Future Care Cherrywood

Inspectors wroteBased on review of the medical record it was determined that the facility failed to develop a baseline care plan which included initial goals based on admission orders and the instructions needed to provide effective and person-centered care that met professional standards of quality care. This was evident for 1 (#2) of 3 residents reviewed during a complaint survey.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to ensure advance directives were offered and documented upon admission for 5 (Residents #1, #2, #5, #70, and #159) of 9 residents reviewed.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to ensure that Resident #36 was provided assistance with meals in a manner that promoted dignity and respect. The failure resulted in the resident's meal tray being left unopened at bedside without staff assistance.

Inspectors wroteBased on record review and facility staff interviews, it was determined that the facility failed to notify the court-appointed representative of the resident's discharge and to have that representative involved in discharge planning. This was evident for 1 (Resident #161) out of 1 residents reviewed for court-appointed guardianship.

Inspectors wroteBased on medical record review and interviews with facility staff it was determined the facility staff neglected to provide continence care to a resident who was dependent on staff for assistance. This was found to be evident for 1 (Resident #139) of 5 residents reviewed for Accidents during the facility's survey.

Inspectors wroteBased on staff interviews and record review, it was determined that the facility failed to involve the court-appointed representative in the development of the discharge plan and failed to ensure that the assisted living facility was a licensed facility for safe discharge. This was evident for 1 (Resident #161) out of 1 residents reviewed for safe discharge.

Inspectors wroteBased in staff interviews and record review, it was determined that the facility failed to notify and coordinate with the court-appointed guardian of the resident for discharge proceedings to ensure a safe discharge. This was evident for 1 (Resident #161) out of 1 residents reviewed for safe discharge.

Inspectors wroteBased on observations, medical record review and interviews with facility staff it was determined the facility staff failed to follow professional standards of practice when administering medications to a resident. This was found to be evident during medication administration observation for 1 (Resident # 20) of 49 resident's observed during the survey.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure a resident's dignity, respect, and quality of life by not providing access to a call bell. This deficient practice was evident for 1 (Resident #159) of 10 residents reviewed for dignity concerns.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure nursing staff were licensed, certified, or registered in accordance with applicable State laws. This deficient practice was evident for 1 (Staff #3) of 2 staff reviewed.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to maintain accurate and complete records for residents. This deficient practice was evident for 2 (Residents #139 and #161) of 3 residents reviewed during the facility's recertification survey.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to implement infection prevention and control practices by not ensuring oxygen equipment was dated when placed into use and by not ensuring staff donned appropriate personal protective equipment (PPE) while providing care to a resident on Enhanced Barrier Precautions (EBP). This deficient practice was evident for 2 (Residents #70 and #17) of 30 residents reviewed for infection control practices during the facility's recertification survey.

Inspectors wroteBased on a review of resident medical records and interviews with facility staff, it was determined that the facility failed to 1) hold/document care plan meetings of the interdisciplinary team for residents at the time of the quarterly revision of their care plan, and 2) revise residents' care plan based on their health status. This was evident for 8 (#18, #29, #40, #44, #49, #67, #111, and #115) of 10 residents reviewed for care plan meetings during the annual survey.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to adhere to professional standards for food service safety. This was evidenced by the facility's failure to: 1) seal, label, and properly store food, 2) maintain proper function of the walk-in freezer, 3) monitor refrigerator temperatures, 4) monitor food temperatures, and 5) ensure the removal of expired food supplements. This was evident in the facility kitchen and 2 of 3 unit nourishment rooms observed during the survey. This had the potential to affect all residents.

Inspectors wroteBased on observation, record review and interview, it was determined that the facility failed to develop and implement appropriate, comprehensive, person centered care plans. The care plan was not developed for 3 (Residents #18, #53, and #356), or implemented for 2 (Resident #18 and #67) of 11 residents reviewed during the annual survey.

Inspectors wroteBased on reviews of a clinical record and a facility reported incident (FRI), review of the facility investigation, and interviews with the resident and staff, it was determined that the facility staff failed to treat residents with dignity and respect by not assisting a resident with toileting when requested. This was evident for 1 (Resident #50) of 24 residents reviewed for abuse during the survey.

Inspectors wroteBased on observations and interviews with the facility staff and resident, it was determined the facility failed to ensure that a resident who chooses to go to the 1st floor to eat lunch in the main dining room and attend activities like bingo and music is aided to get prepared and transferred out of bed to a wheelchair for escort assistance. This was evident for 1 (#127) of 4 residents investigated for activities during a Medicare/Medicaid survey.

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to 1) ensure the resident/responsible party was provided information in a manner easily understood by the resident or resident representative to formulate an advanced directive and offered the opportunity to develop an advanced directive, and 2) document/file the resident's advanced directive on their medical record. This was evident for 2 (Resident #40 and #111) of 10 sampled residents for advanced directives, and one resident ( #44) of 10 residents' advanced directive reviewed during the annual survey.

Inspectors wroteBased on observation, interviews, and reviews of the facility administrative records, it was determined that facility staff failed to promote care for a resident in an environment that maintains or enhances each resident's dignity and privacy. This was evident for 2 (Resident #6, #259) of 2 residents observed during the annual recertification survey.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure that resident care areas were in good repair. This was evident for 3 of 33 resident rooms located on the first floor, and 1 of 3 unit nourishment rooms.

Inspectors wroteBased on observation, review of a medical record, and staff interview, it was determined the facility staff failed to obtain a physician's order to use a restraint on a resident. This was evident for 1 (Resident #117) of 2 residents reviewed for physical restraints during an annual recertification survey.

Inspectors wroteBased on reviews of a facility reported incident, reviews of administrative records, and staff interviews, it was determined that 2 GNA staff members failed to immediately notify administrative staff when they observed bruising to a resident's left hand. This was evident for 2 (GNA's #35, #38) of 2 GNA's reviewed for abuse during an annual recertification survey.

Inspectors wroteBased on staff interviews and a review of the facility's self-report investigations, it was determined that the facility failed to thoroughly investigate alleged violations and employee-to-resident abuse. This was evident for 2 (Resident #6 and #18) of 22 facility reported incidents of abuse allegations investigated during the annual survey.

Inspectors wroteBased on a review of a complaint intake, medical record review, and staff interview it was determined that the facility failed to document the bases leading up to a transfer of a resident to the hospital in the medical record including an accurate reason for the transfer. This was evident for 1 (Resident #349) of 5 residents reviewed for hospitalization.

Inspectors wroteBased on medical record review and interview, it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 1(#142) of 5 residents reviewed for hospitalization during the annual survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was identified for 2 (#73 and #349) of 5 residents reviewed for hospitalization during the annual survey.

Inspectors wroteBased on medical record review and interview it was determined the facility failed to notify the resident/resident representative in writing of the bed hold policy upon transfer of a resident to an acute care facility. This was evident for 1 (#142) of 5 residents reviewed for hospitalization during the annual survey.

Inspectors wroteBased on observation, record review, and interviews, it was determined that the facility failed to accurately complete a resident's Minimum Data Set (MDS) assessment. This was evident for 1 (Resident #67) of 2 residents reviewed for position and mobility, and 1 (Resident #97) of 3 residents reviewed for misappropriation of property during this annual survey.

Inspectors wroteBased on record review and interviews it was determined that the facility failed to provide the resident and their representative with a summary of the baseline care plan. This was evident for 1 (Resident #67) of 5 residents reviewed for baseline care plan.

Inspectors wroteBased on a complaint, reviews of active and closed records, and staff interviews, it was determined that the facility staff failed to administer eye medications to a resident as prescribed by the resident's physician. This was evident for 1 (Resident #352) of 13 residents reviewed for quality of care during an annual recertification survey.

Inspectors wroteBased on observation and interviews it was determined that the facility failed to ensure that the resident's environment remained free of accident hazards. This was evident for 1 of 3 unit nourishment areas observed.

Inspectors wroteBased on a complaint, reviews of a medical record, and staff interviews, it was determined that the facility staff failed to 1) ensure follow-up with the pain doctor and 2) ensure documenting pain assessment evidenced by no pain assessment recorded for a resident whose pain noted by a geriatric nurse aide. This was evident for 2 (Resident #44 and #356) of 5 residents reviewed for pain management during the annual survey.

Inspectors wroteBased on medical record review and staff interview it was determined the physician's progress notes were not in the resident medical records the day the resident was seen. This was evident for 1 (#73) of 5 residents reviewed for hospitalization during the annual survey.

Inspectors wroteBased on complaint and reviews of a closed clinical record, it was determined the facility failed to timely provide a medication to meet the needs of a resident. This was evident for 1 (Resident #355) of 14 complaints reviewed during a recertification survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by failing to follow the physician-ordered blood pressure parameters for administration. This was evident for 1 (#29) of 6 residents reviewed for unnecessary drugs during the annual survey.

Inspectors wroteBased on observation, staff interview, and reviews of administrative records, it was determined that facility staff failed to keep medication carts locked when unattended, and keep medications labeled/in their packaging. This was evident for 1 of 3 nursing units observed during the annual recertification survey.

Inspectors wroteBased on medical record review and interview it was determined that facility staff failed to follow up on dental care. This was evident for 1 (resident #44) of 2 residents reviewed for dental during the annual survey.

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to maintain medical records that are complete and accurately documented. This was evident for 1 (Resident #67) of 5 residents reviewed for pressure ulcers.

Inspectors wroteBased on reviews of a facility reported incident, reviews of administrative records, and staff interviews, it was determined that the facility failed to confirm, and agency geriatric nursing assistant (GNA) had received abuse education prior to allowing the agency GNA to work with residents. This was evident for 1 (staff #35) of 2 GNA's reviewed for abuse education during an annual recertification survey.

Inspectors wroteBased on review of medical records and other pertinent documentation and interviews it was determined that the facility failed to ensure that staff immediately reported observations of suspected abuse to the Administrator as evidenced by abuse being observed on three separate occasions by three different staff members prior to it being reported to the Administrator; failed to ensure supervisory staff reported abuse allegations to the Administrator within 2 hours after the allegation was made as evidenced by nursing supervisor waiting more than 8 hours before reporting the allegation to a Unit Nurse Manager (Resident #41); and failed to report allegations of abuse to the state survey agency (Resident #6). This was found to be evident for 2 out of the 38 residents reviewed during the survey. [...]

Inspectors wroteBased on medical record review and interview with the facility staff it was determined that the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the resident's status as evidenced by failure to: 1. assess medication usage and 2. assess the resident's skin condition. This was found to be evident for 1 out of 8 residents (Resident #46) reviewed for pressure ulcers and 1 out 7 residents (Resident #42) reviewed for unnecessary medication during the investigative stage of the survey.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility failed to develop a care plan related to a resident's activities preference/needs. This was evident for 1 out of 5 residents (Resident #122) reviewed for activities.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to have effective systems in place to ensure residents and or responsible parties were included in the development and review of a resident's care plan (Resident #56); and the facility failed to revise care plans related to a residents transition to long term care (Resident #56); significant weight loss (Resident #127 and #122); activity preferences (Resident #131); development of a rash (#108); and a series of falls (Resident #115). This was found to be evident for 6 out of 38 residents reviewed during the investigative portion of the survey.

Inspectors wroteBased on medical record review, interview and observation it was determined that the facility failed to: have an effective system in place to ensure restorative nursing services were put in place after a resident was discharged from therapy (Resident #87 and #122); and to provide adequate assistance to the resident for nutritional intake while providing independence (Resident #57). This was found to be evident for 2 out of 2 residents reviewed for Rehab and Restorative services and 1 out of 4 meal observations.

Inspectors wroteBased on medical record review, observation and interview with facility staff it was determined that the facility failed to provide activities for an individual based on their assessment. This was evident for 3 of 5 residents reviewed for activities (Resident #122, #131 and #41).

Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility staff failed to promote dignity for a resident in a manner and in an environment that maintained or enhanced the resident's dignity and respect by failing to provide privacy for the resident who needed to use a bedside commode. This was found to be true for 1 (Resident #100) out of 1 resident reviewed for dignity.

Inspectors wroteBased on observation, interview with the resident and facility staff it was determined that the facility failed to accommodate the toileting needs of the resident by not accommodating the wheelchair size used by a resident. This was true for 1 out of 4 residents (Resident #100) reviewed for activities of daily living in the investigative stage of the survey.

Inspectors wroteBased on medical record review and interview with staff, it was determined that the facility failed to document and provide showers according to a resident's preference. This was found to be evident for 1 out of 4 residents (Resident #131) reviewed for activities of daily living.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility failed to notify a resident's representative (RP) regarding 1. weight loss and 2. when the residents gastrostomy tube was dislodged. This was evident during the review of 1 of 12 residents (Resident #122) reviewed for nutrition.

Inspectors wroteBased on medical record review and interview with the facility staff, it was determined that the facility failed to provide adequate notification and detailed notice to residents informing them that Medicare may deny payments for procedures or treatments and that residents may be personally responsible for full payment. This was evident in 2 of 3 residents (Resident #148 and #144) reviewed during beneficiary protection notification.

Inspectors wroteBased on review of medical records and other pertinent documentation and interviews it was determined that the facility 1) failed to ensure allegations of abuse were thoroughly investigated by facility staff as evidenced by failure to document a statement from one of three identified eye witnesses. This was found to be evident for 1 out of 7 residents (Resident #41) reviewed for abuse during the survey.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility staff failed to follow the standard of nursing practice in regard to care of a gastrostomy tube. This was evident in the review of 1 of 5 residents for hospitalization. (Resident #122).

Inspectors wroteBased on record review, observations and interviews it was determined that the facility failed to identify environmental hazards and/or assess individual resident risks of an accident, including the need for supervision and/or assistive devices for Resident #115. This was evident for 1 out of 1 investigated for accidents during the survey process.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility failed to identify and modify a residents' diet regimen when a significant weight loss occurred. This was evident during the review of 2 of 10 residents reviewed for nutrition. (Resident #122 and #127)

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to ensure residents were seen by a primary care physician at least once every 30 days for the first 90 days and failed to ensure a resident was seen at least once every 60 days. This was found to be evident for 1 out of 6 resident's (Resident #56) reviewed for unnecessary medications.

Inspectors wroteBased on review of medical records and interview with staff it was determined that the facility failed to ensure sufficient staff to provide restorative nursing services. This was found to be evident during the review of Rehab and Restorative services and has the potential to affect all residents.

Inspectors wroteBased on medical record and employee file review and interviews it was determined that the facility failed to ensure that geriatric nursing assistants (GNA) and nurses demonstrated skills competency prior to being allowed to work independently with residents. This was found to be evident for 1 out of 3 recently hired GNAs (GNA #40) and 1 out of 1 newly hired nurses.

Inspectors wroteBased on clinical records review and interview with the facility staff the facility failed to ensure when a resident was displaying mental adjustment concerns the facility failed to follow up or acknowledge the behavioral health recommendation. This was true for 1 out of 38 (#100) residents reviewed in the investigative stage of the survey.

Inspectors wroteBased on medical record review and interview with staff it was determined that the staff failed to have a system in place to ensure that physician response to the pharmacist recommendations were followed and that pharmacist recommendations was reviewed/addressed by the physicians in a timely manner This was evident for 1 of 7 residents (Resident #100) reviewed for unnecessary medications in the investigative stage of the long term care survey process.

Inspectors wroteBased on medical record review and interviews with facility staff it was determined the facility failed to ensure that a resident was free from unnecessary medications by ensuring that residents who receive psychotropic medications are evaluated every 14 days for continued use. This was found to be evident for 1 (Resident #41) of 5 residents reviewed for unnecessary medications during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to ensure medical records were accurately documented as evidenced by 1) failure of the primary care physician to document the correct code status in the progress notes, 2) failure to ensure physician progress notes were documented in the medical record, and 3) failure to ensure resident assessment information was accurately documented in the physician progress notes. This was found to be evident for 3 out of 38 residents (Resident #56, #96 and #100 ) who had investigations completed during the investigative portion of the survey.

Inspectors wroteBased on completion of a resident council meeting, review of pertinent documentation and interview with facility staff, it was determined that the facility failed to implement an acceptable plan to address resident concerns related to staff failure to answer call bells timely. This was evident secondary to the resident council task.

Inspectors wroteBased on medical record review, observation and interviews with facility staff it was determined the facility failed to adhere to infection control practices and procedures during a dressing change. This was evident for 1 (Resident #41) of 3 residents reviewed for pressure ulcers and failed to use proper hand sanitation between residents on two separate observations of staff passing out lunch trays to residents.

Inspectors wroteBased on observation and interview with staff it was determined that the facility failed to provide privacy to a resident when the resident needed to complete bathing and toileting. This was true for 1 out of 1 resident (#100) reviewed for privacy during the investigation stage of the survey process.

Inspectors wroteBased on observation of the facility's lunch time meal, the facility failed to ensure that residents who were eating in the first floor activity room/dining room were able to all sit together at the main table as there were not enough places for the resident chairs to congregate and have social interaction at meal time. This observation was true for 2 of 4 dining room observations made during the survey and affected residents #75, #124 and #22.

Inspectors wroteBased on review of medical records and other pertinent documentation and interview with staff it was determined that the facility failed to 1. ensure their staff were trained on activities that constitute abuse as well as procedures for reporting incidents of abuse as evidenced by failure of staff to identify inappropriate touching of a dependent resident as abuse and failure of staff to immediately report this abuse to the Administrator once it was identified; 2. to ensure all nursing and geriatric nursing assistant staff received education regarding these specific issues after the educational deficit was identified by administration; and 3. to ensure all nursing staff received annual abuse training (Nurse #18 and GNA #29) . These failures directly affected 1 of 7 residents (#41) reviewed for abuse but has the potential to affect all the residents.