Candlewood Rehabilitation And Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility policy, and interviews for one sampled resident (Resident #76) reviewed for respiratory care, the facility failed to ensure cautionary and safety signage was posted outside the room of a resident receiving oxygen therapy. The findings include: Resident #76's diagnoses included Chronic Obstructive Pulmonary Disease (COPD), dementia, and hypertension.The physician's order dated 7/3/2025 directed Resident #76 to receive oxygen at a rate of zero to four liters(L) per minute (min) to maintain SpO2 (peripheral capillary oxygen saturation) above 90%.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #76 had a Brief Interview of Mental Status (BIMS) score of 5 indicative of severely impaired cognition, required moderate assistance for rolling left and right, and required maximum assistance for personal hygiene. Additionally, the MDS identified Resident #76 was receiving oxygen therapy.The Resident Care Plan (RCP) dated 3/11/2026…

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, observations, and interviews for the only sampled resident (Resident #14) reviewed for behaviors, the facility failed to ensure recommendations from a community psychiatrist were obtained to address a resident's behavioral health care needs in a timely manner. The findings include: Resident #14 had diagnoses that included dementia with behaviors, anxiety, and agitation. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #14 had severely impaired cognition, was always incontinent of bowel and bladder, was dependent on staff for personal hygiene, dressing, and transfers. The MDS further identified Resident #14 exhibited behaviors 1 to 3 days a week directed towards others such as hitting, screaming, or making disruptive sounds.The Resident Care Plan (RCP) dated 2/4/26 identified Resident #14 had dementia with behavioral symptoms of sundowning and agitation. Interventions directed to redirect resident as needed,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility policy, and interviews for the only sampled resident (Resident #50) reviewed for tube feeding, the facility failed to wear appropriate Personal Protective Equipment (PPE) during care, and for 1 of 3 residents (Resident #88) reviewed for pressure ulcer, the facility failed to maintain proper infection control and practice hand washing between glove changes during wound care. The findings include:1. Resident #50's had diagnoses that included cancer of the upper throat, difficulty swallowing, and malnutrition. The Resident Care Plan (RCP) dated 3/11/26 identified that Resident #50 received tube feedings related to difficulty swallowing and malnutrition, with interventions that included administering tube feedings as ordered. The physician's order dated 3/11/26 directed to administer continuous tube feeding, change tube feeding supplies such as the nutrient bag, tubing, and irrigation set daily, and to maintain Enhanced Barrier Precautions (EBP) related…

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 #3) reviewed for accidents, the facility failed to ensure neurological assessments were completed following an unwitnessed fall per physician's order. The findings include:Resident #3 was admitted to the facility on [DATE] with diagnoses that included pneumonia, clostridium difficile, atrial fibrillation, depression, and lung cancer with brain metastasis. The Resident Care Plan (RCP) dated 8/14/24 identified Resident #3 was at risk for falls and bleeding related to anticoagulant therapy. Interventions directed to keep the call bell and commonly used items within reach, encourage call light use, administer medications per physician orders, monitor for signs and symptoms of bleeding and bruising, and maintain a safe environment. The physician's order dated 8/14/24 directed to administer Eliquis (blood thinner) 2.5 milligram twice a day, monitoring every 30 minutes for 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.

Based on observations, facility documentation and facility policy and interviews, the facility failed to ensure the environment was maintained in a safe secured manner on a locked unit for residents with special needs. The findings include: An observation of the facility memory care unit with the Director of Nursing Services and Assistant Director of Nursing Services on 6/06/24 at 12:35 PM identified the following: 1. One door labeled identified as the 'Soiled Utility' was unable to be fully closed, latched, and locked. 2. One door labeled 'Supply Room' was unable to be fully closed, latched, and locked. 3. One door labeled 'Clean Utility' was unable to be fully closed, latched, and locked. 4. The door identified as 'Shower' was not locked. There were no accessible sharps or hazardous material in all the rooms and no residents in the immediate area. An interview with the Director of Nursing Services on 6/06/24 at 12:35 PM identified the doors should be remain securely locked on the memory care unit. An interview with the Director of Maintenance on 6/07/24 at 8:59 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 of the facility Medication Storage, facility policy reviewed and staff interviews for (4 of 7) medication carts, the facility failed to store and label medications to meet professional standards and within accordance to facility policy. The findings included: 1. Review of the medication cart on Elm Tree unit on [DATE] at 11:00 AM identified Resident #23 was prescribed Latanoprost .005% OPT SOLN (1 drop eye to be given at Bed). The directions directed that the medications be stored in the refrigerator upon opening and to discarded 6 weeks after opening (LPN) # 1 was unsure when the medication was opened). S/he also indicated the medication is stored in the top draw in the right back corner of the medication cart. The clinical record indicated the resident was last given the Latanoprost .005% optical solution on [DATE] at 7:59 PM. Interview with LPN#1 on [DATE] at 11:01AM indicated medications are expected to be stored according to directions and stated the last nurse who used the medication…

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 of the environment, review of facility documentation, facility policy, and interviews, the facility failed to ensure laundry room vents and a smoke detector were free of debris. The findings include: 1. During a tour of the laundry area on 6/5/24 at 11:30 AM, 2 vents and a smoke detector were covered in gray debris. One vent was in the dirty laundry area and the second vent was in the clean laundry area near a folding table. The smoke detector was also located in the clean laundry area. Interview and observation with Laundry Supervisor #1 on 6/5/24 at 11:30 AM identified the vents should be cleaned monthly. He was also unsure when the last time the vents and smoke detector were cleaned. The Laundry Supervisor # 1 stated he would check the logs; he would have to get the logs because they were not in the laundry area. In an interview and observation with the Infection Preventionist (IP)/LPN #2 on 6/5/24 at 11:45 AM identified the vents should be cleaned weekly by the laundry aide and there are cleaning logs. She also stated she was unsure why the policy was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical records, facility documentation, facility policy and interviews for 2 of 2 residents (Residents #23 and #30) reviewed for Resident Rights, the facility failed to ensure residents were treated with dignity by a nurse aide. The findings include: 1. Resident #23's diagnoses included Chronic Obstructive Pulmonary Disease (COPD), emphysema, and chronic respiratory failure. The Resident Care Plan dated 5/16/24 identified the resident required supervision and assistance with Activities of Daily Living (ADL). Interventions included assisting the resident with ADL daily for optimal independence. The social services note dated 5/31/24 at 1:55 PM written by (Social Worker) SW #3, identified the resident as alert and oriented and able to make his/her needs known. Additionally, the note indicated Resident #23 did not have any roommate or behavioral issues. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #23 as cognitively intact and required partial assistance…

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 of 3 sampled residents (Resident #427) reviewed for change of condition, the facility failed to notify the physician of a change in status for a resident exhibiting reoccurring symptoms in a timely manner. The findings include: Resident #427's diagnoses included acute kidney failure and duodenitis (inflammation of the first section of the small intestine) without bleeding. The hospital discharge documentation dated 5/30/24 identified Resident #427 was admitted and treated for acute kidney injury and duodenitis. Resident #427's abdomen was soft, non-distended, non-tender with normal bowel sounds, no documented diarrhea and noted the resident was stable for discharge to short term rehabilitation. The Nursing admission assessment dated [DATE] identified Resident #427 as alert and oriented to person, place, and time, had a distended abdomen, with no problems with digestion and no documented diarrhea. The (baseline)…

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, review of policy and staff interviews, for 1 of 2 resident reviewed for abuse (Resident #48), the facility failed to keep Resident #48 free from abuse during a witnessed resident-to-resident altercation. The findings include: 1. Resident #48's diagnoses including Alzheimer' disease and insomnia. A quarterly MDS assessment dated [DATE] identified Resident #48 as severely cognitively impaired and independent with eating and ambulation. Additionally, the MDS indicated that the resident did not experience any wandering or behaviors exhibited towards self or others. 2. Resident #75's diagnosis that included Alzheimer's disease and cognitive communication deficit. The quarterly MDS assessment dated [DATE] indicated Resident #75 had severe cognitive impairment and had not exhibited behaviors directed towards self or others. A facility Incident Report dated 4/30/2022 identified Resident #48 was struck in the chest by another resident (Resident # 75). The 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 clinical record review, observation and staff interviews for 1 of 1 resident reviewed for accidents (Resident #48), the facility failed to ensure the resident was administered medications as prescribed by the physician and within accordance to professional practice . The findings include: Resident #48's diagnoses including Alzheimer' disease and insomnia. The quarterly MDS assessment dated [DATE] indicated Resident #48 had severe cognitive impairment and was independent with eating and ambulation. The resident required partial or moderate assistance with personal hygiene and dressing. Additionally, the quarterly MDS indicated Resident #48 did not have any swallowing disorders. A care plan dated 5/8/2024 indicated the resident was at risk for aspiration related to dysphagia, advanced dementia, and requiring a ground diet consistency. Interventions included reporting signs of aspiration, keeping the head of the bed elevated during meals, and speech therapy as needed. The care plan also indicated 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, observations, facility documentation, facility policy and interviews for 1 of 3 sampled residents (Resident #427) reviewed for change of condition, the facility failed to ensure a nursing assessment was completed for resident with experiencing new onset of symptoms. The findings include: Resident #427's diagnoses included acute kidney failure and duodenitis (inflammation of the first section of the small intestine) without bleeding. a. The hospital discharge documentation dated 5/30/24 identified Resident #427 was admitted and treated for acute kidney injury and duodenitis. Resident #427's abdomen was soft, non-distended, non-tender with normal bowel sounds, no documented diarrhea and noted the resident was stable for discharge to short term rehabilitation. The Nursing admission assessment dated [DATE] identified Resident #427 as alert and oriented to person, place, and time, had a distended abdomen, with no problems with digestion and no documented diarrhea. The (baseline)…

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 sampled residents (Resident #103) reviewed for pressure ulcers, the facility failed to reassess the nutritional status and needs of a resident with newly identified wound(s). The findings include: Resident #103's diagnoses that included type II diabetes mellitus, obstructive sleep apnea and malignant neoplasm of the urethra/ bladder. The readmission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #103 was cognitively intact, required partial assist with bed mobility, total (2 person) assist with transfers, was at risk for the development of pressure ulcers and had one or more unhealed pressure ulcers. The Resident Care Plan dated 4/17/24 identified Resident #103 was at risk for impaired skin integrity related to impaired mobility and at nutritional risk due to malnutrition/terminal cancer. Interventions directed to implement the facility skin care protocol to include turning/positioning,…

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, observations, facility policy and interviews for 2 of 3 sampled residents (Resident #71 and Resident #103) reviewed for respiratory care, the facility failed to ensure respiratory equipment was stored and maintained in accordance with standards of practice. The findings include: 1. Resident #71's diagnoses included chronic obstructive pulmonary disease and essential hypertension. The quarterly Minimum Data (MDS) assessment dated [DATE] identified Resident #71 as moderately cognitively impaired and partial to moderate assist with activities of daily living. The Resident Care Plan (RCP) dated 3/21/24 identified Resident #71 had a respiratory therapy care plan with interventions that directed to administer nebulizer treatments as directed and observe for side effects. A physician's order dated 6/3/24 directed budesonide suspension for nebulizer 0.5mg/2ml via inhalation twice daily at 9:00 AM and 5:00 PM and Ipratropium-albuterol solution for nebulization 0.5mg/2.5mg base four times…

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 staff interviews for 1 of 5 resident (Resident #430) reviewed for Unnecessary Medication, the facility failed to ensure a psychotropic medication was re-evaluated for use. The findings include: Resident #430 's diagnoses included anxiety disorder, Major Depressive Disorder, and vascular dementia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #430 was (cognitive impaired) and required maximal assistance with eating and dressing and dependent with mobility. A physician's order dated [DATE] directed to give Lorazepam Intensol - Schedule IV concentrate; 2 mg/mL; amt: 0.5 mg (0.25 ml); oral Special Instructions: give every 4 hours and when needed (PRN) for restlessness/agitation Every 4 Hours - PRN PRN 1, PRN 2, PRN 3, PRN 4, PRN 5, PRN 6 End date indicates open ended Additionally notes indicates behavioral monitoring. A nurses note dated [DATE] at 11:04 AM indicated Resident #430 PRN Lorazepam and Haldol…

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, observations, facility documentation, facility policy and interviews for 2 of 25 sampled residents (Resident #121 and Resident #52) reviewed for food preferences, the facility failed to ensure a resident preference for food choice was honored. The findings include: 1. Resident #121's diagnoses included diverticulitis, atherosclerosis, and alcohol abuse. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #121 as moderately cognitively impaired and independent with activities of daily living. The Resident Care Plan dated 4/10/24 identified Resident #121 utilized an antidepressant to manage anxiety. Interventions directed to take complaints seriously and, understand likes and dislikes. The physician's orders dated 6/2/24 directed regular low fiber diet. Resident #121's meal ticket identified Resident #121 Liked selective menus and Disliked cereal. An interview with Resident #121 on 6/3/24 at 12:04 PM identified the residents were served real eggs and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for one of three sampled residents (Resident #2) who required bladder scans after the discontinuation of an indwelling urinary catheter, the facility failed to ensure the non-functioning bladder scanner (a non-invasive, portable ultrasound device that provides a virtual 3D image of the bladder and the volume of urine retained within the bladder) was repaired or replaced to conduct every shift bladder scans in accordance with the physician's order. The findings include: Resident #2's diagnoses included hydroureter, hydronephrosis with renal and ureteral calculous obstruction, urinary tract infections (UTI), tubule-interstitial nephritis, obstructive and reflux uropathy, megaloureter, calculus or ureter and congenital megaureter. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 rarely or never made decisions regarding tasks of daily life, was totally dependent on two (2) staff for turning 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 review of the clinical record, facility documentation and interviews for 1 of 3 residents (Resident #41) reviewed for nutrition, the facility failed to ensure the physician was notified of a significant weight loss. The findings include: Resident #41's diagnoses included end stage renal disease and cognitive communication deficit. The admission MDS dated [DATE] identified Resident #41 had moderately impaired cognition, required extensive assistance of two staff for transfers, required only set up for eating, weighed 251 pounds, and was receiving a specialized treatment for his/her diagnoses. The care plan dated 8/25/21 identified Resident #41 had a problem/concern of nutrition risk related to therapeutic diet, anemia, end stage renal disease and variable oral intake. Interventions included dietary consult as needed and notify physician of changes. Physician's order dated 8/17/21 directed diet: No concentrated sweets, low potassium, low phosphorus, regular consistency, thin liquids, and fluid restriction…

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, review of the clinical record, facility documentation and interviews for 3 residents (Resident #3, 39 and 98) on one unit, the facility failed to ensure rooms were maintained in a clean, homelike manner and in good repair. The findings included: Observation on 10/7/21 between 10:00 AM to 10:27 AM during a tour of the Apple Blossom unit the following observations were identified: a. In Resident #3's room, the edges of the squared-shaped louvers, of the ceiling vent, over the resident's bed were soiled with rust. The borders of the suspension grid for the ceiling tiles, to the right of the resident's bed and in the areas over the window, were soiled with a rust-colored like substance. A ceiling tile over the roommate's bed was identified as having a circular-shaped rust stain. The base board heater in the bathroom was identified as being soiled with specks of rust on its surface. The lower area of the door frame of the bathroom was identified as being marred and scarred with black smudges and linear markings. b. In Resident #39's room, the baseboard heater in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility documentation, facility policies, and interviews for one of three sampled residents (Resident#130) who ambulated independently with limited supervision, the facility failed to ensure the resident was free from being restrained in a chair. The findings include: Resident #130's diagnoses include vascular dementia with behavioral disturbances, anxiety and depression. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #130 rarely or never made decisions regarding tasks of daily life, required limited assistance of one (1) person with repositioning while in the bed, getting in and out of the bed and chair, ambulating on the unit, utilized a walker when ambulating and a restraint was not utilized. The resident care plan dated 2/12/20 identified Resident #130 is unable to be independent with self-care secondary to inability to sequence or initiate tasks related to dementia. Interventions included to provide assistance with activities of daily…

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 of three residents (Resident#130) who ambulated independently with limited supervision and was witnessed by staff to be restrained in a chair on two (2) separate occasions during one (1) shift, the facility failed to report the first incident to the licensed staff to prevent a second incident. The findings include: Resident #130's diagnoses include vascular dementia with behavioral disturbances, anxiety and depression. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #130 rarely or never made decisions regarding tasks of daily life, required limited assistance of one (1) person with repositioning while in the bed, getting in and out of the bed and chair, ambulating on the unit, utilized a walker when ambulating and a restraint was not utilized. The resident care plan dated 2/12/20 identified Resident #130 is unable to be independent with self-care secondary to inability to sequence or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation and interviews for 1 of 3 residents (Resident #41) reviewed for nutrition, the facility failed to ensure weights were monitored and failed to ensure weight loss was reported to physician and dietician. The findings include: Resident #41's diagnoses included end stage renal disease and cognitive communication deficit. The admission MDS dated [DATE] identified Resident #41 had moderately impaired cognition, required extensive assistance of two staff for transfers, required only set up for eating, weighed 251 pounds, and was receiving a specialized treatment for his/her diagnoses. The care plan dated 8/25/21 identified Resident #41 had a problem/concern of nutrition risk related to therapeutic diet, anemia, end stage renal disease and variable oral intake. Interventions included dietary consult as needed and notify physician of changes. Physician's order dated 8/17/21 directed diet: No concentrated sweets, low potassium, low phosphorus, regular…

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, facility policies, and interviews for one of three sampled residents (Resident #127) who had a change of condition and required Cardio-Pulmonary Resuscitation (CPR), the facility failed to ensure staff were educated on the requirement of oxygen with an Ambu bag. The findings include: Resident #127's diagnoses included dementia, carotid artery stenosis and diverticulitis. The admission Minimum Data Set assessment dated [DATE] identified Resident #127 rarely or never made decisions regarding tasks of daily life and required extensive assistance of one (1) or two (2) staff with activities of daily living. A physician's order dated [DATE] directed a Full Code for the Advanced Directives. A physician's order dated [DATE] directed to obtain a chest x-ray to rule out pneumonia and as needed oxygen via nasal cannula titrate to maintain oxygen saturation level of 92%. The nurse's note dated [DATE] at 11:26 PM Resident #127 continued on antibiotics for 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 review of the clinical record, facility documentation and interviews for 1 resident (Resident #41) receiving a specialized treatment, the facility failed to ensure the resident did not receive a medication that was contraindicated for his/her diagnosis. The findings include: Resident #41's diagnoses included end stage renal disease. The admission MDS dated [DATE] identified the resident had moderately impaired cognition, required extensive assistance of two staff for toileting, and was receiving a specialized treatment for his/her diagnosis. The care plan dated 8/25/21 identified the resident had end stage renal disease with interventions that included to educate the resident if necessary. A physician's order dated 8/9/21 directed to administer Bisacodyl (OTC) suppository 10 mg, per rectal administration as needed once a day for constipation, use second, on 8/15/21, without effect. Additionally, the order directed to administer a disposable enema, (sodium phosphates) (OTC) 19-7 grams/118 ml, one enema…

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 and interviews for 1 resident (Resident #41) receiving a specialized treatment, the pharmacist failed to identify and report an irregularity. The findings include: Based on review of the clinical record, interviews and review of facility policy, for one of one resident reviewed for Dialysis, Resident # 41, the facility pharmacist failed to identify and report an irregularity in medication orders for a resident receiving dialysis. The findings include: Resident #41's diagnoses included end stage renal disease. The admission MDS dated [DATE] identified the resident had moderately impaired cognition, required extensive assistance of two staff for toileting, and was receiving a specialized treatment for his/her diagnosis. The care plan dated 8/25/21 identified the resident had end stage renal disease with interventions that included to educate the resident if necessary. A physician's order dated 8/9/21 directed to administer Bisacodyl (OTC) suppository…

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 interview for 1 of 3 residents reviewed (Resident #131) the facility failed to ensure that the resident's record was complete. The finding included: Resident #131's diagnosis included left femoral neck fracture with surgical repair. An admission assessment dated [DATE] identified that the resident was admitted to the facility at 3:45 PM and was alert and nonverbal and appeared to understand simple questions and tasks and the resident was cooperative with care. The admission assessment further identified that the resident required extensive assistance for ADLs and ambulation, was partially incontinent of bowel and had a Foley (indwelling) catheter that was patent and draining clear yellow urine. The assessment failed to identify the amount of urine output. Review of a care plan dated 5/28/21 identified that the resident had a Foley catheter with interventions that included to provide catheter care per facility protocol, empty…

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, review of facility documentation and interviews, the facility failed to ensure the walk-in freezer and walk-in refrigerator was maintain in safe operating condition. The findings included: On 10/7/21 at 9:30 AM to 9:55 AM during tour of the Kitchen with the Food Service Director (FSD) observations of the following concerns were identified: a. The walk-in freezer had four large patches of ice on the floor in an opened space in front of a storage rack where frozen foods are stored and retrieved by staff. It was further noted that the ceiling area of the walk-in freezer was covered with several frozen droplets of ice. An interview with the FSD at the time, indicated that she hadn't seen the patches of ice or frozen droplets prior to the inspection and had no explanation as to how the ice had formed or why it was there, but would ensure that the patches and droplets of ice would be removed. b. The walk-in refrigerator was noted as having a large puddle of water on the floor to the right of the door. An interview with the FSD at the time indicated she wasn't aware…

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.