Nathaniel Witherell, The

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 (Resident #1) reviewed for accidents, the facility failed to ensure the clinical record was complete and accurate to include a fall intervention after the resident had a fall. The findings include: For Resident #1, clinical record review, facility documentation review, and interviews identified Resident #1 had diagnoses that included dementia, muscle weakness, hypertension, and type 2 diabetes mellitus. A physician's order dated 8/1/24 directed that Resident #1 can ambulate in the hallway with a rolling walker. The care plan dated 8/19/24 identified Resident #1 was a moderate risk for falls related to deconditioning with interventions that directed to encourage the resident not to rock back in the chair, encourage resident to use call bell for assist during the night to go to the bathroom, educate the resident and caregivers about safety reminders. The quarterly MDS dated [DATE]…

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 reviews, facility documentation review, and interviews for 4 of 4 residents (Resident #11, #86, #117 and #137) reviewed for infection control, the facility failed to ensure that infection control practices related to glucometer cleaning and disinfection in between resident and the facility failed to ensure personal protective equipment (PPE) carts were available outside every resident room who required the use of PPE, evidence of infection surveillance, evidence of annual review of the Intravenous and Infection Control Policy books, evidence facility water management plan and for 1 of 3 residents evaluated for pressure ulcers (Resident #24), the facility failed to ensure staff used appropriate personal protective equipment (PPE) when performing dressing changes and for 1 of 6 sampled residents (Resident #25) reviewed for infection control, the facility failed to appropriate personal protection equipment (PPE) was worn while providing personal hands-on care to a resident 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 clinical record reviews, facility documentation, facility policy and interviews for 3 of 40 sampled residents (Resident #25, Resident #227 and Resident #228) reviewed for advanced directives, the facility failed ensure a resident's code status was complete and accurate for a newly admitted /readmitted resident. The findings included 1. Resident #25 was readmitted to the facility on [DATE] with diagnoses that included pneumonia, asthma and chronic obstructive pulmonary disease. The admission record identified Resident #25 was not self-responsible. The Resident Code Status Form dated 7/22/24 did not identify a code status, was signed by the physician and was not signed by the responsible party or witness. The physician's orders dated 7/22/24 directed that Resident # 25 was to receive full code measures meaning lifesaving interventions would be initiated if necessitated. An interview with the Director of Nursing Services, (DNS) on 8/05/24 at 11:49 AM identified she would expect that the advanced directive…

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 and interviews for 2 of 3 residents reviewed for respiratory infection (Residents #91 and #276) the facility failed to ensure the care plan was revised to reflect the resident status requiring transmission-based precautions and 1 of 1 resident (#117) reviewed for Activities of Daily Living, the facility failed to ensure the residents care plan reflected the bathing preference of the resident. The findings included. 1. Resident #91's diagnoses included anemia, hypertension and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #91 was cognitively intact. The care plan dated 6/18/2024 indicated Resident #91 had impaired cognitive function related to dementia with interventions including in part to keep routine simple and consistent. A physician's order dated 7/16/2024 directed to provide transmission-based precautions for COVID 19 until 7/26/2024. Interview and record review with RN #3 the Assistant Director of Nursing Services…

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 interviews and review of facility documentation, the facility failed to ensure staff received ongoing education for Intravenous (IV) Therapy and perform competency evaluations to ensure staff remained competent to provide IV therapy. The findings include. Interview and facility document review with the DNS on 7/30/2024 at 12:05 PM identified s/he was unable to locate ongoing IV therapy education and competency evaluations for licensed nursing staff that provide IV therapy at the facility. The DNS further indicated the Infection Preventionist who was the only staff member who had access to the electronic files was not on duty and s/he now realized other staff members should have access in the event of his/her absence.

Based on the tour of the kitchen, observations and staff interview, the facility failed to ensure dinner and breakfast were served within the 14-hour gap. The findings include: Tour of the kitchen on 7/24/24 at 10:00AM during the initial walk through with the Food Service Director identified the following: Interview with Dietary Director on 7/24/24 at 10:00AM identified residents are served meals between 8:00 AM to 9:30 AM and dinner is served by 6:30 PM. Interview on 7/24/24 at 11:23 am with Residents #18 and #126 indicated that breakfast arrives late. Observation on 7/25/24 at 10:20 AM, Resident #50 is observed in bed, NA was getting ready to start feeding Resident #50. Observation on 7/31/24 at 7:45 AM identified food carts arriving on the units between 7:45 AM to 8:00 AM. Observation on 7/31/24 at 7:50 AM of food cart identified the cart arriving to the 2nd floor dining area. Residents #101 and #118 was noted in the dining area and observed being served at 8:50 AM. Observation at 9:23AM of residents on 2nd floor (who eat in their room) were still not served ( Indicating a 15…

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 the tour of the kitchen, observations, facility documentation, review of policy and staff interviews, the facility failed to ensure the dietary department consistently labeled food to reflect their age or shelf life and failed to ensure the nourishment fridge and snacks cabinets on each unit were adequately stocked. The findings included: A tour of the kitchen on 7/24/24 at 10:00AM during the initial walk through with the Food Service Director identified the following: a. The Pastry freezer was observed with a Boston Cream Pie without a label and noted with no open date. The preparation fridge was observed with mashed potatoes without a label or date. Interview with Food Service Director on 7/24/24 at 10:20 AM indicated the preparation staff and/ or chef are responsible for labeling items. After surveyor inquiry, the food items were labeled. Interview with Food Service Director on 7/24/24 at 10:30 AM indicated the facility does not have a snack cart. She/he reported each floor has nourishment refrigerators. b. Observation of the nourishment refrigerator and snack cabinets…

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 Infection Control program, review of facility document, facility policy and staff interview, the facility failed to ensure an Antibiotic Stewardship Program was in place and available for review. The findings include. An interview and facility document review on 7/30/2024 with the DNS indicated the Infection Preventionist (IP) was out of the facility and the Antibiotic Stewardship information along with the infection control program was on the computer and the IP was the only person who had access. The DNS was able to provide a facility policy for Antibiotic Stewardship, unknown date of last annual review, and the pharmacy list of antibiotics used for the last month. The DNS was also unable to provide evidence of an Antibiotic Stewardship Program actively in place. The DNS further indicated that in lieu of the absence of the IP other staff should be able to gain access to the files for the infection control program. On 7/31/2024 at 12:15 PM the Assistant Director of Nursing Services (ADNS) indicated the Staff Development Nurse (IP back up Wednesday…

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 clinical record review, facility documentation, facility policy and interviews for 1 of 3 sampled residents (Resident # 226) reviewed for change in condition, the facility failed ensure the physician was notified of a resident change in condition in a timely manner. The findings include: Resident #226 was admitted with diagnoses that included osteoarthritis of the left knee and hypertension. The admission clinical record identified Resident #226 as self-responsible. The hospital Inter-Agency Referral Report dated 7/22/24 identified Resident #226 was discharged with medications that include Valsartan (Anti-hypertensive) 80 Milligrams (MG) once daily. The nursing admission note dated 7/22/24 at 5:23 PM identified Resident #226 was alert and oriented to person place and time, communicated verbally, speech was clear, was able to understand and be understood when speaking. The physician's orders dated 7/22/24 directed Valsartan 80 MG once daily in the morning at 9:00 AM. The Blood Pressure log dated 7/22/24 at 4:19 PM identified Resident #226's BP was 165 / 83 (Normal Range…

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, facility policy and interviews for 1of 3 sampled residents (Resident #35) reviewed for dignity, the facility failed to follow up with a resident reported concerns in a timely manner. The findings include: Resident #35's diagnoses included obesity and Chronic Obstructive Pulmonary Disease (COPD). The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 35 was cognitively intact and required partial to moderate assist with Activities of Daily Living (ADL) and supervision with eating. The Resident Care Plan (RCP) dated 7/6/24 identified Resident #35 had- a concern related to psychosocial wellbeing related to anxiety. Interventions directed to provide staff assistance and support to set realistic goals. A Social Service Note dated 7/15/24 identified Resident #35 indicated s/he felt ok and was not depressed. No questions or concerns were reported, and social services would be available to provide continued support. An interview with…

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

Based on record review and staff interview for one of three residents (Resident #227) reviewed for abuse, the facility failed to ensure an alleged staff member was removed from the schedule after an allegation of mistreatment. The findings include: Resident #227 had a diagnosis of anxiety and history of a fall. Incident report dated 7/25/2024 at 2 PM identified Resident #227 alleged he/she rang the call bell around 3 AM and the NA stated, you know it is 3 in the morning. Resident #227 had been incontinent of urine and stool and alleged while the NA was giving care she pushed the towel into me and was rough. When the NA turned Resident #227 over, Resident #227 alleged he/she was nervous and reached out to hold onto the NA's arm for comfort, saying I am very nervous. The NA was alleged to respond by saying do not touch me. Nursing note dated 7/25/24 identified abuse was reported, and an investigation was started. The resident alleged the NA was rough on him/her. The supervisor and Director of Nursing (DNS) were notified. Record review identified NA #8 was not working when 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 clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #176) reviewed for discharge planning, the facility failed to ensure Durable Medical Equipment (DME) was ordered timely for a planned discharge. The findings include: Resident # 176's diagnoses included foot drop of right and left feet, polyneuropathy (damage to nerves in the body), and hemiplegia (partial or complete inability to move a part of the body) unspecified affecting right dominant side. Physical Therapy (PT) note dated 6/16/2023 recommended that Resident #176 was to be discharged home with a Hoyer lift. The Quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #176 was dependent for ADLs. The Resident Care Plan (RCP) dated 6/20/2023 identified decreased mobility and weakness, impaired ability to self-transfer, and high risk for falling. Interventions directed assist with transfers. Inter-agency patient referral report dated 9/14/2023 for a planned…

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, and interviews for 1 of 3 residents (Resident #109) reviewed for change in condition, the facility failed to complete a Significant Change Status Assessment (SCSA) MDS assessment when the resident was admitted to hospice. The findings include: Resident #109 's diagnoses included adult hypertrophic pyloric stenosis, atrial fibrillation, type 2 diabetes mellitus, and hypertension. Review of Consent and Election of Medicare Hospice Benefit dated 6/1/24 identified Resident #109 elected for Medicare Hospice benefit. The nurse's notes dated 6/2/24 at 2:46 PM identified the hospice nurse assessed Resident #109 for hospice care and s/he was admitted to hospice care. The recreation notes dated 6/3/24 at 2:15 PM identified Resident #109 was in hospice care and the end-of-life service would continue to provide 1 to 1 bedside support and assist as needed. The physician's order dated 6/3/24 directed Do Not Resuscitate (DNR) and noted hospice. The Significant Change MDS…

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 and interviews for 1 of 3 residents ( Resident #117) reviewed for Activities of Daily Living, the facility failed to ensure a resident received a shower on per plan of care. The findings include. Resident #117 diagnosis included diabetes mellitus and anemia The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #117 required partial/moderate assistance for bathing. The care plan dated 7/31/2024 indicated Resident #117 had an ADL deficit due to fatigue and anemia with intervention for the resident prefers dressing and grooming for AM care An interview and record review on 7/31/2024 at 11:40 AM with Licensed Practical Nurse (LPN # 6) indicated per the posted shower list, not dated, Resident #117 had a shower scheduled weekly on Monday on the 3-11 PM shift. LPN # 6 was not able to find the Nurse Aides documentation of showers being provided but indicated if the resident refuses a shower s/he LPN # 6 who document the refusal in the progress notes. An interview…

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, review of the clinical record and facility policy and interviews for 1 of 4 residents (Resident #426) reviewed for pressure ulcers, the facility failed to follow physicians order regarding pressure reliving device. The findings include: Resident #426's diagnoses included muscle weakness and unspecified dementia. The care plan dated 6/20/24 identified pressure ulcer. Interventions include providing wound care per treatment order. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #426 is cognitively impaired. Resident #426 requires one person to assist in bed mobility and toilet use and requires two-person physical assist in transfers. A progress notes dated 7/23/ 24 identified new Deep Tissue Injury measuring 2 Centimeter (CM) x 2 CM x 0 CM. Calculated area is 4 square CM. A physician's order dated 7/24/24 at 3:30 PM and 5:00 PM directed When available-bilateral waffle boots to bilateral feel at all times for pressure relief of heels. Remove for hygiene only. and 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 observations, record reviews, review of facility documentation, review of policy and staff interviews for 2 of 4 residents reviewed for accidents for( Resident # 22), the facility failed to implement intervention to prevent future falls and for (Resident #47), the facility failed to ensure adequate supervision of a resident who left a nursing unit unauthorized .The findings include The findings included: 1.Resident #22's diagnoses included Muscle weakness, difficulty walking and history of falls. The care plan dated 4/5/24 indicated Resident #22 was a fall risk and interventions include to place Resident #22 in the common area for close monitoring and to not leave the resident alone in the room until family member arrives. The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #22 has impaired cognition. Resident #22 requires maximal assistance in toilet transfers, chair to bed transfers and sit to stand. A physician's order dated 7/30/24 directed to check placement in lowest position…

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 of 3 sampled residents (Resident #35) reviewed for nutrition, the facility failed to confirm weight loss according to policy. The findings include: Resident #35 's diagnoses included obesity and Chronic Obstructive Pulmonary Disease. The admission Minimum Data Set (MDS) dated [DATE] identified Resident # 35 as cognitively intact and required partial to moderate assist with activities of daily living and supervision with eating. The Resident Care Plan dated 7/6/24 identified Resident #35 had a nutritional problem related to comorbidities. Interventions directed to assist with meals as needed and monitor weight weekly. The weight record log dated 7/14/24 identified a recorded weight of 156.8 lbs. The weight record dated 7/20/24 identified a recorded weight of 144.2 lbs. reflecting a -8.16 % loss with no documented re-weight. An interview with the Dietitian on 8/01/24 01:34 PM identified nursing staff were responsible 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 record review and staff interview for one of three residents (Resident #227) reviewed for abuse the facility failed to ensure the clinical record was complete and accurate to include an RN assessment after an allegation of mistreatment. The findings include: Resident #227 was admitted to the facility with diagnoses of fracture of left femur, anxiety, and fall. The nursing admission assessment dated [DATE] identified Resident #227 was alert and oriented and required assistance with ADLs. Incident report dated 7/25/2024 at 2 PM identified Resident #227 alleged he/she rang the call bell around 3 AM and the NA stated, you know it is 3 in the morning. Resident #227 had been incontinent of urine and stool and alleged while the NA was giving care she pushed the towel into me and was rough. When the NA turned Resident #227 over, Resident #227 alleged he/she was nervous and reached out to hold onto the NA's arm for comfort, saying I am very nervous. The NA was alleged to respond by saying do not touch me.…

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 policies and interviews for one of three sampled residents (Resident #1) who were reviewed for a fall, a facility staff member failed to report a fall to the licensed staff when the resident had reported the unwitnessed fall so an assessment could be conducted to determine if the resident had sustained an injury or struck their head. The findings include: Resident #1's diagnoses included Alzheimer's Disease, difficulty walking, generalized muscle weakness, a history of urinary tract infections and osteoarthritis. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily living, required maximum assistance with toileting, moderate assistance with turning and repositioning when in bed and getting in and out of the bed and chair, supervision or touching assistance when ambulating, and utilized a walker when ambulating and wheelchair for mobility. The Resident Care Plan 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 review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for a change in condition, the facility failed to ensure a change in condition it was reported timely to the physician timely and failed to report a change in condition to a responsible party. The findings include: 1) Resident # 1 had diagnoses that included hypertension, generalized muscle weakness, difficulty walking, and dysphagia. Review of a face sheet dated [DATE] identified that Resident #1's responsible party was Person #1. The quarterly MDS dated [DATE] identified Resident #1 had moderately impaired cognition, was occasionally incontinent of bowel and bladder, and required extensive assistance with Activities of Daily Living (ADL's). A care plan dated [DATE] identified Resident #1 had impaired ability to self-transfer, ambulate, dress, toilet, and maintain personal hygiene with interventions that directed to provide extensive assistance with bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3)residents, (Resident #2) reviewed for abuse, the facility failed to ensure the resident was free from physical abuse. The findings include: Resident # 1 had diagnoses that included displaced intertrochanteric fracture of left hip, osteoporosis, attention deficit hyperactivity disorder, and difficulty walking. The nursing admission assessment dated [DATE] identified Resident #2 had intact cognition, was continent of bowel and bladder, and required moderate assistance with bed mobility, transfers, personal hygiene, toileting, and dressing. The care plan dated 2/7/2024 identified Resident #2 had acute pain secondary to hip surgery with interventions that directed to administer pain medication per order and evaluate effectiveness of pain-relieving interventions. A physician's order dated 2/7/2024 directed to administer Resident #1 oxycodone 10 milligrams (a narcotic pain medication) every six hours…

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, (Resident #1), reviewed for abuse, the facility failed to report an allegation of abuse to the state agency within the required time frame. The findings include: Please cross reference F 600 Resident # 1 had diagnoses that included displaced intertrochanteric fracture of left hip, osteoporosis, attention deficit hyperactivity disorder, and difficulty walking. The nursing admission assessment dated [DATE] identified Resident #2 had intact cognition, was continent of bowel and bladder, and required moderate assistance with bed mobility, transfers, personal hygiene, toileting, and dressing. The care plan dated 2/7/2024 identified Resident #2 had acute pain secondary to hip surgery with interventions directed to administer pain medication per order and evaluate effectiveness of pain-relieving interventions. A physician's order dated 2/7/2024 directed to administer Resident #1 oxycodone…

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, (Resident #1) reviewed for abuse, the facility failed to conduct a complete and thorough investigation for an allegation of abuse. The findings include: Resident # 1 was admitted to the facility with diagnoses that included displaced intertrochanteric fracture of left hip, osteoporosis, attention deficit hyperactivity disorder, and difficulty walking. Please cross reference F 600 The nursing admission assessment dated [DATE] identified Resident #2 had intact cognition, was continent of bowel and bladder, and required moderate assistance with bed mobility, transfers, personal hygiene, toileting, and dressing. The care plan dated 2/7/2024 identified Resident #2 had acute pain secondary to hip surgery. Interventions directed to administer pain medication per order and evaluate effectiveness of pain-relieving interventions. A physician's order dated 2/7/2024 directed to administer…

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 one of three sampled residents (Resident #1) who were reviewed for wound care, the facility failed to ensure a resident with a declining wound was seen at a wound center as recommended by the Advanced Practice Registered Nurse (APRN) and the clinical record failed to reflect documentation the attending physician or APRN assessed the wound. The findings include: Resident #1's diagnoses included vascular dementia, history of transient ischemic attach and cerebral infarction, anemia, muscle weakness, and Vitamin B-12 deficiency anemia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, was always incontinent of bowel and bladder, required extensive assistance with turning and repositioning while in bed, and getting in and out of the bed and chair, and was totally dependent with dressing and personal hygiene. The Resident Care Plan 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 clinical record review, facility documentation review, facility policy review, and interviews for one (1) of three (3) residents, (Resident #1) , reviewed for abuse, the facility failed to report an allegation of abuse to a State Agency and to immediately remove an alleged employee off the schedule in a timely manner after an allegation of abuse was identified. The findings include: Resident #1 had diagnoses that included Parkinson's disease, chronic obstructive pulmonary disease, pneumonia, and sepsis. The Resident Care Plan (RCP) dated 07/14/23 identified Resident #1 is on anticoagulant therapy. Interventions include administering anticoagulants and evaluating effectiveness and to observe for signs of active bleeding (nosebleeds, bleeding gums, petechiae, purpura, ecchymotic areas, hematoma, blood in urine, blood in stools, hemoptysis, elevated temperatures, pain in joints, and abdominal pain). The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired…

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, facility policy, and interviews for one (1) of three (3) residents, (Resident #2), reviewed for dignity, the facility failed to ensure a resident was treated in a dignifed manner. The findings include: Resident #2's diagnoses included irritable bowel syndrome, delusional disorders, anxiety disorder, and major depressive disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 made consistent and reasonable decisions regarding tasks of daily life and was supervision for locomotion and transfers. The Resident Care Plan (RCP) dated 05/17/23 identified Resident #2 may refuse care related to assistance with dressing. At times, resident rejects being incontinent and may appear oblivious when incontinent of stool and urine with interventions that included to approach in a calm manner, redirect back to unit if soiled/incontinent, educate resident to call for assistance if he/she is incontinent of stool, and encourage…

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 documentation, review of facility policy, and interviews the facility failed to ensure the environment was maintained in a homelike manner. The findings include: Observations on 3/1/22 at 7:27 AM through 7:33 AM, with the Administrator and Maintenance Supervisor on the 4th floor, and 1st floor identified the following issues: 1. Damaged, chipped, marred, and peeling paint on the doors in the bathroom on 1st floor unit in rooms 101, 102, 103, 104, 105, 106, 107, 108, 109, 114, 116, 117, 118, 119, 120, 121, 122, 123, 124, and 125. Additionally on the 4th floor unit in rooms 401, 403, 404, 405, 411, 414, 415, 416, 418, 419, 420, 421, 422, 423, 424, and 425, and the hallways on the 4th floor. 2. Damaged and stains on bedroom ceiling tiles in bedroom [ROOM NUMBER]. 3. Damage, chipped, marred bedroom wall in bedroom [ROOM NUMBER] and 416. Review of the environmental round forms 1/1/21 through 3/1/22 identified environmental rounds were only completed and documented twice, 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.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 5 residents (Resident #54, 122, 162, 272, and 274) reviewed for immunizations, the facility failed to obtain and document consent or declination and administer the Prevnar 13 and Pneumococcal 23 vaccinations. The findings include: 1. Resident # 54 was admitted to the facility with diagnoses that included dysphagia following cerebral infarction and transient ischemic attack. Review of the clinical record failed to reflect the Prevnar 13 vaccination had been offered and/or administered. 2. Resident #122 was admitted to the facility with diagnoses that included aspiration pneumonia, and Parkinson disease. Review of the clinical record failed to reflect the Prevnar 13 vaccination had been offered and/or administered. 3. Resident # 162 was admitted to the facility with diagnoses that included diabetes. Review of the clinical record failed to reflect the Prevnar 13 and Pneumococcal 23 vaccinations had been offered and/or administered. 4. Resident # 272 was admitted to the facility 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 clinical record reviews, review of facility documentation, facility policies and interviews for one of four sampled residents (Residents #97) who were reviewed for an allegation of mistreatment, the facility failed to ensure the resident was treated in a manner that maintained the resident's dignity and respect. The findings include: Resident #97's diagnoses included dementia with Lewy Bodies dementia, cognitive communication deficit, agitation, and restlessness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #97 rarely or never made self-understood, rarely or never understood others, had short and long-term memory problems, and rarely or never made decisions regarding tasks of daily life. The Resident Care Plan dated 7/29/21 identified Resident #97 was often resistive and combative to care, hitting, grabbing, and pinching staff. Interventions directed when resistive to return in thirty (30) minutes to continue care and consistency of caregivers. The nurse's note 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, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #162) reviewed for notification of change, the facility failed to ensure the physician and family were notified of a weight loss. The findings include: Resident #162 was admitted to the facility on [DATE] with diagnoses that included diabetes and a lumbar laminectomy, and osteomyelitis of back. The hospital Discharge summary dated [DATE] noted Resident #162 weighted 169.6 lbs. The weekly weight sheet dated 11/12/21 identified Resident #162 weighed 175.3 lbs. Hospital documentation dated 11/24/21 identified Resident #162 weighed 177.3 lbs. The weekly weight sheet dated 11/26/21 identified Resident #162 weighed 160 lbs. a loss of 9.6 lbs. The weekly weight sheet dated 12/3 and 12/10/21 identified Resident #162 was at the hospital. Hospital documentation dated 12/15/21 identified Resident #162 weighed 168 lbs. The weekly weight sheet dated 12/16/21 identified Resident #162…

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 resident (Resident #128) reviewed for abuse, the facility failed to ensure Resident #128 was free from abuse by Resident #39. The findings include: a. Resident #39 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease and anxiety disorder. The MDS dated [DATE] identified Resident #39 had moderately impaired cognition and required limited assistance with locomotion on and off the unit. The care plan dated 9/16/21 identified Resident #39 had cognitive loss/dementia and behavioral symptoms by being socially inappropriate, and repeatedly approaching other residents. Interventions included to supervise while out of bed and ambulating on the unit, allow resident to have control over situations if possible and if anxious or combative, leave, reproach and notify the nurse. b. Resident #128 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease 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 clinical record reviews, review of facility documentation, facility policies and interviews for one of four sampled residents (Residents #97) who were reviewed for an allegation of mistreatment, the facility failed to report the results of the investigation within five (5) working days to the state agency. The findings include: Resident #97's diagnoses included dementia with Lewy Bodies dementia, cognitive communication deficit, agitation, and restlessness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #97 rarely or never made self-understood, rarely or never understood others, had short and long-term memory problems, and rarely or never made decisions regarding tasks of daily life. The Resident Care Plan dated 7/29/21 identified Resident #97 was often resistive and combative to care, hitting, grabbing, and pinching staff. Interventions directed when resistive to return in thirty (30) minutes to continue care and consistency of caregivers. The nurse's note dated 9/13/21 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 1 (Resident #67) reviewed for Preadmission Screening and Resident Review (PASARR), the facility failed to ensure recommendations for a re-evaluation were requested in accordance with established timeframes. The findings include: Resident #67 was admitted with diagnoses that included heart failure and hypertension. A PASRR Level I screen dated 11/12/12 identified Resident #67 did not have a diagnosis of mental illness or dementia with recommendations to submit for evaluation if there was a change in treatments needs or suspected of a serious mental illness. Resident #67 was re-admitted to the facility on [DATE] with diagnoses that included dementia, psychosis and major depressive disorder. The annual MDS dated [DATE] identified Resident #67 had a diagnosis of serious mental illness with no associated PASARR coding. Interview with APRN #1 on 2/28/22 at 2:36 PM identified Resident #67's behaviors were associated with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 Residents (Resident #271) reviewed for dialysis, the facility failed to ensure a baseline care plan for dialysis management. The findings include: Resident #271 was admitted to the facility on [DATE] with diagnoses that included heart transplant, end stage renal disease, acute kidney failure, and dependance on renal dialysis. The baseline care plan dated 2/15/22 failed to reflect interventions to address the resident's dialysis needs. A physician's order dated 2/16/22 directed to send Resident #271 to dialysis on Tuesday/Thursday/Saturday 8:00 AM - 2:00 PM. Monitor right upper chest permacath for signs and symptoms of infection every shift. Vital signs Tuesday/Thursday/Saturday after dialysis between 5:00 PM - 11:00 PM. Additionally, residents who require off site dialysis will have their access site checked for signs of infection or bleeding daily and will have their blood pressure taken upon…

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 and interviews for 1of 4 residents (Residents #97) who were reviewed for an allegation of mistreatment, the facility failed to review and revise the plan of care to address an incident between a staff member and the resident, and for 2 residents (Resident #39 and 128) reviewed for falls and resident to resident abuse, the facility failed revise the care plan following repeated falls and failed to ensure the care plan was revised for a resident who was the victim of physical abuse. The findings include: 1. Resident #97's diagnoses included dementia with Lewy Bodies dementia, cognitive communication deficit, agitation, and restlessness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #97 rarely or never made self-understood, rarely or never understood others, had short and long-term memory problems, and rarely or never made decisions regarding tasks of daily life. The Resident Care Plan dated 7/29/21 identified Resident #97…

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 2 residents (Resident # 54 and #122) reviewed for Cardio-pulmonary resuscitation (CPR), the facility failed to ensure facility staff had immediately documented discussions with the resident or resident representative, the resident's wishes with regard to CPR or DNR, upon admission including, as appropriate, a resident's wish to refuse CPR. The findings include: 1. The hospital Discharge summary dated [DATE] identified Resident #54 was status post cervical spinal fusion, closed nondisplaced fifth cervical vertebra, and dysphagia following a stroke. The Pre-admission assessment dated [DATE] identified the residents code status at current hospital and nursing home was no code, Do Not Resuscitate (DNR), and no ACLS. Resident #54 was admitted to the facility on [DATE] with diagnoses that included dysphagia following cerebral infarction and transient ischemic attack. The admission MDS dated [DATE]…

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 #97) reviewed for unnecessary medications, the facility failed to ensure recommendations were responded to for a resident requiring psychiatric services. The findings include: Resident #97 was admitted on [DATE] with diagnoses that included dementia with Lewy bodies, psychosis and anxiety disorder. The MDS dated [DATE] identified Resident #97 had severely impaired cognition, required extensive assistance with personal care and received antipsychotic medications. The care plan dated 7/29/21 identified Resident #97 was at risk for consequences related to receiving antipsychotic medications. Interventions included to assess for effectiveness and monitor behaviors. A Physician's order dated 8/1/21 directed to administer Seroquel (antipsychotic medication) 75mg twice daily. A psychiatric consultation dated 8/19/21 recommended to increase the Seroquel to 75mg in the morning and 100mg in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #162) reviewed for nutrition, the facility failed to monitor weights and implement dietary recommendations. The findings include: Resident #162 was admitted to the facility on [DATE] with diagnoses that included diabetes and a lumbar laminectomy, and osteomyelitis of back. The weekly weight sheet dated 11/12/21 identified Resident #162 weighed 175.3 lbs. Hospital documentation dated 11/24/21 identified Resident #162 weighed 177.3 lbs. The weekly weight sheet dated 11/26/21 identified Resident #162 weighed 160 lbs. a loss of 9.6 lbs. The weekly weight sheet dated 12/3 and 12/10/21 identified Resident #162 was at the hospital. Hospital documentation dated 12/15/21 identified Resident #162 weighed 168 lbs. The weekly weight sheet dated 12/16/21 identified Resident #162 weighed 146 lbs. A dietitian assessment dated [DATE] identified Resident #162 had a 29 lbs. unintentional…

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, review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #106), reviewed for dialysis the facility failed to monitor the dialysis access site (Arterio-Venous (AV) fistula) for a thrill/bruit and failed to ensure that the resident was assess for signs and symptoms of infection and bleeding. The findings included: Resident #106's diagnoses included end stage renal disease, anemia in chronic kidney disease, diabetes, and hypertension. The quarterly MDS dated [DATE] identified Resident #106 had severely impaired cognition, required extensive assistance with bed mobility, dressing and personal hygiene. Review of hospital documentation dated 8/20/21 identified Resident #106 underwent a creation of a left AV fistula. Upon completing the procedure, the resident had a strong pulse in the brachial artery and there was a good thrill in the fistula. A physician's order dated 9/7/21 directed Resident #106 receive dialysis Monday, Wednesday 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 observation, review of facility policy, and interviews, for 4 of 6 medication carts, the facility failed to maintain medication carts in a clean and sanitary manner and failed to ensure a medication cart was secured and in a designated area. The findings include: 1. Observation of the first floor unit medication cart on 3/1/22 at 9:05 AM with the DNS and LPN #2 identified a moderate amount of loose pills of assorted sizes and colors and blister pack back covers located at the bottom of the first and second drawer. Interview with LPN #2 on 3/1/22 at 9:05 AM identified she was not aware of the loose pills and blister pack back covers located at the bottom of the first and second drawer. LPN #2 indicated it is every nurse responsibility to clean the medication cart and after themselves. 2. Observation of the second floor unit medication cart on 3/1/22 at 9:15 AM with the DNS and LPN #3 identified moderate amount of loose pills of assorted sizes and colors and blister pack back covers located at the bottom of the first and second drawer. Interview with LPN #3 on 3/1/22 at 9:15…

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, review of facility documentation, facility policy, and interviews the facility failed to ensure the kitchen was maintained in a clean and sanitary manner and failed to ensure food items were covered and dated according to policy. The findings include: Observation on 2/27/22 at 7:15AM identified of the kitchen identified the following: Dry storage room with moderate amounts dry food spillage under (2) racks. Kitchen floor with moderate amount of dry brown spillage and dried crusted flecks of white material with concentrated under food counters and sides of wall. Refrigerator identified as 'milk cooler' with moderate amount dried brown spillage around the sides and under racks. Three- and one-half trays of gelatin cups not covered and without a date. A steel container containing tuna salad without a date. Refrigerator identified as 'cold food cooler' in the main kitchen and a larger 'cold food cooler in the back of the kitchen with moderate amounts of congealed brown spillage on the floor including under the racks in the refrigerator with moderate amount green…

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 a review of the clinical record, review of facility documentation, review of facility policies and procedures, and interviews for one of three residents (Resident #83) reviewed for mistreatment, the facility failed to treat the resident in a dignified manner. The findings include: Resident # 83's diagnoses included Depression, Mental Retardation with psychosis, and Cerebral Palsy. The quarterly MDS assessment dated [DATE] identified Resident #83 was without cognitive impairment. The Resident Care Plan (RCP) dated 7/31/18 identified a history of being verbally abusive with peers, known to fabricate stories and had issues which included yelling, screaming, pointing his/her finger and shouting at staff. Interventions directed to provide quiet, non hurried environment, redirect inappropriate behavior, monitor behaviors, involve the resident in decision making, and speak clearly and adjust tone as needed. Review of the physician's order dated 7/1/18 directed to apply Salonpas (methyl salicylate-menthol)…

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, review of facility documentation, review of facility policy, and interviews for one of two sampled residents reviewed for choices (Resident #55), the facility failed to ensure Resident #55's preference related to getting out of bed was followed. The findings include: Resident #55's diagnoses included dysphagia, type 2 diabetes, dementia without behavioral disturbance, and major depressive disorder. A Recreational therapy note dated 3/18/19 at 11:34 AM identified that Resident #55 was alert and oriented to place and person, able to make needs known, needs reminders and prompting at times due to confusion and forgetfulness. A Social Service note dated 4/23/19 at 9:47 AM identified that Resident #55 was moving to a new room on 4/29/19. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #55 was without cognitive impairment and required extensive assistance with bed mobility, transfers, dressing and toilet use. The Resident Care Plan (RCP)…

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 records reviewed, review of facility documentation, review of facility policy, and interviews for one of three residents (Resident #145) reviewed for abuse, the facility failed to keep the resident free from abuse. The findings include: Resident # 145's diagnoses included dementia without behavioral disturbance and anxiety disorder. The quarterly MDS assessment dated [DATE] identified Resident #145 was severely cognitively impaired. The Resident Care Plan (RCP) dated 7/12/18 identified a cognitive memory/recall problem related to dementia and anxiety with interventions directed to provide verbal and visual reminders to the resident. Review of the reportable event dated 8/2/18 at 10:45 AM identified that Person #3 heard yelling from the dining room. Person #3 went to the dining room and observed Dietary Aid #1 yelling at Resident #145 for touching the napkins that he had set at the table. Person #3 also observed Dietary Aid #1 pulling the chair out with full force where the resident was seated.…

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 records, facility documentation, facility policies and procedures, and interviews for one of three residents (Resident #41) reviewed for abuse, the facility failed to complete a thorough investigation of a bruise of unknown origin in accordance to facility policy. The findings include: Resident #41's diagnoses included vascular dementia and anxiety disorder. The quarterly MDS assessment dated [DATE] identified Resident #41 without cognitive impairment and required total assistance with two for transfers. The Resident Care Plan (RCP) dated 11/14/18 identified a potential for skin tears or lacerations related to accidentally scratching him/herself while upset in the past and skin tears over purpura with interventions directed to analyze resident's injuries to determine pattern/trend, keep skin lubricated with lotion, and monitor the skin and report any signs of skin tears and infections. Further review of the RCP identified a behavior plan where the resident has expressed discomfort…

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, review of facility documentation, and interviews for one sampled residents reviewed for special needs during dining (Resident #83), the facility failed to ensure supervision during a meal. The findings include: Resident #83's diagnoses included dysphagia and a history of pneumonitis due to inhalation of food and vomit. Speech therapy notes dated 5/24/19 identified that Resident #83 identified patient/caregiver training: constant supervision with meals. The Speech therapy notes also identified that Resident #83 was being discharged from services, provide constant supervision at meals, no straws, aspiration precautions, and provide oral hygiene before meals. The 30 day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #83 was without cognitive impairment and required limited assistance with eating. A physician's order dated 7/2/19 directed to provide a puree, thin liquid diet, no straws, with swallowing guideline for constant/supervision, aspiration…

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.