Wilton Meadows Health Care 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 2 of 2 residents (Resident #30 and 100) reviewed for Activities of Daily Living (ADL), the facility failed to ensure the residents were provided a shower on scheduled shower days. The findings include: 1. Resident #30 was admitted to the facility in September 2024 with diagnoses that included heart failure, depressive episodes, and anxiety disorder. The physician's order dated 9/14/24 directed to provide a weekly body audit every week on the first shower day of the week. If the resident refuses shower or body audit update the supervisor and document in the progress notes. Shower once a day on Tuesday on the 7:00 AM - 3:00 PM shift. The care plan dated 9/14/24 identified Resident #30 had an Activity Daily Living (ADL's) functional deficit and needs assistance with mobility and self-care needs related to: weakness, dorsalgia, and advanced age. Interventions included to provide assistance and provide privacy to 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 interview for 5 residents (Resident #13, 26, 32, 274 and 378) the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices. For 1 resident (Resident #13) reviewed for choices, the facility failed to ensure the resident was walked daily per the physician's order, for 1 of 3 residents (Resident #26) reviewed for nutrition, the facility failed to obtain daily weights per the physician's order and failed to document education and interventions when the resident refused the weights, for 1 resident (Resident #32) reviewed for a specialized medical treatment, the facility failed to ensure a medication was restarted following a medical procedure, for 1 resident (Resident #274) reviewed for new admission, the facility failed to administer two different glaucoma medications and subsequently the resident missed 4 doses…

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 3 of 3 residents (Resident #26, 87 and 378) reviewed for pressure ulcers, for Resident #26 the facility failed to ensure weekly skin audits were completed per the physician's order, and failed to ensure a complete and accurate nursing assessment was documented, upon identifying a new skin issue, and for Resident #87 the facility failed to ensure weekly body audits and Braden scales were completed per physician's order, failed to complete a RN assessment of a newly identified pressure ulcer, failed to immediately obtain a treatment order for a newly identified pressure ulcer, failed to perform weekly pressure ulcer assessments, failed to notify the dietitian timely of new pressure ulcer, and complete treatments daily per the physician's order and for Resident #378 the facility failed to ensure that an initial nursing skin assessment was completed upon the resident's admission and readmission to 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 the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #56) reviewed for nutrition, the facility failed to ensure weights were obtained per the physician's order; failed to notify the physician of a significant weight loss and failed to implement interventions following a significant weight loss. The findings include: Resident #56 was admitted to the facility in September 2024 with diagnoses that included spinal fracture at T11 - T12, prostate cancer, and urinary retention. The physician's orders dated 9/4/24 directed to weigh the resident every week on the 1st shower day of the week (Monday 3:00 PM - 11:00 PM shift) for 4 weeks and then once monthly. Review of the clinical record identified Resident #56 weighed 275 lbs. at admission on [DATE]. The care plan dated 9/9/24 identified that Resident #56 was at risk for alteration in nutritional status due to new admission and decreased intake. Interventions included obtain weights…

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 5 residents (Resident #28 and 66) reviewed for unnecessary medications, the facility failed to ensure pharmacy recommendations were responded to by the physician or APRN. The findings include: 1. Resident #28 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, type 2 diabetes mellitus, and bipolar disorder. The quarterly MDS dated [DATE] identified Resident #28 had intact cognition and had received medications from the following high-risk drug classes in the last 7 days: antidepressant, opioid, and hypoglycemic. The care plan dated 4/26/24 identified Resident #28 was taking psychotropic medications daily related to bipolar disorder and adjustment disorder with depression and anxiety. Interventions included administering medications as ordered and decrease dosage of psychotropic medications as ordered. The care plan further identified Resident #28 had type 2 diabetes…

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 the facility failed to ensure the infection preventionist, (IP) conducted environmental rounds at least quarterly per the facility policy, and for 1 of 3 residents (Resident #87) reviewed for pressure ulcer, the facility failed to use appropriate infection control practices when providing wound care, and for 1 of 3 residents (Resident #374) reviewed for transmission-based precautions, the facility failed to ensure that nursing staff maintained proper infection control techniques and hand hygiene for a resident with a highly contagious bacteria, and failed to ensure that resident nourishment areas were maintained in a clean and sanitary manner. The findings include: 1. Interview with RN #1 on 10/7/24 at 11:40 AM indicated that she was responsible to do the environmental rounds monthly. RN #1 indicated that she looks daily at the environment but does not write anything down. RN #1 indicated that she did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents reviewed for medication errors, (Resident #1), the facility failed to ensure a significant medication error was reported timely to the physician. The findings include: Resident #1 was admitted to the facility on [DATE] for palliative care with diagnoses that included cirrhosis, heart failure, chronic kidney disease, and severe sepsis with septic shock. The admission assessment dated [DATE] identified Resident #1 was alert, oriented to person place, time, and situation. The baseline care plan dated 4/19/24 identified Resident #1 at danger for reoccurrence of acute medical condition with interventions directing to administer medications per MD orders and vital signs per facility protocol. The physician's order dated 4/19/24 at 8:05 P.M. directed to administer morphine solution 2 mg per /1 ml oral solution, amount 2.5 ml, every 4 hours around the clock. Review of the facility's accident…

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 (1) of three (3) residents reviewed for medication errors, (Resident #1), the facility failed to ensure the clinical record was complete and accurate to include vital signs. The findings include: Resident #1 was admitted to the facility on [DATE] for palliative care with diagnoses that included cirrhosis, heart failure, chronic kidney disease, and severe sepsis with septic shock. The admission assessment dated [DATE] identified Resident #1 was alert, oriented to person place, time, and situation. The baseline care plan dated 4/19/24 identified Resident #1 at danger for re-occurrence of acute medical condition with interventions directing to administer medications per MD orders and vital signs per facility protocol. The physician's order dated 4/19/24 at 8:05 P.M. directed to administer morphine solution 2 mg per 1 ml oral solution, amount 2.5 ml, every 4 hours around the clock. Review of the facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) sampled residents (Resident #1) who required the assistance of two (2) staff members with getting in and out of the bed and chair, the facility failed to ensure the physician's order for transfer status was followed to prevent an injury, Resident #1 sustained a laceration to the right lower leg. The findings include: Resident #1's diagnoses included Alzheimer's Disease and dementia. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily living and required extensive two (2) person assistance with getting in and out of the bed and chair. The Resident Care Plan dated 2/6/24 identified Resident #1 as at risk for falls. Interventions directed to encourage the resident to eat meals in the dining room, physical therapy screen, and offer to transfer the resident to bed at approximately 9:00 PM daily. A physician's order dated 3/21/24 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 review of clinical records and interview for one (1) of (3) three residents, (Resident #1), reviewed for a impaired skin integrity, the facility failed to follow physician's orders. The findings included: Resident #1's diagnoses included a sacral pressure ulcer, Stage III pressure ulcer, hemiparesis and hemiplegia of the left side, and unspecified dementia. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 as cognitively intact and requiring extensive assistance with transfers, dressing, toileting, and personal hygiene. The Resident Care Plan with a revision date of 12/14/22 identified impaired skin integrity with interventions that directed to apply treatment per physician order, minimize skin exposure to moisture, and provide incontinent care after each incontinent episode. Review of Wound Consult documentation dated 12/14/22 identified a new fungal dermatitis with regional denudation (loss of skin) noted on the sacrum, with sacral moisture associated skin dermatitis with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and interview for one (1) of three (3) residents reviewed for pressure ulcers, (Resident #1), the facility failed to follow a physician's orders for wound care, failed to measure a pressure ulcer in accordance to facility policy, and failed to ensure a pressure relieving device was in place. The findings included: 1. Resident #1's diagnoses included a sacral pressure ulcer, Stage III pressure ulcer, hemiparesis and hemiplegia of the left side, and unspecified dementia. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 as cognitively intact and requiring extensive assistance with transfers, dressing, toileting, and personal hygiene, and a pressure reducing device for bed and chair and application of med/ointment. The Resident Care Plan with a revision date of 12/14/22 identified impaired skin integrity with a stage 3 pressure ulcer on left and right iliac crest/sacrum with interventions that directed to apply treatments per physicians orders, minimize…

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 facility documentation and interview for one (1) of three (3) residents reviewed for pressure ulcers, the facility failed to ensure nursing staff had education prior to caring for a resident that required a specialized therapy. The findings included: Resident #1 diagnoses included pressure ulcer of the sacral region, Stage 4 pressure ulcer, hemiplegia and hemiparesis, and unspecified dementia. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 as cognitively intact and requiring extensive assistance with transfers, dressing, toileting, and personal hygiene with a pressure reducing device for bed and chair and application of med/ointment to the skin. The Resident Care Plan revised on 3/2/23 identified impaired skin integrity and a Stage IV sacral wound with wound vac treatment. Interventions directed to apply treatment per physician order, minimize skin exposure to moisture, and provide incontinent care after each incontinent episode. A physician's order dated 3/2/23…

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 reviews, facility documentation, facility policy and interviews for one of three sampled residents (Resident #1) who required staff assistance with transferring in and out of the bed and chair or on and off the toilet, the facility failed to utilize a mechanical lift and the number of staff required to transfer the resident in accordance with the physician's order to prevent a fall. The findings include: Resident #1's diagnoses included encephalopathy, dementia, and muscle weakness. The fall risk assessment dated [DATE] identified Resident #1 was a high risk for falls. A physician's order dated 1/10/24 directed Resident #1 was a fall risk, to conduct frequent checks every shift, ensure the call light and personal items are always within reach, and the bed in a low position for seventy-two (72) hours. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 made reasonable and consistent decisions regarding tasks of daily living, required moderate to substantial…

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 four residents (Resident #1) reviewed for abuse, the facility failed ensure the resident was free from mistreatment. The findings include: Resident #1 was admitted with diagnoses that included difficulty in walking, Alzheimer's disease, anxiety, and depression. A 5-day Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severe cognitive impairment and required moderate assistance for bed mobility, personal hygiene, and transfer to a wheelchair. A Resident Care Plan (RCP) dated 1/15/2024 identified Resident #1 had a problem with physical aggression, mood related to dementia and needed assistance with activities of daily living (ADLs). Interventions directed to encourage verbalization of feelings, give choices when providing care, provide verbal cues allowing time for follow through, move to a quiet area and reassure as needed, and to not try to reason with reason with resident 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.

Based on observations, facility documentation review, facility policy, and interviews for five of seven medication carts, the facility failed to ensure medications were stored in a clean, sanitary manner, and were labeled properly. The findings include: 1. Observations on 12/20/23 at 11:06 AM of the Deerfield 2 unit's medication cart with a charge nurse, Licensed Practical Nurse (LPN) #5, identified seventeen (17) loose pills in the second drawer located on the left side of the medication cart and seven (7) loose pills in the third drawer located on the left side of the medication cart. Further observations identified four (4) Zofran pills in a package and three (3) Oseltamivir Phosphate pills in a package located in the top drawer on the right side of the medication cart without the benefit of a resident's name. Interview with LPN #5 at the time of observations identified it was the nurse's responsibility to ensure the medication cart was clean. 2. Observations on 12/20/23 at 11:30 AM of the Deerfield 1 unit's medication cart with LPN #4 identified ten (10) loose pills in 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 clinical record review, facility documentation and interviews, for one sampled resident (Resident #1) who received a medication to treat a certain type of breast cancer, the facility failed to administer the medication per the physician's order. The findings include: Resident #1's diagnoses included malignant neoplasm of lower-inner quadrant of left breast and Alzheimer's disease. A monthly physician's order dated 2/23/23 directed Ibrance capsule 125 milligrams (mg) oral once a day, give for twenty-one (21) days, hold for seven (7) days and then resume cycle. The nurse's note dated 3/9/23 at 2:20 PM identified the Ibrance was delivered today by a family member and to be started on Monday 3/13/23. The nurse's note dated 3/10/23 at 4:50 PM identified the Ibrance scheduled to be administered on 3/13/23 was given on 3/10/23, three (3) days earlier. The note indicated Resident #1 was alert and verbal, no change in condition was noted, Resident #1 denied any pain or discomfort, no shortness of breath or respiratory distress was noted, Resident #1's family was notified, and 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 2 of 3 residents (Resident #51 and 91) reviewed for allegations of resident to resident abuse, the facility failed to protect the resident from physical abuse by another resident. The findings include: 1a. Resident #51 was admitted to the facility with diagnoses that included congestive heart failure, bilateral macular degeneration, and osteoporosis. The care plan dated 9/7/21 identified Resident #51 had congestive heart failure with interventions to elevate the resident ' s legs due to edema as resident allows. The quarterly MDS dated [DATE] identified Resident #51 had intact cognition and required extensive assistance for transfers, bed mobility, dressing, toileting, and personal hygiene. A physician's order dated 12/17/21 directed to get the resident out of bed to a standard wheelchair and may self-propel. Additionally, administer Lasix 30mg daily. A physician note dated 12/13/21 identified Resident #51 had 1+…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #104) reviewed for code status (the level of medical intervention a person wishes to have started if their heart or breathing were to stop), the facility failed to verify the presence of advance directives or the resident ' s wishes with regard to CPR, upon admission, and failed to immediately document discussions with the resident or resident representative, including, as appropriate, a resident ' s wish to refuse CPR. The findings include: Resident #104 was admitted to the facility on [DATE] with diagnoses that included dementia, adult failure to thrive, and sepsis. The hospital interagency referral form dated [DATE] indicated Resident #104 had a code status of do not resuscitate (DNR). A physician's order dated [DATE] directed in the event of cardiopulmonary arrest, do not resuscitate (DNR). The admission MDS dated [DATE] identified Resident #104 had moderately impaired cognition required…

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 and interviews for 1 resident (Resident #49) reviewed for pressure ulcers, the facility failed to ensure the specialty air mattress was consistently maintained on the appropriate setting according to the residents weight and as per the physicians orders. The findings included: Resident #49's diagnoses included stroke, aphasia, seizures, dementia, anxiety, depression, and cervical root disorder. The significant change in status MDS dated [DATE] identified Resident #49 had severely impaired cognition, required extensive assistance with bed mobility, and dressing and total assistance with transfers and locomotion. The MDS further identified the resident had unhealed pressure ulcers and was at risk for developing pressure ulcer. The care plan dated 5/24/22 identified Resident #49 was at risk for deterioration in activities of daily living, contracture and further functional changes related to limited range of motion, dementia, idiopathic…

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 5 residents, (Resident #20 and 21) the facility failed to administer the pneumococcal vaccine after the resident representative signed the consent to do so, and for 1 of 5 residents (Resident #65) the facility the facility failed to ensure the pneumococcal vaccine was offered on admission. The findings include: 1. Resident #20 was admitted to the facility on [DATE]. The Pneumococcal Immunization Informed Consent dated 4/16/21 was noted to have been signed by the responsible party. A documented physicians order was not identified in the clinical record. Although the responsible party consented to the administration of the pneumococcal vaccine on 4/16/21, the vaccine was not administered. 2. Resident #21 was admitted on [DATE]. The Pneumococcal Immunization Informed Consent was signed dated 6/27/17 was noted to have been signed by the responsible party. A documented physician ' s order was not identified in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, facility policy and interviews during the initial kitchen tour, the facility failed to appropriately label open food and refrigerated food to ensure food is stored, prepared and distributed in accordance with professional standards for food service safety. The findings included: During the initial tour with the Food Service Supervisor on 1/13/20 at 7:10 A.M. the following were identified: 1. Unlabeled undated food in the dry storage included the following: a.An unlabeled and undated container that was identified by the Food Service Supervisor as bread crumbs and subsequently discarded. The following items were in the walk in refrigerator open and unlabeled: 1.So Frito with an expiration date of 5/6/24 but unlabeled with a use by date when opened 2.Pickles without an expiration date and unlabeled with a use by date when opened 3.Ranch dressing without an expiration date and unlabeled with a use by date when opened 4.Cocktail sauce without an expiration date and unlabeled with a use by date…

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/or procedures and interviews for one of two residents reviewed for accidents (Resident #54) the facility failed to implement a fall assessment to determine the resident's risk for falls to ensure the facility meet professional standards. The findings include: Resident #54's diagnoses included vascular dementia without behavioral disturbance, generalized muscle weakness, difficulty walking and a history for cerebral infarct without residue effects and Transient Ischemic Attacks (TIA). A quarterly MDS assessment dated [DATE] identified the resident as moderately impaired for decision-making skills requiring supervision from staff for some and limited assistance from staff for most ADL. The Resident Care Plan (RCP) updated on 7/15/19 identified risk for falls as the problem. Approaches included to keep call light in easy reach, keep frequently used items with in frequent reach, report any functional decline in ADLs and cognition to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, review of facility documentation, and interviews for one sampled resident (Resident #58) reviewed for medication administration, the facility failed to follow a physician order to take a blood pressure. The findings include: Resident #58's diagnoses included hypertension, Parkinson's disease and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #58 had both long and short term memory problems and required extensive assistance with eating. The Resident Care Plan (RCP) dated 12/1/19 identified a risk for decreased cardiac output related to hypertension. Interventions directed to monitor blood pressure weekly and notify the physician if Resident #58 presents with hypotension or hypertension. A physician's order dated 12/13/19 through 1/13/20 directed to administer Lisinopril 5 mg ( Anti-hypertensive), one tablet daily, to hold for a systolic blood pressure less than 100 mg/Hg. Observations on 1/30/20 at 8:55 A.M. 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 observation, clinical record review and interview for one of two residents in survey sample reviewed for indwelling catheter use (Resident #118), the facility failed to maintain the catheter in accordance to professional standards to prevent the spread of infection. The findings include: Resident #118 was admitted to facility on 12/23/2019 with diagnoses that included sacrum fractured and retention of urine. An admission MDS assessment dated [DATE] identified Resident #118 had severely impaired cognition, required extensive assistance with care and utilized an indwelling catheter. A physician's orders dated 1/9/2020 directed to discontinue Foley Catheter on 1/9/2020 at 6:00 A.M. A physician's orders dated 1/11/2020 directed to insert Foley catheter 14 French and monitor output. The Resident Care Plan dated 1/13/20 identified a problem with the resident requiring an indwelling urinary catheter related to urinary retention and low output. Interventions included : to store collection bag inside 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 clinical record, interviews and review of facility policy for one of five residents reviewed for Infection Control (immunizations) Resident #5, the facility failed to implement the facility policy for pneumococcal vaccination. The findings include: Resident #5's diagnoses included Congestive Heart Failure, dementia, chronic kidney disease and chronic respiratory failure with hypoxia. Review of Resident # 5's Immunization/Preventive healthcare documentation identified the resident had received the pneumococcal vaccine PPSV23 on 10/23/14, and did not reflect any information regarding Prevnar 13. The annual MDS assessment dated [DATE] identified Resident # 5 had moderate cognitive impairment, required extensive assistance of two staff for bed mobility and transfers, and received oxygen therapy. The care plan dated 10/17/19 and updated on 1/9/20 identified Resident #5 was at risk for alteration in respiratory status due to chronic respiratory failure, and history of pneumonia and aspiration.…

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.