Prosper Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure timely Activities of Daily Living (ADL) care for 3 of 6 sampled residents, as evidenced by a lack of timely incontinence care for Residents #23 and #89, failure to trim a fingernail for Resident #23, and failure to ensure mouth care for Resident #1. The findings included: Review of the policy ADL Care and Services, revised 01/2024 documented, Procedure: . 4. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, nail care, and oral care); . c. Elimination (toileting) . 1) Review of the record revealed Resident #23 was admitted to the facility on [DATE], admitted to Hospice services on 03/04/22, and moved to her current room on 07/14/22. Review of the Annual Minimum Data Set (MDS) assessment 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 ensure a specialty air mattress and protective boots were provided for 1 of 2 sampled residents. Resident #1 was identified as having a facility acquired pressure injury. The findings included: Review of the record revealed Resident #1 was admitted to the facility on [DATE] and was moved to her current room after a short hospitalization stay on 03/28/24. Review of the current Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident was totally dependent upon staff for all Activities of Daily Living and had three current pressure injuries. A care plan initiated on 01/11/24 documented Resident #1 had a pressure injury to her sacrum and an intervention included the use of a pressure relieving/reducing mattress as ordered or indicated. A care plan initiated on 03/21/24 documented the resident had a stage 2 pressure injury to her left heel. This care plan lacked the intervention of offloading the resident's heels or 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 ensure documented provision of dialysis and ongoing communication with the dialysis facility for 1 of 1 sampled resident (Resident #55). The findings included: Review of the policy, Dialysis Care revised 08/2023 documented, Standard: To encourage residents' compliance with dialysis schedule/appointment, . Procedure: 2. Facility personnel will provide information that is useful or necessary for the care of the resident to the dialysis center as needed. 4. Correspondence from the dialysis center will be addressed by facility staff and will be recorded in the plan of care as indicated. Review of the record revealed Resident #55 was admitted to the facility on [DATE]. Review of the orders revealed Resident #55 was scheduled for dialysis services at a dialysis center on Monday, Wednesdays, and Fridays. On 04/04/24 in the afternoon, staff at the North nurses' station were asked how the facility ensures ongoing communication with the dialysis centers. Nursing…

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 complete and accurate medical records for 4 of (Residents #20, #5, #98, #53, and #55). The findings included: 1) Resident #20 had the following current orders documented on her March 2024 electronic medication and treatment administration record (eMAR/eTAR): a) Treatment for Bilateral Buttocks: Cleanse with soap and water, pat dry, and apply Zinc Oxide every shift for prevention. b) Mupirocin External Ointment 2 % Apply to Mid back topically every day shift for wound care; Cleanse wound to mid back with Dakin's, pat dry, apply skin prep to peri wound, lightly fill wound with plain packing strip moistened with mupirocin, change daily and PRN (as needed). c) Nystop External Powder 100000 unit/gm apply to sacrum topically twice daily for rash d) Body audit daily every day shift for Skin observation e) Behavior monitoring every shift. A review of the March 2024 eMAR and eTAR showed no staff initials signifying completion of the above…

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 ensure timely provision of physician ordered antibiotics for 1 of 1 sampled resident (Resident #78). The findings included: Review of the record revealed Resident #78 was admitted to the facility on [DATE]. Review of the current Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating she was cognitively intact. A progress note dated 03/31/24 at 12:06 PM, by Staff N, the physician, revealed Resident #78 complained of a cough. The physician's plan included the initiation of the IV (intravenous) antibiotic Zosyn, to be given every 6 hours for seven days. Further review of the record revealed an order dated 03/31/24 at 12:41 for the placement of a midline (intravenous access). The order for the Zosyn was entered into the electronic medical record on 03/31/24 at 12:51 by Staff M, Registered Nurse (RN). A progress note written by Staff M, RN,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical and administrative record review and interview, the facility failed to ensure timely completion of the Comprehensive Assessments for 2 of 3 sampled resident, Residents #2 and #3, as evidenced by lack of timely initial and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. The findings included: 1. Review of the clinical record for Resident #2 on 03/05/24 revealed the resident was admitted to the facility on [DATE]. Review of the record failed to provide evidence that the resident had a Comprehensive Assessment completed for the resident. The Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes. It is a core set of screening, clinical and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment. Review of the electronic record, MDS, noted that 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 clinical and administrative record review and interview, the facility failed to provide evidence that an accurate nutritional assessment was completed for 1 of 2 sampled residents reviewed for weight loss, Resident #1, who experienced a weight loss. The findings included: 1. Review of the clinical record for Resident # 1 revealed the resident was admitted to the facility on [DATE] with a diagnosis that included Chronic Respiratory Failure with Hypoxia. The resident has a gastrotomy tube (GT / PEG) receiving enteral tube feeding. On 10/05/23, the facility had identified a concern that the resident required tube feeding (GT) related to Dysphagia, CVA (cerebral vascular accident); and had elevated needs for wound healing. The tube feeding provided the resident's sole source of nutrition and had remained NPO (nothing by mouth). Review of the resident's admissions and discharges documented the following: -transferred to the hospital on [DATE]; returned on 10/29/23. -transferred to hospital on [DATE];…

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, clinical and administrative record review and interview, the facility failed to ensure the staff maintained the resident's respiratory supplies and equipment that are consistent with acceptable standards of practice and physician orders, as evidenced by the observation of multiple resident's respiratory supplies not dated, were expired or were improperly stored. The findings included: Review of the facility's policy, titled, Cleaning and Disinfection of Resident-Care Items and Equipment, documented, in part, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OHSA Bloodborne Pathogens Standard. b. Semi-critical items consist of items that may come in contact with mucous membranes or non-intact skin (e.g., respiratory therapy equipment). Such devices should be free from all microorganisms, although small numbers of bacterial spores are permissible. Physician order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by an Interdisciplinary Team (IDT) composed of individuals with direct care knowledge of the resident and his/her needs. This impacted 1 of 2 sampled residents, Resident #1, reviewed for care plans. The findings included: Clinical record review conducted on 10/03/23 revealed Resident #1 was admitted to the facility on [DATE] with diagnosis that included Cerebrovascular Accident (CVA/stroke). Review of Resident #1's Minimum Data Set (MDS), admission assessment with reference date of 06/29/23, revealed the resident was assessed as moderately impaired for skills of daily decision making and required extensive assistance with activity of daily living (ADLs). Review of Resident #1's Interdisciplinary Team (IDT) Care Conference of 07/05/23 revealed no registered nurse with direct care responsibility for the resident, no nurse aide / certified nursing assistant with direct…

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, policy reviews, and interview, the facility failed to ensure care and services were provided to 1 of 2 sampled residents, Resident #1, that included failure to implement recommended discharge instructions for follow up diagnostic studies, failure to obtain recommended consults and failure to communicate and coordinate with the resident's responsible party the changes in treatment plan; and facility staff failed to report a skin injury, and subsequently did not investigate and implement additional interventions to minimize reoccurrence for 1 of 2 sampled residents, Resident #1. The findings included: 1. Clinical record review conducted on 10/03/23 revealed Resident #1 was admitted to the facility on [DATE] for rehabilitation services. The resident's diagnosis included Cerebrovascular Accident (CVA/stroke) with severe deficits. Review of the Minimum Data Set (MDS) admission assessment with reference date 06/29/23 revealed the resident was assessed as moderately impaired for skills of daily…

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, policy review and interview, the nursing staff were unable to demonstrate competency related to the provision of nursing assessments and reporting changes in condition. This failure affected 2 of 2 sampled residents, Residents #1 and #2. The findings included: 1. Clinical record review conducted on 10/03/23 revealed Resident #1 was admitted to the facility on [DATE] for rehabilitation services. The resident's diagnosis included Cerebrovascular Accident (CVA/stroke) with severe deficits. The Minimum Data Set (MDS) admission assessment with reference date 06/29/23 revealed the resident was assessed as moderately impaired for skills of daily decision making, required extensive assistance with activity of daily living (ADLs) and had no skin conditions. The baseline plan of care dated 06/22/23 and comprehensive plan initiated on 07/13/23 documented the resident has altered cardiovascular status related to Atrial Fibrillation, High Cholesterol and Hypertension. The interventions…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 5. Review of the record reviewed Resident #17 was admitted to the facility on [DATE]. Further review revealed the most recent Minimum Data Set (MDS) assessment was completed 09/28/22. The record lacked any evidence of a care plan meeting with participation of the IDT (Interdisciplinary Team), the resident and or his representative. During an interview on 01/06/23, the Social Services Director (SSD) stated Resident #17 was scheduled to have a care plan meeting soon, in conjunction with the current quarterly assessment dated [DATE]. The SSD was asked to locate and provide evidence of the care plan meeting in conjunction with the September 2022 MDS assessment. During a subsequent interview on 01/06/23 at 12:10 PM, the SSD stated she was unable to find any evidence of a previous care plan meeting. 3. Resident #6 was admitted to the facility on [DATE]. During interview with Resident #6 on 01/03/23, she stated that she did not recall anyone discussing her plan of care or attending a care plan meeting. On 12/28/22, a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and policy review, the facility failed to maintain an infection prevention and control program to prevent the development and transmission of communicable diseases and infections for 6 of 7 sampled residents, as evidenced by: Staff failed to ensure COVID-19 symptom monitoring for Residents #17, #306, #65, #53, and #355; failed to ensure proper indwelling urinary catheter maintenance and care for Residents #53 and #49; and failed to ensure an ointment belonging to another resident was not used for Resident #49. The findings included: Review of the policy COVID-19 Clinical Monitoring and Measures Plan, dated 10/10/22, documented, Standard Measures: Complete COVID-19 Screening UDA, including vital signs on all symptomatic patients. Enhanced Measures: Enhanced Measures become effective when any employee presents with a positive COVID-19 test OR a resident test [sig] positive AND was not previously being cared for in transmission based (airborne-droplet) precautions…

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 3 of 3 sampled residents were spoken to and treated in a dignified manner (Residents #303, #304, and #305). The findings included: 1. Review of the record revealed Resident #303 was admitted to the facility on [DATE] and resided on the 200 Unit. Review of the admission progress note, dated 12/29/22 at 7:22 PM, documented she was alert and oriented. This note revealed the resident had a mass to her left arm, with a biopsy incision, sutures, and a dressing. During an interview on 01/03/23 at 11:31 AM, when asked if staff treated her with respect and dignity, Resident #303 became weepy and explained that she was unable to fully use her right arm because of a childhood deformity, and was currently unable to use her left because of a surgical procedure. The resident continued to explain she was choking on phlegm the other night and could not reach the Kleenex. Resident #303 stated a nurse came in and just threw the Kleenex at her. 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 develop and update care plans to reflect the status of behaviors such as combativeness, agitation and wandering; and the use of antianxiety and antibiotic medications for 1 of 23 sampled residents, Resident #36. The findings included: Clinical record review revealed Resident #36 was admitted to the facility on [DATE] with diagnoses that included: Fracture and Parkinson's Disease. The admission minimum data set (MDS), assessment reference date 10/19/22, revealed a brief interview for mental status (BIMS) score of 03, indicating Resident #36 was cognitively impaired. This MDS recorded that Resident #36 had no behavior issue, it indicated behavior was not exhibited. The clinical records revealed care plans was initiated on 10/12/22. The care plans were started to be reviewed on 10/25/22 with review completion date on 12/13/22. Further review of clinical records revealed the following Physician orders: a. dated 11/21/22, Ativan Injection…

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 timely treatment of a fungal rash for 1 of 4 sampled residents reviewed for non-pressure ulcer skin conditions (Resident #306). The findings included: Review of the record revealed Resident #306 was admitted to the facility on [DATE]. Review of the admission Evaluation dated 12/31/22 at 9:45 PM documented redness and a rash to the resident's sacrum and groin. A subsequent admission progress note dated 12/31/22 at 11:11 PM documented redness and rashes noted to both groin and buttock, and that medications were verified with the physician. Review of the physician orders lacked any type of skin treatment for the rash until 01/04/23. The physician's order dated 01/04/23 documented to apply Zinc Oxide ointment topically every shift until antifungal cream was available, and then to apply Nystatin External Cream topically every shift for 21 days for an acute fungal rash. The resident's base line care plan lacked any skin issues or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the provision of ordered pain medications for 1 of 2 sampled residents (Resident #304). The findings included: Review of the record revealed Resident #304 was admitted to the facility on [DATE]. Review of the admission Evaluation and baseline care plan dated 12/22/22 at 11:09 PM documented the resident had additional diagnoses of fibromyalgia and neuropathy, both of which can be painful. This admission assessment documented the resident had frequent pain relieved by medication, and the baseline care plan documented to provide medications as ordered. During an observation and interview on 01/03/23 at 1:23 PM, Resident #304 was lying in bed, grimacing, and moaning. When asked what was wrong, Resident #304 stated she had not had her pain medication since yesterday, and finally got it about 30 minutes ago. Resident #304 explained when she asked for pain medication yesterday, the nurse sent in an aide to tell her they only had Tylenol…

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 staff interview, the facility failed to ensure staff adequately monitored Blood Pressure and provided Blood Pressure medications as per physician-ordered parameters for 2 of 5 sampled residents reviewed for unnecessary medications (Residents #6 and #17). The findings included: 1. Resident #6 was admitted with diagnosis to include Coronary Artery Disease. Resident #6's Care Plan, initiated on 06/06/19 and last revised on 12/28/22, documented Resident #6 had Cardiac Disease related to Hyperlipidemia, Hypertension, and Coronary Artery Bypass with stents. The interventions included, Administer medications as ordered, obtain vital signs as indicated. A review of the December 2022 electronic Medication Administration Record (e-MARs) showed orders for the following blood pressure medications with parameters: Metoprolol 25 mg bid [twice daily] for HTN (Hypertension), hold for SBP (systolic blood pressure) < [less than] 110, HR (heart rate) <60. Clonidine HCI 0.1 mg q 8 hrs [every 8 hours] as…

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 ensure medications were secured for 1 of 6 medication carts, utilized by two different nurses on the 400 pod. The findings included: On 01/03/23 at 12:30 PM, the 400-pod medication cart was observed left unlock and unattended. Staff C, a licensed practical nurse (LPN), was in room [ROOM NUMBER] assisting residents, at the location where the medication cart was placed. Staff C would not have been able to see the medication cart. At 12:33 PM, when Staff C came out the room, she was made aware of the unlock medication cart. She acknowledged the finding. On 01/04/22 at 10:31 AM, the 400-medication cart was left unlock and unattended. The nurse went to administer medications in room [ROOM NUMBER]. During that time, Resident #36 (a resident with confusion, BIMS of 03), was observed sitting immediately next to the medication cart. Resident #36 was observed touching the medication cart. There were 3 other residents with confusion sitting on the 400 pod. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interview, the facility failed to provide individual activities for bed bound and/or cognitively impaired residents based on their comprehensive assessments, care plans and personal preferences to support their physical, mental, and psychosocial well-being for 5 of 5 sampled residents (Resident #16, #43, #52, #69, and #73) reviewed for activities. The findings included: 1) Record review revealed Resident #16 has diagnoses which include Cerebrovascular Disease, Psychotic Disorder with Delusions, Dementia with Behaviors, Anxiety Disorder, Repeated Falls, Major Depressive Disorder, and Alzheimer's. Her most recent quarterly MDS (Minimum Data Set) assessment, dated 07/11/21, documents a Brief Interview for Mental Score (BIMS) of 3, indicating severe cognitive impairment. Resident #16's Annual MDS, dated [DATE], documents for her Activity Preferences that it was very important for this resident to listen to music she likes and to participate in religious services. It was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed ensure that the environment remained free of accident hazards that included excessive hot water temperatures in the resident rooms for 2 (100 and 200 Pod) of 6 residential Pods. The findings included: During the observation tour of the 200 POD on 10/11/21 at 10 AM, it was noted that the temperature of the hot water in the bathroom of room [ROOM NUMBER] was hot/scalding to the touch. At the request of the surveyor the temperature of the hot water was taken with the facility's calibrated bayonet thermometer and was recorded at 120 degrees F. The Maintenance Director who accompanied the surveyor stated that room temperatures are checked randomly and do not exceed 110 degrees F. The Director also stated that there are 2 hot water heaters that supply the North Wings Pods (100 & 200) . The boiler room was also observed that houses the hot water heaters and it was noted that the heater was set to 150 degrees F due to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the nursing staff failed to ensure 1 of 1 sampled resident reviewed for respiratory care (Resident #18) was provided Oxygen therapy per physician's order. The findings included: Record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses which included Pneumonia, Heart Failure, COPD, Acute Respiratory Failure, and Pleural Effusion. On 10/11/21 at 10:30 AM, Resident #18's Oxygen (O2) concentrator was observed to be set at 3.5 liters per minute (lpm); O2 tubing was dated 9/29/21 (photographic evidence obtained). A review of the electronic Treatment Administration Record (eTAR) and physician's orders related to Oxygen therapy for Resident #18 showed a Physician's order, dated 08/16/21, for Oxygen at 2 liters via Nasal Cannula for every shift for COPD. On 10/11/21 at 12:35 PM, Staff A (Licensed Nurse assigned to POD 5) was notified to check O2 order and O2 concentrator setting for Resident #18. This nurse went into Resident #18's room…

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 obtain physician ordered laboratory tests for 1 of 5 sampled resident reviewed (Resident #72). The findings included: On 10/12/21 at 3:11 PM clinical records review for Resident #72; revealed a Physician's order dated 09/01/21 for the following laboratory tests: 1. TSH (Thyroid-stimulating hormone), the thyroid is a small, butterfly-shaped gland located near the throat, the thyroid makes hormones that plays an important role in regulating weights, body temperature, muscles strength and mood. 2. HGBA1c (hemoglobin A1c) a test that measures the amount of blood sugar attached to hemoglobin. Resident #72's records lacked evidence of these ordered test and there was no documentation of the reason for the omission of these labs. On 10/13/21 at 2:54 PM a side by side review of Resident #72's records and interview was conducted with the Director of Nursing (DON), an inquiry was made of the mentioned laboratory test results. The DON showed a lab requisition…

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, it was determined that the facility failed to ensure 1 (Resident #69) of 4 sampled residents reviewed for Nutrition was assessed and provided with adaptive eating equipment that included all drinking cups and mugs to be provided with lids and straws. The findings included: Observation conducted of Resident #69 on 10/12/21 at 12:15 PM noted the food tray was served to the room of Rresident #69. Further observation noted the diet tray card to document all drinking cups to have lids and straws and mug with a lid and straw. Observation of the resident during the meal noted that only a mug with a lid and straw was provided for the hot tea and no cups with lids and straws were provided for the 3 cold beverages. The resident was noted to be blind but eats independently with set-up from staff. It was also noted that the resident requested to eat from a semi reclining position and spillage from the hot and cold beverages was at a high potential. During this observation, Staff stated that the resident requested beverages to be served in a…

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