Majestic Care Of Connersville

Based on observation, interview and record review the facility failed to provide fresh fluids and keep fluids within reach for 3 of 3 residents reviewed for hydration (Resident 54, Resident 18 and Resident 1). Findings include: 1. During an observation, on 7/24/24 at 11:36 a.m., Resident 54 was lying in bed, the resident had a 1/4 a cup of juice on the bedside table, the table was across the room out of reach of the resident, and the resident did not have any water in his room. During an observation, on 7/25/24 at 10:54 a.m., Resident 54 was lying in bed, the resident had no water or any type of fluids in his room. During an observation, on 7/25/24 at 12:53 p.m., Resident 54 was lying in bed, the resident had no water or any type of fluids in his room. During an observation, on 7/26/24 at 11:47 a.m., Resident 54 was lying in bed, the resident had a Styrofoam cup with ice water in it on the bedside table, the table was across the room and out of the resident's reach. Review of the record of Resident 54, on 7/29/24 at 11:28 a.m., indicated the diagnoses included, but were not limited…

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 in room self-initiated activities for 1 of 3 residents reviewed for activities (Resident 1). Finding include: During an observation and interview with Resident 1, on 7/23/24 at 12:44 p.m., they were lying in bed, awake, and staring at the ceiling. Their television was unplugged with no music, books, magazines, puzzles, daily chronicle, or any type of activity was available for the resident. The resident indicated she did not like her room. During an observation and interview with Resident 1, on 7/25/24 at 11:00 a.m., they were lying in bed, awake, and staring at the ceiling. Their television remained unplugged with no music, books, magazines, puzzles, daily chronicle, or any type of activity was available for the resident. The resident indicated she hated her room. The resident indicated she did not necessarily like to do activities with other people. So, she stayed to herself and did her own thing. The resident refused to tell the writer what her favorite activity was. Review of the record of Resident…

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

Based on observation, interview, and record review, the facility failed to ensure a resident's urinary catheter drainage bag and/or tubing remained free of contact with the floor for 1 of 2 residents reviewed for indwelling urinary catheters. (Resident 33) Findings include: The clinical record for Resident 33 was reviewed on 7/26/2024 at 11:35 a.m. The medical diagnoses included obstructive uropathy, urinary tract infections, and dysuria. A Quarterly Minimum Data Set Assessment, dated 5/3/2024, indicated that Resident 33 was mildly cognitively impaired, had an indwelling urinary catheter, and needed extensive assistance of staff for toileting needs. A urinary catheter care plan, revised on 2/23/2023, indicated that Resident 33 was at risk for complications and infection related to utilizing an indwelling catheter for treatment of obstructive uropathy. A physician order, dated 6/11/2024, indicated that Resident 33 utilized an indwelling catheter for obstructive uropathy. An observation of Resident 33, on 7/23/2024 at 2:10 p.m., indicated he was sitting in his wheelchair by 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 observation, interview, and record review, the facility failed to routinely assess a resident receiving pain medications and administer narcotic pain medication for a resident with chronic pain for 1 of 1 resident reviewed for pain. (Resident 12) Findings include: The clinical record for Resident 12 was reviewed on 7/25/2024 at 1:15 p.m. The medical diagnosis included chronic pain syndrome. A Quarterly Minimum Data Set Assessment, dated 5/20/2024, indicated that Resident 12 was cognitively intact, received routine and as needed pain medication, and was almost constantly in pain. A pain care plan, revised on 3/8/2024, indicated Resident 12 was at risk for pain related to her chronic pain syndrome. A care planned intervention of administering medications as ordered was dated 5/3/2021. A physician order, dated 7/11/2024, indicated for Resident 12 to receive tramadol 50 milligrams (mg) three times a day routinely for pain. A physician order, dated 5/18/2023, indicated for Resident 12 to receive Tylenol 650 mg by mouth every six hours routinely for pain. During an interview, 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.

Based on observation, interview, and record review, the facility failed to timely follow-up on scheduling a resident's appointment for a CT (computerized tomography-diagnostic imaging procedure that uses x-rays and computers to create detailed images of the inside of the body) scan for 1 of 2 residents reviewed for skin conditions. (Resident 52) Findings include: The clinical record for Resident 52 was reviewed on 7/26/24 at 2:15 p.m. His diagnoses included, but were not limited to, osteoarthritis and end stage renal disease. An observation and interview was conducted with Resident 52 on 7/25/24 at 2:29 p.m. He was lying in bed in his room. He indicated he knew he was supposed to have a CT scan of his back, but the facility never followed up with him on when the appointment would be. The physician's orders indicated a referral for a CT scan of the spine without contrast including cervical, lumbar, and thoracic spine with a local hospital provider, effective 7/10/24. The 7/10/24 order note indicated the following, New order received by NP (nurse practitioner) for a CT scan of 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 observation, interview and record review, the facility failed to ensure a resident was seen for routine dental services for 1 of 4 residents reviewed for dental services. (Resident 1) Findings include: During an observation and interview with Resident 1, on 7/25/24 at 11:00 a.m., she indicated it was difficult for her to eat because she did not have any teeth. The resident indicated she would like to have dentures. The resident was observed to have no lower or upper teeth. Review of the record of Resident 1, on 7/25/24 at 11:50 a.m., indicated the resident's diagnoses included, but were not limited to, Parkinsonism, chronic obstructive pulmonary disease, dementia, diabetes, atherosclerotic heart disease, major depressive disorder, paranoid personality disorder, and conversion disorder with seizures. The Annual Minimum Data Set assessment for Resident 1, dated 4/4/24, indicated the resident was cognitively intact for daily decision making. The resident was edentulous (no natural teeth). During an interview with Social Services 1, on 7/26/24 at 11:04 a.m., indicated Resident…

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 document treatments were completed, or refused, and failed to document if enteral feeding were administered, or refused, for 1 of 23 residents reviewed for documentation (Resident C). Finding include: Review of the record of Resident C, on 7/26/24 at 2:14 p.m., indicated the diagnoses included, but were not limited to, chronic respiratory failure with hypoxia, quadriplegia, dependence on respirator (ventilator) status, neuromuscular dysfunction, tracheotomy and gastrostomy (g-tube) status. During an interview with the Corporate Director of Respiratory, on 7/29/24 at 2:42 p.m., he verified the following treatments were not documented as completed, or refused on the May 2024 Treatment Administration Record (TAR) and verified that the enteral g-tube feeding was not documented as provided or refused. The May 2024 TAR for Resident C indicated Dakins (1/2 strength) external solution to left buttock every shift. Apply wound cleanser, Dakins moistened fluffed gauze, and cover with an ABD (abdominal) pad. There was no documentation…

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 colostomy care in a manner to promote dignity for 1 of 3 residents reviewed for colostomy care (Resident G). Findings include: Review of the clinical record of Resident G on 5/22/24 at 11:55 a.m., indicated the resident's diagnosis included, but was not limited to acute and chronic respiratory failure, dysphagia, colostomy status, and depression. During an interview with Resident G on 5/21/24 at 3:00 p.m. indicated that 3 to 4 days ago, a nurses aide ran out of the correct fitting nursing supplies during the evening shift and placed a regular clear plastic trash bag over his stoma site and it was not changed with a correct fitting colostomy bag until the following morning. The resident indicated that my dignity was crushed when they did this and it made me feel worthless. During an interview with CNA 7 on 5/22/24 at 12:05 p.m., indicated she was working second shift and Resident G did not have a colostomy bag over his stoma. She indicated that she was told that they had ran out of the colostomy bags and had nothing…

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 develop a plan of care for a resident who would refuse to wear a pulse oximeter for 1 of 3 residents reviewed for respiratory care (Resident J). The finding include: Review of the clinical record of Resident J on 5/21/24 at 2:45 p.m. indicated the resident's diagnosis included, but was not limited to chronic respiratory failure with hypoxia, dependence on respirator (ventilator) status, and anxiety disorder. The physician Recapulation (recap), dated May 2024, indicated Resident J had order continuous pulse oximeter. During an observation and interview on 5/21/24 at 1:05 p.m., Resident J was lying in bed with no pulse oximeter on or in his room. Resident J indicated he refused to wear his pulse oximeter. During an Interview 5/21/24 at 1:30 p.m. with Respiratory Therapist (RT) 1 indicated that Resident J refused to wear the pulse oximeter. During an interview with the Director of Nursing (DON) 5/22/24 at 12:30 p.m. indicated that it was Social Services responsibility to implement a care plan for Resident J'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 interview and record review, the facility failed to ensure an interdisciplinary team review of a post fall event that would include a root cause analysis and implementation of fall interventions for 1 of 3 residents reviewed for accidents. (Resident B) Findings include: The clinical record for Resident B was reviewed on 5/24/24 at 10:47 a.m. The diagnoses included, but were not limited to, encephalopathy, anemia, hypertension, repeated falls, psychotic disorder, diabetes mellitus, and anxiety disorder. A fall care plan, initiated on 7/18/22 and revised on 5/17/24, indicated Resident B was at risk for falls related to history of falls, cognitive deficits, dementia, and use of medications. The interventions added most recently was on 3/28/24 for the following: Bed in lowest position while in bed, Provide reacher, & Bright colored tape to call light on bed. A fall report, dated 5/6/24, indicated the following, .CNA [certified nursing aide] yelled for nurse. upon entering dining room resident was lying on the floor, no injuries noted at this time. Resident helped writer and CNA…

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

Based on observation, interview, and record review the facility failed to provide colostomy services with professional standards when reviewing 1 out of 3 residents for colostomy care (Resident G). The findings include: The clinical record for Resident G reviewed on 5/22/24 at 11:55 a.m., indicated the resident's diagnosis included, but was not limited to acute and chronic respiratory failure, dysphagia, colostomy status, and depression. The physician Recapulation (recap), dated for May 2024, indicated colostomy care every shift and as needed and to rinse colostomy bag with water after emptying . During an observation on 5/21/24 at 1:52 p.m. with QMA 4, Resident G had a colostomy bag intact with clear tape reinforced around it. During an interview with Resident G on 5/22/24 at 11:32 a.m. the resident indicated that staff used a small trash bag instead of a colostomy bag to cover his stoma. The residient also indicated that he took a picture with his phone of the trash bag over his stoma to provide proof to the facility that the staff had done this. During an interview with CNA 7 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 have pulse oximeter (measures oxygenated hemoglobin in the blood and heart rate) in place as ordered by the physician for ventilator residents, failed to ensure Respiratory Therapist was knowledgeable where to locate respiratory supplies, failed to provide education to the resident on the importance of wearing the pulse oximeter and failed to notify the physician of the resident's refusal to wear the pulse oximeter for 2 of 3 residents reviewed for respiratory care (Resident C and Resident J). Findings include: 1.) Review of the record of Resident C on 5/22/24 at 1:40 p.m., indicated the resident's diagnosis included, but were not limited to, chronic respiratory failure with or without hypoxia or hypercapnia, diabetes, acute embolism with chronic kidney disease, anemia, anxiety, paraplegia, dependence on ventilator and tracheotomy status. The May 2024 Recapitulation for Resident C, indicated the resident was ordered to have an continuous…

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 develop a care plan, for blood pressure medications, for a resident with hypertensive heart disease. This affected 1 of 28 residents reviewed for care plan development. (Resident 21) Findings include: Resident 21's record was reviewed on 2/07/24 at 1:36 p.m. The record indicated Resident 21 had diagnoses that included, but were not limited to, presence of cardiac pacemaker, pulmonary hypertension, and hypertensive heart disease without heart failure. Current physician's orders indicated the resident received the following medications: Amlodipine 10 milligrams by mouth, one time a day, for hypertensive heart disease without heart failure, hold if systolic blood pressure is less than 110, with a start date of 12/11/23. Lisinopril 20 milligrams by mouth, one time a day, for hypertensive heart disease without heart failure, with a start date of 10/16/23. Clonidine 0.1 milligrams by mouth, two times a day, hold for systolic blood pressure less than 150 and/or diastolic blood pressure less than 80, for hypertensive heart disease…

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 each resident and their representative(s) are invited to care plan meetings for 1 of 3 residents reviewed for care plan meetings. (Resident 40) Findings include: The clinical record of Resident 40 was reviewed on 2-9-24 at 10:10 a.m. It indicated she has been a resident of the facility for over one year. A review of her most recent Minimum Data Set (MDS) assessment, dated 12-12-23, indicated she was cognitively intact. In an interview with Resident 40 on 2-5-24 at 2:33 p.m., she indicated she could not recall being asked to participate in a care plan meeting or previously participating in a care plan meeting and would like to do so. In a review of care plan meeting notes, the clinical record reflected Resident 40 had participated in care plan meetings on 8-10-23, 10-3-23 and 12-11-23, but did not participate or attend a care plan meeting on 9-13-23. A review of the IDT [interdisciplinary team] Care Plan Conference Summary, for 9-13-23, the the form queried if the resident was unable to attend, what other methods…

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, observations, and record review, the facility failed to ensure a dependent resident had facial hair to their preferences for 1 of 3 residents reviewed for activities of daily living. (Resident 28) Findings include: The clinical record for Resident 28 was reviewed on 2/8/2024 at 1:45 p.m. The medical diagnosis included muscle weakness. An annual Minimum Data Set Assessment, dated 12/23/2023, indicated Resident 28 was moderately cognitively impaired. An interview and observation of Resident 28 on 2/6/2024 at 11:02 a.m. indicated she was in her wheelchair. She has some noticeable facial hair upon her upper lip. She stated she used to be able to take care of it by herself, but she's been needing more help recently and prefers to not have facial hair. An interview with Unit Manager 3 on 2/7/2024 at 1:00 p.m. indicated that Resident 28 needs extensive assistance with activities of daily living and utilizes a mechanical lift for transfers. An observation on 2/9/2024 at 11:35 a.m., indicated Resident 28 was sitting in the dining room with other residents listening 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 observation, record review and interview, the facility failed to administer pain medication according to the physician's orders, for 1 of 3 medication administration pass opportunities. (Resident 41) Findings include: During a medication pass observation, on 2/08/24, at 8:58 a.m., QMA 4 prepared hydrocodone (narcotic pain medication)and acetaminophen 5/325 milligrams (mg), 1 tablet, and 1/2 of a hydrocodone/acetaminophen 5/375 mg tablet and administered the medication to resident 41. The medication as given equaled 7.5 mg of hydrocodone and 487.5 mg of acetaminophen which was 162.5 mg more than the prescribed order for acetaminophen for each medication administration. The physician's order, dated 5/12/23, indicated the following order: Hydrocodone-Acetaminophen Oral Tablet 7.5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 6 hours for pain Resident 41's record was reviewed on 2/12/24 at 11:45 a.m. and indicated diagnoses that included, but were not limited to, rheumatoid arthritis with rheumatoid factor of multiple sites, fibromyalgia (widespread pain), and…

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

Based on interview, observations, and record review, the facility failed to ensure fall interventions of nonskid strips were in place for 1 of 6 residents reviewed for falls. (Resident 15) Findings include: The clinical record for Resident 15 was reviewed on 2/5/2024 at 1:45 p.m. The medical diagnosis included traumatic brain injury. A fall care plan with an interventions, dated 4/29/2021, indicated Resident 15 was to have nonskid strips in front of his toilet to avoid slippage. An interview and observation on 2/5/2024 at 1:00 p.m., indicated Resident 15 did not have nonskid strips in front of his toilet. He stated in the morning he gets himself out of bed and he feels like the floor is too slick beside his bed and in the bathroom. He stated he is afraid of falling and he is supposed to have those black strips on the floor. An observations on 2/5/2024 at 1:25 p.m. after CNA 2 had left the bathroom in Resident 15's room indicated that Resident 15 did not have nonskid strips in front of his toilet. A policy entitled, Fall Management, was provided by the DON on 2/9/2024 at 10:35 a.m.…

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

Based on observation, interview and record review, the facility failed to ensure each medication in the medication cart was appropriately labeled, including directions for use, for 1 of 4 medication cart observations. (Resident 31) Findings include: During a medication cart observation of the 300 hall with LPN 3 on 2-12-24 at 10:30 a.m., a Basaglar Pen, of 100 units per milliliter strength, was observed lying in an upper drawer, without a protective bag nor directions for use present. The pen did have the name of Resident 31 present, along with the expiration date, the lot number and a handwritten date of 12-28 on the pen. In an interview with LPN 3 at this time, he indicated he could not locate a bag for this medication which typically has the above information, as well as the specific directions for use. LPN 3 indicated it appeared with the date of 12-28-23 as the open date, the medication should have been discarded due to expiration date of greater than a month. An additional eight (8) pens of the same medication were located in the refrigerator of the 300 hall medication storage…

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 Weekly Nursing Summary Assessment for 1 of 2 residents reviewed for Weekly Nursing Summary Assessment accuracy. (Resident 16) Findings include: The clinical record for Resident 16 was reviewed on 2/8/2024 at 1:35 p.m. The medical diagnosis included dementia. An Annual Minimum Data Set Assessment, dated 12/23/2023, indicated Resident 16 was moderately cognitively impaired. Review of Resident 16's Medication Administration Record for January 2024 indicated Resident 16 received as needed (or PRN) Tylenol for pain on 1/5/2024 and 1/17/2024. A Weekly Nursing Summary Assessment for Resident 16, dated 1/6/2024, indicated Resident 16 did not received any PRN pain medication in the last seven days. A Weekly Nursing Summary Assessment for Resident 16, dated 1/20/2024, indicated Resident 16 did not received any PRN pain medication in the last seven days. A policy entitled, Documentation in the Medical Record, was provided by the DON on 2/9/2024 at 10:35 a.m. The policy indicated, .Each resident's medical record shall contain…

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

Based on observation, interview, and record review, the facility failed to ensure a homelike environment on the 300-hallway due to strong urine odor present near Resident G's room. Findings include: Observations were conducted of the 300-hallway to where there was a urine odor present near and around Resident G's room on the following date(s)/time(s): 8/16/23 at 1:15 p.m., 8/16/23 at 2:39 p.m., 8/17/23 at 9:12 a.m., 8/18/23 at 9:29 a.m., 8/18/23 at 10:16 a.m., & 8/18/23 at 11:42 a.m. An interview conducted with Housekeeping Staff 3, on 8/17/23 at 9:33 a.m., indicated she had worked at the facility for about 4 months. The urine odor comes and goes but she was unsure where it's coming from. She conducted cleaning to all rooms on the 300-hallway daily. She doesn't have any special instructions to clean Resident G's room regarding frequency. An interview with Licensed Practical Nurse (LPN) 4, on 8/17/23 at 9:35 a.m., indicated there was a urine odor near Resident G's room. Resident G tends to refuse showers and care. An observation was conducted, on 8/18/23 at 11:42 a.m., to where 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure pressure ulcers were assessed upon admission/readmission to the facility, ensure treatments were initiated timely for identified pressure ulcers, follow-up with recommendations from a wound care provider, and ensure ongoing treatment for pressure ulcers for 2 of 6 residents reviewed for pressure ulcers. (Resident H and Resident J) Findings include: 1a. The clinical record for Resident H was reviewed on 8/18/23 at 10:27 a.m. The diagnoses included, but were not limited to, osteomyelitis of vertebra, pressure ulcer of sacral region, diabetes mellitus, chronic pain syndrome, and contracture. An admission minimum data set (MDS) assessment, dated 7/10/23, indicated Resident H was cognitively intact along with a stage 2 pressure ulcer, a stage 4 pressure ulcer, and 3 deep tissue injuries documented as noted upon admission to the facility. An impaired skin integrity care plan, revised 8/22/23, indicated Resident H had a stage 3 pressure ulcer to left…

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 implement the fall interventions for Resident K for 1 of 3 residents reviewed for falls. Findings include: The clinical record for Resident K was reviewed on 8/22/2023 at 3:35 p.m. The medical diagnoses included bipolar disorder and acquired absence of the left and right leg. A Quarterly minimum data set assessment, dated for 6/20/2023, indicated Resident K was cognitively intact. A fall risk assessment, dated for 11/14/2022, indicated Resident K was a high risk for falls. A nursing progress note, dated for 3/9/2023, indicated Resident K had attempted to self-transfer back to bed, resulting in a fall. An intradisciplinary team note, dated for 3/16/2023, indicated the team reviewed Resident K's fall from 3/9/2023 and would implement an intervention of assisting Resident K back to bed after smoke breaks. During an interview with Resident K on 8/21/2023 at 1:29 p.m., she indicated staff does not always offer to assist her back to bed after smoking. During an interview with CNA 8 on 8/22/2023 at 1:45 p.m., 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.