Cheshire House Health Care Facility & Rehab Center

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 #1) reviewed for falls, the facility failed to develop and implement a comprehensive care plan for a resident at risk for falls and for the only sampled resident (Resident #38) reviewed for activities of daily living, the facility failed to ensure that the care plan was followed for assist of two for direct care. The findings include: 1. Resident #1 had diagnoses that included chronic obstructive pulmonary disease, cervical radiculopathy, and congestive heart failure. A Physical Therapy evaluation dated 4/18/23 identified Resident #1 presented with impairments in functional strength, mobility and activity tolerance due to recent surgery and Resident #1 had a fall on 7/18/23. A fall risk assessment completed after Resident #1 fell and dated 7/18/23 identified Resident #1 was at risk for falls. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had intact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 1 resident (Resident #15) reviewed for a non-pressure skin condition, the facility failed to supervise Resident #15 to ensure proper technique when Resident #15 was self performing wound care and for 1 of 3 residents (Resident #219) reviewed for nutrition, the facility failed to follow the physician order for daily weights. The findings include: 1. Resident #15 had diagnoses that included cellulitis of the left lower limb, chronic respiratory failure with hypoxia, and lymphedema. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #15 was cognitively intact, used a motorized wheelchair, required supervision or touching assistance with eating, and was independent with personal hygiene and transfers. The Resident Care Plan (RCP) dated 2/11/25 identified Resident #15 was at risk for alteration in skin integrity. Interventions included to report any new areas, provide…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #17) reviewed for pressure ulcers, the facility failed to ensure the wound consultant recommendations were followed up by the facility. The findings included: Resident #17's diagnoses included pressure ulcer of the sacral region, dementia with severe anxiety and mild neurocognitive disorder with behavioral disturbances. The annual Minimum Data Assessment (MDS) dated [DATE] identified Resident #17 was mildly cognitively impaired, required maximum assistance for personal hygiene, assistance of 2 staff members for bed mobility, and was bedfast most of the time. The Resident Care Plan dated 2/18/25 identified skin Integrity as an area of concern with an unstageable pressure ulcer on the coccyx. Interventions included to follow skin care protocols, physical therapy/occupational therapy (PT/OT) consultation for positioning, low air loss pressure mattress, treatment as order,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 1 of 2 residents (Resident #17) reviewed for pressure ulcers, the facility failed to ensure infection control practices were followed during a dressing change and protective personal equipment (PPE) was worn during the dressing change for a resident on Enhanced Barrier Precautions (EBP). The findings include: Resident #17's diagnoses included pressure ulcer of the sacral region, dementia with severe anxiety and mild neurocognitive disorder with behavioral disturbances. The annual Minimum Data (MDS) assessment dated [DATE] identified Resident #17 was mildly cognitively impaired and required maximum assistance for personal hygiene, assistance of 2 staff members for bed mobility, and was bedfast most of the time. The MDS further identified Resident #17 was at risk for the developing pressure ulcers, and had a Stage 1 or greater pressure ulcer over a bony prominence. The Resident Care Plan dated 2/18/25…

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 required blood sugar monitoring, the facility failed to assess the resident's blood sugar when the resident experienced mental status changes. The findings include: Resident #1's diagnoses included bacteremia (a blood infection), carcinoma of the liver, and diabetes mellitus. The nursing admission assessment dated [DATE] identified Resident #1 was alert and oriented to person, place, and time, and required staff assistance with activities of daily living. A physician's order dated 12/21/24 identified weekly blood work every Monday and fingerstick blood sugars twice a day. The Resident Care Plan dated 12/23/24 identified Resident #1 was at risk for hyperglycemia or hypoglycemia related to diabetes mellitus. Interventions directed to monitor for signs and symptoms of hyperglycemia, thirst, drowsiness, headaches, and behavior changes and to monitor for signs 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, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for accidents, the facility failed to follow act on a request for a room change timely. The findings include: Resident #1's diagnoses included surgical aftercare and Parkinson's disease. The nursing admission assessment dated [DATE] identified Resident #1 was alert, verbal with unclear speech, was inattentive, and agitated. The Resident Care Plan (RCP) dated 1/15/2025 identified an ADL deficit related to recent hospitalization. Interventions directed assist of one (1) for ADLs, toilet transfers and tasks using rolling walker. Record review identified Resident #1 had a family member identified as a Power of Attorney (POA) for financial and care decisions. Social work progress note dated 1/15/2025 indicated resident had A Brief Interview for Mental Status (BIMS) on 1/15/2025 indicated a score of six out of fifteen, indicative of severe cognitive impairment. 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 review of facility documentation, facility policy, and interviews, the facility failed to address the resident's grievances for lengthy wait times times to call light response identified during several resident council meetings. The findings include: A review of the Resident Council Meeting Minutes dated 9/26/24 identified residents had concerns with call bells not being answered in a timely manner. The residents stated the call bell issues on the second shift are ongoing but understand audits are being conducted and are helping with the issue. The residents appreciate the ongoing audits and staff education the DNS is working on to resolve the issues. A review of the Resident Council Meeting Minutes dated 10/27/24 identified residents (unidentified residents) had concerns with call bells not being answered in a timely manner. The residents state the call bell issues on the second shift are ongoing but understand audits are being conducted and are helping with the issue. The residents appreciate the ongoing audits and staff education the DNS is working on to resolve 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 (1) of three (3) residents (Resident #1) reviewed for change in condition, the facility failed to ensure the physician was notified when the resident experienced a change in condition. The findings include: Resident #1 had diagnoses that included type 2 diabetes mellitus and thrombocytopenia. The care plan dated 10/26/24 identified Resident #1 requires assistance with bathing, dressing, hygiene, and with assist of two (2) staff members. The admission MDS dated [DATE] identified Resident #1 had Brief Interview for Mental Status score of fifteen (15) indicative of intact cognition and assistance with ADL's. A nurse's note dated 11/26/24 at 6:18 P.M. written by LPN #3 identified Resident #1 was complaining that h/she caught h/her family members cold. LPN #3 identified Resident #1 is complaining of feeling very malaise, body aches, chills, and no appetite, the note further identified that Resident #1's had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #2) reviewed for abuse, the facility failed to provide adequate supervision to prevent sexual abuse. The findings include: 1. Resident #2 had diagnoses that included dementia, adjustment disorder, and dysthymic disorder. The care plan dated 12/9/24 identified Resident #2 has a consensual friendly relationship with another resident (Resident #3) that has been approved by the family with interventions that directed per family Resident #3 okay to spend time with Resident #2, sit with resident, kiss on cheek, hold hands, yellow tape was placed at Resident #2's room threshold as a reminder for male resident (Resident #2) not to enter the room unaccompanied, and social services to follow up to ensure residents are abiding by guidelines set forth by family. Review of SW #2's (psych) note dated 12/16/24 at 12:40 P.M. identified asked to assess Resident #2's cognition and judgement…

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 and policies and interviews for five (5) of seven (7) sampled residents (Residents #2, # 3, #4, and #5) who were reviewed for the misappropriation of personal property, the facility failed to ensure the residents' controlled medications and the controlled disposition sheets were not removed from the facility by a licensed nurse. The findings include: 1. Resident #2's diagnoses included fracture of right femur, anxiety, and joint replacement. The admission Minimum Data Set assessment dated [DATE] identified Resident #2 was alert and oriented to person, place, and time and received pain medication. The Resident Care Plan dated [DATE] identified Resident #2 was at risk of pain. Interventions directed to monitor for pain and administer medications as ordered. A physician's order dated [DATE] directed to administer Oxycodone 10 milligrams (mg) every six (6) hours as needed for pain. 2. Resident #3's diagnoses included low back pain, muscle weakness, 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 reviews, facility documentation, and interviews for one (1) of three (3) sampled residents (Resident #1) who were new admissions, the facility failed to address the hospital's discharge recommendation for a treatment order. The findings include: Resident #1's diagnoses included left knee replacement, pain, and osteoarthritis. The hospital Discharge summary dated [DATE] identified a discharge order for cryocuff, a type of cold compress, to the affected knee, recharge every four (4) hours and as needed. Review of the facility's admission orders dated 7/26/24 failed to reflect an order for the cryocuff or cold compress treatment. The nursing admission sheet dated 7/26/24 identified Resident #1 was alert and oriented to person, place and time and required partial to moderate assistance with activities of daily living. The Resident Care Plan dated 7/26/24 identified Resident #1 was at risk for pain. Interventions directed to monitor pain, use non-drug interventions as needed, and administer…

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 (1) of three (3) sampled residents (Resident #1) who were reviewed for discharge, the facility failed to ensure the correct medications were sent home with the resident. The findings include: Resident #1's diagnoses included left knee replacement, history of falling, and weakness. The nursing admission sheet dated 7/26/24 identified Resident #1 was alert and oriented to person, place and time and required partial to moderate assistance with activities of daily living. The Resident Care Plan dated 7/29/24 identified Resident #1 was to return home after completion of rehab and nursing therapy. Interventions directed education for caregivers to perform required care and referral to be made for skilled home care services. A physician's order dated 8/1/24 directed to discharge Resident #1 home with medications and services. The Discharge summary dated [DATE] identified the Nursing Supervisor reviewed, educated, 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 reviews, facility documentation, facility policy and interviews for one of three sampled residents (Resident #3) who were reviewed for an allegation of verbal abuse by a staff member, the facility failed to ensure the resident was treated in a respectful and dignified manner. The findings include: Resident #3's diagnoses included respiratory failure and anxiety. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #l made reasonable and consistent decisions regarding tasks of daily living, exhibited no behavioral symptoms, required one (1) person supervision when ambulating, and required oxygen therapy. The Resident Care Plan dated 5/2023 identified Resident #1 had a history of accusatory behaviors or suspiciousness prior to admission to the facility. Interventions directed regular visits to establish rapport and trust, consistent caregivers, and allow for choice and decisions. Review of the grievance log identified on 7/17/23 Resident #1 reported to the social…

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, observations, facility documentation, facility policy and interviews for one of three sampled residents (Resident #1) who were reviewed for an allegation of verbal abuse, the facility failed to report the incident to the Administrator and/or Director of Nursing at the time the incident occurred. The findings include: Resident #1's diagnoses included hypertension, hypothyroidism, and generalized muscle weakness. The admission clinical assessment dated [DATE] identified Resident #1 was oriented to person only, required cues, and had disorganized thinking, forgetfulness, and confusion. The Facility Reported Incident form dated 7/13/23 at 7:40 AM identified a nurse aide, Nurse Aide (NA) #1, reported another nurse aide, NA #2, was verbally abusive toward Resident #1 during care. The report indicated the nurse aide stated to Resident #1 I'm not here to lift your big a_ _, you need to do it yourself so I can change you. The report identified that the incident had occurred the 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.

Based on review of the Grievance Log, Resident Council meeting, staff and resident interviews, observations and facility policy, the facility failed to resolve repeated grievances regarding staff not wearing name badges and failed to respond to Resident #559 not getting out of bed timely. The findings include: 1. Review of the Grievance/Concern Log dated 6/14/22 indicated Resident #558 identified a Nurse Aide (NA) on the 7:00 AM to 3:00 PM shift was not wearing an identification (ID) badge. The corrective action was the ID badge was located and worn. Review of Grievance/Concern Log, Human Resource Comments section, dated 6/16/22 indicated that NA #9 must be wearing a photo ID due to being out of uniform. Observation of NA #2 on 4/24/23 at 11:00 AM failed to identify that she was wearing any form of ID (photo/name badge). She further identified that she was awaiting a replacement ID because she had lost hers. Observation of Registered Nurse (RN) #5 on 4/24/23 at 11:45 AM failed to identify that she was wearing any form of ID (photo/name badge). Interview with Resident #463 on 4/24/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation, facility policy, and interviews for 3 of 4 sampled residents (Resident #559, Resident #561 and Resident #608) with an allegation of lack of care (Resident #559 and Resident #608) and misappropriation of property (Resident #561), the facility failed to report the allegations to the State Agency. The findings include: 1. Resident #559 was admitted to the facility on [DATE] with diagnoses that included femur fracture, difficulty walking, hemiplegia, dementia, and anemia. The admission Resident Care Plan dated 12/30/21 identified Resident #559 had a self-care deficit related to hemiplegia, difficulty walking and dementia. Interventions included to provide assistance with activities of daily living, turning and positioning every 2 hours, and assistance of two people for transfers. The quarterly MDS assessment dated [DATE] identified that Resident #559 had a short/long term memory problem, required extensive assistance with two people for bed mobility,…

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 2 of 4 sampled residents (Resident #558 and #559) with an allegation of mistreatment, the facility failed to complete an investigation regarding the allegation of mistreatment. The findings include: 1. Resident #558's diagnoses included chronic obstructive pulmonary disease (COPD), malignant neoplasm of the lung, and osteoarthritis. The admission Resident Care Plan (RCP) dated 5/22/22 identified Resident #558 had a self-care deficit related to COPD and osteoarthritis. Interventions included to provide assistance with bathing, dressing, hygiene, transfers, and ambulation. The RCP further identified Resident #558 was dependent on oxygen with oxygen (O2) saturation levels to be completed to monitor the effectiveness of O2, elevating the head of the bed and encouraging breathing exercises. The admission MDS assessment dated [DATE] identified Resident #558 was cognitively intact, required extensive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy, and interviews for 2 of 4 residents (Resident #3 and Resident #8) reviewed for nutrition, the facility failed to conduct monthly weights for residents who were subsequently noted to have a significant weight loss. The findings include: 1. Resident #3's diagnoses included dysphagia, hypothyroidism, anxiety, and dementia. The Resident Care Plan dated 2/2/22 identified Resident #3 was prescribed a ground, no added salt diet. Interventions included to weigh the resident as ordered, according to the facility policy and provide Registered Dietician (RD) and Speech Therapy evaluations as needed, The Annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 was severely cognitively impaired, required extensive assistance with one staff for dressing and eating, and was totally dependent on two staff for transfers. The Dietician Quarterly Nutritional assessment dated [DATE] identified Resident #3 had no weight loss and the plan was to monitor 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 observation, review of facility policy and interviews for four resident bathrooms on one of three units nursing units, the facility failed to ensure bed pans were properly labeled, covered, and stored according to facility policy and in a manner to maintain the residents' clean, comfortable, and homelike environment. The findings included: Observation and interview with NA #6 on 4/24/23 at 11:40 AM identified the following: • room [ROOM NUMBER]'s shared bathroom contained a bed pan that was unlabeled, uncovered and was wedged between the towel rack and the wall on the right side of the toilet. The open side of the bed pan was touching the wall. The bathroom also contained three additional bedpans located on the floor next to the toilet, two of which were stacked on top of each other and were also unlabeled and uncovered. • room [ROOM NUMBER]'s shared bathroom contained a bed pan that was placed on the windowsill. NA #6 indicated it is the NA's responsibility to label, clean, cover, and store 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, review of facility documentation, review of facility policy, and interviews for 1 of 4 sampled residents (Resident #561) with an allegation of a missing item, the facility failed to ensure that the personal property was safeguarded. The findings include: Resident #561 was admitted to the facility on [DATE] with diagnoses that included cerebral ischemia, adult failure to thrive and cardiomyopathy. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #561 had a short/long term memory problem and required extensive assistance of one person for bed mobility, dressing, toilet use, personal hygiene and eating. Additionally, Resident #561 required total assistance with one person for transfers. The Resident Care Plan (RCP) dated 4/28/22 identified Resident #561 had a self-care deficit related to cerebral ischemia, bilateral hand contractures and cardiomyopathy. Interventions included total assistance with bathing, dressing, hygiene, daily care to bilateral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record reviews and interviews, for 1 of 7 sampled residents (Resident #17) reviewed for medication administration, and for 1 of 3 sampled residents (Resident #36) reviewed for skin conditions, the facility failed to ensure a medication order was transcribed competely with the specific dose noted and failed to ensure a prescribed medication was administered by a licensed nurse. The findings include 1. Resident #17's diagnoses included respiratory failure, obstructive sleep apnea, and congestive heart failure. A Resident Care Plan dated 11/23/22 identified Resident #17 had increased risk for respiratory distress with interventions to administer respiratory treatments, medications and therapy as ordered. The Annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #17 was cognitively intact, required no assistance with bed mobility and toilet use, required set up assistance with dressing and eating, and required supervision with one person for transfers. A hospital…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, review of facility policy and interviews for sample 1 of 3 sampled residents (Resident #40) who required total care for personal hygiene and bathing, the facility failed to ensure the resident was showered as ordered. The findings include: Resident #40's diagnoses included hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side, gastroenteritis, and colitis. The annual Minimum Data Set assessment dated [DATE] identified Resident #40 had intact cognition and required total assistance with personal hygiene and bathing. The Resident Care Plan dated 2/7/23 identified Resident #40 had an ADL (activities of daily living) deficit related to a right frontal cerebrovascular accident (CVA) with left sided flaccidity with an intervention for weekly skin inspections on shower days. A review of physician's orders for the months of March/2023 and April/2023 directed facility staff to conduct weekly skin checks on bath/shower day (every Monday…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observations, review of facility documentation, review of facility policy and interviews for 1 of 5 sampled residents (Resident #8) reviewed for nutrition, and for one sampled resident (Resident #40) who had a physician's order for a consultation, The facility failed to follow physician's orders for oxygen satureation levels, weekly skin assessments and failed to ensure the resident was able to attend a scheduled appointment with an outside medical provider. The findings include: 1. Resident #8 's diagnoses included Down Syndrome, diabetes, chronic respiratory failure, and morbid obesity. The quarterly MDS assessment dated [DATE] identified Resident #8 had moderately impaired cognition, and required extensive assistance with bed mobility, walking, personal hygiene, and dressing. Review of Resident #8's care plan dated 2/22/23 (initiation date of 8/28/22) identified a concern with respiratory status, care plan interventions included: report signs and symptoms of respiratory…

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 4 sampled residents (Resident #24) who had a pressure ulcer/injury, the facility failed to ensure a positioning device was appropriately applied. The findings include: Resident #24's diagnoses included Alzheimer's disease, adult failure to thrive, and anemia. The quarterly MDS assessment dated [DATE] identified Resident #24 had severely impaired cognition, required extensive assist for bed mobility, and transfers. Resident #24's care plan dated 1/10/23 identified he/she was at risk for friction, shearing, and immobility with interventions that included: off-load heels while in bed and in the chair, use off-loading boots, turn, and reposition every two hours, and to not allow the resident to remain on back for long periods. The physician's orders in effect for the month of April/2023 directed Resident #24 to be turned side to side every two hours to relieve pressure areas and maintain skin integrity. The orders further 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility policy, and interviews for 1 of 2 sampled residents (Resident #24) reviewed for urinary tract infections the facility failed to conduct on-going assessments following a medical provider's order. The findings include: Resident #24's diagnoses included Alzheimer's disease, adult failure to thrive, and blindness. The quarterly MDS assessment dated [DATE] identified Resident #24 had severely impaired cognition, required extensive assistance for personal hygiene, required total assistance for transfers and was always incontinent of bowel and bladder. The Resident Care Plan dated 1/10/23 identified Resident #24 was incontinent of bowel and bladder with interventions that included: perform incontinence care approximately every two hours, or as needed, keep resident clean and dry, and provide incontinence protection. In addition, the care plan identified the resident was on comfort measures with interventions that included withhold intravenous hydration, tube feeds,…

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, staff interview, and review of facility policy for the only sampled resident (Resident #460) reviewed for dialysis, the facility failed to obtain daily weights as ordered. The findings include: The Resident #460's diagnosis included, chronic kidney disease with renal dialysis, muscle weakness, and cardiac disease with a pacemaker. The admission Resident Care Plan dated 4/4/23 identified renal insufficiency. Interventions included to monitor vital signs as ordered, monitor nutritional status and monitor weights as ordered and per facility policy. Physician orders dated 4/4/23 directed Resident #460 required hemodialysis every Tuesday, Thursday and Saturday and to obtain a daily weight at 6:00 AM. An admission Minimum Date Set (MDS) assessment dated [DATE] identified Resident #460 was moderately cognitively impaired, required extensive assistance of 2 staff for bed mobility, transfers, and dressing, toilet use and personal hygiene, and required assistance of 1 staff with setup for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, review of the clinical records, and facility policies for 1 of 6 sampled residents (Resident # 458) reviewed for Activities of Daily Living (ADL) and for 1 of 7 sampled residents (Resident # 460) reviewed for Medication Administration, the facility failed to ensure appropriate hand hygiene was utilized. The findings include: 1. Resident #458's diagnoses included left lower extremity amputation, anemia, and history of falls. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #458 was cognitively intact and required extensive, 2 person assistance with bed mobility, transfers, and limited assistance with dressing. The care plan dated 4/22/23 identified Resident #458 required assistance with ADLs, had an amputation of the left lower extremity, and required daily wound care. Interventions included to complete surgical incision wound care according to the physician order, monitor the site for signs and symptoms of infection, and assist to apply his/her…

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 staff interviews, facility documentation, and review of the clinical record for 1 of 5 Residents (Resident #52) reviewed for immunizations, the facility failed to ensure upon admission, the resident or resident representative was educated and given an opportunity to consent or decline the COVID-19 booster. The findings include: Resident #52 was admitted to the facility on [DATE] with a diagnoses that included hypertension, urinary tract infection, and hyponatremia (low sodium). Interview and review of facility immunization tracking with RN #4, the acting Infection Preventionist, on 4/27/23 at 1:05 PM, identified that although Resident #52 had a historical record of receiving his/her first COVID-19 vaccination 20 months prior to admission, s/he had not been offered education or an opportunity to receive or decline a COVID-19 booster since admission (3 months). RN #4 indicated that the facility should be aware of residents who needed to receive COVID-19 boosters because the facility does not keep COVID-19…

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, facility documentation, facility policy, and interviews, the facility failed to discard expired food items and ensure food items were dated or labeled. The findings include: 1. Tour of the Dietary Department and interview with the Dietary Supervisor on 5/17/21 at 10:15 AM identified the following: a. The main Dietary walk in refrigerator was noted to contain 2 cooked apple pies on the shelves dated 5/11/21 (6 days old) and a metal bowl with chopped carrots, celery and onions dated 5/13/21 (4 days old). b. The refrigerator proximal to the stove was noted with 2 slices of French toast in plastic wrap dated 5/12/21 (5 days old), 5 waffles dated 5/12/21 (5 days old), 2 quarts in a clear container of pureed pineapples that was not dated, and one liter of pickle spears in a clear plastic container with plastic wrap dated 4/17/21 (30 days old), in a 2 quart container there was 1 quart of tuna salad dated 5/13/21 (5 days old), beef gravy dated 5/13/21(4 days old) in a clear bowl, a partially used…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation and interviews for one sampled resident (Resident #59) requiring assistance with activities of daily living, the facility failed to ensure Resident #59 was treated with respect and dignity. The findings include: Resident #59's diagnosis included hip replacement, cerebrovascular accident, anxiety and major depressive disorder. The Resident Care Plan (RCP) dated 5/14/21 identified Resident #59 with a history of bladder incontinence. Interventions included to provide incontinent care every two hours and as needed and apply barrier skin protectant following incontinent care. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #59 had intact cognition, required extensive assistance of 1 with bed mobility, toilet use, transfers, and personal hygiene. Additionally, the MDS identified Resident #59 was occasionally incontinent of bowel and bladder. Observation of Resident #59 on 5/17/21 at 12:00 PM identified Resident #59 to be…

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 2 residents (Resident #15 and Resident #36) reviewed for abuse, the facility failed to protect the residents to be free from mistreatment. The findings include: 1. Resident #15's diagnoses included Alzheimer's disease, major depressive disorder and heart failure. The quarterly Minimum Data Set, dated [DATE] identified Resident #15 was severely cognitively impaired and required extensive assistance of 1 with personal hygiene. The Resident Care Plan (RCP) dated 3/24/21 identified Resident #15 had a problem with an activities of daily living deficit related to weakness, dementia and unsteady gait. Interventions included to assist with gathering and setting up clothing, toiletries and equipment, encourage self-performance, praise all attempts and allow sufficient time for task completion. Additionally, the RCP identified interventions to explain tasks to resident, purpose and breakdown of tasks into…

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 2 residents (Resident #15 and Resident #36) reviewed for abuse, the facility failed to report an allegation of mistreatment in a timely manner. The findings include: 1. Resident #15's diagnoses included Alzheimer's disease, major depressive disorder and heart failure. The quarterly Minimum Data Set, dated [DATE] identified Resident #15 was severely cognitively impaired and required extensive assistance of 1 with personal hygiene. The Resident Care Plan (RCP) dated 3/24/21 identified Resident #15 had a problem with a deficit in activities of daily living (ADL) related to weakness, dementia and unsteady gait. Interventions included to assist with gathering and setting up clothing, toiletries and equipment, encourage self-performance, praise all attempts and allow sufficient time for task completion. Additionally, the RCP identified interventions to explain to resident tasks, purpose and breakdown…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for 2 of 3 residents (Residents #13 and Resident #23) reviewed for accidents, the facility failed to ensure neurological checks were completed after falls. The findings include: 1. Resident #13 was admitted to the facility on [DATE] with diagnoses that included dementia without behavioral disturbances and a history of falls. The fall risk assessement dated 8/11/20 identified a score of 21, indicating high fall risk. The nursing admission evaluation also dated 8/11/20 identified more than 3 falls in the past 3 months. The baseline Resident Care Plan (RCP) dated 8/11/20 included the goal that the resident will remain safe. The RCP dated 8/12/20 identified a problem with being at risk for falls secondary to cognitive impairment, weakness, and unsteady gait with Resident #13 getting up on his/her own without asking for assistance. Interventions included physical therapy screen for treatment, evaluation for alternate…

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.

On 05/20/21 at 11:30 AM, the surveyor was not provided with documentation from the maintenance representative, to show that the facility's annual update of the water management book had been conducted and has documented meetings of the facility Water Management Committee.