Waters Of Hobart Skilled Nursing Facility, The

Based on record review and interview, the facility failed to ensure blood pressure and heart rate parameters were monitored for 1 of 6 residents reviewed for unnecessary medications. (Resident 5) Finding includes: The record for Resident 5 was reviewed on 6/11/25 at 2:52 p.m. Diagnoses included, but were not limited to, ischemic heart disease, hypertensive heart disease with heart failure, and congestive heart failure (CHF). The Quarterly Minimum Data Set (MDS) assessment, dated 5/23/25, indicated the resident had moderate cognitive impairment. A Physician's Order, dated 3/25/25 and listed as current on the June 2025 Physician's Order Summary (POS), indicated the resident was to receive Metoprolol Tartrate (a medication used to treat high blood pressure and chest pain) 25 milligrams (mg), give 0.5 tablet twice a day. Hold for a heart rate less than 60 and systolic blood pressure (top number) greater than 110. The May and June 2025 Medication Administration Records (MARs), indicated the medication had been signed out as being given twice a day as ordered, however, 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 the medical record was complete and accurately documented related to infection monitoring for 2 of 3 records reviewed for infections. (Residents 3 and 36) Findings include: 1. The record for Resident 3 was reviewed on 6/11/25 at 1:29 p.m. Diagnoses included, but were not limited to, stroke, hemiplegia (paralysis of one side of the body), and hearing loss. The 4/21/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident had severe cognitive impairment and was dependent in activities of daily living (ADLs). The June 2025 Medication Administration Record (MAR) indicated, Monitor for s/s [signs/symptoms] of infection to include: fever, new/worsening skin impairments, sore throat, nausea/vomiting/diarrhea every day shift for change in condition screening-Start Date 05/17/2025. The documentation for 6/7/25 and 6/8/25 was y. The record lacked any other documentation of the resident having signs or symptoms of an infection on 6/7/25 and 6/8/25. During an interview on 6/17/25 at 12:14 p.m., the Director 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, record review, and interview, the facility failed to ensure infection control practices were in place and implemented related to the cleaning of a shared glucometer before and after use for 1 of 1 glucometer (machine used to test blood sugar levels) test observed. (Resident 34) Finding includes: On 6/9/25 at 11:43 p.m., LPN 2 indicated she was going to check Resident 34's blood sugar level. The LPN walked in with the glucometer and indicated she had already cleaned the monitor, but she would clean it again. She grabbed a bottle of germicidal wipes and donned a new pair of gloves, she grabbed a couple of pieces of dry tissue and placed it on the bedside table. She then used the germicidal wipe to clean the glucometer. After cleaning the monitor she immediately wiped it dry with the dry tissue. Once the glucometer was dry, LPN 2 proceeded to obtain the resident's blood sugar. When the blood sugar test was completed, she walked the glucometer back to the medication cart and proceeded to clean the glucometer with a germicidal wipe. She again, immediately dried off…

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 with a pressure ulcer received the necessary treatment and services to promote healing, related to treatments not completed as ordered for 1 of 3 residents reviewed for pressure ulcers. (Resident F) Finding includes: During an observation on 10/28/24 at 9:34 a.m., CNA 1 and QMA 2 were providing morning care to Resident F. The resident was turned to the right side and an uncovered pressure area was observed to the right side of the sacral area. The area had depth and was approximately 3 centimeters (cm) by 2 cm in size. There was no observed drainage. CNA 1 indicated she had not received the information in morning report at 6:30 a.m. that the dressing was off. She indicated the night staff had reported they last completed rounds around 5 a.m. CNA 1 left the room to report the dressing was not in place to the nurse. During an observation on 10/28/24 at 10 a.m., LPN 1 entered the room. He indicated he had not been informed by the night nurse during the shift report that the dressing was off 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 appropriate treatment and services were provided to residents with feeding tubes, related to physician's orders not followed when checking for proper placement of the feeding tubes, for 2 of 3 residents reviewed for feeding tube care. (Residents B and E) Findings include: 1) Resident B's closed record was reviewed on 10/28/24 at 1:06 p.m. The diagnoses included, but were not limited to, stroke. A Quarterly Minimum Data Set (MDS) assessment, dated 9/14/24, indicated a severely impaired cognitive status, a feeding tube was present and supplied 51% or more of nutrition and 501 cubic centimeters (cc) or more of fluids daily. A Physician's Order, dated 6/7/24, indicated the feeding tube placement was to be checked for placement and the residual was to be documented prior to the administration of medications, formula, and flushing. A Care Plan, dated 6/13/24, indicated a feeding tube was required. The interventions included, the tube would be checked for placement and gastric contents/residual volume would be recorded.…

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 have ongoing communication with a resident's dialysis center, related to the facility not checking on a resident's location when they did not return from a dialysis appointment, for 1 of 2 residents reviewed for dialysis. (Resident C) Finding includes: Resident C's closed record was reviewed on 10/29/24 at 8:06 a.m. The diagnoses included, but were not limited to, end stage renal disease with dialysis, stroke, and dementia. An Modification of the admission Minimum Data Set assessment, dated 6/17/24, indicated a severely impaired cognitive status, dependent on staff for all activities of daily living, and received dialysis. A Care Plan, dated 6/11/24, indicated dialysis was required. The interventions included, dialysis would be provided as scheduled. A Physician's Order, indicated dialysis was to be completed at a dialysis center on Monday, Wednesday, and Friday. A Nurse's Progress Note, dated 8/5/24 (Monday) at 4:39 p.m. and signed by LPN 3, indicated the medications were not administered due to the resident was…

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

Based on record review and interview, the facility failed to ensure a resident's record had thorough and accurate documentation related to a Physician consult appointment, admission cardiac assessment, pressure ulcer assessment, and documentation of pressure ulcers, for 1 of 5 residents reviewed for medical record documentation. (Resident B) Finding includes: Resident B's closed record was reviewed on 10/28/24 at 1:06 p.m. The diagnoses included, but were not limited to stroke. a) A Nurse's admission Assessment, dated 6/7/24, indicated a pacemaker and defibrillator was present. There were no physician's orders for routine pacemaker monitoring. The Chest Physician Consult from the hospital, dated 6/4/24, lacked documentation of a pacemaker and/or defibrillator. The Nurse Practitioner's admission Progress Note, dated 6/18/24 at 1:38 p.m., indicated the cardiovascular status was normal cardiac rhythm and no murmurs. There was no documentation that indicated a pacemaker and defibrillator was present. A Nurse's Progress Note, dated 6/21/24 at 10:27 a.m., indicated an open area in the…

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

Based on observation, interview, and record review, the facility failed to ensure correct Personal Protective Equipment (PPE) was used by staff members (CNA 5, CNA 1, and QMA 2) when providing care to residents (Residents E and F) who were in Enhanced Barrier Precautions (EBP) for two random observations for infection control. Findings include: 1) During an observation on 10/28/24 at 8:51 a.m., Resident E had a sign on the room door that indicated the resident was in EBP. There was PPE located at the doorway to the room. Upon entering the room, CNA 5 was completing morning care on the resident. Gloves were worn. She indicated she had just finished washing him and provided incontinent care. The feeding tube insertion site was clean. CNA 5 was applying lotion to the resident's legs. She indicated the resident was no longer in EBP and stated, he doesn't have anything, they just forgot to take the signs down. She then completed the resident's oral care. Resident E's record was reviewed on 10/29/24 at 10:58 a.m. The diagnoses included, but were not limited to, severe protein deficiency.…

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 ensure the residents' environment was clean and in good repair, related to personal items not contained in a shared environment, discolored floor tile, missing caulk around toilet bases, leaking toilets, dried tube feeding on the base of poles, and urine odors in 1 of 2 units. (West Unit) Findings include: During the Environmental tour on the [NAME] Unit with the Maintenance Director on 7/10/24 at 2:36 p.m., the following was observed: a. room [ROOM NUMBER]: the floor tile was discolored, the caulk around the base of the toilet was missing and discolored and the toilet was leaking around the base. There were tooth brushes and hair brushes sitting out on the bathroom counter not contained. Two residents shared the bathroom b. room [ROOM NUMBER]: there was a strong urine odor. c. room [ROOM NUMBER]: there was dried tube feeding on the base of the tube feeding pole. d. room [ROOM NUMBER]: the bathroom tile floor was discolored and there was a pink wash…

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 physician's orders for medications and an assessment to self-administer their own medications for 2 of 2 residents reviewed for self-administration of medication. (Residents 100 and 2) Findings include: 1. During a random observation on 7/8/24 at 3:19 p.m., Resident 100 was observed in his room in bed. At that time, a tube of over the counter hydrocortisone cream was observed on his over bed table with the cap off as well as an Albuterol Sulfate inhaler. During an interview at that time, the resident indicated he left the medications on his over bed table in case he needed them. During random observations on 7/9/24 at 9:00 a.m. and 3:00 p.m. and 7/10/24 at 8:55 a.m. and 11:42 a.m., the inhaler remained on the resident's over bed table. The record for Resident 100 was reviewed on 7/8/24 at 3:30 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), pneumonia, emphysema, and anxiety. The admission Minimum Data Set (MDS) assessment, dated 6/28/24,…

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 ADL (activities of daily living) assistance to dependent residents related to nail care and the removal of facial hair for 2 of 7 residents reviewed for ADL care. (Residents 44 and 22) Findings include: 1. On 7/8/24 at 11:25 a.m., Resident 44 was in her room seated in a wheelchair. The resident's fingernails were long with a dark substance underneath and she had an accumulation of facial hair. At 3:18 p.m., the resident was observed in bed sleeping. The facial hair remained to her chin and her hands were covered with a blanket. On 7/9/24 at 9:03 a.m. and 3:00 p.m., the resident's fingernails remained long and dirty and the gray facial hair remained to her chin. On 7/10/24 at 8:58 a.m. and 11:42 a.m., the resident's fingernails remained long and dirty and the gray facial hair remained to her chin. The record for Resident 44 was reviewed on 7/10/24 at 11:12 a.m. Diagnoses included, but were not limited to, stroke, sepsis, dysphagia…

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 areas of bruising were assessed and monitored for 1 of 1 resident reviewed for skin conditions non-pressure related(Resident 100), failed to administer medications according to physician's orders related to not following parameters for 1 of 6 residents reviewed for unnecessary medications (Resident 44), and failed to identify and assess a resident's edema (swelling) for 1 of 1 resident reviewed for edema. (Resident 250) Findings include: 1. On 7/8/24 at 10:31 a.m., Resident 100 was observed in his room in bed. Areas of reddish/purple discolorations were observed on his left and right forearms. During an interview at that time, the resident indicated the bruises may have been from lab draws, but he wasn't sure. The record for Resident 100 was reviewed on 7/8/24 at 3:30 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), pneumonia, emphysema, anemia, and anxiety. The admission Minimum Data Set (MDS) assessment, dated 6/28/24, indicated the resident was…

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

Based on observation, record review, and interview, the facility failed to ensure a Podiatrist's recommendations were followed related to thick, painful, and fungal toenails for 1 of 7 residents reviewed for ADLs (activities of daily living). (Resident 40) Finding includes: On 7/8/24 at 11:00 a.m., Resident 40 was observed with long, thick and yellow discolored toenails. During an interview at that time, the resident indicated he had seen the Podiatrist and was told he had a fungus on his toenails. The record for Resident 40 was reviewed on 7/9/24 at 1:00 p.m. Diagnoses included, but were not limited to, stroke, left side hemiplegia, major depressive disorder, heart disease, and atrial flutter. The Annual 5/15/24 Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. The resident had an impairment of functional range of motion to one side for his upper and lower extremity. A Podiatry Exam Note, dated 1/26/24, indicated the resident had pain on the on left great toe, left 2nd toe, left 3rd toe, left 4th toe, left 5th toe, right…

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 splint was ordered and in place as recommended by therapy for 1 of 1 resident reviewed for limited range of motion (ROM). (Resident 40) Finding includes: During an observation on 7/8/24 at 11:02 a.m., Resident 40 was observed with a left hand contracture (fixed tightening of muscle, tendons, ligaments, or skin which prevents normal movement of the associated body part.) The resident was not able to voluntarily open his left hand, he had to use his right hand to lift it and open it. During an interview at that time, the resident indicated he had a splint and it was supposed to be on at night, however, he had to ask staff to put on the splint, because they did not put it on every night. He indicated the splint was not placed on his left hand the previous night. At that time, the splint was observed on top of the night stand. During an interview on 7/9/24 at 9:13 a.m., the resident indicated the splint was not placed on his left hand the previous night. The record for Resident 40 was reviewed on 7/9/24…

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 random observations, record review, and interview, the facility failed to ensure a suprapubic foley catheter (urinary catheter that is inserted into the bladder from a small cut in the lower abdomen) bag and tubing was kept off the floor for 1 of 1 resident reviewed for urinary catheters. (Resident 22) Finding includes: During random observations on 7/8/24 at 8:03 a.m., 10:33 a.m., and 2:14 p.m., Resident 22 was observed sitting in a wheelchair. At those times, a foley catheter bag was observed under the wheelchair and the bottom of the bag was touching the floor. During random observations on 7/10/24 at 9:00 a.m., 9:30 a.m., and 11:15 a.m., the resident was observed sitting in a wheelchair. At those times, a foley catheter bag and tubing were observed under the wheelchair and both were on the floor. The record for Resident 22 was reviewed on 79/24 at 9:50 a.m. Diagnoses included, but were not limited to, type 2 diabetes, urinary tract infection (UTI), dementia without behaviors, high blood pressure, obstructive and reflux uropathy (a condition where urine cannot drain into…

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 enteral tube feedings were infusing at the correct time and flow rate through a peg tube (a tube inserted directly into the stomach for nutrition) for 2 of 3 residents reviewed for tube feeding. (Residents 2 and 251) Findings include: 1. On 7/8/24 at 7:55 a.m., Resident 2 was observed lying in bed. At that time, an enteral tube feeding was infusing at 55 cubic centimeters (cc) an hour through the peg tube. At 10:22 a.m., the resident's enteral feeding was observed to be turned off. On 7/8/24 at 10:48 a.m., 11:10 a.m., 11:30 a.m., and 1:45 p.m., the resident was in bed and the enteral tube feeding remained off. The record for Resident 2 was reviewed on 7/9/24 at 1:52 p.m. Diagnoses included, but were not limited to, left side hemiplegia, stroke, type 2 diabetes, heart disease, dementia, dysphagia (swallowing difficulties), and adult failure to thrive. The Quarterly Minimum Data Set (MDS) assessment, dated 6/6/24, indicated the resident was moderately impaired for daily decision making. The 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, record review, and interview, the facility failed to ensure oxygen was set at the correct flow rate and ordered by the physician for 3 of 4 residents reviewed for respiratory care. (Residents 13, 251, and 254) Findings include: 1. During random observations on 7/8/24 at 8:07 a.m., 10:20 a.m., 11:10 a.m., and 11:30 a.m., on 7/9/24 at 9:12 a.m., 9:52 a.m., 12:50 p.m., and 3:00 p.m., and on 7/10/24 at 9:00 a.m. and 11:30 a.m., Resident 13 was observed lying in bed and wearing oxygen per nasal cannula. The center of the oxygen bubble was below the 3 liter mark and above the 2.5 liter mark. The record for Resident 13 was reviewed on 7/9/24 at 9:30 a.m. Diagnoses included, but were not limited to, stroke, type 2 diabetes, dysphagia (difficulty swallowing), and anemia. The 4/30/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. The resident did not receive oxygen and was currently on hospice. There was no care plan for oxygen therapy. Physician's Orders, dated 7/8/24, indicated oxygen at 2 liters…

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 Physician's Orders for monitoring an external cardiac device were followed for 1 of 1 residents reviewed for specialty care. (Resident B) Finding includes: Resident B's record was reviewed on 3/4/24 at 9:55 a.m. Diagnoses included, but were not limited to, cerebral infarction, congestive heart failure, and cardiomyopathy. The admission Minimum Data Set (MDS) assessment, dated 2/6/24, indicated the resident was severely cognitively impaired for daily decision making. A Care Plan, dated 2/3/24, indicated the resident had an external cardiac device. Interventions included, but were not limited to, every 24 hours change and recharge the batteries. A Physician's Order, dated 2/2/24, indicated to check external cardiac device placement every shift. A Physician's Order, dated 2/3/24, indicated to change the battery pack on the external cardiac device daily at 10:00 a.m., nurse to affirm vibration box located within the vest. The February and March 2024 Treatment Administration Record (TAR) indicated the external cardiac…

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, including those to prevent and/or contain COVID-19, related to personal protective equipment (PPE) not worn before entering a COVID-19 positive resident room, droplet/contact isolation room, and hand hygiene not completed before donning PPE, for random observations for infection control on 1 of 3 units observed. Findings include: 1. During a random observation, Hospice Aid 1 entered Resident C's room on 3/4/24 at 10:47 a.m. The door had a sign indicating the resident was in droplet and contact isolation, as the resident had human metapneumovirus (an upper or lower respiratory disease). The sign indicated a gown, gloves, eye protection, and N95 mask were required to enter. Hospice Aid 1 entered the room without performing hand hygiene, and did not don any of the required personal protective equipment (PPE). At the time, Hospice Nurse 1 was observed talking to the resident at the bedside. She was not wearing any of the required PPE. 2. During a…

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

Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% for 2 of 4 residents observed during medication pass. Four errors were observed during 27 opportunities for errors during medication administration. This resulted in a medication error rate of 14.8%. (Residents E and F) Findings include: 1. On 2/6/24 at 9:10 a.m., medication pass was observed with RN 1. LPN 1 was also present to observe. The RN prepared Resident E's medications. She placed 6 tablets in a packet and crushed them, then mixed with pudding in a plastic cup. There was one chewable vitamin in another cup. She administered the medications to the resident. The resident's medications were reconciled on 2/7/24. The February 2024 Medication Administration Record (MAR) indicated the resident was also to receive the following medications in the morning: - Miralax 17 grams - Trelegy 200/ 62.5 mg inhaler - Voltaren 1% gel, 4 grams These medications had been signed out on the MAR, but had not been given during medication observation. 2. On 2/7/24 at 8:15 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 record review and interview, the facility failed to ensure pharmacy services were provided for a resident, related to a scheduled pain medication not provided as ordered, for 1 of 3 residents reviewed for pharmacy services. (Resident C) Finding includes: The closed record for Resident C was reviewed on 2/6/24 at 9:28 a.m. Diagnoses included, but were not limited to, breast cancer, liver and bile duct cancer, pleural effusions and depression. The resident was discharged from the facility on 12/18/23. The Quarterly Minimum Data Set assessment, dated 11/13/23, indicated the resident was cognitively intact. She required extensive assist of 2 staff for transfers and toileting, and extensive assist of 1 for bed mobility. A Physician's Order, dated 11/8/23, indicated to give Oxycodone/acetaminophen 5 milligrams (mg) /325 mg (an opioid pain analgesic) every evening for severe pain. The November 2023 Medication Administration Record (MAR) indicated, between 11/8/23 and 11/30/23, the medication was not given 22 times. The December 2023 MAR indicated, between 12/1/23 and 12/18/23, 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 and interview, the facility failed to ensure infection control measures were in place and implemented, related to lack of hand hygiene during medication pass and wound care, for two random observations for infection control. (QMA 1 and LPN 1) Findings include: 1. On 2/7/24 at 8:15 a.m., medication pass was observed with QMA 1. LPN 1 was present also to observe. The QMA prepared the medication for Resident E and administered it. She then returned to the medication cart, and began preparing medication for the next resident. She prepared Resident F's medication and gave it to him. The QMA did not perform hand hygiene between the two residents' medications. During an interview with the QMA after the observation, she indicated she did not complete hand hygiene between the two residents. 2. On 2/7/24 at 9:55 a.m., wound care was observed with LPN 1. LPN 1 positioned the resident on his side to change a dressing on his sacrum. She donned gloves and removed the old dressing. She then cleansed the area with wound wash, patted the area dry, and then applied a new…

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 pain was managed related to lack of monitoring for signs of narcotic withdrawal and medication effectiveness, lack of non-pharmacological interventions provided, and incomplete pain assessments 1 of 1 residents reviewed for pain. (Resident B) Finding includes: Resident B was observed in the conference room on 11/29/23 at 9:20 a.m. She was propelling herself in a wheelchair and had a distressed facial expression. She indicated she had severe degenerative joint disease in her shoulder and back and the facility had recently discontinued her Percocet (opioid pain medication) and she was now getting only Tylenol, which was not working. The record for Resident B was reviewed on 11/29/23 at 11:58 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, osteoarthritis, degenerative joint disease (DJD) and heart failure. The Quarterly Minimum Data Set assessment, dated 11/6/23, indicated the resident was cognitively intact, and required partial/ moderate 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed ensure a resident's preference to receive medications at a different time were honored to not interrupt sleep patterns for 1 of 3 residents reviewed for Intravenous (IV) antibiotics. (Resident B) Finding includes: The closed record for Resident B was reviewed on 8/29/23 at 2:45 p.m. The resident was admitted to the facility on [DATE] and discharged home on 6/15/23. Diagnoses included, but were not limited to, diverticulitis, atrial fibrillation, heart disease, insomnia, and anxiety. The admission Minimum Data Set (MDS) assessment, dated 6/8/23, indicated the resident was alert and oriented and received IV medications while a resident. Physician's Orders, dated 6/1/23, indicated change IV tubing every 24 hours. Assess IV site every shift and monitor for signs and symptoms of infiltration and infection every shift. A Physician's Order, dated 6/2/23 and discontinued on 6/9/23, indicated Piperacillin (an antibiotic) 3.375 grams intravenously every 8 hours for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a dependent resident received help with Activities of Daily Living (ADLs) related to the timeliness of incontinence care for 1 of 3 residents reviewed for ADLs. (Resident H) Finding includes: On 8/29/23 at 9:02 a.m. LPN 1 was observed turning Resident H to view 2 wounds located on the resident's lower back and sacrum. There was dried stool covering the wound bed. The resident had a bowel incontinence episode and requested to be changed. Resident H was observed on 8/29/23 at 3:34 p.m. The room had a strong urine odor. The resident indicated she was just changed a few minutes ago. Interview with Resident H at the time of observation, indicated she was on a diuretic (water pill) and she urinated constantly. She was last changed that morning when LPN 1 showed the surveyor her wounds. The record for Resident H was reviewed on 8/29/23 at 10:01 a.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, atrial…

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 a resident with a history of pressure ulcers received the necessary treatment and services to promote healing related to turning and repositioning, ensuring treatments were in place, completing treatments as ordered, and initiating treatments in a timely manner for 3 of 3 residents reviewed for pressure ulcers. (Residents J, N, and H) Findings include: 1. On 8/29/23 at 9:07 a.m., Resident J was observed in his room in bed. LPN 2 was present in the room and the resident was identified as having a pressure ulcer to his bottom. The resident's brief was unfastened and a skin assessment was completed. The resident did not have a dressing in place to his left or right buttock. The LPN indicated at that time the area looked healed and maybe that was why he didn't have a dressing on. The record for Resident J was reviewed on 8/29/23 at 11:48 a.m. Diagnoses included, but were not limited to, stroke, hemiplegia (paralysis on one side 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure Intravenous (IV) catheters were monitored, assessed, and bandages and tubing were changed for 3 of 3 residents reviewed for IV antibiotics. (Residents K, B and E) Findings include: 1. On 8/29/23 at 1:30 p.m., Resident K was observed in bed. A single lumen PICC (peripherally inserted central catheter) line was observed in the right upper arm. There was no date on the bandage covering the PICC line. On 8/30/23 at 9:15 a.m., the resident was being transferred back to bed. There was still no date on the PICC line bandage. The record for Resident K was reviewed on 8/29/23 at 11:35 a.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, heart disease, stroke, anxiety disorder, high blood pressure, and chest pain. The resident was admitted to the hospital on [DATE] and returned back to the facility on 8/15/23. The admission Minimum Data Set (MDS) assessment, dated 8/22/23, was still in progress. A Care Plan,…

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 establish and/or maintain a system that accounted for, periodically reconciled, and ensured the disposition of all controlled drugs, related to incomplete and inaccurate documentation of narcotic medications for 3 of 3 residents reviewed for narcotics. (Residents G, K, and L) This had the potential to affect all residents who received narcotic medication. Findings include: 1. Interview with Resident G on 8/29/23 at 1:45 p.m., indicated she had no issues with pain. She also indicated Tylenol controls her pain and she doesn't need anything stronger. The record for Resident G was reviewed on 8/30/23 at 10:26 a.m. Diagnoses included, but were not limited to, spinal stenosis, intervertebral disc replacement of the lumbar region, and spondylosis (osteoarthritis of the spine). The Quarterly Minimum Data Set (MDS) assessment, dated 7/25/23, indicated the resident was cognitively intact. She required extensive assistance with bed mobility 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 and interview, the facility failed to ensure a sanitary kitchen for food preparation related to trash behind the stove, grease on the vent hood above the stove, and dried food spillage on the steam table in 1 of 1 kitchens observed (Main Kitchen). This had the potential to affect all 46 residents who received food from the kitchen. Findings include: During the initial kitchen tour on 5/08/23 at 9:20 a.m., with dietary manager, the following was observed: a. There was trash on the floor behind the stove. b. There was grease on the vent hood above the stove. c. There was dried food spillage on the steam table. Interview with the Dietary Manager at that time, indicated she would clean the areas and there should not have been trash on the floor. 3.1-21(i)(3)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to manage medications appropriately related to administering medications as ordered, monitoring blood glucose levels prior to the administration of insulin, and monitoring blood pressures and respiratory rates for 4 of 7 residents reviewed for unnecessary medications. (Residents 92, 18, 91 and 16) Findings include: 1. The record for Resident 92 was reviewed on 5/9/23 at 1:15 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, chronic kidney disease, high blood pressure, failure to thrive, and history of transient ischemic attacks. The 5/1/23 admission Minimum Data Set (MDS) assessment, indicated the resident was moderately impaired for decision making. A Care Plan, dated 4/25/23, indicated the resident had chronic cardiovascular disease. The approaches were to monitor vital signs at least weekly and monitor labs as ordered. A Physician's Order, dated 4/25/23, indicated Clonidine 0.1 milligrams (mg), give…

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 Physician's Orders for medications and an assessment to self-administer their own medications for 2 of 2 residents reviewed for self-administration of medication. (Residents 21 and 23) Findings include: 1. On 5/8/23 at 10:06 a.m., Resident 21 was observed in her room. There was a white pill in a medicine cup on her bedside table. The resident indicated that it was her Tylenol that she received this morning, but she did not need it a the time so she wanted to wait to take it at a later time when she had pain. Resident 21's record was reviewed on 5/9/23 at 1:23 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, dementia without behavioral disturbance, and chronic pain. The Quarterly Minimum Data Set (MDS) assessment, dated 2/1/23, indicated the resident was cognitively intact for daily decision making. A Physician's Order, dated 1/4/23, indicated Tylenol 8 hour arthritis pain tablet extended release 650 milligram (mg) two times a day. A Care Plan, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a resident who was dependent with Activities of Daily Living (ADLs) received the necessary services related to long and dirty fingernails for 1 of 3 residents reviewed for ADLs. (Resident 18) Finding includes: On 5/8/23 at 10:27 a.m., on 5/9/23 at 10:00 a.m., and 5/10/23 at 1:45 p.m., Resident 18 was observed in bed. At those times, her left hand was clenched in the shape of a fist and there was no anti-contracture device noted. Her fingernails were not visible. On 5/11/23 at 9:00 a.m., the Director of Nursing (DON) was asked to perform a skin assessment to the resident's left hand. At that time, the resident was observed sitting up in a broda chair in her room. CNA 1 was observed standing by the resident and had just finished morning care. The resident had a rolled wash cloth in her left hand and her fingernails were visible. The resident had very long and dirty nails observed to the left hand. LPN 2 walked into the room with a…

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

Based on interview and record review, the facility failed to implement an ongoing resident-centered activity program that incorporated a resident's preferences for 1 of 2 residents reviewed for activities. (Resident 21) Finding includes: Interview with Resident 21 on 5/8/23 at 10:26 a.m., indicated the resident wanted to be read to daily as she was legally blind. She had asked many staff members to read to her, however a lot of staff had refused. Resident 21's record was reviewed on 5/9/23 at 1:23 p.m. Diagnoses included, but were not limited to, glaucoma, macular degeneration, and legal blindness. The Quarterly Minimum Data Set (MDS) assessment, dated 2/1/23, indicated the resident was cognitively intact for daily decision making. A Care Plan, dated 5/12/22, indicated the resident had a visual impairment as seen by blindness and glaucoma. Interventions included, but were not limited to, keep environment free of clutter and use large print materials with resident during activities. Interview with the Activity Director on 5/11/23 at 2:50 p.m., indicated the Activity Department would…

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 monitor, assess, and obtain treatments for diabetic ulcers at the time of admission and monitor bruises for 2 of 4 residents reviewed for non-pressure ulcers. (Residents 91 and 92) Findings include: 1. On 5/8/23 at 11:28 a.m., Resident 91 was observed in bed with his eyes closed. At that time, he was asked if he had an ulcer on his foot and indicated he did not know. CNA 1 was asked to remove the resident's socks to both of his feet. She pulled off the sock to his left foot and a large amount of flaky, dry, peeling skin flew in the air. There were dark black areas noted to several toes on his left foot. There was also a large necrotic ulcer to the bottom of his left foot. The CNA removed the sock to his right foot and again the flaky, dry, and peeling skin flew in the air. There were no open areas on his right foot. The record for Resident 91 was reviewed on 5/9/23 at 1:50 p.m. The resident was admitted to the facility on [DATE].…

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 received proper treatment and care related to oxygen administration flow rate for 2 of 2 residents reviewed for respiratory care. (Residents 21 and 33) Findings include: 1. On 5/8/23 at 10:19 a.m., Resident 21 was observed in her room with a nasal cannula in place. The oxygen concentrator was set to 3.5 liters per minute. Resident 21's record was reviewed on 5/9/23 at 1:23 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, dementia without behavioral disturbance, and anemia. The Quarterly Minimum Data Set (MDS) assessment, dated 2/1/23, indicated the resident was cognitively intact for daily decision making. She required the use of oxygen while a resident in the facility. A Physician's Order, dated 5/2/23, indicated the resident required oxygen at 2 liters per minute per nasal cannula continuously. A Care Plan, dated 5/3/22, indicated the resident had the potential for exacerbation of chronic obstructive pulmonary…

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 resident with complaints of pain received scheduled medication to relieve the pain for 1 of 3 residents reviewed for pain. (Resident 16) Finding includes: Interview with Resident 16 on 5/8/23 at 2:07 p.m., indicated she was supposed to get her scheduled pain medicine, but there had been many times that she did not receive it because the facility indicated they had run out of the medication. Resident 16's record was reviewed on 5/9/23 at 1:46 p.m. Diagnoses included, but were not limited to, heart failure, chronic respiratory failure, gastritis (inflamed lining of stomach), and chronic kidney disease. The Significant Change in Status Minimum Data Set (MDS) assessment, dated 2/15/23, indicated the resident was cognitively intact for daily decision making. The resident had received an opioid medication daily. A Physician's Order, dated 4/18/23, indicated oxycodone-acetaminophen oral tablet 10-325 milligram (mg), 1 tablet every 8 hours. The April 2023 Medication Administration Record (MAR) indicated the resident'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the Physician was promptly notified of abnormal laboratory results for 1 of 7 residents reviewed for unnecessary medications. (Resident 92) Finding includes: The record for Resident 92 was reviewed on 5/9/23 at 1:15 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, chronic kidney disease, failure to thrive, and history of transient ischemic attacks. The 5/1/23 admission Minimum Data Set (MDS) assessment, indicated the resident was moderately impaired for decision making. A Care Plan, dated 4/25/23, indicated the resident had chronic cardiovascular disease. The approaches were to monitor vital signs at least weekly and monitor labs as ordered. A Physician's Order, dated 5/2/23, indicated Complete Blood Count (CBC) and a Complete Metabolic Panel (CMP). The CMP and CBC were completed on 5/4/23 with abnormal results as follows: - Potassium level was 5.1 (normal 3.6-5) - Blood Urea Nitrogen (BUN)…

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 infection control guidelines were in place and implemented, including those to prevent and/or contain COVID-19, related to not completing the respiratory screening assessments for 2 of 2 residents reviewed for COVID-19. (Residents 242 and 35) Findings include: 1. The record for Resident 242 was reviewed on 5/11/23 at 2:05 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, COPD, high blood pressure, dependence on oxygen, and COVID-19. A COVID-19 Symptom Screener for Positive Residents Assessment, dated 5/3/23 at 3:21 p.m., indicated the resident tested positive for COVID-19. A Physician's Order, dated 4/21/23, indicated COVID-19 test as needed for COVID-19 screening. A Physician's Order, dated 5/3/23, indicated Isolation: Contact - In a single room and not allowed to leave room - stop sign in place on door. All services provided in room. The COVID-19 Symptom Screener for Positive 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.