Village Green Rehabilitation And Healthcare Center

Based on review of employee files, facility documentation review, and facility policy review and interviews, the facility failed to ensure annual performance evaluations were completed for nurse aide staff for 2023 and 2024. The findings included: Review of a facility employee listing provided to the survey team upon entrance to the facility as part of an annual recertification survey identified NA #3 had a hire date of 10/2/2000, NA #4 had a hire date of 7/3/12, and NA #2 had a hire date of 12/12/23. A review of annual performance evaluations for facility nurse aide staff for 2023, the facility failed to provide any documentation of annual performance evaluations for completed for NA #3 and NA #4. A review of annual performance evaluations for facility nurse aide staff for 2024, the facility failed to provide any documentation of annual performance evaluations for completed for NA #2 and NA #4. Interview with the Director of HR on 3/12/25 at 11:05 AM identified she was responsible for notifying the DNS of the facility when nursing staff had performance evaluations that were due to…

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 review of the clinical record, observation, facility policy and interviews for the only resident reviewed for skin conditions (Resident #46) and the only resident (Resident #224) reviewed for tube feeding, the facility failed to follow the Enhanced Barrier Precautions guidelines. The findings include: 1. Resident #46's diagnoses included Venous Insufficiency, edema, essential hypertension. The Resident Care Plan dated 2/17/25 identified the resident had a lesion on his/her right dorsal foot. Interventions included weekly skin checks by licensed nurses, and floating heels while in bed. The admission Minimum Data Set assessment dated [DATE] identified Resident #46 was cognitively intact and required maximum assistance with showering, toileting, and required moderate assistance with personal hygiene. A physician's order dated 3/9/2025 directed to place resident on enhanced barrier precautions every shift secondary to a wound. A physician's note dated 2/14/25 at 7:56 AM written by Medical Doctor (MD #2)…

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 clinical record reviews, observations, review of facility policy and interviews for 2 of 5 ( Residents # 40 and # 325) reviewed for the environment,, the facility did not ensure that residents call bell were within reach. The findings included: 1. Resident #40 was admitted to the facility on [DATE] with diagnoses that included a neurological disorder and dependence on a ventilator. A care plan dated [DATE] indicated Resident #40 was at risk for alteration in comfort related to chronic pain. Interventions included advising the resident to request pain medication before the pain becomes severe. The care plan also indicated the resident had an Advanced Directive to perform Cardio CPR during an emergency. The quarterly MDS assessment dated [DATE] indicated the resident had severe cognitive impairment, usually understood others. The MDS assessment further indicated the resident required substantial/maximal assistance with mobility and was dependent on personal hygiene and toileting. An observation in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, observations, review of facility documents, review of policy and interviews, the facility failed to ensure 2 therapeutic modality machines in the Therapy Department had been evaluated annually for safety in 2022 and 2023 and for 1 of 4 residents ( Resident # 8) reviewed for Respiratory Care, the facility failed to ensure signage was on a resident's door to indicate oxygen was in use. The findings included: 1. An observation on 3/11/2025 starting at 2:00PM and ending at 3:15 PM of the Therapy Department that uses the same room and equipment for residents in the facility and for outpatient physical therapy. Further observations identified the therapy modality machines was without stickers to indicated when was the last time the machine had been evaluated for safety. An interview with the Maintenance Director on 3/11/2025 at 3:15 PM indicated she/he could not find stickers on either modality machine of when the last safety evaluation was conducted and indicated she/he would look 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 review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2) residents (Resident #1) reviewed for falls, the facility failed to complete neurological checks for an unwitnessed fall in full per facility protocol. The findings include: Resident #1 was admitted to the facility with diagnoses that included fibromyalgia and repeated falls. A care plan dated 2/4/25 identified Resident #1 was at risk for falls with interventions that included to assist the resident with ambulation and transfers, and if a fall occurs, to initiate frequent neurological and bleeding evaluation per facility protocol. The fall risk evaluation dated 2/5/25 identified Resident #1 scored fifteen (15) indictive of being at risk for falls. The admission MDS dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of fourteen (14) indicative of intact cognition, required one staff physical assist for toilet use, transfers and bed mobility, and had a fall in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #5), reviewed for infection control, the facility failed to implement the required transmission-based precautions as per the facility policy. The findings include: Resident #5 was admitted with chronic respiratory failure dependent on a ventilator, dementia, amyotrophic lateral sclerosis (ALS), epilepsy (seizure disorder) and extended spectrum beta lactamase resistance (ESBL- presence of a bacteria resistant to common antibiotics). A hospital transfer document dated 5/13/2024 identified Resident #5 had a chronic methicillin (antibiotic) resistive staphylococcus aureus (MRSA)(bacteria) infection in his/her tracheostomy site. A physician's order dated 12/22/2024 directed contact precautions until further notice for positive MRSA, ESBL. A quarterly minimum data set (MDS) dated [DATE] identified Resident #5 had severely impaired cognition (BIMS of 6) and required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of seven residents (Resident #1) reviewed for quality of care, the facility failed to ensure the clinical record was complete and accurate to include wound care documentation, and for two of seven residents (Resident #5 and #6) reviewed for quality of care, the facility failed to ensure the clinical record was complete and accurate to include resident care. The findings include: 1. Resident #1's diagnoses included dementia, and cerebral infarction with hemiplegia and hemiparesis (paralysis and weakness). The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was unable to perform a Brief Interview for Mental Status (BIMS), indicative of severely impaired cognition and was dependent with all ADL's (activities of daily living). The Resident Care Plan (RCP) dated 7/2/2024 identified a risk for skin breakdown related to decreased activity, fail skin, history of pressure ulcer,…

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 clinical record review, observations, facility documentation review, facility policy review, and interviews for one of three residents (Resident #6) reviewed for wound care treatment, the facility failed to ensure wound care was provided in accordance with accepted infection control practices. The findings include: Resident #6's diagnoses included chronic kidney disease and heart failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #6 had severe cognitive impairment and was dependent on staff for ADLs. The Resident Care Plan (RCP) dated 11/10/2024 identified resident was at risk for skin breakdown related to immobility or has actual skin breakdown and had contractures. Interventions directed to monitor skin. A physician order dated 11/8/2024 directed to cleanse an open blister on the back of the left calf and right calf with wound wash, apply xeroform and foam dressing change daily and as needed. Continuous observation of Resident #6's wound care on 11/20/2024…

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 review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3)residents reviewed for abuse, the facility failed to ensure the State Agency was notified timely of allegations of abuse. Resident #1's diagnoses included generalized muscle weakness and major depressive disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was cognitively intact, exhibited no behaviors and required substantial assistance with bed mobility, was dependent on staff for transfers and toileting hygiene. The Resident Care Plan (RCP) dated 7/16/24 identified that Resident #1 required assistance with Activities of Daily Living (ADLs) with interventions that included to provide an assist of one with ADLs, monitor for complications of immobility and to utilize bed rails as an enabler. Review of the Reportable Event dated 9/6/24 at 12:00 AM identified that outside vendor, Person #3 stated that Person #2 was told by Resident #1 that profanity 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 review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3)residents reviewed for abuse, the facility failed to investigate allegations of abuse. The findings include: Resident #1's diagnoses included generalized muscle weakness and major depressive disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was cognitively intact, exhibited no behaviors and required substantial assistance with bed mobility, was dependent on staff for transfers and toileting hygiene. The Resident Care Plan (RCP) dated 7/16/24 identified that Resident #1 required assistance with Activities of Daily Living (ADLs). Interventions included to provide an assist of one with ADLs, monitor for complications of immobility and bed rails to be used as an enabler. Interview with Person #1 on 9/24/24 at 9:43 AM identified that he/she received a call from Person #2 on 9/3/24 stating that Resident #1 reported being thrown like a rag doll and was sworn…

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 review of the clinical record, facility policy, and interviews for the one (1) of three (3) residents (Resident #1) reviewed for behaviors, the facility failed to revise the care plan indicating refusals of personal care. The findings include: Resident #1's diagnoses included generalized muscle weakness and major depressive disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was cognitively intact, exhibited no behaviors and required substantial assistance with bed mobility, was dependent on staff for transfers and toileting hygiene. Review of the Point of Care (POC) NA documentation on September 24, 2024 identified that there was no documentation on bathing for Resident #1 on the 7:00 AM to 3:00 PM shift since 9/2/24 and no documentation on the 3:00 PM to 11:00 PM shift since 9/13/24. Interview with NA #1 on 9/24/24 at 11:23 AM identified that she often cares for Resident #1 and that he/she is incontinent of both bladder and bowel often but will refuse care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for two of three residents (Resident #2) reviewed for abuse, the facility failed ensure the resident was free from mistreatment. The findings include: 1. Resident #1 was admitted with diagnoses that included dementia and adjustment disorder with anxiety. A Resident Care Plan (RCP) dated 1/17/2024 identified Resident #1 had wandering behaviors, had a potential to exhibit physical behaviors related to cognitive loss and violent tendencies prior to admission. The RCP directed to monitor physical behaviors, explain all care one step at a time if resident becomes combative/postpone care and to redirect away from doorways or exits. An admission MDS assessment dated [DATE] identified Resident #1 was severely cognitively impaired, was independent for transfers and walking. A facility psychiatric evaluation and consultation dated 1/19/2024 identified Resident #1 was oriented to self, was confused, and the confusion…

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, review of facility policy, facility documentation and interview for 1 resident (Resident #63) reviewed for the environment, the facility failed to ensure resident's wheelchair was maintained in a clean and sanitary manner and for 2 of 3 units, the facility failed to maintain a clean, sanitary, comfortable and homelike environment. The findings include: 1. Resident #63's diagnoses included schizophrenia, heart failure and depression. The quarterly MDS dated [DATE] identified Resident #63 had intact cognition and required supervision with locomotion on and off unit, was independent with ambulation and used a walker and wheelchair for mobility. Observation of Resident #63's wheelchair on 2/22/23 at 9:40 AM with the Account Manager (Housekeeping) and the District Manager of Healthcare Services Group, (the facility's contracted housekeeping company), identified a thick coating of dust and debris on both foot rests and the metal wheelchair frame. Interview with the Account Manager (Housekeeping)…

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 review of the clinical record, facility documentation, facility policy and interviews for 4 of 4 residents (Resident #12, 41, 62 and 63) reviewed for smoking, the facility failed to ensure that smoking assessments were completed timely. The findings include: 1. Resident #12 was admitted to the facility with diagnoses that included Schizophrenia, COPD, and nicotine dependence. The quarterly MDS dated [DATE] identified Resident #12 had intact cognition. The care plan dated 2/1/23 identified that Resident #12 may smoke with supervision per the smoking assessment. Interventions included to educate the resident/health care decision maker on the facility's smoking policy and to supervise the resident with smoking in accordance with assessed needs. A physician's order dated 2/1/23 directed that Resident #12 required set up and assistance for all ADL tasks. Review of clinical record failed to reflect that smoking assessments had been completed quarterly after 7/27/22 (7 months ago). Further, the clinical record…

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 review of facility documentation, facility policy, and interviews, the facility failed to complete nursing competencies related to IV and respiratory therapy. The findings include: 1. Although requested, the DNS did not provide IV Therapy nurse and nurse aide competencies for 2022. Interview with the DNS on 2/23/23 at 10:24 AM indicated she was responsible to make sure IV Therapy nurse and nurse aide competencies were completed annually and she indicated they had not been done since 2021. Review of the Intravenous Infusion Therapy Manual identified the purpose was to provide comprehensive and integrated infusion care to patients. The facility administrator is responsible for staffing qualified nurses to care for patients' infusion therapy. It is the responsibility of the individual nurse to comply with state nurse act and state regulatory agencies. 2. Facility documentation identified 22 residents had a tracheostomy and 15 residents were on a mechanical ventilator. Interview with Administrator and DNS on 3/1/23 at 9:10 AM identified the mandatory respiratory education 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 clinical record review, facility policy, facility contractual agreement, and interviews for 1 of 2 sampled residents reviewed for hospice, the facility failed to ensure care was coordinated between the contracted hospice provider and the facility. The findings include: Resident #9 was admitted to the facility, with diagnoses that included alcohol use disorder, gastrointestinal hemorrhage, and atherosclerotic heart disease. A physician's order dated 3/9/2021 directed Resident #9 to have a hospice consult. Review of the hospice physician certification dated 3/10/2021 identified Resident #9 was certified for hospice care due to a terminal diagnosis of senile degeneration of the brain. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #9 had intact cognition, required an assist of 1 for eating and toileting. Additionally, Resident #9 was receiving hospice care. The facility Resident Care Plan dated 12/19/2022 identified Resident #9 was receiving services with a contracted…

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, review of the clinical record, facility policy and interview for 2 of 2 residents (Resident #3 and 239) the facility failed to store personal toiletries according to infection control standards, and the facility failed to review the policy and procedure manual annually, and failed to ensure the environmental rounds for infection control were conducted per facility policy. The findings include: 1. Resident #3's diagnoses included diabetes, chronic obstructive pulmonary disease and dementia. The annual MDS dated [DATE] identified Resident #3 was moderately cognitively impaired and required supervision with toilet use, was independent with ambulation and used a walker for mobility. Resident #3 was always continent of urine and had frequent bowel incontinence. Resident #239's diagnoses included heart failure, atrial fibrillation, and anxiety. The admission MDS dated [DATE] identified Resident #239 had intact cognition, required extensive 2-person assistance with bed mobility, transfers and…

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

Based on facility documentation, facility policy and interviews the facility failed to track infections per the facility policy. The findings include: Review of the October, November, and December 2022 antibiotic stewardship line lists failed to identify if the infections were community or facility acquired and failed to identify if the resident had met the criteria for an infection. Interview with the Infection Preventionist, (LPN #3) on 2/23/22 at 10:30 AM indicated she uses the McGeers Criteria (infection surveillance definitions to provide standardized guidance for infection surveillance activities) to look at infections and antibiotic use but does not add that documentation to the monthly infection line list. In review of the October, November, and December 2022 line lists, LPN #3 was not able to identify which resident's had symptoms of infection, what symptoms they had, and if the resident had met the McGeers Criteria. LPN #3 indicated she tracks residents that were prescribed antibiotics. LPN #3 noted she does not monitor or investigate residents based on infection symptoms…

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, review of the clinical record, facility documentation, facility policy, and interviews for 5 of 5 residents (Resident #33, 49, 54, 55, and 66) reviewed for vaccines, the facility failed to ensure the resident and/or resident representative were educated about and offered the Influenza and Pneumococcal Vaccines. The findings include: 1. Resident #33 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease and dementia. The quarterly MDS dated [DATE] identified Resident #33 had severely impaired cognition and was not offered and did not receive the Pneumococcal Vaccine. The Influenza and Pneumococcal Vaccine Informed Consent Forms in the record were blank. Interview and review of the clinical record with LPN #3 and the DNS on 2/23/23 at 11:40 AM indicated in Resident #33's chart had blank Influenza and Pneumococcal consents forms. The DNS noted that in the electronic medical record, only the Covid vaccine was documented as given. 2. Resident #49 was admitted to…

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 review of the clinical record, facility policy, and interview for 1 of 5 sampled residents (Resident #54) reviewed for unnecessary medications, the facility failed to implement behavior monitoring interventions according to the care plan for a resident on a psychotropic medication. The findings include: Resident #54's diagnoses included depression, and unspecified dementia and Parkinson's disease. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #54 was moderately cognitively impaired and required extensive assistance with dressing, personal hygiene, toileting, and limited assistance with eating. The Resident Care Plan dated 2/16/23 identified Resident #54 was at risk for complications related to the use of psychotropic drugs. Interventions directed to complete a behavior monitoring flow sheet. A physician's order dated 2/22/23 directed to administer duloxetine HCl 20 mg daily, and mirtazapine 15mg at bedtime to be given to Resident #54. Review of the Physicians orders 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, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #79) reviewed for enteral feeding, the facility failed to ensure the resident's feeding system was labeled according to the policy. The findings include: Resident #79 was admitted to the facility with diagnoses that included anoxic brain damage and chronic respiratory failure. A physician's order dated 2/10/23 directed to administer enteral feeding every shift Jevity 1.2 at 55 ml per hour continuous (until Jevity 1.5 is available). The quarterly MDS dated [DATE] identified Resident #79 had severely impaired cognition and was totally dependent for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Additionally, Resident #79 required a feeding tube providing more than 51% of total calories per day. The care plan dated 2/13/23 identified Resident #79 was at nutritional risk related to enteral feeding for nutrition support. Interventions included to give tube…

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, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 7 residents (Resident #49) reviewed for medication administration, the facility failed to ensure the medications were administered via feeding tube per facility policy and gastric residuals were checked prior to medication administration. The findings include: Resident #49 was admitted to the facility with diagnoses that included gastrostomy and tracheostomy. The care plan dated 12/15/22 identified a nutritional risk with interventions that included to provide tube feeding and flushes as ordered. The quarterly MDS dated [DATE] identified Resident #49 had severely impaired cognition and required a feeding tube that provided more than 51% of total calories per day. A physician's order dated 1/9/23 directed to give liquid protein 30 ml daily, Baclofen 5mg every 8 hours, Lorazepam 0.5mg every 8 hours, Insulin Glargine 25 units subcutaneously daily, and Enoxaparin 40 mg intramuscular daily.…

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