Woodstock Valley Health and Rehabilitation

Based on staff interview, and facility document review, the facility staff failed to complete an annual performance review for four of five CNA (certified nursing assistant) reviews. The findings include:For CNA #3, CNA #4, CNA #5, and CNA #6, the facility staff failed to complete an annual performance review. CNA #3 was hired on 8/22/23. CNA #3's most recent performance review was completed on 8/27/24.CNA #4 was hired on 6/13/23. CNA #4's most recent performance review was completed on 7/23/24.CNA #5 was hired on 7/20/21. CNA #5's most recent performance review was completed on 7/22/24.CNA #6 was hired on 2/15/23. CNA #6's most recent performance review was completed on 7/31/24. On 9/25/25 at 1:45 p.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated she did not know who was responsible for ensuring the completion of CNA performance reviews because she had only been the director of nursing since April 2025 and had never been a director of nursing before then. ASM #2 stated she assumed CNA performance reviews should be…

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 facility staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure medications were available for administration for two of 16 residents in the survey sample, Residents #3 and #7.The findings include:1) For Resident #3 (R3), the facility staff failed to ensure medications were available for administration during dates in February and March of 2025. Review of the eMAR (electronic medication administration record) for R3 dated 2/1/25-2/28/25 failed to evidence administration of the following medication on the dates listed below: Daptomycin-Sodium Chloride Intravenous Solution 500-0.9 MG (milligram)/50ML (milliliter)-% (Daptomycin-Sodium Chloride) Use 500 mg intravenously in the morning related to Sepsis, Unspecified Organism. On 2/9/25 and 2/21/25. (antibiotic to treat infection) (1). The eMAR for 2/9/25 was observed to be blank and 2/21/25 eMAR progress note documented “ordered call to pharmacy.” Epoetin Alfa-epbx Injection Solution 40000 UNIT/ML (Epoetin Alfa-epbx) Inject 1 ml subcutaneously one time 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 observation, staff interview and facility document review, facility staff failed to provide residents with the correct amount of food according to the facility's menu in one of one facility kitchens. The findings include:On 09/22/2025 at approximately 2:00 p.m. an observation in the facility's kitchen revealed OSM (other staff member) #10, acting dietary manager plating Caesar salad into bowls using a beige/ off-white handle scoop. Further observations revealed OSM #10 placing one scoop of salad into each bowl. At approximately 4:24 p.m. an observation of the facility's kitchen tray line revealed the cook plating food for the resident's dinner. Observations of the serving utensils being used by the cook to plate the food revealed he was using a grey handle scoop for serving lasagna, and a red handle scoop for sliced carrots. Continued observations revealed the cook placed one scoop of lasagna, carrots on the resident's dinner plates and one bowl of Caesar salad on each meal tray. The facility's menu for dinner on 09/22/2025 documented in part, Monday. Entree. Lasagna w/…

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

Based on observation and staff interview, it was determined that the facility staff failed to serve palatable food on one of two facility units, Rosewood Unit. The findings include:On 09/22/2025 at approximately 5:45 p.m., a test tray consisting of lasagna with meat sauce, sliced carrots, green beans and mash potatoes were placed on a food cart in the facility's kitchen and sent to the Rosewood Unit of the facility. The cart was followed by the surveyor, OSM (other staff member) #11, district manager for dietary. At approximately 6:05 p.m., the last dinner tray was served to a resident on the Rosewood Unit and OSM #11 was asked to remove cover from the test plate then proceeded to take the temperatures of the food. Two surveyors observed OSM #11 obtaining the food temperatures of the test tray. The lasagna with meat sauce was 127-degrees F (Fahrenheit), the green beans were 117-degrees F, sliced carrots were 113-degrees F and the potatoes were 112-degrees F. The test tray was sampled by two surveyors, OSM #11 for appropriate holding temperatures and palatable taste. When asked 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 resident interview, staff interview and facility document review, facility staff failed to provide HS (hours of sleep) snacks on two of two resident units, Dogwood and Rosewood units. The findings include:The facility's Meal Delivery Schedule documented in part, Breakfast (7:30 a.m.)-8:00 (a.m.)). Rosewood (unit) 8:00. Dinner 4:30 (p.m.)-5:15 (p.m.). Rosewood 5:15. According to the Meal Delivery Schedule there are 14 hours and 15 minutes between the last full evening meal and the first full meal of the next day. On 09/24/2025 at approximately 10:40 a.m. an interview was conducted with Resident #2 (R2), resident council president for the Rosewood unit, about snacks being provided to resident during the night shift. She stated that the residents are not offered snacks and that the resident council had never agreed to allow up to 16 hours to elapse between a substantial evening meal and breakfast the following day. On 09/24/2025 at approximately 10:50 a.m. an interview was conducted with R16, resident council president for the Dogwood unit, about snacks being provided 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 observations and staff interviews, the facility staff failed to serve food in a sanitary manner in one of one facility kitchens. The findings include:On 09/22/2025 at approximately 5:30 p.m. an observation in the facility kitchen revealed OSM (other staff member) #10, acting dietary manager and OSM #11 , district manager for dietary, hand drying 20 resident meal trays, placing them on the tray line. Continuing observation revealed kitchen staff at the tray line, sliding the meal trays down the tray line, placing resident's meals on the tray and placing the tray in the food carts to be taken to the unit floors. On 09/25/2025 at approximately 1:30 p.m. an interview was conducted with OSM #11. When informed of the observation as stated above OSM #11 stated that the meal trays should have been air dried to prevent contamination. On 9/25/2025 at approximately 4:58 p.m. ASM (administrative staff member) #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, were made aware of the above findings. No further information…

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 evidence of an updated contract with an outside provider for one of eight contracts reviewed, potentially affecting seven residents who received respiratory equipment services. The findings include:The facility staff failed to provide an updated contract for respiratory equipment. A review of facility contracts with outside service providers revealed there was no current contractual agreement with the respiratory equipment provider. The contract was between the outside provider and the name of the previous owner of the facility, a company no longer in existence. On 9/25/25 at 1:54 p.m., an interview was conducted with ASM (administrative staff member) #1 (the executive director). ASM #1 stated that when the new company began ownership of the facility (June 2025), she had to reach out to all vendors, write up new contracts, send the contracts to the new company's legal team for review, send the contracts back to the vendors for changes, then send the contracts back to the new company's legal…

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, it was determined that facility staff failed to promote a resident's dignity for one of 16 current residents in the survey sample, Residents #8 (R8). The findings include:For R8, facility staff stood while providing feeding assistance. R8 was admitted to the facility with diagnoses that included but were not limited to swallowing difficulties. On the most recent comprehensive MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 08/13/2025, R8 scored 3 (three) out of 15 on the BIMS (brief interview for mental status), indicating R8 was severely impaired of cognition for making daily decisions. GG0130 Self-Care coded R8 as being dependent for eating. 09/23/2025 at approximately 8:08 a.m., an observation revealed R9 in bed being fed by CNA (certified nursing assistant) #2. Further observations revealed CNA #2 standing next to the bed while feeding R8. Observation of R9's meal tray revealed food was p[placed in bowls. The comprehensive care plan for R8 dated 10/29/2018…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, facility document review and clinical record review, the facility staff failed to maintain a resident's right to be treated with respect and dignity, including the right to retain their personal belongings for one of 16 residents in the survey sample, Resident #2. The findings include: For Resident #2 (R2), the facility staff failed to maintain the resident's right to display her personal belongings.The resident was admitted to the facility on [DATE], with diagnoses that included but were not limited to: diabetes, obesity, high blood pressure, sleep terrors, insomnia, depressive disorder, anxiety disorder, osteoarthritis, post-traumatic stress disorder, and pain. On the most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 8/3/25, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section E - Behavior, 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 facility document review, the facility staff failed to secure confidential resident clinical records for one of 16 residents in the survey sample, Resident #1. The findings include:For Resident #1 (R1), the facility staff failed to maintain confidentiality of a document from the resident's clinical record. An email from LPN (licensed practical nurse) #5 to ASM (administrative staff member) #1 (the executive director) dated 8/22/25 documented, This morning I was standing at my cart getting ready to start morning Med [sic] pass. A CNA (certified nursing assistant) came to me and stated that (LPN #6) wanted me to print off a progress note for her. I asked what progress note and CNA said something about (R1). I asked where she was, and she said in (OSM [other staff member] #2's [the former staffing coordinator's]) office. By the time I went to (OSM #2's) office (LPN #6) had left. I needed to speak to (OSM #2) about my schedule. And that's what we did. At the end of our conversation I asked where (LPN #6) was and if she was coming back in because she wanted…

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

Based on clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to ensure discharge needs were met for one of 16 residents in the survey sample, Resident #4.The findings include:For Resident #4 (R4), the facility staff failed to evidence 1) that written discharge instructions were given to the resident, 2) that home medications were arranged prior to discharge and 3) that the resident was given provider information that included standardized patient assessment data, and information on quality measures and resource use (where that data is available) to choose a home health provider prior to discharge.On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 1/29/2024, the resident was assessed as being cognitively intact for making daily decisions.The resident admission demographic information documented R4 being their own responsible party with contact information listed for their spouse under contacts. The demographic information documented the discharge date 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 review, staff interview and facility document review, it was determined that the facility staff failed to develop a baseline care plan for one of 16 residents in the survey sample, Resident #3.The findings include:For Resident #3 (R3), the facility staff failed to develop a baseline care plan.The nursing admission assessment for R3 dated 1/23/2025 documented the resident admitted with a PICC (peripherally inserted central catheter) access, always being incontinent of bowel and bladder, having multiple wounds present on admission, a colostomy, and taking insulin.Review of the clinical record failed to evidence a baseline care plan developed within 48 hours of R3's admission of 1/23/2025.On 9/24/2025 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that the baseline care plan was developed by the admitting nurse. She stated that the purpose of the care plan was to give them a place to go to see how to take care of the residents. She stated that the admitting nurse would put things in the care plan like diet, ability 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 staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of practice for two of 16 residents in the survey sample, Residents #1, and #3. The findings include:1. For Resident #1 (R1), the facility staff failed to obtain the physician's authorization to transcribe orders for tramadol and oxycodone. Back dated orders were written on 8/19/25 for 8/10/25 and the physician was unaware of this. A review of R1's clinical record revealed the following physician's orders: 5/18/25-tramadol 50mg (milligrams). One tablet by mouth every four hours as needed for pain. 6/19/25-oxycodone 5mg. One tablet every six hours as needed for pain. R1 was transferred to the hospital on 7/29/25. R1 returned to the facility on 8/4/25 and the orders for tramadol and oxycodone were discontinued on that date. A review of R1's controlled medication utilization records revealed the resident was administered one tablet of tramadol 50mg on 8/10/25 at 9:15 a.m. 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, resident interview, staff interview, and clinical record review, the facility staff failed to provide respiratory care and services for one of 14 residents in the survey sample, Resident #110. The findings include:For Resident #110 (R110), the facility staff failed to obtain a physician's order for the use of an incentive spirometer (1) and failed to store the incentive spirometer in a sanitary manner. R110's admission minimum data set assessment was not complete. A clinical admission assessment dated [DATE] documented R110 was alert and oriented times four (to person, place, time, and situation). A review of R110's clinical record failed to reveal a physician's order for an incentive spirometer. On 12/1/25 at 1:44 p.m., R110 was observed sitting up in bed. An incentive spirometer was observed sitting on the resident's nightstand, with the mouthpiece uncovered. R110 stated she used the incentive spirometer, and staff had not provided a cover for the device. On 12/1/25 at 3:51 p.m., an…

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 ensure a resident was free from unnecessary medications for one of 16 residents in the survey sample, Resident #1. The findings include:For Resident #1 (R1), the facility staff failed to obtain and/or ensure a physician's order was in place prior to administering tramadol and oxycodone to the resident on 8/10/25. A review of R1's clinical record revealed the following physician's orders:5/18/25-tramadol 50mg (milligrams). One tablet by mouth every four hours as needed for pain.6/19/25-oxycodone 5mg. One tablet every six hours as needed for pain. R1 was transferred to the hospital on 7/29/25. R1 returned to the facility on 8/4/25 and the orders for tramadol and oxycodone were discontinued on that date. A review of R1's controlled medication utilization records revealed the resident was administered one tablet of tramadol 50mg on 8/10/25 at 9:15 a.m. and one tablet of oxycodone 5mg on 8/10/25 at 11:30 a.m. A review of R1's August 2025 physician's orders and August 2025 MAR…

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, the facility staff failed to provide services in compliance with State code for one of 16 residents in the survey sample, Resident #1. The findings include:For Resident #1 (R1), the facility staff failed to obtain a physician's order for tramadol and oxycodone prior to administering the medications on 8/10/25. The Virginia Administrative Code 12VAC5-371-300 (E). Pharmaceutical services. documents, Excluding cannabidiol oil and THC-A oil, no drug or medication shall be administered to any resident without a valid verbal order or a written, dated and signed order from a physician, dentist, podiatrist, nurse practitioner, or physician assistant, licensed in Virginia. A review of R1's clinical record revealed the following physician's orders:5/18/25-tramadol 50mg (milligrams). One tablet by mouth every four hours as needed for pain.6/19/25-oxycodone 5mg. One tablet every six hours as needed for pain. R1 was transferred to the hospital on 7/29/25. R1 returned to the facility on 8/4/25 and the orders for tramadol and oxycodone were…

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

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to maintain a complete and accurate medical record for three of 16 residents in the survey sample, Residents #3, #2, and #1.The findings include:1) For Resident #3 (R3), the facility staff failed to maintain a complete and accurate medical record. The resident admission demographics for R3 documented a discharge date of 4/8/2025. The resident census information documented a stop billing date of 4/8/2025. Review of the clinical record documented a fall risk evaluation, Braden scale for predicting pressure sore risk and elopement risk evaluation for R3 completed and dated 4/30/2025. On 9/25/2025 at 4:05 p.m., an interview was conducted with LPN (licensed practical nurse) #1 who stated that assessments should be documented for the date that they are done and the assessments for R3 dated 4/30/2025 probably should have been late entries because the resident no longer resided at the facility at that time. She stated that the medical record was not accurate…

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 implement infection control practices for one of 14 residents in the survey sample, Resident #104. The findings include:For Resident #104 (R104), the facility staff failed to implement enhanced barrier precautions (1) during wound care. A review of R104's clinical record revealed a wound care physician note dated 11/28/25 that documented R104 presented with a stage four pressure injury (2) on the sacrum. A physician's order dated 12/1/25 documented, Cleanse wound with wound cleanser. Pat dry. Apply medihoney and foam to wound bed QD (every day) one time a day for Wound care. Further review of R104's clinical record failed to reveal a physician's order for enhanced barrier precautions. On 12/2/25 at 11:24 a.m., LPN (Licensed Practical Nurse) #5 was observed performing wound care on R104's sacral wound. LPN #5 did not wear a gown during wound care. A Centers for Disease Control sign on R104's room door documented, ENHANCED BARRIER PRECAUTIONS. EVERYONE MUST Clean…

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 family interview, staff interview, facility document review, and clinical record review, the facility staff failed to notify the physician and/or responsible party of a change in a resident's condition for five of 43 residents in the survey sample, Residents #64, #336, #13, #47, and #13. The findings include: 1. For Resident #64, the facility staff failed to notify the physician and responsible party (RP) of an allegation of misappropriation of the resident's property. A review of R64's clinical record revealed the following order dated 4/3/24: Haloperidol Lactate Oral Concentrate 2 mg/ml (milligrams per milliliter. Give 0.25 ml by mouth every 4 hours as needed for agitation. A review of R64's care plan dated 4/17/24 revealed, in part: The resident has behaviors .r/t (related to) terminal diagnosis .[R64] is on an antipsychotic medication r/t end of life care. Psychosis and terminal agitation. A review of a facility synopsis of events dated 5/13/24 revealed, in part: Incident Date 5/10/24 .Report Date…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 5. The facility staff failed to post notice of employee rights regarding abuse reporting in a conspicuous location in the facility for staff. On [DATE] at 9:25 a.m., an observation was made of the facility employee break room, no abuse reporting employee rights posting was observed. On [DATE] at 9:27 a.m., a request was made to OSM (other staff member) #11, the director of social services for the location of the posting, OSM #11 stated that she thought there was a poster in the employee break room and proceeded to check the bulletin boards located in the room. On [DATE] at 9:29 a.m., ASM (administrative staff member) #1, the administrator, stated that there was a posting hanging on the bulletin board in the employee break room at the facility. ASM #1 observed the bulletin boards in the break room and stated that it was not there and may have been taken down by mistake. An observation was made of each nurses station bulletin board with ASM #1 also, and no posting was seen, ASM #1 stated that the notice was 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 staff interview, facility document review, and clinical record review, the facility staff failed to report allegations of abuse in a timely manner for five of 43 residents in the survey sample, Residents #17, #59, #64, #136, and #38. The findings include: 1. For Resident #17 (R17), the facility staff failed to report an allegation of misappropriation of R17's property in a timely manner. A review of a facility synopsis of events dated 5/13/24 revealed, in part: Incident Date 5/10/24 .Report Date 5/13/24 .CNA (certified nursing assistant) reported nurse saying she was giving medication to [Resident #17] without an order .Investigation on allegation began. Please see F605 and F607 for additional details regarding R17. 2. For Resident #59 (R59), the facility staff failed to report an allegation of abuse and misappropriation of property in a timely manner. On 5/22/24 at 10:32 a.m., ASM #5 was interviewed. She stated: Yesterday morning, they were telling me something about the Morphine. I didn't know anything about the Morphine until yesterday morning (5/21/24). [LPN #5] was 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 documentation, clinical record review the facility staff failed to report allegations of abuse in a atimely manner for 5 of 43 residents in the survey sample (Residents #17, #59, #64, #136, and #38) 1. For Resident #17 (R17), the facility staff failed to report an allegation of misappropriation of R17's property in a timely manner. A review of a facility synopsis of events dated 5/13/24 revealed, in part: Incident Date 5/10/24 .Report Date 5/13/24 .CNA (certified nursing assistant) reported nurse saying she was giving medication to [Resident #17] without an order .Investigation on allegation began. Please see F605 and F607 for additional details regarding R17. 2. For Resident #59 (R59), the facility staff failed to report an allegation of abuse and misappropriation of property in a timely manner. On 5/22/24 at 10:32 a.m., ASM #5 was interviewed. She stated: Yesterday morning, they were telling me something about the Morphine. I didn't know anything about the Morphine until yesterday morning (5/21/24). [LPN #5] was the one who shared it with me. She…

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, facility document review, and clinical record review, it was determined the facility staff failed to develop and/or implement the comprehensive care plan for five of 43 residents in the survey sample, Residents #45, #13, #16, #47, and #25. The findings include: 1. For Resident #45, the facility staff failed to implement the comprehensive care plan for the bilateral leg wound treatments as ordered. The comprehensive care plan dated, last revised on 8/25/23, documented in part, Focus: (R45) has potential for impairment to skin r/t (related to) PVD (peripheral vascular disease), Venous insufficiency, left lower extremity wound. The Interventions documented in part, Treatments as ordered. The care plan also documented in part on 9/7/23, Focus: (R45) has a venous/stasis ulcer of the left lower extremity r/t PVD. The Interventions documented in part, Treatments per MD (medical doctor) orders. The physician order dated, 3/27/24 documented, Cleanse Left shin and left calf with wound cleanser. Pat dry with 4x4 (gauze pad). Apply…

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 review and revise the comprehensive care plan for six of 43 residents in the survey sample, Residents #42, #61, #48, #58, #45, and #73. The findings include: 1. For Resident #42 (R42), the facility staff failed to review and revise the resident's comprehensive care plan after the resident fell on 1/5/24. A change in condition note dated 1/5/24 documented, a CNA (certified nursing assistant) reported R42 rolled out of bed during peri-care. A review of R42's comprehensive care plan (initiated on 6/25/21) failed to reveal the care plan was reviewed and revised after the resident's 1/5/24 fall. Further review of R42's clinical record revealed the resident fell again on 4/30/24. On 5/21/24 at 4:01 p.m., an interview was conducted with RN (registered nurse) #4. RN #4 stated the care plan drives all of the care that staff provides residents. RN #4 stated residents' care plans should be reviewed and revised after each fall and staff should look at the care plan and make…

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, and clinical record review, it was determined the facility staff failed to provide care and services to promote the highest level of well-being for four of 43 residents in the survey sample, Residents #45, #235, #13 and #336. The findings include: 1. For Resident #45, the facility staff failed to administer the treatments per the physician orders. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 5/4/24, the resident scored a 13 out of 15 on the BIMS (brief interview for mental status) score indicating the resident was not cognitively impaired for making daily decisions. The physician order dated, 3/27/24 documented, Cleanse Left shin and left calf with wound cleanser. Pat dry with 4x4 (gauze pad). Apply moist 4x4's with 1/4 strength Dakins solution. Cover with gauze, wrap with ace wrap two times a day. The physician order dated, 3/27/24, documented, Cleanse right shin and right calf with wound…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and facility document review, it was determined that the facility staff failed to staff accordingly to ensure the director of nursing did not serve as a floor nurse for five of 30 days reviewed for nurse staffing. The findings include: The facility staff failed to staff the facility to ensure the director of nursing did not serve as a floor nurse when the facility had a census greater than 60 residents on 4/21/2024, 4/26/2024, 5/4/2024, 5/5/2024 and 5/18/2024. Review of the PBJ Staffing Data Report for 10/1/2023-12/31/2023 revealed concerns related to one star staffing. On 5/20/2024 at approximately 10:03 a.m., during entrance conference, ASM (administrative staff member) #1, the administrator stated that the facility did not have any staffing waivers in place in the facility. Review of the as worked nursing schedules from 4/20/2024 to the present documented the director of nursing working on the floor on 4/21/2024 6:45 a.m. to 7:15 p.m. with a facility census of 76, on 4/26/2024 from…

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

Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to administer medications at a error rate of less than 5%. There were eight errors out of 28 opportunities, with a medication error rate of 28.57%. The findings include: On 5/20/24 at 10:29 a.m. observation was made of RN (registered nurse) #2 administering medications to Resident #37. The following medications were administered: Duloxetine 30 mg (milligrams) - 1 capsule (used to treat depression) Apixaban 5 mg - 1 tablet (clot prevention) Furosemide tablet 20 mg - 1/2 tablet (diuretic) Metformin 500 mg - 1 tablet - (diabetes) Omeprazole 20 mg - 1 tablet (gastroesophageal reflux disease) Oxcarbazepine 300 mg -1 tablet (bipolar disorder) Potassium Chloride 20 mEq (milliequivalent) - 1 tablet (potassium supplement) Risperdal 0.5 mg - 1 tablet (bipolar disorder) Tizanidine 2 mg - 1 tablet (muscle spasms) Vitamin D 50 mcg (micrograms) - 1 tablet - (supplement) Basaglar Kwik Pen Solution 16 units (diabetes) injected at 10:53 a.m. The Medication…

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 facility staff failed to store, prepare, and serve food in a sanitary manner in one of one facility kitchens. The findings include: On 05/20/2024 at approximately 9:55 a.m., an observation of the facility's kitchen revealed the following: 1. Observation of a ladder rack set between the steamer cabinet and the convection oven in the facility's kitchen revealed three sheet pans of frozen chicken breast thawing directly above two sheet pans of uncooked diced potatoes. 2. Observation of the facility dry storage room revealed three 50 pound bags, one each of flour, with approximately 25 pounds remaining, sugar, with approximately 25 pounds and corn meal, with approximately 5 pounds remaining, sitting on a bottom shelf and open to the environment, a 25-pound box of powder thickener sitting on the bottom another shelf, with approximately 20 pounds remaining, open to the environment and two loaves of bread with approximately one-third remaining, open to the environment. 3. Observation of the walk-in…

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

Based on staff interview and facility document review, the facility staff failed to maintain an effective training program for six of ten employee record reviews and failed to develop and implement a training program based on the facility assessment. The findings include: The facility staff failed to implement training for multiple training topics, including communication, resident rights, abuse/neglect/exploitation, QAPI, compliance/ethics, and behavioral health, was completed by all required staff. Refer to F941, F952, F943, F944, 945, F946, F947, and F949 for specific staff and topics that were not in compliance. A review of the facility assessment was conducted during the survey. This review revealed, in part: Facility Assessment Tool dated 3/15/24: Are there training, education and/or competency needs based on resident and/or staff data or trends identified in the Facility Assessment .Areas Facility Assessment Informed/Action to Be Taken/Already Taken This Year .Infection Prevention/Control .Training Continuously .Training Competencies Yearly Relias Training. On 5/23/24 at 2:30…

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 required training on QAPI for five of seven employee records reviewed, CNA (certified nursing assistant) #8, CNA #5, RN (registered nurse) #2, OSM (other staff member) #6, a cook, and OSM # 22, a housekeeper. The findings include: For CNA #8, hired 9/17/21, the facility failed to provide the required training in QAPI (quality assurance and performance improvement). For CNA #5, hired 6/19/21, the facility failed to provide the required training in QAPI. For RN #2, hired 3/19/24, the facility failed to provide the required training in QAPI. For OSM#6, hired 12/4/19, the facility failed to provide the required training in QAPI. For OSM #22, hired 9/6/18, the facility failed to provide the required training in QAPI. On 5/23/24 at 3:38 p.m., OSM (other staff member) #14, the human resources coordinator, was interviewed. She stated she had only been employed at the facility for a short while, and she was in the process of auditing everything for which she was responsible. She stated she 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 staff interview and employee record review it was determined that the facility staff failed to ensure that four of five CNA (certified nursing assistant) records reviewed received the required 12 hours of annual training, and/or received annual dementia training, CNA #8, CNA #3, CNA #9 and CNA #10. The findings include: The facility staff failed to ensure that four of five CNAs selected met the required 12-hours of annual training and one of five did not complete annual dementia training. Review of CNA #8's record documented a hire date of 9/17/2021. Further review of the education transcripts documented a total amount of training hours of 9.25 hours in the past year. Review of CNA #3's record documented a hire date of 9/26/2022. Further review of the education transcripts documented a total amount of training hours of 3 hours in the past year and no dementia training. Review of CNA #9's record documented a hire date of 1/23/2023. Further review of the education transcripts documented a total amount of training hours of 2 hours in the past year. Review of CNA #10's record…

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

Based on observation, resident interview, staff interview and clinical record review, it was determined that the facility staff failed to maintain the call bell in a position accessible to the resident for one of 43 residents in the survey sample, Resident #17. The findings include: 1. For Resident #17 (R17), the facility staff failed to maintain the call light in a position where they could access it. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/21/2024, the resident scored eight out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. The assessment coded R17 as requiring substantial/maximal assistance with toileting and bed mobility. It further documented R17 not having any impairment in the upper extremities. On 5/20/2024 at 3:40 p.m., an observation was made of R17 in their room. R17 was observed in bed, the call bell was observed lying in the recliner located to the left of R17's bed. At this 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.

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 protect one of 43 residents in the survey sample, Resident #136, from verbal abuse from another resident, Resident #38. The findings include: For Resident #136, the facility staff failed to protect him from a verbal threat by Resident #38 on 4/14/24. Resident #38: On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 4/23/24, the resident scored a 9 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired for making daily decisions. In Section E - Behaviors, the resident was coded as having verbal behavioral symptoms direct toward others (e.g., threatening others, screaming at others, cursing at others). This behavior occurred one to three days during the look back period. The nurse's note dated, 4/15/24 at 12:39 a.m. documented, Staff responded to shouting in this room.…

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 protect a resident from misappropriation of medication for one of 43 residents in the survey sample, Resident #64. The findings include: For Resident #64 (R64), the facility staff failed to protect him from misappropriation of his Haldol (1) when the medication was administered to another Resident #17 (R17). A review of R64's clinical record revealed the following order dated 4/3/24: Haloperidol Lactate Oral Concentrate 2 mg/ml (milligrams per milliliter. Give 0.25 ml by mouth every 4 hours as needed for agitation. A review of R64's care plan dated 4/17/24 revealed, in part: The resident has behaviors .r/t (related to) terminal diagnosis .[R64] is on an antipsychotic medication r/t end of life care. Psychosis and terminal agitation. A review of a facility synopsis of events dated 5/13/24 revealed, in part: CNA (certified nursing assistant) reported nurse saying she was giving medication to [Resident #17] without an order .Investigation on allegation began. A review of 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, the facility staff failed to prevent a resident from being chemically restrained for one of 43 residents in the survey sample, Resident #17. The findings include: For Resident #17 (R17), the facility staff chemically restrained the resident by administering Haldol (1) from Resident #64's supply to R17 without a physician's order. A review of R17's clinical record, including April and May 2024 physician's orders and MARs (medication administration records) revealed no evidence of an order for Haldol. A review of R17's care plan dated 4/26/24 revealed no information related to the resident's receiving Haldol. A review of a facility synopsis of events dated 5/13/24 revealed, in part: CNA (certified nursing assistant) reported nurse saying she was giving medication to [Resident #17] without an order .Investigation on allegation began. A review of a facility synopsis of events dated 5/16/24 revealed, in part: The initial report that was filed on 5/13/24 stated that [R17] was the resident involved in the…

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

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide the receiving facility the care plan goals upon transfer for one of 43 residents in the survey sample, Resident #45. The findings include: For Resident #45 (R45), the facility staff failed to provide the receiving hospital the care plan goals upon transfer on 4/17/24. The Transfer from SNF/NF (skilled nursing facility/nursing facility) dated 4/17/24, failed to evidence documentation that the care plan goals were sent with the resident upon transfer. The nurse's notes failed to evidence documentation on 4/17/24 as to if the care plan goals were sent to the hospital with the resident. A request was made for the evidence that the care plan goals were sent with the resident on 4/17/24. ASM (administrative staff member) #1, the administrator, stated on 05/22/24 11:20 a.m. that they could not find evidence that the care plan goals were sent with the resident to the hospital on 4/17/24. An interview was conducted with LPN (licensed practical nurse) #5 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 staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to develop and/or implement the baseline care plan for two of 43 residents in the survey sample, Resident #235, and Resident #336. The findings include: 1. a. For Resident #235 (R235), the facility staff failed to develop, on the baseline care plan, the care for the resident's right foot wounds. The admission assessment completed on 5/8/24, documented the resident had no memory difficulties. The form documented, Concerns on Feet: Yes. Description: Diabetic ulcer on the right foot second toe/right helix. Right foot. Charcot's joint of foot. The baseline care plan dated, 5/8/24 failed to document anything under, Altered Skin Integrity/Potential for. The top of the form documented, Care Plan Areas marked with an X are required to be addressed. Altered Skin Integrity/Potential for had an X marked. Nothing was checked off or written in on this section. 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, facility document review, and clinical record review, the facility staff failed to follow professional standards of practice for two of 43 residents in the survey sample, Residents #58, and #336. The findings include: 1. For Resident #58 (R58), the facility staff failed to clarify a physician's order for alcohol. A review of R58's clinical record revealed a physician's order dated 5/26/23 that documented, May have alcohol once a week. A nurse's note dated 9/27/23 documented, Staff went to change and assist resident to bed for the night. Patient reeked of alcohol had urinated on himself in the wheelchair, slurred speech, unable to assist staff to help him into bed. Patient stated to staff I have only been drinking mt dew. Three 24oz cans of 8% alcohol found in resident's room. Educated resident on the interactions that could occur with mixing alcohol with his medication. 2 staff assisted resident into bed changed his clothes and brief placed pillows under sheet to help assist resident from rolling out of bed, fall mat placed on the floor and bed put in low…

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, it was determined that the facility staff failed to provide care and services to ensure communication devices were in place for one of 43 residents in the survey sample, Resident #47. The findings include: For Resident #47 (R47), the facility staff failed to attempt or provide alternate communication devices for a documented language barrier. On the most recent MDS (minimum data set), a quarterly assessment, with an ARD (assessment reference date) of 4/14/2024, the resident was assessed as being severely impaired for making daily decisions. The assessment further documented R47 having a preferred language of Korean and wanting or needing an interpreter to communicate with the doctor or health care staff. The assessment further documented R47 having adequate vision and hearing, clear speech, sometimes understood and sometimes able to understand others. On 5/15/2024 at 12:31 p.m., an observation was made of R47 in their room. R47 was observed in bed eating lunch. 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 observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide ADL (activities of daily living) care to dependent residents for two of 43 residents in the survey sample, Residents #25 and #17. The findings include: 1.a. For Resident #25 (R25), the facility staff failed to transfer him from his bed to his wheelchair on 5/13/24, 5/14/24, and 5/15/24. R25 was admitted to the facility with diagnoses including cerebral palsy and quadriplegia. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/26/24, R25 was coded as being completely dependent on staff for chair/bed-to-chair transfers. On the following dates and times, R25 was observed sitting up in his bed: 5/13/24 at 3:33 p.m.; 5/14/24 at 11:51 a.m. and 3:37 p.m.; 5/15/24 at 11:40 a.m. and 2:56 p.m. A review of R25's care plan dated 5/15/24 revealed, in part: [R25] has an ADL self-care performance deficit r/t (related to) cerebral palsy, bilateral upper and lower extremity contractures .The resident is totally…

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, it was determined that the facility staff failed to provide individualized resident centered activities for one of 43 residents in the survey sample, Resident #47. The findings include: For Resident #47 (R47), the facility staff failed to provide consistent resident centered activities to accommodate the resident's preferred primary language, documented language barrier and assessed activity preferences. On the most recent MDS (minimum data set), a quarterly assessment, with an ARD (assessment reference date) of 4/14/2024, the resident was assessed as being severely impaired for making daily decisions. The assessment further documented R47 having a preferred language of Korean and wanting or needing an interpreter to communicate with the doctor or health care staff. The assessment further documented R47 having adequate vision and hearing, clear speech, sometimes understood and sometimes able to understand others. Section F of the admission MDS with an ARD of 1/13/2024 documented group…

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 facility staff failed to provide respiratory care and services for 2 (two) of 43 residents in the survey sample, Residents #76 (R76) and R16. The findings include: 1. For R76, the facility staff failed to store a nebulizer (1) mask in a sanitary manner. R76 was admitted to the facility with diagnoses that included but were not limited to emphysema (2). On the most recent comprehensive MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 04/09/2024, R76 scored 11 out of 15 on the BIMS (brief interview for mental status), indicating R76 was moderately impaired of cognition for making daily decisions. On 05/21/24 at approximately 8:25 a.m., an observation of R76's nebulizer mask revealed the mask hanging off the bedside table uncovered. On 05/21/24 at approximately 12:10 p.m., an observation of R76's nebulizer mask revealed the mask hanging off the bedside table uncovered. The physician's order for R76 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 staff interview, facility document review, and clinical record review, the facility staff failed to implement bed rail requirements for one of 43 residents in the survey sample, Resident #63. The findings include: For Resident #63 (R63), the facility staff failed to review the risks and benefits of bed rails with the resident (or resident representative) and obtain informed consent. A review of R63's clinical record revealed a physician's order dated 4/10/23 for side rails (bed rails) for bed mobility. On 5/21/24 at 8:32 a.m., R63 was observed lying in bed with bilateral one fourth bed rails in the upright position. Further review of R63's clinical record (including nurses' notes) failed to reveal the staff reviewed the risks and benefits of the bed rails with the resident (or the resident's representative) or obtained informed consent. On 5/21/24 at 4:01 p.m., an interview was conducted with RN (registered nurse) #4. RN #4 stated nurses should educate residents on the risks and benefits of bed rails, obtain informed consent, and document this in a nurse's note. On 5/22/24…

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 provide physician oversight of a resident's care for one of 43 residents in the survey sample, Resident #336. The findings include: For Resident #336 (R336), the physician failed to initiate orders for the resident's Penrose drain, wound/skin assessment, and fluid restriction when the resident was admitted . R336 was admitted to the facility on [DATE] with a past medical history of heart failure, chronic obstructive pulmonary disease, and a recurrent perirectal (area around the rectum) abscess. A review of R336's hospital Discharge summary dated [DATE] revealed, in part: Discharge Diagnoses: Acute hypoxic respiratory failure, Acute diastolic heart failure, Pulmonary edema, Pulmonary hypertension .Patient has history of 40 pack per year smoking .She will be discharged home on .fluid restriction, recommendation for daily weight monitoring. A review of R336's admission Nursing assessment dated [DATE]…

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

Based on observation, staff interview and facility document review, it was determined the facility failed to have sufficient staffing for the nurse to give the medications in the prescribed timeframe on one of two units. The findings include: On 5/20/24 at 10:29 a.m. observation was made of RN (registered nurse) #2 administering medications to Resident #37. The following medications were administered: Duloxetine 30 mg (milligrams) - 1 capsule (used to treat depression) Apixaban 5 mg - 1 tablet (clot prevention) Furosemide tablet 20 mg - 1/2 tablet (diuretic) Metformin 500 mg - 1 tablet - (diabetes) Omeprazole 20 mg - 1 tablet (gastroesophageal reflux disease) Oxcarbazepine 300 mg -1 tablet (bipolar disorder) Potassium Chloride 20 mEq (milliequivalent) - 1 tablet (potassium supplement) Risperdal 0.5 mg - 1 tablet (bipolar disorder) Tizanidine 2 mg - 1 tablet (muscle spasms) Vitamin D 50 mcg (micrograms) - 1 tablet - (supplement) Basaglar Kwik Pen Solution 16 units (diabetes) injected at 10:53 a.m. The Medication Administration Records were reviewed and documented the above orders. An…

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 three of five CNA (certified nursing assistant) records reviewed received annual performance reviews, CNA #3, CNA #9 and CNA #10. The findings include: The facility staff failed to ensure that three of five CNAs selected received an annual performance evaluation. CNA #3's record documented a hire date of 9/26/2022. On 5/23/2024 at 1:39 p.m., OSM (other staff member) #14, human resource coordinator, stated that they did not have a performance review to provide for CNA #3. CNA #9's record documented a hire date of 1/23/2023. On 5/23/2024 at 1:39 p.m., OSM #14, human resource coordinator, stated that they did not have a performance review to provide for CNA #9. CNA #10's record documented a hire date of 2/15/2023. On 5/23/2024 at 1:39 p.m., OSM #14, human resource coordinator, stated that they did not have a performance review to provide for CNA #10. On 5/23/2024 at 3:30 p.m., an interview was conducted with OSM #14, human resource coordinator. OSM #14 stated that they…

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 medically related social services for two of 43 residents in the survey sample, Residents #61, and #48. The findings include: 1. For Resident #61 (R61), the facility staff failed to assess the psychosocial well-being of the resident after another resident became upset, threw a vase, and the vase or a piece of the vase accidentally hit R61 in the head. A facility synopsis of events dated 4/29/24 documented that on 4/29/24, R61 reported that on 4/28/24, R58 became upset in the dining room (due to not being able to go outside to smoke), threw vases, and a vase or piece of vase hit R61 in the head. A note signed by the nurse practitioner on 4/29/24 documented, Advised by staff resident states she was struck in head while another resident was throwing vases in the dining hall. She states it struck her on the left side of her head and it is painful. Plan: Recommend routine checks by staff . The nurse practitioner's note did not document any psychosocial assessment. 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 staff interview, facility document review, and clinical record review, the facility staff failed to prevent residents from receiving unnecessary psychoactive medications for one of 43 residents in the survey sample, Residents #17. The findings include: For Resident #17 (R17), the facility staff administered Haldol (1) from Resident #64's supply to R17 without a physician's order. A review of R17's clinical record, including April and May 2024 physician's orders and MARs (medication administration records) revealed no evidence of an order for Haldol. A review of R17's care plan dated 4/26/24 revealed no information related to the resident's receiving Haldol. A review of a facility synopsis of events dated 5/13/24 revealed, in part: CNA (certified nursing assistant) reported nurse saying she was giving medication to [Resident #17] without an order .Investigation on allegation began. A review of a facility synopsis of events dated 5/16/24 revealed, in part: The initial report that was filed on 5/13/24 stated that [R17] was the resident involved in the report, but with the…

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

Based on staff interview, and clinical record review, and facility document review, it was determined that facility staff failed to obtain physician ordered laboratory tests for 1 (one) of 43 residents in the survey sample, Residents #65 (R65). The findings include: For R65, the facility staff failed to obtain physician ordered laboratory (lab) tests of CBC (complete blood count) (1), CMP (comprehensive metabolic panel) (2), CRP (C-Reactive protein) (3), ESR (erythrocyte sedimentation rate) (4), CPK (creatine phosphokinase) (5), on 04/04/2024, 04/25/2024 and 05/02/2024. R65 was admitted to the facility with diagnoses that included but were not limited to osteomyelitis (6) of ankle and foot. On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 04/26/2024, R65 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R65 was cognitively intact for making daily decisions. The physician's orders for R65 documented: Lab draw weekly on Thursday through ABT labs to include CBC (complete blood…

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 maintain a complete and accurate clinical record for three of 43 residents in the survey sample, Residents #48, #47, and #336. The findings include: 1. For Resident #48 (R48), the facility staff failed to document an incident with another resident on 3/28/24 in the clinical record. A facility synopsis of events dated 3/29/24 documented that on that date, R58 became upset with kitchen staff then accidentally ran his wheelchair into R48's wheelchair and bumped R48's leg. A review of R48's clinical record failed to reveal any documentation regarding the event. On 5/22/24 at 9:23 a.m., an interview was conducted with OSM (other staff member) #11 (the director of social services). OSM #11 stated that if a resident is hit by another resident in a wheelchair while the other resident is having a behavior outburst, then this incident should be documented in both residents' clinical records. On 5/22/24 at 5:35 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #5…

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 implement infection control measures for three of 43 residents in the survey sample, Residents #17, #25, and #85. The findings include: 1. For Resident #17 (R17), who has a Foley catheter (1), the facility staff failed to implement enhanced barrier precautions (2). On the following dates and times, R17 was observed lying in bed, with a Foley catheter collection bag visible hanging on the bed frame: 5/13/23 at 3:36 p.m. and 5/14/24 at 11:41 a.m. At all of these observations, no sign for enhanced barrier precautions or PPE (personal protective equipment) were on or near R17's door. Staff members were observed going in and out of the room without putting on any PPE. A review of R17's physician orders and care plan revealed orders and interventions related to care of R17's Foley catheter. On 5/14/24 at 11:52 a.m., RN (registered nurse) #5, who was administering medications on the resident's hallway, stated the resident was not on any sort of isolation. On 5/15/24 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 required training on effective communication for one of seven employee records reviewed, CNA (certified nursing assistant) #8. The findings include: For CNA #8, hired 9/17/21, the facility failed to provide the required training in effective communication. On 5/23/24 at 3:38 p.m., OSM (other staff member) #14, the human resources coordinator, was interviewed. She stated she had only been employed at the facility for a short while, and she was in the process of auditing everything for which she was responsible. She stated she is responsible for all training, and is aware there are some things that have not been completed. On 5/23/24 at 3:15 p.m., ASM (administrative staff member) #5 the regional director of clinical services, ASM #6, the regional vice president of operations, and OSM #11, social services director, were informed of these concerns. A review of the facility policy, In-Service Training-General, revealed, in part: 1. The Executive Director and/or the Director of Nursing /designee…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and facility document review, the facility staff failed to provide required training on resident rights and facility responsibilities for one of seven employee records reviewed, CNA (certified nursing assistant) #8, The findings include: For CNA #8, hired 9/17/21, the facility failed to provide the required training in resident rights and facility responsibilities. On 5/23/24 at 3:38 p.m., OSM (other staff member) #14, the human resources coordinator, was interviewed. She stated she had only been employed at the facility for a short while, and she was in the process of auditing everything for which she was responsible. She stated she is responsible for all training, and is aware there are some things that have not been completed. On 5/23/24 at 3:15 p.m., ASM (administrative staff member) #5 the regional director of clinical services, ASM #6, the regional vice president of operations, and OSM #11, social [NAME] director, were informed of these concerns. A review of 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.

Based on staff interview and facility document review, the facility staff failed to provide required training compliance and ethics for two of seven employee records reviewed, OSM (other staff member) #6, a cook, and OSM # 22, a housekeeper. The findings include: For OSM#6, hired 12/4/19, the facility failed to provide the required training in compliance and ethics. For OSM #22, hired 9/6/18, the facility failed to provide the required training in compliance and ethics. On 5/23/24 at 3:38 p.m., OSM (other staff member) #14, the human resources coordinator, was interviewed. She stated she had only been employed at the facility for a short while, and she was in the process of auditing everything for which she was responsible. She stated she is responsible for all training, and is aware there are some things that have not been completed. On 5/23/24 at 3:15 p.m., ASM (administrative staff member) #5 the regional director of clinical services, ASM #6, the regional vice president of operations, and OSM #11, social services director, were informed of these concerns. 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.

Based on staff interview and facility document review, the facility staff failed to provide required training on meeting behavioral needs for four of seven employee records reviewed, OSM (other staff member) #3, an occupational therapist, RN (registered nurse) #2, OSM (other staff member) #6, a cook, and OSM # 22, a housekeeper. The findings include: For OSM #3, hired 9/11/23 the facility failed to provide the required training in meeting behavioral needs. For RN #2, hired 3/19/24, the facility failed to provide the required training in meeting behavioral needs. For OSM#6, hired 12/4/19, the facility failed to provide the required training in meeting behavioral needs. For OSM #22, hired 9/6/18, the facility failed to provide the required training in meeting behavioral needs. On 5/23/24 at 3:38 p.m., OSM (other staff member) #14, the human resources coordinator, was interviewed. She stated she had only been employed at the facility for a short while, and she was in the process of auditing everything for which she was responsible. She stated she is responsible for all training, and 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 staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide the care and services to treat a pressure injury for one of seven residents in the survey sample, Resident #1. The findings include: The facility failed to ensure pressure injury care was provided to Resident #1 per physician orders. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 11/14/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as being dependent for bathing, bed mobility, transfer, dressing, hygiene and limited assistance for eating. A review of Section M- skin conditions coded the resident as having one Stage 2 pressure injury (1,2), and one Unstageable pressure injury (3) which were present on admission. A review of the comprehensive care plan dated 11/8/23 revealed, FOCUS: Resident has pressure…

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 care and services for a urinary catheter for one of seven residents in the survey sample, Resident #1. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: renal disease, diabetes and acute cystitis. A review of the comprehensive care plan dated 11/8/23 revealed, FOCUS: Resident has an indwelling catheter due to atonal bladder and status post CVA (cerebrovascular accident). INTERVENTIONS: Catheter care every shift and as needed. Monitor and document intake and output as per facility protocol. Monitor/record/report to physician signs and symptoms (s/s) related to UTI. A review of the physician orders dated 11/7/23 revealed, Catheter care every shift and as needed. Monitor catheter for patency and drainage every shift. Monitor urine for s/s infection every shift. If present document and notify physician. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to implement the care plan for one of seven residents in the survey sample, Resident #1. The findings include: For Resident #1, the facility staff failed to implement the comprehensive care plan for pressure injury and catheter care. Resident #1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), renal disease, UTI (urinary tract infection) and chronic cystitis. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 11/14/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as being dependent for bathing, bed mobility, transfer, dressing, hygiene and limited assistance for eating. A 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 staff interview, facility document review, and clinical record review, it was determined the facility staff to prevent the misappropriation of resident property, specifically narcotic medications, for five of 37 residents in the survey sample, Resident #128, #52, #22, #129, and #27. This is cited as past non-compliance. The findings include: Facility staff found narcotic medication cards tampered with as follows: 1. For Resident #128 (R128), the facility staff failed to prevent the misappropriation of Oxycodone - Acetaminophen (Percocet) used to treat moderate to severe pain. (1). The physician order dated, 12/4/2021, documented, Oxycodone-Acetaminophen Tablet 5-325 MG (milligrams); give 2 tablets by mouth every 4 hours as needed for severe pain 8/10 - 10/10. (pain rating of 8 to 10 and 10 being the worse pain on a pain scale of 1-10). The Narcotic Card contained spaces for 30 tablets. There were 25 tablets in the card at the time of discovery. All the 25 tablets had been tampered with. According to the clinical record, this resident had been discharged prior 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, clinical record review and facility document review, it was determined the facility staff failed to provide evidence of providing ADLs (activities of daily living) care for one of 37 residents, Resident #276. The findings include: The facility staff failed to provide evidence of transfer (in and out of bed) and bed mobility for Resident #276. Resident #276 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: fracture of right femur with hip replacement, coronary artery disease (CAD), diabetes mellitus and arthritis. The most recent MDS (minimum data set) assessment, a five-day Medicare assessment, with an ARD (assessment reference date) of 6/29/22, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring limited assistance for bed mobility, transfer, locomotion, dressing,…

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 care and services for indwelling urinary catheter care for one of 37 residents, Resident #276. The findings include: Resident #276 was admitted to the facility with a urinary catheter on 6/24/22 however there was no documentation of catheter care until 7/2/22. Resident #276 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: fracture of right femur with hip replacement. Review of physician orders did not include the use of a catheter or care until 7/2/22. Physician orders dated 7/2/22, read, Foley catheter 16 French 10 cc (cubic centimeter) balloon, measure urinary output every shift and as needed. Change catheter as needed. Change catheter bag as needed. Catheter care every shift and as needed. A review of the June 2022 TAR (treatment administration record) and the July 2022 TAR, revealed catheter care was not documented from admission 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 staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure medications were available for administration for two of 37 residents, Resident #276 and Resident #48. The findings include: 1. For Resident #276, the facility staff failed to ensure Levothyroxine 125 mcg (microgram), Lidocaine patch 5%, Methocarbamol 500 mg (milligram), Oxycodone 10 mg and Pregabalin capsule 100 mg were available for administration. Resident #276 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: fracture of right femur with hip replacement, coronary artery disease (CAD), diabetes mellitus and arthritis. A review of the comprehensive care plan dated 7/7/22, which revealed, FOCUS: The resident has pain related to fracture of right femur. INTERVENTIONS: Administer medications per physician orders. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. A review of the physician…

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 the facility staff failed to maintain two of two shower rooms in a sanitary manner, Rosewood and Dogwood hall shower rooms. The findings include: On 4/18/2023 at 11:03 a.m. OSM (other staff member) #7, the director of maintenance, was asked if the facility had any concerns with reported black mold the summer of 2022. OSM #7 stated, no. Observation was made of the shower rooms on both hallways on 4/19/2023 at approximately 2:45 p.m. On the Dogwood Hall there were two shower stalls in the shower room. There was a brown and black substance the junction of the walls and floors on both sides of the shower room. On the Rosewood Hall there were two shower stalls observed. There was a brown and black substance noted on both sides of the stall where the floor meets the walls. There was also a brown substance covering the grout on the left side where the side wall met the back wall. A brown and black substance was noted on the right side, where the side wall meets the back wall. On 4/19/2023 at 2:01 p.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 staff interview, facility document review and clinical record review, it was determined the facility staff failed to review an advanced directive periodically for one of 37 residents in the survey sample, Resident #51. The findings include: For Resident #51, a DDNR (durable do not resuscitate) form dated 4/25/2021 was in the clinical record. An Advance Directives Discussion Document was dated 4/25/2021. Further review of the clinical record failed to evidence any documentation related to reviewing the advance directive with the resident. On the most recent MDS assessment, a quarterly assessment, with an assessment reference date 2/7/2023, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score indicating the resident was not cognitively impaired for making daily decisions. The comprehensive care plan dated 7/11/2021, documented in part, Focus: Resident has advanced directives r/t (related to) DNR AEB (as evidenced by) DNR (do not resuscitate). The Interventions documented, Discuss advanced directives with resident and or residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and facility document review, it was determined the facility staff failed to notify the physician of the inability to administer newly ordered medications for one of 37 residents in the survey sample, Resident #276. The findings include: The facility failed to notify the physician of failure to obtain and administer admission medications for Resident #276. Resident #276 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: fracture of right femur with hip replacement, coronary artery disease (CAD), diabetes mellitus and arthritis. The most recent MDS (minimum data set) assessment, a five-day Medicare assessment, with an ARD (assessment reference date) of 6/29/22, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the comprehensive care plan dated 7/7/22, revealed, FOCUS: The resident has pain related to fracture of right femur.…

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 evidence of the required documents sent to the receiving facility upon transfer, for two of 37 residents in the survey sample, Residents #30 and #48. The findings include: 1. For Resident #30, the facility staff failed to evidence what required documents were sent with the resident upon transfer to the hospital on 2/6/2023. The nurse's note dated, 2/6/2023 at 9:23 p.m. documented, Pt (patient) c/o (complain of) acid reflux but cannot describe the chest pressure. Pt is also c/o on shortness of breath on exertion. RLE (right lower extremity) is red, warm to touch. Pt is requesting to be sent to ED (emergency department) for further evaluation. Paperwork sent with pt. VS (vital signs) = 116/68, HR (heart rate) 89, RESP (respiration) 18, TEMP (temperature) 97.8, and 97% on room air. The Change in Condition form dated, 2/6/2023, failed to evidence documentation of documents sent 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 staff interview, clinical record review, and facility document review, it was determined the facility staff failed to develop and implement a baseline care plan for one of 37 residents in the survey sample, Resident #276. The findings include: The facility failed to develop and implement a baseline care plan regarding pain medication and an indwelling urinary catheter (Foley catheter) that was present upon admission for Resident #276. Resident #276 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: fracture of right femur with hip replacement, coronary artery disease (CAD), diabetes mellitus and arthritis. A review of the baseline care plan dated 6/24/22 revealed, FOCUS: Fracture: Hip. INTERVENTIONS: Weight bearing as tolerated. Monitor pain and treat as ordered. Assist with repositioning. Rehab orders/recommendations. A review of the physician orders dated 6/24/22 revealed, Lidocaine patch 5% apply to right hip topically one time a day for pain and remove 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.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to implement the comprehensive care plan for two of 37 residents in the survey sample, Residents #51 and #66. The findings include: 1. For Resident #51, the facility staff failed to implement the comprehensive care plan for reviewing advance directives. On the most recent MDS assessment, a quarterly assessment, with an assessment reference date 2/7/2023, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score indicating the resident was not cognitively impaired for making daily decisions. The comprehensive care plan dated 7/11/2021, documented in part, Focus: Resident has advanced directives r/t (related to) DNR AEB (as evidenced by) DNR (do not resuscitate). The Interventions documented, Discuss advanced directives with resident and or resident's representative. Physician order for DNR. A DDNR (durable do not resuscitate) form dated 4/25/2021 was in the clinical record. An Advance Directives Discussion Document was 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 staff interview, facility document review, and clinical record review, it was determined the facility staff failed to follow professional standards of practice for the medication administration for two of 37 residents in the survey sample, Resident #13 and Resident #48. The findings include: For Resident #13, the nurse documented a narcotic medication as administered although it was not administered to the resident. On the most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 1/13/2023, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. The facility synopsis of the event for 1/4/2023, documented in part, The DCS (director of clinical services) and the executive director on the afternoon of January 4, 2023, were in the process of completing a reconciliation of narcotic medications to ensure accuracy of the narcotics .While completing the reconciliation it was noted that a hydrocodone (used 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, it was determined the facility staff failed to administer oxygen per the physician's order for one of 37 residents in the survey sample, Resident #66. The findings include: For Resident #66 (R66), the facility staff failed to administer the oxygen at the prescribed rate of 2 LPM (liters per minute). R66 was observed on 4/18/2023 at 8:45 a.m. in bed asleep with oxygen via nasal cannula in place. The setting on the oxygen concentrator was between 1.5 LPM and 2.0 LPM. The ball was sitting with the top of the ball on the 2.0 line and the bottom of the ball sitting on the 1.5 line. A second observation was made on 4/19/2023 at 8:22 a.m., again R66 was in bed with the oxygen on with the setting on the oxygen concentrator between 1.5 LPM and 2.0 LPM. The ball was sitting with the top of the ball on the 2.0 line and the bottom of the ball sitting on the 1.5 line. The physician order dated, 4/10/2023, documented, Respiratory: Oxygen 2L (liters) continuous NC (nasal cannula) every shift for oxygen.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and facility document review, the facility staff failed to store food in a safe manner in one of two unit nourishment rooms, the dogwood nourishment room, and failed to serve food in a sanitary manner on one of two units, the rosewood unit. The findings include: 1. The facility staff failed to label food stored in the dogwood nourishment room refrigerator. On 4/18/23 at 2:42 p.m., an observation of the dogwood nourishment room refrigerator was conducted with CNA (certified nursing assistant) #1. The refrigerator contained an opened container of pre-cooked macaroni and cheese, an opened container of pre-cooked mashed potatoes, and an opened container of pre-cooked barbeque. All containers were covered with aluminum foil and were not labeled with the resident's name or date. At this time, an interview was conducted with CNA #1. CNA #1 stated staff is supposed to label food with the resident's name and date. On 4/18/23 at 4:10 p.m., ASM (administrative staff member) #1, 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 facility document review, the facility staff failed to implement their policy for ensuring that all staff were fully vaccinated for COVID-19, or who have been granted exemptions for three of 79 employee records reviewed. The findings include: The facility COVID-19 records documented that 3 staff were partially vaccinated, however there was no follow up information documented. An interview was conducted on 4/17/23 with ASM #2, the director of clinical services, who was filling in for the Infection Preventionist who had been out of the building for approximately one month. ASM #2 stated, My start date was in February, so I am learning a lot, and I am trying to keep up with the documentation but not everything is in the form. On 4/18/23, the facility provided the F888, staff vaccination matrix, which listed three employees as partially vaccinated, LPN (licensed practical nurse) #3, CNA (certified nursing assistant) #8 and OSM (other staff member) #6. On 4/19/23, a request was made for the hire dates for the three employees with partial vaccinations. 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.

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 evidence notification to the ombudsman of hospital transfer/discharges for four of 41 residents in the survey sample, Residents #331, #71, #129, and #45. 1. The facility staff failed to notify the ombudsman of Resident #331's discharge to the hospital on 9/17/21. 2. The facility staff failed to provide written notification of transfer to the ombudsman for Resident #71, when the resident was transferred to the hospital on 9/26/21. 3. Resident #129 was transferred to the hospital on 9/20/21. The facility staff failed to provide written notification of the transfer to the ombudsman. 4. The facility staff failed to evidence that the ombudsman was notified of a facility-initiated transfer on 08/05/2021 for Resident # 45. The findings include: 1. Resident #331 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses including a broken right arm,…

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, family interview, staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for eight of 41 residents in the survey sample, Residents #53, #26, #33, #8, #24, #28, #129, and #59. The findings include: 1.a. The facility staff failed to implement Resident #53's comprehensive care plan to provide the resident a shower, multiple times in August and September 2021. Resident #53 was admitted to the facility on [DATE] with diagnoses including cerebral palsy, hardening and disintegration of the spinal cord bones, quadriplegia and nerve pain. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/6/21, Resident #53 was coded as being moderately impaired for making daily decisions, having scored 12 out of 15 on the BIMS (brief interview for mental status). He 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 observation, staff interview, facility document review, and clinical record review, it was determined that the facility failed to provide care and services for the treatment of a pressure ulcer for two of 41 residents in the survey sample, Residents #26 and #33. The facility staff failed to provide preventative pressure ulcer treatments, and failed to provide treatments for Resident #26's pressure ulcer and Resident #33's pressure ulcer on multiple dates in August, September, and October 2021. The findings include: 1. Resident #26 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses including diabetes, peripheral artery disease, and end stage kidney disease. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/23/21, Resident #26 was coded as being cognitively intact for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). Resident #26 was coded as requiring…

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 care and services related to dialysis consistent with the plan of care for one of 41 residents in the survey sample, Resident #26. The facility staff failed to ensure assessments of Resident #26 prior to, and post dialysis appointments as ordered, and failed to communicate with the dialysis center on multiple occasions during August, September, and October 2021. The findings include: Resident #26 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses including diabetes, peripheral artery disease, and end stage kidney disease. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/23/21, Resident #26 was coded as being cognitively intact for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). Resident #26 was coded as having received…

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 evidence documentation that COVID-19 testing was completed for fourteen of 45 employee reviews. The facility staff failed to evidence documentation that COVID-19 testing was completed and the results of each staff test for multiple employees in September 2021 and October 2021. The findings include: Review of facility documentation revealed the facility began COVID-19 outbreak status on 8/26/21. Further review of facility documentation failed to reveal evidence that the facility staff tracked employee COVID-19 testing from 8/26/21 to the beginning of survey (10/19/21). Review of individual employee tests revealed the following: -For OSM #13 (temporary nurse aide) hired on 9/15/21, the facility staff failed to evidence documentation of completed testing for the weeks ending 10/9/21 and 10/16/21. -For CNA #14 hired on 9/17/21, the facility staff failed to evidence documentation of completed testing for the weeks ending 9/25/21, 10/2/21 and 10/16/21. -For RN #2 hired on 9/21/21,…

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 the facility staff failed to maintain an operational call bell system for two of 41 residents in the survey sample, Residents #8 and #130. The findings include: 1. The facility staff failed to ensure Resident #8's call bell was operational since July 2021. Resident #8 was admitted to the facility on [DATE]. Resident #8's diagnoses included but were not limited to major depressive disorder, diabetes and muscle weakness. Resident #8's annual minimum data set assessment with an assessment reference date of 8/2/21, coded the resident as being cognitively intact. Section G coded Resident #8 as requiring extensive assistance of two or more staff with bed mobility. On 10/19/21 at 10:09 a.m., Resident #8 was observed lying in bed. The resident's call bell was not operational. There was no light or sound signal when the call bell was pressed. An interview was conducted with Resident #8 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, it was determined that the facility staff failed to provide care in a manner to ensure dignity for one of 41 residents in the survey sample, Resident #28. The facility staff failed to maintain Resident #28's Foley urinary catheter (1) in a dignified manner. Urine in the catheter bag was observed from the hall while Resident #28 was lying in bed. The findings include: Resident #28 was admitted to the facility on [DATE]. Resident #28's diagnoses included but were not limited to congestive heart failure, muscle weakness and dementia. Resident #28's quarterly minimum data set assessment with an assessment reference date of 8/31/21, coded the resident's cognition as moderately impaired. Review of Resident #28's clinical record revealed a physician's order dated 3/23/21 for a Foley catheter due to urinary retention. Resident #28's comprehensive care plan dated 3/15/21 documented, (Resident #28) has Indwelling Foley Catheter r/t (related to) obstructive…

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 the facility staff failed to provide accommodation of needs for two of 41 residents in the survey sample, Residents #8 and #28. The facility staff failed to ensure Resident #8 and Resident #28's call bell or ring bell was within reach. The findings include: 1. The facility staff failed to ensure Resident #8's hand held ring bell was within the resident's reach. Resident #8 was admitted to the facility on [DATE]. Resident #8's diagnoses included but were not limited to major depressive disorder, diabetes and muscle weakness. Resident #8's annual minimum data set assessment with an assessment reference date of 8/2/21, coded the resident as being cognitively intact. Section G coded Resident #8 as requiring extensive assistance of two or more staff with bed mobility. Resident #8's electric call bell was not operational during the survey. On 10/19/21 at 10:09 a.m., Resident #8 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, it was determined that the facility staff failed to notify the physician of a possible need to alter treatment for two of 41 residents in the survey sample, Residents #24 and #129. The facility staff failed to notify Resident #24's physician when the medication Eliquis was not available for administration on 7/5/21 and 7/29/21, and failed to notify Resident #129's physician when the medication guaifenesin was not available for administration on 9/28/21, 9/29/21 and 9/30/21. The findings include: 1. Resident #24 was admitted to the facility on [DATE]. Resident #24's diagnoses included but were not limited to diabetes, atrial fibrillation (1) and a history of stroke. Resident #24's quarterly minimum data set assessment with an assessment reference date of 8/27/21, coded the resident's cognitive skills for daily decision making as modified independence. Review of Resident #24's clinical record revealed a physician's order dated 3/12/21 for Eliquis (1) 2.5 mg…

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 maintain a clean, comfortable, homelike environment for one of 17 residents in the survey sample, Resident #102. Resident #102 was observed on multiple occasions sitting in a Broda chair (specialized reclining wheelchair) which was observed with dried yellow material on the right side of the headrest cushion and both armrests and multiple tears in the headrest cushions. The findings include: Resident #102 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses including dementia, severe kidney disease, and diabetes. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 12/2/21, Resident #102 was coded as being severely cognitively impaired for making daily decisions, having scored two out of 15 on the BIMS (brief interview for mental status). Resident #102 was coded as 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.

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 evidence transfer discharge requirements transfer to the hospital for one of forty-one residents in the survey sample, Resident #71. The facility staff failed to evidence required transfer documentation/documents, to include: contact information of the practitioner responsible for the care of the resident, resident information including contact information, advance directives, comprehensive care plan goals, special care instructions, and all other necessary information as applicable to ensure safe and effective transition of care for Resident #71, were provided to the receiving hospital on 9/26/21, when the resident was transferred to the hospital . The findings include: Resident #71 was admitted to the facility on [DATE]. Resident #71's diagnoses included but were not limited to: chronic obstructive pulmonary disease 'COPD' (chronic non-reversible lung disease) (1), cellulitis…

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 three of 41 residents in the survey sample, Residents #130, #229 and Resident #230. 1. The facility staff failed to develop a baseline care plans for Resident #130 who was admitted to the facility on [DATE]. 2. The facility staff failed to develop a baseline care plans for Resident #229 admitted to the facility on [DATE]. 3. The facility staff failed to develop a baseline care plan to address Resident #230's mood and statements regarding self harm. The findings include: 1. Resident #130 was admitted to the facility on [DATE]. Resident #130's diagnoses included but were not limited to congestive heart failure, diabetes and chronic kidney disease. Resident #130's admission MDS (minimum data set) assessment with an assessment reference date of 10/21/21, coded the resident as being cognitively intact. On 10/20/21, Review of Resident #130's clinical record…

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 review and revise the comprehensive care plan for two of 41 residents in the survey sample, Residents #331 and #8. The facility staff failed to revise the comprehensive care plan for Resident #331 to address a urinary catheter and failed to review and revise Resident #8's comprehensive care plan for the use of bed rails. The findings include: 1. Resident #331 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses including a broken right arm, diabetes, and history of a stroke. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/30/21, Resident #331 was coded as being severely cognitively impaired for making daily decisions, having scored three out of 15 on the BIMS (brief interview for mental status. Resident #331 was coded as not having a catheter (1) in her bladder 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 observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to follow professional standards of practice for one of 41 residents in the survey sample, Resident #33. The facility staff failed to clarify two conflicting physician orders for treatment of a Stage 3 pressure ulcer. The findings include: Resident #33 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses of diabetes, history of a stroke, and dementia. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/6/21, Resident #33 was coded as being severely cognitively impaired for making daily decisions; the resident was not able to be interviewed for the BIMS (brief interview for mental status). The resident was coded as being dependent on staff assistance for all activities of daily living. She was coded as having a Stage 3 (1) pressure ulcer (2). On 10/21/21 at 10:51 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, family interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide ADL (activities of daily living) care assistance to one resident dependant on staff for care, (Resident #53), in a survey sample of 41 residents. Resident #53, who was coded as being dependent on the assistance of staff for personal hygiene and bathing, was not provided a shower or bed bath by facility staff on multiple occasions during August and September 2021. The findings include: Resident #53 was admitted to the facility on [DATE] with diagnoses including cerebral palsy, hardening and disintegration of the spinal cord bones, quadriplegia and nerve pain. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/6/21, Resident #53 was coded as being moderately impaired for making daily decisions, having scored 12 out of 15 on the BIMS (brief interview for mental status). He 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 resident interview, family interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide care and services to maintain the highest level of well-being for two of 41 residents in the survey sample, Residents #26 and #129. 1. The facility staff failed to monitor Resident #26's fluid intake as ordered by the physician. 2. a. The facility staff failed to ensure the medication guaifenesin (1) was available for administration to Resident #129 on 9/28/21, 9/29/21 and 9/30/21. 2. b. The facility staff failed to obtain Resident #129's weekly weight per physician's order on 8/16/21. The findings include: 1. Resident #26 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses including diabetes, peripheral artery disease, and end stage kidney disease. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/23/21, Resident #26 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 Based on observation, staff interview and clinical record review, it was determined that the facility staff failed to provide care and services for a Foley catheter for two of 41 residents in the survey sample, Residents #28 and #331. 1. The facility staff failed to maintain Resident #28's Foley urinary catheter (1) tubing and bag in a manner to prevent infections. The resident's tubing and bag were observed directly touching the floor on 10/20/21. 2. The facility staff failed to ensure medical justification for Resident #331's indwelling catheter and failed to ensure the catheter was discontinued as soon as clinically warranted. The findings include: 1. Resident #28 was admitted to the facility on [DATE]. Resident #28's diagnoses included but were not limited to congestive heart failure, muscle weakness and dementia. Resident #28's quarterly minimum data set assessment with an assessment reference date of 8/31/21, coded the resident's cognition as moderately impaired. Review of Resident #28's clinical record…

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, it was determined that the facility staff failed to provide respiratory services consistent with professional standards for one of 41 residents in the survey sample, Resident #129. The facility staff administered oxygen to Resident #129 without a physicians order. The findings include: Resident #129 was admitted to the facility on [DATE]. Resident #129's diagnoses included but were not limited to high blood pressure, diabetes and COVID-19. Resident #129's quarterly minimum data set assessment with an assessment reference date of 10/3/21, coded the resident's cognition as severely impaired. Review of Resident #129's current physician orders failed to reveal a physician's order for oxygen. Resident #129's comprehensive care plan dated 6/25/21 failed to reveal documentation regarding oxygen administration. On 10/19/21 at 8:52 a.m. and 10:09 a.m., Resident #129 was observed in their room, receiving oxygen at 1.5 liters per minute…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement a complete pain management program for one of 41 residents in the survey sample, Resident #70. The facility staff failed to attempt non-pharmacological interventions for Resident #70 prior to the administration of as needed acetaminophen (Tylenol) on 9/19/21, 10/6/21, 10/12/21 and 10/16/21. The findings include: Resident #70 was admitted to the facility on [DATE]. Resident #70's diagnoses included but were not limited to high blood pressure, diabetes and chronic pain syndrome. Resident #70's quarterly minimum data set assessment with an assessment reference date of 10/10/21, coded the resident as being cognitively intact, scoring a 15 on a scale from 0 to 15 on the brief interview for mental status. Section J documented Resident #70 reported occasional pain. Review of Resident #70's clinical record revealed a physician's order for acetaminophen 500 mg…

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, family interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide sufficient staffing to meet the needs of two of 41 residents in the survey sample, Residents #53 and #129. 1. The facility did not provide sufficient staffing to ensure a shower/bath was provided on multiple occasions in August and September 2021, to Resident #53, who was assessed as being dependent on the assistance of staff for personal hygiene and bathing. 2. The facility staff failed to provide sufficient staffing to obtain Resident #129's weight per the physician's order on 8/16/21. The findings include: 1. Resident #53 was admitted to the facility on [DATE] with diagnoses including cerebral palsy, hardening and disintegration of the spinal cord bones, quadriplegia and nerve pain. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/6/21, the resident was coded as 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.

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 one of three CNA record reviews, (CNA #6) The facility staff failed to complete an annual performance review for CNA #6. The findings include: CNA #6 was hired on 5/8/04. Review of CNA #6's record revealed the last performance review was completed on 7/1/10. On 10/20/21 at 9:36 a.m., an interview was conducted with OSM (other staff member) #3 (the human resources coordinator). OSM #3 stated performance reviews are supposed to be done annually. OSM #3 stated she began employment on 5/31/21 or 6/1/21. OSM #3 stated she audited employee files and noticed performance reviews had not been done. OSM #3 stated she has been trying to implement action for this but there has been so many other things to do. On 10/20/21 at 5:12 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of clinical services) were made aware of the above concern. The facility policy titled, Employee Job…

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 provide pharmacy services for two of 41 residents in the survey sample, Resident #24 and Resident #53. 1. The facility staff failed to assure the medication Eliquis (1) was available for administration to Resident #24 on 7/5/21 and 7/29/21. 2. The facility staff failed to assure the medication Diazepam was acquired, and received for administration to Resident #53, per the physician order on 10/21/21 through 10/23/21. The findings include: Resident #24 was admitted to the facility on [DATE]. Resident #24's diagnoses included but were not limited to diabetes, atrial fibrillation (1) and a history of stroke. Resident #24's quarterly minimum data set assessment with an assessment reference date of 8/27/21, coded the resident's cognitive skills for daily decision making as modified independence. Resident #24's comprehensive care plan dated 8/2/20 documented, (Resident #24) has Peripheral Artery Disease. Give…

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 ensure a resident was free from a significant medication error for one of 41 residents in the survey sample, Resident #24 The facility staff failed to administer the blood thinning medication Eliquis (1) to Resident #24 on 7/5/21 and 7/29/21. The findings include: Resident #24 was admitted to the facility on [DATE]. Resident #24's diagnoses included but were not limited to diabetes, atrial fibrillation (1) and a history of stroke. Resident #24's quarterly minimum data set assessment with an assessment reference date of 8/27/21, coded the resident's cognitive skills for daily decision making as modified independence. Resident #24's comprehensive care plan dated 8/2/20 documented, (Resident #24) has Peripheral Artery Disease. Give medications for improved blood flow or anticoagulants as ordered . Review of Resident #24's clinical record revealed a physician's order dated 3/12/21 for Eliquis 2.5 mg (milligrams)…

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 laboratory testing for one of 41 residents in the survey sample, Resident #26. The facility staff failed to provide laboratory testing ordered for Resident #26 on 9/30/20. The findings include: Resident #26 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses including diabetes, peripheral artery disease, and end stage kidney disease. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/23/21, Resident #26 was coded as being cognitively intact for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). The resident was coded as requiring the assistance of staff for bed mobility, dressing, toileting, personal hygiene, and bathing. He was coded as having received dialysis services during the look back period. A review of Resident #26'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 staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure a complete and accurate medical record for two of forty-one residents in the survey sample, Resident #230 and Resident #2. 1. The facility failed to provide a complete and accurate medical record for Resident #230, for documentation on the TAR (treatment administration record) for the wound vacuum continuously running as ordered on 8/24/21 night shift and 8/30/21 day shift, and ostomy care every shift as ordered on 8/24/21, 8/25/21 and 8/26/21 as well as day shift on 8/30/21. 2. The facility failed to provide a complete and accurate medical record for the documentation of pain levels prior to the administration of pain medication on the MAR (medication administration record) for Resident #2. The findings include: 1. Resident #230 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Diabetes mellitus (inability of insulin to function normally…

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 trainings for two of three CNA record reviews, (CNA #5 and CNA #6). The facility staff failed to ensure CNA #5 completed annual abuse training and failed to ensure CNA #6 completed annual dementia or abuse training. The findings include: CNA #5 was hired on 8/6/13. Review of CNA #5's record failed to reveal evidence that the CNA had completed annual abuse training. CNA #6 was hired on 5/8/04. Review of CNA #6's record failed to reveal evidence that the CNA had completed annual dementia or annual abuse training. On 10/20/21 at 9:36 a.m., an interview was conducted with OSM (other staff member) #3 (the human resources coordinator). OSM #3 stated all training are completed through a computer program and the system prompts employees for trainings that must be completed. OSM #3 stated she thought abuse and dementia trainings must be done annually. OSM #3 stated she printed out each employee's trainings after…

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