Kingwood Healthcare Center

Following record review and interviews, the facility failed to obtain an order to utilize a pain scale for the administration of pain medication. Additionally, facility staff did not assess residents after administering pain medication, to ensure effective pain management, as per professional standards of practice. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #103 and #319. Facility census: 117. Findings included: a) Resident #103: Record review, and interview, revealed that Resident #103 had been prescribed the following medication: Tylenol Oral Tablet 325 MG X2 every 6 hours as needed for pain. Order date 08/11/24 at 11:13 AM. Record review conducted on 11/05/24, at approximately 10:00 AM revealed that a pain scale had not been prescribed for the administration of medication. Staff administered medication even when the resident's pain level was recorded as zero (0). Additionally, there were no documented assessments of post-administration pain levels available for review, to evaluate the effectiveness of 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.

Based on record review and staff interview, the facility failed to complete annual performance reviews for Nurse Aides (NA). This was true for five (5) of five (5) reviewed for staffing during the Long-Term Survey Process (LTCSP). Facility census: 117. Findings included: a) Facility NA's Annual Evaluations A facility record review revealed NA #29, NA #34, NA #60, NA #14, and NA #18 did not receive their 12-month evaluation. During an interview, on 11/06/24 at 4:04 PM, the Human Resource Manager confirmed there were no annual evaluations completed for NA #29, NA #34, NA #60, NA #14, and NA #18. She stated that NA evaluations were something the facility was working on getting completed.

Based on record review, and staff interview, the facility failed to ensure the physician documented the actions or rational if no action taken to monthly drug regimen reviews. This was true for four (4) of five (5) reviewed for unnecessary medications and the pharmacist failed to identify clinically significant risks associated with concurrent use of a Benzodiazepines and opioids. Resident identifiers: #22, #77, #101 and #17. Facility census: 117. Findings included: a) Resident #22 Record review of the facility's policy titled, Medication Regimen Review, showed: -Attending Physician Responsibilities: 1. The resident's attending physician must document in the medical record that the identified irregularity has been reviewed, and what if any action has been taken to address it. 2. If there is to be no change in the medications, the attending physician must document his/her rationale in the resident's medical record. A medical record review for Resident #22 revealed monthly drug regimen reviews response without actions or rational if no action taken by the physician. --06/27/24…

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

Based on observation and staff interviews, the facility failed to keep unit refrigerators free from medical supplies that could contaminate food and store food and supplies in accordance with professional standards for food service safety. This has the ability to affect more than a limited number of Residents. Facility census: 117. Findings included: a) Unit Pantry's During the initial tour of pantries with the Dietary Manager on 11/04/24 at 11:30 AM an observation of the south pantry found five (5) used resident cold gel Icepacks for injury or surgical procedures stored in the Resident freezer. The continued tour of the north pantry on 11/04/24 at 11:44 AM found five (5) used resident cold gel Icepacks for injury or surgical procedures stored in the Resident freezer and the ice scoop stored in the ice cooler. On 11/04/24 at 12:00 PM during an interview with the Dietary Manager (DM) verified that medical supplies should not be stored in Resident refrigerators or freezers and the ice scoop should be placed in the scoop holder, not in the ice chest.

Based on record review and staff interview, the facility failed to maintain accurate records on four (4) out of 24 sampled residents in the Long-Term Care Survey Process. Resident identifiers: #71, #68, #110, and #93. Facility census: 117. Findings included: a) Resident #71 A record review, on 11/04/24 at 12:44 PM, revealed a Physician Orders for Scope of Treatment (POST) form in Resident #71's electronic medical record. The POST form was dated 07/30/22. Section E of the POST form, entitled Signature: Patient or Patient Representative/Surrogate/Guardian was unsigned and undated. On 11/05/24 at 2:45 PM, a review of resident's paper chart at nurses' station revealed the original POST was also not signed by resident/resident representative. The directions for completing the POST form, compiled by the [NAME] Virginia Center for End of Life, state, The signature section provides a declaration on behalf of the patient (or incapacitated patient's Medical Power of Attorney representative or health care surrogate) related to their voluntary participation in the completion of the POST form…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review and staff interview, the facility failed to facilitate the inclusion of the resident representative in person-centered care planning. This was true for one (1) of 24 residents reviewed in the Long-Term Care Survey Process. Resident identifier: #74. Facility census: 117. Findings included: a) Resident #74 An electronic medical record review, conducted on 11/05/24 at 9:10 PM, revealed: -Resident #74 had been admitted to the hospital on [DATE] -During Resident #74's stay in the hospital, it was determined that the resident did not have the capacity to make medical decisions, and a Health Care Surrogate (HCS) was appointed to be the legal decision maker on Resident #74's behalf. -The hospital's 07/18/24 After Visit Summary clearly stated that a surrogate decision-maker had been recorded during resident's hospitalization. Details of the After Visit Summary were scanned in Resident #74's electronic medical record. However, the HCS form appointing a legal decision maker on Resident #74's behalf…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review and interview, the facility failed to notify the resident's legal representative of a change in health status and transfer to the hospital. This failed practice was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifier: #74. Facility census: 117. Findings included: a) Resident #74 An electronic medical record review, conducted on 11/05/24 at 9:10 PM, revealed: -A nurses note, dated 07/15/24 at 6:00 PM, stated, Resident transferred to [Name of a local hospital] as direct admit. Transported via facility staff and van. Left facility in stable condition. Resident with capacity. MD (medical doctor) aware. There was no evidence that resident's emergency contact/family member had been notified of the need for acute care or transfer to the hospital. -An eInteract Transfer form, dated 07/15/25 at 8:00 PM, indicated that Resident #74 was her own resident representative and that she was aware of the acute transfer and her clinical situation. During an interview on 11/06/24 at 3:10 PM, the 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 record review and staff interview, the facility failed to issue the required Notification of Medicare Non-Coverage (NOMNC) in a timely fashion for one (1) of three (3) residents reviewed for beneficiary protection notification. This failure had the potential to place the resident at risk of not being informed of her rights prior to the end of Medicare Part A covered services. Resident identifier: #269. Facility census: 117. Findings included: a) Beneficiary Notice Review On 11/05/24 at 7:25 PM, a review was completed regarding the beneficiary protection notification liability notice(s) given for Resident #269 who was discharged to home with a family member following his last covered day of Medicare Part A services. Resident #269's last covered day of Part A Services was on 09/05/24. There was no evidence in the electronic medical record that the required Notification of Medicare Non-Coverage (NOMNC) was issued. The Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 state: The NOMNC must be delivered at least two calendar days before Medicare covered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 random observations and interviews, the facility failed to ensure a Resident's medical and health information was protected during MDS Interviews. Resident identifiers: #18 and #77. Facility census: 117. Findings included: a) Resident #18 A random observation on 11/04/24 at 1:33 PM, overheard the MDS Licensed Practical Nurse #16 Interviewing Resident #18 from the hallway. The Brief Interview for Mental Status was being assessed. Resident #18's door was open and MDS LPN was speaking loudly. This practice found resident's answers could be overheard by other residents, staff and visitors. b) Resident #77 A random observation on 11/05/24 at 2:38 PM, overheard MDS Licensed Practical Nurse #16 interviewing Resident #77 from the hallway. The Brief Interview for Mental Status was being assessed. Resident #77 was sitting in the MDS open doorway and MDS LPN was speaking loudly. This practice found resident's answers could be overheard by other residents, staff and visitors. On 11/05/24 at 2:40 PM, an interview with the Social Service Director confirmed the information could be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure the appropriate information was communicated to the receiving health care institution when the facility transferred Resident #167 to the hospital. This deficient practice was true for one (1) of five (5) residents reviewed under the hospitalization pathway. Resident identifier: #167. Facility census: 117. Findings included: a) Resident #167 An electronic medical record review, completed on 11/05/24 at 8:42 PM, reflected that resident was transferred to the hospital on [DATE]. There was no evidence that an eInteract Transfer form had been completed or that the following items had been sent with the resident upon his transfer to the hospital: -Contact information of the practitioner responsible for the care of the resident -Resident representative information including contact information -Advance Directive information -All special instructions or precautions for ongoing care, as appropriate -Comprehensive care plan goals -All other…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review, outside agency interview, and staff interview, the facility failed to allow a resident to return to the facility following a brief hospitalization. When the facility did not allow the resident to return, the facility failed to initiate a discharge and did not comply with transfer and discharge requirements at 42 CFR 483.15(c). This was true for one (1) of two (2) residents reviewed under the discharge pathway throughout the survey process. Resident identifier #167. Facility census: 117. Findings included: a) Resident #167 Resident #167 was admitted to the facility on [DATE] as a skilled patient (receiving physical and occupational therapy to help resident regain strength, maximize his independence with activities of daily living, and improve his quality of life following an acute hospitalization.) Resident #167 had the following diagnoses: - Schizoaffective disorder, depressive type. The 2025 edition of the International Classification of Diseases, Tenth Revision, Clinical Modification…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review, and staff interview, the facility failed to provide physician-ordered treatment and services to a resident admitted with limited range of motion. This deficient practice affected potential one (1) of one (1) residents reviewed for position/mobility. Resident identifier: #1. Facility census: 117. a) Resident #1 Review of Resident #1's progress notes showed a therapy note from 09/30/24 at 5:59 PM that stated, Patient given [NAME] air short opponens orthosis this date to gradually lift flexed digits in R [right] hand. Nurse and aide instructed to keep it on for an hour and then to remove d/t [due to] newness. Patient to wear as tolerated. Review of Resident #1's physicians' orders showed the following order written on 10/01/24, [NAME] air short opponens orthosis to right hand on for an hour and the remove, to wear as tolerated. On 11/06/24 at 9:45 AM Licensed Practical Nurse (LPN) #10 stated she didn't know if Resident #1 had any devices ordered for his hand. LPN #10 looked at the resident's…

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

Based on record review and staff interviews, the facility failed to ensure the environment remained as free of accident hazards as is possible and assistance devices to prevent accidents for Resident #101. This was true for one (1) of five (5) residents reviewed for accident hazards. Resident identifier: #101. Facility census: 47. Findings included: a) Resident #101 Review of the nurse's progress notes dated 08/20/24, Resident #101 was sitting in a nonfunctioning scoop chair, in the up position, which caused her to fall into the floor in the hallway. During an interview with Director of Nursing(DON) # 68, on 11/06/24 at approximately 4:30 AM, she stated she would look into it. On 11/07/24, the DON returned with copies of the Nursing Progress notes from the date of fall (08/20/24), and acknowledged the faulty scoop chair was the cause of Resident #101's fall on 08/20/24. On 8/20/24 at 5:08 PM Note Text: CNA alert this nurse resident was laying on floor on 300 hallway. Resident was sitting up in scoop chair prior to fall. Resident assessed for injury, denies hitting head, ROM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Residents were not given the opportunity to clean/sanitize their hands prior to eating lunch in their rooms. This practice has the potential to affect more than a limited number of residents. Resident identifiers: #105, #68 and #46. Facility census: 111. Findings include: a) Observations of lunch on 9/18/23 at 11:48 AM on the 100 hall found Nurse Aide (NA) #14 delivering and setting up meal trays to Resident (R) #68 and R#46 in their rooms. Neither resident was given the opportunity to clean or sanitize their hands before eating. During an interview with NA #14 immediately after this observation she reported the trays do not contain hand wipes for the residents to use prior to eating and agreed she did not offer them the opportunity to wash their hands at the sink or use of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review, family interview and staff interview, the facility failed to make prompt efforts to resolve a grievance and make restitution for a lost cell phone. This is true for one of three phones lost in the facility. Resident identifier: #201. Facility census: 111. Findings include: a) Facility records On [DATE] the facility completed a concern/grievance form for Resident (R) #201 for a missing cell phone. On [DATE] it was determined the cell phone pinged to an employee's home address. The police were notified and took leadership of the investigation. On [DATE] the facility instituted the abuse protocol and notified all appropriate agencies. The five day follow-up form dated [DATE] and signed by the Social Services Director states the suspected employee was suspended pending the investigation and has since quit. The police plan to arrest and charge the nurse aide. The facility will make restitution for the phone. Review of facility records on [DATE], revealed no evidence the facility reimbursed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 staff interview, the facility failed to establish and maintain an effective infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to perform proper hand hygiene when having direct resident contact or contact with high touch areas for a resident in Transmission Based Precautions (TBP), failed to ensure facility staff utilized appropriate Personal Protection Equipment (PPE) procedures for donning and doffing when caring for residents in TBP, failed to ensure proper disposal of used PPE, and used materials located in a resident's room who was in TBP and failed to ensure Enhanced Barrier Precautions were implemented for residents identified with wounds, and/or indwelling medical devices, placing residents at risk for transmission of infections. This practice had the potential to affect more than a limited number…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on Resident Council meeting, review of Resident Council minutes, resident and staff interviews, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life in regards to privacy, meal costs and meal services. This was by a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifiers: #1, #24, #46, and #71. Census: 109. a) Resident Council During Resident Council on 12/14/22 at 3:30 PM, the members voiced their concern about the cutbacks on food and snacks. They stated that the staff keep telling them they are unable to have certain food items that was previously available because they cost too much. During Resident Council, Resident #62 stated that the facility could make them biscuits and white gravy instead of bacon and eggs for breakfast, to save money. Review of Resident Council Minutes, dietary…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, staff interview, and facility documentation review, the facility failed to ensure each resident had the right to personal privacy during care and treatments and failed to ensure confidentiality of resident's personal and medical information. Facility staff failed to provide privacy during a treatment/personal care for Resident #30 and Resident #162. The facility staff failed to safeguard confidential information related to residents on the 400 hall, by leaving out assignment sheets in plain view. These failed practices were identified through a random observation for discovery during the Long-Term Care Survey Process (LTCSP), and had the potential to affect more than limited number of residents. Resident identifiers: Resident #30 and Resident # 162. Census: 109. Findings included: a) Resident #162 On 12/13/22 at 11:55 AM, an interview was being conducted with Resident #162's roommate. Resident #162 was not noticed to be in the room. During the interview, Nurse Aide (NA) #1 came 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.

Based on operation policy review, observation, and staff interview, the facility failed to report an alleged violations related to neglect and/or abuse, and report the results of all investigation to the proper authorities within the prescribed time frames. This was true for two (2) of three (3) allegations of abuse. Resident identifier: #34. Facility census: 109. Record review of the facility's policy titled, Abuse, Neglect, Exploitation, showed: -The abuse coordinator will report allegations or suspected abuse, neglect, or exploitation immediately to the Administrator, other officials in accordance with state law, and State survey and certification agency through established procedures. Findings included: a) Resident #34 During an interview on 12/12/22 at 1:34 PM Resident #34 stated that a male nurse aide reaches up under my gown and grabbed my scrotum. He has done it four (4) times. He stated that he has reported it to other aides. He also provided a name of the accused. On 12/12/22 at 2:15 PM, the alleged allegation of sexual was reported abuse to the Administrator (NHA). 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 operation policy review, resident interview, and staff interview, the facility failed to take actions to thoroughly investigate an alleged violation related to, sexual and physical abuse and accurately documenting a follow up . Resident identifiers: #34, #73. Facility census: 109. Record review of the facility's policy titled, Abuse, Neglect, Exploitation, showed: - Once a patient is cared for and initial reporting has occurred, an investigation should be conducted, - identifying and interviewing all involved persons including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation. - Providing complete and thorough documentation of the investigation. - Responding immediately to protect the alleged victim and integrity of the investigation. - Room or staff changes, if necessary, to protect the patient from the alleged perpetrator. Findings included: a) Resident #34 1. Alleged Sexual Abuse During an interview on 12/12/22 at 1:34 PM Resident #34 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 record review, staff and resident interview, the facility failed to develop and implement a baseline care plan within 48 hours of the resident's admission, which included goals and interventions for immediate health and safety needs and failed to provide the resident or resident's representative a summary of the baseline care plan. This was true for one (1) of seven (7) newly admitted residents reviewed during the LTCSP. Resident identifier: Resident #164. Census: 109 Findings included: a) Resident #164 A record review, conducted on 12/13/22 for #164, showed an admission date of 12/06/22. A review of the admission orders, showed an order dated 12/07/22, for an anti-psychotic medication, Olanzapine 2.5 MG tablet was to be given at bedtime for psychotic disorder AEB; agitation with direction to monitor for side effects. A physician's capacity statement , dated 12/08/22, noted the resident to have capacity to make medical decisions. Additional information was requested from staff (Director of Nursing (DON), on 12/13/22 at 08:00 AM, regarding evidence of behavior monitoring and…

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

Based on resident and staff interviews, observations and record review, the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services. This was true for 1 of 1 resident interviewed. This failed practice had the potential to affect a limited number of residents that currently reside at the facility. Resident identifier: #18. Facility census: 109. Findings Included: Resident #18 on 12/12/22 at 1:31 PM stated that the facility was doing nothing for the increased limited motion in her right hand. She stated that she had therapy for her arm but has never been given therapy for her hand. Resident #18 reports that she is unable to properly ambulate in the wheelchair or able to do things she did to due to the limited range of motion in her hand. On 12/13/22 at 1:13 PM an interview with Occupational Therapist (OT) #21 stated that the resident's right hand was not limited in 2019 during occupational therapy. Based on recent observations the OT #21 stated that he was aware of an increased limited range of motion in Resident #18 right hand. 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 record review and staff interview, the facility failed to ensure the attending physician documented a rationale for no action taken when reviewing monthly Medication Regimen Review recommendations from the licensed pharmacist. This was true for one (1) of five (5) residents reviewed under the unnecessary medication pathway. Resident identifier #92. Facility census: 109. Findings included: a) Resident #92 On 12/13/22 at 10:15 AM, a medical record review revealed the consulting pharmacist had completed a monthly Medication Regimen Review (MRR) on 09/28/22 and recommended, Practice guidelines for major depression in primary care recommend continuing the same dose for 4-9 months following the acute phase. Whether a patient is to continue therapy in this maintenance phase depends on the established history of previous depressive episodes and the physician assessment. A trial dose reduction may be reasonable at this time. The MRR form noted, on 10/04/22, MD aware - declines. The physician did not document on the MRR form nor was there a rationale as to why no action was taken.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 record review, staff and resident interview, the facility failed to ensure a resident was not administered a psychotropic drug unless, based on a comprehensive assessment of the resident, the drug was medically necessary to treat a specific condition as diagnosed and documented in the resident's medical record. Resident #164 was receiving an anti-psychotic medication without a specific diagnosed behavior, behavior monitoring did not contain a documented specific behavior to be observed and was incomplete. The resident was unaware and had not signed a consent for the administration of the medication. This failed practice was identified in one (1) of five (5) residents reviewed for unnecessary medications during the LTCSP. Resident identifier: Resident #164. Census: 109 Findings included: a) Resident #164 A record review of the electronic medical record for Resident #164 showed the resident was admitted to the facility on [DATE]. Physician's orders showed the anti-psychotic medication, Olanzapine Tablet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 failed to secure Marinol (Dronabinol) a Schedule III narcotic in a separately locked permanently affixed compartment. This is true for one of two medication rooms reviewed. Resident identifier: 314. Facility census: 109. Findings include: a) An observation of the medication room on the 100/200 hall was completed with Licensed Practical Nurse (LPN) #49 on 12/12/22 at 3:40 PM. This review identified a Marinol (Dronabinol) five milligram punch card for Resident #314 not secured in the permanently affixed compartment in the medication refrigerator. The Marinol punch card was sitting on top of the locked plastic affixed box in the refrigerator. During this observation LPN #49 reported the Marinol is a form of marijuana and is required to be locked up and dispensed like other controlled medications. LPN #49 added it always sits on top of the locked plastic permanently fixed compartment in the refrigerator. .

Based on observation, resident interview, record review and facility documentation review, the facility failed to ensure a reasonable effort was put forth when providing food items to residents to meet the individual needs and preferences of the resident. This was identified in one (1) of two (2) residents reviewed for food during the LTCSP. The facility failed to provide Resident #1 food items during meals based on an assessed and identified food preference. Resident identifier: Resident #1. Census:109. Findings included: a) Resident #1 An interview with Resident #1, on 12/12/22 at 11:45 AM, revealed food preferences are not always honored after being identified with dietary personnel. Resident #1 stated she preferred two slices of toast for breakfast and preferred diet sugar and diet jelly when served. A record review for Resident #1 showed an order for a regular diet with a resident preference of two (2) slices of toast in the AM. An observation of the breakfast meal on 12/13/22 at 08:15 AM, revealed Resident #1 received the breakfast tray with one piece of toast with regular…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 policy review, observation, and staff interview, the facility failed to ensure food items kept in the north nourishment room were labeled and dated. This had the potential to affect all residents receiving nourishment from the refrigerator on the north side of the facility. Resident identifier: 34. Facility census: 109. Findings included: a) North Nourishment Room Review of the facility's Use and Storage of Food Brought in by Family or Visitors policy, revised 05/03/21, indicated all food items brought in by family or visitors must be labeled with content and dated. During an observation, on 12/13/22 at 11:34 AM, the north nourishment room refrigerator had a 2 lb. container of potato salad that was opened, but undated. During a subsequent interview, CNA #49 identified the potato salad belonged to Resident #34 and was not dated as per facility protocol. .

Based on record review and staff interview, the facility failed to maintain an accurate medical record for one (1) of four (4) sampled residents reviewed for Advance Directives during the Long-Term Care Survey process. Resident identifier: #312. Facility census: 109. Findings included: a) Resident #312 A record review, completed on 12/12/22 at 3:14 PM, identifed the following records: -A Medical Power of Attorney (MPOA), dated 03/26/2007, indicating I am giving the following SPECIAL DIRECTIVES OR LIMITATIONS ON THIS POWER: I do not wish to be placed on artificial life support. -A Physician Orders for Scope of Treatment (POST) form, dated 02/26/22, indicating the MPOA had selected Full Treatments under Section B of the POST. Subsequent review of of theUsing the POST Form Guidance for Health Care Professionals indicated all support measures needed to maintain and extend life are utilized. Use intubation, advanced airway interventions, mechanical ventilation, and electrical cardioversion as indicated. It also indicated healthcare providers are to review a patient ' s advance directives…

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