Mary Wade Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Surveyor: Green, [NAME] Based on facility policy and interviews for 8 residents (Resident #7, Resident #13, Resident #24, Resident #39, Resident #62, Resident #72, Resident #73, and Resident #76) reviewed for Resident Council, the facility failed to provide a selective menu for residents to make selections for meals. 1. Interview with Resident #72 on 2/11/2025 at 11:25 AM identified he/she did not receive a selective menu and would like to be able to choose what he/she is served at mealtime. Resident #72 indicated food was often overcooked and meats tough. Interview with Resident #76 on 2/11/2025 at 2:00 PM identified Resident #76 did not know what he/she would be served at mealtimes until the tray arrived. Resident #76 indicated he/she was not provided a selective menu and indicated he/she would like a menu to choose from because he/she was served the same foods repeatedly. During the Resident Council meeting on 2/13/2025 at 1:30 PM Resident #7, Resident #13, Resident #24, Resident #39, Resident #62, 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, review of the clinical record, facility policy and interviews for 4 of 4 residents (Resident #13, Resident #21, Resident #35, and Resident #57) reviewed for oxygen therapy, the facility failed to label, date and store oxygen tubing per facility policy. The findings include: 1. Resident #13 was admitted to the facility in July of 2022 and had diagnoses that included chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, and congestive heart failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 15), received oxygen therapy, was independent with eating, and required partial/moderate assistance with bed mobility and transfers. The Resident Care Plan (RCP) dated 2/5/2025 identified Resident #13 was at risk for altered cardiopulmonary status. Interventions included changing oxygen tubing weekly and monitor oxygen concentrator every shift. Observation on 2/13/2025 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, interviews, review of the clinical record, facility documentation, and facility policy for 1 of 3 residents (Resident #46) reviewed for urinary catheters, the facility failed to maintain dignity for a resident with a urinary catheter drainage bag. The findings include: Resident #46 was admitted to the facility in October of 2023 with diagnoses that included osteoarthritis of bilateral knees, neuromuscular dysfunction of bladder, generalized muscle weakness and cognitive communication deficit. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #46 had moderate cognitive impairment (Brief Interview for Mental Status (BIMS) score of 12), and was dependent on toileting hygiene, personal hygiene, bed mobility and transfers. The MDS identified that Resident #46 had an indwelling catheter, and was always incontinent of bowel. The Resident Care Plan dated 1/1/24 identified Resident #46 had an indwelling catheter due to obstructive uropathy (a urinary tract disorder…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #20) reviewed for abuse, the facility failed to keep Resident #20 free from physical restraint. The findings include: Resident #20 was admitted to the facility in June of 2022, with diagnoses that included Alzheimer ' s disease, dementia with other behavioral disturbance and anxiety disorder. The quarterly Minimum Data Set assessment dated [DATE], identified Resident #20 was cognitively impaired (Brief Interview for Mental Status (BIMS) score of 3), was dependent for bed mobility, transfer and toileting, was non-ambulatory, and was independent with eating. A Resident Care Plan dated 10/12/2024 (start date of 7/12/23) identified increased combative behaviors and anxiety with medications and an intervention to start Trazadone 30 minutes prior to morning and evening care twice daily. The Accident and Incident report dated 10/31/2024, identified NA #10 alleged that LPN #9 hit…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record and facility policy for 1 of 3 residents (Resident #80) reviewed for elopement the facility failed to develop a comprehensive Resident Care Plan (RCP) for a resident at risk for elopement. The findings include: Resident #80 was admitted to the facility in May of 2024 and had diagnoses that included dementia, hypertension and depression. The Elopement Risk assessment dated [DATE] identified Resident #80 was at risk for elopement and precautions must be initiated. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #80 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 3), had fluctuating behaviors of inattention, fluctuating behaviors of disorganized thinking, was independent with eating, transfers and ambulating at least 150 feet without an assistive device. The RCP dated 9/18/2024 identified Resident #80 was alert and oriented to self with confusion and forgetfulness and walked around the unit. Interventions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility policy and interviews for 2 of 4 residents (Resident #21 and Resident #57) reviewed for oxygen therapy the facility failed to revise the Resident Care Plan (RCP) for residents on oxygen therapy per facility policy. The findings include: 1. Resident #21 was admitted to the facility in August of 2024 and had diagnoses that included Alzheimer's disease, chronic obstructive pulmonary disease (COPD), and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #21 was severely cognitively impaired, required substantial/maximal assistance for eating and bed mobility, and dependent for transfers. The Resident Care Plan (RCP) dated 1/8/2025 identified Resident #21 was at risk for altered cardiopulmonary status. Interventions included assessing lung sounds per provider orders and consult with respiratory therapist as needed. The RCP failed to identify interventions for administration of continuous/intermittent oxygen with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility policy and interviews for 1 of 4 residents (Resident #62) reviewed for dining the facility failed to provide supervision for a resident who required supervised feeding. The findings include: Resident #62 was admitted to the facility in November of 2020 and had diagnoses that included dementia, respiratory failure with hypoxia, and dysphagia. A Physician ' s Order dated 7/25/2024 directed an assist of 2 staff members for activities of daily living and assist of 1 staff member for supervision for feeding. A Physician Order dated 12/12/2024 directed for a dysphagia evaluation with treatment 3 times a week for 4 weeks. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] identified Resident #62 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 15), was on a mechanically altered diet, started speech therapy on 12/12/2024, required setup or clean-up assistance with eating, and was dependent for bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, review of the clinical record, facility documentation, and facility policy for 1 of 3 residents (Resident #46) reviewed for pressure ulcers, the facility failed to follow the plan of care for a resident with a pressure ulcer. The findings include: Resident #46 was admitted to the facility in October of 2023 with diagnoses that included abnormal weight gain, osteoarthritis of bilateral knees, neuromuscular dysfunction of bladder, generalized muscle weakness and cognitive communication deficit. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #46 had moderate cognitive impairment (Brief Interview for Mental Status (BIMS) score of 12), and was dependent on toileting hygiene, personal hygiene, bed mobility and transfers. The MDS identified that Resident #46 had an indwelling catheter, was always incontinent of bowel, was at risk of developing pressure ulcers and had a pressure reducing device for bed. The Resident Care Plan (RCP) dated 12/18/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy, and interviews for 2 of 3 residents (Resident #14 and Resident #80) reviewed for elopement, the facility failed to provide adequate supervision to prevent elopement. The findings include: 1. Resident #14 was admitted to the facility in September of 2024 with diagnoses that included alcohol and opiate use disorder, cognitive impairment, major depressive disorder and diabetes. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 15), was independent with eating, required partial/moderate assistance with transfers and ambulated with a walker. An Elopement risk assessment performed on 11/4/24 identified Resident #14 as at risk for elopement. A Physician ' s order dated 12/23/25 by Physician Assistant (PA#1), directed to apply a wander guard (a wearable monitoring device to ensure resident safety and prevention of exiting the facility) to left ankle and check…

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

Based on review of facility documentation, facility policy and interviews for 3 of 5 employee files, the facility failed to ensure that the required Communication training/in-service was completed. The findings include: 1. NA #1's date of hire was 12/11/24. Review of the facility documentation for NA #1 identified that she had worked in the facility between 1/28/25 and 2/13/25. Review of the employee file for NA #1 failed to identify that required Communication training/in-service had been provided and included in the files from the date of hire until present. Although requested, the facility could not provide documentation that the required Communication training had been completed for NA #1. 2. NA #2's date of hire was 12/23/24. Review of the facility documentation for NA #2 identified that she had worked in the facility between 1/28/25 and 2/13/25. Review of the employee file for NA #2 failed to identify that the required Communication training/in-service had been provided and included in the files from the date of hire until present. Although requested, the facility could not…

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

Based on review of facility documentation, facility policy and interviews for 3 of 3 nurse aides, the facility failed to provide required annual training. The findings include: 1. NA #1's date of hire was 12/11/24. Review of the facility documentation for NA #1 identified that she had worked in the facility between 1/28/25 and 2/13/25. Review of the employee file for NA #1 failed to identify that in-service training had been provided (Resident Rights, Dementia, Communication and Behavioral Health) and included in the files from the date of hire until present. Although requested, the facility could not provide documentation that the required trainings had been completed for NA #1. 2. NA #2's date of hire was 12/23/24. Review of the facility documentation for NA #2 identified that she had worked in the facility between 1/28/25 and 2/13/25. Review of the employee file for NA #2 failed to identify that in-service training had been provided (Resident Rights, Dementia, Communication and Behavioral Health) and included in the files from the date of hire until present. Although requested,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policies and interviews for three (3) of four (4) sampled residents (Residents #1, #2, and #3) who were reviewed for allegations of staff to resident verbal and physical abuse, the facility failed to ensure Resident #1 was not physically and verbally abused, and Residents #2 and #3 were not verbally abused by a nurse aide. The findings include: Resident #1's diagnoses included Parkinsons, depression, diabetes mellitus, and dementia. The Resident Care Plan dated 10/2/24 identified Resident #1 had a self-care deficit. Interventions directed for assistance of one (1) staff with activities of daily living and to contact the family if resident refused care. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily life and required moderate assistance from staff for bed mobility, and transfers. Resident #2's diagnoses included chronic obstructive pulmonary disease, muscle…

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 reviews, facility documentation, facility policies and interviews for four (4) sampled residents (Resident #1) who were reviewed for allegations of staff to resident verbal and physical abuse, the facility failed to report the allegations of abuse to the Administrator and/or designee within two (2) hours in accordance with the facility policy. The findings include: The Facility Reported Incident forms dated 11/25/24 identified there were three (3) incidents that occurred on 11/24/24 that involved a 3-11PM nurse aide and Residents #1, #2, and #3. Interview with the Director of Nursing (DON) on 12/9/24 at 12:15 PM identified on 11/25/24 a 3-11PM nurse, that wished to remain anonymous, notified her of concerns regarding a 3-11PM nurse aide, Nurse Aide (NA) #2, and residents she cared for on 11/24/24. The DON indicated the nurse asked her to talk with Resident #1. The DON identified another nurse aide, NA #1 had reported her concerns with Resident #1 to the nurse on 11/24/24. The DON identified while initially interviewing staff and residents they were reluctant…

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 #1) reviewed for quality of care, the facility failed to ensure staff notified the physician/APRN timely after a resident's verbalization of self-harm. The findings include: Resident #1's diagnoses included dementia, and major depressive disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of five out of fifteen (5/15), indicative of severely impaired cognition and was independent with ADLs and mobility with a walker. The Resident Care Plan (RCP) dated 11/2/24 identified Resident #1 had a history of verbalization of suicidal ideation/intent. Interventions directed to allow to express fears and emotions, know resident's whereabouts, and involve with planning. A nursing note dated 11/8/2024 at 10:52 AM by LPN #1 identified Resident #1 was alert and able to make needs known.…

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 four sampled residents (Resident #12) who were reviewed for medication administration, the facility failed to ensure a medication to treat Resident #12's anxiety was not discontinued without a physician's order to prevent the omission of several doses. The findings include: Resident #12's diagnoses included Paranoid schizophrenia. The quarterly Minimum Data Set, dated [DATE] identified Resident #12 made reasonable and consistent decisions regarding tasks of daily life and received antipsychotic, antianxiety and antidepressant medications. The Resident Care Plan dated 1/1/24 identified a potential or alteration in mood as related to schizophrenia. Interventions directed to allow for expression of feelings as desired, medicate per the physician order, monitor safety, observe mood state, provide emotional support and reassurance, and update physician on onset of new symptoms. A physician's order dated 1/22/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for one of three sampled residents (Resident #1) who had an open area and required daily wound treatments, the facility failed to ensure the physician's order was followed and wound care was conducted daily. The findings include: Resident #1's diagnoses included rhabdomyolysis, anxiety, depression, heart failure, and age-related cognitive deficit. A physician's order dated 3/1/24 directed to apply a dry, clean dressing to the left outer knee skin tear and monitor the left knee skin tear for signs and symptoms of infection daily on the evening shift. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 made reasonable and consistent decisions regarding tasks of daily life, required extensive assistance with turning and repositioning and had a skin tear with the application of a non-surgical dressing. The Resident Care Plan dated 2/29/24 identified a potential for skin breakdown. Interventions directed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for one of four sampled residents (Resident #2) who were reviewed for medication administration, the facility failed to administer the correct intravenous solution as prescribed by the physician. The findings include: Resident #2's diagnoses included dementia, protein and calorie malnutrition and failure to thrive. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 made reasonable and consistent decisions regarding tasks of daily life and required set-up with meals. The Resident Care Plan dated 10/18/23 identified the need for adequate nutrition and hydration. Interventions directed to allow ample time to consume meals, consult registered dietitian (RD) as needed, diet as ordered: regular, thin liquids, encourage completion of meals and fluids on tray, offer fluids between meals, selective menu, update dietary preferences as needed and snacks and beverages as desired. A physician's order dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents,(Resident #1) reviewed for activities of daily living, the facility failed to ensure the resident was transported per the care plan. The findings include: Resident #1 was admitted to the facility with diagnoses that included type II diabetes, anxiety disorder, osteoarthritis, and heart failure. Review of the fall risk assessment dated [DATE] identified Resident #1 was at high risk for falls. A physician's order dated 6/13/23 directed assist of two staff for transfers at wheelchair level. The annual MDS dated [DATE] identified Resident #1 had severely impaired cognition, required extensive assistance of two staff for transfers, used a wheelchair and required total dependency of one staff for bathing. The care plan dated 8/24/23 identified Resident #1 was at risk for falling and altered mobility with interventions that included assistance of two staff for transfers with gait belt using…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for two (2) of three (3) residents (Resident #1 and Resident #3) reviewed for falls, the facility failed to ensure fall risk assessments were completed in accordance with facility policies. The findings include: 1. Resident #1 was admitted to the facility with diagnoses that included type II diabetes, anxiety disorder, osteoarthritis, and heart failure. Review of the fall risk assessment dated [DATE] identified Resident #1 was at high risk for falls. A physician's order dated 6/13/23 directed assistance of two staff for transfers at wheelchair level. The annual MDS dated [DATE] identified Resident #1 had severely impaired cognition, required extensive assistance of two staff for transfers, used a wheelchair and required total dependency of one staff for bathing. The care plan dated 8/24/23 identified Resident #1 was at risk for falling and altered mobility. Interventions included to reassess the resident's fall risk…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, facility policy review and interviews for 1 of 3 residents (Resident #29) reviewed for accident, the facility failed to implement/ revise the NA assignment card immediately to prevent future falls with injury. The findings include: Resident #29's diagnoses included dementia, atrial fibrillation, protein malnutrition, osteoporosis, and epilepsy. The Resident # 29 quarterly MDS assessment dated [DATE] identified Resident #29 had severe cognition impairment and required extensive assist with 2 people with transfer, bed mobility, toileting and hygiene and non-ambulatory. Resident #29 also required an extensive assist of 1 with eating. The Resident Care Plan (RCP) dated 7/7/22 identified Resident #29 at risk for fall related to history of fall. Intervention included: to re-assess the resident fall risk quarterly after each fall, medication review per policy, call bell in reach at all times, body pillow when in bed and dycem (anti-slip material) to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, review of facility documentation and facility policy for 1 of 1 sampled resident (Resident #27) reviewed for faulty medical equipment, the facility failed to ensure the medical equipment was in good repair and preventative maintenance was conducted per facility policy. The finding include: Resident #27 diagnosis included primary generalized arthritis, difficulty in walking, and generalized muscle weakness. The annual MDS assessment dated [DATE] identified Resident #27 had intact cognition and required limited assistance of 1 with bed mobility, transfers, and locomotion on/off the unit. The Resident Care Plan (RCP) dated 7/25/22 identified Resident #27 had a problem with alteration in mobility due to decreased mobility. Interventions included Resident #27 was independent for all transfers at wheelchair level, monitor gait, and physical therapy screen as ordered. Physician orders dated 8/25/22 directed a Dycem (a non-slip material pad) in the wheelchair at all times and check for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility policy review and interviews for 1 of 3 residents (Resident #61) reviewed for Advanced Directives, the facility failed to obtain a physician's order reflecting a change from Do Not Resuscitate to the resident's choice of CPR. The findings include. Resident #61's diagnoses included Type 2 diabetes mellitus, hypertension, and anxiety. A physician's order dated [DATE] directed to Do Not Resuscitate for code status. The Resident Care Plan (RCP) with a start date of [DATE] for Advanced Directives had an intervention Do Not Resuscitate (DNR). The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 61 had a moderate cognitive impairment and the resident required extensive assistance with most Activities of Daily Living (ADL). Resident #61's Cardiopulmonary Resuscitation (CPR) form indicated the resident's desire for CPR to be initiated, signed by the resident on [DATE]. A quarterly MDS assessment dated [DATE] indicated no cognitive impairment 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 2 residents (Resident #9 and Resident #60) reviewed for nutrition, the facility failed to address a significant weight discrepancy according to policy by failing to notify the APRN and dietician of a significant weight discrepancy. The findings included: 1. Resident #9 was admitted with diagnoses that included schizophrenia, diabetes, and stomach reflex disease. Resident #9's monthly weight for November dated 11/11/22 at 11:00 AM was 177 pounds (lbs.). An annual Minimum data set (MDS) assessment dated [DATE] identified Resident #9 was severely cognitively impaired requiring extensive help of 1 staff member for personal hygiene and eating. The recorded weight for Resident #9 was 177 lbs. A care plan last reviewed on 12/14/22 identified Resident #9 had an identified need for adequate nutrition and hydration with a goal to maintain a stable weight. Interventions included for Resident # 9 to sit upright with head of bed 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, observation, facility policy review and interviews for 1 of 2 residents (Resident #29) reviewed for privacy, the facility failed to provide privacy by not posting instructions for the resident's dental needs on the wall in a semi-private room and within public view. The findings include: Resident # 29's diagnoses included dementia, dysphagia, hypothyroid and hypertension. The physician's order dated 2/21/22 directed to collect the denture at bedtime and apply in the morning. The significant change in status MDS assessment dated [DATE] identified Resident #29 had severe cognition impairment and required extensive assistance of 1 person with transfer, dressing, toileting, and non-ambulatory. The Resident Care Plan (RCP) dated 10/25/22 identified Resident #29 had a partial bottom denture. Interventions included: to assist resident with applying and removing denture daily, assist with oral care and denture in for all meal. Observation on 12/28/22 at 9:50 AM identified Resident #29 in…

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 1 resident (Resident # 61) reviewed for Abuse, the facility failed to ensure an allegation of abuse was reported to the state agency. The findings include: Resident #61's diagnoses included Type 2 diabetes mellitus, hypertension, and anxiety. The quarterly MDS assessment dated [DATE] identified Resident # 61 had no cognitive impairment and required extensive assistance of one person for bed mobility and transfer. A progress note dated 7/12/2022 at 8:44 AM indicated in part that at approximately 6:00 AM Resident #61 made a report to a nurse aide that during the night a strange, masked man had entered her/his room and touched her/his on the hip. The progress notes further indicated, in part, the staff on duty and the roommate of Resident #61 were interviewed without findings and the DNS and the Assistant Director of Nursing Services (ADNS) were notified. A facility statement written by Nurse Aide (NA#2) dated…

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

Based on clinical record review, facility policy review and interview for 1 of 5 residents (Resident #38) reviewed for unnecessary medication, the facility failed to ensure that a significant change MDS assessment was completed within 14 days of the resident electing hospice services. The findings include: Resident #38's diagnoses included dysphagia, diabetes mellitus, and hospice terminal diagnosis of malnutrition. The quarterly Minimum Data Set (MDS) assessment dated 11/07 2022 identified Resident # 38 was able to make consist, reasonable decisions independently. The MDS assessment further indicated Resident #38 requires extensive assistance of 2 persons for bed mobility and transfer and supervision with assistance of one person for eating. The care plan in part, dated 11/9/2022 indicated a plan for Advanced Directive with approaches including Do Not Resuscitate, to check bracelet every shift and to provide education on end-of-life issues as indicated. The care plan further indicated a problem regarding cancer that required surgery and chemotherapy with a resulting history of 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 observations, facility policy review and interviews for 1 resident (Resident # 338) reviewed for Urinary Catheter, the facility failed to ensure a residents Foley catheter collection tubing and bag was noted off the floor within accordance to facility policy to reduce the potential for developing an infection and for 1 of 18 sampled residents (Resident #27) reviewed for participation in care planning, the facility failed to document in the medical record the resident's participation, refusal, or input into the care planning meeting process. The findings included: 1. Resident #338's diagnoses included Benign Prostatic Hyperplasia (BPH) with lower urinary tract symptoms, hematuria, and diabetes mellitus. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 338 had no cognitive impairment and required extensive assistance of one person for bed mobility, transfer, and toilet use. The Resident Care Plan (RCP) dated 12/01/2022 identified in part a decline in functional ability…

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 staff interviews and clinical record review for 1 of 3 sampled residents (Resident #36) reviewed for abuse, the facility failed to follow professional standards of care for documenting a provider assessment and notification to responsible party following an incident with another resident. The findings include: Resident #36's diagnoses included dementia with behavioral disturbance, major depressive disorder, psychotic disorder and idiopathic normal pressure hydrocephalus. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #36 was moderately cognitively impaired, required extensive assistance with one person for bed mobility, transfers, dressing, toilet use and personal hygiene. A Resident Care Plan dated 07/22/2022 identified that Resident #36 had a problem with psychosocial well-being with interventions that included to encourage participation in programs, provide emotional support and social work visits as needed. The facility Reportable Event (RE) form dated 09/06/2022 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, observation, facility policy review and interviews for 1 of 2 residents (Resident #336) reviewed for edema, the facility failed to follow physician's instruction orders consistently to prevent medication errors. The findings include: Resident # 336's diagnoses included spinal stenosis, emphysema, atrial fibrillation, hypertension, and localized edema. The admission MDS assessment dated [DATE] identified Resident #336 had intact cognition and required extensive assistance of 1 person with transfer, dressing, toileting, and hygiene. The physician's order dated 12/19/22 directed to administered furosemide (anti-diuretic medication) 20 MG by mouth daily as needed if weight greater than 245 pounds. Observation on 12/27/22 at 9:50 AM identified Resident #336 sitting on the wheelchair with bilateral leg edema and a blue foam boot on the left foot. Review of the weight record from 12/20/22 through 12/29/22 identified Resident #336 weights were recorded greater than 245 pounds on 12/20,…

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 #9) reviewed for nutrition and 1 resident (Resident # 60) reviewed for edema, the facility failed to address a significant weight discrepancy according to policy by failing to have the dietician evaluate a significant weight discrepancy timely. The findings included: 1. Resident #9 was admitted with diagnoses that included schizophrenia, diabetes mellitus, and stomach reflex disease. Resident #9's monthly weight for November dated 11/11/22 at 11:00 AM was 177 pounds (lbs.). An annual MDS assessment dated [DATE] identified Resident #9 was severely cognitively impaired requiring extensive help of 1 staff member for personal hygiene and eating. The recorded weight for Resident #9 was 177 lbs. A care plan last reviewed on 12/14/22 identified Resident #9 had an identified need for adequate nutrition and hydration with a goal to maintain a stable weight. Interventions included to sit upright with head 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 observation, clinical record review, review of facility policy and interview for 1 sampled resident, (Resident #387), reviewed for Intravenous (IV) Therapy, the facility failed to ensure scheduled dressing changes, monitoring and catheter measurements were completed per facility policy and consistent with professional standards of practice. The findings include: Resident #387 was admitted to the facility on [DATE]. Diagnoses included infection associated with internal left hip prosthesis, iron deficiency anemia and hyperlipidemia. A physician's order dated 12/16/22 directed Cefepime 2 grams (g) intravenous every 12 hours, 9:00AM, 9:00PM. An Infusion Order Medication Administration Record for December 2022, which was in a binder at the nurse's station, and used to document the PICC line dressing changes and external catheter measurements, indicated the dressing was to be changed weekly and as needed. Review of the flow sheet indicated the dressing was to be changed on the 7:00AM-3:00PM shift and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure medications were maintained in a secure location. The findings include. During an observation on 1/04/2023 at 9:00AM a medication cart was observed between rooms [ROOM NUMBERS] unattended, unlocked with 2 clear medication cups with what appeared to be applesauce with crushed medications and the other with a red-orange opaque substance and spoon in each. On 1/04/2022 at 9:02 AM further observations identified LPN #7 walked over to the medication cart and indicated she was called away to assist another resident for an emergency nosebleed and left the medications and the cart at its location in the hall while she went to see what the emergency with the resident was. LPN #7 further indicated that one medication cup contained applesauce and medications that were crushed and the other contained potassium that was thickened. On 1/4/2022 at 10:10 AM an interview with the DNS identified she would expect the medication cart to be locked and without…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review and interviews for 1 resident (Resident #387) reviewed for choices, the facility failed to provide laboratory services as ordered by the physician. The findings include. Resident # 387's diagnoses included infection of a surgical site, iron deficiency anemia, hypertension, and hyperlipidemia. A physician's Discharge summary dated [DATE] indicated in part Resident #387 would require Intravenous antibiotic therapy every 12 hours for six weeks and would require weekly laboratory work. The Resident Care Plan (RCP) dated 12/16/2022 identified a plan to return to the community once resident completes the course of treatment as outlined in the plan of care. Interventions included in part to assess discharge potential, refer to a home health agency to provide education to the resident and family as needed and for the social worker to consult as needed. A physician's order dated 12/20/2022 directed to obtain laboratory blood work including a Complete Blood…

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 staff interview, observations and review of the clinical record for 1 of 4 sampled residents (Resident #59) reviewed for dining, the facility failed to ensure the menu was followed and a nutritional supplement was provided according to the ticket menu. The findings include: Resident #59's diagnoses included schizophrenia, dysphagia, anxiety, prediabetes, and being underweight. The quarterly MDS assessment dated [DATE] identified Resident #59 was severely cognitively impaired, had progressed from eating with limited assist of one to extensive assistance of one. A Resident Care Plan dated 10/18/22 identified Resident #59 was at risk for getting adequate nutrition and hydration, decreased ability to perform activities of daily living (ADL's), and decreased level of consciousness. Interventions included to assist with meals, ensure resident was upright at 90 degrees, encourage completion of meals/fluids on tray, offer fluids between meals and provide supplements (Ensure plus & Magic cup daily). On 12/27/22…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, facility policy review, and interviews for 1 residents (Resident # 338) reviewed for urinary catheter, the facility failed to ensure a residents Foley catheter collection tubing and bag was maintained in a sanitary manner to reduce the potential for developing an infection, failed to ensure that the guidelines for disinfecting the glucometer were followed and failed to store the bath basin and bed pan in a sanitary way and in accordance to the facility practice. The findings included: 1. Resident #338's diagnoses included Benign Prostatic Hyperplasia (BPH), with lower urinary tract symptoms, hematuria, and Diabetes. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 338 had no cognitive impairment and required extensive assistance of one person for bed mobility, transfer, and toilet use. The Resident Care Plan (RCP) dated 12/01/2022 identified in part a decline in functional ability due to illness with the potential for improvement.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, review of facility policy, and interviews, for one of three sampled residents (Resident #26) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to provide an occupational therapy evaluation and failed to obtain previous psychiatric records per the PASRR recommendations. The findings include: Review of the PASRR Level II assessment for Resident #26 dated 8/26/19 identified recommendations for an occupational therapy evaluation and to obtain psychiatric records. Resident #26's was admitted on [DATE] with a diagnoses that included paranoid schizophrenia, anxiety, and Parkinson's disease. A physician's order dated 8/27/19 directed to administer Olanzapine 2.5 mg at bedtime. The admission Resident Care Plan (RCP) dated 8/28/19 identified schizophrenia. Interventions directed to medicate with Olanzapine and provide psychiatric consultation as needed. The admission Minimum Data Set (MDS) assessment dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, review of facility policy, and interviews, for 3 of 5 residents (Residents #20, # 21, and #86) reviewed for immunizations, the facility failed to ensure that pneumococcal vaccines were administered according to standards of practice and facility policy. The findings include: a. Resident #20 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus and chronic obstructive pulmonary disease. The Medication Administration Record dated 6/2/2017 identified that Resident #20 received the Prevnar 13 (PCV 13) but failed to provide evidence that Resident #20 was offered the Pneumovax 23 a year after being administered the PCV 13 or since residing in the facility. b. Resident #21 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease and dementia. The Medication Administration Record dated 3/20/18 identified that Resident #21 received the PCV 13 vaccine but failed to provide…

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