The Shores Post-Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain infection prevention practices for six of 38 sampled residents (218, 75, 65, 8, 147, 448) when: 1. Resident 218's urinary catheter tubing was in contact with the floor; 2. A wrist splint for Resident 75 was not maintained in a sanitary manner; 3. Oxygen tubings were undated for Residents 65 and 8; 4. Disposable gowns were not used for direct care of residents (147, 448) who were on Enhanced Barrier Precautions (EBP, infection control measures to reduce the spread of germs). These failures had the potential to spread germs to residents and staff. Findings: 1. Resident 218 was readmitted to the facility on [DATE], with diagnoses which included urinary tract infection (infection in the bladder), per the facility's admission Record. An observation was conducted of Resident 218 in bed on 12/2/24 at 9:23 A.M. A urinary catheter bag was clipped to the left side of the bed frame and was visible upon entering the room. Approximately 12…

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 related to the use of a urinary catheter bag (a flexible, plastic tube inserted into the body, in order to drain urine to an external collection bag) was maintained for one of three residents' (Resident 218) reviewed for dignity and resident rights. This failure had the potential for Resident 218, to feel embarrassed or humiliated when the draining urine was visible to others. Findings: Resident 218 was readmitted to the facility on [DATE], with diagnoses which included urinary tract infection (infection in the urine), per the facility's admission Record. An observation was conducted on 12/2/24 at 9:23 A.M. Resident 218 was in bed. A urinary catheter bag was clipped to the left side of the bed frame and was visible upon entering the room. The urinary catheter bag was ¼ full of cloudy, pale colored urine. A dignity bag (a dark colored bag which covers the urine collection bag to protect a resident's dignity) was not present.…

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 a written notice of transfer to a resident's responsible party (RP) and the Long-Term Care Ombudsman for one of three residents (Resident 296) reviewed for closed records. This deficient practice had the potential for the Resident 296's RP to not be aware of the resident's rights pertaining to transfers. Findings: A review of Resident 296's admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 296's Alert Charting dated 9/27/24, indicated the resident was found unconscious and was transferred to the hospital for evaluation. On 12/5/24 at 11:40 A.M., an interview was conducted with the director of nursing (DON). The DON stated she reviewed Resident 296's clinical record and that there was no documentation a written notice of transfer was provided to the resident's RP, nor sent to the Long-Term Care Ombudsman. The DON stated Resident 296's written notice of discharge should have been completed by…

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 one of one resident's (Resident 75) sampled for a Significant Change of Condition to the Centers for Medicare and Medicaid Services (CMS, a federal health care agency). This failure had the potential for CMS to not be informed of Resident 75's current health status. Findings: Resident 75 was readmitted to the facility on [DATE], with diagnoses which included sprain to left wrist secondary to fall, per the facility's admission Record. An observation of Resident 75 was conducted on 12/2/24 at 9:42 A.M., in the activity room. Resident 75 was dressed, sitting in a wheelchair, with a plaster-type splint on top and beneath her left wrist. The splint was held in place with a [brand of gauze dressing] wrap near the left forearm. The splint had dark brown/black smudges over the top and bottom areas near the palm of her left hand and wrist. Resident 75's clinical record was reviewed on 12/2/24: According to the SBAR (Situation, Background, Assessment,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to update a care plan to include a positioning aide to prevent falls for one of 38 sampled residents (273). As a result, the positioning aide may not have been used consistently among staff caring for Resident 273. Findings: Per the facility's admission record, Resident 273 was admitted to the facility on [DATE] with diagnoses which included dementia (a mental and physical decline), weakness, and repeated falls. On 12/3/24 at 3:50 P.M., an observation of Resident 273 was conducted. Resident 273 was lying in bed. A pillow was under the sheet at the exit of the bed. On 12/4/24 a review of Resident 273's medical record was conducted. There were no orders or care plans that included instructions to place a pillow under the sheet, or for a positioning aide to prevent the resident from falling out of the bed. On 12/4/24 at 10:01 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated, he often placed a pillow under…

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 low air loss (LAL) mattress (a specialized mattress designed to prevent and treat pressure related wounds) for one of two residents (Resident 105) reviewed for pressure injuries (injury to the skin caused by pressure, usually over bony areas). As a result, there was a potential for Resident 105 to develop new wounds and/or for his pressure injuries to become worse. Findings: According to the admission Record, Resident 105 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (weakness on one side of the body) affecting left non-dominant side, pressure ulcer of the back, left upper back, and left hip. On 12/3/24 at 9:35 A.M., Resident 105 was observed laying on his back in bed, on a regular mattress. A review of Resident 105's physician's orders dated 10/22/24 indicated, Apply LAL mattress for wound management/preventive measures. Check placement, settings and functionality QS (every shift). On 12/3/24 at…

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 complete a quarterly safe Smoking Assessment, and ensure a resident's meal was set to ensure safety while eating, for two of 38 sampled resident's (283, 259). As a result, residents were placed at an increased risk of injury. Findings: 1. Resident 283 was admitted to the facility on [DATE], with diagnoses which include chronic kidney disease (when the kidneys are damaged and cannot filter blood toxins properly), per the facility's admission Record. An observation and interview was conducted with Resident 283 in his room on 12/2/24 at 8:29 A.M. Resident 283 was standing up, dressed, and checking his watch, stating I can go and smoke at 9 A.M. Resident 283's clinical record was reviewed on 12/3/24: According to the Minimum Data Set (MDS; a clinical assessment tool) dated 7/29/24, a cognitive score of 14 was listed, indicating cognition was intact. An initial Smoking assessment dated [DATE] was reviewed. The assessment indicated the 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 observation, interview, and record review, the facility failed to ensure a physician's order was followed for one of four residents observed during medication administration, when Resident 58's medication was held (not administered) without an order. This failure had the potential for Resident 58's needs to go unmet. Findings: Resident 58 was admitted to the facility on [DATE] with a diagnosis including hypertensive chronic kidney disease (a cycle where kidney damage leads to high blood pressure and high blood pressure leads to kidney damage) per the admission Record. A medication administration observation was conducted on 12/4/24 at 9:49 A.M. Licensed Nurse (LN) 13 administered medications to Resident 58. However, LN 13 did not administer prazosin (a medication used to treat high blood pressure in patients with kidney disease) to Resident 58. A review of Resident 58's active physician's orders was conducted on 12/4/24, which indicated prazosin was ordered starting on 6/27/24. There were no hold…

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 38 sampled residents' (145) medication was properly stored when a medication was left unattended at the bedside. This failure had the potential for medication misuse and/or unauthorized person to have access, take/use the medication wrongfully. Findings: Resident 145 was re-admitted to the facility on [DATE] with diagnoses which included a history of atherosclerotic heart disease (a condition that could lead to heart attacks), per the admission Record. On 12/3/24 at 8:04 A.M., an observation and interview was conducted with Licensed Nurse (LN) 56, in Resident 145's room. Resident 145 was asleep with bed linens covering his head. Next to Resident 145's bed was his bedside table, that had two cups containing red juice, and an unlabeled medication cup that contained an oval shaped yellow pill. LN 56 stated that the medication cup with the pill should not have been left unattended because that was not a safe practice. LN 56…

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 food that accommodated resident's preferences for one of 38 sampled residents (51). This failure resulted with Resident 51 receiving coffee which was listed as a food the resident disliked. Findings: Resident 51 was re-admitted to the facility on [DATE] with diagnoses which included a history of congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), per the admission Record. On 12/2/24 at 11:55 A.M., an interview was conducted with Resident 51, in Resident 51's room. Resident 51 stated that he did not eat his breakfast because he liked to eat pancakes with two butter packets. Resident 51 stated that he preferred to be given two butter packets on his breakfast tray but they [the facility staff] always forget. On 12/2/24 at 1:10 P.M., an observation and interview was conducted with Resident 51, in Resident 51's room. Resident 51 was in bed…

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 accurately document a resident's current status for two of 38 sampled residents (183, 105) when: 1. A post (after) dialysis (a procedure that removes toxins from the blood since the kidneys are unable to provide that function) assessment did not accurately reflect Resident 183's access site (a surgically created connection to the blood stream that allowed blood to be cleaned and returned to the body during dialysis), when reviewed for dialysis; 2. A low air loss mattress (pressure relieving mattress) was not accurately documented on the electronic medication administration record (eMAR) (Resident 105); This failure had to potential to not accurately represent the residents' (183, 105) current medical record. Findings: 1. Resident 183 was admitted to the facility on [DATE], with diagnoses which included acute kidney failure (a sudden decline in kidney function), per the facility's admission Record. Resident 183's clinical record was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure facility policy related to elopement (leaving; wandering off without notice) was implemented (followed) when one resident (1) eloped from the facility. As a result, a facility-wide emergency to locate Resident 1 was not initiated immediately upon finding out that Resident 1 was missing. This failure had the potential to affect Resident 1's health and safety. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included a history of paranoid schizophrenia (brain disorder that affects the way a person thinks and behaves; characterized by suspicious feelings and difficulty distinguishing between what is real and what is not) per Resident 1's admission Record. On 5/7/24, an unannounced visit was made to the facility in response to a facility reported incident that occured on 5/5/24. A review of Resident 1's record was conducted. The Elopement Risk assessment dated [DATE], indicated Resident 1 scored seven (7) out of 29…

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 transcribe an admission order for an intravenous (IV-medication given through a vein) antibiotic for one of three residents (Resident 1). This failure had the potential to result in a medication error for Resident 1. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses of sepsis (serious condition in which the body responds improperly to an infection) and pyomyositis (bacterial infection of the skeletal muscle). Per the nursing admission assessment record, dated 2/13/24, Resident 1 was transferred from another facility with medication orders to continue at the admitting facility. A review of Resident 1 ' s physician ' s orders from the transferring facility, dated 2/6/24, included an order for Ertapenem 1 g (gm; gram) IV Q24H (every 24 hours). A review of Resident 1 ' s admission physician ' s orders, dated 2/13/24, included an order for Ertapenem 1 GM - Inject 1 gram intramuscularly (injection administered deep into…

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 accurate dispensing of medication and controlled-drug reconciliation for two of three residents (Resident 76 and Resident 288) when: 1. Resident 76's Controlled Drug Record for Norco (a narcotic pain medication) did not match with the resident's medication administration record (MAR). 2. Resident 288 medication was not administered as ordered by the physician. These failures had the potential for loss, drug diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) and medication errors for Resident 76. In addition, Resident 288 had the potential to not receive the therapeutic level (dosage range for effectiveness) of the medication. Findings: 1. A record review of Resident 76's clinical record, titled admission Record or face sheet (contains demographic information) indicated Resident 76 was re-admitted on [DATE] with a diagnosis of chronic obstructive pulmonary disease (a group…

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 food that was palatable, attractive, and appetizing to Resident 236, 14 confidential residents, and to 8 of 9 residents interviewed during a confidential group meeting. As a result, residents stated they did not like the food which had the potential to cause weight loss and to effect the residents' quality of life. Findings: A review of Resident 236's admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 236's physician order dated 11/21/23, indicated the resident received a regular pureed diet (food consistency that does not require chewing such as pudding). On 1/8/24 at 8:50 A.M., an observation and interview was conducted with Resident 236 while inside the resident's room. Resident 236 stated she was not happy with the food that was being served at the facility. Resident 236 had a food tray on her overbed table. Resident 236 stated, Look at it, and removed the plate cover on her…

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 document review, the facility failed to implement their Facility Assessment (determines the resources and training necessary to care for residents competently during the day-to-day operations) as written when training on how to care for residents with post-traumatic stress disorder (PTSD: mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety) was not provided to all staff. This failure had the potential to affect the staff's ability to effectively identify the needs of residents with PTSD and provide the necessary care. Cross reference F740 and F741 Findings: A review of the Facility Assessment, dated 8/18/17, was conducted. The document listed resident diagnoses that the facility accepted for admission. The list included residents diagnoses with PTSD. The document also indicated that the facility will provide training to their staff on Caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and /or post-traumatic disorder, . On 1/11/24, at 9:30 A.M., an…

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 licensed nurses (LNs) accurately documented the monitoring of potential side effects for anti-hypertensive medications (drugs used to control high blood pressure) for three of three residents (Resident 59, 131, and 236) when it had been documented that the residents were monitored for pregnancy and fetal toxicity (affects the development of a fetus potentially causing fetal death) and this had not been done. As a result, the resident's medical records did not accurately reflect care/treatment that had been provided. Findings: A review of Resident 59's admission Record indicated the resident was readmitted on [DATE]. The admission Record further indicated the resident was over the age of eighty. A review of Resident 59's physician order dated 5/30/23, indicated the LN was to monitor for fetal toxicity related to the resident's use of lisinopril (a medication to control blood pressure) and .When pregnancy is detected, discontinue lisinopril 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 interview, and record review, the facility failed to ensure a Minimum Data Set (MDS- an assessment tool) was accurately coded for one of eight residents (Resident 127) reviewed for MDS assessments. Resident 127's MDS did not indicate a fall had occurred. This failure had the potential for Resident 127 to receive inappropriate care due to inaccurate assessment. Findings. A review of Resident's admission Record indicated that Resident 127 was admitted to the facility on [DATE] with diagnoses that included Unspecified Psychosis (an individual with thinking disorders characterized by a disconnection from reality), Dementia (a condition characterized by progressive or persistent loss of intellectual functioning), and History of falling. During a concurrent interview and record review with MDSN (Minimum Data Set Nurse) MDSN 1, stated Resident 127 had a fall incident on November 28, 2023, but it was missed and not coded in the Quarterly assessment on 12/25/2023. MDSN 1 stated that the MDS was coded incorrectly…

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-specific care plans were developed for two of 35 residents (Resident 131 and Resident 59) when: 1. Resident 131 did not have a written care plan developed to address his behavior of disruptive yelling. 2. Resident 59 did not have a written care plan developed to address her risk of wandering and elopement (leaving the premises unauthorized). In addition, Resident 59's elopement risk had not been assessed quarterly. As a result of this deficient practice, there was the potential for residents to not receive individualized care that met their needs. Findings: 1. A review of Resident 131's admission Record indicated the resident was admitted on [DATE] and readmitted on [DATE] with diagnosis to include intracerebral hemorrhage (brain bleed), paralysis and weakness affecting the left side, and aphasia (difficulty speaking) following a stroke. A review of Resident 131's physican order dated 6/2/23 for behavior monitoring related…

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 a low air loss mattress (LAL - mattress that helps reduce and prevent skin breakdown by relieving pressure to skin) was set according to the physician's order for one of four residents (Resident 602) reviewed for pressure ulcers. This failure increased the risk of skin breakdown to Resident 602. Findings: A review of Resident 602's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing). An observation of Resident 602 was conducted on 1/8/24 at 8:30am, in Resident 602's room. Resident 602 was laying down in bed with the low air loss mattress setting on 450 pounds (lbs.). A review of Resident 602's physician order, dated 12/29/23, indicated, Apply (LAL) mattress for wound management .Check placement, settings and functionality QS (every shift). A record review of Resident 602's weight on 1/3/23, Resident was 181 lbs. A concurrent observation,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an environment that promotes the highest practicable physical, mental, and psychosocial well-being and develop a person-centered care plan for one of six sampled residents (Resident 169) with post-traumatic stress disorder (PTSD: mental health condition triggered by a terrifying event, causing flashbacks, nightmares, and severe anxiety). This failure had the potential to cause Resident 169 emotional distress, and affect her physical, mental and psychosocial well-being. Cross reference F741 and F838 Findings: A review of Resident 169's clinical record, titled admission Record, or face sheet (contains demographic information) indicated Resident 169 was admitted on [DATE] with diagnosis to include PTSD, and depression (constant feeling of sadness and loss of interest, which stops you doing your normal activities). An observation and interview was conducted with Resident 169 on 1/9/24 at 8:38 A.M., in the resident's room. Resident 169…

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 post traumatic stress disorder (PTSD: mental health condition triggered by a terrifying event, causing flashbacks, nightmares, and severe anxiety) training to all staff. This failure had the potential to affect the provision of care to meet the needs of residents with PTSD. Cross reference F740 and F838 Findings: A review of Resident 169's clinical record, titled admission Record or face sheet (contains demographic information) indicated Resident 169 was admitted on [DATE] with diagnosis that included PTSD and depression (constant feeling of sadness and loss of interest, which stops you doing your normal activities). An observation and interview was conducted with Resident 169 on 1/10/24 at 9:16 A.M., in the resident's room. Resident 169 stated that her PTSD resulted from childhood trauma she suffered from being sexually abused by a relative. Resident 169 stated that PTSD triggers included loud, domineering personalities, 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 of five residents (Resident 59) was free from unnecessary psychotropic medications (used to control mood, behavior, and thoughts) when: 1. Resident 59's quetiapine (a psychotropic medication, specifically an antipsychotic medication used to treat mental illness) was continued upon the resident's return from the acute care hospital without re-evaluating the appropriateness of its continued use. 2. Non-pharmacological interventions were not documented as having been attempted to manage Resident 59's behaviors related to the use of quetiapine. 3. Behavior monitoring (identified behaviors to justify the continued use of a psychotropic medication) for quetiapine was inappropriate and did not support Resident 59 in exercising her resident right to refuse care. As a result, there was the potential for Resident 59 to receive unnecessary psychotropic medication which could cause harm or serious side effects. Findings: 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 interview and record review, the facility failed to ensure that one of three sampled residents (Resident 74) received an antiarrhythmic (medication used to treat abnormal heart rhythms that are usually too fast or irregular) medication as ordered by the physician. This failure had the potential for Resident 74 to experience life threatening cardiac (heart) complications such as heart attack (the heart stops beating and is unable to supply blood flow throughout the body) or stroke (a brain attack resulting from poor blood flow to the brain). Findings: A record review of Resident 74's clinical record, titled admission Record or face sheet (contains demographic information) indicated Resident 74 was re-admitted on [DATE] with a diagnosis of atrial fibrillation (A-Fib: an abnormal heart rhythm causing a rapid, erratic heart rate). On 1/11/24 at 8:06 AM., Licensed Nurse (LN) 50 was observed outside of Resident 74's room preparing medications for administration to Resident 74. During reconciliation 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, record review and document review, the facility failed to practice effective infection control for one of 36 sampled residents (Resident 251), when Resident 251's bathroom floor was soiled with feces (bowel movement) for approximately five to six hours. This failure had the potential to spread infection amongst residents, staff, and facility visitors. Findings: A record review of Resident 251's clinical record, titled admission Record or face sheet (contains demographic information) indicated Resident 251 was re-admitted on [DATE] with a diagnosis of hypertensive heart and chronic kidney disease with heart failure (a heart problem when poorly untreated that results in high blood pressure where the heart needs to pump harder to get blood to the kidneys resulting in muscle strain of the heart). A record review of the Resident 251's Minimum Data Set (MDS, nursing assessment tool), dated 10/14/23, indicated Resident 251's cognition (the understanding of thought processing with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a patient centered care plan regarding an employee to resident abuse allegation for one resident (Resident 5). This failure had the potential to affect the delivery of care, miscommunication among caregivers, and decreased psychosocial well-being for Resident 5. Findings: Resident 5 was admitted to the facility on [DATE] with the diagnoses which included hemiplegia (total or partial paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction (disrupted blood flow to the brain) affecting the right dominant side according to the facility's admission Record. During a review of nurse's notes dated 8/16/23, the nurse's notes indicated Resident 5 was discharged to home. An interview was conducted with the social services assistant (SSA) on 8/23/23, at 9:57 A.M. The SSA stated Resident 5 reported a CNA who was rough with care. The SSA stated on 8/11/23, Resident 5 pressed 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 provide two of three sampled residents (Resident 1 and Resident 2) written notification of bed hold at transfer to the hospital. This deficient practice resulted in two residents (Resident 1 and Resident 2) not receiving notification of their right to return to the facility. Findings: 1) Resident 1 was admitted to the facility on [DATE] with diagnosis of paraplegia (inability to move the lower half of the body) and gastroparesis (a disorder that slows or stops the movement of food from your stomach to lower intestines). Resident 1 was transferred to a general acute care hospital (GACH) on 5/12/23 for a clogged feeding tube. 2) Resident 2 was admitted to the facility on [DATE] with a diagnosis of diabetes (abnormal blood sugar condition). Resident 2 was transferred to a general acute care hospital (GACH) on 4/24/23 for treatment of a soft tissue infection of the right lower limb. A review of the facility census on 8/10/23 indicated Resident 1 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 observations, interviews, and record reviews the facility failed to ensure overall systematic operations was effectively executed for its food and nutrition services department when: 1. A resident with a 10.4% significant weight loss in six months was not consistently monitored. 2. Facility Menus were not approved by the RD, and the emergency menus and recipes were not followed as printed. (fortified diet) 3. Evening nourishments were not consistently offered to all residents at bedtime. 4. The kitchen environment was unsanitary and unsafe with open ceiling holes and uncovered and broken floor tiles were exposed in the walk in refrigerator and Pots & pans, 5. Kitchen staff competence issues- thermometer calibration, dish machine and red bucket sanitizer strength levels. These failures exposed residents to potentially unsafe and unsanitary foods that could negatively affect their nutrition and health status. The facility census was 258. Cross reference F692, F802, F803, F805, F809, F812, F921 Findings:…

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 facility document review, the facility failed to ensure the competency of the Food and Nutrition Services Director (FNDS) and Registered Dietitian 1 (RD 1) when multiple issues relating to a safe and sanitary kitchen environment, serving food preferences and appropriate texture of food, and staff competency for using the dish machine were identified. This failure had the potential for decreased nutrient intake for 2 residents; as well as the potential for contamination of food, equipment, utensils leading to food borne illness and/or spread of disease for 264 residents who received food from the kitchen out of a facility census of 267. Findings: During the Federal Re-certification Re-visit survey conducted from 5/3/22 to 5/5/22, multiple issues were identified with 1.) storing and preparing food and a safe and sanitary environment including floors were in poor condition and dirty, ceiling tiles were in poor condition and dirty, a dish machine vent was in poor condition, fans were not maintained so they were clean, a wall space was dirty and not…

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 kitchen staff carried out the tasks of the food and nutrition services department in accordance with the standard of practice for the following kitchen competencies: 1. Kitchen staff did not know how to calibrate food thermometers. 2. Kitchen staff did not follow the facility policy and procedure for fortifying resident diets. 3. Kitchen staff did not follow the facility policy and procedure for liquefied pureed diet for residents. 4. Kitchen staff did not know the quaternary ammonium concentration of the kitchen sanitizer buckets. 5. Kitchen staff did not wash cantaloupe in a safe manner prior to serving. 6. A kitchen dishwasher did not know how to correctly test PPM concentration of the dishwashing solution with the chlorine test strip. These failures had the potential to expose 258 residents who consume food from the kitchen to practices associated with the transmission of foodborne illness. Reference F- 800, F-803, F-812. Findings: 1. On 2/14/22 at 3:44 P.M., an observation and interview with…

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

Based on observation, staff interviews, and record review, the facility failed to follow the recipes and therapeutic menus as planned and printed, according to facility policy. This failure had the potential to result in weight loss of 247 of 258 residents who consumed food from the kichen due to reduced food intake, which could have resulted in a decline in activities of daily living, and may have further compromised their nutritional status. Cross reference E015 and F812 Findings: 1. During an initial kitchen tour observation on 2/14/22 at 9:45 A.M. with the Certified Dietary Manager (CDM), a record review of the facility's menus was requested. The Regular Menu and the Therapeutic Cook's Spreadsheet menu were not followed as planned and printed. Furthermore, none of the facility's menus including the posted regular menu, therapeutic Cook's spreadsheet menu, or alternate menu were signed or dated by the facility's Registered Dietitian (RD). On 2/15/22 9:30 A.M., an interview was conducted with the RD. The RD stated she did not know all the facility's menus had to be approved by 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 observation, interview and record review, the facility failed to ensure proper safe and sanitary food practices, storage, and sanitation requirements were met when: 1. The walk-in freezer had 10 ice cream boxes stacked directly onto the floor area 2. The walk-in refrigerator #2 had a circulation fan unit detached from the ceiling and had unidentifiable black substance mixed with rust; an exposed piece of pipe connected to the ceiling with rust on it; exposed open ceiling holes without covering; 2 large holes open uncovered by the entrance door and freezer entrance door; and several dirty clear plastic cool air strips laying on top of a food cart. 3. No air gaps under the Food prep /produce wash sink or under the three compartment sinks in pots and pans room. 4. Three sink compartment room had three fans debris and dust blowing air directly on cleaned washed scoops and serving utensils. 5. A cart had a stack of wet dish containers on top of it stored as dry. 6. A green handled scoop in the clean utensil bin…

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's Quality Assessment and Assurance (QA) committee failed to identify, develop, and implement plan of action related to infection control practices between the green zone (unit for unaffected residents with no COVID-19 (a highly contagious virus) exposure, and red zone (unit for residents with positive COVID-19) (Refer to F880). This failure had the potential to put residents and staff at risk for COVID-19 infections. Findings: On 2/22/22 11:21 A.M., Quality Assurance & Performance Improvement (QAPI) interview was conducted with the ADM 1, ADM 2, the DON, RD, and the IP. The IP stated she was not aware the staff assigned to the red zone were crossing over to the green and back to the red zone during the same shift. She further stated she had not been conducting audits of staff crossing the different zones. The IP stated she should have monitored the staff assignments between the red and green zone to ensure that proper infection control practices were being followed. The IP acknowledged that staff practices of going 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 2. Resident 27 was re-admitted to the facility on [DATE], with diagnoses which included end stage renal disease (inability for the kidneys to filter blood) with dependence of renal dialysis (a machine which filters the blood of toxins and fluid), per the facility's admission Record. On 2/14/22 at 8:56 A.M., an observation was conducted in the facility's north/west hallway. Resident 27's room was at the end of the hallway, close to an exit door, labeled for dialysis transport. Resident 27's room had a bright yellow cart outside the door entrance, which contained three drawers of PPE supplies. A sign was posted on the outside door frame indicating what PPE was required when entering the room. The required equipment had check marks next to face mask, face shield, gown, and gloves. On 2/14/22 at 8:57 A.M., an interview was conducted with Resident 27 in her room. Resident 27 stated she was transported to dialysis every Monday, Wednesday, and Friday. Resident 27 stated she was recently discharged from the hospital…

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 reviews the facility failed to ensure all residents were consistently offered evening bedtime nourishments and snacks according to facility policy. This failure had the potential to negatively affect nutrition status and wellbeing of all residents. The facility census was 258. Cross reference F692, F800 Findings: On 2/15/22 at 3:40 PM, an interview was conducted with CNA 11 about nourishments and snacks provided by the facility. CNA 11 stated she had not seen any snacks or nourishments offered to all residents in the evening or at night. CNA 11 stated residents can ask for certain snacks at night and the staff can try to get them from the kitchen. On 2/17/22 at 8:53 AM, an interview was conducted with the ACT about resident snacks. The ACT stated she occasionally distributed snacks during the activity sessions on Fridays or during special events. The ACT stated she had not seen routine snacks regularly offered to residents. On 2/17/22 at 5:23 PM, an interview was…

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

Based on observation, interview and facility policy review, the facility failed to implement their policy and procedure related to food brought from the outside to residents for 2 of 5 residents' refrigerators when the food inside the refrigerators were not labeled or dated, and expired food was not discarded. This failure had the potential to expose the facility's residents to unsafe food storage practices which could lead to foodborne illness. Findings: 1. On 2/15/22, at 4:02 P.M., an observation of the residents' refrigerator on Station 3 and a concurrent interview & facility policy review with LN 36 was conducted. The following food items were observed: a. An undated clear plastic container with a red lid and resident name and room number on it. b. An open clear plastic store bought soup with a resident's name, room number and the following dates: handwritten 2/9/22, and manufacturer's date of 12/29/21. LN 36 validated the above listed items as not being properly labeled and stated, the food items should have been labeled with the resident(s) name and date it was placed in 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 privacy and dignity was provided to three of five residents when: 1. Resident 188 did not have shower as scheduled; 2. CNA 12 did not knock or announce herself before entering the residents' room (86); and 3. Resident 59 was provided personal care while in the dining room with others present. These failures had the potential to lower the self esteem and self-worth for Resident 188, Resident 86, and Resident 59. Findings: 1. Resident 188 was readmitted to the facility on [DATE], with diagnoses which included hemiplegia (paralysis on one side of the body), per the facility's admission Record. Resident 188's history and physical, dated 8/1/21, indicated he had the capacity to understand and make decisions. On 2/14/22 at 11:03 A.M., an observation and interview with Resident 188 in his room was conducted. Resident 188 was sitting up in bed, pulled himself up using an overbed trapeze. Resident 188 stated he has not had a shower for over…

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 three of five residents (59) reviewed for privacy, was provided with privacy, when Resident 59's personal care was conducted in the dining room in front of other residents. This failure had the potential to devalue the resident's self-esteem and self-worth. Findings: Resident 59 was admitted to the facility on [DATE], with diagnoses which included dementia with behavioral disturbance (a decline in mental ability that affects daily living) and disorientation (a temporary or permanent state of confusion regarding place, time or personal identity), per the facility's admission Record. A review of Resident 59's History and Physical, dated 8/25/21, indicated that the resident did not have the capacity to understand and make decisions on her own. During a meal observation on 2/14/22 at 12:20 P.M., Resident 59 was observed walking around the small dining area in Station one. Resident 59 wore a hospital gown with no undergarment. 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 observation, interview, and record review, the facility failed to ensure two of 38 sampled residents (218, 59) care plans were implemented related to: 1. Resident 218's turning, and repositioning; and 2. Resident 59's privacy related to blowel and bladder care. These failures had the potential for decline in skin prevention for Resident 218 and a decline in toilet training for Resident 59. Findings: 1. Resident 218 was readmitted to the facility on [DATE], with diagnoses which included Parkinson's disease (progressive nervous system disorder that affects movements), per the facility's admission Record. A review of Resident 218's MDS (assessment tool), dated 1/12/22, indicated that the resident had a BIMS (a cognitive assessment) score of two (0-7 indicated severe cognitive impairment). Per the Functional Status, Resident 218 was totally dependent on staff for bed mobility. A review of Resident 218's care plan titled, Risk of Development of Skin Breakdown, dated 4/8/14 indicated, .Provide a therapeutic…

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 2. Resident 224 was admitted to the facility on [DATE], with diagnoses including diabetes (abnormal blood sugar), unspecified open wound on resident's scrotum, cellulitis (skin infection) of the buttocks, per the facility's admission Record. Resident 224's clinical records was reviewed. The MDS (an assessment tool), dated 2/5/22, under Skin Conditions indicated there was an unhealed Stage II pressure ulcer (characterized by partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough) on admission, open lesions, and Moisture Associated Damage (MASD), and that the resident needed pressure ulcer care. Per the physicians order, May have LAL for wound management/preventative measures. Check placement and functionality, every shift . Per the care plan, titled, .is at risk for pressure injury development skin breakdown r/t diabetes, hx of pressure injury, immobility, incontinence, and vascular disease .Apply Low Air Loss Mattress as ordered to relieve pressure points 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, interviews, and record review, the facility failed to ensure a comprehensive and effective systematic approach was implemented to monitor and maintain acceptable parameters of nutritional status for one of 38 sampled resident's (Resident 39's) when: 1. The facility failed to implement a physician's order for fortified milk, health shake, yogurt (those were food items used as nutritional interventions for weight loss) and 2 bowls of soup. 2. The facility failed to ensure a resident with significant unplanned weight loss was monitored effectively as per facility Policy and standard of care. Resident 39 experienced unplanned 20.17 percent weight loss in a year that was not monitored effectively as per facility Policy and standard of care. As a result, Resident 39 had an unplanned significant weight loss. Cross reference 800, 803, 812 Findings: Per the facility's Face sheet, Resident 39 was admitted to the facility on [DATE] with a diagnosis of Parkinson's Disease (a brain disorder affecting…

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 two sampled residents (39) were free from unnecessary drugs. This failure had the potential to negatively impact the resident's well-being. Findings: Resident 39 was admitted to the facility on [DATE], with diagnoses which included Parkinson's Disease (a brain disorder affecting coordination), per the facility's admission Record. According to Resident 39's physician order, indicated the following: Multi-Vitamin / Minerals Tablet (Supplement), give 1 tablet by mouth one time a day. Order date 2/15/19; order status active. Vitamin C Tablet 500 milligram (mg) (a supplement), Give 1 tablet by mouth one time a day for 30 days Supplement for wound healing last dose 3/1/19. Order date 2/15/19; the order was still listed as active. On 2/22/22 at 9:40 A.M., a concurrent interview and record review was conducted with the ADON 36. ADON 36 stated, the Vitamin C order should have been discontinued after the 30 days. The LNs should have…

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 there was adequate indication for the use of a psychotropic medication (used to stabilize or improve mood, mental, status, or behavior) for one of five residents (Resident 95) reviewed for unnecessary use of medication. This failure had the potential for Resident 95 to be exposed to the psychotropic medication side effects which could adversely affect the Resident 95's behavior and well-being. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia (loss of cognitive functioning, thinking, remembering, and reasoning) with behavioral disturbance, mood disorder, unspecified anxiety disorder, unspecified recurrent major depressive disorder, and unspecified psychosis (disconnection to reality), per the facility's Resident Face sheet. A review of Resident 95's physician's order summary report dated 2/16/22 indicated, on 10/21/21, Resident 95 was prescribed with Seroquel…

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, interviews, and record review, the facility failed to ensure the appropriate food textures were provided when one of 4 residents (Residents 39) with Fortified liquefied pureed diet order (a diet in liquid form that requires no chewing for one who has difficulty chewing and/ or swallowing) had lumps in their breakfast oatmeal, Chocolate chip bar dessert and pudding. This failure had the potential to place the resident at risk of choking and aspiration and decrease nutritional status. Cross reference F692, F800, F803 Findings: A review of facility document dated February 14, 2022, titled Diet Orders List, indicated . four residents received Fortified Liquefied Pureed Diet . During an interview on 2/15/22, at 1:01 PM, with [NAME] Helper 1 (CKH), at kitchen, CKH 1 demonstrated how he made liquified pureed diet. CKH 1 used a fork to stir a scoop of pureed bread with an ounce of hot water in a six ounce mug. After stirring for about 15 seconds, the texture was semi- smooth with a few visible lumps. CKH 1 acknowledged the lumps and stated liquified pureed diet texture…

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 facility document review, the facility failed to: 1. provide a substitute entree of similar nutritive value and provide a vegetarian diet when a resident (Resident 1) had a documented preference for a vegetarian diet; and 2. serve the proper consistency food and preference of food to 1 resident (Resident 2). This failure had the potential for two residents (Resident 1 and 2) to consume fewer nutrients than indicated for the approved menu and for one resident (Resident 2) to not tolerate the consistency of food provided resulting in choking, out of 264 residents who received food from the kitchen. Findings: 1. A record review for Resident 1, showed in the admission Record he was a [AGE] year-old male admitted on [DATE] with diagnoses including dementia, major depressive disorder, and generalized muscle weakness. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], showed under the section titled Cognitive Patterns, Resident 1 had a Brief Interview of Mental…

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 one sampled resident (218) turning, and repositioning was accurately documented in the resident's medical record. These failures had the potential to cause miscommunication of the care provided to Resident 218 and to the other health care providers. Findings: Resident 218 was readmitted to the facility on [DATE], with diagnoses which included Parkinson's disease (progressive nervous system disorder that affects movements), per the facility's admission Record. A review of Resident 218's MDS (assessment tool), dated 1/12/22, indicated that the resident had a BIMS (a cognitive assessment) score of two (0-7 indicated severe cognitive impairment). Per the Functional Status, Resident 218 was totally dependent on staff for bed mobility. A review of Resident 218's care plan titled, Risk of Development of Skin Breakdown, dated 4/8/14 indicated, .Provide a therapeutic mattress and reposition every 2 hours According to the physicians…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a hospice calendar was in the resident's hospice binder for one of five residents (20) reviewed for hospice. This failure had the potential for miscommunication and lack of collaboration with the hospice agency related to Resident 20's care. Findings: Resident 20 was admitted to the facility on [DATE], with diagnoses which included ataxia (involuntary movements), per the facility's admission Record. A review of Resident 20's record was conducted on 2/17/22. Resident 20's MDS (an assessment tool), dated 4/3/21, indicated Resident 20's brief interview for mental status (BIMS) score was 4, which meant Resident 20's cognition was severely impaired. On 2/15/22 at 3:51 P.M., a concurrent interview and record review with LN 12 was conducted. LN 12 stated she could not find the January and February calendar schedule for hospice. LN 12 stated the personalized hospice calendar was important so the nurses knew when the hospice staff would…

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.