Charming Lakes Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and policy review, the facility did not ensure a safe, clean, and homelike environment related to proper cleaning and maintenance in nine resident bathrooms (400, 401, 402, 403, 404, 405, 406, 407, and 409) out of ten bathrooms reviewed, two resident room baseboards (402 and 407) out of ten resident rooms observed, and one resident room wall (407) out of ten resident rooms observed. Findings included: An observation was made on 5/22/23 at 9:30 a.m. in the bathroom of resident room [ROOM NUMBER]. The bathroom toilet had a black and brown substance at the base of the toilet, a space between the base of the toilet and the floor was visible. The screws for the bowl base were rusted and dusty. (Photographic Evidence Obtained.) An observation was made on 5/22/23 at 9:40 a.m. in the bathroom of resident room [ROOM NUMBER]. The bathroom toilet had a brown substance at the base of the toilet. On the window wall beneath the air conditioner the baseboard was not sticking to the wall. 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 record review, staff interviews, and review of the facility's policy, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR's) were completed accurately for 5 of 6 residents reviewed, (#60, #18, #68, #16 and #1). Findings included: A review of Resident #60's admission record showed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include major depressive disorder. A review of current physician orders for Resident #60 dated 05/05/23 showed the resident was receiving Mirtazapine 7.5 MG (Milligrams) by mouth daily for depression. A minimum data set (MDS) dated [DATE], section I, showed the resident had a diagnosis of depression. A review of a level I PASARR for Resident #60 dated 12/20/22 revealed no diagnosis were checked. A review of Resident #18's admission record dated 05/23/23revealed the resident was admitted to the facility on [DATE] with diagnoses to include Major depressive disorder, Vascular Dementia with behavioral…

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 interviews, record review and review of facility policy, the facility did not ensure one resident (#60) of one reviewed had access to his personal funds. Findings included: On 05/22/23 at 10:17 a.m., an interview was conducted with Resident #60. He stated he had been asking how much money was in his account and no one could give him that information. He stated he had requested a statement without success. Resident #60 stated he did not know what happened to his money upon admission. A review of Resident #60's admission record showed the resident was originally admitted to the facility on [DATE] and readmitted on [DATE]. A review of a document for Resident #60, titled, Resident Fund Management Service, dated 02/06/23, showed an incomplete form that did not show accountability of the resident's funds. On 05/23/23 at 12:18 p.m., an interview was conducted with Staff I, the Human Resource Director, and Resident Accounts Manager. Staff I stated this resident did not have any funds that she knew of. Staff I…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure proper treatment of newly identified skin impairments and failed to ensure proper treatment of existing skin conditions were implemented for one (Resident #12) of three residents sampled for skin conditions. Findings included: A review of Resident #12's medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, hypertension, and muscle weakness. A review of Resident #12's physician's orders revealed a wound care order dated 5/22/2023 to cleanse wound to right shin with normal saline, pat dry, apply xeroform gauze layers, and cover with abdominal pad twice weekly on Monday and Thursday on the 7 AM to 3 PM (Day) shift and as needed. A review of Resident #12's care plan revealed a Focus, reviewed on 5/2/2023, Resident #12 has skin breakdown of a skin tear to the right shin. Interventions included to administer treatments as ordered and monitor for effectiveness and follow…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide adequate nutrition to maintain acceptable parameters of nutritional status for one (Resident #32) of two residents sampled for nutritional requirements. Findings included: A review of Resident #32's medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses of pneumonia, muscular dystrophy, quadriplegia, and gastrostomy status. A review of Resident #32's physician's orders revealed an enteral feed order dated 2/28/2023 for Glucerna 1.2 Cal administered at 70 milliliters (ml) per hour over 20 hours, off at 10 AM and on at 2 PM. Resident #32's physician's orders also revealed an order dated 2/28/2023 for Nothing by Mouth (NPO). A review of Resident #32's care plan revealed a Focus, initiated on 2/28/2023, Resident #32 has impaired swallowing related to muscular dystrophy and was NPO. Interventions included follow diet as prescribed and enteral feedings as ordered. A review of Resident #32's weight…

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 interviews, and record reviews the facility failed to provide pain medication to one (#40) of two residents surveyed for pain management. Findings include: An interview was conducted with Resident #40 on 05/24/23 at 03:36 PM. Resident #40 is a [AGE] year old male admitted to this facility on 5/3/23 for rehabilitation and reconditioning after lengthy illness following complications from cardiac surgery. During the interview Resident #40 said he returned just from the hospital, because the facility did not have his pain medication. Resident #40 said on Monday (5/22/23) night he requested pain medication but the facility did not have it because they ran out and it was not reordered in time (Oxycodone 7.5 mg tablet by mouth every 6 hours as needed for pain). Resident #40 said that when he is in pain his breathing gets faster which leads to increased pain and starts a cycle that is hard to get under control. He said he was told the facility was unable to provide him with the medication and would not be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to monitor behaviors and side effects of psychotropic medications for two (Resident #23 and 68) of the sampled five residents. Findings included: 1. A review of the admission Record for Resident #23 showed she was admitted on [DATE] with diagnoses that included Alzheimer's Disease, persistent mood disorder, depression, schizophreniform disorder, mood disorder, and anxiety disorder. Section N Medications of the quarterly Minimum Data Set (MDS) dated [DATE] showed Resident #23 took antipsychotic medications for seven days and antidepressants for seven days. A review of the Active Orders as of 05/25/23 revealed the following: -Olanzapine Tablet 5 MG (milligrams) - Give 1 tablet po (by mouth) daily related to Schizophreniform Disorder -Trazodone HCL Tablet 150 MG- Give 1 tablet po at bedtime for depression monitor for s/s (signs/symptoms) of depression There was no order in place for behavior and side effect monitoring. A review of the Medication…

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

Based on observations, interviews, and record reviews, the facility failed to ensure a medication error rate of less than 5%. A total of thirty medication opportunities were observed with three errors for two (Resident #56 and Resident #70) of five residents observed for medication administration, resulting in a medication error rate of 10%. Findings included: A review of Resident #56's physician's orders revealed the following orders: - An order dated 5/4/2023 for Acetaminophen 325 milligrams (mg), 2 tablets = 650 mg, by mouth two times a day. - An order dated 3/20/2023 for Calcium-Carb (Carbonate) 600 mg by mouth three times a day. - An order dated 3/17/2023 for Cholecalciferol (Vitamin D3) 1,000 units by mouth one time daily. - An order dated 3/17/2023 for Divalproex Sodium 125 mg by mouth two times a day. - An order dated 3/17/2023 for Fish Oil capsule 1,000 mg give 2 capsules = 2,000 mg by mouth one time a day. - An order dated 3/17/2023 for Lisinopril 2.5 mg by mouth one time a day. - An order dated 3/18/2023 for Memantine Hydrochloride (HCl) 10 mg by mouth two times a day. 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 interviews and record reviews, the facility failed to document complete and accurate medical records for one (Resident #32) of forty-two sampled residents. Findings included: A review of Resident #32's medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses of pneumonia, muscular dystrophy, quadriplegia, and sepsis. A review of Resident #32's physician's order revealed an order dated 3/10/2023 for oxygen saturation monitoring every shift. A review of Resident #32's Medication Administration Record (MAR) from 5/1/2023 on the 7 AM to 3 PM shift (Day) shift to 5/24/2023 on the Day shift revealed the task for oxygen saturation every shift was being documented as completed but no oxygen saturation readings were documented on the MAR. A review of Resident #32's oxygen saturation readings from 5/1/2023 on the Day shift to 5/24/2023 on the Day shift revealed Resident #32's oxygen saturation levels were not documented every shift as ordered. A total of fourteen oxygen…

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, record review, interviews and the facility policy review, and the Plan of Correction review, the facility failed to ensure that it had a functioning Quality Assurance Committee. The facility was actively involved in the effective creation, implementation and monitoring of the plan of correction for deficient practice during a recertification survey that was conducted on 5/22/23 through 5/25/23 and was cited F692. On 7/27/23 the facility was recited for F692. The facility had developed a Plan of Correction with a completion date 6/24/23. Findings included: Ongoing non-compliance was identified at the revisit related to the administration of nutritional supplement as ordered by the physician to ensure the resident received an adequate amount of nutritional supplement through his gastrostomy tube. The facility developed a plan of correction that included: Licensed nurses were re-educated by the Director of Nursing (DON)/designee on 6/5/23, the components of this regulation with emphasis on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and review of facility policy and procedures, the facility failed to ensure medications and biologicals were stored, secured, and disposed of in accordance with professional standards related to 1.) not ensuring 1 of 2 treatment carts in the facility remained secured and locked, 2.) not ensuring that 1 of 5 medication carts in the facility remained secured and locked, 3.) not ensuring medications had proper labeling in 1 of 3 medication carts observed, 4.) not ensuring that medications were disposed of and stored properly during observation of medication administration for 1 (Resident #503) of 7 residents observed during medication administration and 5.) not ensuring medications were properly secured during a tour of the facility on 1 of 4 days. Findings included: An observation was made on [DATE] at 08:27 AM of a treatment cart on the 600 unit of the facility. The treatment cart was observed to be unlocked in the unit hallway with no staff members observed in the immediate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility did not ensure resident and non-resident areas were maintained in a safe and sanitary manner at the North EXIT door area in Hallway 200, and in six out of ten resident rooms in hallway 200 for three of four days of the survey (08/10/21, 08/11/21 and 08/12/21). Findings included: During the initial facility tour on 08/10/21 at 06:26 a.m., an observation of the North EXIT door area revealed debris on the floor. The metal threshold was covered with bio growth and built up debris. The area was also observed with dead insects, estimated count of 60 insects. Photographic evidence was obtained. On 08/10/21 and 08/11/21, during multiple facility tours of hallway 200, observations revealed resident rooms 211, 213, 208, and 205 with dust, debris, food crumbs, and dead insects on the floor. On 08/10/21 06:32 a.m., an interview was conducted with Staff B, Unit Manager who made the observations. Staff B said, The gnats were reported yesterday, I also reported…

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 record review, interview, and review of facility policy, the facility did not ensure that two residents (Resident #94 and Resident #97) out of 3 residents sampled for pre-admission screening had a correctly completed Pre-admission Screening and Resident Review (PASRR). Findings included: 1. A review of Resident #97's Medical Record revealed that Resident #97 was admitted to the facility on [DATE] with a diagnosis of Trisomy 21 (a form of Down Syndrome). A review of Resident #97's Care Plan revealed a problem, last revised on 06/16/2021, that Resident #97 had impaired cognitive function and/or impaired thought process related to Trisomy 21. Interventions included to keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. A review of Resident #97's Minimum Data Set (MDS) assessment revealed, under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impact.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to implement care plan interventions related to oxygen use, and proper oxygen flow rate for one (Resident #38) of thirty-one sampled residents, during two of four days observed (8/10/2021, and 8/11/2021). Findings included: Review of Resident #38's current care plans with next review date 9/13/2021 revealed the following areas: - Resident #38 has Hypertension, Shortness of Breath with interventions in place - Resident #38 has oxygen therapy as needed for shortness of breath with interventions in place to include but not limited to: Given medications as ordered by the Physician, Monitor for signs and symptoms of respiratory distress and report to the Physician as need On 8/10/2021 at 6:50 a.m. and 10:30 a.m., Resident #38 was observed in her room and lying in bed. The call light was placed within her reach. Resident #38 was observed with oxygen tubing leading from the oxygen concentrator to her nasal cannula. An interview with 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 observations, interviews and record review, the facility failed to ensure assistance with Activities of Daily Living (ADL)s was provided for one (Resident # 54) of three residents sampled. Findings included: Resident #54 was admitted to the facility on [DATE] with pertinent diagnoses of unspecified dementia with behavioral disturbance, generalized anxiety disorder, difficulty walking, and mood disorder. Review of the MDS (minimum data set) dated 06/25/21 revealed a BIMS (brief interview for mental status) of 13. Section G, Functional status, under dressing revealed that Resident #54 required extensive assistance for dressing - how resident put on, fastened and took off all items of clothing, including putting on and changing clothing. Under Toilet use, how the resident used the toilet room, commode, bed pan or urinal, cleaned self after elimination, changed and adjusted clothes. Resident #54 required one-person physical assist. Care plan with a last review date 07/05/21 revealed that Resident #54 had 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 record review, interviews, observation, and policy review the facility did not ensure a hospice care plan and/or assessment and appropriate communication related to hospice services including updates for a change of condition were in the medical record for one resident (#64) of nine residents receiving hospice care at the facility. Also based on interview and policy review the facility did not ensure there was a contract with the hospice provider for one resident (#64) of nine residents receiving hospice care. Findings included: Resident #64 was readmitted to the facility on [DATE] with diagnoses including but not limited to, heart failure, type II diabetes mellitus, and Afib (atrial fibrillation), according to the face sheet in the admission record. A review of the Minimum Data Set (MDS) assessment dated [DATE], reflected a Brief Interview of Mental Status (BIMS) score of 14, indicating Resident #64 was cognitively intact. Further review under Functional Status reflected the need for supervision 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 observations, interviews, and record reviews, the facility failed to provide respiratory care in accordance with professional standards for 2 (Resident #499 and Resident #17) of 3 residents sampled for respiratory care. Findings included: 1. A review of Resident #499's Physician's Orders revealed that Resident #499 was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). A review of Resident #499's Physician's Orders revealed an order, dated 08/03/2021, for continuous oxygen at 4 liters per minute (lpm) via nasal cannula. A review of Resident #499's Care Plan revealed a problem, revised on 08/05/2021, that Resident #499 had Emphysema/COPD. Interventions included continuous oxygen via nasal prongs at 4 lpm (liters per minute), monitor for difficulty breathing on exertion, and monitor/document any signs and symptoms of respiratory infection. An observation was conducted on 08/10/2021 at 11:47 AM in Resident #499's room. A nasal cannula with oxygen tubing 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.

Based on observations and staff interviews, the facility failed to post the current Nurse Staffing Information to include all shifts for the day/night, the resident census, and numbers of each disciplined nursing staff for each shift, during one of four days observed, (8/10/2021). It was observed that the facility had the Daily Staffing Sheet posted and displayed with a date of four days prior. Findings included: On 8/10/2021 6:02 a.m., the front lobby doors were approached from the outside parking lot. Upon reaching the doors, they were observed locked. A sign on the door indicated to call a number to have someone come to the front door to let anyone in. The number was called and a staff member, Nurse Employee B indicated she would be right up to the door. At 6:06 a.m. Employee B came to the front door. However, another staff member let the team inside the facility. Upon entering the facility, Employee B was notified of the team and the visit reason. She indicates she was in charge during the current shift and is actually the North unit manager during the days. While Employee B 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.

Based on observations, interviews, and record reviews, the facility failed to ensure a medication administration error rate below 5%. A total of 31 administration opportunities were observed with 4 errors for 4 (Resident #2, Resident #81, Resident #92 and Resident #502) of 5 residents observed for medication administration, resulting in a medications administration error rate of 12.9%. Findings included: An observation of medication administration was conducted on 08/12/2021 at 08:55 AM with Staff A, Registered Nurse (RN) on the 500 unit of the facility. The following medications were administered to Resident #92 during the observation: - Multi Vitamin with Minerals 1 tablet by mouth. - Aspirin 81 milligrams (mg) by mouth. - Fluticasone propionate and salmeterol inhalation powder 250 micrograms (mcg)-50 mcg/dose 1 puff inhalation. - Celexa 20 mg by mouth. - Losartan 25 mg by mouth. - Metformin 500 mg by mouth. - Metoprolol 25 mg by mouth. - Artificial tears solution 1 drop in each eye. After verifying Resident #92's medications, Staff A, RN entered the resident's room and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, observation, and policy review the facility did not ensure services were obtained to determine the appropriate therapeutic diet for one resident (#64) of nine residents receiving hospice care at the facility. Findings included: Resident #64 was readmitted to the facility on [DATE] with diagnoses including but not limited to, heart failure, type II diabetes mellitus, and Afib (atrial fibrillation), according to the face sheet in the admission record. A review of the Minimum Data Set (MDS) assessment dated [DATE], reflected a Brief Interview of Mental Status (BIMS) score of 14, indicating Resident #64 was cognitively intact. Further review under Functional Status reflected the need for supervision with set up help for eating. A review of Section K, Swallowing/Nutritional Status, revealed Resident #64 did not have a swallowing disorder at the time of the assessment, nor was he receiving a therapeutic diet. Review of Section O, Special Treatments, Procedures, and Programs…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, review of facility policy, and review of the Center for Disease Control and Prevention (CDC) guidelines, the facility failed to implement and maintain an infection prevention and control program to mitigate the spread of COVID-19 by 1.) failing to post appropriate signage related to transmission based precautions on 2 resident rooms (406 and 408) of 11 resident rooms under transmission based precautions, 2.) failing to ensure that two staff members (H, A) donned appropriate Personal Protective Equipment (PPE) before entering the rooms of 2 resident's rooms (606 and 608) of 11 resident rooms on transmission based precautions, 3.) failing to ensure that PPE was doffed by 3 staff members (G, H, A) prior to exiting the rooms of 2 residents (406 and 606) of 11 resident rooms under transmission based precautions, 4.) two staff members (H, W) failing to wear protective face masks properly throughout the facility in 2 hallways (200 and 600) of 6 hallways 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, and staff interviews, the facility failed to ensure resident traffic areas and resident spaces were kept safe during three of four days observed (8/10/2021, 8/11/2021, and 8/12/2201). It was determined that a large remote air conditioner handler was plugged into an extension cord, which was stretched out causing a non-safe walking area. Two (#65, #69) of seven total residents that were ambulatory were observed to be walking near the cords. Findings included: On 8/10/2021 from 6:10 a.m. through to at least 2:00 p.m. the North wing was toured and observed on the main floor, across from the nurse station and next to the soiled utility room, there was a large satellite air conditioner handler with tubing leading from the machine and going up through ceiling tiles. Interview with the floor staff had all indicated the air conditioning was not working well on the hallways and this unit has been placed in this spot for about three weeks or so. The unit was observed in an area where staff 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.