Chelsea Place Care Center LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for five (5) of eleven (11) residents (Residents #1, 2, 3, 8 and 9) reviewed for abuse, the facility failed to ensure the residents were free from misappropriation of the resident's medications. The findings include: 1. Resident #1 was admitted with diagnoses that included osteomyelitis, and contractures. An annual Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of eight (8) indicative of moderately impaired cognition, and occasionally experienced pain in the last five (5) days. The Resident Care Plan (RCP) dated 3/25/2024 identified Resident #1 was at risk for skin breakdown. RCP directed to assist with repositioning changes, and wound care as ordered. A physician order dated 5/2/2024 directed to administer Oxycodone (a narcotic pain medication) immediate release (IR) 10 milligram (mg) tablet by mouth every eight (8) hours. A review of the controlled…

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 nine of eleven residents (Residents #1, 2, 3, 4, 5, 6, 7, 8 and 9) reviewed for misappropriation, the facility failed to maintain controlled drug accountability records controls sheets (CDSR) as required. The findings include: 1. Resident #1 was admitted with diagnoses that included osteomyelitis, and contractures. An annual Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of eight (8) indicative of moderately impaired cognition, and occasionally experienced pain in the last five (5) days. The Resident Care Plan (RCP) dated 3/25/2024 identified Resident #1 was at risk for skin breakdown. RCP directed to assist with repositioning changes, offer right hand wrist splints and wound care as ordered. A physician order dated 5/2/2024 directed to administer Oxycodone (a narcotic pain medication) immediate release (IR) 10 milligram (mg) tablet by mouth every…

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 five of eleven (11) residents (Residents #1, 2, 3, 8, and 9) reviewed for misappropriation, the facility failed to ensure the State Agency was notified timely of an allegation of misappropriation when an alleged diversion was identified. The findings include: 1. Resident #1 was admitted with diagnoses that included osteomyelitis, and contractures. An annual Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of eight (8) indicative of moderately impaired cognition, and occasionally experienced pain in the last five (5) days. The Resident Care Plan (RCP) dated 3/25/2024 identified Resident #1 was at risk for skin breakdown. RCP directed to assist with repositioning changes, offer right hand wrist splints and wound care as ordered. A physician order dated 5/2/2024 directed to administer Oxycodone (a narcotic pain medication) immediate release (IR) 10…

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 #12) reviewed for accidents, the facility failed to ensure complete documentation regarding resident behaviors and failed to ensure that administered medications were signed off and the effectiveness of the medications were documented on in the clinical record. Resident #12's diagnoses included dementia, schizophrenia and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #12 had a Brief Mental Interview for Mental Status (BIMS) of twelve (12) indicative of a moderate cognitive impairment and required set-up assistance for bed mobility, transfers and ambulation. The Resident Care Plan (RCP) dated 10/3/24 identified that Resident #12 has altered mood and behavior secondary to schizophrenia and will often start speaking about God and asking for forgiveness with interventions that included to observe for an indication of increased…

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 of the Environment, review of facility documentation, review of facility policy and staff interviews, the facility failed to ensure toilets in 2 shower rooms were maintained in a safe manner and the facility failed failed to ensure a safe and sanitary environment to promote a home like environment and for 1 of 8 residents reviewed for the environment for (Resident #79), the facility failed to maintain a homelike environment by ensuring the resident bathroom was free of holes and peeling paint and for 1 sampled resident ( Resident # 193), the facility failed to ensure the resident's personal clothing was labeled according to facility practice and not missing. The findings included: 1. An observation and interview on 11/04/24 at 7:10 AM of unit 2 behavioral unit shower room bathroom with RN #9 identified the toilet with the toilet seat on the floor next to the side of the toilet. Further observations identified the toilet with small amount of floating bowel movement and a dried-out…

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 facility policy, facility documentation and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment and for 1 of 2 showers, the facility failed to ensure that sharp containers were emptied to ensure a safe environment. The findings included: 1. Observations on initial tour on 11/04/24 at 7:35 AM and again during the survey on 11/7/24 at 9:55 AM with the Director of Maintenance identified the following: a. room [ROOM NUMBER]. Marred mirror in the bathroom, marred walls in the resident room, broken tile under the bed near the window and in front of bathroom. b. room [ROOM NUMBER]. Broken/ marred wall strip/baseboard. Broken wall/baseboard strip on the side of closet. [NAME] buildup around toilet. Broken tile under the bed near the window. Garbage on the floor including (2) peanut butter jars, various pieces of cardboard, 2 cracker boxes. c. Room#304. Stained tile on ceiling. d room [ROOM NUMBER]. Marred/ missing baseboard to closet.…

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, resident interview, observations and staff interviews for 1 of 6 residents ( Resident # 133) reviewed for respiratory care, the facility failed to ensure that call bells were answered timely and for 1 of 5 residents reviewed for Choices ( Resident # 140), the facility failed to ensure the call bell was accessible to the resident. The findings included: Resident #133 was admitted with diagnoses that included chronic respiratory failure, Chronic Obstructive Pulmonary Disease ( COPD), and anxiety. The quarterly Minimum Data Set ( MDS) assessment dated [DATE] identified Resident #133 was cognitively intact and required partial/moderate assistance for bed mobility. The MDS assessment also indicated the resident had experienced shortness of breath or trouble breathing when lying flat. A physician's order dated 9/18/2024 directed the administration of ipratropium-albuterol 0.5 milligrams (mg)-2.5 Milligrams ( MG) (a medication that increases airflow to the lungs) every six hours. 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 policy review and interviews for 1 resident (Resident #12) reviewed for dental, the facility failed to ensure a comprehensive care plan was developed. The findings include Resident #12's diagnosis included depression and bipolar disorder. The Annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #12 was severely cognitively impaired. An interview with charge nurse (RN #10) on 11/05/24 at 9:40 AM identified Resident #12 told the surveyor she/he had toothache and showed the surveyor her/his right lower jaw with broken and discolored teeth. RN #10 indicated Resident #12 was waiting for a tooth extraction and s/he would offer Resident # 12 medication and indicated the resident usually does not complain of discomfort. On 11/5/2024 at 9:45 AM of the clinical record identified an attempt made by the visiting dentist to see Resident #12 on 2/22/2018 but Resident#12 refused to be seen on that date. No other dental visits were found after the 2/22/2018 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 clinical record reviews, review of facility policy and interviews for 1 of 1 resident ( Resident # 12) reviewed for dental and 2 of 4 residents (Residents # 25 and # 460 reviewed for abuse, the facility failed to revise the residents care plan timely. The findings included : 1. Resident #12's diagnosis included depression and bipolar disorder. The Annual Minimum Data Set assessment dated [DATE] indicated Resident #12 was severely cognitively impaired. The care plan dated 10/30/2024 for at risk for decline in wellbeing due to chronic medical and psychiatric conditions. Interventions included consulting with the social worker as needed, encouraging group activities and to report any changes to the physician. An interview and record review with the MDS Coordinator Nurse (RN # 8) on 11/08/24 from 8:45 AM to 9:20 AM identified the Annual Minimum Data Set assessment dated [DATE] indicated through the Care Area Assessments (CAA) Process of completing a comprehensive directed to proceed with a dental care plan…

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 policy and interviews for and 3 of 6 residents reviewed for Respiratory Care( Residents.#65, #69, and #129), the facility failed to ensure oxygen supplies were stored and tabled properly and for 1 of 6 residents reviewed for Respiratory Care (Resident #196), the facility failed to provide tracheal suctioning in accordance with professional standards. The findings included: 1. Resident #65's diagnoses that included morbid obesity with alveolar hypoventilation (inadequate ventilation). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #65 was cognitively intact, required one to two person assist with activities of daily living (ADL), set up assist with eating and personal care. The Resident Care Plan (RCP) dated 10/30/24 identified Resident #65 had impaired respiratory status related to respiratory failure and pneumonia. Interventions directed to apply oxygen if saturation falls below parameters and administer respiratory…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy and staff interviews for 1 of 1 resident reviewed for tracheostomy care (Resident #196), the facility failed to ensure staff were competent in providing tracheal suctioning. The findings include: Resident #196 was admitted on [DATE] with diagnoses that included brain damage, pneumonia, and sepsis. A physician's order dated 9/19/2024 directed tracheostomy care every shift and suction as needed. The quarterly MDS assessment dated [DATE] identified Resident #196 was in a persistent vegetative state and required tracheostomy care and suctioning. On 11/6/2024 at 12:20 PM, LPN#4 was observed providing tracheal suction to Resident #196. LPN#4 donned clean gloves, poured sterile water into a non-sterile clear plastic cup, opened the drawer of the resident's nightstand, and retrieved a suction catheter from a clear plastic belongings bag. LPN#4 then proceeded to provide tracheal suctioning, obtaining pale yellow secretions; then LPN#4 placed the tip of the suction catheter…

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 the tour of the kitchen, observations and staff interviews, the facility failed to ensure food storage equipment was free of hard black matter and food was stored in an organized manner and the facility failed to ensure staff applied a beard guard while preparing food. The findings included: Tour of the initial walk through of the kitchen on 11/4/24 at 6:35AM with the Food Service Director identified the following: 1. An observation of the [NAME] Refrigerator identified hard black matter in the corners of the refrigerator. Interview with the Director of Food Service on 11/4/24 at 6:42AM identified all staff are responsible to cleaning and maintaining the refrigerator area. After inquiry, kitchen staff was directed to mop/ clean the [NAME] Refrigerator. 2. Observation of the dry food storage area identified stacks of boxes (empty and filled) were on the floor and some noted falling over. Boxes were also blocking the emergency stock. Interview with the Director of Food Services on 11/4/24 at 6:48 AM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations and staff interviews for 1 of 1 resident reviewed for tracheostomy care (Resident #196), the facility failed to ensure that staff used appropriate Personal Protective Equipment (PPE) when providing tracheal suctioning and failed to ensure linen was stored in sanitary manner. The findings include: 1. Resident #196 was admitted on [DATE] with diagnoses that included brain damage, pneumonia, and sepsis. A physician's order dated 9/19/2024 directed tracheostomy care every shift and suction as needed. The quarterly MDS assessment dated [DATE] identified Resident #196 was in a persistent vegetative state and required tracheostomy care and suctioning. On 11/6/2024 at 12:20 PM, LPN#4 was observed providing tracheal suction to Resident #196. Prior to entering the room, an orange sign for enhanced barrier precautions was noted on top of an isolation cart that contained gowns and masks. The enhanced barrier precautions indicated that staff performing high-contact care, such as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation and staff interviews for 1 of 3 residents (Resident #40) reviewed for Beneficiary Notification, the facility failed to ensure the notification was received by the responsible party timely to ensure the responsible party was aware of his/her rights. The findings include: Resident #40's diagnosis include dementia and Schizophrenia. The Annual Minimum Data Set assessment dated [DATE] indicated Resident #40 was severely cognitively impaired. The PPS (Prospective Payment System) Part A (Medicare part A) Discharge (End of Stay) MDS dated [DATE] indicated Resident #40's Medicare stay ended on 5/9/2024. On 11/05/24 at 3:10 PM during an interview and facility document review with the MDS Nurse (RN #9) of the facility Beneficiary Notification paperwork including the Notification of Medicare Non-Coverage for Resident # 40 identified the notification was dated as provided timely and emailed to the resident's responsible party on 5/7/2024. Although the date of notification on 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, observations and interviews, for two (2) of six (6) residents reviewed for resident rights (Resident #1 and Resident #2), the facility failed to ensure that language used within close proximity of residents was appropriate. The findings included: 1. Resident #1 had a diagnoses that included paranoid schizophrenia. A quarterly Minimum Data Set (MDS) dated [DATE] identified that the resident had a Brief Interview for Mental Status (BIMS) of three (3), indicative of severe cognitive impairment and required set-up with Activities of Daily Living (ADLs). A care plan dated 9/20/24 identified that the resident required assistance with ADL's with interventions including explanation of care, and to report any decline in ADLs to the therapy department. 2. Resident #2 had diagnoses that included encephalopathy. A quarterly MDS dated [DATE] identified a Brief Interview for Mental Status (BIMS) of three (3), indicative of severe cognitive impairment 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 the clinical record review, facility documentation, facility policy and interviews for one (1) of four (4) residents (Resident #4) reviewed for abuse, the facility failed to ensure the residents were free from physical abuse within the facility. The findings include: Resident #4's diagnoses included anxiety disorder, mood disorder and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had a Brief Mental Interview for Mental Status (BIMS) of seven (7) indicative of impaired cognition, exhibited no behaviors and required extensive assistance with bed mobility, transfers and toileting. The Resident Care Plan (RCP) dated 9/25/24 identified that Resident #4 has the potential for a mood problem related to the allegation of physical abuse by a caregiver with interventions that included to obtain behavioral health consults as needed, monitor/document/report any risk for harm to self, monitor/record mood, social service support visits per policy and 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 reviews, facility documentation, facility policies and interviews for one of two sampled residents (Resident #2) who had a history of substance abuse, the facility failed to ensure the resident's rights regarding a leave of absence, a urine screen upon return from a leave of absence, restriction of visitors and by making a leave of absence contingent on identified behaviors were not violated. The findings include: Resident #2's diagnoses included psychoactive substance abuse, alcohol use, schizoaffective disorder, bipolar type and post-traumatic stress disorder. The Resident Care Plan dated 1/3/24 identified that Resident #2 had a history of alcohol abuse. Interventions directed counseling and education regarding substance abuse and implementation of non-invasive search upon return from leave of absence (LOA) and visits as indicated. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had no memory deficits and was independent in activities of daily living. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policies and interviews for two of two sampled residents (Resident #2) who had a history of substance abuse, the facility failed to ensure the resident's rights was not violated by searching the resident's room for suspected contraband because Resident #2 had tested positive for cocaine on a urine toxicology test. The findings include: Resident #2's diagnoses included psychoactive substance abuse, alcohol use, schizoaffective disorder, bipolar type and post-traumatic stress disorder. The Resident Care Plan dated 1/3/24 identified that Resident #2 had a history of alcohol abuse. Interventions directed counseling and education regarding substance abuse and implementation of non-invasive search upon return from leave of absence (LOA) and visits as indicated. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had no memory deficits and was independent in activities of daily living. A physician's order dated 2/22/24 directed…

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 sampled resident (Resident #1) who was removed from the facility by the local authorities, the facility failed to issue a thirty (30) day discharge notice. The findings include: Resident #1's diagnoses included hemiplegia, type 2 diabetes mellitus, abnormalities of gait and disability, and depression. The annual Minimum Data Set assessment dated [DATE] identified Resident #1was cognitively intact, required set up or clean up assistance with eating, hygiene, showers, dressing, and transfers, and utilized a wheelchair for mobility. The last psychiatric visit note dated 4/27/24 identified Resident #1 was not currently a danger to self/others and there were no prominent mood features noted. The Resident Care Plan dated 5/15/24 identified Resident #1 had a past criminal history and was responsible to report to the location of a state agency. Interventions directed for social work to assist and educate the resident 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, facility documentation, facility policies and interviews for one sampled resident (Resident #1) who was removed from the facility by the local authorities, the facility failed to permit the resident to return to the facility after the resident received medical treatment in a hospital and was ready for discharge to a long-term care facility. The findings include: Resident #1's diagnoses included hemiplegia, type 2 diabetes mellitus, abnormalities of gait and disability, and depression. The annual Minimum Data Set assessment dated [DATE] identified Resident #1was cognitively intact, required set up or clean up assistance with eating, hygiene, showers, dressing, and transfers, and utilized a wheelchair for mobility. The last psychiatric visit note dated 4/27/24 identified Resident #1 was not currently a danger to self/others and there were no prominent mood features noted. The Resident Care Plan dated 5/15/24 identified Resident #1 had a past criminal history and was responsible 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.

Based on a review of facility documentation and interviews, the facility failed to honor resident rights by the exclusion of specific information in the facility leave of absence policy. The findings include: Review of the facility's Authorize Leave of Absence (LOA) policy dated 11/29/23 directed that a physician's order was required for a LOA and the resident needed to be accompanied by a responsible person. The policy indicated the procedure for residents leaving the facility was to have a Travel Pass Request Form completed, the physician would authorize or deny the issuance for a Travel Pass and denote it on the Travel Pass Request Form. The policy directs the resident or their responsible person to provide sufficient notice to request a Travel Pass and that the Interdisciplinary Team (IDT) would review each request to develop recommendations for individualized safety needs for each resident prior to a leave of absence from the facility. These recommendations would be documented by the IDT on the Travel Pass Request Form. The policy did not identify if the Travel Pass process…

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 sampled resident (Resident #1) reviewed for pressure wounds, the facility failed to ensure a comprehensive care plan for a resident with refusals of care. The findings include: Resident #1's diagnoses included non-pressure chronic ulcers, diabetes mellitus, and dysphagia. The admission Minimum Date Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition and required partial/moderate assistance with bathing and lower body dressing. The Resident Care Plan (RCP) dated 12/6/2023 identified Resident #1 was at risk for skin breakdown related to bilateral wounds on heels on admission. Interventions directed a pressure reduction mattress as appropriate, encourage/assist resident with repositioning and off-loading heels, treatment as ordered, monitor for worsening condition/infection, and wound tracking per protocol. Clinical record review identified the following: • Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one resident (Resident #1) reviewed for nutrition, the facility failed to ensure a reweight was obtained timely for a resident and failed to ensure the dietician and physician were notified timely of a significant weight loss. The finding includes: Resident #1's diagnoses included diabetes mellitus, severe protein-calorie malnutrition, chronic non-pressure ulcers, dysphagia, and adjustment disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition and was independent for eating. The Resident Care Plan (RCP) dated 12/6/2023 identified Resident #1 was at risk for alteration in nutritional status related to diabetes, malnutrition, hyperlipidemia, and dysphagia. Interventions directed to provide diet and supplements as ordered, offer alternate meal choice as indicated, obtain weights as order, monitor diet tolerance, monitor 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 review, facility documentation review, facility policy review and interviews for one resident (Resident #1) reviewed for nutrition, the facility failed to ensure the clinical record was complete and accurate to include accurate treatment documentation, and failed to ensure medical record access was maintained to ensure records were available timely. The findings include: a. Resident #1's diagnoses included non-pressure chronic ulcers, diabetes mellitus, and dysphagia. The admission Minimum Date Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition and required partial/moderate assistance with bathing and lower body dressing. The Resident Care Plan (RCP) dated 12/6/2023 identified Resident #1 was at risk for skin breakdown related to bilateral wounds on heels on admission. Interventions directed a pressure reduction mattress as appropriate, encourage/assist resident with repositioning and off-loading heels, treatment as ordered, monitor for worsening…

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 resident, (Resident #1), who was reviewed for abuse, the facility failed to ensure a comprehensive care plan was developed for a resident known to flail upper and lower extremities about while in bed who subsequently sustained a serious injury of unknown origin. The findings include: Resident #1 had diagnoses that included vascular dementia and unspecified abnormalities of gait and mobility. The Quarterly Minimum data set (MDS) assessment dated [DATE] identified Resident #1 had severe cognitive impairment, required one person assist with bed mobility, two person with transfer using a mechanical lift and one person assist with toileting. The Resident Care Plan (RCP) dated 5/16/23 identified Resident #1 had impaired cognition and required assistance with activities of daily living (ADL) due to dementia with nterventions directed to monitor and report changes to the physician, explain what you are going to do before…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and review of facility documentation for 1 of 13 rooms on the 2A unit (room [ROOM NUMBER]) and for 2 of 13 rooms on the 2 B unit (room [ROOM NUMBER] and #224), for 1 of 15 rooms on the 4 A unit (room [ROOM NUMBER]), and for 1 of 13 rooms on the 4 B unit (room [ROOM NUMBER]), the facility failed to ensure the residents' rooms and furnishings were maintained in a clean, safe, homelike and sanitary manner and in good repair. The findings included: 1. On 3/7/22 from 12:25 PM to 12:46 PM, observation of a room [ROOM NUMBER] where Residents #3 and #166 reside on the 4 B unit identified the following: a. A floor tile off-white in color, in the area of the room where Resident #3 resided was noted as having a pinkish-red stain on the floor, at the right side of the resident's bed. b. The surface of the wall which was facing Resident #166's bed and being just below the headboard was marred and scarred with black linear marks on the wood panel section of the wall. c. An area of the wall…

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, staff interviews and review of facility policy, the facility failed to ensure dishware and utensils were cleaned and sanitized according to facility policy and manufacture's recommendations. The findings include: 1. An initial tour of the kitchen on 3/7/22 at 10:20 AM noted Dietary Assistant (DA) #1 loading breakfast soiled dishware and utensils into the dishwasher. DA #1 identified the dishwasher final rinse temperature at 172-degree Fahrenheit. Interview with the Food Service Director (FSD) at that time identified the dishwasher as a hot water sanitizing machine. The FSD further identified that sanitizing rinse acceptable temperature was above 180 degree F (the final rinse cycle was noted to be 172 degrees F) and DA #2 checked the dishwasher temperature and documented on the Hot Temp Dishwasher- Temperature sheet before staff had begun washing dishware in the morning. Review of the Hot Temp Dishwasher-Temperature sheet identified after each meal from 3/2/22 breakfast time through 3/7/22…

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 procedures and interviews for two of three residents (Resident #18 and Resident #118) reviewed for activities of daily living (ADLs), the facility failed to ensure care and services were provided to maintain good grooming or personal hygiene. The findings included: 1. Resident #18's diagnoses included schizoaffective disorder, osteopenia, bilateral knee pain and bipolar disorder. An annual MDS assessment dated [DATE] identified Resident #18 was severely cognitively impaired, required total assistance from staff for all ADLs and had no impairment in functional limitations for range of motion to the upper and lower extremities. The Resident Care Plan dated 9/30/21 identified a problem with ADLs with interventions that included to provide total assistance for ADLs. On 3/8/22 at 11:47 AM it was noted upon observation that Resident #18's fingers and thumb of the left hand were swollen in the joint areas, his/her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility policy/procedures and interviews for one of three residents (Resident #18) reviewed for activities of daily living (ADLs), the facility failed to ensure care/treatment to Resident #18's swollen hand joint/hand contracture was completed. The findings included: Resident #18's diagnoses included schizoaffective disorder, osteopenia, bilateral knee pain and bipolar disorder. An annual MDS assessment dated [DATE] identified Resident #18 was severely cognitively impaired, required total assistance from staff for all activities of daily living and had no impairment in functional limitations for range of motion to the upper and lower extremities. The Resident Care Plan (RCP) dated 9/30/21 identified a problem with ADLs with interventions that included to provide total assistance for ADLs. On 3/8/22 at 11:47 AM Resident #18 was observed lying in bed watching television. Upon observation of Resident #18's left hand, it was noted that his/her fingers and thumb…

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, review of facility documentation, review of facility policy, and interviews for one of two sampled residents (Resident #70) reviewed for abuse, the facility failed to ensure timely physician notification of an injury of unknown origin and/or for one sampled resident (Resident #175) reviewed for edema, the facility failed to ensure a significant weight gain was reported to the Physician/Advanced Practice Registered Nurse (APRN) and/or a significant change in condition was reported to the Physician/APRN. The findings include: a. Resident #70 ' s diagnoses included schizoaffective disorder and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #70 had both long and short term memory problems, showed constant signs of delirium behaviors including hallucinations and delusions, and was totally dependent on staff for all Activities of Daily Living (ADL's) including bed mobility and transfers. The Resident Care Plan (RCP) dated 10/18/18 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility documentation, review of facility policy, and interviews, for 1 resident (Resident #66) reviewed for cleanliness of environment, the facility failed to maintain the cleanliness of Resident #66's customized wheelchair (CWC). The findings include: Resident #66 was admitted to the facility on [DATE] with diagnoses that included acute hypoxic respiratory failure, atelectasis, hypertension, mood disorder, cerebrovascular accident, and spastic hemiplegia. The annual Minimum Data Set (MDS) dated [DATE] identified Resident #66 had absence of spoken words, was always incontinent of bowel and bladder and required total dependence on two staff for transfers, and required extensive assistance of one for eating. The care plan dated 12/11/17 identified Resident #66 had a customized electric wheelchair. Interventions directed to transfer to CWC with assist of 2 using Hoyer Lift. The care plan dated 11/1/18 identified Resident #66 was at risk for skin breakdown. Interventions directed 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 clinical record review, review of facility documentation, review of facility policy, and interviews for two of two sampled residents (Residents #33 and 70) reviewed for abuse, the facility failed to ensure an injury of unknown origin was reported to the state agency in a timely manner. The findings include: a. Resident #33's diagnoses included Dementia, Mood Disorder, Seizure Disorder, Traumatic Brain Injury, and Spastic Quadriplegia. The resident care plan for Activities of Daily Living (ADLs) updated on 8/09/18 indicated spastic and frequent movements, at risk for skin breakdown and bruising, and history of osteoporosis and fractures. Approaches included two padded half rails on bed, observe for any bruising, and transfer to wheelchair with Hoyer lift. The Minimum Data Set (MDS) dated [DATE] indicated Resident #33 had severe cognitive impairment, had severely impaired vision, was unable to speak, and had limited ability to make self understood. It further identified that Resident #33 was totally…

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, review of facility documentation, review of facility policy, and interviews for two of two sampled residents (Residents #33 and #70) reviewed for abuse, the facility failed to ensure an injury of unknown origin was investigated in a timely manner. The findings include: a. Resident #33 diagnoses included Dementia, Mood Disorder, Seizure Disorder, Traumatic Brain Injury, and Spastic Quadriplegia. The resident care plan for ADLs updated on 8/09/18 indicated spastic and frequent movements, at risk for skin breakdown and bruising, and history of osteoporosis and fractures. Approaches included two padded half rails on bed, observe for any bruising, and transfer to wheelchair with Hoyer lift. The Minimum Data Set (MDS) dated [DATE] indicated Resident #33 had severe cognitive impairment, had severely impaired vision, was unable to speak, and had limited ability to make self understood. It further identified Resident #33 was totally dependent on facility staff for movement, personal…

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 documentation and interviews, for one of four residents reviewed for Pre-admission Screening and Resident Review (PASRR), (Resident #208), the facility failed to request an extension for medical needs and/or failed submit a referral for a level II assessment in a timely manner. The findings include: Resident #208's diagnoses included bipolar disorder, generalized anxiety disorder, opioid with dependence, right foot fracture with surgical repair, degenerative arthritis, and a history for cellulitis. A quarterly assessment dated [DATE] identified Resident #208 as cognitively intact, without behaviors, and independent for most activities of daily. The Resident Care Plan (RCP) updated [DATE] identified a problem Pre-admission screening for services. Intervention included reviewing recommended services with resident and provided and/or make referral for services as ordered and/or as indicated. Review of the clinical record identified the resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, review of facility policy, and interviews, for 1 resident (Resident # 41) reviewed for quality of care, the facility failed to follow a physician's order and/or one sampled resident (Resident #175) reviewed for edema, the facility failed to ensure a resident's weight was monitored per the physician's order. The findings include: a. Resident # 41 was admitted to the facility on [DATE] with diagnoses that included, small bowel obstruction, dementia with delusional psychosis, multiple sclerosis, asthma, traumatic brain injury, Vitamin D deficiency, hyperlipidemia, hypothyroidism, and developmental delays. According to the medication management assessment from dated 10/9/18, no recent neurology consult was noted in the record and input from Neurology would be helpful in asessment. A physician ' s order dated 10/9/18 at 12 PM identified neurology consult requested related to multiple sclerosis. Evaluate propulsive gait, periods of freezing and current…

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 five sampled resident (Resident # 72) reviewed for falls, the facility failed to ensure the necessary services were provided to prevent an accident. The findings include: Resident #72 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular accident, non-Alzheimer's dementia, depression, and obesity. A falls risk assessment dated [DATE] identified Resident #72 was at risk for falls. The quarterly MDS assessment dated [DATE] identified Resident #72 was without cognitive impairment, required extensive assistance with transfers, and with the use of a wheelchair for locomotion. A nurse aide assignment information sheet for Resident #72 dated 11/13/18 instructed to use a customized wheelchair (CWC) and to remind Resident #72 to sit in his/her own chair. A physician's order dated 12/3/18 directed Resident #72 to be out of bed to custom wheelchair with 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 observations, clinical record review, review of facility documentation, review of facility policy, and interviews for one sampled resident, (Resident #144) reviewed for an indwelling urinary catheter, the facility failed to consistently monitor daily urinary output and/or notify the physician that the urinary catheter was not changed as ordered. The findings include: Resident #144 was admitted to the facility on [DATE] with diagnoses that included retention of urine, unspecified hydronephrosis, urinary tract infection, and hematuria. A current physician's order originally dated 10/18/18 directed to change the indwelling foley catheter monthly on the 15th of every month with a 16 French catheter and monitor intake and output every shift. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #144 had severely impaired cognition and required extensive assistance with bathroom use. The Resident Care Plan (RCP) dated 12/15/18 failed to include that Resident #144 had an indwelling…

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, review of facility documentation, review of facility policy, and interviews, for 1 of 6 residents (Resident #41) reviewed for unnecessary medications, the facility failed to monitor orthostatic blood pressures per physician's orders. The findings include: Resident #41 was admitted to the facility on [DATE] with diagnoses that included, small bowel obstruction, dementia with delusional psychosis, multiple sclerosis, asthma, traumatic brain injury, Vitamin D deficiency, hyperlipidemia, hypothyroidism, and developmental delays. A physician's order originally dated 12/7/17 directed to check orthostatic blood pressures monthly on Monday on 7-3 shift. A physician's order dated 5/8/18 directed to administer Risperidone 2mg by mouth at bedtime and Risperidone 3mg by mouth in the morning. Care plan dated 5/25/18 identified Resident #41 had impaired cognition due and received psychotropic medications. Interventions directed to call resident by first name, use…

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 procedures, and interviews for one of five residents reviewed for unnecessary medications (Resident #109), the facility failed to document targeted behaviors for the purpose of monitoring behavioral symptoms. The findings include: Resident #109's diagnoses included anxiety, major depression disorder, dementia, epilepsy, psychosis, alcohol dependency, and insomnia. An admission assessment dated [DATE] and a quarterly assessment dated [DATE] both identified Resident #109 as without cognitive impairment, was independent for all activities of daily living, and was receiving antipsychotic, anti-anxiety, and anti-depression medications within the past 7 days. The Resident Care Plan (RCP) dated 8/30/18 and updated on 12/4/18 identified a problem for dementia, anxiety, mood, and alcohol dependency. Interventions included counseling, 1:1 visit as needed, psych visits for medication and symptom management, and look for signs of depression, sad mood,…

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 for 1 resident (Resident #66) reviewed for dental, the facility failed to follow up on denture appointments in a timely manner. The findings include: Resident #66 was admitted to the facility on [DATE] with diagnoses that included acute hypoxic respiratory failure, atelectasis, hypertension, mood disorder, cerebrovascular accident, spastic hemiplegia, and polysubstance abuse. The Minimum Data Set, dated [DATE] identified Resident #66 was cognitively impaired and was totally dependent on facility staff for Activities of Daily Living. Consult note dated 5/16/18 identified for Resident #66, extracted all remaining maxillary and mandibular teeth. Disposable sutures in place. One week follow up requested. Nurses note dated 5/17/18 at 11:40 AM identified resident very happy and looking forward to dentures. Record failed to reflect that the follow up was completed in one week. Nurses note dated 7/9/18 identified Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and review of documentation, for one resident (Resident # 139) the facility failed to maintain mechanical wheelchair in safe operating condition. The findings include: Resident #139's diagnoses included anemia, hemiplegia, and dysphagia. The Minimum Data Set, dated [DATE] identified Resident #139 as cognitively impaired but able to make needs known, required assistance with Activities of Daily Living, and was independent with locomotion on and off the unit. On 01/14/2019, at 9:10 AM, Resident #139 was observed in a wheelchair and it was noted that there was no arm rest on left side of wheelchair, just metal bar and a screw. Resident #139 identified that there has not been an arm rest for a while, more than a week. Resident #139 identified that he/she reported it to staff but no person did anything. Resident # 139 further identified that he/she has pain in left arm because there is no arm rest. On 1/14/2019, at 9:30 AM interview with LPN #2, indicated that the procedure 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.