Aviata At Rosewood

Based on observation, interview, and record review, the facility failed to follow podiatry treatment plan and ensure a timely follow-up appointment with a podiatrist for 1 of 1 residents reviewed for podiatry, of a total sample of 4 residents, (#1). Findings: Review of resident #1's medical record revealed diagnoses of type 2 diabetes mellitus, peripheral vascular disease, hemiplegia (severe loss of strength) and hemiparesis (weakness) following stroke affecting left non-dominant side. The American Diabetes Association's in the section titled, Foot Complications described, People with diabetes can develop many different foot problems. Even ordinary problems can get worse and lead to serious complications (retrieved from www.diabetes.org on 10/02/24). Review of resident #1's medical record revealed a podiatry visit report with a date of service of 8/22/24. The report detailed on physical exam the podiatrist noted resident #1 was unable to differentiate sharp/dull sensations in both feet. Resident #1 had three nonpalpable (could not be felt by hand) and one diminished pulse, regarding…

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 interview and record review, the facility failed to ensure a resident who was continent of bladder and bowel received services such as scheduled toileting or prompted voiding, and the needed assistance to maintain their continence, for 1 of 3 residents reviewed for bowel and bladder/incontinence care, of a total sample of 4 residents, (#1). Findings: Resdient #1 was admitted to the facility on [DATE] with diagnoses that included stroke, type 2 diabetes mellitus, and partial weakness and paralysis of the left non-dominant side after stroke. Review of resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #1 was cognitively intact with no behavioral symptoms or rejection of care necessary to achieve the resident's goals for health and well-being. Section H of the assessment indicated she was always incontinent of bowel and bladder and that a toileting program (e.g. scheduled toileting, prompted voiding, or bladder training) had not been attempted upon admission or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to provide the resident and his responsible party access to his personal and medical records following a written request for 1 of 1 residents reviewed for medical grievances, of a total of 6 residents, (#2). Findings: Resident #2 was admitted to the facility on [DATE], with a diagnosis of seizures, type 2 diabetes, protein-calorie malnutrition, hypertension, alcohol dependence, anxiety, and history of a brain abscess. The admission Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 12/15, which indicated the resident was cognitively intact. Review of the resident's electronic medical record revealed a document titled Healthcare Power of Attorney which was scanned into the resident's chart on 3/23/24. Under the section Designation of health care agent, the document listed the resident's brother to serve as his health care agent. Under the section titled Medical information and Medical records it indicated,…

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 interview and record review, the facility failed to revise a fall care plan to reflect fall interventions for 1 of 3 residents reviewed for care plans, of a total sample of 6 residents, (#1). Findings: Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including multiple fractures of pelvis, fracture of left patella, dislocation of right hip, displaced fracture of lateral malleolus of left fibula and unsteadiness on feet. Review of resident #1's medical record revealed a Change in Condition evaluation completed dated 3/03/24 which indicated resident #1 slipped out of his wheelchair and was observed sitting on the footrest. Staff assisted resident back into his wheelchair. The form did not list any new interventions to be implemented. The medical record also contained a Change in Condition evaluation dated 3/24/24 which indicated resident #1 was observed as he slid from the seat of his wheelchair onto the footrests. The form also did not list any new 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 interview and record review, the facility failed to ensure appropriate fall interventions were in place to prevent further falls for 1 of 3 residents reviewed for falls, of a total sample of 6 residents, (#1). Findings: Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including multiple fractures of pelvis, fracture of left patella, dislocation of right hip, displaced fracture of lateral malleolus of left fibula and unsteadiness on feet. Review of the Minimum Data Set quarterly assessment with assessment reference date 2/25/24 revealed resident #1 had long-term and short-term memory problems and severely impaired cognitive skills for daily decision making. He was dependent on staff for activities of daily living and used a wheelchair for mobility. Review of the facility's incident log revealed resident #1 fell on 1/22/24, 3/03/24 and 3/24/24. Review of the medical record revealed a Change in Condition evaluation completed by Licensed Practical Nurse (LPN) 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.

Based on observation and interview, the facility failed to ensure dishware were rinsed with the proper level of sanitizer in regard to the manufacturer's instructions. Finding: On 4/22/24 at 10:15 AM, during kitchen observation, staff were observed running dishware through the dish machine. Dietary Aide G was observed removing items from the machine and placing them on racks and shelves in the kitchen. The Dietary Manager stated the dish machine was a low temperature machine which used a chemical to sanitize the dishes. He stated the chemical should be at 100 parts per million (ppm) and attempted to test the ppm level twice. The test strips did not activate. The Dietary Manager explained staff could not be sure the dishes were properly sanitized if the chemicals in the strips did not register. He left the dish area to place a call to the chemical supplier. Dietary Aide G continued to remove plates from the machine and stacked them on top of other plates in the plate warmer. The Dietary Manager did not attempt to stop her from mixing unsanitized dishware with sanitized dishware. 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 observation, interview, and record review, the facility failed to obtain physician orders, and provide intravenous (IV) care and services according to professional standards of practice to prevent the potential for infection for 2 of 2 residents reviewed for IVs, of a total sample of 39 residents, (#209, & #79). Findings: 1. Resident #209 was admitted to the facility from an acute care hospital on 4/03/24 with diagnoses including sepsis, respiratory failure, perforation of intestine, muscle weakness, difficulty walking, lack of coordination, anemia, end stage renal disease (ESRD), dependent on dialysis, congestive heart failure and cardiomyopathy. The Agency for Healthcare Administration Hospital Transfer Form 5000-3008 dated 4/03/24 showed resident #209 had a primary diagnosis of sepsis, and the skin assessment showed he had a dialysis catheter and Peripherally Inserted Central Catheter (PICC) line. A PICC is a thin, flexible tube inserted into a vein in the upper arm and guided (threaded) into a large…

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, interview, and record review, the facility failed to obtain a physician order for Oxygen (O2) therapy and failed to administer O2 therapy as ordered by the physician for 3 of 3 residents reviewed for respiratory care, of a total sample of 39 residents, (#11, #2, and #310). Findings: 1. Resident #11 was admitted to the facility on [DATE] from an acute care hospital. Her diagnoses included hemiplegia (one sided weakness) following cerebral infarction (stroke), muscle weakness, encephalopathy, chronic obstructive pulmonary disease, Alzheimer's disease, slurred speech, lack of coordination, pleural effusion, atrial fibrillation, and coronary artery disease. The 3008-Hospital transfer form dated 3/19/24 included treatment device listed as, Oxygen 2 L (liters) prn [as needed]. On 4/22/24 at 10:55 AM, resident #11 was observed lying in bed alert and confused. It was noted she was not wearing the oxygen nasal cannula (NC). The tubing was instead laying across her chest connected to the concentrator…

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, interview, and record review, the facility failed to provide adequate monitoring for potential side effects of anticoagulant medication such as bleeding and bruising for 1 of 1 residents reviewed for Anticoagulant medication, of a total sample of 39 residents, (#209). Findings: Resident #209 was admitted to the facility from acute care hospital on 4/03/24 with diagnoses including sepsis, respiratory failure, perforation of intestine, muscle weakness, difficulty walking, lack of coordination, anemia, end stage renal disease, dependent on dialysis, congestive heart failure and cardiomyopathy. Review of the admission Minimum Data Set assessment dated [DATE] revealed Brief Interview for Mental Status score of 15/15 which indicated the resident was cognitively intact. The assessment indicated resident #209 was on high-risk medications including a hypnotic and anticoagulant. Special treatments included dialysis while a resident at the facility. Review of resident #209's medical record revealed 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 interview, and record review, the facility failed to provide care and services to prevent significant medication error for oral antibiotic therapy, which led to the omission of fourteen (14) doses of the prescribed medication for 1 of 5 residents reviewed for unnecessary medications, of a total sample of 39 residents, (#48). Findings: Resident #48 was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included atherosclerosis of coronary artery bypass graft(s), embolism, and thrombosis of arteries of the lower extremities, right above knee amputation (AKA), left AKA, hyperlipidemia, and hypertension. The resident's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's cognition was intact with a Brief Interview For Mental Status score of 15 out of 15. The assessment noted the resident received antibiotics over the look back period used to complete the assessment. Review of the resident's outpatient office visit note dated 2/14/24 revealed a plan for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an evaluation for self-administration of medication was completed, failed to obtain a physician's order for self-administration of medications, and failed to ensure medications were not stored at the resident's bedside for 1 of 3 residents reviewed for choices, of a total sample of 39 residents, (#95). Findings: Resident # 95 was admitted to the facility on [DATE] with diagnoses that included quadriplegia, dislocation of C3/C4 cervical vertebrae, chronic obstructive pulmonary disease, and right and left side lumbago with sciatica. Review of the resident's admission Minimum Data Set assessment with Assessment Reference Date of 2/23/24 revealed the resident's cognition was intact with a Brief Interview For Mental Status score of 15 out of 15. The assessment noted the resident was dependent on staff assistance for his activities of daily living, and mobility needs. On 4/22/24 at 2:05 PM, resident # 95 was resting in bed watching…

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 interview and record review, the facility failed to request a Preadmission Screening and Resident Review (PASARR) level 1 and level II evaluation after a new major mental disorder diagnosis for 1 of 5 residents reviewed for PASARR, of a total sample of 39 residents, (#60). Findings: Review of the medical record revealed resident #60 was admitted to the facility on [DATE] from the hospital. His diagnosis included hemiplegia and hemiparesis following cerebral infarction, major depressive disorder, and cocaine abuse. Resident # 60 received a new diagnosis of psychotic disorder with delusions on 10/03/23. Resident # 60's Annual Minimum Data Set assessment with assessment reference date of 3/12/24 revealed the resident scored 12 out of 15 on the Brief Interview for Mental Status which indicated he had moderate cognitive impairment with no change in behavior. Review of resident # 60's medical record revealed a Care Plan with revised interventions on 12/04/23 which included psychiatric consult as needed 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 observation, interview, and record review, the facility failed to develop and implement a person-centered care plan for 1 of 3 residents reviewed for activities, (#11) and 1 of 1 resident reviewed for anticoagulant use, (#209), of a total sample of 39 residents. Findings: 1. Resident #11 was admitted to the facility on [DATE] from an acute care hospital. Her diagnoses included hemiplegia (one-sided weakness) following cerebral infarction (stroke), muscle weakness, encephalopathy, chronic obstructive pulmonary disease, chronic pain, glaucoma, Alzheimer's disease, slurred speech, lack of coordination, pleural effusion, atrial fibrillation, and coronary artery disease. Review of the electronic medical record on 4/25/24 at 1:06 PM, did not reveal any documentation evaluations or progress notes regarding activities. The current care plans in effect included limited mobility, impaired cognitive function related to Alzheimer's disease, mood problem, impaired vision related to glaucoma, risk of pressure ulcer…

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, interview, and record review, the facility failed to provide a resident centered activities program which met the individual interests and needs of the resident and encouraged both independent and group interactions for 1 out 3 residents reviewed for activities, of a total sample of 39 residents, (#11). Findings: Resident #11 was admitted to the facility on [DATE] from an acute care hospital. Her diagnoses included hemiplegia (one sided weakness) following cerebral infarction (stroke), muscle weakness, encephalopathy, chronic obstructive pulmonary disease, chronic pain, glaucoma, Alzheimer's disease, slurred speech, lack of coordination, pleural effusion, atrial fibrillation, and coronary artery disease. Review of the 5-day Minimum Data Set assessment dated [DATE] revealed her Brief Interview for Mental Status score was 3/15 which indicated severe cognitive impairment. The Daily Activity Preferences showed it was very important to her to listen to music, go outside for fresh air, 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 observation, interview, and record review, the facility failed to provide appropriate care and services related to following physician orders for 1 of 3 residents reviewed for gastric tube feeding, of a total sample of 39 residents, (#96). Findings: Review of the medical record revealed resident # 96 was admitted to the facility on [DATE] from the hospital. His diagnosis included dysphagia (trouble swallowing) following cerebral infarction (stroke), hemiplegia, and hemiparesis, and gastrostomy status. Tube Feeding (enteral nutrition) uses a feeding tube to supply nutrients and fluids to your body if you can't safely chew or swallow (Retrieved on 4/29/24 from my.clevelandclinic.org). The Medicare 5- day Minimum Data Set assessment with an assessment reference date of 4/02/24 revealed resident #96 scored 13 out of 15 on the Brief Interview for Mental Status which indicated he was cognitively intact. The assessment also indicated resident #96 had a feeding tube which provided 51 percent or more of his…

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, interview and record review, the facility failed to ensure residents who experienced trauma received trauma-informed care for 1 of 2 residents reviewed for mood/behavior, of a total sample of 39 residents, (#84). Findings: Resident #84 was admitted to the facility on [DATE] with diagnoses including injured in motor-vehicle accident, fracture of sacrum, fracture of one rib, fracture of right femur and fracture of left femur. Diagnoses of anxiety disorder and major depressive disorder were added with an onset date of 10/25/23. Review of the Minimum Data Set (MDS) quarterly assessment with assessment reference date of 1/25/24 revealed resident #84 had a Brief Interview for Mental Status score of 15 which indicated she was cognitively intact. She had impairment to both lower extremities and was dependent on staff for activities of daily living (ADLs). The document revealed resident #84 felt down/depressed/hopeless with little interest or pleasure in doing things nearly every day. She had active…

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, interview, and record review, the facility failed to ensure the medication error rate was below 5%, by failing to administer the correct dosage of medications per physician's orders for 1 of 3 residents observed for medication administration, of a total sample of 39 residents, (#88). Findings: Resident #88 was admitted to the facility on [DATE] with diagnoses that included chronic embolism and thrombosis of deep veins of the left lower extremity, acute respiratory failure, bipolar disorder, schizophrenia, anxiety disorder, and thiamine deficiency. On 4/22/24 at 10:03 AM, medication administration observation for resident #88 was conducted with Licensed Practical Nurse (LPN) M. Medications administered by LPN M included Folic acid 400 micrograms (mcg), and Guaifenesin 400 milligram (mg). Folic acid is a B vitamin. It helps the body make healthy new cells (retrieved on 5/01/24 from medlineplus.gov). Guaifenesin is used to relieve chest congestion (retrieved on 5/01/24 from medlineplus.gov).…

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 interview, and record review, the facility failed to effectively use its resources to ensure medications were transferred accurately and completely to the facility's Electronic Medical Records (EMR), to prevent significant medication error, and to maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents reviewed for unnecessary medication, of a total sample of 39 residents, (#48). Findings: Resident #48 was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included atherosclerosis of coronary artery bypass graft(s), embolism, and thrombosis of arteries of the lower extremities, right above knee amputation (AKA), left AKA, hyperlipidemia, and hypertension. Review of the resident's outpatient office visit note dated 2/14/24 revealed the plan for the resident to continue suppressive antibiotic therapy with oral Cephalexin (Keflex), 500 milligram (mg) twice daily. The prescription dated 2/14/24 was for Keflex 500 mg capsule, take one…

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 interview, and record review, the facility failed to ensure documentation in the medical record was complete and accurate according to accepted professional standards and practices regarding intravenous (IV) dressing change for 1 of 2 residents reviewed for IV care, of a total sample of 39 residents, (#79). Findings: Resident # 79 was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included left above the knee amputation, dysphagia, acute respiratory failure, diabetes type II, gastrostomy, and end stage renal disease. Review of the resident's physician orders showed an order dated 4/05/24 to change IV dressing every 72 hours, and as needed. A progress note dated 4/11/24 revealed a midline was inserted in the resident's right upper arm. A midline (midline catheter) is a long, thin, flexible tube that is inserted into a large vein in the upper arm. It is used to safely administer medication into the bloodstream A midline can stay in place for approximately four weeks (retrieved…

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, interview, and record review, the facility failed to ensure physician's order for contact isolation precautions were implemented for 1 of 1 resident reviewed for Transmission Based Precaution (TBP), of a total sample of 39 residents, (#63). Findings: Resident #63 was admitted to the facility on [DATE] with diagnoses which included encephalopathy, depression, hypertension, and generalized muscle weakness. A physician's order dated 4/18/24, was for Contact isolation every shift for infection-Extended Spectrum Beta-Lactamase (ESBL) in the urine. Extended Spectrum Beta-Lactamase (ESBLs) are enzymes or chemicals produced by germs like certain bacteria. These enzymes make bacterial infections harder to treat with antibiotics (retrieved on 5/03/24 from webmd.com). On 4/22/24 at 1:34 PM, and on 4/23/24 at 11:51 AM, observations showed an Enhanced Barrier Precaution sign posted on resident #63's room door, and an overdoor container with Personal Protective Equipment (PPE) was in place. Signage for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to promote dignity related to privacy of catheter drainage bag for 1 of 1 resident reviewed for dignity, out of a total sample of 36 residents, (#69). Findings: Resident #69 was admitted to the facility on [DATE] with diagnoses including infection and inflammatory reaction due to cystostomy catheter, neuromuscular dysfunction of bladder and retention of urine. Review of the Minimum Data Set (MDS) admission assessment with assessment reference date of 11/06/22 revealed resident #69 had a Brief Interview for Mental Status score of 11 out of 15 which indicated he had moderate cognitive impairment. The document indicated the resident used an indwelling catheter and had a diagnosis of neurogenic bladder. A care plan for an indwelling catheter with neurogenic bladder was initiated on 11/01/22. Interventions included to position catheter bag and tubing below the level of the bladder and away from entrance room door. On 1/08/23 at 10:09 AM, 1/08/23…

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 observation, interview, and record review, the facility failed to notify the physician of change in condition for 1 of 1 resident reviewed for change of condition from a total sample of 36 residents, (#52). Findings: Resident #52 was admitted on [DATE], discharged to the hospital on [DATE], and re-admitted to the facility on [DATE] with diagnoses of paranoid schizophrenia, major depressive disorder, and urinary tract infection (UTI). Review of the resident's medical record revealed the quarterly 5-day Minimum Data Set (MDS) assessment with reference date (ARD) 12/16/2022 identified the resident was moderately cognitively impaired, required extensive assistance for activities of daily living, and the resident received antipsychotic medications for 5 of 7 days in the look back period. The resident's care plan for psychotropic medications dated 9/07/22 included monitoring for side effects and effectiveness of psychoactive medications every shift. Resident #52's active medication orders included Valproate…

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 interview, and record review, the facility failed to refer residents with a newly evident mental disorder for Level II Preadmission Screening and Resident Review (PASRR) evaluation and determination for 2 of 3 residents reviewed for PASRR, out of a total sample of 36 residents, (#21 and #76). Findings: 1. Resident #21 was admitted to the facility on [DATE] with diagnoses including insomnia, hypertension, transient cerebral ischemic attack, acquired absence of right leg above knee and other recurrent depressive disorders. Review of the Minimum Data Set (MDS) quarterly assessment with assessment reference date (ARD) of 12/02/22 revealed resident #21 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated she had moderate cognitive impairment. The document indicated her active diagnoses included depression and schizophrenia. Review of resident #21's care plan revealed a behavior care plan initiated 2/01/21 which indicated the resident exhibited behavior problems related 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 interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 3 residents reviewed for activities of a total sample of 36 residents, (#49). Findings: Resident #49 was admitted to the facility on [DATE] with diagnoses including Rhabdomyolysis, mood disorder, major depressive disorder, coronary artery disease, end stage renal disease, and acute kidney disease. Review of resident #49's medical record revealed the admission Minimum Data Set (MDS) with assessment reference date (ARD) 11/21/2022 identified the resident was cognitively intact and required extensive assistance for activities of daily living (ADL). The MDS completed by the Community Life Director for preferences of activities indicated it was very important for the resident to listen to preferred music, go outside, and do group activities. On 1/09/2023 at 10:30 AM, resident #49 said he was not provided information for facility activities. Review of resident #49's care plan 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.