Lotus Nursing And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care and treatment was provided according to professional standards of practice to meet the resident's need, and prevent the potential decline in the residents' physical, mental, and/or psychosocial well-being for 1 of 4 residents reviewed for change in condition of a total sample of 10 residents, (#1). Findings: Resident #1, was admitted to the facility on [DATE] and resided on the Memory Care Unit. Her diagnoses included dementia with agitation, diabetes type II, cerebral infarction, mood affective disorder, major depressive disorder, and chronic kidney disease stage 2. Review of the resident's admission Minimum Data Set (MDS) assessment with Assessment Reference Date of 11/09/23 revealed the resident's cognition was severely impaired, with a Brief Interview for Mental Status (BIMS) score of 02 out of 15. The assessment revealed the resident required substantial to maximal assistance for toileting hygiene, required partial to moderate…

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's administration failed to effectively utilize its resources to implement processes to identify and address deficient practices, and failed to provide adequate oversight of staff to ensure the provision of necessary care and services to maintain the highest practicable well-being for all residents. Findings: Review of the Facility Assessment updated on 2/24/23 revealed the facility was a 180-bed skilled nursing facility that could meet the needs of residents with common diseases and special conditions. The document indicated residents would receive care and services as determined by their needs and plans of care to include assistance with activities of daily living (ADL) care, prevention of falls, promotion of skin integrity, medication management and administration, and infection control and prevention. The Facility Assessment revealed the facility's intent to offer person-centered care such as build relationship with resident/get to know him/her;…

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, interview, and record review, the facility failed to honor the right to be treated with dignity and respect while receiving assistance with meals, (#53, #115 & #105), during personal care, (#61), and for all residents in and near a common area (West Wing Day Room), of a total sample of 66 residents. Findings: 1. Review of resident #53's medical record revealed she had dementia and moderate cognitive impairment. Her care plan for activities of daily living (ADLs) self-care performance deficit was initiated on 12/22/22, and read, The resident requires extensive assistance by staff to eat. On 3/01/23 at 1:00 PM, resident #53 was seated at a table in the middle of the [NAME] Wing Day Room. Certified Nursing Assistant (CNA) O stood in front of resident #53 as she fed her. There were twelve additional residents seated in the room and the clear glass windows around the perimeter of the room allowed residents, staff, and visitors to visualize the activities in the room. Licensed Practical Nurse (LPN) M stood outside the [NAME] Wing Day Room and observed CNA O's method…

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, and interview, the facility failed to provide adequate supervision to prevent elopements for 1 of 3 residents reviewed for elopement, in a total sample of 66 residents, (#134). Findings: Review of the medical record revealed resident #134 was admitted to the facility's secure Memory Care Unit on 3/01/22. Her diagnoses included Schizophrenia, Delusional Disorder, Hypertension, and Bipolar Disorder. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] noted the resident had a Brief Interview for Mental Status score of 15 out of 15, which indicated she was cognitively intact. The MDS assessment revealed resident #134 was able to walk independently in her room, but she required supervision of one staff member to person for locomotion both on and off the Memory Care Unit. An Elopement Risk Evaluation dated 7/14/22 indicated resident #134 was at risk for elopement. Review of resident #134's medical record was being seen by a psychiatric provider and there were several notes…

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 pharmaceutical services related to safe administration of controlled release medications, and accurate and/or timely acquisition of medication to meet the needs of 12 residents who received controlled release medications, of a total sample of 66 residents, (#8, #40, #49, #50, #69, #110, #112, #125, #126, #131, #141 & #146). Findings: 1. Review of resident #112's medical record revealed he was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included atherosclerotic heart disease, hypertension, and mini-strokes. Review of resident #112's active Order Summary Report revealed a physician order dated 2/05/23 for Isosorbide Mononitrate ER 24 hour 30 milligrams (mg) once daily for hypertension. Controlled release drugs which include those with the suffixes ER (Extended Release) and DR (Delayed Release) are designed to release medicine over an extended period of time to promote smooth release and a longer…

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, record review, and interview, the facility failed to label stored foods in the walk-in refrigerator and defrost frozen foods under running water. Findings: Review of the facility menu revealed broccoli florets would be served at the lunch meal on 2/27/23. During an initial kitchen inspection on 2/27/23 at 6:16 AM, the facility's walk-in refrigerator was observed. There were two half-pans covered with foil paper. One of the pans had lima beans and the other pan contained cooked rice. The pans were not labeled with the date or the contents. The prep sink was filled with water and there were eight bags floating in the water. The water faucet was not running and the sink was not draining. At 6:34 AM, a Dietary Aide drained the prep sink, removed the bags of broccoli and placed them in a steam table pan. The bags of broccoli were warm to the touch and some of the bags of broccoli were full of water. The prep sink did not have a drain stop and the Dietary Aide explained she used one of the bags of broccoli as a drain stop. On 2/27/23 at 6:54 AM, the walk-in…

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 determine if self-administration of medication was clinically appropriate and safe for 1 of 8 residents reviewed for choices and resident rights, of a total sample of 66 residents, (#132). Findings: Review of resident #132's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Chronic Obstructive Pulmonary Disease (COPD), Anemia, Anxiety, and Mood Disorder. Review of the physician orders revealed resident #132 received two inhalation medications: Breo Ellipta Inhalation Aerosol Powder Breath Activated 200-225 micrograms per inhalation (mcg/INH), one puff every day, and Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) mcg per actuation, two puffs every four hours as needed. On 2/27/23 at 9:36 AM, resident #132 was in bed with cough drops, one Breo Ellipta inhaler, and one Albuterol Sulfate inhaler to the left of her pillow. When asked about the inhalers, the resident explained she had COPD 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 interview and record review, the facility failed to honor the right to refuse treatment related to a Do Not Resuscitate Order (DNRO), for 1 of 1 resident reviewed for advance directives, of a total sample of 66 residents, (#44). Findings: Review of the medical record revealed resident #44 was admitted to the facility on [DATE], and re-admitted on [DATE] after a hospital stay. His diagnoses included cerebrovascular disease, seizures, hypertension, Alzheimer's disease, and protein-calorie malnutrition. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated [DATE] revealed resident #44's primary diagnosis in the hospital was septic shock. Septic shock is the final and most severe stage of sepsis, which is the body's extreme reaction to an infection. The inflammation throughout the body can cause dangerously low blood pressure and is life-threatening (retrieved on [DATE] from www.my.clevelandclinic.org). The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement its policies and procedures to prohibit Abuse and Neglect for 1 of 1 resident reviewed for Abuse, of a total sample of 66 residents, (#61). Findings: Resident #61's medical record revealed she was admitted to the facility on [DATE] with diagnoses including cerebrovascular disease, heart disease, depression, anxiety, and insomnia. The Quarterly Minimum Data Set (MDS) assessment with assessment reference date of 1/23/23 revealed resident #61 had a Brief Interview for Mental Status score of 15 which indicated she was cognitively intact. The document noted she had no mood or behavioral issues and did not reject care that was necessary to achieve the resident's goals for health and well-being. Resident #61 required limited assistance for bed mobility, and extensive assistance for transfers, dressing, and personal hygiene. The MDS assessment showed the resident had no impairments in functional range of motion of her extremities. 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 interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed for discharge from the facility, out of a total sample of 66 residents, (#160). Findings: Review of resident #160's medical record revealed he was admitted to the facility on [DATE] with diagnoses of Cerebral Vascular Accident (CVA), Acute Subdural Hemorrhage, Seizures, Hypertension, and Major Depressive Disorder. Resident #160 had a physician's order to discharge home on 2/08/23 with Home Health Services, Home Health Aide, standard wheelchair, and Physical and Occupational Therapy. Review of a nursing progress note dated 2/09/22 at 10:20 AM indicated resident #160 was discharged home with his wife. The Short-Term Social Service Director's (SSD) progress note dated 2/14/23 at 8:30 AM documented resident #160's spouse had expressed that the resident was doing well at home. Review of the Discharge Return Not Anticipated MDS assessment dated [DATE] documented…

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 the Preadmission Screening and Record Review (PASARR) Level I was correct upon admission and corrected after admission for 2 of 3 residents reviewed for PASARR, out of a total sample of 66 residents, (#15 & #146). Findings: 1. Review of resident #15's medical record revealed she was admitted to the facility on [DATE] with diagnoses of Schizophrenia, Psychosis, and Major Depressive Disorder. The resident's physician orders included Trazodone 50 milligrams (mg) by mouth (PO), give 0.5 tablet daily for depression, and Ziprasidone 20 mg PO two times a day for psychosis. Review of resident #15's PASARR Level I form dated 7/23/22 documented no diagnosis of Serious Mental Illness (SMI) or Intellectual Disability (ID). 2. Review of resident #146's medical record revealed she was admitted to the facility on [DATE] with diagnoses of Schizoaffective Disorder, Major Depressive Disorder and Anxiety Disorder. The resident's physician orders included Trazodone…

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 a resident with identified mental illness for a Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination for 1 of 3 residents reviewed for PASARR, out of a total sample of 66 residents, (#38). Findings: Review of the medical record revealed resident #38 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, major depressive disorder, anxiety disorder and hypertension. Review of the Minimum Data Set quarterly assessment with assessment reference date of 1/11/23 revealed resident #38 had a Brief Interview for Mental Status score of 7 which indicated he was severely cognitively impaired. The document indicated his active diagnoses included anxiety disorder, depression (other than bipolar) and psychotic disorder (other than schizophrenia). Review of resident #38's care plans revealed a behavior care plan initiated on 1/17/19 which indicated he was resistive to care related to schizophrenia,…

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 3. Resident #89 was admitted to the facility on [DATE] with diagnoses including unspecified sequelae of nontraumatic intracerebral hemorrhage, type 2 diabetes, essential hypertension, end stage renal disease, chronic embolism and thrombosis of other specified veins, seizures, major depressive disorder and insomnia. Review of the MDS admission assessment with assessment reference date of 1/17/23 revealed resident #89 had a Brief Interview for Mental Status score of 15 which indicated he was cognitively intact. His active diagnoses included non-traumatic brain dysfunction, coronary artery disease, deep venous thrombosis and/or pulmonary embolus, hypertension, renal failure, diabetes mellitus, seizure disorder and depression. The MDS indicated resident #89 received oxygen therapy, intravenous medications and dialysis. The Care Area Assessment (CAA) associated with the admission MDS assessment dated [DATE] indicated resident had conditions which required further evaluation. The identified areas were visual function,…

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 follow a dietitian's recommendations to maintain sufficient fluid intake and adequate hydration for 1 of 1 resident reviewed for hydration, of a total sample of 66 residents, (#44). Findings: Review of the medical record revealed resident #44 was admitted to the facility on [DATE], and re-admitted on [DATE] after a hospital stay. His diagnoses included cerebrovascular disease, difficulty swallowing, Alzheimer's disease, protein-calorie malnutrition, and gastrostomy. A gastrostomy tube or G-tube is a feeding tube that is inserted directly into the stomach through a surgical incision in the abdominal wall. A feeding tube is necessary if someone has difficulty swallowing as it allows the person to receive adequate nutrition, hydration, and medication (retrieved on 3/10/23 from www.my.clevelandclinic.org). The Minimum Data Set (MDS) Significant Change in Status assessment with assessment reference date of 11/29/22 revealed resident #44 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure behavior monitoring and documentation were implemented and conducted for the use of antipsychotic medications for 1 of 2 residents reviewed for behavioral/emotional monitoring, out of a total sample of 66 residents, (#157). Findings: Review of resident #157's medical record revealed he was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, Seizures, Heart Failure, Chronic Atrial Fibrillation, Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety. The admission Minimum Data Set (MDS) assessment dated [DATE] documented short-term and long-term memory problems, independence with cognitive skills for daily decision making, and no behavioral symptoms. The MDS assessment revealed resident #157 required extensive assistance of one to two staff for activities of daily living (ADL), used a wheel chair for mobility, and was frequently incontinent of bowel and bladder. He received antipsychotic medication 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 maintain a medication error rate of less than five percent for 2 of 4 residents reviewed for medication administration, of a total sample of 66 residents, (#5 & #112). The facility's medication error rate was 14.81% Findings: 1. Review of resident #112's medical record revealed he was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included atherosclerotic heart disease, hypertension, and mini-strokes. On 2/27/23 at 7:49 AM, Licensed Practical Nurse (LPN) M prepared to administer resident #112's eight scheduled morning medications. LPN M stood at the medication cart and crushed all the tablets which included one tablet Isosorbide Mononitrate Extended Release (ER) 30 milligrams (mg) and one tablet Chewable Aspirin 81 mg. He then mixed six crushed tablets, one whole capsule and the contents of one capsule into applesauce in a small plastic cup. On 2/27/23 at 7:57 AM, LPN M approached resident #112 to administer…

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 maintain proper infection control practices to prevent contamination during medication administration for 1 of 4 residents reviewed for medication administration (#112), and during wound care for 1 of 1 resident observed for wound care of 5 residents reviewed for skin conditions and pressure injuries (#44), of a total sample of 66 residents. Findings: 1. Review of resident #112's medical record revealed he was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included atherosclerotic heart disease, hypertension, and mini-strokes. On 2/27/23 at 7:49 AM, Licensed Practical Nurse (LPN) M prepared to administer resident #112's scheduled morning medications. He did not perform hand hygiene prior to beginning the task although a bottle of alcohol-based hand sanitizer was on the medication cart. LPN M retrieved two capsules Gabapentin 100 milligrams (mg) and added them to the small plastic cup that contained other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure residents completed pneumococcal vaccine consent forms and received pneumococcal vaccines upon request, for 2 of 5 residents reviewed for immunizations, out of a total sample of 66 residents, (#120 & #137). Findings: 1. Review of the medical record revealed resident #120 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The medical record indicated pneumococcal vaccine consent was obtained by telephone consent from the resident's guardian on 12/28/21. The box was checked to note the facility received permission to administer the pneumococcal vaccine. Review of the immunization audit report and the Medication Administration Records did not reveal administration of the pneumococcal vaccine to resident #120. 2. Review of the medical record revealed resident #137 was admitted to the facility on [DATE], with a previous admission on [DATE]. Review of the electronic medical record's immunization section, and the immunization…

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 for 1 of 3 residents reviewed for oxygen therapy out of a total sample of 64 residents, (#77). Findings: Resident #77 was initially admitted to the facility on [DATE], then readmitted on [DATE]. His diagnoses included chronic obstructive pulmonary disease, cerebral infarction, hypertensive heart failure, and vascular dementia. Review of the resident's quarterly Minimum Date Set (MDS) assessment with assessment reference date of 3/2/2021 revealed resident #77 was cognitively impaired, required extensive assistance of 2 staff for activities of daily living (ADL), and used oxygen for respiratory treatment. On 4/19/21 at 10:33 AM, resident #77 was lying in bed. The resident was not interviewable. He had oxygen tubing with a nasal cannula attached to an oxygen concentrator. The regulator was set at 4.5 liters of oxygen per minute (LPM). On 4/19/21 at 10:44 AM, Licensed Practical Nurse (LPN )E acknowledged the regulator…

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 accuracy of the Minimum Data Set (MDS) assessment for 1 of 8 residents reviewed for falls (#52) and 1 of 1 resident reviewed for discharge to community (#157) out of a total sample of 64 residents. Findings: 1. According to the Centers for Medicare and Medicaid Services (www.cms.gov) dated November 14, 2012, read, . the MDS provides a comprehensive assessment of each resident's functional capabilities and helps the nursing home staff identify health problems and . helps provide the foundation upon which the resident's individual care plan is formulated Review of resident #52's medical record revealed he was admitted to the facility on [DATE] with diagnoses including Cerebral Vascular Accident (CVA) Respiratory Failure, Pneumonia, Chronic Obstructive Pulmonary Disease (COPD) , Chronic Kidney Failure and Mood Disorder. Review of the facility's Incident Log revealed resident #52 had sustained falls on 12/09/20, 12/23/20 and 01/04/21. Review 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 observation, interview and record review, the facility failed to provide nail care for 1 of 5 dependent residents reviewed for activities of daily living (ADL) of a total sample of 64 residents (#131). Findings: Resident #131 was initially admitted to the facility on [DATE] then readmitted on [DATE]. His diagnoses included Dementia, Diabetes Mellitus Type 2, Schizophrenia, and Epilepsy. The quarterly Minimum Data Set (MDS) assessment with assessment reference date of 03/31/21 revealed resident #131 had severely impaired cognition, and was totally dependent on 1 staff person for personal hygiene and bathing. On 04/18/21 at 3:40 PM, resident #131 was in bed, alert and watching television. His fingers nails to both hands were approximately 3/4 centimeters (cm) long with hardened, yellowish debris underneath. His main language was Spanish but he was able to answer minimal English questions. His right hand was able to move freely without limitation. His left hand was contracted. On 04/19/21 at 10:19 AM,…

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.