Glenhaven Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure bedside curtains for one (1) of two sampled residents (Resident 2) was fully closed, when Resident 2 tested positive for influenza (a severe lung infection) and required to be on droplet precaution (a set of infection control measures used to prevent the spread of respiratory infections from a patient to others) in accordance to public health guidelines on influenza outbreak taking place in the facility. This deficient practice had the potential to result in wide spread influenza infectiion spreading to other residents and staffs in the facility. Findings: During an observation on 1/28/25 at 2:15pm in Room A, the curtain for Resident 2 was partially open, two other beds were occupied with other residents, a certified Nurse Assistant (CNA 3) was observed wearing simple face mask in the room. During a review of Resident 2's admission Record, Resident 2 was admitted on [DATE] with medical diagnoses that included Diabetes Mellitus…

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 the necessary care and interventions to prevent pressure injury (PI-damage to an area of the skin caused by constant pressure on the area for a long time) for one (1) of three (3) sampled residents (Resident 1) by failing to turn, reposition and to off-offload (release pressure) from an area of the body every two hours while in bed, keep clean and dry after a bowel movement or wetness from urine due to incontinence (unwanted passage of urine or stool that you can ' t control). These deficient practices resulted in: 1. Resident 1 developed a facility-acquired Stage 2 (partial-thickness loss of skin, presenting as a shallow open sore or wound) PI on sacrococcyx (tailbone) area on 10/15/24, and proceeded to Stage 3 (Full-thickness loss of skin. Dead and black tissue may be visible) with drainage on 10/22/24. 2. A sacrococcyx PI reopened on 12/18/24 after MASD (Moisture Associated Skin Damage) developed on 12/8/24, and on 12/26/24…

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 garbage and refuse (food waste, scraps) properly by not covering one of one metal dumpsters (large trash container designed to be emptied into a truck) due to overflowing trash bags filled with garbage, and leaving additional trash bags, boxes, and an old mattress on the ground by the garbage area. This deficient practice had a potential to attract birds, flies, insects, pest, rodents, and possibly spread infection to residents and staffs in the facility. Findings: During a concurrent observation and interview on 11/18/2024 at 10:55 AM with the Maintenance Supervisor (MS) in the facility's garbage area, one metal dumpster was observed with the lid open due to overflowing trash bags filled with garbage, and additional trash bags, boxes, and an old mattress on the ground by the garbage area next to the bin. The MS stated, the housekeeping supervisor was responsible of making sure the trash bin was empty, and the garbage area was clean. The MS stated, we were also responsible in making sure this area 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 observation, interview and record review, the facility failed to accommodate the needs of three of three sampled residents (Resident 1, 9, and 45) by failing to ensure residents call light (a device used by residents to signal his or her needs for assistance) was within reach. These deficient practices had the potential for Resident 1, 9, and 45 not able to call the facility staff to ask for help or assistance. Findings: 1. During a review of Resident 9's admission Record indicated the facility admitted Resident 9 on 1/23/2024 with diagnoses that included dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and blindness of left eye. During a review of Resident 9's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 8/9/2024, indicated Resident 9 had severely impaired memory and cognition (ability to think and reason). The MDS indicated Resident 9 was dependent with oral hygiene, shower/bathe…

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 and record review the facility did not follow policy and procedure for Food Storage Principle, on food storage, and in accordance with professional standards for food service safety by failing to: 1. Discard 15 ham sandwiches in a steel pan in the refrigerator with an expired used by date of 11/14/2024. 2. Label and date an open plastic bag with two hotdog buns in the refrigerator. 3. Discard six breaded fish in an open plastic bag in the freezer with an expired used by date of 11/10/2024. 4. Label and date a pitcher of prune juice in the refrigerator. These deficient practices had the potential to result in food contamination, growth of microorganisms (disease causing organism) that could cause foodborne illness (food poisoning or food illness due to pathogens (harmful organism that cause illness such as bacteria, viruses, or parasites) and toxins that contaminate food and negatively affect the health of the residents who consumed it. Findings: During a concurrent observation and interview on 11/18/2024 at 8:30 AM with the Dietary Service…

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 implement the facility 's policy and procedure on infection control to prevent the spread of infection for 3 of 6 sampled residents (Resident 101, Resident 5, and Resident 39) by failing ensure Certified Nurse Assistant (CNA) 6 practice proper hand hygiene and wear gloves or gowns in Resident 5's contact precaution (a set of measures to prevent the spread of infectious agents through direct or indirect contact with individuals or an environment) room. These deficient practices had the potential to result in the spread of infection (a process when a microorganism, such as bacteria, fungi, or a virus, enters a person's body and causes harm). Findings: During a review of Resident 5's admission Record, the facility admitted Resident 5 on 3/5/2021 and readmitted her on 10/4/2024 with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD, a chronic lung disease causing difficulty in breathing), muscle weakness, and metabolic…

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 certified nurse assistant (CNA) 3 was seated when assisting one of eight sampled Residents (Resident 2) during mealtime. This deficient practice had the potential to result in feelings of decreased self-esteem and self-worth for Residents 2. Findings: During a review of Resident 2's admission Record indicated the facility originally admitted Resident 2 on 5/18/2016 and readmitted her on 9/10/2024 with diagnoses that included dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and hemiplegia (a condition that causes partial or complete paralysis on one side of the body). During a review of Resident 2's Initial History and Physical, dated 9/13/2024, indicated Resident 2 does not have the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 9/14/2024, indicated Resident 2 was dependent with eating, oral hygiene, shower/bathe self, toilet…

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 an advance directive (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) and Physician Orders for Life Sustaining Treatment (POLST, a medical order form that tell medical staff what to do if you have a medical emergency and are unable to speak for yourself) was accessible in residents medical records (physical paper chart) for one of eight sampled residents (Resident 41). Resident 41's paper chart did not have a copy of the Advance Directive Acknowledgement and the original POLST. This deficient practice had the potential for Resident 41's medical treatment, provisions, to be delayed and/or not be carried out, according to the Resident 41's and/or Responsible Party's request during an emergency, which can negatively affect Resident 41's quality of care. Findings: During a review of Resident 41 ' s admission Record 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 observation, interview, and record review, the facility failed to provide adequate supervision for two of two sampled residents (Residents 4 and 23) when: 1. Resident 4, who was a high risk for fall, was observed in bed reaching for his drinks by the bedside table, without a floor mat as per plan of care to prevent injury from fall. 2. Resident 23, who was a high risk for fall, and had a fall incident on 11/18/2024 in Room B (RB-not Resident 23's room) witnessed by a Resident in Room B (RRB), was not frequently monitored, or supervised as per plan of care. These deficient practices had the potential for to cause major injury from a fall and negatively affect Residents 4's and 23's quality of life. Findings: 1. During a review of Resident 4 ' s admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included psychosis (symptoms that cause a person to lose touch with reality, or have a break in their thoughts and perceptions),…

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 attempt to use appropriate alternative interventions before the installation of bilateral ¼ siderails (quarter bars that are attached to the side of the bed to help with safety and comfort) for one of four sampled residents (Resident 31). This failure had the potential for Resident 31 to be at risk for entrapment (when a resident can get caught by the head, neck, chest, or other body parts in tight spaces around the siderail) and physical injury. Findings: During a review of Resident 31 ' s admission Record, the facility admitted Resident 31 on 6/22/2023 and readmitted Resident 31 on 12/28/2023 with diagnoses that included hypertensive heart (heart problems that occur because of high blood pressure over time) and chronic kidney disease (kidney damage over time) with heart failure (heart cannot pump enough blood to meet the body ' s needs) and muscle weakness (the muscle does not have enough strength to move normally). During a review of Resident 31 ' s History and Physical (H&P, a comprehensive physician ' 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain a complete and accurate medical records in accordance with the facility ' s policy and procedure (P&P) titled, Documentation Guidelines, for two of four sampled residents (Resident 14 and Resident 50) by failing to: 1. Ensure the Infection Preventionist document wound care treatment as provided to Resident 14 on 9/5/24. The IP stated she was covering for the treatment nurse and forgot to document it in the Treatment Administration Record (TAR). 2. Document Resident 50 ' s discharge disposition (the location to which the resident was transferred to) in the resident ' s discharge record. These deficient practices had the potential to negatively impact the delivery of services to Resident 14 and had resulted in Resident 50 ' s discharge record to be inaccurate. Findings: 1.During a review of Resident 14 ' s admission record indicated the facility originally admitted Resident 14 on 12/22/2021 and readmitted on [DATE], with diagnoses that included…

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 residents received treatment care and services, in accordance with professional standards of practice, for one of three sampled residents (Resident 1) by: 1. Failing to honor Resident 1 ' s request to transfer to the acute hospital on 9/6/26 due to a change in condition for more than 4 hours. 2. Failing to assess, recognize, intervene, after Resident 1 had a change of condition on 9/6/24. 3. Failing to document Resident 1 ' s condition in the facility forms titled SBAR (Situation, Background, Action, Respond). These deficient practices had the potential to delay in the delivery of necessary care and services for Resident 1 and negatively affect Resident 1 ' s psychosocial wellbeing. Findings: During a review of Resident 1's Face Sheet (admission record), the Face Sheet indicated the facility admitted the resident on 8/30/2024 with diagnoses including chronic obstructive pulmonary disease(lung disease causing restricted airflow and breathing problems), respiratory failure (a serious condition that makes it difficult…

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 the interview and record review, the facility failed to ensure that LVN (Licensed Vocational Nurse)1 who was from a Nursing Registry [a business or agency that provides nursing staff to hospitals], demonstrated the necessary competency to provide adequate care for one of three sampled residents, (Resident 1). This deficiency had the potential to negatively impact Resident 1's psychosocial well-being and delay the delivery of critical care. Findings: During a review of Resident 1's Face Sheet (admission record), the Face Sheet indicated the facility admitted the resident on 8/30/2024 with diagnoses including chronic obstructive pulmonary disease(lung disease causing restricted airflow and breathing problems), respiratory failure (a serious condition that makes it difficult to breathe on your own which develops when the lungs can't get enough oxygen into the blood), and generalized anxiety disorder( a mental disorder that causes people to experience excessive, uncontrollable, and irrational worry that interfered with their daily living). During a review of Resident 1'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 ensure safe and sanitary food preparation practices in the kitchen when one of two dietary staff, Dietary Staff (DS) did not perform hand hygiene (a way of cleaning the hands, which can prevent the spread of germs) and/or change gloves in between preparing sandwiches for 40 residents, and also touching the coffee machine, and the menu, sheet during tray line (a system of food preparation, used in hospitals, in which trays move along an assembly line) observation for lunch. This deficient practice had the potential to result in a harmful bacteria cross contamination (transfer of harmful bacteria from one person, object, or place to another) that could lead to foodborne illness (caused by consuming contaminated foods or beverages) that could negatively affect residents who received food from the kitchen. Findings: During a food preparation observation in the kitchen on 11/28/2023 at 11:50 PM, the DS touched the surface of the coffee machine and then touched the lunch menu sheet without performing hand hygiene…

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 privacy and dignity to 1 of 4 sampled residents (Resident 25) when Certified Nurse Assistant (CNA 6) did not cover the Resident 25's naked body and did not close door while transporting Resident 25 from bedside commode to bed. This deficient practice had the potential for others to see Resident 25's naked body which may cause psychosocial harm to the resident. Findings: During an observation on 11/27/2023, observed CNA 6, use a mechanical lift to transport Resident 25 from the bedside commode to Resident 25's bed. Resident 25's naked body was exposed resulting in the potential for visitors to see Resident 25's naked body. The bathroom and bed are in Resident 25's room. The door was open to the hallway where persons were walking during the transfer. During an interview on 11/30/23 at 9:10 AM, with CNA 6, CNA 6 stated, I do not close the door to the room because I am inside the room. During an interview on 11/30/23 at 9:23 AM, with Charge Nurse (16-another identifier?) stated, When a resident is moved…

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 obtain an informed consent from the responsible party for one of two sampled residents (Resident 28) who was prescribed Lorazepam (medication used to treat anxiety [a mental disorder that result in having the fear of the unknown]); Zyprexa (a medication used to treat psychotic conditions such as schizophrenia [a serious mental illness that affects how a person thinks, feels, and behave] and bipolar disorder [mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration], Depakene (medication used to treat seizure disorders [burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements] that stabilizes mood, and Clozapine (a medication to treat medication for treatment-resistant schizophrenia). This failure violated Resident 28's rights to be informed about the side effects (undesired effect of medication) and when choosing the type of care or treatment to be received, make decisions on alternative…

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 accurately assess, reflective of the resident's status at the time of the assessment for one of four residents (Resident 41). The Social Service Designee (SSD) did not assess Resident 41's communication needs due to the resident being asleep during the assessment and documented Resident 41 was not interview able. As a result of this deficient practice, Resident 41 did not receive the communication tools needed to communicate needs which had the potential for the resident not to receive the care and services needed to maintain the highest well-being. Findings: A review of Resident 41's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses of, but not limited to, dysphagia (difficulty swallowing), urinary tract infection (An infection in any part of the urinary system, the kidneys, bladder, or urethra) and chronic heart failure (A chronic condition in which the heart doesn't pump blood as well as it should). 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 obtain a Preadmission Screening and Resident Review (PASARR - a federally required screening for mental health; PASARR Level I identifies suspected mental illness, intellectual/developmental disability, or related condition; Level II screening determines if the individual would benefit from specialized mental health services) Level II evaluation for two of two sampled residents (Resident 22 and 3). This failure had the potential to result in Resident 22 and Resident 3 not to receive necessary mental health services which can negatively affect their quality of life. Findings: 1. A review of Resident 22s facesheet indicated the resident was initially admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses of schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should ) 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 person- centered care plan addressing resident specific interventions for one of four sampled residents (Resident 16). This deficient practice had the potential to negatively affect the delivery of care and services related to the residents' health conditions and needs. Findings: A review of Resident 16's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of, but not limited to, hemiplegia (paralysis that affects one side of the body), dysphagia (difficulty swallowing), and epilepsy (A disorder in which nerve cell activity in the brain is disturbed, causing seizures). A review of Resident 16's comprehensive admission Minimum Data Set (MDS - a standardized assessment and screening tool) dated 10/7/2023, indicated the resident had severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making. The MDS 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, the facility failed to revise the care plan for one of four sampled residents (Resident 29) to indicate diet modifications. These deficient practices had the potential to result in Resident 29 not receiving the proper diet. Findings: A review of Resident 29's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of, but not limited to, dysphagia (difficulty swallowing), encephalopathy (A broad term for any brain disease that alters brain function or structure), and diabetes (A group of diseases that result in too much sugar in the blood). A review of Resident 29's comprehensive admission Minimum Data Set (MDS - a standardized assessment and screening tool) dated 9/1/2023, indicated the resident had severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making. The MDS indicated the resident was totally dependent on staff for activities of daily…

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 good personal hygiene and activities of daily living (ADL) by ensuring the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) was within reach for 2 of 2 sampled residents (Resident 38 and Resident 18) who needed assistance with ADLs as indicated in the facility's policy and procedure, titled Answering the Call Light and the resident's care plan. This deficient practice had the potential for Resident 38 and 18 not to receive needed assistance to achieve their highest potential and wellbeing. Findings: 1. A review of Resident 38s admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included generalized muscle weakness, generalized anxiety disorder (persistent and excessive worry that interferes with daily activities), abnormalities of gait and mobility (weakness of the hip and lower extremity…

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 assistive device, such as a call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) within reach for two of two sampled residents (Resident 38 and Resident 18) who were at high risk for fall. This deficient practice had the potential for Resident 38 and 18 not to be assisted when needed assistance with activities of daily living (ADL) or in an event of emergency and result in accidents and injury. Findings: 1. A review of Resident 38s admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included generalized muscle weakness, generalized anxiety disorder (persistent and excessive worry that interferes with daily activities), abnormalities of gait and mobility (weakness of the hip and lower extremity muscles), and chronic obstructive pulmonary disease (COPD-an inflammatory lung disease that causes…

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 provide medically related social services to one of four residents sampled (Resident 41). The Social Service Designee (SSD) failed to accurately assess and arrange Resident 41's communication needs through the resident's primary method of communication or in a language that the resident understood. As a result of this deficient practice, Resident 41 had the potential not to receive the care and services especially during an emergency needed to maintain or achieve the highest practicable mental and psychosocial well-being. Findings: A review of Resident 41's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses of, but not limited to, dysphagia (difficulty swallowing), urinary tract infection (An infection in any part of the urinary system, the kidneys, bladder, or urethra) and chronic heart failure (A chronic condition in which the heart doesn't pump blood as well as it should). A review of Resident 41'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.