Vanderman Place

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY [NAME], [NAME] P. Based on clinical record review, facility documentation review, facility policy review, and interviews for four of four residents (Resident #1 and #3) reviewed for comprehensive care plans, the facility failed to ensure the care plans included bed rail usage/interventions. The findings include: 1. A. Resident #1's diagnoses included dementia and contractures. Physician order dated 1/28/2025 directed to provide half side rails on every shift. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of zero out of fifteen (0/15), indicative of severe impaired cognition and was dependent with ADLs (activities of daily living). The Resident Care Plan (RCP) dated 2/15/2025 identified Resident #1 had an ADL self-care deficit related to dementia. Interventions directed required staff to turn and reposition in bed and allow staff to maximize independence with turning and repositioning in bed. A nursing quarterly…

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 four of four residents (Resident #1, #2, #3, and #4) reviewed for quality of care, the facility failed to provide education and obtain consents for use of bed rails, and the facility failed to date completed bed rail testing/audits, and failed to perform bed rail audits at six-month intervals in accordance with facility policy, and failed to ensure staff accurately performed a side rail test for risk of entrapment per device manufacture guidelines. The findings include: 1. A. Resident #1's diagnoses included dementia and contractures. Physician order dated 1/28/2025 directed to provide half side rails on every shift. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of zero out of fifteen (0/15), indicative of severe impaired cognition and was dependent with ADLs (activities of daily living). The Resident Care…

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 one (1) of three (3) residents (Resident #1) reviewed for behaviors, the facility failed to ensure that behavior monitoring was completed on a resident receiving antipsychotic medications. The findings include: Resident #1's diagnoses included anxiety disorder, schizoaffective disorder and bipolar disorder. A physician's order dated 10/9/24 directed to administer Aripiprazole 5 milligram (mg) tablet by mouth at bedtime for bipolar disorder. A physician's order dated 6/11/24 directed to administer Cariprazine (an antipsychotic medication used to treat schizophrenia, bipolar disorder and major depression) 6 milligram (mg) capsule by mouth once daily. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition and was dependent on staff for transfer assistance. The Resident Care Plan (RCP) dated 12/26/24 identified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #2) reviewed for hospitalizations, the facility failed to ensure complete and accurate documentation including an oxygen level when the resident was noted to have increased respirations and breathing heavily, provider notification and ensuring documentation of a physician's order related to a Emergency Department (ED) transfer. The findings include: Resident #2's diagnoses included acute and chronic respiratory failure, congestive heart failure, chronic kidney disease and kidney failure. The Resident Care Plan (RCP) dated 1/15/24 identified that Resident #2 has altered cardiovascular status related to atrial fibrillation (irregular heartbeat) with interventions that included to assess for chest pain, shortness of breath, monitor vital signs and notify the physician of significant abnormalities, and monitor/document/report as needed any changes in lung sounds on auscultation,…

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) who was at risk for elopement , the facility failed to develop an at risk for elopement care plan . The findings include: Resident #1's diagnoses included Parkinson's disease, dementia with behavioral disturbances, adjustment disorder (excessive reactions to stress) and repeated falls. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition and required supervision assistance with transfers and ambulation with a walker. Review of the Elopement Risk Evaluation dated 6/24/24 identified that Resident #1 was at risk for elopement. A nurse's note dated 9/7/24 at 9:21 AM identified that the resident insisted on leaving the facility to attend church and he/she was unable to be redirected. The nurse supervisor followed the resident out the front door,…

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 elopement, the facility failed to obtain a physician's order timely for a Wanderguard to be placed after the resident was identified as at risk for elopement and failed to ensure that staff was monitoring the placement and functionality of the Wanderguard in accordance with facility policy. The findings include: Resident #1's diagnoses included Parkinson's disease, dementia with behavioral disturbances, adjustment disorder (excessive reactions to stress) and repeated falls. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition and required supervision assistance with transfers and ambulation with a walker. Review of the Elopement Risk Evaluation dated 6/24/24 identified that Resident #1 was at risk for elopement. There was no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility policy and interviews for one (1) of three (3) residents (Resident #4) reviewed for a room change, the facility failed to ensure a room change was documented and social service support was provided regarding a room change. The findings include: Resident #4's diagnoses included major depressive disorder and conversion disorder (mental health issues causing physical symptoms). The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) indicative of intact cognition and was independent with bed mobility and required moderate assistance for transfers and ambulation. Review of the facility census identified that Resident #4 was admitted to the facility on [DATE] and his/her room was changed on 1/17/23. A nurse's note dated 1/17/23 at 4:34 AM identified that Resident #4 expressed agitation with the roommate's behaviors of blasting music and television during the night. A voice…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews, for 3 of 4 residents (Resident #6, 13 and 229), the facility failed to ensure advance directives were reviewed with the resident or the resident representative to ensure that their choices were honored. The findings include: 1. Resident #6 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis of the left knee, bipolar disorder, and schizophrenia. The admission record also identified that Resident #6 had a conservator of person (COP). The quarterly MDS dated [DATE] identified Resident #6 had intact cognition and required assistance of one staff member with transfers and bathing. The care plan dated [DATE] identified Resident #6 had an advance directive status of full code, (full code means that if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive. This process can include chest compressions, intubation, 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.

Based on review of facility documentation, facility policy and interviews, the facility failed to ensure annual competencies were completed timely for facility nursing staff. The findings included: A request was made on 5/1/23 for documentation of annual nursing competencies for 2021, 2022, and 2023 for licensed nursing staff. The facility failed to provide any documentation regarding completion of annual competencies. Interview on 5/2/23 at 11:23 AM with the DNS identified she was unable to locate any requested documentation showing completion of annual competencies for licensed nursing staff, but that competencies were completed during new hire orientation. The DNS also identified that the facility did not have a set time frame for completion of annual competencies, and that competencies were completed as they come up, if we notice they haven't been done in a while. The DNS was also unable to identify a timeframe when the last annual competencies were completed. Interview with LPN #4 on 5/2/23 at 1:52 PM identified she could not remember the last time she completed annual…

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

Based on observation, review of facility documentation, facility policy, and interviews, the facility failed to ensure hair nets and beard guards were worn in the kitchen, that employee food was not stored in resident refrigerators, and sanitizing solutions were adequate to disinfect surfaces in the kitchen. The findings include: 1. Observation on 4/25/23 at 9:50 AM identified the Dietary Supervisor carrying food into the walk-in refrigerator with his beard guard bunched up under his chin against his neck with the 4 - 5-inch chin hair not restrained. Dietary Aide #1 was standing in the kitchen next to the counter with his hair net in a bowl shape on the top of his head above ear level with 50% (3- 4 inches of his hair) not restrained or covered. Dietary Aide #2 was exiting the dish room in the kitchen carrying clean dishes with her hair net in a bun with pieces hanging at the top of her head with at least 75% of her hair not restrained. Interview with the Dietary Supervisor on 4/25/23 at 9:51 AM indicated he was putting out the food that was delivered and indicated that the hair…

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 ensure the annual 12 hour required in-service training was completed timely for nurse aide staff. The findings include: A request was made on 5/1/23 to the facility to provide documentation showing completion of the annual required 12 hours of nurse aide in-service training for 2021, 2022, and 2023. Interview on 5/2/23 at 11:23 AM with the DNS identified she was unable to locate any documentation showing completion of the annual required 12 hours of in-service training for facility nurse aide staff. The DNS identified the facility did not have a set time frame for completion of the in-service training and they were completed as they come up, if we notice they haven't been done in a while. The DNS also failed to identify the date that the last annual in-services were completed. Interview with NA #3 and NA #4 on 5/2/23 at 1:58 PM identified they could not remember the last time they had completed any type of nurse aide training. NA #3 identified she could not remember when the last time…

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 sampled resident (Resident #33) who was calling out to the staff, the facility failed to treat the resident with respect and dignity. The findings include: Resident #33's diagnoses included vascular dementia without behavioral disturbance, anxiety, and mild cognitive impairment. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #33 rarely or never made decisions regarding tasks of daily life, had disorganized thinking, difficulty focusing and exhibited physical behaviors towards others. The nurse's note dated 2/24/22 at 2:45 PM identified a staff member reported to the Director of Nursing (DON) and Administrator that last evening another staff member told Resident #33 to shut up. The note indicated when following up with Resident #33, he/she was alert to himself only and confused and Resident #33 was unable to give any account of the evening before. When asked if Resident #33 had any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #3) reviewed for care planning, the facility failed to invite the resident to the care plan meetings, and for 1 of 2 residents (Resident #6), the facility failed to ensure that care plan meetings were held timely. The findings include: 1. Resident #3 was admitted to the facility with diagnoses that included stroke affecting the right side. The quarterly MDS dated [DATE] and 6/22/22 identified Resident #3 had intact cognition. Review of the Interdisciplinary Care Conference Form dated 6/28/22 identified the meeting was attended by the MDS coordinator, Social Worker, dietary and Recreation, however, Resident #3 did not sign in as having attended. The quarterly MDS dated [DATE], 12/15/22, and 1/5/23 identified Resident #3 had intact cognition. Review of the Interdisciplinary Care Plan Schedules from 7/1/22 through 4/2023 identified Resident #3 had scheduled care plan meetings on 9/29/22,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, review of facility documentation, facility policies and interviews for one of three sampled residents (Resident #33) who were reviewed for an allegation of mistreatment, the facility failed to report the allegation to the Administrator or the Director of Nursing at the time the allegation of mistreatment was identified. The findings include: Resident #33's diagnoses included vascular dementia without behavioral disturbance, anxiety, and mild cognitive impairment. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #33 rarely or never made decisions regarding tasks of daily life, had disorganized thinking, difficulty focusing and exhibited physical behaviors towards others. The nurse's note dated 2/24/22 at 2:45 PM identified a staff member reported to the Director of Nursing (DON) and Administrator that last evening another staff member told Resident #33 to shut up. The note indicated when following up with Resident #33, he/she was alert to himself only…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interview for 2 of 2 residents (Resident #33 and 36), who had been transferred to the hospital, the facility failed to notify the Office of the State Long-Term Care Ombudsman of the hospital transfers. The findings include: 1. Resident #33 was admitted to the facility in February 2021 with diagnoses that included vascular dementia, psychotic disturbance, mood disturbance, and anxiety. a. Review of the census form identified Resident #33 was transferred to the hospital and admitted on [DATE]. Review of the census form identified Resident #33 was readmitted to the facility on [DATE]. b. Review of the census form identified Resident #33 was transferred to the hospital on 1/30/23. Review of the census form identified Resident #33 was readmitted to the facility on [DATE]. 2. Resident #36 was admitted to the facility in December 2022 with diagnoses that included diabetes mellitus, and end stage renal disease. Review of the census form…

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 interview for 1 of 3 residents (Resident #33) who was reviewed for an allegation of mistreatment, the facility failed to review and revise the care plan after a witnessed allegation of mistreatment, and for 1 of 2 residents (Resident #63) reviewed for accidents, the facility failed to develop and implement a comprehensive care plan related to smoking. The findings include: 1. Resident #33's diagnoses included vascular dementia without behavioral disturbance, anxiety, and mild cognitive impairment. The quarterly MDS dated [DATE] identified Resident #33 rarely or never made decisions regarding tasks of daily life, had disorganized thinking, difficulty focusing and exhibited physical behaviors towards others. The nurse's note dated 2/24/22 at 2:45 PM identified a staff member reported to the DNS and Administrator that last evening another staff member told Resident #33 to shut up. The note indicated when following up…

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 #33) who was reviewed for allegation of mistreatment, the facility failed to review and revise Resident #33's care plan to prevent the reoccurrence and protect the safety of residents after a witnessed allegation of mistreatment. The findings include: Resident #33's diagnoses included vascular dementia without behavioral disturbance, anxiety, and mild cognitive impairment. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #33 had severe cognitive impairment, required extensive assistance with bed mobility and transfer. The nurse's note dated 2/24/23 at 2:45PM identified a staff member reported to the DON and the Administrator that last evening another staff member told Resident #33 to shut up. when following up with Resident #33, he/she was alert to himself only and confused. Resident #33 was unable to give any account of the evening before. When asked if…

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 1of 4 residents (Resident #5) reviewed for medication administration, the facility failed to follow the physician's orders, for 1 resident (Resident #10) reviewed for quality of care, the facility failed to ensure communication while on leave of absence (LOA) or maintain records of when resident went LOA to the day program and for 1 resident (Resident #74) reviewed for blood glucose monitoring, the facility failed to add parameters of notification to the physician for blood sugars outside of normal parameters. The findings include: 1. Resident #5 was admitted to the facility with diagnoses that included gastroparesis, irritable bowel syndrome, and dementia. The quarterly MDS dated [DATE] identified Resident #5 had moderately impaired cognition and required limited assistance with dressing and personal hygiene. A physician's order dated 2/17/23 directed to give Erythromycin Base 250 mg tablet every 8…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy and interviews, for 1 of 2 residents (Resident #63) reviewed for accidents, the facility failed to follow the smoking policy, including completing a smoking assessment, care plan and education for a resident who was actively smoking. The findings include: Resident # 63 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, anemia, and generalized muscle weakness. The admission nursing assessment dated [DATE] identified that Resident #63 reported he/she quit smoking 2 weeks prior to admission. The initial care plan dated 11/26/22 identified Resident #63 did not smoke and failed to identify a recent history of tobacco use. A nursing note dated 2/9/23 at 7:02 PM identified that Resident #63 requested to smoke at the facility and that a smoking assessment had been requested. A subsequent nursing note dated 2/17/22 at 2:15 PM identified that Resident #63 was out to smoke with other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interview for 1 of 5 residents (Resident #229) reviewed for nutrition, the facility failed to ensure weights were completed per facility policy and physician's orders. The findings include: Resident #229's hospital Discharge summary dated [DATE] identified Resident #229 weighed 84.7 lbs. Resident #229 was admitted to the facility on [DATE] with diagnoses that included moderate protein calorie malnutrition, diabetes, and hypercholesterolemia. A physician's order dated 4/7/23 directed to weigh the resident on admission, and weekly for 4 weeks, then monthly unless otherwise indicated. The end date for this order was 4/8/23. Review of progress notes dated 4/7/23 - 4/25/23 did not reflect the resident had refused to have his/her weight obtained. Review of the clinical record identified Resident #229 weighed 88.2 lbs. on 4/10/23. The admission MDS dated [DATE] identified Resident #229 had intact cognition and 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 observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #10) reviewed for nutrition, the facility failed to label and date g-tube equipment. The findings include: Resident #10 was admitted to the facility with diagnoses that included dysphasia and dementia. The care plan dated 2/14/23 identified the resident had a g-tube for all nutritional needs. Interventions included for the resident to receive nothing by mouth. The quarterly MDS dated [DATE] identified Resident #10 had severely impaired cognition and required total assistance for feeding, dressing, and transfers. Additionally, Resident #10 required tube feeding for greater than 50% of nutritional intake. A physician's order dated 3/20/23 directed to administer Glucerna liquid 1.2 calorie at 50 ml per hour via pump\turn on at 6:00 PM and turn off at 6:00 AM, and administer a bolus of 240 ml's via g-tube at 11:00 AM. Additionally, change the feeding bottle every other day or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #11) reviewed for respiratory services, the facility failed to label and date oxygen tubing per the physician's order. The findings include: Resident #11 was admitted to the facility with diagnoses that included acute and chronic respiratory failure and chronic obstructive pulmonary disease. The care plan dated 2/15/23 identified the resident had chronic obstructive pulmonary disease with interventions that included to apply oxygen at 2 liters per minute via nasal cannula. A physician's order dated 3/29/23 directed to change the oxygen tubing weekly and ensure the tubing is labeled and dated. The quarterly MDS dated [DATE] identified Resident #11 had intact cognition and required limited assistance with transfer, dressing, toileting, and personal hygiene. Additionally, Resident #11 required oxygen. Observation on 4/26/23 at 9:50 AM identified Resident #11 was sitting in the lounge…

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 interview for 1 resident (Resident #17) reviewed pressure ulcers, the facility failed to ensure that staff maintained proper infection control technique and hand hygiene during a dressing change. The findings included: Resident #17 was admitted to the facility on [DATE] with diagnoses that included stroke, diabetes and heart failure. The care plan dated 3/31/23 identified Resident #17 had an alteration in skin integrity due to a right heel wound. Interventions included offloading heels in bed and administering treatments as ordered. The quarterly MDS dated [DATE] identified that Resident #17 had moderately impaired cognition, required the assistance of one staff member with transfers, personal hygiene, dressing, toileting, and was frequently incontinent of bowel and bladder. Resident #17 was also identified to have a stage 3 pressure ulcer. A wound care physician's note dated 4/25/23 identified that Resident #17 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 a clinical record review, a review of the facility documentation, staff interviews, and a review of the facility policy for four of six residents reviewed for allegations of abuse and neglect, Resident #11, #44 and #78, the facility failed to ensure the resident was free from verbal abuse, and for Resident #22, the facility failed to ensure the resident was free from neglect. The findings include: 1. Resident (R) #11 was admitted to the facility on [DATE] with diagnoses that included bipolar depression, and alcohol abuse. The quarterly Minimum Data Set (MDS) dated [DATE] identified intact cognition and the resident had the ability to understand and make him/herself understood. The care plan dated 6/24/20 identified a potential for mood changes due to depression and anxiety with interventions that included medication changes as needed, identify possible triggers to anxiety, encourage verbalization of thoughts and feelings, provide emotional support, observe for significant changes in behavior, and notify…

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

Based on a review of the facility documentation, staff interviews, and a review of the facilities polices for 1 of 3 employees, the facility failed to ensure performance evaluations were completed annually in accordance with the facility policy, and the facility failed to ensure comprehensive nurse aide training was conducted annually. The findings include: 1. Review of NA #2's employee file and interview with the Director of Human Resources (HR) on 9/10/20 at 2:00 PM identified NA #2 was hired on 6/2/02 and his/her file contained performance evaluations from 11/11/14, 6/30/16, and 7/23/18. An annual performance evaluation was not conducted in 2015 or 2019. The Director of HR indicated she had been in her position for one month and was working to reorganize the files and ensure required items were available. Interview with RN #3 (Nursing Supervisor) on 9/10/20 at 3:15 PM identified she was the staff development nurse last year and it was the responsibility of the 3:00 PM-11:00 PM supervisor to complete the annual performance appraisals and she did not know why the evaluations 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.

Based on observation, review of facility documentation, facility policy and interview for 1 of 3 medication storage rooms, the facility failed to ensure the medication refrigerator temperatures were maintained according to recommended parameters. The findings include: Observation on 9/17/20 at 11:20AM with RN #1 identified 2 medication refrigerators in the Unit 1 medication storage room. One refrigerator was designated for house stock medications, and the other for unit 1 resident medications. The house Stock refrigerator contained multiple unopened insulin pens and unopened purified protein derivative (PPD) vials. Two thermometers located in the house stock refrigerator, within close proximity of each other, read different temperatures. One thermometer read 39 degrees Fahrenheit (F), the other read 28 degrees F. Review of the August 2020 temperature log identified for 26 of the 31 days of the month, the temperatures ranged between 30 - 35 degrees F. Review of the Refrigerator Temperature Log documentation for September 2020 identified temperatures ranged between 32 - 35 degrees F.…

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, staff interviews, and a review of the facility documentation for one sampled resident (Resident #35 ), the facility failed to ensure an aerosolized medication was administered in a manner consistent with current infection control standards, and for one of three sampled residents (Resident #65), the facility failed to ensure a resident donned a facial mask when transported in the hallway, and for one sampled resident (Resident #288), the facility failed to ensure staff donned a facial mask while assisting the resident with care who was on droplet precautions, and the facility failed to ensure a comprehensive water management plan was in place, and failed to ensure only vendors that provided emergency services were allowed to enter the building . The findings include: 1. Resident #35's diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease (COPD), and acute respiratory failure (ARF). The resident's care plan dated 7/29/20 identified 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 a clinical record review, a review of the facility documentation, staff interviews for three of six residents reviewed for abuse, (Resident #11,#44 and #78), the facility failed to report a substantiated allegation of verbal abuse to the appropriate state agency and for one of three residents reviewed for abuse, (Resident#22), the facility failed to ensure an allegation of neglect was reported and investigated in a timely manner in accordance with facility policy. The findings include: 1. Resident (R) #11 was admitted to the facility on [DATE] with diagnoses that included bipolar depression, and alcohol abuse. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified intact cognition and the resident had the ability to understand and make him/herself understood. The care plan dated 6/24/20 identified the potential for mood changes due to depression and anxiety with interventions that included medication changes as needed, identify possible triggers for anxiety, encourage verbalization 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 a clinical record review, staff interviews, a review of the facility documentation and a review of the facility policy for one of three residents who were at risk for falls, (Resident #58), the facility failed to ensure proper footwear was in place in accordance with the plan of care. The findings include: Resident #58 had a diagnosis of dementia and diabetes. A care plan dated 6/8/20 identified Resident #58 was a fall risk related to weakness, an abnormal gait, and a history of falls with interventions that included to ensure proper footwear was worn, and to have gripper socks or shoes on at all times. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified severe cognitive impairment, extensive assistance with transfers, toilet use, and a history of falls. A fall risk assessment dated [DATE] identified Resident #58 was a high risk for falls. A nurse's note dated 9/2/20 at 1:30 AM identified Resident #58 was found on the floor on his/her knees facing away from the bed, and not wearing…

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 interview for one sampled resident (Resident # 32) reviewed for specialized treatment, the facility failed to consistently monitor and document fluid intake for a resident on a fluid restriction and failed to follow a recommendation for a specialized treatment. The findings include: 1. Resident #32's diagnoses included end stage renal disease, renal mass and anemia. The quarterly MDS dated [DATE] identified Resident #32 had moderately impaired cognition, required total assistance with transfers, toilet use, bathing, and dressing, and was independent with eating after set up. The care plan dated 7/30/20 identified Resident #32 had a potential for alteration in fluid balance related to end stage renal disease. Interventions included to monitor and document intake and output (I&O) every shift and report significant changes to the physician. Physician's order dated 8/1/20 directed to maintain a fluid restriction of 1200 ml per day. Review of the Total…

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 a clinical record review, observations and staff interviews for one of two sampled residents with pressure ulcers (Resident #57), the facility failed to ensure mattress settings were accurate and monitored in accordance with the resident's weight. The findings included: Resident #57's diagnoses included coronary artery disease, hypertension, renal insufficiency, diabetes mellitus, cerebrovascular disease, Parkinson's and Alzheimer's disease. The care plan dated 7/22/20 identified the resident required the use of a low air loss mattress secondary to skin breakdown to the coccyx. Interventions included to set the mattress at soft plus, and to check the placement and functioning of the mattress every shift. The physician's order dated 7/23/20 directed an air mattress with a soft plus setting, and to ensure the function and setting of the mattress every shift. The Minimum Data Set (MDS) assessment dated [DATE] identified severe cognitive impairment, extensive assistance with bed mobility, and total…

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 #26) who required venous access (port-a-cath), the facility failed to ensure the physician orders and pharmacy directions were followed and for 1 resident (Resident #77) reviewed for intravenous (IV) therapy, the facility failed to ensure annual education/training/supervision/competencies were completed, the facility failed to ensure physician orders for IV therapy were transcribed according to policy and standard of care, and the facility failed to ensure that expired antibiotics were discarded timely to prevent administration. The findings include: 1. Resident #26's diagnoses included clostridial myonecrosis, methicillin resistant staphylococcus, diabetes, hypertension, atrial fibrillation, endocarditis, cardiac arrest and dementia. The admission Minimum Data Set (MDS) assessment dated [DATE] identified moderate cognitive impairment, extensive assistance with 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 observations, a review of the facility documentation, staff interviews, for one of three residents reviewed for neglect, (Resident#22), the facility failed to ensure staffing was adequately distributed throughout the facility to meet the needs of the resident. The findings include: Resident #22 had a diagnosis of dementia and heart failure. A care plan dated 7/14/20 identified that Resident #22 had the potential for alteration in skin integrity related to requiring assistance with bed mobility, and incontinence with interventions that included to provide incontinent care every two (2) hours and as needed, and to reposition every 2 hours and as needed. A care plan dated 8/4/20 identified that the resident #22 did not want personal care from male Nurse Aides. A quarterly Minimum Data Set, dated [DATE] identified that Resident #22 had moderate cognitive impairment, required extensive assistance with bed mobility, was frequently incontinence, and was at risk for developing pressure ulcers. Interview with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a clinical record review, staff interviews and a review of the facility policy for one of five residents (Resident #54), the facility failed to ensure an order for a psychoactive medication was limited to fourteen days. The findings include: Resident # 54 was admitted to the facility on [DATE] with diagnosis that included dementia, psychotic disorder, anxiety, and depression. The Minimum Data Set (MDS) assessment dated [DATE] identified severe cognitive impairment, exhibited difficulty with concentration for 2-6 days, daily behaviors of wandering, and received antidepressant and antianxiety medications for 7 days. The care plan dated 8/10/20 identified a problem with anxiety with interventions that included to observe for periods of anxiety and document, provide a calm, quiet environment, psychiatric consultations as ordered, and to report medication ineffectiveness to the practitioner. Review of the physician's orders dated 9/9/20 directed Trazadone 50 milligrams (mg) orally, every eight hours as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interview for 1 resident (Resident #87) reviewed for death, the facility failed to accurately document the pronouncement of death for a resident without a physician's order for nurse pronouncement. The findings include: Resident #87's diagnoses included morbid obesity, obstructive sleep apnea, type 1 diabetes mellitus and schizophrenia. Physician's order dated [DATE] directed Resident #87's code status as Full Code (in the event of cardiopulmonary arrest, perform CPR). The admission MDS dated [DATE] identified Resident #87 had moderately impaired cognition and required extensive assistance with all ADL's. The care plan dated [DATE] identified Resident #87's advanced directive status was full code. Interventions included to discuss advanced directives with patient, family or legal representative, call 911 and initiate CPR in the event of cardiopulmonary arrest. A nurse's note dated [DATE] at 4:05 AM identified Resident #87 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 observations, a review of facility documentation and staff interviews for one sampled resident (Resident #44), reviewed for activities of daily living, the facility failed to provide a wheelchair that was sanitary and comfortable. The findings include: Resident (R) #44 was admitted to the facility on [DATE] with diagnosis that included morbid obesity, osteoarthritis, chronic pain syndrome, paranoid schizophrenia, and anxiety. The physician orders dated 7/10/20 directed a power custom wheelchair and supervision for all wheel chair use. The quarterly Minimum Data Set (MDS) dated [DATE] identified intact cognition, extensive assistance of one person for bed mobility, dependent on two staff members for transfers, non-ambulatory, and used a wheelchair for mobility. The care plan dated 8/18/20 identified R#44 required a custom power wheelchair for mobility secondary to weakness, polyneuropathy, chronic pain and chronic obstructive pulmonary disease. The physical therapy notes dated 9/4/20 identified R#44 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.