Brickyard Healthcare - Terrace Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to administer medications as ordered related to antibiotic therapy for 3 of 3 residents reviewed for Intravenous Therapy and failed to ensure wound treatments were completed and signed out as ordered for 1 of 3 residents reviewed for non-pressure related skin conditions. (Residents C, F and G) Findings include: 1. Resident C's record was reviewed on 5/19/25 at 9:38 a.m. The diagnoses included, but were not limited to, local infection of the skin and subcutaneous tissue unspecified, depression, hypertension (high blood pressure), kidney failure, asthma, and pain in unspecified hip. The admission Minimum Data Set (MDS) assessment, dated 4/24/25, indicated Resident C was cognitively intact for daily decision making. Eating, oral hygiene, personal hygiene, and upper body dressing required set up or clean up assistance. Toileting required supervision or touching assistance. Shower and bathing required partial/moderate assistance, and lower body…

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 safety after an exit alarm sounded for 1 of 1 resident reviewed for accidents. (Resident C) The deficient practice was corrected on 10/4/24, prior to the start of the survey, and was therefore past noncompliance. The facility completed an investigation and inserviced staff and families regarding elopement and alarm procedures. Finding includes: The record for Resident C was reviewed on 10/24/24 at 11:23 a.m. Diagnoses included, but were not limited to, sleep disorder, weakness, fall, dementia with anxiety, major depressive disorder, and fracture of the neck of the left femur. The 7/15/24 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. She had no behaviors and no episodes of wandering. The resident utilized a walker for ambulation. The Elopement Risk Evaluation, dated 7/14/24, indicated the resident was not at risk to elope at the time, placement on the elopement risk protocol was not indicated. The resident had no Care Plan related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure all covered individuals (anyone who was an owner, operator, employee, manager, agent, or contractor of the facility) was notified annually of their obligation and requirement to comply with the reporting of reasonable suspicion of crimes against a resident, related to an allegation of sexual abuse for 1 of 2 residents reviewed for abuse. (Resident B) Finding includes: During an observation on 6/17/24 at 9:40 a.m., Resident B was observed in bed and awake. At that time, she was able to confirm she was going home soon and no longer need hemodialysis. During an interview at the time, the resident indicated that she did not remember any male nurse forcing her to take her medications or asking her for sexual favors. The resident indicated she remembered on one night, the room was very dark, and a male came into her room and that scared her. She did not know who he was, but the room was so dark, it had just startled her. The record 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 record review and interview, the facility failed to ensure continuity of care was provided after a resident was discharged home with orders for intravenous (IV) antibiotic medications and the care of a PICC (a peripherally inserted central catheter) line for continued treatment for a bone infection for 1 of 3 residents reviewed for discharge. (Resident C) Finding includes: The closed record for Resident C was reviewed on 6/17/24 at 2:05 p.m. The resident was admitted to the facility on [DATE] and discharged to home on 5/30/24. Diagnoses included, but were not limited to, osteomyelitis (bone infection) of the left ankle and foot, type 2 diabetes, abscess of the left lower limb, heart disease, acute kidney failure, high blood pressure, and obesity. The admission Minimum Data Set (MDS) assessment, dated 5/14/24, indicated the resident was cognitively intact for daily decision making. A Nurses' Note, dated 5/7/24 at 6:40 p.m., indicated the resident was admitted to the facility from the hospital. He…

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 palatable and attractive food was served for 1 of 2 meals observed and for 2 of 3 residents reviewed for food. (The breakfast meal, Residents 34 and 41) Findings include: 1. During the Resident Council interview on 4/16/24 at 1:57 p.m., 10 residents were in attendance. Over half of the residents in attendance indicated breakfast was not good that morning. They indicated the bacon looked raw and the eggs were discolored. One resident indicated her bacon was raw on one end and burnt on the other. Several of the residents indicated the fried eggs looked green and they didn't want to eat them. One resident stated, the eggs looked like the Dr. Seuss book [NAME] Eggs and Ham. Some of the residents also indicated the sausage patties served for the breakfast meal on 4/14/24 were hard like hockey pucks. During an interview on 4/16/24 at 2:30 p.m., the Administrator indicated the facility had a new Dietary Food Manager and the Resident Council concerns would be addressed. 2. During an interview on 4/14/24 at 9:41 a.m., 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 and interview, the facility failed to prepare a pureed (blended smooth) diet designed to meet the needs of the residents. This had the potential to affect 10 of 10 residents who received a pureed diet. Finding includes: On 4/17/24 at 11:12 a.m., [NAME] 1 was observed preparing a pureed cabbage braised recipe. [NAME] 1 added 10 scoops of cabbage to the mixer and turned on the mix cycle. [NAME] 1 then added 2 cups of sauerkraut juice. The mixer was turned back on and stirred. The mixture was observed to be watery and [NAME] 1 added a tablespoon of thickener. The mixer was turned back on and then stirred to review consistency. [NAME] 1 then added another tablespoon of thickener and turned on the mixer. A total of 7 tablespoons of thickener were added to the recipe. Once the mixture was completed, the pureed meal was appropriate consistency and was free of lumps or chunks. During an interview on 4/17/24 at 11:25 a.m., [NAME] 1 indicated the cabbage was too watery and she had to add more thickener. During an interview on 4/17/24 at 11:29 a.m., [NAME] 1 indicated 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 meals were served as scheduled for 2 of 2 meal observations. (The lunch meal) Findings include: 1. On 4/16/24 at 12:20 p.m., residents were observed seated at their tables in the main dining room. Staff started passing beverages to the residents at 12:35 p.m. and the first tray served to the residents was at 1:15 p.m. The residents were observed becoming impatient and wanting their food. On 4/17/24 at 1:01 p.m., a food cart was taken to the Memory Lane Unit from the kitchen. At 1:10 p.m., a second cart was sent to Memory Lane. At 1:11 p.m. on 4/17/24, the first tray in the main dining room was served. The posted meal times indicated Memory Lane was to be served lunch at 12:30 p.m. and the Main Dining Room at 1:00 p.m. During an interview on 4/18/24 at 10:00 a.m., the Administrator indicated the dietary staff was a contracted service for the facility and the meals should have been served on time. 2. During the Resident Council interview on 4/16/24 at 1:57 p.m., 10 residents were in attendance. The majority of the…

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

Based on observation, record review, and interview, the facility failed to ensure a self-medication administration assessment was completed for residents with medications at the bedside for 2 of 2 random observations. (Residents 105 and 2) Findings include: 1. On 4/15/24 at 9:34 a.m., Resident 105 was observed sitting on the side of her bed. There was a medication cup that contained a small amount of medication solution on top of the bedside table. The record for Resident 105 was reviewed on 4/15/24 at 2:15 p.m. The diagnoses included, but were not limited to, depression, diabetes, traumatic amputation of left foot, hypertension (high blood pressure), and urinary tract infection. The admission Minimum Data Set (MDS) assessment, dated 1/29/24, indicated the resident was cognitively intact for daily decision making. A Physicians' Order, dated 3/30/24, indicated to give 30 milliliters (ml) of ProT Gold (supplement) once a day. There was no self-medication administration assessment. There was no Physician order to self-administer medications. During an interview on 4/16/21 at 11:20…

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 provide ADL (activities of daily living) assistance to dependant residents related to nail care and the removal of facial hair, for 1 of 2 residents reviewed for ADL care. (Resident 41) Finding includes: During an interview on 4/14/24 at 11:40 a.m., Resident 41 indicated his nails were long and dirty and someone usually came in to clean them, but they had not been done in awhile. At that time, the resident's nails were long with a dark colored substance underneath them. The resident was also unshaven. During random observations on 4/15/24 at 1:33 p.m. and on 4/16/24 at 9:00 a.m., the resident was observed in bed. At those times, the resident's nails were long and dirty and he was unshaven. The record for Resident 41 was reviewed on 4/15/24 at 2:40 p.m. Diagnoses included, but were not limited to, senile degeneration, high blood pressure, hallucinations, anxiety, and pain. The 2/6/24 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was moderately impaired for daily decision making and 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.

Based on observation, record review, and interview, the facility failed to ensure non-pressure skin treatments were completed as ordered and TED (compression support stockings) hose were in use for a resident with edema, for 2 of 4 residents reviewed for non-pressure skin conditions. (Residents 64 and 122) Findings include: During a random observation on 4/14/24 at 1:30 p.m., Resident 64 was observed sitting in his wheelchair. At that time, the resident's lower legs were observed with dry scaly skin and were red in color. The resident indicated staff complete a treatment to them a couple times a week. The record for Resident 64 was reviewed on 4/15/24 at 2:12 p.m. Diagnoses included, but were not limited to, stroke, heart failure, cellulitis, high blood pressure, and atrial fibrillation. The Annual Minimum Data Set (MDS) assessment, dated 3/4/24, indicated the resident was not cognitively intact for daily decision making. The resident was at risk for pressure ulcers, but currently had none. The Care Plan, revised on 3/21/24, indicated the resident had cellulitis. Physician's Orders,…

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 ankle braces were applied as ordered for 1 of 1 residents reviewed for limited range of motion (ROM). (Resident 40) Finding includes: On 4/14/24 at 8:41 a.m., 11:45 a.m., and 2:11 p.m., Resident 40 was observed in his broda chair (a positioning wheelchair). The resident was wearing his shoes and no ankle braces were in use. On 4/15/24 at 1:26 p.m., the resident was again observed in his broda chair. The resident had shoes on and no ankle braces were in use. On 4/16/24 at 8:42 a.m., the resident was seated in his broda chair by the nurses' station. He was wearing shoes and no ankle braces were in use. The resident's right foot was leaning on the right side of the foot rest. At 1:15 p.m., the resident's right foot was again leaning on the right side of the foot rest on the broda chair. No ankle braces were in use. At 3:35 p.m., the resident's left foot was leaning on the left side of the foot rest. Again, no ankle braces were in use. On 4/17/24 at 1:17 p.m., the resident was seated in his broda chair by…

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 provide adequate supervision for a resident in the shower room which resulted in a fall, for 1 of 3 residents reviewed for accidents. (Resident 34) Finding includes: During an interview on 4/14/24 at 9:44 a.m., Resident 34 indicated she was left alone in the shower room, went to stand up to clean her buttocks, slipped and fell. She indicated the shower chair was not locked, that's why I fell. Staff assisted her into the shower room and they knew she was in there by herself. During an interview on 4/17/24 at 1:30 p.m., the resident was asked again about her fall in the shower room. At that time, she indicated she was helped into the shower room by staff and there were other CNAs in the room talking. One of the CNAs helped her wash her back, and then after she was finished, she did not hear any more talking and indicated she knew was left alone in there, so she continued to wash herself and stood up to wash behind her, went to sit back down and fell to the floor because the wheels on the shower chair were not locked. 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, record review, and interview, the facility failed to ensure foley (urinary) catheter bags and tubing were kept off the floor, for 1 of 4 residents reviewed for catheters. (Resident 53 ) Finding includes: On 4/14/24 at 10:58 a.m., Resident 53 was observed sitting in his wheelchair. The foley bag was resting on the ground underneath the resident's wheelchair. On 4/14/24 at 11:25 a.m., the resident was observed sitting in his wheelchair asleep. The foley bag was resting on the floor underneath his wheelchair. On 4/14/24 at 2:16 p.m., the resident was observed sitting in his wheelchair watching his tablet. The foley bag remained resting on the floor beneath his wheelchair. The record for Resident 53 was reviewed on 4/15/24 at 1:44 p.m. Diagnoses included, but were not limited to, cerebral palsy, high blood pressure, urine retention, acute kidney disease, and obstructive uropathy. The Quarterly Minimum Data Set (MDS) assessment, dated 1/17/24, indicated the resident was cognitively intact and had a indwelling catheter. The resident was dependent with toileting…

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 oxygen was set at the correct flow rate, for 3 of 5 residents reviewed for respiratory care (Residents 228, 37 and 116) Findings include: 1. During random observations on 4/14/24 at 9:10 a.m. and 11:10 a.m., Resident 228 was observed wearing oxygen per nasal cannula. At those times, the flow rate on the room concentrator was set at 2 liters per minute. On 4/15/24 at 9:30 a.m., and 1:25 p.m., the resident was observed wearing oxygen per nasal cannula. At those times the oxygen was above the 2 liter mark but below the 2.5 liter mark. The record for Resident 228 was reviewed on 4/15/24 at 1:50 p.m. Diagnoses included, but were not limited to, respiratory failure, congestive heart failure, heart disease, high blood pressure, and shortness of breath. The 3/27/24 admission Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact for daily decision making and used oxygen while a resident. The 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 medications were labeled with a date opened and not expired, related to a multi-dose insulin vial and insulin pens, for 2 of 3 medication carts observed. (Rainbow and Reflections medication carts) Findings include: 1. On [DATE] at 10:34 a.m., a medication cart on the Rainbow unit was observed. At that time, there was 1 multi-dose vial of Novolog insulin with an open date of [DATE]. During an interview at that time, the Rainbow Unit Manager indicated it should have been discarded after 28 days. 2. On [DATE] at 10:46 a.m., a medication cart on the Reflections unit was observed. At that time, there was 1 Basaglar and 1 Lantus insulin kwikpens observed with no date opened. During an interview at that time, LPN 1 indicated both pens should have been labeled with a date opened. During an interview on [DATE] at 1:00 p.m., the Nurse Consultant indicated the pens were to be dated when opened and the Novolog multi-dose vial was expired. 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 provide dental services to a resident requesting dentures, for 1 of 1 resident reviewed for dental care. (Resident 19) Finding includes: During an interview on 4/15/24 at 2:35 p.m., Resident 19 indicated his dentures needed to be tightened up. The resident's upper denture was observed to be loose and flapped when the resident spoke. The record for Resident 19 was reviewed on 4/15/24 at 2:58 p.m. Diagnoses included, but were not limited to, high blood pressure, transient cerebral ischemic attack, type 2 diabetes, major depressive disorder, and acute respiratory failure. The Quarterly Minimum Data Set (MDS) assessment, dated 1/22/24, indicated the resident was moderately impaired for decision making and had no oral problems. A Care Plan, updated 2/19/2024, indicated the resident had oral/dental problems. A Dental Visit Note, dated 1/19/23, indicated all the resident's teeth were loose, decayed and broken down. The plan was to extract all remaining teeth and have a complete upper and lower denture made. There were no follow…

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 clinical records were complete and accurately documented related to sliding scale insulin administration, for 1 of 5 residents reviewed for unnecessary medications. (Resident 107) Finding includes: The record for Resident 107 was reviewed on 4/16/23 at 9:10 a.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus and mild cognitive impairment. The Significant Change Minimum Data Set (MDS) assessment, dated 2/15/24, indicated the resident had short and long term memory problems and she was severely impaired for daily decision making. The resident had also received insulin during the assessment reference period. A Physician's Order, dated 3/21/24, indicated the resident was to receive Lispro Insulin (a short acting insulin) before meals and at bedtime based on the following sliding scale: 151 - 200 = 2 units 201 - 250 = 4 units 251 - 300 = 6 units 301 - 350 = 8 units 351 - 400 = 10 units If blood sugar was greater than 400, give 12 units and call the Physician. Notify the Physician if 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, record review and interview, the facility failed to ensure fall interventions were in place as care planned for a resident with a history of falls, for 1 of 3 residents reviewed for falls. (Resident B) Finding includes: On 2/27/24 at 11:45 a.m., Resident B was observed seated in a wheelchair near the nurses' station. Her room was observed to have a standard mattress on the bed and there was no floor mat visible. On 2/27/24 at 3:00 p.m., with the Director of Nursing (DON) present, the resident was observed in her bed with her eyes closed. She was on a standard mattress and there was not a mat on the floor next to the bed. The resident's record was reviewed on 2/27/24 at 1:56 p.m. Diagnoses included, but were not limited to, Alzheimer's dementia, osteoporosis and a history of fall. The resident resided on the memory care unit. The Quarterly Minimum Data Set assessment, dated 2/13/24, indicated the resident had severe cognitive deficits and required extensive assistance of two staff for bed mobility, toileting and transfers. The current Fall Care Plan indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents maintained acceptable parameters of nutritional status related to meal consumption records not completed for residents with weight loss for 1 of 3 residents reviewed for nutrition. (Resident B) Finding includes: Resident B's record was reviewed on 1/8/23 at 9:06 a.m. The resident was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Diagnoses included, but were not limited to, multiple sclerosis, respiratory failure, diabetes mellitus, and chronic kidney disease. The Discharge Return Anticipated Minimum Data Set (MDS) assessment, dated 12/11/23, indicated the resident was severely impaired for daily decision making. He required assistance with eating and received a mechanically altered diet. A shower sheet, dated 11/20/23, indicated the resident weighed 149.6 pounds. On 12/8/23, Resident B's weight was 143.3 pounds. A Care Plan, dated 12/2/23, indicated the resident was at nutritional risk related to varying…

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 medications were managed appropriately related to medications not signed out as ordered for 2 of 3 residents reviewed for unnecessary medications (Residents B and C). Findings include: 1. Resident B's record was reviewed on 1/8/23 at 9:06 a.m. Diagnoses included, but were not limited to, multiple sclerosis, respiratory failure, diabetes mellitus, and chronic kidney disease. The Discharge Return Anticipated Minimum Data Set (MDS) assessment, dated 12/11/23, indicated the resident was severely impaired for daily decision making. He received an antidepressant, anti-anxiety, and opioid medication. The November 2023 Physician Order Summary (POS), indicated the resident received the following medications: - Actos (diabetic medication) tablet 30 milligrams (mg) by mouth once daily - Diazepam (antidepressant medication) tablet 2 mg by mouth three times daily - Glimepiride (diabetic medication) tablet 1 mg by mouth once daily - Protonix (reduces amount of acid in the stomach) tablet delayed release 20 mg by mouth once daily…

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 side effects for antipsychotic medications were monitored for 1 of 3 residents reviewed for unnecessary medications. (Resident J) Finding includes: The record for Resident J was reviewed on 9/26/23 at 1:58 P.M. Diagnoses included, but were not limited to, heart failure, asthma, respiratory failure, diabetes, and cirrhosis (liver failure). The admission Minimum Data Set (MDS) assessment, dated 8/4/23, indicated the resident was cognitively intact. In the last 7 days, the resident received antipsychotic, anti-anxiety, and antidepressant medications 7 times. A Care Plan, dated on 8/14/23, indicated the resident used anti-anxiety medication, hypnotic medication and antidepressant medication. The approaches were to observe for side effects of each of the medications. A Physician's order, dated 7/29/23 and updated on 9/25/23, indicated Bupropion (an anti-depressant medication) 150 milligrams (mg) to be given by mouth one time a day for depression. A Physician's order, dated 7/29/23 and updated on 9/25/23, indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure labs were completed as ordered and the Physician was notified of the results for 2 of 3 residents reviewed for lab services. (Residents G and D) Findings include: 1. Resident G's record was reviewed on 9/26/23 at 12:45 p.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to, congestive heart failure, cardiomyopathy and hypertension. A Physician's Order, dated 9/22/23, indicated to obtain a CMP (complete metabolic panel), a CBC with diff (complete blood count with differential), folate, TSH (thyroid stimulating hormone), hemoglobin A1C (a lab to monitor blood sugar control) and a vitamin D level on 9/25/23. There was no documentation the lab draw had been completed on 9/25/23, why it had not been completed or if it was rescheduled. Interview with LPN 1 on 9/26/23 at 2:20 p.m., indicated labs had not been completed for the resident. At 2:30 p.m., the Nurse Consultant was notified of the above and asked to confirm if…

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 provide ADL (activities of daily living) assistance to dependent residents related to incontinence care, nail care, changing urinary catheters, and dining assistance for 4 of 7 residents reviewed for ADL care. (Residents 66, 74, 218, and E) Findings include: 1. On 1/18/23 at 2:09 p.m., Resident 66 was seated in a chair in the activity lounge. A urine odor was noted. When the resident stood from the chair, the back of her pants were wet and the area extended to mid thigh. The resident proceeded to the other activity room located across the hall. At 2:18 p.m., 2:45 p.m., and 3:10 p.m., the resident continued to go back and forth between the activity rooms. The resident remained in the wet pants. Multiple staff were in the activity rooms and the resident was not provided assistance to change her pants. The record for Resident 66 was reviewed on 1/20/23 at 9:53 a.m. Diagnoses included, but were not limited to, Alzheimer's disease with early onset, psychosis, and delirium. The 10/29/22 Quarterly Minimum Data Set…

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

Based on interview, observation, and record review, the facility failed to ensure food served to resident rooms was palatable for 1 of 1 units observed. This had the potential to affect the 19 residents who resided on that unit and received food from the kitchen. (Residents 44, 54 and Rainbow Unit) Findings include: 1. Interview with Resident 44, who resided on the Rainbow Unit, on 1/18/23 at 2:29 p.m., indicated she received her meals in her room. The food was not warm for a lot of the meals she had been served. A follow up interview with Resident 44 on 1/24/23 at 10:30 a.m., indicated the lunch that she had received the day before was cold. 2. Interview with Resident 54, who resided on the Rainbow Unit, on 1/19/23 at 10:12 a.m., indicated she sometimes would eat her meals in her room. The vegetables were often raw and the food overall was not served hot. On 1/23/23 at 12:23 p.m., the lunch trays were delivered to the Rainbow Unit in a food cart. The last tray was removed at 12:31 p.m. The tray had a plastic dome lid covering the plate. At that time, the Dietary Manager (DM)…

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 related to built up grease on the flat top, stove top, and sides of the oven in 1 of 1 kitchens observed (Main Kitchen). This had the potential to affect 116 residents who received food from the kitchen. Findings include: 1. During the initial kitchen tour on 1/18/23 at 9:18 a.m., with [NAME] 1, the following was observed: - The flat top, stove top, and sides of the oven had a build up of grease. 2. During the follow-up tour in the kitchen on 1/23/23 at 11:46 a.m., with the Dietary Manager the following was still observed: - The flat top, stove top, and sides of the oven had a build up of grease. Interview with the Dietary Manager at that time indicated the dietary staff was responsible for cleaning. There should not have been a build up of grease on the cooking appliances. 3.1-21(i)(3)

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the residents' environment, as well as the kitchen area, was clean and in good repair related to dirty floors, marred walls, marred doors, loose baseboards, lime build up on faucets, leaking faucets, slow draining sinks, burnt out light bulbs, dirty sinks, and dirty soap dispensers in 1 of 1 kitchen areas and on 3 of 3 units. (The Main Kitchen, Rainbow, Reflections, and Memory Lane Units) Findings include: 1. During the Environmental tour with the Director of Maintenance on 1/24/23 at 3:34 p.m., the following was observed: Rainbow Unit a. The over bed light fixture in room [ROOM NUMBER] for bed 1 had a burnt out light bulb. The bathroom faucet was leaking water around the knobs after being turned on. The wall behind the toilet was gouged and marred. The walls in the bathroom were marred. The corner wall by the closet was marred and a section of baseboard was missing. Two residents resided in the room and shared the bathroom. b. The faucet leaked…

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 edema was assessed and monitored and Physician's Orders were obtained for moisture associated skin damage (MASD - which is caused by prolonged exposure to various sources of moisture, including urine or stool.) for 1 of 2 residents reviewed for edema and for 1 of 6 residents reviewed for skin conditions non-pressure related. (Residents D and E) Findings include: 1. The closed record for Resident D was reviewed on 1/23/23 at 2:37 p.m. The resident was admitted to the facility on [DATE] and left against medical advice on 8/24/22. Diagnoses included, but were not limited to, morbid obesity, type 2 diabetes, cancer of the cervix, anemia, edema, and sepsis. There was no Minimum Data Set (MDS) assessment available for review. There was no Care Plan for the MASD. A Nurses' Note, dated 8/23/22 at 7:50 p.m., indicated the resident arrived at the facility at 7:15 p.m. There were multiple bruises noted to the lower abdomen, excoriation to 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 follow up visits to an Ophthalmologist occurred for a resident needing cataract surgery for 1 of 1 residents reviewed for vision and hearing. (Resident 85) Finding includes: During an interview on 1/18/23 at 11:06 a.m., Resident 85 indicated he had a consult about cataract surgery but had not heard anything more about it. The record for Resident 85 was reviewed on 1/20/23 at 10:40 a.m. Diagnoses included, but were not limited to, type 2 diabetes, chronic pain, high blood pressure, and anxiety. The Significant Change Minimum Data Set (MDS) assessment, dated 12/26/22, indicated the resident was cognitively intact. Interview with Social Service (SS) Employee 1 on 1/23/23 at 4:10 p.m., indicated after 2020, they had trouble getting vision services for the residents, so they were sending residents out to local eye doctors. She did remember the resident going out to see the Optometrist and would look into it. A SS Note, dated 1/23/23 at 5:10 p.m., indicated the resident was seen by an Optometrist on 3/3/22. He was 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, record review, and interview, the facility failed to ensure Physician's orders were in place for a wedge positioning device for 1 of 2 residents reviewed for limited range of motion (ROM). (Resident 62) Finding includes: On 1/20/23 at 9:44 a.m. and again at 11:15 a.m., Resident 62 was observed sitting in a wheelchair in her room. The resident had a wedge device between both of her legs. A Velcro strap was attached to the device and around the resident's left leg. Another Velcro strap was attached to the device and around the resident's right leg but not strapped closed. On 1/20/23 at 1:27 p.m., Resident 62 was observed sitting in a wheelchair by the nurse's station. The resident had a wedge device between both of her legs with the Velcro straps around both legs and strapped. Record review for Resident 62 was completed on 1/20/23 at 1:04 p.m. Diagnoses included, but were not limited to, stroke and dementia. The Quarterly Minimum Data Set (MDS) assessment, dated 11/2/22, indicated the resident was cognitively impaired. The resident required an extensive 2+ person…

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 acceptable parameters of nutrition were maintained related to completing food consumption documentation for residents with a history of weight loss for 2 of 3 residents reviewed for nutrition. (Residents 34 and 74) Findings include: 1. The record for Resident 34 was reviewed on 1/20/23 at 11:52 a.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus and dementia with behavior disturbance. The Quarterly Minimum Data Set (MDS) assessment, dated 12/23/22, indicated the resident was moderately impaired for daily decision making and she needed extensive assistance with eating. The resident also received a mechanically altered, therapeutic diet. A Care Plan, dated 12/10/22, indicated the resident was at nutritional risk related to obesity, she required a therapeutic and mechanically altered diet, her meal intakes varied, and she had decreased ability to feed herself at meals. The resident had significant weight losses…

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 check placement for a peg tube prior to the administration of medication for 1 of 1 peg tubes observed during medication pass. (Resident 49) Finding includes: On 1/19/23 at 4:14 p.m., LPN 1 was observed preparing and pouring medications for Resident 49. All the medications were crushed separately and to be administered through the peg tube. He entered the resident's room, washed his hands with soap and water, and donned clean gloves. He placed the enteral feeding on hold and listened to the resident's bowel sounds by using a stethoscope. He proceeded to flush the peg tube and administer the medication one by one. He did not did not check for placement prior to administration. The record for Resident 49 was reviewed on 1/24/23 at 9:16 a.m. Diagnoses included, but were not limited to, stroke, peg tube, and dysphagia (difficulty swallowing). Physician's Orders, dated 8/22/22, indicated the resident was NPO (nothing by mouth). Jevity enteral feeding was to be infused at 64 cubic centimeters (cc) per hour…

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 narcotic pain medication was available for a resident who was newly admitted and experiencing severe pain for 1 of 2 residents reviewed for pain. (Resident 224) Finding includes: During an interview with Resident 224 on 1/19/23 at 8:52 a.m., she indicated her pain medications were not available for 2 days after she was admitted . She wanted a pain pill yesterday evening and was told there were none available. During an interview on 1/19/23 at 3:30 p.m., the resident indicated the nurse told her only 3 pills were available and they were still waiting for the doctor to sign the pain prescription. During an interview on 1/20/23 at 9:35 a.m., the resident indicated her pain medication was not available in the middle of the night. She asked for a pain pill around 8:00 p.m. and received it, however nothing was available after that. Her pain level was currently a 9 out of 10. The record for Resident 224 was reviewed on 1/23/23 at 10:10 a.m. The…

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

Based on record review and interview, the facility failed to manage medications appropriately related to not signing out medications as ordered for 1 of 7 residents reviewed for unnecessary medications. (Resident C) Finding includes: The record for Resident C was reviewed on 1/23/23 at 9:45 a.m. Diagnoses included, but were not limited to, dementia with behavior disturbance. The 12/31/22 Quarterly Minimum Data Set (MDS) assessment, indicated the resident had short and long term memory problems and was moderately impaired for daily decision making. The resident also had trouble sleeping during the last 7-11 days. A Physician's Order, dated 2/14/22, indicated the resident was to receive Aricept (a medication for dementia) 5 milligrams (mg) every evening and Namenda (a medication for dementia) 5 mg at bedtime. A Physician's Order, dated 2/20/22, indicated the resident was to receive Melatonin 5 mg at bedtime related to a sleep disorder. The September 2022 Medication Administration Record (MAR), indicated the Aricept, Namenda, and Melatonin were not signed out as being given on 9/27/22.…

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 was free of a significant medication error related to receiving the wrong medications for 1 of 7 residents reviewed for unnecessary medications. (Resident B) Finding includes: The record for Resident B was reviewed on 1/20/23 at 10:36 a.m. Diagnoses included, but were not limited to, dementia with behavior disturbance, psychotic disorder, hypertension, and type 2 diabetes mellitus. The Annual Minimum Data Set (MDS) assessment, dated 11/17/22, indicated the resident was cognitively intact. During the assessment reference period, the resident had received injections, antipsychotic medications, anti-anxiety medications, antidepressant medications, and a diuretic (water pill). A Care Plan, reviewed on 10/17/22, indicated the resident was at risk for impaired cognition related to Schizophrenia, Mood Disorder, and Dementia. Interventions included, but were not limited to, Zyprexa (an antipsychotic medication) and Depakote (mood stabilizer) as ordered. A Change of Condition note, dated 8/26/22 at 9:18 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.