Autumn Lake Healthcare At Norwalk

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, review of facility documentation and staff interviews for 1 of 4 (Residents #17) reviewed for accidents, the facility failed to ensure that a resident's environment was free of potential hazards and failed to provide adequate interventions to mitigate fall risk, including ensuring safe footwear and a clear ambulatory path during a period of increased risk related to a recent lower extremity injury and the facility failed to ensure that the main entrance non-smoking area was free of cigarette butts to prevent a potential hazard. The findings included: Resident #17's diagnoses included orthopedic conditions, phantom limb syndrome with pain, cervical disc degeneration, chronic pain syndrome, cervical radiculopathy, heart failure, asthma, bipolar disorder, depression, anxiety, and schizoaffective disorder. A Resident Care Plan (RCP) initiated 7/14/24 and last updated 9/9/25, indicated the resident preferred to wear gripper socks and declined shoes. Interventions included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record, review of facility policy and staff interviews for 1of 1 resident (Resident # 5) reviewed for specialized treatment, the facility failed to ensure physician orders were obtained for a specialized type of venous access site, its location, assessment and care for the access site and failed to avoid medications prohibited as outlined in the facility policy. The findings include:Resident #5's diagnosis includes End Stage Renal(kidney) Failure. The physician's orders dated 2/7/2026 directed to have Resident #5 attend appointments at a specialized service facility for treatment of the End Stage Renal Failure 3 times per week.A physician's order dated 2/7/2026 included to provide Milk of Magnesia 30 milliliters (ml) by mouth as needed for constipation and a Fleet enema (brand name rectal solution used for constipation for quick results) on day 3 if there is no bowel movement after day 2. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #5 was cognitively intact…

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, observation and staff interviews for 1 of 5 residents (Resident # 130) reviewed for unnecessary medications, the facility failed to ensure the physician acted upon a pharmacy recommendation timely. The finding included. Resident # 130's diagnoses included adjustment disorder, atherosclerotic heart disease, cerebral infarction, hypertension, anemia, cystic disease of the liver, cystic of the kidney, polyneuropathy, bradycardia and osteoarthritis.A Medicare 5-Day Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #17 was cognitively intact. The resident used no assistive device for mobility, had a reduced range of motion on one side of the upper extremities, required set-up assistance for eating and showering, moderate assistance for toilet hygiene and repositioning, and was independent with oral hygiene, dressing, and transfers .A review of the Pharmacy Recommendation report dated 11/9/25 for Resident # 130 noted a recommendation…

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

Based on review of the clinical records, review of facility policy and staff interview for 1 of 4 residents (Resident # 130) reviewed for accidents, the facility failed to ensure the clinical record was complete and accurate. The findings include: Resident #130's diagnosis included dementia and cerebral infarction.The 06/13/2025 quarterly Minimum Data Set (MDS) Assessment indicate Resident #130 had moderate cognitive decline.The care plan dated 06/18/2025 indicated Resident #130 had altered cardiovascular status with interventions to assess for chest pain, shortness of breath and cyanosis(when oxygen moves away from the lips and nail beds, leaving the skin/nailbeds a blue/gray color versus pink), and to report changes to the physician.A progress note labeled Change in Condition dated 08/15/2025 at 05:06 PM indicated resident #130 was sitting in a wheelchair and noted to be pale and unresponsive the physician was notified and an order obtained to be sent to the emergency room. 911 was called while awaiting their arrival Resident #130 had become alert and was at his/her baseline 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 record review, facility documentation, and staff interviews for one of three residents (Resident #1) reviewed for advanced directives, the facility failed to ensure the code status was obtained from the legal representative, and failed to ensure the medical record included the accurate advance directives. The findings include: Resident #1 had a diagnosis of dementia, hypertension (high blood pressure), and cirrhosis of the liver. Record review identified Resident #1 had a court appointed Conservator of Person (COP), with an effective date of [DATE]. The COP was listed as Emergency Contact #1 in the record. Advanced Directives Level of Treatment Options dated [DATE] identified the form directed DNR (Do Not resuscitate) - No CPR will be performed, CMO (Comfort Measures Only/DNR/DNI (Do Not Intubate) - no CPR will be performed. The form was signed by Emergency Contact #2. Additional review identified the line for the COP to sign was blank, and the line for the physician to sign was blank. Physician…

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 record review, facility documentation, and staff interviews for one of three residents (Resident #1) reviewed for quality of care, the facility failed to ensure the medical record was complete and accurate to include the responsible party was notified of a change in condition. The findings include: Resident #1 had a diagnosis of dementia, hypertension (high blood pressure), and cirrhosis of the liver. Record review identified Resident #1 had a court appointed Conservator of Person (COP), effective [DATE]. The COP was listed as Emergency Contact #1 in the record. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #1 had a Brief Interview Mental Status (BIMS) score of 7 indicating severely impaired cognition. Resident Care Plan (RCP) dated [DATE] identified a full code status with interventions that directed to administer Cardiopulmonary Resuscitation (CPR) as needed. The nursing note dated [DATE] at 9:23 AM identified staff notified the supervisor at approximately 8:15 or 8:20 AM 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 clinical record review and staff interview for one of three residents (Resident #1) reviewed for discharge the facility failed to notify the discharging facility timely that they would not readmit the resident following hospitalization. The findings include: Resident #2's diagnoses included anxiety, depressive episodes, and substance abuse. A quarterly MDS dated [DATE] identified Resident #2 was alert and oriented, and was independent with ADLs and transfers. The RCP dated 10/4/2023 identified Resident #2 had intermittent agitation, inappropriate behaviors toward staff in a sexual nature, and non-complaint with care. Interventions directed to explain why behavior is inappropriate. APRN note dated 10/30/2023 at 10:12 AM identified Resident #2 was seen for angry and defensive behaviors, making verbal threats to staff and visitors. Directed to transfer to the hospital for evaluation due to threats of bodily harm to staff. Police were notified and with resident pending transfer. Record review identified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview for one of three residents (Resident #1) reviewed for discharge, the facility failed to ensure a complete and accurate record to include documentation regarding a readmission or refusal to readmit a resident. The findings include: Resident #2's diagnoses included anxiety, depressive episodes, and substance abuse. A quarterly MDS dated [DATE] identified Resident #2 was alert and oriented, and was independent with ADLs and transfers. The RCP dated 10/4/2023 identified Resident #2 had intermittent agitation, inappropriate behaviors toward staff in a sexual nature, and non-complaint with care. Interventions directed to explain why behavior is inappropriate. APRN note dated 10/30/2023 at 10:12 AM identified Resident #2 was seen for angry and defensive behaviors, making verbal threats to staff and visitors. Directed to transfer to the hospital for evaluation due to threats of bodily harm to staff. Police were notified and with resident pending transfer. Record review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #93) reviewed for personal property, the facility failed to ensure the resident's personal property was kept safe from loss and based on tour of the environment, the facility failed to maintain a safe, clean, comfortable, and homelike environment. The findings include: 1. Resident #93 was admitted to the facility on [DATE] with diagnoses that included hypertension, chronic kidney disease, and depression. Review of the social services notes and grievance log dated 4/25/24 through 7/22/24, three months, failed to identify that Resident #93 had reported personal items were missing. The admission MDS dated [DATE] identified Resident #93 was cognitively intact, had no active neurological diagnoses (including dementia), required set-up assistance for upper body dressing, and required a partial assist for lower body dressing. The care plan dated 5/13/24 failed to identify 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 observation, review of facility policy and interviews, the facility failed to ensure food was prepared under sanitary conditions within professional standards. The findings included: Observation on 7/16/24 at 9:36 AM during BFSI tour of the kitchen with the Maintenance Assistance identified [NAME] #1 at the three compartment sinks thawing frozen chicken in a deep pot under running cold water in the third sink. The first sink was full of dirty pots and bowls soaking in a sink full of water with suds. The second sink was identified with a moderate amount of soap suds and food debris. The third sink was identified with a deep pot with chicken under running cold water with [NAME] #1 preparing the chicken without the benefit of gloves. Interview with the Dining Services Director (DSD) on 7/16/24 at 10:40 AM identified he was not aware of the issue. The DSD indicated [NAME] #1 should not have used the three compartment sinks for prepping or thawing out the chicken. The DSD indicated the kitchen has 2 preparation sinks and one of the preparation sinks is used for meat. Interview…

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 1 resident (Resident #23) who required hospice care, the facility failed to honor the request for a specific hospice provider. The findings include: Resident #23 was admitted to the facility with diagnoses that included dementia, weight loss, and chronic obstructive pulmonary disease. The quarterly MDS dated [DATE] identified Resident #23 had severely impaired cognition, was always incontinent of bowel and bladder and required extensive assistance with dressing, toileting, and personal hygiene. The care plan dated 3/23/24 identified advanced directives. Interventions included providing end of life care per resident wishes and discuss with resident and resident representative. The APRN progress note dated 7/8/24 at 4:00 PM identified she spoke with Person #1 about overall generalized decline with weight loss, increased sleeping, and poor oral intake. Person #1 would like Hospice Agency #1 referral, they have used…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interview for 1 resident (Resident #44) who had a personal funds account managed by the facility, the facility failed to ensure the resident had ready and reasonable access to those funds. The findings include: Resident #44 was admitted to the facility on [DATE] with diagnoses that included cardiomyopathy, insulin dependent diabetes, and anxiety disorder. The quarterly MDS dated [DATE] identified Resident # 44 had intact cognition. The care plan dated 11/3/23 identified Resident #44 had been admitted to the facility for short term rehab. Interventions included collaboration between the interdisciplinary team and the resident to develop a discharge plan. Interview with Resident #44 on 7/14/24 at 10:25 AM identified he/she had several issues with accessing personal funds at the facility. Resident #44 identified that he/she should be receiving $75 monthly but since admission to the facility in July 2023, access to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interview for 1 resident (Resident #44) reviewed for personal funds, the facility failed to ensure that a resident who had funds managed by the facility was provided quarterly statements, in a clear and understandable manner and upon request, failed to ensure that facility staff utilized generally accepted accounting principles and failed to ensure the funds were in an interest bearing account. The findings include: Resident #44 was admitted to the facility on [DATE] with diagnoses that included cardiomyopathy, insulin dependent diabetes, and anxiety disorder. The quarterly MDS dated [DATE] identified Resident #44 had intact cognition. The care plan dated 11/3/23 identified Resident #44 had been admitted to the facility for short term rehab. Interventions included collaboration between the interdisciplinary team and the resident to develop a discharge plan. A social service note dated 4/9/24 identified she sent an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, and interviews for 2 of 3 residents (Resident #45 and 93) reviewed for advance directives, the facility failed to obtain, as soon as possible after admission, the resident/resident representatives wish for code status (code status refers to the level of medical interventions a person wishes to have started if their heart or breathing stops). The findings include: 1. Resident #45 was admitted to the facility on [DATE] with diagnoses that included acute kidney failure and dementia. The admission MDS dated [DATE] identified Resident #45 had severely impaired cognition. The care plan dated [DATE] had interventions that included discussing Resident #45's code status with the resident and resident representative and have consent signed. Review of the clinical record including the admission paperwork on [DATE], over 2 months after the resident's admission, identified the 2-page Advance Directives Level of Treatment Options forms were blank. Interview with LPN #6…

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 1 of 3 residents (Resident #110) reviewed for accidents, the facility failed to notify the physician when the resident returned from the hospital with a new mild anterior displacement of the right humerus with regards to the glenoid which could represent an anterior glenohumeral dislocation. The findings include: Resident #110 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, pulmonary embolism, rheumatoid arthritis, and repeated falls. The quarterly MDS dated [DATE] identified Resident #110 had intact cognition and required maximum assistance toileting and moderate assistance with dressing and personal hygiene. Additionally, was extensive assistance for transfers. The care plan dated 5/14/24 identified Resident #110 was at risk for falls related to history of falls. Interventions included to encourage out of bed daily and wear proper footwear. 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 1 of 4 residents (Resident #42) reviewed for Preadmission Screening and Resident Review (PASARR), the facility failed to complete a PASARR rescreen after the expiration of a 30-day approval. The findings include: A Notice of PASARR Level I Screen Outcome dated [DATE] identified Resident #42 received an outcome of exempted hospital discharge 30-day approval. The outcome rationale directs that a 30-day or less stay in the nursing facility is authorized and a re-screening must occur by or before the 30th day if the individual is expected to remain in the nursing facility beyond the authorization timeframe. Resident #42 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, schizophrenia, bipolar disorder, and depressive episodes. The admission MDS dated [DATE] identified Resident #42 had intact cognition and had not been evaluated by Level II PASARR and was determined to have 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, facility policy, and interviews for 2 of 5 residents (Resident #2 and 39) reviewed for Preadmission Screening and Resident Review (PASARR), the facility failed to notify the state mental health authority of a change in mental health diagnosis. The findings include: 1. A PASARR (received from prior facility) dated 9/21/18 identified Resident #2 had a diagnosis of anxiety and bipolar disorder. The resident was approved for long term care on 9/14/18 with specialized services recommended. Resident #2 was admitted to the facility on [DATE] with diagnoses that included anxiety and bipolar disorder. A physician's order dated 9/2/21 directed to obtain a psychiatric evaluation and to treat resident as indicated. The care plan dated 9/2/21 identified Resident #2 had impaired cognition. Interventions included administering psychotropic medications per the physician's order. The admission MDS dated [DATE] identified Resident #2 had severely impaired 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 policy, and interviews for 1 of 5 residents (Resident #49) reviewed for unnecessary medications, the facility failed to develop a comprehensive care plan for a resident with a history of dementia. The findings include: Resident #49 was admitted to the facility on [DATE] with diagnoses that included moderate dementia with other behavioral disturbances and delirium due to a known physiological condition. The quarterly MDS dated [DATE] identified Resident #49 had moderately impaired cognition, non-Alzheimer's dementia, and was receiving anti-psychotic medication on a routine basis. The care plan dated 6/19/24 failed to identify goals and interventions for the residents diagnoses dementia. Interview with the DNS on 7/23/24 at 9:54 AM identified that she would expect to see a dementia care plan, and that there is documentation that the resident had non-Alzheimer's dementia diagnosis in the baseline care plan, so she was unsure why it was not carried over 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 review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #44) reviewed for personal funds, the facility failed to invite the resident and resident representative to the resident care conferences and failed to ensure the resident care conferences were held timely. The findings include: Resident #44 was admitted to the facility on [DATE] with diagnoses that included cardiomyopathy, insulin dependent diabetes, and anxiety disorder. The quarterly MDS dated [DATE] identified Resident #44 had intact cognition. The care plan dated 11/3/23 identified Resident #44 had been admitted to the facility for short term rehab. Interventions included collaboration between the interdisciplinary team and the resident to develop a discharge plan. Interview with Resident #44 on 7/14/24 at 10:25 AM identified that he/she could not remember the last time he/she was invited to or participated in a care conference with facility staff. Review of the clinical record on 7/14/24…

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 review of the clinical record, facility documentation, facility policy, and interviews for 2 of 3 residents (Resident #6 and 112) reviewed for accidents, the facility failed to ensure the Registered Nurse (RN) completed an assessment after a fall and prior to moving the resident off the floor or that neurological assessments were completed after falls or the RN assessed the resident after new bruising of the skin was found. The findings include: 1. Resident #6 was admitted to the facility with diagnoses that included drug induced parkinsonism, schizophrenia, hearing loss, hypertension, and osteoporosis. The quarterly MDS dated [DATE] identified Resident #6 had severely impaired cognition and required extensive assistance with dressing, bed mobility, and transfers. Resident #6 was supervision using a walker or wheelchair for locomotion in the room and on unit. Resident #6 was not steady with walking, turning around, moving on and off toilet, and moving from a seated to standing position. 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 review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #23) reviewed for positioning, the facility failed to ensure the air mattress was set to the resident's weight as per the physician's order and for 1 resident (Resident #94), who was dependent of staff for care, the facility failed to ensure a helmet, which was recommended by a neurosurgeon to be worn while the resident was out of bed, was consistently applied. The findings include: 1. Resident #23 was admitted to the facility with diagnoses that included dementia, weight loss, and chronic obstructive pulmonary disease. A physician order dated 5/12/24 directed the use of an air mattress to be set at 160lbs. - 200 lbs., check setting and function every shift and provide the assistance of 2 out of bed. The quarterly MDS dated [DATE] identified Resident #23 had severely impaired cognition, was always incontinent of bowel and bladder and required extensive assistance with dressing, toileting, 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 policy, and interviews for 2 of 4 residents (Resident #94 and 111) reviewed for pressure ulcer/injury, the facility failed to ensure the Braden Scale (an assessment tool used to assess a resident's risk of developing pressure ulcers) and weekly skin assessments were completed per the physician's order and failed to ensure an RN assessment was documented in the clinical record upon the identification of a new pressure ulcer. The findings include: 1. Resident #94 was admitted to the facility on [DATE] with diagnoses that included a stroke, middle cerebral artery syndrome, and dysphagia. A physician's order dated 2/2/24 directed to complete a body audit on admission and daily for a total of 3 days, then every Wednesday on the evening shift. The Admit/Readmit Screener dated 2/2/24 identified Resident #94 had a surgical incision, including 61 staples to the scalp and a coccyx pressure injury, (without measurements). Although requested, a Braden Risk Assessment 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 observations, review of facility documentation, facility policy, and interviews, for 6 residents (Residents #8, 11, 57, 64, 88, and 120) who attend the fall prevention program, the facility failed to ensure adequate supervision was maintained and for 1 resident (Resident #97) who had been found smoking at the facility and had contraband in his/her possession, the facility failed to ensure adequate supervision of the resident to ensure the resident's individual safety, as well as the safety of others in the facility and for 2 of 5 residents (Resident #111 and 94) who were reviewed for accidents and/or wandered, the facility failed to ensure interventions were revised to prevent future falls and failed to provide supervision to prevent an elopement. The findings include: 1. Residents #8, 11, 57, 64, 88, and 120 had care plans that indicated they were at risk for injuries related to falls. Interventions included allowing the resident to choose the time to participate in the fall program and to encourage…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, and interviews for 1 resident (Resident #42) reviewed for pain management, the facility failed to administer an as needed (PRN) pain medication when the resident had pain and requested the medication. The findings include: Resident #42 was admitted to the facility on [DATE] with diagnoses that included an infection following a procedure, deep incisional surgical site, infective bursitis, cellulitis, and phantom limb syndrome with pain. The physician's order dated 6/6/24 directed to administer the following. 975mg Acetaminophen, by mouth, three times daily, for pain 2mg Benztropine Mesylate, by mouth, once daily, for phantom pain 4mg Hydromorphone, by mouth, every 6 hours as needed (PRN), for severe pain (verbal report 8-10). The admission MDS dated [DATE] identified Resident #42 had intact cognition, had a surgical wound, was receiving IV (intravenous) antibiotics, and reported occasional moderate pain. The care plan dated 6/21/24 identified Resident #42…

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, facility policy, and interviews for 2 of 7 medication carts, the facility failed to ensure shift to shift controlled drugs count was consistently completed. The findings include: a. Observation on 7/22/24 at 9:47 AM of the medication carts on the first floor with the DNS identified the July 2024 controlled drugs count record (the on-coming and off-going nurses complete to ensure all controlled drugs are counted) were missing signatures on multiple dates on the 7:00 AM - 3:00 PM shift, 3:00 PM - 11:00 PM shift, and 11:00 PM - 7:00 AM shift on the 1B unit. The 1B unit controlled drugs count record was missing 11 signatures. Interview with the DNS on 7/22/24 at 9:50 AM identified she was not aware of the missing controlled drugs count signatures until now. The DNS indicated it was the responsibility of all the nurses to sign the controlled drugs count record at the beginning of the shift and at the end of each shift when the controlled drugs count is completed. b. Observation on 7/23/24 at 6:45 AM of the medication carts on 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.

Based on observation, review of facility policy, and interviews the facility failed to store personal protective equipment, PPE (protective items or garments worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross-transmission) in a sanitary manner for a resident identified on transmission-based precautions. The findings include: Observation on 7/14/24 at 8:09 AM with LPN #3 identified an isolation cart containing PPE. LPN #3 reached into the cart, into the 3rd drawer area from the side (there was no 3rd drawer), and the PPE was observed to be stored on the floor in the 3rd drawer slot. LPN #3 could not provide an explanation of the missing drawer or contents being stored on the floor. The policy for PPE storage identified that appropriate infection prevention and control equipment and supplies are obtained, stored and used in accordance with current guidelines and manufacturer instructions.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for a resident to resident altercation the facility failed to ensure that an intervention entered into the plan of care was specific to identify how the resident would be monitored after the incident. The findings include: Resident # 1 had diagnoses that included dementia with behavioral disturbances, adjustment disorder with depressed mood, and anxiety. The quarterly Minimum Data Set, dated [DATE] identified Resident #1 had severely impaired cognition, had bowel and bladder incontinence, required substantial assistance with activities of daily living and could be physically aggressive as evidenced by hitting and punching staff during care with interventions that directed to provide two staff with care. Review of the Facility's Accident and Incident form dated 2/22/2024 at 11:20 A.M. LPN #1 reported that while she was at the nurse's station she heard someone…

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 interviews for one resident (Resident #38) reviewed for choices, the facility failed to accommodate the resident's preferences regarding showers. The findings include: Resident #38 was admitted to the facility in August 2017 with diagnoses that included hemiplegia and hemiparesis following a cerebral infarction affecting right dominant side and diabetes mellitus. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #38 had intact cognition, was frequently incontinent of bladder and always incontinent of bowel. The assessment also noted the resident required extensive assistance with dressing, toileting, personal hygiene, transfers with assist of 1 staff. The care plan dated 9/29/21 identified a had occasional incontinence. Interventions directed to do biweekly skin checks on shower days and as needed. Additionally, noted requires staff participation in bathing and to check nail length and trim and clean on bath…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record reviews, facility policy and interviews for one resident (Resident #33) reviewed for Ambulation, the facility failed to ensure restorative ambulation was completed per physician's order and for one sampled resident ( Resident # 38) reviewed for splint application the facility failed to ensure the resident's splint was applied with in accordance to the plan of care and for one sampled resident ( Resident # 83) reviewed for oxygen /BIPAP use, the facility failed to ensure that physician's orders were obtained for oxygen use /BIPAP . The findings included: 1.Resident #33 was admitted to the facility in May 2020 with diagnoses that included dementia with behavioral disturbances, subdural hemorrhage, displaced fracture of olecranon, fracture of nasal bone, fracture of orbital floor, displaced fracture of the 5th cervical vertebra, fracture of lateral condyle, of right tibia, and fracture of sacrum. The annual MDS assessment dated [DATE] identified Resident #33 had severely…

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, observations, review of facility policy and interviews for one resident (Resident #83) reviewed for oxygen therapy, the facility failed to obtain a physician's order for the utilization of the oxygen, changing the resident's oxygen tubing and Bipap tubing/mask within accordance to facility policy. The findings include: Resident #83 was readmitted to the facility on [DATE] with diagnoses that included obstructive sleep apnea, chronic obstructive pulmonary disease, chronic respiratory failure with hypercapnia and encephalopathy. The Resident Care Plan dated 9/21/21 identified Resident #83 had altered respiratory status/Difficulty Breathing related to Respiratory Failure, Restrictive Lung Disease, shortness of breath and chronic obstructive pulmonary disease. Interventions directed to elevate head of bed as resident can tolerate, encourage sustained deep breaths by: Using demonstration (emphasizing slow inhalation, holding end inspiration for a few seconds, and passive…

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.