Ravenwood Specialty Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident, family and staff interview the facility failed to complete oral cares as required for 1 of 4 residents reviewed (Resident #1). The facility census was 120 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS listed Resident #1 as dependent on staff for oral care and eating. The MDS included diagnoses of hypertension (high blood pressure), cerebrovascular accident (stroke), hemiplegia or hemiparesis, (muscle weakness or partial paralysis on one side of the body that affect the arms, legs and facial muscles), anxiety and depression. The MDS documented Resident #1 denied pain. The Care Plan Focus of activities of daily living (ADLs) initiated 9/29/23 included an intervention that Resident #1 required maximum assistance of 1 person with oral hygiene. Resident #1's February 2025 Documentation Survey Report lacked documentation 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.

Based on observation, policy review and staff interviews, the facility failed to date, date, cover, or label items after opening. In addition, the facility failed to have clean dishes when serving the meal. The facility reported a census of 114 residents. Findings include: 1. On 12/30/24 at 9:45 AM observed in the drink area refrigerator with the Certified Dietary Manager (CDM) present revealed the following: a. An open, undated, and uncovered piece of cherry pie. b. An undated and unlabeled, covered plate covered with a prior day's meal. c. Unlabeled and undated items in a clear plastic small container. D. Two unlabeled and undated juice pitchers. During an interview 12/30/24 at 10:00 AM the CDM reported the staff should have covered, dated, and labeled the items. 2. During the 12/30/24 lunch meal, observed the staff serve the following: a. 11:25 AM: Staff A, Cook, served fish, hashbrown casserole, and mixed vegetables on a dirty plate containing dried food particles. Staff A got another dirty plate and served the same meal on the new dirty plate contained dried food particles for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review, and staff interviews, the facility failed to have a consistent code status between the physician orders, the electronic health record (EHR), and the Care Plan for 1 of 1 resident reviewed for Advanced Directives (Resident #101). The facility reported a census of 116 residents. Findings include: Resident #101's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition. Resident #101's Clinical Physician Orders included an order dated [DATE] for cardiopulmonary resuscitation (CPR). Review of the facility form titled, Cardiopulmonary Resuscitation and DNR order Declaration Form, signed by Resident #101 on [DATE], indicated he desired to have CPR initiated to prolong his life when biological death (final death) is not imminent. The Care Plan Focus initiated [DATE] reflected Resident #101 had an Advanced Directives code status of do not resuscitate (DNR). The Care Plan documented the goal…

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 record review and staff interviews the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice of Non coverage form CMS 10055 (SNF ABN) for 1 of 3 residents (Resident #372) reviewed. The facility reported a census of 116. Findings include: Resident #372 Minimum Data set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMs) score of 11, indicating moderately impaired cognition. The MDS indicated Resident #372 required supervision or touching assistance (helper provides verbal cues and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for sit to stand, chair/bed to chair transfer, toileting, and walking. Resident #372's MDS included diagnoses of cancer, coronary artery disease (impaired blood vessels), heart failure, diabetes mellitus, cerebrovascular accident (stroke), wound infection, non traumatic ischemic (dead tissue) infarction (inadequate blood supply) 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 clinical record review and staff interview, the facility failed to submit a Preadmission Screening and Resident Review (PASRR) evaluation for 1 of 2 residents reviewed with a new mental health diagnosis (Resident #63). The facility reported a census of 116 residents. Findings include: Resident #63's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The MDS included diagnoses of anxiety, depression, psychotic disorder, post-traumatic stress disorder (PTSD). In addition, Resident #63 received antipsychotic and depression medications during the lookback period. The Care Plan Focus initiated 1/18/23 reflected Resident #63 had the potential for psychosocial well-being problems related to anxiety, depression, PTSD, psychosis, delusions, and hallucinations, due to his loss of independence and being away from family following his recent admission to the facility. The Psychological Service Progress Note…

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 record review, policy review and staff interview the facility failed to ensure staff use the assistance of two certified nursing assistants (CNA) when using the full body mechanical lift (transferring a person using a sling that are dependent upon staff to move from the bed and/or chair) to transfer for 2 of 3 residents sampled (Resident #12 and #34). The facility reported a census of 116 residents. Findings include: 1. Resident #12's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #12 had a functional limitation of both lower extremities. They required the use of a wheelchair and total staff assistance for chair to bed/chair to chair transfers. The MDS included a diagnosis of a cerebrovascular accident (stroke). The Care Plan Focus dated 11/14/23 related to Activities of Daily Living (ADLs) directed the following: a. Resident #12 didn't walk b. Resident #12 required the use of two staff…

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 record review, policy review and staff interview, the facility failed to provide clean peri care per the standards of practice for 1 of 2 residents sampled (Resident #65). As the staff provided peri-care to Resident #65, they failed to wipe front to back, change their gloves as completing a dirty task, complete hand hygiene prior to applying gloves, and removing their gloves. The facility identified a census of 116 residents. Findings include: Resident #65's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition. Resident #65 required total staff assistance for toileting hygiene. The MDS listed Resident #65 as always incontinent of urine and frequently incontinent of bowel. The MDS included diagnoses of Alzheimer's disease and non Alzheimer's dementia. The Care Plan Focus revised 7/12/24 indicated Resident #65 had bowel and bladder incontinence related to her Alzheimer's disease. 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 record review, family and staff interviews the facility failed to complete an informed consent for a psychotropic medication for 1 of 1 resident reviewed (Resident #1). The facility reported a census of 127 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) Score of 3, indicating severe cognitive impairment. The MDS included diagnoses of diabetes, Alzheimer's disease, depression and anxiety. The Prescription dated 3/25/24 directed to start Risperdal (antipsychotic) 0.25 milligrams (MG) by mouth twice daily. The facility noted the order on 3/26/24 at 12:13 AM. The Nurses Note dated 3/2/24 at 10:45 AM reflected the wife knew of Resident #1's new orders. During an interview on 7/12/24 at 11:30 AM Resident #1's daughter and wife reported the facility didn't notify them of the risk of using risperidone (Risperdal). In addition, the facility didn't go over it to consent. During an interview on 7/12/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff and resident interviews, and observations, the facility failed to provide comfortable and therapeutic dining accommodations for 1 of 17 residents reviewed (Resident #2). The facility reported a census of 123 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #2 had diagnoses which included stroke, diabetes, heart failure, arthritis, anxiety, and depression. The resident has residual paralysis to the left extremities and required extensive assistance of 2 staff for transfers, personal hygiene, bed positioning, and can feed herself with set up assistance from the staff. The resident utilized a wheelchair with a power back rest. Review of the undated Care Plan informed the staff the resident was independent with eating but needed set up assistance and to encourage the resident to eat her meals in the main dining room. Observation on 3/18/24 at 11:38 am revealed Resident #2 in the main dining room sitting in her wheelchair, pushed up 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.

Based on observation, policy review and staff interview the facility failed to provide a homelike environment by serving 2 of 3 dining rooms (A wing and B wing dining areas) meals on plastic food serving trays. The facility identified a census of 138 residents. An initial observation of the B wing dining room on 7/31/23 at 11:46 a.m. 15 residents sat in the dining room eating their lunch meals off of black plastic food trays. Observation on 8/01/23 at 7:56 a.m. revealed Resident #11, #60, #119, and #120 seated at their dining room tables eating breakfast off of black plastic food trays. Further observation revealed 12 dirty black food tray on a cart that had been removed from the tables with all dishes contained on the food trays. Observation on 8/01/23 at 8:32 a.m. revealed 13 residents sat in the A wing dining room eating breakfast from black plastic food trays. On 8/01/23 at approximately 10:00 a.m. Resident #104 out walking on the B wing reported look at this place. It is like a prison here. During an observation on 08/01/23 at 8:04 a.m. 43 residents sat in the main dining 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.

Based on observation, staff interviews, resident interviews, and policy review, the facility failed to provide 4 of 6 residents reviewed with functioning call system devices to allow resident to staff communication (Resident #7, #10 #12, #32). The facility reported a census of 138. Findings include: The Minimum Data Set (MDS) for Resident #7 dated 06/09/23 listed diagnoses that included diabetes, seizure disorder/epilepsy, and pain. The MDS section for Brief Interview of Mental Status (BIMS) scored 9 indicated resident cognition is moderately impaired. The Care Plan dated 7/5/23 for Resident #7 documented to call for assistance with cleaning up after defecating in bed. The MDS for Resident #10 dated 05/30/23 listed diagnoses that included heart/lung disease, diabetes, and pain. The BIMS assessment scored 15 indicated resident cognition is intact. The Care Plan revised 6/22/23 for Resident #10 documented risk for falls, interventions included to ensure my call light is within reach and encourage me to use it for assistance as needed. I need prompt response to all requests for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff and resident interviews, and policy review, the facility failed to assure residents were treated with respect and dignity for 1 of 5 residents reviewed (Resident #123). The facility reported a census of 138 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #123 had a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognitive status. The MDS further documented the resident had diagnoses including medically complex conditions, neurogenic bladder, other fracture, paraplegia, and malnutrition. The Care Plan for Resident #123 revised 4/8/23 with a focus area ADL's documented the resident was dependent for all ADL's due to being paralyzed with a goal of resident will be able to participate in part of ADL's with tasks. The Care Plan directed staff to wake the resident up for breakfast and further documented full staff assistance is needed for transfer, mobility, bathing, dressing, and eating. Facility record review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, staff and resident interviews, and policy review, the facility failed to accommodate residents needs with assurance of accessibility to call lights within resident's reach and ability to operate for 1 of 1 residents reviewed (Resident #123). The facility reported a census of 138 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #123 had a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognitive status. The MDS further documented the resident had diagnoses including medically complex conditions, neurogenic bladder, other fracture, paraplegia, and malnutrition. The MDS further indicated under functional limitation in range of motion the resident has impairment on both sides of upper extremity (shoulder, elbow, wrist, hand). The Care Plan for Resident #123 revised 4/8/23 with a focus area ADL's documented the resident was dependent for all ADL's due to being paralyzed and further documented under interventions 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 clinical record review, document review, and staff interview the facility failed to provide the resident or the resident's legal representative with a Skilled Nursing Advance Beneficiary Notice of Non-Coverage (SNF/ABN) and Notice of Medicare Non-Coverage (NOMNC) to document an appeal decision and the date of notification of Medicare non-coverage for 1 of 3 residents sampled (Resident #130). The facility identified a census of 138 residents. Findings include: Resident #130's Electronic Census Record detailed the Resident admitted into Medicare Part A skilled services on 6/12/23. The MDS listed a diagnosis of a displaced fracture of the greater trochanter of the right femur (hip fracture) and detailed Resident #130 had received four days of speech-language pathology treatment; 4 days of occupational therapy treatment and 3 days of physical therapy treatment. Resident #130's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 13 indicating intact…

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, resident interviews, staff interviews and policy review the facility failed to make efforts to investigate or resolve resident grievances regarding a lost hearing aid for 1 of 3 resident reviewed (Resident #121). The facility reported a census of 138 residents. Findings include: Facility inventory sheet for Resident #121 dated 4/27/23, listed hearing aid charger and hearing aids present on admission. Electronic Health Record (EHR) revealed the task history, revised 6/13/23, included resident care for hearing aides. admission Progress Note dated 6/13/23, documented resident required bilateral hearing aides. The Minimum Data Set (MDS) assessment dated [DATE] revealed the Brief Interview for Mental Status (BIMS) score a 10 (moderate cognitive impairment). On 7/31/23 10:01 AM, observed Resident #121 without hearing aides in either ear and speaking volume increase required during conversation. Resident #121 reported missing a hearing aid for around one month and stated staff were notified 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 clinical record review and staff interview, the facility failed to submit a Level 2 Preadmission Screening and Resident Review (PASRR) evaluation for 1 of 1 residents reviewed with a new mental health diagnosis (Resident #69). The facility reported a census of 138 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #69 had a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognition. The MDS further documented diagnoses including anxiety, depression, and psychotic disorder and the resident received an antipsychotic medication 7 out of the past 7 days. The Care Plan for Resident #69 initiated 1/18/23 revealed the resident was at risk for side effects from antipsychotic drug use and utilized Olanzapine (antipsychotic) related to diagnoses of psychosis and hallucinations. Clinical record review for Resident #69 revealed she had a diagnosis of unspecified psychosis not due to a substance or known physiological condition dated 7/13/22. The clinical record…

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 record review and staff interview, the facility failed to submit a Level 1 Preadmission Screening and Resident Review (PASRR) evaluation to the appropriate state-designated authority prior to the expiration date for 1 of 1 residents reviewed (Resident #17). The facility reported a census of 138 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #17 had a Brief Interview for Mental Status (BIMS) of 10 indicating moderate impairment. The MDS further documented the resident had diagnoses including non-Alzheimer's dementia, anxiety disorder, depression, bipolar disorder, and post traumatic stress disorder (PTSD). The Care Plan for Resident #17 revised 6/13/23 with a focus area PASRR, documented a PASRR had been completed prior to admission to the facility with a goal the facility will ensure the nursing home is the proper placement. Clinical record review of a facility submitted Level 1 PASRR completed by Maximus for Resident #17 documented a determination 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, clinical record review, resident and staff interviews, the facility failed to follow the physician ordered wound treatment for 1 of 4 residents sampled (Resident #97). The facility identified a census of 138 residents. Findings include: Resident #97 MDS dated [DATE] showed a BIMS score of 15 indicating no cognitive loss. The Resident required extensive assistance of one staff member for bed mobility, transfer, dressing, toilet use, and personal hygiene. The MDS listed diagnoses of type 2 diabetes mellitus with diabetic neuropathy (nerve damage), anemia, heart failure, hypertension, end stage renal disease, chronic obstructive pulmonary disease (COPD), venous insufficiency, morbid obesity, and history of a Methicillin resistant Staphylococcus infection (an infection that is difficult to treat because of resistance to some antibiotics). An Order Summary Report, signed by the Provider on 7/06/23 documented a physician order to apply an ABD pad to the left leg below knee amputation (BKA) site,…

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 record review, policy reviews, and resident and staff interviews, the facility failed to provide cleanliness and grooming by neglecting nail care for dependent residents for 1 of 5 reviewed (Resident #54); failed to complete residents' baths for 2 of 3 residents reviewed for bathing (Resident #123 and Resident #125) and failed to provide appropriate peri care for 1 of 3 residents reviewed (resident #90). The facility reported a census of 138 residents. Findings included: The Minimum Data Set (MDS) dated [DATE] documented diagnosis of traumatic brain dysfunction, coded for always incontinent, non-verbal, total staff dependence for bed mobility, transfer, dressing, eating, toilet use, and hygiene. The Care Plan updated 6/30/23 noted Resident #54 was unable to participate in activities due to traumatic brain injury, is non-verbal and bed bound, needed daily observation of skin with routine care. On 07/31/23 at 01:33 PM observation of resident lying in bed, right hand revealed long…

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 record review, document review, policy review, and staff interviews, the facility failed to apply a left-hand orthotic device and failed to reposition to prevent contracture and skin breakdown per the care plan for 1 of 3 residents sampled. (Resident #90). The facility identified a census of 138 residents. Findings include: Resident #90's MDS dated [DATE] showed a BIMS score of 1 indicating severe cognitive loss. The Resident required extensive assistance of two staff for bed mobility, transfer, toilet use, and personal hygiene. The MDS documented Resident #90 as frequently incontinent of urine and always incontinent of bowel. The MDS detailed Resident #90 with upper extremity (shoulder, elbow, wrist, hand) and lower body (hip, knee, ankle, foot) limitation in functional range of motion to one side of the body. The MDS listed diagnoses of stroke, hypertension, aphasia (a disorder that results from damage to portions of the brain that are responsible for language), and seizure…

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 record review, policy review, and staff interview the facility failed to place a urinal within reach, provide incontinence check and failed to prevent catheter tubing from coming into contact with the floor for 2 of 3 residents sampled (Resident #25 and #34). The Facility identified a census of 138 residents. Findings include: 1. Resident #25's MDS dated [DATE] showed a BIMS score of 11 indicating moderate cognitive loss. The Resident required extensive assistance of two staff for transfers, dressing, toilet use, and personal hygiene. Resident #25 had occasional incontinence of urine and frequent incontinence of bowel. The MDS listed diagnoses of stroke, diabetes mellitus, Non-Alzheimer's Dementia, anxiety, depression, psychotic disorder, and history of falling. The MDS documented Resident #25 at risk of a pressure ulcer. The Care Plan revised 2/14/23 documented Resident #25 at risk of developing pressure ulcers and directed the staff to develop a turning/repositioning plan 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.

Based on clinical record review, policy review, and staff interview, the facility failed to limit as needed (PRN) medication to 14 days without a rationale from the physician to extend the medication for 1 of 5 residents reviewed for unnecessary medications (Resident #79). The facility reported a census of 138 residents. Findings include: The Minimum Data Set (MDS) for Resident #79 documented a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognition. The MDS further revealed the resident had diagnoses including anxiety, depression, and non-Alzheimer's dementia. The Care Plan dated 9/28/22 documented Resident #79 used anti-anxiety medication with the goal the resident would be free from discomfort or adverse reactions related to anti-anxiety therapy. The Care Plan directed staff to monitor for side effects from anti-anxiety medication. Review of the August 2023 Medication Administration Record (MAR) for Resident #79 revealed she had an order for Clonazepam (psychotropic) 0.5 milligram tablet by mouth every 12 hours as needed for anxiety with a start date 5/25/23.…

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, policy review, and staff interviews, the facility failed to ensure open items were dated, covered and labeled, refrigerators were kept clean and milk served was in a safe temperature range. The facility reported a census of 138 residents. Findings include: 1. Observation 7/31/23 at 9:25 AM in the main kitchen with the Certified Dietary Manager (CDM) present revealed the following: a. Open undated bag of approximately 1 gallon of rice krispies b. Open undated bag of approximately 1 gallon frozen french fries c. Open undated approximately 1 gallon frozen breadsticks During an interview 7/31/23 at 9:35 AM the CDM revealed the items should have been dated when opened. 2. Observation of the B hallway dining room on 8/1/23 at 12:05 PM revealed the following: a. Open container of Pepsi plastic bottle without an open date or name documented b. Open plastic water bottle without an open date or name documented c. Undated and unlabeled container of what appeared to be sliced tomatoes d. Red liquid…

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 and staff interviews, the facility failed to maintain a clean and sanitary environment for the residents. The facility reported a census of 138 residents. Findings Include: An Interview on 7/31/23 at 1:23 p.m. Resident # 84 reported the carpet down hallways are dirty with stains and feels that the facility is not addressing the carpet. An observation 7/31/23 at 2:00 p.m. of the carpet down the hallways showed it soiled with several stains noted down hallway C and E and the carpet to the general population dining room and the nurses station. Newer carpet down halls F and G noted to have spots of stains. An observation on 8/1/23 at 12:45 p.m. noted spots and stains on carpet to all areas remain. An interview on 8/2/23 at 11:20 a.m. with Staff L, Housekeeping Aide, reported the facility did not have staff that cleans the carpet. The carpet is contracted out. An interview on 8/2/23 at 1:00 p.m. with the Housekeeping Supervisor, reported that in March [NAME] Steamers cleaned the carpets 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.