Complete Care At Kimberly Hall-South

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 #8) reviewed for non-pressure skin condition, the facility failed to document an RN assessment when the resident was identified with a scabbed area on the forehead, and for 1 resident (Resident #68) reviewed for Activities of Daily Living (ADLs), the facility failed to ensure that a low air loss mattress was set per the physician's orders. The findings include: 1. Resident #8 was admitted to the facility in January 2023 with diagnoses that included dementia and end stage renal disease requiring dialysis. The nursing admission assessment dated [DATE] identified a healed abrasion to the mid forehead. The physician's admission history and physician dated 1/24/23 did not reflect an area to the forehead. The quarterly MDS dated [DATE] identified Resident #8 had severely impaired cognition. a. Review of the provider notes and nurse's notes dated 1/1/24 to 5/12/24 did not reflect the area to the 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 review of the clinical record, facility documentation, facility policy and interviews for 1 resident (Resident #6) who required a specialty medical intervention and fluid restriction, the facility failed to ensure fluid intake and output were monitored according to professional standards and facility policy. The findings include: Resident #6 was admitted to the facility in August 2024 with diagnoses that included end stage renal disease, dependence on renal dialysis, and congestive heart failure. The admission MDS dated [DATE] identified Resident #6 had moderate cognitive impairment, required supervision with eating and dependent with toileting hygiene. The care plan dated 9/16/24 identified Resident #6 exhibited impaired renal function and was at risk for complications related to dependence of hemodialysis. Interventions included hemodialysis on Monday, Wednesday, and Friday at the dialysis center. Observe, document, and report to the MD/APRN for signs and symptoms of fluid overload (increase shortness…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy, and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for change in condition, the facility failed to ensure the physician was notified at the time when there was a new onset of drainage from the surgical incision after the incision was bumped. The findings include: Resident #1 had diagnoses that included acquired absence of right leg below the knee, gangrene, type 2 diabetes mellitus, and end stage renal disease. A physician's order dated 8/28/24 directed to don Nutmegger (stocking to shrink stump) to the right lower extremity at all times, remove every shift for skin inspections, leave the sutures in place to the right below the knee amputation, monitor the incision line every shift for signs and symptoms of infection, and update the physician or Advanced Practice Registered Nurse (APRN) as needed with noted abnormalities. The resident care plan dated 8/29/24 identified Resident #1 was admitted with a right…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy, and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for wound treatments, the facility failed to assess the surgical site every shift in accordance with the physician's order and document when the resident refused the assessment be conducted. The findings include: Resident #1 had diagnoses that included acquired absence of right leg below the knee, gangrene, type 2 diabetes mellitus, and end stage renal disease. A physician's order dated 8/28/24 directed to don Nutmegger (stocking to shrink stump) to the right lower extremity at all times, remove every shift for skin inspections, leave the sutures in place to the right below the knee amputation, monitor the incision line every shift for signs and symptoms of infection, and update the physician or Advanced Practice Registered Nurse (APRN) as needed with noted abnormalities. The resident care plan dated 8/29/24 identified Resident #1 was admitted with a right…

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 reviews, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for pressure injury to the left heel, the facility failed to ensure a wound assessment was conducted. The findings include: Resident #1 had diagnoses that included acquired absence of right leg below the knee, gangrene, type 2 diabetes mellitus, and end stage renal disease. A physician's order dated 8/28/24 directed to monitor the deep tissue site to left heel for changes, update the physician with noted abnormal changes, and apply skin prep to left heel every evening shift for prevention. The resident care plan dated 8/29/24 identified Resident #1 was at risk for alteration in skin and had a left deep tissue injury on admission. Interventions directed weekly skin check by the licensed nurse. Review of the Treatment Administration Record from 8/29/24 to 9/4/24 identified the skin prep was applied to the left heel every evening shift. Review of the clinical record failed to identify documentation related to a completed wound assessment…

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 medications administration, the facility failed to notify the physician when a medication was not administered in accordance with physician orders. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of prostate and heart failure. Review of the hospital discharge instructions dated 6/24/24 identified to continue taking abiraterone 250 mg tablet four tablets by mouth every morning on an empty stomach (a medication used to treat prostate cancer) . The medication was last administered in the hospital on 6/24/24 at 6:00 AM. The nursing admission assessment dated [DATE] identified Resident #1 was admitted to the facility for metastatic prostate cancer to the bone. Resident #1 was alert and oriented and required extensive assistance with activities of daily living (ADL's). A physician's order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for medications, the facility failed to ensure medications were administered in accordance with physician orders. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of prostate and heart failure. Review of the hospital discharge instructions dated 6/24/24 identified to continue taking abiraterone 250 mg tablet four tablets by mouth every morning on an empty stomach (a medication used to treat prostate cancer) . The medication was last administered in the hospital on 6/24/24 at 6:00 AM. The nursing admission assessment dated [DATE] identified Resident #1 was admitted to the facility for metastatic prostate cancer to the bone. Resident #1 was alert and oriented and required extensive assistance with activities of daily living (ADL's). A physician's order dated 6/24/24 directed Abiraterone…

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 four sampled residents (Resident #1) who were dependent on staff for activities of daily living, the facility failed to ensure incontinent care was provided timely and failed to check on the resident every one (1) hour and reposition the resident every two (2) hours in accordance with the physician's orders and the care plan. The findings include: Resident #1's diagnoses included quadriplegia, anxiety, neuropathic bladder, and neurogenic bowel. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was cognitively intact, was always incontinent of urine and stool, was at risk for skin breakdown, required extensive two (2) person assistance with turning and repositioning when in bed for bed, bathing and extensive one (1) person assistance with dressing and personal hygiene. The Resident Care Plan dated 5/3/24 identified Resident #1 was at risk for skin breakdown, had a self-care deficit…

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 reviews, facility documentation, and interviews for one of three sampled residents (Resident #1) who were reviewed for the administration of the morning medication, the facility failed to administer medications in accordance with the standard of practice, one hour before or after the designated time per the physician's order. The findings include: Resident #1's diagnoses included malignant neoplasm of the bladder neck and bladder, malignant neoplasm of the medulla of the left adrenal gland, and pulmonary embolism. An admission physician's order dated 9/27/23 directed Midodrine HCL 4 milligrams (MG) give one tablet by mouth before meals for low blood pressure, Cyproheptadine HCL 4 mg give one tablet by mouth before meals at bedtime, Calcium Carbonate 500 mg give two tablets by mouth with meals, Prednisone 5mg give two tablets by mouth once a day, Fludrocortisone Acetate 0.1 mg once a day, Lidoderm patch 5% apply to lower back topically one time a day for back pain at bedtime remove, Polyethylene Glycol 3350 powder give 17 gram once a day, Oxycodone HCL ER 12…

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 facility policy and staff interviews for three of five medication rooms, the facility failed to ensure that medications were within acceptable expiration dates to meet profession standard of practice. The findings included: 1. Observation on 5/17/22 at 3:05 PM of the second floor Fairfield Unit medication room identified the following expired medications: Budesonide Suspension with an expiration date of 10/21, Ventolin AFA with an expiration date of 4/22, hydrogen peroxide with expiration date of 8/20 and hydrocortisone suppository with expiration date of 11/21. Interview with LPN #2 on 5/17/22 at 3:20 PM. identified she was unable to identify who was responsible for checking expired medications in the medication room. LPN #2 on 5/17/22 was also unable to identify how often the nurse should check for the expired medication. 2.Observation on 5/17/22 at 3:15 PM of the [NAME] (E) unit identified multiple expired medications: an open bottle of prednisolone solution 15mg/5ml opened…

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 upon observation, clinical record reviews and interviews, the facility failed to provide resident specific food preferences for meals for five sampled residents (Residents #16, #17, #74, #83 and #444) reviewed for food preferences at mealtime. The findings included: 1.Resident #16's diagnoses included acute on chronic diastolic (congestive heart failure), and dementia. The quarterly MDS assessment dated [DATE] identified the resident was moderately cognitively impaired, required limited one-person physical assistance with eating and noted no weight loss or gain of 5% in the last month and no weight loss or gain of 10% in the last month or 6 months. 5/16/22 12:20PM during dining Resident #16's meal ticket noted the resident requested salad but was served baked chicken, cubed oven baked potatoes and a roll, no vegetables. The resident was observed with no salad at time of the observation. When a family member inquired about the resident salad the NA indicated there was no salad. Observation of the kitchen…

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, review of facility policy and interviews, the facility failed to ensure that residents' laundry was handled by donning appropriately and failed to clean Personal Protective Equipment (PPE) to prevent the spread of infection. The findings included: 1.Observation of the laundry on 5/17/22 at 11:00 AM AM with the Infection Preventionist identified laundry staff #1 attempted to correctly don a Personal Protection Equipment gown that was hanging on a hook, inside out with success on the third try. The gown was a 3-armhole isolation gown that is donned by placing arms into the traditional sleeves and then sliding the left arm through the opening in the protective panel and in the failed attempts, Laundry Staff # 1 first placed his head through the hole in the protective panel each time which would not allow him to put his arms through the gown's sleeves so that he could don the gown properly. Interview with Laundry staff #1 identified that it was the regular staff's day off, but he was covering and had completed the Resident laundry that morning, donning the gown,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of the facility policy and staff interviews for one of three sampled residents (Resident # 68) reviewed for discharge, the facility failed to notify the resident's responsible party of the facility's bed hold policy in a timely manner. The findings include: Resident's diagnoses included neuromuscular dysfunction of the bladder, primary insomnia, COVID 19, pulmonary fibrosis, hyperlipidemia, depression, gastrostomy, chronic respiratory failure with hypoxia, Parkinson disease, dementia without behavior disturbances, tracheostomy status, history transient ischemic attack, CVA, atrial fibrillation, anemia, hypertension, and pneumonia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident was severely cognitively impaired, required extensive assistance with bed mobility and personal hygiene. The physician's order dated 5/5/22 directed for transfer Do Not Resuscitate. The discharge assessment return anticipated dated 5/5/22 identified the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for one resident (Resident # 19) reviewed for hydration, the facility failed to ensure the resident's comprehensive care plan was reviewed and revised by the interdisciplinary team when Resident #19 had a change in condition. The findings include: Resident # 19 was admitted to the facility on [DATE] with diagnoses that included dysphagia following cerebral infarction, hemiplegia and hemiparesis following stroke, aphasia following cerebral infarction. The quarterly MDS assessment dated [DATE] identified Resident # 19 had intact cognition, was frequently incontinent of bowel and bladder and required extensive assistance of 1 with bed mobility and personal hygiene. The quarterly assessment also noted the resident requires assist of one for eating, The care plan dated 3/14/2022 failed to identify a revision to the care plan after a change in condition. The care plan failed to identify that Resident #1 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, review of facility policy and interviews for 2 of 3 residents reviewed for accidents (Resident #64 and Resident #69), the facility failed to secure the biohazard room and the housekeeping cart to keep the environment free from accident hazards. The findings included: 1. Resident #64 was admitted to the facility on [DATE] with diagnoses that included vascular dementia with behavioral disturbances. The physician's order dated 1/17/22 directed to utilize a Wander Guard/Wander Elopement Device due to poor safety awareness which expires 1/2022 and to update the physician's order with new date when bracelet is changed. Additionally, the physician's orders dated 1/17/22 directed to check the device and functioning every night. The physician's order dated 1/18/2022 directed to utilize a Wander Guard/Wander Elopement Device due to poor safety awareness, which expires 4/20/25. The quarterly MDS assessment dated [DATE] identified Resident #64 had severely impaired cognition, 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 observations, review of facility policy, clinical record review and interviews for one of five residents (Resident #69) reviewed for immunizations, the facility failed to screen and offer the Resident the influenza vaccine. The findings include: Resident #69 was admitted to the facility with diagnoses that included dementia and hypertension. A review of the Resident #69's clinical record identified an Influenza Vaccination Form dated 12/11/19 that documented the resident had refused the influenza vaccination but failed to provide any documentation that Resident #69 was screened or offered the influenza vaccination when admitted to the facility. Interview with the DNS on 5/32/22 at 9:30 AM identified that Resident #69 was evacuated from another corporate facility and admitted [DATE]. The DNS continued by stating that she assumed the Resident had been offered the influenza vaccine at the other facility and that the other facility had offered the Resident the influenza vaccine. The DNS added that it was an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation and staff interview for one of three sampled residents (Resident # 20) who required assistance with Activities of Daily Living, the facility failed to ensure the resident received showers in accordance his/her plan of care. The finding include: Resident # 20's diagnoses included diabetes mellitus type 2, major depression, Benign Prostatic Hyperplasia (BPH), osteoarthritis, anxiety, congestive heart failure, morbid obesity, chronic atrial fibrillation and insomnia. The quarterly MDS assessment dated [DATE] identified the resident's cognition and memory were intact and the resident required total dependence from the staff with bed mobility, transfers and toilet use. A review of the ADL flow sheet dated for June 2019 identified the resident had a bed baths on 6/3/19, 6/5/19 6/6/19 , 6/17/19, 618/19, 6/19/19, 6/20/19, 6/22/19 and 6/24/19. Additionally the ADL flow sheets for July 2019 identified the resident had a bed baths on July 2019 on 7/1/19,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation and staff interview for one of three sampled residents (Resident # 20) who required assistance with Activities of Daily Living, the facility failed to honor the resident's preference regarding bed time. The findings include: Resident # 20's diagnoses included diabetes mellitus type 2, major depression, Benign Prostatic Hyperplasia (BPH), osteoarthritis, anxiety, congestive heart failure, morbid obesity, chronic atrial fibrillation and insomnia. The quarterly MDS assessment dated [DATE] identified the resident's cognition and memory were intact and the resident required total dependence from the staff with bed mobility, transfers and toilet use. Interview with Resident #20 on 10/21/19 at 3:45 P.M. identified that Nurse Aide (NA) #5 who recently assisted him/her with hour of sleep care handled him/her roughly and would not listen to him/her when he/she ( Resident # 20) told NA # 5 he/she did not want to go to bed at 6:15 P.M. Resident # 20 also…

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 procedures for one of three residents noted with a change in condition (Resident #50), the facility failed to develop a comprehensive plan of care with interventions, goal and timeframes to address the resident's contractures and diagnosis of osteoporosis. The findings include: Resident #50's diagnoses included osteoarthritis, diabetes mellitus II, and dementia with behavioral disturbance, vascular wound to the left calf, Peripheral Vascular Disease (PVD) and peripheral arterial disease, dysphagia, aphasia, and glaucoma and mood disorder. A quarterly MDS assessment dated [DATE] identified the resident as severely impaired for decision-making skills, requiring total assistance from staff for most ADL, functional limitation in range of motion on both sides for upper and lower extremities and without having a fracture in the past 6 months. A Reportable Event (RE) dated 9/30/19 at 3:09 P.M. noted in part, Resident #50 had an X-Ray of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview for one of three residents in the survey sample reviewed for accidents (Resident # 396), the facility failed to ensure the neurological data collection related to the frequency of the assessment after a fall with a suspected head injury was based on professional standards of quality. The findings include: Resident # 396 was admitted to the facility on [DATE] with diagnoses that included pyogenic arthritis of the left knee, end stage renal disease, ischemic heart disease, diabetes mellitus, and adjustment disorder with depressed mood. An admission MDS assessment dated [DATE] indicated Resident # 396 had no cognitive impairment, no behaviors, noted the resident required extensive assist with bed mobility and transfer, did not walk, had a history of a fall in the last 2-6 months prior to admission, and indicated the resident received a dialysis. A RCP dated June 2019 identified a problem related to risk for falls related to impaired mobility. Interventions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interview for one of three residents ( Resident #21) reviewed for pressure ulcer, the facility failed to ensure the resident's pressure reduction device was in the in the resident's wheel chair when the resident went for his/her specialized treatment . The finding included: Resident diagnoses included major depression, obesity, osteoarthritis, hypertension neuropathy. The quarterly MDS assessment dated [DATE] identified the resident's cognition and memory were intact, the resident required total dependence from the staff with bed mobility, transfers, toileting and personal hygiene. The RCP dated 5/2/19 and 8/15/19 for at risk for skin breakdown related to impaired sensation, limited mobility and actual skin breakdown secondary to moisture and excessive perspiration. Interventions directed to encourage the resident to get out of bed into the wheel chair on Monday/ Wednesday /Friday as agreed, to turn and reposition the resident and check skin four times per shift and frequently…

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

Based on review of the clinical record, facility policy and procedures and interview for one of five residents reviewed for Unnecessary Mediation and behaviors (Resident #72), the facility failed to ensure the resident's target behaviors were monitored. The findings include: Resident #72's diagnoses included Diabetes Mellitus type II, PVD, anxiety disorder, mood disorder and dementia with behavioral disturbance. The RCP updated 9/19/19 identified resistive to care as the focus. Interventions included: to monitor conditions that may contribute to resistance to care, observe medications, especially new and/or changed and/or discontinued for side effects and the resident's response contributing to resisting care. The psychiatric notes dated 9/23/19 identified in part, the resident's Remeron was increased from 22.5 MG to 45 MG. Resident # 72 was seen for symptoms of being angry and refusing care. The psychiatric note also indicated the resident was not a currently a risk for suicide and was not currently a harm others A review of Psychiatry Communication form dated 9/23/19 listed target…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility documentation and interview for one sampled resident (Resident #23) reviewed for dental needs, the facility failed to ensure the resident was seen by the dental staff per resident request. The finding include: Resident # 23's diagnoses included depression, hypertension and Diabetes Mellitus Type 2. The admission Record identified the resident was admitted to the facility on [DATE]. The Dental Health Drive Form dated 1/3/19 for request for services identified No- I will make alternate arrangements for dental services. The Health Drive form dated 5/2/19 for request for services not Yes- I request to be seen by the dentist. The quarterly MDS assessment dated [DATE] cognition and memory intact and the resident required extensive assistance with personal hygiene. The RCP dated 8/19/19 identified risk for oral health or dental care problems evidenced by broken, loose and carious teeth. Interventions included to obtain dental referral as needed. The physician's orders…

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.