Peterson Rehabilitation And Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . The facility failed to provide an environment that was free from accident hazards over which it had control. This was a random opportunity for discovery. Water temperatures were found to be above 120 degrees Fahrenheit (F). This deficient practice had the potential to negatively effect more than a limited number of residents. Facility census: 132. Findings included: a) State Operations Manual Appendix PP Review of the State Operations Manual Appendix PP found in the interpretive guidelines for F689 the following concern regarding water temperatures: - Water temperature of 124 degrees Fahrenheit will cause a 3rd degree burn in 3 minutes. - Water temperature of 120 degrees Fahrenheit will cause a 3rd degree burn in 5 minutes. - Burns can occur even at water temperatures below those identified, depending on an individual's condition and the length of exposure. -Third-degree burns penetrate the entire thickness of the skin and permanently destroy tissue. These present as loss of skin layers, often painless (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 observation, staff interview, and food tray temperatures the facility failed to serve food to residents that was at an appetizing temperature. This failed practice was true for one (1) of two (2) wings tested for food tray temperatures throughout the Long-Term Care Survey Process. Facility census: 132. Findings included: a) Wing 1 Lunch Time Meal Observation During an observation on 02/12/25 at 12:53 PM, it was noted that a food truck was brought out of the kitchen with all resident lunch trays for residents on the 100 Wing. Staff members immediately began to deliver the trays to the residents' rooms. At 1:03 PM, when four (4) trays were left on the food truck, the Surveyor requested that CNA #135 select one tray that would be served last. CNA #135 selected Resident #45's tray and stated that she was actually getting ready to go out to eat with her family member and would not need her lunch tray. Registered Nurse (RN) #62 was asked to call the kitchen and ask them to come to the wing in order to temp the last tray on the food cart. On 02/12/25 at 1:07 PM, Dietary Aide #300…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 equipment manual review the facility failed to keep the ice machine in safe operating condition. This had the potential to affect all Residents who get their nutrition from the kitchen, and residents who attend food related activities. Facility Census: 132. Findings Included: a) Ice Machines On 02/13/25 at 12:40 PM a tour with the Maintenance Director found the ice machines located in the Kitchen area had a drainpipe running on the floor to a drain. Nutrition rooms on units one (1) and three (3) had no required air gap on the ice machine drains. The drainpipes were touching the drains. Continued tour found unit one (1), five (5) and six (6) had no required filter on the ice machines. On 02/13/25 throughout the tour, the Maintenance Director confirmed the drainpipes should not be touching the floor or drain and all the ice machines should have a filter.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to provide an accurate and complete medical record for seven (7) of 32 residents. Resident identifiers: #3, #17, #280, #128, #123, #71 and #75. Facility Census: 132. Findings Include: a) Resident #3 On [DATE] at 9:18 AM, a record review was completed for Resident #3. The review found the [NAME] Virginia (WV) Physicians Orders for Scope of Treatment (POST) was incomplete. The resident's signature under section E was not dated. On [DATE] at 2:21 PM, the Director of Nursing was notified and confirmed the resident's signature was not dated. b) Resident #17 On [DATE] at 9:30 AM, a record review was completed for Resident #17. The review found the WV POST form under section B had both selective treatments and comfort-focused treatments selected. The directions under section B specify pick one (1). On [DATE] at 2:21 PM, the DON was notified and confirmed both choices were selected and only one (1) should have been selected. c) Resident #280 On [DATE] at…

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

Based on observation, record review, and interview the Facility failed to reasonably accommodate the needs of Resident #86 by ensuring the call light was in reach. This was a random opportunity for discovery. Facility census: 132. Findings included: a) Resident #86 a) On 02/12/25 at 1:10 PM the resident was observed sitting in wheelchair in her room watching television. She stated that she would like to go to bed and that she was hurting from sitting in the wheelchair. When asked if she could reach her call light, she attempted to and replied no. Her call light was behind her, wrapped around her bedrail. I rang the call light on the opposite side of the room and Nurses Aide (NA) #61 entered the room and acknowledge that resident did not have her call light. She handed call light to her and stated You don't have your light, here you go. NA #61 told her that she would get someone to help and be right back to assist her. She promptly returned with NA #135 and they assisted the resident with her needs using the hoyer lift.

Based on record review and staff interview, the facility failed to have residents Pre-admission Screening and Record Review (PASSAR) reflect a new diagnosis after admission. This is true for one of (1) of six (6) residents reviewed for the care area of PAS-R during the long term care survey process. Resident Identifier: Resident #13. Facility Census 132. Findings included: a) Resident #13 A record review completed on 02/12/25 at 9:14 PM revealed Resident #13's most recent PASSAR dated 04/05/24 included the following: -Section III. MI/MR Assessment, Question 30. Current Diagnosis (check all that apply), was marked a. None. Question 47. The individual has a primary diagnosis of: was marked dementia b) Review of resident's diagnoses list revealed residents primary diagnosis was unspecified psychosis not due to substance or known physiological condition on 02/20/24. She was also given a diagnosis of hallucinations, unspecified on 02/20/24. c) During an interview with Social Worker #147 on 02/12/25 at 2:24 PM, they acknowledged Resident # 13 did not have a PASSAR that reflected her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses. This was true for two (2) out of six (6) residents reviewed for the category of PASARR (Pre-admission Screening and Record Review, during the Long-Term Care Survey Process. Resident identifiers: #125 and #67. Facility census: 132. Findings included: a) Resident #125 A medical record review, completed on 02/11/25 at 9:07 AM, revealed Resident #125 had been admitted to the facility on [DATE] with the following diagnoses: -Bipolar -Major Depression Disorder A PAS, completed on 01/28/25, marked NONE under Section III Question 30 entitled, Current Diagnosis (Check all that apply). Additionally, Section V Question 40 entitled, Major Mental Illness (MI) or Suspected MI was also marked NONE. During an interview on 02/12/25 at 2:24 PM, the Director of Social Services reported that resident's Bipolar and Major Depression Disorder diagnoses had not been captured on 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 medical record review and interview, the facility failed to ensure each resident had a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial need regarding schizoaffective disorder. This practice affected one (1) of (28) resident's care plans reviewed. Resident identifier: #27. Facility census: 132. Findings included: a) Resident #27 On 02/12/25 a review of Resident #27's) medical records revealed a diagnosis of schizoaffective disorder on admission. A review of the current care plan showed there was no care plan addressing schizoaffective disorder. During an interview on 02/13/25 at 1:55 PM the Director of Nursing (DON) confirmed there was no schizoaffective disorder care plan for Resident #27.

Based on record review and staff interview, the facility failed to revise the care plan regarding an appropriate diagnosis for Resident #128's urinary catheter, antipsychotic medication and behavior monitoring for Resident #90; and the discontinuation of a feeding tube for Resident #86. This was true for three (3) of 32 sampled residents reviewed during the survey process. Resident Identifier: #128, #90 and #86. Facility Census: 132. Findings Include: a) Resident #128 On 02/11/25 at 3:21 PM, a record review was completed for Resident #128. The review found the care plan listed the resident's need for a urinary catheter was personal preference. However, further review of the record found urinary retention as the correct diagnosis for the urinary catheter. On 02/12/25 at 2:22 PM, the Director of Nursing (DON) confirmed the diagnosis for the urinary catheter on the care plan was incorrect. The DON stated, I don't know why that was on the care plan .the reason was urinary retention. b) Resident #90 On 02/12/25 at 8:30 PM, a record review was completed for Resident #90. The review of the…

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

Based on record review and staff interview, the facility failed to follow physician's orders regarding medication administration, behavior monitoring, pain score, side effects of a antipsychotic, and supplement. This was true of two (2) of five (5) residents reviewed under the care area of unnecessary medications. Resident Identifiers: #13 and #58. Facility Census: 132. Findings Include: a) Resident #13 On 02/13/25 at 12:24 PM, a record review was completed for Resident #13. The review found blanks on the 02/2025 Medication Administration Record (MAR). The following is the list of the missed behavior and side effect monitoring: --02/04/25 physically abusive behavior --02/04/25 antianxiety medication side effect tracking --02/04/25 antipsychotic medication side effect tracking --02/04/25 socially inappropriate or disruptive behavior --02/04/25 verbally abuse behavior On 02/13/24 at approximately 2:30 PM, the DON confirmed the missing documentation on 02/04/25. b) Resident #58 On 02/13/25 at 1:00 PM, a record review was completed for Resident #58. The review found blanks on 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 observation, record review and staff interview, the facility failed to date insulin upon opening for Resident #3 and dispose of expired insulin for Resident #18. These were random opportunities for discovery. Resident Identifiers: #3 and #18. Facility Census: 132. Findings Include: a) Medication Cart 800 wing On [DATE] at 1:00 PM, a tour of the medication cart on the 800 wing was completed. The tour found Resident #3's insulin glargine not dated upon opening and Resident #18's Novolog insulin expired on [DATE] after 28 days from opening. Registered Nurse (RN) #119 confirmed the insulin glargine was not dated upon opening and the Novolog insulin was expired. b) Facility policy On [DATE] at 2:30 PM, a review of the facility policy was completed. The facility policy, entitled Medication Labeling and Storage, under the section entitled Medication Labeling section 5 states, Multi-dose vials that have been opened or accessed are dated and discarded within 28 days . On [DATE] at 3:30 PM, the Director of…

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

Based on observation, and staff interview, the facility failed to maintain an appropriate infection control program for foley catheter care. This was a random opportunity for discovery. Resident Identifier: 85. Facility Census: 132. Findings Include: a) Resident #85 On 02/10/25 at 12:46 PM, an observation of Resident #85's urinary catheter drainage bag touched the floor. On 02/10/25 at 12:48 PM, Nurse Aide (NA) #163 confirmed the drainage bag was touching the floor. NA #163 stated, let me raise the bed .it shouldn't be touching the floor. On 02/10/25 at approximately 2:00 PM, the Director of Nursing (DON) was notified. The DON confirmed the urinary catheter drainage bag should not be touching the floor.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to ensure all alleged violations involving abuse were reported in a timely fashion to all appropriate state agencies. This was true for one (1) out of five (5) resident-to-resident altercations reviewed during the complaint process. Facility census: 135. Resident identifiers: #39 and #137. Findings include: a) The Facility's Abuse/Neglect Policy Review of the facility's Abuse/Neglect policy revealed the following reporting requirements: -All alleged violations of abuse are to be reported by the facility to the SA (State Agency) and Adult Protective Services (APS). b) Alleged Resident-to-Resident Sexual Abuse An electronic medical review, completed on 05/21/24 at 9:45 AM, revealed the following details: -RN Unit Manager #28 documented in a nursing note, dated 02/14/24 at 9:04 AM, At 0150 [1:50] this AM, Staff entered resident's room and observed Resident [#137] on top of roommate [Resident #39] naked, making humping motion, and attempting to remove…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 revise residents care plans after an occurrence of resident-to-resident sexual abuse. This was a random opportunity for discovery throughout the complaint survey process. Resident identifiers: #137 and #39. Facility census: 135 Findings included: a) Resident #137 An electronic medical review, completed on 05/21/24 at 9:45 AM, revealed the following details regarding Resident #137. -RN Unit Manager #28 documented in a nursing note, dated 02/14/24 at 9:04 AM, At 0150 [1:50] this AM, Staff entered resident's room and observed Resident [#137] on top of roommate [Resident #39] naked, making humping motion, and attempting to remove roommates [roommate's] gown and incontinence brief. -RN Unit Manager #28 documented in a nursing note, dated 02/14/24 at 6:59 AM, Aide alarmed this nurse about resident being sexually inappropriate with resident in room. -A written statement from Nurse Aide (NA) #6 stated NA #210 requested help in the resident room. NA #6…

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

Based on observations and staff interviews, the facility failed to ensure hallway temperatures were set at least 71 degrees Fahrenheit (F). This was a random observation. Facility census: 133. Findings included: a) On 10/16/23 at 4:30 PM, a tour of the Second floor found wall thermostats temperatures set at 59 to 69 degrees Fahrenheit (F). Charge Nurse #7 on Unit 800 confirmed the thermostat was set on 69 F and that it was cold. Residents were observed in their rooms covered with two (2) blankets. The Maintenance Director (MD) #99 was called and confirmed temperatures were set to low and all of the thermostats would be checked and adjustments made. On 10/19/23 at 10:15 AM, during an interview with the Director of Nursing (DON), the DON was informed of issues with the temperatures on all units on second floor. The DON stated they had a contract to service ceiling air conditioning units. At 10:25 AM on this same day during a discussion with MD #99 it was mentioned that the thermostat on the 800 Hall was set below 71 degrees and the ceiling vents were covered in gray dust. MD #99…

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

Based on facility record review, medical record review and staff interview, the facility failed to ensure there is sufficient qualified staff available at all times to meet the needs of the residents. The nursing supervisor failed to deploy staff in a manner to ensure all residents were assigned a care giver. This practice has the potential to affect more than a limited number of residents. Resident identifiers: #73 and #48. Facility census: 132. Findings included: a) Staff Postings The staff posting dated 07/29/23 lists two (2) Registered Nurses (RN), two (2) Licensed Practical Nurses (LPNs) and six (6) Nurse Aides (NAs) for the 11:00 PM to 7:00 AM shift to care for 135 residents on seven (7) halls. b) Reportable Allegations The facility's reportable allegations dated 07/30/23 identify concerns related to care not being provided to R#73 and R#48 during the night shift (11:00 PM - 7:00 AM) on 07/29/23. Investigation by the facility includes a witness statement written by NA #11. NA #11 reported she was moved to Wing Five (5) at 2:00 AM and was not aware she was supposed to float 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 facility record review, medical record review and staff interview, staff neglected to provide incontinence care to Residents #73 and #48. This is true for two (2) of two (2) residents reviewed for neglect related to incontinence care. Resident identifiers: #73 and #48. Facility census: 132. Findings included: a) Resident (R) #73 Review of the medical record on 08/22/23 revealed R#73's diagnoses include dementia with out behaviors, a psychotic disorder with delusion, anxiety, and falls. The annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 05/17/23 noted R #73 is frequently incontinent of urine, always incontinent of bowel, and requires extensive assistance with transfers, bed mobility, toileting and hygiene. The progress notes include the following documentation: --7/29/23 at 11:24 PM R#73 observed sliding on his buttocks across the floor. Assessment noted no injuries or pain. R#73 was assisted to his wheel chair and brought to the nurse's station. Record reviewed, continue plan of care. Staff to monitor more often in the evenings. written by Nurse Unit…

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

Based on facility record review, medical record review and staff interview, the facility failed to ensure incontinence care is provided to residents in according with professional standards of care. This is true for two (2) of four (4) residents reviewed for incontinence care. Resident identifiers: R#73 and R#48. Facility census: 132. Findings included: a) Resident (R) #73 Review of the medical record on 08/22/23 revealed R#73's diagnoses include dementia with out behaviors, a psychotic disorder with delusion, anxiety, and falls. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/17/23 noted R #73 is frequently incontinent of urine, always incontinent of bowel, and requires extensive assistance with transfers, bed mobility, toileting and hygiene. The progress notes include the following documentation: --7/29/23 at 11:24 PM R#73 observed sliding on his buttocks across the floor. Assessment noted no injuries or pain. R#73 was assisted to his wheel chair and brought to the nurse's station. Record reviewed, continue plan of care. Staff to monitor more often…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 complete and accurate medical records. Physician Orders for Scope of Treatment (POST) forms were incomplete and/or inaccurate for 17 of 18 records reviewed for accurate POST forms. Additionally, one (1) of 18 records reviewed had a missing POST form that was not part of the electronic medical record or the chart. Resident identifiers: #4, #19, #27, #29, #44, #87, #115, #119, #132, #28, #39, #71, #131, #90, #118, #246, #74, and #65. Facility census: 138. Findings included: a) Resident #4 Review of Resident #4's POST form showed that verbal consent was obtained from the resident's representative on 10/09/22. However, the resident representative's actual signature was never obtained. Additionally, the Nurse Practitioner's (NP) name was not printed, and the phone number was not provided. The 2021 POST form guidance titled, Using the POST Form: Guidance for Health Care Professionals states, The patient (or incapacitated patient's MPOA [medical power of attorney] representative or health care surrogate) must sign…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 follow a physician's order for the administration of an antibiotic. This was true for one (1) of three (3) residents reviewed for antibiotics. The facility failed to notify the physician when blood sugar levels were above 400 or when a blood sugar level was below 70. This was true for two (2) of three (3) residents reviewed for insulin. The facility failed to ensure the Physician Orders and the Physician Orders for Scope of Treatment (POST) form matched. This was true for two (2) of 18 residents reviewed for advance directives. Resident identifiers: #19, #44, #29, #95, #107. Facility census: 138. Findings included: a) Resident #19 A record review, completed on [DATE] at 2:48 PM, found a physician order for Bactrim DS Tablet 800-160 MG. The order directed, give one (1) tablet by mouth two (2) times a day for a urinary tract infection for seven (7) days. A review of the [DATE] Medication Administration Record (MAR) revealed Resident #19 began…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure the daily nurse staffing was posted in a prominent place and readily accessible to residents on the second floor. This was a random opportunity for discovery. Facility Census: 138. Findings included: a) Posting of Nurse Staffing On 06/05/23 at 10:45 AM, a tour of the facility's second floor revealed nurse staffing was not posted. The second floor of the facility is home to the 500 wing, 600 wing, 700 wing, and 800 wing. During an interview on 06/05/23 at 11:40 AM, the Director of Nursing (DON) acknowledged that nurse staffing was not posted in a prominent place that would be readily accessible to residents on the second floor of the facility adding, It's always been that way since I've been here. I will address it now.

Based on observations and staff interviews, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered a stove drip pan was heavily soiled with grease, eight (8) storage racks had a heavy dust build-up, the threshold to walk-in freezer was damaged. The floors to the walk-in freezer and reach-in coolers needed to be cleaned. Also, the ice machines located on each of the 8 hallways were not draining properly. These deficient practices had the potential to affect any resident receiving nourishment from the kitchen and ice from the eight (8) ice machines located in the Medical Storage Rooms. Facility census: 138. Findings included: a) Kitchen tour During the kitchen tour on 06/05/23 at 10:45 AM, it was discovered the drip pan for the main stove was heavily soiled from grease build-up. In the Dry Storage area there were eight (8) shelving units with all the bottom shelves crusted with dirt and dust. The walk-in freezer had a rusted threshold strip and both the walk-in freezer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure meal trays were delivered in a manner to protect and promote resident dignity by failing to serve roommates a meal tray at the same time. This was based on two (2) random opportunities for discovery and had the potential to affect a limited number of residents. Resident identifiers: #115 and #55. Facility census: 138. Findings included: a) Resident #115 An observation, on 06/05/23 at 12:45 PM, found Resident #115's roommate was being fed by LPN #186. Resident #115 was in the room and had not been served lunch. Resident #115 sat and watched as the roommate ate. After watching the roommate eat for 14 minutes, Resident #115 rummaged in her bedside table and pulled out cookies to eat. During an interview, on 06/05/23 at 1:05 PM, Licensed Practical Nurse (LPN) #186 confirmed she had just finished feeding Resident #115's roommate and that Resident #115 had still not yet been served lunch. The LPN #186 explained it was facility protocol to feed those residents who required assistance with their meals prior to the tray…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 family interview, record review, and staff interview, the facility failed to notify a resident's Medical Power of Attorney (MPOA) regarding a change in condition. This was true for one (1) of 35 sample residents reviewed during the Long-Term Care Survey Process. Resident #39 had testing ordered on 06/02/23 and the MPOA was not informed of the appointment. Resident identifier: #39. Facility census: 138. Findings included: a) Resident #39 During a family interview with the MPOA on 06/05/23 at 12:11 PM, the MPOA reported she had not been informed of the barium swallow testing until just before the interview occurred. The test was ordered on 06/02/23 and the staff informed her of the upcoming scheduled barium swallow study on 06/05/23. A review of the medical record revealed an order had been written on 06/02/23 for a barium swallow study on 06/27/23 at 8:30 AM for Resident #39. In an interview with the Director of Nursing (DON) on 06/07/23 at 10:18 AM, the DON verified the MPOA had not been notified timely regarding the order for the barium swallow study.

Based on medical record review and staff interview, the facility failed to provide a resident with a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN). This is true for one (1) of three (3) residents reviewed for beneficiary notification. Resident identifier: #4. Facility census: 138. Findings included: a) Resident #4 Review of the medical record on 06/06/23 revealed Resident #4 received a Notice of Medicare Non-Coverage (NOMNC) on 12/14/22 indicating her coverage of Part A Medicare service would end on 12/19/22. The record lacked information indicating Resident #4 received a SNF ABN with the NOMNC . During an interview on 06/06/23 at 9:06 AM, Social Services (SS) #110 acknowledged the SNF ABN was not given to Resident #4 and should have been given since she elected to reside in the facility.

Based on interviews with a resident's Medical Power of Attorney (MPOA), staff interview and record review, the facility failed to make prompt efforts to resolve a grievance and to keep the resident notified of progress toward resolution. This was true for one (1) of three (3) reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifier: #17. Facility census: 138. Findings included: On 06/05/23 at 11:14 AM during an interview with Resident #17's MPOA stated that the facility lost her prescription eyeglasses, and they have never replaced them. A record review of the Grievance log found on 03/11/23 Resident #17's glasses was reported missing. Continued review revealed an appointment was made for 4/17/23. A subsequent review found Resident #17 did not go to this appointment. No further action was taken by the facility. On 06/06/23 at 11:29 PM the Social Worker (SW) verified a rescheduled appointment was not made until surveyor intervention. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on medical record review, observation, and staff interview, the facility failed to implement the care plan and ensure emergency equipment was at the bedside and readily available for a resident with a tracheostomy. In addition, care plans were not developed for a resident admitted with a urinary catheter and a resident diagnosed with Post Traumatic Stress Disorder (PTSD). This was true for three (3) of 35 residents reviewed for care plans. Resident identifiers: #107, #123, #131. Facility census: 138. Findings included: a) Resident #107 Review of the medical record on 06/07/23 revealed Resident #107 had a tracheostomy and was at risk for respiratory impairment and dislodgement of his trachea because of a large stoma and history of mucous plugs. The care plan with a revision date of 05/18/23, noted to keep an ambu bag in the room at all times. Random observations on 06/06/23 revealed an emergency ambu bag was not visible and readily available in Resident #107's room. On 06/07/23 at 10:40 AM an observation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 medical record review and staff interview, the facility failed to update the care plan to reflect a change in code status. This is true for one (1) of 18 residents reviewed for code status. Resident identifier: #95. Facility census: 138. Findings included: a) Resident #95 Review of the medical record on [DATE] revealed Resident #95 was readmitted to the facility on [DATE]. The [NAME] Virginia Physician Order for Scope of Treatment (POST) form signed and dated [DATE], states no cardiac pulmonary resuscitation (CPR). Utilize comfort focused treatments. The care plan initiated [DATE] notes Resident #95's advanced directives as a full code indicating CPR will be performed. The care plan was not updated when the residents POST form was completed. On [DATE] at 10:35 AM, the Director of Nursing (DON) reviewed Resident #95's POST form and confirmed the care plan was not updated to reflect the resident's change in code status.

Based on observation, resident interview, staff interview, and record review, the facility failed to ensure proper treatment related to vision impairment for one (1) of one (1) residents reviewed in the care area of communication/sensory. Resident identifier: #17. Facility census: 138. Findings included: On 06/05/23 at 11:14 AM during an interview with Resident #17's Medical Power of Attorney stated that the facility lost her prescription eye glasses, and they have never replaced them. A record review of the Grievance log found on 03/11/23 Resident #17's glasses were reported missing. Continued review revealed an appointment was made for 4/17/23. Subsequently additional review found Resident #17 did not go to this appointment. No further action was taken by the facility. On 06/06/23 at 11:29 PM the Social Worker (SW) verified a rescheduled appointment wasn't made until surveyor intervention.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on medical record review and staff interview, the facility failed to ensure a resident admitted with a urinary catheter had a written physician order with an appropriate indication for use and guidelines for monitoring and maintaining. This was true for one (1) of five (5) reviewed for urinary catheters. Resident identifier: #123. Facility census: 138. Findings included: a) Resident #123 Review of the medical record on 06/07/23 revealed Resident #123 was admitted to the facility on [DATE] with a urinary catheter to assist with wound healing. The admission minimum data set (MDS) assessment with an Assessment Reference Date (ARD) of 05/09/23, was coded yes in section H0100 confirming Resident #123's indwelling urinary catheter. The current physician orders lack any information related to Resident #123's indwelling urinary catheter. On 06/07/23 at 9:30 AM, Licensed Practical Nurse (LPN) #40 confirmed Resident#123 was admitted with a urinary catheter because of multiple wounds. LPN #40 reviewed the physician…

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

Based on medical record review, observations, and staff interview, the facility failed to ensure emergency equipment was at the bedside and readily available for a resident with a tracheostomy. This is true for 1 of 2 reviewed for tracheostomy. Resident identifier: 107. Facility census: 138. Findings include: a) Resident #107 Review of the medical record on 06/07/23 revealed Resident#107 had a tracheostomy and was at risk for respiratory impairment and dislodgement of his trache because of a large stoma and history of mucous plugs. The physician orders dated 05/16/23 and the care plan with a revision date of 05/18/23, stated to keep emergency equipment including an ambu bag in the room at all times. Random observations on 06/06/23 revealed an emergency ambu bag was not visible and readily available in R#107's room. On 06/07/23 at 10:40 AM an observation with Licensed Practical Nurse (LPN) #72 confirmed there was no ambu bag in R#107's room. During an interview on 06/07/23 at 10:45 AM Corporate Nurse #201 and the Director of Nursing confirmed an ambu bag should be in Resident#107'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, record review and staff interviews, the facility failed to ensure one (1) of two (2) residents reviewed for the care area of dialysis during the Long-Term Care Survey Process (LTCSP), received such services consistent with physician's orders for care. Resident #103 did not have a dialysis emergency kit maintained at the bedside in accordance with physician's orders. Resident identifier: Resident #103. Census: 138. Findings included: a) Resident #103 A record review for Resident #103, showed current physician's orders for Dialysis Precautions which included maintaining an emergency kit at the bedside. In accordance with the physician's order, the emergency kit was to contain a tourniquet, sterile gauze, and gloves for the right arm in case of excessive uncontrolled bleeding from the arterio-venous shunt. An observation, on 06/06/23 at 10:25 AM, revealed no evidence of an emergency kit located in Resident #103's room. On 06/06/23 at 10:27 AM, Licensed Practical Nurse (LPN) #153, was requested to show the surveyor the dialysis emergency kit in the resident's room,…

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

Based on medical record review and staff interview the facility failed to follow a monthly medication regimen review (MRR) recommendation and attempt a gradual dose reduction of a psychotropic medication. This is true for one of five reviewed for unnecessary medications. Resident identifier: 95. Facility census: 138. Findings include: a) Resident (R) #95 Review of the medical record on 06/06/23 revealed a pharmacy recommendation dated 04/25/23 recommending an attempted gradual dose reduction (GDR) of Temazepam / Restoril (an hypnotic agent used to treat insomnia) 15 milligram (mg) every night. On 04/27/23, the nurse practitioner (NP) agreed and wrote to make the Temazepam as needed on the MRR form. The NP progress note dated 04/27/23 identified the gradual dose reduction and stated: .At this time noted patient takes Restoril (Temazepam) 15 mg at night for insomnia. At this time we will attempt a gradual dose reduction of the Restoril. At this time no reports of insomnia . The physician orders and the monthly medication administration record contain the original order dated 12/27/22,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 ensure medications were not stored and administered to residents past the manufacturer's date of use. This failed practice was identified through a random opportunity for discovery and was found to be true during one (1) of four (4) medication cart reviews. An insulin vial, containing Humalog insulin, currently stored in the medication cart and being administered to a resident, was being administered past the manufacturer's guidelines for safe usage. Resident identifiers: Resident #79. Facility census: 138. Findings included: a) Resident #79 An observation, during the review of Wing one (1) medication cart, on 06/06/23 at 11:35 AM, revealed a vial of Humalog insulin, dated as opened on 05/08/23. An interview with Licensed Practical Nurse (LPN) #72, during the observation on 06/06/23 at 11:35 AM, verified the Humalog insulin had been opened 05/08/23 and was still in use. It was further stated the insulin would be good for 28 or 30 days. According to manufacturer's instruction, opened vials of Humalog of insulin were to…

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

Based on Resident Council meeting interviews and staff interviews, the facility failed to serve food at a palatable temperature. During the last breakfast test tray on the 800 hallway, it was discovered Resident #55's food was not being served at an appetizing temperature. This had the potential to affect more than a limited number of residents. Resident identifier: #55. Facility census: 135. Findings included: a) Appetizing food temperatures During the breakfast test tray on the 800 hallway on 06/07/23 at 8:05 AM, it was discovered the temperature of the egg omelet was 120 degrees Fahrenheit. This temperature was obtained by Nurse Aide (NA) #171. She was able to locate a food thermometer in a room near the food cart. NA #171 reported the omelet should be near 135 degrees Fahrenheit. She then called the kitchen to obtain another breakfast tray. In an interview with the Certified Dietary Manager (CDM) on 06/07/23 at 8:13 AM, verified the egg omelet was not served at a palatable temperature. She also reported the temperature should be 135 degrees Fahrenheit.

Based on record review, resident interview, and staff interview, the facility failed to provide food that accommodated resident preferences. This was true for two (2) of 35 residents sampled in the Long-Term Care Survey Process. Resident identifiers: #1 and #46. Facility Census: 138. Findings included: a) Minutes of the 05/17/23 Resident Council Meeting On 06/05/12 at 6:23 PM, a review of the 05/17/23 Resident Council minutes revealed residents in attendance had requested the kitchen put gravy on meat and potatoes, asked that vegetables be put in bowls not on the plate to prevent bread from being soggy from the vegetable juices, and baked potatoes be served with more butter and sour cream. The documented departmental follow-up stated the Dietary Manager would meet with specific residents and update their tray cards to reflect their preferences. b) Resident Council meeting on 06/06/23 at 11:00 AM During a resident council meeting on 06/06/23 at 11:00 AM, Resident #1 and Resident #46 reported they had attended the 05/17/23 meeting and had requested gravy on their meat and potatoes.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 care planned that their center policy limited visitation from outside family and friends to protect the well-being of their residents from COVID-19, despite the Centers for Medicare and Medicaid Services (CMS) guidance opening visitation to all residents, at all times. This was a random opportunity for discovery. Resident identifiers: #132, #101, and #5. Facility Census: 145. Findings included: a) Revised Guidance from CMS On 11/12/21 CMS issued revised guidance, QSO-20-39-NH, directing Visitation is now allowed for all residents at all times. b) Resident #132 A medical record review, completed on 02/21/22 at 3:00 PM, revealed Resident #132 was admitted to the facility on [DATE]. Resident #132's care plan listed the following goal: Resident will not show any signs of depression/ anxiety or ill effects related to current center policy that limits visitation from outside family/ friends. The goal was initiated on 11/23/21 and revised on 12/20/21. c)…

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

c) Resident #108 A medical record review, completed on 02/16/22 at 7:33 PM, revealed Resident #108 experienced an unwitnessed fall on 07/25/21 at 10:18 AM. RN #61 documented, Call to room where patient sitting on buttocks on floor beside of bed. Patient stated she was asleep and woke up on floor. Assessed with no injuries. Transferred back to bed with PT [physical therapy]. Resident's Brief Interview for Mental Status (BIMS) score, on July 16, 2021, was determined to be a 09 indicating Resident #109 was cognitively impaired. During an interview on 02/17/22 at 2:14 PM, the DON stated neuro checks were not done following Resident #108's fall. The DON went on to acknowledge neuro checks should have been since it was an unwitnessed fall. d) Resident #91 On 02/17/22 at 2:08 PM, an electronic medical record review completed. There was an order for Resident #91 to receive insulin on a sliding scale. The term sliding scare refers to the progressive increase in doses, based on pre-defined blood glucose ranges. The physician order outlined the following: HumaLOG Solution 100 UNIT/ML (Insulin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 maintain a medical record for each resident which contained complete and accurately documented information. Treatments were not documented for Residents #98, #25, and #84. This was true for three (3) of four (4) residents reviewed under the pressure ulcer care area. Facility census: 145. Findings included: a) Resident #98 A record review revealed Resident #98 had physician's orders to receive a treatment to a sacral wound daily. A review of the Treatment Administration Record (TAR) showed treatments for 01/06/22, 01/07/22, 01/24/22 and 02/09/22 had not been documented as being provided. There was no evidence Resident #98 had refused the treatment or was out of the facility on these dates. b) Resident #84 A record review revealed Resident #84 had physician's orders for wound care to the upper thigh, right and left ischium and sacral area on day and evening shifts. A review of the TAR showed no evidence of documentation of treatments for 01/13/22, 01/14/22. 01/16/22. 01/20/22, 01/30/22, 02/08/22 and 02/12/22. 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 observation, resident interview, and staff interview, the facility failed to ensure residents were treated with dignity and respect. A Resident had signage posted in the room that discussed treatment and care that was visible to anyone in the room and from the hallway. This was a random opportunity for discovery. Resident identifier: #133. Facility census: 145. Findings included: Record review of the facility's policy titled Quality of life-Dignity, revised on August 2009, showed signs indicating the resident's clinical status or care needs shall not be openly posted in the resident's room. a) Resident #133 An observation, on 02/14/22 at 11:25 AM, revealed a sign visible from hallway that stated, Fluid Restriction 711-2 see nurse. During an interview on 02/14/22 at 11:25 AM, Resident #133 stated there was no understanding why a fluid restriction was in place. An observation, on 02/16/22 at 11:45 AM, showed a sign visible from hallway that stated, Fluid Restriction 711-2 see nurse. During an interview on 02/16/22 at 11:46 AM, Resident #133 stated that when the Surveyor finds…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 one (1) of 36 residents reviewed during the long-term care survey process had advance directives completed as recognized by State Law. Resident #73's Selection of Health Care Surrogate (HCS) form failed to document the appointed HCS's telephone number and address, thereby providing no way to contact the appointed representative in an emergency. Resident identifier: #73. Facility census: 145. Findings included: a) Resident #73 A medical record review, completed on 02/15/22 at 1:56 PM, found Resident #73's attending physician had documented Resident #73 was unable to make medical decisions. Further, the attending physician had appointed a Health Care Surrogate (HCS) to make medical decisions on Resident #73's behalf. The Selection of Health Care Surrogate (HCS) form did not include the address and telephone number of the appointed HCS. During an interview, on 02/16/22 at 8:49 AM, Social Worker #20 confirmed the HCS form was not completed in its entirety. The Social Worker #20 agreed it gave no way for the HCS to…

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

Based on observation, staff interview, and policy review, the facility failed to ensure the confidentiality and privacy of Resident #101's personal medical records. Resident #101's Medial Power of Attorney paperwork was filed on another resident's chart. This was a random opportunity for discovery. Resident identifier: #101. Facility census: 145. Findings included: a) Policy Review Review of the facility's Management and Protection of Protected Health Information policy revealed it was considered to be the responsibility of all personnel who have access to resident information to ensure that such information is managed and protected to prevent unauthorized release or disclosure. b) Resident #101 An observation on, 02/15/21 at 11:51 AM, revealed Resident #101's Medical Power of Attorney paperwork was erroneously filed on Resident #127's chart. On 02/16/22 at 8:13 AM, Licensed Practical Nurse (LPN) #84 verified Resident #101's Medical Power of Attorney paperwork was incorrectly filed on Resident #127's chart. LPN #84 stated, That's a big problem and confirmed Resident #101 did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on medical record review and staff interview, the facility failed to provide evidence a bed hold notification was given to a resident or the resident's representative before being transferred to an acute care hospital. This had the potential to affect all residents being transferred. Resident identifier: Resident #73. Facility census: 145. Findings included: a) Resident #73 A medical record review was completed on 02/15/22 at 1:42 PM. Resident #73 was transferred/discharged to the hospital on [DATE]. There was no evidence the facility had provided the resident or resident's representatives a bed hold notification at the time of the transfer/discharge. In an interview on 02/17/22 at 1:13 PM, the Director of Nursing reported the facility had no evidence a detailed written bed hold notice had been provided to Resident #73 upon transfer/discharge to the hospital. .

Based on record review and staff interview, the facility failed to accurately assess/document a resident's medical diagnosis. This was true for one (1) resident reviewed. Resident identifier: #86 Facility census 145. Findings included: a) Resident #86 On 2/16/22 at 11:15 AM, review of residents most recent Medium Data Set (MDS) on 1/24/22 dementia diagnosis was not claimed.On 2/16/22 at 2:15 PM, interview with Registered Nurse Assessment Coordinator(RNAC) #58 how a new diagnosis would be captured RNAC #58 stated, usually when reviewing the orders and residents chart. This surveyor requested for section I and N to be printed to review, found dementia diagnosis not claimed on 1/24/22 most recent MDS. On 2/17/22 at 2:30 PM, interview with Director of Nursing (DON) when asking when diagnosis of dementia was given to resident # 86 and DON stated, on January 6th 2022 when Nurse Practitioner (NP) gave dementia diagnosis with start of new medication. .

The facility failed to ensure comprehensive care plans were revised in the area of visitor restrictions. This was a random opportunity for discovery. Resident Identifiers: #62, #7. Facility census: 145. Findings included: a) Revised Guidance from the Centers for Medicare and Medicaid Services (CMS) On 11/12/21 CMS issued revised guidance, QSO-20-39-NH, directing Visitation is now allowed for all residents at all times. b) Resident #62 A medical record review, completed on 02/21/22 at 5:00 PM, revealed Resident #62's care plan listed the following goal: Resident will not show any signs of depression/ anxiety or ill effects related to current center policy that limits visitation from outside family/ friends. The goal was initiated on 11/11/21 and revised on 11/16/21. c) Resident #7 A medical record review, completed on 02/21/22 at 5:45 PM, revealed Resident #7's care plan listed the following goal: Resident will not show any signs of depression/ anxiety or ill effects related to current center policy that limits visitation from outside family/ friends. This goal was initiated on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, record review, and staff interview, the facility failed to ensure two (2) of three (3) residents reviewed for the care area of activities of daily living (ADL's) received the necessary care and services to maintain good grooming and personal hygiene. Resident #91 had unwanted facial hair. Resident #296 did not receive showers. Resident identifiers: #91 and #296. Facility census: 145. Findings included: a) Resident #91 During an interview on 02/14/22 at 12:17 PM, Resident #91 was observed with an abundant amount of facial hair on her chin. Certified Nursing Assistant (CNA) #137 confirmed the presence of the facial hair on Resident #74 and stated, We have to help her with shaving. She cannot do it independently. A brief medical record review, completed on 02/16/22 at 11:09 AM, revealed Resident #91 required one-person physical assist with personal hygiene which is defined as combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands. During a second interview 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 observation, record review, and staff interview, the facility failed to provide one (1) on one (1) supervision to a resident during meal time. This was a random opportunity for discovery. Resident identifier: #35. Facility census: #145. Findings included: a) Resident #35 An observation, on 02/15/22 at 2:00 PM, showed Resident #35 eating alone in the 700 hall day room. A review of Resident #35's medical record showed a physician order dated 07/26/21 that stated, 1 on 1 CONSTANT SUPERVISION for meals. An observation, on 02/16/22 at 1:10 PM, showed Resident #35 eating alone in the 700 hall day room. During an interview on 02/16/22 at 1:20 PM, Nurse Aide (NA) #163, stated that staff watch over Resident # 35 when eating but there were six (6) more residents on the 700 hall that needed assistance with feeding, so NA #163 just periodically checks on Resident #35 to make sure Resident #35 was not choking. NA #163 acknowledged the order that Resident #35 was a one (1) on one (1) during meals but stated just frequent checks was what usually occurred. During an interview on 02/16/22…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 obtain weekly weights for a resident with a feeding tube. This was true for one (1) out of three (3) residents reviewed for Tube Feedings. Resident identifiers: #34. Facility census: 145. Findings included: a) Resident #34 A review of Resident #34's medical record showed a physician order dated 12/16/21 that stated, Weekly weights due to enteral feeding. Further review of Resident #34's medical record showed the Weights Summary page. The following weeks Resident #34 was not weighed per physician order: No weights obtained for the week of 12/19/21-12/25/2021 No weights obtained for the week of 01/23/22-01/29/22 During an interview on 02/16/22 at 12:40 PM, Administrator stated that the physician order that instructed the weekly weights for eternal feedings for Resident #34 was not followed. .