Ryze At Homewood

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent and protect a resident from staff to resident misappropriation of resident property. This failure affected one resident (R1) out of three residents reviewed for abuse. As a result of this failure, R1 felt awful, targeted, afraid, trapped, and unsafe. Findings include: R1 is a [AGE] year-old resident admitted to the facility on [DATE], and has diagnoses including but not limited to chronic respiratory failure with hypoxia, encephalopathy, and generalized anxiety disorder. R1'S Minimum Data Set (MDS), dated [DATE] section C0500, documents Brief Interview for Mental Status (BIMS) score of 15, which indicates cognition is intact. MDS section GG0130, dated 4/10/2025, documents resident requires supervision or touching assistance for eating and oral hygiene. Resident is dependent for the following: toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. On 6/24/2025, 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.

Based on observation, interview, and record review, the facility failed to have a Dietary Manager available to ensure daily Dietary services were performed appropriately and efficiently resulting in residents not receiving meals according to their preferences, requests, needs, or the facility's menu; residents not being served in a timely and consistent manner; residents not receiving food at an appetizing temperature; and dry food not being stored under sanitary conditions. These failures applies to all 131 residents receiving food from the facility. Findings include: On 06/12/2025 at 9:51 AM, R1 stated, Yesterday, (Wednesday), they were serving fish for lunch. I asked for a cheeseburger instead and was still served the fish. I was told 'sorry we missed your nam'e, even though they have a list. R1 stated the food sometimes is served lukewarm. The facility's lunch menu for Wednesday (06/11/2025) of the week three menu cycle included: Fried Fish. On 06/12/2025 at 10:22 AM, R2 stated yesterday he requested a salad for lunch. They had him marked as no salad, although salad was not 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 its Quality Assurance Performance Improvement (QAPI) program effectively identified quality deficiencies and described how the facility would evaluate the effectiveness of corrective actions and performance improvement activities to address repeated deficiencies regarding infection control. This deficient practice had the potential to affect all residents residing in the facility. Findings include: Review of the facility survey history, documented in Casper Report 003D Provider History Profile, updated on 11/19/2024, revealed repeated non-compliance at Federal tag F880, infection control for 11/2021, 10/2022, and 9/2023. The facility's corrective actions following these deficiencies included re-educating nursing staff on infection control, and requiring the Director of Nursing (DON) or designee to conduct facility-wide infection control audits to ensure staff adherence to proper practices. Further review of training and education documentation, dated 9/26/2023, indicated facility staff were provided education on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain a physician order for the administration of medication, oxygen and enhance barrier precautions. This deficiency affects all five (R14, R41, R56, R108, and R177) residents in the sample of 26 reviewed for Professional Standards of Practice. Findings include: 1. R177 wass admitted on [DATE], with diagnoses listed in part but not limited to Alzheimer's disease, Malignant neoplasm of stomach. Active physician order sheet indicated EBP (Enhanced barrier precaution) due to urinary catheter, dated 12/3/24. Order was written after surveyor inquired. On 12/3/24 at 11:00AM, R177 was on enhanced barrier precaution (EBP) set up. V17, LPN (Licensed Practical Nurse), said R177 is on EBP due to indwelling catheter. On 12/4/24 at 10:06AM, R177 was lying in bed. She was confused. Observed medication ointment placed on 30ml medication cup, not labeled, at bedside. V17, LPN, said, It's probably barrier cream left by treatment nurse. No medication…

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 determine self-administration of medication was appropriate for a resident whose medication was left at the bedside for the resident to self-administer for one of one resident (R20) reviewed for self-administration of medications in sample of 26. Findings include: An order summary report, dated 12/3/2024, indicates R20 has diagnoses of atrial fibrillation, mood disorder, Hypertensive heart and chronic kidney disease, Cardiopulmonary disease, asthma, chronic respiratory failure, major depressive disorder, GERD, diabetes mellitus, and peripheral vascular disease. R20's has medication orders for sodium bicarbonate 650mg, tamsulosin cap 0.4mg, torsemide 20mg, tums chewable 500mg, omeprazole 20mg, citalopram hydrobromide 20mg, Eliquis 5mg, farxiga 10mg, finasteride 5mg, carvedilol 6.25mg, multivitamin with minerals. R20's care-plan, dated 7/18/2024, indicates an intervention to give medications as ordered by a physician and monitor and document for side effects and effectiveness. On 12/3/2024 at 11:00 AM, R20…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident call light was within reach. This deficiency affects two (R46, R72) of three residents in the sample for 26 reviewed for accommodation of needs. Findings include: 1. R72 was admitted on [DATE], with diagnoses listed in part but not limited to cerebral infarction, covid-19, unspecified asthma, history of falling. R72 has a focus care plan for at risk for falls related to cerebral infarction, asthma, congestive heart failure. Intervention dated 8/19/24 -Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. On 12/03/24 at 10:23 AM, R72 observed in room, in bed, and call light observed on floor behind privacy curtain. On 12/03/24 at 10:29 AM, V16 (Certified Nurse Aide) verified the call light was not within reach, and said R72 should have it next to her in bed in case she needs assistance to call 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.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibits prevention of resident abuse. This deficient practice 3 of 5 residents (R29, R41, R123) reviewed for abuse prevention program in a sample of 26. Findings include: On 12/5/2024 at 11:45 AM, R29 was noted with admission date of 11/13/2024 and Criminal History Information Response Process was initiated on 11/20/2024. R41 was noted with admission date of 11/1/2024 and Criminal History Information Response Process was initiated on 11/4/2024. R123 was noted with admission date of 11/2/2024 and Criminal History Information Response Process was initiated on 11/4/2024. On 12/5/2024 at 12:24 PM, V18 (Admissions) stated Criminal History Information Response Process (Background check) is done within 72 hours of admission, and is impossible to do within 24 hours, because V18 does not work after hours and on weekends. V18 said they have no policy on running and checking Criminal History Information Response Process. On 12/5/2024 at 02:15 PM, V1 (Administrator) stated all new…

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 and interview, the facility failed to submit information for preadmission screening and resident review for level l Preadmission screening and Resident Review (Preadmission screening resident review PASRR) and for a level ll evaluation for 1 of 4 resident's (R20) reviewed for PASRR in a sample of 26. Findings include: An order Summary Report indicates R20 has diagnoses of Post traumatic stress disorder, Unspecified Mood (Affective) Disorder, insomnia due to other mental disorder, major depressive disorder. On 12/5/2024 at 12:10 PM, V23 (Unit Manager) said, (R20) has very manipulative behavior. On 12/5/2024 V1 (Administrator) said, I do not have a Level 1 or a Level ll (PASRR) screening for (R20). I know all residents under [AGE] years of age should have a screening, and if indicated a level ll, but I do not have it. On 12/6/2024, V18 (Admissions Director) said, I am responsible for obtaining a preadmission screening and (R20) was grandfathered in. I was not aware I had to do a PASRR level…

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 manufacturer's recommendation in using low air loss mattress to resident who has stage 4 pressure ulcer. This deficiency affects one (R6) of three resident in the sample of 26 reviewed for Pressure ulcer Management. Findings include: R6 was admitted on [DATE], with admitting diagnoses of Dementia, Type 2 Diabetes mellitus, Peripheral Vascular Disease, Acquired absence of left leg below knee. R6's active physician sheet indicated: Resident to have alternating pressure air mattresses to promote wound healing. Right hip- cleanse with normal saline, pat dry, apply xeroform and cover with a bordered gauze 3 times a week and PRN (as needed). Right buttocks- cleanse with normal saline, pat dry, apply xeroform and cover with a bordered gauze 3 times a week and PRN. R6's comprehensive care plan indicated: She has re-opened stage 4 pressure ulcer on right hip and right buttocks related to history of pressure ulcers and immobility. R6's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review ,the facility failed to implement fall preventive measures for a resident who has history of falls. This deficiency affects two (R21 and R56) of three residents in the sample of 26 reviewed for Fall prevention management. Findings include: 1. R56 was admitted on [DATE], with diagnoses listed in part but not limited to Chronic Obstructive pulmonary disease (COPD), Cognitive communication deficit, adult failure to thrive, Difficulty walking. R56's admission Fall assessment and most recent assessment dated [DATE], indicated she is at risk for fall. R56's comprehensive care plan indicated she is at risk for falls related to COPD, Respiratory failure. R56's unwitnessed fall incident, dated 11/26/24 at 6:50 PM, indicated: The resident was found lying on the floor on the side of her bed. She stated that she was getting up to use the bathroom. She was sent to the hospital for evaluation. Fall investigation/Root cause analysis was done. New care plan intervention 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 observation, interview, and record review, the facility failed to followa a physician's order for oxygen administration. This deficiency affects one (R96) of three residents in the sample of 26 reviewed for oxygen management. Findings include: R96 was admitted on [DATE], with diagnoses listed in part but not limited to chronic obstructive pulmonary disease, unspecified asthma, unspecified chronic bronchitis, hypoxemia, dependence on supplemental oxygen. Active physician order sheet indicates: Change oxygen tubing weekly every night shift, Oxygen @ 4LPM (liters per minute) per nasal cannula, continuously. On 12/03/24 at 10:42 AM, R96 was observed in dining area, sitting in wheelchair with oxygen concentrator @ 6LPM (liters per minute) via nasal cannula, and no date or label on oxygen tubing. On 12/03/24 at 10:45 AM, V13 (Registered Nurse) verified R96 was receiving oxygen at 6LPM (liters per minute) via nasal cannula. V13 verified R92's physician order states R96 should be receiving oxygen at 4LPM…

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 act upon and implement medication recommendations in a timely manner. This deficiency affects two (R56 and R114) in the sample of three residents in the sample of 26 reviewed for Pharmacy medication review. Findings include: 1. R114 was admitted on [DATE], with diagnoses listed in part but not limited to Alzheimer's disease, Fracture of right femur, Abnormality of gait and mobility, Repeated falls. R114's active physician order sheet indicated Aricept (Donepezil HCl) tablet 5mg give 1 tab by mouth one time a day for dementia ordered date 10/25/24. November 2024 indicated Aricept 5mg (Donepezil) 1 tablet by mouth given at 9AM daily. R114's Pharmacist drug regimen review, dated 11/11/24, indicated: Please take the following action described below. See report. R114's Pharmacist recommendation note to attending physician, dated 11/11/24, indicated, This resident has an order of Aricept (Donepezil) at 9am. Aricept should be dosed at bedtime…

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 have appropriate diagnosis for resident receiving anti-psychotic medications. This deficiency affects one (R110) of three residents reviewed for Psychotropic medication management. Findings include: R110 was admitted on [DATE], with diagnoses listed in part but not limited to Hemiplegia and hemiparesis following non traumatic intracerebral hemorrhage affecting right dominant side, Aphasia, Vascular dementia with agitation, Anxiety disorder, Depression. R110's active physician order sheet indicates Risperdal (Risperidone) oral tablet 0.5mg give 1 tablet by mouth one time a day for Vascular Dementia for agitation, ordered 10/11/24. R110's comprehensive care plan did not address the anti-psychotic medication R110 is receiving. No care plan formulated for usage of anti-psychotic (Risperdal). No qualifying diagnosis. R110's AIMS (Abnormal Involuntary Movement Scale) was completed by Unit Manager/Psychotropic Nurse dated 12/4/24, after surveyor…

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 hospice coordinated communication and plan of care are available and accessible to facility staff. This deficiency affects one (R177) of three residents in the sample of 26 reviewed for Hospice care services. Finding include: R177 was admitted on [DATE], with diagnoses listed in part but not limited to Alzheimer's disease, Malignant neoplasm of stomach. Active physician order sheet indicates that she is on hospice care upon admission. R177's comprehensive care plan indicates she is receiving end of life services with admitting diagnosis of Malignant neoplasm of stomach. No intervention was written in care plan. On 12/3/24 at 11:16AM, R177 was lying in bed, with oxygen via nasal cannula at 3 liters per minute (LPM). She has an indwelling catheter. She was confused, and needs total care with activity of daily living and transfers. V17, Licensed Practical Nurse, said she is on hospice care. On 12/4/24 at 10:12AM, V19, Social Service…

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 infection control practices, such as hand hygiene and used of personal protective equipment (PPE), were performed during enteral feeding assessment, and failed to ensure the urinary catheter tubing and drainage bag was not touching the floor for infection control. This deficient practice has the potential to affect 1 of 3 residents reviewed for enteral feeding procedure (R51) and 1 of 2 residents reviewed for urinary catheter management (R177) in a sample of 26. Findings include: 1. R1's records indicate: Order Summary Report: Diagnoses: Gastrostomy Status, Dysphagia, Oropharyngeal Phase Order date 6/20/2024: Enteral Feed order every shift. Care Plan: Focus: R51 requires Enhanced Barrier Precaution d/t G-tube. On 12/4/2024 at 9:47 AM, V9 (Licensed Practical Nurse) entered R51's room, which displayed signage for Enhanced Barrier Precautions (EBP). V9, without performing hand hygiene, put her gloves on and proceeded to the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident's representative of a resident discharge from the facility, including the reasons for the move in writing, and failed to have a record that the local Ombudsman was notified of the discharge. This failure affected one (R3) of three residents reviewed for discharge. Findings include: R3 is a [AGE] year-old male admitted to the facility on [DATE], past medical history includes: Abdominal aortic aneurysm without rupture, essential primary hypertension, diabetes, other lack of coordination, need for assistance with personal care, alcohol abuse, history of falling, etc. Physician order. dated 6/11/2024. states: Discharge Home with Home Health, RN, Wound Care RN, Ok to Take Medication from facility. Progress note, dated 7/5/2024, states as follows: Resident discharged with belongings and medication. Transferred to community living home. Social service progress note, dated 7/2/2024, reads: (R3) is scheduled to discharge on [DATE] at 1PM.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain the environment in good repair and failed to maintain a clean and sanitary environment. These failures have the potential to affect all thirty residents residing on the fifth floor of the facility. Findings include: On 4/26/2024, V1 (Administrator) presented the facility's Daily Census document, which shows the resident census on the fifth floor was 30. On 4/26/2024 between 2:30 PM and 3:15 PM during facility rounds with V1, Administrator and V4, Maintenance Director, the following environmental conditions were observed: room [ROOM NUMBER] has some peeling paint on the wall; there are things all around the room that are in disarray; there are clean clothes and clean towels placed on top of the chair with other dirty clothes underneath; several disposable wipes are laying on top of the bedside table; the wall fan has a lot of dust and debris; the overbed light has a lot of dust and debris; there is a shoe horn and hanger in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to identify and regularly assess a resident for arterial ulcers, who then developed necrosis to the right heel and right great toe. This failure applied to one (R3) of three residents reviewed for nursing care. Findings include: R3's Physician's Order Sheet, printed on 12/8/23, shows R3 was admitted to the facility on [DATE], with diagnoses including Right Femur Fracture, Dementia, and Peripheral Vascular Disease. R3's Nurse's Notes, dated 11/10/2,3 states, Writer informed per CNA (Certified Nursing Assistant) resident had drainage on his sock upon removal, assessment done resident had brown drainage note on resident his sock great toe area, great noted with thick toenail, dry skin no visible open area noted, observed small amount of brown drainage from right great toe, nail bed, denies any pain or discomfort, ROM WNL (Range of Motion within normal limits), first aid rendered, dry dressing applied . On 12/8/23 at 12:20 PM, V5 (LPN- Wound…

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 provided personal privacy during a physical assessment by a medical provider, and failed to ensure residents were provided privacy during blood glucose monitoring and insulin administration. These failures applied to six (R49, R71, R84, R94, R101, and R112) of six residents reviewed for nursing care in the sample of 33 residents. Findings include: R49 is [AGE] years of age. Current diagnoses include but are not limited to: Type 2 Diabetes Mellitus, Dementia and Chronic Kidney Disease. R71 is [AGE] years of age. Current diagnoses include but are not limited to: Parkinson's Disease, Paranoid Schizophrenia, Dementia and Cognitive Communication Deficit. R84 is [AGE] years of age. Current diagnoses include but are not limited to: Type 2 Diabetes Mellitus, Dementia and Schizophrenia. R94 is [AGE] years of age. Current diagnoses include but are not limited to: Alzheimer's Disease, Hypertension, Type 2 Diabetes Mellitus 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 observation, interview, and record review, the facility failed to follow their policy for infection control related to glucometer cleaning after resident use; failed to ensure that reusable equipment (wrist blood pressure cuff) was cleaned between use of residents; failed to perform hand hygiene prior to putting on PPE (Personal Protective Equipment) and after performing blood glucose monitoring; and failed to ensure infection control was maintained during tracheostomy care for a resident. These failures applied to four (R38, R101, R110, and R135) of four residents reviewed for nursing care in a sample of 29 residents. Findings include: R38 is [AGE] years of age. Current diagnoses include but are not limited to: Paraplegia, Tracheostomy status. R110 is [AGE] years of age. Current diagnoses include but are not limited to: Glaucoma and Type 2 diabetes mellitus with other diabetic ophthalmic complication. R135 is [AGE] years of age. Current diagnoses include but are not limited to: Hemiplegia 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 observation, interview, and record review, the facility failed to promptly address a resident's urinary catheter care needs by allowing the resident to continue the use of the same catheter that was leaking, while the resident was experiencing adverse symptoms, for a resident with a history of urinary tract infection (UTI). This failure applied to one (R78) of five residents reviewed for catheter care/UTI. Findings include: R78 is [AGE] years old, admitted to the facility on [DATE] with past medical history of type two diabetes, recent left BKA, end stage renal disease, chronic kidney disease stage 3, atrial fibrillation, hypertension, hypokalemia, iron deficiency anemia, and history of falling. On 09/08/2023 at 1:07 PM, Nurse practitioner note documented the following: HPI (History of Present Illness): Resident is a [AGE] year-old male, being seen in a follow up for Bacteriuria. Seen s/p (status post) recent hospitalization for two amputations on left leg, with the 2nd being a left BKA (below knee…

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 procedures for pain management by not regularly assessing and monitoring a resident's complaints of pain and by not communicating resident pain to a provider in a timely manner following a fracture. This failure applied to one (R7) of one resident reviewed for pain management. Findings include: R7 is a [AGE] year old male with a diagnoses history of Quadriplegia, Parkinson's Disease, Epilepsy, Anxiety Disorder, Major Depressive Disorder, Cognitive Communication Deficit, and Osteoarthritis, who was admitted to the facility 04/02/2019. R7's progress note dated 09/13/2023 02:46 PM documents during repositioning R7 complained pain. Relief received, will continue to monitor. R7's progress note, dated 09/17/2023 at 11:16 AM, documents he was received in bed quietly with eyes open. R7's lower left extremity shows swelling and is warm to touch. Pain meds administered and became effective at this time. Nurse Practitioner…

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 medications were available during medication administration per physician orders for one (R135) of five residents reviewed during medication administration observation. Findings include: R135 is [AGE] years of age. Current diagnoses include but are not limited to: Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side, Essential (primary hypertension, Age related nuclear cataract, bilateral, Presbyopia, and Myopia, bilateral. On 09/19/23 at 8:26 PM, medication administration was observed with V5, RN/Registered Nurse, on unit 100. V5 prepared medications for R135, and the following medications were not available for administration per the physician's order: *Lubricant Eye drop (carboxymethylcellulose-glycerin) 0.5%-0.9% administer 2 drops to each eye twice a day due to dry eyes. V5, RN, stated, I'm not seeing it (eye drops) here, I'll have to reorder it. The medication was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were three medication errors out of 25 medication opportunities resulting in a 12% medication error rate. This failure applied to two (R110, R135) residents reviewed during the medication administration task. Findings include: R135 is [AGE] years of age. Current diagnoses include but are not limited to: Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side, Essential (primary hypertension, Age related nuclear cataract, bilateral, Presbyopia, and Myopia, bilateral. R110 is [AGE] years of age. Current diagnoses include but are not limited to: Glaucoma and Type 2 diabetes mellitus with other diabetic ophthalmic complication. On 09/19/23 at 8:26 PM, medication administration was observed with V5, RN/Registered Nurse, on unit 100. V5 prepared medications for R135 and the following medications were not available 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 notify a physician about residents not receiving their ordered medications for four (R3, R4, R5, R6) of six reviewed for physician notification. Findings Include: 1. R3 is a [AGE] year old with the following diagnosis: type 2 diabetes, hypertension, and transient ischemic attacks. The Medication Administration Record, dated 08/2023, documents on 8/20/23, R3 did not receive the following ordered medications: Aspirin 81 milligrams (mg) - 1 tablet at 9AM; Insulin glargine 100 units/milliliter (mL) - 32 units at 9PM; Metformin 500 mg - 2 tablets at 9PM; Metoprolol 25 mg - 1 tablet at 9AM; Insulin NPH 100 unit/mL - 2 units at 4PM and 11PM; and Xarelto 2.5mg - 1 tablet at 9AM. Aspirin and Xarelto prevent blood clot formation, Insulin and Metformin help control blood sugar levels, and Metoprolol helps control high blood pressure. 2. R4 is a [AGE] year old with the following diagnosis: quadriplegia, adult failure to thrive, hypertension, chronic…

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 replace two open nursing shifts on day shift (7AM - 7 PM), and three open nursing shifts on night shift (7PM - 7AM) on 8/20/23, leaving two units during the day and three units during the night without a scheduled nurse, affecting 69 residents. Findings Include: R3 is a [AGE] year old with the following diagnosis: type 2 diabetes, hypertension, and transient ischemic attacks. R4 is a [AGE] year old with the following diagnosis: quadriplegia, adult failure to thrive, hypertension, chronic embolism/thrombosis of the veins, and idiopathic epilepsy. R5 is a [AGE] year old with the following diagnosis: congestive heart failure, type 2 diabetes and hypertension. R6 is a [AGE] year old with the following diagnosis: hemiplegia following a cerebral infarction, cognitive communication deficit, chronic kidney disease, and hypertensive heart failure. R6 was interviewed during this investigation, but was not able to remember if the facility was short staffed or if…

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 administration of medication as ordered by the physician. This affected four of four residents (R3-R6) reviewed for medication error, omission and medication administration. findings Include: 1. R3 is a [AGE] year old with the following diagnosis: type 2 diabetes, hypertension, and transient ischemic attacks. The Medication Administration Record. dated 08/2023. documents on 8/20/23. R3 did not receive the following ordered medications: Aspirin 81 milligrams (mg) - 1 tablet at 9AM; Insulin glargine 100 units/milliliter (mL) - 32 units at 9PM; Metformin 500 mg - 2 tablets at 9PM; Metoprolol 25 mg - 1 tablet at 9AM; Insulin NPH 100 unit/mL - 2 units at 4PM and 11PM; and Xarelto 2.5mg - 1 tablet at 9AM. Aspirin and Xarelto prevent blood clot formation, Insulin and Metformin help control blood sugar levels, and Metoprolol helps control high blood pressure. 2. R4 is a [AGE] year old with the following diagnosis: quadriplegia, adult failure to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their bed hold policy by not providing bed hold notice at time of transfer for 4 of 4 (R32, R281, R2, R121) residents reviewed for bed hold. Findings Include: 1. R32 progress note, dated 10/12/22, documents: Resident is desaturating due to noncompliance and states she wants to go to the hospital. Resident was 72% pulse ox without oxygen and 90% pulse ox with oxygen. Doctor made aware family made aware new order carried out to transfer resident to ER. Review of R32's medical record does not document any bed hold notice given to resident. 2. R281 progress note, dated 6/14/22, documents R281 was transferred to local hospital due to change in condition. There is no documentation of bed hold notice given to resident. Review of R281's medical record does not document any bed hold notice given to resident. 3. Review of R2's medical record, dated 9/3/22, notes R2 was transported and admitted to the local hospital. There is no documentation found in R2's…

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

Based on observation, interview, and record review, the facility failed to follow their policy for dietary services to ensure its canned goods are dent free to prevent contamination of meals served to its residents. This failure has the potential to affect all 133 residents that consume meals prepared by this facility. Findings include: A review of the current CMS 672 shows there are 133 residents residing in the facility. On 10/17/22 at 9:30 AM, this surveyor completed an initial tour of this facility's food storage room with V16 (Dietary Manager). There were (3) 106-ounce cans of spaghetti sauce and (1) 5 pound 10 ounce can of pizza sauce observed on the storage shelf to be deeply dented. On 10/17/22 at 9:30 AM, V16 (Dietary Manager) stated dented cans should not be accepted on delivery. V16 stated the dented cans should not have been placed on shelf to be used. V16 stated these cans should be thrown out to ensure not used for resident meals. V16 removed the dented cans from shelf and placed on a table. On 10/17/22 at 12:15 PM, this surveyor observed the 4 dented cans still in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their call light policy for 1 of 1 (R39) by not ensuring the call light within reach. Findings include: R39's Minimum Data Set (MDS), dated [DATE] section C (cognitive pattern), documents a score of fourteen, which indicates cognitively intact. Section G (functional status) documents limited assistance with one person physical assist for toilet use and personal hygiene. No impairment to the upper extremities. Section H (bowel continence) documents frequently incontinent. On 10/16/22 at 11:30 AM, R39 was observed in bed. R39 said, I had a bowel movement. I need assistance to be changed. I don't know where my call light is located. R39's call light was observed on the floor out of reach, near the base of R39's head board. V8 (MDS Coordinator) said, (R39's) call light should be in reach. On 10/16/22 at 4:48 PM, V3 (Assistant Director of Nursing/ADON) said, The call light should be within reach. Answering the call light, revised 2008,…

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 follow their policy for Advance Directives. The facility failed to put an order for a resident with a change of Advance Directives (Code Status). This deficient practice affects one resident (R1) of three residents reviewed for Advance Directives. Findings Include: R1's initial facility admission was dated 1/4/22. R1's Face Sheet, documents : There is no Advanced Directives selected for this resident. R1's DO-NOT-RESUSCITATE (DNR) PRACTITIONER ODERS FOR LIFE-SUSTAINING TREATMENT (POLST) FORM, documents R1 would like to be DNR (Do Not Resuscitate); R1's signature, dated 9/15/22, Social Service Director (V12) signature, dated 9/15/22 and Nurse Practitioner's signature, dated 9/20/22. R1's Physician Order Report for Active Orders shows there is no order for Code status stating R1 is on DNR code status. On 10/19/22 at 10:59 AM, V12 (Social Service Director) stated, We get doctor's order to become a DNR. R1 requested to change R1's code status from full code to DNR. Form was completed by me and with Nurse practitioner. Advance…

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 hot water policy and ensure the water temperatures in the resident room was between 105 and 115 Fahrenheit for 2 residents in the sample of 133 residents reviewed for water temperatures. Findings include: On 10/16/22 at 11:42 AM, R119 said the water is cold when the staff gives him a bed bath. On 10/18/22 at 2:02 PM, during tour to check water temperature, R113's room water temperature was noted to be 69.9 degrees Fahrenheit, shower room temp was noted to be 102.8; R119's room water temp was noted to be 104.5 degrees Fahrenheit. On 10/18/22 at 2:02 PM, V30 (Maintenance Supervisor) said the water temperature should be 106-107 degrees Fahrenheit. Facility policy no titled noted shows in-part to ensure patient room water temperature are between 105 and 115.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their transfer and discharge policy by not providing a safe discharge from the facility. This affected 1 of 3 residents (R132) reviewed for discharge and transfer. Findings include: R132 facility face sheet shows R132 has diagnosis of other seizures, hypothyroidism, essential hypertension, intraspinal abscess, pressure ulcer, end stage renal disease, anemia, personal history of venous thrombus, depression, history myocardial infraction, congestive heart failure, anxiety, GERD, vertigo, osteoporosis, chronic pain, and diabetes mellitus. R132's discharge MDS (Minimum Data Set), dated 9/29/22, shows discharged , return not anticipated, discharged to community. BIMS (Brief Interview for Mental Status) ( cognitive status) is blank, cognitive skills for daily decision making is 2 moderately impaired; other behavior not directed toward others, rejection of care. Section G for functional status shows R132 needs extensive assist with bed mobility,…

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 transfer and discharge policy and give a 30 day notice of plan to discharge to 1 resident (R132) reviewed for discharge notice in a sample of 133. Findings Include: R132 face sheets documents R132 has diagnosis of other seizures, hypothyroidism, essential hypertension, intraspinal abscess, pressure ulcer, end stage renal disease, anemia, personal history of venous thrombus, depression, history myocardial infraction, congestive heart failure, anxiety, GERD, vertigo, osteoporosis, chronic pain, and diabetes mellitus. On 10/17/22 at 3:59 PM, R132 said the social worker at the facility asked her if they could search her belongings, and she signed consent for the search. R132 said when searching her belongings, the facility said they found drugs in her belongings. R132 said that's when she told them they could no longer search her things, because she knew she did not have drugs, and she did not know what they was talking about, R132 said she…

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 resident assessments accurately reflect the resident's current status for 1 resident (R99) out of 3 reviewed for special treatments and programs in a sample of 133. Findings include: On 10/17/22 3:05 PM, V14 (Minimum Data Set/MDS coordinator) stated resident assessments are completed upon admission, quarterly, and with any significant change. V14 stated she reviews the resident's medical record for hospice orders. V14 stated she also receives an updated list of all residents in facility receiving hospice care from social services. V14 stated she does not recall if R99 is currently on hospice care. R99's MDS (Minimum Data Set), dated 9/1/22, was reviewed with V14. V14 stated it notes R99 is receiving hospice care. R99's POS reviewed with V14. V14 stated R99's order for hospice was discontinued on 3/10/22. V14 stated she will need to complete a modification of R99's assessments to remove hospice services. On 10/17/22 3:15 PM V12 (Director of Social Services) stated she has a binder with list of all residents currently…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a comprehensive care plan to incliude fall interventions and the use of psychopharmacologic medications. This affects 3 residents (R2, R90, and R99) out of three residents reviewed for care plans in a sample of 133. Findings include: 1. Review of R2's medical record, dated 8/18/22, notes R2 slid out of wheelchair onto floor. Review of R2's falls care plan, dated 5/6/22, notes R2 is at risk for falls related to abnormalities of gait and mobility. Intervention identified: R2 will be protected from injury/trauma. Review of R2's medical record, dated 6/7/22, notes R2 developed a wound on right distal first toe, full thickness. There is no documentation found in R2's medical record noting a care plan was developed related to R2's right toe wound or ADLs (activities of daily living). 2. Review of R99's medical record, dated 2/18/22, notes R99 was observed lying on the floor; unwitnessed fall. Review of R99's falls care plan, dated 6/9/22, notes R99…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop, coordinate, and initiate a safe discharge for a vulnerable dependent resident. This affected 1 of 3 residents (R132) reviewed for safe discharge. Findings include: R132's facility face sheet shows R132 has diagnosis of other seizures, hypothyroidism, essential hypertension, intraspinal abscess, pressure ulcer, end stage renal disease, anemia, personal history of venous thrombus, depression, history myocardial infraction, congestive heart failure, anxiety, GERD, vertigo, osteoporosis, chronic pain, and diabetes mellitus. R132's discharge MDS (Minimum Data Set), dated 9/29/22, shows, discharged , return not anticipated, discharged to community, BIMS ( cognitive status) is blank, cognitive skills for daily decision making is 2 moderately impaired, other behavior not directed toward others, rejection of care. Section G for functional status shows R132 needs extensive assist with bed mobility, transfers, locomotion on and off unit, dressing, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their discharge policy and supply the resident a discharge summary and or discharge records for continuity of care. This affects 1 resident (R132) reviewed for discharge summary. Findings nclude: Review of R132's care plan shows there is no plan of care noted for discharge planning. Review of R132's assessments shows there were no discharge plans noted for R132. R132's facility face sheet shows R132 has diagnosis of other seizures, hypothyroidism, essential hypertension, intraspinal abscess, pressure ulcer, end stage renal disease, anemia, personal history of venous thrombus, depression, history myocardial infraction, congestive heart failure, anxiety, GERD, vertigo, osteoporosis, chronic pain, and diabetes mellitus. R132's discharge MDS (Minimum Data Set), dated 9/29/22, shows discharged , return not anticipated, discharged to community, BIMS (Brief Interview for Mental Status) ( cognitive status) is blank, cognitive skills for daily decision…

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 and record review, the facility failed to follow physician orders for one residents (R93) wound treatment for a diabetic heel ulcer for one of three residents reviewed for wounds. Findings include: R93 was admitted to the facility on [DATE], with a diagnosis of type II diabetes, end stage renal disease and hypertension. R93 physician order, dated 10/4/22, documents: cleanse wound with normal saline. Apply calcium alginate and wrap with (gauze dressing) three times a week. R93 wound care note, dated 10/11/22, documents: diabetic wound to left heel measuring 0.5x1.2x0.1cm. Dressing treatment plan continue alginate calcium three times a week. On 10/16/22 at 11:56 AM, V10(Nurse) removed gauze dressing from R93 left heel. V10 said there was no other treatment to site. V10 said she applied gauze dressing to left heel on 10/15/22, but did not have access to any wound care supplies, and just wrapped the foot with gauze dressing.

Based on observation, interview, and record review, the facility failed to follow physician's orders for splint application and failed to develop interventions to reduce or prevent the decline in mobility. This affected 2 of residents (R81, R2) reviewed for range of motion. Findings include: 1. R81 Physician orde,r dated 12/15/202,1 documents: Apply left hand splint daily as tolerated. On in AM off in PM. On 10/16/22 at 11:35 AM, R81 was observed with a left contracted hand. R81's fingers were closed in a fist. R81, who was assessed to be alert and oriented, said, I am supposed to have a carrot in my hand. On 10/16/22 at 4:43 PM, V9 (Restorative Nurse) said, (R81) has a splint for his hand. We follow the doctors orders. (R81's) splint should have been in place. 2. On 10/18/22 12:20 PM, V15, PTA (Physical Therapy Assistant) stated R2 is not currently receiving skilled therapy. V15 stated R2 was discharged from skilled therapy because R2 had plateaued in therapy. V15 stated skilled therapy provides recommendations in writing to restorative therapy, as well as a copy is given 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 observations, interviews, and record reviews, the facility failed to follow their Oxygen Administration Policy by not administering oxygen rate as ordered by the physician. This affects one resident (R95) out of three residents reviewed for Respiratory Program. Findings Include: 1. R95's physician order includes Oxygen order with a start date of 3/12/22 reads: Oxygen: Trach Rate 6 liters per minute. Humidity 35%. Continuous: and Oxygen: Change tubing and mask weekly and PRN (as needed) (Label). On 10/16/22 at 10:45 AM, R95 was in bed. There was an Oxygen concentrator in room reading 5 liters per minute. On 10/16/22 at 10:50 AM, confirmed with V26 (Nurse) Oxygen level for R95 was at 5 liters per minute. V26 stated R95 was supposed to be on 6 liters per minute, as ordered by the attending physician. V26 observed adjusting oxygen concentrator from 5 liters per minute to 6 liters per minute. 2. R29's physician orders includes Oxygen order with a start date of 1/4/22 reads: Oxygen: Nasal Cannula, Rate Oxygen 3 liters per minute; And Oxygen: change tubing and mask weekly and PRN…

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 reconcile controlled medication for 3 of 3 (R78, R79 and R94) reviewed for labeling and storage. Findings Include: On 10/17/22 at 3:57PM, V24 (nurse), said, I gave (R79's) lorazepam 1mg tablet by mouth at 2pm. I forgot to sign the medication out of the controlled drug receipt form. Its twenty-five pills in (R79's) bingo pack. (R79's) controlled drug form documents twenty-six pills left. The amount written on the controlled drug receipt form and the actual pills in the bingo card should be the same number. On 10/17/22 at 4:03 PM, during medication cart review with V24, R78 was observed with twenty pills of clonazepam 0.5mg in the bingo card. R78's controlled drug receipt form documents nineteen pills left. R94 was observed with five pills of lorazepam 0.5mg pills in the bingo card. R94's controlled drug form document six pill left. On 10/17/22 at 4:25 PM, V3 (Assistant Director of Nursing/ADON) said, Pills should be signed out as given. The controlled drug receipt should match the same number of bills in the…

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

Based on interviews and record reviews, this facility failed to obtain informed consent noting diagnosis or reason for medication, dosage, frequency, side effects, and benefits/risks prior to initiating psychotropic medication usage and monitor the effectiveness or adverse consequences of psychotropic medications by monitoring AIMS (Abnormal Involuntary Movement Scale) every 6 months. This affected 1 of 4 residents (R94) reviewed for psychotropic medication usage in a sample 133 Findings include: Review of R94's medical record notes R94 with diagnoses including major depressive disorder, anxiety disorder, and schizophrenia. On 10/17/22 3:20 PM, V2 DON (Director of Nursing) stated psychotropic medication consents are obtained by the nurse prior to the initiation of any psychotropic medications. V2 stated the completed consents are uploaded into the resident's electronic medical record. On 10/18/22 at 2:00 PM, V19 (nurse supervisor) stated psychotropic medication consents are obtained from the family or resident, if alert enough, prior to administering psychotropic medications. V19…

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 there was a plan in place for a resident to recieve dental services. This affected 1 resident (R10) reviewed for dental services in a sample of 133. Findings include: On 10/16/22 at 11:01 AM, R49 was observed with broken lower bottom teeth, R49 said she has not seen the dentist. R49 said she would like to see the dentist. On 10/18/22 at 12:29 PM, V3 (Assistant Director of Nursing/ADON) said R49 has not seen the dentist and R49 is on the list to see the dentist. Request was made to review the facility dental list. V3 presented with a document, dated 10/18/22, showing the facility intends to see patients including R49, as monthly visits will be scheduled via our clinical scheduling department, and relayed to (facility) appointed dental contact people in social service. During this survey, the facility did not present any documentation or a schedule showing a date R59 is scheduled to see the dentist. R49 census shows R49 was admitted to facility on 1/28/2021. On 10/19/22 at 5:00 PM, V31 (Resident Liaison) said she is…

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 food preference of a resident. This affects one resident (R6) out of three residents reviewed for dietary services. Findings Include: On 10/16/22 at 12:30 PM, R6's lunch tray was served. R6's lunch tray had broccoli on R6's plate. R6 stated, They always give me broccoli, green beans or cauliflower with my meals, and it says on my diet card No Broccoli I swear, the staff don't read my diet card. On 10/16/22 at 12:32 PM, dietary ticket on R6's lunch tray had R6's name, room number, and diet orders written on it. Also written in the bottom portion of the dietary ticket, *No Broccoli-Cauliflower-Green Beans*. On 10/18/22 at 1:40 PM, V16 (Dietary Supervisor) stated, Dietary tickets will show resident's food preferences. Dietary ticket is placed on the meal tray of each residents for each meal. During tray line food preparation in the kitchen, dietary aide will review the dietary ticket prior to setting the meal tray. Dietary aide needs to follow what is written on the dietary ticket. A couple of dietary…

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

Based on observation, interview, and record review, the facility failed maintain an effective infection control practice by not following their Equipment Change Schedule Policy for Oxygen equipment, isolation policy, and glucometer cleaning policy. This affected 4 residents (R95, R29,R126, R93) reviewed for infection control in a sample of 133. Findings Include: 1. R95's physician order reports for active orders reviewed. Oxygen order, with a start date of 3/12/22 reads: Oxygen: Trach Rate 6 liters per minute. Humidity 35%. Continuous: and Oxygen: Change tubing and mask weekly and PRN (as needed) (Label). On 10/16/22 at 10:45 AM, R95 was in bed. Oxygen concentrator was in room. Oxygen water bottle (bubbler) connected to the oxygen concentrator machine does not have date written on it. Oxygen tubing connected to the bubbler to trach set up for R95 shows a written date of 9/28/22. On 10/16/22 at 10:50 AM, confirmed with V26 (Nurse) the date written on oxygen tubing was 9/28/22. 2. R29's physician order reports for active orders reviewed. Oxygen order, with a start date of 1/4/22…

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.