The Woods, A Nightingale Community

Based on observations, interviews, record review, and facility policy review the facility failed to ensure staff provided proper incontinence care to 1 (Resident #6) sampled resident. The findings include: A review of the significant change Minimum Data Set (MDS) with the Assessment Reference Date of 8/31/2024 revealed Resident #6 had a Brief Interview of Mental Status (BIMS) score of 10, indicating moderate cognitive impairment, and indicated the resident was incontinent of bowel and bladder. A plan of care for Resident #6 (revision date: 9/02/2024) revealed Resident #6 had bowel and bladder incontinence related to disease process and used adult disposable briefs. On 9/25/2024 at 2:00 PM, the Surveyor observed Certified Nursing Assistant (CNA) #4 improperly clean Resident #6. The resident had experienced an incontinence episode, and when CNA #4 cleaned the resident's genital region with wipes, the CNA wiped back to front, a practice that can spread germs and cause urinary tract infections. CNA #4 did not completely clean the resident's genital area. The surveyor observed that…

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

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure staff used proper hand hygiene while providing care to 1 (Resident #6) sampled resident. The findings include: A review of the significant change Minimum Data Set (MDS) with the Assessment Reference Date of 8/31/2024 revealed Resident #6 had a Brief Interview of Mental Status (BIMS) score of 10 indicating moderate cognitive impairment and was always incontinent of bowel and bladder. A plan of care for Resident #6 (revision date: 9/02/2024) revealed Resident #6 had bowel and bladder incontinence related to disease process and used adult disposable briefs. On 9/25/2024 at 2:00 PM, the Surveyor observed Certified Nursing Assistant (CNA) #4 touch objects in the room such as the bedside drawer with dirty gloved hands while providing care to Resident #6. On 9/25/2024 at 2:12 PM, CNA #4 stated she had touched the handles on drawer and privacy curtains with dirty gloved hands. On 09/26/24 at 1:15 PM, the Director of Nursing (DON) stated the staff member contaminated the items touched…

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

Based on interviews and record review, it was determined the facility failed to notify the State of Long Term-Care Ombudsman in writing of a transfer to the hospital for 1 resident (Resident #1) reviewed for hospitalization. Findings include: A review of a facility policy titled: Transfer and Discharge dated 09/26/24 at 11:10 AM provided by Administrator indicated, .The nursing facility shall send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. On 09/26/24 the Administrator was asked to provide proof that the State Ombudsman had been notified of Resident #1 hospitalizations. A review of the Census tab for Resident #1's electronic health record indicated the resident was sent to the hospital four times between the dates 05/23/2024 and 09/05/2024. On 09/26/24 at 12:10 PM, the Administrator reported she was having trouble getting into Assistant Director of Nursing's computer to locate notifications sent to State Ombudsman. On 09/26/24 at 1:40 PM, Director of Nursing reported the Administrator was working on getting the transfer/discharge…

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 ensure an assistive communication device was utilized to facilitate communication between a resident and staff for 1 (Resident #3) sampled resident who required an assistive communication device. The findings are: Resident #3's Medical Diagnosis record was reviewed and indicated diagnoses of an opening in the neck and into the windpipe tracheostomy) an opening in the neck that assists with breathing and abnormal cells in the throat (carcinoma in situ of pharynx). A quarterly Minimum Data Set with an Assessment Reference Date of 07/21/2024 was reviewed and indicated Resident #3 had a Brief Interview for Mental Status score of 13, which indicated the resident was cognitively intact, and had a tracheostomy. Resident #3's plan of care, dated 08/07/2024, was reviewed and indicated the resident had a communication problem and required a [brand name] valve to assist with communication. Staff were to ensure the device was available and functioning. On 09/26/2024 at 9:01 AM, Resident #3 was lying in bed with eyes…

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, interview, and record review, the facility failed to ensure the enteral feed and flush was administered at the physician's ordered rate for 1 (Resident #3) sampled resident who received enteral nutrition and water through a Percutaneous Endoscopic Gastrostomy (PEG) tube. The findings are: Resident #3 's medical diagnosis screen was reviewed and indicated the resident had a diagnosis of difficulty swallowing (dysphagia) and an opening into the stomach wall (gastrostomy status). A quarterly Minimum Data Set with an Assessment Reference Date of 07/21/2024, was reviewed and indicated Resident #3 had a Brief Interview for Mental Status score of 13, which indicated cognitively intact and had a feeding tube. Resident #3's Order Summary Report was reviewed and indicated a physician's order, dated 09/13/2024, for [brand name] enteral feed to be administered at 53 milliliters per hour (ml/hr.) and flush at 40 ml every 1 hour. On 09/25/2024 at 9:01 AM, Resident #3 was observed lying in bed, awake with the head of bed up. The feeding pump displayed feed 43 ml/hr and flush…

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 interview, the facility failed to ensure expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen; foods stored in the refrigerator and dry storage area were covered and sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; foods were dated when opened to assure first in, first out usage to prevent potential for food bone illness, cooking equipment, ceiling tiles and air vents were free of greasy food crumbs, stains and rust and were maintained in clean sanitary conditions to prevent potential for cross contamination; dietary staff. washed their hands before handling clean. equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to 69 affect residents who received. meals from the kitchen, (total census: 72). The findings are: 1. On 04/01/2024 at 11:15 AM, the Surveyor observed two 32-ounce boxes of half 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 observation, interview, and record review, the facility failed to ensure meals were served in a method that maintained the appearance of cold products and at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during meals observed. This failed practice had the potential to affect 6 residents who receive meal trays in their rooms on the East Hall, 6 residents who receive meal trays on the North Hall, and 12 residents who receive meal trays in their room on the South hall. The findings are: 1. On 04/01/2024 at 03:32 PM, during an interview, Resident #55 was asked about the food here and the resident stated the temperature was lukewarm by the time it was delivered to the resident's room and if the resident eats in the dining room, the food is hot. 2. On 04/01/2024 at 08:13 AM, during observation, an unheated food cart that contained 8 trays for lunch was delivered to the front hall by Certified Nursing Assistant (CNA) #1. At 08:27 AM, immediately after the last resident was served in their room on the front hall,…

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, interview and record review, the facility failed to ensure fingernails were clean, smooth, and trimmed to promote good personal hygiene and grooming for 1 (Resident #49) sampled resident who required staff assistance for nail care. The findings are: 1. Review of the March 2024 Order Summary noted Resident #49 had a diagnosis of Type 2 diabetes, Dementia, and Presbyopia (eyes inability to focus on nearby objects). a. Review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/08/2024 documented Resident #49 had a Brief Interview for Mental Status (BIMS) score of 03 (00-07 indicates severe cognitive impairment). b. Review of a Care plan revised on 11/08/2023 documented Resident #49 had an ADL [activities of daily living] self-care performance deficit and required limited assistance of one staff member with bathing and personal hygiene. c. Review of the ADL-Bathing sheets documented Resident #49 received physical help in part of the bathing activity on 03/20/2024, 03/22/2024, 03/25/2024, 03/27/2024, 04/01/2024 and 04/23/2024. d.…

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, interview, and record review, the facility failed to ensure a raised toilet seat and outer toilet bowl was cleansed of a dark brown substance to promote a clean and sanitary environment for 1 (Resident #173) of 1 sampled resident who used the bathroom in their room. The findings are: 1. Resident #173 had diagnoses of Legal blindness (small amount of useful vision) and Morbid obesity (more than 80 to 100 pounds over your ideal body weight). a. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/06/2024 documented Resident #173 had a Brief Interview for Mental Status (BIMS) score of 11 (08-12 indicates moderately cognitive impaired) and required set-up or clean-up assistance with toileting hygiene. b. Review of the Care Plan with a review date of 12/26/2023 documented Resident #173 had an ADL (activities of daily living) self-care performance deficit and required assistance of staff for personal hygiene. c. Review of the Nurses Note dated 03/29/2024 at 07:04 (7:04 AM) documented, .Resident sleeping up in recliner with feet…

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 interview, the facility failed to ensure the oven was maintained in good working condition; employees washed their hands and changed gloves when contaminated to decrease the potential for food borne illness for residents receiving food from 1 of 1 kitchen, ensure refrigerator temperatures were maintained at 41 degrees Fahrenheit or below to prevent the potential for food spoilage and/or bacteria growth for residents who received food from 1 of 1 kitchen. The failed practices had the potential to affect 63 residents who received meal trays from the kitchen (total census: 67) as identified on the list provided by the Dietary Supervisor on 03/28/23 at 2:50 PM. The findings are: 1. On 03/27/23 at 11:00 AM, the Dietary Supervisor placed three pans of chicken in the oven and stated, We only have one side of the oven working. The Surveyor asked how long it had been going on. The Dietary Supervisor stated, It has been going on since after the last survey. The first resident received their lunch tray in the Dining Room at 1:04 PM. It took 2 hours and 4 minutes 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 record review, and interview, the facility failed to inform residents, their representatives, and families, of suspected or confirmed COVID-19 cases in the facility by 5:00 PM the next day. This failed practice had the potential to affect all 68 residents in the facility as documented on the Resident Census and Conditions of Residents provided by the Clinical Consultant on 03/27/23 at 1:48 PM. The findings are: 1. The Center for Clinical Standards and Quality/Quality, Safety & Oversight Group (QSO-20-29-NH) Memorandum for Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes dated 05/06/20 documented, .The facility must: Inform residents, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other . 2. Resident #51 had a diagnosis of Heart Failure and COVID-19. The admission Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure residents or resident representatives were supplied the information, and provided the opportunity, to file an appeal for skilled therapy services when Medicare Part A services ended for 2 (Residents #66 and #67) of 3 (Residents #66, #67 and #68) sampled residents. The failed practice had the potential to affect 68 residents whose Medicare Part A services ended since the facility's last recertification as documented on a list provided by the Administrator on 03/29/23 at 1:46 PM. The findings are: 1. Resident #66 had diagnoses of Anxiety, Diabetes Type II, and Alzheimer's. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/24/22 documented the resident scored 8 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS). a. The Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form dated 09/12/22 provided by the Director of Nursing (DON) on 03/28/23 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded for 1 (Resident #43) of 2 (Residents #6 and #43) sampled residents who received tube feedings and 1 (Resident #70) of 1 closed record sampled resident who was discharged home. The findings are: 1. Resident #43 had diagnoses of Cerebral Palsy, Muscular Dystrophy and Severe Intellectual Disabilities. The Quarterly MDSs with an Assessment Reference Dates (ARD) of 11/22/22 and 02/21/23 documented the resident was severely impaired in cognitive skills for daily decision-making per a Staff Assessment of Mental Status (SAMS) and the resident activity of eating did not occur. a. The Care Plan with a revision date of 01/10/23 documented, .has an ADL [Activities of Daily Living] self-care deficit .has little or no activity involvement r/t [related to] MR [Mental Retardation], Physical Limitations, need for total care with ADL's .Eating NPO [nothing by mouth] totally dependent on staff for nutrition…

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 ensure facial hair was removed to promote dignity and good grooming for 2 (Residents #6 and #47) and failed to ensure fingernails were clean, filed, and trimmed for 2 (Residents #2 and #19) of 24 (Residents #1, #2, #6, #9, #19, #22, #24, #28, #31 ,#38, #40, #41, #43, #45, #47, #48, #49, #50, #51, #54, #55, #61, #218 and #266) sampled residents who required assistance with shaving and nail care as documented on a list provided by the Administrator on 03/29/23 at 1:46 PM. The findings are: 1. Resident #6 had a diagnosis of Hemiplegia and Hemiparesis following Unspecified Cerebrovascular Disease affecting Right Dominant Side. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/02/23 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and was totally dependent on two plus persons with personal hygiene and one person with bathing. a. The Care Plan with a revision date of 08/12/22 documented, .has an ADL [activities of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Surveyor: Rather, [NAME] Based on observation, record review, and interview, the facility failed to obtain Physician Orders for oxygen therapy for 1 (Resident #28) and failed to ensure oxygen was administered at the flow rate ordered by the physician to prevent potential hypoxia or other respiratory complications for 1 (Resident #31) of 7 (Residents #1, #6, #13, #19, #28, #31 and #39) sampled residents who received oxygen therapy as documented on a list provided by the Director of Nursing (DON) on 03/29/23 at 10:00 AM. The findings are: 1. Resident #28 had a diagnosis of Pneumonia. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/12/23 documented the resident scored 4 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and did not receive oxygen therapy. a. The Care Plan with a revision date of 01/24/23 documented, .has altered respiratory status/difficulty breathing r/t [related to] abnormal breath sounds . Administer medication/treatment as…

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 ensure the appropriate use of Personal Protective Equipment (PPE) and Isolation Protocols for Transmission Based Precautions for COVID-19 to prevent the spread of infection. This failed practice had the potential to affect all 67 residents in the facility as documented on the Resident Census and Conditions of Residents provided by the Clinical Consultant on 03/27/23 at 10:46 AM. The findings are: 1. Resident #51 had diagnoses of Heart Failure and COVID-19. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/10/23 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS). a. A Progress Note dated 03/21/23 documented, .had an elevated temp of 100.6, cough, and c/o [complained of] sore throat, notified the DON [Director of Nursing] of these findings and given instructions to obtain flu and covid swabs in which res [resident] was negative for flu and positive for Covid . b. A Physician's Order dated 03/21/23…

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

Based on record review, and interview, the facility failed to ensure the Infection Preventionist had adequate time to perform the duties of the position and to adequately monitor and manage the Infection Prevention and Control Program, as evidenced by multiple Infection Control findings during the Annual Recertification Survey. This failed practice had the potential to affect all 67 residents in the facility as documented on the Resident Census and Conditions of Residents which was provided by the Clinical Consultant on 03/27/23 at 1:48 PM. The findings are: 1. On 03/21/23 at approximately 8:31 AM, Resident #51 tested positive for COVID. The facility failed to inform the residents, their representatives, and families of suspected or confirmed COVID-19 cases in the facility by 5:00 PM the next day. 2. On 03/27/23 at 3:21 PM, Certified Nursing Assistant (CNA) #5 and CNA #6 failed to wear goggles or face shields into Resident #51 ' s room who was in Transmission Based Precautions for COVID. They doffed their masks and gowns outside of the room and placed them in a biohazard container…

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

Based on interview, and record review, the facility failed to ensure the Pneumococcal immunizations were administered to eligible residents and immunization records were accurately documented for 4 (Residents #19, #41, #55, and #61) of 5 (Residents #19, #41, #48, #55 and #61) sampled residents whose charts were reviewed for the completion of the Pneumococcal vaccines. This failed practice had the potential to affect 63 residents who resided in the facility as documented on a list of residents not receiving Hospice services provided by the Director of Nursing (DON) on 03/29/23. The findings are: 1. Resident #19 had a diagnosis of Cerebral Palsy. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/14/23 documented the resident was severely impaired in cognitive skills for daily decision-making per a Staff Assessment of Mental Status (SAMS). a. The electronic health records, in the immunization tab, there was a Pneumococcal consent form dated 8/9/22. There was no documentation of a Pneumococcal Immunization being given. 2. Resident #41 had a diagnosis 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, record review, and interview, the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) within 14 days of the identification of a decline and/or improvement in two or more activities of daily living (ADLs) for 1 (Resident #47) of 15 (Residents #1, #9, #13, #22, #39, #40, #41, #45 #48, #49, #50, #51, #54, #55 and #61) sampled residents whose MDSs were reviewed. This failed practice had the potential to affect all 67 residents who resided in the facility as documented on the Resident Census and Conditions of Residents provided by the Nurse Consultant on 03/27/23 at 1:15 PM. The findings are: 1.Resident #47 had a diagnosis of Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. The Quarterly MDS with an Assessment Reference Date (ARD) of 01/27/23 documented the resident scored 6 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required extensive physical assistance of one person with bed mobility, transfers, 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 record review, and interview, the facility failed to refer 1 (Resident #39) of 6 (Residents #13, #22, #24, #28, #39 and #54) sampled residents who was identified with possibly serious mental illnesses or intellectual disabilities to the appropriate state-designated authority for a Level II Preadmission Screening and Annual Resident Review (PASARR) evaluation and determination. This failed practice had the potential to affect 12 residents in the facility who had a diagnosis of serious mental illness or intellectual disability as documented on a list provided by the Administrator on 03/30/23 at 12:48 PM. The findings are: 1. Resident #39 had diagnoses of Schizophrenia, Unspecified and Paranoid Schizophrenia. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/10/23 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and received an antidepressant 7 of the 7 day look back period. a. On 03/27/23 at 2:33 PM, there was no PASSAR in Resident #38's electronic medical record. b. The Care…

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, interview, and record review, the facility failed to ensure residents were care planned for required assistance with Activities of Daily Living (ADL) for 1 (Resident #19) of 22 (Resident #1, #2, #6, #13, #19, #24, #28, #31, #39, #40, #41, #43, #47, #48, #49, #50, #54, #61, #63, #64, #218, and #266) sampled residents residing in facility. The findings are: 1. Resident #19 had a diagnosis of Cerebral Palsy. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/14/23 documented the resident was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS) and required extensive physical assistance of two plus persons with bed mobility, transfer, dressing, toilet use, and personal hygiene and was totally dependent of one person with bathing. a. The Care Plan with a revision date of 03/22/23 did not address activities of daily living. b. On 03/27/23 at 1:05 PM, Resident #19 was sitting in his wheelchair. His…

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, interview, and record review, the facility failed to follow their policy for storage of residents' lighters, matches, electronic cigarettes as well as other smoking related items to prevent the potential for accidents for 1 (Resident #54) of 2 (Residents #22 and #54) sampled residents who smoke as documented on a list provided by the Administrator on 03/27/23 at 10:44 AM. The findings are: 1. The facility policy titled, SMOKING, provided by the Administrator on 03/29/23 at 1:46 PM documented, .It is the policy of this facility to ensure a safe environment for all residents who wish to smoke outside at the facility . Procedure: 1. Any resident that wishes to smoke while a resident at this facility will be required to keep their lighters, matches, electronic cigarettes, as well as other smoking related items, locked up. 2. Resident #54 had diagnoses of Major Depressive Disorder Recurrent, Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Pain in Right Hand, Unspecified Convulsions and Schizoaffective Disorder, Bipolar…

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 interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 1 of 1 meal observed. The failed practice had the potential to affect 7 residents who received pureed diets as documented on the Diet List provided by the Food Service Supervisor on 03/28/23. The findings are: 1. On 03/27/23 at 11:20 AM, Dietary Employee (DE) #1 used a 4 ounce spoon to place 7 servings of blackeye peas into a blender, pureed and poured in a pan. She covered the pan with foil and placed it in the oven to be served to the residents who had Physicians Orders for pureed diets. The consistency of the pureed blackeye peas was thick. 2. On 03/27/23 at 12:34 PM, DE #4 placed 7 servings of oven fried chicken into the blender, added beef broth and pureed. He poured the pureed chicken into a pan. He covered the pan with foil and placed it in the oven to be served to the residents who had Physicians Orders for pureed diets. The consistency 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure the physician's plan of care for thickened liquids was followed for 1 (Resident #266) of 2 (Residents #266 and #218) sampled residents who had Physician Orders for thickened liquids according to a list provided the Dietary Supervisor on 03/28/23 at 2:50 PM. The findings are: 1. Resident #266 had diagnoses of Cerebral Infarction due to Thrombosis of Unspecified Precerebral Artery and Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Dominant Side. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/05/23 was in process. a. A Hospital Discharge summary dated [DATE] documented, .Mechanical altered diet-require change in texture of food or liquids (e.g. [for example], pureed food, thickened liquids) . b. A Physicians Order dated 03/24/23 documented, .Regular diet, mechanical soft texture mildly thick (nectar) consistency . c. A Physicians Order dated 03/28/23 documented, .Speech…

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.