Harbor Village North Health And Rehabilitation Cen

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, review of clinical records and policy for 2 of 3 residents (Resident #8 and #93) reviewed for respiratory care, the facility failed to ensure a resident receiving oxygen had a physician's order for oxygen and failed to ensure oxygen administration was set according to the physician order. The findings include:1. Resident #8's diagnoses included Chronic Obstructive Pulmonary Disease (COPD), acute pulmonary edema, and anxiety disorder.The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 had a Brief Interview of Mental Status score of 15 indicating normal cognitive function, and was independent for oral hygiene, personal hygiene and transfers.The Resident Care Plan (RCP) dated 1/8/26 identified Resident #8 had COPD related to smoking. Interventions included monitoring difficulty breathing and elevating the head of bed or assist to an upright position in a chair during episodes of difficulty breathing.Observation on 2/25/26 at 11:05 AM 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 observations, reviews of the clinical record, policy and interviews for the only sampled resident (Resident #1) reviewed for hemolytic treatment, the facility failed to ensure a physician ordered fluid restriction was maintained. The findings include:Resident #1's diagnoses included end stage renal disease, diabetes and dependence on renal hemolytic treatment.The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status score of 15 indicating intact cognition and required set up assistance for eating and bed mobility, partial moderate assistance with dressing and toileting, supervision with hygiene and transfers.The Resident Care plan dated 1/27/26 identified hemolytic treatment related to renal failure. Interventions included hemolytic treatment on Tuesday, Thursday and Saturday, left chest catheter site, left arm Arteriovenous (AV) site (new), diet as ordered, and fluid restriction as ordered.A physician's order dated 1/29/26 directed a fluid…

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, interviews and policy review, the facility failed to ensure medications were stored according to professional standards and that controlled substance narcotic medications were double locked per the requirement. The findings include:Observation on 2/27/26 10:01 AM identified the South-Central medication cart containing a singly locked narcotic box was stored in the hallway parallel to the front door, across the front lobby without the benefit of being locked, and without the benefit of a nurse in view of the medication cart. Additionally in the lobby, the ADNS was noted to walk by, and 3 residents were seated there, as well as 2 housekeeping staff and the receptionist. At 10:03 AM 4 Residents were identified to walk past the medication cart, along with the Dietary Director and a rehabilitation staff member. At 10:06 AM an APRN passed by, and at 10:07 AM a resident passed by as well as a visitor entered the lobby. At 10:09 AM the scheduler, and an LPN walked past, followed by the psychiatric APRN and a resident, and at 10:10 AM 2 Nurse Aids also passed…

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 interviews, review of clinical records, and policy for the only sampled resident, (Resident #10) reviewed for dental, the facility failed to follow up on a request for upper-level denture replacement for a resident with Medicaid insurance. The findings include:Resident #10's diagnoses included chronic obstructive pulmonary disease, anxiety disorder, and hypertension.The admission minimum data set assessment dated [DATE] identified Resident #10 had a Brief Interview of Mental Status score of 7 indicating moderate cognitive impairment, was independent for oral hygiene, and required supervision/touching assistance for transfers.The Resident Care Plan dated 3/25/26 identified Resident #10 had dental concerns related to broken and missing teeth. Interventions included dental consultation and treatment.A nurse progress note dated 3/21/25 at 9:03 PM identified that Resident #10 had lost upper dentures at the last facility to which he/she was previously admitted . Additionally, the note identified that Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility policy and interviews for 1 of 3 residents (Resident #11) reviewed for pressure ulcers, the facility failed to perform hand hygiene while performing a dressing change and after cleaning a glucometer. The findings include:1. Resident #11's diagnoses included severe protein calorie malnutrition, diabetes with neuropathy and retention of urine.The admission Minimum Data Set assessment dated [DATE] identified Resident #11 had a Brief Interview for Mental Status (BIMS) score of 14 indicating no cognitive impairment and was totally dependent on staff for dressing, toileting, and bed mobility. Additionally, Resident #11 currently had a stage 4 pressure injury/ulcer and 2 unstageable pressure injuries. The Resident Care Plan dated 10/30/25 identified an actual impairment to skin integrity related to a deep tissue injury, unstageable left heel. Interventions included keeping skin clean and dry, offload wound, and provide a wound physician as needed.The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for five (5) of five (5) residents (Residents #1, 2, 3, 4 and 5) reviewed for resident-to-resident abuse, the facility failed to complete a full investigation regarding resident-to-resident abuse. The findings include: 1. Resident #1's diagnoses included paranoid schizophrenia, antisocial personality disorder, adjustment disorder and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was cognitively intact and was independent with bed mobility, transfers and personal hygiene. The Resident Care Plan (RCP) dated 7/23/24 identified that Resident #1 has the potential for altered mood related to diagnoses of paranoid schizophrenia, anxiety disorder, depression and adjustment disorder with interventions that included to allow the resident to express feelings, staff to speak softly and clearly when communicating, observe for changes in mood/depression and notify physician 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 review of the clinical record, facility documentation, facility policy and interviews for 5 (five) of 5 (five) residents (Residents #1, 2, 3, 4 and 5) reviewed for resident-to-resident abuse, the facility failed to ensure that the residents were provided social services support timely after resident-to-resident abuse occurred within the facility. The findings include: 1. Resident #1's diagnoses included paranoid schizophrenia, antisocial personality disorder, adjustment disorder and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was cognitively intact and was independent with bed mobility, transfers and personal hygiene. The Resident Care Plan (RCP) dated 7/23/24 identified that Resident #1 has the potential for altered mood related to diagnoses of paranoid schizophrenia, anxiety disorder, depression and adjustment disorder. Interventions included to allow the resident to express feelings, staff to speak softly and clearly when communicating,…

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 ten residents (Resident #3) reviewed for abuse, the facility failed to ensure the resident was free from mistreatement. The findings include: Resident #2's diagnoses included chronic obstructive pulmonary disease (COPD), schizophrenia, and post-traumatic stress disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was alert and oriented and was independent for mobility with wheelchair. The Resident Care Plan (RCP) dated 5/5/2023 identified Resident #2 received antipsychotic medications to treat schizoaffective disorder, and had a history of aggressive and violent behaviors. Interventions directed to administer medications as ordered, and assess behaviors for potential danger to the resident and/or others and intervene as needed. Resident #3's diagnoses included anxiety disorder, post-traumatic stress disorder, and bipolar disorder. The quarterly MDS assessment…

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, interviews, and facility documents for one (1) of three (3) residents (Resident #9) reviewed for abuse, the facility failed to complete close observation checks in accordance with physician's orders. The findings included: Resident #9's diagnoses included neurocognitive disorder with Lewy Bodies, dementia, and generalized anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #9 was severely cognitively impaired, was independent for mobility, and exhibited physical behaviors (hitting, kicking, pushing, scratching, and grabbing) and verbal behaviors (threatening others, screaming at others, and cursing at others). The Resident Care Plan (RCP) dated 05/1/24 identified Resident #9 identified mood/behaviors including: combative with care, pacing, restlessness, fidgeting, difficult to redirect, difficult to redirect, wandering, and actual resident to resident altercations. Interventions directed to observe changes in behavior and report…

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 residents (Resident #2 and Resident #4) reviewed for behavioral health, the facility failed to ensure resident behaviors were monitored and accurately reflect the behaviors that were exhibited. The findings include: 1. Resident #2's diagnoses included chronic obstructive pulmonary disease (COPD), schizophrenia, and post-traumatic stress disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was alert and oriented and was independent for mobility with wheelchair. The Resident Care Plan (RCP) dated 5/5/2023 identified Resident #2 received antipsychotic medications to treat schizoaffective disorder and had a history of aggressive and violent behaviors. Interventions directed to administer medications as ordered and to monitor behavior and response to medications. Physician orders dated 7/21/2023, and review of physician orders through 1/3/2024 identified orders 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, review of facility policy, and interviews, the facility failed to ensure that the kitchen was kept in a clean and sanitary manner and failed to discard expired foods. The findings include: During a tour of the Dietary Department on 6/26/24 at 9:50 AM with the Food Service Manager the following was identified: • One ceiling fan covered with a heavy coat of brownish dust-like matter blowing directly over washed silverware and mugs. • The walls of the dish washing room area were covered with a coat of greyish dust-like matter. • The sink area in the dish washing room was noted to have a foul odor with an accumulation of grime and dirt on the walls underneath the sink with the exposed pipes under the sink noted to have a thick black coating. • The walls above the paper towel dispenser at the handwashing sink before entering the dishwashing room noted to have a heavy accumulation of dust. • The ceiling tiles in the dish room, and the food cart placement area noted to have an accumulation of dust and dirt. • The vent above the stove noted to have an accumulation 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.

Based on observation, facility documentation review, facility policy review, and interviews, the facility failed to follow through a resolution after identifying an issue during environmental rounds and failed to maintain a clean laundry area. The findings include: Review of the monthly facility environmental rounds from January 2024 to June 2024 identified the facility noted issues of the cleanliness in the kitchen, further review of the documentation failed to identify how the lack of cleanliness was addressed. Interview with Infection Control Nurse (ICN) LPN #5 in the presence of RN# 5 (Regional Clinical Specialist) on 7/3/24 at 10:45 AM identified that the maintenance, housekeeping, and LPN #5 were responsible for conducting the monthly environmental rounds. LPN #5 had noted an issue of the cleanliness in the kitchen during the monthly environmental rounds. She identified that the facility had 10 days to offer a resolution and/or resolve the issue found in the environmental rounds; however, she could not provide evidence that the cleanliness noted in the monthly environmental…

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 sampled residents (Resident #16 and Resident #43) reviewed for significant change in condition, the facility failed to notify the physician when the residents experienced a significant changes in condition. The findings include: 1. Resident #16 's diagnoses included chronic anemia secondary to blood loss, cirrhosis of the liver, chronic kidney disease, gastroesophageal reflux disease (GERD), abdominal hernia, atrial fibrillation, heart failure, and congenital malformation of heart. The quarterly MDS assessment dated [DATE] identified Resident #16 was cognitively intact, required limited assistance for toileting, dressing, and hygiene, was independent with bed mobility, transfers, and was ambulatory with a rolling walker. The care plan dated 6/8/24 identified Resident #16 had a gastro-intestinal problem related to an abdominal hernia and GERD. Care plan interventions directed to observe 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 observations, review of clinical records, review of the facility assessment and interviews for thirty-eight sampled residents (R#2, R#9, R#10, R#15, R#23, R#25, R#26, R#28, R#31, R#33, R#41, R#45, R#53, R#60, R#65, R#68, R#71, R#73, R#74, R#75, R#76, R#81, R#82, R#83, R#89, R#91, R#92, R#94, R#95, R#98, R#101, R#102, R#103, R#105, R#106, R#108, R#112 & R#318) residing on the secured dementia unit (South unit) of the total census of 115, the facility failed to assess, care plan, demonstrate that the secured unit was the least restrictive setting, and obtain consents for residents who were selected to reside on the secured unit. The findings include: Observations during all days of the survey June 26th, July 1, 2, 3, 8 & 9, 2024 identified the secured unit (South Unit) located on the first floor had double doors that bordered the center unit that required a number code to be punched into the key pad in order for the doors to open. The unit also contained an exit in the southwest end of the hallway where there was an emergency exit and on the southeast corner of the unit 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, and interviews for one sampled resident (Resident #39) reviewed for activities of daily living, the facility failed to provide the necessary services to maintain good grooming and personal care related to toenail care. The finding includes: Resident #39's diagnoses included injury of the lumbar spinal cord, sequela, and paraplegia. The treatment administration record for April, May, and June 2024 identified that body assessments and weekly skin checks were completed on shower days. The quarterly MDS assessment dated [DATE] identified Resident #39 had intact cognition, and an impairment on both sides to the upper and lower body and used a wheelchair. Physician's orders dated 6/10/2024 directed for podiatry, audiology, dental, and ophthalmology consults as needed. The care plan dated 5/17/2024 identified Resident #39 had a self-care and mobility performance deficit and needed assistance with hygiene and mobility related to the resident's diagnoses. The 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 observation, interview, and review of facility policy for two of two sampled residents, (Resident #20) reviewed for food, the facility failed to provide food that was prepared in a manner to conserve nutritive value and in a palatable manner. The findings include: 1. Resident #20's diagnoses included unspecified dementia, major depressive disorder, and diabetes insipidus. The quarterly MDS assessment dated [DATE] identified Resident #20 had moderately impaired cognition, utilized a cane/crutch, utilized set up or clean up assistance with eating, independent with oral hygiene, supervision with toileting, set up or clean up assistance with personal care and dressing. Resident #33's care plan dated 5/6/24 identified a nutritional problem or potential nutritional problem r/t morbid obesity, diuretic use, diabetes, hypertension, and GERD. Care plan interventions directed: controlled carbohydrate diet, no added salt, regular consistency with thin liquids, small starch portions. Interview with Resident #20 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 observations, review of facility documentation and interviews for resident rooms #'s 15, 18, 20, 26 and the hallway in the Northeast wing of the facility, the facility failed to ensure the environment was free of pests, specifically flies and fruit flies and the facility failed to ensure the kitchen food storage environment was free from visible signs of rodent infestation. The findings include: 1. Observations on 6/26/2024 at approximately 1:30 PM of rooms (rm)15, 18, and 20 of the Northeast wing identified fruit flies were present. In room [ROOM NUMBER], there were cups of orange juice with caps and a sandwich wrapped in a paper towel. There were an excessive amount of fruit flies in the room, on the cups, on the resident's overbed table, side table and bed. Rm 15 also had fruit flies near the window and on the room divider curtain. The area near the window had items stacked on top of one another, clothing was piled on some of the boxes. There was no food that was able to be visualized. Rm 20 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy, and interviews for one sampled resident (Resident #33) reviewed for dignity, the facility failed to provide care and speak to the resident in a dignified manner. The findings include: Resident #33's diagnoses included unspecified dementia, personal history of traumatic brain injury, and Asperger's syndrome. The quarterly MDS assessment dated [DATE] identified Resident #33 had moderately impaired cognition, utilized a manual wheelchair, was dependent for eating, oral hygiene, toileting, bathing, personal care, and dressing. Resident #33's care plan dated 6/4/24 identified an ADL (activities of daily living) self-care performance deficit and noted the resident required assistance, had poor motivation, cognitive impairments, weakness, weakness, and kyphosis with interventions that directed: provide privacy for all care, encourage resident to assist with care, anticipate needs. Observation on 7/2/24 at 5:20 AM identified NA#1 providing morning hygiene care to Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and review of facility policy for one of one sampled resident, (Resident #33) observed for personal care, the facility failed to provide privacy for the resident while receiving care. The findings include: Resident #33's diagnoses included unspecified dementia, personal history of traumatic brain injury, and Asperger's syndrome. The quarterly MDS assessment dated [DATE] identified Resident #33 had moderately impaired cognition, utilized a manual wheelchair, was dependent for eating, oral hygiene, toileting, bathing, personal care and dressing. Resident #33's care plan dated 6/4/24 identified an ADL (activities of daily living) self-care performance deficit and noted the resident required assist for thoroughness, had poor motivation, cognitive impairments, weakness, impaired gait, weakness and kyphosis. Care plan interventions directed: one for care if in bed, provide privacy for all care, encourage resident to assist with care, anticipate needs. Observation on 7/2/24 at 5:20 AM…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for two of three residents (Resident #16 and Resident #43) reviewed for change in condition and change in weight, the facility failed to consistently monitor and assess residents for worsening health condition and failed to assess a significant weight gain. The findings include: 1. Resident #16 's diagnoses included chronic anemia secondary to blood loss, cirrhosis of the liver, chronic kidney disease, gastroesophageal reflux disease (GERD), abdominal hernia, atrial fibrillation, heart failure, and congenital malformation of heart. The quarterly MDS assessment dated [DATE] identified Resident #16 had no cognitive impairments, required limited assistance for toileting, dressing, and hygiene, was independent with bed mobility, transfers, and was ambulatory with a rolling walker. The care plan dated 6/8/24 identified Resident #16 had a gastro-intestinal problem related to abdominal hernia and GERD. 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, review of facility policy and interviews for two of five sampled residents (Residents #14 & #33) reviewed for unnecessary medication, the facility failed to implement pharmacy review recommendations. The findings include: 1. Resident #14's diagnoses included gastro-esophageal reflux disease (GERD), bipolar disorder, and chronic obstructive pulmonary disease (COPD). The admission MDS assessment dated [DATE] identified Resident #14 had intact cognition, independent with toileting hygiene, bed mobility, required supervision with personal hygiene, and utilized a walker. Resident #14's care plan dated 10/31/23 identified Resident #14 utilized pain medication and psychotropic medication with interventions that included observing for potential or possible side effects such as constipation and diarrhea. The physician's order from December 2023 through July 2024 directed Miralax oral packet (Polyethylene Glycol 3350) to give one packet by mouth as needed for constipation. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility policy, and interview for one of two sampled residents (Resident #111) reviewed for Medication Administration, the facility failed to ensure a medication error rate of less than 5%. The findings include: Resident #111's diagnoses included hypertension, depression, repeated falls, and anxiety. The Minimum Data Set (MDS) assessment dated [DATE] identified that Resident # 111 was severely cognitively impaired, required moderate assistance for personal hygiene, bed mobility and transfers and supervision assistance with eating. Physician's order in effect on 7/1/24 directed to give oral chewable Aspirin enteric coated (EC) 81mg, 1 tablet by mouth one time a day for blood thinner, Bupropion Hydrochloride (HCl) extended release (ER) 150mg, 1 tablet by mouth one time a day for depressive episodes and Metoprolol succinate ER Tartrate 25 mg, I tablet by mouth one time a day for hypertension, (HTN, blood pressure). Observation of medication preparation for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for two of four residents (Resident #1 and Resident #2) reviewed for abuse, the facility failed ensure the resident was free from mistreatment. The findings include: 1. Resident #1 was admitted with diagnoses that included dementia, attention-deficit hyperactivity disorder, and depression with anxiety. An admission MDS assessment dated [DATE] identified Resident #1 had severely impaired cognition with behaviors that included significant intrusion on the privacy of others disrupting care or living environment. Resident #1 was independent with bed mobility, transfers and walking, and had unclear speech with occasionally understanding others. A resident care plan (RCP) dated 4/19/2024 identified Resident #1 was an elopement risk, had a mood/behavioral disorder that included behaviors that were combative with care, pacing, restlessness, intrusive, difficult to redirect, wandering and had actual resident to 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 clinical record reviews, facility documentation, facility policy, and staff interviews for one of three sampled residents (Resident #1) who were dependent on staff for toilet use, the facility failed to ensure incontinent care was provided at the time the resident voiced the need for care and every two (2) to four (4) hours in accordance with the care plan. The findings include: Resident #1's diagnoses included morbid obesity, abnormalities of gait and mobility, and generalized muscle weakness. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 made reasonable decisions regarding tasks of daily life, was always incontinent of urine and stool, was at risk for skin breakdown, required extensive assistance of two (2) for turning and repositioning when in bed for bed mobility, dressing and toilet use and extensive one (1)person assistance for personal hygiene. The Resident Care Plan (RCP) dated 9/29/23 identified Resident #1 was at risk for skin breakdown, had a self-care deficit,…

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 accidents, the facility failed to ensure the plan of care was updated after a fall. The findings include: Resident #1 was admitted with diagnoses that included Alzheimer's disease, dementia, unsteadiness, and adjustment disorder. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 as severely cognitively impaired and was independent with transfers and walking in his/her room. The Resident Care Plan (RCP) dated 7/6/2023 identified Resident #1 was at risk for falls due to impaired cognition and the use of psychotropic (used to treat mood alterations) medications. Interventions directed to encourage to wear nonskid socks and shoes when out of bed, provide adequate light keeping the area free of clutter, and to observe for potential medication side effects that included dizziness, drowsiness, weakness, and unsteadiness. A facility incident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility policy and interviews for one of four residents (Resident #70) reviewed for accidents, the facility failed revise and implement an intervention from the resident's care plan following a fall. The findings include: Resident #70 had diagnoses that included Parkinson's disease, chronic obstructive pulmonary disease, anxiety disorder, epilepsy, and schizophrenia. The quarterly MDS assessment dated [DATE] identified Resident #70 had moderate cognitive impairment, limited assistance with one-person physical support for all Activities of Daily Living (ADL). The care plan 9/2021 dated identified for falls identified resident is at moderate risk for falls or fall related injury related to cognitive and sensory factors such as Parkinson's/dementia, history of falls in community, psychiatric medication use, epilepsy and non-compliance with transfer and ambulation orders. Interventions included: to ensure floor mats are in place. Assist of two, stand/pivot with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record and interview for one of two residents reviewed for discharge (Resident #114), the facility failed to ensure the resident received documentation regarding medications last administered in the facility post discharge and failed to notify the primary physician the resident had left Against Medical Advice. The findings include: Resident # 114 was admitted to the facility on [DATE]. The resident's diagnoses included Post Traumatic Stress Disorder (PTSD), bipolar disorder and right knee (ORIF) Open Reduction and Internal Fixation. A review of the admission nurse's note dated 11/9/21 identified the resident was admitted to the facility post right knee ORIF which required rehabilitation services. A review of the Medication Administration Record for November 2021 identified the resident received Oxycodone IR 5 Milligrams by mouth every 6 hours for when needed pain, Wellbutrin XL (anti-depressant) 150 MG twice a day, Seroquel (anti-psychotic) 300 MG at 9:00 PM and Lovenox (anticoagulant) 40…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interview for one of one of two sampled resident reviewed for discharge (Resident # 113), the facility failed to ensure the resident's Registered Nurse Pronouncement (RNP) physician's orders had a date and was within accordance to professional standards per facility practice. The findings include Resident # 113's diagnoses included dementia with behavioral disturbances, major depression, type diabetes mellitus, hypertension and peripheral vascular disease. The admission MDS assessment dated [DATE] identified the resident was severely cognitively impaired, required extensive assistance with ADL and noted no hospice. A review of the August 2021 Medication Administration Record noted RNP dated 8/24/21 but lack a physician's order for August 2021 for RNP. However, review of the physician's orders dated 9/2021 through 11/2021 failed to reflect the physician's orders for RNP with a current date and physician's signature. The progress note dated 11/10/21 noted DNR/DNI and noted the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility policy and interviews for one resident (Resident #70) reviewed for respiratory care, the facility failed to change the resident's oxygen tubing per facility policy and practice. The findings include: Resident #70's diagnoses included Parkinson's disease, chronic obstructive pulmonary disease, anxiety disorder, epilepsy, and schizophrenia. The quarterly MDS assessment dated [DATE] identified Resident #70 had moderate cognitive impairment, limited assistance with one-person physical support for ADL and identified no utilization of oxygen therapy within the last 14 days. The care plan 9/2021 dated identified for altered respiratory status identified resident has altered respiratory status/difficulty breathing related to COPD. The resident will maintain normal breathing pattern. Interventions included: to provide oxygen as prescribed by the physician. Administer medication/puffers as ordered. Monitor for effectiveness and side effects. Monitor/document…

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.