Complete Care At Harrington Court

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for 3 of 8 residents (Resident #69, 99 and 269) reviewed for abuse and misappropriation, the facility failed to immediately report the allegations of abuse and misappropriation to the Administrator and the State Agency according to established timeframes. The findings include: 1. Resident #69 was admitted to the facility in February 2025 with diagnoses that included chronic kidney disease, diabetes, and surgery of the left leg. A physician's order dated 2/13/25 directed Resident #69 may go on a leave of absence with medications and responsible party. The admission MDS dated [DATE] identified Resident #69 had intact cognition and required moderate assistance with toileting, lower body dressing, transfers, and personal hygiene. The care plan dated 2/20/25 identified Resident #69 is resistive to care. Interventions included providing consistent, trusted caregiver, and structured daily routine, when possible. The social…

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 1 of 8 residents (Resident # 99) reviewed for abuse, the facility failed to take immediate steps to prevent further abuse from occurring while the investigation was in progress. The findings include: Resident #99 was admitted to the facility in January 2024 with diagnoses that included Parkinson's disease, dementia, mood disturbance, anxiety disorder, hallucinations, delusional disorders, psychotic disorder with delusions, depressive disorder, and wandering in disease. The quarterly MDS dated [DATE] identified Resident #99 was moderately cognitively impaired and required partial/moderate assistance with toileting hygiene. Additionally, Resident #99 had no behaviors of physical or verbal symptoms directed towards others, and no wandering. Further Resident #99 does not use a wheelchair. The care plan dated 2/26/25 identified Resident #99 is at risk for complications related to the use of psychotropic drugs:…

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 2 of 3 residents (Resident #38 and 65) reviewed for Pre-admission Screening and Record Review (PASARR), the facility failed to ensure a PASARR rescreen was completed upon admission to the facility for a resident with a long-standing history of a serious mental health diagnosis and after a new mental health diagnosis was identified. The findings include: 1. Resident 38 was admitted to the facility in July 2024 with diagnoses that included chronic obstructive pulmonary disease, tracheostomy, and body dysmorphic disorder. Review of a PASARR level 1 screen outcome dated 7/10/24, prior to admission to the facility, identified that Resident #38 had not received any mental health services in the past and did not have any legal intervention due to mental health symptoms or behaviors. The PASARR level 1 outcome determined a level II was not required due to no evidence of a PASARR condition related to an intellectual disability or serious…

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 interviews for 1 of 5 residents (Resident #77) reviewed for medication administration, the facility failed to ensure a medication was administered in accordance with the physician's orders. The findings include: Resident #77 was admitted to the facility in November 2024 with diagnoses that included fractures of the left lower leg and patella, anemia, and bipolar disorder. A completed physician's order dated 1/24/25 with an end date of 2/21/25 directed to administer Cefadroxil oral capsule (antibiotic), give 500mg by mouth twice daily for four weeks, for septic arthritis. The quarterly MDS dated [DATE] identified Resident #77 had intact cognition and was currently taking an antibiotic. The care plan dated 3/12/25 identified Resident #77 was at risk for impaired skin integrity due to immobility and presence of cam boot (orthopedic footwear used to immobilize the foot and ankle). Interventions included turning and repositioning 4 times per…

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 interviews for 4 residents (Resident #39, 69, 81, 268) the facility failed to provide care according to professional standards, facility policy and physician's orders. For 1 of 2 residents, Resident #39) reviewed for falls, the facility failed to ensure the functionality of a remote cardiac transmission device. For 1 resident (Resident #69) the facility failed to administer medications according to the physician's orders. For 1 of 5 residents (Resident #81) reviewed for unnecessary medications, the facility failed to follow the physician's orders and complete RN assessments when the resident had multiple episodes of hyperglycemia and hypoglycemia that required additional treatment. For 1 of 5 residents (Resident #268) reviewed for medication administration, the facility failed to ensure medications were administered per the physician's order. The findings include: 1. Resident #39 was admitted to the facility in January 2016 with diagnoses…

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 1 of 3 residents (Resident #91) reviewed for pressure ulcer, the facility failed to ensure appropriate care according to professional standards and facility policy when a new pressure ulcer was identified. The findings include: Resident #91 was admitted to the facility on [DATE] and readmission on [DATE] with diagnoses that included fall with left femur fracture, and dementia. The quarterly MDS dated [DATE] identified Resident #91 had severely impaired cognition, was always incontinent of bowel and bladder and required moderate assistance with rolling left to right and transfers chair/bed to chair transfers. Additionally, Resident #91 required maximum assistance with perineal hygiene and dressing. Resident #91 was at risk for developing a pressure ulcer but did not have any pressure ulcers. The readmission nursing assessment dated [DATE] identified Resident #91's skin was intact except for periorbital bruising 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 observation, review of the clinical record, facility policy, and interviews for 2 of 3 residents (Resident #22 and 65) reviewed for respiratory care, the facility failed to ensure the CPAP (continuous positive airway pressure) tubing, filter, and mask were changed in accordance with the manufacturer's recommendations. The findings include: 1. Resident #22 was admitted to the facility on [DATE] with diagnoses that included sleep apnea, obesity, and chronic obstructive pulmonary disease (COPD). The annual MDS dated [DATE] identified Resident # 22 had intact cognition and required a non-invasive mechanical ventilator (CPAP or Bi-pap). The quarterly MDS dated [DATE] identified Resident #22 had intact cognition and required maximum assistance with toileting, bathing, and personal hygiene. and required a non-invasive mechanical ventilator (CPAP or Bi pap). The care plan dated 2/3/25 identified Resident #22 has altered respiratory status and difficulty breathing related to COPD and sleep apnea. Interventions…

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 policies, and interviews for 1 of 5 residents (Resident #65) reviewed for unnecessary medications, the facility failed to ensure a medication for the treatment of a mental health diagnosis was administered per the physician's order. The findings include: Resident #65 was admitted to the facility in November 2021 with diagnoses that included anxiety disorder, dysthymic disorder, major depressive mood disorder (MDD), and post-traumatic stress disorder (PTSD). The quarterly MDS dated [DATE] identified Resident #65 had intact cognition, and the resident mood interview identified the following symptoms and frequency: little interest or pleasure in doing things (several days) and feeling down, depressed, or hopeless (several days). The care plan dated 3/27/25 identified Resident #65 was at risk for distressed/fluctuating mood symptoms related to diagnoses of dysthymic disorder, generalized anxiety disorder, and PTSD. Interventions included observing for signs 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 review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #269) reviewed for unnecessary medications, the facility failed to conduct a gradual dose reduction of Risperidone upon admission when the clinical record failed to reflect a psychiatric diagnosis. The findings include: Resident #269 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease and dementia. Notice of PASRR Level 1 Screen Outcome dated 3/31/25 identified Resident #269 had no mental health diagnosis that was known or suspected. A physician's order dated 4/1/25 directed to give Risperidone (antipsychotic medication) 0.25mg by mouth 3 times a day. The psychiatric APRN #2 note dated 4/1/25 identified Resident #269 was seen and assessed today for initial evaluation and will continue Risperidone 0.25mg by mouth three times a day for a diagnosis of Bipolar (this diagnosis is in conflict with the hospital and facility clinical records). The care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for two (2) of thirteen (13) residents (Resident #1 and Resident #10) reviewed for abuse, the facility failed to ensure the residents were free from abuse. The findings include: 1. Resident #1's diagnoses included cerebral infarction (when blood flow to the brain is interrupted, causing brain tissue damage), legal blindness, anxiety disorder and depression. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition and required moderate assistance with bed mobility and transfers. Additionally, the MDS identified Resident #1 ' s hearing was adequate with no difficulties. The Resident Care Plan (RCP) dated 3/6/25 identified Resident #1 had the potential to be verbally aggressive related to ineffective coping skills, poor impulse control and poor anger management and Resident #1 alleged a staff 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 clinical records, interviews, and review of facility policies for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure a resident's treatment order was entered correctly to ensure timely initiation of the practitioner's directive. The findings included the following: Resident #1 had diagnoses which included lymphedema, atherosclerotic heart disease, and adjustment order with anxiety. Review of Resident #1's Care Plan dated 1/7/25 identified the resident was at risk for skin breakdown related to reduced mobility and has actual skin breakdown and bilateral lower extremity lymphedema with interventions that directed to ace wraps as ordered for lymphedema. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of thirteen (13) indicative of intact cognition. The MDS further identified Resident #1 was dependent with bathing and toileting hygiene, 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 review of clinical records, interviews, and review of facility policies for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure that a resident was not provided an allergen at meal time. The findings included the following: Resident #1 had diagnoses which included dysphagia, atherosclerotic heart disease, and adjustment order with anxiety. Review of Resident #1's Care Plan dated 1/6/25 identified a risk for allergic reaction related to known allergy to cephalexin, erythromycin, sulfa antibiotics, pineapple, and shellfish with interventions that directed to note allergy in Point Click Care (the resident's electronic medical record) and to notify the physician of any signs and symptoms of an allergic reaction. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of thirteen (13) indicative of intact cognition. The MDS further identified Resident #1 was dependent…

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, review of facility policy, and interviews for one (1) of four (4) sampled residents (Resident #4) who were reviewed for a resident-to-resident physical altercation, the facility failed to ensure Resident #4 was free from physical abuse when Resident #4 was hit on the head. The findings include: Resident #4's diagnoses included multiple sclerosis, schizoaffective disorder, and major depressive disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #4 was alert and oriented and required extensive assistance from staff with most activities of daily living. Resident #3's diagnoses included respiratory failure with hypoxia, schizoaffective disorder, adjustment disorder, and dementia. The Nursing re-admission assessment dated [DATE] identified Resident #3 required assistance of facility staff for most activities of daily living and had severe cognitive impairment at baseline. The Resident Care Plan dated 10/23/24identified Resident #3 has an incident 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 review of the clinical record, facility documentation, facility policy and interviews for four (4) of nine (9) residents (Residents #1, 2, 3 and 4) reviewed for misappropriation, the facility failed to prevent the misappropriation of the residents' controlled narcotic medications. The findings include: 1. Resident #1's diagnoses included chronic pain syndrome, low back pain and polyneuropathy (damage of the peripheral nerves, affecting the skin, muscles and organs). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition, frequently experienced moderate pain and was independent with eating, transfers and ambulation. The Resident Care Plan (RCP) dated [DATE] identified that Resident #1 has pain and receives pain medication related to gout, polyneuropathy and low back pain with interventions that included monitoring for non-verbal signs of pain, evaluating pain characteristics,…

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 four (4) residents (Resident #1) reviewed for medication administration, the facility failed to follow physician's orders when administering a medication. The findings include: Resident #1's diagnoses included insomnia (difficulty sleeping), chronic pain syndrome, low back pain and polyneuropathy (damage of the peripheral nerves, affecting the skin, muscles and organs). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition and was independent with eating, transfers and ambulation. The Resident Care Plan (RCP) dated 6/19/24 identified that Resident #1 takes a sedative/hypnotic medication related to insomnia wit interventions that included to administer sedative/hypnotic medications as ordered by the physician and monitor and document side effects and effectiveness every shift.…

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 four (4) residents (Resident #1) reviewed for medication misappropriation, the facility failed to ensure that as needed narcotics were documented as administered and evaluated for effectiveness in the clinical record. The findings include: Resident #1's diagnoses included chronic pain syndrome, low back pain and polyneuropathy (damage of the peripheral nerves, affecting the skin, muscles and organs). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition, frequently experienced moderate pain and was independent with eating, transfers and ambulation. The Resident Care Plan (RCP) dated 7/19/24 identified that Resident #1 has pain and receives pain medication related to gout, polyneuropathy and low back pain. Interventions included monitoring for non-verbal signs of pain,…

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, and interviews for one of three residents (Resident #3) reviewed for abuse, the facility failed to ensure the clinical record was complete an accurate to include an incident that required social service follow up. The findings include: Resident #3's included dementia with behavioral disturbance, delirium, and major depression. The 5-day Minimum Data Set (MDS) dated [DATE] identified Resident #3 had no behaviors, was alert and oriented, and ambulated with supervision. The care plan dated 3/19/2023 identified a potential for verbal behaviors related to dementia. Interventions directed to evaluate the circumstances of verbal behaviors, provide psychiatric/behavioral health consultations, and social service visits to provide support. The psychiatric note dated 3/27/2023 identified asked to see Resident #3 for alleged inappropriate interaction with a male peer. The note indicated Social Services reported a male resident asked Resident #3 to show a body…

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, facility documentation, facility policy, and interviews for 1 sampled resident (Resident #1), who was reviewed for abuse, the facility failed to ensure a resident was treated in a respectful and dignified manner. The findings include: Resident #1's diagnoses included unspecified dementia and aphasia (unable to formulate language) following a cerebral infarction (death of brain tissue following lack of oxygen). The quarterly Minimum Data Set assessment dated [DATE] identified Resident # 1 had severe cognitive impairment and was independent with activities of daily living (ADL). The Resident Care Plan dated 4/18/23 identified Resident #1 expressed that it was important to engage in daily routines that were important to him/her and could demonstrate verbal behaviors related to cognitive loss with interventions that directed to monitor for perseverating behavior, remove from the environment while speaking in a calm, reassuring voice and allow time for expression of feelings, provide…

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, facility documentation, facility policy, and interviews for 1 sampled resident, (Resident #2), who was reviewed for medication administration, the facility failed to ensure medication was administered in accordance with physician's orders. The findings include: Resident #2 had diagnoses that included streptococcal meningitis. The admission nursing assessment dated [DATE] identified Resident #2 was alert and oriented to person place time, situation and appropriate. A review of the admission clinical record identified Resident #2 was self-responsible. A physician's orders dated 7/18/23 directed ceftriaxone sodium injection solution (an antibiotic) reconstituted 2grams every 12 hours intravenously at 9:00 AM and 9:00 PM for a diagnosis of sepsis (a blood stream infection) through 8/7/23. (The medication was not ordered STAT (as soon as possible)). The Pharmacy receipt dated 7/19/23 identified ceftriaxone sodium injection solution reconstituted 2 grams was delivered to the facility…

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

Based on observations of the dietary tray line, and review of facility documentation and interview, the facility failed to provide food at an appetizing temperature and failed to indicate holding temperature of sweet potatoes. The findings included: 1a. Observation of the dietary tray line and a test tray with Food Service Director of the lunch meal on 7/11/23 began at 11:23 AM identified the last cart left the kitchen at 12:46 PM and arrived at 600's wing at 12:48 PM, serving began at 12:52 PM, and the last resident tray was served to Resident #32 at 1:04 PM. A review of the food test tray with the surveyor in the presence of the Food Service Director on 7/11/23 at 1:04 PM identified the following food temperatures surveyor/ Food Service Director: the main meal item (ham with a temperature (in degrees Fahrenheit) of 103.5/103.4, sweet potatoes at 117/116, creamed spinach at 117.7/116.6, and fruit cup at 63.8/63.3. Interview with the Food Service Director at time of the observation identified the food should be held at 135 or greater. b. Review of Facility documentation of Holding…

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 and interviews for 1 of 1 sampled resident (Resident #391) reviewed for constipation/diarrhea, the facility failed to ensure a baseline care plan was completed to address the resident's constipation. The findings include. Resident #391's diagnoses included polyneuropathy chronic pain syndrome, atrial fibrillation, deep vein thrombosis and Urinary Tract Infection (UTI). A physician's order dated 6/30/2023 at 8:50 PM directed to provide Senna (a stool softener) 8.6. Milligrams (MG) 2 tablets by mouth daily for constipation. A physician's order dated 6/30/23 at 8:57 PM directed to administer Macrobid (an antibiotic) 100 MG orally twice daily for UTI. A physician order dated 6/30/23 at 9:21 PM directed to provide Oxycodone Hydrochloride (a narcotic analgesic) 10 MG tablet one tablet by mouth every 8 hours as needed for pain. Physician orders dated 6/30/23 at 9:22 PM directed to provide Oxycontin 40 MG (narcotic analgesic) extended release every 12 hours one tablet twice daily for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, observations, facility documentation review, facility policy review, and interviews for one of three residents (Resident #50) reviewed for wound prevention and healing, the facility failed to follow the residents plan of care and the physician's orders to off load/float heels when the resident was identified with wounds on both heels and for one of three residents ( Resident # 5) at risk for pressure ulcer development, the facility failed to ensure the resident's air mattress was set according to the plan of care. The findings included: 1. Resident #50's diagnoses included diabetes, osteomyelitis, malnutrition, pressure ulcer, malignant neoplasm of lung, disc degeneration lumbar region and chronic pain syndrome. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #50 had intact cognition, was at risk of developing pressure ulcer/injury, had one or more unhealed pressure ulcers/injuries and required extensive assistance with bed mobility, transfer,…

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, facility policy and interview for 1 of 2 sampled residents (Resident #389) reviewed for hydration, the facility failed to maintain fluid intake per physician's order. The findings included: Resident #389's diagnoses included chronic diastolic Congestive Heart Failure ( CHF), dyspnea, and hypertensive urgency. A physician's order dated 6/6/2023 directed to monitor a daily fluid restriction total of 1500ml per day. The admission Minimum Data Set assessment dated [DATE] identified Resident #389 as cognitively intact, requiring extensive assistance with toileting and personal hygiene and indicated independent with eating. The Resident's Care Plan dated 6/22/23, revised on 7/7/2023, identified the resident was at risk for dehydration as evidenced by fluid restriction/insufficient intake. An intervention directs to monitor intake and output per protocol. The nurse's note and certified nursing assistant's fluid intake/output documentation dated 6/13/23 through 7/11/23 identified…

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 the facility Payroll Based Journal (PBJ) records, interview, and review of facility policy for 4 out of 4 quarters reviewed, the facility failed to maintain weekend staffing at a level that was above excessively low, and for 2 of 4 quarters, failed to ensure the facility did not receive a 1 star rating for staffing. The findings include: Review of the Payroll Based Journal records for the second, third, fourth and first fiscal quarters of 2022 identified that during the second quarter, (January 1 through March 31), the third quarter, (April 1 through June 30), the fourth quarter, (July 1 through September 30) and first quarter, (October 1 through December 31, 2022), the facility electronically reported excessively low weekend staffing. Additionally, during the third and fourth quarters, the facility had a 1 star rating for staffing. Interview with RN # 12 the corporate nurse on 7/13/23 at 1:40 PM identified that the facility did not actually have excessively low weekend staffing but, according to RN # 12, who had conducted extensive research into the PBJ 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, staff interviews, policy review, and facility documentation, for 1 of 1 sampled resident (Resident #65), reviewed for respiratory care, and for 1 of 1 sampled resident, (Resident #439), reviewed for infection prevention, the facility failed to ensure that infection prevention practices were followed and for one of six units, the facility failed to ensure bed pans were properly labeled and stored according to facility policy. The findings included: 1. Resident #65's diagnoses included chronic obstructive pulmonary disease, heart failure, atrial fibrillation, diabetes mellitus, and dementia. An Annual MDS assessment dated [DATE] identified Resident #65 was alert and cognitively intact, and required total dependence of one for toilet use, personal hygiene, extensive assistance of two with bed mobility, extensive assistance of one with dressing, and independence with set-up for meals. A Resident Care Plan revised dated 4/3/23 identified the resident required oxygen…

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

Based on observations of the kitchen, facility documentation and interview, the facility failed to properly store food in sanitary conditions. The findings include: During the initial kitchen tour with the District Food Manager on 7/5/2023 beginning at 10:38 AM identified the following: The ice maker was noted to be filled with ice with outside scoop on wall in closed container. Further observation identified the inside of ice maker on the top right and left interior above the ready to be used ice with several dark black patches. Interview on 7/5/23 at 11:51 AM with District Food Manager identified the black patches as mold. She further indicated that the cleaning schedule is monthly and was last done in June 2023 and was not done correctly. Observation of facility documentation indicated that the ice maker was last cleaned on 6/27/23 and further identified the ice maker cleaning log was not signed off as cleaned in the month of May 2023. Manufacturer specifications for the Ice Maker's vendor notes interior of the bin is lined with antimicrobial-treated polyurethane, which helps…

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 one of five residents (Resident #30) reviewed for unnecessary medications, the facility failed to monitor recommended resident behaviors. The findings include: Resident #30's diagnoses included dementia with behavioral disturbances. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #30 had intact cognition, exhibited no behaviors and was independent or required supervisor with Activities of Daily Living (ADL). An Advanced Practice Registered Nurse (APRN) note dated 4/5/20 identified episodes of forgetfulness, depressive behaviors, anxiety and a recent readmission after a psychiatric hospitalization for combativeness. The note also indicated a low dose of Risperdal (an Antipsychotic medication) was initiated and that Trazodone (an Antidepressant medication) was replaced with Remeron (an Antidepressant medication). The APRN recommended to continue to monitor for behaviors of delusions and combativeness. 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 review of the clinical record, review of facility policy and interviews for one of two sampled residents (Resident #30) reviewed for dental, the facility failed to ensure dental services were provided to replace the resident's lost dentures. The findings include: Resident #30 diagnoses included dementia with behavioral disturbances, congestive heart failure and depression. The Oral Health Evaluations dated 10/2/19 and 10/2/20 identified the resident had both natural teeth, dentures/partials and upper full denture. The annual Minimum Data Set (MDS) assessment dated [DATE] identified the resident had intact cognition, was independent or required supervisor with Activities of Daily Living (ADL), experienced no weight loss and had no oral/dental issues. The Resident Care Plan (RCP) initiated 10/2/19 and last revised 4/6/21 identified the resident exhibited or was at risk for oral health or dental care problems. Interventions included: to brush/clean dentures two times per day and as needed, to monitor 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 review of facility documentation, facility employee job description and interview, the facility failed to designate a specific individual (with the required training and qualification) to oversee the facility infection control program. The findings include: Interview with the DNS on 5/10/21 at 1:53 P.M. identified the facility does not have a dedicated Infection Preventionist Nurse. The DNS also indicated she oversees both the infection control program, and the DNS position. The DNS stated that she had been overseeing the infection control program since the Infection Preventionist Nurse resigned on 4/9/21. The DNS identified the facility had been without a dedicated Infection Preventionist Nurse since 4/9/21 (approximately one month) and indicated the facility did not have a second, qualified, Infection Preventionist Nurse as a backup employed for the facility. According to the DNS, the facility was in the process of hiring an Infection Preventionist Nurse. The DNS indicated she and the ADNS are in the process of going through the required infection Preventionist education…

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, review of facility policy and interviews for one of twenty-four residents (Resident #26), reviewed for Advance Directives, the facility failed to ensure physician's order was in place that honored the resident's health care instructions for Advanced Directives. The findings include: Resident #26 with diagnoses that included dementia without behavioral symptoms and hypertension. The physician's orders dated [DATE] directed that Resident # 26 was a Do Not Resuscitate (DNR). The admission 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #26 was severely cognitively impaired requiring extensive assistance of 1 staff for bed mobility, transfer, and personal hygiene. A physician's progress note dated [DATE] at 12:40 P.M. identified that Resident # 26's code status was a DNR. Review of the facility's health care instructions (Advanced Directive form) dated [DATE] identified in the event of Cardiopulmonary Arrest, Resident # 26 was to have Cardiopulmonary…

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, review of facility policy and interviews for the only sampled resident (Resident # 56) reviewed for notification of change, the facility failed to notify the conservator of an abnormal diagnostic result. The findings include: Resident #56 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction due to unspecified occlusion or stenosis of basilar artery, cognitive communication deficit and tracheostomy status. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #56 had severely impaired cognition and required extensive assistance with personal hygiene. The Situation, Background, Assessment, Recommendation (SBAR) Summary note dated 4/29/21 at 2:04 P.M. identified Resident #56's respiratory assessment revealed abnormal lung sounds (rales, rhonchi, wheezing), nursing observations, and recommendations were: Chest x-ray (CXR). The Physician Assistant (PA#1) was notified with new orders to obtain a chest x-ray. 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 review of the clinical record, facility policy and interviews for one of three residents (Resident #67) reviewed for choices and for the only sampled resident (Resident #70) reviewed for specialized treatment, the facility failed to ensure a comprehensive person centered care plan was developed for the residents. The findings included: 1.Resident #67's diagnoses included tremors, diabetes mellitus and Parkinson's disease. A physician's order dated 4/11/21 directed to administer Carbidopa-Levodopa (Sinemet) 25-100 milligrams (mg), give two tablets by mouth three times a day for Parkinson's disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #67 was without cognitive impairment, required supervision with Activities of Daily Living (ADL) and was independent with eating. Interview with Resident #67 on 5/06/21 at 10:37 A.M. identified that within the last two to three weeks, she/he did not receive his/her Sinemet (Anti- Parkinsonian medication) for 36 hours and began…

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 staff interview for one of five residents in the survey sample reviewed for unnecessary medications, (Resident #17), the facility failed to revise the resident care plan related to antipsychotic medication use. The findings include: Resident #17's diagnoses included vascular dementia with behavioral disturbance. A quarterly Minimum Data Set ( MDS) assessment dated [DATE] identified no cognitive problem, no mood or behavior problems, the resident had received antipsychotic medications for the last seven (7) days, and received antipsychotic medications on a routine basis. The Resident Care Plan (RCP) dated 3/01/21 identified Resident #17 was at risk for complications related to the use of antipsychotic medications. Interventions included: to utilize the smallest most effective dose without side effects, conduct Abnormal Involuntary Movement Scale (AIMS) assessments, behavioral monitoring, to monitor for mental status changes, and noted Gradual Dose…

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 and interviews for one of three sampled residents (Resident #67) reviewed for choices, the facility failed to ensure a medication was available and administered per the physician's order. The findings include: Resident #67's diagnoses included tremors, diabetes mellitus and Parkinson's disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #67 was without cognitive impairment, required supervision with Activities of Daily Living (ADL) and was independent with eating. A physician's order dated 4/11/21 directed to administer Carbidopa-Levodopa (Sinemet) 25-100 Milligrams (MG) Anti-Parkinson medication two tablets by mouth three times a day for Parkinson's disease. The April 2021 Medication Administration Record (MAR) identified the abbreviation NN (indicating to reference the nurse's notes). The abbreviation NN was used on the MAR instead of the licensed staff initials that would indicate Sinemet was administered to Resident #67 per 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.