Mountain Laurel Rehabilitation and Nursing

Inspectors wroteBased on staff interviews, clinical record review, and facility document review, and in the course of a complaint investigation, the facility staff failed to protect a resident's right to be free from physical and mental abuse for one (1) of fifty-five (55) sampled residents (Resident #454). The scope and severity were originally cited at Immediate Jeopardy, Level IV isolated, beginning on 8/30/24, and was reduced to a Level III isolated after the facility was cleared of Immediate Jeopardy. The facility staff provided an abatement plan that was verified by the survey team through additional observations, interviews, and document reviews. The facility staff was notified that Immediate Jeopardy was removed on 4/3/25 at 5:30 PM.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to provide treatment and care services in accordance with professional standards of practice for twenty-one (21) of fifty-five (55) sampled residents (Resident #103, Resident #453, Resident #41, Resident #17, Resident #454, Resident #71, Resident #153, Resident #32, Resident #40, Resident #50, Resident #78, Resident #254, Resident #255, Resident #13, Resident #85, Resident #93, Resident #23, Resident #96, Resident #353, Resident #100, and Resident #55). The scope and severity were originally cited at Immediate Jeopardy, Level IV isolated for Resident #103 and Resident #453, beginning on 2/24/25, and was reduced to a Level III isolated after the facility was cleared of Immediate Jeopardy. [...]

Inspectors wrote2. For R454, the facility staff failed to appropriately assess and treat a hospice patient with a history of trauma, by involving the family in the comprehensive admission assessment and administering medications ordered by the provider for paranoia and agitation. R454's diagnoses according to the facility diagnoses sheet, included but were not limited to, other seizures, chronic obstructive pulmonary disease, hypertension, anxiety, heart failure, personal history of suicidal behavior, traumatic brain injury, major depressive disorder, and vascular dementia with psychotic disturbance. R454's minimum data set (MDS) assessment with an assessment reference date of [DATE] assigned the resident a brief interview for mental status score of 11 out of 15 indicating moderate cognitive impairment. [...]

Inspectors wrote2. For Resident #13 the facility staff failed to sent resident to day support program. Resident #13's face sheet listed diagnoses which included spastic quadriplegic cerebral palsy, unspecified intellectual disabilities, and anxiety. Resident #13's most recent minimum data set with an assessment reference date of 02/07/25 assigned the resident a brief interview for mental status score of 15 out o15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #13's comprehensive care plan was reviewed and contained care plans for Resident perceives that daily routine is much different than that of community living, Self-Care Deficit-Total dependent on staff for completion of ADL's (activities of daily living) related to CP (cerebral palsy), functional quadriplegia and intellectual disability and Resident with Level II assessment: Specialized Services: [...]

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to obtain the provider ordered laboratory test urinalysis for 1 of 55 sampled residents, Resident #21. This resulted in Resident #21 being transferred to a higher level of care and being treated in the emergency department with IV (intravenously) fluids and an antibiotic for a urinary tract infection (UTI), dehydration, and altered mental status.

Inspectors wrote2. For Resident #93, the facility staff failed to follow the medical provider order to obtain a chest x-ray (CXR) in a timely manner. Resident #93's diagnosis list indicated diagnoses, which included, but not limited to Cerebral Infarction, Metabolic Encephalopathy, Convulsions, Unspecified Psychosis, Major Depressive Disorder, and Generalized Anxiety Disorder. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 2/15/25 assigned the resident a brief interview for mental status (BIMS) summary score of 11 out of 15 indicating the resident was moderately cognitively impaired. Resident #93's clinical record included a nursing progress note dated 1/05/25 at 1:10 PM which read in part Nurse was notified by CNA [certified nursing assistant] and another nurse that resident appeared to be choking. [...]

Inspectors wroteBased on resident, family and staff interviews, clinical record review and facility document review, the facility staff failed to promptly notify the provider of diagnostic results requiring urgent follow up for 1 of 55 residents in the survey sample, resident # 17 (R17).

Inspectors wroteBased on observations, resident interview, staff interview, and facility document review the facility staff failed to consider the views of the resident group and act promptly upon the grievances and recommendations of the group concerning issues of resident care and life in the facility and the facility staff failed to demonstrate a response to the concerns of the group.

Inspectors wrote6. For Resident #93, the facility staff failed to accurately complete the resident's DDNR (Durable Do Not Resuscitate) Order form. All boxes on the DDNR Order form were left unchecked. Resident #93's diagnosis list indicated diagnoses, which included, but not limited to Cerebral Infarction, Metabolic Encephalopathy, Convulsions, Unspecified Psychosis, Major Depressive Disorder, and Generalized Anxiety Disorder. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 2/15/25 assigned the resident a brief interview for mental status (BIMS) summary score of 11 out of 15 indicating the resident was moderately cognitively impaired. A review of Resident #93's clinical record revealed a medical provider order dated 11/13/24 stating Do NOT Resuscitate. [...]

Inspectors wrote4. The facility staff failed to ensure a comfortable, homelike environment for the residents of the facility by failing to ensure residents have knives included with their meals.

Inspectors wroteBased on staff interview, employee record review, and facility document review, the facility staff failed to implement their policy regarding new hires for 13 of 25 new hires. New hires #1, #2, #3, #6, #11, #12, #13, #15, #18, #19, #22, #23, and #25.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to provide written notification of reasons for transfer and/or discharge to the resident and the resident's representative(s) for four (4) of fifty-five (55) sampled residents, (Resident #63, Resident #103, Resident #455, and Resident #21) and the facility staff failed to provide evidence the ombudsman was notified of transfer and/or discharge for one (1) of fifty-five (55) sampled residents (Resident #455).

Inspectors wrote2. For Resident #63 the facility failed to provide the resident and/or the resident's representative with the facility bed-hold policy upon transfer on 1/10/25. Resident #63's diagnosis list indicated diagnoses that included but were not limited to Cerebral Infarction Affecting Right Dominant Side, Type 2 Diabetes Mellitus, Repeated Falls, Chronic Kidney Disease, Peripheral Vascular Disease, Dementia, Mood Affective Disorder, Depression, Anxiety, Restlessness and Agitation, and Acute Respiratory Failure with Hypoxia. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 1/17/25, assigned the resident a brief interview for mental status (BIMS) summary score of 6 out of 15 for cognitive abilities, indicating the resident was severely impaired in cognition. A review of the clinical record indicated Resident #63 was transferred to the hospital on 1/10/25. [...]

Inspectors wrote7. For Resident #23, the facility staff failed to provide the resident and/or resident representative with a summary of the baseline care plan. Resident 23's diagnosis list indicated diagnoses, which included, but not limited to Sepsis, Metabolic Encephalopathy, Urinary Tract Infection, Obstructive and Reflux Uropathy, and Parkinson's Disease. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 3/08/25 assigned the resident a brief interview for mental status (BIMS) summary score of 7 out of 15 indicating the resident was severely cognitively impaired. Resident #23's clinical record included a baseline care plan dated 3/03/25. A checkmark was placed by the statement I have a copy of the Baseline Care Plan, it has been reviewed with me, I understand my plan of care, and I have had the opportunity to add or modify my plan of care. [...]

Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to develop and/or revise the comprehensive person-centered care plan to meet the resident's needs for 5 of 55 sampled residents (Residents #454, 17, 65, 96 and Resident #40). 1. For resident #454 (R454), the facility staff failed to update the comprehensive care plan to reflect the resident's pertinent mental health history and diagnoses, failed to develop individualized person-centered interventions and failed to follow the care plan, specifically to administer medications that were ordered as a result of behaviors. [...]

Inspectors wrote5. The facility staff failed to follow professional standards of practice related to Resident #153's duplicate allopurinol medication orders. (Allopurinol is a medication ordered orally for Resident #153 to address gout.) Resident #153's admission minimum data set (MDS) assessment was not due and had yet to be submitted prior to the surveyor's review of the resident's clinical record. A medical provider assessment indicated Resident #153 was alert and oriented times three (3). Resident #153 was documented as having adequate vision. Resident #153's hearing was documented as being grossly intact. Resident #153's clinical documentation included two (2) orders for allopurinol 100mg one (1) tablet by mouth once a day for gout. The first allopurinol order was ordered on 3/26/25 at 5:56 p.m.; the medical provider signed this order on 3/31/25 at 2:43 p.m. [...]

Inspectors wrote4. For Resident #454 the facility staff failed to ensure the resident was offered a full bed bath/shower at least twice a week. Resident #454's diagnosis list indicated diagnoses that included, but were not limited to, Atrial Fibrillation, Glaucoma, Seizures, Hypertension, Chronic Obstructive Pulmonary Disease, History of Falls, Dementia with Agitation, Depression, Anxiety Disorder, Heart Failure, Vascular Dementia-severe with Psychotic Disturbance, Traumatic Brain Injury, History of Suicidal Behavior, and Thyrotoxicosis. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 8/28/24, assigned the resident a brief interview for mental status (BIMS) summary score of 11 out of 15 for cognitive abilities, indicating the resident was moderately impaired in cognition. [...]

Inspectors wrote2. For Residents #6, #21, #32, #34, and #50 Licensed Practical Nurse (LPN) #15 documented they were unable to complete provider orders due to increased patient load. A review of Resident #21's clinical record revealed that on 02/19/25 at 7:41 p.m. LPN #15 documented they were unable to complete due to increased patient load. This note did not reference what the nursing staff was not able to complete and during the clinical record review the surveyor was unable to find any medication and/or treatment that had been coded as being incomplete. This note type was identified in the clinical record as being a medication administration note. Resident #21 was not interviewable. On 04/07/25 at 9:34 a.m., the surveyor requested the facility census and work assignment for this nurse for 02/19/25. [...]

Inspectors wrote3. For Resident #9, the facility staff failed to obtain PT/INR (prothrombin time with international normalized ratio) laboratory testing as ordered by the medical provider on three (3) separate occasions. A PT/INR test measures how long it takes for blood to form a clot and is used to monitor blood-thinner treatment (anticoagulant) medications. Resident #9's diagnosis list indicated diagnoses, which included, but not limited to Chronic Atrial Fibrillation, Displaced Fracture of the Right Femur, and Osteoarthritis. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 3/04/25 assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 indicating the resident was cognitively intact. [...]

Inspectors wroteBased on observations, staff interviews, and facility document review, the facility staff failed to: (a) store food in accordance with professional standards for food service safety and (b) failed to serve food according to menu serving size.

Inspectors wroteBased on observations and staff interviews, the facility staff failed to ensure proper disposal and/or containment of the facility's garbage/waste.

Inspectors wrote2. For Resident #453, the facility staff failed to maintain an accurately documented clinical record by inaccurately documenting a left hip x-ray was completed on 3/9/25. Resident #453's diagnosis list indicated diagnoses that included, but were not limited to, Hypertension, Atrial Fibrillation, Diverticulosis, Macular Degeneration, Unsteadiness on Feet, Depression, Difficulty Walking, Weakness, Polyosteoarthritis, Dementia, Alzheimer's, Chronic Kidney Disease-Stage 2, and Nightmare Disorder. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 2/19/25, assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating the resident was cognitively intact. [...]

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to ensure a Quality Assurance and Performance Improvement (QAPI) Program to meet the needs of the facility and failed to monitor and revise as needed the plan of corrections for the standard recertification and abbreviated surveys dated 7/01/21 through 1/23/25, in order to maintain compliance as evidenced by repeated deficiencies in the areas of Quality of Care, Pharmacy Services, Food and Nutrition Services, and Infection Control.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide quality assurance and performance improvement (QAPI) training to the facility staff.

Inspectors wroteBased on observation, staff interview, and resident interview the facility staff failed to treat resident with dignity and respect for 1 of 55 residents, Resident #1.

Inspectors wroteBased on staff interview, clinical record review and facility document review, the facility staff failed to notify the physician of a significant change in condition for 1 of 55 residents in the survey sample, resident # 74 (R74).

Inspectors wroteBased on observation, staff interview, resident interview, and clinical record review the facility staff failed to ensure personal privacy during activities of daily living care for 1 of 55 residents, Resident #1.

Inspectors wroteBased on interview, record review and facility document review the facility staff failed to permit each resident to remain in the facility and not transfer or discharge the resident for one of 14 residents in the survey sample, resident # 454 (R454). R454's diagnoses according to the facility diagnoses sheet, included but were not limited to, other seizures, chronic obstructive pulmonary disease, hypertension, anxiety, heart failure, personal history of suicidal behavior, traumatic brain injury, major depressive disorder, and vascular dementia with psychotic disturbance. R454's minimum data set (MDS) assessment with an assessment reference date of 8/28/24 assigned the resident a brief interview for mental status score of 11 out of 15 indicating moderate cognitive impairment. [...]

Inspectors wroteBased on staff interviews, clinical record review, and facility document review, the facility staff failed to ensure a resident's medication needs were addressed as part of admission orders for one (1) of 55 sampled residents (Resident #153).

Inspectors wrote2. For Resident #93, the facility staff incorrectly coded the 2/15/25 minimum data set (MDS) assessment for the use of anticoagulant medication. Resident #93's diagnosis list indicated diagnoses, which included, but not limited to Cerebral Infarction, Metabolic Encephalopathy, Convulsions, Unspecified Psychosis, Major Depressive Disorder, and Generalized Anxiety Disorder. The most recent MDS with an assessment reference date (ARD) of 2/15/25 assigned the resident a brief interview for mental status (BIMS) summary score of 11 out of 15 indicating the resident was moderately cognitively impaired. The 2/15/25 MDS coded Resident #93 as taking an anticoagulant medication during the last seven (7) days. Surveyor reviewed Resident #93's clinical record and was unable to locate evidence of the resident receiving an anticoagulant medication during the seven-day period prior to the 2/15/25 MDS. [...]

Inspectors wrote2. For Resident #93, the facility staff failed to ensure a Level I Preadmission Screening and Resident Review (PASARR) was completed. Resident #93's diagnosis list indicated diagnoses, which included, but not limited to Cerebral Infarction, Metabolic Encephalopathy, Convulsions, Unspecified Psychosis, Major Depressive Disorder, and Generalized Anxiety Disorder. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 2/15/25 assigned the resident a brief interview for mental status (BIMS) summary score of 11 out of 15 indicating the resident was moderately cognitively impaired. The MDS was coded for the presence of delusions and wandering behavior. Surveyor reviewed Resident #93's clinical record and was unable to locate a Level I PASARR. Resident #93 had resided at the facility for approximately five (5) months. [...]

Inspectors wroteBased on interview, record review and facility document review, the facility staff failed to complete a discharge summary including a recapitulation of resident's stay and final summary of resident's status, to the continuing care provider and other authorized persons at the time of discharge for one of 14 residents reviewed, resident # 454 (R454).

Inspectors wroteBased on staff interview and clinical record review the facility staff failed to provide an on-going person-centered activity program to support resident choice, interests, and physical, mental and psychosocial well-being for 1 of 55 residents in the survey sample, resident #454 (R454)

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility nursing staff failed to complete a provider ordered treatment to a pressure ulcer for 1 of 55 sampled residents, Resident #34.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review the facility staff failed to ensure resident environment remains free of accident hazards and failed to provide adequate supervision to prevent accident for 1 of 55 residents, Resident #36. The findings of included: For Resident #36 the facility staff failed to provide an environment free of accident hazards and failed to provide adequate supervision to prevent accidents. Resident #36's face sheet listed diagnoses which included but not limited to suicidal ideations, major depressive disorder, and bipolar disorder, severe, with psychotic features. Resident #36's most recent minimum data set with an assessment reference of 02/04/25 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. [...]

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to provide a therapeutic diet to one (1) of fifty-five (55) sampled residents, (Resident #454). For Resident #454, the facility staff failed to provide evidence the resident received or refused a therapeutic diet as ordered by the medical provider during evening meals on 8/21/24, 9/9/24, and 9/10/24. Resident #454's diagnosis list indicated diagnoses that included, but were not limited to, Atrial Fibrillation, Glaucoma, Seizures, Hypertension, Chronic Obstructive Pulmonary Disease, History of Falls, Dementia with Agitation, Depression, Anxiety Disorder, Heart Failure, Vascular Dementia-severe with Psychotic Disturbance, Traumatic Brain Injury, History of Suicidal Behavior, and Thyrotoxicosis. [...]

Inspectors wroteBased on staff interviews and clinical record review, the facility staff failed to provide ordered respiratory care and/or treatments for two (2) of 55 sampled residents (Resident #90 and Resident #100).

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to coordinate care with the dialysis center for 1 of 1 dialysis residents in the survey sample. Resident #255.

Inspectors wroteBased on staff interviews and clinical document review, the facility's medical providers failed to ensure resident's orders addressed the resident needs for two (2) of 55 residents (Resident #90 and Resident #153).

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to review the resident's total program of care, including medications and treatments for one (1) of fifty-five (55) sampled residents (Resident #77).

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility document review the facility staff failed to provide the necessary health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 of 55 residents in the survey sample, resident # 454.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to ensure medical provider ordered medications were available for administration for 3 of 55 sampled residents (Resident #354, Resident #356, and Resident #9).

Inspectors wrote2. For Resident #86 the facility staff failed to provide evidence of the 2/24/25 medication regimen review being reported to and acted upon by the medical provider in a timely manner. Resident #86's diagnosis list indicated diagnoses that included but were not limited to Progressive Multifocal Leukoencephalopathy, Anorexia, Chronic Kidney Disease, Acute Kidney Failure, Anxiety Disorder, Repeated Falls, Ataxia, Acute Respiratory Failure with Hypoxia, and Wasting Disease Syndrome. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 3/23/25, did not assign the resident a brief interview for mental status (BIMS) summary score for cognitive abilities, but a review of the clinical record revealed resident was assigned 15 out of 15 on the BIMs, which indicated the resident was cognitively intact. [...]

Inspectors wroteBased on staff interview, clinical record review and facility document review the facility staff failed to ensure that 1 of 55 residents was free from unnecessary medications, Resident #85.

Inspectors wroteBased on staff interview, clinical record review and facility document review, the facility staff failed to ensure (2) two of fifty-five (55) sampled residents were free from unnecessary psychotropic medications (Resident #455 and Resident #86).

Inspectors wroteBased on observation, staff interview, clinical record review the facility staff failed to ensure a medication error rate of less than 5%. There were two (2) medication errors in 28 opportunities for a medication error rate of 7.14%. These medication errors affected Resident #253 (R253).

Inspectors wroteBased on clinical record review and facility document review, the facility staff failed to ensure that residents are free of any significant medication errors for (1) one of fifty-five (55) sampled residents (Resident #86).

Inspectors wroteBased on observation and staff interview, the facility staff failed to dispose of expired medications and/or biological's in 1 of 2 medication rooms, the [NAME] side medication room.

Inspectors wroteBased on staff interview, resident interview, clinical record review and facility document review the facility staff obtained laboratory test without a physician's order for 1 of 55 residents, Resident #85.

Inspectors wroteBased on observation, staff interview, resident interview, clinical record review and facility document review the facility staff failed to provide food to accommodate the resident's preferences for 1 of 55 residents, Resident #1.

Inspectors wroteBased on family interview, staff interview, clinical record review, and facility document review the facility staff failed to ensure the timeliness of radiology services furnished by an agency outside the facility under an arrangement for (1) one of fifty-five (55) sampled residents (Resident #453).

Inspectors wroteBased on staff interviews and clinical record review, the facility staff failed to obtain the Medical Director's assistance when having trouble scheduling a surgical consult/appointment for one (1) of 55 sampled residents (Resident #55).

Inspectors wroteBased on staff interview, clinical record review and facility document review, the facility staff failed to meet the requirements set forth in the Nursing Facility Services Agreement to designate a member of the nursing home's interdisciplinary team to coordinate care with the hospice provider for 1 of 55 residents in the survey sample, resident 454 (R454).

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review the facility staff failed to follow established infection control guidelines for 1 of 55 residents, Resident #13.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to offer a pneumococcal vaccine in accordance with nationally recognized standards for 2 of 5 residents reviewed for immunizations, Resident #47, and Resident #68.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to post the nurse staffing information daily.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to provide pain management to residents consistent according to professional standards of practice, and the medical provider orders for 1 of 17 sampled residents (Resident #1).

Inspectors wroteBased on observation, staff interview and facility document review the facility staff failed to ensure resident call bells were accessible to residents on 1 of 3 halls on [NAME] unit of the facility.

Inspectors wroteBased on observation, staff interview, and facility document review the facility staff failed to ensure a safe, clean, comfortable, and homelike environment for 1 of 3 halls on the [NAME] wing of the facility.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure residents receive treatment and care in accordance with the comprehensive person-centered care plan and medical provider orders for 1 of 9 sampled residents, Resident #104.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure medical provider ordered medications were available for administration for 1 of 9 sampled residents, Resident #103.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to ensure residents were free of significant medication errors for 1 of 17 sampled residents (Resident #10).

Inspectors wroteBased on observation, staff interview, and facility document review the facility staff failed to follow facility established infection control procedures for 3 of 17 residents, Resident #5, Resident #16, and Resident #17.

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to complete a review of every nurse aide at least every 12 months and failed to provide regular in-service education based on the outcome of these reviews.

Inspectors wroteBased on staff interviews and clinical record review the facility staff failed to maintain a complete medical record on each resident for all residents with a medical regimen review without recommendations and also for two of 29 residents in the survey sample. 1. While conducting medication regimen reviews, surveyors were unable to locate routine monthly medication regimen reviews after December 2022. Some residents had documented recommendations. No regimen reviews without recommendations were recorded in the clinical records. Surveyors asked nursing staff where medication regimen reviews without recommendations were documented. The pharmacy was changed in January 2023. The current pharmacy sends an e-mail to the director of nursing with the list of residents reviewed and recommendations. The recommendations are placed in the clinical record after the physician acts on them. [...]

Inspectors wroteBased on staff interview and facility document review, the facility staff failed to provide 12 hours of in-service training for nurse aides.

Inspectors wroteBased on staff interviews and facility document reviews the facility staff failed to prevent misappropriation of resident funds for 7 residents residing at the facility at the time of the incident.

Inspectors wroteBased on observation, staff interview, resident interview, family interview, clinical record review, and facility document review, the facility staff failed to provide activity of daily living (ADL's) care for 2 of 29 dependent care residents, Resident #44 and #71.

Inspectors wroteBased on clinical record review, facility document review, and staff interview, the facility staff failed to provide care and services as ordered for 3 of 29 residents records reviewed. (Res #359, #44, #71)

Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility staff failed to anchor an indwelling foley catheter for 1 of 29 residents, Resident #85.

Inspectors wroteBased on staff interview, clinical record review the facility staff failed to remove an IV access per policy for 1 of 29 sampled residents. (Resident #209). Resident #209 was admitted to the facility with multiple diagnoses including encephalopathy, diabetes mellitus, morbid obesity, hypertension, dysphagia, atherosclerotic heart disease, chronic obstructive pulmonary disease, sepsis, cerebral infarction, and heart failure. On the Minimum Data Set assessment with assessment reference date 5/4/2022, the resident scored 3/15 on the brief interview for mental status, indicating the resident had impaired cognitive function. Clinical record review revealed a physician order dated 5/5/2022 for Sodium chloride 0.9% use 1 liter one time only for dehydration for 1 day 300 ml (milliliter) bolus then run at 125 ml per hour until complete. A nursing Health Status Note dated 5/5/2022 at 18:51: [...]

Inspectors wroteBased on clinical record review, facility document review, and staff interview the facility staff failed to ensure medical supervision of care for 1 of 29 residents review. (Res #96)

Inspectors wroteBased on staff interview and facility document review the facility staff failed to ensure licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Inspectors wroteBased on staff interviews and facility document review the facility staff failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for one staff member employed by the facility.

Inspectors wroteBased on staff interview and [NAME] Report review, the facility staff failed to electronically submit staffing information to The Centers for Medicare & Medicaid Services (CMS) for 2 quarters.

Inspectors wroteBased on observation and staff interview the facility staff failed to meet safety requirements by storing food that reflected expired use by dates and boxes of unfrozen ice cream.

Inspectors wroteBased on staff interview, clinical record review, facility document review, and during a medication pass and pour observation, the facility staff failed to ensure the residents receive treatment and care in accordance with the comprehensive person-centered care plan for 5 of 28 residents in the survey sample, Residents #58, #49, #57, #61, and #9.

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review the facility staff failed to ensure an effective infection control program for 3 of 28 residents (Resident #57, Resident #75, and Resident #58) and 1 of 2 units.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure the resident's right to formulate an advanced directive by failing to complete a DDNR (durable do not resuscitate) order form for 1 of 28 residents in the survey sample, Resident #79.

Inspectors wroteBased on staff interview, facility document review and clinical record review the facility staff failed to notify the facility physician of a change in condition for 1 of 28 residents, Resident #57.

Inspectors wroteBased on observation and staff interview, facility staff failed to provide for confidentiality of personal and medical records by not securing resident identifiable information on one of six resident care halls. On 07/01/21 at 2:10 PM, the surveyor walked up to the medication cart on the 400 hall. The laptop was open to a resident's file, a clipboard with the resident names and room numbers and notes was face up on the medication cart, and reorder stickers were on the border of the display. The nurse came out of a resident room and stated she had been trying to draw some blood before 2 PM. When asked about resident information being visible, the nurse apologized and covered the information. The surveyor notified the administrator and director of nursing of the concern during a summary meeting on 7/1/2021.

Inspectors wrote2. For Resident #79, the facility staff failed to initiate treatment to a DTI (deep tissue injury) to the right heel on admission on [DATE]. Resident #79's diagnosis list indicated diagnoses, which included, but not limited to Acute Respiratory Failure with Hypoxia, Vascular Dementia without Behavioral Disturbance, Unspecified Atrial Fibrillation, Chronic Obstructive Pulmonary Disease Unspecified, and Chronic Kidney Disease Stage 3 Unspecified. The most recent admission MDS (minimum data set) with an ARD (assessment reference date) of 6/07/21 coded the resident as being moderately impaired in cognitive skills for daily decision making with short-time and long-term memory loss in section C, Cognitive Patterns. The resident was unable to complete the BIMS (brief interview for mental status) interview. [...]

Inspectors wroteBased on observation, staff interview, and clinical record review, facility staff failed to offer the therapeutic diet indicated by the speech therapy assessment for 1 of 28 residents in the survey sample (Resident #203). Resident #203 was admitted to the facility with diagnoses including cerebral infarction, essential thrombocytopenia, pneumonia, atherosclerotic heart disease, acute kidney failure, dysphagia, oropharyngeal phase, hypertension, and hemiplegia. The resident did not have a minimum data set assessment on file. On 6/29/ 2021, the resident reported that being unable to feed self due to inability to move arms. The resident's tray had a pureed diet, set up by staff. The surveyor asked the nurse if someone would help the resident and the nurse said the resident could use one arm to self feed. The resident was absent from the building on 6/30/21 from 7:30 AM to late evening. [...]

Inspectors wroteBased on observation, interviews, and clinical record review, the facility staff failed to provide pharmaceutical services by obtaining physician ordered medications for 2 of 28 residents in the survey sample (Resident #2 and #33) and failed to ensure a medication was ingested prior to leaving the resident's room for 1 of 28 residents in the survey sample (Resident #11). 1. For Resident #2, the facility staff failed to ensure the medication Briviact (an anticonvulsant drug used to treat partial-onset seizures) was available for administration. Resident #2's diagnosis list indicated diagnoses, which included, but not limited to Epilepsy Unspecified Not Intractable without Status Epilepticus, Urinary Tract Infection Site Unspecified, Schizoaffective Disorder Depressive Type, Type 2 Diabetes Mellitus without Complications, Heart Failure Unspecified, and Bipolar Disorder. [...]

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to ensure that residents were free of significant medication errors for 2 of 28 residents in the survey sample, Residents #49 and #5. 1. For Resident #49, the facility staff failed to follow physician's orders for the administration of Novolog (a rapid-acting insulin) on five separate occasions. Resident #49's diagnosis list indicated diagnoses, which included, but not limited to Type 2 Diabetes Mellitus without Complications, Cerebral Palsy Unspecified, Unspecified Dementia without Behavioral Disturbance, Schizophrenia Unspecified, and Barrett's Esophagus without Dysplasia. [...]

Inspectors wroteBased on interviews and the review of documents, it was determined the facility staff failed to assess pneumococcal immunization status and/or address pneumococcal immunization needs for two (2) of five (5) residents sampled for immunization review (Resident #17 and Resident #70).