Holston Health & Rehabilitation

3. The facility staff failed to notify the ombudsman of Resident #90's transfer/discharge to a local hospital. Resident #90's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/26/25, was signed as completed on 1/29/25. Resident #90 was assessed as usually able to make self understood and as usually able to understand others. Resident #90's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact or borderline cognition. Resident #90's clinical documentation indicated the resident was admitted to a local hospital on 1/26/25. No evidence was found by or provided to the surveyor to indicate the ombudsman had been notified of this discharge/transfer. The following information was found in a facility policy titled Transfer or Discharge, Preparing a Resident for (with a revised date of December 2016): The business office is responsible for: a. Informing appropriate departments of the resident's transfer or discharge; b. Informing the resident, or his or her representative (sponsor) of our facility'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.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide and document sufficient preparation and orientation to the resident to ensure a safe and orderly transfer/discharge from the facility for (1) of (30) sampled residents, (Resident #65). The findings included: For Resident #65 the facility staff failed to provide and document sufficient preparation and orientation was provided to the resident in the clinical record to ensure a safe and orderly transfer/discharge to a higher level of care on 2/4/25. Resident #65's diagnosis list indicated diagnoses, which included, but not limited to, Heart Failure, Atherosclerotic Heart Disease of Native Coronary Artery, Chronic Respiratory Failure with Hypoxia, Atrial Fibrillation, Myocardial Infarction, Type 2 Diabetes Mellitus, Cardiomyopathy, Presence of Prosthetic Heart Valve, Presence of Cardiac Pacemaker, Transient Ischemic Attack, and Anxiety Disorder. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 2/14/25 assigned the resident a brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide residents and/or resident's representative with a facility bed hold policy upon transfer for one (1) of thirty (30) sampled residents, (Resident #65) The findings include: For Resident #65, the facility staff failed to provide the resident and/or the resident's representative with the facility bed-hold policy upon transfer/discharge to a higher level of care on 2/4/25. Resident #65's diagnosis list indicated diagnoses, which included, but not limited to, Heart Failure, Atherosclerotic Heart Disease of Native Coronary Artery, Chronic Respiratory Failure with Hypoxia, Atrial Fibrillation, Myocardial Infarction, Type 2 Diabetes Mellitus, Cardiomyopathy, Presence of Prosthetic Heart Valve, Presence of Cardiac Pacemaker, Transient Ischemic Attack, and Anxiety Disorder. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 2/14/25 assigned the resident a brief interview for…

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

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure accurate minimum data set (MDS) assessments for one (1) of 30 sampled residents (Resident #59). The findings include: The facility staff failed to ensure that Resident #59's minimum data set (MDS) assessments correctly captured the resident's lower extremity functional range of motion. Resident #59's MDS assessment, with an Assessment Reference Date (ARD) of 2/19/25, was signed as completed on 2/20/25. Resident #59 was assessed as able to make self understood and as able to understand others. Resident #59's Brief Interview for Mental Status (BIMS) summary score was documented as a 00 out of 15; this indicated severe cognitive impairment. Resident #59's MDS assessment, with an ARD of 2/19/25, had the resident's functional limitation in range of motion assessed as both lower extremities having impairment. Resident #59's MDS assessment, with an ARD of 11/19/24, had the resident's functional limitation in range of motion assessed as both lower extremities having impairment. These two…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, resident interview, clinical record review and facility document review the facility staff failed to develop and implement a care plan for 2 of 30 residents, Resident #51 and Resident #77. The findings included: 1. For Resident #51 the facility staff failed to develop and implement a care plan for oxygen usage. Resident #51's clinical record listed diagnoses which included but not limited to chronic respiratory failure with hypoxia, morbid obesity, and obstructive sleep apnea. Resident #51's most recent minimum data set (MDS) with an assessment reference date of [DATE] assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Section O, special treatments, procedures, and programs coded the resident as using oxygen while a resident. Resident #51's comprehensive care plan was reviewed, and surveyor could not locate a care plan related to oxygen usage. Resident…

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

Based on staff interview, resident interview, clinical record review and facility document review, the facility staff failed to review and revise the comprehensive care plan for 2 of 30 residents, Resident #51, Resident #85. The findings included: 1. For Resident #51 the facility staff failed to review and revise the care plan for oxygen usage. Resident #51's clinical record listed diagnoses which included but not limited to chronic respiratory failure with hypoxia, morbid obesity, and obstructive sleep apnea. Resident #51's most recent minimum data set (MDS) with an assessment reference date of 02/28/25 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Section O, special treatments, procedures, and programs coded the resident as using oxygen while a resident. It did not code the resident as using CPAP (continuous positive airway pressure). Resident #51's comprehensive care plan was reviewed, and contained a care plan for The resident is resistive to care r/t…

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, the facility staff failed to document tube feeding residuals for one (1) of 30 sampled residents (Resident #67). The findings include: The facility staff failed to document the amount when checking Resident #67's tube feeding residuals. Resident #67's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 3/13/25, was signed as completed on 3/14/25. Resident #67 was assessed as usually able to make self understood and as usually able to understand others. Resident #67's Brief Interview for Mental Status (BIMS) summary score was documented as a 10 out of 15; this indicated moderate cognitive impairment. Resident #67's clinical record included an order dated 8/13/24 at 1:17 p.m. for Enteral: Check gastric residual volume prior to feeding. Hold if >150 and notify MD. The Order Summary for this order included the following instructions: three times a day check gastric residuals: if greater than 150 hold and notify MD. (Enteral feeding is when an individual who is unable to eat or drink…

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

Based on observation, staff interview, resident interview, clinical record review and facility document review the facility staff failed to provide respiratory services per the physician's orders for 1 of 30 residents, Resident #51. The findings included: For Resident #51 the facility staff failed to provide oxygen per the physician's order. Resident #51's clinical record listed diagnoses which included but not limited to chronic respiratory failure with hypoxia, morbid obesity, and obstructive sleep apnea. Resident #51's most recent minimum data set (MDS) with an assessment reference date of 02/28/25 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Section O, special treatments, procedures, and programs coded the resident as using oxygen while a resident. Resident #51's clinical record was reviewed and contained a physician's order summary which read in part, 02 via NC (nasal cannula) at 2L/min (liters per minute) via NC every day shift for 02 dropping and unable…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide appropriate care and services to address trauma-informed care in accordance with professional standards of practice for (1) one of (30) thirty sampled residents, (Resident #77) The findings included: For Resident #77, the facility staff failed to properly assess the residents' experiences and preferences in order to identify and/or eliminate and/or mitigate potential triggers that have the potential to cause re-traumatization in relation to a diagnosis of post-traumatic stress disorder (PTSD). Resident #77's diagnosis list indicated diagnoses, which included, but not limited to, Hemiplegia and Hemiparesis, Cerebral Infarction, Type 2 Diabetes Mellitus, Hypertensive Heart Disease, Depressive Episodes, Anxiety Disorder, Post-Traumatic Stress Disorder (PTSD), Suicidal Ideations, and Mood Affective Disorder. The most recent minimum data set (MDS) with an assessment reference date (ARD) of [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 interviews, clinical record review, and facility document review, the facility staff failed to ensure medical provider orders were signed by the ordering provider when the orders were entered into residents' clinical records by non-prescribing facility staff members for 1 of 30 sampled residents (Resident #90). The findings include: A medical provider failed to sign orders entered by non-prescribing facility staff members on behalf of the prescriber. Resident #90's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/26/25, was signed as completed on 1/29/25. Resident #90 was assessed as usually able to make self understood and as usually able to understand others. Resident #90's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact or borderline cognition. Resident #90's following orders, which were entered by non-prescribing staff members, were not signed by a medical provider: - An order for pantoprazole 40mg by mouth once a day was ordered on 1/22/25 at 2:39 p.m. - An order for…

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

Based on observations, staff interview, facility document review, and during a medication pass and pour observation, the facility staff failed to maintain an accurate record of controlled drugs for (2) two of (30) sampled residents, (Resident #201 and Resident #51). The findings included: Surveyor observed a medication pass and pour with licensed practical nurse (LPN#1) on 4/30/25. On 4/30/25 at 9:21 AM, surveyor observed LPN#1 prepare medications for Resident #201, that included one (1) tablet of Oxycodone 5/325 mg (milligrams). LPN#1 did not sign the medication out in the narcotics book at the time of preparation. The nurse administered the Oxycodone at 9:34 AM to Resident #201. LPN#1 did not sign the medication out in the narcotics book after returning to the medication cart. Surveyor observed a medication pass and pour with LPN#2 on 4/30/25. On 4/30/25 at 9:48 AM, surveyor observed LPN#2 prepare medications for Resident #51, that included (1) one tablet of Gabapentin 100 mg. LPN#2 did not sign the medication out in the narcotics book at the time of preparation. The nurse…

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 the facility staff failed to ensure the medical provider reviewed medication regimen reviews in a timely manner for (1) one of (30) sampled residents, (Resident #36). The findings included: For Resident #36 the facility staff failed to provide evidence of the 8/26/24 medication regimen review (MRR) being reported to and acted upon by the medical provider in a timely manner. Resident #36's diagnosis list indicated diagnoses that included but were not limited to Hypertension, Seborrheic Dermatitis, Alzheimer's Disease with Early Onset, Chronic Respiratory Failure with Hypoxia, Cerebrovascular Disease, Type 2 Diabetes Mellitus, Epilepsy, Depression, Anxiety, Dementia, Chronic Kidney Disease-Stage 2, and Schizoaffective Disorder. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 3/6/25, assigned the resident a brief interview for mental status (BIMS) summary score of 5 out of 15 for cognitive abilities, indicating the resident was severely impaired in cognition. Progress notes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to ensure residents were free of significant medication errors for 3 of 30 sampled residents (Resident #26, Resident #62, and Resident #4). The findings included: 1. For Resident #26, the facility staff failed to correctly transcribe and administer an intravenous (IV) antibiotic as ordered by the medical provider to treat a urinary tract infection. Resident #26's diagnosis list indicated diagnoses, which included, but not limited to Acute Cerebrovascular Insufficiency and History of Urinary Tract Infections. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 2/26/25 assigned the resident a brief interview for mental status (BIMS) summary score of 6 out of 15 indicating the resident was severely cognitively impaired. Resident #26's comprehensive person-centered care plan included a focus area stating the resident had a history of urinary tract infections (UTIs). Resident #26 was readmitted to the facility…

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

Based on observation, staff interview, and facility document review, the facility staff failed to ensure the safe and secure storage of medications and biologicals for (1) one of (5) five facility medication carts. The findings included: On 4/30/25 at 11:39AM, surveyor observed an unattended, unlocked medication cart on the nursing unit. Licensed practical nurse #1 (LPN#1) approached the medication cart and surveyor asked her if this was her medication cart and she stated, Yes. Surveyor informed LPN#1 the cart was observed unlocked and the nurse then locked the medication cart. This concern was discussed at the end of day meeting on 4/30/25 at 4:57 PM with the administrator, director of nursing, and administrator in training. Surveyor requested and received a facility policy titled, Security of Medication Cart, that read in part, .4. Medication carts must be securely locked at all times when out of the nurse's view . No other information was provided to the survey team prior to exit on 5/7/25.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to obtain laboratory services to meet the needs of 2 of 30 sampled residents, Resident #348 and #77. The findings included: 1. For Resident #348, the facility staff failed to obtain a urinalysis as ordered on 4/25/25. Resident #348's diagnosis list indicated diagnoses, which included, but not limited to Streptococcal Sepsis, Chronic Kidney Disease Stage 5, and Hypertensive Heart Disease. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 4/26/25 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #348's comprehensive person-centered care plan included a focus area stating, The resident has renal insufficiency r/t [related to] Chronic Kidney Disease Stage 5, history of Kidney Stones and UTIs [urinary tract infections] with an intervention stating, 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 staff interview, record review and facility document review the facility staff failed to promptly notify the ordering provider of laboratory results that fell outside clinical reference ranges, in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for 1 (one) of 30 residents in the survey sample, resident # 15 (R15). The findings included: For R15 the facility failed repeatedly to notify the provider of urinalysis with culture and sensitivity results that indicated the resident had a urinary tract infection (UTI) which delayed treatment for the UTI. R15's diagnoses included but were not limited to, chronic renal failure stage IV (severe), benign prostatic hypertension, and obstructive and reflux uropathy. The minimum data set (MDS) assessment for R15 with an assessment reference date of 2/20/25 assigned the resident a brief interview for mental status (BIMS) score of 7 out of 15, indicating moderate cognitive impairment. During a review of the clinical record, a progress note dated 2/24/25 at 3:19 PM…

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, the facility staff failed to obtain timely diagnostic services to meet the needs of the residents for 1 of 30 sampled residents (Resident #4). The findings included: For Resident #4, the facility staff failed to follow the medical provider order to obtain a chest x-ray (CXR) in a timely manner. Resident #4's diagnosis list indicated diagnoses, which included, but not limited to Chronic Obstructive Pulmonary Disease, Multiple Myeloma, and Paroxysmal Atrial Fibrillation. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 4/19/25 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #4 was seen by the nurse practitioner (NP) on 4/09/25, the progress note read in part .presenting with a mild fever and chills .A chest x-ray will be ordered to rule out any respiratory infections that could be causing the fever . An order for a CXR to rule out pneumonia was entered into Resident #4'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.

Based on observation, staff interview, and facility document review, the facility staff failed to maintain infection prevention and control practices during medication administration for 1 of 2 nursing units. The findings included: Surveyor observed a medication pass and pour with licensed practical nurse (LPN#1) on 4/30/25. At 9:16 AM surveyor observed LPN#1 place 1 tablet of a medication for Resident #198 in a small plastic pill cup. LPN#1 was then observed to place another medication cup with medications for Resident #199 on top of Resident #198's pill cup. LPN #1 then took both pill cups (stacked together) into Resident #199's room and administered medications to Resident #199. The nurse then proceeded to take Resident #198's medication to his room for administration. At 9:18 AM, LPN#1 began the medication pass for Resident #201 and donned gloves. She pulled the medications with gloves and then scored a Lasix tablet while wearing the same gloves. At 9:31 AM, LPN#1 took the pill cup containing the left-over ½ of Lasix tablet into Resident #201's bathroom and discarded it into the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and facility document review, the facility staff failed to provide effective communication training for one of five sampled direct care staff members, Certified Nursing Assistant (CNA) #1. The findings included: The facility staff failed to provide evidence of effective communication training for CNA #1. On 5/06/25, surveyor reviewed CNA #1's provided in-service training record. The record failed to include evidence of effective communication training. Surveyor requested and received the Facility assessment dated [DATE] which read in part .Our facility makes a good faith effort to provide the staff training/education and competencies necessary to provide the level and types of support and care needed for our resident population. Our facility has identified the following training topics that may be utilized by our staff including managers, nursing, direct care staff, contracted individuals and volunteers consistent with their expected roles. This is not an inclusive list. Communication:…

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 ensure professional staff had a valid license to practice in accordance with applicable state laws for 1 of 6 sampled licensed nurses, Licensed Practical Nurse (LPN) #12. The findings included: For LPN #12, the facility staff failed to ensure the nurse had a valid LPN license to practice in the Commonwealth of Virginia. LPN #12 was no longer employed at the facility. On 4/30/25, surveyor requested and received LPN #12's employee file which indicated they were hired on 3/06/23. LPN #12's employee records included a [NAME] Virginia (WV) State Board of Examiners for Licensed Practical Nurses Primary Source License Verification Report dated 3/06/23 at 10:26 AM indicating LPN #12 had an active WV Single State LPN license with an expiration date of 6/30/23. An undated, unsigned, handwritten note on the license verification report stated, applied for multi state lic. LPN #12's file also included an additional license verification report dated 4/27/23 also indicating the LPN had a single state WV LPN…

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

Based on staff interviews, clinical record review, and facility document review, the facility staff failed to ensure that medical providers co-signed verbal orders, telephone orders, and/or orders documented in the Rounding Binders. The findings include: Review of residents' electronic orders failed to show evidence of orders being co-signed by the medical provider who had given the orders. On 1/30/24 at 11:10 a.m., Nurse Practitioner (NP) #1 reported they do not enter their own orders into the residents' electronic record. NP #1 stated orders are given by telephone, verbal, and/or entered into the communication book. NP #1 reported they do not co-sign orders that are entered into the residents' electronic clinical record. NP #1 stated, in the past they had been given a printed page to sign that contained multiple orders for a single resident; NP #1 reported this has not occurred for at least two (2) months. The following information was found in a facility document titled Verbal Orders (with a revised date of September 2017): - Verbal (also called telephone) orders shall be written…

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 interviews, clinical record review, and facility document review, the facility staff failed to notify a medical provider and/or a responsible party of a change in condition for two (2) of 12 sampled residents (Resident #2 and Resident #11). The findings include: 1. The facility staff failed to promptly notify a medical provider of Resident #11 developing symptoms which could have been an indication of a medical emergency. A communication form, which included information on multiple residents, indicated Resident #11 experienced slurred speech, facial droop, and weakness. This entry was not timed, dated, or signed by a facility staff member. A medical provider documented on the same form (m)eds adjusted and no facial (d)[NAME] noted; the medical provider did not date, time, or sign their entry on this document. This document was not maintained as part of Resident #11's clinical record (multiple residents had information documented on this form). The top of this form included the date of 6/30/23.…

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

Based on staff interviews, clinical record review, and facility document review, the facility staff failed to complete a significant change Minimum Data Set (MDS) assessment for one (1) of 12 sampled residents (Resident #11). The findings include: The facility staff failed to complete a significant change MDS for Resident #11. Resident #11's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 6/21/23, was signed as completed on 6/22/23. Resident #11 was assessed as being able to make self understood and as being able to understand others. Resident #11's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact and/or borderline cognition. Resident #11 was assessed as requiring assistance with bed mobility, transfers, dressing, toilet use, and bathing. Resident #11 experience multiple changes in their condition after the completion of the MDS assessment with an ARD of 6/21/23. - On 6/27/23, Resident #11 was ordered oxygen. - On 6/30/23, Resident #11 was documented as having suicidal thoughts. - On 7/1/23,…

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, the facility staff failed to review and revise the comprehensive care plan for one of 12 residents in the survey sample. The findings include: For resident # 10, the facility staff failed to update the comprehensive care plan to include the need and insertion of a foley catheter, and to address a significant weight loss. This was a closed record review. Resident # 10's diagnosis included but were not limited to, essential hypertension, atrial fibrillation, chronic obstructive pulmonary disorder, edema, muscle weakness, osteoarthritis and major depressive disorder. Resident # 10's minimum data set (MDS) with an assessment reference date of 11/15/23 assigned the resident a brief interview for mental status (BIMS) score of 8 indicating moderate cognitive impairment. In the clinical record, a progress note from the Nurse Practitioner dated 12/7/23 read in part, Chief complaint: decreased urinary output. History of present illness: staff reports that patient has had little to none urinary output. Patient…

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

Based on staff interviews, clinical record review, and facility document review the facility staff failed to follow professional standards of practice for 1 of 12 residents sampled, Resident #1. The findings were: On 05/02/23, a licensed practical nurse (LPN #4) failed to ensure the eight rights of medication administration were followed as evidenced by administering Resident #1 an unnamed resident's medications. The facility's drug handbook was provided and reviewed. The Nursing2016 Drug Handbook dated 2016 contained the eight rights of medication administration on page 17. It read in part, Traditionally, nurses have been taught the 'five rights' of medication administration. These are broadly stated goals and practices to help individual nurses administer drugs safely. 1. The right drug . 2. The right patient: Confirm the patient's identity by checking two patient identifiers. 3. The right dose . 4. The right time . 5. The right route . In addition to the traditional 'five rights' of individual practice, best-practice researchers have added three additional 'rights': 6. The right…

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, the facility staff failed to provide activities of daily living (ADL) care to two of 12 residents, resident # 10 and resident # 12. The findings include: 1. For resident #10 the facility staff failed to provide ADL care in regard to bathing. This was a closed record review. Resident # 10's diagnosis included but were not limited to, essential hypertension, atrial fibrillation, chronic obstructive pulmonary disorder, edema, muscle weakness, osteoarthritis and major depressive disorder. Resident # 10's minimum data set (MDS) with an assessment reference date of 11/15/23 assigned the resident a brief interview for mental status (BIMS) score of 8 indicating moderate cognitive impairment. Resident # 10's care plan had a focus that read, Resident requires staff assistance to complete activities of daily living. and a goal that read, Resident will have assistance as needed to complete toileting, bathing, dressing, grooming to maintain dignity Staff will provide assistance with transfers, ambulation. and or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, clinical record reviews, and facility document review, the facility staff failed to provide treatment and care to address residents' needs for three (3) of 12 sampled residents. The findings include: 1. The facility staff failed to provide immediate care to Resident #11 when the resident was experiencing slurred speech, facial droop, and weakness. The facility staff failed to provide skin/wound care according to medical provider orders and/or facility policies. Resident #11's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 6/21/23, was signed as completed on 6/22/23. Resident #11 was assessed as being able to make self understood and as being able to understand others. Resident #11's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact and/or borderline cognition. Resident #11 was assessed as requiring assistance with bed mobility, transfers, dressing, toilet use, and bathing. The facility staff…

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

Based on staff interview, clinical record review and facility document review, the facility failed to provide an environment free from accidents and hazards for two of 12 residents, resident # 10 and # 12. The findings include: 1. For resident # 10 the facility staff failed to assess fall risk and failed to implement interventions to reduce the risk of falls. Review of resident # 10's clinical record revealed they fell on 3/9/23, 3/21/23, 5/11/23, 6/4/23, and 7/29/23. The progress notes were reviewed. The note on 3/9/23 indicated that resident # 10 fell while reaching for something. There was no intervention mentioned in the note. There was no fall assessment to correspond with the fall. The note on 3/21/23 indicated that resident had a fall. There was no intervention mentioned in the note. There was no fall assessment to correspond with the fall. A note on 5/11/23 stated resident # 10 slipped off the commode to the floor. There was no mention of an intervention in the note. There was no fall assessment to correspond with the fall. A note on 6/4/23 read that resident had a fall to…

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

Based on staff interview, clinical record review and facility document review, the facility staff failed to ensure residents maintained, to the extent possible, acceptable parameters of nutritional status. The findings include: For resident # 10, the facility staff failed to prevent a significant weight loss over six months. This was a closed record review. Resident # 10's diagnosis included but were not limited to, essential hypertension, atrial fibrillation, chronic obstructive pulmonary disorder, edema, muscle weakness, osteoarthritis and major depressive disorder. Resident # 10's minimum data set (MDS) with an assessment reference date of 11/15/23 assigned the resident a brief interview for mental status (BIMS) score of 8 indicating moderate cognitive impairment. Review of resident # 10's clinical record revealed a weight of 160.1 pounds in August and September of 2023 and a weight of 134.8 pounds in November 2023. There was no October weight documented. A progress note dated 11/24/23 and signed by the Registered Dietician read, CBW: 134#, BMI: 22.43 WNL. Weight triggered for…

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

Based on interviews, clinical record review, and facility document review, the facility staff failed to provide respiratory care and/or treatment to address the needs of one (1) of 12 sampled residents (Resident #5). The findings include: Licensed Practical Nurse (LPN) #6 failed to provide Resident #5's the correct nebulizer medication on 1/26/24. Resident #5's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/24/24, was signed as completed on 1/25/24. Resident #5 was documented as able to make self understood and as able to understand others. Resident #5's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact and/or borderline cognition. Resident #5 was documented as requiring assistance with toileting hygiene, shower/bathing, and dressing. On 1/31/24 at 2:20 p.m., LPN #6 reported they provided Resident #5 a nebulizer treatment on 1/26/24. On 2/1/24 at 12:45 p.m., the facility's Administrator confirmed there was not a note on 1/26/24 in Resident #5's chart about a nebulizer treatment 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 interviews, clinical record review, and facility document review, the facility staff failed to provide social services according to a medical provider's guidance for one (1) of twelve sampled residents (Resident #11). The findings include: The facility staff failed to provide social services care according to Resident #11's medical provider's instructions. Resident #11's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 6/21/23, was signed as completed on 6/22/23. Resident #11 was assessed as able to make self understood and as able to understand others. Resident #11's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact and/or borderline cognition. Resident #11 was assessed as requiring assistance with bed mobility, transfers, dressing, toilet use, and bathing. The following statement was found as part of a Psychiatric Mental Health Nurse Practitioner (PMHNP) progress note for Resident #11 (this progress note had a date of service as 6/29/23): Referral [sic] patient to social worker…

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

Based on staff interviews, clinical record review, and facility document review, the facility staff failed to ensure a resident was free of an unnecessary medication for one (1) of 12 sampled residents (Resident #11). The findings include: The facility staff failed to ensure Resident #11's was free of unnecessary medications. The facility staff failed to ensure Resident #11 was correctly administered olanzapine (an antipsychotic medication). The facility staff failed to ensure Resident #11 was monitored for side effects and behaviors related to receiving olanzapine. Resident #11's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 6/21/23, was signed as completed on 6/22/23. Resident #11 was assessed as able to make self understood and as able to understand others. Resident #11's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact and/or borderline cognition. Resident #11 was assessed as requiring assistance with bed mobility, transfers, dressing, toilet use, and bathing. Resident #11's Interim…

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

Based on staff interviews, facility document review, and clinical record review, the facility staff failed to maintain complete and/or accurate clinical records for two (2) of 12 sampled residents (Resident #5 and Resident #10). The findings include: 1. The facility staff failed to document Resident #5's respiratory care received on 1/26/24. Resident #5's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/24/24, was signed as completed on 1/25/24. Resident #5 was documented as able to make self understood and as able to understand others. Resident #5's Brief Interview for Mental Status (BIMS) summary score was documented as a 15 out of 15; this indicated intact and/or borderline cognition. Resident #5 was documented as requiring assistance with toileting hygiene, shower/bathing, and dressing. On 1/31/24 at 2:20 p.m., LPN #6 reported they provided Resident #5 a nebulizer treatment on 1/26/24. On 2/1/24 at 12:45 p.m., the facility's Administrator confirmed there was not a note on 1/26/24 in Resident #5's chart about a nebulizer treatment 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 observations, staff interviews, clinical record review, and facility document review, (a) the facility staff failed to correctly perform hand hygiene during wound care for one (1) of 12 sampled residents (Resident #4) and (b) the facility staff failed to store residents' nebulizer equipment in a sanitary manner for three (3) of four (4) residents observed with nebulizer equipment (Resident #5, Resident #6, and Resident #8). The findings include: 1. The facility staff failed to correctly perform hand hygiene/hand washing during Resident #4's wound care. Resident #4's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/8/24, was signed as completed on 1/10/24. Resident #4 was documented as sometimes able to make self understood and as able to understand others. Resident #4's Brief Interview for Mental Status (BIMS) summary score was documented as a two (2) out of 15; this indicated severe cognitive impairment. Resident #4 was documented as being dependent for eating, toileting hygiene, shower/bathing, and dressing. On 2/2/24 at 9:40 a.m.,…

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

Based on observations, staff interviews, and document review, the facility staff failed to maintain residents' nebulizer equipment according to manufacturer's directions for use. The findings include: The facility staff failed to ensure nebulizer machines were maintained according to manufacturers' guidance. The facility staff also failed to ensure the nebulizer machines used by the facility were appropriate for multiple-patient medical facilities. Observations indicated the facility was using at least three (3) different types of nebulizer machines for patient care. Two types of the nebulizer machines (Nebulizer Machine #1 and Nebulizer Machine #2) were selected for review of the manufacturers' guidance/instructions. Nebulizer Machine #1's manufacturer's guidance included the following information: - (Device name omitted) is an AC-powered air compressor nebulizer system intended to provide a source of compressed air for medical purposes in home healthcare. - Check the filter at least once each week. Replace the filter when dirty. On 1/31/24 at 4:00 p.m., the facility'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.

Based on staff interview and clinical record review, the facility staff failed to complete drug regimen reviews for 2 of 18 Residents Resident #28 and #42 and failed to act upon recommendations for 1 of 18 resident #28. The facility staff failed to provide the surveyor with evidence of drug regimen reviews that were completed in March 2022 for Resident #28 and #42 and failed to follow up on pharmacy recommendations for Residents #28. The findings included: 1. Resident #28 had been admitted to the facility after the previous standard survey. Section C (cognitive patterns) of Resident #28's annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 03/02/22 included a Brief Interview for Mental Status Summary (BIMS) score of 11 out of a possible 15 points. Diagnoses included, but were not limited to, Parkinson's disease, diabetes, chronic kidney disease, and hypertension. During the record review, the surveyor was unable to find any evidence of a drug regimen review that was completed for March 2022. On 05/12/22 9:40 a.m., the Assistant Director of Nursing…

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, the facility staff failed to ensure a complete, and accurately documented clinical record for 1 of 18 residents in the survey sample (Resident #45). For Resident #45, the facility staff failed to document the resident's blood glucose readings. The findings included: Resident #45's diagnosis list indicated diagnoses, which included, but not limited to Type 2 Diabetes Mellitus, Chronic Kidney Disease Stage 3, Acute on Chronic Congestive Heart Failure, Paranoid Schizophrenia, Bipolar II Disorder, and Chronic Respiratory Failure. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 3/28/22 assigned the resident a brief interview for mental status (BIMS) summary score of 12 out of 15 indicating Resident #45 was moderately cognitively impaired. Upon surveyor review on 5/10/22, Resident #45's current physician's orders included an order dated 3/28/22 for accuchecks twice daily and notify MD/NP (nurse practitioner) of blood glucose less than 60 or above 400. Surveyor…

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, interviews, and document review the facility staff failed to properly implement COVID-19 testing processes and/or procedures for 1 of 1 COVID-19 staff testing observations, CNA#1. An observation of the staffing coordinator (CNA#1) obtaining a COVID-19 nasal swab test for one licensed practical nurse (LPN) identified the specimen was not collected according to manufacturer's instructions. The findings were: On 5/10/2022 at 2:38 p.m., the staffing coordinator (CNA#1) was observed obtaining a COVID-19 nasal swab test from a licensed practical nurse (LPN). Prior to obtaining the LPN's specimen, CNA#1 described the process for swabbing the nostrils. She reported rotating the swab inside each nare for approximately 5 seconds each side. The surveyor observed CNA#1 place the swab inside one nostril and rotate it 5 times and then repeating the process in the other nostril. The surveyor timed the collection which lasted 6-7 seconds in total. CNA#1 acknowledged she rotated the swab for about 3 seconds in each nostril and reported being taught how to collect the specimens…

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, facility document review, and clinical record review, the facility staff failed to follow the bowel protocol for 1 of 25 residents (Resident #17). The findings included: The facility staff failed to follow the bowel protocol for bowel management for Resident #17. The clinical record of Resident #17 was reviewed 6/4/19 through 6/7/19. Resident #17 was admitted to the facility 3/23/18 with diagnoses, that included but not limited to multiple sclerosis, urinary tract infection, cellulitis and abscess of the mouth, major depressive disorder, chronic pain syndrome, anxiety, insomnia, slow transit constipation, tobacco use, nicotine dependence, iron deficiency anemia, and dysuria. Resident #17's annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/12/19 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Section H assessed that the resident was always incontinent of bowel. Bowel Patterns was marked that constipation was present. Resident #17's current comprehensive care plan…

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 ensure 4 of 25 residents were free of an unnecessary psychotropic medication (Resident #87, Resident #26, Resident #62, and Resident #105). The findings included: 1. The facility staff failed to identify and monitor resident specific target behaviors, identify non-pharmacological interventions, and monitor for effectiveness associated with the use of Trazodone for Resident # 87. The clinical record of Resident #87 was reviewed 6/4/19 through 6/7/19. Resident #87 was admitted to the facility 5/3/17 with diagnoses that included but not limited to flaccid hemiplegia affecting right dominant side, epilepsy, quadriplegia, chronic pain, anemia, hyperlipidemia, dementia without behavioral disturbances, and seborrheic dermatitis. Resident #87's annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 5/7/19 assessed the resident with a BIMS (brief interview for mental status) as 6/15.…

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

Based on observation and staff interview, the facility staff failed to dispose of expired medications on 2 of 2 units. The findings included: 1. The facility failed to dispose of expired medications on unit B. The surveyor checked cart #1 on the B unit on 06/05/19 at 3:44 p.m. with LPN #10. This medication cart included 1 opened box of culturelle that contained 15 capsules. The expiration date on the box was 05/2019. LPN #10 stated she was going to discard this medication. The surveyor and LPN #10 then checked the medication room. The medication room included 2-30 capsule boxes of culturelle with an expiration date of 05/2019, 4-60 soft gel bottles of flaxseed oil 1000 mg with an expiration date of 03/2018, 9-100 tablet bottles of vitamin D with a use by date of 01/2019, and 1-10 ounce bottle of mag citrate with an expiration date of 03/2019. LPN #10 stated she would discard this medication. The administrative staff were notified of the issue with the expired medications on 06/05/19 at approximately 4:45 p.m. No further information regarding this issue was provided to the survey…

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 ensure food was palatable and served at an appetizing temperature on one of two units (unit B). The findings included: The facility staff failed to provide palatable foods at an appropriate temperature to residents on unit B. During the survey from 6/4/19 through 6/7/19, three resident interviews were completed with Resident #40, Resident #87, and Resident #17. Resident #40 stated the food was always cold. Resident #87 stated the food was cold. Resident #17 stated the food was terrible and the menu was a lie. We get soup every day. The surveyor conducted a lunch test tray on 6/6/19 beginning at 11:26 a.m. Food temperatures obtained at 11:26 a.m. were as follows: Coffee-133 degrees Iced tea-36.8 degrees Milk-33.4 degrees Creamed green beans (pureed)-176 degrees Green beans-200 degrees Mashed potatoes-179 degrees Pureed sloppy joes-191 degrees Pork chops-175 degrees Sloppy [NAME]-167 degrees…

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 a dignified dining experience for 3 of 25 residents (Resident # 87, Resident #62, and Resident #40) and failed to knock or announce themselves before entering residents rooms for 1 of 25 residents (Resident #17). The findings included: 1. The facility staff failed to provide a dignified dining experience for Resident #87. Resident #87's roommate (Resident # 105) was served breakfast 30 minutes before Resident #87 received his tray. Resident #87's roommate completed breakfast before the resident received his breakfast tray. Resident #87 stated the breakfast was cold when the tray arrived. The clinical record of Resident #87 was reviewed 6/4/19 through 6/7/19. Resident #87 was admitted to the facility 5/3/17 with diagnoses that included but not limited to flaccid hemiplegia affecting right dominant side, epilepsy, quadriplegia, chronic pain, anemia, hyperlipidemia, dementia without behavioral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review the facility staff failed to notify the physician of a change in condition and failed to inform a resident that he would not receive ferrous sulfate during his morning medication pass for 2 of 25 residents in the survey sample (Residents #17 and #59). The findings included: 1. The facility staff failed to inform the physician of a change in condition when medication (Methadone) was not available for Resident #17. The clinical record of Resident #17 was reviewed 6/4/19 through 6/7/19. Resident #17 was admitted to the facility 3/23/18 with diagnoses, that included but not limited to multiple sclerosis, urinary tract infection, cellulitis and abscess of the mouth, major depressive disorder, chronic pain syndrome, anxiety, insomnia, slow transit constipation, tobacco use, nicotine dependence, iron deficiency anemia, and dysuria. Resident #17's annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/12/19 assessed the resident with 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, facility document review, and clinical record review, the facility staff failed to ensure a clean, comfortable, homelike environment for 1of 25 residents (Resident #26). The findings included: The facility staff failed to ensure Resident #26's Broda chair was clean. The clinical record of Resident #26 was reviewed 6/4/19 through 6/7/19. Resident #26 was admitted to the facility 12/30/15 with diagnoses that included but not limited to Alzheimer's disease, orthostatic hypotension, pain, anxiety, syncope and collapse, adult failure to thrive, irritable bowel syndrome without diarrhea, and unspecified mood. Resident #26's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/19/19 assessed the resident with a BIMS (brief interview for mental status) Summary Score as 2/15. The surveyor observed Resident #26 during the initial tour on 6/4/19 at 2:30 p.m. The resident was observed sitting in the dining room in a Broda chair. The surveyor observed both armrests with food debris on them. The surveyor observed Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, facility staff failed to ensure accuracy of Minimum Data Set assessments for 2 of 26 residents in the survey sample (Resident #104 and supplemental resident #1). 1. For Resident #104, facility staff failed to ensure the admission minimum data set assessment accurately documented hospice and hemodialysis status. Resident #104 was admitted to the facility on [DATE] 04:05 PM. Diagnoses included hypertension, end stage Alzheimer's disease, malnutrition, anxiety, and depression. On the admission Minimum Data Set assessment with Assessment Reference Date 5/20/19, the resident was assessed with short and long-term memory deficits, severely impaired decision-making ability, fluctuating signs of delirium, and without signs of psychosis or delirium. The resident was admitted with an order for hospice (5/9/19). The MD'S was not coded for hospice. The MD'S was coded for dialysis. The resident did not have an order for hemodialysis or a renal failure diagnosis. 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 clinical record review and staff interview, the facility staff failed to review and revise the comprehensive plan of care for 1 of 26 Residents in the survey sample, Resident # 41. The findings included: The facility staff failed to review and revise the comprehensive plan of care for Resident # 41 to include port-a-cath. Resident # 41 was a [AGE] year-old-female who was admitted to the facility on [DATE], with a readmission date of 5/31/18. Diagnoses included but were not limited to, chronic kidney disease, vitamin E deficiency, atrial fibrillation, and heart failure. The clinical record for Resident # 41 was reviewed on 6/4/19 at 1:37 pm. The most recent MDS (minimum data set) assessment for Resident # 41 was a quarterly assessment with an ARD (assessment reference date) of 4/4/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 41 had a BIMS (brief interview for mental status) score of 12 out of 15, which indicated that Resident # 41's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, family interview, staff interview and clinical record review, the facility staff failed to provide nail care to 1 of 25 dependent residents (Resident #62). The findings included: The facility staff failed to provide nail care to Resident #62. The clinical record of Resident #62 was reviewed 6/4/19 through 6/7/19. Resident #62 was admitted to the facility 11/18/11 and readmitted [DATE] with diagnoses that included but not limited to pulmonary embolism, mild protein malnutrition, gastro-esophageal reflux disease, anxiety, depression, hypokalemia, chronic obstructive pulmonary disease, irritable bowel syndrome, constipation, and chronic kidney disease, stage 3. Resident #62's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 4/18/19 assessed the resident with a BIMS (brief interview for mental status) Summary Score as 13/15. No signs or symptoms of behaviors affecting others, delirium, or psychosis. Resident #62 was assessed to require…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to follow the physician's orders for 1 of 25 residents (Resident #40) for the care of an indwelling Foley catheters. The findings included: The facility staff failed to ensure Resident #40 received the appropriate size of Foley catheter. The clinical record of Resident #40 was reviewed 6/4/19 through 6/7/19. Resident #40 was admitted to the facility 1/18/17 and readmitted [DATE] with diagnoses that included but not limited to hemiplegia affecting left non-dominant side, mood disorder, type 2 diabetes mellitus, major depression, anxiety, sacral pressure ulcer, stage 4, urinary tract infection with extended spectrum beta lactamase resistance (ESBL), subacute osteomyelitis of left ankle and foot, hypertension, iron deficiency anemia, peripheral vascular disease, conduct disorder, and edema. Resident #40's significant change in assessment minimum data set (MDS) with an assessment reference 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 Based on clinical record review, staff interview, and facility document review, the facility staff failed to ensure that 1 of 26 Residents in the survey sample received port-a-cath care consistent with professional standards of practice, Resident # 41. The findings included: a. The facility staff failed to follow physician's order to flush port-a-cath every month for Resident # 41. b. The facility staff failed to ensure that the port-a-cath for Resident # 41 was accessed and flushed by a Registered Nurse. c. The facility staff failed to ensure that Resident # 41's port-a-cath orders specified what the port-a-cath was to be flushed with, the amount that was to be flushed, and the date the port-a-cath was to be flushed on. Resident # 41 was a [AGE] year-old-female who was admitted to the facility on [DATE], with a readmission date of 5/31/18. Diagnoses included but were not limited to, chronic kidney disease, vitamin E deficiency, atrial fibrillation, and heart failure. The clinical record for Resident # 41 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, Resident interview, facility document review, and clinical record review the facility staff failed to properly maintain oxygen equipment or to deliver the ordered dose for 3 of 26 Residents, Resident #52, Resident #59. and Resident #62). The findings included: 1. For Resident #52 the facility staff failed to ensure the Resident's C-PAP (continuous-positive airway pressure) mask was covered/bagged when not in use. Resident #52 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included but not limited to hypertension, urinary tract infection, diabetes mellitus, anxiety, depression, bipolar disorder, constipation, gastroesophageal reflux disease, sleep apnea, and obsessive-compulsive disorder. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 04/12/19 coded the Resident as 14 out of 15 in section C, cognitive patterns. This is a quarterly MDS. Surveyor spoke with Resident #52 on 06/04/19 at approximately 1400. Surveyor…

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, facility document review, and clinical record review, the facility staff failed to provide pain management to 1 of 25 residents (Resident #17). The findings included: The facility staff failed to administer pain medications per physician orders to Resident #17. The clinical record of Resident #17 was reviewed 6/4/19 through 6/7/19. Resident #17 was admitted to the facility 3/23/18 with diagnoses, that included but not limited to multiple sclerosis, urinary tract infection, cellulitis and abscess of the mouth, major depressive disorder, chronic pain syndrome, anxiety, insomnia, slow transit constipation, tobacco use, nicotine dependence, iron deficiency anemia, and dysuria. Resident #17's annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/12/19 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Section J Health Conditions was marked that Resident #17 received scheduled pain medication and prn (as needed) pain medication. Resident #17 did not receive non-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 resident interview, staff interview, clinical record review, and facility document review, failed to ensure physician ordered medications were available for 1 out of 25 residents (Resident #17).1. The facility staff failed to ensure physician ordered medications were available for Resident #17. Methadone, Oxycodone, and a Nicoderm patch were not available for administration. The clinical record of Resident #17 was reviewed 6/4/19 through 6/7/19. Resident #17 was admitted to the facility 3/23/18 with diagnoses, that included but not limited to multiple sclerosis, urinary tract infection, cellulitis and abscess of the mouth, major depressive disorder, chronic pain syndrome, anxiety, insomnia, slow transit constipation, tobacco use, nicotine dependence, iron deficiency anemia, and dysuria. Resident #17's annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 3/12/19 assessed the resident with a BIMS (brief interview for mental status) as 15/15. The surveyor interviewed Resident #17 on 6/5/19 at 2:51 p.m. During the interview, Resident #17 stated…

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

Based on clinical record review, and medication pass and pour observation the facility staff failed to ensure a medication error rate of less than 5%. There were 3 errors in 31 opportunities resulting in a medication error rate of 9.68 %. Medication errors affected Resident # 76, Resident # 83, and Resident # 59. The findings included The facility staff had a 9.68% medication error rate following medication pass and pour observation. On 6/5/19 at 7:36 am, the surveyor conducted a medication pass and pour observation with LPN # 2 (licensed practical nurse). The surveyor observed LPN # 2 as she prepared and administered medications to Resident # 76 (unsampled). The surveyor observed LPN # 2 as she prepared Apriso 0.375 gm (gram) 4 capsules. The surveyor observed LPN # 2 as she opened the 4 capsules of Apriso and sprinkled the contents of the capsules in applesauce. The surveyor observed LPN # 2 as she administered the medications to Resident # 76. After the medication administration observation the surveyor utilized Resident # 76's clinical record to reconcile 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review the facility staff failed to ensure three of 26 Residents were free of significant medication errors, Resident #33, Resident #25 and Resident #40. The findings included: 1. For Resident #33 the facility staff held the long acting insulin, Levimir, without a physician's order. Resident #33 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included but not limited to hypertension, peripheral vascular disease, gastroesophageal reflux disease, diabetes mellitus, Alzheimer's disease, dementia and malnutrition. The most recent annual MDS (minimum data set) with an ARD (assessment reference date) of 03/22/19 assigned the Resident a BIMS (brief interview for mental status) score of 3 out of 15 points in section C, cognitive patterns. Resident #33's CCP (comprehensive care plan) was reviewed and contained a care plan for I have diabetes. Approaches for this care plan include Administer medications as ordered. Resident #33'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.

Based on observation, resident interview, staff interview, facility document review and clinical record review facility staff failed to ensure infection treatment as ordered for 1 of 26 residents in the survey sample (Resident #77) and proper hand-washing. Resident #77 Infections (not UTI or Respiratory) 06/05/19 11:36 AM resident reported that staff had run out of his antibiotic while he was here. He is on nafcillin 2 gm in 50 ml ns at 50 ml/hr every 4 hours for 8 weeks from 4/22-6/14. MAR indicated 'N' on 6/2 at 9AM, 1 PM, 5 PM, and 9 PM and on 6/3 at 1 AM; in May MAR indicated 'N' on 5/7 at 5 PM, and many other times. Notes indicate the medication will be administered when meds are available or that the medication was not available. During an interview on 6/6/19, the assistant director of nursing reported that, in her role as infection control nurse, she does not track whether resident receive antibiotics as ordered. 2. The facility staff failed to implement proper handwashing practices during medication pass and pour observation and failed to clean durable medical equipment…

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.