The Blossoms at White Hall Rehab & Nursing Center

Based on observation, record review and interview, the facility failed to ensure meals were served at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 2 of 2 meals observed. The failed practices had the potential to affect 22 residents who received their meal trays in the their rooms on the 100 Hall, 10 residents who received their meal trays in the room on the 200 Hall, 11 residents who received their meal trays on the 300 Hall, 13 residents who received their meal trays in their room on the 400 Hall, 21 residents who received their meat trays in the room on 500 Hall and 4 residents who received their meal trays in their room on 600 Hall, as documented on a list provided by the Dietary Supervisor on 02/06/2024 10:10 AM. The findings are: 1. Resident #284 had diagnoses of Hero sclerotic heart disease of native coronary aorta, without Angina pectoris. The admission Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 01/23/2024 documented the resident scored 12 (8-12 indicates moderately impaired) on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure that pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 1 of 1 meal observed. The failed practice had the potential to affect 4 residents who received pureed diets, as documented on the list Dietary Supervisor provided by the Food Service Supervisor on 02/06/2024 The findings are: On 02/05/24 at 10:45 AM Dietary Employee (DE) #1 placed 6 servings of pork loins into a blender, added its juice and pureed. At 10::50 AM (DE) #1 poured the pureed pork loins into a pan. She covered the pan with foil and placed it in a pan of hot water on the stove. The consistency of the pureed pork [NAME] was gritty and not smooth. 2. On 02/05/24 at 10:58 AM (DE) #1 used #8 scoop to place 7 servings of white rice into a blender, added sauce and pureed into a pan. At 11:00 AM She covered the pan with foil and placed it in a pan of hot water on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure trash was properly contained within 1 of 1 dumpster, to minimize the presence of foul odors and decrease the potential for pest infestation. The failed practice had the potential to affect all the residents who resided in the facility, as documented on the list provided by the Dietary Supervisor on 2/6/2024 at 010:10 AM. The findings are: 1. On 02/06/24 10:10 at the one dumpster used by the facility was located outside approximately 67 feet from the door leading into the kitchen. The dumpster was overflowing with several trash bags on the ground. There was one clear bag that contained incontinent briefs that was hanging down from the door of the dumpster. There were 30 clear bags full of trash on the ground by the dumpster. There was another clear bag behind the dumpster that contained soiled briefs. The surveyor asked the Dietary Supervisor how many of the trash bags were dumped on the ground and was also asked how often the dumpster was emptied.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to notify the Ombudsman required for 1 (Resident #31) of 6 (Residents #11, #14, #31, #59, #64, and #53) sampled residents who were transferred to the hospital in the last month. The findings are: 1. Resident #31 had a diagnosis of Schizophrenia. a. An Incident and Accident (I&A) form dated 01/12/2024 at 6:41 PM documented resident #31 was sitting in a wheelchair with wounds to the abdomen area. The wounds which were self-inflicted with a razor. The razor cap was noted in the resident's lap. b. The Nurse's Notes dated 01/12/2024 at 7:12 PM documented Resident #31 was noted in the dining hall with self-inflicted wounds to abdomen area. Resident #31 was sent to the emergency room for medical observation. c. On 02/06/2024 at 4:14 PM, the Administrator provided a list of residents who were transferred to the hospital from [DATE] to 01/31/2024 with Resident #31 name listed on the list. d. On 02/08/2024 at 09:31 AM, the Social Services Director provided a…

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 the Minimum Data Set (MDS) was coded accurately to reflect the resident's nutritional status for 1 sampled resident (R#37). The findings are: On 12/27/2023, the resident weighed: a. Per record review, resident #11 weighed 277.4 pounds on 12/27/23. On 01/24/2024, the resident weighed 273.8 pounds which is a -1.30 % Loss.2/05/24 12:PM . On 08/23/2023, the resident weighed 305.6 lbs. On 01/24/2024, the resident weighed 273.8 pounds which is a -10.41 % Loss. b. A Minimum Data Set, dated [DATE] did not document in section K that there was a weight loss. c. On 2/7/24 at 09:02 AM a Minimum Data Set Coordinator (MDSC) was asked to access resident #37's Minimum Data Set (MDS) in the Electronic Record and look in K section under weight loss. MDSC stated Resident #37 should have been coded for weight loss. Surveyor asked MDSC why is it important for the MDS to be coded correctly. d. On 2/08/24 at 10:22 AM the Director of Nurses (DON) was asked…

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 services were provided to minimize the potential for further decline in range of motion (ROM) for 1 (Resident #59) of 3 (Residents #16, #31 and #59) sampled residents who had limited range of motion as documented on a list provided by the Administrator on 2/7/24 at 11:13 AM. The findings are: 1. Resident #59 had diagnoses of Cerebral [brain] Infarction [death of tissue], Frontal Lobe and Hemiplegia [paralysis], Affecting Right Dominant Side. a. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/23/24 documented the resident scored 3 (3=severely impaired) on a Staff Assessment for Mental Status (SAMS), had impairment on one side in the upper extremity, received no days in a Restorative Nursing Program and received Occupational Therapy from 2/16/23 to 5/12/23 and Physical Therapy from 4/20/23 to 6/16/23. b. On 02/04/24 at 11:54 AM resident #59 was in bed and the left (L) hand was closed and did not open it when asked by this surveyor. c. On 02/05/24 at 3:03 PM resident #59 was…

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 that interventions that were care planed were utilized to prevent potential accident hazards as possible by continuing to fall for 1 of 1 Resident (#11) 1 sampled resident. The findings are: 1. On 02/04/24 at 12:40 PM, Resident #11 was in bed with a neck brace around her neck. Observed about a 3inch dark purple area under right. eye. Above the left eye was a 2.5 cm raised area surrounded with dark purple color with dried blood over it. Resident #11 stated, I fell a couple weeks ago. A dark purple area below right eye about 3 inches long. Resident stated, I just don't want to bother anyone. I leaned on my table, and it moved with me. I got up and that's all I remember. a. On 02/05/24 at 08:39 AM Resident #11 was lying in the bed with a neck brace around her neck and under both eyes had dark purple areas under them. Raised area above right eye. Observed a bedside table on the right side of the bed. There were no padded tables in the room. b. Review of hospitalization record dated 1/23/24, documented…

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 medications were allowed to flow by gravity through a Percutaneous Endoscopic Gastrostomy (PEG) Tube to decrease the potential for gastric complications for 1 (Resident #16) of 1 (Resident 16) sampled resident whose medications were administered through a PEG Tube. The findings are: 1. Resident #16 had a diagnosis of Dysphagia, Oropharyngeal Phase and Gastrostomy Status. a. February 2024 Physician's Orders documented resident #16 diet was nothing by mouth active 11/04/2023 and may crush meds (medications) and administer together in tap water via (by way of) G (Gastrostomy)-Tube every shift active 11/04/2023. b. On 2/7/24 at 11:10 AM, after preparing the resident's medications, LPN #4 crushed all the meds and placed them in two separate 8 oz (ounce) cups with water. After stirring each cup, she sanitized her hands, put on gloves, placed the pump on hold, checked placement and placed the end of the administration set in a cap. She used a 60 cc syringe, drew up the meds and liquid from the first cup,…

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 proper hand hygiene was performed while providing incontinent care to decrease the potential for the spread of bacteria and promote good hygiene for 1 (Resident #59) of 1 sampled resident who received incontinent care. The findings are: 1. Resident #59 had diagnoses of Cerebral infarction, frontal lobe and executive function deficit and Hemiplegia, unspecified affecting right dominant side. a. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/23/2024 documented the resident scored 3 (3= indicates severely impaired) on a Staff Assessment for Mental Status (SAMS) and was dependent for toileting hygiene, bathing and personal hygiene. b. A Care Plan with a completion date of 01/25/2024 documented, . [Resident #59] has potential for complications associated with incontinence of bowel and bladder . Check every two hours and PRN [as needed] for incontinence . I require extensive assist x 2 with .toileting, personal hygiene . If I am incontinent of bowel and bladder . give me…

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 medications were stored and administered appropriately at the bedside, and failed to ensure medication was not sent to the kitchen on food trays. The findings are: a. On 12/27/2023 at 09:35 AM, the Surveyor was reviewing menus in the kitchen and observed a medication cup sitting in a window near the Dietary Manager (DM) office. The cup held a white oblong pill with G650 written on the outside. The DM was asked what was in the medication cup, and how it came to be in the kitchen area. The DM picked up a bottle of pain reliever and told the Surveyor she thought it was from their personal use bottle. The DM opened the bottle and was observed shaking a pill into the lid. The Surveyor pointed out the pills did not match. The DM picked up the medication cup and quickly disposed of it in a kitchen trash can. b. On 12/27/2023 at 12:00 PM, the DM approached the Surveyor and said kitchen staff told her that they found the medication cup containing a white pill on a tray that came back to the kitchen and had sat…

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 dignity was maintained by providing privacy during incontinent care for 1 (Resident #4) of 1 sampled resident. The findings are: 1. On 12/27/23 at 02:12 PM, as the Surveyor was making rounds, Resident #4 was being provided incontinent care by Certified Nursing Assistant (CNA) #1. The door to Resident #4's room was completely open and the curtain was not closed allowing anyone in the hallway to visually witness the incontinent care being provided. Resident #4 was not covered. a. On 12/27/23 at 12:18PM, CNA#1 looked in the hall at the Surveyor and continued with incontinence care without providing privacy. b. On 12/27/23 at 12:21, CNA #1 was asked if it was normal for incontinent care to be provided with the door open, curtain not closed, and resident not covered. CNA #1 stated, No. CNA #1 further stated, I didn't provide privacy for the resident. c. On 12/28/23 at 08:32 AM, the Director of Nursing (DON) was asked how she expected incontinence care to be provided. The DON replied, I expect them to gather…

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 food was warm when served to residents to prevent germs and bacteria growth, and appealing taste to the residents. This failed practice had the potential to affect 76 residents that eat from the kitchen. The findings are: a. On 12/27/2023 at 12:00 PM, the Surveyor observed Certified Nursing Assistant (CNA) #2 holding the rolling food cart doors open while loading lunch trays, plates have a warmer top without a warmer bottom. The food temperatures from the kitchen are as follows: meat 190 F, ground meat 180 degrees Fahrenheit (F), starch 185 degrees F, green beans 175 degrees F, Puree 180 degrees F, salad 38 degrees F. b. On 12/27/2023 at 12:48 PM, the Dietary Manager (DM) was asked if there have been any recent resident concerns about the meals. The DM said, Some do not like tomatoes, and we take them out of their salad. During the interview the Surveyor asked the DM if there had been any concerns with the food temperatures by the residents. The DM told the Surveyor that they have ordered bottoms to the plate warmers,…

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 wound care was performed as ordered for one (R#5) of six (R#1, #2, #3, #4, #5 and #6) sampled residents. The findings are: 1. Resident #1 had diagnoses of Type 2 Diabetes Mellitus, venous insufficiency, and partial amputation of right foot. The admission Minimum Data Set [MDS] with an assessment reference date [ARD] of 10/17/2023 documented a brief interview of mental status [BIMS] of 15 (13-15 cognitive). a. The physician order dated 10/24/2023 documented, .RT (right) Foot /Toes, Staples; Cleanse with wound cleanser, apply betadine to wound bed cover with 4x4s, abd (Abdominal) pad, wrap with gauze bandage and an ace bandage. every day shift for surgical wound .left subclavian Perma Cath - Monitor catheter for bleeding and intact dressing every shift. every shift . There are no physician's orders for treatment to scalp or to left cheek documented on November physician orders. There are orders documented on the order overview as follows; 1.TOP OF SCALP: CLEANSE WITH WD CLEANSER, COVER WITH XEROFORM…

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 dietary staff washed their hands and changed gloves before handling food items to prevent the potential for cross contamination for residents who received meals from 1 of 1 kitchen and 1 of 2 ice machines were maintained in a clean and sanitary condition to prevent potential contamination of resident fluids for residents who received ice in their rooms. These failed practices had the potential to affect 19 residents on the 100 Hall, 12 residents on the 200 Hall, 10 residents on the 300 Hall, 12 residents on the 400 Hall, 17 residents on the 500 Hall, 3 residents the 600 Hall and 3 residents on the 700 Hall who received ice in their rooms, (Total Census: 76 ) according to the list provided by the Dietary Supervisor on 11/10/2022 at 8:39 AM. The findings are: 1. On 11/09/22 at 10:00 AM, there were 6 cartons of whole milk on top of a cart in the walk-in refrigerator. The Surveyor immediately asked the Dietary Supervisor to check the temperature of the milk. She did and it was 45.8 degrees Fahrenheit. She…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents' decisions as to whether they desired to have, or did have, an advanced directive, were documented in a prominent part of the clinical record and correct to ensure their wishes were known regarding acceptance or rejection of any life-sustaining treatments in the event of their incapacitation for 2 (Residents #51 and #55) of 2 sampled residents whose advance directives were reviewed. This failed practice had the potential to affect all 76 residents in the facility as documented on the Resident Census and Conditions of Residents provided by the Administrator on [DATE] at 9:10 AM. The findings are: 1. Resident #55 was admitted on [DATE] with a diagnosis of Generalized Anxiety Disorder, Other Specified Depressive Episodes, Dementia in Other Diseases Classified Elsewhere, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety, Parkinson's Disease. The admission Minimum Data Set (MDS) with…

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 a resident's room did not have a strong urine odor from the catheter bag dripping for 1 (Resident #29) of 1 sampled resident who had a urinary catheter. This failed practice had the potential to affect 3 residents in the facility who had urinary catheters according to the Resident Census and Conditions of Residents provided by the Administrator on 11/8/22 at 9:10 AM. The findings are: 1. Resident #29 had diagnoses of Cerebrovascular Accident and Obstructive and Reflux Neuropathy. The Quarterly Minimum Data Set (MDS) with a Staff Assessment Date (ARD) documented the resident was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status (SAMS) and had an indwelling catheter. a. On 11/09/22 at 9:23 AM, Resident #29 was lying in bed. The resident's room smelled highly of urine. The Surveyor asked Resident #29, Are you wet? He shook his head no. A body audit was done by Certified Nursing Assistant (CNA) #6 and CNA #5 to see if the resident's catheter was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a Minimum Data Set (MDS) assessment was completed in a timely manner for 1 (Resident #55) of 9 (Residents #15, #27, #34, #42, #55, #70, #74, #377 and #379) sampled residents who were admitted within the last 90 days and 1 (Resident #70) of 5 (Residents #5, #34, #15, #377 and #70) sampled residents who were discharged within the last 90 days. The findings are: 1. Resident #55 was admitted on [DATE] with diagnoses of Generalized Anxiety Disorder, Other Specified Depressive Episodes, Dementia in Other Diseases Classified Elsewhere, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety and Parkinson's Disease. The admission MDS with an Assessment Reference Date (ARD) of 8/22/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). a. The admission MDS in the electronic health record (EHR) documented the completed and locked date was…

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 Minimum Data Set (MDS) assessment accurately reflected the use of a restraint for 1 (Resident #19) of 1 sampled resident. The findings are: 1. Resident #19 had diagnoses of Glaucoma, Dementia, Muscle Weakness and Heart Failure. The MDS with an Assessment Reference Date (ARD) of 08/03/2022 documented the resident scored 12 (8-12 indicates moderately cognitively intact) on a Brief Interview Mental Status (BIMS). a. On 11/09/22 at 10:05 AM, the MDS Indicator for this resident documented, Restraints. The Quarterly MDS with an ARD of 05/03/22 documented under Physical Restraints and Alarms, . 1. Used less than daily .Used in Chair or Out of Bed . G. Chair Prevents Rising . b. The Quarterly MDS with an ARD of 08/02/22 documented under Physical Restraints and Alarms, . 1. Used less than daily .Used in Chair or Out of Bed .G. Chair Prevents Rising. c. On 11/09/22 at 2:24 PM, the Surveyor asked the MDS Consultant why [Resident #19] was coded for a restraint. He stated, I don't know why that is on there, but I will modify…

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 resident clothing was regularly changed and wasn't worn for 2 to 5 consecutive days to promote cleanliness and good personal hygiene for 2 (Residents #34 and #51), failed to ensure residents were regularly shaved for 1 (Resident #51) and nail care was regularly provided to promote good personal hygiene for 2 (Residents #56 and #377) of 21 (Residents #2, #5, #7, #8, #13, #15, #16, #17, #19, #20, #27, #29, #34, #42, #47, #48, #51, #56, #377, #379, and #380) sampled residents who were dependent for nail care and/or personal hygiene according to the lists provided by the Regional Consultant on 11/09/22 at 4:07 pm. The findings are: 1. Resident #34 had diagnoses of Spinal Cord Injury, Morbid Obesity and Rheumatoid Arthritis. The Medicare 5-Day admission Minimum Data Set (MDS) with an Assessment Date (ARD) of 05/13/22 documented the resident scored 15 (indicates cognitively intact) on a Brief Interview Mental Status (BIMS) and required…

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 environment was as free from accidents and hazards as possible, as evidenced by failure to store potentially hazard chemicals in a secure location to prevent potential access by cognitively impaired and or mobile residents on the 400 Hall. This failed practice had the potential to affect 13 residents who resided on the 400 Hall and were ambulatory or wheelchair mobile as documented on a list provided by the Administrator on 11/10/22 at 12:05 PM. The findings are: 1. On 11/7/22 at 10:45 AM, during initial rounds, a spray can of [Brand] paint primer was located in the unlocked bathroom of Resident room [ROOM NUMBER] A and B. 2. On 11/7/22 at 10:45 AM, the Surveyor asked Housekeeper #1 (who was cleaning the room) to come to the bathroom. The Surveyor asked, Did you leave this can in the bathroom? She stated, No ma'am. I haven't cleaned the bathroom yet and I don't use that. It's probably left from painting the bathroom. The…

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

Based on observation, record review, and interview, the facility failed to ensure a physician's order was obtained for the administration and use of oxygen and a Trilogy machine to prevent potential complications for 1 (Resident #51) of 8 (Residents #5, #7, #16, #19, #27, #34, #51 and #380) sampled residents who received oxygen and 1 (Resident #51) of 1 sampled resident who used a Trilogy machine. This failed practice had the potential to affect 16 residents residing in the facility who used oxygen and 1 resident in the facility who used a Trilogy machine according to the list provided by the Administrator on 11/09/22 at 3:50 PM. The findings are: 1. Resident # 51 had diagnoses of Chronic Obstructive Pulmonary Disease, Depression, Anxiety, and Congestive Heart Failure. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/12/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required oxygen therapy. a. The Plan of Care dated 10/05/22 documented, .Administer oxygen as ordered . b.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident's drug regimen review was followed up on according to facility policy and Resident Assessment Instructions guidelines for 1 (Resident #377) of 1 sampled resident who received Lithium. The findings are: 1.Resident #377 was admitted on [DATE] with a diagnosis of Tobacco Use, Suicidal Ideations and Diabetes Mellites. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/06/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and received an antipsychotic medication 6 of the 7 day look back period. a. The Physician Orders dated 10/04/22 documented, .Lithium Carbonate Tablet 300 MG [milligrams] Give 1 tablet by mouth two times a day for Antipsychotics/Antimanic Agent . b. The Medication Regimen Review dated 10/10/2022 documented, .NEW ADMIT REVIEW . 1) Medication Consideration(s): - On the following psychotropics: Sertraline & [and] Lithium…

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 develop a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet the needs of a resident who smoked tobacco for 1 (Resident #377) of 5 (Residents #8, #19, #42, #74 and #377) sampled residents who smoked. The findings are: 1.Resident #377 was admitted on [DATE] with diagnoses of Tobacco Use, Suicidal Ideations and Diabetes Mellites. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/6/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required supervision and setup help with bed mobility, transfers, walking in the room and corridor and toilet use. a. The Admission/readmission Nursing Evaluations Packet dated 10/26/22 documented, .1. Does resident use smoking/tobacco/nicotine products? a. Yes . 2. Which products are being used by the resident? . a. Cigarette . Smoking Habit Evaluation . 4. Does…

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 toenail care was regularly provided to promote good foot care for 1 (Resident #47) of 21 (Residents #2, #5, #7, #8, #13, #15, #16, #17, #19, #20, #27, #29, #34, #42, #47, #48, #51, #56, #377, #379, and #380) sampled residents who were dependent for nail care/personal hygiene according to the lists provided by the Regional Consultant on 11/09/22 at 4:07 PM. The findings are: 1. Resident #47 had diagnoses of Diabetes Mellitus II, Fluid Overload, Generalized Edema, and Paroxysmal Atrial Fibrillation. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/08/22 documented the resident scored 8 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and required supervision and setup help with dressing and personal hygiene and physical help of one person in part of bathing activity. a. The Plan of Care with a review start date of 8/27/22 documented, .requires assistance with ADL (activities of daily living) functions . Dressing: One assist…

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 meals were prepared and served in accordance with the planned, written menu to meet the nutritional needs of the residents for 1 of 2 meals observed. These failed practices had the potential to affect 52 residents who received regular diets and 17 residents who received mechanical soft diets, (Total census: 76) according to a list provided by the Dietary Supervisor on 11/10/2022. The findings are: 1. On 11/9/2022, the menu for the lunch meal documented the residents on regular diets and mechanical soft diets were to receive Squash Au Gratin #8 scoop = (equals) ½ cup each. a. On 1109/22 at 12:10 PM, Dietary Employee (DE) #1 served a single portion of Zucchini Au Gratin to the residents who were on regular and mechanical soft diets with a #10 scoop (3 ounces). b. On 11/09/22 at 1:00 PM, the kitchen ran out of Zucchini Au Gratin and 3 residents were served cut green beans with no cheese. c. On 11/09/22 at 1:05 PM, the Surveyor asked DE #2, How many residents were supposed to receive Zucchini Au Gratin 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.