Maple Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the medication administration was in accordance with the professional standard of practice for one of three sampled residents (Resident 1). For Resident 1, the facility failed to record the administration site when Resident 1 was given the Lantus (drug used to control the amount of sugar in the blood) 20 units subcutaneously (SQ, under the skin) during the month of 12/24. This deficient practice had the potential for Resident 1 to have the Lantus given SQ in the same injection site that could lead to skin damage. Findings: During a review of the admission Record indicated the facility originally admitted Resident 1 on 7/21/23 and re-admitted on [DATE] with diagnoses including diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), long term use of insulin (hormone that removes excess sugar from the blood, can be produced by the body or given artificially by medication) and lack 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 interview and record review the facility failed to reconcile (a process of reviewing complete medication regimen during admission, transfer or discharge) a physician order upon re-admission to the facility for one for three sampled residents (Resident 1). For Resident 1, the facility failed to continue the physician's order for Lantus (drug used to control the amount of sugar in the blood) 20 units subcutaneously (SQ, under the skin) once a day at bedtime when Resident 1 was re-admitted to the facility on [DATE]. This deficient practice resulted in Resident 1 not given the Lantus 20 units SQ for six days and had the potential for Resident 1 to suffer from hyperglycemia (high blood sugar). Findings: During a review of the admission Record indicated the facility originally admitted Resident 1 on 7/21/23 and re-admitted on [DATE] with diagnoses including diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), long term use of insulin (hormone that…

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

Based on interview and record review the facility failed to implement measures to prevent loss of personal belongings for one of three sampled residents (Resident 1). For Resident 1, the facility failed to: 1.Ensure Resident 1's belongings list was reviewed and itemized to ensure all the personal belongings were given to Resident 1 when Resident 1 was discharged from the facility on 12/6/24. 2.Ensure the replacement hearing aids received by Resident 1 on 1/7/25 was an appropriate and correct fit for Resident 1. These deficient practices resulted in Resident 1 not given his right to keep his belongings secure while at the facility and to receive all the belongings when Resident 1 was discharged from the facility on 12/6/24. Findings: During a review of admission Record of Resident 1, the admission Record indicated the facility admitted Resident 1 on 2/9/24 with diagnoses including dementia (progressive state of decline in mental abilities), difficulty walking and abnormalities of gait and mobility. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool)…

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 develop and implement care plan for one of three sampled residents (Resident 1). For Resident 1 who had severe hearing loss on the left and right ears, the facility failed to: 1. Ensure Resident 1's care plan included appropriate interventions for Resident 1 who had severe hearing loss and needed hearing aids to hear clearly. 2. Address and provide appropriate interventions when Resident 1 constantly misplaced his hearing aids. Resident 1 lost his hearing aids on 5/7/24 and lost the replacement hearing aids on 9/26/24. These deficient practices had the potential for Resident 1 to have sensory deprivation and affect Resident 1's mental, physical, and psychosocial well-being. Findings: During a review of the admission Record of Resident 1, the admission Record indicated the facility admitted Resident 1 on 2/9/24 with diagnoses including dementia (progressive state of decline in mental abilities), difficulty walking and abnormalities of gait and mobility. During a review of Resident 1's Care Plan initiated on 3/18/24, the Care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident 1), who had severe cognitive impairment, had legally documented representation for decision making on behalf of the resident. This deficient practice caused Resident 1's rights to be violated as a resident living in the facility. Findings: A review of Resident 1's admission record (facesheet) indicated the resident was admitted to the facility on [DATE], with diagnoses including epilepsy (a disorder in which nerve cell activity in the brain is disturbed), schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), unspecified psychosis (a mental disorder characterized by a disconnection from reality), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). The admission record indicated Resident 1 was self responsible. A review of Resident 1's History and Physical dated 6/4/24 indicated, General consent for medical care 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 observation, interview, and record review, the facility failed to ensure one sampled resident (Resident 1), who had severe cognitive impairment, or the resident representative was informed and participated in the resident's care and treatment. This deficient practice caused Resident 1's rights to be violated as a resident living in the facility. Findings: A review of Resident 1's admission record (facesheet) indicated the resident was admitted to the facility on [DATE], with diagnoses including epilepsy (a disorder in which nerve cell activity in the brain is disturbed), schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), unspecified psychosis (a mental disorder characterized by a disconnection from reality), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). The admission record indicated Resident 1 was self responsible. A review of Resident 1's History and Physical dated 6/4/24 indicated, General consent 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Staff 1 (the housekeeper) had proper documentation of a background check in the employee file as part of abuse prevention. This failure had the potential to result in an employee working at the facility with potential violations of abuse. Findings: A review of Resident 3's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses including fracture of the left tibia (the inner and typically larger of the two bones between the knee and the ankle), lack of coordination, essential hypertension (high blood pressure). A review of Resident 3's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 3/27/24 indicated the resident had no acute change in mental status, had symptoms of feeling down with little interest or pleasure in doing things. A review of Resident 3's care plan for Alteration in Psychosocial Wellbeing related to alleged physical altercation with staff (Staff 1, housekeeper)…

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 one of two sampled residents (Resident 2), who was a known wanderer, received services to prevent accidents. Resident 2 was not supervised or monitored per the physician's order and the person centered care plan. This deficient practice caused an increased risk for accidents and injuries. Findings: A review of Resident 2 ' s admission Record (Face Sheet) indicated the facility admitted the resident on 6/3/2024, with diagnoses including dementia (loss of cognitive functioning- thinking, remembering, and reasoning- to such an extent that the loss interferes with a person ' s daily life and activities), schizophrenia (a serious mental disorder in which people interpret reality abnormally), and anxiety disorder (a condition in which a person has excessive feelings of fear, and uneasiness). A review of the admission / re-admission Data Tool Form dated 6/3/2024, indicated Resident 2 was transferred from another facility due to the need for close monitoring because of his confusion, and per his family request. 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 observation and interview, the facility failed to provide a clean, free of odor, safe and home like environment by failing to ensure that: 1. One of seven sampled residents (Resident 2) had a home like environment free of offensive odors. 2. The kitchen staff had a safe and sanitary environment to work in. This deficient practice resulted in Resident 2 having feelings of disgust and feeling unheard as well as lead to a disruption in disruption of their duties. Findings: 1. A review of the admission Record (FS) for Resident 2 indicated that Resident 2 was admitted on [DATE] with diagnoses including major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities), and essential (primary) hypertension (hypertension occurs when you have abnormally high…

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 report an allegation of abuse to the State Survey Agency, local law enforcement, and Ombudsman within two hours for one of five sampled residents (Resident 1). The deficient practice resulted in a delay of an on-site inspection by the State Survey Agency to ensure investigating Resident 1's allegation of abuse. Findings: A review of Resident 1's Face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including lack of coordination, schizoaffective disorder - unspecified, and major depressive disorder without psychotic features. During an interview on 8/28/2024 at 11:30 AM, Resident 1 stated over a week ago, she was trying to return a coffee cup to the kitchen and got hit on her back by one of the residents (Resident 2). Resident 1 stated, early morning around 6 AM (unable to recall specific day) Resident 2 came behind her cursing at her, asking why she was getting a coffee, then Resident 2 hit Resident 1 on the back…

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 the physician responded to the consultant pharmacist's recommendation from 4/17/24 and 5/8/24, to justify the use of risperidone (a medication used to treat mental illness) in one of five sampled residents (Resident 8.) -Ensure the physician responded to the consultant pharmacist's recommendation from 3/18/24 to obtain an ammonia level (a lab value used to ensure certain medications are used safely) related to the use of divalproex sodium (anticonvulsant, a medication used to treat seizures) in one of five sampled residents (Resident 8.) -Ensure the physician responded to the consultant pharmacist's recommendation from 3/18/24, 4/17/24, and 5/8/24, to justify the use of quetiapine (Seroquel, a medication used to treat mental illness) in one of five sampled residents (Resident 35.) The deficient practice of failing to ensure the physician evaluated and responded to medication irregularities (potential issues with a resident's medication regimen)…

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 that its medication error rate was less than five percent (%). Four medication errors out of 26 total opportunities contributed to an overall medication error rate of 15.38 % affecting three of five residents observed for medication administration (Residents 19, 35, and 45.) The medication errors noted were as follows: -Administration of clonazepam (Klonopin, a controlled substance medication, sedative, used to treat mental illness) to Resident 45 without a Physician's Order. -Allowed Resident 19 to self-administer fluticasone nasal spray (Flovent, a medication used to treat allergies) without prior approval. -Administration of Vitamin C (a supplement) to Resident 35 without a Physician's Order -Omitted one dose of Calcium/Vitamin D (a supplement) to Resident 35 The deficient practice of failing to administer medications in accordance with the physician's orders, including any required time frame, increased the risk that Residents…

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: -Discard and replace two expired insulin (a medication used to treat high blood sugar) pens affecting Residents 38 and 43 in one of two inspected medication carts (Medication Cart 2.) -Label one open bottle of latanoprost (a medication used to treat eye problems) with an open date affecting Resident 33 in one of two inspected medication carts (Medication Cart 1.) -Ensure an opened insulin (a medication is used to control high blood sugar) was not stored in the refrigerator per the manufacturer's requirements for Resident 26. The deficient practices of failing to label medications per the manufacturers' requirements and remove expired medications from the medication carts increased the risk that Residents 33, 38, and 43 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization or death. The deficient practice of ensuring an opened insulin was not stored in the refrigerator had the potential for Resident 26…

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

Based on observations, interviews, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills as followed: a. Staff failed to verbalize when to perform hand hygiene, when going from dirty to clean area. b. Staff failed to verbalize proper dishwashing for air drying. c. Staff failed to verbalize how to check dish machine temperatures. d. Staff failed to verbalize and follow the manufacturer's guidelines of chlorine test paper (a type of test strip) when checking the chlorine (a chemical used to disinfect dishes) sanitizer concentration. e. Staff failed to demonstrate how to properly check Quaternary ammonium (QUAT, a chemical used to sanitize kitchen surfaces) sanitizer concentration based on manufacturer's instruction. These failures had a potential to result in cross-contamination (a transfer of bacteria from one object to another), unsanitized dishware and bacterial growth to food that could lead to food borne illness (an illness caused by contaminated food and beverages) in 44 of 45 medically compromised residents who…

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

Based on observation, interview, and record review, the facility failed to follow the facility menu when residents on a regular diet consistency (diets with no restriction) had no gravy on their trays. This deficient practice had the potential to cause a decrease in food intake resulting to unintentional (not done on purpose) weight loss to 39 of 45 residents. Findings: A review of the facility's menu spreadsheet (a list containing types and amount of foods of what each diet type would receive) titled Daily Spreadsheet dated 7/8/2024, Monday, indicated residents on the following diets would receive gravy: -Regular diet one ounce ([1 oz] a unit of measurement) -No added salt diet ([NAS], no salt packets on the trays) 1 oz -Regular diet, large portion 2 oz -Regular diet, small portion 1 oz -Consistent Carbohydrate (diet that contained same servings of carbohydrate per meal to control blood glucose level), NAS 1 oz. During an observation of the trayline (an area where resident's foods were assembled) on 7/8/2024 at 12:06 PM, regular consistency diet trays had no gravy. During…

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 prepare food by methods that conserved appetizing temperatures when cold foods were in the danger zone (a range of temperature 41 degrees Fahrenheit ([°F], a scale of temperature) to 135°F in which bacteria grow rapidly) during trayline service. This deficient practice placed 44 of 45 facility residents at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen. Findings: A review of the facility's menu spreadsheet (a list containing types and amount of foods of what each diet type would receive) titled Daily Spreadsheet dated 7/8/2024, Monday, indicated regular, no added salt ([NAS], no salt packets on the tray), and consistent carbohydrate (diet that contained same serving of carbohydrate per meal aim to control blood glucose levels),NAS diet included the following food items on the tray: -Pork carnitas one (1) each -Great northern beans ½ cup ([c], a unit of measurement) -Gravy 1 oz -Fresh beets with orange ½ c -Flour tortilla 1 each -Choice of beverage 1 c -Apple…

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 storage and food preparation practices in the kitchen, including cross-contamination (transfer of harmful bacteria from one place to another), cleanliness of kitchen equipment, and hand hygiene. These failures had the potential to result in harmful bacteria growth and cross contamination which could lead to foodborne illness (transfer of bacteria from one object to another) in 44 of 45 medically compromised residents who received food and ice from the kitchen. Findings: A. a) During an initial kitchen tour observation on 7/8/2024 at 8:11 AM, the Dietary Supervisor (DS) was not wearing hairnet while working in the kitchen. The hairnet was not available in the front entrance instead hairnets were in the back entrance door. During an interview on 7/8/2024 at 8:15 AM, the DS stated the hair box on the front entrance broke last Friday and she was not able to have it fixed, as she was not here last Friday. The DS stated it was important to have hairnets available by the kitchen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents do not self-administer medications without prior approval by allowing one of five residents observed for medication administration (Resident 19) to self-administer fluticasone (a medication used to treat allergies) nasal spray without an interdisciplinary team (IDT - a multi-discipline group of healthcare professionals involved in periodically meeting and planning care for individual residents) evaluation or a physician's approval. The deficient practice of allowing Resident 19 to self-administer medication without an IDT evaluation for safety or physician's order increased the risk that he may have administered the wrong dose of fluticasone due to poor technique possibly resulting in medical complications. Findings: During an observation on 7/9/24 at 8:40 AM, Resident 19 was observed self-administering Fluticasone (Flonase) nasal spray prepared by the licensed vocational nurse (LVN 2). A review of Resident 19's admission…

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 report a resident-to-resident altercation to the State Survey Agency (SSA) within the appropriate time frame for two of three sampled residents (Resident 35 and Resident 206). This deficient practice resulted in a delay of onsite inspections by the Department of Public Health (DPH) and placed the residents at risks of further abuse (inappropriate treatment of an individual). Findings: A review of Resident 206's admission Record indicated the facility admitted the resident on 5/8/2024, with diagnoses including schizophrenia (a serious mental disorder in which people interpret reality abnormally), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), Parkinson disease (a brain condition that causes problems with movement, mental health, sleep, pain and other health issues), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss 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, the facility failed to ensure the Minimum Data Set (MDS - a standardized assessment and carescreening tool) was transmitted timely to the Centers for Medicare and Medicaid Services (CMS) system for one sampled resident (Resident 29). This deficient practice had the potential to result in delayed services for the resident. Findings: A review of Resident 29's admission Record indicated the facility admitted the resident on 2/4/2023, with diagnoses including anxiety disorder (a condition in which a person has excessive worry and feelings of fear), and insomnia (a sleep disorder in which you have trouble falling and/or staying asleep). A review of Resident 29's MDS initiated on 3/7/2024, indicated the reason for this assessment was Resident 29's discharge, that the discharge was planned, and the assessment was completed on 7/9/2024. A review of the Physician's Order dated 3/7/2024, indicated Resident 29 was clear for discharge from the facility on 3/7/2024 at 3 PM. A review of Resident 29's Discharge Summary Report dated 3/7/2024, indicated 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 interview and record review, the facility failed to accurately complete the minimum data set (MDS - a comprehensive resident assessment and care screening tool) assessment Section N (medications) on 3/28/24 by failing to indicate the resident's routine use of antipsychotic medication (medications used to treat mental illness) in one of five residents sampled for unnecessary medications (Resident 35.) The deficient practice of failing to accurately assess and indicate Resident 35's routine use of antipsychotic medication on the MDS comprehensive assessment Section N increased the risk that Resident 35 may not have received care planning and treatment according to his needs possibly leading to a decline in his overall health and well-being. Findings: A review of Resident 35's admission Record dated 7/9/24, indicated he was admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including dementia (a group of conditions characterized by a decline in mental function…

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 develop a baseline care plan for one of two sampled residents (Resident 47) within 48 hours of resident's admission. This deficient practice had the potential for delayed administration of necessary care and services. Findings: A review of Resident 47's admission Record (Face Sheet) indicated the facility admitted the resident on 2/7/2024, with diagnoses including anxiety disorder (a condition with excessive worry and fear that interferes with daily activities), and dementia (loss of the ability to think, remember, and reason to levels that affect daily life and activities). A review of Resident 47's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 5/13/2024, indicated the resident's cognitive skills (ability to think, remember and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 47 was independent for eating, oral hygiene, toileting hygiene, upper and lower body dressing, showering/bathing, and personal hygiene. 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 interview and record review, the facility failed to develop individualized comprehensive person-centered care plan to meet the resident's needs for two of five sampled residents (Resident 8 and Resident 26) as evidenced by: -Failing to create a comprehensive care plan to address problematic behaviors of auditory and visual hallucinations seeing and hearing voices of people that are not there related to the use of risperidone (a medication used to treat mental illness) for Resident 8. This deficient practice increased the risk that psychotropic medications (affect brain activities associated with mental processes and behavior) used to manage behaviors would not be periodically reevaluated as intended. This increased the risk that Resident 8 may have experienced adverse effects related to psychotropic medications possibly leading to impairment or decline in her mental or physical condition, functional status, or psychosocial status. -Failing to develop a care plan with goal and interventions 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to update and revise the care plan for two of three sampled resident's (Resident 12 and Resident 27). For Resident 27 after the resident sustained a fall on 5/31/2024 and Resident 12's hospice care plan (specialized care that provides physical comfort and emotional, social, and spiritual support for people nearing the end of life) did not reflect current physician's orders and had no been updated for over 10 months. This failure resulted in Resident 27 sustaining another fall on 7/2/2024 and had the potential to result in Resident 12 receiving inadequate care and services. Findings: a. A review of the face sheet indicated Resident 27 was re-admitted to the facility on [DATE], with diagnoses that included anxiety, depression, and congestive heart failure (a condition when the heart does not pump enough blood in the body). A review of the Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 7/3/2024 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.

Based on observation, interview, and record review, the facility failed to provide oral care to one of three sampled residents (Resident 12). Resident 12 had dry, cracked lips and did not receive oral care per the physician's order for 28 occurrences. This deficient practice had the potential for Resident 12 to develop a mouth infection and cause difficulty breathing. Findings: A review of Resident 12's admission Record indicated the facility re-admitted the resident on 9/16/2023 with diagnoses that included dementia (loss of thinking, remembering, and reasoning), encounter for palliative care (specialized medical care for people living with a serious illness, such as cancer or heart failure), muscle wasting and atrophy (decrease in size and thinning of muscle tissue), and contracture of muscle (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity). A review of Resident 12's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 4/16/2024, indicated the resident had severely impaired cognitive skills for 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.

Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident 48) skin protective arm sleeve was applied. This failure resulted in Resident 48's left arm to swell and turn red. Findings: A review of Resident 48's History and Physical dated 6/4/2024, indicated the resident had a past medical history of dementia (loss of memory, thinking and reasoning), with psychotic features (a mental disorder characterized by a disconnect from reality), seizure disorder (excessive surge of electrical activity in the brain), and anxiety disorder (mental health disorder characterized with feelings of worry or fear that interferes with one's daily activities). Resident 48 had diffused cherry angiomas (harmless, pinhead like bumps on skin) on skin. A review the Resident 48's Order Summary Report dated 6/6/2024 indicated may use a Geri-Sleeves (a device that protects the arm from skin abrasions, bruises, snags, and tears) as tolerated for skin management. A review of Resident 48's Minimum Data Set (MDS - a standardized assessment and care screening…

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 the correct Low Air Loss Mattress (LALM, a mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) settings for one of three sampled residents (Resident 12). This deficient practice had the potential to lead to poor circulation (reduced blood flow to various body parts) and cause a pressure injury (localized skin and soft tissue injuries that form because of prolonged pressure and shear, usually exerted over bony prominence's) for Resident 12. Findings: A review of Resident 12's admission Record indicated the facility re-admitted the resident on 9/16/2023 with diagnoses that included dementia (loss of memory, thinking and reasoning), encounter for palliative care (specialized medical care for people living with a serious illness, such as cancer or heart failure), muscle wasting and atrophy (decrease in size and thinning of muscle tissue), and contracture of muscle (occurs when your muscles, tendons, joints, or other tissues tighten or…

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 adequate supervision to prevent accidents for one of three sampled residents (Resident 27). Resident 27 did not receive frequent visual checks to monitor location, per the At Risk for Falls care plan. This failure resulted in the resident sustaining a fall on 5/31/24 and 7/2/24. Findings: A review of the face sheet indicated Resident 27 was re-admitted to the facility on [DATE], with diagnoses that included anxiety, depression, and congestive heart failure (a condition when the heart does not pump enough blood in the body). A review of the Minimum Data Set (MDS, a standardized assessment and care-screening tool) indicated Resident 27 was cognitively intact and needed supervision when ambulating due to issues with generalized weakness and impaired gait and mobility (difficulty with moving). A review of the At Risk for Falls care plan dated on 5/11/2024, indicated the goal for Resident 27 was to minimize the resident's risk for fall and injuries…

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 one of three sampled residents (Resident 47) maintained acceptable parameters of nutritional status by failing to obtain accurate weight and perform a nutritional assessment. This deficient practice had the potential to result in increased weight loss for Resident 47. Findings: A review of Resident 47's admission Record (Face Sheet) indicated the facility admitted the resident on 2/7/2024, with diagnoses including anxiety disorder (a condition with excessive worry and fear that interferes with daily activities), insomnia (a sleep disorder in which you have trouble falling and/or staying asleep), and dementia (loss of the ability to think, remember, and reason to levels that affect daily life and activities). A review of Resident 47's Nutritional Assessment Form for admission dated 2/7/2024, indicated the resident's most recent weight was 209 Pounds (lbs.- a unit of weight) which was measured by a standing scale. The assessment form 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.

Based on observation, interview, and record review, the facility failed to ensure residents receiving respiratory care was in accordance with the physician's order for one sampled resident (Resident 48). Resident 48's oxygen flow rate was not set to the physician ordered 2 liters. This failure had the potential to result in Resident 48 experiencing shortness of breath and lower oxygen saturation (the amount of oxygen carried by the red blood cells). Findings: A review of Resident 48's History and Physical dated 6/4/2024, indicated the resident had past medical history of chronic obstructive pulmonary disease (COPD - a lung disease that blocks airflow and make it difficult to breathe). A review the Resident 48's Order Summary Report, dated 6/3/2024, indicated, oxygen at 2 liters per minute via nasal cannula (thin, flexible tube that hooks around ears, with two prongs in the nose that delivers oxygen) continuously for diagnosis of COPD. A review of Resident 48's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 6/9/2024, indicated the resident 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.

Based on interview and record review, the facility failed to ensure staff competency evaluations were completed for one of three sampled Certified Nursing Assistants (CNA) 1. This failure had the potential for a knowledge, training, and certification deficit which could lead to inadequate resident care. Findings: A review of CNA 1's employee file it indicated that CNA 1 was hired on 1/1/2023 and there was no competency evaluation completed. During a concurrent interview and record review on 7/11/2024 at 10:11 AM, the Director of Staff Development (DSD) stated the DSD was responsible for ensuring that newly hired employees completed their competency skills evaluation for their position. The DSD stated that completing a competency evaluation was important to determine if an employee was competent for the position. The DSD reviewed CNA 1's employee file and was unable to provide a competency skills evaluation for CNA 1. A review of the facility's revised policy and procedure dated April 11, 2024 and titled, Competency of Nursing Staff, indicated all nursing staff must meet the specific…

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 accurately account for two doses of controlled medications (a high potential for abuse) affecting Residents 2 and 3 in one of two inspected medication carts (Medication Cart 1). This deficient practice increased the risk of diversion (any use other than that intended by the prescriber) of controlled mediations and that Residents 2 and 3 could have received too much or too little medication due to lack of documentation, possibly resulting in serious health complications requiring hospitalization. Findings: During an observation and concurrent interview of Medication Cart 1, on 8/27/24 at 11:21 AM, with the Director of Staff Development (DSD), the following discrepancies were found between the Controlled Drug Record (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication): -Resident 2's Controlled Drug…

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 sufficient documentation to support a diagnosis of seizure disorder in one of five residents sampled for unnecessary medications (Resident 8.) -Monitor valproic acid levels (a laboratory test used to ensure medications used to treat seizures are present at a safe and effect level in the blood) related to the use of divalproex sodium (a medication used to treat seizures) in one of five residents sampled for unnecessary medications (Resident 8.) The deficient practices of failing to sufficiently document a diagnosis of seizure disorder and monitor valproic acid levels related to the use of divalproex increased the risk that Resident 8 could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) or seizures related to valproic acid levels being too high or too low leading to medical complications possibly resulting in hospitalization. Findings: A review of Resident 8's admission Record dated 7/9/24,…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide sufficient documentation to support a diagnosis of schizophrenia (a mental illness characterized by seeing or hearing things that are not there) related to the use of risperidone (a medication used to treat mental illness) in one of five residents sampled for unnecessary medications (Resident 8.) The deficient practice of failing to ensure risperidone was only used to treat a medical condition as diagnosed and documented in the medical record increased the risk that Resident 8 could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to her medication therapy possibly leading to impairment or decline in her mental or physical condition or functional or psychosocial status. Findings: A review of Resident 8's admission Record indicated she was admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including encephalopathy (a brain disorder 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.

Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by not maintaining the trash area free from excess trash, plastic, empty plastic bottles, soiled gloves, and other dirt debris. This deficient practice had a potential to attract birds, flies, insects, pest and possibly spread infection to 44 of 45 facility residents. Findings: During an observation of the dumpster area outside of the facility on 7/8/2024 at 11:40 AM, plastic bottles, paper, soiled gloves, trash was on the ground. During a concurrent interview the Dietary Supervisor (DS) stated the trash fell from the trash bins during the truck garbage collection and that it was important to maintain the cleanliness of the garbage for infection and pest control as it would prevent flies and mice from going in the kitchen. The DS stated it was housekeeping responsibilities to maintain the cleanliness of the area. During an interview with the Housekeeping Supervisor (HKS) on 7/9/2024 at 10:46 PM, she stated she was responsible for cleaning the trash area and that they clean…

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 complete and accurate medical record by failing to record administered doses of clonazepam (Klonopin, a medication used to treat mental illness) for one of five sampled residents (Resident 45) observed for medication administration in the Medication Administration Record (MAR - a record of all medications administered, and monitoring performed for a resident) between 7/4/24 and 7/9/24. The deficient practice of failing to record administered doses of Klonopin in the MAR increased the risk that Resident 45 could have experienced medical complications related to administering Klonopin too frequently, possibly resulting in hospitalization. Findings: A review of Resident 45's admission Record indicated she was admitted to the facility on [DATE] with diagnoses including anxiety disorder (a mental health disorder characterized by feeling or worry or fear that are strong enough to interfere with daily activities). A review of the…

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

Based on observation, interview, and record review, the facility failed to maintain a safe, comfortable environment for one sample resident (Resident 44). Resident 44's toilet seat was not secure which had the potential to place the resident at risk for injury. Findings: During an observation on 7/8/2024 at 8:29 AM, Resident 44's the toilet seat not secured. During a concurrent interview, Resident 44 stated the toilet seat in his bathroom was wiggly and that it was difficult for him to get up from the toilet seat because it was loose. Resident 44 also stated that he informed staff, but no one had come to fix it. During an interview on 7/9/2024 at 7:29 AM, Licensed Vocational Nurse (LVN) 2 stated that when there was a maintenance request it was written down in the maintenance log located in the nursing station. LVN 2 stated she was unaware of the loose toilet seat for Resident 44 and that the resident's toilet seat should not be loose. LVN 2 stated it was a safety hazard for the resident and she would request for the toilet seat to be fixed. During an interview with the Maintenance…

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 sanitary conditions in the food services department when two flies were observed in the kitchen. This deficient practice had a potential to result in 44 of 45 residents, who received food from the kitchen, to acquire food borne illnesses (caused by consuming contaminated foods or beverages) by consuming potentially contaminated food. Findings: During an observation of the facility's kitchen back door on 7/8/2024 at 8:20 AM, the back door was wide open. During concurrent observation of the facility's kitchen and interview with the Dietary Supervisor (DS) on 7/8/2024, at 9:29 AM, the DS stated the back door had been open since this morning and they kept it open because it was too hot in the kitchen, but the door was usually closed. During concurrent observation of the lunch trayline (an area where resident's food was assembled) and interview with the DS on 7/8/2024 at 12:06 PM, there was a fly flying around the trayline area. The DS stated the fly came from the outside because the back door was opened…

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 and implement a comprehensive care plan for one of two sample residents (Resident 1). For Resident 1, the facility failed to develop a care plan that would address Resident 1's diagnosis of pulmonary histoplasmosis [fungal (yeast or mold) infection affecting the lungs [organs in the chest that control breathing]. This deficient practice resulted in facility failing to meet Resident 1's needs that would help Resident 1 attain his highest practicable well-being. Findings: During a review of the admission Record indicated the facility admitted Resident 1 initially on 6/29/23 and re-admitted on [DATE]. During a review of the GACH 1 History and Physical (H&P, a physician's examination of the resident) dated 2/23/24 indicated Resident 1 had dementia (impaired ability to remember, think or make decisions that interferes with doing everyday activities) and pulmonary histoplasmosis. During a review of Resident 1's Progress Notes (Health Status Notes)…

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 necessary care was consistently provided for one of three sampled residents (Resident 1), who was receiving hospice service (a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease, offers physical, emotional, social, and spiritual support for residents and their families), by failing to: -Ensure the hospice agency staff signed the hospice sign in sheet. -Obtain the most recent hospice plan of care. -Communicate with the hospice staff participating in the care of the resident to ensure quality care for the resident. These deficient practices had the potential to result in a delay of care and lack of coordination in delivery of hospice care and services to Resident 1. Findings: A review of Resident 1's admission Record, indicated the facility admitted the resident on 3/23/2017, with diagnoses including dementia (loss of the ability to think, remember, and reason to levels that affect daily life and activities), dysphagia…

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 protect the resident ' s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of four sampled residents (Resident 2). By failing to ensure CNA3 who was assigned to monitor Resident 2 did not leave the resident unsupervised on 4/20/2024. As a result, Resident 1 punched Resident 2 with a closed fist in the face on 4/20/2024 at 7:15 P.M., after Resident 1 wandered into Resident 2 ' s room. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 10/27/2023 with diagnoses including chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme high manic episodes to low…

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/and or implement a resident specific care plan (a document that outlines the facility ' s plan to provide personalized care to a resident based on the resident ' s needs) for one of four sampled residents (Resident 4) by failing to develop and implement a care plan to monitor and provide interventions for Resident 4 ' s Zyprexa (a medication to treat mental disorders) use. This failure had the potential to result in Resident 4 not being assessed and monitored for the side effects of Zyprexa which included dizziness, constipation, bladder pain, difficulty swallowing, and swelling of hands and feet. Findings: A review of Resident 4 ' s admission Record indicated the resident was originally admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses that included polyneuropathy (weakness, numbness, and burning pain in the hands and feet and sometimes to other parts of the body), opioid dependence (reliance on a substance found…

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 protect the resident's rights and dignity for one of three sampled residents (Resident 1). On 3/4/2024, Resident 2 struck Resident 1 with a closed fist. Findings: A review of Resident 1's admission Record indicated the facility originally admitted the resident on 2/2/2023, and re-admitted on [DATE], with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and schizoaffective disorder (a mental health problem where you experience psychosis [when people lose some contact with reality] as well as mood symptoms). A review of Resident 1's Minimum Data Set (MDS - an assessment and care screening tool) dated 2/8/2024, indicated the resident had severely impaired cognition (never/rarely made decisions). The MDS indicated Resident 1 required moderate assistance with personal hygiene, oral hygiene, upper and lower body dressing, shower/bathing, and toileting…

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

Based on interview and record review, the facility failed to ensure the discharge summary documented by the physician properly reflected the correct reason for discharge / transfer for one of three sampled residents (Resident 3). This deficient practice resulted in the inaccurate information conveyed upon discharge for Resident 3. Findings: A review of Resident 3 ' s admission Record (Face Sheet) indicated the facility admitted the resident on 1/31/2024, with diagnoses including schizophrenia (a serious mental disorder in which people interpret reality abnormally), and fracture of lower end of left femur (thigh bone). A review of Resident 3 ' s Minimum Data Set (MDS - a standardized assessment and screening tool) dated 2/6/2024, indicated the resident had severely impaired cognition (never/rarely made decisions) and required maximum assistance with toileting hygiene, showering/bathing, and upper body dressing. A review of the Physician's undated Discharge Summary Report, indicated Resident 3's transfer / discharge was necessary because the resident's health had improved sufficiently…

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 follow its policy and procedure titled, Smoking Policy- Residents, and ensure a completed smoking assessment for one of three sampled residents (Resident 2). This deficient practice had the potential to lead to the inadequate care of Resident 2. Findings: A review of the admission Record (Face Sheet) indicated the facility admitted Resident 2 on 10/27/2023, with diagnoses including schizophrenia (a serious mental disorder in which people interpret reality abnormally), epilepsy (a brain condition that causes recurring seizures [a sudden, uncontrolled burst of electrical activity in the brain]), and anxiety disorder (a mental health disorder characterized by feelings of worry, or fear that are strong enough to interfere with one`s daily activities). A review of Resident 2's SBAR Communication Form (Situation-Background-Assessment and Recommendation) dated 11/12/2023, indicated the resident had aggressive behavior towards the staff such as striking 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 interview and record review, the facility failed to review and revise the Alteration in Psychosocial Well Being Care Plan for one of three sampled residents (Resident 1 ). This deficient practice had the potential to result in Resident 1 receiving inadequate care and supervision at the facility. Findings: A review of Resident 1 ' s admission Record indicated the facility originally admitted the resident on 2/2/2023, and re-admitted on [DATE], with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and schizoaffective disorder (a mental health problem where you experience psychosis [ when people lose some contact with reality] as well as mood symptoms). A review of Resident 1 ' s Minimum Data Set (MDS - an assessment and care screening tool) dated 2/8/2024, indicated the resident had severely impaired cognition (never/rarely made decisions) and required moderate assistance with personal hygiene, oral…

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 Administration failed to provide effective leadership and oversight of processes and policies and procedures to ensure an effective system was in place to ensure Resident 4, who was known to have eloped twice from a previous facility, and all residents at risk for elopement (leaving the facility without notice or permission, presenting an imminent threat to resident's health and safety) did not elope from their facility. As a result, Resident 4 eloped from the facility on 2/22/2024. Resident was at risk of decline in physical, mental, and psychosocial condition due to interrupted medical care and medications, injury, pain, serious harm, or death. Resident had not been found nor returned to the facility as of 2/29/2024. Findings: A review of Resident 4's admission Record (background information; a document containing demographic and diagnostic information), indicated, Resident 4 was admitted to the facility on [DATE] with the diagnoses including…

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 order physician prescribed medications from pharmacy and also failed to follow up on the ordered medications with the pharmacy for one of three sampled residents (Resident 1). The facility admitted Resident 1 on 12/12/23, ordered Resident 1 ' s medications on 12/13/23, and administered the medications to Resident 1 on 12/14/23. These deficient practices resulted in Resident 1 not receiving her medications for 24 hours from 12/13/2023 to 12/14/2023 which delayed the care and treatment to meet the needs of Resident 1. Findings: During a review of the admission Record for Resident 1, indicated the facility admitted Resident 1 on 12/12/23 with diagnoses including major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizophrenia (serious mental illness that affects how a person thinks, feel, and behaves) and anxiety disorder. During a review of the Physician Telephone Order dated 12/12/23 at 5:57 p.m., 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop baseline care plan for two of three sampled residents, Resident 1 and Resident 2. The facility failed to develop the baseline care plan within 48 hours of admission for Resident 1 who was admitted on [DATE] and for Resident 2 who was admitted on [DATE]. These deficient practices had the potential for the facility not to meet the residents ' immediate care needs. Findings: 1. A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 7/11/23 with diagnoses including paranoid schizophrenia (mental disorder where a person feels distrustful and suspicious of other people), bipolar disorder (chronic mood disorder that causes intense shifts in mood, energy level and behavior) and anxiety disorder. During a review of the Minimum Data Set (MDS, standardized care and screening tool) dated 7/17/23, indicated Resident 1 had moderately impaired cognition (condition in which people have more memory or thinking problems than other…

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 medications were administered as ordered by the physician for one of three sampled residents (Resident 2). For Resident 2, the facility failed to: 1.Document medications were administered as soon as given and failed to document the reasons why the medications were not administered. 2.Ensure routine medications were administered as prescribed by the physician and medication was readily available to be administered. These deficient practices resulted in facility failing to determine if the medications were administered to the resident, prevent the potential for medication errors, medication duplication and delay in care and treatment to meet the needs of the resident. Findings: A review of Resident 2's admission Record indicated the facility admitted Resident 2 on 7/13/23 with diagnoses including schizoaffective disorder (mental condition that causes loss of contact with reality and mood problems), major depression, anxiety disorder…

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 pharmaceutical services met the needs of each resident for one sampled resident (Resident 22) and failed to establish a system of pharmaceutical records. The facility did not reassess Resident 22 for continued need of pain medication, did not ensure the Emergency Medication Kit (E-Kit) that contained controlled (medications with a high potential for abuse or addiction) medication was replaced and did not remain in the facility for over 60 days once opened, and did not accurately document the physical inventory of controlled medications. These deficient practices had the potential for necessary medications not to be readily available when urgently needed for a resident and increased the risk for misuse, abuse, or diversion of controlled medications. Findings: a. A review of Resident 22's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including age-related Osteoporosis (a disease 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 observation, interview, and record review, the nursing staff failed to initiate a care plan for Enoxaparin (a blood thinner used to prevent and treat blood clots) for 1 of 14 sampled residents Resident 39. This deficient practice could have resulted in Resident 39 experiencing side effects from Enoxaparin such as uncontrolled bleeding, increased confusion and severe skin bruising. Findings: A review of Resident 39's admission record on 11/2/2021 indicated Resident 39 was admitted to the facility on [DATE] with Dementia (memory loss that gets worse over time), high cholesterol, high blood pressure. A review of the Minimum Data Set, dated [DATE], indicated Resident 39 had some difficulty with memory and answering some questions correctly. A review of Resident 39's Care Plan on 11/2/2021 at 10:40 AM did not indicate a Care Plan for use for Enoxaparin. During an interview and medication administration observation on 11/2/2021 at 10:40 AM, LVN 2 injected Enoxaparin 40 mg=0.4 ml into Resident 39's left lower…

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 correctly administer the medication Enoxaparin (a medication used to prevent blood clots) to one of 15 sampled resident (Resident 39), when a nurse injected the resident with Enoxaparin in the same location multiple days in a row. This deficient practice could have caused Resident 39 to have unnecessary bleeding, increased confusion, and painful severe skin bruising. Findings: A review of Resident 39's admission Record indicated Resident 39 was admitted to the facility on [DATE] with a diagnoses including Dementia (a brain condition that causes memory loss and mental confusion), high cholesterol, and high blood pressure. A review of the History and Physical Examination, dated 9/26/2021, indicated Resident 39 had medical diagnoses of dementia, high cholesterol, and high blood pressure, and could make decisions regarding his care. A review of the Minimum Data Set, dated [DATE], indicated Resident 39 had some difficulty with memory 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 follow their policy and procedures for medication storage to prevent deterioration of medications stored under refrigeration for the facility's one of one medication room's refrigerator. The facility failed to have a thermometer in the refrigerator to accurately monitor and document refrigerator temperature, to ensure appropriate storage of medications requiring refrigeration. This deficient practice had the potential to affect residents' well-being and health negatively by increasing their risk of receiving medications that may have become ineffective. Findings: During an observation and interview on 11/3/2021, at 11:20 a.m., with the Director of Nursing (DON) inside the facility's medication room, located behind Nursing Station 1, the DON opened the medication refrigerator. There was no thermometer observed inside the refrigerator and the DON stated, I do not see a thermometer in the refrigerator. There is a thermometer in the freezer. The DON stated the facility staff must have missed placed 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 and interview. the facility failed to follow their policy and procedure for infection control for two of six sampled residents (Resident 51 and Resident 12) during medication pass observation. The facility failed to ensure a licensed vocational nurse (LVN 1) washed and/or sanitized her hands before administering Resident 51 and Resident 12's morning medications. This deficient practice increased risk for the spread of infection and had the potential for the transmission of infectious agent between residents. Findings: During an observation on 11/3/2021 between 9:04 a.m. to 9:12 a.m., during a medication pass observation, LVN 1 prepared Resident 51's morning medications. LVN 1 stated she prepared three morning medications for Resident 51. LVN 1 during medication preparation was observed using her hands to repeatedly open and close the medication cart to remove and replace medication from the medication cart in the preparation of Resident 51's medication. LVN 1 was observed carrying the prepared medications into Resident 51's room and administered the medications…

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.