Hewitt Health & Rehabilitation Center, INC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record and policy reviews for 1 of 3 residents (Resident #106) sampled for pressure injuries, the facility failed to provide treatment for a wound per physician's order and failed to transcribe wound orders accurately. The findings included: Resident #106's diagnoses included a stage 3 pressure ulcer of the sacral region, muscle weakness and osteomyelitis of vertebral, sacral and sacrococcygeal region. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #106 was cognitively intact, and required substantial/maximal assistance for dressing, toileting and changing position in bed. Additionally, the MDS identified Resident #106 had a Stage 3 pressure ulcer defined as full thickness loss, with subcutaneous fat visible but bone, tendon or muscle was not exposed. Slough was present but did not obscure the depth of tissue loss, may include undermining and tunnelling. The Resident Care Plan dated 3/12/25 identified Resident #106 had a pressure ulcer or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #25) reviewed for medication administration, the facility failed to administer medications per the physician's order resulting in a medication error rate greater than 5%. The findings include: Resident #25's diagnoses included dementia, atrial fibrillation and history of venous thrombus and embolism (blood clot). The annual Minimum Data Set assessment dated [DATE] identified Resident #25 was severely cognitively impaired and required substantial/maximal assistance with bed mobility and toileting and was dependent with transfers. The Resident Care Plan dated 3/6/25 identified constipation and a history of deep vein thrombosis (blood clot). Interventions included to administer medications as ordered and initiate bowel regimen as per the physician's orders. A physician's order dated 5/1/25 directed to administer Aspirin EC 81mg by mouth one time a day for atrial fibrillation 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 observation(s), review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #18) reviewed for skin condition (non-pressure), and for 1 of 4 residents (Resident #106) reviewed for pressure injury, the facility failed to ensure proper personal protective equipment (PPE) were donned ( placed on ) during wound care for a resident on enhanced barrier precautions (EBP) and the facility failed to ensure proper hand hygiene was performed during wound care. The findings include: 1. Resident #18's diagnoses included dementia, anemia, and non-thrombocytopenic purpura. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #18 was severely cognitively impaired and was dependent for transfers, toileting, and bed mobility. Additionally, the MDS identified Resident #18 had venous/arterial ulcers and skin tears. The Resident Care Plan dated 4/15/25 identified venous ulcers and a skin tear to the lower extremities and EBP 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 reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #2) who were reviewed for an accident, the facility failed to ensure Resident #2 had Geri-leg sleeves applied per the physician's order to prevent a left leg laceration that required sutures and steri-strips. The findings include: Resident #2's diagnoses included Parkinson's Disease without dyskinesia, dementia, psychotic disorder, muscle weakness and history of falls. A physician order dated 9/2/24 directed to apply Geri-legs on Resident #2's legs in the morning and remove at night. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15) indicting severe cognitive impairment and Resident #2 required extensive one (1) person assistance with transfers. The Resident Care Plan dated 9/4/24 identified risk for skin impairment. Interventions directed to apply Geri-legs in…

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 #1) who exhibited behavioral symptoms, the facility failed to ensure a change in the anti-anxiety medication, Ativan, order was sent to the pharmacy and a follow through with the pharmacy when the Ativan was not available to prevent missed doses which resulted in Resident #1 having increased anxiety and agitation. The findings include: Resident #1's diagnoses included Alzheimer's Disease and depression. The Resident Care Plan dated 11/1/24 identified Resident #1 was at risk for potential adverse effects of psychotropic drug use. Interventions directed to be aware of the resident's mood and behavior, be aware of mental status functioning on an ongoing basis, identify common behavioral expressions and expected responses to interventions, implement appropriate individualized, person centered interventions and document results. The admission Minimum Data Set assessment 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 clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for an allegation of abuse and neglect, the facility failed to ensure resident safety by removing a staff member from resident care after an allegation of abuse was reported in accordance with the facility's policy. The findings include: Resident #1's diagnoses included vascular dementia, anxiety, and depression. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 was alert and oriented to person, place and time and required substantial/maximal assistance with transfers, personal care, and dressing. The Resident Care Plan dated 10/21/24 identified mood disorder related to anxiety, depression, and dementia. Interventions directed to follow with psych, medication, and assist with care. The nurse's note dated 10/19/24 at 7:00 AM identified the 11PM-7AM charge nurse was informed by the 11PM-7AM Nursing Supervisor that Resident #1…

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 #3) who were reviewed for comprehensive care plans, the facility failed to develop a care plan to address Resident #3's scissoring movements of his/her legs. The findings include: Resident #3's diagnoses included Parkinson's Disease, dementia, cognitive communication deficit and muscle weakness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 rarely or never made decisions regarding tasks of daily life, required extensive assistance with toileting, and dressing, was dependent for showering and bathing and lower body dressing and required moderate assistance with personal hygiene. The Resident Care Plan dated 12/14/23 identified Resident #3 was at risk for skin breakdown related to decreased mobility, poor nutrition, poor circulation, and altered sensation. Interventions directed gentle handling during all transfers and care procedures, inspect the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policies and interviews for one of three sampled residents (Resident #1) who were discharged home, the facility failed to provide documentation a medication reconciliation and review was conducted with the resident and/or family member to ensure a safe discharge. The findings include: Resident #1's diagnoses included congestive heart failure, anemia, and atrial fibrillation. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had some short- and long-term memory deficits. The November 2023 physician orders identified Resident #1's medications regimen included Acetaminophen 325 milligrams (mg) two (2) tablets by mouth every four (4) hours as needed for pain, (a medication to treat high blood pressure) Amiodarone HCL 200 mg daily, (a blood thinning medication) Apixaban 2.5 mg every twelve (12) hours, (iron supplement) Ferrous Sulfate 325 mg one (1) every other day, (a medication to treat high blood pressure) Metoprolol 100…

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 six (6) residents, (Resident #2), who was reviewed for abuse, the facility failed to ensure incontinent care was provided to a resident who required total care with incontinent care. The findings include: Resident #2's diagnoses included dementia, legal blindness, and amputation of the left leg below the knee. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had moderate cognitive impairment, required two person assist with bed mobility, one person assist with toileting, and was incontinent of bowel and bladder. The Resident Care Plan dated 9/5/23 identified Resident #2 preferred to stay in bed most of the time and had fluctuations of incontinence with bowel and bladder with interventions that directed to provide incontinent care every 2-3 hours and clean thoroughly after each incontinent episode. A physician's order dated 9/1/23 directed bed mobility with assist of one, transfers…

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 six (6) residents who were reviewed for abuse, (Resident #1), the facility failed suspend an employee pending the outcome of an abuse investigation. The findings included: 1) Resident #1's diagnoses included unspecified dementia, type II diabetes and osteoarthritis. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had severe cognitive impairment, required two person assist with bed mobility, transfers and toileting. The Resident Care Plan dated 5/4/23 identified Resident #1 required assistance with activities of daily living (ADL) and had a history of urinary tract infections with interventions that directed to provide incontinent care as needed and respond promptly to the call light. A Grievance form dated 7/3/23 and submitted by Person #1 identified on 7/1/23 incontinent care was not provided to Resident #1 every two hours and that NA #3 walked off the unit and went downstairs…

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 six (6) residents reviewed for allegations of abuse, (Resident #1), the facility failed to report an allegation of neglect to the state agency within required time frames. The findings include: Resident #1's diagnoses included unspecified dementia, type II diabetes and osteoarthritis. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had severe cognitive impairment, required two person assist with bed mobility, transfers and toileting. The Resident Care Plan dated 5/4/23 identified Resident #1 required assistance with activities of daily living (ADL) and had a history of urinary tract infections with interventions directed provide incontinent care as needed and respond promptly to the call light. A Grievance form dated 7/3/23 and submitted by Person #1 identified on 7/1/23 incontinent care was not provided to resident #1 every two hours and that NA #3 walked off the unit and went…

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) residents reviewed for abuse, (Resident #1),the facility failed to ensure a complete and thorough investigation was completed and finalized in a timely manner following an allegation of neglect. The findings include: Resident #1's diagnoses included unspecified dementia, type II diabetes and osteoarthritis. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had severe cognitive impairment, required two person assist with bed mobility, transfers and toileting and was incontinent of bowel and bladder The Resident Care Plan dated 5/4/23 identified Resident #1 required assistance with activities of daily living (ADL) and had a history of urinary tract infections with interventions that directed to provide incontinent care as needed and respond promptly to the call light. A Grievance form dated 7/3/23 and submitted by Person #1 identified on 7/1/23 incontinent care was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of six (6) residents reviewed for allegations of neglect, (Resident #1), the facility failed to ensure that a resident who is dependent on staff for care was provided with incontinent in a timely manner. The findings include: Resident #1's diagnoses included unspecified dementia, type II diabetes and osteoarthritis. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had severe cognitive impairment, required two person assist with activities of daily living and was always incontinent of bowel and bladder. The Resident Care Plan dated 5/4/23 identified Resident #1 required assistance with activities of daily living (ADL) and had a history of urinary tract infections with interventions that directed to provide incontinent care as needed and respond promptly to the call light. A reportable event dated that on 7/6/23 the facility became aware that Resident #1 was not provided with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility documentation, facility policy and interviews, the facility failed to ensure sufficient staffing levels to meet the needs of the residents. The findings include: Resident #1's diagnoses included unspecified dementia, type II diabetes and osteoarthritis. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had severe cognitive impairment, required two person assist with activities of daily living and was always incontinent of bowel and bladder. The Resident Care Plan dated 5/4/23 identified Resident #1 required assistance with activities of daily living (ADL) and had a history of urinary tract infections. With interventions directed provide incontinent care as needed and respond promptly to the call light. A Reportable Event(s) dated 7/6/23 identified Person #1 alleged on 7/1/23 and on 7/2/23 that incontinent care was not provided to Resident #1. A review of the staffing schedules dated 7/1/23 through 7/2/23 identified on 7/1/23 where Resident #1 resided, there was one…

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 two (2) of six (6) residents, (Resident #2 and Resident #3) who were reviewed for abuse, the facility failed to ensure a complete and accurate clinical record. The findings include: 1. Resident #1's diagnoses included unspecified dementia, type II diabetes and osteoarthritis. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had severe cognitive impairment, required two person assist with bed mobility, transfers and toileting. The Resident Care Plan dated 5/4/23 identified Resident #1 required assistance with activities of daily living (ADL) and had a history of urinary tract infections. Interventions directed provide incontinent care as needed and respond promptly to the call light. A review of the ADL flow sheets dated 7/1/23 through 7/14/23 identified no documented ADL tasks for dressing 10 of 56 opportunities, no documentation for bladder elimination for 5 of 56 opportunities and no…

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, staff interview and review of facility policy for 4 of 9 sampled residents (Resident #22, Resident #31, Resident #49 and Resident #56) observed for dining, the facility failed to provide a dignified dining experience as evident by utilizing hospital gowns (Resident #22, Resident #31 and Resident #49) and a bath towel (Resident #56) as clothing protectors during a meal. The findings include: 1. Resident #22's diagnoses included dementia with agitation, major depressive disorder and anxiety. An Annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #22 was severely cognitively impaired and required extensive assistance of 2 for bed mobility and transfers. Additionally, the MDS identified Resident #22 required extensive assistance of 1 for dressing, personal hygiene and supervision with 1 person physical assistance for eating. A Resident Care Plan (not dated) identified Resident #22 required assistance with activities of daily living: bathing, dressing, transfers, toilet…

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 tour with the Maintenance Director, observations, and interview, the facility failed to ensure a clean, comfortable, homelike environment related to marred furniture, soiled privacy curtains, walls in disrepair, main hall hand rails marred and overhead hall lights with debris and/or black specs. Observation of the environment on 1/9/23 at 10:53 AM and on 1/17/23 at 11:50 AM with the facility Maintenance Supervisor identified the following on Unit 1 A: 1. room [ROOM NUMBER]-1: the facility provided nightstand handle of the top drawer was dangling and the laminate trim was missing from around the table top, exposing the press board beneath. Additionally, the radiator in the room was marred and rusty. 2. room [ROOM NUMBER]: The bathroom and closet doors were marred. 3. room [ROOM NUMBER]: The bathroom door was marred, the wall adjacent to the left of the bathroom was marred. 4. room [ROOM NUMBER]: The privacy curtain was soiled and the shelving unit next to the closet was observed with the trim strip…

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, staff interviews and clinical record review for 1 of 1 sampled residents (Resident #20) reviewed for enteral tube feeding, the facility failed to ensure water bolus physician orders were completed. The findings include: Resident #20's diagnoses included quadriplegia, dysphagia, rheumatoid arthritis and utilization of a gastrostomy (g-tube). The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #20 was severely cognitively impaired and was totally dependent with two staff for bed mobility, transfers, dressing and toilet use. The MDS further identified Resident #20 required total dependence of 2 for personal hygiene and required a feeding tube. A Resident Care Plan dated 2/3/21 identified Resident #20 being at risk for a decline in nutritional status secondary to dysphagia and dehydration or fluid overload. Interventions included for a Dietitian (RD) to evaluate quarterly and as needed to monitor caloric intake, estimate needs and make recommendations for changes 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.

Based on review of facility staff training documentation and interviews, the facility failed to ensure that staff completed annual training and competencies related to providing Intravenous Therapy. The findings include: A review of the state agency documentation offsite review identified the facility has a licensed capacity of 160 and an IV therapy program. An interview with RN#5 on 1/17/2023 at 1:30 PM indicated that she was not able to locate IV training and competencies for staff for January 2021 through December 15, 2022. Interview and review of the IV log with RN #4 on 1/17/2023 at 1:40 PM identified IV therapy was provided to residents from January 2021 through 12/15/2022 but no IV therapy had been provided after 12/15/22. RN #4 further indicated that she was unable to locate any staff training or competencies for licensed nurses regarding yearly annual IV training and competency. Review of the Facility Assessment on signed by the Administrator on 1/17/2023 indicated that yearly required in-services that are mandatory for all staff include IV training and competencies 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident # 40) reviewed for accidents, the facility failed to ensure a resident's medication was stored in a safe manner and inaccessible to a resident not assessed for self-medication administration and 1 of 3 medication rooms, the facility failed to monitor and document medication refrigerator storage temperatures. The finding included: 1. Resident #40 was admitted with diagnoses that included chronic obstructive pulmonary disease (COPD), schizophrenia and unspecified dementia. The quarterly MDS assessment dated [DATE] identified Resident #40 had moderate cognitive impairment and required supervised assist with ADL skills. The care plan dated 12/1/22 identified Resident #40 required assistance at times with ADL and at times refused medications. Interventions included to provide encouragement and to explain what each medication is when asked. The physician orders dated 1/4/23 directed…

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 a review of the facility Infection Control Program for Immunizations, review of facility documentation and interview for 3 out of 5 residents ( Residents # 16 and #58), the facility failed to provide evidence that a consent and education for influenza and pneumovax vaccines were provided to the residents prior to the administration of the vaccine and failed to provide evidence that for ( Resident # 83 ),the pneumovax vaccine was offered to the resident. The findings include: A review of the facility Infection Control Program for Immunizations and a review of facility documentation on 1/17/23 failed to reflect a consent and or that education had been provided to Residents # 16 prior to the administration flu vaccine on 10/6/2022 and Resident # 58 who received the flu vaccine on 12/28/2022. Further review of facility documentation regarding immunization lacked evidence that the pneumovax vaccine was offered to Resident # 83. A review of facility documentation on 1/17/23 with RN # 4 at 1:15 PM during a discussion identified she could not provide the missing documentation 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, observation, facility policy and interviews for 1 resident (Resident # 30) reviewed for accommodation of needs, the facility failed to ensure a call light was accessible for the resident. The findings include: Resident #30 was admitted with diagnoses that included hemorrhage affecting non dominant side, poly neuropathy and anxiety. The care plan dated 10/20/22 identified Resident # 30 had a behavior problem where s/he may become easily frustrated when unable to express self or have to wait for care. The care plan also identified Resident #30 was at risk for falls. Interventions included keeping the call light within reach when in his/her room and to anticipate/ensure the resident's needs were met. The quarterly Minimum Data Set (MDS) assessment dated [DATE] and 12/25/22 identified Resident #30 had severe cognitive impairment and required extensive two person assist with bed mobility, total 2 person assist with transfers. An interview on 1/11/23 at 2:35 PM with Person #1…

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, observation, facility policy, and interviews for 1 resident (Resident # 30) reviewed for choices, the facility failed to ensure a resident's preference for returning to bed was honored. The findings include: Resident #30 was admitted with diagnoses that included hemiplegia/hemiparesis affecting the non-dominant side, poly neuropathy and anxiety. The care plan dated 10/20/22 identified Resident # 30 had a behavior problem where s/he may become easily frustrated when unable to express self or have to wait for care. The care plan also identified Resident #30 required assist with ADL related to a history of CVA (cerebral vascular accident) and left sided weakness. Interventions included anticipate/ensure needs were met, transfer per physician orders and to encourage rest periods between tasks due to poor strength and endurance. The quarterly MDS assessment dated [DATE] and 12/25/22 identified Resident #30 had severe cognitive impairment and required extensive two person 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 clinical record review, facility policy review, and interviews for 1 of 3 residents (Resident #94) reviewed for advanced directives, the facility failed to ensure a physician's order was obtained per facility policy. The findings include: Resident #94's diagnosis included diabetes mellitus, atherosclerotic heart disease and hypertension. The Resident Care Plan (RCP) dated [DATE] indicated a need for assistance with activities of daily living. Interventions included, in part advanced directives will be followed as indicated by the resident/responsible party and the physician's orders. A facility document labeled, Medical Intervention Consent Form, was signed by Resident #94, a staff member, and the physician on [DATE]. The form indicated Resident #94 consented to Cardiopulmonary Resuscitation (CPR), intravenous fluids, and hospitalization but no artificial nutrition. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #94 had no cognitive impairment. On [DATE] at 2:40 PM 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 documentation, facility policy, and interviews for 1 resident (Resident # 68) reviewed for hospitalizations, the facility failed to notify the Advanced Practice Registered Nurse (APRN) and the physician of a medication error. The findings include: Resident #68 was admitted with diagnoses that included aphasia secondary to cerebral infarction, gastrostomy and chronic respiratory failure. The quarterly MDS assessment dated [DATE] identified Resident #68 had severe cognitive impairment, required extensive two person assist with bed mobility and personal care and total dependence with transfers and eating. The assessment noted the resident had an enteral feeding tube. The care plan dated 11/1/22 identified Resident #68 had a diagnosis of diabetes mellitus and a feeding tube. Interventions included monitoring and reporting signs of hyper/hypoglycemia and monitor for signs of aspiration. The care plan also identified a need for assist with dental care with interventions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation review, facility policy review, and interviews for 2 of 3 residents reviewed for abuse and neglect for (Resident #60), the facility failed to prevent physical abuse and for (Resident #65), the facility failed to ensure the resident was free from neglect as the resident was not provided incontinent care and repositioning in accordance with facility policy. The findings included: 1. Resident #60 was admitted to the facility with diagnoses that included stroke, major depressive disorder, and hemiplegia (1 sided of the body paralysis). A care plan last reviewed on 3/8/22 at a Resident Care Conference identified Resident #60 had a behavior problem and can be disrespectful of personal boundaries. Interventions included when the resident is observed on other units encourage to return to the unit. A care plan updated on 7/22/22 to identified that Resident #60 have begun yelling at staff making demands. A quarterly MDS assessment dated [DATE] 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 clinical record review, review of facility documentation and interviews for 1 resident (Resident # 55) reviewed for electronic movement alarms, the facility failed to notify the state agency within 5 days of an injury of unknown origin. The findings include: Resident #55 was admitted with diagnoses that included spinal stenosis, polyneuropathy and hypertension. The quarterly MDS assessment dated [DATE] identified Resident #55 had severe cognitive impairment and required extensive of 2 persons assist with bed mobility and personal care. The care plan dated 11/11/22 identified Resident #55 was at risk for falls due to deconditioning, unsteady gait, and poor safety awareness. Interventions included ensuring the call light was within reach, to have commonly used articles within reach and to ensure floor mats were in place on both sides of the bed. The Reportable Event dated 12/2/22 identified Resident #55 sustained an injury of unknown origin after complaining of tenderness and limited range of motion. 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 clinical record reviews, facility policy review, and interviews for 1 sampled resident (Resident #60) reviewed for hospitalization, the facility failed to provide evidence of transfer documentation to an acute care facility for a change in status and for 1 residents (Resident # 96) reviewed for discharge, the facility failed to ensure a physician's order for the resident's discharge was obtained in accordance to facility policy. The findings included: 1. Resident #60's diagnoses included encephalopathy, Covid-19, seizures, and respiratory failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #60 was severely cognitively impaired, required total assistance with one person for personal hygiene and bathing, and extensive assistance with one person for dressing and toilet use. The MDS assessment further identified Resident #60 required limited assistance with one person for bed mobility and required setup for eating. A Resident Care Plan dated 11/3/22 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 clinical record reviews, facility policy, and interviews for 1 resident (Resident #55) reviewed for care planning, the facility failed to develop and implement a comprehensive person-centered care plan with interventions that included a reduction plan for the use of a position change alarm and failed to ensure floor mats were properly placed at the bedside for a resident at risk for falls. The findings included: 1. Resident #55 was admitted with diagnoses that included spinal stenosis, polyneuropathy and hypertension. The quarterly MDS assessment dated [DATE] identified Resident #55 had severe cognitive impairment and required extensive of 2 persons assist with bed mobility and personal care. The care plan dated 11/2/22 identified Resident #55 was at risk for falls due to deconditioning, unsteady gait, and poor safety awareness. Interventions included ensuring the call light was within reach, to have commonly used articles within reach and ensure floor mats were in place on both sides of the bed. a. 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 # 68) reviewed for hospitalizations, the facility failed to ensure medications were administered according to standards of care for a resident prescribed antibiotic therapy upon re-admission and a medication error report was completed in accordance to facility practice to meet professional standards. The findings include: Resident #68 was admitted with diagnoses that included aphasia secondary to cerebral infarction, gastrostomy and chronic respiratory failure. The quarterly MDS assessment dated [DATE] identified Resident #68 had severe cognitive impairment, required extensive two person assist with bed mobility and personal care and total dependence with transfers and eating. The assessment noted the resident had an enteral feeding tube. The care plan dated 11/1/22 identified Resident #68 had a diagnosis of diabetes mellitus and a feeding tube. Interventions included monitoring and reporting…

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 1 of 1 sampled residents (Resident #6) reviewed for a non-pressure wound, the facility failed to measure the wound when it developed and for 1 resident (Resident #65) reviewed for pressure ulcer prevention, the facility failed to ensure the residents low air loss (LAL) mattress was assessed for function every shift and failed to ensure there was an physician's order present to check the function of the LAL mattress and for 1 resident (Resident # 68) reviewed for hospitalizations, the facility failed to follow hospital discharge recommendations for a resident requiring continued use for antibiotic therapy and enteral tube feedings and use of respiratory equipment. The findings included: 1. Resident #6's diagnoses included dementia, diabetes with polyneuropathy, peripheral vascular disease and atrial fibrillation. A Resident Care Plan (RCP) dated 2/21/22 identified Resident #6 being at risk for skin integrity issues 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 5 residents reviewed for weight loss for ( Resident # 24), the facility failed to monitor the residents weights and for (Resident # 68) reviewed for nutrition, the facility failed to address a significant weight discrepancy in a timely manner and according to facility policy. The findings included: 1 .Resident # 24's diagnoses included wedge compression fracture of first lumbar vertebra, abdominal hernia with gangrene, anemia, heart failure, muscle weakness, and cognitive communication deficit. The physician's orders dated 11/14/22 directed to obtain weekly weights for 4 weeks. The readmission MDS assessment dated [DATE] noted the resident was severely cognitively impaired, required extensive assistance with ADL but was independent with eating. The assessment also noted a weight of 137 lbs. The 11/17/22 nutritional assessment noted identified the resident's meal intake was variable with 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, observations, facility policy and interviews for 1 resident (Resident # 68) reviewed for respiratory equipment, the facility failed to ensure respiratory equipment was stored according to infection control standards and failed to ensure that staff followed facility practice for glucometer cleaning and 1 of 1 sampled residents (Resident #20) reviewed for enteral tube feeding, the facility failed to ensure cleanliness of the tube feeding pump. The findings included: 1. Resident #68 was admitted with diagnoses that included aphasia secondary to cerebral infarction, gastrostomy, and chronic respiratory failure. The quarterly MDS assessment dated [DATE] identified Resident #68 had severe cognitive impairment, required extensive two person assist with bed mobility and personal care. The resident also required total care with transfers and eating and had an enteral feeding tube. The care plan dated 11/1/22 identified Resident #68 had a feeding tube. Interventions included 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 observations and interview, the facility failed to ensure 3 sections of handrails were attached securely to the wall. Observation on 1/9/23 at 10:53 AM and on 1/17/23 at 11:50 AM with the facility Maintenance Supervisor identified the following: 3 sections of handrails were not securely attached to the wall on Unit 1 A located between room [ROOM NUMBER] and room [ROOM NUMBER], between the nursing station and the utility room, and by elevator A which was next to the Purell hand sanitizer station. Interview with the Maintenance Supervisor on 1/17/23 during the 11:50 AM tour indicated although environmental rounds are completed monthly he did not identify loose handrails.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, facility policy, and interviews for 1 of 6 sampled residents (Resident #31) reviewed for, pre-admission screening and resident review (PASRR), the facility failed to ensure a referral was made to the state designated authority when a new psychiatric diagnoses were identified. The findings include: Resident #31 was admitted to the facility on [DATE] with diagnoses that included, early onset cerebellar ataxia, atrial fibrillation and neuromuscular dysfunction of the bladder and quadriplegia. The PASRR level 1 assessment dated [DATE] identified the resident did not have a level 2 condition, therefore, the outcome was that the resident had a negative level 1 (level 1 negative means that there isn't a qualifying psychiatric diagnosis to warrant conducting a level 2 assessment. The outcome of the PASRR level 1 assessment with a review date of 04/20/12 determined the resident had long term approval. The quarterly MDS assessment dated [DATE] 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 clinical record review, review of facility documentation, review of facility policy, and interviews for 3 sampled residents (Residents #2, #14 & #33) reviewed for medication administration and activities of daily living, the facility failed to ensure sufficient staff to provide timely care and services. The findings include: 1. Resident #2's diagnoses included Congestive heart failure (CHF), Chronic kidney disease (CKD) and Hypertension (HTN). A quarterly MDS assessment dated [DATE] identified Resident #2 had moderate cognitive impairments, required supervision with ADLs and received antidepressant and diuretics during the last even (7) days. Resident care plan dated 2/6/20 identified a problem with coronary artery disease related to Atrial Fibrillation, HTN, presence of a pacemaker and CKD. Interventions included to encourage compliance to treatment regimen and to administer all cardiac medications as ordered by the physician. Same care plan identified a problem with an infection with Clostridium…

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, review of facility policy, and interviews for one sampled resident (Resident #33) who required assistance with activities of daily living, the facility failed to ensure the provision of care in a timely manner. The findings include: Resident #33's diagnoses included Alzheimer's disease, history of femur fracture, depression and anxiety. The 5 day significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #33 was severely cognitively impaired, required extensive assistance with bed mobility and was totally dependent on staff for toileting and personal hygiene. Additionally, Resident #33 was always incontinent of bowel and bladder. The resident care plan (RCP) dated 11/29/19 identified the issue of urinary incontinence related to cognitive loss/dementia. Care plan interventions included to assist resident with perineal care as needed and respond promptly to requests for toileting. Interview with Person #2 on 2/18/20 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 observations, clinical record review, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #37) reviewed for choices, the facility failed to ensure that a resident who was self-administering a medication was assessed for safety. The findings include: Resident #37's diagnoses included congestive heart failure, chronic obstructive pulmonary disease and anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #37 was without cognitive impairments and was independent with activities of daily living (ADL's). The Resident Care Plan (RCP) dated 1/7/20 identified the resident was independent with most ADL's and may need assistance at times. Interventions included, keep frequently used articles within reach, assist as needed and assure safety while performing ADL's. A physician's order dated 2/18/20 directed that it was ok to keep Mouth Kote (oral moisturizer) spray with the resident at the bedside and can administer 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 2 of 4 sampled residents (Resident #29 & #502) reviewed for falls, the facility failed to implement care plan interventions and provide the necessary supervision for residents with a history of falls. The findings include: 1. Resident #29 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, vascular dementia with behavioral disturbance, bipolar disorder and a current episode of mania with severe psychotic features. A nurse's note dated 12/5/19 at 10:05 PM identified Resident #29 arrived via ambulance at 3:00 PM from an acute care hospital. A fall risk assessment dated [DATE] identified Resident #29 had a fall risk score of 16 (A score of 10 or above indicates a resident is at risk for falls). A reportable event dated 12/11/19 identified Resident #29 was found in his/her room on the floor laying on the right side at 4:00 PM. Interventions subsequent to the fall…

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, review of facility policy, and interviews for one sampled resident (Resident #62) reviewed for nutrition, the facility failed to ensure weights were obtained according to dietitian recommendations. The findings include: Resident #62's diagnoses included dementia, depression and cerebral palsy. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #62 was moderately cognitively impaired and required extensive assistance with personal hygiene and eating. The assessment further identified that the resident's height was 68 inches, weight was 133 pounds, the resident had not had a weight loss or weight gain in the past 6 months and the resident had a mechanically altered diet. The Resident Care Plan (RCP) dated 10/17/19 identified the potential for a nutritional decline with interventions that included, offer an alternate meal if the resident does not like what is served, offer to set up meals, provide me with my diet 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 observations, clinical record review, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #65) reviewed for dignity, the facility failed to appropriate provide care and treatment for a resident with dementia. The findings include: Resident #65's diagnoses included anxiety, depression and dementia. The quarterly minimum data set (MDS) assessment dated [DATE] identified Resident #65 was severely cognitively impaired, did not exhibit behavioral symptoms and required extensive assistance with bed mobility transfers and personal hygiene, and required supervision with locomotion on the unit. The Resident Care Plan (RCP) dated [DATE] identified a cognition and communication barrier, psychotropic medication use and mood and behavior with periods of sadness related to a diagnosis of depression, anxiety and dementia. Interventions included, be patient and reassure resident, be aware of mood and behavior, and potential for ongoing depression (crying,…

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, clinical record review and facility staff interviews for 1 of 4 sampled residents (Resident #14) observed for medication administration, the facility failed to administer medications as directed by the physician, resulting in a medication error rate over 5%. The findings included: Resident #14's diagnoses included chronic obstruction pulmonary disease (COPD), hypertension (HTN) and chronic kidney disease (CKD). A quarterly MDS assessment dated [DATE] identified Resident #14 had moderate cognitive impairments, required extensive assistance with bed mobility, transfers, dressing, hygiene and toilet use. The assessment further identified that the resident was on a scheduled pain management regimen, experienced pain on an almost constant basis over the last 5 days and noted the pain level was moderate (the parameters are mild, moderate, severe and very severe). Resident#14's care plan dated 12/5/19 identified a problem with respiratory status due to the diagnoses of COPD with interventions 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 observations, clinical record review, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #37) reviewed for choices, the facility failed to ensure a medication was stored in a secure location. The findings include: Resident #37's diagnoses included congestive heart failure, chronic obstructive pulmonary disease and anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #37 was without cognitive impairments and was independent with activities of daily living (ADL's). The Resident Care Plan (RCP) dated 1/7/20 identified the resident was independent with most ADL's and may need assistance at times. Interventions included, keep frequently used articles within reach, assist as needed and assure safety while performing ADL's. A physician's order dated 2/18/20 directed that it was ok to keep Mouth Kote (oral moisturizer) spray with the resident at the bedside and can administer as needed for dry mouth. Observation 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.