Allure Of Walnut

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to perform a PASARR (Pre-admission Screening and Resident Review) rescreen after the emergence of a newly diagnosed severe mental illness for two of three residents (R4, R27) reviewed for PASARR screening, in the sample of 24. Findings include: The (undated) facility policy, Resident Assessment- Coordination with PASARR (Pre-admission Screening and Resident Review) Program directs staff, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability or a related condition receives care and services in the most integrated setting appropriate to their needs. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. 1. R4's (facility) Face…

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 a PASARR (Preadmission Screening and Resident Review) Level II screening was completed for one of three residents (R31) reviewed for PASARR screenings in the sample of 24. Findings include: The facility's Resident Assessment- Coordination with PASARR (Preadmission Screening and Resident Review) policy documents the following: All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. This same policy documents, Positive Level I Screen- necessitates a PASARR Level II evaluation prior to admission. This policy also documents, The Level II resident review must be completed within 40 calendar days of admission. R31's medical record documents R31's current diagnoses to include: Psychotic Disorder with Hallucinations due to known Physiological Condition; Anxiety Disorder; and Major Depressive Disorder. R31's medical…

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, observation and record review, the facility failed to ensure a pressure ulcer treatment was completed as ordered for one of two residents (R31) reviewed for pressure ulcers in the sample of 24. Findings include: The facility's Wound Treatment Management policy (dated 2024) documents the following; Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. R31's Wound Evaluation and Management Summary (dated 04/22/25) documents the following after V8 (Wound Physician) examined R31 on 04/22/25: Stage III pressure wound of the left sacrum full thickness. Surgical Excisional Debridement Procedure: The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, curette was used to surgically excise 3.70 square centimeters of devitalized tissue including slough, biofilm and non-viable subcutaneous level tissues were removed at a depth of 0.2 centimeters and healthy bleeding tissue was observed. This same…

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, observation and record review, the facility failed to ensure a range of motion program was implemented for a resident with functional limitations for one of four residents (R31) reviewed for range of motion in the sample of 24. Findings include: R31's Medical Record documents R31's current diagnoses to include: Parkinson's Disease with Dyskinesia; Adult Failure to Thrive, and Chronic Pain. R31's Minimum Data Set Assessment (dated 03/13/25) documents the following in Section GG: R31 has impairment on both sides of his lower extremities. R31's Restorative Observations form (dated 03/13/25) documents the following: R31 has mild (75% of normal) state of mobility in his neck, left hip, right hip, left ankle, and left foot; R31 has moderate (50% of normal) state of mobility in his left knee, right knee, right ankle, and right foot. On 04/21/25 at 01:40 PM, R31 was sitting reclined in a high-back reclining chair in the hallway near his room with a fall alarm in place. R31 was wearing glasses and non-slip socks. A wheelchair cushion with a raised, padded section 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, observation and record review, the facility failed to ensure tubing for an enteral tube feeding was dated, and items utilized during a tube feeding remained clean for one of two residents (R1) reviewed for tube feedings in the sample of 24. Findings include: The facility's Care and Treatment of Feeding Tubes policy (dated 2024) documents, It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. This policy also documents, Use of infection control precautions and related techniques to minimize the risk of contamination. R1's current Physician's Orders document the following nutritional order: Jevity (nutritional feeding) 1.2 kilocalories per milliliter give 85 milliliters per hour via gastrostomy tube in the evening. Run at 85 milliliters per hour for 16 hours and remove per schedule. R1's current Care Plan documents the following focus: (R1) requires a tube feeding related to dysphagia due to a stroke. She is NPO (nothing by mouth). 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 implement specific PTSD/Post Traumatic Stress Disorder interventions for one of one (R27) residents reviewed for Post Traumatic Stress Disorder in a sample of 24. Findings include: The facility's Trauma Informed Care policy, undated, documents it is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatizing. This form documents that trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being. R27's current Face Sheet documents the following diagnosis: Insomnia, Delusional Disorder, Post-Traumatic Stress Disorder, Dementia, unspecified severity, with…

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

Based on interview, observation, and record review, the facility failed to ensure Enhanced Barrier Precautions were implemented prior to administering cares for two of eight residents (R31 and R41) reviewed for Transmission Based Precautions in the sample of 24. Findings include: The facility's Enhanced Barrier Precautions policy (dated 2025) documents the following: It is the policy of this facility to implement Enhanced Barrier Precautions for the prevention of transmission of multi-resistant drug organisms. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug resistant organisms that employs targeted gown and gloves use during high contact resident care activities. This policy also documents, High-contact resident care activities include: Dressing; Bathing, Transferring; Providing hygiene; Changing linens; Changing briefs or assisting with toileting; Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC (peripherally inserted central…

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 prevent an incident of resident to resident physical abuse, re-assess resident's risk for abuse and revise abuse care plans after founded physical abuse occurred for two of three residents (R1, R2) reviewed for abuse in the sample of three. Findings include: The facility's Abuse, Neglect and Exploitation policy, dated 8/2024, documents It is the policy of this facility to provide protections for health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Physical Abuse includes but it not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. This same policy also documents The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: The identification, ongoing assessment, care planning 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 record review and interview, the facility failed to identify the indication for the prolonged duration of use for 1 of 1 (R22) resident with a prescribed antibiotic maintenance dose in a sample of 12 residents. Findings include: On 11/24/22, R22's Physician ordered an Antibiotic for maintenance dose for a history of frequent of Urinary Tract Infections with no stop date. On 2/22/24, R22's Careplan documents (R22) has developed a UTI (Urinary Tract Infection). Doctor ordered no stop date and would like R22 to be on a maintenance dose of Antibiotic therapy. On 8/21/23, R22's Physician ordered an Antibiotic for treatment of a Urinary Tract Infection for 7 days. On 5/7/24, R22's Physician ordered an Antibiotic for treatment of a Urinary Tract Infection for 10 days. On 5/22/24 at 11:45 AM, V3 (Infection Control Preventionist) stated I don't know why R22 is on it (maintenance Antibiotic). It (maintenance Antibiotic) hasn't stopped R22 from getting UTI's.

Based on observation, interview and record review, the facility failed to administer medications as ordered by the physician for three residents (R4, R27 and R31) on the sample of 10 residents reviewed for medication pass. This failure resulted in four medication errors out of thirty- one opportunities for error, for a 21.9% medication error rate. FINDINGS INCLUDE: The facility policy, Medication Administration, dated (7/1/23) directs staff, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Ensure the six rights of medication administration are followed: right resident, right drug, right dosage, right route, right time and right documentation. 1. R4's current Physician Order Sheet, dated May 2024 includes the following medications: Baclofen 10 MG (1/2 tab) one tablet twice daily; Eliquis 5 MG one tab twice daily; Glucophage 500 MG one tablet two times daily with food; Tylenol 500 MG…

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 identify, track, monitor and analyze for trends in data for 2 of 2 (R3, R22) in a sample of 12 residents. Findings include: The Infection Prevention and Control Policy and Procedure policy, dated 7/28/21, documents an Infection Criteria Checklist includes the date the infection was first suspected, evidence the infection was or was not present upon admission, what infection is present, testing, treatment, outcome and follow-up. The Infection Prevention and Control Monthly Log will be completed and used to track infections in the facility and noting trends that may be present. R3's Physician's Orders dated 4/4/24, 4/10/24 and 4/18/24 documents an Antibiotic was ordered for treatment of a Urinary Tract Infection. The Infection Prevention and Control Monthly Log dated April 2024 lacked documentation of R3's Urinary Tract Infection and the other required data. R22's Physician's Orders dated 11/22/23 documents an Antibiotic was ordered for an Upper Respiratory Infection. The Infection Prevention and Control Monthly Log dated…

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 revise the care plan to to include preference to exclude specific staff from providing care for one (R2) of two residents reviewed for care plans. Findings include: On 8/2/23 at 1:10 pm, R2 stated that V4, CNA is always in a hurry to get to the next resident We don't see eye to eye. R2 stated that V4 was changing him in the sit to stand lift and was trying to balance on his bad foot and bad hip/leg. R2 stated V4 doesn't clean him well, just wipes with dry paper. R2 stated that he told them he didn't want V4 as a caregiver again and it was ok for 2-3 days, then V4 answered my light and came in to help me go to the bathroom. On 8/3/23 at 12:15 pm, V2 DON (Director of Nursing) stated R2 did notify her that he did not want V4 to provide care. V2 stated they should have updated R2's care plan with R2's request. Current care plan did not include any documentation that R2 did not want V4 providing his care.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to identify an appropriate indication for administration of an antipsychotic medication for two residents with a diagnosis of Dementia (R31, R42) of three residents reviewed for unnecessary antipsychotic medications in the sample of 18. Findings include: Facility Policy/Psychotropic Medication dated/revised 11/28/17 documents: These medications are to be given to treat a specific condition/medical symptom that is diagnosed and documented in the medical record. Specific condition/medical symptoms alone are not enough to justify pharmalogical use. An evaluation must be done to determine other possible physical, mental, behavioral, psychosocial needs. Additionally, antipsychotic medication may be indicated for use if: Behavioral symptoms present a danger to the resident or others; Expressions or indications of distress that are significant distress to the resident. 1) Physician's Order Summary Report indicates R31 was admitted to the facility…

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