Trinity Hill Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, review of facility policy/procedure and interviews for one of two sampled residents (Resident #119) reviewed for dental, the facility failed to ensure the resident was seen by a dentist/hygienist. The findings include: Resident #119 was admitted to the facility in May of 2024 with diagnoses that included fracture of right femur, fracture of left tibia and fibula, depression and anxiety. The admission MDS assessment dated [DATE] identified Resident #119 was cognitively intact, required total dependence with oral hygiene, dressing, personal hygiene, transfers and did not ambulate. The assessment further identified that the resident had obvious or likely cavity or broken natural teeth. The care plan dated 6/11/24 identified Resident #119 required assistance with ADL's related to bilateral lower extremity fractures with interventions that included monitor resident's status for any changes, improvement, decline and report to MD and therapy, 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 review of facility documentation, review of facility policy and interviews, reviewed for the infection control and prevention program, the facility failed to ensure that the annual water management plan meeting was conducted. The findings include: Review of the facility Water Management Plan for 2023 to 2024 with the Director of Maintenance on 10/24/24 at 2:23 PM failed to identify that the facility had a water management meeting to review the updated and revised plan provided by the company that was contracted by the facility to manage the facility's water management plan. Review of the safety committee meeting minutes dated 5/29/24 identified that the water management meeting (quarterly) was schedule to be completed on 7/12/2024. Interview with the Director of Maintenance on 10/24/24 at 3:27 PM identified that it was the policy of the facility to have an annual meeting to discuss and review the water management plan revision and update provided by the contracted company. The Director of Maintenance identified that the meeting was not done as he lost track of time, as the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility policy and interviews for one of twenty-four sampled residents (Resident #377) reviewed for advance directives, the facility failed to ensure the physician's order accurately reflected the resident's chosen code status. The findings include: Resident #377's diagnoses included osteomyelitis, viral hepatitis C and major depressive disorder. The Nursing admission assessment dated [DATE] identified Resident #377 was cognitively intact. Resident #377's Advance Directives/Code Status Consent form indicated the resident elected a code status of Do Not Resuscitate (DNR), which means to withhold cardiopulmonary resuscitation (CPR)in the event that the resident stops breathing. The form was signed by APRN #1 on [DATE]. Review of the MD Order/Progress Note form dated [DATE] and also located in the same location of the clinical record as the advance directives/code status consent form identified APRN #1 reviewed advance directives with Resident #377 and determined…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility policy and interviews for one of two sampled residents (Resident #59) reviewed for choices, the facility failed to ensure the implementation of the admissions policy when the resident was admitted to the facility. Resident #59 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder recurrent severe with psychotic symptoms, schizoaffective disorder, polyneuropathy, and extrapyramidal symptoms. The admission face sheet located in the electronic health record identified Resident #59 was conserved and indicated the conservator's contact information. The baseline care plan dated 6/18/24 identified Resident #59 was at risk for behaviors related to psychiatric disorders. Interventions included: encourage participation in behavioral program and recreational groups, residence on a secured unit, monitor behaviors, and provide mental health professional services as indicated The admission MDS assessment dated [DATE] 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 the clinical record, review of facility policy and interviews for one sampled resident (Resident #377) reviewed for antibiotic use, the facility failed to ensure admission orders were verified prior to administration and failed to ensure that a physician's orders directing the treatment and care a a central line catheter. The findings include: Resident #377 was admitted to the facility on [DATE], with diagnoses that included osteomyelitis, viral hepatitis C and major depressive disorder. The Nursing admission assessment dated [DATE] identified Resident #377 was cognitively intact and had a peripherally inserted central catheter (PICC). Review of the Inter-Agency Referral Report (W-10) from the hospital dated 10/11/24 identified the following discharge medications: 1. Bisacodyl 5milligram (mg) Enteric Coated (EC) give 10mg by mouth daily as needed 2. Bisacodyl 10mg suppository rectally daily as needed 3. Ceftriaxone 1 gram give 2 grams intravenous daily 4. Folic Acid 1mg by mouth…

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, review of facility policy, and interviews for one sampled resident (Resident #70) reviewed for respiratory care, the facility failed to ensure a physician's order was in place directing the use of oxygen therapy for a resident utilizing oxygen. The findings included: Resident #70s diagnoses included end stage renal disease, chronic obstructive pulmonary disease, anxiety, and heart failure. The quarterly MDS assessment dated [DATE], identified Resident #70 was cognitively intact, required moderate assistance with transfers, toileting, personal hygiene, and identified that the resident utilized a wheelchair for mobility. The assessment did not indicate the use of oxygen. The care plan dated 8/31/24 identified Resident #70 was at risk for breathing problems related to chronic pulmonary disease, with interventions that included providing oxygen as needed to maintain oxygen levels. Elevating the head of the bed to prevent shortness of breath, and to 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 review of the clinical record, review of facility documentation, review of facility policy/procedure and interviews for one sampled resident (Resident #115) reviewed for pain, the facility failed to administer pain medication in a timely manner. The findings included: Resident #115's diagnoses included puncture wound without foreign body of the right thigh, and muscle weakness. The admission MDS assessment dated [DATE] identified Resident #115 was cognitively intact, had no behaviors, required set up or clean up assistance with eating, oral hygiene, utilized partial to moderate assistance with toileting, showers, personal hygiene and dressing. The assessment further identified Resident #115 utilized a wheelchair for mobility, and almost constantly was in pain with a rating of 10 in pain intensity on a scale of 0-10 with 10 being the most intense. The care plan dated 7/16/24 identified Resident #115 had pain related to a gunshot wound with interventions that included provide pain medication as ordered…

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, review of facility documentation, review of facility policy and procedures and interviews for one sampled resident reviewed for hospitalization, the facility failed to ensure access to emergency supply medication and failed to ensure the implementation of a system to account for the receipt, usage, disposition, and reconciliation. The findings include: 1. Resident #73's diagnoses included unspecified open wound left foot, anxiety disorder, and post-traumatic stress disorder. The admission MDS assessment dated [DATE] identified Resident #1 was cognitively intact, had no behaviors, required set up or clean up assistance with eating, toileting hygiene, and supervision with shower bathing and dressing. The assessment further identified the resident utilized a wheelchair for mobility Physicians order dated 10/18/24 directed Lorazepam 1mg by mouth every 4 hours as needed for anxiety. The nurse's note dated 10/18/24 at 3:16 PM identified Resident #73 was very…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, review of facility policy and interviews for two of five sampled residents (Resident #59 and Resident #78) reviewed for unnecessary medications and for one of five sampled residents (Resident #32), reviewed for abuse, the facility failed to ensure resident medical records were complete, accurately documented and readily accessible. The findings include: 1. Resident #32's diagnoses included alcohol induced dementia, anxiety disorder and adjustment disorder. The quarterly MDS assessment dated [DATE] identified Resident #32 had moderate cognitive impairment, had no behaviors, required moderate assistance with personal hygiene, dressing, independent with bed mobility, transfers and ambulation. The physician's orders dated 6/3/24 directed to discontinue one to one constant observation and start every 15 minutes checks for 48 hours. The physician's order dated 6/11/24 directed every 15 minutes checks for 48 hours until 6/12/24 at 3:00 PM. The nurse's note dated 6/11/24 at 1:47 PM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2) residents,(Resident #1), who resided on a secured unit, the facility failed to ensure Resident Rights were maintained by not permitting the resident to leave the unit without being escorted by a staff member. The findings include: Resident # 1 was admitted with diagnoses that included depression, mood disorder, and schizoaffective disorder. The quarterly MDS dated [DATE] identified Resident #1 had moderately impaired cognition, was continent of bowel and bladder, and was independent with oral hygiene, toileting, personal hygiene, locomotion, bed mobility, transfers, dressing upper and lower body. The care plan dated 10/30/2023 identified Resident #1 will pursue self-directed leisure time activities daily including watching T.V., listening to music, coloring, and socializing with staff and my peers throughout the facility with interventions that directed to provide 1:1 therapeutic visits 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 clinical record review, facility documentation review, facility policy review and interviews for one of three residents (Resident #2) reviewed for accidents, the facility failed to maintain a complete and accurate medical record to include offering and refusals of support services. The findings include: Resident #2 was admitted with diagnoses that included substance abuse disorder with an opioid addiction, cervical spine degeneration with disc compression and muscle weakness. A quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #2 was alert, oriented and walked independently. The Resident Care plan (RCP) identified Resident #2 had a substance abuse disorder and was actively using substances prior to admission, with a goal to not use alcohol, or illegal substances. The RCP directed to encourage to participate in the facilities substance use recovery services, provide supervised visits until comfortable in the recovery process and resident would not use alcohol or illegal substances through…

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 four residents, (Resident #1), reviewed for medication administration, the facility failed to ensure insulin was administered and blood sugar monitoring was performed in accordance with physician orders. The findings include: Resident #1 was admitted during 12/2022 with diagnoses that included insulin dependent Diabetes Mellitus (DM) and end stage renal disease. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #1 had a diagnosis of diabetes and received no insulin injections during the prior seven (7) days. Review of the clinical record identified admission orders dated 1/2/2023 directed Lantus (insulin used to manage diabetes) 100 units/milliliter (u/ml) 16 units (0.16 ml) subcutaneously every day at bedtime. Review of the Medication Administration Record (MAR) dated 1/2/2023 failed to identify the physician order dated 1/2/2023 for Lantus insulin 100u/ml: 16…

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, facility policy and interviews, the facility failed to provide and maintain a clean, sanitary and homelike environment. The findings included: 1. Observations on the first floor on 3/7/22 between 10:30 - 10:45 AM, on 3/8/22 at 9:30 AM and 3/9/22 at 1:30 PM identified the following: a. room [ROOM NUMBER] D had scuffed marks, pen scribbling, paint chipping and an approximate 2-inch hole in the wall of the bathroom door. There were two approximately 1-inch holes on the wall facing the resident's bed with scuffed marks. There was a line, approximately 36 inches long, of dirt and caked on brown substance coated on the floor underneath the resident's bed. b. room [ROOM NUMBER] W had an approximate 4-inch hole close to the floor on the wall against the head of the resident's bed. There were rodent droppings on the floor at the base of the hole. c. room [ROOM NUMBER] N had ceiling tiles in the bathroom and over the bed with stain. 2. Observation on the 2nd floor 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 review, review of facility documentation, review of facility policy and procedures and interviews for one sampled resident (Resident #2) reviewed for misappropriation of resident property, the facility failed to report an allegation of misappropriation of resident property to the State Agency. The findings include: Resident #2's diagnoses included diabetes mellitus, mood disorder, anxiety disorder, and opioid abuse. The annual Minimum Data Set assessment dated [DATE] identified Resident #2 had no short or long-term memory problems, was independent with daily activities of living, and received opioid medication daily. The Resident Care Plan dated 11/17/21 identified independent with daily activities of living. Interventions directed to observe for any changes in independent daily activities of living status. On 12/2/21 Resident #2 was discharged to the hospital due to a significant change in status. The hospital medicine progress note dated 12/2/21 noted Resident #2 appeared to be…

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, review of facility policy and procedure and interviews for three sampled residents (Residents #2, #7, and #8) who were reviewed for a transfer to the Emergency Department, the facility failed to allow the resident to return to the facility after being provided with a thirty (30) day involuntary discharge notice prior to the hospital transfer and failed to readmit residents identified with active COVID-19 infections. The findings include: 1. Resident #2's diagnoses included diabetes mellitus, mood disorder, anxiety disorder, and opioid abuse. The annual Minimum Data Set assessment dated [DATE] identified Resident #2 had no memory recall problems, was independent with activities of daily living, and received opioid medication daily. The nurse's note dated 12/1/21 at 4:21 PM identified Resident #2 was observed unconscious on the bathroom floor, upon assessment Resident #2 was breathing and had a pulse, sternal rub provided without effect, Narcan 4…

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, interviews, review of facility documentation, and review of facility policy and procedure for one of three sampled residents (Resident #1) who had a significant change in condition, the facility failed to ensure an assessment was conducted by a Registered Nurse when the resident was noted to have a change in status. The findings include: Resident #1's diagnoses included schizophrenia, personality disorder and diabetes mellitus. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 made reasonable and consistent decisions regarding tasks of daily life, did not exhibit behavioral symptoms, was independent or required supervision with activities of daily living, and received psychotropic medications daily. The Resident Care Plan dated 12/16/21 identified I have a diagnosis of Schizophrenia, I may have psychotic symptoms such as delusions, hallucinations and disorganization of thought and behavior. Interventions included I take medication that may cause me 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 reviews, review of facility documentation, review of facility policy and procedures and interviews for one of three sampled residents (Resident #1) who received anti psychotropic medications daily, the facility failed to complete behavior monitoring in accordance with the facility policy. The findings include: Resident #1's diagnoses included schizophrenia, personality disorder and diabetes mellitus. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 made reasonable and consistent decisions regarding tasks of daily life, did not exhibit behavioral symptoms, was independent or required supervision with activities of daily living, and received psychotropic medications daily. The Resident Care Plan dated 12/16/21 identified I have a diagnosis of Schizophrenia, I may have psychotic symptoms such as delusions, hallucinations and disorganization of thought and behavior. Interventions directed to monitor the resident for muscle movements the resident cannot control,…

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, interviews and review of facility policy for 4 of 5 residents reviewed (Resident #76, Resident #104, Resident #118, and Resident #141) for advanced directives (a written instruction, such as a living will or durable power of attorney for health care, relating to the provision of health care when the individual is incapacitated), the facility failed to review advanced directives with the resident and/or failed to ensure the physician orders reflected the resident's choice of code status and/or failed to ensure the resident's choice of advance directive was identified. The findings include: 1. Resident #76 was admitted to the facility on [DATE] with diagnoses that included discitis, kidney failure, and infections of the bone and blood. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #76 had no cognitive impairment and was independent with set up help for dressing, eating, toilet use, and personal hygiene. The resident care plan (RCP) dated 11/29/18…

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 2 sampled residents reviewed for hospice (Resident #54), the facility failed to honor Resident #54's right to refuse hospice services after hospice services were initiated. Resident #54's diagnoses included an autoimmune disease, encephalopathy, sepsis and dementia with behavioral disturbances. The hospital Discharge summary dated [DATE] identified Resident #54 was noncompliant with medications and had a conservator. The discharge summary further identified that Resident #54 was unwilling to receive care, had a poor prognosis and was made palliative care. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #54 was moderately cognitively impaired and required extensive assistance of two for bed mobility and transfers. The MDS further identified Resident #54 required total assistance of two for toileting, personal hygiene and ambulation in the room/corridor did not occur. The resident care plan dated 11/8/18 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 observations, clinical record review, review of facility documentation, review of facility policy, and interviews for 1 of 1 sampled resident reviewed for edema (Resident #124), the facility failed to notify the physician that the resident refused laboratory blood work testing. The findings include: Resident #124 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, primary essential hypertension, and anxiety. An annual Minimum Data Set, dated [DATE] identified Resident #124 with mildly impaired cognition, independent with eating, totally dependent on staff for bed mobility, transfers, dressing, and personal hygiene. The resident care plan (RCP) dated 1/2/19 identified Resident #124 had a problem with hypertension with interventions to observe for signs and symptoms of cardiac distress, chest pain, and any changes in heart rate. A Situation, Background, Assessment, Recommendation (SBAR) assessment nursing progress note dated 1/2/19 completed by RN #2 identified Resident #124…

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 3 residents (Resident # 5) reviewed for abuse, the facility failed to identify and/or report a potential incident involving mistreatment to the State Agency. The findings include: Resident #5 was admitted to the facility on [DATE] with diagnoses that included chronic systolic and diastolic heart failure, atrial fibrillation and major depressive disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #5 was cognitively intact, was independent with activities of daily living and required set up supervision only with personal care. The resident care plan dated 7/10/18 identified Resident #5's psychological well-being was at risk secondary to a diagnosis of depression and morbid obesity. Interventions included social services as needed for any concerns and psychiatric consultation as needed. A Resident Grievance Report dated 9/17/18 identified on 9/12/18 at 12:30 PM,…

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 3 residents (Resident #5) reviewed for abuse, the facility failed to investigate a potential incident involving mistreatment. The findings include: Resident #5 was admitted to the facility on [DATE] with diagnoses that included chronic systolic and diastolic heart failure, atrial fibrillation and major depressive disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #5 was cognitively intact, was independent with activities of daily living and required set up supervision only with personal care. The resident care plan dated 7/10/18 identified Resident #5's psychological well-being was at risk secondary to a diagnosis of depression and morbid obesity. Interventions included social services as needed for any concerns and psychiatric consultation as needed. A Resident Grievance Report dated 9/17/18 identified on 9/12/18 at 12:30 PM, Resident #5 reported he/she 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 observations, clinical record review, review of facility documentation, review of facility policy, and interviews for 1 of 1 sampled resident reviewed for edema (Resident #124), the facility failed to follow physician orders for obtaining bloodwork and/or and for 1 of 3 sampled residents reviewed for nutrition (Resident #141), the facility failed to obtain daily weights as per physician ordered. The findings include: 1. Resident #124 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, primary essential hypertension, and anxiety. An annual Minimum Data Set, dated [DATE] identified Resident #124 with moderately impaired cognition, independent with eating, totally dependent on staff for bed mobility, transfers, dressing, and personal hygiene. The resident care plan (RCP) dated 1/2/19 identified a problem with hypertension with interventions that included to observe for signs and symptoms of cardiac distress, chest pain, and any changes in heart rate. A Situation, Background,…

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, interviews and review of facility policy for 1 of 1 sampled resident reviewed for urinary catheter/urinary tract infections (Resident #118), the facility failed to provide appropriate care for a resident with a supra-pubic tube by ensuring the resident seen by the physician in accordance to the plan of care. The findings include: Resident #118's diagnoses included diabetes, quadriplegia, bipolar disorder and neurogenic bladder. The urology consultation report dated 3/26/18 directed that staff schedule Resident # 118 for a follow up visit on 3/30/18. However a review of the clinical record identified the resident was not seen on 3/30/18 but the appointment was re-scheduled for 4/13/18. However, a review of the clinical record failed to reflect the resident had been seen by urologist on 4/13/18. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #118 as having intact cognition and requiring extensive assistance of two for bed mobility. The 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, interviews and review of facility policy for 7 of 53 residents reviewed for physician visits (Resident #25, Resident #51, Resident #104, Resident #130, Resident #142, Resident #292, and Resident #293), the facility failed to ensure physician visits were timely. The findings include: 1. Resident #25 was admitted to the facility on [DATE]. Review of the clinical record on 1/8/19 lacked documentation of a physician visit during 2018. 2. Resident #51 was re-admitted to the facility on [DATE]. Review of the clinical record on 1/8/19 identified Resident #51 was last seen by physician (MD) #2 on May 31, 2018 and APRN #1 on 1/4/19. The clinical record lacked documentation of physician/APRN visits from 5/31/18 to 1/4/19. 3. Resident #104 was re-admitted to the facility on [DATE]. Review of the clinical record on 1/8/19 identified Resident #104 was last seen by MD #2 on 8/16/18 and APRN #1 on 1/7/19. The clinical record lacked documation for physician/APRN visits from 8/16/18 to 1/7/19. 4.…

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, interviews and review of facility documentation for 1 of 1 sampled resident reviewed for death (Resident #142), the facility failed to ensure a complete and/or accurate clinical record. The findings include: Resident #142 was admitted on [DATE] with diagnoses that included diabetes, major depressive disorder, suicidal ideation, cocaine abuse, traumatic brain injury, weakness, acquired absence of left leg below knee, and bipolar disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #142 had moderate cognitive impairment, required limited assistance for transfers, toilet use and personal hygiene and was independent in eating. The most recent signed physician order renewals dated [DATE] directed full code. The resident care plan dated [DATE] identified Resident #142's code status was full code. A nurses note dated [DATE] at 8:23 AM identified Resident #142 was found unresponsive at 6:50 AM, backboard placed in 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.