Evergreen Center For Health & Rehabilitation

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 # 136) reviewed for accidents, the facility failed to provide the necessary supervision to prevent a resident from eloping. The findings include: Resident #136 's diagnoses included hemiplegia and hemiparesis, TIA, and Cerebral Infarction. The Resident Care Plan dated 9/25/24 identified Resident #136 had a deficit in self-care. Interventions included to provide assist of 1 for eating, toileting and self-care. A physician's order dated 9/25/24 directed assistance with all self-care activities. The admission Minimum Data Set assessment dated [DATE] identified Resident #136 was severely cognitively impaired and noted dependence for all activities of daily living and personal care. A nurse's note dated 11/19/24 at 6:59 PM identified Resident #136 was seen by staff outside the front door self-propelling in his/her wheelchair. Resident # 136 was alert and confused. An elopement assessment was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, and interviews for 1 of 5 residents (Resident # 101) for Unnecessary Medication Review, the facility failed to ensure the pharmacist recommendations were provided to the physician for review and response. The findings include: Resident #101's diagnosis included Post-Traumatic Stress Disorder (PTSD), and dementia with psychotic disturbance. The Comprehensive Significant Change Minimum Data Set (MDS) assessment dated 8/8/2023 indicated Resident #101 had severe cognitive impairment. The quarterly MDS assessment dated [DATE] indicated Resident #101 had severe cognitive impairment A consultant progress note dated 2/21/2024 at 6:26 PM identified recommendations were made for the Prescriber to review the physician's order for Naloxone (Used to reverse overdose) when needed. A consultant progress note dated 6/20/2024 at 8:32 AM and 7/21/2024 at 4:25 PM identified recommendations were made for the Prescriber for a recommendation to add a stop date 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 clinical record reviews and staff interviews for 2 of the 4 residents (Residents # 12 and # 91) reviewed for hospice, the facility failed to ensure the resident's hospice notes were complete. The findings include: 1. Resident #12 ' s diagnosis included dementia, and heart failure. Resident #12 ' s quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #12 had severe cognition impairment. Resident #12 elected Hospice services on 11/5/2024. The care plan dated 11/6/2024 indicated to coordinate palliative care services with hospice initiated 11/5/2024 Intervention included in part to collaborate with the hospice provider to ensure a review of the effectiveness of the care and services provided. 2. Resident #91's diagnoses included Alzheimer's disease and palliative care. Resident #91 elected hospice services on 12/18/2023. The care plan dated 12/27/2023 indicated hospice services related to end stage dementia. Interventions included honor choices and coordinating care for residents'…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, review of policy and staff interviews for 1 of 4 resident (Resident # 135) reviewed for abuse, the facility failed to ensure the resident was seen by social service within three days after an allegation of mistreatment per facility practice and failed to report the allegation of mistreatment to other state agency. The findings include: Resident # 135 was admitted to the facility on [DATE]. The resident diagnoses included hypothyroidism, hyperlipidemia, hypertension, fall, osteoarthritis left hip and knee and Transient Ischemic Attack (TIA). The hospital Discharge summary dated [DATE] identified a history of stroke, left side weakness and indicated the patient presented in Emergency Department (ED) for left leg pain. However, studies showed no fracture. Patients ambulate with a walker but have difficulty due to left foot pain. Additionally, noted a need rehabilitation. The patient presents with significant impairment of mobility due to recent fall. 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 review, facility documentation, review of policy and staff interviews for 1 of 4 resident (Resident # 135) reviewed for abuse, the facility failed to ensure the resident was free from mistreatment. The findings include: Resident # 135 was admitted to the facility on [DATE]. The resident diagnoses included hypothyroidism, hyperlipidemia, hypertension, fall, osteoarthritis left hip and knee and Transient Ischemic Attack (TIA). The hospital Discharge summary dated [DATE] identified a history of stroke, left side weakness and indicated the patient presented in Emergency Department (ED) for left leg pain. However, studies showed no fracture. Patients ambulate with a walker but have difficulty due to left foot pain. Additionally, noted a need rehabilitation. The patient presents with significant impairment of mobility due to recent fall. The patient will require short term stay rehabilitation secondary to unsafe discharge to home at this time. Patient reported that she/he fell 12 hours prior…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, review of policy and staff interviews for 1 of 4 resident (Resident # 135) reviewed for abuse, the facility failed to report an allegation of mistreatment to the state agency timely. The findings include: Resident # 135 was admitted to the facility on [DATE]. The resident diagnoses included hypothyroidism, hyperlipidemia, hypertension, fall, osteoarthritis left hip and knee and Transient Ischemic Attack (TIA). The hospital Discharge summary dated [DATE] identified a history of stroke, left side weakness and indicated the patient presented in Emergency Department (ED) for left leg pain. However, studies showed no fracture. Patients ambulate with a walker but have difficulty due to left foot pain. Additionally, noted a need rehabilitation. The patient presents with significant impairment of mobility due to recent fall. The patient will require short term stay rehabilitation secondary to unsafe discharge to home at this time. Patient reported that she/he fell…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #15) reviewed for abuse, the facility failed to ensure a resident was treated with respectt and dignity. The findings include: Resident #15's diagnoses included fractured humerus, heart failure and localized edema. The admission Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #15 was alert and oriented, required maximal assistance for toilet use, and was occasionally incontinent of urine and continent of bowel. The Resident Care Plan (RCP) dated 7/9/2024 identified Resident #15 required assistance with toileting due to recent hospitalization for fractured humerus. Interventions directed assist with ADLs and toileting. A physician's order dated 7/5/2024 directed to Furosemide (diuretic use to treat edema and heart failure) oral tablet 80 mg give one (1) tablet by mouth two times a day for congestive heart failure. Review of facility Reportable Events…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for one resident (Resident #11) reviewed for Activities of Daily Living, the facility failed to document and follow up on resident grievances accurately and timely. The findings include: Resident #11's diagnoses included sacrococcygeal disorders, overactive bladder, difficulty in walking, and weakness. The 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #11 was moderately cognitively impaired and required extensive assist for bed mobility, transfers, toileting, and personal hygiene. An Administrator progress note dated 6/29/23 at 11:52 A.M. identified that s/he (Administrator #2) spoke to Resident #11 regarding concerns with care over the past few days. Further, the progress note indicated concerns received from the spouse, and s/he reached out to him/her and discussed the issues. The note identified the Administrator will meet with the resident daily to discuss care and any further concerns.…

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 two of five residents, (Resident # 1 and #4), reviewed for abuse or neglect, the facility failed to ensure a resident was free from abuse or neglect. The findings include: 1. Resident #1 was admitted to the facility on [DATE] for short term rehabilitation after sustaining a spinal cord injury. On admission to the facility, Resident #1 had diagnoses that included injury at the C1 level of the cervical spine, bipolar 1 disorder, depression, and paralysis. The MDS assessment dated [DATE] indicated Resident #1 had no cognitive impairment and required an extensive assist of 2 for transfers and bed mobility, an extensive assist of 1 for dressing and toileting, and total dependence for bathing. The care plan dated 5/18/20 identified a goal of coping with triggers and had interventions to include 1:1 visit with a social worker to establish a relationship and trust. The care plan dated 5/29/20 indicated Resident #1 had…

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 three of five residents reviewed for allegation of abuse (Resident #4, #5 and #20), the facility failed to ensure that complete and correct information was reported to the state agency after a staff member was terminated for pushing the resident. Additionally, for two residents the facility failed to ensure a staff member reported an allegation of abuse to the supervisor in a timely manner and for one sampled resident the facility failed to immediately report the allegation of abuse to the state agency no later than two (2) hours after being notified of the alleged abuse in accordance with facility policy. The findings include: 1. Resident #4's diagnoses included osteoporosis, dysphagia, depression, and dementia. The quarterly MDS assessment dated [DATE] identified Resident #4 had severe cognitive impairment, exhibited no behavioral symptoms, and required two (2) person extensive assistance with bed mobility, transfer,…

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 23 residents (Resident #11) reviewed for accuracy and completion of assessments, the facility failed to ensure admission assessments were complete or accurately code a Minimum Data Set (MDS) assessment. The findings include: 1. Resident #9 was admitted to the facility on [DATE] with diagnoses that included sepsis, urinary track infection, hypertension and weakness. Review of resident care plans initiated 7/16/21 indicated a risk for falls secondary to cognitive impairment and a risk for skin breakdown related to bowel incontinence. A progress noted dated 7/16/21, timed 11:43 P.M. indicated Resident #9 was admitted to the facility at 9:30 P.M. A subsequent progress note dated 7/18/21 indicated the resident and poor safety awareness and required constant supervision for a high fall risk. Facility documentation dated 7/18/21, 5:00 P.M. indicated the resident was witnessed to pull a dressing off his right antecubital area causing a skin tear that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for one resident (Resident #11) reviewed for bowel and bladder, the facility failed to implement a person-centered care plan on a resident who was identified as needing assistance with toileting. The findings include: Resident #11's diagnoses included overactive bladder, difficulty in walking, and weakness. The 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #11 was moderately cognitively impaired and required extensive assist for bed mobility, transfers, toileting, and personal hygiene. Additionally, it identified that Resident #11 was occasionally incontinent of both bowel and bladder. Review of Physical Therapy notes dated 6/22/23 indicated that Resident #11 was a sit to stand at the grab bar with minimal assistance of 2 staff or moderate assistance of 1 staff and recommended to remind resident to not get up on his own and offer toileting at night as indicated. Review of the clinical record…

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.

Resident #15 had diagnosis that included personality disorder, anxiety disorder, depressive episodes, chronic obstructive pulmonary disease and chronic systolic congestive heart failure. Review of the clinical record, the care plan dated 3/4/2022 identified Focus: Behavior and mood patterns, and the resident becomes loud, yells and swears at the staff when agitated, easily upset and mood changes quickly with the intervention for two NA's for care. Review of the NA care card dated 3/10/2022 identified two NA's or staff for care. Review of the progress notes identified the following: : -2/25/2022 documented by RN#8: the resident became belligerent, pointing he/his finger at the nurse aide (NA) when the NA explained that the order the resident requested was already called into dietary. The resident continued to yell down the hall, when RN#8 went to assess the resident , the resident told the RN that she/he was a psychiatric (psych) patient and you don't know what triggers me and when people don't listen it makes me want to hit them, but I am a psych patient and I will behave for now.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one sampled resident (Resident #18) reviewed for elopement and four of four residents (Resident #6, # 7, # 11 and #13) reviewed for accidents, the facility failed to prevent a cognitively impaired resident from exiting the facility without staff supervision and failed to implement interventions to reduce hazards and risks following a fall, and failed to implement a person-centered care plan on a resident who was identified as at risk for falls. The findings include: 1. Resident #18's diagnoses included dementia, macular degeneration, glaucoma, metabolic encephalopathy, diabetes, and heart disease. The care plan dated 2/14/21 identified Resident #18 at risk for falls. Interventions included directions to instruct the resident in proper use of a device to aid with balance/transfers, orient to surroundings and instructed to ask for assistance prior to attempting to transfer or ambulate as needed. Review of 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 review, review of facility policy and procedure and interviews with facility staff for 3 of 3 residents (Resident #12, #13 and #16) who had physician orders that directed obtaining resident weights, or physician orders that directed intake and output monitoring, or who experienced weight loss, the facility failed to obtain a weight, monitor intake and output, or reweigh when ordered. The findings include: 1. Resident #12 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, unspecified severity with agitation, chronic kidney disease, history of falling and essential hypertension. The physician's order dated 11/17/2022 directed to weigh the resident on admission and four consecutive weeks post admission. Review of the Weights and Vitals Summary from 11/18/2022 through 3/15/2023 identified that the resident was weighed on 11/18/2022 and the weight was 122.5 pounds, 12/21/2022 the weight was 122.7 pounds (five weeks later) and 12/26/2022 weight was 122.7…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, review of the facility policy and procedure, and interviews for 2 of 2 residents reviewed for pain management (Resident #14 and #23), the facility failed to identify and intervene timely for complaints of pain. The findings include: 1. Resident #14 was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease, congestive heart failure, and chronic pain syndrome. A MDS assessment dated [DATE] identified no cognitive impairment, extensive assistance with transfers and bed mobility, and the resident was receiving a scheduled pain medication. An RCP dated 2/22/22 identified a potential for pain related to back pain. Interventions included administering pain medications as ordered, assessing characteristics of pain, location, severity on a scale of 0-10, and discussing with the resident factors that may precipitate pain and what may reduce it. Review of progress notes from 5/13/22 though 6/13/22 identified the Resident was reporting pain at 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.

Based on review of personnel files for 3 of 5 Nurse Aides (NA #7, NA #11, and NA #12), facility policy and interviews, the facility failed to complete annual performance evaluations. The findings include: NA #7's Date of Hire (DOH) was documented as 7/27/22 and no performance evaluation was located in NA #7's personnel file. NA #11's DOH was documented as 11/7/17 and the last performance evaluation in NA #11's personnel file was dated 9/14/20 (over 3 years ago). NA #12's DOH was documented as 11/21/11 and the last performance evaluation in NA #12's personnel file was dated 10/31/19 (over 4 years ago). Interview and facility documentation review with the DNS on 6/3/24 at 11:00 AM identified that performance evaluations throughout the entire building have not been done consistently but that they should be done annually on all staff. She reported department heads are responsible for performance evaluations for their respective departments, and then nursing works together to complete the nurses and NA evaluations. All evaluations should then be signed off by the Administrator. She…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, review of facility policy, and interviews for one sampled resident reviewed for psychosocial services and follow up (Resident #1), the facility failed to ensure a resident received appropriate treatment and services to correct an assessed problem to support attaining the highest practicable mental and psychosocial well-being. The findings include: Resident #1 was admitted to the facility on [DATE] for short term rehabilitation after sustaining a spinal cord injury. On admission to the facility, Resident #1 had diagnoses that included injury at the C-1 level of the cervical spine, bipolar 1 disorder, depression, and paralysis. The MDS assessment dated [DATE] indicated Resident #1 had no cognitive impairment and required an extensive assist of 2 for transfers and bed mobility, an extensive assist of 1 for dressing and toileting, and total dependence for bathing. The care plan dated 5/18/20 identified a goal of coping with triggers and had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, review of facility documentation, and interview with facility staff for one resident (Resident #16) who had an order for a laboratory test, the facility failed to obtain the specimen timely in accordance with physician orders. The findings include: Resident #16 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, diabetes mellitus, chronic obstructive pulmonary disease, anxiety, and atrial fibrillation. A pressure ulcer assessment dated [DATE] identified a facility acquired pressure ulcer which measured 1 centimeter (cm) by 1.5 cm with a small amount of sanguineous drainage. A corresponding RCP identified the resident is at risk for skin breakdown with interventions that included weekly skin assessments and treatments as ordered. A progress note dated [DATE] indicated the coccyx wound was deteriorating and was graded to a stage 3. The note further identified the patient stopped feeding herself. The note further identified the wound…

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 clincial record, review of facility documentaion and interview with facility staff for one resident who had a signficant change in condition (Resident #16), the facility failed to ensure documentation was completed to reflect the resident's condition. The findings include: Resident #16 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, diabetes mellitus, chronic obstructive pulmonary disease, anxiety, and atrial fibrillation. A physician order dated [DATE] directed the resident's code status as a full code. A MDS assessment dated [DATE] identified the resident required extensive assistance with transfers, bathing and hygiene. A corresponding RCP identified a diagnosis of chronic obstructive pulmonary disease with interventions that included signs and symptoms of exacerbation, may include, dyspnea, rapid/shallow respirations, shortness of breath, cyanosis, wheezing, increased anxiety, and diminished ling sounds. Review of a nursing progress notes 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 review, facility documentation, facility policy, and interviews for (1) one of (3) three residents, (Resident #1), reviewed for medication management, the facility failed to reassess a resident whom had a change in status, to ensure continued capability of self administration of medication. The findings include: Resident #1's diagnoses included diabetes. An Interdisciplinary Care Plan dated 2/20/2024 identified the resident may self-administer medication (insulin pump) with interventions that directed for resident to show competency with use of medication, self-administration of medication form to be completed to assess for accurate dispersion of medication, nurse will evaluate on a day-to-day basis need to administer medications themselves, and nurse will continue to monitor for side effects of medication. A self administration of medications informed consent and assessment dated [DATE] identified that the resident was able to answer all questions about the insulin pump correctly and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for discharge planning, the facility failed to ensure that the discharge instructions/paperwork included the use of a specialized device used to deliver medication . The findings include: Resident #1's diagnoses included diabetes. Review of hospital Inter-Agency Patient Referral Report dated 2/20/2024 identified that the resident was on an insulin pump during h/her hospital stay, the plan is was for discharge to rehab, and to remain on insulin pump as the skilled nursing facility had accepted the resident with the insulin pump. Discharge orders included a check blood of blood sugars before meals and at bedtime. The insulin pump basal rates (continuous insulin administration) set for varying times of day at varying rates with a total insulin dose of 19.325 units/day, An insulin-sensitivity factor (ISF) setting at 1.35 mg/dl (milligram/deciliter) (measures how much…

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, facility documentation, facility policy, and interviews for one (1) of (3) three residents, (Resident #1), reviewed for medication management, the facility failed to ensure medical device maintenance was provided in accordance with manufacturer's guidance. The findings include: Resident #1's diagnoses included diabetes. Review of hospital Inter-Agency Patient Referral Report dated 2/20/2024 included progress notes dated 2/20/2024 by an endocrinology provider that indicated that the patient would remain on the insulin pump (a device that delivers insulin into the body through a device outside of the body) after discharge at the skilled nursing facility. The report further identified that the insulin infusion set (includes the needle that is inserted into the body and the tubing) was due to be changed on 2/22/2024. An Interdisciplinary Care Plan dated 2/20/2024 identified the resident may self-administer medication with interventions directed for resident to show competency with use of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews, and facility policy review for reviewed for medication management, the facility failed to ensure facility staff were trained and competent in managing and monitoring a specialized medical device. The findings include: Resident #1's diagnoses included diabetes. An Interdisciplinary Care Plan dated 2/20/2024 identified the resident may self-administer medication (insulin pump) with interventions that directed for resident to show competency with use of medication, self-administration of medication form to be completed to assess for accurate dispersion of medication, nurse will evaluate on a day-to-day basis need to administer medications themselves, and nurse will continue to monitor for side effects of medication. Review of hospital Inter-Agency Patient Referral Report dated 2/20/2024 included progress notes dated 2/20/2024 identified that the patient would remain on the insulin pump (a device that delivers insulin into the body through a device outside of the body)…

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 one of three residents (Resident #1) reviewed for pressure wounds, the facility failed ensure the responsible party was notified timely of a change in condition. The findings include: Resident #1 was admitted with diagnoses that included prostate cancer, neurogenic bladder, stroke, and status post hip replacement with open reduction. An admission MDS assessment dated [DATE] identified Resident #1 was alert and oriented and was at risk for pressure ulcers. A Resident Care Plan (RCP) dated 10/18/2023 identified Resident #1 was at risk for skin breakdown. Interventions directed to off load heels, turn and position every two (2) hours, and use of a pressure reducing mattress/cushion. A nursing note dated 12/26/2023 at 9:55 PM identified RN #1 was called to evaluate Resident #1 and identified an area on the left ischium (part of the pelvis bone that forms the lower back part of the hip bone). The area was approximately 4 centimeters (cm) by 5…

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, facility documentation review, facility policy review, and interviews for two of three residents (Resident #1 and #2) reviewed for pressure wounds, the facility failed to ensure the clinical record was complete and accurate to include weekly pressure wound assessments. The findings include: 1. Resident #1 was admitted with diagnoses that included prostate cancer, neurogenic bladder, stroke, and status post hip replacement with open reduction. An admission MDS assessment dated [DATE] identified Resident #1 was alert and oriented and was at risk for pressure ulcers. A Resident Care Plan (RCP) dated 10/18/2023 identified Resident #1 was at risk for skin breakdown. Interventions directed to off load heels, turn and position every two (2) hours, and use of a pressure reducing mattress/cushion. A physician's order dated 11/6/2023 directed as per facility skin protocol to complete weekly wound documentation every Thursday. A facility consulting wound physician note 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #29) reviewed for positioning, the facility failed to ensure the leg rests and calf pad were on the adaptive wheelchair for positioning per therapy recommendations. The findings include: Resident #29 was admitted to the facility with diagnoses which included history of falling, hearing loss, dementia, and cerebral infarction without residual deficits. The Physical Therapy Evaluation and Plan of Treatment dated 3/3/21 indicated Resident #29 was in a modified custom wheelchair which included tilt in space with headrest and non-elevating leg rests. Lower extremities frequently dangling behind leg rests. Applied leg buddy/calf pad to prevent lower extremities from falling behind leg rests. Resident #29's nursing assistant care card dated 3/10/22 identified Resident #29 was non ambulatory, dependent in wheelchair, assist of 2 for transfers to adaptive wheelchair, and offload heels. 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 one of three sampled resident (Resident #29) reviewed for Physicians Orders, the facility failed to ensure the monthly physicians orders were signed by the physician and progress notes were legible. The findings include: Resident #29 was admitted to the facility with diagnoses that include dementia, and cerebral infarction without residual deficits. The annual MDS assessment dated [DATE] identified Resident #29 had severely impaired cognition, was always incontinent of bowel and bladder and required extensive assistance for bed mobility and transfers with 2-person physical assist, and totally dependent with eating and toilet use with 1-person physical assist, and extensive assist for dressing and personal hygiene with 1 person physical assist. The March 2022 care plan identified activities of high blood pressure and anxiety. Interventions directed to administer medications per physicians orders. A physician's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, review of facility documentation, facility policy and interview for 1 of 3 residents reviewed for pressure ulcers (Resident #112) the facility failed to ensure weekly skin assessments were consistently conducted on a resident at risk for developing a pressure ulcer . The findings include: Resident #112 was admitted to the facility on [DATE] with diagnoses that included hypertension, glaucoma, anxiety and dementia. The Norton Plus assessment tool (used to predict the likelihood of developing pressure ulcers) dated 5/8/19 identified a score of 12, indicating Resident #112 was at a moderate risk for developing a pressure ulcer. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #112 was severely cognitively impaired and required extensive 2 person assistance with bed mobility and transfers and extensive 1 person assistance with bathing, dressing, grooming, toilet use, ambulation in room, and locomotion on and off the unit. Additionally, 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 policy/procedures and interviews for 1 of 3 residents reviewed for accidents (Resident #61), the facility failed to ensure a fall was reported by the Nurse Aide's (NA) to ensure an assessment could be completed by the Registered Nurse (RN) and for 1 of 1 sampled resident reviewed for an altercation (Resident #104), the facility failed to conduct and document an assessment, consistently complete and document every 15 minute observational safety checks and/or provide documentation of timely behavioral health follow up as per the plan of care subsequent to a resident to resident altercation. The findings include: 1. Resident #61's was admitted to the facility on [DATE] with diagnoses that included falls, dementia, psychotic disorder with delusions due to known physiological condition and an eating disorder. The Resident Care Plan dated 3/18/19 identified a risk for falls. Interventions included to keep in common areas when awake, instruct to ask for assistance prior…

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 policy and interviews for 1 of 3 sampled residents reviewed for nutrition and weight loss (Resident #150), the facility failed to implement measures to address a weight loss with variable intake in a timely manner as recommended by the Dietician. The findings include: Resident #150 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus, congestive heart failure, encephalopathy and dementia. The admission Minimum Data Set assessment dated [DATE] identified that Resident #150 had no cognitive impairment, independent for eating, a weight of 120 pounds (lbs), no weight loss and received a therapeutic diet. The Resident Care Plan dated 6/21/19 identified a potential for impaired nutritional status with interventions that included to monitor the resident's weight, monitor food and snack intake as needed and document percentage of consumed solids and fluids. Physician's orders dated 7/6/19 directed a Controlled Carbohydrate diet. The…

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

Based on observations, interviews and review of the facility policy for medication storage, the facility failed to store a medication in a safe manner. The findings include: An observation on 10/3/19 at 10:00 AM identified a bottle of medication (Imodium HCL 2mg) containing 19 caplets sitting unsecured on the desk at the nurse's station to the right of the computer on the right side of the station. Interview and observation of the medication bottle on 10/3/19 at 10:05 AM with Registered Nurse (RN) #2 identified the medication bottle should have been locked and secured at all times and did not know the reason the bottle was on the desk. Further, RN #2 indicated there are residents who can ambulate independently on the unit, however there were no residents that wander into the nurse's station. Subsequent to survey inquiry, RN #2 discarded the medication. Interview with Licensed Practical Nurse (LPN) #2 on 10/3/19 at 10:10AM identified LPN #3 had informed her at the beginning of the shift that LPN #3 found a bottle of Imodium in a resident's room and LPN #2 told LPN #3 to discard 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.