Orlando Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #56 was a long-term care resident who admitted to the facility on [DATE]. Review of the level I PASARR dated 9/20/13, noted section 1A was blank and did not include any diagnoses of potential mental illness or intellectual disability. Review of the resident's current diagnoses included dementia, epilepsy, depression, anxiety and psychotic disorder. Record review revealed during a session with the Psychologist on 4/28/25, the resident was noted with a depressed mood and expressed feelings of being overwhelmed. There was not any evidence in the medical record that the level I PASARR had been updated. On 6/19/25 the Social Service Director was ask to provide a copy of the resident's level I PASARR. On 6/20/25 at 1:35 PM, the Social Service Director provided the requested copy of the PASARR dated 9/20/13 and a copy of a new PASARR which was updated on 6/19/25. He could not explain why the resident's PASARR had not been updated prior to 6/19/25. The Facilty's Policy and Procedure dated February 2021…

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 I and level II evaluation for 2 of 5 residents reviewed for PASARR, of a total sample of 103 residents, (#70, and #123). Findings: 1. Resident #123 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included vascular dementia, major depressive disorder, adjustment disorder, congestive heart failure, cerebral infarction, and acute respiratory failure with hypoxia. Review of resident #123's Minimum Data Set (MDS) quarterly assessment with an assessment reference date of 4/04/25 revealed the resident was cognitively impaired and listed depression as a psychiatric diagnosis. A review of the electronic medical record revealed a PASARR dated 1/12/23 and no diagnoses were listed in Section 1 A. On 6/19/25 at 1:45 PM, the Social Services Director stated he was responsible for PASARRs. He acknowledged that no diagnoses were listed in section 1 A 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 a resident centered activities program to meet the needs of residents who required 1:1 in room activities for 5 of 6 residents reviewed for in room activities, of a total sample of 103 residents, ( #152, #174, #345, #349, & #359). Findings: The following residents resided on the locked unit and were observed daily for five days, from 6/16/25-6/20/25, between the hours of 8:15 AM to 9:30 AM, and 11:30 AM to 4:30 PM. During those times no activities for the residents were observed. 1. Resident #152 was admitted to the facility on [DATE] with diagnoses to include dementia, mood disorder, repeated falls. Resident #152's activity care plan indicated, resident requires staff assistance with involvement of activities related to behavioral symptoms that may affect participation. Cognitive deficits .requires staff visits for supplies and assistance with partaking in passive activities in his room, initiated on 2/11/25). The goal was 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 interview, and record review, the facility failed to timely provide coordination of care for diagnostic imaging/laboratory services and a specialty gastrointestinal (GI) consult for 2 of 2 residents reviewed for coordination of care, (#159 and #22); and failed to obtain physician's wound treatment orders and complete weekly wound measurement assessments for 1 of 5 residents reviewed for non- pressure skin condition concerns, (#120), of a total of 103 sampled residents. Findings: 1. Review of resident #159's medical record revealed an admission date of 5/23/22. Her diagnoses included volvulus (twisting intestines) and abdominal distension-gaseous. Review of resident #159's Quarterly Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status of 13/15, which indicated her cognitive function was intact. On 6/16/25 at 1:34 PM, both resident #159's family member and resident #159 said the size of the resident's abdominal area had increased over time since she had been at the facility.…

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 care and services related to management and application of orthotic devices to prevent worsening of contractures and promote skin integrity for 1 of 1 residents reviewed for limited range of motion (ROM) and reduced mobility, of a total sample of 103 residents, (#249). Findings: Review of the medical record revealed resident #249 was admitted to the facility on [DATE] with diagnoses including stroke with left side weakness and paralysis, type 2 diabetes, and cataracts. Review of the Minimum Data Set (MDS) annual assessment with Assessment Reference Date of 3/09/25 revealed resident #249 had a Brief Interview for Mental Status score of 15 out of 15 which indicated she was cognitively intact. The MDS assessment indicated the resident did not exhibit behavioral symptoms or reject evaluation or care that was necessary to achieve her goals for health and well-being. The MDS assessment revealed resident #249 had functional limitation 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.

Based on observation, interview, and record review the facilty failed to provide care and services for a Peripherally Inserted Central Catheter (PICC) intravenous (IV) line for 1 of 1 residents reviewed for central line catheters, of a total sample of 103 residents, (#922). Findings: Resident #922 admitted to the facility from the hospital on 6/10/25. Her diagnoses included type 2 diabetes, heart failure, abdominal hernia, epilepsy and ventricular tachycardia (fast heartbeat). The hospital transfer form did not indicate the resident had an IV line. Staff noted in a progress note dated 6/10/25, the resident had an IV line that was located in the resident's right arm. On 6/16/25 at 2:59 PM, the resident was observed in the therapy gym and said the facilty did not use her PICC line. She conveyed she did not receive antibiotics through the line nor did the facility staff flush it. The PICC dressing had a date of 6/07/25, before she was admitted to the facility, which meant the dressing had not been changed since she had been at the facility. A PICC line is a thin, flexible tube inserted…

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 address a resident's pain timely for 1 of 2 residents reviewed for pain, of a total sample of 103 residents, (#250). Findings: Resident #250 was admitted to the facility on [DATE]. His diagnoses included unspecified polyneuropathy, fusion of the spine thoracic region, fusion of the spine lumbar region, pain in right foot, unspecified fracture of the sacrum sequelae, unspecified fracture of the right and left acetabulum sequelae, unspecified fracture of the the shaft of the right tibia, unspecified fracture of the right and left calcaneous (heel bones), and displaced fracture of the fourth metatarsal bone right foot sequelae. Review of resident #250's annual Minimum Data Set assessment dated [DATE] revealed he had no cognitive deficiencies. Resident #250 had a physician order dated 4/14/24 for the pain medication Lyrica (Pregabalin) 100 milligrams (mg) to be administered every eight hours. On 6/16/25 at 5:19 PM, resident #250 stated he currently was 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 ensure that residents who experienced trauma received trauma-informed care for 1 of 4 residents reviewed for behavioral-emotional concerns, of a total sample of 103 residents, (#251). Findings: Resident #251 was admitted to the facility on [DATE] with diagnoses including heart failure, adjustment disorder with other symptoms, claustrophobia, atrial fibrillation and chronic kidney disease. Diagnoses of post-traumatic stress disorder (PTSD), personal history of physical and sexual abuse in childhood and insomnia due to other mental disorder were added with an onset date of 10/15/24. Review of the Minimum Data Set (MDS) quarterly assessment with assessment reference date (ARD) of 4/02/25 revealed resident #251 had a Brief Interview for Mental Status score of 14/15 which indicated she was cognitively intact. The document revealed resident #251 had an active diagnosis of PTSD and received anti-depressant medications. Review of prior MDS…

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 act upon the pharmacist medication recommendations made for one of five residents reviewed for pharmacist recommendations, of a total sample of 103 residents, (#256). Findings: Resident #256 was admitted on [DATE] with the diagnoses of encephalopathy (brain dysfunction), type II diabetes mellitus, history of liver transplant, sepsis, atrial fibrillation, and acute kidney failure. Review of the medical record revealed physician orders included Procrit injection solution 10000 units/milliliter (Epoetin Alfa), one application subcutaneously (under the skin), once a day every Wednesday for prophylaxis until 08/06/25. On 5/23/25, the pharmacist recommended to change the route of administration of the Procrit from intramuscular to subcutaneous and to hold the dose of Procrit for hemoglobin of 10 or more. The physician responded he was in agreement with the recommendation, and that the changes were made to the orders. Upon review of the current physician…

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 ensure medications were administered according to physician orders to prevent medication errors for 1 of 5 residents observed during the medication administration task, of a total sample of 103 residents, (#1). Findings: On 6/17/25 at 10:30 AM, during an observation of medication administration for resident #1, Registered Nurse (RN) B placed two Levetiracetam tablets, 750 milligrams (mg) each in a medication cup. Review of the medication card read, give 1250 mgs. RN B took the medications to the bedside and just before she administered the medication to resident #1, the nurse was asked to bring the cup of medications to the cart. RN B was asked to open her computer and read the order for Levetiracetam. She confirmed the order indicated 1250 mg of Levetiracetam was ordered. RN B verified two 750 mg tablets were in the medication cup she was about to administer to resident #1. RN B then took one of the tablets from the cup and stated she was going to cut it in half. RN B then read the medication card for 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 honor food preferences and accommodate residents who required alternate meal times due to appointments/procedures/treatments for 1 of 1 residents reviewed for renal dialysis, of a total sample of 103 residents, (#358). Findings: Resident #358 was admitted to the facility on [DATE] with diagnoses of need for assistance with personal care, type II diabetes mellitus with polyneuropathy, depression, anxiety, heart failure, and end stage renal disease with renal dialysis. The admission Minimum Data Set assessment dated [DATE] indicated the resident had no cognitive impairment. On 6/17/25 at 8:50 AM, resident #358 stated she had a concern about her nutrition. She stated she had already spoken to two dietitians, telling them she didn't want any bread with her meals, but she still received it. She said she asked them to replace her bread with a small salad at lunch and dinner, but often didn't get the salads. She stated she has diabetes and at…

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 #99 was admitted to the facility on [DATE] with diagnoses of dementia, disorder of the brain, aphasia (inability to speak) and schizophrenia. The annual Minimum Data Set (MDS) dated [DATE] indicated the Brief Interview for Mental Status (BIMS) evaluation was not conducted as resident #99 was rarely or never understood and her cognitive abilities were severely impaired. The Care Plan indicated resident #99 was totally dependent on staff for eating and most other Activities of Daily Living (ADL's). 4. Resident #206 was admitted on [DATE] with diagnoses of disorders of muscle, type II diabetes mellitus with polyneuropathy, heart failure, chronic obstructive pulmonary disease, end stage renal disease, and dysphagia (trouble swallowing). Her annual MDS dated [DATE] indicated the BIMS evaluation was not completed as the resident was rarely or never understood and her cognitive abilities were severely impaired. Her Care Plan indicated she was totally dependent on staff for eating and most other ADL's. 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 ensure medications were administered as per physician orders and according to professional standards of practice for 2 out of 5 residents reviewed for medication administration, (#2, #3) Findings: Review of resident #2's medical record revealed she was admitted to the facility on [DATE] with diagnoses including type 1 diabetes with hyperglycemia, chronic respiratory failure, aphonia, cardiac arrest, asthma, acute transverse myelitis, insomnia, depression and anxiety disorder. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented she had a Brief Interview for Mental Status (BIMs) score of 15 out of 15 that indicated she was cognitively intact. Review of resident #2's Medication Administration Record (MAR) for July and August 2024 revealed physician orders for the following medications: Doxepin Hydrochloride (HCL) 10 milligrams (m)g at bedtime for insomnia with an order date of 7/27/24 Melatonin 10 mg at bedtime 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.

Based on observation and interview, the facility failed to ensure food was stored, prepared, and served in a safe and sanitary manner to prevent foodborne illness in the main kitchen and 4 out of 6 pantries. Findings: 1. On 3/03/24 at 11:30 AM, during the initial kitchen inspection the following were observed: A pan of jelly was found partially covered and without a label or date in the walk-in refrigerator #2. A large rack that held 5 sheet pans contained a variety of wrapped sandwiches that were not labeled or dated. The Assistant Food Service Manager KK acknowledged the findings and explained the food items were supposed to be labeled and dated. The Food Service Manager stated the Assistant Food Service Manager KK, was responsible to ensure all stored food items were covered, labeled and dated. The internal thermometer in the walk in refrigerator #3 indicated a temperature of 48 degrees Fahrenheit (F). A carton of half and half cream was not cold to the touch. The Food Service Manager took the temperature of the half and half cream and reported it was 47 degrees F. In the…

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

Based on observation, interview, and record review, the facility failed to ensure 32 of 32 dependent residents on the memory care unit reviewed for dining were provided a homelike environment during mealtimes, of a total sample of 109 residents. Findings: On 3/03/24 at 1:41 PM, resident #107 was observed sitting in a chair outside her room in the hallway of the memory care unit. The resident's cognition was impaired and she was not able to answer questions appropriately. The resident stated she was hungry and asked Licensed Practical Nurse (LPN) RR when lunch was coming. The LPN responded, it will be here soon. At 1:56 PM Certified Nursing Assistants (CNAs) PP and SS were observed on the memory care unit while they distributed lunch trays to 32 residents. Resident #107 stated she didn't want to eat in her room. CNA PP told the resident she would bring her lunch tray to her room. The resident followed the CNA to her room where she remained while she ate her lunch. On 3/03/24 at 1:56 PM, CNA SS explained the memory care unit normally staffed 2 CNAs to pass meal trays to residents. She…

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 and interview, the facility failed to provide housekeeping and maintenance services necessary to ensure shower rooms were clean, sanitary, and homelike on 3 of 6 units (A wing, C Wing, G-Wing), failed to ensure Air Condition (AC) units were clean and in good repair in 5 rooms on the C Wing (C-09, 10, 12, 13, 25), failed to provide a comfortable interior in 2 rooms on the H-Wing, (1205, 1211) and failed to ensure return of residents clothing from the laundry for 3 of 10 residents reviewed for personal property (#4, #7, #307) of a total sample of 109 residents Findings: 1. Observations conducted on multiple units of the facility on various dates and times showed the following: On 3/04/24 at 5:38 PM, observation of the shower room on the G Wing with Certified Nursing Assistant (CNA) MM, showed towels on the floor, and on the shower chair. Three industrial mop buckets were stored against the wall in the shower room. The observation was confirmed by the CNA, and she said after each shower CNAs…

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 written Notification of Transfer or Discharge forms to the residents or their representative, and the state Ombudsman for 6 of 7 residents reviewed for hospitalizations out of a total sample of 109 residents, (#58, #198, #727, #155, #3, and #61). Findings: 1. Resident #58 was admitted to the facility on [DATE] with diagnoses that included traumatic brain injury, epilepsy, heart failure, and alcohol abuse. A progress note dated 2/13/24 revealed resident #58 had escalating behavior and aggressiveness and auditory hallucinations and was placed on one to one observation. Further review of resident #58's medical record revealed the Clinical Psychologist ordered he be sent to the hospital for an involuntary examination on 2/13/24 for auditory hallucinations, and homicidal statements. A transfer note indicated resident #58 was sent to a higher level of care by emergency medical services (EMS) at 10:28 AM on 2/23/24. Review of resident #58's medical…

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 Activities of Daily Living (ADL) care with respect to oral care, bathing, grooming, nail care and change of clothing for 9 of 18 residents identified to have concerns with lack of ADL care in a total sample of 109 residents, (#300, #246, #110, #87, #435, #29, #434, #238, #137). Findings: 1. Resident #434 was initially admitted to the facility on [DATE]. The resident was transferred to the hospital on 2/18/24 and readmitted to the facility on [DATE]. Resident #434's diagnoses included cerebral infarction, muscle wasting and neuromuscular dysfunction of bladder. On Monday, 3/04/21, at 12:55 PM resident #434 was observed in bed, dressed in a gown. There was a tube feeding pump to his right and his mouth and lips were dry. The resident complained his mouth was dry and sticky strings of saliva were observed on the right side of his mouth as he spoke. The resident requested a cup of water from staff who were present in the room. 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 provide a resident centered activities program which met the individual interests and needs of the resident, which encouraged both independent and group interactions for 11 out 17 residents identified not to have any meaningful activities of a total sample of 109 residents, (#246, #107, #309, #202, #137, #435, #434, #47, #238, #285 and #7). Findings: 1. Resident #309 admitted to the facility on [DATE]. Her diagnoses included type II diabetes, degenerative disease of the nervous system and dementia. The admission Minimum Data Set assessment dated [DATE] noted in Section F that it was very important to the resident to do her favorite activities and it was very important for her to participate in religious services or activities. The quarterly activity assessment dated [DATE] indicated the resident required physical assistance with activities and that she enjoyed reading, watching television, socializing, puzzles, music and outdoors. 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 obtain a physician's order for removal and care of an indwelling urinary catheter for 1 of 2 residents observed for indwelling catheters of a total sample of 109 residents, (#136). Findings: Review of the medical record revealed resident #136 was admitted to the facility on [DATE] and readmitted on [DATE] from the hospital. Her diagnosis included dementia, cerebral infarction, transient cerebral ischemic attack, Alzheimer's Disease, major depressive disorder, and other specified disorders of the bladder. Resident #136's Quarterly Minimum Data Set (MDS) with an assessment reference date of 1/17/24 revealed the resident scored 09 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated she had moderate cognitive impairment. The assessment noted resident #136 was totally dependent on staff for toileting and was incontinent of bowel and bladder. Review of resident #136's Medical Certification for Medicaid Long-Term Care…

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 accurate interpretation of a physician order, (#437); proper acquisition, storage, and administration of medication, (#586); appropriate storage of medications at bedside, (#256); and safe administration of medication according to professional standards, (#284), for 4 of 109 sampled residents. Findings: 1. Review of the medical record revealed resident #437 was admitted to the facility on [DATE] with diagnoses including heart attack, chronic ischemic heart disease, palpitations, and a heart murmur. Review of the Medication Review Report revealed resident #437 had a physician order dated 3/01/24 for Midodrine HCl 5 milligrams (mg) oral tablet, give one tablet by mouth three times daily for hypotension or low blood pressure. The order included a parameter to hold the drug if the resident's systolic blood pressure was greater than 130 millimeters of mercury (mm Hg). The American Heart Association…

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 interview, and review of facility documentation, the facility failed to ensure implementation of policies to the extent of including thorough monitoring of previously identified areas of concern and adequately tracking performance to ensure prior improvement measures were realized and sustained. Findings: Review of the facility's policy, Quality Assessment and Assurance (QA&A) Compliance revealed the following: Department Heads/disciplines are required to develop department specific audit plans and report activities and audit findings to the Committee at intervals determined by department specific risk analysis, and at the direction of the Nursing Home Administrator. Audit findings that identify opportunities for improvement are addressed through education, development of a Quality Assurance and Performance Improvement Plan (QAPI) or Performance Improvement Plan (PIP), or other means as indicated. Systems failures and/or in-depth analysis of processes are addressed through development of a QAPI. QAPI requires a systematic review of data, identification of the root cause(s)…

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

Based on observation, and interview, the facility failed to maintain mechanical, and electrical equipment in the kitchen in safe operating condition. Findings: On 3/03/24 at 12:30 PM, dietary staff on the tray line assembling meal trays stood in a large, approximately 6 feet wide by 12 feet long, pool of water on the floor. The Food Service Manager stated there had been 2 leaks in the tray line but one was fixed a few weeks ago and she was waiting for their equipment contractor to fix the second leak. On 3/07/24 at 11:45 AM, the dietary staff were observed on tray line assembling trays while again, standing in a pool of water approximately 6 feet wide by 12 feet long due to the leak from the steam table well. The Food Service Manager explained the repair company came to the facility on 3/04/24 but could not repair the steam table as a part was needed. She stated the first repair to the steam table was 3 months ago and the repair company did not have time to repair the second leak during that visit. She stated she had been trying to get the leak repaired since then. She noted when…

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 conduct medication self-administration assessment to ensure safety for 3 of 3 residents reviewed for self-administration of medications, out of a total sample of 109 residents, (#256, #284 and #586). Findings: 1. Resident #256 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, chronic obstructive pulmonary disease, respiratory disorders, osteoarthritis, heart failure and sleep apnea. Review of the Minimum Data Set (MDS) quarterly assessment with assessment reference date (ARD) of 12/04/23 revealed resident #256 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated she was cognitively intact. On 3/04/24 at 12:50 PM, resident #256 was observed standing with her walker in the doorway to her room. She stated a nurse came in earlier and told her she was not allowed to have vitamins and supplements in her room. When asked what she had, resident #256 removed a bag from the chair in 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents and/or their representatives had the opportunity to refuse room transfers for 1 of 11 residents identified to have concerns related to resident rights, in a total sample of 109 residents, (#122). Findings: Resident #122 was originally admitted to the facility on [DATE] with diagnoses of Cognition Communicative Deficit, Falls, Dementia and Muscle Disorder. On 12/28/23 the resident was re-admitted to the facility to the B Wing room [ROOM NUMBER]. The re-admission Minimum Data Set assessment noted the resident's Brief Interview for Mental Status score was 7 out of 15 which indicated the resident's cognition was moderately impaired. On 3/4/24 at 2:48 PM, resident #122 was observed in her wheelchair on the B Wing in room [ROOM NUMBER]. The resident appeared upset and said she was moved from her old room to here and was not given a choice. She added, she was not given a reason why she had to move. On 3/5/24 at 12:12 PM,…

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 promote resident rights related to choice of type and frequency of baths for 1 of 17 residents reviewed for choices, out of a total sample of 109 residents, (#156). Findings: Review of the medical record revealed resident #156 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including quadriplegia, muscle wasting, lack of coordination, and recurrent major depressive disorder. Review of the Minimum Data Set (MDS) admission assessment with assessment reference date (ARD) of 4/21/23, revealed resident #156 had a Brief Interview for Mental Status score of 15 which indicated he was cognitively intact. The document showed the resident was the primary respondent for questions in Section F - Preferences for Customary Routine and Activities, and his responses indicated he felt it was very important to be able to choose between a tub bath, shower, bed bath, or sponge bath. Review of the MDS Quarterly assessment with ARD 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 interview and record review, the facility failed to conduct thorough, periodic reviews of Advance Directives to ensure resuscitation status related to Do Not Resuscitate Orders (DNROs) was appropriately documented in the medical record to effectively communicate choices regarding withholding life-sustaining measures for 3 of 4 residents reviewed for Advance Directives, out of a total sample of 109 residents, (#184, #246, and #165). Findings: 1. Review of the medical record revealed resident #184 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including cerebrovascular disease, stroke with left side weakness and paralysis, abdominal aortic aneurysm, hypertension, chronic obstructive pulmonary disease, dementia, and left carotid artery occlusion and stenosis. Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date (ARD) of [DATE] revealed resident #184 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated she 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 interview and record review, the facility failed to follow their grievance process related to homelike environment for 1 of 1 resident reviewed for grievances in a total sample of 109 residents, (#267). Findings: On 3/03/24 at 12:48 PM, resident #267 stated the bottom drawer of the dresser next to her bed did not go all the way and she had mentioned it to staff a few times, but it had not been fixed. Observations on 3/04/24 at 11:16 AM and 3/08/24 at 9:44 AM, revealed the bottom drawer did not close completely. Review of resident #267's medical record revealed she was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy, and lack of coordination. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 out of 15 which indicated intact cognition. Review of a Grievance/Concern Report form dated 2/08/24 filed by resident #267's daughter read, daughter reports mom needs bottom drawer fixed or dresser replaced,…

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 complete a Preadmission Screening and Resident Review (PASARR) for a newly diagnosed Serious Mental Illness (SMI) for 1 of 10 residents reviewed for PASARR from a total sample of 109 residents, (#138). Findings: Review of resident #138's medical record revealed she was originally admitted to the facility on [DATE] with diagnoses including type 2 diabetes, heart failure and chronic kidney disease. Diagnoses of schizoaffective disorder, bipolar type, anxiety, and major depressive disorder were added to the resident's plan of care after she was admitted . Review of resident #138's quarterly Minimum Data Set (MDS) with Assessment Reference Date 1/30/24 revealed she had a Brief Interview for Mental Status score of 10 out of 15 which indicated moderate cognitive impairment. The MDS assessment showed resident #138 required assistance from staff for activities of daily living. The assessment revealed a Mood Interview was conducted and no symptoms…

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 evaluations for 1 of 10 residents reviewed for PASARR from a total sample of 109 residents, (#12). Findings: Review of the medical record revealed resident #12 was admitted to the facility on [DATE] from the hospital. His diagnosis included vascular dementia, antisocial personality disorder, paranoid schizophrenia, major depressive disorder, and unspecified psychosis. Resident #12's admission Minimum Data Set (MDS) with an assessment reference date of 10/19/2018 revealed the resident was admitted to the facility with psychotic disorder, schizophrenia, and dementia. The assessment noted the resident's high-risk medications included antipsychotics that were administered on a routine basis. The admission assessment noted the resident was not considered for a level II PASAAR. Resident #12's Annual MDS with an assessment reference date of 12/6/23 revealed the resident 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 interview, and record review, the facility failed to ensure the opportunity to participate in the development, implementation, and evaluation of their care plan was provided to 1 of 3 residents reviewed for care planning, of a total sample of 109 residents, (#29). Findings: Resident #29 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included malignant neoplasm of cerebrum, legal blindness, cardiomyopathy, and encephalopathy. Review of the resident's annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's vision was severely impaired, and the resident's cognition was intact with a Brief Interview For Mental Status (BIMS) score of 14 out of 15. On 3/04/24 at 2:19 PM, resident #29 stated he had not been to a care plan meeting did not have any family to attend the care plan meetings. On 03/07/24 at 10:16 AM, Licensed Practical Nurse/Clinical Reimbursement Specialist (LPN /CRS) S, stated resident #29 had a responsible party whom the invitation…

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 treatment to promote healing of a pressure ulcer for 1 of 1 resident reviewed for pressure ulcers of a total sample of 109 residents, (#295). Findings: Review of resident #295's medical record revealed he was readmitted to the facility on [DATE] from an acute care hospital with diagnoses of pressure ulcer of left hip, stage 4, pressure ulcer of sacral region, stage 3 and paraplegia. Review of the Minimum Data Set 5-day assessment with Assessment Reference Date (ARD) of 12/09/23 revealed resident #295's Brief Interview for Mental Status score was 14 out of 15 which indicated intact cognition. The assessment showed resident #295 had one Stage 3 and one Stage 4 pressure ulcers. A Stage 3 pressure ulcer is a Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the resident's environment was free of accident hazards related to an unsecured oxygen cylinder for 1 of 10 residents reviewed for accidents, out of a total sample of 109 residents, (#71). Findings: Resident #71 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, acute respiratory failure, shortness of breath, chronic respiratory failure and anxiety disorder. Review of the Minimum Data Set quarterly assessment with assessment reference date 2/23/24 revealed resident #71 had a Brief Interview for Mental Status (BIMs) score of 15 out of 15 which indicated he was cognitively intact. A care plan initiated 6/09/23, revised 3/05/24 indicated resident #71 was on oxygen therapy as needed related to shortness of breath. Interventions included administer oxygen as ordered and report changes in respiratory status to the physician. Review of resident #71's medical record revealed a physician…

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 as per physician orders for 1 of 1 resident reviewed for gastric tube feeding out of a total sample of 109 residents, (#222). Findings: Review of the medical record revealed resident #222 was admitted to the facility on [DATE] from the hospital. Her diagnosis included stroke, hemiplegia and hemiparesis, aphasia, dysphagia, gastrostomy tube, moderate protein-calorie malnutrition, type II diabetes, obesity, and anxiety disorder. The significant change in status Minimum Data Set (MDS) with an assessment reference date of 1/24/24 revealed resident #222 had severely impaired cognitive skills for daily decision making. The assessment also indicated resident #222 had a feeding tube that provided 51 percent or more of her total caloric intake and 501 cubic centimeters (cc) or more of her fluid intake per day. Review of resident #222's medical record revealed a care plan was initiated on 3/22/21 that 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 observation, interview and record review, the facility failed to maintain oxygen flow rate as ordered by the physician for 2 of 5 residents reviewed for respiratory care from a total sample of 109 residents, (#137 and #157). Findings: 1. Resident #137 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include traumatic brain injury, acute respiratory failure, and subdural hemorrhage. The Minimum Data Set (MDS) significant change in status assessment noted resident #137 scored rarely or never understood on the Brief Interview for Mental Status (BIMS) evaluation which indicated the resident had severe cognitive impairment. On 3/03/24 at 2:45 PM, resident #137 was observed lying in bed with oxygen by concentrator at rate of 3.5 liters per minute (LPM). On 3/04/24 at 12:25 PM, the resident # 137 was in bed and received oxygen by concentrator at 3.5 LPM. On 03/04/24 at 12:36 PM, Registered Nurse (RN) FF reviewed the physician order and stated the resident's oxygen should be at…

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 adequate communication with the dialysis center, follow the comprehensive person-centered care plan and ensure post-dialysis assessments were completed for 3 of 4 resident reviewed for dialysis of a total sample of 109 residents, (#109, #220, and #313). Findings: 1. Review of the medical record revealed resident #220 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included end-stage renal disease (ESRD) with dependence on dialysis, type 2 diabetes, and hypertension. Review of the Minimum Data Set (MDS) Quarterly assessment with Assessment Reference Date (ARD) of 12/15/23 revealed resident #220's Brief Interview for Mental Status (BIMS) score was 15 out of 15 which indicated intact cognition. The assessment showed the resident had no behavioral symptoms and did not reject evaluation or care that was necessary to achieve his goals for health and well-being. The assessment revealed resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications were administered according to physician orders to prevent medication errors for 2 of 6 residents observed during the medication administration task, out of a total sample of 109 residents, (#437 and #584). There were 2 errors in 25 opportunities for a medication error rate of 8%. Findings: 1. Review of the medical record revealed resident #437 was admitted to the facility on [DATE] with diagnoses including heart attack, chronic ischemic heart disease, palpitations, and a heart murmur. On 3/03/24 at 5:31 PM, Registered Nurse (RN) K checked resident #437's blood pressure with an electronic wrist cuff and showed the reading of 122/77. She checked the electronic medical record and explained she would not administer the resident's scheduled 5:00 PM due to parameters given by the physician. RN K said, The blood pressure was okay. Review of the Medication Review Report revealed resident #437 had a physician order dated…

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 meals and alternatives that met nutritional needs and food preferences for 1 of 4 residents reviewed for dialysis, (#109); and failed to provide fortified foods to meet nutritional adequacy according to the plan of care for 1 of 10 residents reviewed for food and nutrition services, (#238), out of a total sample of 109 residents. Findings: 1. Review of the medical record revealed resident #109 was admitted to the facility on [DATE] with diagnoses including end stage renal disease with dependence on dialysis, muscle wasting and atrophy, anemia, type 2 diabetes, and severe protein-calorie malnutrition. The Minimum Data Set (MDS) admission assessment with assessment reference date of 2/13/24 revealed resident #109 had adequate hearing, clear speech, and was able to make her ideas and wants understood. The resident had a Brief Interview for Mental Status of 14 which indicated she was cognitively intact. The MDS assessment revealed…

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 medical record reflected actual medication administration time for 1 of 4 residents reviewed for dialysis, (#109), and accurate blood glucose level and insulin administration time for 1 of 6 residents reviewed during the medication administration task, (#584), out of a total sample of 109 residents. Findings: 1. Review of the medical record revealed resident #109 was admitted to the facility on [DATE] with diagnoses including end stage renal disease with dependence on dialysis, heart disease, type 2 diabetes, and gastroesophageal reflux disease. Review of the Order Summary Report revealed resident #109's physician orders included Apixaban 2.5 milligrams (mg) once daily for atrial fibrillation (2/08/24), Loperamide 2 mg once daily for diarrhea (2/14/24), Losartan Potassium 25 mg once daily for high blood pressure (2/07/24), Novasource renal supplement 237 milliliters once daily and record the percentage consumed (2/11/24), Pantoprazole Sodium…

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 adhere to proper infection control practices related to hand hygiene during lunch meal service on 1 of 6 units, (B Wing). Findings: On 3/03/24 at 12:23 PM, the lunch meal cart arrived on the B Wing and staff pushed it towards the first hallway to be served. On 3/03/24 at 12:27 PM, Certified Nursing Assistants (CNAs) G and L opened the door of the meal cart and removed trays without performing hand hygiene. They entered room [ROOM NUMBER] and placed the trays on both residents' tables. While in the room, they removed the plate covers, opened containers, and used the residents' utensils during set-up of the meal. Both CNAs left the room and returned to the meal cart, but neither CNA G nor CNA L performed hand hygiene before removing the next trays, although there were containers of hand sanitizer located on the walls nearby. On 3/03/24 at approximately 12:30 PM, CNA L entered room [ROOM NUMBER] with a lunch tray and performed meal set up…

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 investigation for alleged neglect was submitted to the State Survey Agency, within 5 working days of the incident for 1 of 2 residents reviewed for neglect, of a total sample of 109 residents, (#67). Findings: Resident #67 was originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included pressure ulcer sacral region, stage 4, liver disease, pulmonary embolism, epilepsy, and down syndrome. Review of the facility's Reportable log, revealed an entry dated 1/11/24 for resident #67, pertaining to alleged neglect. On 3/05/24 at 3:28 PM, the allegation of neglect was reviewed and discussed with the Risk Manager (RM). She stated resident #67 was hospitalized on [DATE], and on 1/11/24 at 11:30 AM, a representative from Adult Protective Services visited the facility, and informed them of an allegation of neglect related to wounds for resident # 67. The RM stated that an investigation was initiated, and the Nursing Homes…

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 thorough investigation was completed pertaining to a fall for 1 of 11 residents reviewed for accidents, of a total sample of 109 residents, (#436). Findings: Resident #436 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included disorders of muscle, diabetes type II, respiratory disorders, vascular dementia, psychotic disturbance, abnormality of gait and mobility, generalized muscle weakness, lack of coordination, and Alzheimer's disease. Review of the resident's annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was rarely/never understood. The assessment revealed the resident required extensive assistance from staff with bed mobility and required extensive assistance of two staff for transfer. Review of the facility's Incident Log revealed an entry regarding an unwitnessed fall for resident #436 on 4/08/23. A nursing progress note dated 4/08/23 at 11:00 AM indicated 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.

Based on observation and interview, the facility failed to dispose of garbage properly and maintain the garbage storage area in a sanitary manner. Finding: On 5/02/22 at approximately 10:30 AM, a tour of the garbage storage area was conducted. Observation of the area revealed there was a trash compactor located near the recycled materials dumpster. There were several, clear plastic bags of garbage piled from the ground to a height of approximately four feet along the length of the recycled materials dumpster. The clear plastic bags contained soiled, disposable incontinence pads and briefs and other waste products. The Maintenance Director stated the trash compactor stopped working on the previous day, Sunday. He stated he called the garbage contractor on Sunday evening and left a message, and called again on Monday morning at about 7:00 AM. When asked if he requested another dumpster as a temporary solution, the Maintenance Director did not provide an answer. The Housekeeping Supervisor stated housekeeping staff and the floor technician brought garbage out of the facility to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide written notification to the Office of the State Long-Term Care Ombudsman regarding transfers and discharges for 5 of 6 residents reviewed for transfer/discharge status, of a total sample of 95 residents, (#409, #229, #173, #230 & #291). Findings: 1. Resident #409's record revealed the resident was admitted to the facility on [DATE] for therapy services. The resident's diagnoses were Necrotizing Fasciitis, Anxiety, and Cancer of the Rectum and Colon. The Minimum Data Set (MDS) admission assessment noted resident #409 scored 15 on the Brief Interview for Mental Status (BIMS) evaluation which indicated intact cognition. The MDS assessment did not identify any mood or behavior problems. Review of the physician orders revealed the resident was able to go on Leave of Absence independently and did not require staff or escort supervision while out of the facility. Review of a facility investigation statement revealed on 2/23/22, the resident complained…

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's Consultant Pharmacist failed to identify and report irregularities related to use of a medication contrary to a physician's order for 1 of 5 residents reviewed for unnecessary medications, of a total sample of 95 residents (#142). Findings: Resident #142's record revealed the resident was admitted to the facility on [DATE] with diagnoses including Multiple Sclerosis, vascular headache, hypertension, anxiety, and depression. The Order Summary Report included a physician order dated 8/29/21 for Ativan 1 milligram (mg) by mouth every 12 hours as needed for seizures. Ativan is a prescription medicine used to treat anxiety disorders. Misuse of this drug can cause addiction, overdose, or death (retrieved on 5/13/22 from www.drugs.com). Review of the Medication Administration Record forms for September 2021 to May 2022 revealed over the 9-month period, resident #142 received 35 doses of Ativan 1 mg in September 2021, 34 doses in October 2021, 33 doses in November…

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 medical record review, the facility gave a prescribed medication without adequate indications for use to 1 of 5 sampled residents reviewed for medication administration, of a total sample of 95 residents (#142). Findings: Resident #142's record revealed the resident was admitted to the facility on [DATE] with diagnoses including Multiple Sclerosis, vascular headache, hypertension, anxiety, and depression. The Order Summary Report included an order dated 8/29/21 for Ativan 1 milligram (mg) by mouth every 12 hours as needed for seizures. Ativan is a prescription medicine used to treat anxiety disorders. Misuse of this drug can cause addiction, overdose, or death (retrieved on 5/13/22 from www.drugs.com) Review of the Medication Administration Record forms for September 2021 to May 2022 revealed over the 9-month period, resident #142 received 35 doses of Ativan 1 mg in September 2021, 34 doses in October 2021, 33 doses in November 2021, 29 doses in December 2021, 27 doses in January 2022, 32…

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 ensure dietary staff utilized hair restraints, stored food correctly, maintained kitchenware and equipment in a clean, sanitary and functional manner. Findings: 1. On 5/02/22 at 9:29 AM, the initial kitchen inspection was conducted. On a wire shelf in the dry pantry, there was an eleven-pound tub of vanilla frosting dated that it was opened on 4/20/22. The label on the container provided the manufacturer's directions for use. Instruction #6 read, Once icing container has been opened, the icing can be stored covered at room temperature for one week. After this time period, store covered in the cooler. When asked if the kitchen staff read the manufacturer's directions, the Certified Dietary Manager (CDM) said, Probably not. 2. On 5/02/22 at 10:00 AM, a cook prepared a salad plate in the food preparation area. He had a full, bushy beard and wore an N95 respirator mask, but no beard guard. The N95 respirator mask did not restrain all of his facial hair. The cook acknowledged he had not applied a beard guard and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a baseline care plan in a timely manner related to intravenous (IV) services and treatments for1 of 1 newly readmitted residents reviewed for IV therapy services, of a total sample of 95 residents (#716). Findings: Resident #716's record revealed the resdient was initially admitted to the facility on [DATE] with diagnoses that included diabetes, a partial traumatic amputation of the right midfoot, osteomyelitis of the right foot and ankle, and an acute myocardial infarction. On the day of admission, the facility transferred the resident back to the hospital due to acute respiratory failure and hypoxia. Resident #716 was readmitted to the facility on [DATE]. Review of hospital discharge paperwork revealed physician orders to administer the antibiotic medications Vancomycin 1.25 grams (gm) daily and Cefepime 1 gm every 8 hours for 15 days. Both antibiotics were ordered to be given intravenously through a peripherally inserted…

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 a comprehensive care plan for continuous oxygen (O2) therapy via a nasal cannula and oxygen concentrator for 1 of 5 residents reviewed for respiratory care services, of a total sample of 95 residents (#120). Findings: Resident #120's record revealed the resdient was initially admitted to the facility on [DATE]. He was hospitalized on [DATE] and readmitted to the facility on [DATE]. His primary diagnoses were congestive heart exacerbation and shortness of breath. Other diagnoses included chronic obstructive pulmonary disease and orthostatic hypotension. The hospital to facility transfer form dated 12/01/21 revealed the resident received O2 at 3 liters per minute (l/m) via a nasal cannula during his hospitalization and required continuous oxygen therapy. On 5/02/22 at 10:25 AM, resident #120 was observed in bed. He received O2 at 2.5 l/m via a nasal cannula and O2 concentrator. The resident verbalized he needed the oxygen to breathe…

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 continuous oxygen (O2) therapy for 1 of 5 residents reviewed for respiratory care services of a total sample of 95 residents (#120). Findings: Resident #120's recored revealed the resident was initially admitted to the facility on [DATE]. He was hospitalized on [DATE] and readmitted to the facility on [DATE]. His primary diagnoses were congestive heart exacerbation and shortness of breath. Other diagnoses included Chronic Obstructive Pulmonary Disease (COPD) and orthostatic hypotension. The hospital to facility transfer form dated 12/01/21 revealed the resident received O2 at 3 liters per minute (l/m) via a nasal cannula during his hospitalization and required continuous O2 therapy. Resident #120's Nursing readmission Data Collection evaluation dated 12/01/21 at 9:20 PM revealed the resident had shortness of breath upon exertion. A Pulmonolgist's consultation note dated 12/02/22 indicated resident #120 was 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 provide pharmaceutical services to ensure medications were administered according to physician orders for 1 of 5 residents reviewed for medication administration, of a total sample of 95 residents (#716). Findings: Resident #716's record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included diabetes, osteomyelitis of the right foot and ankle, partial amputation of the right midfoot, and an acute myocardial infarction. On the day of admission, the facility transferred the resident back to the hospital due to acute respiratory failure and hypoxia. Resident #716 was readmitted to the facility on [DATE] at 2:36 PM. Review of hospital discharge paperwork revealed a physician's order for the intravenous (IV) antibiotic Cefepime 1 gram (gm) to be administered every 8 hours for an acute right foot osteomyelitis. The Cefepime was ordered to be given intravenously via a peripherally inserted central…

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.