Apple Rehab Middletown

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, observation, facility policy and interviews for 2 of 4 sampled residents (Resident #17 and Resident #52) reviewed for self-medication administration, the facility failed to ensure a medication self-administration assessment were completed according to policy for a resident receiving medication assisted therapy. The findings include: 1. Resident #17's diagnoses included opioids use and psychoactive substance abuse. The Self Administration of Medications assessment dated [DATE] identified Resident #17 wished to self-administer medications, was alert, oriented, able to name medication, dose, side effects, was physically able to open medications as packaged and drink water independently. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #17 as cognitively intact and independent with activities of daily living (ADL). The Resident Care Plan (RCP) dated 9/27/24 identified Resident #17 was at risk for potential side effects related to psychiatric drug 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 observations, clinical record reviews , facility policy and staff interviews for 1 resident reviewed for hospitalization( Resident #6), the facility failed to ensure medication was available for the resident and for 3 of 3 residents reviewed for bathing( Residents #26, 27 and #52), the facility failed to ensure staff consistently provided evidence of the provision of showers, and for 1 resident ( Resident #215), reviewed for admission nursing assessment, the facility failed to ensure a body audit was completed on admission to ensure treatment orders were followed as prescribed by the physician and for 1 of 6 sampled residents (Resident #415) reviewed for medication administration, the facility failed to initiate a new treatment order per physician and for 1 of 2 residents ( Resident # 64) reviewed for intake and output, the facility failed to consistently monitor the resident's output according to the plan of care and facility policy .The findings included: 1. Resident #6's diagnosis included…

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

Based on observations, review of facility documentation, and staff interviews, the facility failed to maintain the dry food storage to ensure the area was free from insects and failed to follow recommendations their pest control program. The findings include: The facility pest control log identified a service report by an outside pest control company dated 6/22/24 indicating one fly light was installed in the kitchen storage area. The service report also indicated, under a sanitation/housekeeping section, that bananas needed to be covered. A Pest Control Service Report dated 7/26/2024 indicated fruit flies were noted by a food cart in the hallway and that recommendations were to remove the carts from the hallway. The service report further indicated treatment for fruit flies was applied to the kitchen and hallway. On 9/30/24 at 10:35 AM, a tour of the facility kitchen with the Director of Dietary #2 identified a large cardboard box in the corner of the dry storage room that contained many bananas with the majority of them ripe with black and brown spots and several bananas that were…

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 policy and staff interviews for 3 of 22 residents (Resident #20, 41, and #59) observed for call bell location within reach, the facility failed to ensure call bells were within reach of each resident. The findings included: 1. Resident #20's diagnosis included Parkinson's disease, dementia and cognitive communication deficit. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #20 as moderately cognitively Impaired. The Resident Care Plan (RCP) dated 7/23/2024 indicated Resident #20 could be impulsive Interventions included: to encourage the resident to call a staff member for assistance when needing to transfer, pick items off the floor and any other assistance. The care plan also indicated Resident #20 was at risk for falls with interventions including in part to encourage to the resident ask and wait for staff assistance for transfers and toileting. An observation and interview on 10/2/2024 at 2:50 PM identified Resident #20 sitting in a wheelchair…

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

Based on review of the Resident Council Minutes and staff interview, the facility failed to ensure written responses to residents' concerns voiced about call bells within reach and or staff response time to call bells during Resident Council meetings were addressed timely by administration. The findings include. A review of the Resident Council Minutes from January 2024 through August 2024 identified residents expressed concerns regarding call bells being within reach and /or answered. Further review of the Resident Council Minutes identified the facility did not address the resident's call bell concerns until September 2024 minutes. An interview and interview with the Recreation Director on 10/07/24 at 11:04 identifed a form exists for Resident Council Concerns that are written and passed onto the appropriate person responsible for overseeing the concern. However the Resident Council forms had not been consistently used. The Recreation Director was able to provide 2 completed forms but was unable to provide forms for the other concerns voiced at Resident Council or any written…

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 policy and staff interview for the 1 resident (Resident #10) reviewed for Advanced Directives, the facility failed to ensure the resident's advanced directives were obtained timely and reviewed each care plan meeting. The findings include. Resident #10's diagnosis included severe dementia, hypertension, and hyperlipidemia. The admission Minimum Data Set, (MDS) assessment dated [DATE] indicated Resident #10 was moderately cognitively impaired. The Care plan dated [DATE] indicated Resident #10 had a progressive decline in intellectual functioning due to the dementia process. Interventions included: to gently redirect when exhibiting inappropriate action/behaviors, and to give one instruction at a time. However, further review identified no care plan was in place regarding advanced directives. An observation of the clinical record on [DATE] 8:38 AM (159 days after admission) identified a blank advanced directive forms in the clinical record with no indication 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, observation and staff interviews for 1 of 6 sampled residents (Resident #415) reviewed for medication administration, the facility failed to notify the physician when the medication was not available for administration. The findings include: Resident #415 was admitted with diagnoses that included sepsis, dysphagia and generalized anxiety disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #415 without cognitive impairment, was independent for personal hygiene, bed mobility and transfers. The Resident Care Plan dated 9/17/24 identified Resident #415 needed staff assistance with activities of daily living as needed. Interventions included providing setting up for Resident #415 at bedside or in bathroom and allowing the resident to do for him/herself what he/she and assisting when the resident cannot perform task. The physician's orders dated 9/17/24 directed to apply Kerasal Nail Renewal External Liquid to all toenails topically two times 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 review, review of facility documentation, review of facility policy and staff interviews for 1 sampled resident( Resident # 64) reviewed for abuse, the facility failed to ensure the resident was free from physical abuse by Resident #36. The findings include: 1. Resident # 64's diagnoses included mild dementia without behavior disturbances, anxiety, mood disturbances, hypertension, thrombophilia, legally blind and paroxysmal atrial fibrillation. The MDS assessment dated [DATE] identified the resident was moderately cognitively impaired and had a history of rejection of care. The RCP for psychiatric drug use and potential for adverse side effects of psychotropic drug dated 6/6/24. Interventions included: to have Medical Doctor ( MD) evaluate effectiveness and side effects of medications for possible decrease/elimination of psychotropic drugs and conduct vital signs per facility policy. The care card for June 2024 and August 2024 identified the resident required total care with bathing. 2.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy, and interviews for 1 resident (Resident #166) reviewed for Specialized Treatment, the facility failed to ensure a care plan was in place. The findings included: 1. Resident #166 was admitted to the facility on [DATE] with diagnoses that included severe end stage renal disease with specialized treatment, diabetes mellitus, and polyneuropathy. A physician's order dated 4/11/23 directed a renal diet with a 2000 ml fluid restriction per day. The Specialized Treatment Center was on Monday, Wednesday, and Friday. The physician's orders dated 4/11/23 to 4/22/23 did not reflect where the resident's fistula was located or the monitoring of the fistula for a bruit and thrill every shift. The admission MDS assessment dated [DATE] identified Resident #166 had intact impaired cognition, was occasionally incontinent of bowel and bladder and required extensive assistance personal hygiene, dressing, and transfers. Resident #166 required set up and clean…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy and interviews for 1 of 6 residents (Resident #165) reviewed for care planning, the facility failed to revise the resident's care plan and care card related to resident's showers. The findings include: Resident #165 was admitted to the facility on [DATE] with diagnoses that included dementia, Covid-19, and weakness. A physician's order dated 10/21/22 directed to perform a body audit on admission and weekly on shower day by a nurse. The progress notes dated 10/21/22 through 11/4/22 did not reflect Resident #165 had refused a shower or that Resident #165 was provided a shower versus a bed bath weekly. The admission MDS assessment dated [DATE] identified Resident #165 had severely impaired cognition, was occasionally incontinent of bowel and bladder and required extensive assistance personal hygiene, toileting, and transfers. Additionally, Resident #165 indicated that it was very important to choose a shower, tub bath, bed bath, or sponge bath and needed…

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 policy and staff interviews for 1 of 4 residents reviewed for accidents (Resident #52) the facility failed to provide the necessary supervision and to educate staff regarding interventions for 1:1 monitoring in common area to ensure a safe environment. The findings include: Resident #52's diagnoses included opioid dependence, depression, and generalized anxiety disorder. A physician's order dated 11/16/23 identified Resident #52 was on a Methadone Maintenance Program for substance abuse disorder. The admission Minimum Data Set assessment dated [DATE] identified Resident #52 was cognitively intact and required maximum assistance with eating, oral hygiene, and was dependent for personal hygiene. A nurse's note dated 1/14/24 at 12:57 PM identified Resident #52's evening medications were not administered as resident was lethargic. Resident admitted to RN supervisor that s/he snorted heroin in her/his room on Friday night and Saturday night. The resident also stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy and interviews for 1 of 2 residents reviewed for nutrition (Resident # 57), the facility failed to ensure monthly weights were completed in the clinical record. The findings include: Resident #57's diagnoses included Type 2 diabetes mellitus and hypertension. The Resident Care plan dated 7/24/24 indicated Resident #57 has the potential for a nutritional decline related to recent hospitalization. Intervention include weigh as ordered. The Minimum Data Set assessment dated [DATE] noted resident is cognitively intact and is independent with eating but requires set up for oral hygiene. A physician's order dated 1/15/24 directed weigh weekly for 4 weeks every evening shift for 30 days. No follow up orders noted. Review of Residents #57 Weights identified missing weights for the months of January, February, May, June and August 2024. Interview with RN #5 on 10/07/24 10:42 AM indicated weights should be done monthly after admission period (weekly for 4 weeks) and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record reviews, facility policy and interviews for the 2 of 2 sampled resident (Residents # 40 and # 366) reviewed for Respiratory Care and utilized oxygen, the facility failed to administer oxygen per physician's order and label the oxygen tubing per facility practice The findings included: 1. Resident #40's diagnoses included diabetes mellitus, hypertension, and muscle weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #40 was severely cognitively impaired, was dependent on staff for personal hygiene and toileting and required maximum assistance for bed mobility. Additionally noted no utilization of oxygen therapy. The Resident Care Plan dated 10/1/24 identified Resident #40 was at risk of cardiac issues related to cardiovascular disease. Interventions included: checking oxygen saturation as ordered and per policy, monitoring for signs and symptoms of respiratory distress, and encouraging rest periods as needed. Observations on 10/1/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review and staff interviews for 1 resident (Resident # 215) who had a food allergy to eggs, the facility failed to ensure a food item listed as an allergy was not served to the resident. The findings include: Resident #215 was admitted on [DATE] with diagnoses which included cellulitis of the lower limb, dysphagia and anxiety. The admission Nursing assessment V6 dated 9/29/2024 at 9:59 PM indicated in part Resident #215 had an allergy to eggs. The diet slip dated 9/29/2024 completed by the admitting RN indicated Resident #215 had eggs as a pertinent food allergy. The care plan dated 9/30/2024 indicated Resident was planning for discharge after short term rehabilitation. Interventions included: to facilitate a discharge plan with the resident/family when appropriate. An interview with Resident #215 on 9/30/24 at 1:08 PM identified she/he received French toast which is made with eggs at breakfast and after telling the server s/he was not able to eat eggs plain toast was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical records, facility policy and interviews for 2 of 2 residents (Resident #165 and #166) reviewed for discharge, the facility failed to ensure the facility communicated important medical information to the resident and continuing care provider at time of anticipated discharge. The findings include: 1. Resident #165 was admitted to the facility on [DATE] with diagnoses that included dementia, Covid-19, and weakness. The care plan dated 10/22/22 identified discharge planning Interventions included to establish a discharge plan with resident and resident representative. Resident #165 was alert but confused. The Social Service Initial assessment dated [DATE] at 9:01 AM identified Resident #165 resides with the resident's representative and had home care services in the past. The discharge plan was to return home. The admission MDS assessment dated [DATE] identified Resident #165 as severely cognitively impaired, noted occasionally incontinent of bowel and bladder and the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, review of facility policy and interviews for 2 of 2 residents (Resident #165 and 166) reviewed for physician orders, the facility failed to ensure the weekly body audits and Braden scales were completed per the physician orders for a resident at risk for skin breakdown. The findings include: 1. Resident #165 was admitted to the facility on [DATE] with diagnoses that included dementia, Covid-19, and weakness. The baseline care plan dated 10/21/22 did not identify Resident #165 was at risk for pressure ulcers and identified the resident was continent of bowel and bladder. The care plan did not identify any intervention to prevent pressure ulcers. A physician's order dated 10/21/22 directed to Braden scale on admission and weekly times 4 weeks. Braden scale dated 10/21/22 identified Resident #165 was at risk for pressure ulcers due to limited ability to respond to pressure related discomfort, being occasionally moist, only walks occasionally, and probably inadequate nutrition.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, and interviews for 1 of 2 resident (Resident #166) reviewed for specialized treatment, the facility failed to ensure the resident's fluid restriction was maintained and failed to ensure monitoring of the fistula. The findings include: Resident #166 was admitted to the facility on [DATE] with diagnoses that included severe end stage renal disease with specialized treatment, diabetes mellitus, and polyneuropathy. a. The baseline care plan not dated identified Resident #166 was on renal diet with a 2000 ml fluid restriction but did not identify resident was a specialized treatment resident. A physician's order dated 4/11/23 directed a renal diet with a 2000 ml fluid restriction per day. The Specialized Treatment Center was on Monday, Wednesday, and Friday. Review of progress notes dated 4/11/23 through 4/21/24 did not reflect if resident was above or below the fluid restriction in any 24-hour period. The intake and output recording dated 4/11/23 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 review of the clinical record, facility policy, and interviews for 2 of 2 residents (Resident #165 and #166) reviewed for physician's orders, the facility failed to ensure the admission, interim, and discharge order were signed by the physician. The findings include: 1. Resident #165 was admitted to the facility on [DATE] with diagnoses that included dementia, Covid-19, and weakness. The admission physician's orders dated 10/21/22 were not signed and dated by MD #1 or APRN. The care plan dated 10/22/22 identified discharge planning. Interventions included to establish a discharge plan with resident and resident representative. A physician's order dated 10/24/22 directed to give oxygen 2 liters per minute via mask as needed to maintain saturation level greater than 90% not signed by the APRN/MD. The admission MDS assessment dated [DATE] identified Resident #165 as severely impaired cognitively, occasionally incontinent of bowel and bladder and noted the resident required extensive assistance 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 facility documentation and facility policy reviewed for Resident Rights regarding respect and dignity, the facility failed to ensure residents were not exposed to a verbal and physical altercation between three (3) staff members that involved two (2) charge nurses and one (1) nurse aide. The findings include: Review of the facility policy titled [NAME] of Rights/Residents, directs residents shall be treated according to the guidelines in the resident [NAME] of Rights at all times and employees not following the [NAME] of Rights shall be disciplined. Review of the facility policy title Workplace Violence, directed, in part, violent behavior of any kind or threats of violence either implied or direct, are prohibited at this facility, and the facility maintains a zero-tolerance standard of violence in the workplace. The policy directed, in part, violence in the workplace may include, but is not limited to the following list of prohibited behaviors directed at or by a co-worker, supervisor, vendor, or…

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 abuse, the facility failed ensure staff acted on an allegation of mistreatment timely and failed to notify the State Agency of an allegation of abuse in a timely manner. The findings include: Resident #2's diagnoses included atrial fibrillation, chronic kidney disease, diabetes mellitus, and morbid obesity. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was alert and oriented and required extensive assistance with the assistance of two person for ADL's. The Resident Care Plan (RCP) dated 7/14/2023 identified Resident #2 required assistance with ADLs. Interventions directed to assist with care as indicated. Resident #3 had diagnoses that included dementia with psychotic disturbances and schizophrenia. The admission MDS assessment dated [DATE] identified Resident #3 had moderate cognitive impairment, had dementia 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 clinical record review, facility documentation review, facility policy review, and interviews for one resident (Resident #1) reviewed for quality of care, the facility failed to ensure staff completed neurological assessments timely for a resident after an unwitnessed fall per facility policy. The findings include: Resident #1's diagnoses included vascular dementia, osteoporosis, major depressive disorder, and anxiety disorder. The quarterly Minimum Data Set (MDS) form dated 3/10/2023 identified that Resident #1 had severe cognitive impairment and required extensive assistance of one person for bed mobility, transfers, and locomotion. The Resident Care Plan (RCP) dated 4/1/2023 identified Resident #1 was at risk for falls due to multiple risk factors (non-compliance with use of mobility aide). Interventions directed to encourage Resident #1 to stay in the common area/dining room for afternoon activities, encourage to transfer/change positions slowly, offer to change during last rounds of 11 PM-7 AM shift, ensure the height of bed at an appropriate height for self-transfers,…

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

Based on clinical record review, facility documentation review, and interviews for one resident (Resident #1) reviewed for quality of care, the facility failed to ensure a comprehensive investigation was completed after unwitnessed resident falls and the facility failed to ensure the care plan was updated timely after resident falls. The findings include: Resident #1's diagnoses included vascular dementia, osteoporosis, major depressive disorder, and anxiety disorder. The quarterly Minimum Data Set (MDS) form dated 3/10/2023 identified that Resident #1 had severe cognitive impairment and required extensive assistance of one person for bed mobility, transfers, and locomotion. The Resident Care Plan (RCP) dated 4/1/2023 identified Resident #1 was at risk for falls due to multiple risk factors (non-compliance with use of mobility aide). Interventions directed to encourage Resident #1 to stay in the common area/dining room for afternoon activities, encourage to transfer/change positions slowly, offer to change during last rounds of 11 PM-7 AM shift, ensure the height of bed at an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation and interviews for one of three sampled residents (Resident #1) who was reviewed for inappropriate sexual conduct, the facility failed to consistently document on resident locator (one to one observation or every fifteen (15) minute) monitoring flowsheet form Resident #1's location while on every fifteen (15) minute monitoring. The findings include: Resident #1's diagnoses included alcohol induced persisting dementia. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, required supervision when walking in the corridor and on the unit, and was independent with walking in the room. The Resident Care Plan dated 7/7/23 identified Resident #1 had problem characterized by inappropriate behavior, Resident #1 had been noted to be inappropriate related to his/her sexual behavior towards staff. Interventions directed to document and report all instances of being inappropriate and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for one of three sampled residents (Resident #2) who was not able to make decisions for himself/herself, the facility failed to ensure the resident was free from inappropriate sexual conduct by another resident. The findings include: 1. Resident #1's diagnoses included alcohol induced persisting dementia. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life, required supervision when walking in the corridor and on the unit, and was independent with walking in the room. The Resident Care Plan dated 7/7/23 identified Resident #1 had problem characterized by inappropriate behavior, Resident #1 had been noted to be inappropriate related to his/her sexual behavior towards staff. Interventions directed to document and report all instances of being inappropriate and psychiatric evaluation. The psychiatric progress note dated 7/8/23 identified…

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

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 two residents (Resident #6) reviewed for advance directives, the facility failed to ensure that the resident's advance directive choices were reflected accurately in the resident record. The findings included: Resident #6 was admitted during 11/2020 with diagnoses that included bipolar depression and tardive dyskinesia. Clinical record review identified a Medical Intervention Consent Form dated [DATE] signed by Resident #6 that directed advanced directives were Do Not Resuscitate (DNR). A quarterly Minimum Data Set (MDS) completed [DATE] identified Resident #6 was alert and oriented, and required extensive assist with personal hygiene. Review of physician's orders dated [DATE] failed to identify advanced directives for Resident #6. Review of the Medication Administration Record (MAR) for [DATE] and [DATE] identified Resident #6 had advanced directives listed as CPR (full code). The Resident 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 clinical record review, observations, facility documentation review, facility policy review, and interviews for one resident, (Resident #38) reviewed for hemodialysis, the facility failed to ensure physician ' s order were obtained timely for hemodialysis and to direct staff to avoid blood pressures in the arm with the dialysis site, and failed to ensure staff monitored the dialysis right arm arteriovenous fistula (AVF) dialysis site for any adverse signs and symptoms and bruit and thrill per the facility policy. The findings include: Resident #38's diagnoses included End Stage Renal Disease (ESRD) dependent on hemodialysis, dementia. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #38 was alert and oriented. The Resident Care Plan (RCP) dated 11/4/2021 identified Resident #38 had chronic kidney disease, was dependent on hemodialysis with a left arm arteriovenous fistula (dialysis access). Interventions directed to observe the dialysis site as ordered. Observations 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, observations, facility documentation review, facility policy review, and interviews for the one sampled resident, (Resident #27) reviewed for choices, the facility failed to ensure a recliner chair was positioned per the resident's wishes. The findings include: Resident #27's diagnosis included dementia, anxiety, glaucoma. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #27 had had moderate cognitive impairment, and required physical assistance with bathing. Interview with Person #4 (Resident #27's responsible party) on 5/4/2022 at 10:56 AM identified Resident #27 wanted his/her recliner chair placed off the wall so that he/she could see into the hallway. Person #4 indicated that he/she put signs up to remind the staff, but that the signs are removed, and the note was not observed today, 5/4/2022. Review of the Resident Care Plan (RCP) dated 3/15/2022 and Nurse Aid (NA) care card failed to identify that Resident #27 preferred recliner placement.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, facility policy review, and interviews for one sampled Resident (Resident #25) reviewed for catheterization, the facility failed to ensure the physician was notified of a change in condition timely. The findings include: Resident #25's diagnosis included hemiplegia and hemiparesis following a cerebrovascular disease, and neurogenic bladder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #25 had moderate cognitive impairment, required extensive assistance of one staff for toileting and had and indwelling catheter. The Resident Care Plan (RCP) dated 3/15/2022 identified Resident #25 required an indwelling catheter. Interventions directed to observe the urine for sediment, cloudy/bloody scant or foul-smelling urine and report to the physician. Observations on 5/3 at 11:10 AM, 5/4 at 9:26 AM, and 5/5/2022 at 9:23 AM identified Resident #25 had purple urine in the urinary collection tube and urinary collection bag. Review of the MD/APRN…

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

Based on observations, facility documentation review, facility policy review, and interviews for environment review, the facility failed to ensure fans were maintained in a clean condition without debris. The findings include: Observation on 5/3 at 11:10 AM, 5/4 at 9:26 AM, and 5/5/22 at 10:02 AM identified the bathroom ventilation fan grate in Resident #25's bathroom with a coating of a gray lint-like debris/substance clinging to the grate that was located above the toilet. Observation on 5/4 at 1:42 PM and 5/5/2022 at 10:10 AM identified the bathroom ventilation fan grate in Resident #27's bathroom, with a coating of a gray lint-like debris/substance clinging to the grate that was located above the toilet. Observations on 5/3 at 10:32 AM, 5/4 at 9:34 AM, and 5/5/22 at 12:26 PM, identified the bathroom ventilation fan grate in Resident #38's bathroom, with a coating of a gray lint-like debris/substance clinging to the grate that was located above the toilet. Additionally, observations on the same days for Resident #38 identified an oscillating fan that was mounted on 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 clinical record review, observations, facility policy review, and interviews for one sampled Resident (Resident #27) reviewed for a hearing deficit, the facility failed to ensure the care plan reflected the resident's hearing deficit and failed to ensure the NA care card reflected the need for hearing aids, and for one sampled resident (Resident #42), reviewed for behaviors, the facility failed to ensure that a comprehensive care plan was developed to address the resident's history of aggressive and accusatory behaviors. The findings included: 1. Resident #27's diagnosis included dementia, anxiety, glaucoma. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #27 had had moderate cognitive impairment and required a hearing aid. The Resident Care Plan (RCP) dated 3/15/22 failed to identify that Resident #27 had a hearing deficit or required hearing aids. Interview with Person #4 (Resident #27's responsible party) on 5/4/2022 at 10:56 AM identified that Resident #27's hearing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, facility policy review, and interviews for three of four residents (Resident #11, #25 and #27) reviewed for Activities of Daily Living (ADL's), the facility failed to ensure a dependent resident received appropriate assistance with grooming and hygiene timely. The findings include: 1. Resident # 11's diagnoses included anxiety, depression and dementia. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #11 had moderate cognitive impairment and required extensive assistance with personal hygiene. The Resident Care Plan (RCP) dated 2/24/22 identified Resident #11 required assistance with all my ADL's, with interventions that directed to provide assistance with care as needed. Observations on 5/3 at 10:51 AM, 5/4 at 9:30 AM, and 5/5/2022 at 12:45 PM identified Resident #11 was unshaven. Review of the nurse's notes from 4/26 through 5/5/2022 failed to indicated that Resident #11 had refused shaving. Observation and interview on 5/5/2022 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, facility policy review, and interviews for two of three residents (Resident #11, Resident #27) reviewed for a sensory deficit, the facility failed to ensure dependent residents had access to eye glasses and hearing aids timely. The findings include: Resident # 11's diagnoses included anxiety, depression, macular degeneration and dementia. Review of the eye examination information dated 10/21/2021 and 2/23/2022 identified Resident #11 required glasses and should be encouraged to wear the glasses for full time use for distance and reading. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #11 had moderate cognitive impairment, required extensive assistance with personal hygiene and required corrective lenses. The Resident Care Plan (RCP) dated 2/24/2022 identified Resident #11 had impaired vision. Interventions directed to encourage the use of glasses for distance and reading, to assist with putting on glasses, and to keep glasses within my…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for two of three residents (Resident #41 and #44) reviewed for the nutrition, the facility failed to obtain weekly weights per the dietitian recommendations and the physician's orders. The findings include: 1. Resident #41's diagnosis included Alzheimer's dementia and chronic kidney disease. A Nutritional assessment dated [DATE] identified a weight of 119.8 taken on 1/26/2022, indicative of a decrease of 9% over thirty days and a decrease of 8% over 180 days. Recent decline in weight was related to decreased intake and appetite with noted nausea and COVID-19 positive diagnosis. The nursing staff was updated of the recommendation to monitor Resident #41's weekly weights and nutritional status at weekly nutrition risk meeting. A physician's order dated 1/26/2022 directed to obtain weekly weights every week for four weeks until 2/23/2022. A. The quarterly Minimum Data Set (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.

Based on facility documentation review, and interviews for five of five employee file review (NA #2, 3, 4, 5 and 6) reviewed for abuse, the facility failed to ensure annual employee evaluations were conducted timely. The findings include: Review of NA #2, 3, 4, 5 and 6 employee files identified all NAs were employed longer than 12 months. Review of NA #2 employee file identified the most recent performance evaluation completed was dated 2/19/2020. Review of NA #3, 4, 5, and 6 employee files failed to identify an annual performance evaluation was included in the files. Interview and facility documentation review with the Administrator on 5/10/2022 at 1:40 PM identified although employee evaluations should be completed annually, she was unable to provide documentation that performance evaluations were completed timely for NA #2, 3, 4, 5 and 6. The Administrator further indicated that she did not know why they were not completed. Review of facility undated Performance and Review Policy directed in part, a performance review will be completed at the end of an employee's introductory…

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 five residents, (Resident #38) reviewed for pharmacy review, the facility failed to ensure staff acted upon a Pharmacy Consultant recommendation timely. The findings include: Resident #38's diagnoses included End Stage Renal Disease (ESRD) dependent on hemodialysis, dementia. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #38 was alert and oriented. The Resident Care Plan (RCP) dated 11/4/2021 identified Resident #38 had chronic kidney disease, was dependent on hemodialysis with a left arm arteriovenous fistula (dialysis access). Interventions directed to observe the dialysis site as ordered. Interview with RN #2 on 5/5/22 at 10:26 AM identified that Resident #38 received Cymbalta 40 milligrams (mg) prior to leaving for dialysis three times a week. Interview on 5/5/22 at 11:14 AM with Person #1 who worked at the hemodialysis administration facility identified that…

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

Based on observations, clinical record review, facility policy review, and interviews for facility Medication Storage review, the facility failed to ensure insulin vials and pens in the medication carts were labeled and dated timely. The findings include: 1. Interview and observation with LPN #2 on 5/10/2022 at 9:38 AM identified an Aspart insulin flex pen 100 units in the medication cart labeled by the pharmacy for Resident # 15, was open (had been used) and was not dated to identify when staff opened the insulin pen. LPN #2 indicated he/she could not tell how much insulin was left in the pen. LPN #2 further indicated the insulin pen should have been dated when opened and was good for 20 days from the date when opened. 2. Interview and observation with LPN #2 on 5/10/2022 at 9:40 AM identified two insulin vials inside a specimen cup with a green lid, without pharmacy labels or resident names. LPN #2 indicated the vials were for Resident #24, and the specimen cup was labeled with Resident #24's last name and the number 9. One vial, Humalog U-100 3 ml vial, was approximately ¼ full,…

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

Based on clinical record review, facility documentation review, and interviews the facility failed to utilize resources effectively to ensure resident needs were met timely. The findings include: Review of pharmacy recommendations and Dietitian recommendations from 11/1/2021 through 5/9/2022 failed to consistently identify recommendations from consulting staff were addressed timely. Interview with the DNS on 5/10/2022 at 11:08 AM identified that she was new to the position as of November 2021 and that the facility has been staffing challenged. The DNS indicated that from 5/3 through 5/9/2022 she had worked as a charge nurse on Tuesday (5/3) on the 3:00 to 11:00 PM shift; Sunday (5/8), on the 7:00 AM to 7:00 PM shift; and on Tuesday (5/9/2022) she had worked from 3:00 PM to 11:50 PM (a total of 29 hours over 5 days). The DNS indicated that prior to 5/3/2022, in addition to working 40 hours as the DNS, she had been working an average of two to three shifts per week. The DNS stated that open nursing managerial staff positions included Staff Development Nurse (SD), Infection 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 clinical record review, facility documentation review, facility policy review, and interviews for three residents (Resident #6, #25, #27 and #31) reviewed for care and services, the facility failed to ensure the clinical record was complete and accurate, to include nurse's notes of an allegation of mistreatment timely, to include accurate information on the medication/treatment record, and refusals of dental care. The findings include: 1. Resident #6 was admitted during 11/2020 with diagnoses of falls, weakness, bipolar depression, anxiety, & tardive dyskinesia. A quarterly Minimum Data Set (MDS) completed 1/29/2022 identified that Resident #6 was alert and oriented, and required extensive assist with transfers and personal hygiene including brushing teeth. Clinical record review identified Resident #6 became Title 19 (Medicaid) status effective 3/1/2021. Review of the clinical record identified that Resident #6 was seen by a dentist on 2/28/2022. The dentist identified Resident #6 had very poor…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the clinical record, staff interviews, observations, and a review of the facility policy for one of three sampled Residents (Resident #47), reviewed for respiratory care, the facility failed to obtain a physician's order for the administration of oxygen. The findings included: Review of the clinical record identified Resident #47 was admitted to the facility on [DATE] with diagnosis that included cerebral vascular disease, rhabdomyolysis, heart failure, pneumonia and non Alzheimer dementia. Review of the nurses notes dated 4/28/19 identified Resident #47 was short of breath, had audible wheezing with a pulse oximeter reading of 84% (Normal 90-100 %). A respiratory treatment was administered and oxygen was applied at 2 liters/minute via nasal cannula. The minimum data set (MDS) assessment dated [DATE] identified intact cognition, extensive assistance with bed mobility, transfers, dressing, toilet use, locomotion off the unit, shortness of breath with exertion and at rest and oxygen therapy.…

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

Based on observations, staff interview and a review of the facility policy reviewed for dining, the facility failed to ensure staff served and/or distributed food in a sanitary manner . The findings include: a. Interview and observations of tray line on 8/12/19 at 12:11 PM with the Food Service Manager, identified Dietary Aid #1 pulled up his pants with both hands, then he took a plate with food from the cook without washing his hands, and served the plate that contained the food to a resident. Additionally, Dietary Aid #1 was observed rubbing his nose with his hand, took a plate of food from the cook without washing his hands, and served the plate that contained the food to a resident. Interview with the Food Service Manager on 8/12/19 at 12:15 PM identified she witnessed Dietary Aid #1 pick up his pants and the take a plate from the cook without washing his hands and serve it to a resident. She also indicated Dietary Aid #1 rubbed his nose and took a plate of food from the cook without washing his hands and then served the plate of food to the resident. The Food Service Manager…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a clinical record review, a review of facility documentation, staff interviews and a review of the facility policy for one sampled resident (Resident #32) reviewed for pressure ulcers, the facility failed to implement measures to prevent the development of a pressure ulcer and/or failed to conduct an initial comprehensive wound assessment and/or failed to conduct weekly wound assessments. The findings include: Resident #32 was admitted to the facility on [DATE] with diagnoses that included a urinary tract infection, atrial fibrillation and weakness. The admission Minimum Data Set (MDS) assessment dated [DATE] identified moderate cognitive impairment, extensive assistance of 2 staff for bed mobility, transfers, toilet use, and ambulation in the room. Extensive assistance of 1 staff was required for dressing, grooming, ambulation in the corridor and locomotion on and off the unit. The resident was at risk for the development of pressure ulcers, the use of pressure reducing devices for the bed and chair…

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 1of 5 residents (Resident #15) reviewed for unnecessary medications, the facility failed to follow the pharmacy recommendations for a dose reduction of a Proton-Pump Inhibitor. The findings include: Resident #15 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, dementia, reflux disease, and dyspepsia. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #15 independence with eating, and a therapeutic diet without swallowing difficulties. The care plan dated 6/2/19 identified a nutritional risk related to diabetes, dementia, obesity with interventions that included to check laboratory values as ordered, encourage compliance with the resident's diet, monitor intake, evaluate and make diet change recommendations as needed, administer medications as ordered, set up meals and provide assistance, watch for chewing, swallowing and/or a decline in intake 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.