Viera Del Mar Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to accurately document the discharge plan and disposition in the medical record; and the Activities of Daily Living (ADLs) for 1 of 2 residents reviewed for discharge status and ADLs, of a total sample of 7 residents, (#2). Findings:Cross Reference F628 Review of resident #2's medical record revealed he was readmitted to the facility on [DATE] with diagnoses including nontraumatic subacute subdural hemorrhage (brain bleed), chronic obstructive pulmonary disease, type 2 diabetes, repeated falls, speech and language deficits, abnormalities of gait and mobility, and difficulty walking. Review of resident #2's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 5/11/25 revealed the resident participated in the assessment, and there was an active discharge plan for return to the community. Review of the Discharge MDS assessment with ARD of 7/06/25 revealed a planned discharge home, return not anticipated. Review of 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 interview and record review, the facility failed to report possible neglect for 1 of 3 residents reviewed for neglect, of a total sample of 4 residents, (#1). Findings: Review of the medical record revealed resident #1, an [AGE] year old female was admitted to the facility from an acute care hospital on 7/12/24 with diagnoses including acute respiratory failure, sepsis (blood infection), primary thrombocytopenia (slow blood clotting), urinary tract infection (UTI), muscle weakness, major depressive disorder, dementia with behavioral disturbance, need for assistance with personal care, and difficulty in walking. Hospital medical records dated 10/05/24, indicated resident #1 sustained a fall with a head injury that required emergency transport to the hospital. While at the hospital, the resident received emergency physician assessments, monitoring, treatment, diagnostic laboratory blood work, prescription medication orders, and Computed Tomography (CT) imaging. The CT imaging found the resident sustained…

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 thoroughly investigate and identify possible neglect for 1 of 3 residents reviewed for neglect, of a total sample of 4 residents, (#1). Findings: Review of the medical record revealed resident #1, an [AGE] year old female was admitted to the facility from an acute care hospital on 7/12/24 with diagnoses including acute respiratory failure, sepsis (blood infection), primary thrombocytopenia (slow blood clotting), urinary tract infection (UTI), muscle weakness, dementia with behavioral disturbance, need for assistance with personal care, and difficulty in walking. Hospital records dated 10/05/24, revealed resident #1 sustained a fall with a head injury that required emergency transport to the hospital. While at the hospital, the resident received emergency physician assessments, monitoring, treatment, diagnostic laboratory blood work, prescription medication orders, and imaging. Review of the most recent Minimum Data Set admission 5-day assessment with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure 1 of 3 residents reviewed for administration had a complete and readily accessible medical record, of a total sample of 4 residents, (#1). Findings: Review of the medical record revealed resident #1, an [AGE] year old female was admitted to the facility from an acute care hospital on 7/12/24 with diagnoses including acute respiratory failure, sepsis (blood infection), primary thrombocytopenia (slow blood clotting), urinary tract infection (UTI), muscle weakness, dementia with behavioral disturbance, need for assistance with personal care, and difficulty in walking. On 10/15/24 at 10:39 AM, Licensed Practical Nurse (LPN) H said nurses reviewed residents' (Emergency Room) ER and hospital records to implement follow up needs, alert physicians, and obtain orders. The LPN explained hospital records were placed in an upload bin at the nurse's station for Medical Records personnel to scan to the electronic health record (EHR). On 10/15/24 at 2:36 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 provide pharmaceutical services, consistent with professional standards of practice, to ensure proper acquisition and administration of routine medication; and failed to appropriately dispose of discontinued medication to promote medication safety, for 1 of 2 residents reviewed for hospitalization, out of a total sample of 43 residents, (#547). Findings: Review of the medical record revealed resident #574, a [AGE] year-old female, was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a brain disorder) and liver cirrhosis. The resident was discharged to the hospital on 6/20/24. According to the American College of Gastroenterology, Cirrhosis of the liver refers to scarring of the liver which results in abnormal liver function. One of the symptoms associated with cirrhosis is hepatic encephalopathy caused by decreased filtration of toxins from the blood. The resulting buildup of poisons such as ammonia in the brain can…

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 a palatability test, the facility failed to serve palatable food at the appropriate temperature to residents in two of five halls, (300 and 600), in the facility. Findings: On the Recertification survey from 7/29/24 to 8/01/24 several residents on the 300 and 600 halls complained about cold food to the surveyors: On 7/29/24 at 11:06 AM, resident #105 stated the food was often cold, especially the eggs. On 7/29/24 at 12:38 PM, resident #104 stated the meals were sometimes late, which could cause food to be cold. On 7/30/24 at 11:00 AM, resident #79 described he often had cold food during his meals. On 7/30/24 at 11:44 AM, resident #37 complained breakfast was consistently cold and said other residents complained about the cold food too. Per the meal times posted at each nurse's station, the dining room and contained in the admission packet, the first lunch tray was scheduled to be sent out of the kitchen at 11:45 AM to the first hall to be served. The 600 hall was the last hall in the facility to be served meal trays out of the five dining areas.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement the recommended restorative care to provide a splint application to prevent the potential for worsening of contractures for 1 of 2 residents reviewed for mobility/range of motion, of a total sample of 43 residents, (#85). Findings: Review of the medical record revealed resident #85 was admitted to the facility on [DATE] from the hospital. His diagnoses included spinal stenosis, muscle weakness, and rheumatoid arthritis. Resident # 85's Annual Minimum Data Set (MDS) with an assessment reference date of 6/15/24 revealed the resident scored 14 out of 15 on the Brief Interview for Mental Status which indicated the resident did not have any cognitive impairment. The MDS assessment noted the resident had upper extremity impairment on both sides and required substantial/maximal assistance with upper body dressing. The MDS assessment also noted the resident did not exhibit behavior symptoms or rejection of care that was necessary 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 observation, interview and record review, the facility failed to maintain oxygen flow rates as ordered by the physician for 1 of 2 residents reviewed for respiratory care, of a total sample of 43 residents, (#75). Findings: Review of the medical record revealed resident #75 was admitted to the facility on [DATE] from the hospital. His diagnosis included rhabdomyolysis, chronic respiratory failure with hypoxia, heart failure, muscle weakness, and chronic obstructive pulmonary disease (COPD). Resident # 75's admission Minimum Data Set (MDS) with an assessment reference date of 5/06/24 revealed the resident scored 15 out of 15 on the Brief Interview for Mental Status which indicated the resident did not have any cognitive impairment. The MDS assessment noted the resident required partial/moderate assistance with sit to stand transfer and upper body dressing and received oxygen therapy. The MDS assessment also noted the resident did not exhibit behavior symptoms or rejection of care that was necessary to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to effectively communicate and implement the standards of its compliance and ethics program to promote ethical conduct, and failed to adequately enforce those requirements to deter violations and ensure the provision of quality care and promote the highest practicable well-being for resident #1 and all residents in the facility. Findings: Review of the facility's Compliance and Ethics Program Overview (2022) revealed the key corporate values of the operating organization were Performance, Integrity, and Transparency. The document indicated the program included a Code of Conduct, policies and procedures, education, monitoring, reporting noncompliance, disciplinary actions, and program oversight. Participation in the compliance and ethics program was mandatory for all staff and its goal was to improve the overall quality of care received by residents. The document read, The Facility strives to cultivate an environment of transparency.requires all of its…

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 nursing staff had the appropriate competencies and skill sets required to meet residents' needs as determined by assessments and indicated in the plans of care. Findings: Review of the Facility assessment dated [DATE] revealed the facility would admit and care for residents with common diseases including psychiatric, neurological, musculoskeletal, metabolic, and skin disorders. The document indicated staff would provide activities of daily living care, mobility and fall or fall with injury prevention services, incontinence care, toileting assistance, pressure injury prevention and care, nutrition services, and management of medical conditions. The Facility Assessment revealed the facility provided person-centered care such as providing family support, identifying risks and hazards, preventing abuse and neglect, and ensuring staff honored residents' preferences and routines. The facility's Staffing Plan showed the Assistant Director…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility's administration failed to effectively utilize its resources to provide adequate education, support and oversight for the Nursing department to ensure residents received appropriate care and services according to the plans of care. Findings: 1. On 12/13/23 at 10:32 AM, the facility's Wound Nurse stated she was scheduled to work from Monday through Friday, and rounded with the wound care physician for the entire day on Mondays. She explained if a resident was admitted on a Friday, she would not do a skin assessment until the following Tuesday. The Wound Nurse stated her daily process was to identify any newly admitted resident and complete their skin assessments. She validated she had not been looking at residents who were re-admitted so the floor nurses did those skin evaluations. The Wound Nurse confirmed there was a resident who now had pressure injuries that she felt were present on admission, but probably missed by the floor nurse. She said,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement its policy and procedures to prohibit abuse and neglect by not identifying, reporting, and investigating incidents and events to rule out abuse and/or neglect, and ensure the safety of 2 of 12 sampled residents, (#1 & #10). Findings: Review of the facility's policy and procedures for Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of Unknown Origin, revised October 2022, revealed residents had the right to be free from abuse and neglect. The document listed events that should be identified as potential abuse or neglect such as any indication of possible willful infliction to include unexplained bruising and failure to provide necessary care and services. Staff who heard of or witnessed these types of events were expected to report them to the Administrator, Supervisor and/or the Director of Nursing (DON). In order to protect residents, any staff member suspected of abusive behavior would be removed from…

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/or implement person-centered care plan interventions that accurately reflected the plans of care and promoted the highest practicable well-being for 3 of 12 sampled residents, (#1, #9, and #12). Findings: 1. Review of the medical record revealed resident #1 was admitted to the facility on [DATE] with diagnoses including alcohol dependence with alcohol-induced persisting dementia and psychotic disorder with delusions, metabolic encephalopathy (brain dysfunction), Wernicke's encephalopathy (a neurological disorder associated with alcohol abuse), mini-stroke, alcoholic liver disease, and convulsions. The Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 11/10/23 revealed resident #1 had a Brief Interview for Mental Status score of 14 which indicated he was cognitively intact. The document showed the resident did not reject evaluation or care that was necessary to achieve his goals for health and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to effectively implement the discharge planning process to arrange necessary post-discharge care and services for 1 of 3 residents reviewed for discharge planning, out of a total sample of 12 residents, (#4). Findings: Review of the medical record revealed resident #4 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, generalized muscle weakness, unsteadiness on his feet, osteoarthritis, and cognitive communication deficit. Resident #4 was discharged from the facility on [DATE]. The Minimum Data Set (MDS) Discharge - Return Not Anticipated assessment with assessment reference date of [DATE] revealed resident #4 had a Brief Interview for Mental Status score of 6 which indicated severe cognitive impairment. The resident required set-up to supervision assistance for activities of daily living and transfers, and he used a wheelchair for mobility. Resident #4 received Occupational, Physical, and Speech Therapy services from…

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 for 2 of 6 residents reviewed for ADL care out of a total sample of 12 residents, (#9 & #10). Findings: 1. Review of the medical record revealed resident #9 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, viral pneumonia, adult failure to thrive, generalized muscle weakness, and unsteadiness on his feet. The Minimum Data Set (MDS) admission assessment with assessment reference date of 10/10/23 revealed resident #9 had clear speech, was able to communicate his needs and wants, and had no issues with comprehension. The MDS assessment showed the resident did not reject evaluation or care that is necessary to achieve the resident's goals for health and well-being. The resident used a walker or wheelchair and required moderate assistance for mobility. The document showed he needed substantial assistance from staff for toileting hygiene and moderate assistance…

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 to promote skin integrity and prevent the development of an avoidable pressure ulcer for 1 of 3 residents reviewed for pressure ulcers, out of a total sample of 12 residents, (#10). Findings: Review of the medical record revealed resident #10 was admitted to the facility on [DATE] with diagnoses including prostate cancer, dementia, and insomnia. Review of the admission Nursing Evaluation dated 12/01/23 revealed resident #10 required assistance with activities of daily living (ADLs) including bed mobility, transfers, grooming, hygiene, and toileting. The skin evaluation indicated the admission nurse noted the resident's skin was intact, with no rashes discolorations, scars, decubitus ulcers or questionable markings. The National Pressure Injury Advisory Panel defines a pressure injury or decubitus ulcer as localized damage to the skin and underlying soft tissue usually over a bony prominence.The injury can present…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain a secure environment and provide adequate supervision to prevent unauthorized, unsupervised egress from the facility and the safety of its property, for 1 of 3 residents reviewed for elopement risk, (#1); and failed to ensure a post-fall approach was implemented to prevent further injuries for 1 of 5 residents reviewed for falls, (#10), out of a total sample of 12 residents. Findings: 1. Review of the medical record revealed resident #1 was admitted to the facility on [DATE] with diagnoses including alcohol dependence with alcohol-induced persisting dementia and psychotic disorder with delusions, metabolic encephalopathy (brain dysfunction), Wernicke's encephalopathy (a neurological disorder associated with alcohol abuse), mini-stroke, alcoholic liver disease, and convulsions. The Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 11/10/23 revealed resident #1 had a Brief Interview for Mental Status…

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 to prevent complications related to tube feedings for 1 of 1 resident reviewed for tube feeding, out of a total sample of 12 residents (#11). Findings: Review of the medical record revealed resident #11 was admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included stroke with left side weakness and paralysis, dysphagia or difficulty swallowing, protein-calorie malnutrition, and gastrostomy. A gastrostomy is a surgical procedure in which a tube is inserted directly into the stomach through an incision in the abdomen wall. The tube is used to provide feeding or medications (retrieved on 12/28/23 from www. medical-dictionary.thefreedictionary.com/gastrostomy) A Minimum Data Set (MDS) Significant Change in Status assessment with assessment reference date of 11/08/23 revealed resident #11 had severely impaired cognitive skills for daily decision making and altered level 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 maintain a medical record that accurately documented behaviors for 1 of 3 residents reviewed for elopement risk, out of a total sample of 12 residents, (#1). Findings: Review of the medical record revealed resident #1 was admitted to the facility on [DATE] with diagnoses including alcohol dependence with alcohol-induced persisting dementia and psychotic disorder with delusions, metabolic encephalopathy (brain dysfunction), Wernicke's encephalopathy (a neurological disorder associated with alcohol abuse), mini-stroke, alcoholic liver disease, and convulsions. The Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 11/10/23 revealed resident #1 had a Brief Interview for Mental Status score of 14 which indicated he was cognitively intact. He had no functional limitation in range of motion, did not use a mobility device, and ambulated independently. Review of the medical record revealed resident #1 had a care plan for elopement…

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 2. Review of the medical record revealed resident #207 was admitted to the facility on [DATE]. She was on hospice services for congestive heart failure and had additional diagnoses including fibromyalgia, a history of cerebral infarctions with left sided weakness, asthma, and anxiety. On 7/12/22 at 5:45 PM, resident #207 was observed resting in bed. She had multiple, long, light and dark colored facial hairs located on and under her chin, above her upper lip in the shape of a mustache, and beneath her bottom lip. The facial hairs measured approximately 1/4 inch to 3/4 inch long. On 7/13/22 at 12:30 PM, resident #207's long, facial hairs were unchanged. On 7/14/22 at 11:15 AM, resident #207 was in her room with a family member. The facial hairs noted on the previous two days were still present. The resident stated she did not like the facial hair and when at home she usually removed them with tweezers. The family member explained the resident could no longer do as much for herself after the strokes she suffered.…

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 food stored in the kitchen's walk-in refrigerator was appropriately labeled and dated. Findings: On 7/11/22 at 10:30 AM, during observation of the kitchen's walk-in refrigerator with the Dietary Manager and Registered Dietitian (RD), an unlabeled, heavy, clear plastic container with a green lid contained chopped onions was identified. A square, metal pan covered with plastic wrap that contained multiple sausages was also unlabeled. A large, heavy clear plastic container that contained 8 quarts of lemonade, a clear plastic container with 10 quarts of ice tea and a clear plastic container with 10 quarts of fruit punch were all noted to have no labels. The Dietary Manager explained all containers in the refrigerator should be labeled with the name of the food product and dated. Two disposable foil pans covered with aluminum foil contained macaroni and cheese and neither container was labeled or dated. The Dietary Manager said, All food products not in original packaging is required to be labeled and 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 interview and record review, the facility failed to develop a comprehensive person-centered care plan for Activities of Daily Living (ADLs) for 1 of 3 residents reviewed for ADLs of a total sample of 40 residents, (#36). Findings: Clinical record review revealed resident #36 was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included fracture of the right femur, squamous cell carcinoma of the skin, scalp, and neck, generalized muscle weakness, and dementia. Review of the resident's admission Minimum Data Set (MDS) assessment with assessment reference date (ARD) of 5/20/22 revealed the resident's cognition was moderately impaired with a Brief Interview for Mental Status score of 10/15. The assessment indicated the resident required extensive assistance with physical assistance from one person for bed mobility, transfers, dressing, and personal hygiene. She had functional limitation in range of motion to one lower extremity, and was frequently incontinent of bladder and bowel.…

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 care plan meeting was scheduled in a timely manner to allow the resident and/or resident representative involvement in developing comprehensive, person-centered plans of care for 2 of 3 residents reviewed for participation in care planning, of a total sample of 40 residents, (#71 & #70). Findings: 1. Clinical record review revealed resident #71 was admitted to the facility on [DATE], with diagnoses including influenza and Alzheimer's disease. The resident's admission Minimum Data Set (MDS) assessment with assessment reference date (ARD) of 6/18/22 revealed the resident's cognition was severely impaired with a Brief Interview for Mental Status (BIMS) score of 7/15. The assessment indicated the resident required extensive assistance from one person for bed mobility and toilet use. The resident required limited assistance with transfers, dressing, and personal hygiene. On 7/11/22 at 11:46 AM, resident #71's responsible party stated during 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 oxygen (O2) therapy for 1 of 2 residents reviewed for O2 therapy, of a total sample of 40 residents, (#165). Findings: Review of the medical record revealed resident #165 was admitted to the facility on [DATE] with diagnoses including sepsis, pneumonia, acute respiratory failure, emphysema, and chronic obstructive pulmonary disease. Observations on 7/12/22 at 9:57 AM and on 7/13/22 at 11:28 AM showed resident #165 received O2 at 3 liters per minute (LPM) via nasal cannula. Review of the resident's clinical record revealed no physician's order for O2 therapy. Review of the resident's O2 Sats or O2 saturation level summary for the period 7/05/22 to 7/14/22 revealed the resident's O2 saturation level was monitored while the resident received O2 on 7/05/22, 7/07/22, 7/08/22, 7/10/22,7/11/22, 7/12/22, 7/13/22, and 7/14/22. On 7/14/22 at 12:18 PM, Licensed Practical Nurse (LPN) F stated he was the resident'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to honor meal preferences for 2 of 10 residents reviewed for food out of a total sample of 40 residents, (#50 & #105). Findings: 1. Review of resident #50's medical record revealed she was admitted to the facility on [DATE] with diagnoses of Diabetes Mellitus, Hyperlipidemia and Gastroesophageal Reflux Disease (GERD) and Iron Deficiency Anemia. She was cognitively intact and independent with eating. Review of her physician's orders documented a Consistent Carbohydrate (CCHO), regular texture, thin consistency with No Added Salt (NAS) diet. On 7/11/22 at 1:55 PM, resident #50 stated all her meals were cold and she did not receive the meals she ordered. The resident said, This is very frustrating. On 7/12/22 at 5:47 PM, resident #50's meal consisted of chicken, cubed potatoes and a mix of broccoli and cauliflower which she had not eaten. Resident #50 explained she continuously wrote No vegetables on the meal slip, but she kept getting…

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.