Ashby Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure one of 13 sampled residents was free from physical restraints when the facility staff placed Resident 167 in a Geri chair with a hard table cover over the Geri chair (a large, padded chair that is designed to help seniors with limited mobility), preventing Resident 167's freedom of movement (change in place or position for the body or any part of the body that the person is physically able to control) and from getting in and out of the Geri chair at his own will. This failure placed Resident 167 at risk of self-injury, of not attaining and maintaining their highest practicable well-being or good quality of life. Findings: During a record review of Resident 167's Facesheet (FC), the FC indicated Resident 167 was admitted to the facility on [DATE]. FC also indicated Resident 167 had diagnoses of essential primary hypertension (a chronic condition of persistent high blood pressure with no identifiable cause), nontraumatic intracerebral…

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, the facility failed to ensure the Infection Preventionists (infection control nurse or designee) had completed specialized training in infection prevention and control. This failure had the potential to contribute to the residents' development of contracting healthcare acquired infections (infections from receiving treatment at a facility). Findings: During a concurrent interview and record review on 5/20/25, at 2:44 p.m., with the Director of Nursing/Infection Preventionist (DON/IP), in the presence of Administrator/MDSC (ADM/MDSC), the DON/IP stated two staff members were designated Infection Preventionists, including DON and Administrator (ADM). DON/IP also stated she had not completed the specialized training in infection prevention. Furthermore, the ADM/MDSC revealed she also had not completed the specialized training in infection prevention.

The facility failed to ensure proper medication storage when: 1. Medication refrigerator was not padlocked 2. Medication room dry storage temperature log did not have entries for December 2 and 3, 2024 3. Medication room refrigerator had nutritional supplements along with food items that were not labeled with names and dates 4. The medication room had a staff's clothing item hanging on the door. This failure can potentially result in unsafe medication storage practices and impact the safety and well-being of all 29 residents. Findings: 1. During a concurrent observation and interview on 12/4/24, at 10:15 a.m., with Licensed Vocational Nurse (LVN) 1, the medication refrigerator in the medication room was found not padlocked. During a concurrent observation and interview on 12/4/24, at 11:10 a.m., with Administrator (ADM), ADM stated the medication refrigerator should have been padlocked. During an interview on 5/8/25, at 9:30 a.m., with Director of Nursing (DON), the DON stated the medication refrigerator should have been padlocked as it had E-kit (emergency kit containing…

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 The facility failed to ensure infection control measures were followed when: 1. Outside resident room [ROOM NUMBER] was an open lid bin which contained a used yellow gown. Next to this open bin was a container of unused personal protective equipment (PPE) supplies 2. Inside the medication room, a bag of adult brief pads was found on the floor 3. Inside the medication room, under the sink was a half-full container of water and located next to two containers of chemical agents, one of which was perineal wash. 4. Biohazard door was unlocked. This failure can potentially result to cross contamination of clean product items and impact the physical health, safety and well-being of all 29 residents. Findings: 1. During a concurrent observation and interview on 12/4/24, at 10:15 a.m., with Licensed Vocational Nurse (LVN) 1, in the hallway was an open lid bin with used yellow gown was noted outside of resident room [ROOM NUMBER]. Next to this open lid bin was a container with unused PPE supplies. LVN 1 stated the lid…

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, interviews, and record review, the facility failed to facilitate the resident's right to organize resident group (council) meetings. The group council meetings stopped during the COVID-19 (a respiratory virus that is easily spread causing mild, moderate, or serious illness) lockdown and were never resumed. There was no designated staff person approved by the residents to be responsible for assisting and responding to the resident's concerns or requests that result from group meetings. This failure had the potential to cause residents emotional distress and a decline in their quality of life. Findings: During an interview on 10/16/23 at 9:44 a.m., Resident 3 stated the resident council meeting was not held for a long time since the COVID-19 lockdown in 2020 because there was no staff to assist with meeting arrangements. Resident 3 further stated he would like the residents 'council meetings restarted to discuss activities and concerns. Review of the Minimum Data Set (MDS - an assessment…

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 provide an ongoing activity program to support residents in their choice of activities. The facility did not have an active activity program or staff responsible for providing assistance with the activities program. This failure had the potential to cause residents emotional distress and decline in their quality of life. Findings: 1. Review of Annual Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 4/21/23, indicated: Resident 3's Basic Interview of Mental status (BIMS- score was 14 meaning cognitively intact). Resident 3's activity preferences included listening to music, doing things with groups of people and participate in religious services or practices that were very important. Resident 3's diagnoses included schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly). Review of the activity care plan initiated on 7/1/21 indicated for staff to invite Resident 3 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical review, the facility failed to provide pharmaceutical services to meet the needs of four of 14 sampled residents (Residents 63, 162, 163, and 170) when the facility failed to perform daily glucometer (small machine that measures blood glucose or sugar level) quality control checks to ensure accurate readings. This failure had the potential risk of adverse consequences associated with the glucometer used for Residents 163 and 170 whose insulin dosage (medication that lowers the blood glucose) were dependent on the accuracy of the glucometer readings. For Residents 63 and 162, this had the risk of incorrect blood glucose readings and inappropriate medical interventions for Residents 63 and 162. Findings: 1. During a concurrent interview and record review on [DATE], at 11:50 a.m., with Administrator (Adm), the glucometer quality control log was reviewed. There was no record of the glucometer quality control checks being done since [DATE]. Adm confirmed the findings 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 have Registered Dietitian (RD) oversight of the kitchen and clinical nutrition care (ensuring residents are consuming an adequate amount of nutrients for good health) since 7/28/23. There was no full-time Dietary Manager (DM) to manage kitchen operations when the menu was not being followed (cross-reference 803), unsanitary conditions in the kitchen (cross-reference 812), no pest control program (cross-reference 925), and the nutrition status of one (Resident 159) was not being maintained (cross-reference 692). These failures placed 26 of 26 residents who received food from the kitchen at risk for compromised nutritional status and had the potential for transmission of food borne illness. Findings: During an interview on 10/16/23 at 09:30 a.m., with the Dietary [NAME] (Cook), [NAME] stated the facility did not have a Dietary Manager (DM) for the past three years and the RD had not come into the facility for the past three months. [NAME] stated he was solely responsible for the cooking, cleaning, and ordering…

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

Based on observation, staff interview, and facility document review, the facility failed to ensure the planned menu was followed when the Cold [NAME] Bean Salad was substituted for Creamy Cucumber Celery Salad on Monday 10/16/23. The lunch menu for 10/16/23 had already included a hot green bean side dish. This failure had the potential to result in not meeting the nutritional needs of the residents and compromising the nutritional status of the residents. Findings: During a review of the Fall Menu Week 3 Monday: 9/18/23, 10/16/23, 11/13/23: Therapeutic Spreadsheets and the Weekly Menu: October 16 - 22, 2023, undated showed Creamy Cucumber & Celery Salad was listed on the lunch menu for all diets. During a concurrent observation and interview on 10/16/23 at 10:42 a.m., with Dietary [NAME] (Cook) of the Trayline food service in the kitchen, Cold [NAME] Bean Salad was substituted for Creamy Cucumber & Celery Salad on the lunch trays. [NAME] stated the Creamy Cucumber & Celery Salad was on the weekly menu and on the therapeutic spreadsheet and was not provided to the residents. During 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.

Based on observation, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety when: 1. A refrigerator in the kitchen was dirty, food was not labeled and dated, the door was dirty with smudges. The top freezer of the refrigerator had crusted food and food crumbs, and food was not labeled and dated. A reach-in freezer had food crumbs and the door had dark, brown build-up. This had the potential to contaminate the food or the hands of food workers, that could lead to food borne illness. 2. Dry food storage bins had yellow and brown stains and were not safe for storing food. This had the potential to contaminate the food stored inside. 3. Island shelves storing clean dishware and trays were sticky with grime and food crumbs in the corners. The utensil storage container, storing clean utensils had food crumbs. This had the potential to contaminate food and clean dishware. 4. All the upper cabinetry and lower cabinets in the kitchen were made of wood that was deteriorating. Chunks of the wood were…

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, the facility failed to develop an effective Quality Assurance and Performance Improvement plan (QAPI) that identified and addressed the following: - Lack of activity program for residents, - No designated staff person responsible for providing assistance with resident group meetings and activities program, - No resident group meetings since 2020, - Late completion and transmission of Minimum Data Set (MDS- Resident Assessment tool used to guide care). These failures had the potential to cause the residents emotional distress, and decline in residents quality of life and quality of care. Findings: During an interview on 10/19/23 at 12:15 p.m., Registered Nurse/Administrator (RN/Admin) stated the facility did not identify or address with QAPI, about the residents lack of an activity program, open position for activity staff, and no designated staff person responsible for providing assistance with resident council meetings. There were no resident group meetings since COVID-19 lockdown in 2020 and were never resumed, and had late completion 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop a policy and procedure for an active water management program to address prevention of Legionnaires (LD) and other opportunistic pathogens (disease causing) in water. The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. This failure had the potential to cause spread of water borne pathogen growth in the facility. Findings: During an interview on 10/18/23 at 1:20 p.m., with Registered Nurse/Administrator (RN/Admin)accompanied by Assistant Director of Nursing (ADON), RN/Admin stated, facility had no water treatment program at this time. RN/ Admin could not provide documentation for facility's water treatment program to prevent Legionnaire and spread of water pathogen. RN/Admin stated facility was not aware of water management measures for…

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 following equipment was maintained in good repair as follows: 1. [NAME] refrigerator with top freezer: the bottom right side of the rubber gasket on the freezer door was torn and peeled away from the door. 2. Reach-in stainless steel freezer: the door frame was broken off the hinges, the rubber gasket was torn across the top of the lid and there was ice buildup on the inside walls. The Freezer had a crack with the insulation covered with masking tape. This failure had the potential for the refrigerator and freezers to not maintain appropriate temperatures and put the facility at risk for diminished quality of food stored in the freezer and/or affecting the safe storage of food leading to foodborne illness for 26 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview on 10/16/23 at 10:47 a.m., during the initial kitchen tour, the rubber gaskets around the interior perimeter of the two reach-in refrigerators, and one reach-in freezer doors were torn.…

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 maintain a functioning call light (communication system) for four of 26 sampled residents (Residents 8, 158, 159, and 160). The facility had no documented call light system tests since 6/9/22. This deficient practice resulted in Residents 8, 158, 159, and 160 not being able to summon staff for care and assistance in an emergency. For all residents, this had the potential for being unable to call for help if the call lights fail to work. Findings: During a concurrent observation and interview on 10/16/23, at 10:54 a.m., with Licensed Vocational Nurse (LVN)1, in room [ROOM NUMBER], Residents 159 and 160's call light strings were not within the resident's reach and were not alarming and lighting outside the resident's door when the strings were pulled. LVN 1 confirmed the call lights were not within residents' reach and were not working. LVN 1 further stated, the facility should have provided Residents 159 and 160 with call bells at 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, interview, and record review, the facility failed to ensure a pest free environment when pest droppings and cobwebs were seen in the kitchen and inside the dry food storage. This failure had the potential to contaminate food and cause foodborne illness to 27 of 27 medically compromised residents who received food from the kitchen. Findings: During a concurrent observation and interview on 10/16/23 at 12:55 p.m., with Dietary [NAME] (Cook), there were droppings on the light switch by the handwashing station. There was also a hole extending behind the backsplash on the counter and potential entry point. room [ROOM NUMBER] dry storage area had cobwebs under the shelves and under the stainless-steel sink. [NAME] stated he was not aware of any Pest Control services performed in a few months. [NAME] further stated he was solely responsible for cleaning the kitchen and had not performed a cleaning in over a year. During an interview on 10/18/23 at 11:49 a.m., with Administrator (Admin), Admin…

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 conduct comprehensive Minimum Data Set assessments (MDS, an assessment tool used to direct resident care) for six of thirteen sampled residents (Resident 5, 58, 60, 61, 62 and 63) as required by the regulation. These failures had the potential to result in not planning and meeting the residents' needs, strengths, and goals of care. Findings: Review of Resident 5's MDS assessment indicated the last comprehensive assessment was completed on 1/21/2019. Review of Resident 58's MDS assessment indicated Resident 58 was admitted on [DATE]. Resident 58's admission comprehensive assessment with ARD (Assessment Reference Date,is the last day of the observation period the assessment covers for the resident) of 7/13/2023 was not completed. Review of Resident 60's MDS assessment indicated the last comprehensive assessment was completed 10/01/2019. Review of Resident 61's MDS assessment indicated the last comprehensive assessment was completed 11/6/2021. Review 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 interview and record review, for six (Resident 4, 5, 60, 61, 63 and 159) of thirteen sampled residents, the facility failed to complete the quarterly Minimum Data Set assessments (MDS - Resident Assessment and care guide tool) according to the regulation. This failure had the potential to result in the delayed assessment of residents' needs, goals of care and inability to monitor each residents' progress over time. Findings: The following MDS record reviews were not completed every three months as follows: Review of Resident 4' MDS assessment indicated the last quarterly MDS assessment was completed 12/22/22. Review of Resident 5's MDS assessment indicated the last quarterly assessment was completed on 4/24/23. Review of Resident 60's MDS assessment indicated the last quarterly assessment was completed on 1/1/2023. Review of Resident 61's MDS assessment indicated the last quarterly assessment was completed on 2/6/2023. Review of Resident 63's MDS assessment indicated the last quarterly assessment was completed on 5/2/2022. Review of Resident 159's MDS assessment indicated…

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, for four (Resident 3, 59, 61, and 164) of 13 sampled residents , the facility failed to electronically transmit accurate and complete Minimum Data Set (MDS - an assessment screening tool used to guide care), data to the CMS system within 14 days after the facility completes a resident's assessment. Definition: CMS - The Centers for Medicare & Medicaid Services provides health coverage through Medicare and Medicaid-a government national health insurance program that provided health insurance for adults and children with limited income and resources. These failures had the potential to result in the delay of assessment of residents' needs, goals of care and inability to monitor each residents progress over time. Findings: Review of the MDS 3.0 Final Validation report dated 10/16/23 indicated Resident 3's quarterly assessments were completed on 7/22/2022 and the comprehensive assessment on 4/21/23 and was transmitted on 10/16/2023. Further review indicated Resident 3's…

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

Based on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutrition status for one ( (Resident 159) of three residents when Resident 159 lost 24% of her body weight in the last nine months. Resident 159 was not seen by a Registered Dietitian (RD) for a dietary evaluation since June 2023. This failure had the potential to cause additional weight loss and increase Resident 159's risk of morbidity (the condition of suffering from a disease or medical condition) and mortality (death). Findings: 1. During an observation on 10/16/23 at 12:20 PM, Resident 159 was in bed. She was not able to respond to questions with yes or no. Her food tray was on the side table and appeared untouched. The tray ticket (identifies patient name, their diet, and food likes and dislikes) indicated, Resident 159 was on a regular diet, mechanical soft texture, thin liquid diet. The tray had two items 1) a small bowl of porridge and 2) a 12 oz (ounce) can of soda. The resident was having trouble feeding herself and was spilling food on herself. A review 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 Based on interviews and record review, the facility failed to ensure two (Resident 59 and 2 ) of five sampled residents were free from unnecessary drug when; 1. Resident 59 was administered Zyprexa (antipsychotic) drug without adequate clinical indication for its use. Antipsychotic medications are used to treat mental health conditions, capable of affecting the mind, emotions, and behavior. 2. Resident 2's PRN (as needed) order for Haldol (antipsychotic) drug had no informed consent and stop date. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Zyprexa can increase the risk of death in elderly people who have memory loss and is not approved for use in psychotic conditions related to dementia. [Reference: www.[NAME].comp]. These failures had the potential for residents to receive unnecessary drugs and suffer adverse medication side effects. Findings: Review of Minimum Data Set (MDS, a resident assessment and care guide tool), dated 9/10/23,…

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 observation, interview, and record review, the facility failed to dispose of expired medications. These failures had the potential to result in the administration of expired medications to the residents and possible adverse (unwanted, undesirable) side effects or receiving medications that have become less effective for treatment. Findings: During a concurrent observation and interview on 10/17/23, at 10:51 a.m., with the Administrator (Adm), about the Medication Cart 1 ten tablets of expired famotidine (medication for excess stomach acid) 10 mg (milligram) were found inside Medication Cart 1's top drawer. Adm stated, the expired medications should not be in the cart and should have been disposed. During an interview on 10/19/23, at 11:06 a.m., with the Pharmacist Consultant (PC), PC stated, she was responsible for the disposal of expired medications from the medication cart. PC stated, expired medications should not be in the medication cart because of the possibility of giving the residents the expired medications. PC further stated, the residents could suffer the adverse…

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 maintain accurate records and account of discontinued controlled medications (medications which fall under United States Drug Enforcement Agency (DEA) Scheduled II-V (2 through 5) which have a potential for abuse, ranging from low to high, and may also lead to physical or psychosocial dependency) medications for two (Resident 153, and Resident 159) of three sampled residents. This failure had the potential for the diversion of the antianxiety medication Ativan (lorazepam) and sedative temazepam (Restoril) for unauthorized use. Findings: During a review of Resident 153's face sheet, Resident 153 was admitted to the facility in 2016 with diagnoses that included unspecified dementia (general term for the impaired ability to remember, think, or make decisions, that interferes with doing everyday activities) with behavioral disturbances. During a review of Resident 159's face sheet, Resident 159 was admitted to the facility with diagnoses 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for one of 13 sampled residents (Resident 157), the facility failed to complete the annual Minimum Data Set (MDS, an assessment tool used to guide care) as required. This deficient practice had the potential to result in Resident 157 not receiving the appropriate care and services. Findings: During a review of the admission Face Sheet for Resident 157, Resident 157 was admitted to the facility with multiple diagnoses that included cognitive (mental) deficits following a cerebral infarction (stroke). During an interview and concurrent record review with the Minimum Data Set Coordinator (MDSC), on 6/16/21 at 11:20 a.m., MDSC stated Resident 157's annual MDS dated [DATE], was not completed and should have been completed within 14 days of 9/19/20. MDSC further stated Resident 157's annual MDS assessment was comprehensive (full assessment) which identifies the resident's care needs. Review of Resident 157's annual MDS, dated [DATE], indicated the Assessment Reference 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 observation, interview, and record review, the facility staff did not notify the physician to re-evaluate the resident's mental capability or capacity to be their own responsible party (RP) for medical decisions for one, (Resident 110) of six sampled residents. After hospitalization, Resident 110 became more aggressive and confused and was not able to give consent in the absence of a conservator (a judge appoints a RP to care for another adult who does not have the capacity to make decisions about their health and finances). This resulted in Resident 110 signing consents for antipsychotic (Seroquel) and anti-anxiety medications (Ativan) without full awareness and understanding of the medications and their potential side effects or have a conservator act on the resident's behalf. Definition: Antipsychotic medication: Used to alter the brain chemistry to decrease psychotic episodes such as hallucinations (seeing or hearing things that no one else can) and delusions (false beliefs). Findings: During the initial tour of the facility on 6/14/21 at 9:15 a.m., Resident 110 stated…

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.