Gardner Heights Health Care Center, INC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, and interviews for 3 of 4 sampled residents (Resident #44, #56, and #85) reviewed for Activities of Daily Living (ADLs), the facility failed to ensure residents were free of facial hair. The findings include: 1. Resident #44's diagnoses included dementia, contracture of right-hand muscle, and generalized muscle weakness. The quarterly MDS assessment dated [DATE] identified Resident #44 was moderately cognitively impaired and required moderate assistance with personal hygiene, set up assistance with eating, and supervision with oral hygiene. The RCP in effect on 8/10/24 identified Resident #44 required assistance with ADL's. Interventions included assistance with personal hygiene, set up assistance with eating and supervision with oral hygiene. Intermittent observations throughout the day on 8/13/24, 8/14/24 and 8/15/24, identified Resident #44 with visibly long, black facial hair noted below the lower lip. Physicians order in effect from 7/1/24 through…

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 the only sampled resident (Resident #75) reviewed for dental services, during the clinical record review, it was noted that the facility failed to ensure blood pressures were taken prior to the administration of an antihypertensive (blood pressure reduction) medication . The findings include: Resident #75 was admitted to the facility on [DATE] with a diagnosis that included dementia and hypertension. The Social Services admission assessment dated [DATE] identified Resident #75 had vascular dementia and was confused and forgetful at times. The Resident Care Plan (RCP) in effect on 8/2/22 identified Resident #75 with cardiovascular disease. Interventions included administering medications as ordered, obtaining weights and vital signs as ordered. A physician's order dated 8/3/22 directed facility staff to take Resident #75's blood pressure prior to the administration of lisinopril 20 milligrams (mg) by mouth and to hold (not administer) 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 observations, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #42) reviewed for pressure injuries, the facility failed to ensure off-loading for a dependent resident according to the plan of care and failed to ensure a hospice recommendation was reviewed by a provider. The findings include: Resident # 42's diagnoses included Alzheimer's disease, Lupus, peripheral vascular disease, and diabetes. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #42 was severely cognitively impaired, was dependent with eating, required substantial/maximal assistance with rolling left and right, was dependent for bed to chair transfer, and was at risk for pressure ulcer development. a. The Resident Care Plan dated 5/24/24 identified Resident #42 was at risk for pressure injuries. Interventions included to follow the facility protocol for treatment of pressure injuries, offload heels as appropriate, and turning and repositioning…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility policy, and interviews for 3 of 5 residents (Resident #8, #33 and #46) reviewed for a limited range of motion, the facility failed to apply positioning devices according to the physician orders and rehabilitation plan of care. The findings include: 1. Resident #8's diagnoses included osteoarthritis, contractures, rheumatoid arthritis, and post-traumatic stress disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 was severely cognitively impaired and required partial/moderate assistance with eating, substantial/maximal assistance with upper body dressing, and was dependent for toileting, and transfers. The Resident Care Plan dated 7/22/24 identified Resident #8 had rheumatoid arthritis. Interventions included to monitor/document and report to the physician, any joint stiffness, decline in mobility, and contracture formation/joint shape change. Physician orders in effect from 8/1/24 to 8/14/24 directed to apply…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, review of the clinical record, facility documentation, and facility policy for the only sampled resident (Resident #17) reviewed for accidents, the facility failed to complete a safe transfer with the mechanical lift. The findings include: Resident #17's diagnoses included left sided hemiplegia and hemiparesis (muscle weakness) following a cerebral infarction (stroke), abnormalities of gait and mobility, and need for assistance with personal care. A physician's order dated 2/8/23 directed to transfer Resident #17 via total mechanical lift, that Resident #17 was non-ambulatory, and that Resident #17 was independent with adaptive wheelchair with left leg rest (use both leg rests for transport). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #17 was moderately cognitively impaired, in a wheelchair, and required total dependance with toileting hygiene, bathing, and chair to bed transfers. Additionally, the MDS did not identify any previous falls.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy, and interviews for one (1) of three (3) sampled residents (Resident #2) who were reviewed for a change in condition, the facility failed to notify the family at the time the resident tested positive for COVID-19. The findings include: Resident #2 was admitted with diagnoses that included Alzheimer's disease, chronic kidney disease, diabetes mellitus with diabetic nerve damage, and anemia. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 rarely or never made decisions regarding tasks of daily life and was dependent on staff for transfers, personal hygiene and required extensive assistance for bed mobility. The resident care plan dated 2/21/22 identified Resident #2 may have difficulties adjusting to long term care environment and was at risk for contracting coronavirus due to going out for appointments and dialysis. Interventions directed to involve the family and loved ones and to keep them updated on how I 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, facility policy and interviews for one (1) sampled resident (Resident #1) who was reviewed for an allegation of abuse or neglect, the facility failed to implement their abuse policy when an allegation of abuse was reported to the Director of Nursing. The findings include: Resident #1 was admitted with diagnoses that included cirrhosis of the liver, hepatic encephalopathy (brain disorder that impacts brain function caused by liver disease), hepatitis C (liver infection), bipolar disorder and morbid obesity. The resident care plan dated 4/24/24 identified Resident #1 had made accusatory statements about staff's care and identified Resident #1 bruised easily. Interventions directed to allow to verbalize preferences to allow a sense of control, ammonia levels as ordered, monitor for ascites (fluid buildup in the abdomen and the abdominal organs), monitor for confusion. The 5-day Minimum Data Set assessment dated [DATE] identified Resident #1 made poor…

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

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of six (6) residents, (Resident #1), who were reviewed for elopement risk, the facility failed to ensure physicians orders were obtained for the placement and monitoring of a wandering device and failed to transcribe physician orders to discontinue a wandering device for a resident who previously eloped from the facility. The findings include: Resident #1 was admitted from the community on 8/30/23 with diagnoses that included dementia. The Preadmission Screening and Resident Review (PASRR) dated 8/30/23 identified Resident #1 required supervision with activities of daily living (ADL), hands on assist with toileting/continent care and supervision while ambulating for safety. The Brief Mental Status (tests for cognitive impairment) dated 8/30/23 identified Resident #1 had severe cognitive impairment. The Resident Care Plan (RCP) dated 8/30/23 identified Resident #1 had impaired cognition related to dementia and was at risk for elopement with interventions that directed to offer gentle…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy, and interviews for one of three sampled residents (Resident #1) who had a behavior of taking items that did not belong to the resident, the facility failed to ensure Resident #1 was not able to obtain and store sharp items such as razors and scissors that were found in the resident's room. The findings include: Resident #1's diagnoses included dementia, depression, and major neurocognitive disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 made poor decisions regarding tasks of daily life, utilized a wheelchair for mobility and was independent with movement on the unit. The care plan dated 6/23/23 identified Resident #1 had a behavior of going into other resident's rooms and taking things that do not belong to the resident and hiding them in his/her mattress. Interventions included attempt to keep resident busy with own belongings such as pictures, puzzles, phone, follow up with psychiatry as needed,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility documentation, facility policy and interviews, the facility failed to maintain a clean, comfortable, home like environment. The findings included: Observation during initial tour of the facility on 1/24/22 at 11:00 AM and on 1/25/22 at 3:30 PM with the Administrator, Director of Maintenance, and Director of Housekeeping/Laundry identified the following: a. Rooms #100, 102, 107, 108, 111, 114, 120, 250, 252, 255, 263, 265, 301, 302, 304, 314, #400, 403, 406, 412, 416 and the Cedar shower room were observed with damaged, chipped, holes and/or marred walls/wall paneling. b. The bathrooms in Rooms #101, 102, and 112 and the Cedar hallway were noted with damaged, chipped, rusty and/or marred radiator covers. c. Rooms #100, 112, 314 and 405 were noted with damaged, chipped, rusty and/or marred radiator covers in the bedroom area. d. Rooms #100, 101, 102, 112, and 120 were noted with damaged, dirty, and peeling cove base. e. room [ROOM NUMBER]'s bedroom and bathroom, the Cedar…

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 #78) reviewed for Advance Directives, the facility failed to obtain a physician's order for Resident #78's code status to ensure the resident ' s wishes were followed. The findings include: Resident #78 was admitted to the facility on [DATE] with diagnoses that included a terminal illness and Parkinson's Disease. A Medical Interventions Consent form dated 3/26/20 identified Resident #78's Conservator of Person (COP) requested that in the event of cardiopulmonary arrest, the resident not receive Cardiopulmonary Resuscitation, and be Do Not Resuscitate (DNR) status. Review of physician's orders dated 1/1/22 through 1/25/22 failed to reflect an order for DNR status of Resident #78. The significant change MDS dated [DATE] identified Resident #78 had intact cognition and required extensive assistance with personal hygiene. Interview with the DNS on 1/25/22 at 3:27 PM identified he was not aware…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interview for 1 of 2 residents (Resident #16) reviewed for pressure ulcers, the facility failed to ensure timely notification to the resident's representative when the resident developed a stage 2 pressure ulcer. The findings include: Resident #16 was admitted to the facility in April 2017 with diagnoses that included Parkinson's disease, diabetes, vascular dementia, and adult failure to thrive. The quarterly MDS dated [DATE] identified Resident #16 had severely impaired cognition and required extensive 2-person assistance with bed mobility. A nurse's note, written by LPN #2, dated 12/10/21 at 4:11 PM identified Resident #16 was noted with a new pressure ulcer on the coccyx. The note further identified the wound nurse and the RN supervisor were notified, and a new order to apply Triad every shift and monitor the area was obtained. The note failed to reflect that the resident's representative had been notified of the new pressure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interview for 1 resident (Resident #77) reviewed for a grievance, the facility failed to provide thorough follow up. The findings include: Resident #77's diagnoses included chronic obstructive pulmonary disease, heart failure and anxiety. The annual MDS dated [DATE] identified Resident #77 had intact cognition and required extensive 1-person assistance with bed mobility, transfers, bathing, dressing, grooming, ambulation, locomotion on the unit and was independent with eating after set up. The care plan dated 1/3/22 identified Resident #77 had a problem with decreased mobility and contractures of bilateral hands requiring assistance with all activities of daily living (ADLs). Interventions included to provide extensive assistance with ADLs, encourage Resident #77 to complete as much care as he/she is able to and offer assistance only after the resident attempts to complete the task independently. Monthly physician's orders 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 review of the clinical record, facility documentation, facility policy and interview for 1 of 3 residents (Resident #84) reviewed for abuse, the facility failed to ensure the resident was free from physical abuse by another resident. The findings include: a. Resident #84's diagnoses included Alzheimer's disease and delusional disorder. The annual MDS dated [DATE] identified Resident #84 had severely impaired cognition and was independent with ambulation on and off the unit. The care plan dated 7/15/20 identified Resident #84 had chronic/progressive decline in intellectual functioning characterized by deficit in memory, judgement, decision making and thought processes. Interventions included to gently redirect when exhibiting inappropriate actions/behaviors and offer consistent daily routines. The physician's order dated 8/29/20 directed Resident #84 may transfer and ambulate independently. b. Resident #79's diagnoses included dementia with Lewy bodies, post-traumatic stress disorder and hyperlipidemia.…

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 #78) reviewed for abuse, the facility failed to complete a thorough investigation after the allegation was made. The findings include: Resident #78 was admitted to the facility in March 2020 with diagnoses that included pseudobulbar affect, depression, anxiety disorder, malignant neoplasm of lymph nodes, head, face, and neck. The quarterly MDS dated [DATE] identified Resident #78 had moderately impaired cognition and required extensive assistance with personal hygiene. A nurse's note, written by LPN #3 dated 10/16/21 at 1:49 PM identified Resident #78 continues with random outbursts, crying, and screaming episodes per baseline. All needs were met and call bell within reach. Resident #78 denies any pain or discomfort. A nurse's note dated 10/16/21 at 9:31 PM identified RN #5 received a phone call at 6:45 PM from Person #1 reporting Resident #78 stated he/she was hit by a nurse aide at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #1) reviewed for care plan conference attendance, the facility failed to invite the resident to the care plan conference. The findings include: Resident #1 was admitted to the facility in August 2021 with diagnoses that included chronic kidney disease, atrial fibrillation, peripheral vascular disease. The admission MDS dated [DATE] identified Resident #1 had moderately impaired cognition and required extensive 2-person assistance with personal hygiene. Review of the care plan meeting sign-in form dated 9/9/21 failed to reflect documentation that Resident #1 attended the meeting. Interview with Resident #1 on 1/24/22 at 11:39 AM identified he/she has never been invited to a care plan meeting since being admitted to the facility. Resident #1 indicated the facility probably invited his/her representative to the meeting. Interview and review of the clinical record with LPN #1 on 1/25/22 at 4:10 PM…

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 #16) reviewed for pressure ulcer, the facility failed to ensure a timely RN assessment when the resident had a skin change to the coccyx, and failed to notify the dietician in a timely manner. The findings include: Resident #16 was admitted to the facility in April 2017 with diagnoses that included Parkinson's disease, type II diabetes mellitus, vascular dementia, and adult failure to thrive. The quarterly MDS dated [DATE] identified Resident #16 had severely impaired cognition, required extensive 2-person assistance with bed mobility, total dependence with toilet use and had no pressure ulcers. The nurse's note written by LPN #2 dated 12/10/21 at 4:11 PM identified Resident #16 had a pressure ulcer noted to the coccyx. The wound nurse and RN supervisor were notified and obtained a new order to apply Triad every shift and monitor the area. The care plan dated 12/13/21 identified 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 interview for 1 of 4 residents (Resident #79) reviewed for accidents, the facility failed to follow the plan of care to prevent 3 falls. The findings include: Resident #79 was admitted to the facility in June 2021 with diagnoses that included dementia with Lewy bodies. The admission MDS dated [DATE] identified Resident #79 had severely impaired cognition, required extensive 2-person assistance with bed mobility, total 2-person assistance with transfers and toilet use, did not walk, and had falls with fractures prior to admission. The care plan dated 6/30/21 identified Resident #79 was at risk to fall due to poor safety awareness and noncompliance with transfer and walking status (gets up unassisted). Interventions included to keep Resident #79 in a supervised area when awake and out of bed. a. A Reportable Event Form dated 7/16/21 at 11:15 AM identified Resident #79 was found sitting in the hallway on leg rests of wheelchair on…

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

Based on observation, review of facility documentation, facility policy and interviews, the facility failed to maintain an accurate record of the dishwasher temperatures. The findings include: Observation with the Food Services Director on 1/24/22 at 10:40 AM identified the dishwasher temperatures for the upcoming lunch meal had been entered, in advance, on the log. The FSD was not aware that staff had entered the dishwashing temperatures onto the log prior to taking the temperatures and indicated that the Dietary Aide (DA) who is assigned in the clean dish area is the one responsible for checking and entering the dish machine temperature in the log. She further identified that the dishwasher temperatures are checked prior to washing the dishes after each meal. Interview with DA #1 on 1/24/22 at 10:42 AM identified she was responsible for checking the temperature and she was the one who checked the temperature earlier that morning. She further stated that the dishwasher temperatures should be taken and logged after meals, prior to washing the dishes. Subsequent to surveyor inquiry,…

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/or procedures and interviews for 4 of 20 sampled residents reviewed for advanced directives (Resident #27, Resident #40, Resident #59 and Resident #96), the facility failed to ensure the resident's advanced directives were updated to reflect the wishes of the new conservator (Resident #27) and/or failed to ensure physician orders were written to reflect code status (Resident #40, Resident #59 and Resident #96). The findings included: 1. Resident #27's was admitted to the facility on [DATE] with diagnoses that included low back pain, muscle weakness, right arm pain, unsteady gait, hypertension and osteoarthritis. Probate court documentation dated [DATE] identified Person #2 submitted his/her resignation as the conservator of person for Resident #27 and requested the court to appoint a successor. In lieu of Person #2's request, on [DATE] Person #1 was made the resident's representative. A quarterly Minimum Data Set, dated [DATE] identified Resident #27 as…

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 sampled resident reviewed for dental (Resident #8), the facility failed to respond to the recommendations provided by a consulting dentist. The findings include: Resident #8 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, bipolar disorder, heart failure, and anxiety disorder. The annual Minimal Data Set assessment dated [DATE] identified Resident #8 had severely impaired cognition, was always incontinent of urine, frequently incontinent of bowel and required extensive assistance with personal hygiene. The Resident Care Plan dated 11/15/18 identified Resident #8 required extensive to total assist with activities of daily living. Interventions included dentist as ordered/needed and extensive to total assist with washing, dressing, bed mobility, personal and oral hygiene, toileting/incontinent care. A physician's order dated February 2019 directed dental…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, and interviews for 2 of 5 residents reviewed for unnecessary medications (Resident #34 and Resident #56), the facility failed to ensure behavior monitoring was completed in accordance with identified target behaviors. The findings include: 1. Resident #34's diagnoses include cerebral vascular accident, traumatic brain injury, stratus post craniotomy and adjustment disorder. A physician's order dated 3/12/19 directed Zyprexa 2.5 milligrams (mg) (an antipsychotic medication) by mouth at bedtime (as part of a gradual dose reduction). An annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #34 had moderately impaired cognition and required extensive assistance of two for bed mobility. The MDS also identified Resident #34 required total assistance of two for transfers and total assistance of one for dressing and toilet use. Additionally, the MDS identified Resident #34 received antipsychotic, antidepressant, and opiod medication. The Resident 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.

Based on staff interviews, review of facility documentation and observation of the medication rooms failed to ensure a clean and sanitary environment for 1 of 3 medication rooms. The findings include: Observation of the Cedar Unit's Medication Room on 8/19/19 at 11:30 PM identified cracked, moist and crumbling dry-wall beneath the windowsill. Below the long wall crack there were two large patches of chipped paint exposing a black substance attached to the uncleaned surface. The wall was moist to touch and movable under light pressure. Additionally, the medication room was noted to contain a working window air conditioner with a heavy accumulation of black substance attached to the inside of the top grills. The left corner of the inside windowsill was noted to contain a pile of grayish/ brownish unidentified material and live slug type insect sitting on a small, green color piece of paper. Interview with Licensed Practical Nurse (LPN) #2 on 8/19/19 at 12:10 PM identified the previous Maintenance Director was notified of the problem with the Medication Room approximately a month ago.…

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.