Waterford Care Center, The

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to a.) label/date food items in resident personal refrigerator, b.) discard undated and expired foods in resident personal refrigerator, c.) ensure resident refrigerator is in proper working order. This has the potential to effect one resident (R45) in a total sample of 28.Findings include:On 01/20/2026 at 11:50 AM, observed R45 with large amount of food around room including along the windowsill. Also observed that he had a personal refrigerator in his room. R45 stated he orders food from Uber Eats on a regular basis and prefers to eat that food to the food served at the facility. R45 stated he is not able to walk and that the staff put the leftover food for him in his refrigerator. R45 stated someone looks inside his refrigerator every other day. He is not sure if anyone checks the temperature of his personal refrigerator and/or if there is a thermometer inside. On 01/20/2026 at 11:52 AM, surveyor asked R45 for permission to look inside his…

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 place a resident (R143) with wounds on enhanced barrier precautions (EBP). The facility also failed to ensure staff performed hand hygiene during meal tray distribution/feeding for one (R12) resident in a total sample of 28 residents.Findings Include: 1.R12 has diagnosis not limited to Hyperlipidemia, Long Term (Current) use of Insulin, Long Term (Current) use of Oral Hypoglycemic Drugs, Glaucoma, Mild Intellectual Disabilities, Tachycardia, Metabolic Encephalopathy, Chronic Respiratory Failure with Hypoxia, Protein-Calorie Malnutrition, Dementia, Dysphagia, Lack of Coordination, Abnormal Posture, Type 2 Diabetes Mellitus with Hyperglycemia, Anxiety Disorder, Vitamin D Deficiency, Acute Kidney Failure, Anemia, Difficulty in Walking, and Peripheral Vascular Disease. R12's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) indicate R12 is rarely/never understood. R12's Care Plan documents: Focus: The resident has nutritional problem or potential nutritional problem of inadequate energy intake…

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 an allegation of injury of unknown origin was reported to the abuse coordinator and to the State Agency (SA) for 1 (R1) out of 3 residents reviewed for abuse. Findings Include: R1's clinical records show a re-admission date of 4/8/25, with included diagnoses not limited to long term use of anticoagulants, malignant neoplasm of large intestine, cognitive communication deficit, and encounter for attention to colostomy. R1's Minimum Data Set, dated [DATE] ,shows R1 was cognitively impaired. R1's comprehensive care plan and progress notes from 4/8/25 to 5/10/25 revealed no documentation of R1's vaginal bruising and bleeding. No documentation of bruising on R1's groin and perineal area. R1's progress notes, dated 4/8/25 and 4/19/25, show R1 was noted with bruising on both lower and upper extremities. On 5/22/25 at 9:33 AM, a phone interview was conducted with V3 (Hospital emergency room Nurse). V3 stated she was the ER (Emergency Room) nurse in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record reviews the facility failed to ensure an allegation of injury of unknown origin was investigated for 1 (R1) out of 3 residents reviewed for abuse. Findings Include: R1's clinical records show a re-admission date of 4/8/25, with included diagnoses but not limited to long term use of anticoagulants, malignant neoplasm of large intestine, cognitive communication deficit, and encounter for attention to colostomy. R1's Minimum Data Set, dated [DATE], shows R1 was cognitively impaired. R1's comprehensive care plan and progress notes from 4/8/25 to 5/10/25 revealed no documentation of R1's vaginal bruising and bleeding. No documentation of bruising on R1's groin and perineal area. R1's progress notes, dated 4/8/25 and 4/19/25, show R1 was noted with bruising on both lower and upper extremities. On 5/22/25 at 9:33 AM, a phone interview was conducted with V3 (Hospital emergency room Nurse). V3 stated she was the ER (Emergency Room) nurse in charge of R1 when R1 was hospitalized on [DATE]. V3…

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 notify a resident's state guardian when the resident experienced a change in condition for one (R6) resident out of four residents reviewed for notification of changes in a total sample of six. Findings include: R6's face sheet documents R6 is a [AGE] year-old individual with diagnoses not limited to: dementia in other diseases classified elsewhere, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, schizoaffective disorder, depressive type, and major depressive disorder. R6's Minimum Data Set (MDS), dated [DATE], documents R6 has a Brief Interview for Mental Status (BIMS) of 09 out of 15, indicating R6 has moderately impaired cognition. R6's nurses note, dated 02/27/2025 at 5:44 PM, documents, resident (R6) was observed with a choking episode while eating dinner in the dining room. Resident was unable to swallow or cough out the obstructing food. The nurse on duty performed Heimlich maneuver and cleared her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care according to professional standards and properly label medication that had been open for resident use. These failures affect one (R1) resident out of three residents reviewed for medications. Findings Include: R1's physician order sheet/POS documents the following orders: Baclofen Tablet 10 MG- Give 1 tablet by mouth one time a day for musculoskeletal therapy agents. On [DATE] at 9:54 AM, V3 (Registered Nurse/RN) stated he has begun his medication administration pass already and is about to prepare R1's medications to administer. A medication bingo card was labeled Baclofen 5 mg, with a residents' name torn off of the label. R1's name was handwritten in black marker on the Baclofen medication bingo card. On [DATE] at 10:04 AM, V3 stated there was an issue with R1's Baclofen medication. V3 stated he was the nurse assigned to care for R1 on [DATE], and noticed R1's Baclofen medication was not available in the facility, and for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medications were administered as ordered by the residents' physician for one (R1) resident out of three residents reviewed. Findings Include: R1's physician order sheet/POS documents the following order: Ambien Oral Tablet 5 MG (Zolpidem Tartrate) *Controlled Drug*- Give 1 tablet by mouth at bedtime for Sleeplessness. On 03/23/2025 at 10:41 AM, R1 stated she did not receive her Ambien medication for 2 days after returning to the facility from completing her knee surgery at the hospital. R1 stated V2 (Director of Nursing/DON) told her that her Ambien medication was not available, and V2 was in the process of trying to get it. On 03/23/2025 at 3:33 PM, V7 (Registered Nurse/RN) stated when R1 came back from the hospital, R1 was prescribed Ambien, but it was not available. V7 stated she then called the pharmacy and made the DON aware. V7 stated she did not administer R1's Ambien to R1 on 03/05/2025, because it was not available. V7 stated if there…

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 follow proper sanitation and food storage practices as evidenced by food not properly labeled, and food not properly stored. These deficient practices have the potential to affect all 128 residents receiving food prepared for the nursing skilled facility. Findings include: On 12/17/24 at 9:11 AM, during initial kitchen tour with V17 [Dietary Manager], the following items were found in walk-in freezer: Box of turkey frank hot dogs uncovered with no open or discard date. Box of chicken patties uncovered with no open or discard date. Box of chicken leg quarters uncovered with no open or discard date. On 12/17/24 at 9:33 AM, on the clean dish rack, surveyor and V17 observed two cell phones and pair of eyeglasses next to the clean dishes. On 12/17/24 at 9:45 AM, V17 [Dietary Manager] stated, All food items, once removed from the box, the items need to be dated. The food items should have a label with an open date and expiration date. If dietary staff prepare food, not knowing how long the food has been open, it…

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 initiate a new Level I screen for four (R6, R7, R11, R32) residents reviewed for Pre-admission Screening and Record Review (PASARR) in a total sample of 26 residents reviewed. Findings include: 1. R11s' Face sheet documents R11 was admitted to the facility on [DATE], with diagnoses not limited to: schizoaffective disorder, bipolar type, major depressive disorder, and bipolar disorder. On 12/18/2024 at 10:30AM, surveyor requests the PASARR screenings for R11 from V1 (Administrator). On 12/18/2024 at 11:00AM, V1 provided R11s' PASARR screenings to surveyor. R11s' PASARR screening, dated 12/18/2024, titled Notice of PASRR Level I Screen Outcome documents to refer R11 to Level II Onsite. There is no documentation to show R11 was referred to the appropriate state-designated authority for a Level I or Level II PASARR evaluation and determination prior to 12/18/2024. 2.R6 was admitted to the facility on [DATE], with diagnoses onset date starting 10/01/13 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.

Based on observation, interview, and record review, the facility failed to ensure low air loss mattress devices were on the correct weights setting for four residents (R2, R29, R40, R122) out of four who are high risk in developing pressure ulcers in a final sample of 26 residents. Findings Include: 1. On 12/17/24 at 11:29 AM, R29 was sleeping in bed on a low air loss mattress, with the machine set to 290 pounds (lbs.). On 12/18/24 at 10:17 AM, Surveyor entered R29's room with V8 (Registered Nurse) and noted R29 was lying in bed on a low air loss mattress with the machine set to 290 lbs. R29's BRADEN score dated 9/29/24 is 12. V7 stated 12 means high risk for developing pressure ulcer. R29 needs assistance with bed mobility and R29's current weight is 219 pounds (lbs.) dated 12/4/24. 2. On 12/17/24 at 11:26 AM, R122 was sleeping in bed on a low air loss mattress, with the machine set to 120 lbs. R122's BRADEN score dated 9/25/24 is 12 (high risk for developing pressure ulcer). R122 needs assistance with bed mobility and R122's current weight is 86 lbs. dated 12/4/24. 3. On 12/17/24…

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 dispose a house stock medication after the expiration date, and failed to ensure medications were locked and secured while unattended for two out of three carts reviewed for medication storage and labeling. These failures have the potential to affect 86 residents residing in the facility. Findings Include: On 12/17/24 at 9:47 AM, Surveyor observed a medication cart in the first-floor hallway unattended and unlocked. V6 (Licensed Practical Nurse) stated V6 was responsible for this medication cart. V6 stated, This medication cart stores medications for residents on the first floor of the facility. On 12/17/24 at 11:45 AM, second floor medication cart was inspected with V8 (Registered Nurse) and found a bottle of vitamin D tablets, with expiration date of 11/24 on the label. V8 stated expired medications should be discarded on the expired date to prevent it for being administered to the residents. On 12/18/24 at 12:01 PM, V2 (Director of Nursing) stated, When medication cart is left unattended, there should be…

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 the facility linen was stored on a linen cart to prevent contamination and failed to ensure staff wore the proper PPE (Personal Protective Equipment) while caring for 1 (R32) resident on Enhanced Barrier Precautions. These failures have the potential to affect 49 residents residing on the third floor based on the facilities census. Findings Include: 1. R32 was admitted to the facility 09/22/08, with diagnosis onset dates starting 10/01/13, that is not limited to Long Term (Current) use of Anticoagulants, Hemiplegia and Hemiparesis Following other Cerebrovascular Disease Affecting Right Dominant Side, Anemia, Chronic Kidney Disease, Blind Loop Syndrome, Diverticulosis of Large Intestine, Spondylosis, Atherosclerosis of Aorta, Calculus of Gallbladder, Gastro-Esophageal Reflux Disease, Hyperlipidemia, Insomnia, History of Falling, Interstitial Pulmonary Disease, Contracture of Muscle, Left Lower Leg, Gastrostomy, Dysphagia, Aphasia Following Cerebral Infarction, Major Depressive Disorder, Dementia,…

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 resident dignity was maintained by not covering the body of 1 (R6) to prevent exposure of their body to others, failed to address the behaviors of disrobing for 1 (R6) resident exposing their body and failed to ensure the urinary drainage bag (a device that urine drains into) was covered and/or placed in a dignity bag for 1 (R117) resident for residents reviewed for resident rights. Findings included: 1. R6 was admitted to the facility on [DATE], with diagnoses onset date starting 10/01/13 not limited to Acquired Absence of Right Breast and Nipple, Personal History of Malignant Neoplasm of Breast, Parkinsonism, Hypokalemia, Fracture of Shaft of Right Tibia, Effusion, Right Knee, Cervical Disc Degeneration, Displaced Fracture of Lateral Condyle of Right Tibia, Displaced Fracture of Medial Condyle of Right Femur, Chronic Obstructive Pulmonary Disease, Dementia, Unspecified Severity, with Psychotic Disturbance, Hypertensive Heart…

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 the resident's care plan to ensure physician order was followed and administer the correct oxygen (O2) flow rate for one (R29) out of one resident reviewed for respiratory care in the final sample of 26. Findings Include: R29's clinical records show R29 has included diagnoses but not limited to acute and chronic respiratory failure with hypoxia and unspecified asthma. R29's Minimum Data Set (MDS), dated [DATE], shows R29 is cognitively intact and is dependent with staff assistance for transfers and bed mobility. R29's comprehensive care plan reads in part: R29 presents with altered respiratory function secondary to COPD requiring O2 as ordered for shortness of breath with one intervention that reads, Administer oxygen per MD orders. Assist with application as needed (date initiated 4/29/23). On 12/17/24 at 11:29 AM, R29 was sleeping in bed, using oxygen via nasal cannula. R29's oxygen flow rate was set to 2 liters per minute (LPM).…

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 cooking equipment was properly sanitized per manufacturer guidelines, failed to conduct hand washing in between handling dirty and clean plate ware/equipment, and failed to follow facility procedure for hand washing for appropriate length of time. These failures have the potential to affect all 132 residents receiving food prepared in the facility's kitchen. Findings include: On 01/10/24 at 10:41 AM, V25 (Dietary Cook) took the dirty blender, used for pureed food preparation, and put it into the dishwasher. At 10:42 AM, V25 pulled out a clean blender from the dishwasher. Hand hygiene was not done in between handing the dirty and clean blender. On 01/10/24 at 10:43 AM, V25 brought the same blender to the three-compartment sink and washed, rinsed, and dipped the blender into the sanitizing sink for 2-3 seconds, and then gave the blender to V24 (Dietary Cook). V25 did not perform any hand hygiene in between taking the blender from the dishwasher area to the three-compartment sink. On 01/10/24 at 10:49 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that 1 (R2) resident on TBP (Transmission Based Precaution) have proper signage indicating contact precautions and instructions on the use of specific PPE (Personal Protective Equipment) posted outside of R'2 room; failed to implement written EBP (Enhance Barrier Precaution) policy and procedures for 4 (R3, R57, R61, R113) residents; failed to ensure that staff was safely handling linens by not properly bagging soiled linens to prevent the spread of infection; and failed to review IPCP (Infection Prevention and Control Program) policy at least annually. These failures can potentially affect 136 residents residing in the facility, as of census dated 1/9/24. The findings include: 1. R2's health record showed original admission date of 8/26/20, with diagnoses not limited to Encounter for surgical aftercare following surgery on the genitourinary system, Pneumonia, Gastrointestinal hemorrhage, Bacteremia, Severe sepsis without septic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their policy and procedure by not obtaining a physician's order for 1 resident's (R128) code status, and to ensure code status were accurately addressed in the residents' comprehensive care plans for 4 (R2, R8, R24, R40) out of 27 residents reviewed for advance directives in a final sample of 27 residents. The findings include: 1. R2's health record showed original admission date of 8/26/20, with diagnoses not limited to Encounter for surgical aftercare following surgery on the genitourinary system, Pneumonia, Bacteremia, Severe sepsis without septic shock, Infection and inflammatory reaction due to indwelling urethral catheter, Chronic gastric ulcer without hemorrhage or perforation, Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side, Aphasia following cerebral infarction, Dysphasia following nontraumatic intracerebral hemorrhage, Dysphagia following cerebral infarction, Right…

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 eligible residents and/or resident representatives education regarding the benefits and potential side effects of available influenza vaccine for 3 (R3, R57, R113) residents; failed to provide eligible residents and/or resident representatives education regarding the benefits and potential side effects of all available pneumococcal vaccinations for 4 (R19, R57, R61, R113) residents; failed to assess eligibility and offer pneumococcal vaccinations to 4 (R19, R57, R61 and R113) residents; and failed to update the facility's Pneumococcal and Influenza vaccine policy. These failures have the potential to affect 5 (R3, R19, R57, R61 and R113) out of 6 residents reviewed for influenza and pneumonia vaccination. The findings include: 1. R3's health record showed admission date of 5/24/2022, with diagnoses not limited to Dysphagia following unspecified cerebrovascular disease, Chronic obstructive pulmonary disease, Type 2 diabetes mellitus with other…

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 assess eligibility and offer COVID-19 vaccination to 5 (R2, R3, R19, R57, and R113) residents; and failed to provide eligible residents and/or resident representatives education regarding the benefits and potential side effects of available Covid 19 vaccination for 5 (R2, R3, R19, R57, and R113) residents out 6 residents reviewed for COVID 19 immunization. The findings include: R2's health record showed admission date of 8/26/20, with diagnoses not limited to Encounter for urgical aftercare following surgery on the genitourinary system, Pneumonia, Gastrointestinal hemorrhage, Bacteremia, Severe sepsis without septic shock, Infection and inflammatory reaction due to indwelling urethral catheter, Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side, Aphasia following cerebral infarction, Dysphasia following nontraumatic intracerebral hemorrhage, Dysphagia following cerebral infarction, Right hydronephrosis, Iron deficiency anemia, Obstructive and reflux uropathy, Encounter…

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 the correct oxygen flow rate setting used per physician order. This failure applied to 1 resident (R12) out of 11 reviewed for oxygen therapy out of a total sample of 27. Findings include: R12's diagnosis included but not limited to Chronic Obstructive Pulmonary Disease with Acute Exacerbation Morbid (Severe) Obesity, Chronic Respiratory Failure with Hypoxia, Lymphedema, Obstructive Sleep Apnea, Dependence on Supplemental Oxygen, Need For Assistance with Personal Care, and Chronic Diastolic (Congestive) Heart Failure. R12's Order Summary Report, dated 01/10/23, documents oxygen at two liters per minute via nasal canula continuously every shift ordered 06/03/23. R12's MDS (Minimum Data Set), dated 12/05/23, indicates intact cognition with BIMS (Brief Interview for Mental Status) 15/15. On 01/09/24 at 1:42 PM, R12 was sitting up in bed with oxygen infusing via nasal canula. R12 stated R12's oxygen runs all the time. Oxygen concentrator was located behind R12 off to the corner, out of R12's reach. Oxygen…

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 their policies and procedures to ensure a resident received their medications according to the physician's order for 1 (R118) out of 6 residents reviewed for pharmaceutical services in a sample of 27. Findings Include: R118 ' s Minimum Data Set (MDS), dated [DATE], shows R118 is cognitively intact. R118's Physician Order Sheet (POS) with active orders as of 01/09/24 shows an order for sennoside 8.6 MG, to give 1 tab 2 times a day. R118's clinical records had no documentation showing R118 is safe to administer R118 ' s own medications. A review of R118's clinical records do not show a self-administration of medication assessment was completed. On 01/09/24 at 12:44 PM, surveyor and V12 (Registered Nurse) entered R118 ' s room, and observed 24 small, hard brown pills in the top lid of R118's water pitcher at R118 ' s bedside. R118 stated the pills are Senna, and R118 does not take them anymore because R118 goes to the bathroom on his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record, review the facility failed to ensure the care plan was revised for 1 (R3) of 4 residents reviewed for care plan revision. The care plan did not accurately indicate R3 as being a totally dependent resident requiring two-person assistance for bed mobility and transfers. Findings Include: R3 has diagnosis not limited to History of Falling, Polyosteoarthritis, Chronic Pain, Displaced Spiral Fracture Of Shaft Of Humerus, Right Arm, Subsequent Encounter For Fracture With Routine Healing Personal History of Covid-19, Chronic Obstructive Pulmonary Disease With (Acute) Exacerbation, Acute and Chronic Respiratory Failure With Hypoxia, Acute and Chronic Respiratory Failure With Hypercapnia, Bipolar Disorder, Current Episode Mixed, Severe, With Psychotic Features, Type 2 Diabetes Mellitus With Hyperglycemia, Essential (Primary) Hypertension, Acute Embolism And Thrombosis of Right Popliteal Vein, Anxiety Disorder, Morbid (Severe) Obesity Due To Excess Calories, Hyperlipidemia, Type 2 Diabetes…

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 provide timely incontinence care to a dependent resident (R4) for one out of ten residents reviewed for Activities of Daily Living (ADL) care. Findings include: R4's face sheet documents medical diagnoses of lack of coordination and weakness. R4's comprehensive care plan, last revised 9/12/2023, documents R4 has limited physical mobility related to weakness and decreased energy. Intervention, dated 9/12/2023, documents R4 requires one to two staff assist with ADL/mobility task. On 9/26/2023 at 11:56 AM, R4 was alert and oriented to person, place, and month. R4 stated staff sometimes take a long time to answer call lights and carry out the care requested. R4 stated this results in R4 lying in a urine-soaked incontinence product for one to two hours. At 1:43 PM, R4 was lying in bed, and stated needing staff assistance for incontinence care. R4 pressed the call light at 1:44 PM. At 1:45 PM, V6 (Nurse) answered the call light. R4 requested assistance with incontinence care. V6 left the room and notified V7…

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 provide an antiretroviral medication for a resident with Human Immunodeficiency Virus (HIV), and failed to notify the prescribing physician the medication was not available to the resident for one (R2) of ten residents reviewed for medications. Findings include: R2's face sheet documents medical diagnosis of HIV disease. R2's physicians' order sheets document an order for Abacavir-Dolutegravir-Lamivud Tablet 600-50-300 MG (milligram) Give 1 tablet by mouth at bedtime for HIV infection. On 9/26/2023 at 11:32 AM, R2 was alert and oriented to person, place, and date. R2 stated R2 recently restarted the antiretroviral medication after R2's appointment with V18 (Infectious Disease Doctor) on 9/05/2023. R2 stated R2 was off the medication for a few months because the facility did not have it, and did not get it from the pharmacy. R2's September Medication Administration Records (MAR) document a charting code of 9 for 9/01/2023-9/03/2023 for R2's Abacavir-Dolutegravir-Lamivud. Per MAR Chart Codes, 9 indicates Other / See…

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 their policy and provide transfer assistance to two dependent residents (R1, R3) out of three residents reviewed for Activities of Daily Living (ADL). Findings include: 1. R1's face sheet documents in part medical diagnoses of paraplegia. R1's comprehensive care plan contains a focus last revised on 11/30/2022. It documents R1 has an ADL self-care performance deficit related to impaired balance, limited mobility, limited range of motion, pain, history of stroke, paraplegia, wounds to feet, and stiffness in the left hand. Intervention initiated on 9/28/2021 documents: TRANSFER: The resident requires 1-2 staff assistance to move between surfaces and as necessary. A focus last revised on 2/26/2023 documents R1 has limited physical mobility related to weakness to upper and lower extremities, both shoulders, wounds on leg, and paraplegia. R1 uses a motorized wheelchair for mobility support and needs assistance with ADL/mobility task.…

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 adequate Medication Administration Records (MARs) for two (R1, R2) of two residents observed during medication pass. Findings include: 1. On 9/12/2023 at 9:30 AM, V7 (Nurse) prepared medications for R2. V7 used R2's electronic Medication Administration Record (eMAR) to determine which medications to pull from the medication cart. When V7 came across the order for Betamethasone lotion, V7 stated V7 will ask R2 if it is needed. V7 administered the oral suspensions at 9:42 AM. V7 started feeding the oral pills to R2 in applesauce at 9:50 AM. V7 marked off the medications on the eMAR at 9:54 AM. At 9:57 AM, V7 stated completing R2's morning medication pass. At 10:19 AM, V9 (Escort) assisted R2 towards elevators to go for dental appointment. At 10:48 AM and 12:54 PM, surveyor compared observations with R2's MAR and Physician Order Sheets (POS). POS (Physician Order Sheet) and MAR documents: Betamethasone Dipropionate Lotion 0.05 % Apply to scalp topically one time a day for itchy scalp. MAR documents in…

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

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent for two (R1, R2) of two residents observed during medication pass. There were six medication errors out of a total of 39 opportunities. This resulted in a 15.38% medication error rate. Findings include: 1. R2's comprehensive care plan contains a focus last revised on 7/31/2020. It documents R2 has altered respirator status/difficulty breathing related to diagnosis of asthma, chronic bronchitis, shortness of breath and heart failure. Intervention initiated 7/31/2020 documents in part: Administer medication/puffers as ordered. Monitor for effectiveness and side effects. On 9/12/2023 at 9:30 AM, V7 (Nurse) prepared medications for R2. V7 used R2's electronic Medication Administration Record (eMAR) to determine which medications to pull from the medication cart. When V7 came across the order for Betamethasone lotion, V7 stated V7 will ask R2 if it is needed. V7 administered the oral suspensions at 9:42 AM. V7 started feeding the oral pills to R2 in…

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

Based on observation, interview, and record review, the facility failed to ensure that two residents (R1, R2) were free of any significant medication errors for two of two residents observed for medication pass. Findings include: 1. Administration Record (eMAR) to determine which medications to pull from the medication cart. At 9:57 AM, V7 stated completing R2's morning medication pass. At 10:48 AM and 12:54 PM, surveyor compared observations with R2's MAR and Physician Order Sheets (POS). POS and MAR document: Advair Diskus Aerosol Powder Breath Activated 250-50 MCG [microgram]/dose (Fluticasone-Salmeterol) 1 inhalation inhale orally every 12 hours. MAR documents it is scheduled for 9:00 AM. V7 did not prepare or administer this medication. On 9/12/2023 at 3:44 PM, R2 stated R2 did not receive the Advair in the morning. R2 stated R2 needs staff assistance with the medication due to hand tremors. 2. R1's comprehensive care plan contains a focus last revised on 2/26/2023. It documents R1 has altered cardiovascular status related to hypertension, hyperlipidemia, history of stroke, 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.

Based on observation, interview, and record review, the facility failed to follow infection control procedures during medication administration for one (R1) out of two residents observed during medication pass. Findings include: On 9/12/2023 at 10:19 AM, V7 (Nurse) prepared medications for R1. V7 used R1's eMAR to determine which medications to pull from the medication cart. Facility uses blister packs for residents' medications. While preparing R1's medications, V7 repeatedly popped out multiple oral pills and capsules into bare hand, and then placed them into the medication cup. At one point, V7 popped Furosemide pill and missed the medication cup. The pill landed on top of the medication cart. V7 picked up the pill with a bare hand, and placed it into the medicine cup. At 10:29 AM, V7 handed the medicine cup to R1. At 3:08 PM, V2 (Director of Nursing) stated nurses are not supposed to have contact with the medications with their bare hands. V2 stated nurses are supposed to pop them from the blister packs directly into a medicine cup. Facility's Administering Medications policy,…

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.