Shady Knoll Center For Health & Rehabilitation

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 #103) reviewed for choices, the facility failed to support a resident's choice related to assistance with oral care. The findings include:Resident #103 had diagnoses that included hemiplegia (paralysis)and hemiparesis (muscle weakness) following a stroke affecting the left side, Moyamoya disease, and cognitive communication deficit.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #103 was moderately cognitively impaired and the behavior of rejection of care was not exhibited. The MDS assessment also identified Resident #103 required setup or clean-up assistance with oral hygiene, was dependent with personal hygiene, and required substantial/maximal assistance with bed mobility.The Resident Care Plan (RCP) dated 5/27/25 identified Resident #103 required assistance with activities of daily living (ADL) care and mobility related to a significant…

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 5 residents (Resident #35) reviewed for unnecessary medications, the facility failed to ensure that weekly weight monitoring was completed timely. Additionally, for 1 of 5, (Resident #44) reviewed for activities of daily living (ADL), the facility failed to re-evaluate the continued use of mobility equipment and plan of care for its continued use following the removal of a motorized chair. The findings include:1.Resident # 35 was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), and heart failure.A hospital Inter-Agency Referral (W-10) document dated 4/2/25 identified Resident #35 was hospitalized from [DATE] to 4/2/25 for acute and chronic respiratory failure. The hospital documentation identified that Resident #35 was discharged to the long-term care facility on 4/2/25 with medication orders to continue…

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, and interviews for 1 of 5 residents (Resident # 44) reviewed for unnecessary medications, the facility failed to ensure that a resident with recent history of tobacco use was assessed for smoking upon admission and re-admission to the facility; and failed to ensure that the resident was free of smoking materials within the facility; and failed to ensure interventions were in place following the identification of smoking/vaping materials within the facility. The findings include:Resident # 44 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), diabetes, and failure to thrive. A hospital Discharge summary dated [DATE] identified Resident #44 was transferred to the long term care facility on 3/1/25 following hospitalization. The hospital discharge summary further identified Resident #44 had a prior history of vape use, and recent tobacco use which included smoking a 1/2 pack of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, facility documentation, facility policy and interviews for 1 of 3 sampled residents (Resident #67) reviewed for choices, the facility failed to ensure a meal was provided according to preference and served in a timely manner. The findings include:Resident #67 had diagnoses that included chronic kidney disease and calculus of the gallbladder.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #67 was cognitively intact and independent with eating.The Resident Care Plan dated 5/19/25 identified Resident #67 with a nutritional diagnosis of obesity with limited mobility. Interventions included providing the diet as ordered and honoring the resident's food/beverage preferences.Physician orders dated 5/30/25 directed a 2 gram (GM) Sodium (2 GM Na+) diet, regular texture with thin (no thickening agent required) consistency fluids.An interview with Resident #67 on 6/23/25 at 11:04 AM identified he/she cannot have salt or milk as it caused…

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, staff interviews, and facility policy for 1 of 4 residents (Resident #102) reviewed for activities of daily living (ADL), the facility failed to refer resident to physical therapy (PT) and occupational therapy (OT) after identifying a decline in ADLs. The findings include:Resident #102's diagnoses included unspecified Alzheimer's disease, functional quadriplegia, and weakness.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #102 was severely cognitively impaired and required setup or clean-up assistance with eating, supervision or touching assistance with oral hygiene, and partial to moderate assistance with personal hygiene.The quarterly MDS assessment dated [DATE] identified Resident #102 was severely cognitively impaired and dependent on staff for eating, oral hygiene, and personal hygiene (a decline from the 1/29/25 quarterly MDS).The Resident Care Plan dated 5/19/25 identified Resident #102 had a deficit in self-care related 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 clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for dialysis, the facility failed to ensure the physician was notified of a missed dialysis treatment timely. The findings include: Resident #2's diagnoses included end stage renal disease. The annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident # 2 was alert and oriented and required dialysis. The Resident Care Plan (RCP) dated 12/4/2022 identified that Resident #2 required hemodialysis. Interventions directed resident requires dialysis three (3) times per week, and facility to provide/schedule transportation. A physician order dated 12/27/2022 directed dialysis days: Monday, Wednesday, and Friday, AMR ambulance pick up at 10:10 AM via wheelchair to dialysis center. The nursing note dated 12/28/2022 at 4:31 AM identified the dialysis center called and indicated that since Resident #2 was positive for COVID-19, Resident #2 would need…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review and interviews for one of three residents (Resident #2) reviewed for dialysis, the facility failed to ensure transportation was scheduled timely for a resident who required dialysis treatments, and failed to maintain a dialysis communication book for a resident who required dialysis treatments. The findings include: Resident #2's diagnoses included end stage renal disease. The annual Minimum Data Set (MDS) assessment dated [DATE] identified that Resident # 2 was alert and oriented and required dialysis. The Resident Care Plan (RCP) dated 12/4/2022 identified that Resident #2 required hemodialysis. Interventions directed resident requires dialysis three (3) times per week, and facility to provide/schedule transportation. A physician order dated 12/27/2022 directed dialysis days: Monday, Wednesday, and Friday, AMR ambulance pick up at 10:10 AM via wheelchair to dialysis center. The nursing note dated 12/28/2022 at 4:31 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 #1) reviewed for ADLs, the facility failed to ensure the clinical record was complete and accurate to include oral care provided and/or refused. The findings include: Resident #1's diagnoses included Parkinson's disease, dysphagia (difficulty swallowing) and a cognitive communication deficit. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition and required set up assistance with oral hygiene. The Resident Care Plan (RCP) dated 4/9/2024 identified Resident #1 had forgetfulness/confusion at times due to dementia and Parkinson's. Interventions directed allow the resident to make daily decisions about clothing, daily care, meal alternatives, offer support/reassurance as needed. Review of nurse aide care card dated/revised 4/5/2024 directed set up for personal hygiene. Review of May 2024 ADL flowsheet indicated…

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, facility documentation, and interviews for one (1) of three (3) residents reviewed for a change in condition, (Resident #1), the facility failed to notify the physician of a decline in a resident's oral intake. The findings included: Resident #1's diagnoses included diffuse traumatic brain injury, and hemiplegia. Review of the Care Card dated 7/27/23 identified Resident #1 was a total feed. Review of the Quarterly Diet Nutrition Evaluation dated 12/18/23 identified that the resident required an estimated fluid need of 1975 milliliters (ml) to 2370 ml per day. The Quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had sever cognitive impairment and was dependent with eating. The Resident Care Plan dated 1/9/24 identified Resident #1 as at risk for dehydration related to fluid volume deficit, at increased nutritional risk due to mechanically altered diet, dysphagia, and required staff to feed at meal time with interventions that directed to monitor intake…

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 and interviews of the third floor call bell system, the facility failed to ensure that the call bell system was audible at the call bell panel at the nurse's station and could be heard throughout the nursing unit. The findings include: Tour of the third floor on 4/16/24 at 9:45 AM identified that rooms [ROOM NUMBERS] call lights were lit up and blinking above the door, however, the call bell had no audible sound and could not be heard. Observation of the nurse's station where the call bell system panel was located identified that the rooms where the call bells were activated were lit up on the system, however there was no sound coming from the system panel. When standing by the medication room, adjacent from the nurses station, a faint call bell sound could be heard, although the the sound was not loud enough to be heard on the nursing unit. Interview with the Administrator at the time of the observation identified that the call bell should be ringing at the nurse's station loud enough 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 job descriptions, and interviews, for 5 of 5 units, the facility failed to ensure the environment was maintained in good repair and in a homelike manner. The findings include: Observation on 10/18/23 at 2:55 PM through 3:08 PM identified the following. a. Damaged, chipped, holes, stains, and/or marred bedroom walls on Magnolia C unit in rooms 201, 202, 203, 204, 205, 207, 210, and 212. Magnolia B unit in rooms 215, 216, 218, 220, 222, and 224. Magnolia A unit in rooms 226, 227, 233, and 234. [NAME] B unit in rooms [ROOM NUMBER]. [NAME] A unit in rooms [ROOM NUMBER]. b. Damaged, and stains on the bedroom ceiling tiles on [NAME] A unit in room [ROOM NUMBER]. c. Damaged, chipped, stains, and/or marred bedroom radiators on [NAME] A unit in rooms 328, and 333. Willow B unit Lounge: Damaged, chipped, holes, stains, and/or marred walls. Damaged, and stains on the ceiling tiles. Third floor exit door to the elevator corridor: Damaged, stains, and/or marred on door. Interview on 10/18/23…

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, the facility failed to ensure that licensed staff maintained their Cardio-Pulmonary Resuscitation (CPR) certification. The findings include: Review of facility documentation identified 6 licensed personnel currently have expired CPR certifications. Interview with the DNS [DATE] at 10:40 AM regarding CPR certification identified 6 licensed personnel currently have expired CPR certifications. The DNS indicated it is her expectation that licensed personnel maintain CPR certifications and identified she would reach out to a CPR facility to have someone come in and train the unlicensed staff as soon as possible. The DNS also indicated there would be a CPR certified supervisor on each shift until all certification matters have been resolved. Although requested a policy on CPR was not provided.

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 2 residents (Resident #59 and 119) reviewed for diabetes management, the facility failed to follow the physician's order for elevated blood sugars, and for 5 residents (Resident #37, 55, 66, 85, 87) reviewed for accidents and behaviors, the facility failed to monitor vital signs according to facility policy, and for 1 of 5 residents (Resident #106) reviewed for hospitalization, the facility failed to ensure vital signs were monitored in accordance with the facility's policy. The findings include. 1. Resident #59 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, dementia, and anxiety disorder. The annual MDS dated [DATE] identified Resident #59 had severely impaired cognition, was independent with eating, and had received daily Insulin injections during the last seven days. The care plan dated 9/15/23 identified Resident #59 had Insulin Dependent Diabetes Mellitus.…

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

Based on observations, review of facility documentation, facility policy, and interviews, the facility failed to ensure that kitchen equipment was clean and sanitary, failed to ensure the chemical sanitizing solution was maintained at the manufacturer recommended sanitization concentrations, and failed to ensure that food items stored for the emergency 3-day supply were within use by date perimeters. The findings include. 1. Observation during an initial tour of the kitchen on 10/10/23 at 11:05 AM with the Dietary Director identified that multiple pieces of equipment used for or near food preparation areas were observed to have large amounts of debris. The covers over the stove for the exhaust vents located above the stoves and ovens had a thick scattered layer of grey matter, which appeared to be lint like material, attached to the vent covers. Further observations of the kitchen equipment identified that the microwave oven had hardened particles of various sizes and colors attached to the interior walls and the glass turntable of the appliance. Observations also identified that…

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

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 2 resident (Resident #117) reviewed for choices, the facility failed to ensure resident choices were accommodated when the resident requested to go to bed, and staff did not assist the resident for 2 hours and 30 minutes. The findings include: Resident #117 was admitted to the facility in September 2023 with diagnoses that included respiratory failure, pressure ulcer sacral stage II, pressure ulcer buttock stage III, and pressure ulcer heel unstageable. The care plan dated 9/12/23 identified Resident #117's transfer status was assistance of 2 persons to wheelchair. The admission MDS dated [DATE] identified Resident #117 had intact cognition and required extensive two persons assistance with transfer, and bed mobility. The care plan dated 9/25/23 identified Resident #117 needed assist with bed mobility, transfers, and ambulation due to deconditioning related to hospitalization for pleural effusion.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, and interviews for 2 of 2 residents (Resident #59) reviewed for diabetes management, the facility failed to ensure the physician and the resident's representative were notified when the resident's blood glucose (BG) levels were outside the parameters per the physician's order. The findings include. 1. Resident #59 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, dementia, and anxiety disorder. The annual MDS dated [DATE] identified Resident #59 had severely impaired cognition, was independent with eating, and had received daily Insulin injections during the last seven days. The care plan dated 9/15/23 identified Resident #59 had Insulin dependent diabetes mellitus. Interventions included monitoring blood glucose levels per the physician's order, utilizing the sliding scale as ordered, administering Insulin as ordered, and monitoring for signs of hyperglycemia and hypoglycemia. A physician's order dated 6/30/23…

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 #55) reviewed for behaviors, the facility failed to ensure that the Preadmission Screening and Resident Review (PASSAR) re-screening was completed following a newly identified mental health diagnosis. The findings include: Resident #55 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, peripheral vascular disease, and hypertension. A Level I PASSAR completed on 3/16/22 identified a level II evaluation was not indicated as Resident #55 had no evidence of a serious behavioral health condition. The PASSAR also identified Resident #55 did not have any diagnoses of dementia or neurocognitive disorders. The care plan dated 1/19/23 identified Resident #55 had a history of exhibiting inappropriate sexual behaviors, including in common areas. Interventions included offering redirection and education as needed during signs and symptoms of behaviors. A physician's…

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 #55) reviewed for behaviors, the facility failed to ensure that qualified staff provided targeted behavior observation and monitoring for a resident that required 1:1 constant observation for inappropriate behaviors. The findings include: Resident #55 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, peripheral vascular disease, and hypertension. Review of the resident census sheet identified Resident #55 was hospitalized from [DATE] - [DATE] for inappropriate behaviors. Review of the resident census sheet identified Resident #55 was re-admitted to the facility on [DATE] with a new diagnosis of dementia with behavioral disturbance. The physician's orders dated [DATE] directed Resident #55 required 1:1 constant observation at all times and required behavior monitoring for hallucinations, inappropriate sexual behaviors, and insomnia. 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 of 2 residents (Resident #95) reviewed for Activities of Daily Living (ADL), the facility failed to ensure the resident was provided a shower on scheduled shower days. The findings include: Resident #95 was admitted to the facility in May 2023 with diagnoses that included morbid severe obesity, end stage renal disease, and chronic obstructive pulmonary disease. The quarterly MDS dated [DATE] identified Resident #95 had moderately impaired cognition and required extensive assistance with personal hygiene. The physician's order dated 9/1/23 directed to provide weekly skin checks on bath/shower day every Wednesday 7:00 AM - 3:00 PM shift. The care plan dated 9/7/23 identified Resident #95 had an Activity Daily Living (ADL's) deficit related to: Generalized weakness and recent hospitalization for chronic kidney failure. Interventions included to provide assistance with ADL's and provide privacy while…

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 3 of 8 residents (Resident #8, 55 and 222) reviewed for accidents, for Resident #8 the facility failed to ensure the resident's environment was free of an accident hazards, for Resident #55 the facility failed to ensure that adequate supervision by trained staff was provided to a resident who required 1:1 constant observation for inappropriate behaviors, and for Resident #222 the facility failed to ensure the resident was properly positioned and supported during the application of a pain patch to the residents lowered back and subsequently, fell face first out of the bed onto the floor. The findings include. 1. Resident #8 was admitted to the facility on [DATE] with diagnoses that included dementia, hypothyroidism, and dysphagia. A physician's order dated 1/28/23 directed to administer Levothyroxine 25mcg Sodium (a thyroid medication) daily. The quarterly MDS dated [DATE] identified Resident #8 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #48) reviewed for respiratory status, the facility failed to store the oxygen nasal canula in a sanitary manner. The findings include. Resident #48 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebra infarction affecting left dominate side, heart failure unspecified dependence on supplemental oxygen. A physician's order dated 6/9/23 directed to apply oxygen via nasal cannula at 2 liters per min every shift. The quarterly MDS dated [DATE] identified Resident #48 had intact cognition, required extensive assistance with bed mobility, transferring, dressing and toileting, required limited assistance with locomotion and personal hygiene, used a wheelchair for mobility, and was dependent on supplemental oxygen. The care plan dated 8/17/23 identified a focus on oxygen dependency with interventions that included the provision 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 staff interviews for 1 resident (Resident #222) reviewed for discharge, the facility failed to remove 2 discontinued medications from the medication cart after they were discontinued by the physician, and both were subsequently sent home with the resident upon his/her discharge. The findings include: Resident #222 was admitted to the facility on [DATE] with diagnoses that included stage II pressure ulcer, moderate protein-calorie malnutrition, and hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. Physician's order dated 9/3/22 directed to administer Ativan 0.5 mg as needed for anxiety for 14 days and Trazadone HCL 25 mg as needed for insomnia for 14 days at hours of sleep. Physician's order dated 9/8/22 directed to discontinued Trazadone HCL 25 mg as needed at hour of sleep. Physician's order dated 9/17/22 directed to discontinued Ativan 0.5 mg as needed for anxiety for 14 days. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 4 residents (Resident #222) reviewed for discharge, the facility failed to ensure the recapitulation of the resident's stay included when the resident fell and was evaluated in the hospital, and failed to ensure medications sent home with the resident were current and not discontinued. The findings include. Resident #222 was admitted to the facility on [DATE]with diagnoses that included pressure ulcer of sacral stage II, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. The physician's order dated 9/3/22 directed to administer Ativan 0.5 mg tablet by mouth as needed for anxiety for 14 days and Trazadone HCL 25 mg tablet by mouth as needed for insomnia for 14 days at hours of sleep. A reportable event form dated 9/6/22 at 8:30 PM identified Resident #222 fell forward to the floor and bumped the left side of his/her forehead. The resident was alert and oriented 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, facility policy, and interviews for 2 of 3 residents (Resident #117, and 222) reviewed for pressure ulcers, the facility failed to implement a pressure relieving device on the resident's bed when the resident was admitted to the facility with multiple pressure ulcers. The findings include: 1. Resident #117 was admitted to the facility in September 2023 with diagnoses that included respiratory failure, pressure ulcer sacral stage II, pressure ulcer buttock stage III, and pressure ulcer heel unstageable. The physician's order dated 9/8/23 directed to complete a weekly skin check on shower day (Wednesday on the 7:00 AM - 3:00 PM shift), apply Skin Prep to heels twice a day every day and evening shift for 14 days, and offload heels every shift as tolerated. The physician's order dated 9/8/23 failed to direct the use of an alternating pressure mattress. The physician's order dated 9/9/23 directed to cleanse the left heel, right shin, bilateral buttocks,…

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/procedures and interviews for two of three sampled residents (Resident #38) reviewed for an injury of unknown origin and (Resident #355) reviewed for verbal mistreatment , the facility failed to ensure that the injury of unknown origin and the alleged verbal mistreatment was reported to the DNS, Administrator and to the State Survey Agency within the appropriate time parameters. The findings include: 1. Resident #38's diagnoses included vascular dementia without behavioral disturbances, peripheral vascular disease, atrial fibrillation, and quadriplegia. A quarterly MDS assessment dated [DATE] identified the resident had severe cognitive impairment and required total assistance of two staff for most activities of daily living. The RCP dated 4/24/21 identified the resident had the potential for skin impairment with interventions that included; use of a draw sheet or lifting device to move resident, use caution during transfers and bed mobility 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 clinical record reviews, review of facility policy/procedures, review of facility documentation and interviews for two of three sampled residents (Resident #38) reviewed for an injury of unknown origin, and (Resident #355) reviewed for an allegation of mistreatment, the facility failed to immediately initiate an investigation for a bruise of unknown origin and for an allegation of verbal mistreatment and failed to protect the residents from potential further mistreatment. The findings include: 1. Resident #38's diagnoses included vascular dementia without behavioral disturbances, peripheral vascular disease, atrial fibrillation, and quadriplegia. The RCP dated 4/24/21 identified the resident had the potential for skin impairment with interventions that included; use a draw sheet or lifting device to move resident, use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surfaces, educate resident/family/caregivers of causative factors and measures…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for one of three sampled residents (Resident #49) reviewed for an allegation of mistreatment the facility failed to ensure that care was provided in a dignified manner. The findings included: Resident #49's diagnoses included: contracture of the right knee, obesity, diabetes mellitus type II, sleep apnea, polyneuropathy and a history for falls. An admission assessment dated [DATE] identified the Resident was cognitively intact, required extensive assistance from staff for bed mobility and toileting and was incontinent of bowel. The RCP dated 2/2/21 identified the Resident was incontinent of bowel with interventions that included: offer bedpan/toilet assist approximately every two hours as needed, provide incontinent care every two hours and prn (as needed). The reportable event (RE) dated 2/10/21 at 3:43 PM identified that a male nurse aide (NA#5) made a negative statement to Resident #49…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for one of three sample residents (Resident #38) reviewed for skin integrity the facility failed to ensure the resident's physician and responsible party were notified of an injury of unknown origin in a timely manner. The findings included: Resident #38's diagnoses included vascular dementia without behavioral disturbances, peripheral vascular disease, atrial fibrillation, and quadriplegia. The RCP dated 4/24/21 identified the resident had the potential for skin impairment with interventions that included; use a draw sheet or lifting device to move resident, use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surfaces, educate resident/family/caregivers of causative factors and measures to prevent skin injury, monitor/document location, size and treatment of skin injury, report abnormalities to physician, and inspect skin 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 and interviews, the facility failed to ensure equipment was in good repair and safe for usage in rooms [ROOM NUMBERS]. The findings include: Observations on 7/23/21 at 10:03 AM of room [ROOM NUMBER] identified a dresser drawer with a detached handle and the privacy curtain between bed-A and bed-B had seven small to medium sized holes in the upper portions of the curtain. Interview and review of facility documentation (maintenance log books for the 3rd floor) with the Physical plant manager (PPM) on 7/27/21 at 11:07 AM identified he was unaware of the detached drawer handle and that the staff was to have placed it in the maintenance book which is reviewed by his staff throughout the day so that he can be informed of needed repairs. Subsequent to surveyor's inquiry the drawer handle was placed back into proper alignment and attached to the front panel of the drawer by the PPM. Interview on 7/23/21 at 1: 34 PM with the Housekeeping Supervisor (HS) 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 review of the clinical record, review of facility policy/procedures and interviews for one of three sampled resident (Resident #38) reviewed for skin integrity, the facility failed to ensure that a bruise (injury of unknown origin) was assessed and documented per acceptable standards of care. The findings included: Resident #38's diagnoses included vascular dementia without behavioral disturbances, peripheral vascular disease, atrial fibrillation, and quadriplegia. The RCP dated 4/24/21 identified the resident had the potential for skin impairment with interventions that included; use a draw sheet or lifting device to move resident, use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surfaces, educate resident/family/caregivers of causative factors and measures to prevent skin injury, monitor/document location, size and treatment of skin injury, report abnormalities to physician, and inspect skin for signs or symptoms of redness or breakdown…

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 #605) who required an assist of two for transfers, the facility failed to ensure the resident was transferred with the assistance of two staff. The findings include: Resident #605 was admitted to the facility from an acute care hospital in July of 2021 with diagnoses that included: history of falls, laceration to head and dementia with behavioral disturbances. Review of a psychiatric evaluation performed in the hospital dated 7/19/21 identified Resident #605 was confused and had had a fall with injury. A physician's progress note, and a fall risk assessment dated [DATE] identified Resident #605 was a fall risk. The physician's order dated 7/21/21 directed to transfer Resident #605 with an assist of two staff members. The initial Resident Care Plan (RCP) dated 7/22/21 identified the need for assist with mobility and gait related to decreased mobility and weakness with an intervention to provide transfer assist…

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, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #81) reviewed for respiratory care, the facility failed to obtain a physician's order for oxygen treatment in a timely manner. The findings include: Resident #11 was admitted to the facility with diagnoses that included: malignant neoplasm, diabetes mellitus (DM), pulmonary nodule, hypertension, atrial flutter and weakness. The admission MDS assessment dated [DATE] identified Resident #81 had moderate cognitive impairment, required extensive assistance of one staff member for bed mobility and personal hygiene, required extensive assistive of two staff members for toileting and was totally dependent on staff for dressing. An APRN progress note dated 7/19/21 at 8:14 PM identified Resident #81 had no new cough, breathing was not labored, and the resident was not short of breath (SOB). Observations on 7/22/21 at 3:02 PM and 7/23/21 at 9:45 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident # 358) reviewed for transmission based precautions (TBP), facility failed to ensure infection control practices were followed according to policy for required use of eye protection when providing care. The findings include: Resident #358 was admitted on [DATE] with diagnoses that included hypertension, Type II diabetes and anemia. RN Progress note dated 7/24/21 noted Resident #358 was not vaccinated and would be placed on transmission based precautions (TBP). Observation on 7/27/21 at 5:53 AM identified NA #2 enter resident #358's room after donning a gown and gloves (a face mask was already in place) without the benefit of wearing eye protection. NA #2 proceeded to provide care for Resident #358. An interview on 7/27/21 at 6:00 AM with NA #2 identified she did not don eye protection because there was no eye protective equipment located on the cart. NA #2 indicated that while she…

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.