Aperion Care Dekalb

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure medication orders were verified prior to administering medications for 1 of 4 residents (R1) reviewed for pharmacy services in the sample of 8. The findings include: R1's face sheet shows she was admitted to the facility on [DATE] with diagnoses including: joint replacement surgery, major depressive disorder and history of falls. A nursing progress note completed on 10/14/24 at 1:56 PM for R1, shows R1 had went out to an appointment with a podiatrist and returned to the facility with new orders for Oxycodone 10-325 milligrams (mg.) every six hours as needed for pain, and to discontinue the current order for Hydrocodone 5-325 mg. R1's Medication Administration Record (MAR) dated 10/1/24-10/31/24 and her current Physicians Order Summary both show the order was carried out and Oxycodone was started, and Hydrocodone was discontinued on 10/14/24. On 10/15/24 at 8:45 AM, R1 said she had gone out to a doctor's appointment yesterday and her medications…

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 implement their abuse policy by not removing staff from resident care during an abuse investigation for 1 of 3 residents (R1) reviewed for abuse in the sample of 6. The findings include: On 9/17/24 at 11:27 AM, V6 Certified Nursing Assistant (CNA) said the morning of 9/12/24 she was assigned to the north hall. V6 said she went to the south hall to retrieve a sling. V6 said V2 Social Services Director stopped her on the south hall and asked her to assist R1. V6 said she went into R1's room and assisted him to clean up, get dressed and transferred to a wheelchair. V6 said R1 became rude and agitated that V6 had to leave to continue providing care on her assigned hall. V6 said she did not push or lay her hands on R1 in an aggressive manner. V6 said she left the room and reported to the nurse R1's change in temperament and the need for another staff person to approach him. V6 said she returned to the north hall to continue providing care for the residents for at least an hour before she was called in to a meeting with V2 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 4. On 7/15/24 at 9:58 AM, R61's bed (hospital bed that raised up and down) and air mattress pump were plugged into a power strip. 5. On 7/15/24 at 10:17 AM, R11 had an air mattress pump hanging on the headboard of the bed. The air mattress pump was plugged into a power strip. 6. On 7/15/24 at 10:03 AM, R53 had an air mattress pump hanging on the headboard of the bed. The air mattress pump was plugged into a power strip. On 7/15/24 at 12:40 PM, V12 (Maintenance Director) said medical equipment should be plugged into wall outlets and not power strips. V12 added power strips are not used because they can be turned off or easily lose power. V12 said medical equipment should be plugged into a wall outlet because a wall outlet provided a more reliable source of electricity. Based on observation, interview and record review the facility failed to supervise 1 resident (R36) at risk for aspirating foods during meals. The facility failed to ensure 2 residents (R34, R46) were transferred in a safe manner. The facility…

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 prepare and distribute food in accordance with professional standards for food service safety. This applies to 5 of 5 (R3, R26, R14, R36, R23) residents reviewed for pureed diets in the sample of 74. The findings include: On 7/15/24 at 11:04 AM, V17 (Cook) was observed at the food prep table making pureed pasta and meat. V17 picked up an oven mitt which had fallen on the floor and placed it back onto the clean food prep table near the blender and did not wash her hands. On 7/17/24 at 8:41 AM, V15 (Food Service Director/FSD) said if things fall on the floor they should be put in a dirty area and not near clean food. V15 said hand washing should be completed after picking something up from the floor. The facility provided pureed diet list dated 7/18/24 shows R3, R26, R14, R36, R23 as being on pureed diets.

Based on observation, interview and record review the facility failed to ensure incontinence care was provided for a resident dependent on staff for cares. This applies to 1 one 18 residents (R18) reviewed for Activities of Daily Living (ADL's) in the sample of 18. The findings include: R18's ADL care plan initiated on 5/22/24 shows she is totally dependent on staff for toileting and bed mobility. R18's 5/7/24 Minimum Data Set assessment shows she is cognitively intact. On 7/15/24 at 9:48 AM, R18 was lying in bed a faint odor of urine was noted. R18 stated, I haven't been changed since about 5 AM today. I need staff to change me, and they are busy and have not been in. I am incontinent of urine and wear a brief and course I am wet I take a water pill. On 7/15/24 at 10:05 AM, V9 (Certified Nursing Assistant) said R18 had not been changed yet that morning and she would be in to change her. V9 said incontinence care should be done every 2 hours and as needed. The facility provided Incontinence Care Policy revised on 1/16/18 shows the purpose of incontinence care is to prevent skin…

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 the necessary treatment for a resident's fractured arm. The facility failed to obtain daily weights for a resident with a diagnosis of congestive heart failure. These failures apply to 2 of 18 residents (R34, R18) reviewed for quality of care in the sample of 18. The findings include: 1. R34's fall note and nurses notes dated 7/5/24 showed R34 had an unwitnessed fall in the facility. R34 was sent to a local hospital for an evaluation where she was diagnosed with a fracture of her left ulna (arm). R34's nurses note dated 7/12/24 showed R34 was seen by an orthopedic physician for her fractured arm. The note showed, The paperwork the resident returned with said for her to continue to maintain splint at all times and to cover when showering. Splint may be removed at the sink to wash arm/hand but avoid wrist/forearm motion when splint comes off for cleaning at the sink . A physician order for R34, dated 7/11/24, showed R34 was to continue to maintain her left arm splint at all times and to cover it when…

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

Based on observation, interview and record review the facility failed to obtain physician prescribed medication and failed to follow physician orders for eye drops for 2 of 18 residents (R2, R32) reviewed for physician services in the sample of 18. The findings include: 1. R2's 7/1/24-7/31/24 Medication Administration Summary shows she should receive Farxiga 5 milligrams (mg.) at 9:00 AM and Memantine 10 mg. at 9:00 AM and 5:00 PM. R2's active Physician Order Summary shows orders for both Farxiga and Memantine. On 7/16/24 at 8:10 AM, V8 (Registered Nurse/RN) administered medication to R2 and omitted Memantine and Farxiga because he did not have it in the cart and said it looks like it was ordered from the pharmacy on 6/14/24 but has not arrived at the facility. On 7/16/24 at 9:44 AM, V2 (Director of Nursing) said she was aware that R2 did not receive the 2 morning medications that were prescribed, and she called the pharmacy who told her it was a medication reordered too soon. V2 said she asked pharmacy to check why the medication is considered too soon to fill and was awaiting a…

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

Based on interview and record review the facility failed to ensure a resident on a PRN (as needed) antipsychotic medication was evaluated by a physician after 14 days and failed to monitor a resident for antipsychotic side effects by not doing an AIMS (Abnormal Involuntary Movement Scale) test every 6 months for 2 of 5 residents (R32, R11) reviewed for psychotropic medications in the sample of 18. The findings include: 1. R32's Physician Order shows an active order dated 5/28/24 for Seroquel Oral Tablet 25 mg (milligrams). Give 25 mg by mouth every 24 hours PRN for anxiety. R32's Consultant Pharmacist Recommendations to MD (physician) dated 6/28/24 shows Resident has an order for the antipsychotic quetiapine (Seroquel) 25 mg 1 tab(let) every 24 hours PRN with no stop date. In accordance with State and Federal Guidelines PRN (as needed) orders for antipsychotic medications are limited to 14 days with no exceptions. To continue use of PRN antipsychotic beyond 14 days, the attending physician or prescribing practitioner must first directly evaluate the resident to determine…

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 administer physician prescribed medications as ordered. There were 29 opportunities with 3 errors resulting in a 10.34% error rate. This applies to 2 of 4 residents (R2, R12) observed during medication pass. The findings include: 1. R2's July 2024 Medication Administration Summary shows she should receive Farxiga 5 milligrams (mg.) at 9:00 AM and Memantine 10 mg. at 9:00 AM and 5:00 PM. R2's active Physician Order Summary shows orders for both Farxiga and Memantine. On 7/16/24 at 8:20 AM, V8 (Registered Nurse/RN) administered medication to R2 and omitted Memantine and Farxiga because he did not have it in the cart. V8 said he could not give those medications because they were not in the medication dispensing system the facility has. On 7/16/24 at 9:44 AM, V2 (Director of Nursing) said she was aware that R2 did not receive the 2 morning medications that were prescribed. 2. R12's Physician Order Summary dated 12/17/22 and Medication Administration Record dated July 2024 each showed R12 was to receive a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to explain binding arbitration in a manner the resident understood. This applies 1 of 3 (R68) in the sample of 18 reviewed for arbitration. The findings include: On 7/16/24 at 9:08 AM, R68 said she does not recall signing an arbitration agreement. R68 said if she did it was one of those sign here things and wasn't explained. R68 said she does not recall being told about arbitration at all. R68 said she would not have signed a document like that if it was explained to her. R68 said she would not give up her right to litigation. On 7/16/24 at 12:46 PM, V1 (Administrator) said the arbitration agreement is completed upon admission. V1 said residents aren't required to sign it to be admitted , they have 30 days to rescind it, the arbitrator's decision is final, and the resident will not be entitled to attorney fees. R68's Minimum Data Set (MDS) dated [DATE] shows a BIMS score for 15, cognitively intact. R68's admission Record show's an admission date 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.

Based on observation, interview, and record review the facility failed to ensure staff wore Personal Protective Equipment (PPE) for a resident on Contact Isolation and a resident on Enhanced Barrier Precautions for 2 of 18 residents (R6, R16) reviewed for infection control in the sample of 18. The findings include: On 7/15/24 at 9:52 AM, R6 had a contact isolation sign posted outside the room. Two staff where observed walking into R6's room with no PPE on. V12 (Certified Nursing Assistant/CNA) and V14 (Licensed Practical Nurse/LPN) came out of R6's room at 9:54 AM. R6 was observed sitting up in bed. V12 stated We boosted her up, me and the nurse. We should have worn PPE, a gown and gloves because she is on contact isolation for a urinary tract infection and is incontinent. R6's Urine Culture Lab Report dated 7/2/24 shows Positive for ESBL (Extended-spectrum beta-lactamase. ESBL-producing organisms are resistant to common antibiotics). Isolation precautions may be required. Please refer to you Infection Control Policy. On 07/16/24 at 01:27 PM, V2 (Director of Nursing) said for a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a safe transfer for 1 of 3 residents (R1) reviewed for safety in the sample of 3. The findings include: R1's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include disease of spinal cord, Parkinson's Disease, weakness, repeated falls, ataxia, schizophrenia, and anxiety disorder. R1's physical therapy evaluation dated 9/19/23 showed he was a two person max assist for transfers. R1's Post Fall Assessment form dated 9/21/23 showed R1 fell during a staff assisted transfer. This assessment showed, Resident unable to bear weight during transfer . R1's 9/25/23 Fall IDT (Interdisciplinary team) note showed, . Resident was lowered to the floor during a transfer after [R1's] knees buckled. Root cause of fall: Resident was inappropriately transferred via 2 CNA assist . On 11/17/23 at 1:00 PM, V7 CNA said they are always supposed to use a gait belt for residents who require assistance for transfers to prevent…

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 fall interventions were in place for 1 of 3 residents (R2) reviewed for falls in the sample of 8. The finding include: R2's face sheet showed a [AGE] year-old female admitted to the facility 6/22/23 with diagnosis of hydrocephalus, cerebral cysts, cerebral infarction, dementia, metabolic encephalopathy, and attention deficit hyperactivity disorder. This face sheet photograph showed a smiling female with a helmet on. R2 was not provided activities or access to a call light during observations. On 10/11/23 at 8:38 AM, R2 was seated in a recliner near the south nurse's station. There was no call light available for R2's use at that location. At 8:42 AM, R2 was assisted to ambulate from the south hall to the dining room by V8 Certified Nursing Assistant- CNA. R2 had a shuffling gait (walking while dragging feet without lifting the feet fully from the ground). V8 held R2's hand while walking with her and did not use a gait belt. R2 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) assistance for residents' requiring extensive assistance with ADLs for two of three residents (R2, R3) reviewed for ADL assistance in the sample of three. The findings include: 1. R2's Face Sheet shows he was admitted to the facility on [DATE], with diagnoses including primary lateral sclerosis, dysphagia, exposure to Covid-19, osteoarthritis, lack of coordination, urinary tract infection, bipolar, motor neuron disease, urinary incontinence, cognitive communication deficit, and pain. R2's MDS (Minimum Data Set) dated August 8, 2023, shows R2 is cognitively intact. R2 has showed no rejection of care behaviors and requires extensive assistance of two staff for toilet use and requires total assistance with personal hygiene. R2 is always incontinent of bowel and bladder. On September 27, 2023, R2 was observed in the same spot in his room and in his wheeled recliner at various times from 9:32 AM-12:18…

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 multidose insulin pens were labeled with an open date for 4 of 4 (R59, R8, R33, R37) residents reviewed for medication storage in the sample of 18. The findings include: On 8/15/2023 at 1:11PM, the facility's southwest medication cart was checked with V17 Registered Nurse (RN). On 8/15/2023 at 1:11PM, R8's Lispro Insulin pen was not labeled with an opened date. On 8/15/2023 at 1:57PM, the facility's southeast medication cart was checked with V7 RN. On 8/15/2023 at 1:57PM, R37's Lispro Insulin (Lyumjev Kwik) pen was not labeled with an opened date. On 8/15/2023 at 1:57PM, R59's Insulin Glargine pen and Insulin Lispro pen were not labeled with an opened date. On 8/15/2023 at 1:57PM, R33's Humalog Kwik insulin pen was not labeled with an opened date. V17 said R8's insulin pen was in use and should be labeled with an open date. V17 said the insulin pen is good for 28 days after being opened. On 8/15/2023 at 1:57PM, V7 said R37, R59, and R33's insulin pens were in use and did not have an opened date. V7 said…

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

Based on observation, interview, and record review the facility failed to follow their lunch menu by not serving the pureed bread option for four of four residents (R45, R60, R19, R36) reviewed for food menus in the sample of 18. The findings include: The facility's Menu dated August 13-August 19, 2023, shows a dinner roll on the menu for the lunch meal on August 14, 2023. The facility's Diet Spreadsheet dated Spring/Summer 2023 shows residents on pureed diet should receive a pureed dinner roll. 1. R45's Medication Review Report dated August 16, 2023, shows R45 was admitted to the facility with diagnoses including dementia and an order for a pureed diet. 2. R60's Order Summary Report dated August 16, 2023, shows R60 was admitted to the facility with diagnoses including cognitive communication deficit and altered mental status and an order for a pureed diet. 3. R19's Order Summary Report dated August 16, 2023, shows R19 was admitted to the facility with diagnoses including dementia and an order for a pureed diet. 4. R36's Order Summary Report dated August 16, 2023, shows R36 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to assist a resident with discharge planning. This applies to 1 of 18 residents (R35) reviewed for discharge planning in the sample of 18. The findings include: R35's electronic medical record (EMR) shows he is a [AGE] year old male that was admitted to the facility on [DATE] (1 year and 1/2 ago) with a fractured hip. His EMR lists his diagnoses to include: discitis lumbar region, congestive heart failure, chronic obstructive pulmonary disease, alcohol dependence with alcohol-induced persisting dementia, hypertension, unspecified dementia, alcoholic polyneuropathy, fracture of right femur, gastro-esophageal reflux disease, alcohol abuse, major depressive disorder and vascular dementia. On August 14, 2023, at 9:48 AM, R35 stated, he wants to leave the facility and doesn't belong there. They aren't helping me get out of here. They tell me to do my homework and won't help me. I am [AGE] years old and don't relate with these people here. They are…

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 ADL (activities of daily living) assistance for residents' requiring staff assistance to complete ADLs for 2 of 18 residents (R54, R32) reviewed for activities of daily living in the sample of 18. The findings include: 1. R54's current care plan showed R54 required the assistance of 1-2 staff for toileting and bathing related to his diagnosis of cerebrovascular accident (CVA) with right arm and right leg deficits. The care plan showed R54 was incontinent of bowel and bladder. On August 14, 2023, at 9:44 AM, R54's call light was on. R54's call light was answered by V4 CNA (Certified Nursing Assistant) and V5 CNA. R54 stated, I need to get cleaned up. R54 was in bed, dressed in a soiled shirt and soiled incontinence brief. R54's hair was greasy and not combed. V4 and V5 began providing cares to R54. R54's incontinence brief was removed. R54's brief contained a large amount of urine and mushy brown stool. Stool was noted leaking out 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 interventions to promote healing were in place to a non-pressure wound for 1 of 18 residents (R25) reviewed for quality of care in the sample of 18. The findings include: R25's admission Record showed R25 was admitted to the facility on [DATE], with diagnoses including Type 2 Diabetes Mellitus, obesity, lower extremity edema, and a non-pressure, chronic ulcer of her left heel and midfoot, with necrosis of bone. R25's Wound Evaluation Summary dated July 28, 2023, showed R25's left heel (diabetic) wound measured 1.0 cm (centimeters) x 0.3 cm x 0.7 cm. The summary showed R25 was to wear a pressure relieving boot on her left heel with recommendations of off-loading her left heel wound as much as possible. R25's Wound Evaluation Summary dated August 11, 2023, showed R25's left heel wound measured 0.4 cm x 0.4 cm x 2.2 cm. On August 14, 2023, at 10:30 AM, R25 was seated in a wheelchair in her room. An elastic wrap dressing was noted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility to prevent a decline in range of motion for 1 of 6 (R17) residents reviewed for range of motion in the sample of 18. The findings include: On 8/14/2023 at 11:15AM, R17 was observed lying in bed. R17 had expressive aphagia when interviewed. R17 appeared to have decreased range of motion to her right side as she did not move her right leg or right arm. R17 did move her left arm and leg without difficulty. On 8/15/2023 at 10:20AM, V16 Restorative Registered Nurse said residents not in physical therapy receive restorative services. V16 said all residents receiving restorative services should be getting restorative services three times per day. V16 said R17 was receiving passive and active range of motion as part of her restorative services three times per day. V16 said R17's documentation of active and passive range of motion does not show R17 was receiving range of motion 3 times per day. On 8/15/2023 at 2:56PM, V15 Certified Nursing Assistant (CNA)/…

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 transfer a resident safely. This applies to 1 of 18 residents (R69) reviewed for safety in the sample of 18. The findings include: R69's incident report dated January 16, 2023, shows, Witnessed fall: Resident: R69. Incident location: Resident's room. Incident Description: Nursing Description: This RN (V21 Registered Nurse) was notified by CNA (V12 Certified Nursing Assistant) that resident fell while being transferred to her bed. Went to check the resident in her room and found her on the floor lying on her back. According to the CNA, she was transferring her when the resident lost her balance and fell hitting her back and head on the floor. On August 16, 2023, at 12:28 AM, V12 CNA stated, at the time of R69's fall she was transferring with a slide board. V12 was using the slideboard by herself to transfer R69 to bed. She (R69) lost her balance and fell backwards and hit her head. She stated, R69 is a 2 person assist with transfers. I thought I could do…

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 ongoing communication and collaboration with an outpatient dialysis center for 1 of 1 resident (R31) reviewed for dialysis services in the sample of 18. The findings include: R31's admission Record showed R31 was admitted to the facility on [DATE], with diagnoses including fluid overload and end stage renal disease which required renal dialysis. R31's care plan dated April 8, 2023, showed R31 received hemodialysis every Monday, Wednesday, and Friday, at an outpatient dialysis center. On August 14, 2023, at 12:27 PM, R31 was not in her room or anywhere in the facility. V7 Registered Nurse (RN) stated R31 was out of the facility, at dialysis. When V7 RN was asked for any ongoing dialysis communication records or documentation for R31, between the facility and the outpatient dialysis center, R31 stated, We don't have any records. On August 15, 2023, at 7:55 AM, R31 was seated in her room eating breakfast. V7 RN was passing medications…

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 residents received food that accommodated their food preferences and intolerances for 2 of 18 residents (R228, R26) reviewed for food preferences/intolerances in the sample of 18. The findings include: 1. R228's admission Record showed R228 was admitted to the facility on [DATE], with diagnoses including congestive heart failure, morbid obesity, and Type 2 Diabetes Mellitus. On August 14, 2023, R228 was seated in a wheelchair in her room. R228 stated, I have been here a little over a week. I came from the hospital. I was diagnosed with heart failure. My issue here is the food. I am supposed to have a lower sodium diet. They can't seem to get my diet right. Shortly after I was admitted , I met with (V3 Kitchen Manager). We went over the foods I don't like and the foods I really shouldn't have. They put gravy on everything. I hate gravy. I eat in my room. My breakfast should be here soon. On August 14, 2023, at 9:15 AM, a breakfast…

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 was treated in a dignified manner for one of one resident (R178) reviewed for dignity in the sample of 19. The findings include: R178's face sheet printed 8/4/22 showed diagnoses including but not limited to diabetes mellitus, alcohol use unspecified with alcohol induced persisting amnestic disorder, alcohol dependence in remission, schizoaffective disorder, anxiety, and repeated falls. R178's facility assessment dated [DATE] showed severe cognitive impairment and memory problems. The same assessment showed extensive staff assistance needed for bed mobility, transfers, dressing, toilet use, and hygiene. On 8/2/22 at 1:00 PM, R178 was lying in bed wearing a night gown. The gown was pulled up to his chest and his bare groin area was completely exposed. R178 was fully visible from the room doorway. R178 was calling for help and his right leg was hanging out of the bed. At 1:02 PM, V17 (CNA-Certified Nurse Aide) walked down…

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 shower a resident two times a week. This applies to one of three residents (R228) reviewed for activity of daily living (ADL)'s in the sample of 19. The findings include: The facility face sheet shows R228 has diagnosis to include Type 2 diabetes, chronic pulmonary disease, and schizoaffective disorder. The facility assessment dated [DATE] for R228 shows moderate cognitive impairment and extensive assist of 2 staff for ADL care. On 8/3/2022 at 3:10 PM V11 Certified Nursing Assistant (CNA) said R228 takes a shower just fine for her. On 8/3/2022 at 3:16 PM, V13 CNA said she had never showered R228 before but never heard of her refusing one. On 8/04/22 at 10:15 AM, V2 Director of Nursing (DON) said with R228 behaviors giving showers may be difficult, but I expect the staff to try numerous times, try different approaches and always document if a shower cannot be completed and why. The facility shower sheets for the month of July 2022 shows 2…

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 put interventions in place for a resident (R4) with hemiplegia and hemiparesis (muscle weakness or the inability to move on one side of the body that can affect the arms, legs and facial muscles) for 1 of 1 resident reviewed for range of motion in the sample of 19. The findings include: R4's admission Record provided by the facility on 8/4/22 showed diagnoses including hemiplegia and hemiparesis following cerebral infarction (stroke) affecting right dominant side, aphasia (loss or ability to understand or express speech, caused by brain damage), dementia, dysphagia (difficulty swallowing foods or liquids), cognitive communication deficit and weakness. R4's Nursing Rehab/Restorative program reviewed from July 5, 2022, through August 2, 2022, showing one dressing/grooming program. The program showed (R4) will maintain hygiene and dressing with set up, verbal cues, and extensive 1 assist on right side. The facility assessment dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to prevent a resident fall, failed to assess a resident after a fall, and failed to transfer residents in a safe manner for two of ten residents (R178, R70) reviewed for safety in the sample of 19. The findings include: 1. R178's face sheet printed 8/4/22 showed diagnoses including but not limited to diabetes mellitus, alcohol use unspecified with alcohol induced persisting amnestic disorder, alcohol dependence in remission, schizoaffective disorder, anxiety, and repeated falls. R178's facility assessment dated [DATE] showed severe cognitive impairment and memory problems. The same assessment showed extensive staff assistance needed for bed mobility, transfers, dressing, toilet use, and hygiene. R178's fall risk assessment dated [DATE] showed at risk for falls. R178's care plan showed a focus area initiated 7/8/22 related to activities of daily living and an intervention for: TRANSFER-The resident requires mechanical lift hoyer and 2 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, interview, and record review the facility failed to ensure appropriate incontinence care was given and failed to give incontinence care in a manner to prevent cross contamination for a resident with a history of urinary tract infection for 1 of 1 resident (R51) reviewed for incontinence care in a sample of 19. The findings include: R51's electronic face sheet showed she was admitted to the facility on [DATE]. R51 has diagnoses including but not limited to Alzheimer's disease, urinary tract infection, dementia without behaviors, dementia with behavior, hypertension, and need for assistance with personal care. R51's MDS (Minimum Data Set) dated 6/30/22, shows she is severely cognitively impaired. She requires extensive assist of two person with bed mobility, total dependence of two person with transfers, total dependence with toileting with two persons assist, and R51 is always incontinent of bowel and bladder. R51's Care Plan printed on 8/4/22 showed R51 is incontinent of bowel, and bladder…

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 check placement and residuals of a feeding tube prior to starting liquid nutrition for one of two residents (R15) reviewed for feeding tubes in the sample of 19. The findings include: R15's face sheet printed 8/4/22 showed diagnoses including but not limited to cerebral infarction, dysphagia, dementia, encephalopathy, and heart disease. R15's August 2022 physician orders showed an order for enteral feedings (liquid nutrition via gastrostomy tube) one time a day to start at 9 am and run at 60 ml/hr for 21 hours. Orders also included: Check residuals before beginning a feeding and before medication administration. If greater than 100 cc, hold feedings and recheck in one hour. If not resolved, call MD. On 8/3/22 at 8:59 AM, V18 (Registered Nurse) gathered supplies to begin running R15's feeding tube. V18 used a stethoscope and listened to the pushing of water through R15's feeding tube before starting the liquid nutrition. V18 was questioned about what he was doing and stated he was checking the tube for patency.…

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 remove gloves after providing incontinence care and failed to wear Personal Protective Equipment (PPE) as recommended. This applies to 3 of 4 residents (R22, R70, R56) reviewed for infection control in the sample of 19. The findings include: 1. R70's admission Record provided by the facility on 8/4/22 showed diagnoses including altered mental status, cognitive communication deficit, weakness, abnormalities of gait and mobility and lack of coordination. The facility assessment dated [DATE] showed R70 had severely impaired cognitive skills for daily decision making and required assistance of staff members for bed mobility and toileting. On 8/02/22 at 12:09 PM, R70 was sitting in a geriatric chair in the hallway. R70 said she needs to lay down. V16 (Certified Nursing Assistant-CNA) pulled his surgical mask down to his chin and leaned in towards R70 telling her that she needs to eat first. V16 stood up, saw this surveyor and pulled 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.