Colonial Nursing Home

Based on observation, record review, and interview, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by staff members (Agency CNA 1 and Agency CNA 5) when providing care to residents (Resident D and F) who were in Enhanced Barrier Precautions (EBP) for 2 of 2 residents reviewed for EBP. The facility also failed to ensure hand hygiene was completed by a staff member (Agency CNA 1) after care had been completed on a resident (Resident B) and care initiated on another resident (Resident C) and to ensure a personal care item was used for only 1 resident and was not used for multiple residents (Residents B, C, G, D, and H) by a staff member related to incontinent wipes. (Agency CNA 1) Findings include: 1. During an observation on 3/18/25 at 5:30 a.m., Agency CNA 1 entered Resident D's room to provide care. There was a sign on the outside of the entry door that indicated the resident required EBP during care. Agency CNA 1 applied gloves and was stopped prior to starting care. She indicated she had no idea if the resident required PPE due to EBP. The CNA…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure the residents' environment was clean and in good repair related to scraped paint, nicks and gouges on the walls, dried feeding on the feeding poles, a oxygen concentrator and on the floor, debris and trash on the floors, a dirty floor mat, and a stool with a cracked vinyl seat for 1 of 2 floors. (First Floor). During an environmental tour with the Director of Maintenance/Housekeeping on 3/18/25 from 12:59 through 1:29 p.m., the following was observed: a. room [ROOM NUMBER] - There were paint scrapes behind the head of the bed. During an interview at the time of the observation, the Director of Maintenance/Housekeeping acknowledged the scrapes and indicated when the residents were discharged or moved rooms, the walls were repaired. b. room [ROOM NUMBER], bed 2 - There was dried feeding on the feeding pump pole, the oxygen concentrator and on the floor. The Director of Maintenance/Housekeeping indicated the Housekeeper probably had…

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 ensure residents had a clean and homelike environment related to soiled bed linens for 2 of 8 residents reviewed for a clean and homelike environment. (Residents B and D) Findings include: 1. During an observation on 3/18/25 at 4:58 a.m., Agency CNA 2 entered Resident B's room to completed incontinence care. A soiled incontinent brief was removed, pericare was completed and a clean brief was applied. When the resident was turned to the side, there was a dried urine ring under the resident's incontinent pad. Agency CNA 2 indicated she had not checked the bottom sheet under the incontinent pad when she provided care earlier in the night. Resident B's record was reviewed on 3/18/25 at 10:03 a.m. The diagnoses included, but were not limited to chronic obstructive pulmonary disease. A Quarterly Minimum Data Set (MDS) assessment, dated 1/16/25, indicated a moderately impaired cognitive status, was dependent for toileting, and was always incontinent of bowel and bladder. 2. During an observation on 3/18/25 at 5:40…

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 ensure residents who were dependent on staff received incontinence care for 2 of 7 residents reviewed for activities of daily living. (Residents E and F) Findings include: 1. During an observation on 3/18/25 at 5:26 a.m., RN 1 and Agency CNA 2 entered Resident E's room on the C-Hall, to assist with positioning the resident in bed. The incontinence brief was saturated with urine. The incontinence pad under the resident was soaked with urine and there were circles of dried urine on the sheet under the incontinence pad. The staff repositioned the resident in bed and Agency CNA 2 informed the resident she would be back in a few minutes. She indicated she had last provided incontinence care at 3:00 a.m. During an observation on 3/18/25 at 6:08 a.m., incontinence care had not yet been completed. During an observation on 3/18/25 at 7:19 a.m., CNA 3 and LPN 4 entered the room and and completed incontinence care and a linen change. There was a strong urine odor in the room. LPN 4 acknowledged the saturated brief, wet…

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, record review, and interview, the facility failed to provide a least 80 square feet (SQ FT) per resident in multiple resident rooms and 100 SQ FT in single occupancy rooms. This was evidenced in 8 of 30 resident rooms in the facility. (Rooms 101, 104, 111, 201, 202, 204, 206, and 208) Findings include: 1. The floor area of the following single resident room measured: a. room [ROOM NUMBER] - 1 resident, 96.2 SQ FT. NF. 2. The floor areas of the following multiple resident rooms measured: a. room [ROOM NUMBER] - 1 resident, 150.3 SQ FT, 75.2 SQ FT per bed. NF. b. room [ROOM NUMBER] - 0 resident, 145.0 SQ FT, 72.5 SQ FT per bed. NF. c. room [ROOM NUMBER] - 1 resident, 149.0 SQ FT, 74.5 SQ FT per bed. NF. d. room [ROOM NUMBER] - 1 resident, 144.0 SQ FT, 72.0 SQ FT per bed. NF. e. room [ROOM NUMBER] - 1 resident, 144.0 SQ FT, 72.0 SQ FT per bed. NF. f. room [ROOM NUMBER] - 1 resident, 140.0 SQ FT, 70.0 SQ FT per bed. NF. g. room [ROOM NUMBER] - 1 resident, 146.9 SQ FT, 73.4 SQ FT per bed. NF.…

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 ensure activities were implemented for a cognitively impaired dependent resident for 1 of 1 resident reviewed for activities. (Resident 14) Finding includes: On 8/19/24 at 11:16 a.m., Resident 14 was observed lying in bed with her eyes open and looking up at the ceiling. The room was dark, the television was off, and there was no music playing. On 8/20/24 at 1:07 p.m., Resident 14 was was observed lying in bed with her eyes open and looking up at the ceiling. The room was dark, the television was off, and there was no music playing. On 8/20/24 at 2:25 p.m., Resident 14 was was observed lying in bed with her eyes open and looking up at the ceiling. The room was dark and the television was not on. A bingo activity was being played in the dining area and in some resident rooms. Record review for Resident 14 was completed on 8/20/24 at 1:27 p.m. Diagnoses included, but were not limited to, stroke, aphasia (loss of ability to understand or express speech) and depression. The Annual Minimum Data Set (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.

Based on observation, record review and interview, the facility failed to ensure a resident's wounds were assessed and monitored for 1 of 3 residents reviewed for non-pressure skin conditions. (Resident 10) Finding includes: On 8/19/24 at 3:10 p.m. and on 8/20/24 at 2:15 p.m., Resident 10 was observed lying in bed. She had two open areas, approximately 3 centimeters round each, on her right shin. She indicated they had been fluid filled blisters that had opened. The resident's record was reviewed on 8/20/24 at 11:33 a.m. Diagnoses included, but were not limited to, hemiparesis (one sided weakness) and hemiplegia (one sided paralysis) following a cerebral vascular accident, Diabetes Mellitus and heart failure. The Annual Minimum Data Set assessment, dated 6/30/24, indicated the resident was cognitively intact and was dependent on assistance for bed mobility and transfers. A Nursing Note, dated 8/14/24, indicated the resident had been up in a chair for five hours and fluid filled blisters developed to her right leg. The Nurse Practitioner was notified and orders were received to apply…

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, record review, and interview, the facility failed to follow up on an Occupational Therapy recommendation for a resting hand splint for 1 of 2 residents reviewed for position/mobility. (Resident 8) Finding includes: On 8/19/24 at 10:59 a.m., Resident 8 was observed seated in her wheelchair. Her right hand was contracted (tightening of muscle, tendons and skin that causes joints to shorten and become very stiff)and there was not a splint in place. The resident's record was reviewed on 8/20/24 at 2:40 p.m. Diagnoses included, but were not limited to, hemiplegia (one sided weakness) and hemiparesis (one sided paralysis) and unspecified dementia. The Quarterly Minimum Data Set assessment, dated 6/11/24, indicated the resident had severe cognitive impairment and was dependent for bed mobility and transfers. The resident received Occupational Therapy from 1/30/24 to 3/29/24. An Occupational Therapy Discharge summary, dated [DATE], indicated the resident was to tolerate a resting hand splint for 5…

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 catheter care was completed and urinary output was recorded for 1 of 3 residents reviewed for urinary catheters. (Resident D) Finding includes: The closed record for Resident D was reviewed on 8/22/24 at 10:20 a.m. Diagnoses included, but were not limited to, cerebral infarction, type 2 diabetes mellitus, and malignant neoplasm of the prostate. The resident was admitted to the facility on [DATE] and discharged to the hospital on 4/12/24. The admission Minimum Data Set (MDS) assessment, dated 3/11/24, indicated the resident was cognitively impaired and had an indwelling urinary catheter. A Care Plan, updated 3/26/24, indicated the resident had an indwelling urinary catheter. An intervention indicated to monitor and document intake and output. A Physician's Order, dated 3/8/24, indicated 10 cc (cubic centimeters) 18 fr (french, catheter size) Foley catheter with drainage bag to gravity, monitor every shift. The Medication Administration Records…

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 care for a PICC line (peripherally inserted central catheter, intravenous catheter placed into the peripheral veins of the upper arm) in accordance with professional standards of practice, related to flushing the PICC line for 1 of 1 resident reviewed for intravenous care. (Resident 25) Finding includes: On 8/19/24 at 2:00 p.m., Resident 25 was observed lying in bed in her room. There was a PICC line in place to her right upper arm. She indicated she had surgery last week and was now getting antibiotics through the line. Resident 25's record was reviewed on 8/20/24 at 3:03 p.m. Diagnoses included, but were not limited to, hypertension, abdominal aortic aneurysm, major depressive disorder. The admission Minimum Data Set (MDS) assessment, dated 7/18/24, indicated the resident was cognitively impaired. A Care Plan, updated 8/17/24, indicated the resident was receiving IV (intravenous) antibiotics for a urinary tract infection. A Care Plan, updated 8/19/24, indicated the resident had a PICC line. An intervention…

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 ensure a resident received the necessary care and treatment related to incorrect oxygen flow rate for 1 of 2 residents reviewed for respiratory care. (Resident 22) Finding includes: On 8/19/24 at 10:06 a.m., Resident 22 was observed seated in his room. He had a nasal cannula in place that was attached to an oxygen concentrator and the flow rate was set on 2 liters per minute (lpm). On 8/20/24 at 2:25 p.m., the resident was observed seated in his room. His oxygen was on and flowing at 2.5 lpm. The resident's record was reviewed on 8/21/24 at 10:50 a.m. Diagnoses included, but were not limited to, chronic respiratory failure and chronic obstructive pulmonary disease. The Quarterly Minimum Data Set assessment, dated 6/4/24, indicated the resident was cognitively intact and was on oxygen. A Physician's Order, dated 7/16/23, indicated the resident was to receive oxygen at 3 lpm continuously. On 8/21/24 at 1:27 p.m., the oxygen concentrator was observed with the Director of Nursing. She indicated it was set on 2.5…

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 resident's medical record was complete and accurate related to incontinence care logs, for 1 of 3 residents reviewed for incontinence care. (Resident B) Finding includes: Resident B's closed record was reviewed on 4/15/24 at 10:37 a.m. Diagnoses included, but were not limited to, acute respiratory failure, heart failure, and bipolar disorder. The resident was admitted to the facility on [DATE] and discharged on 1/18/24. The Discharge Minimum Data Set (MDS) assessment, dated 1/18/24, indicated the resident was cognitively intact for daily decision making, was occasionally incontinent of bowel and bladder and required assistance with toileting. A Care Plan, dated 12/22/23, indicated the resident had an activity of daily living (ADL) self-care performance deficit related to activity intolerance, chronic obstructive pulmonary disease, and respiratory failure. Interventions included, but were not limited to, the resident required staff…

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

Based observation, record review, and interview, the facility failed to ensure food was served and stored under sanitary conditions related to unlabeled and expired food in the refrigerator, dirty refrigerator shelves, lack of hand hygiene during food preparation, dirty utensil bins and a broken oven door. This had the potential to affect 30 residents who received food from the kitchen. (The Main Kitchen) Findings include: 1. During the initial kitchen tour on 6/26/23 at 8:07 a.m., the following was observed in the reach in refrigerator with the Dietary Aide (DA): - an open pack of sliced cheddar cheese, undated - an open pack of Swiss cheese, undated - sliced ham, dated 5/22/23 - bag of sliced red onions, undated - open bag of shredded cabbage, with a use by date of 6/21/23 - open pack of breaded fish, undated - open pack of breaded chicken, undated There was liquid spillage and food debris on the refrigerator shelves and on the bottom of the refrigerator. Interview with the DA at the time of the observation, indicated the items should be dated when opened, the expired items were…

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, record review, and interview, the facility failed to provide a least 80 square feet (SQ FT) per resident in multiple resident rooms and 100 SQ FT in single occupancy rooms. This was evidenced in 8 of 30 resident rooms in the facility. (Rooms 101, 104, 111, 201, 202, 204, 206, and 208) Findings include: 1. The floor area of the following single resident room measured: a. room [ROOM NUMBER] - 1 resident, 96.2 SQ FT. NF. 2. The floor areas of the following multiple resident rooms measured: a. room [ROOM NUMBER] - 1 resident, 150.3 SQ FT, 75.2 SQ FT per bed. NF. b. room [ROOM NUMBER] - 0 resident, 145.0 SQ FT, 72.5 SQ FT per bed. NF. c. room [ROOM NUMBER] - 1 resident, 149.0 SQ FT, 74.5 SQ FT per bed. NF. d. room [ROOM NUMBER] - 1 resident, 144.0 SQ FT, 72.0 SQ FT per bed. NF. e. room [ROOM NUMBER] - 1 resident, 144.0 SQ FT, 72.0 SQ FT per bed. NF. f. room [ROOM NUMBER] - 1 resident, 140.0 SQ FT, 70.0 SQ FT per bed. NF. g. room [ROOM NUMBER] - 1 resident, 146.9 SQ FT, 73.4 SQ FT per bed. NF.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain a functional, safe, and homelike environment related to bent or loose baseboard heater covers, marred and gouged doors and walls, a ripped and torn wheelchair armrest, loose thermostat cover and broken floor tiles for 4 of 30 resident rooms (Rooms 111, 112, 124 and 202) and 2 of 2 units (first and second floor). Findings include: During the Environmental Tour on 6/29/23 from 1:15 p.m.-1:30 p.m. with the Maintenance Supervisor, the following was observed: 1. First floor: a. In room [ROOM NUMBER], the baseboard heater cover was bent, loose, and pulling away from the wall. One resident resided in the room. b. In room [ROOM NUMBER], the baseboard heater cover was bent and falling off. One resident resided in the room. c. In room [ROOM NUMBER], Resident 7's wheelchair armrest was torn and ripped. d. In the dining room, the baseboard heater covers were loose and bent, and the endcap was falling off one end. e. In the hall near the elevator, 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 record review and interview, the facility failed to ensure a comprehensive care plan was in place for a resident receiving an antipsychotic medication for 1 of 13 residents whose care plans were reviewed. (Resident 33) Finding includes: The record for Resident 33 was reviewed on 6/27/23 at 11:20 a.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, hypertension, and osteoarthritis. The admission MDS (Minimum Data Set) assessment, dated 4/10/23, indicated the resident had received antipsychotic medication in the past seven days. The June 2023 Physician's Order Summary indicated an order for olanzapine (an antipsychotic medication) 5 mg (milligrams) daily. The June 2023 Medication Administration Record (MAR) indicated the resident received the antipsychotic medication as ordered. Interview with the Administrator on 6/27/23 at 3:31 p.m., indicated there had not been a care plan for the antipsychotic medication but staff had now initiated one. 3.1-35(a)

Based on record review and interview, the facility failed to ensure a resident was invited to their care plan conference for 1 of 13 residents whose plans of care were reviewed. (Resident 19) Finding includes: Interview with Resident 19 on 6/26/23 at 8:59 a.m., indicated she had not been invited to any recent care plan meetings and she could not remember attending one. The record for Resident 19 was reviewed on 6/26/23 at 2:44 p.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, hypertension, and congestive heart failure. The Quarterly Minimum Data Set (MDS) assessment, dated 6/9/23, indicated the resident was cognitively intact. A Care Plan Note, dated 1/25/23, indicated the IDT (interdisciplinary team) had met with the resident and her daughter. The care plans were reviewed, discussed, and updated. There was lack of documentation the resident had been invited to any care plan meetings or any care plan meetings had been held since 1/25/23. Interview with the Administrator on 6/27/23 at 3:31 p.m., indicated there had been no formal care plan meetings for 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 record review and interview, the facility failed to develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions related to lack of planning, education, and supplies for a resident's caregivers on how to care for the resident's ileostomy before the resident's discharge home from the facility for 1 of 1 residents reviewed for ileostomy care. (Resident C) Finding includes: A closed record review for Resident C was completed on 6/28/23 at 1:54 p.m. Diagnoses included, but were not limited to, stroke, hemiplegia (paralysis on one side of the body), hypertension, and seizure disorder. The resident was admitted to the facility on [DATE] and discharged home on 6/24/23. The admission Minimum Data Set (MDS) assessment, dated 5/26/23, indicated the resident was cognitively moderately impaired.…

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 a discharged resident had a discharge summary completed, including a post-discharge plan of care with the resident and responsible party, for 1 of 2 residents reviewed for discharges. (Resident C) Finding includes: Record review for Resident C was completed on 6/28/23 at 1:54 p.m. Diagnoses included, but were not limited to, stroke, hemiplegia (paralysis on one side of the body), hypertension, and seizure disorder. The resident was admitted to the facility on [DATE] and discharged home on 6/24/23. The admission Minimum Data Set (MDS) assessment, dated 5/26/23, indicated the resident was cognitively moderately impaired. The resident required an extensive 2+ person assistance with bed mobility, transfers, and toilet use. The resident required an extensive 1 person assistance for locomotion, dressing, eating, and personal hygiene. The resident had an impairment on one side of his upper extremities for functional limitation in range of motion (ROM).…

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 ensure a lymphedema sleeve was applied as ordered and a scabbed area was assessed and monitored for 1 of 1 residents reviewed for edema and non-pressure skin conditions. (Resident 25) Finding includes: On 6/26/23 at 12:56 p.m., Resident 25 was observed lying in bed watching television. The resident did not have a lymphedema sleeve applied to the left arm. The resident had a visible black scabbed area to the base of his 2nd toenail on the left foot. On 6/27/23 at 1:10 p.m., Resident 25 was observed lying in bed watching television. The resident did not have a lymphedema sleeve applied to the left arm. The black scabbed area was still observed to the base of his 2nd toenail on the left foot. Record review for Resident 25 was completed on 6/27/23 at 9:15 a.m. Diagnoses included, but were not limited to, anemia, atrial fibrillation, deep vein thrombosis (DVT), heart failure and diabetes mellitus. The admission Minimum Data Set (MDS) assessment, dated 5/3/23, indicated the resident was cognitively impaired. 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 record review and interview, the facility failed to ensure pain medications were available for a newly admitted resident experiencing pain for 1 of 1 residents reviewed for pain management. (Resident B) Finding includes: The closed record for Resident B was reviewed on 6/26/23 at 1:04 a.m. The resident was admitted on [DATE], and left against medical advice on 4/22/23. Diagnoses included, but were not limited to, left femur fracture, rectal cancer and spinal stenosis. A 4/21/23 Nursing admission Assessment indicated the resident had a surgical incision on the left hip with 33 staples. A Physician's Order, dated 4/1/23, indicated to give hydrocodone-acetaminophen, (an opioid pain medication) 7.5 milligrams (mg) /325 mg every 6 hours as needed for pain. A Skilled Nursing Note, dated 4/22/23 at 2:03 a.m., indicated at 10:55 p.m., (4/21/23) a call was placed to the pharmacy for authorization to pull hydrocodone-acetaminophen from the EDK (emergency drug kit), The pharmacist informed the nurse there was no…

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 ensure each resident's medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being, related to labs not completed as ordered for 1 of 5 residents reviewed for unnecessary medications. (Resident 25) Finding includes: Record review for Resident 25 was completed on 6/27/23 at 9:15 a.m. Diagnoses included, but were not limited to, anemia, atrial fibrillation, deep vein thrombosis (DVT), heart failure and diabetes mellitus. The admission Minimum Data Set (MDS) assessment, dated 5/3/23, indicated the resident was cognitively impaired. The resident required an extensive 2+ person assistance for bed mobility, transfers, dressing, and toilet use. The resident had an impairment on both sides of his upper and lower extremities for a functional limitation in range of motion (ROM). The June 2023 Physician's Order Summary, indicated the following laboratory orders: - weekly BMP (basic metabolic panel) ordered 5/11/23 - iron studies, Vitamin B12, 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 observation, interview, and record review, the facility failed to ensure food was prepared in form to meet individual needs related to not following a recipe for pureed food. This had the potential to affect 1 resident who received a pureed diet. (Main Kitchen) Finding includes: On 6/29/23 at 11:15 a.m., the [NAME] was observed preparing pureed cornbread. She indicated she had already made the pureed food for the resident, but would demonstrate how the cornbread was made. She placed a piece of cornbread in the blender, then added some milk. The milk was not measured. There was no recipe in use. She blended the items together. The mixture was thin and soupy. She then took some of the previously prepared pureed cornbread and added it to the mixture in the blender. She indicated there were recipes for everything in the recipe book. The previously prepared pureed cornbread and pureed BBQ riblette were removed from the warming oven. The [NAME] indicated they were ready to be served. The cornbread was thick and dry. The Dietary Manager (DM) indicated it was too thick. The BBQ…

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 ensure infection control guidelines were in place and implemented related to improper cleaning of reusable equipment for 3 of 4 medication pass observations. (RN 1, LPN 1) Findings include: 1. On 6/28/23 at 9:03 a.m., RN 1 was observed preparing a resident's medications. She placed a wrist blood pressure cuff on the resident's wrist and checked his blood pressure. She then removed the blood pressure cuff and cleaned it using an alcohol prep pad and set it on top of the medication cart. She administered the resident's medications and went on to the next resident. At 9:20 a.m., she prepared the next resident's medications, placed the wrist blood pressure cuff on the resident's wrist, and checked her blood pressure. She then removed the blood pressure cuff and cleaned it using an alcohol prep pad and set it on top of the medication cart. She administered the resident's medications and went on to the next resident. 2. On 6/28/23 at 9:41 a.m., LPN 1 was observed preparing a resident's medications. There was a sign…

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.