Brickyard Healthcare - Brandywine Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to timely follow up on a resident's request to be transferred to the hospital for treatment regarding scrotal swelling and pain for 1 of 2 residents reviewed for choices. (Resident J) Findings include: The clinical record for Resident J was reviewed on 3/21/2025 at 12:45 p.m. The medical diagnoses included respiratory failure and diabetes. A Quarterly Minimum Data Set assessment, dated 2/7/2025, indicated Resident J was cognitively intact and did not exhibit behaviors. A care plan, revised 11/15/2023, indicated Resident J had depression and a psychotic disorder. Interventions were listed to allow and encourage choices. During an interview on 3/19/2025 at 12:12 p.m., Resident J indicated earlier this month he had swelling to his scrotum. He requested to go to the emergency room, but the nurse came in and told him to take some pain medicine. He stated he took the pain medicine and then asked to go to the ER [emergency room], but she wouldn't send him. 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 a grievance was forwarded to the grievance official and failed to implement a resolution of a grievance for 2 of 2 residents reviewed for grievances. (Resident H and Resident B) Findings include: 1a. The clinical record for Resident H was reviewed on 3/21/2025 at 11:30 a.m. The medical diagnoses included diabetes and chronic obstructive pulmonary disease. An admission Minimum Data Set assessment, dated 2/10/2025, indicated Resident H was cognitively intact, did not reject care, and was frequently incontinent of bowel and bladder. Care plans, revised 2/24/2025, indicated Resident H had incontinence of bowel and bladder and required the need for assistance with incontinence care. During an interview with Resident H on 3/18/2025 at 1:45 p.m., she indicated she filled out two grievances since she had been in the facility. She believed one grievance was filled out at the end of February, the other was filled out about two weeks ago, and both were given to Qualified Medication Aide (QMA) 9. Review 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 interview and record review, the facility failed to accurately input medication data into the Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed for MDS accuracy. (Resident 70) Findings include: The clinical record for Resident 70 was reviewed on 3/20/25 at 11:41 a.m. The diagnoses included, but were not limited to, diabetes mellitus and dementia. The admission MDS assessment, dated 2/14/25, indicated Resident 70 was on an anti-coagulant (blood thinner) and an antibiotic. Resident 70's Electronic Health Record (EHR) indicated no current order for an antibiotic or an anti-coagulant. The EHR indicated Resident 70 was on Plavix, which is considered an anti-platelet drug, not an anti-coagulant. During an interview with the MDS Coordinator on 3/20/25 at 12:08 p.m., she indicated she should have marked the anti-platelet tab and not the anti-coagulant tab while entering information into the Resident Assessment Instrument for inputting data. The MDS Coordinator indicated it was her error. The MDS Coordinator also indicated she thought Resident 70 was still on an…

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 establish care plans for refusals of care (Resident H), psychological needs (Resident J), and transfer/ambulation status (Resident 190) for 3 of 8 residents reviewed for care planning. Findings include: 1. The clinical record for Resident H was reviewed on 3/21/2025 at 11:30 a.m. The medical diagnoses included diabetes and chronic obstructive pulmonary disease. An admission Minimum Data Set assessment, dated 2/10/2025, indicated Resident H was cognitively intact, did not reject care, and was frequently incontinent of bowel and bladder. Review of shower documentation for Resident H indicated she refused nine showers in the last 60 days. No care plan was on file for Resident H's refusals of care. 2. The clinical record for Resident J was reviewed on 3/21/2025 at 12:15 p.m. The medical diagnoses included respiratory failure and diabetes. A Quarterly Minimum Data Set assessment, dated 2/7/2025, indicated Resident J was cognitively intact and did not exhibit behaviors. During an interview on 3/19/2025 at 12:12…

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 wound dressing remained in place as ordered (Resident G) and weekly skin assessments were conducted per the facility policy (Resident 59) for 2 of 3 residents reviewed for non-pressure skin concerns. Findings include: 1. The clinical record for Resident G was reviewed on 3/19/25 at 2:58 p.m. The diagnoses included, but were not limited to, dementia, anxiety disorder, insomnia, vertigo, and neoplasm of uncertain behavior of skin. An Annual Minimum Data Set (MDS) assessment, dated 1/16/25, indicated Resident G was severely cognitively impaired and had open lesions. A care plan, revised 1/25/25, indicated Resident G had skin impairment related to skin cancer to the right temple. The interventions included, but were not limited to, follow facility protocols for treatment of injury. A physician order, dated 2/18/25, indicated the cleanse the right forehead with wound cleanser, pat dry, apply Vaseline, then cover with foam every other day and as needed for soilage. An interview conducted with a family…

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 had weekly skin assessments for 1 of 4 residents reviewed for pressure injuries. (Resident 39) Findings include: The clinical record for Resident 39 was reviewed on 3/19/25 at 2:23 p.m. The diagnoses included, but were not limited to, polyneuropathy, pain, and anxiety. Resident 39 had a care plan, initiated 1/20/25, for potential for pressure ulcer development with an intervention to follow facility policies/protocols for the prevention/treatment of skin breakdown. The Braden Scale (for predicting pressure ulcer risk evaluation document), dated 2/24/25, indicated Resident 39 had a Braden score of 12, indicating Resident 39 was at high risk for developing pressure ulcers. The Annual Minimum Data Set assessment, dated 2/26/25, indicated Resident 39 was cognitively intact, was dependent on a mechanical lift for transfer, was chairfast, always incontinent of bowel and bladder, and was at risk for pressure injuries. Resident 39's weekly skin assessments indicated they had a skin assessment,…

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 and implement a Range of Motion (ROM) program and splint program for a resident with limited ROM for 1 of 1 resident reviewed for ROM (Resident 75). Findings include During an interview with Resident 75 on 3/19/25 at 11:29 a.m., he indicated the facility does not provide him with ROM exercises. The resident indicated he was stiff and needed assistance moving all his extremities. The resident indicated he would like to be provided with ROM exercises. Review of the clinical record of Resident 75, on 3/19/25 at 2:00 p.m., indicated the diagnoses included, but were not limited to, hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting the right dominant side, muscle weakness, difficulty walking, depression and anxiety. The Occupational Therapy evaluation and plan for Resident 75, dated 8/2/24, indicated the goal was for the resident's family and caregivers to be provided with education and training on adaptive hemi-techniques, approach, encouragement, and safest strategies 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 interview and record review, the facility failed to fully conduct a fall follow-up and implement interventions after a fall for 1 of 2 residents reviewed for falls. (Resident 59) Findings include: The clinical record for Resident 59 was reviewed on 3/21/25 at 12:33 p.m. The diagnoses included, but were not limited to, asthma, Alzheimer's disease, chronic pain, and unspecified psychosis. An Annual Minimum Data Set (MDS) assessment, dated 1/8/25, indicated Resident 59 was severely cognitively impaired, supervision with transferring, supervision with walking, and had a fall with injury since the last MDS assessment. A care plan for falls, revised 1/12/25, indicated Resident 59 was at risk for falls related to confusion and psychoactive drug use. The interventions included, but were not limited to, activities that minimized the potential for falls (initiated on 11/18/24) and staff to help when doing rounds (initiated on 2/28/25). A post fall evaluation note, dated 1/24/25 at 10:46 a.m., indicated Resident 59 fell on 1/21/25 at 12:30 a.m. Resident 59 was startled by a sounding…

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 residents with weight loss were encouraged to consume supplements as recommended by the Registered Dietitian (RD) for 2 of 4 residents reviewed for nutrition. (Resident D and Resident 46) Findings include: 1. The clinical record for Resident D was reviewed on 3/20/25 at 2:58 p.m. The diagnoses included, but were not limited to, schizophrenia, alcohol-induced psychotic disorder, diabetes mellitus, malnutrition, and major depressive disorder. An Annual Minimum Data Set (MDS) assessment, dated 3/3/25, indicated Resident D had moderate cognitive impairment and was dependent on staff with eating. A physician order, dated 3/18/25, indicated Resident D was on a puree diet with nectar/mildly thick consistency for liquids. A care plan for nutrition, revised 3/16/25, indicated Resident D was on a puree diet, had a history of significant weight loss, and food was to be served in mugs and thinned to nectar consistency. The interventions included, but were not limited to, providing and serve diet as ordered,…

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 oxygen tubing was dated for 1 of 1 resident reviewed for oxygen administration. (Resident 241) Findings include: During an observation of Resident 241 on 3/18/25 at 2:22 p.m., Resident 241 had oxygen tubing on by nasal cannula. The oxygen tubing did not have a date to indicate when it was last changed. During an observation of Resident 241 on 3/19/25 at 12:48 p.m., Resident 241 had oxygen tubing on by nasal cannula. The oxygen tubing was not dated. The clinical record for Resident 241 was reviewed on 3/19/25 at 2:15 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease and respiratory failure. A care plan, initiated on 3/13/25, indicated Resident 241 was on continuous oxygen at two liters per minute via nasal cannula. During an observation on 3/21/25 at 2:21 p.m., Resident 241's oxygen tubing was not dated. During an interview with Registered Nurse (RN) 6 on 3/21/25 at 2:22 p.m., they indicated they did not know why the oxygen tubing was not dated. RN 6 indicated…

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 who received scheduled pain medication received follow-up to ensure effectiveness after receiving scheduled pain medication, ensure follow-up after a scheduled appointment pertaining to chronic back pain, and ensure Lidoderm (pain relief) patches were documented when applied and removed after 12 hours for 1 of 2 residents reviewed for pain. (Resident 78) Findings include: 1a. The clinical record for Resident 78 was reviewed on 3/21/25 at 12:39 p.m. The diagnoses included, but were not limited to, chronic back pain, dementia, and hypertension. A Quarterly Minimum Data Set (MDS) assessment, dated 3/13/25, indicated Resident 78 was moderately cognitively impaired, received scheduled pain medication, did not receive as needed pain medication, did not receive non-pharmalogical interventions for pain, had frequent pain in the last five days, and documented the worst pain rating over the last five days as a 5 out of 10. A physician order, dated 8/2/24, was noted for Extra Strength Tylenol 500…

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 15-minute checks were initiated for a resident with behaviors for 1 of 2 residents reviewed for behavior monitoring. (Resident E) Findings include: The clinical record for Resident E was reviewed on 3/20/25 at 9:42 a.m. The diagnoses included, but were not limited to, diffuse traumatic brain injury and alcohol dependence. The Director of Nursing Services provided a facility incident report on 3/20/25 at 11:33 a.m. It indicated an incident occurred, on 2/18/25, when facility staff alleged Resident E had his hand down another resident's pants. It indicated the facility employee was unaware of the location of Resident E's hands and the two residents were immediately separated. A Quarterly Minimum Data Set (MDS) assessment, dated 12/26/24, indicated Resident E had moderate cognitive impairment. A written statement from Certified Nurse Aide (CNA) 8, dated 2/19/25, indicated, on 2/18/25 after dinner, she saw two residents, one of them being Resident E sitting next to each other. She noticed the two residents…

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 timely follow-up on a resident's psychosocial needs regarding his roommate exhibiting inappropriate behavior in front of him for 1 of 4 residents reviewed for behaviors. (Resident J) Findings include: The clinical record for Resident J was reviewed on 3/21/2025 at 12:45 p.m. The medical diagnoses included respiratory failure and diabetes. A Quarterly Minimum Data Set assessment, dated 2/7/2025, indicated Resident J was cognitively intact and did not exhibit behaviors. A care plan, revised 11/15/2023, indicated Resident J had depression and a psychotic disorder. Interventions were listed to encourage activities, provide emotional support, companionship, and to provide opportunities to voice mental health concerns to staff. During an interview on 3/19/2025 at 12:12 p.m., Resident J indicated his roommate (Resident E) will engage in the act of self-pleasure with the door and curtain open. This act made Resident J feel dirty and disgusted. Resident J reported this to staff about a month to six weeks ago per his recall, and 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 administer an anticoagulant medication as ordered by the physician, which resulted in receiving the medication for an excessive duration for 1 of 1 resident reviewed for death. (Resident 88) Findings include: The clinical record for Resident 88 was reviewed on 3/24/25 at 11:53 a.m. Her diagnoses included, but were not limited to, a-fib (atrial fibrillation.) The 8/27/24 care plan indicated she was at risk for complications related to anticoagulant medication due to atrial fibrillation. The goal was for her to remain without complications from bleeding or injury. Interventions, initiated 8/27/24, were to observe for adverse reactions such as cramps, diarrhea, hemorrhage, and signs and symptoms of bleeding such as tarry stools and blood in the urine. The December 2024 physician's orders indicated to administer one five mg tablet of apixaban, also known as Eliquis (anticoagulant medication that makes blood flow through your veins more easily), two times a day, effective 8/26/24. The 12/21/24 at 6:02 p.m. change of condition…

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

Based on observation, interview, and record review, the facility failed to follow-up on dental recommendations for a tooth extraction for 2 of 3 residents reviewed for dental services. (Resident G and Resident 12) Findings include: 1. An observation conducted of Resident G, on 3/19/25 at 10:05 a.m., noted broken teeth. An interview conducted with a family member of Resident G, on 3/19/25 at 11:25 a.m., indicated she was the power of attorney (POA) for Resident G and the facility was not good with communication. Resident G had a tooth infection back in December of 2024. She was unsure if Resident G's infected tooth had been pulled. She signed consent forms for Resident G to be seen by the dentist. She believed he was seen by the in-house dentist on 2/27/25. She indicated she was told the in-house dentist provider would be able to assist with the tooth extraction for Resident G. The clinical record for Resident G was reviewed on 3/19/25 at 2:58 p.m. The diagnoses included, but were not limited to, dementia, anxiety disorder, insomnia, vertigo, and neoplasm of uncertain behavior 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 observation, interview, and record review, the facility failed to ensure the appropriate thickened liquids were provided for 2 of 5 residents observed for dining. (Resident 46 and Resident D) Findings include: 1. An observation was conducted of the lunch meal service in the Alzheimer's Care Unit (ACU) on 3/19/25 from 12:15 p.m. to 12:55 p.m. During the observation, Resident D was assisted with eating by Certified Nurse Aide (CNA) 2. Resident D's food items were a certain consistency and provided in handled cups. Resident D's meal ticket indicated he was on a puree diet with nectar thickened liquids. There was another meal tray located just behind CNA 2 and located on the kitchen island. That meal tray consisted of a meal ticket with Resident 46's name on it with a diet of puree with honey thickened liquids. CNA 2 reached for an orange liquid that was located on Resident 46's meal tray, removed the lid from the cup, and proceeded to assist Resident D with consuming the thickened orange drink. The clinical record for Resident D was reviewed on 3/20/25 at 2:58 p.m. 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 infection control practices were maintained during a medication administration observation for 2 of 5 residents observed for medication administration. (Facility) Findings include: An observation of medication administration was conducted, on 3/20/25 from 8:10 a.m. to 8:40 a.m., with Registered Nurse (RN) 4. RN 4 proceeded to prepare morning medications for Resident 246. RN 4 donned gloves prior to taking a bottle of Mirilax, poured the Mirilax medication into water to dissolve, and gave the morning medications for Resident 246 to take. RN 4 proceeded to remove the gloves but did not conduct hand hygiene after glove removal. RN 4 then went to prepare morning medications for Resident 247. RN 4 donned gloves, without conducting hand hygiene, retrieved an insulin pen, used an alcohol wipe to wipe off the hub of the insulin pen, applied the needle, primed the insulin pen with two units, and then administered the insulin to Resident 247's left thigh. RN 4 returned to the medication cart to place the insulin…

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 physician's order for administration of the 2024-2025 Covid-19 vaccination and administer or arrange for administration of the vaccination, per policy, for 2 residents who consented to receive it out of 5 residents reviewed for Covid-19 vaccination. (Residents 23 and 50) Findings include: 1. The clinical record for Resident 23 was reviewed on 3/25/25 at 9:45 a.m. His diagnoses included, but were not limited to, chronic obstructive pulmonary disease, diabetes mellitus, heart disease, end stage renal disease, and hypertension. He was admitted to the facility on [DATE]. The Covid-19 Vaccine Consent Form, signed by Resident 23 on 10/16/24, indicated he was screened for eligibility, education on the vaccination, and consented to receive the updated Covid-19 vaccine. The immunizations portion of the electronic health record indicated the most recent Covid-19 vaccination for him was administered on 1/26/23. 2. The clinical record for Resident 50 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was free from a physical restraint during a blood sugar check for 1 of 3 residents reviewed for abuse. The deficient practice was corrected on 10/23/24, prior to the start of the survey, and was therefore past noncompliance. (Resident B) Findings include: The clinical record for Resident B was reviewed on 11/12/24 at 12:30 p.m. Her diagnoses included, but were not limited to, dementia, mood disorder, and diabetes. She was admitted to the facility on [DATE] and resided on the memory care unit of the facility. The 8/26/24 dementia care plan indicated the goal was for her to be able to communicate basic needs on a daily basis. Interventions were to explain all procedures and reason before performing, initiated 8/26/24, and pleasant interaction, which reassures patient when confused, initiated 8/26/24. The 10/17/24 psychiatry progress note indicated, Assessment and Plan: 1. Mood disorder: No recent behavioral issues per staff report.…

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 a safe environment regarding use of an outside door for 1 of 3 residents reviewed for environmental hazards. (Resident G) Findings include: The clinical record for Resident G was reviewed on 8/21/24 at 10:58 a.m. The diagnoses included, but were not limited to, borderline personality disorder. An interview was conducted with Resident G on 8/20/24 at 1:45 p.m. He indicated there was a back door at the end of the hallway in the facility that led to the parking lot. The door had sharp edges that cut him several times when he used it. The maintenance staff put a metal piece around the edge of the door, but the piece broke down within months, so now they put duct tape over the broken-down areas on the edge of the door. The duct tape wore through in no time, and had to be replaced every week or so. He felt they needed to replace the door, instead of continuing to put temporary fixes in place. He used the door numerous times a day to smoke or to spend time outside of the facility. He currently had two cuts,…

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 maintain documentation of a complete and thorough investigating to include the identification of potentially vulnerable residents and prevention of further abuse for 3 of 3 investigations reviewed. Findings include: 1. The clinical record for Resident B was reviewed on 8/20/2024 at 11:45 a.m. Medical diagnoses included bipolar disorder, intellectual disabilities, encephalopathy, and anxiety disorder. A Quarterly Minimum Data Set assessment (MDS), dated [DATE], indicated Resident B was severely cognitively impaired, exhibited physical, verbal, and wandering for one to three days of the last seven reviewed, and exhibited rejection of care for four to six of the last seven days reviewed. A behavior care plan, dated 1/24/2024, indicated that Resident B had a history of exhibiting aggressive behaviors such as hitting, grabbing, pinching and kicking. Interventions, dated 1/24/2024, included: Assisting Resident B to not enter other's personal space, redirect…

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 complete a resident's dressing changes timely, as ordered, for 1 of 3 residents reviewed for skin conditions. (Resident D) Findings include: The clinical record for Resident D was reviewed on 8/20/24 at 11:27 a.m. The diagnoses included, but were not limited to, lymphedema, peripheral vascular disease, hypertension, and type 2 diabetes mellitus. He was readmitted to the facility from the hospital on 8/11/24. The 6/5/24 Quarterly MDS (Minimum Data Set) assessment indicated he was cognitively intact. The 8/11/24, 2:22 p.m. Nursing Clinical admission Note indicated, Skin note: cellulitis left leg, weeping and red in appearance. Special Care: .Resident currently on antibiotics. Antibiotic name: cefuroxime Dx [Diagnosis:] cellulitis. The 8/11/24, revised 8/12/24, physician's order indicated, Wound Care: left lateral leg: Cleanse with wound cleanser and pat dry. Apply collagen to wound bed and cover with border gauze. Change every other day and PRN [as needed] if soiled or dislodged. One time a day every other day…

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 promptly notify the resident's representative following a fall with injury for 2 of 4 residents reviewed for falls. (Residents E and G) Findings include: 1. The clinical record of Resident E was reviewed on 7-16-24 at 11:52 a.m. Her diagnoses included, but were not limited to, a neurocognitive disorder with [NAME] Body and unspecified dementia. She was admitted to the facility in, June 2024, for a short-term respite stay of less than 2 weeks, into the facility's secured dementia care unit. Her admission Minimum Data Set assessment, dated 6-25-24, indicated she was severely cognitively impaired, was ambulatory and had a history of falls in the previous one to six months, prior to admission to the facility. A progress note, dated 6-25-24 at 2:00 p.m., indicated Resident E had been agitated and she was taking her clothes off. It indicated a nurse assessed the resident and found [a] bump on her left forehead. A notation, dated 6/25/2024 at 2:21 p.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 interview and record review, the facility failed to honor the time of bathing preferences for 2 of 4 residents reviewed for bathing needs. (Resident 30 and 32) Findings include: 1. The clinical record for Resident 30 was reviewed on 11/8/2024 at 10:48 a.m. The medical diagnosis included dementia. A Quarterly Minimum Data Set (MDS) Assessment, dated 11/6/2023, indicated Resident 30 was cognitively impaired and did not reject care. A resident preference evaluation, dated 11/16/2023, indicated that Resident 30 preferred to take showers in the morning. The facility task documentation indicated to offer Resident 30 showers two times a week on Tuesday and Friday evenings. 2. The clinical record for Resident 32 was reviewed on 1/9/2024 at 10:26 a.m. The medical diagnosis included Alzheimer's disease. A Quarterly MDS Assessment, dated for 12/20/2023, indicated Resident 32 was cognitively intact and did not reject care. An interview with Resident 32 on 1/3/2023 at 11:58 a.m. indicated that she does not get her showers when she would like them. She stated her preference was to have…

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 nail care for a dependent resident with bilateral hand contractures for 1 of 5 residents reviewed for Activities Of Daily Living (ADL) (Resident 29). Finding include: During an observation on 1/03/24 at 11:18 a.m.,. Resident 29 had long fingernails on both hands with peeling fingernail polish, the resident had bilateral hand contractures and the resident's fingernails were pressing into the palms of her hands. During an interview with Resident 29's family member on 1/03/24 at 11:40 a.m., indicated Resident 29's fingernails were too long and needed to be trimmed. During an observation on 1/04/24 at 1:04 p.m., Resident 29 had long fingernails on both hands with peeling fingernail polish, the resident had bilateral hand contractures and the resident's fingernails were pressing into the palms of her hands. During on observation on 1/05/24 at 10:38 a.m., Resident 29 had long fingernails on both hands with peeling fingernail polish, the resident had bilateral hand contractures and the resident's fingernails…

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 obtain daily weights as ordered by the physician for Congestive Heart Failure (CHF), failed to follow the physician order to hold blood pressure medications per parameters and failed to obtain Foley catheter and catheter care orders for 3 of 3 residents reviewed for quality of care (Resident 61, Resident 14 and Resident 9). Findings include: 1.) Review of the record of Resident 61 on 1/8/23 at 11:40 a.m., indicated the resident's diagnosis included, but were not limited to, congestive heart failure. The January 2024 physician Recapitulation order for Resident 61, (original order date 2/23/23), indicated the resident was to have daily weights completed due to congestive heart failure. The facility was to notify the physician/Nurse Practitioner if the resident has 3 pounds or greater gain in 1 day or 5 pounds or more in a week. The Medication Administration Record (MAR) for Resident 61, dated December 2023, indicated the resident weight was 105.8 pounds on 12/23/23, the resident's weight was not completed on 12/24/23,…

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 interview, record review, and observations, the facility failed to utilize pressure relieving boots for a dependent resident at risk for developing pressure areas for 1 of 1 residents reviewed for pressure areas. (Resident 9) Findings include: The clinical record for Resident 9 was reviewed on 1/5/2023 at 2:40 p.m. The medical diagnoses included stroke and Alzheimer's disease. An admission Minimum Data Set Assessment, dated for 12/8/2023, indicated that Resident 9 had both short- and long-term memory problems, was dependent on staff for activities of daily living, utilized an indwelling urinary catheter, was at risk for pressure areas, and currently had three pressure areas. A pressure area care plan, dated for 12/11/2023, indicated for Resident 9 to utilized prevalon boots, a type of pressure reliving boots. An observation on 1/2/2024 at 11:45 a.m. indicated Resident 9 laying in bed with a low air loss mattress in place. Her prevalon boots were sitting next to her bed in a chair. An observation on 1/2/2024 at 1:40 p.m. indicated Resident 9 laying in bed with a low air loss…

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 fortified pudding at lunch as ordered by the physician for a resident with a history of significant weight loss for 1 of 5 residents reviewed for nutrition (Resident 61). Finding include: During an observation on 1/03/24 at 12:33 p.m., Resident 61 was thin in appearance. During an observation on 1/04/24 at 1:02 p.m., Resident 61 was eating lunch in her room, the resident did not have fortified pudding on her tray. During an observation and interview on 1/05/24 at 12:52 p.m., Resident 61 was eating lunch in her room, the resident did not have fortified pudding on her tray. The resident's tray card indicated she was to have fortified pudding. Resident 61 indicated sometimes she received her fortified pudding and sometimes she did not. Review of the record of Resident 61 on 1/8/23 at 11:40 a.m., indicated the resident's diagnoses included, but were not limited to, chronic obstructive pulmonary disease, congestive heart failure, hypertension, muscle weakness, gastro-esophageal reflux and chronic kidney…

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 the attending physician reviewed and signed medication regimen reviews (MRR) for 2 of 5 residents reviewed for unnecessary medications. (Resident 14 and 50) Findings include: 1. The clinical record for Resident 14 was reviewed on 1/9/2024 at 10:32 a.m. The medical diagnoses included anxiety and disorganized schizophrenia. A Quarterly Minimum Data Set Assessment, dated 1/2/2024, indicated Resident 14 was cognitively intact. A MRR review, dated for 6/28/2023, indicated a recommendation for a gradual dose reduction (GDR) for Zoloft or guidance to document a contraindication to the GDR. This MRR was not signed by a provided until 8/28/2023 to reflect to attempt the GDR for Resident 14's Zoloft. The attending physician visited Resident 14 on 7/8/2023. The psychiatric nurse practitioner visited Resident 14 on 7/13/2023. 2. Resident 50's record was reviewed on 1/04/24 at 11:10 a.m. The record indicated Resident 50 had diagnoses that included, but were not limited to, dementia with psychotic disturbance, anxiety, high blood…

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.