Bennington Health & Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to assess Residents for urinary and bowel incontinence on admission to ensure that a resident who is incontinent receives appropriate treatment and services to restore continence to the extent possible for 3 of 4 Residents in the sample (Resident #31, #48, and #105). Findings include: Per record review Resident #105 was admitted in October 2024. A care plan focus and the Resident [NAME] indicate that he/she is incontinent, interventions identified include 1 assist with perineal care as needed, multi-void disposable briefs to contain incontinence. Another care plan focus reflects that Resident #105 is incontinent of urine and is unable to cognitively or physically participate in a retraining program due to Dementia. There is no documented evidence of a urinary or bowel continence assessment in the record. Per interview on 10/22/2024 at 2:45 PM a Licensed Nursing Assistant (LNA) stated that on admission, staff were told that Resident #105 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 interview and record review the facility failed to notify a Resident Representative of a change in condition related to a worsening wound, abnormal laboratory results, and transfer to the hospital. Findings include: Per interview on 10/23/2024 at 9:35 AM Resident #104's Representative stated that s/he had not been notified by the facility that Resident #104's wound had worsened. The Representative also stated that s/he had not been notified by the facility that the Resident's blood work was abnormal, and that the Resident had been transferred to the hospital. Per record review Resident #104 was admitted to the facility in September 2024 with a stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an open/ruptured serum-filled blister) on his/her coccyx and venous stasis ulcers. A care plan focus for Advanced Directives states Inform resident/patient and/or healthcare decision maker of any change in status or care needs. A skin assessment was completed on 9/8/23 reveals 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 interview and record review the facility failed to monitor weights and verify potential significant weight loss and gains as needed for 5 of 6 residents sampled (Residents #2, #3, #4, #5, and #6). Findings include: 1. Per record review Resident #2 has a Physicians order for monthly weights. Review of the Resident's Weight Summary revealed significant weight changes of 12.60% weight loss over one month and 10.82% over six months. On 1/3/24 the Resident's weight was documented as 245 lbs. one month later, on 2/3/24 the weight was documented as 256.0 lbs., an 11 lb. weight gain. There is no evidence that the resident was reweighed. On 5/15/24 the Resident's weight was documented as 250 lbs., on 6/3/24 the weight was documented as 218.5 lbs., a 31.5 lb. weight loss. There is no documentation that reweighs were obtained. 2. Per record review Resident #3 had documented significant weight loss of 6.72% over one month and 10.39% loss over six months. Review of the Resident's Weight Summary reveals that 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.

Based on interview, and record review, the facility failed to ensure that pain management was consistent with professional standards of practice and the comprehensive person-centered care plan was followed for 1 of 3 residents in the sample (Resident #1) as evidenced by a lack of documentation for monitoring of the presence of pain and evaluating the effectiveness of regularly scheduled pain medication. Findings include: Per record review Resident #1 has diagnoses that include chronic pain syndrome, opioid dependence, opioid use disorder /substance abuse disorder (OUD/SUD), and arthritis. Per review of physician's orders Resident #1 has been receiving opioid medications for pain control since admission. A Physician's order dated 6/25/24 states Buprenorphine HCl Sublingual [under the tongue] Tablet Sublingual 8 MG (Buprenorphine HCl) Give 1 tablet sublingually every 12 hours for pain. Another Physician's order dated 6/26/24 states Buprenorphine HCl Sublingual [under the tongue] Tablet Sublingual 2 MG (Buprenorphine HCl) Give 3 tablet sublingually two times a day for pain for 28 Days…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review the facility failed to ensure that staff was provided the necessary training and possessed the necessary competencies to care for residents with diagnoses of OUD (opioid use disorder), SUD (substance abuse disorder), and PTSD (post-traumatic stress disorder) for 1 of 7 sampled residents (Resident #1). Findings include: Per review of 3 Licensed Nursing Assistant's (LNA's) employee training files. 2 of the 3 LNAs had not received any training related to OUD or SUD. 1 of 3 LNAs files revealed no evidence of training related to PTSD and trauma informed care. Per review of 3 Staff Nurse employee files, 1 Registered Nurse (RN) file revealed no evidence of training related to SUD, OUD, PTSD, and trauma informed care. Per interview with the Registered Nurse assigned to Resident #1 on 7/3/24 at 8:35 AM S/he was recently hired on 7/3/24. The RN confirmed that S/he had not received resident specific training regarding SUD, OUD, PTSD, and trauma informed care since being hired. When asked if S/he knew of any residents on her/his assignment who…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview and record review the facility failed to ensure that a resident's right to be treated with dignity and respect was maintained for 1 of 3 residents in the sample (Resident #1). Findings include: During an interview on 5/1/24 at approximately 12:35 PM Resident #1 stated, I have lost my rights as a person, and I feel like I am being targeted . The previous Director of Nursing (DON) hung letters about me at the nurse's station and had things in my care plan that were not true. The resident was visibly upset about the content of the letters, stating s/he felt humiliated that this note was hung for everyone to see. Resident #1 also said that months ago a Nurse who is now the Interim DON had called the police on her/him because s/he got angry when the Nurse would not let her/him go outside alone. Per review of the letter that Resident #1 said had been hung up at the nurses station, it specified three Licensed Nursing Assistants (LNAs) by name who should not provide personal care, and one LNA who should not go in Resident #1's room for any reason unless a true emergency.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interviews, and record reviews the facility failed to ensure that 1 of 3 residents in the sample (Resident #1) received necessary treatment and services consistent with professional standards of practice to prevent infection and a new wound from developing. As a result, Resident #1 developed a toe wound and osteomyelitis (infection of bone) which led to a partial amputation of the toe. Findings include: Per record review Resident #1 was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes. An admission Nursing Progress Note dated 9/1/2023 reflects that Resident #1 had no wounds on admission. Review of Resident#1's care plan initiated on 9/18/2023 reveals that the resident is at risk for skin breakdown. The care plan also identifies a diagnosis of diabetes and reflects an intervention of diabetic foot check daily. Observe feet/toes/ankles/soles/heels noting alteration in skin integrity, color, temperature, and cleanliness. Toenails for shape, length, and color. Inspect shoes for proper…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of facility policy, the facility failed to establish a grievance policy that ensures written grievance decisions meet documentation requirements of issuing a written decision that includes the date the decision was issued to all residents. Findings include: Facility policy titled OPS204 Grievance/Concern, last revised 7/19/23, states that the department manager will Notify the person filing the grievance of resolution in a timely manner. Provide written resolution for Civil Rights grievances, and upon request for all other grievances, by giving a copy of the Grievance/Concern Form to the patient/representative. The policy does not address the regulatory requirements that all residents, not just those that have Civil Rights grievances, be issued a written decision and that the written decision should include the date the written decision was issued. 4 of 4 grievance forms sampled did not indicate that a written decision, or the date that the decision was issued, was provided to the resident. Per interview on 11/1/23 at approximately…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and staff interviews, and record review, the facility failed to ensure there are a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each resident's basic needs and individual needs as required by the resident's diagnoses, medical condition, or plan of care impacting all residents of the facility. Findings include: 1. Review of facility direct care staff schedules and PPD (direct care staff to resident ratios) for September and October 2023 reveals that the facility failed to maintain required minimum staffing levels to allow for 2.0 hours of direct care per resident per day (PPD) on a weekly average by Licensed Nursing Assistants (LNAs) for 7 of the 8 sampled weeks in September and October 2023 and failed to maintain required minimum staffing levels to allow for 3.0 hours of direct care per resident per day (PPD) on a weekly average, including nursing care, personal care, and restorative nursing care for 4 of 8…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide required notice of the bed-hold policy before transferring a resident to the hospital for 2 of 2 residents sampled (Residents #56 and #309). Findings include: 1. Resident #56 was transferred without receiving notice of the facility bed-hold policy. Resident #56 was admitted from home 16 days prior to being transferred and discharged to the local acute care hospital. On 10/3/23 Resident #56 was sent emergently to the local acute care hospital with behavioral symptoms. Per the medical record, a copy of the written discharge notice was sent with the resident and his/her spouse had been notified verbally of the transfer with intent to discharge. On 11/1/23 at 11:30 AM during an interview with the Administrator, Director of Nursing, and Market Clinical Advisor it was confirmed that a bed-hold notice had not been provided. 2. Per record review Resident #309 was admitted to the facility on [DATE] and transferred to the hospital on 7/18/23. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to permit a resident to return to the facility after a hospitalization resulting in a facility-initiated discharge for 2 of 2 residents sampled (Residents #56 and #309). Findings include: 1. On 10/3/23 Resident #56 was sent emergently and discharged to the local acute care hospital with behavioral symptoms. Resident #56 was admitted from home 16 days prior to being transferred and discharged to the local acute care hospital. Resident #56 was admitted with a primary diagnosis of severe vascular dementia with psychotic disturbance. During this brief stay, Resident #56 demonstrated impulsive behaviors including sexual aggression, a severe lack of safety awareness demonstrated by climbing on top of unsteady items of furniture, tireless wandering, and self-injurious head banging. Per the medical record on 10/3/23 the following entry was placed by the Director of Nursing (DON) Case Managers from Southern [NAME] Medical Center (SVMC) had contacted Genesis Central…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the minimum healthcare information necessary to properly care for the resident for 3 of 29 sampled residents (Residents #210, #212, and #33). Findings include: 1. Per record review, Resident #210 was admitted to the facility on [DATE] for post operative care and antibiotic therapy related to surgical amputation to his/her left toes. An admission nursing assessment dated [DATE] reveals that Resident #210 has a history of a mental health disorder and confusion, has moderately impaired vision, has anxiety about their surroundings, and has expressed the desire to leave the facility. A progress note dated 10/15/23 reveals that Resident #210 has expressed sadness or symptoms of depression and experiences loss of interest daily or almost daily. A 10/19/23 Physician assessment reveals that Resident #210 is experiencing a moderate episode of recurrent major depressive order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview and record review, the facility failed to review and revise resident's care plans after each assessment and with the required team for 9 of 29 sampled residents (Residents #37, #42, #16, #31, #10, #14, #45, #9, and #1). Findings include: 1. Per record review during an interview on 11/1/23 at 3:43 PM with the Social Service Director the following was revealed regarding care plan meetings: • Resident #37 had the following assessment dates: 5/3/23 and 7/19/23. A 5/12/23 care plan meeting note following the 5/3/23 assessment does not indicate that the attending physician, a nurse aide, or a food and nutrition service staff member were in attendance or provided input in the development and revision of the care plan. There is no explanation that participation from Resident #37 was not practicable in their medical record. The Social Service Director reported that Resident #37 had a care plan meeting on 8/3/23 but could not produce documentation of the meeting, or any evidence of who was in attendance. • Resident #42 had the following assessment dates: 5/17/23 and 8/2/23.…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to provide services meeting professional standards regarding the use and monitoring of an IV (intravenous line) (Resident #210), and medication administration through a gastrostomy tube (G-tube- a tube that is inserted into the stomach to provide nutritional support in patients with impaired swallowing secondary to various disorders) (Resident #53) for 2 of 29 residents in the sample. Findings include: 1. Per record review, Resident #210 was admitted to the facility on [DATE] for post operative care and IV antibiotic therapy related to surgical amputation to his/her left toes. An admission nursing assessment dated [DATE] reveals that Resident #210 has a left upper arm PICC line (peripherally inserted central catheter; IV). A 10/26/23 progress note reveals that Resident #210's IV became completely dislodged from their left upper arm. A 10/27/23 skin assessment reveals that Resident #210 has a left lower arm IV line. Review of Resident #210 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 Per observation, interview, and record review, the facility failed to provide showers as needed for 2 of 29 sampled residents (Residents #210 and #212) and failed to provide transfer assistance within a reasonable amount of time for 1 of 29 residents (Resident #212). Findings include: 1. Per record review, Resident #210 was admitted to the facility on [DATE] for post operative care and antibiotic therapy related to surgical amputation to his/her left toes. Review of Resident #210's care plan reveals a focus [Resident #210] requires assistance for ADL [activities of daily living] care related to: Recent illness, fall, hospitalization, etc resulting in fatigue, activity intolerance, confusion, etc. Amputation of toes., created 10/13/23, with the intervention, provide resident/patient with limited assist of 1 for bathing, created on 10/13/23. Per observation and interview on 10/30/23 at 1:04 PM, Resident #210 explained that s/he has not been offered a shower since s/he has been here. S/He explained that s/he has…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review, the facility failed to provide an ongoing program to support residents designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for residents on the second-floor unit. Findings include: 1. Per observation on 10/30/23 between 10:55 AM and 11:10 AM, 4 residents were observed in the common area. A movie is playing on the television but none of the 4 residents are paying attention to the movie. One of the residents, Resident #31 is yelling out phrases about dying and her father. There are no staff present during this time. Per observation on 10/30/23 between approximately 3:30 PM and 4:30 PM, three residents were sitting around the second-floor nursing station not doing anything while staff assisted other residents with care. Per observation on 10/31/23 between 9:00 AM and 10:15 AM five residents were sitting around the second-floor nurses' station at 9:20 AM another resident was brought to the nurse's station. 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 record review, the facility failed to ensure that required physician visits occurred every 30 days for the first 90 days after admission and at least 60 days thereafter for 10 of 29 sampled residents (Residents #9, #31, #16, #37, #46, #1, #10, #14, #45, and #42). Findings include: Per record review, the following residents did not have documentation of all regulatory physician visits from 1/1/2023 through 10/31/23: • Resident #9 was admitted to the facility on [DATE]. Resident #9 did not have the required regulatory physician visits for March 2023 or August 2023. • Resident #31 was admitted to the facility on [DATE]. Resident #31 did not have the required regulatory physician visit for August 2023. • Resident #16 was admitted to the facility on [DATE]. Resident #16 did not have the required regulatory physician visit for May 2023. • Resident #37 was admitted to the facility on [DATE]. Resident #37 did not have the required regulatory physician visits for April 2023 or August 2023. •…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, and record reviews, the facility failed to ensure standard precautions were followed to prevent the spread of infection related to hand hygiene and equipment cleaning. On 10/31/2023 at approximately 8:55 AM on the third floor, the Licensed Practice Nurse (LPN) was observed administering medications. She/he administered a nebulizer treatment to Resident #1, assisting the resident to put on an Oxygen mask, then was observed returning to the medication cart, preparing medications for the next resident without performing hand hygiene. She/he was observed donning gloves to administer an Insulin pen, removing the gloves, and returning to the medication cart to continue setting up medications without performing hand hygiene on two occasions during the medication pass. Per a review of the Hand Hygiene policy, it read, Perform hand hygiene before resident care, before an aseptic procedure, after any contact with blood or other body fluids, even if gloves are worn, after patient /resident care, after contact with patient/resident's environment. The policy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to determine whether it is clinically appropriate for residents to self-administer medications for 1 of 29 residents (Resident #20). Findings include: Per record review, Resident #20 was admitted to the facility on [DATE] with diagnoses that include congestive heart failure, respiratory failure, and a need for assistance with personal care. Per observation of Resident #20's room on 10/30/2023 at 11:00, an Albuterol Inhaler (Albuterol is a medication used to prevent the muscles that line the airways from tightening, resulting in wheezing and coughing], was on the bedside table. Per interview on 10/30/23 at approximately 11:00, Resident # 20 stated that she/he uses the inhaler a few times daily. She/he does not advise the nurses when it is used. Review of the facility policy for Medication Self Administration initiated on 6/1/1996 and reviewed by the facility on 3/1/2022, states the following: Patients who request to self-administer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to treat 1 of 29 sampled residents (Resident # 53) with respect and dignity and recognize the resident's individuality. Findings include: Per interview on 10/30/2023 at approximately 11:30 AM with the family of resident #53, a concern was voiced that Resident #53 was called by her/his first name and not her/his middle name as she/he preferred. She/he had requested that their middle name be posted on the room door to alert the staff. Per interview on 10/31/2003 at approximately 10:00 AM an LNA (Licensed Nursing Assistant) stated she/he knew Resident #53 by her/his middle name as it had been told to her several times by family. She/he said the preference should be found in the special instructions area of the medical record. Per record review, Resident #53 was admitted to the facility on [DATE]. A discharge summary from the transfer facility has a note under the resident's legal name that states Prefers to be called [Resident #53's middle…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 upon observation and interview, the facility failed to ensure the right to personal privacy and confidentiality of personal and medical records for 2 residents [Res.#259 and #53] of 29 sampled residents. Findings include: Per observation on 10/31/23 at 8:45 AM during the medication pass on the 3rd floor resident unit, the computer screen on the medication cart was open to a resident name [Res.#259], photograph, medications, and diagnoses. The Staff nurse administering medications was away from cart and in resident room [ROOM NUMBER]. Per observation, 2 residents were in proximity of the medication cart with the open resident screen. Additionally, per observation a second medication cart was located against the wall abutting the elevator across from the nurse's station. Visible in the trash container affixed to the side of the medication cart was a medication blister pack with a label listing a resident's name [Res. #53] and medication name. Per observation, 2 residents were in proximity of 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 interviews and record review the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility without ensuring documentation in the resident's medical record of the danger that failure to transfer or discharge would pose. Additionally, the facility failed to document in the resident's medical record communication with and the provision of required information to the receiving provider by the resident's physician for 1of 2 residents sampled (Resident's # 56) Findings include: Resident #56 was transferred on 10/3/23 with the intent to be discharged and not readmitted . Resident #56 was admitted from home 16 days prior to being transferred and discharged to the local acute care hospital. Resident #56 was admitted for long-term care with a primary diagnosis of severe vascular dementia with psychotic disturbance. During this brief stay, Resident #56 demonstrated impulsive behaviors including sexual aggression, a severe lack of safety…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review, the facility failed to complete a comprehensive assessment within 14 days of admission for 1 of 29 sampled residents (Resident #210). Findings include: Per record review, Resident #210 was admitted to the facility on [DATE]. As of 11/1/23, 19 days after their admission, a comprehensive Minimum Data Set (MDS; a comprehensive assessment used as a care-planning tool) was not completed for Resident #210. Per interview on 11/1/23 at 9:25 AM, the MDS Coordinator confirmed that Resident #210 did not have a complete MDS assessment within 14 days of admission as required.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to conduct a Level I Pre-admission Screening and Resident Review (PASARR) for 1 of 29 sampled residents (Resident #46). This failure had the potential for Resident #46 to not receive specialized services. Findings include: Record review reveals that Resident #46 was admitted to the facility on [DATE] for rehabilitation related to pain management, cancer, and hip fracture. On admission, Resident #46 had a principal diagnosis of schizophrenia. Review of the electronic medical record Documents tab revealed a State of [NAME] Pre-admission Screening and Resident Review (PASRR): Level I For Mental Illness, Intellectual Disability, or Related Condition form signed by a physician for an exemption for a short- stay of 30 days or less. There is no date recorded on this screening form but the document tab reveals it was entered into the record on 3/6/23. There is no evidence that an updated PASARR was completed in full by the facility once Resident #46 exceeded…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview and record review the facility failed to create a comprehensive care plan including the participation of professionals in disciplines as determined by the resident's needs for 1 of 29 sampled residents (Resident #8). Findings include: The care plan for Resident #8 does not include evidence of participation of or input from physical or occupational therapists. Per record review Resident #8 was admitted for skilled rehabilitation services from a local acute care hospital following an accident in which they suffered a knee injury. admission orders for Resident #8 included both physical and occupational therapy evaluations and treatment as recommended. On 9/5/23 Resident #8 was evaluated by the therapy department and a plan of treatment was created to include physical and occupational therapy five times per week. A review of Resident #8's care plan revealed entries from the nursing department for risk for falls which included transfer assistance and an entry for mobility assistance including PT/OT screen as indicated (Physical and Occupational therapies). There is no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 and record review the facility failed to ensure acceptable parameters of nutritional status were monitored for 1 of 29 residents sampled (Resident #8). Findings include: Resident #8 was not weighed per physician orders. Per record review Resident #8 was admitted with diagnoses including diabetes, morbid obesity, hypertension (elevated blood pressure), congestive heart failure (a weakness of the heart muscle resulting in less efficient fluid management), and hyperlipidemia (high cholesterol). A physician order with a start date of 9/2/23 instructs to obtain the weight of Resident #8 every evening shift for 3 days AND every day shift every Wednesday without an end date. Further record review reveals one weight recorded on 9/2/23 which is 228#, there is no weight recorded on 9/3 or 9/4. The next 4 Wednesdays' weight is recorded as #228 each time (9/6,13, 20 and 27th). In October there are no weights recorded on the dates due which are 10/4, 11, 18, and 25 or at all. On 10/31/23 at approximately 10 AM the Director of Nursing confirmed the weight of Resident #8 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to recognize when a resident experienced pain and ensure that pain management was provided to a resident who required such services for 1 of 29 sampled residents (Resident #7). Findings included: On 10/30/2023 at approximately 1:40 PM, Resident # 7 was observed sitting by her/his bedside crying. She/he states she/he has so much pain. She/he reported that she/he gets pain patches in the morning on her/his back and hip, but the staff has been too busy to get them. She/he was told she/he would get them later in the day. Record review indicates Resident # 7 was admitted to the facility on [DATE] for therapy and pain management. Her/his diagnoses include chronic pain and Diabetes. She/he requires assistance with care. Per a review of Resident #7's Medication Administration Record (MAR), there is an order for a Lidocaine External Patch 5% [Lidocaine is a medication that eases pain by numbing the nerves and making them less sensitive to pain]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to develop an individualized care plan that addresses the assessed emotional and psychosocial needs of the resident and failed to provide services that address the assessed needs of the resident for 1 of 29 residents (Resident #210). Findings include: Per record review, Resident #210 was admitted to the facility on [DATE] for post operative care and antibiotic therapy related to surgical amputation to his/her left toes. An admission nursing assessment dated [DATE] reveals that Resident #210 has a history of a mental health disorder and confusion, has anxiety about their surroundings, and has expressed the desire to leave the facility. A progress note dated 10/15/23 reveals that Resident #210 has expressed sadness or symptoms of depression and experiences loss of interest daily or almost daily. A 10/19/23 Physician assessment reveals that Resident #210 is experiencing a moderate episode of recurrent major depressive order and is prescribed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review the facility failed to maintain a medication error rate of less than 5%. Findings include: Between 10/30 and 11/1/23 41 medications were observed being administered with 8 of those medications being given in contrast to facility policy, professional standards, and a prescriber's order resulting in an error rate of 19.5%. On 19/31/23 at 8:26 AM during medication pass observation the surveyor observed a Licensed Practical Nurse (LPN) administer 8 medications simultaneously to Resident #53 via a gastrostomy tube (G-tube) is a tube that is inserted into the stomach to provide nutritional support in patients with impaired swallowing secondary to various disorders). The medications given were: Hyoscyamine 0.125 mg 1 tablet - used for Parkinson's disease. Amlodipine 10mg 1 tablet- used for elevated blood pressure. Multiple Vitamin 1 tablet- used for health maintenance. Vitamin D 1 tablet- used for health maintenance. Citalopram 20 mg 1 tablet- used to treat depression. Eliquis 5 mg 1 tablet- used to avoid blood clots. Prednisone 20 mg 3 tablets-…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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, interviews, and record review the facility failed to provide a therapeutic diet as ordered for 1 of 29 residents sampled (Resident #8). Findings include: Resident # 8 was not provided with the therapeutic diet as ordered. Resident #8 was admitted with diagnoses including diabetes, morbid obesity, hypertension, congestive heart failure, and hyperlipidemia (high cholesterol). The diet order placed as active on 9/12/23 created by the facility's registered dietician and signed by the nurse practitioner was noted to be a consistent carbohydrate diet (a diet intended to keep blood sugar levels stable), regular texture NO high processed breakfast foods, low sodium heart healthy. On 10/30/23 at 12:10 PM during an interview with Resident #8 his/her lunch tray was served with the following components noted: kielbasa and sauerkraut, scalloped potatoes, mixed vegetables, a roll, and a brownie (there were no condiments included). The lunch ticket on the tray included Resident #8's name confirming this was the correct lunch tray for this resident, the ticket listed the diet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 interview and record review the facility failed to provide specialized rehabilitative services as ordered for 1 of 29 residents sampled (Resident #8). Findings include: Resident #8 did not receive skilled physical therapy 12 out of 35 opportunities during a 7-week period. Resident #8 was admitted for skilled rehabilitation services from a local acute care hospital following an accident in which they suffered a knee injury. admission orders for Resident #8 included both physical and occupational therapy evaluations and treatment as recommended. On 9/11/23, Resident# 8 was evaluated by the physical therapy department and a plan of treatment was created to include physical therapy five times per week. A review of the Service Log Matrix on which documentation of the minutes per day of therapy are recorded revealed that in the 7 weeks since Resident #8 began to receive physical therapy s/he should have received treatment 35 times. However, the Service Log Matrix from September 5-October 30 reveals s/he received therapy 20 times with 15 sessions being missed. Of these 15 missed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to review and revise care plan interventions for one resident (#2). Review of resident #2's medical record indicates this resident was admitted on [DATE]. S/he has dysphagia due to a stroke. The resident was hospitalized per a Southern [NAME] Medical Center Emergency Department note (08/17/21) for pneumonia due to aspiration. This resident is on a diet consisting of puree foods and thickened liquids and per a nutrition note (07/11/23) all meals are to be taken out of bed per provider. A care plan (date initiated 07/21/23) intervention indicates Resident will remain out of bed 20 min after meals as tolerated but does not show that all meals are to be taken out of bed. Progress notes indicate the resident refuses to get out of bed for meals most of the time, however one note (08/07/23) indicates Resident unable to get out of bed due to staffing shortage. One LNA on South wing. Observation of the resident and interview with the second-floor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 review of documentation, record review and interview, the facility failed to provide adequate safety supervision and assistance to prevent an accident for one resident (#1). Findings include: On 08/23/23 review of resident #1's medical record indicates the resident was admitted on [DATE] with the following diagnoses: Pneumonia, Chronic Respiratory Failure, Chronic Kidney Disease, Chronic Lower Leg Ulcers and other comorbidities. S/he requires light assistance with ADLs, is continent of urine/bowels and ambulates with a walker. The admission assessment reveals a Brief Interview for Mental Status (BIMS) score of 14. A score of 13-15 suggests the resident is cognitively intact. A nurse note (08/05/23-15:26) reveals the resident was sitting near the elevator and stated, [his/her] father is picking [him/her] up in a black car, refused treatment and would not go back to their room. The resident was later observed sitting south side stairwell by 2nd floor by 2nd floor nurse. Staff assisted [him/her] 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.