American Village

Based on observation, interview, and record review, the facility failed to apply splints, as care-planned, for 1 of 1 resident reviewed for limited range of motion (ROM) (Resident 40). Findings include: The clinical record for Resident 40 was reviewed on 2/18/25 at 1:05 p.m. The diagnoses included, but were not limited to, Alzheimer's disease, multiple sclerosis, osteoarthritis, and chronic pain. A Quarterly Minimum Data Set (MDS) assessment, dated 1/22/25, indicated Resident 40 was cognitively impaired. A care plan, last reviewed 1/23/25, indicated Resident 40 was on the Passive Range of Motion (PROM) program, she was able to tolerate wearing left hand resting splint/brace for four hours, apply in the morning. She has a diagnosis of multiple sclerosis (MS) which contributes to her risk of contractures and need for assistance with daily care. The goal was to reduce the risk of contractures. On 2/18/25 at 3:06 p.m., Resident 40 was observed sitting in her wheelchair in the activities room, with no splint or brace in place. On 2/19/25 at 10:25 a.m., Resident 40 was observed without 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, interview, and record review, the facility failed to timely develop a person-centered behavior management care plan with individualized interventions and document approaches to care for a resident with dementia who exhibited behaviors for 1 of 1 resident reviewed for behaviors. (Resident 62) Findings include: The clinical record for Resident 62 was reviewed on 2/18/25 at 10:55 a.m. The diagnoses included, but were not limited to, dementia, depression, and cognitive communication deficit. An admission Minimum Data Set (MDS) assessment, dated 12/11/24, indicated Resident 62 was severely cognitively impaired. A hospice Master of Social Work (MSW) Visit Note, dated 12/06/24, indicated Resident 62 was experiencing fluctuating emotions, staff reported she had been crying all morning and yelling out. MSW encouraged husband to coordinate care needs with facility to reduce stress and the facility Registered Nurse (RN) was notified. The clinical record did not contain documentation from facility staff of the noted behaviors from the MSW or interventions initiated on…

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

Based on observation, interview, and record review, the facility failed to ensure appropriate social services follow-up, related to a previous allegation of abuse of a resident by a family member, for 1 of 1 resident reviewed for dementia care. (Resident 62) Findings include: The clinical record for Resident 62 was reviewed on 2/18/25 at 10:55 a.m. The diagnoses included, but were not limited to, dementia, depression, and cognitive communication deficit. An admission Minimum Data Set (MDS) assessment, dated 12/11/24, indicated Resident 62 was severely cognitively impaired. An incident report, dated 10/31/24, indicated Resident 62's husband was overheard by staff raising his voice at the resident while assisting her with activities of daily living (ADL) care on the attached Assisted Living (AL) unit of the facility. A Nursing Progress Note, dated 11/2/24, indicated Resident 62's husband had been overheard yelling at the resident. Once staff entered the resident's room the resident's husband began yelling at facility staff to leave the room. Facility staff stayed in 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.

Based on observation, interview, and record review, the facility failed to ensure staff donned personal protective equipment (PPE) prior to a wound dressing for 1 of 1 random observation. (Resident 5) Findings included: The clinical record for Resident 5 was reviewed on 2/18/25 at 1:29 p.m. The diagnoses included, but were not limited to, Alzheimer's disease. A care plan, dated 2/3/25, indicated Resident 5 had pressure ulcer on her sacrum. A physician order, dated 2/3/25, indicated the staff was to cleanse sacrum with wound cleanser, apply collagen powder, and cover with bordered gauze once a day. An observation was made of Resident 5's room on 2/21/25 at 11:30 a.m. Licensed Practical Nurse (LPN) 21 was observed leaving the resident's room with a treatment cart. She indicated she had provided a wound treatment to Resident 5. At that time, an observation was made of the resident's room with the Director of Nursing (DON). The DON had indicated the Enhanced Barrier Precaution signage was placed on the closet doors of Resident 5's room. The trash can in the resident's room did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff provided care services in a manner that promoted privacy, respect, and dignity, and to provide an environment where residents were able to express grievances without fear of reprisal for 11 of 12 residents reviewed for dignity. (Residents' B, C, D, S, T, SS, 45, 69, 80, 85 and an Anonymous Resident) Findings include: 1. During a Resident Council meeting on 1/3/24 at 2:05 p.m., Resident 85 indicated that the staff treat you like s* after they are talked to by the management staff about your complaint. The staff that were complained about comes back and treat you badly after you complain about care that was provided. Residents are scared to complain. Resident 69 and Resident 45 indicated agreement to Resident 85's comments. Resident 80 indicated some of the staff were disrespectful, especially on the weekends. The weekend staff appeared not to care what residents needed. 2. An anonymous interview was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure timely assistance was provided with eating, nail care, incontinent care, residents getting out of bed, and ensure residents that need assistance with incontinence was provided 1 incontinent brief at a time for 8 of 12 residents reviewed for Activities of Daily Living. (Residents' B, H, J, K, M, R, S and SS) Findings include: 1. The clinical record for Resident SS was reviewed on 1/5/24 at 9:00 a.m. The diagnosis for Resident SS included, but was not limited to, fracture of left femur. The resident was admitted to the facility on [DATE]. A nutrition care plan dated 1/4/23 indicated Resident SS was to be assisted with feeding. An Activities of Daily Living (ADL)s care plan dated 1/1/24 indicated Resident SS requires assistance with eating, bed mobility, and transfers. The interventions in place for the resident's plan of care was to assist with placement of dentures, hearing aides and eating. A random observation was made of Resident…

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

Based on interview and record review, the facility failed to administer medications as ordered for 1 of 5 residents reviewed for unnecessary medications and 4 of 5 randomly reviewed residents' for medications administrations; ensure physician orders were followed regarding elevation of bilateral lower extremities (BLE) for 1 of 1 resident reviewed for pressure ulcers, and to timely update and administer a physician's order for a wound treatment and to apply podus (pressure relief) boots as ordered by a physician for 1 of 3 residents reviewed for urinary catheters.(Residents' B, H, T, 40, 44, 83 and 118,) Findings include: 1. The clinical record for Resident B was reviewed on 1/4/24 at 10:00 a.m. The diagnosis for Resident B included, but was not limited to, epilepsy. A care plan dated 8/19/23 for the resident indicated the resident was risk for injury related to seizure activity; has potential for seizure activity. The intervention included but was not limited to, the staff was to administer medications as ordered. A physician order dated 8/18/23 indicated Resident B was to receive…

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 sufficient nursing staff with appropriate competencies or skill sets to ensure ADL (Activities of Daily Living) care was provided in accordance with the plan of care for 8 of 12 residents reviewed for ADL care (Residents B, H, J, K, M, R, S, and SS) and physician orders were effectively provided in accordance with the plan of care for 7 of 14 reviewed for medication administration and treatments (Residents' B, H, T, 40, 44, 83 and 118) Findings include: During this recertification and complaint survey, 1/3/24 to 1/10/24, two deficiencies were cited at a pattern level - F677 E and F684 E. 1. Activities of Daily Living (ADLs): Eight residents out of 12 reviewed in total were not provided ADL care related to incontinence, eating, getting residents out of bed, and nail care. Cross reference F677. 2. Quality of Care: Seven residents did not have medications administered as ordered, follow physician orders for elevation of bilateral lower extremities, and apply pressure relief boots as ordered by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications stored in the facility's medication carts were not expired and/or had current orders for their use and/or were labeled with an opened date; a medication lock box was permanently affixed for narcotics in the medication fridge; and a medication cart remained locked during medication administration for 3 of 6 medication carts and 1 of 2 medication rooms reviewed within the facility. (Facility) Findings include: A review of the facility's medication storage rooms and medication carts was conducted on [DATE]. The following was observed: 1. On the 100 hallway with LPN (Licensed Practical Nurse) 26 at 2:37 p.m., the medication cart contained an albuterol sulfate inhaler for Resident 19 with an expiration date of [DATE]. 2. a. On the Auguste's Cottage hallway with LPN 30 at 2:48 p.m., the medication cart contained a bottle of Zyprexa (an anti-psychotic medication) labeled for Resident 103. The clinical record for Resident 103…

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 infection control by not ensuring gloves were changed and hand hygiene was completed appropriately during incontinent care, while assisting residents to eat, and while passing medications for 1 of 12 residents reviewed for ADL care, 3 of 5 residents randomly observed during medication pass, 3 residents randomly observed for 1 of 1 dinning observations. (Residents' 8, 10, 22, 80, 108, 111 and R). Findings include: 1. A dining observation of the rotunda dining room was conducted on 1/6/24 at 1:03 p.m. The following was observed: Resident 10 was seated at a table by herself with her lunch meal in front of her while Residents 111 and 8 were seating at another table together with their meal in front of them. All three residents required assistance with dining QMA (Qualified Medication Assistant) 2 was attempting to assist all three residents with their meals. She was standing while she would give a spoonful of food to Resident 8, then Resident 111 and then to Resident 10 without performing hand hygiene in…

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 review, the facility failed to timely have the interdisciplinary team (IDT) determine and document that self-administration of medications and treatments were clinically appropriate for 2 of 2 randomly observed residents. (Resident 58 and Resident P) Findings include: 1. The clinical record for Resident 58 was reviewed on 1/3/24 at 3:47 p.m. The diagnosis for Resident 58 included, but was not limited to, type 2 diabetes mellitus. The admissions 12/12/23 Minimum Data Set (MDS) assessment indicated Resident 58 was cognitively intact. A physician order dated 12/6/23 indicated Resident 58 was to receive 1000 milligrams of Tylenol every 6 hours as needed. A physician order dated 1/4/24 indicated Resident 58 was to receive ciclopirox topically for toenails daily. A physician order dated 1/4/24 indicated Resident 58 was to receive 1 spray in each nostril of 50 mcg (micrograms) of Flonase twice a day. An observation was made of Resident 58 on 1/3/24 at 3:47 p.m. The resident was lying in bed in her room. The resident's bedside table was observed 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 observation, interview and record review, the facility failed to ensure residents got out of bed and showered as preference for 2 of 2 residents reviewed for choices. (Resident B and Resident 105) Findings include: 1. The clinical record for Resident B was reviewed on 1/4/24 at 10:00 a.m. The diagnosis for Resident B included, but was not limited to, epilepsy. The quarterly 12/3/23 (MDS) assessment indicated Resident B was severely cognitively impaired. A care plan dated 8/23/23 indicated Resident B has the following daily routine preferences .The approaches .prefers to get showers, 2x's [twice] weekly in the morning . A routine and activities preference form dated 11/30/23 indicated it was very important to her to choose her bathing. The resident's bathing choice was showers. The resident's clinical record did not indicate the resident refuses showers. The December 2023 and January 2024 shower sheets indicated the resident was provided bathing the following days: December 2023: 12/1/23 - did not indicate the type of bathing, 12/4/23 - complete bed bath, 12/8/23 - complete…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident was provided the necessary foot care for 1 of 6 residents reviewed for ADLs (activities of daily living.) (Resident G) Findings include: The clinical record for Resident G was reviewed on 1/3/24 at 2:30 p.m. His diagnoses included, but were not limited to, dementia, hypertension, and chronic kidney disease. He was admitted to the facility on [DATE]. The ADL care plan, revised 12/21/23, indicated to provide assistance with bathing, dressing, grooming, and hygiene, as needed. An observation of Resident G was made on 1/3/24 at 2:36 p.m. He was lying in bed and was not wearing any socks. His lift great toenail was very long and thick, extending significantly past the end of his toe. His right great toenail was very thick. The other toenails were also long and thick, with some of them curling around the tips of his toes. The 5/9/22 Request for Service form included in his admission agreement indicated He requested to be seen…

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

Based on observation, interview, and record review, the facility failed to ensure a resident's wheelchair had 2 functioning anti-tippers and ensure fall interventions were in place for 3 of 4 residents reviewed for accidents. (Residents' K, L and Y) Findings include: 1. The clinical record for Resident Y was reviewed on 1/5/24 at 10:00 a.m. His diagnoses included, but were not limited to, hemiplegia, hemiparesis, and vascular dementia. The 11/20/23 unwitnessed fall event indicated Resident Y was sitting in his wheelchair prior to falling in his room. The 12/14/23 unwitnessed fall event indicated Resident Y was lying in bed prior to falling in his room. The fall care plan, last revised 1/10/24, indicated an intervention was anti-tippers to his wheelchair, starting 12/28/23. An observation was made on 1/5/24 at 10:15 a.m. He was sitting in his wheelchair in the common area of the facility during an activity. He was missing the right anti-tipper to the back of his wheelchair. The left anti-tipper was present. An observation was made on 1/9/24 at 11:28 a.m. He was sitting in his…

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 residents with a urinary catheter had physician orders for such catheters; staff were monitoring and documenting the urinary outputs, and to timely notify the physician of decreased urinary output and urine leaking from a urinary catheter for 2 of 3 residents reviewed for urinary catheters (Residents' 75 and T). Findings include: 1. The clinical record for Resident T was reviewed on 1/4/23 at 9:49 a.m. The Resident's diagnosis included, but were not limited to, obstructive uropathy and diabetes. A care plan, last initiated 4/19/23, indicated he required a suprapubic catheter (catheter which is placed above the pubic area), changed to a foley on 05/17/23, related to obstructive uropathy. The goal was for him to have suprapubic catheter care managed appropriately. The interventions included, but were not limited to, staff to record urinary output in mL (Milliliter), initiated 4/19/23, avoid obstructions in the drainage, initiated 4/19/23, report complications/UTI such as: acute confusion, bladder spasms, low…

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 assure weights were obtained accurately for 1 of 4 residents reviewed for nutrition (Resident BB). Findings include: The clinical record for Resident BB was reviewed on 1/3/23 at 3:49 p.m. The Resident's diagnosis included, but were not limited to, dysphagia (difficulty swallowing) and abnormal weight loss. A physician's order, dated 6/12/23, indicated Resident BB was to be weighed weekly. A Significant Change of Status MDS (Minimum Data Set) Assessment, completed 11/10/23, indicated that he had significant cognitive impairment, needed maximal assistance with eating, and had experienced a significant, unplanned weight loss. During a confidential interview, they indicated the residents' weights were being documented incorrectly due to staff not wanting to document weight changes or concerns. During an interview on 1/3/23 at 3:49 p.m., Family Member 20 indicated Resident BB had lost a lot of weight in the past few months. His weight seemed to go up and down a lot. She wondered how accurate the weight were. She…

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

Based on observation, interview, and record review, the facility failed to administer a resident's oxygen, as ordered, and ensure accuracy of his current oxygen orders in the clinical record for 1 of 4 residents reviewed for respiratory care. (Resident F) Findings include: The clinical record for Resident F was reviewed on 1/3/24 at 2:30 p.m. His diagnoses included, but were not limited to, chronic obstructive pulmonary disease, dementia, and hypertension. The physician's orders indicated he was admitted to hospice services, starting 3/10/23, and for his oxygen to flow at 1.5 liters per nasal cannula, every shift, starting 4/4/23. The impaired gas exchange care plan, last reviewed/revised 10/26/23, indicated an intervention was to administer oxygen as ordered. An observation of Resident F and interview with Hospice Aide 17 was conducted on 1/3/24 at 2:32 p.m. Resident F was sitting in his Broda chair in his room. A home health aide from his hospice company, Hospice Aide 17, was present in the room with him. He was wearing oxygen per nasal cannula. His portable oxygen tank 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 observation, interview, and record review, the facility failed to ensure medication labels were not altered (Resident 103); facility stock of clear needleless connectors and leur lock caps were not expired (Facility); the disposition medications for discharged and/or expired residents was completed timely (Residents 330 and 331); and a resident's home medications were stored appropriately (Resident 119). Findings include: A review of the facility's medication storage rooms and medication carts was conducted on [DATE]. The following was observed: 1. On the Auguste's Cottage unit, in conjunction with LPN (Licensed Practical Nurse) 30 at 2:48 p.m. the medication cart contained a medication bottle had a handwritten label over where the resident's name should have been typed. The handwritten name label identified it as Resident 103's Zyprexa (an antipsychotic medication). LPN 30 peeled the handwritten label off the bottle which revealed a different person's name who never had resided at the facility. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an appropriate justification was in place for the continued utilization of an antipsychotic medication, follow up with the family in regards to side effects of antipsychotic medication, and follow up with an abnormal AIMS (abnormal involuntary movement scale) assessment for 1 of 5 residents reviewed for unnecessary medications. (Resident L) Findings include: The clinical record for Resident L was reviewed on 1/8/24 at 11:48 a.m. The diagnoses included, but were not limited to, dementia, major depressive disorder, muscle weakness, schizophrenia (diagnosis added in 2023), and cerebral ischemia. An observation conducted of Resident L, on 1/8/24 at 2:00 p.m., up in their wheelchair with excessive, repetitive movements to their arms and legs, including lip puckering, and sticking their tongue out. An observation conducted of Resident L, on 1/9/24 at 9:32 a.m., lying in bed with excessive, repetitive movements to their arms and legs. 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 observation, interview, and record review, the facility failed to timely notify hospice of a resident's falls for 1 of 1 resident reviewed for hospice. (Resident F) Findings include: The clinical record for Resident F was reviewed on 1/3/24 at 2:30 p.m. His diagnoses included, but were not limited to, dementia and hypertension. The physician's orders indicated he was admitted to hospice services, starting 3/10/23. An observation of Resident F was made on 1/3/24 at 2:32 p.m. He was sitting in his Broda chair in his room. A home health aide from his hospice company was present in the room with him. The hospice care plan, last revised 10/26/23, indicated an intervention was to notify hospice as needed. The 9/9/23 fall event indicated he had an unwitnessed fall in the hallway in front of the dining area. He was found lying on his right side. The physician and resident representative were notified of the fall. It did not indicate hospice was notified of this fall. The 9/12/23 fall event indicated he had a witnessed fall trying to stand up in front of the nurse's station. 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 monitor and record fluid intake and urine output from a urinary catheter accurately for 1 of 3 residents reviewed for hospitalization. (Resident B) Findings include: The clinical record for Resident B was reviewed on 8/28/23 at 10:30 a.m. The Resident's diagnosis included, but were not limited to, hypertension and fractured left hip. She was discharged from the facility on 7/21/23. A care plan, initiated 5/19/23, indicated that Resident B was at risk for fluid imbalance due to her muscle weakness, difficulty in walking, fractured left hip, hypertension dementia, and diuretic (water pill) medication. The goal was for her to remain free from signs and symptoms of fluid volume deficit (dehydration). The approaches included, but were not limited to, record intake, initiated 5/19/23, labs as ordered, initiated 5/19/23, and administer medications as ordered, initiated 5/19/23. A physician's order, dated 5/24/23, indicated that catheter care was to be done and the nurse was to record urinary output every shift. A Dietician…

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 obtain labs, as ordered by the physician for 1 of 3 residents reviewed for hospitalization. (Resident B) Findings include: The clinical record for Resident B was reviewed on 8/28/23 at 10:30 a.m. The Resident's diagnosis included, but were not limited to, hypertension and fractured left hip. She was discharged from the facility on 7/21/23. A care plan, initiated 5/19/23, indicated that Resident B was at risk for fluid imbalance due to her muscle weakness, difficulty in walking, fractured left hip, hypertension dementia, and diuretic (water pill) medication. The goal was for her to remain free from signs and symptoms of fluid volume deficit (dehydration). The approaches included, but were not limited to, record intake, initiated 5/19/23, labs as ordered, initiated 5/19/23, and administer medications as ordered, initiated 5/19/23. An admission MDS (Minimum Data Set) Assessment, completed 5/25/23, indicated she had severe cognitive impairment, needed extensive assist of 2 staff members for bed mobility, limited assist…

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.