Madison Grove Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a safe and sanitary environment for one of 10 residents (Resident 54) reviewed for smoking, when the rain gutter (a long, hollow channel, often made of metal or plastic, attached to the edge of a roof to collect rainwater and direct it away from the buildings foundation) above the door of the smoking area was not maintained and caused a constant leak to the walkway.This failure had the potential to expose Resident 54 to unsafe walkway conditions when entering the smoking area, due to structural damages and increased the risk for falls.During a review of Resident 54's admission Record (contains demographic and medical information), it indicated, Resident 54 was initially admitted to the facility on [DATE], with the medical diagnosis of Guillain-Barre syndrome (autoimmune condition where the body's immune system mistakenly attacks its own peripheral nerves), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in…

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 adequate supervision was provided to prevent avoidable accidents when one of four residents (Resident 2)'s left knee noted with pain and fracture of the proximal left tibia (break in the long bone of the left lower leg). This failure resulted in Resident 2 a clinically compromised resident being sent to the hospital for evaluation and treatment. Findings: During an observation on March 19, 2025, at 12:35 PM, Resident 2 was lying in bed awake and did not respond verbally. During an interview on March 19, 2025, at 12:50 PM, with Certified Nursing Assistant (CNA 2), the CNA 2 stated, He (Resident 2) does not talk. He is total dependent with ADLs (activity of daily living). I usually give him bath, clean and change him, and reposition him every two hours. During an interview on March 19, 2025, at 1:00 PM, with Licensed Vocational Nurse (LVN 2), LVN 2 stated, [Resident 2's name] does not talk. I don't know what happened, but I know he…

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 prevent a pressure ulcer (damage to area of the skin due to pressure) from developing for one of three sampled residents (Resident 1). This failure placed a clinically compromised Residents (Resident 1) health and safety at risk for potential infection and pain. When the facility failed to prevent the development of a stage 3 pressure ulcer on right trochanter (hip). Findings: During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: esophageal cancer (cancer of the tube from throat to stomach), tracheostomy (tube inserted to help oxygen reach lungs), (diabetes type II (body does not produce enough insulin, or resist insulin), hypertension (high blood pressure). During a review concurrent interview and record review of Resident 1's Medical Record with the Assistant Director of Nurses (ADON and Treatment Nurse (TXT Nurse), reviewed as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to protect the resident ' s right to be free from verbal abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for one of three residents (Resident 1) when staff witnessed a Respiratory Therapist 1 (RT 1, a professional person who is responsible in taking care of patients who has respiratory problems) clapping loudly in Resident 1 ' s face while using foul language. This failure resulted in resident 1 ' s rights being violated and had the potential for Resident 1 to experience psychosocial harm. Findings: During a review of Resident 1 ' s admission Record (contains demographic information), the admission Record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included hypertensive heart disease (number of complications of high blood pressure affecting the heart), chronic kidney disease(disease that cause kidney…

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 adequate supervision was provided to prevent avoidable accidents when one of seven residents (Resident 1) noted to have swelling of the left thigh and knee. This failure contributed to Resident 1 sustaining an acute distal femur shaft fracture (sudden break in the long part of the thigh bone). Findings: During an observation on May 20, 2024, at 4:15 PM, Resident 1 was lying in bed awake and did not respond verbally. During a review of Resident 4 ' admission Record (general demographics) on May 20, 2024, the document indicated Resident 1 was originally admitted to the facility on [DATE], with diagnoses that include traumatic hemorrhage of cerebrum (a condition brain injury), respiratory failure (a condition that makes it difficult to breathe on your own, asthma, seizures (a condition that causes sudden shaking or stiffness), hypertensive (a condition of high blood pressure, and gastrostomy status (a tube inserted through the wall of…

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

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation were maintained, as well as safe and sanitary practices were maintained in the kitchen when: 1. There were food crumbs and grease residue in the oven that had the potential to promote bacteria growth within this area as well as attract microorganism (small organisms which have the potential to cause disease) carrying pests. 2. The floor under the oven and stove had food crumbs and grime that had the potential to attract microorganism carrying pests. 3. There were streaks of white residue on the sides of the oven and stove that had the potential to attract microorganism carrying pests. These failures had the potential to increase risk of resident harm related to disease causing microorganisms contaminating the residents' food which could cause food-borne illness to a population of immuno-compromised residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview on April 19, 2022, at 8:30 AM, with the Dietary Services Director…

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 discuss and provide information on advanced directives (a written statement of a person's wishes regarding medical treatment, should the person is unable to communicate with the doctor) for two of 49 sampled residents (Residents 139 and 141). This failure had the potential to cause Residents 139 and 141's values and desires related to end-of-life care not to be carried out. Findings: 1. A review of Resident 139's face sheet (a document that gives a summary of resident's information), undated, indicated an admission date of February 27, 2021, with a diagnosis of unspecified dementia (a disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) with behavioral disturbance (such as: sleep disturbances and agitation (physical or verbal aggression, general emotional distress, restlessness, pacing, shredding paper or tissues and/or yelling). A review of Resident 139's Physician Orders for Life-Sustaining Treatment (POLST) dated…

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 Pre-admission Screening and Resident Review (PASRR- a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) was re-evaluated after a Significant Change in Status Assessment (SCSA- a comprehensive Minimum Data Set [MDS- a facility assessment tool] assessment done for resident that must be completed when a resident meets the significant change guidelines for either improvement or decline), for one of four residents reviewed for PASRR (Resident 61). This failure had the potential for Resident 61 not to receive the care and services most appropriate for his needs. Findings: During a review of Resident 61's clinical record, the face sheet (contains demographic and medical information), undated, indicated Resident 61 was admitted to the facility on [DATE], with diagnoses that included myasthenia gravis (a 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 ensure collaboration and coordination with contracted hospice services for two of 49 sampled residents (Resident 141 and 138) when: 1. For Resident 141 there was no hospice plan of care available in the facility and there was no schedule on when skilled nursing, hospice aide, social worker or spiritual counselor visits would be conducted. 2. For Resident 138 there was no schedule on when skilled nursing, hospice aide, social worker or spiritual counselor visits would be conducted. This failure had the potential to cause Resident 141 and 138 not to receive hospice services based on a comprehensive person-centered care plan. Findings: 1. A review of Resident 141's face sheet (a document that gives a summary of resident's information), undated, indicated an admission date of November 30, 2021, with a diagnosis of chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Resident…

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 observations, interviews, and record review, the facility failed to provide the necessary treatment and services to prevent new pressures ulcers (a skin breakdown caused by prolong pressure to the skin) from developing, affecting one of seven sampled residents (Resident 27) in accordance with the facility's policy and procedure. The facility: 1. Failed to provide nursing interventions to prevent the occurrence of a new Stage 2 pressure ulcer (a Partial-thickness loss of skin with exposed muscles, presenting as a shallow open ulcer) on Resident 27's Right Shin. 2. Failed to follow through with Physical Therapy's recommendation of the use of leg splints (a brace used to prevent or treat contractures {a permanent tightening of muscle, tendon, skin, that cause the joints to shorten and become stiff}) and leg boot (used for positioning, and pressure reduction) for the Resident 27. 3. Failed to do a daily, weekly skin checks to inspect skin and pressure points (areas where bones are close to the surface,…

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 needed treatment and services to maintain physical function were provided for one of 49 sampled residents (Resident 21) when an order for range of motion was not renewed in a timely manner. This failure had the potential to result in negative outcomes, such as contractures and a further decline in mobility, which would negatively affect Resident 21's physical health and well-being. Findings: During a review of Resident 21's admission Record (contains demographic information), on [DATE], at 12:45 PM, the admission Record indicated, Resident 21 was readmitted to the facility on [DATE] with disencephalopathy (disease of the brain that alters brain function or structure) and hypoxemia (low blood oxygen levels). During a review of Resident 21's Progress Notes, dated [DATE], the Progress Notes indicated, Resident 21 was readmitted to the facility after being hospitalized for encephalopathy and hypoxemia . The Progress Notes further…

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

Based on observation, interview, and record review, the facility failed to ensure the gastrostomy tube (GT, a tube surgically inserted for the administration of medications and nourishment) was verified for placement and flushed prior to and after administration of medications for one of four sampled residents (Resident 31). These failures had the potential to place Resident 31 at risk for complications such as aspiration (a condition in which stomach content enter the lungs) and gastrostomy tube blockage. Findings: During a review of Resident 31's clinical record, the face sheet (contains demographic and medical information), undated, indicated, Resident 31 had diagnoses that included cerebrovascular disease (disease resulting to damage in the brain from interruption of its blood supply), chronic respiratory failure (disease where the body fails to maintain gas exchange) and hypertensive heart disease (high blood pressure). During a medication administration observation on April 21, 2022, at 6:19 AM, inside Resident 31's room, with Licensed Vocational Nurse (LVN 5), LVN 5…

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 care of each resident was supervised by a physician and medical care needs are provided throughout the resident stay for two of 49 sampled residents (Residents 24 and 139) when: 1. For Resident 24, a licensed staff took blood pressure on the resident's right arm when Resident 24's physician's order indicated no blood pressures on the right arm. Resident 24's right arm had a non-functioning Arteriovenous Fistula (AVF, blood connection made of veins and arteries, used during hemodialysis, process of removing toxins and waste from the kidneys). This failure had the potential to affect the health and safety of the resident. 2. For Resident 139, the physician did not sign the Physician Orders for Life-Sustaining Treatment (POLST) within 30 working days. These failures had the potential for Resident 139's right to decide regarding life-sustaining treatment and resuscitation during a medical emergency. Findings: 1. A review of Resident 24's face sheet (a document that gives a summary of resident'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 implement infection control and prevention measures for two of 213 residents (Resident 369 and 114) when: 1. A Respiratory Therapist (RT 1) did not perform hand hygiene after glove removal following a ventilator (breathing machine) check on Resident 369. 2. A Licensed Vocational Nurse (LVN 5) did not perform hand hygiene following a blood sugar check on Resident 114. These failures had the potential for cross contamination and spread of infection which can adversely affect the health and wellbeing of 213 medically compromised residents. Findings: 1. During an observation on April 20, 2022, at 9:26 AM, inside Resident 369's room, RT 1 touched the ventilator screen, circuit and suction cannister (a temporary storage container used to collect infectious medical waste) with gloved hands. RT 1 later removed his gloves, discarded it and exited the resident's room. RT 1 did not perform hand hygiene after he removed his gloves. During an interview on April 20, 2022, at 9:27 AM, with RT 1, RT 1 acknowledged that he…

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 a Minimum Data Set (MDS- a facility assessment tool) assessment was submitted and completed to the Centers of Medicare and Medicaid Services (CMS) in accordance with federal submission timeframes, for eight of eight residents reviewed for resident assessment (Residents 4, 1, 2, 82, 8, 6, 3 and 9). These failures resulted in inadequate monitoring of Residents 4, 1, 2, 82, 8, 6, 3 and 9's progress and decline, and the lack of resident specific information to CMS for payment and quality measure monitoring. Findings: 1. During an interview with the Minimum Data Set Nurse (MDS LVN), on October 14, 2021 at 8:12 AM, the MDS LVN stated discharge assessments were to be submitted and completed to CMS within 14 days. A review of Resident 4's closed record, the face sheet (contains demographic and medical information) indicated Resident 4 was admitted to the facility on [DATE], with diagnoses that included muscle weakness and hypertension (high blood…

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: 1. Activity programs were offered daily in accordance with the facility's policy and procedure. This failure had the potential to jeopardize the mental and psycho-social well-being of a highly vulnerable population of 222 residents, which could lead to feelings of social isolation and depression (persistent feeling of sadness and loss of interest). 2. Two of six residents reviewed for activities (Residents 52 and 66) received activities in accordance with the facility's policy and procedure when: a. For Resident 52, 27 out of 45 activity attendance participation from September 2021 to October 2021 were not offered and documented. b. For Resident 66, 22 out of 45 activity attendance participation from September 2021 to October 2021 were not offered and documented. These failures had the potential to result in inaccurate resident care assessment; to maintain and/or improve the physical, mental, and psychosocial well-being of…

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

Based on observation, interview, and record review, the facility failed to ensure safe, and sanitary food preparation, and storage practices in the kitchen when a tray of outdated tuna sandwiches were found on the shelves of the walk-in refrigerator and was available for use. This failure had the potential to cause foodborne illnesses to 181 medically compromised residents who receive food served by the kitchen. Findings: During a concurrent observation and interview with the Director of Dietary Services (DDS), on October 12, 2021 at 08:33 AM, in the kitchen, a tray of tuna sandwiches with a date October 8, 2021 to October 11, 2021 was found in one of the shelves of the walk-in refrigerator. DDS stated, Theses sandwiches should have been thrown out already. An interview with the Registered Dietician (RD) was conducted on October 14, 2021, at 11:27 PM. The RD stated the outdated tuna sandwiches should have been removed earlier and not be left on the refrigerator together with the other snacks. She further stated, My staff are to remove all any food items with outdated label out of…

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

Based on observation, interview, and record review, the facility failed to ensure infection control and preventions were implemented to prevent the transmission of communicable diseases and infections among vulnerable residents in the universe of 222, when the facility: 1. Failed to ensure multi-patient use glucometer ( a device us to check blood sugar) were properly cleansed and disinfected with an approved and validated EPA (Environmental Protection Agency) disinfectant prior to use for three of 16 residents ( Residents 239, 39, and 250) requiring blood glucose testing. This failure had the potential to expose three of 16 vulnerable residents to bloodborne (infections acquired through use of contaminated blood) infections such as Hepatitis B Virus (liver infection caused by the virus), Hepatitis C Virus (liver infection caused by the virus) Human Immunodeficiency Virus (virus attacks the immune system), Candida Auris ( type of yeast that causes severe infection), Sepsis (body's life threatening response to infection), and Death. 2. Failed to ensure open vials of insulin rubber…

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

Based on observation, interview, and record review, the facility failed to ensure a safe and sanitary environment for 222 residents when a visitor entered the facility without proper protective equipment (PPE). This failure had the potential for the transmission of highly contagious and fatal respiratory infection COVID 19 to vulnerable residents in the facility. Findings: During an observation and concurrent interview, on October 15, 2021 at 5:41 AM, a Vendor for the Food and Nutrition Services (Vendor 1) entered the facility using the Station 1 entrance. He walked through the hallway and passed by six resident rooms. He was not wearing a mask. He was stopped by LVN 20 after being prompted by the Health Facilities Evaluator Nurse. Vendor 1 stated he forgot to wear his mask before entering the facility. During a subsequent interview with LVN 20, on October 15, 2021, at 5:43 AM, she stated everyone is required to wear a mask upon entering and while inside the facility. She further stated He [Vendor 1] should have worn it [mask] because there is a Covid pandemic that is going on right…

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 dignity was maintained for one of three sampled residents (Resident 99) when Resident 99's urinary catheter (flexible tube inserted into the bladder to drain urine) bag, was not covered with a dignity bag (a catheter bag covering). This failure had the potential to compromise Resident 99's dignity and violates her rights to privacy. Findings: During a review of Resident 99's clinical record, the face sheet (containing demographic and medical information), indicated Resident 99 was admitted on [DATE], with diagnoses that included infection of intervertebral disc in the lumbar region (infection that develops in one of the spines vertebral bones), sepsis due to methicillin resistant staphylococcus aureus (bacterial infection in bloodstream that resist many types of antibiotics), and pressure ulcer sacral region stage 4 (skin wound in the lower back that has reached all the way through the skin to muscle, bone or tendon). 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, interview, and record review, the facility failed to ensure resident's needs were accommodated for three of four residents (Residents 37, 118, and 237) when their call lights were not within reach. These failures had the potential to endanger their health and safety. Findings: 1. A review of Resident 37's clinical record, the face sheet (contains demographic and medical information) indicated Resident 37 was admitted to the facility on [DATE], with diagnoses that included polyneuropathy (damage to multiple nerves outside of brain and central nervous system) and epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures). A review of Resident 37's Minimum Data Set (MDS - resident care assessment tool), dated September 20, 2021, under Section B, Hearing, Speech, and Vision, indicated Resident 37's vision was highly impaired. During a concurrent observation and interview, on October 12, 2021, at 9:53 AM, Resident 37 was in bed. His call light was behind his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, clean, and homelike environment for three of 50 sampled residents (Residents 187, 75, and 237) when Residents 187, 75, and 237's shared bathroom had an overwhelming smell and was observed with a smeared dime-sized dried, brownish unknown substance on the floor. This failure had the potential to negatively affect Resident 187, 75, and 237's psychosocial well-being for not having a safe, clean, and homelike environment. Findings: During a review of Resident 187's clinical record, the face sheet (contains demographic and medical information) indicated Resident 187 was admitted to the facility on [DATE], with diagnoses that included polyneuropathy (damage to multiple nerves outside of brain and central nervous system) and chronic obstructive pulmonary disease (lung disease). A review of Resident 187's MDS, dated [DATE], under Section C, Cognitive Pattern, indicated Resident 187' had a Brief Interview for Mental Status (BIMS)…

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 adequate monitoring of anti-depressant (medication to treat depression) side effects were done for one of seven residents (Resident 178). This failure had the potential to result in a delayed diagnosis and early treatment of symptoms that can adversely affect the health and safety of Resident 178. Findings: During an observation on October 13, 2021, at 9:08 AM, in Resident 178's room, Resident 178 was lying on his bed, and watching television. During a review of Resident 178's clinical records, the face sheet (containing demographic and medical information), indicated Resident 178 was admitted to the facility on [DATE], with diagnoses that included major depressive disorder (mental disorder characterized by persistently depressed mood). A review of Resident 178's Physician Order's Sheet dated September 9, 2021, indicated Resident 178 had an order to receive Lexapro (an anti-depressant) 10 mg (milligram) once a day for depression.…

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 of four residents (Resident 49) was provided with needed care and services when Resident 49's order for physical therapy (PT- healthcare specialty that includes the evaluation, assessment, and treatment of individuals with limitations in functional mobility), occupational therapy (OT- healthcare specialty that focuses on improving one's ability to perform activities of daily living), and speech therapy (ST- assessment and treatment of communication problems and speech disorders) evaluations and treatments were not carried out as prescribed by the physician. This failure had the potential to cause contractures, and decreased mobility to Resident 49, negatively affecting her physical health and well-being. Findings: During an observation on October 13, 2021 at 10:52 AM, in Resident 49's room, Resident 49 was lying on her back, with her head was titled to the right side. The head of her bed was slightly elevated. During a review…

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 wound treatment and services was provided in a timely manner for one of three residents reviewed for pressure ulcers (Resident 49). This failure had the potential to lead to worsening of the wound and delayed wound healing which would further compromise the health and welfare of Resident 49. Findings: During an observation on October 13, 2021 at 10:52 AM, in Resident 49's room, Resident 49 was lying on her back, with her head was titled to the right side. The head of her bed was slightly elevated. During a review of Resident 49's clinical record, the face sheet indicated Resident 49 was initially admitted to the facility on [DATE] with diagnoses that included cerebellar hemorrhage (brain bleed), and pressure ulcer (bed sores). Further review indicated she was readmitted to the facility on [DATE]. A review of Resident 49's admission Assessment, dated March 17, 2021, indicated Resident 49 was assessed with a pressure (ulcer) to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 56) received documented urinary catheter flushes as prescribed by the physician. This failure has the potential for Resident 56 to be at risk of urinary catheter blockage, bladder discomfort, bacteria in the urine, urinary tract infections, and even sepsis (life-threatening response to an infection which can lead to tissue damage, organ failure, and death). Findings: During a review of Resident 56's clinical record, the face sheet (contains demographic and medical information), indicated Resident 56 was admitted to the facility on [DATE], with diagnoses that included paraplegia (paralysis of legs and body), neurogenic bowel (loss of normal bowel function), and neuromuscular dysfunction of bladder (lack of bladder control). A concurrent observation and interview were conducted with Resident 56 in his room on October 12, 2021, at 12:16 PM. Resident 56 was sitting up on his motorized wheelchair.…

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 respiratory care was provided for one of two sampled residents reviewed for oxygen (Resident 131) when: 1. Resident 131's oxygen tubing was not connected from oxygen concentrator (a medical device use for delivering oxygen). (Resident 131 had an order to receive oxygen continuously.) 2. Resident 131's oxygen therapy order was not carried out as prescribed by the physician. These failures had the potential to result in a decline in Resident 131's oxygen status, causing shortness of breath, and lung damage placing Resident 131's health and safety at risk. Findings: 1. During a review of Resident 131's clinical records, the face sheet (containing demographic and medical information), indicated Resident 131 was admitted on [DATE], with diagnoses that included chronic obstructive pulmonary disease (lung disease that causes obstructed airflow from the lungs), dependence on supplemental oxygen, and obstructive sleep apnea (condition in…

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 physician's order and perform self-administration of medication assessment for one of one resident (Resident 90). This failure had the potential for unexpected drug reaction, misuse, and potentially cause negative effects to the overall health of the Resident 90. Findings: During a review of Resident 90's clinical record, the face sheet (contains demographic and medical information) indicated Resident 90 was initially admitted to the facility on [DATE], with diagnoses that included end stage renal disease (kidney disease), type 2 diabetes mellitus (high blood sugar), and chest pain. During a concurrent observation and interview with Resident 90, on October 13, 2021, at 11:27 AM, in Resident 90's room, an allergy medication was found on Resident 90's bedside table. Resident 90 stated the medication belongs to him and he needed it for his allergy. He further stated he takes the medicine sometimes and wanted it to be at the bedside…

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 proper disposal of garbage and refuse when: a. Two soiled diapers were found on the floor by the garbage dumpsters. b. A dumpster, used for recycling, was overflowing with cardboard boxes and could not be closed completely. These failures had the potential for the harborage of insects and pests that could affect the health and safety of a highly vulnerable population of 222 residents. Findings: During an inspection of the garbage storage area with the Dietary Director Assistant (DDA), on October 12, 2021, at 3:01 PM, two soiled diapers were observed on the floor by the garbage dumpsters. A dumpster, used for recycling, was overflowing with cardboard boxes. Its lid did not close completely to cover its contents. An interview with the Housekeeping Supervisor (HKS) was conducted on October 12, 2021, at 3:10 PM. He stated the garbage storage area should have been cleaned, and the recycling bin should have been emptied. During an interview with the Registered Dietitian (RD), on October 14, 2021, at 11:50…

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's Quality Assurance and Performance Improvement (QAPI) Committee failed to implement and evaluate systemic measures to ensure oversight of the Nursing Department (refer to F880 Infection Prevention & Control). This failure had the potential to negatively affect the improvement of the residents' quality of care, quality of life, and safety in a highly susceptible population of 222 residents. Findings: During a concurrent interview and record review with the Administrator, on October 19, 2021, at 3:31 PM, the ADMIN stated the QAPI committee included himself, the Medical Director (MD), Director of Nursing (DON), the facility's department heads, Pulmonologist, Dietitian, and Pharmacist. The ADMIN further stated they meet every third Thursday of the month and as needed. During further interview with the ADMIN, on October 19, 2021, at 3:46 PM, he stated the facility was not aware of the issues in the nursing department pertaining to the cleaning and disinfection of glucometers prior to the recertification survey. He stated, Prior to this…

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's Quality Assurance and Performance Improvement (QAPI) Committee failed to identify a systemic issue regarding proper cleaning and disinfection of glucometers by the nursing department. This failure had the potential for the facility not to be able to track problem prone areas which could negatively affect the improvement of the residents' quality of care, quality of life, and safety in a highly susceptible population of 222 residents. Findings: During a concurrent interview and record review with the Administrator, on October 19, 2021, at 3:31 PM, the ADMIN stated the QAPI committee included himself, the Medical Director (MD), Director of Nursing (DON), the facility's department heads, Pulmonologist, Dietitian, and Pharmacist. The ADMIN further stated they meet every third Thursday of the month and as needed. During further interview with the ADMIN, on October 19, 2021, at 3:46 PM, he stated the facility was not aware of the issues in the nursing department pertaining to the cleaning and disinfection of glucometers prior to 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.