Eastview Healthcare & Senior Living

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the right to be free from physical abuse for two (R1, R2) of three residents reviewed for physical abuse from a total sample list of three residents reviewed for abuse. Findings include: The facility provided, Abuse Policy dated 2001 documents that abuse of any kind against residents is strictly prohibited. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Physical abuse includes, but is not limited to hitting, slapping, biting, punching or kicking. 1.) R1's undated diagnosis sheet documents the following diagnosis sheet includes: Unspecified Dementia with Agitation and Behavioral Disturbance, Anxiety, Alzheimer's Disease, Alcohol Abuse, Psychotic Disturbance, and Mood Disturbance. R1's Minimum Data Set, dated [DATE] documents that R1 is severely cognitively impaired. R1's care plan dated 11/8/24 documents impaired cognitive function…

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 thoroughly investigate an injury of unknown origin for one (R3) of three residents reviewed for injuries of unknown origin from a total sample list of four residents. Findings include: The facility provided Abuse Policy dated 2001 documents that bruising, including those found in unusual locations such as the head, neck, lateral locations on the arm, or posterior torso and trunk, or bruises in shapes such as finger prints are to be investigated. R3's undated diagnosis sheet documents the following diagnoses include: Unspecified Disorder of Psychological Development, Schizophrenia, Major Depressive Disorder, and Peripheral Vascular Disease. R3's care plan dated 3/7/24 documents that R3 will remain free of mistreatment or improper care and statements/allegations of mistreatment will be investigated including skin checks for physical marks or injury and interview persons assigned to R3's care. R3's Minimum Data Set, dated [DATE] documents that…

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 employ a full time Director of Nurses and failed to provide eight consecutive hours of Registered Nurse coverage for four of fourteen days reviewed. These failures have the potential to affect all 42 residents residing in the facility. Findings Include: Facility Nursing Staff Daily Assignment Sheets reviewed from 11/1/24 through 11/14/24 document four days (11/5/24, 11/8/24, 11/9/24, 11/10/24) that the facility failed to use the services of a Registered Nurse for at least eight consecutive hours. On 11/14/24 at 2:28 PM V2 Regional Administrator confirmed the facility currently has no Director of Nurses (DON) employed by the facility and the previous DON's last day was 9/18/24. V2 also confirmed there were four days since 11/1/24 that the facility did not have the required eight consecutive hours of Registered Nurse (RN) coverage. From 11/12/24 through 11/15/24 there was no DON observed working in the facility. The Long-Term Care Facility Application for Medicare and Medicaid dated 11/12/24 documents 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 interview and record review the facility failed to ensure required personnel attended the Quality Assessment and Assurance (QAA) committee meetings. This failure has the potential to affect all 42 residents in the facility. Findings Include: The January 2024 QAA meeting attendance signature sheet does not document the facility Director of Nursing or Infection Preventionist was present for the meeting. The April 2024, July 2024, and November 2024 QAA meeting attendance signature sheets do not document the facility Director of Nursing was present for any of these meetings. On 11/14/24 at 2:28 PM V2 Regional Administrator confirmed the facility's Quality Assessment and Assurance Committee meets at least quarterly and the required members include the facility Administrator, the Director of Nurses (DON), the Infection Preventionist (IP), the Medical Director or Designee, and two other staff members. V2 confirmed after review of the last four quarterly QAA sign in sheets, there was no DON present at any of the last four meetings and no IP present at the January 2024 meeting. 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 facility staff failed to don appropriate Personal Protective Equipment (PPE) while providing resident care and failed to prevent cross contamination during medication administration for three of three residents (R11, R26, R5) reviewed for Infection Control in a sample list of 22 residents. This failure has the potential to affect all 42 residents residing in the facility. Findings Include: 1.) R11's undated Face Sheet documents medical diagnoses as Dementia, Alzheimer's Disease and active COVID-19. R11's Physician Order Sheet (POS) dated November 2024 documents a physician order dated 11/10/24 for R11 to be placed on Droplet and Contact Isolation for positive COVID-19 test to end on 11/20/24. R11's Minimum Data Set (MDS) dated [DATE] documents R11 as cognitively intact. R26's undated Face Sheet documents medical diagnoses as Alzheimer's Disease and current COVID-19 infection. R26's Physician Order Sheet (POS) dated November 2024 documents a physician order…

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 specific medical conditions or symptoms necessitating the use of physical restraints, failed to assess safe use of restraints, and failed to release a physical restraint every two hours per plan of care. This failure affects two residents (R24, R28) of two reviewed for restraints in the sample list of 22. Findings Include: The facility policy titled Physical Restraint/Enabler Policy revised 7/24/18 documents physical restraints are any manual method or physical or mechanical device, equipment or material attached, or adjacent to the resident's body which the individual cannot remove easily and which restricts freedom of movement or normal access to his or her body. A device that may constitute a physical restraint may include, but is not limited to: bed rails, self-release waist restraints, soft waist restraints, lap top cushions, vest restraints, Geri-chair with tray table, arm restraints, leg restraints, personal alarms 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 provide timely incontinence care and incontinence care in accordance with facility standards for two of two residents (R22 and R10) reviewed for incontinence care in a sample list of 22 residents. Findings Include: The facility policy titled Perineal Cleansing reviewed 12/17 documents staff should wash pubic area including upper inner aspect of both thighs and frontal portion of perineum prior to washing resident buttocks and to dry areas thoroughly after cleansing. The basic infection control concept for perineal care is to wash from the cleanest to the dirtiest and remember to change or remove gloves and wash hands when going from working with contaminated items to clean items. 1.) R22's undated Face Sheet documents medical diagnoses as Dementia, Cognitive Communication Disorder, Acute Kidney Failure and Diabetes Mellitus Type II. R22's Minimum Data Set (MDS) dated [DATE] documents R22 as severely cognitively impaired. This same MDS…

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 properly store and date nebulizer tubing for one of one resident (R5) reviewed for oxygen in a sample list of 22 residents. Findings Include: The facility policy titled Nebulizer Therapy dated 10/07 documents staff should store Nebulizer tubing in a plastic bag and change mouthpiece tubing and nebulizer weekly. R5's undated Face Sheet documents medical diagnoses as Dementia, Intellectual Disabilities, Chronic Obstructive Pulmonary Disorder (COPD), Glaucoma, Chronic Systolic Heart Failure, Dependence on Wheelchair and Need for Assistance with Personal Care. R5's Minimum Data Set (MDS) dated [DATE] documents R5 as cognitively intact. R5's Physician Order Sheet (POS) dated November 2024 documents a physician order for Oxygen at 3 Liters (L)/minute via nasal cannula continuously. This same POS documents a physician order dated 8/21/24 to Change Hand Held Nebulizer (HHN)Tubing, reservoir and Respiratory bag weekly and as needed (PRN) when 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 ensure therapy services were provided for five (R1, R2, R3, R4 and R5) of five residents reviewed for therapy services from a sample list of five residents. Findings include: On 3/20/24 at 12:55PM, V1 Administrator stated, Therapy's last day in this building was February 19, 2024. We are supposed to have a new company starting later this week. On 3/20/24 and 3/21/23, there no therapy providers were in the facility and no residents were receiving therapy services. 1.) R3's progress notes document that R3 was admitted to the facility on [DATE]. R3's physician orders dated 2/7/24 document orders for speech, occupational and physical therapy services. R3's therapy orders dated 2/8/24 document speech therapy to be done five times a week for four weeks. R3's occupational therapy notes dated 2/8/24 document occupational therapy to be done five times a week for four weeks. R3's physical therapy order dated 2/15/24 document physical therapy to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to employ a Registered Nurse to serve as full time Director of Nurses. This failure has the potential to affect all 45 residents who reside in the facility. Findings Include: On 12/6/2023 at 12:50 PM, V1 Administrator confirmed the facility does not currently employ a Registered Nurse to serve as full time Director of Nurses. Upon survey entrance and throughout the survey (12/6/23- 12/14/23) there was no Director of Nurses present and/or employed by the facility. The facility's Facility assessment dated [DATE], documents a full time Director of Nurses is required in order to meet the resident's needs and provide support and care for the facility's resident population. The facility's Room Roster/Census given on 12/6/2023 documents 45 residents currently reside in the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to properly transfer one resident (R1) of three residents reviewed for falls on the sample list of five. Finding include: R1's undated Face Sheet document R1's diagnoses as Alzheimer's Disease, Fracture of unspecified part of neck of unspecified femur, subsequent encounter for closed fracture with routine healing, methicillin resistant staphylococcus aureus infection as the cause of disease classified elsewhere, Neuralgia and Neuritis, Radiculopathy, R1's admission Minimum Data Set (MDS) dated [DATE], documents R1 has short/long term memory impairment, and totally dependent with two or more staff for assistance with bed mobility, transfers, and toileting. R1's Computerized Tomography (CT) dated 7/5/23, results documents: comminuted (broken in at least two places, a severe trauma due to serious trauma like falls from a high place, creates shatter-like breaks) fracture of right femur involving portions of the neck, intertrochanteric region, and proximal…

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 implement infection control during incontinent care. The facility also failed to properly clean a wound for one resident (R2), of three residents reviewed for infection control in the sample list of five. Findings include: R2's undated Face Sheet documents R2's diagnoses as: Urinary Tract Infection, Diabetes Mellitus Type II, Peripheral Arterial Disease. R2's Wound Evaluation and Management Summary dated 11/2/23, documents a diabetic wound of the right, first toe full thickness and a diabetic wound of the right distal, plantar. lateral foot. R1's Physician Order Sheet (POS) dated 12/2023, documents treatments as: right lateral foot, apply foam and tape to area three times a week; and right first toe, apply two by two gauze soaked with Betadine (Antiseptic) solution, then cut an abdominal (dressing) pad to size and gauze wrap twice a day. On 12/6/23 at 1:15 PM, V2 Licensed Practical Nurse (LPN) performed a treatment to R2's right foot and toe. At this same time, V2 stated R2 had foot drop and R2's toe 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.

Based on observation, interview, and record review the facility failed to employ a full time Director of Nursing and staff a Registered Nurse for eight consecutive hours a day. This failure has the potential to affect all 44 residents residing in the facility. Findings include: The facility's Long Term Care Application for Medicaid and Medicare form dated 10/23/23 and signed by V1 Administrator documents there are 44 residents residing in the facility. On 10/22/23, 10/23/23, and 10/24/23 from 8:30 AM to 4:00 PM there was not a Director of Nursing working in the facility. The facility's nursing schedules dated September 2023 and October 2023 do not document that a Registered Nurse worked for 8 consecutive hours on 9/26/23, 9/29/23, 10/1/23, 10/2/23, 10/10/23, 10/15/23, 10/16/23, 10/20/23, 10/23/23, or 10/24/23. On 10/24/23 at 9:15 AM, V1 Administrator stated there has not been a full time Director of Nursing since 9/15/23. V1 confirmed there was not a Registered Nurse working for 8 consecutive hours per day on 9/26/23, 9/29/23, 10/1/23, 10/2/23, 10/10/23, 10/15/23, 10/16/23,…

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

Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services and failed to employ a person-in-charge (PIC) with the required Food Protection Manager Certification. These failures have the potential to affect all 44 residents in the facility. Findings include: On 10/23/2023 at 10:46 AM, V7 (Dietary Manager) was actively supervising dietary operations in the facility kitchen. V7 reported being the full-time manager of the facility food service (PIC) and reported not being a clinically qualified Certified Dietary Manager or having equivalent training. V7 also denied being a certified Food Protection Manager, as required, and denied any other dietary staff were certified Food Protection Managers. V7 denied: -being a dietician; -being a certified dietary manager; -having an associate's or higher degree in food service management or in hospitality; -having 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting; -being a graduate of a dietetic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to complete Psychotropic medication assessments and care plan targeted behaviors and interventions for five of five residents (R35, R9, R24, R46, R13) reviewed for Unnecessary medications in the sample list of 29. Findings include: 1.) R35's Order Summary Report dated 10/23/23 documents diagnoses including Unspecified Dementia, Unspecified Severity with Agitation, Alzheimer's Disease, Bipolar Disorder, Anxiety Disorder, Metabolic Encephalopathy, Epilepsy and Major Depressive Disorder. This Order Summary Report documents orders for Haloperidol (antipsychotic) 1 mg (milligram) tablet two times a day related to Bipolar Disorder, Seroquel Tablet (antipsychotic) 25 mg give 6.25 mg at bedtime related to Bipolar Disorder and Anxiety Disorder, and Trazodone (antidepressant) 100 mg one tablet in the evening related to Major Depressive Disorder. R35's electronic medical record did not contain any psychotropic medication assessments and R35's paper chart did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to obtain a new PASARR (Pre-admission screening and resident review) screening when a change in behaviors occurred for one (R46) of four residents reviewed for PASARR on the sample list of 29. Findings include: R46's PASARR screening dated 7/19/23 documents R46 has a diagnosis of Dementia and that R46 has no mental health conditions and is not receiving antidepressants, mood stabilizers, antipsychotics, or other mental health medications prescribed currently or in the last six months for mental health. This form documents a level two is not required. This form documents, There is no evidence of a PASARR condition of an intellectual/developmental disability or a serious behavioral health condition. If changes occur or new information refutes these findings, a new screen must be submitted. R46's Electronic Health Record (EHR) documents R46 was admitted to the facility on [DATE]. R46's EHR documents a physician order dated 10/20/23 for Haloperidol Lactate…

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 that a Preadmission Screening and Resident Review (PASARR) level II screening was completed for one (R1) of four residents reviewed for PASARR level II screenings, from a total sample list of 29. Findings Include: R1's level I PASARR dated 8/24/04, documents that a level II PASARR is required due to R1's history of depression with electric shock therapy treatments and inpatient psychiatric hospitalizations. R1's undated diagnosis sheet documents diagnoses of Schizophrenia, Anxiety and Major Depression. R1's October 2023 physician order sheet documents the following psychotropic medications: Risperidone .25 milligrams (mg), to be given six of seven days for schizophrenia, Sertraline 50 mg daily to be given for major depression, Lorazepam .25 mg to be given twice daily for anxiety and Buspar 10 mg to be given twice daily for anxiety. On 10/23/23 at 1:45 PM, V1 Administrator stated, We can't find the Level II PASARR for (R1) and they are saying it wasn't done. She should have had it done.

Based on observation, interview and record review the facility failed to develop a comprehensive care plan for contractures for one of 15 residents (R35) reviewed for care plans on the sample list of 29. Findings include: R35's Occupational Therapy Plan of Care report dated 12/9/21 documents treatment diagnoses including Right Elbow Contracture, Left Elbow Contracture, Right Wrist Contracture, Left Wrist Contracture, Right Hand Contracture and Left Hand Contracture. This report documents a goal of R35 using a resting hand splint for contracture prevention. R35's electronic care plan initiated 6/15/23 does not document any contracture diagnoses nor does it document any contracture as a concern or interventions to prevent decline. On 10/22/23 at 9:08 AM, R35 was in R35's room in R35's wheelchair leaning over the lap cushion. R35's hands were clinched closed and no cushions were in R35's hands but there was one of the cushions on top of the dresser. On 10/22/23 at 12:02 PM, V20 R35's family stated R35's hands are so contracted that V20 is not sure if they can even clean them. V20…

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

Based on interview and record review the facility failed to provide discharge planning to one (R47) of one residents reviewed for discharge planning from a total sample list of 29 residents. Findings include: The facility provided undated transfer and discharge policy documents that the facility and the physician are required to document regarding discharge in the resident's clinical record. R47's undated census sheet documents that R47 discharged from the facility on 10/13/23. R47's medical record does not contain an order for discharge, discharge goals, a discharge plan or R47's needs at the time of discharge. On 10/24/23 at 1:34PM, V1 Administrator said that she thought she recalled R47 wanting to go home but that she could not find any documentation related to the discharge.

Based on interview and record review the facility failed to develop a discharge summary for one (R47) of one residents reviewed for discharge planning from a total sample list of 29 residents. Findings include: The facility provided undated transfer and discharge policy and procedure documents that the facility and the physician are required to document regarding discharge in the resident's clinical record. R47's undated census sheet documents that R47 discharged from the facility on 10/13/23. R47's medical record does not contain a physician's order for discharge, a discharge summary, a reconciliation of medications or plans for outpatient services. R47's discharge summary from physical therapy services dated 10/12/23 documents that R47 had not performed car transfers and is to have outpatient therapy services. On 10/24/23 at 1:34PM, V1 Administrator stated that she thought that R47 was supposed to have outpatient therapy and that there should be discharge information documented in the medical record, but that she was unable to locate any information except the physical therapy…

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

Based on observation, interview, and record review the facility failed to address and implement interventions for a decline in the ability to communicate for one (R23) of 16 residents reviewed for communication on the sample list of 29. Findings include: On 10/23/23 at 10:35 AM, R23 was sitting in the lobby of the facility. R23 could not hear when he was spoken very loudly to. R23 yelled I don't have my hearing aides and I can't hear nothing. I never got them back. I need them. On 10/23/23 at 10:35 AM, V9 Certified Nurse's Assistant stated R23 would be interviewable however the hospital lost his hearing aides a couple months ago. V9 stated R23's glasses are also missing. V9 stated R23 can't communicate with them. On 10/23/23 at 3:33 PM, V12 Transport stated R23 has an internal implant and a processor and when he went to the hospital in July the hearing aide/processor went missing. R23's Health Status Note dated 7/8/2023 at 4:59 AM documents, (R23) agitated this shift due to not having hearing aide. On 10/23/23 at 11:30 AM, V11 Certified Nurse's Assistant stated it's been two or…

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 adaptive equipment to prevent further reduction in Range of Motion for one of one resident (R35) reviewed for Range of Motion in the sample list of 29. Findings include: R35's Occupational Therapy Plan of Care dated 12/28/21 documents diagnoses of Right Elbow Contracture, Left Elbow Contracture, Right Wrist Contracture, Left Wrist Contracture, Right Hand Contracture and Left Hand Contracture. R35's Minimum Data Set (MDS) dated [DATE] documents no impairment in range of motion. R35's MDS dated [DATE] documents no impairment in range of motion. On 10/22/23 at 12:02 PM, V20 R35's family stated that R35's hands are contracted and R35 is supposed to have a hand contracture cushion in both hands but V20 has not seen them in R35's hands for at least a couple of weeks. On 10/22/23 at 9:08 AM, R35 was in R35's room in R35's wheelchair leaning over the lap cushion. R35's hands were clinched closed and no cushions were in R35's hands but there…

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

Based on observation, interview, and record review, the facility failed to elevate the head of bed during enteral feeding and failed to completely transcribe a dietician's enteral feed orders. This failure affects one resident (R13) of one reviewed for enteral feeding in the sample list of 29. Findings include: 1. R13's medical diagnosis list (10/23/2023) documents R13's diagnoses include: Gastro-Esophageal Reflux Disease, Hemiplegia (paralysis of one side of the body), Hemiparesis (weakness on one side of the body), Stroke, Asthma, Chronic Obstructive Pulmonary Disease, Epilepsy (seizure disorder), and Muscle Weakness. R13's comprehensive assessment (7/12/2023) documents R13 requires extensive assistance or is totally dependent on staff to complete all activities of daily living. R13's Physician Orders (10/23/2023) document R13 receives nutrition via enteral feed. R13's Care Plan (10/23/2023) documents R13's head of bed needs to be elevated to 45 degrees during and thirty minutes after receiving enteral feed. On 10/22/2023 at 10:07 AM, R13 was in bed receiving enteral feed solution…

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 oxygen therapy as ordered for one (R1) of one residents reviewed for oxygen therapy on the sample list of 29. Findings include: The facility provided oxygen therapy policy dated 3/2019 documents that oxygen is administered to promote adequate oxygenation and to provide relief of symptoms of respiratory distress. If humidification is indicated, date the prefilled bottles when changed. R1's physician order sheet dated 3/15/23 documents an order for oxygen at three liters per nasal cannula with tubing and humidification changes weekly and as needed. On 10/22/23 at 10:15 AM, R1's concentrator is running at 4 liters per nasal cannula and the humidification bottle is dated 10/12/23. On 10/23/23 at 9:18 AM, R1's concentrator is running at 3 liters per nasal cannula, R1 is lying in bed and R1's water bottle is dry and dated 10/12/23. On 10/24/23 at 1:20 PM, R1 was wearing a nasal cannula in her bedroom with oxygen running at 3 liters per nasal cannula and the water bottle continues to be dry with the 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 interview and record review the facility failed to address a pharmacy recommendation for one (R46) of five residents reviewed for unnecessary medications on the sample list of 29. Findings include: The facility's Pharmacy Consultation Summary report dated 9/20/23 documents a recommendation for R46 for, Valproic Acid (Divalproex Sodium) containing product; monitor SDC (Serum Depakote Concentration). On 10/24/23 at 10:47 AM, V13 sister facility Administrator stated R46's pharmacy recommendation to draw a Depakote level was not addressed by the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to prevent potential cross contamination by failing to perform hand hygiene and change gloves during incontinence care and failing to maintain clean linens for two of two residents (R31, R35) reviewed for incontinence care in the sample list of 29. Findings include: The facility's Perineal Cleansing policy with a reviewed date of December 2017 documents, Policy: To eliminate odor; to prevent irritation or infection and to enhance resident's self-esteem. Note: The basic infection control concept for peri-care (perineal-care) is to wash from the cleanest to the dirtiest area and remember to change or remove gloves and wash hands when going form working with contaminated items to clean items. 1.) R31's Order Summary Report dated 10/24/23 documents diagnoses including Acute Kidney Failure with Tubular Necrosis and Urinary Tract Infection. R31's Minimum Data Set (MDS) dated [DATE] documents R31 is cognitively intact, requires extensive assistance…

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

Based on interview and record review the facility failed to provide education for and offer Pneumococcal vaccines for two of five residents (R23, R24) reviewed for vaccinations on the sample list of 29. Findings Include: 1.) R23's Care Plan with a revised date of 9/6/23 documents diagnoses including Neurocognitive Disorder with Lewy Bodies, Dementia, Parkinson's Disease, Generalized Epilepsy, Morbid Obesity and Cochlear Implant Status. There is no documentation in R23's medical record of Pneumococcal vaccination history or that the facility provided education regarding the Pneumococcal vaccine, offered the vaccine, or that the vaccine was given or declined. 2.) R24's Order Summary Report dated 10/24/23 documents diagnoses including Dementia, Disorder of Thyroid, Cardiomegaly and Chronic Kidney Disease. There is no documentation in R24's medical record of Pneumococcal vaccination history or that the facility provided education regarding the Pneumococcal vaccine, offered the vaccine, or that the vaccine was given or declined. On 10/24/23 at 1:18 PM, V13 Sister Facility Administrator…

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 maintain resident bed side rails in a safe condition. This failure affects two residents (R4, R40) of two reviewed for bed side rails in the sample list of 29. Findings include: R4's medical diagnosis list (10/24/2023) documents R4's diagnoses include: Hemiplegia (paralysis of one side of the body), Hemiparesis (weakness on one side of the body), Stroke, Epilepsy (seizure disorder), and Reduced Mobility. R4's comprehensive assessment (9/6/2023) documents R4 has impaired range of motion in upper and lower extremities and has severely impaired cognition. R4's Physician Orders (10/24/2023) document R4 receives the medication Levetiracetam to prevent seizures. R4's Care Plan (10/24/2023) documents R4 utilizes half-length bed side rails for mobility and staff should observe for injury or entrapment related to the side rail use and to reposition as needed to avoid injury. R40's medical diagnosis list (10/24/2023) documents R40's diagnoses include: Dementia and Muscle Weakness. R40's Physician Orders (10/24/2023)…

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 protect the resident's right to be free from physical abuse by another resident for four of four residents (R3, R4, R1 and R2) reviewed for abuse on the sample list of 9. Findings include: 1. R3's Physician Order Summary Report Sheet (POS) dated 9/15/23 documents the following diagnoses: Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance Psychotic Disturbance Mood Disturbance, Other Reduced Mobility, Dependence On Wheelchair, and Major Depression Disorder. R3's Minimum Data Set (MDS) dated [DATE] documents R3's Brief Interview of Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. The same MDS documents R3 uses a wheelchair and requires supervision and set-up for locomotion on and the unit. The same MDS documents R3 has had no behaviors toward self or others. R4's POS dated 9/15/23 documents the following diagnoses: Unspecified Dementia, Unspecified Severity With Agitation. R4'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 record review and interview the facility failed to maintain complete medical records by failing to document resident physically abusive behaviors toward another resident for one of four residents (R2) reviewed for behavioral tracking on the sample list of nine. Findings include: R2's Care Plan documents a Focus area of concern initiated 8/7/23 as follows: Behavior: Physical Aggression. The resident is/has potential to be physically aggressive r/t (related to) poor impulse control. R2's Behavior Monitoring and Intervention Report documents R2's behaviors and interventions are tracked 9/1/23-9/15/23. There are no behaviors documented 9/1/23 - 9/13/23 on any shift. This includes the following witnessed physical abuse documented below. On 9/15/23 at 1:20 pm V14, Agency LPN stated regarding 9/3/23 allegation I was in the hall just outside the dining room, with my med cart. (R1) was seated in her reclined (geriatric) chair up against the adjacent wall. (R2) was propelling his wheel chair down the middle of the same hall. (R1) was yelling she was ready to eat. (R1) yells, has…

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 protect a resident's right to be free from staff to resident verbal/mental abuse. This failure affected four of five residents (R2, R3, R5, R7) reviewed for staff mistreatment in the sample of nine. Findings Include: The facility's Abuse Prevention Program dated May 2021 documents the facility affirms the rights of the residents to be free from abuse. The policy defines verbal abuse as the use of language that willfully includes disparaging or derogatory terms to residents or within their hearing distance regardless of their age, ability to comprehend, or disability. 1. R2's Medical Diagnoses dated August 2023 documents R2 is diagnosed with Profound Intellectual Disabilities, Cerebral Palsy, Anxiety, Obsessive Compulsive Disorder, Depression, Need for Assistance with Personal Care, and Reduced Mobility. R2's Minimum Data Set, dated [DATE] documents R2 is severely cognitively impaired. The Facility Final Investigation Report dated 8/2/23 documents 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 immediately report alleged staff to resident verbal/mental abuse to the administrator. This failure affected three of five residents (R2, R5, R7) reviewed for staff mistreatment in the sample of nine. Findings Include: The facility's Abuse Prevention Program dated May 2021 documents the facility affirms the rights of the residents to be free from abuse. The policy defines verbal abuse as the use of language that willfully includes disparaging or derogatory terms to residents or within their hearing distance regardless of their age, ability to comprehend, or disability. The policy documents employees are required to immediately report any potential or alleged abuse to their supervisor and administrator. 1. R2's Medical Diagnoses dated August 2023 documents R2 is diagnosed with Profound Intellectual Disabilities, Cerebral Palsy, Anxiety, Obsessive Compulsive Disorder, Depression, Need for Assistance with Personal Care, and Reduced Mobility. R2's Minimum…

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

Based on interview and record review, the facility failed to provide the required eight hours of Registered Nurse staffing coverage per 24-hour period for three of thirteen days reviewed for staffing and failed to employ a qualified Director of Nursing. These failures have the potential to affect all 49 residents in the facility. Findings include: Daily Assignment Sheets (August 2022) document the facility did not have any Registered Nurse working anytime on 9/3/2022, 9/4/2022, and 9/10/2022. On 9/13/2022 at 11:23AM, V1 (Administrator) reported V2 is not a Registered Nurse but is the full-time Director of Nursing for the facility. On 9/14/1022 at 10:54AM, V2 reported working at the facility since May 2022 as the Director of Nursing and reported being a Licensed Practical Nurse and not a Registered Nurse as required to be fully qualified for the Director of Nursing position. V2 reported the facility did not have any Registered Nurse working in the facility on 9/4/2022 and 9/10/2022. On 9/14/2022 at 1:47PM, V2 reported the facility did not have a Registered Nurse working 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 interview and record, the facility Quality Assessment and Assurance (QAA) committee failed to document the identification of quality deficiencies and the facility's efforts to correct those issues in the facility. This failure has the potential to affect all 49 residents in the facility. Findings include: On 9/13/2022 at 11:25AM, V1 (Administrator) provided two attendance sheets (4/14/2022 and 7/6/2022) for the previous year's QAA meetings. V1 was not sure what, if any, facility issues had been identified for improvement by the QAA meeting during the previous year. On 9/14/2022 at 1:29PM, V1 could not locate any additional documentation of what issues the facility has brought to the QAA committee to improve or resolve in the facility. The facility Resident Census and Conditions of Residents report (9/11/2022) documents 49 residents reside in the facility.

Based on interview and record review, the facility failed to complete required quarterly Quality Assessment and Assurance (QAA) committee meetings and failed to ensure required personnel attended the QAA committee meetings. This failure has the potential to affect all 49 residents in the facility. Findings include: On 9/13/2022 at 11:25AM, V1 (Administrator) provided two attendance sheets (4/14/2022 and 7/6/2022) for the previous year's QAA meetings. V1 reported being unsure if the facility had completed more QAA meetings in the previous year than represented on the two signature sheets. The April 2022 QAA meeting attendance signature sheet does not document the facility Director of Nursing was present for the meeting. On 9/14/2022 at 10:45AM, V1 reported the facility is unable to document any additional QAA meetings than above or any issues brought to any QAA meetings. The facility Resident Census and Conditions of Residents report (9/11/2022) documents 49 residents reside in the facility.

Based on interview and record review, the facility failed to respond to a resident council complaint concerning a wandering resident (R6) for four of four residents (R24, R2, R17, R14) reviewed for grievances on the sample list of 29 residents. Findings include: Resident Council Minutes (June 3, 2022) document R24 presented a complaint of R6 wandering into R24's room and another instance where R24 was getting dressed and R6 wandered into R24's room. Resident Council Minutes (July 1, 2022 and August 1, 2022) do not document any follow-up to R24's complaint from the June, 2022 Resident Council meeting. On 9/12/2022 at 9:13AM, R2, R14, R17, and R24 all reported R6 frequently wanders throughout the facility. R17 reported R6 wanders around the facility, into other resident's rooms, and has got on R17's bed before. R14 reported R6 has wandered into R14's room twice. R24 reported a resident laid on R24's bed on 9/11/2022 and also urinated on the bed. On 9/13/2022 at 3:0PM, V10 (Activities Director) reported being the facility grievance official who took R2, R14, R17, and R24's complaints…

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 ensure that one resident (R16) was not subjected to physical abuse by another resident (R18). R16 and R18 are two of two residents reviewed for abuse in a sample list of 29 Findings include: R18's Physician's Order Sheet (POS) for 9/1/22 to 9/30/22 includes the following diagnoses: Depression, Anxiety, and Dementia with Psychosis. R18's Care Plan updated 9/11/22 documents Specific behaviors: Verbal Aggression, Physical Aggression, Tearfulness, Wandering, Toileting in inappropriate areas, Refusal of Care, Rummaging through other's belongings, and yelling. R18's Minimum Data Set (MDS) dated [DATE] documents R18 is severely cognitively impaired and has hallucinations, delusions, physical and verbal behaviors directed toward others, wandering, and other behaviors. R16's Physician's Order Sheet (POS) for 9/1/22 to 9/30/22 includes the following diagnoses: Chronic Severe Cardiovascular Disease, Type II Diabetes, Major Depression, Mild Neurocognitive Disorder,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to obtain physician's orders and assess for the use of physical restraints for three of three residents (R100, R8, R20) reviewed for restraints in the sample list of 29. Findings include: The facility's Physical Restraint/Enabler policy with a revised date of 8/18/11 documents, To allow residents to be free of physical restraints which are not required to treat the resident's medical symptoms or as a therapeutic intervention. Physical restraints shall not be used for the purpose of discipline or convenience. Physical restraints is any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body, which the individual cannot remove easily and which restricts freedom of movement or normal access to one's body. They include, but are not limited to: bed rails, self-release waist restraints, soft waist restraints, lap top cushions, vest restraints, (reclining geriatric) chair with tray table, arm…

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's Order for an indwelling urinary catheter, failed to obtain an order to change and maintain an indwelling catheter and failed to prevent possible cross contamination by failing to keep the indwelling urinary catheter drainage tubing off the floor for one of one resident (R100) reviewed for catheters in the sample list of 29. Findings include: The facility's Urinary Drainage Collection Unit policy with a revised date of 2/2018 documents, Purpose: To provide a sterile collection unit for urinary drainage to minimize entry of bacteria into the bladder. 10. Hang the urinary drainage unit below the bladder level, not touching the floor. R100's Physician Order Sheet (POS) dated 9/1/22 through 9/30/22 documents R100 was admitted on [DATE]. This POS does not document an order for an indwelling urinary catheter use or an order to change and maintain an indwelling urinary catheter. R100's Care Plan dated 8/24/22 documents R100 has…

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 assess a resident for risk of entrapment prior to installing half side rails for one of two residents (R42) reviewed for side rails in the sample list of 29. Findings include: 1.) R42's Physician Order Sheet (POS) dated 9/1/22 through 9/30/22 documents diagnoses including History of Falls, Syncope, Dementia with Behavior Disturbances, Dizziness and Insomnia. R42's Minimum Data Set (MDS) dated [DATE] documents R42 is severely cognitively impaired and requires limited assistance of one staff for bed mobility and extensive assistance of one staff for transfers. R42's Care Plan does not document the use of a side rail. On 9/11/22 at 9:50 AM, R42's bed had a left side rail up, it was loose and was able to be pulled back and forth easily. This side rail had one bar that ran horizontally through the middle and had approximately a 4 inch space above and below the horizontal bar that ran the length of the half side rail. R42's medical record does…

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 resident specific behavioral interventions for one resident (R6) who wanders into other residents' rooms and walks in public areas disrobed. R6 is one of one residents reviewed for unsafe wandering in a sample list of 29 residents. Findings Include: R6's Physician's Orders Sheet (POS) for September 1, 2022 through September 30, 2022 includes the following diagnoses: Bipolar Disorder, Dementia with aggressive behavior, Parkinson's Disease, Anxiety, and major depression. R6's Minimum Data Set (MDS) dated [DATE] documents R6 is severely cognitively impaired and has Hallucinations, Delusions, wanders, and has other behavioral symptoms. R6's Care Plan updated 9/7/22 does not include interventions for wandering. On 9/12/22 at 10:30AM R6 was walking down west hall with no clothes from the waist down exposing his genitals and buttocks. On 9/12/22 at 2:00PM R6 was wandering down east hall going in and out of other resident's rooms. 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 interview and record review the facility failed to obtain informed consent, assess and care plan for the use of psychotropic medications for one resident (R8) of five residents reviewed for psychotropic medications in a sample list of 29 residents. Findings include: R8's Physician's Order Sheet (POS) for September 1,2022 through September 30, 2022 includes the following diagnoses: Dementia with Psychosis, Alzheimer's Disease, Agitation, Anxiety, Depression, Altered Mental Status, and History of Falls. R8 has current physician's orders for the following psychotropic medications: Divalproex (mood stabilizer) 125 mg twice daily. Risperdal (antipsychotic) 0.25 mg twice daily. Trazadone (antidepressant) 50 mg at bed time. R8's Minimum Data Set (MDS) dated [DATE] documents R8 is severely cognitively impaired, has delusions, hallucinations, and behaviors directed toward others. There is no documentation of informed consents for R8's use of Divalproex or Trazadone. R8's most recent Psychotropic 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 appropriately install, inspect for areas of entrapment and maintain side rails for two of two residents (R42, R15) reviewed for side rails in the sample list of 29. Findings include: 1.) R42's Physician Order Sheet (POS) dated 9/1/22 through 9/30/22 documents diagnoses including History of Falls, Syncope, Dementia with Behavior Disturbances, Dizziness and Insomnia. On 9/11/22 at 9:50 AM, R42's bed had a left side rail up, it was loose and was able to be pulled back and forth easily. This side rail had one bar that ran horizontally through the middle and had approximately a 4 inch by 2 1/2 foot space above and below the horizontal bar that runs the length of the half side rail. As the side rail was pulled away from the mattress it created a gap between the mattress and the side rail of approximately 3 to 4 inches wide. 2.) R15's Physician Order Sheet dated 9/1/22 through 9/30/22 documents diagnoses including Mental Retardation, Parkinson's Disease, Morbid Obesity, Dementia and Seizure Disorder. On 9/11/22 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.