Brentwood Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff provided dignified dining experience while assisting two of 15 sampled residents (Residents 4 and 58) during meals; by ensuring Residents 4 and 58 were fed at eye level to maintain face-to-face contact with the residents. This deficient practice had the potential to result in feelings of decreased self-esteem and self-worth for Resident 4 and Resident 58). b. During a review of Resident 58's admission record indicated the facility admitted the resident on 9/26/2024 with diagnoses that included dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing) and muscle weakness (a lack of strength in the muscles). During a review of Resident 58's Skilled Nursing Facility admission History and Physical (H&P), dated 9/27/2024, indicated Resident 58 was recently hospitalized for acute (of sunset onset) or chronic (on going) functional decline, progressive neurologic (relating to the nervous system…

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

Based on observation, interview, and record review, the facility failed to provide on-going activities, based on comprehensive assessment and resident's preferences, that meets the interests and to support the physical, mental, and psychosocial well-being of 57 of 57 facility Residents. This deficient practice had the potential to result in lack of feelings of well-being and meaningfulness for the resident. Cross Reference F680 Findings: During an observation and concurrent interview on 10/16/2024 at 11:35 a.m. Certified Nursing Assistant 6 (CNA 6) was observed seated in the facility communal dining area monitoring residents as the residents watched Television. During an interview CNA 6 stated CNA 6 was covering for the Activities Director (AD) who was on vacation starting 10/15/2024. CNA 6 stated it was CNA 6's first day covering for the AD and that CNA 6 was trained on resident activities. CNA 6 stated CNA 6 was handed a guide (name not provided) on which activities to conduct with the residents. During an interview on 10/16/2024 at 11:38 a.m., the Director of Staff Development…

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 create a comprehensive care plan (a resident-specific plan with defined clinical goals and interventions used to manage identified medical issues or other areas of concern) to meet the needs of two of five sampled residents (Residents 58 and 164) by failing to: -Develop a care plan for Resident 58's psychotropic (a medication that affects behavior, mood, thoughts, or perception) medications and their targeted behavior of visual hallucinations for Resident 58. - Develop a care plan for Resident 164's activities and anticoagulant (medication used to prevent blood clots) medication. These deficient practices placed Residents 58 and 164 at increased risk for suboptimal care from facility staff in these care areas leading to diminished physical, mental, and psychosocial well-being. Findings: a. During a review of Resident 58's admission Record indicated an the facility admitted the resident on 9/26/2024 with diagnoses of dementia (a progressive state 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 provide appropriate monitoring of anticoagulants (blood thinner; a substance that hinders the clotting of blood) and antidepressants (medication used to treat depression [mental health that involves persistent feeling of sadness, loss of interest and low mood that lasts for a long time] for two of ten sampled residents (Resident 6 and Resident 164). These deficient practices had the potential to result in complications from the use of antidepressants and anticoagulants such as bruising, bleeding to Resident 6 and Resident 164. Findings: 1.A review of Resident 6's admission Record indicated the facility originally admitted the resident on 2/13/2020 and re-admitted the resident on 11/1/2023 with diagnoses including atrial fibrillation (AFib - an irregular often rapid heart rate that commonly causes blood clots), transient ischemic attack and cerebral infarction (damage to brain tissues caused by lack of oxygen to the area). A review of the physician…

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 the facility document titled, Facility Verification of Informed Consent, (a principle in medical ethics, medical law, and media studies, that a patient must have sufficient information and understanding before making decisions about their medical care) form was fully completed and properly executed for psychotropic (medications that affect the mind, emotions, and behavior) medication for two of five sampled residents (Residents 58 and 164). This deficient practice had the potential for Residents 58 and 164 not to be fully informed of the risk and benefits of the psychotropic medication they were receiving. Findings: a. A review of Resident 58's admission record indicated Resident 58 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities) with psychotic disturbance anxiety disorder (a mental health condition with feeling of worry, anxiety, or fear interfering…

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 homelike environment by failing to ensure a pest free environment for one of six sampled residents (Resident 214). This deficient practice resulted in Resident 214 being bitten by ants and a potential of a facility wide infestation of ants and other residents being affected by a wider infestation. Findings: A review of Resident 214's admission Record indicated Resident 214 was admitted to the facility on [DATE], with diagnoses that included, anxiety disorder, (restlessness, worried, tense, or afraid of what may happen in the future), muscle weakness (a lack of physical or muscle strength, throughout the body). A review of Resident 214's Minimum Data Set (MDS - a federally mandated resident assessment tool), indicates Resident 214's cognition (the mental ability to make decisions of daily living) was intact, and can make decisions for medical care and perform all activities of daily living. During a concurrent observation 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's interdisciplinary team (IDT-- a group of health care professionals with various areas of expertise who work together toward the goals of their clients) failed to ensure that one of 13 sample residents (Resident 53) did not keep medications at the bedside without a physician's order and/or without being assessed to determine if the resident is capable to self-administer medications. This deficient practice resulted in Resident 53 keeping a white powder like substance inside the medication dispensing cup and self-applying the white powder under the breasts. This deficient also, had the potential for the white powder to be accessed and used by unintended person. Cross Reference F760 Findings: During a review of the admission record indicated Resident 53, was admitted to the facility on [DATE], with diagnoses including acute respiratory failure with hypoxia (a serious medical condition that occurs when the lungs have trouble loading the blood 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 interview and record review, the facility failed to ensure that the residents right to formulate an advanced directive (a legal document indicating resident preference on end-of-life treatment decisions) was recorded for two of 14 sampled residents (Residents 23 and 26). This deficient practice violated Residents 23 and 26 right to be fully informed of the option to formulate advance directives and had the potential to cause conflict with health care wishes for residents 23 and 26. Findings: During a review of Residents 23's admission Record indicated the facility admitted Resident 23 on 3/8/2023 with diagnoses including hyperlipidemia (high level of fats in the blood), hypertension (HTN - elevated blood pressure), and generalized muscle weakness (lack of physical or muscle strength). During a review of Resident 23's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/9/2024, indicated Resident 23 had intact cognitive (mental action or process of acquiring knowledge and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of eight sampled residents (Resident 164's) medical records had accurately documented assessment reflective of the resident's use of an anticoagulant (a substance that prevents or treats blood clots in the heart and blood vessels [tubes that carry blood throughout the body]). This deficient practice resulted in Resident 164's medical records being inaccurate and missing vital information of services being rendered to the resident. Findings: During a review of Residents 164's admission Record indicated the facility admitted Resident 164 on 10/1/2024 with diagnoses including Major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), atrial fibrillation (Afib- an irregular heartbeat that occurs when the electrical signals in the hearts upper chambers fire rapidly and out of synch with the lower chambers), and dysphagia (difficulty swallowing…

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

Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant 6 (CNA 6) was trained and had the appropriate qualifications to serve as a qualified therapeutic recreation specialist or an activities professional to support the physical, mental, and psychosocial well-being of 57 of 57 residents in the facility. This deficient practice had the potential to result in a decline in the physical, mental, and psychosocial well-being the 57 residents. Findings: During an observation and concurrent interview on 10/16/2024 at 11:35 AM., CNA 6 was observed seated in the facility communal dining area monitoring residents as the residents watched Television. During an interview CNA 6 stated CNA 6 was covering for the Activities Director (AD) who was on vacation starting 10/15/2024. CNA 6 stated it was CNA 6's first day covering for the AD and that CNA 6 was trained on resident activities. CNA 6 stated CNA 6 was handed a guide (name not provided) on which activities to conduct with the residents. During an interview on 10/16/2024 at 11:38 AM., the…

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

Based on observation, interview, and record review, the facility failed to develop a care plan (a document outlining a detailed approach to care customized to an individual resident's need) with measurable goals and interventions to address care and treatment of a resident with dementia (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning) for one of one sampled resident (Resident 58). This deficient practice had the potential to negatively affect the delivery of services to Resident 58. Finding: A review of Resident 58's admission record indicated the facility admitted Resident 58 on 9/26/2024 with diagnoses that included dementia (a progressive state of decline in mental abilities) with psychotic disturbance anxiety disorder (a mental health condition with feeling of worry, anxiety, or fear interfering with one`s daily activities) and cognitive communication deficit (a disorder that affects a person's ability to communicate). A review of Resident 58's Physician Orders, dated 9/26/2024…

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 failed to obtain a physician's order and clinical indication to apply medication for one of 13 sample residents (Resident 53). This deficient practice resulted in Resident 53 applying the antifungal powder under the breasts without a physician's order and clinical indication for the antifungal powder. Cross Reference F554 Findings: During a review of the admission record indicated Resident 53, was admitted to the facility on [DATE], with diagnoses including acute respiratory failure with hypoxia (a serious medical condition that occurs when the lungs have trouble loading the blood with enough oxygen and body tissues), congestive heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs), major depressive disorder (a mental health condition that involves persistent feelings of sadness, hopelessness, and a loss of interest in activities), and muscle weakness and dysphagia (medical term for swallowing…

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 document an accurate fall risk assessment (an evaluation to determine a resident's risk for fall based on different variables) for one of three sampled residents, (Resident 1). This deficient practice had the potential to place Resident 1 at risk for fall(s) causing injuries or even death. Findings: A review of Resident 1's admission Record indicated the facility admitted this [AGE] year old female on 2/15/2024 with diagnoses including Osteoporosis (brittle bones) with current pathological fracture (broken bone), Atherosclerotic heart disease (thickening or hardening of the vessels that return blood back to the heart), Chronic Kidney Disease stage 4 (very decreased functioning of the kidney's ability to filter), Sick Sinus Syndrome (type of heart dysrhythmia), presence of cardiac pacemaker, Hyperlipidemia (high cholesterol), Essential Tremor (neurological condition that causes your hands to shake rhythmically), hearing loss left ear, history of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, facility failed to ensure removal and discarding of discontinued medications for four of four sampled discharged residents (Resident 8, 9, 10 and 14) from the medication storage room per facility's policy. This deficient practice resulted in unsafe storage of the medication, and possibly Residents 8, 9, 10 and 14 inabilities to get the prescribed medications paid by residents ' insurance. Findings: 1. A review of Resident 8 ' s admission Record indicated Resident 8 was admitted to the facility on [DATE], with diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body), dysphagia (difficulty swallowing food or liquid) and dysarthria (difficulty in speaking /slurred speech). Resident 8 was discharged on 3/23/2023. A review of Resident 8's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 2/27/2023, indicated Resident 8 has moderately impaired cognition (mental action or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to, for eight of 22 sampled residents (Resident 11, 21, 28, 29, 36, 126, 127 and 227),: 1. Inform or offer advanced directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) information, 2. Maintain a current copy of resident's advance directive in resident's clinical record 3. Followed up and provided additional information on advanced directive upon request. These deficient practices violated the residents' and/or the representatives' right to be fully informed of the option to formulate advanced directives and had the potential to cause conflict with health care wishes for Residents 11, 21, 28, 29, 36, 126, 127 and 227. Findings: A. During a review of Resident 127's admission Record, indicated the facility admitted Resident 127 on 11/25/2022 with diagnoses including sepsis (a life-threatening…

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 10 of 10 sampled residents (Residents 6, 28, 38, 229, 7, 16, 27, 52, 57, and 127) were free from physical restraint by a. failing to ensure the use of side rails (SR) are properly assessed in the Minimum Data Set (MDS - a standardized assessment and care-screening tool). b. failing to ensure the physician's order for one fourth (1/4) side rails (SR) up as enablers for mobility were applied. These deficient practices had the potential to result in entrapment and injury and residents not being treated with respect and dignity with the use of restraints. Findings: A. A review of Resident 6's admission Record indicated resident was admitted to the facility on [DATE], with diagnoses including chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), and type II diabetes mellitus…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that a preadmission screening assessment was done for a resident who was diagnosed with a mental illness prior to admission in the facility for one of one sampled resident (Resident 21). This deficient practice had the potential for not receiving the necessary and appropriate psychiatric (relating to mental illness or its treatment) level of treatment and evaluation in the facility. Cross Reference: F645. Findings: A review of Resident 21's admission Record indicated Resident 21 was admitted to the facility on [DATE], with diagnoses including chronic hepatitis C (an infection caused by a virus that attacks the liver and leads to inflammation), post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), and radiculopathy (injury or damage to nerve roots in the area where they leave the spine). A review of Resident 21's Minimum Data Set (MDS - a comprehensive…

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 safe provision of pharmaceutical services by failing to: 1. Ensure Resident 6's self-administered medication was properly stored. 2. Ensure one of two medication storage refrigerator (refrigerator 1's) temperatures were within the acceptable range. 3. Ensure proper labeling of an opened foil pack of DuoNeb (medication to treat symptoms associated with lung disease) for Resident 6. 4. Ensure ophthalmic (eye) medications were refrigerated per pharmacy for Resident 175 and 232. These deficient practices had the potential to compromise the safety and effectiveness of medications, resulting in possible medication errors. Findings: 1. A review of Resident 6's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), acute respiratory failure (a serious condition that makes it difficult to breathe on…

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 the resident's right to be treated and dignity and to self-determination for two of the 15 sampled residents when: 1. Licensed Vocational Nurse 3 (LVN 3) asked Resident 64 what was Oxycodone (controlled strong pain medication) the maximum dose per day. 2. Resident 4 (female) shared a bathroom with male residents. As a result, Resident 67 felt uncomfortable and Resident 4 felt bad and disgusted every time she had to use the bathroom. Findings: 1a. A review of Resident 4's admission Record indicated Resident 64 was admitted to the facility on [DATE], with diagnoses including dislocation of internal right hip prosthesis (when the ball of the new hip implant comes out of the socket), history of falling, and insomnia (a common sleep disorder where you may have trouble falling asleep, staying asleep, or getting good quality sleep). A review of Resident 4's Minimum Data Set (MDS - a standardized assessment and care screening tool) 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 observation, interview, and record review, the licensed nursing staff failed to ensure that the residents and/or responsible party (RP) were informed in advance, of the risks and benefits of psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness, or behavior) for one of 15 sampled residents (Resident 38). This deficient practice violated the residents' right to make an informed decision regarding the use of psychoactive medications. Findings: A review of Resident 38's admission record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), anxiety (a feeling of fear, dread, and uneasiness. It might cause you to sweat, feel restless and tense, and have a rapid heartbeat), and encephalopathy (any disease that affects the whole brain and alters its structure or how…

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 a preadmission screening assessment was completed for one of threee sampled residents (Resident 21), who was diagnosed with a mental illness prior to admission in the facility. This deficient practice had the potential for Resident 21 not receiving the necessary and appropriate psychiatric (relating to mental illness or its treatment) level of treatment and evaluation in the facility. Cross Reference: F641. Findings: A review of Resident 21's admission Record indicated Resident 21 was admitted to the facility on [DATE], with diagnoses including chronic hepatitis C (an infection caused by a virus that attacks the liver and leads to inflammation), post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), and radiculopathy (injury or damage to nerve roots in the area where they leave the spine). A review of Resident 21's Minimum Data Set (MDS - a comprehensive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for four of 35 sampled residents (Residents 6, 16, 28 and 38) by failing to ensure: 1. Comprehensive care plan was developed and implemented for Resident 16's levetiracetam (medication to treat seizure [a sudden, uncontrolled electrical disturbance in the brain]) use. 2. Residents 6, 28 and 38 had the proper care plan for bed side rails per physician order. These deficient practices had the potential to result negative impact on Residents 6, 16, 28 and 38's health and safety, as well as the quality of care and services received. Findings: 1. A review of Resident 16's admission Record, indicated the facility admitted Resident 16 on 9/13/2023 with diagnoses including osteoporosis (a condition in which bones become weak and brittle), Alzheimer's disease (a progressing brain disorder that destroys memory and other important 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 22 sampled residents (Resident 9) psychoactive medication clonazepam (klonopin- a long-acting benzodiazepine with intermediate onset commonly used to treat panic disorders, severe anxiety, and seizures) 1. Was necessary to treat a specific diagnosis and documented condition. 2. Pharmacist recommendations were followed. This deficient practice had the potential to place Resident 9 at risk of receiving unnecessary medication. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including essential hypertension (high blood pressure that is multi-factorial and doesn't have one distinct cause with above-normal blood pressure is typically anything over 120/80), malignant neoplasm of prostate (Prostate cancer is cancer that occurs in the prostate. The prostate is a small walnut-shaped gland in males that produces the seminal fluid), and radiculopathy, lumber…

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 the appropriate setting of the low air loss mattress (LAL-a mattress designed to prevent and treat pressure wounds) was properly set up for two of two sampled residents, (Residents 38 and 57) according to the residents' needs and professional standard of care. This deficient practice placed Residents 38 and 57 at risk of poor wound healing of the current pressure ulcer (skin and soft tissue injuries that form as a result of constant or prolonged pressure exerted on the skin) and had a potential to develop new pressure sores/wounds. Findings: A. A review of Resident 38's admission record indicated Resident 38 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including severe sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) metabolic encephalopathy (a disease in which the functioning of the brain is affected 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 observation, interview, and record review, the facility failed to implement their policy and procedure (P&P) titled, Personal Alarms, for one of 22 sampled residents, (Resident 28) who are at risk for falls. This deficient practice placed Resident 28 at risk for fall and sustain an accidental injury. Findings: A review of Resident 28's admission Record indicated Resident 28 was admitted to the facility on [DATE], with diagnoses including intervertebral disc degeneration (when the spinal disks wear down), unspecified dementia (loss of cognitive functioning-thinking, remembering, and reasoning) and major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss of interest). A review of Resident 28's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 10/17/2023, indicated Resident 28's cognitive skills for daily decision-making were severely impaired and required maximal assistance from staff for activities of daily living (ADLs- oral hygiene,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility staff failed to ensure resident received appropriate treatment and services to prevent urinary tract infections (UTI-an infection in any part of your urinary system your kidneys, ureters, bladder and urethra) for one of three sampled residents (Resident 177) by failing to ensure Resident 177's indwelling urinary (foley) catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) was placed below the level of the bladder at all times. This deficient practice had the potential to result in urinary tract infections for Resident 177. This deficient practice had the potential for Resident 177 to be at risk for complications related to indwelling catheters such as UTI. Findings: A review of Resident 177's admission Record indicated resident was admitted to the facility on [DATE] with diagnoses including type II diabetes mellitus (DM-a chronic condition that affects the way the body processes 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 that two of 15 sampled residents (Residents 11 and 36) were accurately assessed and monitored by failing to: 1. Identify and assess prevent unplanned significant weight loss of 11.4 pounds (lbs) (6.8 percent) in 9 days for Resident 11. 2. Ensure Resident 36 who was on a fluid restriction, received the daily fluids per physician's order and resident's care plan. These deficient practices resulted in Resident 11 having unplanned significant weight loss of 11.4 pounds in 10 days and placed her at a risk for malnutrition; it also had the potential to cause either fluid overload or dehydration for Resident 36. Findings: A. A review of Resident 1's admission Record indicated Resident 11 was admitted to the facility on [DATE] with diagnoses including hypothyroidism (the thyroid gland [butterfly-shaped gland in the front of the neck] does not produce adequate thyroid hormones to meet the body's needs), overactive bladder (OAB-causes a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to effectively manage pain for one of 15 sampled residents (Resident 64) by not following physician's medication order. This deficient practice resulted in Resident 64 experienced unnecessary pain. Findings: A review of Resident 64's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including displaced fracture (break in bone) in left tibia (also known as the shinbone or shank bone in the leg below the knee), and fracture of left lower leg, depression (a mood disorder that causes persistent feeling of sadness and loss of interest), and sciatica (pain, weakness, numbness, or tingling in the leg). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 10/30/2023, indicated Resident 64's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact. Resident 64 required supervision to moderate…

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 the 22 sampled residents (Resident 9) psychoactive medication clonazepam (klonopin- a long-acting benzodiazepine with intermediate onset commonly used to treat panic disorders, severe anxiety, and seizures [is a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations or states of awareness]), by failing to ensure: 1. Klonopin was necessary to treat a specific diagnosis and the condition documented. 2. The Pharmacist's recommendations were followed. These deficient practice had the potential to place Resident 9 at risk of receiving unnecessary medication. Findings: A review of Resident 9's admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including essential hypertension (high blood pressure that is multi-factorial and doesn't have one distinct cause with above-normal blood pressure is…

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 five sampled residents (Resident 7's) psychotropic (relating to or denoting drugs that affect a person's mental state) medication regimen was managed and monitored to promote or maintain the highest practicable mental, physical, and psychosocial well-being by failing to ensure: 1. The implementation of monitoring episodes of anxiety for Resident 7's alprazolam (anti-anxiety medication) use. 2. The implementation of monitoring for any potential side effect and/or adverse reaction for Resident 7's alprazolam use. 3. The implementation of monitoring episodes of depression for Resident 7's citalopram hydrobromide (anti-depressant medication) use. 4. The implementation of monitoring for any potential side effect and/or adverse reaction for Resident 7's citalopram hydrobromide use. 5. Ensure Resident 7's citalopram hydrobromide use had indicated manifestation of behavior specific for the diagnosis. These deficient practices had 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 maintain accurate medical record in accordance with accepted professional standards and practices for one of 22 sampled residents (Resident 33) by failing to ensure Resident 33's change of condition documentation on 10/25/2023 was documented via late entry. Resident 33 was transferred to an acute care hospital (GACH) on 10/24/2023. This deficient practice had the potential to negatively impact the delivery of service given to Resident 33. Findings: A review of Resident 33's admission Record indicated the facility originally admitted Resident 33 on 8/31/2023 and readmitted on [DATE] with diagnoses including sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), urinary tract infection (UTI-a bacterial infection of the bladder and associated structures). admission Record also indicated Resident 33 was transferred to GACH on 10/24/2023. A review of Resident 33's Minimum Data…

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 that one of one sampled emergency crash cart (set of trays, drawers or shelves on wheels used in a medical facility for transporting and dispensing emergency equipment at site for life support protocols): 1. Ensure crash cart was readily available; Registered Nurse 1 (RN 1) did not know the code and/or which key to use when opening the emergency crash cart. 2. Ensure crash cart log was checked and updated on a daily basis and as needed. These deficient practices had the potential of delayed provisions of emergency care for all the current residents who wishes to have full treatment in a life-threatening situation. Findings: During a concurrent observation and interview with RN 1 on 10/24/2023 at 10:10 a.m., observed missing crash cart checks on the following dates: 9/22/2023; 9/23/2023; 9/29/2023; 9/30/2023; 10/6/2023; 10/7/2023; 10/20/2023; 10/21/2023; 10/22/2023; 10/23/2023; and 10/24/2023. RN 1 stated and verified missing check. RN 1 was unable to open the crash cart and stated not knowing the code…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for three of three sampled residents (Residents 1, 2 and 5) by failing to: 1. Implement a comprehensive and resident-centered care plan regarding Resident 1 and 2's peripherally inserted central catheter (PICC line-type of catheter that is placed in a large vein that allows to give medications intravenously [IV-given via vein]). 2. Develop and implement a resident-centered care plan when Resident 5 refused COVID-19 (a viral infection, highly contagious, that easily transmits from person to person, causing respiratory problems and may cause death) vaccination. These deficient practices had the potential to fail during the delivery of necessary care and services to Residents 1, 2 and 5. Findings: 1a. A review of Resident 1's admission record indicated the resident was admitted on [DATE] with diagnosis including osteomyelitis (infection of the bone), right hip stage 4 pressure ulcer (injury…

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 four sampled residents (Residents 1 and 2) with Intravenous (IV-given via vein) catheter was provided safe care to prevent complications. Residents 1 and 2 had a Peripherally inserted central catheter (PICC line-type of catheter that is placed in a large vein that allows to give medications intravenously) line and the dressing was not changed per facility's policy. This deficient practice had the potential to place Residents 1 and 2 at risk for developing complications such as inflammation of the vein and infection. Findings: a. A review of Resident 1's admission record indicated the resident was admitted on [DATE] with diagnosis including osteomyelitis (infection of the bone), right hip stage 4 pressure ulcer (injury that breaks down the skin and underlying tissue) and Parkinson's disease (brain disorder that causes unintended or uncontrollable movements). A review of Resident 1's Comprehensive Minimum Data Set (MDS-a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that COVID-19 (a viral infection, highly contagious, that easily transmits from person to person, causing respiratory problems and may cause death) booster vaccination was consented properly and complete, educated upon refusals with documentation when offered to one of eight sampled residents (Resident 5). This failure had the potential to result in Resident 5's COVID-19 infection. Findings: During a review of Resident 5's admission Record, indicated that Resident 5 was admitted to the facility on [DATE] with diagnoses including myocardial infarction (heart attack), hypertension (HTN - elevated blood pressure) and dementia (a chronic or persistent disorder of the mental processes caused by brain disease). During a review of Resident 5's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 8/19/2023, the MDS indicated Resident 5 had a moderately impaired cognition (thought processes) for daily decision making and 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 interview, and record review, the facility failed to develop a baseline care plan for one of four sampled residents (Resident 1) within 48 hours of resident's admission. This deficient practice had the potential for delayed administration of necessary care and services. Findings: A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 8/4/2023, with diagnoses including convulsion ( a sudden, irregular movement of the body), and muscle weakness. A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 8/9/2023, indicated the resident had intact cognition (decisions consistent/reasonable). The MDS indicated the resident was independent with bed mobility, transfer, toilet use, dressing, and walking. However, she required supervision as it relates to her personal hygiene. A review of Resident 1`s Assessments on 8/19/2023 at 9:25 AM, indicated the base line care plan was not completed and the status showed in progress. A further review of the assessments indicated that Safety Device/Mobility Device…

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.