from this surveyor. The resident's facial expression reflected pain and/or discomfort. At that time, RN #1 (Registered Nurse) was notified of the resident's complaint of pain and request for pain medication RN #1 stated that they did not know where the resident's assigned nurse was. On 4/10/23 at 4:25 PM a follow up interview was conducted with Resident #10. When asked if anyone had come 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 observation, staff interview, facility document review, and clinical record review, the facility staff failed implement bed rail requirements for two of 32 residents in the survey sample, Residents #29 and #34. The findings include: 1. For Resident #29 (R29), the facility staff failed to review with the resident (and/or resident's representative) the risks and benefits of, and obtain consent for, the use of bed rails. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/13/23, R29 was coded as requiring the extensive assistance of staff for bed mobility and transfers. On 4/10/23 at 12:47 p.m. and 3:11 p.m., and on 4/11/23 at 9:18 a.m., R29 was sitting up in bed. At all three observations, bilateral bed rails (quarter rails) were up. A review of R29's physician orders revealed the following: 2/24/21 Patient is required (sic) bilateral 1/4 side rails to assist with repositioning. Further review of R29's clinical record failed to reveal an assessment for the use of bed rails, education regarding the risks and benefits…

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

Based on staff interview, facility document review and clinical record review, the facility staff failed to provide sufficient staffing for one of 32 residents in the survey sample, Resident #34. The findings include: For Resident #34 (R34), the facility staff failed to administer the medication gabapentin (1) per the physician's order on 3/28/23 and 3/29/23 because there was only one nurse in the facility and two nurses were required to obtain the medication from the facility Omnicell (a machine of medications that are maintained in the facility in case a specific medication for a specific resident is not available). A review of R34's clinical record revealed a physician's order dated 3/2/23 for gabapentin 100mg (milligrams)- two capsules every eight hours for neuropathy. A review of R34's March 2023 MAR (medication administration record) failed to reveal evidence that R34 was administered gabapentin on 3/28/23 at 10:00 p.m. and 3/29/23 at 6:00 a.m. Nurses' notes dated 3/28/23 and 3/29/23 documented, Awaiting delivery from pharmacy. A review of the facility Omnicell list revealed…

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

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to follow the published menu for one of 32 residents in the survey sample, Resident #23. The findings include: For Resident #23 (R23), the facility staff failed to provide the resident with the items on the lunch menu on 4/10/23. On 4/10/23 at 12:31 p.m., R23 was sitting in a wheelchair, with a tray of food on the overbed table that was in front of the resident. The tray did not contain any chocolate pudding. A review of the meal ticket for R23 for this meal included that the resident should get chocolate pudding. On 4/10/23 at 12:34 p.m., OSM #7, a cook, evaluated the items on R23's tray. OSM #7 stated: No, this is not right. [R23] should have chocolate pudding. Somebody substituted applesauce instead, but there should be chocolate pudding on the tray. On 4/10/23 at 2:50 p.m., OSM #8, the dining services manager, was interviewed. OSM #8 stated the dietary aide who stands on the side of the tray line with the trays, condiments, silverware, and cold items, is…

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

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to serve food at the physician-ordered consistency for one of 32 residents in the survey sample, Resident #23. The findings include: For Resident #23 (R23), the facility staff failed to serve pureed spinach at lunch on 4/10/23. On 4/10/23 at 12:31 p.m., R23 was sitting in a wheelchair, with a tray of food on the overbed table in front of the resident. The tray contained pureed meat and pasta. The tray also contained a serving of spinach, which was not pureed. Leaves and stems were visible in the serving cup. On 4/10/23 at 12:34 p.m., OSM #7, a cook, evaluated the items on R23's tray. OSM #7 stated: No, this is not right. That spinach is not pureed. A review of R23's physician orders revealed the following: 3/7/23 Regular diet. Puree texture. On 4/10/23 at 2:50 p.m., OSM #8, the dining services manager, was interviewed. OSM #8 stated the spinach had not been pureed enough at the lunch meal that day. She stated the spinach had been run through the food processor, but…

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

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to serve food according to a resident's preference for one of 32 residents in the survey sample, Resident #23. The findings include: For Resident #23 (R23), the facility staff served chicken, a documented dislike, to the resident at lunch on 4/10/23 On 4/10/23 at 12:31 p.m., R23 was sitting in a wheelchair, with a tray of food on the overbed table that was in front of the resident. The tray contained a serving of chicken and pasta. A review of the meal ticket for R23 stated in two places that R23 disliked chicken. R23's family member was sitting beside the resident. The family member stated: We keep telling them she does not like chicken. She never has. But they keep giving it to her. On 4/10/23 at 12:34 p.m., OSM #7, a cook, evaluated the items on R23's tray. OSM #7 stated: I am so sorry. This is not right. We should not have put chicken on the tray. I know (R23) doesn't like chicken. On 4/10/23 at 2:50 p.m., OSM #8, the dining services manager, was interviewed.…

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 serve food in a sanitary manner in one of one facility kitchen. The findings include: On 4/10/23, a facility dietary staff member was standing at the end of the tray line during lunch service. At the time of the observation, the employee, who had a full beard, was not wearing a beard guard. On 4/10/23 at 12:25 p.m., OSM (other staff member) #6 was standing in the kitchen at the end of the steam table line as lunch trays were being served. OSM #6 had a full beard and mustache. OSM #6 was not wearing a beard guard. OSM #6 stated: But it's my day off. I just dropped something off for them. OSM #8, the dining services manager was serving lunch trays. OSM #8 stated: Yes, he is only here for a few minutes. It's his day off. When asked if anyone in the kitchen is supposed to wear a hair net and/or beard guard when in proximity to the tray line, OSM #8 stated: Yes. That is true. On 4/10/23 at 2:50 p.m., OSM #8 was interviewed. She stated OSM #6 had come to the facility 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 staff interview and facility document review, the facility staff failed to provide abuse training for one of one CNA (certified nursing assistant) records reviewed. The findings include: The facility staff failed to evidence abuse training was provided to CNA #3, who was hired on 9/12/88. On 4/12/23 at 1:39 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern. On 4/13/23 at 12:22 p.m., OSM (other staff member) #4, the human resources manager, stated she could not provide evidence that CNA #3 was provided abuse training. OSM #4 stated the facility uses an online training program and the program changed when the facility was sold in December 2022. OSM #4 stated she sets up the training program then employees receive automatic notifications of certain trainings that are due. OSM #4 stated abuse training is one of the required trainings.

Based on staff interview and facility document review, the facility staff failed to provide infection control training for one of one CNA (certified nursing assistant) records reviewed. The findings include: The facility staff failed to evidence infection control training was provided to CNA #3, who was hired on 9/12/88. On 4/12/23 at 1:39 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern. On 4/13/23 at 12:22 p.m., OSM (other staff member) #4, the human resources manager, stated she could not provide evidence that CNA #3 was provided infection control training. OSM #4 stated the facility uses an online training program and the program changed when the facility was sold in December 2022. OSM #4 stated she sets up the training program then employees receive automatic notifications of certain trainings that are due. OSM #4 stated infection control training is one of the required trainings.

Based on staff interview and facility document review, the facility staff failed to provide 12 hours of annual training for one of one CNA (certified nursing assistant) records reviewed. The findings include: The facility staff failed to evidence 12 hours of annual training was provided to CNA #3, who was hired on 9/12/88. On 4/13/23 at 12:22 p.m., OSM (other staff member) #4, the human resources manager, stated she could not provide evidence that CNA #3 was provided 12 hours of annual training. OSM #4 stated the facility uses an online training program and the program changed when the facility was sold in December 2022. OSM #4 stated she sets up the training program then employees receive automatic notifications of certain trainings that are due. OSM #4 stated she did not know who was responsible for ensuring CNAs receive 12 hours of annual training. On 4/12/23 at 1:39 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern.

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 ensure the required documentation and information was provided to the receiving provider, upon facility-initiated transfers for five of 35 residents in the survey sample. Residents #39, #18, #26, #13 and #32. The facility staff failed to evidence what if any required documentation was provided to the receiving facility for a facility-initiated transfers of Resident #39 on 8/2/2021, and Resident #18 on 6/18/2021. The staff failed to evidence the comprehensive care plan goals were provided to the receiving facility for a facility-initiated transfers of Resident #26 on 7/22/21, Resident #13 on 5/10/2021 and 5/26/2021, and Resident #32 on 7/14/21. The findings include: 1. Resident #39 was admitted to the facility with diagnoses that included but were not limited to pneumonia (1) and end stage renal disease (2). Resident #39's most recent MDS (minimum data set) assessment, a quarterly 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 10. The facility staff failed to develop a comprehensive care plan for Resident #25, who was admitted to the facility on [DATE]. Resident #25 was admitted to the facility with diagnoses that included but were not limited to cerebral infarction (1), diabetes (2) and heart failure (3). Resident #25's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 8/4/2021, coded Resident #25 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15- being cognitively intact for making daily decisions. Section G coded Resident #25 requiring extensive assistance of two or more staff for bed mobility and transfers and total assistance of two or more persons for toileting. Section H coded Resident #25 having an indwelling catheter and always incontinent of bowel. Section J coded Resident #25 having pain occasionally. Section M coded Resident #25 being at risk of developing pressure ulcers/injuries. Section N coded Resident #25 receiving…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement a complete pain management program for three of 35 residents in the survey sample, Residents # 201, # 3, and # 16. The facility staff failed to assess and document the location of pain and failed to attempt and or provide non-pharmacological interventions prior to the administration of a prn [as needed] pain medications to Resident #201, #3 and Resident #16, on multiple occasions during August and September 2021. The findings include: 1. Resident # 201 was admitted to the facility with diagnoses that included but were not limited to: osteoarthritis [1], and chronic pain. Resident # 201's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 08/30/2021, coded Resident # 201 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily…

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

Based on staff interview and facility document review, it was determined that the facility staff failed to have a complete infection control program as evidenced by missing infection control surveillance for April, May and June 2021. The findings include: On 09/09/2021 at approximately 10:00 a.m., a review of the facility's infection control surveillance for the past six months was conducted. Review of the surveillance records failed to evidence infection control surveillance for April, May and June 2021. On 09/09/2021 at approximately 10:33 a.m., an interview was conducted with ASM [administrative staff member] # 1, administrator. When asked about the missing surveillance ASM # 1 stated, We don't have a full six months of surveillance, we're unable to locate them. When asked who was responsible for infection control ASM # 1 stated that it was [ASM # 2], director of nursing who started at the facility on 09/02/2021. On 09/09/2021 at 12:58 p.m. an interview was conducted with ASM # 3, regional nurse. When asked to describe the procedure for maintaining the infection control…

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 and facility document review it was determined that the facility staff failed to provide privacy for three of 35 residents in the survey sample, Resident #301, #33 and #47. Resident #301's urinary catheter bag was visible with urine in the bag from the hallway while the resident was in bed and was not covered with a privacy cover; Resident #33's protected health information was left open on the medication cart in the hallway and was visible to staff and or others passing by, during the medication administration observation; and facility staff failed to provide personal privacy for Resident #47 while she was receiving personal care on 9/7/21. The findings include: 1. On 9/7/2021 at approximately 12:47 p.m., an observation was made of Resident #301 in bed from the facility hallway. Resident #301 was observed lying in bed with a urinary catheter bag attached to the bedframe on the right side of the bed facing the hallway. Urine was observed in the catheter…

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 provide a clean and homelike environment for 2 of 35 residents in the survey sample; Residents #9 and #37. Resident #9's right and Resident #37's wheelchairs were not maintained in a condition of good repair. Resident #9's right wheelchair arm was observed with cracks in the vinyl material, and exposed foam in the cracks. The findings include: 1. Resident #9 was admitted to the facility on [DATE] and had the diagnoses of but not limited to Parkinson's disease, chronic kidney disease, dysphagia, lymphedema, high blood pressure, depression, dementia, heart failure, and osteoarthritis. The annual MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 6/22/21 coded Resident #9 as cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing, hygiene and toileting; extensive assistance for…

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

Based on staff interview and clinical record review, it was determined that the facility staff failed to ensure written notification was provided to the ombudsman, the resident and the resident's representative (RP) for a facility/resident-initiated transfer for one of 35 residents in the survey sample, Residents #32. The facility staff failed to evidence that the ombudsman was notified and Resident # 14 and resident's representative were provided written notification of a resident-initiated transfer on 07/14/2021 for Resident # 32. The findings included: Resident # 32 was admitted to the facility with diagnoses included but were not limited to: fractured clavicle [bone that connects the shoulder to the breastplate], and low blood pressure. Resident # 32's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 08/04/2021, coded Resident # 32 as scoring a seven [7] on the brief interview for mental status (BIMS) of a score of 0 - 15, seven - being severely impaired of cognition for making daily decisions. The nurse's note for 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 resident interview, staff interview, facility document review, and clinical record review, it was determined that facility staff failed to provide a bed hold policy to the resident or the resident's representative upon a transfer to the hospital for one of 35 residents in the survey sample, Residents # 32. The facility staff failed to provide Resident #32 and or the resident's representative with a copy of the bed hold policy prior to and or at the time of transfer to the hospital on [DATE]. The findings included: Resident # 32 was admitted to the facility with diagnoses included but were not limited to: fractured clavicle [bone that connects the shoulder to the breastplate], and low blood pressure. Resident # 32's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 08/04/2021, coded Resident # 32 as scoring a seven [7] on the brief interview for mental status (BIMS) of a score of 0 - 15, seven - being severely impaired of cognition for making daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to ensure an accurate MDS (minimum data set) assessment for two of 35 residents in the survey sample; Residents #37 and #52. 1. The 8/10/21 quarterly MDS assessment for Resident #37 was not completed accurately regarding the coding of Section J1800 falls. The clinical record documented Resident #37 was found on the floor by staff on 6/8/21, and Section J1800 of the 8/10/21, quarterly MDS assessment coded the resident as having 0 falls, since admission/entry or reentry or the prior assessment. 2. The facility staff failed to accurately code Resident # 52's discharge status to community on the discharge MDS (minimum data set) assessment with an ARD (assessment reference date) of 07/22/2021. Instead, the resident's discharge was coded as Acute hospital. The findings include: 1. Resident #37 was admitted to the facility on [DATE] with the diagnoses of but not limited to stroke, dysphagia,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to review and revise the comprehensive care plan for one of 35 residents in the survey sample; Resident #9. The facility staff failed to review and revise Resident #9's comprehensive care plan was to include and address the use of side rails. The findings include: Resident #9 was admitted to the facility on [DATE], with the diagnoses of but not limited to Parkinson's disease, chronic kidney disease, dysphagia, lymphedema, high blood pressure, depression, dementia, heart failure, and osteoarthritis. The annual MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 6/22/21 coded Resident #9 as cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing, hygiene and toileting; extensive assistance for dressing, transfers and bed mobility; independent for eating; and as incontinent of bowel and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure professional standards for the administration of pain medications for one of 35 residents in the survey sample, Resident # 3. The facility staff failed to clarify physician orders for two prescribed as needed pain medications, Percocet and acetaminophen, to determine when and which medication should be administered. The findings include: Resident # 3 was admitted to the facility with diagnoses that include but not limited to: spinal stenosis [3] and osteoarthritis Resident # 3's most recent MDS (minimum data set), an admission assessment with an ARID (assessment reference date) of 06/10/2021, coded Resident # 3 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Section J0300, J0400 and J0600 Pain Assessment Interview coded Resident # 3 as having frequent pain at a level of 4 [four] on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and facility document review, it was determined the facility staff failed to ensure physician ordered fluid restrictions were implemented and monitored per physicians orders for one of 35 residents in the survey sample, Resident # 44. The facility staff failed to ensure the amount of fluid Resident #44 received was monitored and within the physician prescribed fluid restriction amount of 1500 ml (milliliters). The findings include: Resident #44 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: congestive heart failure ( CHF - abnormal condition characterized by circulatory congestion and retention of salt and water by the kidneys) (1), COPD (chronic obstructive pulmonary disease -general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis) (2) and dementia (a progressive state of mental decline, especially memory function and judgement, often accompanied by disorientation.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care and services consistent with professional standards of practice, to promote healing of a pressure injury for one of 35 residents in the survey sample, Resident #40. The facility staff failed to conduct a thorough initial assessment to include measurements of Resident #40's pressure injury upon discovery on 1/2/21, and failed to ensure ongoing assessments including measurements and staging until 2/1/2021. The findings include: Resident #40 was admitted to the facility on [DATE] with a recent readmission on [DATE], with diagnoses that included but were not limited to: dementia (a progressive state of mental decline, especially memory function and judgement, often accompanied by disorientation.)(1), diabetes, COPD (chronic obstructive pulmonary disease - general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic…

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 provide appropriate services, and equipment, to maintain or improve mobility per the physicians order for one of 35 residents in the survey sample, Resident #15. The staff failed to apply Resident #15's physician ordered resting left hand splint on 9/7/21 and 9/8/21. The findings include: Resident #15 was admitted to the facility on [DATE], and most recently readmitted to the facility on [DATE], with diagnoses including cerebral palsy (1) and psychotic disorder (2). On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 7/6/21, Resident #15 was coded as being severely cognitively impaired for making daily decisions, having scored eight out of 15 on the BIMS (brief interview for mental status). She was coded as requiring extensive assistance of staff for all activities of daily living. She was coded as having functional…

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

Based on observation, staff interview, clinical record review, it was determined that facility staff failed to the implement assistive device safety measures to ensure an environment free of accident hazards for one of 35 residents in the survey sample, Resident #32. The facility staff failed to implement Resident #32's fall mat on 9/07/21, 9/08/21, and the morning of 9/09/21, per the comprehensive plan of care. The findings include: Resident # 32 was admitted to the facility with diagnoses included but were not limited to: fractured clavicle [bone that connects the shoulder to the breastplate], low blood pressure, muscle weakness and low blood pressure. Resident # 32's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 08/04/2021, coded Resident # 32 as scoring a seven [7] on the brief interview for mental status (BIMS) of a score of 0 - 15, seven - being severely impaired of cognition for making daily decisions. On 09/07/2021 at 5:00 p.m., an observation of Resident # 32's room revealed Resident # 32 lying in bed. Further…

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

Based on observation, staff interview, resident interview and facility document review it was determined facility staff failed to obtain informed consent for the use of bed rails for one of 35 residents in the survey sample, Resident #301. The facility staff failed to obtain an informed consent prior to the use of bed rails for Resident #301. The findings include: On 9/7/2021 at approximately 12:47 p.m., an observation was made of Resident #301 in bed. Resident #301 was observed lying in bed with an upper side rail in place and up on the right side of the bed. Additional observations on 9/7/2021 at 2:18 p.m., and 9/7/2021 at 4:33 p.m. revealed Resident #301 in bed with the upper side rail in place and up on the right side of the bed. Resident #301 was admitted to the facility with diagnoses that included but were not limited to malignant neoplasm of the bladder (1) and paraplegia (2). Resident #301's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 9/2/2021, coded Resident #301 as scoring a 13 on the staff assessment for mental…

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 that two of 2 nurse aid records reviewed had received required annual competencies, (CNA [certified nursing assistant] #1 and CNA #2). CNA #1 was hired 9/12/1988 and CNA #2 hired 7/16/2019, and neither CNA had annual training and competency evaluations completed. The findings include: Upon entrance on 9/8/21 at approximately 11:45 AM, an Entrance Conference form was provided to the interim Administrator (ASM #1 - Administrative Staff Member). One document on this form was a request for a list of all current CNA (Certified Nursing Assistant) staff who had been employed at the facility for longer than one year. The list provided contained 2 CNA's that had been employed longer than a year and was still employed at the facility (CNA #1 was hired 9/12/1988 and CNA #2 hired 7/16/2019). A request was made for both CNA's #1 and #2 annual training and competency evaluations. On 9/09/21 at 9:51 AM, in an interview with ASM #1, he stated that there were no competencies because 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 observation, staff interview, facility document review and in the course of a complaint investigation, it was determined facility staff failed to remove and discard of expired medications in one of one facility medications rooms and failed to provide pharmacy services for one of 35 residents in the survey sample, Resident # 101. 1. Expired Preservision eye vitamin mineral supplement soft gels with an expiration date of July 2021 were available for resident administration in the one facility medication room. 2. The facility staff failed to ensure Resident #101's physician ordered medication, Meropenem 500 mg (milligrams) every 8 hours for pneumonia for 10 days, was available and administered intravenously as prescribed on 1/11/2021 at 10:00 p.m. The findings include: 1. On 9/7/2021 at approximately 4:49 p.m., an inspection of the facility medication room was conducted with LPN (licensed practical nurse) #3. An unopened bottle of 120 preservision eye vitamin mineral supplements was observed on the bottom…

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 secure medications properly on one of three facility medication carts, the medication cart on the Blue unit. The facility staff failed to lock the medication cart on the Blue unit when the cart was out of the line of sight of the nurse. The findings include: On 9/7/2021 at approximately 4:55 p.m., an observation was made of LPN (licensed practical nurse) #3 administering medications at the facility. LPN #3 placed the medication cart in the hallway against the wall between the resident rooms. LPN #3 was observed preparing medications, including two bottles containing eye drops to administer to a resident. On 9/7/2021 at 5:07 p.m., LPN #3 entered the residents room with the medications while leaving one bottle of eye drops on top of the medication cart. Another staff member was observed exiting the residents room at that time, passing beside the medication cart. On 9/7/2021 at 5:11 p.m., LPN #3 exited the residents room to obtain the bottle with the eye drops from the…

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

Based on observation, staff interview, facility document review and in the course of a complaint investigation, it was determined the facility staff failed to serve food at temperatures that were palatable for meal enjoyment during the evening meal. The findings include: Observation was made of the kitchen during the evening meal tray line on 9/7/2021 at 4:45 p.m. The following foods were at the documented temperatures that were obtained by facility staff using a facility thermometer: Potato wedges - 181.1 degrees Mixed Vegetables - 202.6 Corn flake chicken - 157.4 Ground chicken - 181.1 Puree chicken - 199 Mashed potatoes - 201.2 Puree vegetables - 194 Baked chicken for renal diets - 171.5 Chicken gravy - 188 Cheese Ravioli - 171.3 Mechanical renal chicken - 182.3 Coffee was taken from under the steam table and placed on individual trays. The coffee was not temped prior to being placed on the trays. A test tray was prepared at the end of the tray line. The fourth hall cart was observed. All trays were distributed. At 5:50 p.m., the test tray was taken to the dining room where 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, and during the course of a complaint investigation, it was determined the facility staff failed to maintain a complete and accurate clinical record for one of 35 residents in the survey sample, Resident # 101. Resident #101's January MAR (medication administration record) documented see nurses note on 1/27/21 and 1/28/21, beside the physician ordered medication Flovent. Review of the January 2021, nurses notes for Resident #101 failed to evidence any documentation related to the use of the Flovent. The findings include: Resident #101 was admitted to the facility on [DATE] with a readmission on [DATE], with diagnoses that included but were not limited to: COVID, pneumonia (An infection in one or both of the lungs. Many germs, such as bacteria, viruses, and fungi, can cause pneumonia) (1), high blood pressure, history of breast cancer, anemia (condition in which the hemoglobin content of the blood is below normal limits) (2), depression and pancreatitis…

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 maintain an effective Quality Assurance program. The findings include: On 09/09/2021 at approximately 11:00 a.m., a review of the facility's QAPI [quality assurance performance improving] Meeting sign-in sheets dated January 2021 through March 2021 failed to evidence the signature of the facility's medical director. On 09/09/2021 at approximately 11:28 a.m., an interview was conducted with ASM [administrative staff member] # 1, administrator, regarding the missing signature of the medical director for the date listed above. When asked about the missing signature of the facility's medical director ASM # 1 stated that they did not have any evidence that they had attended. No further information was provided by the end of the survey.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident # 3 was admitted to the facility on [DATE] with a readmission of 07/22/2019 with diagnoses that included but were not limited to respiratory failure, shortness of breath and chronic obstructive pulmonary disease [1]. Resident # 3's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 09/26/19, coded Resident # 3 as scoring a 12 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 12- being moderately impaired of cognition for making daily decisions. Resident # 3 was coded as requiring extensive assistance of one staff member for activities of daily living. Section O Special Treatments, Procedures and Programs coded Resident # 3 for the use of oxygen. On 01/07/2020 at approximately 3:15 p.m., Resident # 3 was observed lying in bed receiving oxygen by nasal cannula connected to an oxygen concentrator that was running. Observation of the oxygen flow meter on the oxygen concentrator revealed a flow rate of one-and-a-half liters per…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to ensure the drug regimen must be free from unnecessary drugs for two of 32 residents in the survey sample, Resident # 3 and # 25. The facility staff failed to attempt non-pharmacological interventions prior to the administration of prn (as needed) pain medications [Oxycodone (1) and Acetaminophen] (2)] to Resident #3 on multiple dates in November and December 2019. The facility staff failed to attempt non-pharmacological interventions prior to the administration of a prn (as needed) pain medication [Hydrocodone- Acetaminophen (2)] to Resident #25 on multiple dates during November, December 2019 and January 2020. The findings include: 1. Resident # 3 was admitted to the facility on [DATE] with a readmission of 07/22/2019 with diagnoses that included but were not limited to lower back pain. Resident # 3's most recent MDS (minimum data set), a quarterly 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.

Based on observation staff interview and review of facility documents it was determined the facility staff failed to store and prepare food in accordance with professional standards for food service safety. The findings include: On 01/072020 at 12:25 p.m., an observation of the facility's kitchen was conducted with OSM [other staff member] # 2, dietary manager. Observation of the reach-in refrigerator in the facility's kitchen revealed the following: One 46-ounce carton of thickened lemon water with approximately half of the contents remaining. One 46-ounce carton of thickened orange juice with approximately three-quarters of the contents remaining. Further One 46-ounce carton of thickened cranberry juice with approximately three-quarters of the contents remaining. Further observation failed to evidence an open date or a use-by-date. One quart of honey thickened milk with most of the contents remaining. One quart of honey thickened milk with most of the contents remaining. Further observation of all items above failed to evidence any open dates or a use-by-dates. OSM # 2 immediately…

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, clinical record review, and facility document review, it was determined that the facility staff failed to follow infection control practices for four of 32 residents in the survey sample; Residents #41, #37, #47, #163, and #25. The facility staff failed to store Resident #41's nebulizer and Incentive spirometer in a manner to prevent infections. Resident #41's nebulizer mask and Incentive spirometer were observed uncovered on the residents over the bed table. The facility staff failed to prepare and administer medications to Resident #37, in a manner to prevent the spread of infection. RN (registered nurse) #1 was observed touching medications in a plastic medication cup with her ungloved finger. The facility staff failed to maintain infection control practices in the storage of a nebulizer for Resident #47, the storage of Resident #163's incentive spirometer and Resident #25's nebulizer and incentive spirometer to prevent infection. The findings…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that facility staff failed to maintain a resident's dignity for one of 32 residents in the survey sample, Resident # 6. The facility staff failed to provide privacy for Resident # 6's catheter, collection bag and urine inside the collection bag was visible from the hallway. The findings include: Resident # 6 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: heart failure, stage 4 kidney disease and high cholesterol. Resident # 6's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/22/19, coded Resident # 6 as scoring a 14 on the brief interview for mental status (BIMS) of a score of 0 - 15, 14 - being cognitively intact for making daily decisions. Resident # 6 was coded as requiring limited assistance of one staff member for activities of daily living. Section H Bladder and Bowel coded…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide the resident representative and Ombudsman with the required written notification of a hospital transfer for one of 36 residents in the survey sample; Resident #65. The facility staff failed to evidence that a written notification of a hospital transfer for Resident #65 on 12/10/19, was provided to the resident representative and Ombudsman. The findings include: Resident #65 was admitted to the facility on [DATE]. Diagnoses included, but are not limited to, brain cancer, aphasia, convulsions, epilepsy, obesity, alcohol abuse, and adult failure to thrive. Due to the short amount of time, the resident was in the facility prior to the hospital transfer the MDS (Minimum Data Set) assessment had not been completed. The admission nursing assessment and admission nursing note dated 12/9/19, documented the resident was alert and oriented to person, place and time. A review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide a written bed hold notice upon a hospital transfer for 1 of 36 residents in the survey sample; Resident #65. The facility staff failed to evidence that a bed hold notice was provided upon Resident #65's hospital transfer on 12/10/19. The findings include: Resident #65 was admitted to the facility on [DATE]. Diagnoses included, but are not limited to, brain cancer, aphasia, convulsions, epilepsy, obesity, alcohol abuse, and adult failure to thrive. Due to the short amount of time, the resident was in the facility prior to the hospital transfer the MDS (Minimum Data Set) assessment had not been completed. The admission nursing assessment and admission nursing note dated 12/9/19, documented the resident was alert and oriented to person, place and time. A review of the clinical record revealed that the resident went to the hospital on [DATE] and did not return to the facility.…

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 develop a baseline care plan for the use of an incentive spirometer [1] for one of 32 residents in the survey sample, Resident # 163. The findings include: Resident # 163 was admitted to the facility on [DATE] with diagnoses that included but were not limited to high blood pressure and chronic obstructive pulmonary disease [2]. The most recent MDS (minimum data set), Resident # 163 was not due at the time of the survey. The facility's admission Data Collection sheet dated 01/03/2020 for Resident # 163 documented in part, Cognition: Alert, Oriented to Person. Under Communication it documented, Usually Understood and Understands. Under Respiratory, it documented, Special Treatments and Procedures: None per history and/or observation. On 01/07/20 at 1:49 p.m., at 2:43 p.m., and at 4:05 p.m., observations of Resident # 163's over-the-bed table revealed an incentive spirometer. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident interview, staff interview, clinical record review and facility document review it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for six of 32 residents in the survey sample, Residents #47, 41, 61, 37, 3, and 25. The comprehensive care plan for Resident #47, failed to evidence documentation for as needed use of oxygen. The facility staff failed to include the use of an incentive spirometer when they developed Resident #41's comprehensive care plan for altered respiratory status, dated 1/7/20, and failed to develop the comprehensive care plan for care and services of the resident's disease process of diabetes. The facility staff failed to include an intervention of a scoop mattress on Resident #61's comprehensive care plan that the facility determined was a required intervention, after a fall on 12/29/19; and failed to follow the care plan for the use of fall mats after a fall on 12/29/19. The facility 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 review and revise the comprehensive care plan, for two of 32 residents in the survey sample, Resident #6 and Resident #25. The facility staff failed to review and revise Resident #6's comprehensive care plan to include hospice care and services and care of an indwelling catheter. The facility staff failed to review and revise the comprehensive care plan for Resident #25 to include the use of an incentive spirometer [1]. The findings include: 1. Resident # 6 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: heart failure, stage 4-kidney disease and high cholesterol. Resident # 6's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/22/19, coded Resident # 6 as scoring a 14 on the brief interview for mental status (BIMS) of a score of 0 - 15, 14 - being cognitively intact for making daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and review of facility documentation it was determined the facility staff failed to provide treatment and care in accordance with professional standards of practice for one of 32 residents in the survey sample, Resident #3. The facility staff failed to administer sliding scale insulin per the physician orders to Resident # 3. On 01/07/2020 at 7:30 a.m., 11:30 a.m. and 4:30 p.m., and 01/08/2020 at 7:30 a.m., 11:30 a.m. there was no documentation of the amount of insulin administered or the location of the injections. The findings include: Resident # 3 was admitted to the facility on [DATE] with a readmission of 07/22/2019 with diagnoses that included but were not limited to type 2 diabetes mellitus with complications [1]. Resident # 3's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 09/26/19, coded Resident # 3 as scoring a 12 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 12- being…

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 ensure environment free of accident hazards and assistance devices to prevent accidents for one of 32 residents in the survey sample; Resident #61. The facility staff failed to implement fall interventions for Resident #61 after a fall on 12/29/19, fall mats and a scoop mattress were determined by the facility to be required interventions. Neither intervention had been implemented as of the survey date of 1/9/20. The findings include: Resident #61 was admitted to the facility on [DATE]; diagnoses include but are not limited to dementia with behaviors, panic disorder, thyroid disorder, restless leg, anxiety disorder, high blood pressure and delirium. The admission / 5-day MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 12/29/19 coded the resident as being severely impaired in ability to make daily life decisions. The resident was coded 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 The facility staff failed to ensure that two of four residents in the Medication Administration task (Residents #41 and #37) were free of medication errors of less than 5%. Out of 32 opportunities, five errors were observed, resulting in a medication error rate of 15.63%. The facility staff failed to ensure that Resident #41 was free of medication errors. Resident #41 was administered a medication that was not ordered for him and staff failed to administer ordered medications. The facility staff failed to ensure that Resident #37 was free of medication errors. Resident #37 was administered a partial dose of the blood pressure medication, Atenolol, and not the full dose that was ordered. The findings include: 1. Resident #41 was admitted to the facility on [DATE]; diagnoses included but are not limited to hydrocephalus, psychotic disorder, right kidney cancer with removal of kidney, cardiac defibrillator, high blood pressure, atrial fibrillation, diabetes, bipolar disorder, spinal stenosis with fusion, 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 observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to ensure that one of 32 residents in the survey sample, Resident #37 was free significant medication errors. Resident #37 was not administered the correct dose of the blood pressure medication Atenolol (2). The findings include: Resident #37 was admitted to the facility on [DATE]; diagnoses included but are not limited to encephalopathy, heart disease, dysphagia, diabetes, atrial flutter, abdominal aortic aneurysm, high blood pressure, cardiac pacemaker, and pneumonia. The admission / 5-day MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 12/17/19 coded the resident as significantly cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing and toileting; extensive assistance for transfers, dressing, and hygiene; was independent for eating; and was coded as incontinent of bowel and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, and clinical record review it was determined that the facility staff failed to maintain a complete and accurate medical record for one of 32 residents in the survey sample, Resident #43. The facility staff failed to maintain an accurate record documenting treatments performed for applying Nystatin (medication used to treat infection) powder topically twice daily and changing the wound vac (The vacuum assisted closure (VAC) therapy (also known as negative pressure wound therapy to assist with wound healing) dressing three times a week. The findings include: Resident #43 was admitted to the facility on [DATE] with diagnoses that included but were not limited to osteomyelitis (1) and diabetes (2). Resident #43's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 12/17/2019, coded Resident #43 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making…

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.