West Melbourne Health & Rehabilitation Center

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 Nurse Program (RNP) to provide mobility and Range of Motion (ROM) services to improve or maintain functional ability for 1 of 2 residents reviewed for rehabilitation and restorative services, out of a total sample of 49 residents, (#13).Findings: Review of resident #13's medical record revealed she was readmitted to the facility on [DATE]. Her diagnoses included Parkinsonism, insomnia, chronic obstructive pulmonary disease, neuropathy, and schizoaffective disorder. Review of the Minimum Data Set quarterly assessment with Assessment Reference Date of 9/29/25 revealed resident #13 had a Brief Interview for Mental Status score of 12 out of 15, indicating moderate cognitive impairment. The MDS assessment noted no rejection of evaluation or care necessary to achieve goals for health and well-being. The MDS assessment showed resident #13 required partial assistance with oral hygiene, substantial 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 obtain physician orders for respiratory treatments for 1 of 2 residents reviewed for respiratory care, of a total sample of 49 residents, (#33).Findings: Review of the medical record revealed resident #33 was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia (low levels of oxygen), chronic obstructive pulmonary disease (COPD), type 2 diabetes, and Cor pulmonale (enlargement of the right ventricle of the heart due to lung diseases). Review of the Minimum Data Set (MDS) admission assessment with an Assessment Reference Date of 11/13/25 revealed resident #33 had a Brief Interview for Mental Status score of 14 out of 15, indicating intact cognition. 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 #33 experienced shortness…

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 2 residents reviewed for mood/behavior, of a total sample of 49 residents, (#9). Findings:Resident #9 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes and obstructive sleep apnea. The facility added the diagnoses generalized anxiety disorder on 2/27/25, post-traumatic stress disorder (PTSD) on 3/13/25, and major depressive disorder on 3/26/25.Review of the Minimum Data Set (MDS) Annual Assessment with Assessment Reference Date of 11/05/25 revealed resident #9 had a Brief Interview for Mental Status score of 15/15 which indicated she was cognitively intact. The MDS listed PTSD as one of her diagnoses, on 3/13/25.The electronic medical record (EMR) contained a Trauma-Informed Care Observation dated 2/09/25 which revealed resident #9 had personally experienced a natural disaster, witnessed an assault with a weapon, and was a victim 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 ensure complete medical records were readily accessible, and not restricted to access for 16 of 16 total sampled residents, (#1, #2, #3, #4, #5, #6, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25); and failed to ensure hard copy medical records were safeguarded for all residents. Findings: On 2/05/24 at 9:40 AM, an entrance conference was held with the Nursing Home Administrator (NHA) and Director of Nursing (DON). The survey team requested items that included access to all residents' complete medical records. On 2/05/24 at 1:20 PM, surveyors were unable to view any sampled residents' Comprehensive Care Plans in the Electronic Health Record (EHR). On 2/05/24 at 3:58 PM, the Minimum Data Set (MDS) Coordinator said she had to obtain records from multiple sources to complete assessments and she didn't have direct access to all the EHRs. She explained the Social Services Director kept residents' behavioral health progress notes 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 interview, and record review, the facility failed to complete dietary assessment within recommended timeframes for 2 of 2 residents and failed to obtain preferences and allergies pertaining to lactose intolerance for 1 resident of a total sample of 16 residents, (#20, #24). Findings: 1. Resident #20, a [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included pulmonary embolism, hypertension, and gastroesophageal reflux disease. Review of the resident's physician orders revealed an entry dated 12/14/23 which indicated the resident was on a regular diet, and Lactose intolerant. No milk. No cheese. On 2/06/24 at 11:55 AM, the Dietary Manager explained that within seventy-two (72) hours of admission, the resident was seen by the Dietary Manager, and an admission Dietary Assessment was completed. The resident's food allergies, and preferences were obtained, and populated to the resident's meal ticket. The Dietary Manager stated she did not complete an admission Assessment/Dietary…

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 for 1 of 1 resident reviewed for hospitalization, out of a total sample of 52 residents, (#5). Findings: Resident #5 was admitted to the facility on [DATE] with diagnoses of acute respiratory failure, acute pulmonary edema, hypertensive heart disease, acute congestive heart failure and cardiomyopathy. Review of resident #5's medical record revealed she was transferred to the hospital on [DATE]. A progress note dated 12/07/23 read, Resident with seizure activity. Physician notified and order obtained to send to emergency department. The medical record did not contain a Notification of Transfer or Discharge form for the hospitalization. On 12/13/23 at 5:04 PM, the Social Services Director (SSD) stated she did not know who completed the Notification of Transfer or Discharge forms. She explained she sent a monthly log to the Ombudsman for residents who were…

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 dishes were washed at the appropriate temperature, with regard to the dish machine's data plate and manufacturer's instructions. Findings: On 12/11/23 at 11:06 AM, during kitchen observation, the Dietary Manager started the dish machine and put a couple of empty dish racks through the machine. The temperature dial on the dish machine showed temperature to be 156 degrees Fahrenheit (F). The Data Plate, on the machine, noted the wash temperature should be 160 degrees F. The dish machine temperature log dated 12/11/23 noted the morning wash temperature was 155 degrees F. The Dietary Manager identified the initials next to the recorded temperature as Dietary Aide L. On 12/11/23 at approximately 11:15 AM, Dietary Aide L verified he recorded the temperatures that morning. He stated he had continued to wash dishes. Dietary Aide L explained that was the first temperature and the water got hotter as he ran the machine but acknowledged he did not record any of those temperatures. Dietary Aide L stated he did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain proper infection control practices to prevent contamination during tracheostomy care for 1 of 4 residents reviewed for respiratory care, (#40) and failed to ensure the appropriate personal protective equipment (PPE) was donned prior to entry to transmission-based precaution rooms to prevent the potential for cross contamination for 2 of 2 residents reviewed for transmission-based precautions, (#109, #199) of a total sample of 52 residents. Findings: 1. Resident #40 was admitted to the facility on [DATE] and readmitted from acute care hospital on [DATE] with diagnoses including chronic respiratory failure, dependence on supplemental oxygen, attention to tracheostomy, anoxic brain damage, cerebral infarction, and seizures. A tracheostomy (also called a tracheotomy) is an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs. After creating the tracheostomy opening in the neck,…

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 baseline care plan within 48 hours of admission for 1 of 1 resident reviewed for pain management of a total sample of 52 residents, (#199). Findings: Resident #199 was admitted to the facility on [DATE]. Her diagnoses included encephalopathy, stage IV pressure ulcer, Klebsiella pneumonia, and resistance to multiple antibiotics. Review of the resident's physician orders revealed entries dated 12/08/23, 12/09/23, and on 12/12/23 for pain management/ medications. Review of the resident's clinical record revealed care plan potential for pain with start date of 12/11/23. A baseline care plan developed within 48 hours of the resident's admission could not be identified. On 12/14/23 at 4:10 PM, the Regional Case Manager stated baseline care plans were developed within 48 hours of admission and were revised when the comprehensive care plan was developed. On 12/14/23 at 4:30 PM, the Registered Nurse/ Minimum Data Set Coordinator (RN/MDS) stated 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 interview, and record review, the facility failed to ensure residents were involved in developing the comprehensive person-centered plan of care for 1 of 3 residents reviewed for participation in care plan, of a total sample of 52 residents, (#52). Findings Resident #52, a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included chronic systolic (congestive) heart failure, diabetes type II, mild intermittent asthma, other chronic pain, and shortness of breath. Review of the resident's annual Minimum Data Set (MDS) assessment, with Assessment Reference Date of 9/20/23 revealed the resident's cognition was intact, with a Brief Interview for Mental Status score of 15 out of 15. On 12/11/23 at 4:04 PM, resident #52 stated she did not get invited to her care plan meetings. On 12/13/23 at 10:42 AM, the Registered Nurse/ Unit Manager (RN/UM) for the 200 Hall stated resident/family were invited to their care plan meeting by the Social Service Director (SSD),…

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 fingernail care for a dependent resident, for 1 of 3 residents reviewed for Activities of Daily Living (ADL) care of a total sample of 52 residents, (#7). Finding: Clinical record review revealed resident #7 was admitted to the facility on [DATE]. Her diagnoses included major depressive disorder, chronic kidney disease, pain, sarcoma, and psychotic disorder with hallucinations. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 10/11/23 revealed the resident's cognition was severely impaired, and the resident was dependent on staff assistance for toileting, shower/bathe, and personal hygiene. On 12/11/23 at 10:29 AM, 12/12/23 at 9:40 AM, resident #7 was lying in bed on her back with her eyes closed. She did not respond when spoken to. The resident's fingernails to both hands were untrimmed, with a dark substance under the fingernails of her left hand. On 12/13/23 at 9:00 AM,…

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

Based on observation, interview, and record review, the facility failed to ensure nurses followed physician's Leave of Absence (LOA) orders and failed to provide necessary monitoring and supervision to mitigate the risk of serious injury for 1 of 7 residents reviewed for Accidents, of a total sample of 52 residents, (#77). Finding: Review of the medical record revealed resident #77 was admitted to the facility from an acute care hospital on 5/29/23 with diagnoses that included substance use disorder, ETOH (alcohol) and opiate (narcotic pain medication) dependence with recent recurrent episode, history of falls, impaired gait, neuropathy (nerve impairment/damage), chronic pain, and shortness of breath. On 12/03/23, the resident was transferred to an acute care hospital and readmitted from an inpatient psychiatric facility on 12/06/23 with diagnoses that included alcohol use disorder, severe, and major depressive disorder, with severe recurrent episode. The MDS Quarterly Assessment with ARD 11/28/23 noted the resident scored 13 out of 15 on the Brief Interview for Mental Status (BIMS)…

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 Midline dressing was changed in accordance with professional standards to prevent the potential for infection for 1 of 1 resident reviewed for antibiotic use of a total sample of 52 residents, (#198). Findings: Resident #198 was admitted to the facility on [DATE] with diagnoses which included peripheral autonomic neuropathy, spinal stenosis, lumbar region, urinary tract infection, multiple myeloma, and bacteremia. The resident's admission Minimum Data Set (MDS) assessment with Assessment Reference Date of 12/08/23 indicated the resident's cognition was moderately impaired with a Brief Interview For Mental Status score of 12/15. The assessment revealed the resident received intravenous medications on admission. Review of the resident's physician orders showed an order dated 12/07/23 with start date of 12/12/23 for Midline dressing change every 7 days. An order dated 12/09/23 noted antibiotic, Ceftriaxone 2 grams every day at 8 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 observation, interview, and record review, the facility failed to provide care and services consistent with professional standards of practice pertaining to tracheostomy care and suctioning for 1 of 4 residents (#40), and failed to ensure Oxygen (O2) therapy was administered per physician's order for 1 of 2 residents reviewed for O2 therapy, (#52) of a total sample of 52 residents. Findings: 1. Resident #40 was admitted to the facility on [DATE] and readmitted from an acute care hospital on [DATE] with diagnoses including chronic respiratory failure, dependence on supplemental oxygen, attention to tracheostomy, anoxic brain damage, cerebral infarction, and seizures. A tracheostomy (also called a tracheotomy) is an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs. After creating the tracheostomy opening in the neck, surgeons insert a tube through it to provide an airway and to remove secretions from the lungs (retrieved on 12/21/23 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 ensure nursing staff were competent to care for residents with tracheostomy for 1 of 4 residents reviewed for respiratory care of a total of 52 residents, (#40). Findings: Resident #40 was admitted to the facility on [DATE] and readmitted from acute care hospital on [DATE] with diagnoses including chronic respiratory failure, dependence on supplemental oxygen, attention to tracheostomy, anoxic brain damage, cerebral infarction, and seizures. A tracheostomy (also called a tracheotomy) is an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs. After creating the tracheostomy opening in the neck, surgeons insert a tube through it to provide an airway and to remove secretions from the lungs (retrieved on 12/21/23 from www.hopkinsmedicine.org). The Minimum Data Set (MDS) assessment dated [DATE] showed resident #40 required oxygen therapy, suctioning and tracheostomy care. Review of 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 and interview, the facility failed to ensure the garbage storage area was maintained in clean and sanitary condition. Finding: During the initial kitchen inspection on 3/13/22, the garbage storage area was observed at 11:10 AM. There was a trash compactor and dumpster for recycling with one of the doors open. Debris was scattered on the ground including white/clear gloves, milk cartons and other refuse. [NAME] Z was in the area and said the dumpster doors should be closed at all times. He said the gloves were used by nursing staff as the kitchen staff used black gloves. He explained he did not know who was responsible for keeping the garbage storage area clean. On 3/16/22 the Certified Dietary Manager indicated he did daily inspections which included the garbage storage area. He explained he did not work on 3/13/22 and did not know who was responsible for inspecting the garbage storage area when he was off work.

Based on observation, interview and record, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program developed and implemented timely and appropriate plans of action to prevent repeat deficient practices related to physical environment and Minimum Data Set (MDS) assessments. Findings: Cross Reference F584, F636, F638 and F640 Review of the facility's survey history revealed repeat deficiencies and systemic concerns with the resident's physical environment over the past four years, and for the current recertification survey. Past deficiencies noted failures in maintaining comfortable resident rooms, resident equipment and furniture. Review of the facility's survey history also revealed repeat deficiency related to resident MDS assessments over the past year and systemic concerns for the current recertification survey with inaccurate assessments, delays in completing and transmitting MDS assessments. On 3/16/22 at 4:52 PM, an interview was conducted with the Administrator and Director of Nursing (DON) regarding the facility's QAPI program. Review…

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 clean, comfortable and homelike environment in 7 resident rooms, (A-109, A-110, A-120, B-202, B-223, C-309, C-324), on 3 of 3 units, (A, B and C Wings). Findings: 1. On 3/14/22 at 10:32 AM, the bottom portion of the walls near the closets in rooms 110 and room [ROOM NUMBER] were noted to be damaged. The walls were gashed and dented and sheet rock was exposed. 2. On 3/13/22 at 12:44 PM, the air conditioning (AC) unit in room [ROOM NUMBER] was noted to have a large amount of thick dust inside the vents and along the length of the filter. There was a saturated, soiled white blanket on the floor that extended from under the AC unit towards the nearby bed. Photographic evidence was obtained. On 3/14/22 at 8:28 AM, the dirty, wet blanket remained on the floor under the AC unit, and the vents and filter were still coated with gray dust. On 3/15/22 at 11:02 AM, the blanket on the floor had been removed but the condition of the AC vents…

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 record review, the facility failed to ensure Annual and Significant Change in Status Minimum Data Set (MDS) assessments were completed within 14 days of the assessment reference date (ARD) for 5 of 16 residents reviewed for Resident Assessment, of a total sample of 56 residents, ( #1, #2, #4, #7 & #12). Findings: 1. Review of resident #1's Annual MDS assessment with ARD of 1/25/22 revealed Section Z0500 was signed by the Registered Nurse (RN) Assessment Coordinator on 3/09/22 to indicate completion of the assessment, 43 days after the ARD. 2. Review of resident #2's Annual MDS assessment with ARD of 1/24/22 revealed Section Z0500 was signed by the RN Assessment Coordinator on 2/25/22, 32 days after the ARD. 3. Review of resident #4's Significant Change in Status MDS assessment with ARD of 1/26/22 revealed Section Z0500 was signed by the RN Assessment Coordinator on 3/02/22, 35 days after the ARD. 4. Review of resident #7's Annual MDS assessment with ARD of 1/30/22 revealed Section Z0500 was signed by the RN Assessment Coordinator on 3/10/22, 39 days after 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 interview and record review, the facility failed to ensure Quarterly Minimum Data Set (MDS) assessments were completed within 14 days of the assessment reference date (ARD) for 7 of 16 residents reviewed for Resident Assessment, of a total sample of 56 residents, ( #3, #6, #10, #11, #14, #16 & #40). Findings: 1. Review of resident #16's Quarterly MDS assessment with ARD of 2/02/22 revealed Section Z0500 was signed by the Registered Nurse (RN) Assessment Coordinator on 2/24/22 to indicate completion of the assessment, 22 days after the ARD. 2. Review of resident #3's Quarterly MDS assessment with ARD of 1/24/22 revealed Section Z0500 was signed by the RN Assessment Coordinator on 2/24/22, 31 days after the ARD. 3. Review of resident #10's Quarterly MDS assessment with ARD of 1/25/22 reveled Section Z0500 was signed by the RN Assessment Coordinator on 2/25/22, 31 days after the ARD. 4. Review of resident #11's Quarterly MDS assessment with ARD of 2/14/22 revealed Section Z0500 was signed by the 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 observation, interview and record review, the facility failed to follow and serve therapeutic diets as per facility's menu and for 2 of 11 residents observed for dining/nutritional concerns, (#128 and #636). Findings: 1. Review of the facility's Diet Census revealed 13 residents had physician orders for pureed diets. Review of the facility's Cycle Menu for week #4 revealed meat lasagna was served for lunch on Sunday, 3/13/22. The other menu items for that meal included vegetable blend, garlic bread and frosted cake. The alternate meal for lunch on 3/13/22 included chicken tenders and french fries. Review of the facility's therapeutic menu revealed residents with physician ordered pureed diets were to receive 6 ounces of pureed meat lasagna and/or pureed chicken tenders. On Sunday, 3/13/22 at 10:35 AM, during the initial kitchen inspection at 10:50 AM, the lunch tray line was in progress. On the steam table were meat lasagna, vegetable blend, chicken tenders, puréed chicken tenders, pureed vegetable…

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 resident dignity during incontinence care for 1 of 5 residents reviewed for dignity of a total sample of 56 residents, (#107). Findings Review of resident #107's medical record documented he was admitted to the facility on [DATE] with diagnoses of stroke and Arteriosclerotic Heart Disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed he was cognitively intact, required extensive assistance with all Activities of Daily Living (ADLs), had impairment on one side of upper and lower extremity and was always incontinent of bowel and bladder. Review of the resident's plan of care revealed the resident was unable to perform self care, required total assistance with ADLs with intervention to provide privacy. On 03/13/22 at 2:27 PM, resident #107 stated he was incontinent and wore a brief. He said the staff had to provide incontinence care and help him to wash up. He explained the staff closed the room door…

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 record review, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted to the Centers for Medicare and Medicaid Services (CMS) within 14 days of completion, for 1 of 16 residents reviewed for Resident Assessment, of a total sample of 56 residents, (#6). Findings: Review of resident #6's Quarterly MDS assessment with ARD of 1/17/22 revealed Section Z0500 was signed by the Registered Nurse (RN) Assessment Coordinator on 2/22/22 to indicate completion of the assessment. The document was transmitted to CMS on 3/09/22, 15 days after completion. On 3/16/22 at 3:56 PM, during review of MDS Assessment Detail forms, the Regional MDS Manager confirmed the Quarterly MDS assessment for resident #6 was not transmitted to CMS within 14 days of completion as required. On 3/16/22 at 5:27 PM, the Director of Nursing (DON) explained the facility's Lead MDS Coordinator resigned in December 2021 and the department was short-staffed until another Lead MDS Coordinator was hired three weeks ago. The DON stated she was not aware of how far behind schedule…

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 incorporate expressed choices for preferred activities into the plan of care, and failed to ensure access to a television provided by family to promote the highest practicable well-being for 1 of 2 residents reviewed for activities, of a total sample of 56 residents, (#8). Findings: Resident #8 was admitted to the facility on [DATE] with diagnoses including gastrostomy tube, tracheostomy, stroke, seizures, brain damage due to lack of oxygen, respiratory failure, dependence on supplemental oxygen. A tracheostomy is a hole that is created surgically through the front of the neck and into the windpipe. A tube is inserted into the hole to keep it open for breathing and to maintain a permanent or temporary airway as indicated. A gastrostomy tube is inserted directly into the stomach through a surgically created opening in the abdominal wall. It is used to provide nutrition and hydration for patients who cannot swallow normally (retrieved 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 oxygen was administered as ordered by the physician for 1 of 5 residents reviewed for respiratory care, of a total sample of 56 residents, (#8). Findings: Resident #8 was admitted to the facility on [DATE] with diagnoses including tracheostomy, dependence on supplemental oxygen, convulsions, stroke, brain damage due to lack of oxygen, shortness of breath, and respiratory failure. A tracheostomy is a hole that is created surgically through the front of the neck and into the windpipe. A tube is inserted into the hole to keep it open for breathing and to maintain a permanent or temporary airway as indicated (retrieved on 3/25/22 from www.mayoclinic.org). Review of the Quarterly Minimum Data Set assessment with assessment reference date of 1/26/22 revealed resident #8 had short and long term memory problems and severely impaired cognitive skills for daily decision making. The assessment indicated she received oxygen therapy,…

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 pain management was provided consistent with professional standards of practice for 1 of 2 sampled residents, of a total sample of 56 residents, (#637). Findings: Resident #637 was admitted to the facility on [DATE] with diagnoses including polyneuropathy, gout, anxiety and chronic pain. Review of the New admission documentation dated 3/9/22 showed resident #637 was alert and oriented to person place and time. The pain management regimen review indicated the resident verbalized pain and his pain would be measured on a 0-10 scale. The resident was not experiencing any pain at the time of the assessment. Review of the facility policy and procedures dated 12/18/19 for Pain Management and Assessment read, Purpose: The detection of the presence of pain, determining the frequency and intensity of pain, and identification of effective pain management interventions and with evidence of new or worsening pain .On-going Pain Assessment: 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 ensure oxygen concentrator's external filter was maintained in a clean and sanitary manner to promote oxygen flow for 1 of 5 residents reviewed for respiratory care of a total sample of 56 residents, (#132). Findings: Review of resident #132's medical record documented she was admitted to the facility on [DATE] with diagnoses including Malignant Neoplasm of the Lung with Lobectomy in 2004, Emphysema, Chronic Obstructive Pulmonary Disease (COPD), Bronchitis and Acute Upper Respiratory Infection. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed the resident received oxygen therapy. Review of the resident's plan of care dated 01/14/22 noted intervention to administer oxygen therapy as ordered, Review of resident #132's physician orders dated 12/02/21 read, continuous oxygen at 2 Liters (L) via nasal cannula. On 03/14/22 at 9:57 AM, the resident's oxygen concentrator's external filter was missing and gray dust 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.