Serenity Spring Senior Living At Northwood

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure accuracy of assessments for 14 of 26 resident records reviewed during the survey. MDS (Minimum Data Set) Assessments did not accurately reflect resident status. (Resident 52, Resident 38, Resident 12, Resident 35, Resident 36, Resident 41, Resident 19, Resident 17, Resident 19, Resident 43, Resident 48, Resident 5, Resident 53) Findings include: 1. On 5/14/24 at 10:49 A.M., Resident 36's room was observed. The bed was observed equipped with small grab bars. On 5/16/24 at 1:52 P.M., Resident 36's clinical record was reviewed. Diagnosis included, but were not limited to, Parkinson's Disease. The most recent Annual MDS Assessment, dated 3/14/24, indicated use of physical restraints in the form of bed rails. Resident 36's clinical record lacked a current physician order for bed rails. Resident 36's clinical record lacked a current care plan related to bed rails. A Physical Device and/or Restraint Evaluation and Review form, 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.

Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan with resident specific needs for 4 of 22 residents reviewed for care plan development and implementation. Resident on hospice did not have a care plan for hospice, resident did not have a care plan for eating meals at a bedside table in the main dining room, residents that were taking an antianxiety, diuretic, and antidepressant did not have care plans for use. (Resident 19, Resident 5, Resident 48, Resident 45) Findings include: 1. On 5/14/24 at 1:41 P.M., Resident 19's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety and atherosclerotic heart disease The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 4/10/24, indicated Resident 19 was cognitively intact, an extensive assist of 1 staff for bed mobility, transfers, toileting, and was on hospice. Current Physician's Orders included, but were not limited to, the following: Admit to [name of hospice company] with diagnosis of atherosclerotic heart disease (ASHD),…

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 residents had care plan conferences and care plans were revised for 1 of 2 residents reviewed for accidents and 3 of 5 residents reviewed for unnecessary medications. A resident moved out of the locked dementia unit and a resident's sleep medication was changed but the care plans were not revised. Residents did not have care plan conferences timely. (Resident 38, Resident 12, Resident 5, Resident 48) Findings include: 1. On 5/13/24 at 11:27 A.M., Resident 38 was observed waiting for lunch in the main dining room. On 5/14/24 at 2:49 P.M., Resident 38's clinical record was reviewed. Diagnoses included, but were not limited to, dementia without behaviors. The most recent Annual MDS (Minimum Data Set) Assessment, dated 4/23/24 indicated Resident 38's cognition was severely impaired and she was an extensive assist of 1 staff for bed mobility, transfers, and toileting. A current Dementia Care Plan, revised 10/13/23, included, but was 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 interview and record review, the facility failed to ensure residents were free from unnecessary medications for 5 of 6 residents reviewed for unnecessary medications. Resident's as needed anti-anxiety medication was ordered for greater than 14 days. A resident had a Physician's Order for an antipsychotic with an unacceptable diagnosis. (Resident 45, Resident 3, Resident 14, Resident 19, Resident 48) Findings include: 1. On 5/15/24 at 8:59 A.M., Resident 48's clinical record was reviewed. Current diagnoses included, but were not limited to, dysphagia and muscle weakness. The most recent Quarterly and State Option Minimum Data Set (MDS) Assessment, dated 3/26/24, indicated Resident 48's cognition was unable to be assessed, and she received an antipsychotic. Current Physician Order's included, but were not limited to, SEROquel [antipsychotic] Oral Tablet 25 MG [milligrams] .Give 25 mg by mouth one time a day related to DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE, UNSPECIFIED SEVERITY, WITHOUT…

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 maintain safe and secure storage of medications for 3 of 4 medication carts observed and 1 of 3 medication storage rooms observed. Loose pills were observed in the medication carts, and refrigerator temperature logs were not filled out completely in the medication room. Findings include: 1. On 5/17/24 at 8:44 A.M., the medication cart on the PARF (Therapy to Home) Hall was reviewed. The medication cart was observed with the following loose pills in the drawers: 1 small oval white pill At that time, LPN (Licensed Practical Nurse) 19 indicated nurses on nights were supposed to go through the medication cart to make sure it was clean. She indicated she did it when she was here also. Pharmacy came once a month to review the carts. On 5/17/24 at 9:50 A.M., 300 Hall medication cart was reviewed. The medication cart was observed with the following loose pills in the drawers: 1 oblong white pill with L484 on one side 1 small oval white pill with…

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 distribution and food service was provided in accordance with professional standards for food service safety for 2 of 2 meals observed, and 1 of 1 meal services observed in the kitchen. (Main Kitchen, Locked Unit Dining Room) Findings include: During a lunch observation on 5/13/24 from 11:56 A.M. through 12:02 P.M., Qualified Medication Aide (QMA) 3 was observed taking cookies out of the packaging with bare hands, and placing on the food trays to serve to the residents. Certified Nurse Aide (CNA) 5 was observed to also touch cookies with bare hands before serving to residents. On 5/16/24 at 10:36 A.M., a meal service was being observed in the kitchen. While preparing the cups and utensils, Dietary Aide 21 was observed transferring coffee mugs with bare hands to the trays touching the insides of the mugs. Dietary Aide 21 was also observed touching the inside lids of the handled cups with bare hands before filling them with drinks. On 5/16/24 at 2:49 P.M., the Kitchen Manager indicated staff was 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 interview, and record review, the facility failed to properly document influenza and pneumococcal vaccines being offered to residents for 3 of 5 residents reviewed for influenza and pneumococcal vaccination. Clinical records lacked the vaccine consent/refusal date, the reason why it was refused, and a date education was provided to the resident and/or resident representative. (Resident 19, Resident 4, Resident 36) Findings include: 1. On 5/14/24 at 1:41 P.M., Resident 19's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety and atherosclerotic heart disease. The most recent Quarterly MDS Assessment, dated 4/10/24, indicated resident was cognitively intact. Resident 19 was [AGE] years old and was admitted to the facility on [DATE]. Resident 19's immunization history was reviewed for his influenza and pneumonia vaccination status. The following vaccination lacked documentation of a refusal date, the reason why it was refused, and a date education was provided to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents for 2 of 5 halls observed, and 1 of 1 common area observed. (Locked Unit, room [ROOM NUMBER] ) Findings include: 1. On 5/14/24 at 11:02 A.M., the bathroom vent in room [ROOM NUMBER] was observed caked with dust. On 5/20/24 at 8:07 A.M., the same was observed. 2. On 5/14/24 at 11:12 A.M., the bathroom vent in room [ROOM NUMBER] was observed caked with dust, and an unlabeled tube of zinc oxide was observed on the back of the toilet. The back of the room door was observed with a metal strip coming away from the door. On 5/20/24 at 8:15 A.M., the same was observed. 3. On 5/14/24 at 11:06 A.M., the bathroom door of room [ROOM NUMBER] was observed with scuff marks, chipping away at the door, and the room floor was sticky. On 5/20/24 at 8:14 A.M., the bathroom in room [ROOM NUMBER] was the same. The floor was not sticky. 4. On 5/14/24 at 10:49 A.M., the grab bar…

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 were treated with respect and dignity for 2 of 2 random observations. A staff member was observed standing while assisting to feed a resident, and a staff member walked away from a resident with visible urine under her chair. (Resident 27, Resident 48) Findings include: 1. On 5/13/24 at 12:02 P.M., Certified Nurse Aide (CNA) 5 was observed standing next to Resident 27 while assisting to feed the resident. 2. During an observation on 5/13/24 at 11:19 A.M., Resident 48 was observed eating in the dining room with a large wet spot under her wheelchair. On 5/13/24 at 11:28 A.M., Licensed Practical Nurse (LPN) 14 sat Resident 48's meal tray in front of her and walked away. During an interview on 5/13/24 at 11:34 A.M., LPN 14 indicated the wet spot was urine. During an interview on 5/16/24 at 4:14 P.M., the Director of Nursing (DON) indicated if a resident was observed with a wet spot under their wheelchair that she would expect staff to bring the resident back to their room and provide care, 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 provide services based on resident preferences for 1 of 5 residents reviewed. The facility failed to provide ice water to one resident when requested. (Resident 45) Findings include: During an interview on 5/14/24 at 9:39 A.M., Resident 45 indicated she didn't get water unless she asked. During an observation on 5/15/24 at 1:37 P.M., CNA (Certified Nurse Aide) 38 assisted Resident 45 from the commode to her recliner. CNA 38 put the bedside table in front of Resident 45 explaining where her cup of lemonade and box of Kleenex were located. She told Resident 45 her water cup only had a small amount of water in it and asked if she would like the cup filled up. Resident 45 told her yes. During an observation on 5/15/24 at 3:16 P.M., Resident 45's water cup had not been filled up. On 5/14/24 at 1:54 P.M., Resident 45's clinical records were reviewed. Diagnosis included, but were not limited to macular degeneration, chronic combined systolic and diastolic heart failure, Sjogren's Syndrome. The most current Quarterly, State Optional…

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 clarify a Resident's code status for 1 of 1 residents reviewed for Advanced Directives. A Resident's current Physician Orders did not match the signed DO NOT RESUSCITATE DECLARATION AND ORDER form. A Resident had a care plan for DNR (Do Not Resuscitate) and CPR (Cardiopulmonary Resuscitation). (Resident 18) Finding includes: On [DATE] at 10:00 A.M., Resident 18's clinical record was reviewed. Current diagnoses included, but was not limited to, end stage renal disease, dependence on renal dialysis and diabetes mellitus. The most recent admission Minimum Data Set (MDS) Assessment, dated [DATE], indicated Resident 18 was cognitively intact. Current Physician's orders included, but was not limited to, ADVANCE DIRECTIVE: Resuscitate (CPR), start date [DATE]. A STATE OF INDIANA OUT OF HOSPITAL DO NOT RESUSCITATE DECLARATION ORDER, dated [DATE], indicated Resident 18 requested to be a DNR and the form was signed by the Physician 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, interview, and record review, the facility failed to ensure the resident right to be free of a physical restraint for 1 of 1 residents reviewed for physical restraints. A bed rail was used as a physical restraint. (Resident 12) Findings include: During an observation on 5/13/24 at 1:54 P.M., Resident 12 was observed in bed with 2 black bed rails that were attached at the top of the mattress 1/3 of the length of the bed. During an interview on 5/13/24 at 2:41 P.M., Resident 12's family member indicated the bed rails were put into place to keep her in bed since she had multiple falls. During an observation on 5/16/24 9:31 A.M., Resident 12 was observed in bed with bed rails up. At that time, she indicated the bed rails are there to keep her from falling out of bed. On 5/15/24 at 2:28 P.M., Resident 12's clinical record was reviewed. Current diagnoses included, but were not limited to hypertension, diabetes mellitus, anxiety, and depression. The most recent Quarterly and State Optional Minimum Data Set (MDS) Assessment, dated 4/30/24 indicated Resident 12 had…

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

Based on observation, interview, and record review, the facility failed to report an allegation of abuse for 1 of 1 residents reviewed for abuse. A Certified Nurse Aide (CNA) physically removed the resident's fingers and hand from the stand aide lift. (Resident 4) Finding includes: During an interview on 5/13/24 at 2:00 P.M., Resident 4 indicated on 5/4/24 CNA 53 ordered her to do things in an abusive tone and the CNA pulled her fingers one by one off of the sit to stand lift. On 5/13/24 at 2:30 P.M., Resident 4's clinical record was reviewed. Current diagnoses included, but were not limited to, anxiety and depression. The most recent Annual (Minimum Data Set Assessment), dated 12/28/23, indicated Resident 4 was cognitively intact and required assistance with transfers. Current Physician's Orders included, but was not limited to, Activity level: up with assist, dated 10/4/13. Current care plans included, but were not limited to, The resident has an ADL [activities of daily living] self care performance deficit R/T [related to] .decreased mobility, stress incontinence, Cerebellar…

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 properly investigate an allegation of abuse for 1 of 1 residents reviewed for abuse. A Certified Nurse Aide (CNA) physically removed the resident's fingers and hand from the stand aide lift. (Resident 4) Finding includes: During an interview on 5/13/24 at 2:00 P.M., Resident 4 indicated on 5/4/24 CNA 53 ordered her to do things in an abusive tone and CNA 53 pulled her fingers one by one off of the sit to stand lift. On 5/13/24 at 2:30 P.M., Resident 4's clinical record was reviewed. Current diagnoses included, but were not limited to, anxiety and depression. The most recent Annual (Minimum Data Set) Assessment, dated 12/28/23, indicated Resident 4 was cognitively intact and required assistance with transfers. Current Physician's Orders included, but was not limited to, Activity level: up with assist, dated 10/4/13. Current care plans included, but were not limited to, The resident has an ADL [activities of daily living] self care performance deficit R/T [related to] .decreased mobility, stress incontinence,…

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 adequate supervision to prevent accidents for 2 of 2 residents reviewed for falls. Neurological checks were not completed after a fall, new interventions were not put into place after falls, and interventions on care plans were not followed for residents at risk for falls resulting in multiple falls. (Resident 38, Resident 52) Findings include: 1. On 5/14/24 at 9:00 A.M., non-skid strips were not observed on the floor in front of the toilet in Resident 38's bathroom. On 5/14/24 at 2:49 P.M., Resident 38's clinical record was reviewed. Diagnoses included, but were not limited to, dementia. The most recent Annual MDS (Minimum Data Set) Assessment, dated 4/23/24 indicated Resident 38's cognition was severely impaired, she was an extensive assist of 1 staff for bed mobility, transfers, and toileting, and had 1 fall since the last MDS Assessment which was a Quarterly Assessment completed on 1/25/24. A current Risk for Falls 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.

Based on observation, interview, and record review, the facility failed to ensure a resident received services and assistance to prevent and treat urinary tract infections (UTI) for 1 of 1 residents reviewed for UTIs. A resident with recurrent UTIs was not treated appropriately, and incontinence care provided lacked appropriate infection control practices to prevent infection. (Resident 36) Finding includes: On 5/14/24 at 2:38 P.M., Resident 36's clinical record was reviewed. Diagnosis included, but were not limited to, Parkinson's Disease and dementia. The most recent Annual MDS (Minimum Data Set) Assessment, dated 3/14/24, indicated no cognitive impairment, no toileting program, and a UTI in the previous 30 days. Resident 36 was frequently incontinent of bladder, and required extensive assistance of one staff with toileting. Current physician orders included, but were not limited to, the following: UTI-Stat Oral Liquid 30ml (milliliters) one time a day for urinary health, dated 5/21/23. Allergies included, but were not limited to, ciprofloxacin (an antibiotic). A current urinary…

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 2. On 5/15/24 at 1:58 P.M., Resident 28's oxygen filter on the side of the oxygen machine was observed to be caked with dust. Resident 28 was sitting in his recliner wearing O2 per nasal cannula at 2 lpm with gauze on the tubing to protect his ears. On 5/16/24 at 9:11 A.M., Resident 28 was observed sitting in his recliner with O2 on at 2 lpm per nasal cannula. The filter on the side of the oxygen machine remains dusty. On 5/15/24 at 2:49 P.M., Resident 28's clinical records were reviewed. Diagnosis included, but were not limited to chronic respiratory failure with hypoxia. The most current Annual MDS (Minimum Data Set) Assessment and State Optional MDS, dated [DATE], indicated Resident 28 was cognitively intact, required, extensive assistance of one for bed mobility and toilet use, limited assistance of one for transfers, and used oxygen. Current physician orders included, but were not limited to the following: Change out O2 tubing every Sunday night (Label with initials and date). Clean filter on the back of…

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

Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed for 2 of 4 residents during observation of incontinence care and 1 of 3 observations of obtaining a blood sugar with a glucometer. Gloves were not changed between dirty and clean tasks during peri care and staff cleaned a glucometer for an unmeasurable amount of time. (Resident 7, Resident 11, Resident 43). Findings include: 1. On 5/16/24 at 10:35 A.M., Qualified Medication Aide (QMA) 59 obtained a blood glucose level on Resident 43. After obtaining the blood glucose level, QMA 59 wiped the glucometer for an unmeasureable amount of time (less than 2 seconds) and placed the glucometer in the medication cart drawer. At that time, he indicated he typically lets the machine dry a minute. 2. On 5/20/24 at 10:04 A.M., incontinence care was performed on Resident 11 by Certified Nurse Aide (CNA) 10 and CNA 12. CNA 12 removed the soiled brief and applied cream to Resident 11's bottom, removed gloves, and placed new gloves on. CNA 12 failed to perform hand hygiene from…

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 timely reporting of an abuse allegation to facility administration and to the state agency for 1 of 2 abuse allegations reviewed. Staff filed an abuse allegation as a grievance rather than immediately notifying the DON (Director of Nursing) or facility administrator, and the allegation was not reported to the state agency within the required 2 hour time frame. (Resident D) Finding includes: During a review of facility reported incidents on 12/12/23 at 11:00 A.M., an incident dated 11/27/23 included that Resident D stated, I had a terrible weekend because my aide (CNA 12) was horribly rude to me. She made me use the restroom by myself. She reminded me that she had other resident to care for and I would have to wait. (CNA 12) finally came to change me after an hour. I told (CNA 12) she should respect her elders and she replied I dont respect anyone. During an interview on 12/12/23 at 11:38 A.M., Resident D indicated a staff member had recently made her walk to the restroom by herself, even though she needed…

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 4. During record review on 2/1/23 at 2:48 P.M., Resident 12 was [AGE] years old when admitted to the facility on [DATE]. Resident 12's diagnosis included, but was not limited to, schizoaffective disorder, diagnosed 3/26/21. Resident 12's most recent significant change MDS, dated [DATE], indicated Resident 12 had schizophrenia and received antipsychotics on a routine basis. Resident 12's current physician orders included, but were not limited to, Zyprexa (antipsychotic medication) 5 milligrams (mg) by mouth two times a day for a diagnosis of schizoaffective disorder. Resident 12's assessments, behavior monitoring, and documentation of diagnosis criteria for schizoaffective disorder was requested, but not received. 5. During record review on 2/3/23 at 1:59 P.M., Resident 2 was [AGE] years old when admitted to the facility on [DATE]. Resident 2's diagnosis included, but was not limited to, schizoaffective disorder, diagnosed 7/28/22. Resident 2's most recent significant change MDS, dated [DATE], indicated Resident…

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

Based on observation, interview, and record review, the facility failed to properly prevent and/or contain COVID-19 during 1 random observation of staff entering a COVID-19 positive resident room, 3 of 5 resident observed for care, and 1 of 4 residents observed for medication administration. Gloves were not changed from dirty to clean tasks, hands were not washed appropriately, staff was not appropriately wearing a face mask, staff did not sanitize hands prior to providing incontinence care, and staff did not sanitize hands prior to handling medications. (Resident B, Resident G, Resident K, Resident M, Resident J) Findings include: 1. On 2/2/23 at 10:32 A.M., CNA (Certified Nurse Aide) 88 was observed to assist Resident B with incontinence care and a shower. CNA 88 assisted Resident B to the shower room already wearing a pair of gloves. CNA 88 pulled the resident's pants and brief down around her ankles, and assisted her to sit on the toilet. After toileting, CNA 88 wiped the resident with 3 (three) wipes, pulled up the resident's brief and pants, put a new pair of gloves on, then…

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 that appropriate treatment and services were provided to for an incontinent resident in 1 of 2 residents reviewed for UTI (urinary tract infections). A resident with a UTI was observed incontinent of urine, and was not cleaned appropriately. (Resident B) Finding includes: On 2/1/23 at 1:46 P.M., Resident B's clinical record was reviewed. Diagnosis included, but were not limited to, urinary tract infection, Alzheimer's disease, and dementia. The most recent significant change MDS (minimum data set) Assessment, dated 12/10/22, indicated Resident B had a significant cognitive impairment, displayed no behaviors, and required extensive assistance of 2 (two) staff for toileting. The MDS indicated Resident B was frequently incontinent of bowel and bladder, and was not on a toileting program. Current physician orders included, but were not limited to, the following orders: Keflex (an antibiotic) 500 mg (milligrams) ordered twice a day for 7 (seven) days for UTI, started 1/25/23 Current care plans included, but…

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 the residents received the necessary respiratory care and services in accordance with the professional standards of practice for 2 of 2 residents reviewed for respiratory care. The facility failed to follow physician oxygenation orders and have an oxygen use care plan. (Resident 29, Resident 303) Finding include: 1. On 2/2/23 at 1:16 P.M., Resident 29 was observed sitting in a recliner in their room with their eyes closed wearing oxygen per nasal cannula with the machine set at 3 LPM (liters per minute). On 2/3/23 at 8:41 A.M., Resident 29 was observed sitting in a recliner in their room with eyes closed, head tilted to the right wearing oxygen per nasal cannula with the machine set at 3 LPM and humidification bottle empty. On 2/3/23 at 1:46 P.M., Resident 29 was observed sitting in a recliner in their room with eyes closed wearing oxygen per nasal cannula with the machine set at 3 LPM and humidification bottle empty. On 2/1/23 at…

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 a communication process with hospice personnel was developed and implemented, including how the communication will be documented between the LTC (long term care) facility and the hospice provider, and to ensure that the needs of the resident were addressed for 1 of 1 residents reviewed for hospice. The clinical record of Resident 41 lacked documentation of ongoing communication between facility staff and hospice staff. (Resident 41) Findings include: On 2/2/23 at 11:21 A.M., Resident 41's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus type II, dementia without behaviors, and cerebral ischemia. The most current significant change MDS (Minimum Data Set) Assessment, dated 11/29/22, indicated the resident was severely cognitively impaired and an extensive assist of 2 (two) staff for bed mobility and transfers. Current physician's orders included, but were not limited to, admitted to (hospice company) with diagnosis of cerebral ischemia on 11/29/22, dated 12/6/22. The current…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff COVID-19 vaccination medical exemptions specified a clinically recognized contraindication for 1 of 1 staff medical exemptions reviewed. (Staff 10) Finding includes: On 2/7/23 at 10:00 A.M., Staff 10's COVID-19 medical exemption was reviewed. The medical exemption, signed 6/7/22, indicated Staff 10 should not receive the COVID-19 vaccine related to family history of Guillian Barre after vaccine. During an interview on 2/6/23 at 3:05 P.M., the Administrator indicated that unvaccinated staff testing and precautions depend on the county rates of transmission of covid. On 1/30/23 at 10:34 A.M., the county rate for COVID-19 community transmission rate was high per the CDC COVID data tracker website. During an interview on 2/7/23 at 11:15 A.M., Staff 10 indicated they have a medical exemption for the COVID-19 vaccine because they had an aunt that passed away from Guillian Barre. They further indicated they have not tested for covid for awhile…

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.