Spring Mill Health Campus

Based on record review and interview, the facility failed to ensure a resident received blood sugar monitoring to determine if insulin was required (sliding scale) for 1 of 3 residents reviewed for unnecessary medications. (Resident B) Finding includes: Resident B's record was reviewed on 2/18/25 at 9 a.m. The diagnoses included, but were not limited to, stroke and diabetes mellitus. A Quarterly Minimum Data Set assessment, dated 11/4/24, indicated a severely impaired cognitive status and received insulin in the past seven days. A Physician's Order, dated 11/13/24, indicated the blood sugars were to be obtained before meals and at bedtime and Humalog insulin was to be administered if the blood sugar was 151 or higher. The doses of insulin was to be given per the results of the blood sugar results (sliding scale). The Medication Administration Record (MAR), dated 12/2024, indicated the blood sugar was not obtained to determine if insulin was required on 12/1/14 at 9 p.m., 12/8/24 at 11:30 a.m., 5:30 p.m., and 9 p.m., 12/21/24 at 9 p.m., and 12/28/24 at 5:30 p.m. and 9 p.m. The MAR,…

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

Based on observation, record review, and interview, the facility failed to ensure a resident's preferences were honored related to allowing the resident to leave their room while in contact isolation for 1 of 1 resident reviewed for choices. (Resident 261) Finding includes: During a random observation on 9/3/24 at 10:31 a.m., Resident 261 indicated she had been confined to her room due to an infection on her back. On 9/4/24 at 3:12 p.m., the resident was observed in her room sitting in her wheelchair. She indicated to LPN 3, who was also in the room, that she was unable to leave her room due to her isolation status. During an interview at the time, LPN 3 indicated she was unsure if the resident could leave her room. LPN 3 was told in shift report that the resident was in contact isolation, but she was a new nurse and was unsure if that meant the resident could not leave her room. The record for Resident 261 was reviewed on 9/4/24 at 11:15 a.m. The diagnoses included, but were not limited to, lymphedema (swelling in arms or legs), hypoxia (inadequate oxygen), difficulty walking,…

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 staff were knowledgeable regarding the residents' code status for 3 of 5 residents reviewed for advanced directives. (Residents 160, 50, and 261) Findings include: 1. The record for Resident 160 was reviewed on 9/4/24 at 3:28 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, non traumatic subarachnoid hemorrhage, type 2 diabetes, asthma, stroke, depressive disorder, and cognitive communication deficit. The admission Minimum Data Set (MDS) assessment, completed on 8/28/24, indicated the resident was moderately impaired for daily decision making. During an interview on 9/4/24 at 11:08 a.m., the Assistant Director of Nursing indicated she was not aware of the resident's code status because there was no documentation in the clinical record or in the advance directive binder located at the nursing station. During an interview on 9/4/24 at 11:11 a.m., the Social Service Director (SSD) indicated 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, record review, and interview, the facility failed to ensure the comprehensive assessment was accurate related to dental status for 1 of 17 residents whose comprehensive assessments were reviewed. (Resident 6) Finding includes: During an observation on 9/3/24 at 11:02 a.m. Resident 6's teeth were observed to be caried and broken off. The resident indicated at that time that he was supposed to get new dentures. The record for Resident 6 was reviewed on 9/5/24 at 8:20 a.m. Diagnoses included, but were not limited to, dementia with psychotic disturbance, type 2 diabetes, epilepsy, paranoid schizophrenia, depressive disorders, anxiety disorder, high blood pressure, and PTSD (post traumatic stress disorder) The 3/11/24 Annual Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact for daily decision making and had no oral or dental problems. The Modification of the Quarterly MDS assessment, dated 7/25/24, indicated the resident was cognitively intact for daily decision making and had no dental issues. There was no care plan for dental care.…

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 dependent residents received at least 2 baths a week and had their hair washed at least weekly for 2 of 4 residents reviewed for activities of daily living. (Residents 41 and 158) Findings include: 1. During an interview on 9/3/24 at 11:20 a.m., Resident 41 indicated he sometimes did not get a bed bath 2 times a week and did not get his hair washed at least weekly. The resident's hair was observed to be greasy. The record for Resident 41 was reviewed on 9/5/24 at 2:50 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, post surgical procedure to the digestive system, osteoarthritis of both knees and hips, disc degeneration, kidney disease, rheumatoid arthritis, and type 2 diabetes. The 7/24/24 admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and was dependent on staff all activities of daily living (ADLs) including…

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 surgical bandages were changed as ordered by the physician for 1 of 2 resident reviewed for skin conditions non-pressure. (Resident 41) Finding includes: On 9/3/24 at 11:25 a.m., Resident 41 was observed lying in bed wearing a hospital gown. At that time, a surgical bandage was observed to his abdomen with a date of 8/30/24. At 11:35 a.m., the Assistant Director of Nursing (ADON) was asked to come to the room and observe the date on the bandage. During an interview at that time, the ADON indicated the bandage was supposed to be changed three times a week on Monday, Wednesday, and Friday. On 9/6/24 at 12:49 p.m., the Wound Nurse was observed changing the bandage to the surgical wound. The wound was pink and was healing. During an interview at that time, the Wound Nurse indicated the bandage should have been changed on 9/2/24 and she was off that day. Nursing staff were to change the bandages when she was not in the facility. 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 resident with a pressure ulcer had interventions in place related to not floating their heels when in bed for 1 of 3 residents reviewed for pressure ulcers. (Resident 31) Finding includes: On 9/4/24 at 10:10 a.m. and 3:07 p.m., Resident 31 was observed awake lying in bed. The resident's heels were not floated off the bed. On 9/05/24 at 10:07 a.m., the resident was observed in bed. CNA 1 lifted the resident's blanket by his feet and the resident did not have his heels floated off the bed. The record for Resident 31 was reviewed on 9/04/24 at 9:35 p.m. The diagnoses included, but were not limited to, diabetes, hemiplegia (paralysis on one side), encephalopathy (swelling in the brain), dementia, and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS) assessment, dated 8/1/24, indicated the resident was severely impaired for daily decision making. The resident had impairment on both sides of his lower extremities and used a wheelchair. The resident had a stage 2 pressure ulcer. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a peg tube (a tube inserted into the stomach for nutrition) was cleaned on a daily basis and according to facility policy for 1 of 2 residents reviewed for peg tubes. (Resident 41) Finding includes: On 9/3/24 at 11:22 a.m., Resident 41 was observed lying in bed wearing a hospital gown. At that time, there was a tube observed near a bandage on his abdomen. The area under the flange had dried crusty blood noted. During an interview at that time, the resident indicated the wound nurse cleaned around the tube when she changed his bandages. On 9/6/24 at 12:49 p.m., the Wound Nurse was observed changing the resident's surgical bandage on his abdomen. During an interview at that time, the Wound Nurse indicated the peg tube was solely placed for decompression and was not used for feeding or flushes. The record for Resident 41 was reviewed on 9/5/24 at 2:50 p.m. The resident was admitted to the facility on [DATE]. Diagnoses 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.

Based on observation, record review, and interview, the facility failed to ensure a resident's PICC (peripherally inserted central catheter) line had Physician's Orders for the care and monitoring of a PICC line for 1 of 1 residents reviewed for PICC lines. (Resident 31) Finding includes: During an observation on 9/3/24 at 11:21 a.m., Resident 31's PICC line bandage was dated 8/29/24 and was peeling off on the top of the dressing. During an observation on 9/4/24 at 10:11 a.m., the PICC line bandage was dated 8/29/24 and was peeling off on the top of the dressing. The record for Resident 31 was reviewed on 9/4/24 at 9:35 p.m. The diagnoses included, but were not limited to, diabetes, hemiplegia (paralysis on one side), encephalopathy (swelling in the brain), dementia, and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS) assessment, dated 8/1/24, indicated the resident was severely impaired for daily decision making. The resident had impairment on both sides of his lower extremities and used a wheelchair. There was no Care Plan for a PICC line or Intravenous…

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 failed to ensure a PRN (as needed) psychotropic medication was not ordered longer than 14 days for 1 of 5 residents reviewed for unnecessary medications. (Resident 25) Finding includes: The record for Resident 25 was reviewed on 9/5/24 at 10:35 a.m. Diagnoses included, but were not limited to, left lung cancer, type 2 diabetes, stroke, osteoarthritis, heart disease, depressive disorder, repeated falls, high blood pressure, paranoid schizophrenia, and atrial fibrillation. The Modification of the Quarterly Minimum Data Set (MDS) assessment, dated 7/16/24, indicated the resident was cognitively intact for daily decision making and received insulin, an antipsychotic, an anxiolytic, an antidepressant, an anticoagulant, and hypoglycemic medications. Physician's Orders, dated 7/17/24, indicated Alprazolam (Xanax, an anti-anxiety medication) 0.5 milligrams (mg), give 1 tablet by mouth every 8 hours as needed for anxiety. The Medication Administration Record (MAR) for the month of 8/2024 indicated the Alprazolam was administered five times and on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to store medicated creams and loose pills properly for 1 of 1 resident and 1 of 2 medication carts observed during medication storage. (Resident 41 and Health Care 2 medication cart) Findings include: 1. During random observations on 9/3/24 at 11:26 a.m. and 3:04 p.m., Resident 41 was observed lying in bed. The resident was severely contracted for both his upper and lower extremities and was unable to use them. At that time, there was a tube of Diclofenac cream (a cream used to reduce swelling in joints and muscles) on the over bed table. During an interview on 9/3/24 at 11:26 a.m., the resident indicated he used the cream for his severe rheumatoid arthritis. During random observations on 9/4/24 at 11:18 a.m. and 2:50 p.m., and on 9/5/24 at 8:09 a.m., 10:20 a.m., and 11:45 a.m., the medicated cream was observed inside the night stand drawer. The record for Resident 41 was reviewed on 9/5/24 at 2:50 p.m. The resident was admitted 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure the resident's environment was clean and sanitary related to an uncontained bed pan for 1 of 3 units. (Health Care Center 2) Finding includes: During random observations on 9/5/24 at 8:09 a.m.,10:20 a.m., and 11:45 a.m., an uncontained bed pan was observed lying on a cloth chair in room [ROOM NUMBER]. During an interview on 9/5/24 at 8:09 a.m., the resident who resided in the room indicated he had diarrhea 8 times yesterday and during the nigh,t and had used the bed pan. During an interview on 9/6/24 at 2:30 p.m., the Director of Nursing (DON) indicated the bed pan was to be contained and put away after each use. The current 3/21/21 Space and Equipment policy, provided by the DON on 9/10/24 at 2:58 p.m., indicated the facility will provide areas of space for storing devices and supplies used for continence. 3.1-19(f)

Based on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented, related to cleaning of reusable equipment and hand hygiene after direct resident contact and glove removal, for random observations of infection control. (Residents P, D, R and S) Findings include: 1. During a random observation on 2/19/24 at 7:18 a.m., RN 1 was observed walking out of Resident P's room, carrying a blood pressure cuff, glucometer, and thermometer. She laid all of those items on top of the medication cart and donned a pair of clean gloves and cleaned the glucometer. After she cleaned the glucometer, she removed her gloves and did not perform hand hygiene. She took all of the items into Resident D's room, donned a pair of clean gloves to both hands, and checked his blood pressure and his blood sugar. She removed her gloves and performed hand hygiene at the medication cart. She did not clean the blood pressure cuff or thermometer after she had used them for Resident P. She entered the room again with the resident's Insulin. 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 bandages were changed and treatments were completed as ordered by the Physician for a diabetic ulcer and a non pressure ulcer, for 1 of 3 residents reviewed for skin conditions. (Resident P) Finding includes: During a random observation on 2/19/24 at 7:40 a.m., Resident P was observed in bed. At that time, there were 2 bandages on the resident's right leg and right great toe with a date of 2/17/24. The resident indicated the bandages were not changed yesterday (2/18) and the doctor had told him they were to be changed every day. The record for Resident P was reviewed on 2/19/24 at 9:45 a.m. Diagnoses included, but were not limited to, osteomyelitis of right foot and ankle, type 2 diabetes, diabetic foot ulcer, and cellulitis of the right lower limb. The admission Minimum Data Set (MDS) assessment, dated 2/5/24, indicated the resident was not cognitively intact. The resident was at risk for pressure ulcers and had a diabetic foot ulcer. The Care Plan, dated 1/31/24, indicated the resident had a diabetic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a resident with pressure ulcers received the necessary care and treatment to promote healing, related to treatments not completed as ordered, and bandages not secure and in place as ordered, for 1 of 3 residents reviewed for pressure ulcers. (Resident O) Finding includes: During a random observation on 2/19/24 at 8:02 a.m., CNA 1 was observed standing at the bedside of Resident O and preparing to get her out of bed. At that time, he was asked to roll the resident over and remove her brief so her buttocks could be observed. The CNA removed the resident's brief and there was no bandage covering a pressure sore on the sacrum. The pressure ulcer was pink with an area of darker red, and some drainage was noted. During an interview at that time, CNA 1 indicated this was the first time he had removed her brief since coming on to his shift at 6 a.m. The record for Resident O was reviewed on 2/20/24 at 12:15 p.m. Diagnoses 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, record review, and interview, the facility failed to ensure gastrostomy enteral feedings were infusing at the correct time, tubing was changed at least every 24 hours, stoma sites were cleaned as ordered, and medications were administered per facility policy, for 3 of 3 residents reviewed for peg tubes (a tube inserted into the stomach for nutrition). (Residents L, D, and M) Findings include: 1. The record for Resident L was reviewed on 2/20/24 at 11 a.m. Diagnoses included, but were not limited to, stroke, dysphagia, contractures, and a peg tube. The 11/10/23 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was not cognitively intact. The resident had a feeding tube and received 51% of nutrition through the tube. A Care Plan, updated on 2/13/24, indicated the resident may be at risk for complications secondary to requiring a peg tube. The approaches were to provide care to the peg tube site as ordered. Physician's Orders, dated 8/18/23 and discontinued on 12/3/23,…

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

Based on record review and interview, the facility failed to manage medications appropriately, related to not administering antibiotic and pain medication as ordered by the Physician, for 2 of 3 residents reviewed for infections and 1 of 3 residents reviewed for pain medications. (Residents B, P and L) Findings includes: 1. The record for Resident B was reviewed on 2/20/24 at 11:22 a.m. Diagnoses included, but were not limited to, type 2 diabetes, heart disease, osteoarthritis, heart failure, and an urinary tract infection (UTI). The 2/7/24 Quarterly Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact for daily decision making. Physician Progress Notes, dated 1/17/24 at 2:01 p.m., indicated the resident's urinalysis was reviewed and was positive for ESBL (Extended Spectrum Beta-Lactamase) and Pseudomonas infections, and antibiotics were ordered. Physician's Orders, dated 1/17/24, indicated Cefdinir (an antibiotic) capsule 300 milligrams (mg), give 1 capsule by mouth two times a day for UTI for 3 days. The Medication Administration Record (MAR) for 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 clinical records were complete, related to the determination to discontinue 15 minute checks for a resident who was observed in his room with an unlit cigarette, for 1 of 3 residents reviewed for supervision. (Resident K) Finding includes: The closed record for Resident K was reviewed on 2/20/24 at 1:45 p.m. Diagnoses included, but were not limited to, sepsis, Chronic Obstructive Pulmonary Disease (COPD), angina, high blood pressure, and paranoid schizophrenia. The admission Minimum Data Set (MDS) assessment, dated 9/21/23, indicated the resident was moderately impaired for daily decision making. The resident required extensive assist with a 2 person physical assist for bed mobility and transfers. There was no Care Plan indicating the resident had attempted to smoke in his room. A Nurses' Note, dated 10/14/23 at 10:15 p.m., indicated the resident's room door would not open upon first attempt. The resident had used his wheelchair to barricade the door closed. After entering the room, the resident was observed asleep…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a Physician's Order was in place for a resident who received oxygen for 1 of 3 residents reviewed for oxygen. (Resident G) Finding includes: On 9/18/23 at 9:47 a.m., Resident G was observed in therapy wearing oxygen via a nasal cannula with a flow rate of 3 liters. On 9/18/23 at 10:20 a.m., the resident was observed in the bathroom. The Director of Nursing (DON) remove the oxygen tank from the back of the resident's wheel chair. She sat the tank on the floor and the tank dial moved from red to green when the position of the tank was changed. The DON indicated the tank was full of oxygen and the resident was to receive 3 liters of oxygen. The record for Resident G was reviewed on 9/18/23 at 2:28 p.m. Diagnosis included, but were not limited to, respiratory failure, dependence on supplemental oxygen, sleep apnea, and asthma. The resident was admitted to the facility on [DATE]. A Care Plan, dated 9/15/23, indicated the resident…

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

Based on observation, record review, and interview, the facility failed to ensure residents had Physician's Orders for medications and an assessment to self-administer their own medications for 1 of 1 residents reviewed for self-administration of medication. (Resident 41) Finding includes: On 8/7/23 at 10:45 a.m., an Arnuity Ellipta 100 micrograms inhaler and a Hylands Natural Restful Legs supplement was noted to be on the bedside table in Resident 41's room. The resident indicated she had brought the supplement in from home. On 8/8/23 at 1:13 p.m., an Arnuity Ellipta inhaler and Hylands Natural Restful Legs supplement were noted to be sitting next to the television on the table in Resident 41's room. Resident 41's record was reviewed on 8/10/23 at 11:35 a.m. Diagnoses included, but were not limited to, acute respiratory failure, end stage renal failure, and restless leg syndrome. The admission Minimum Data Set (MDS) assessment, dated 8/5/23, indicated the resident was cognitively intact for daily decision making. A Physician's Order, dated 8/1/23, indicated fluticasone furoate…

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 dependent residents received assistance with ADLs (activities of daily living) related to bathing, nail care, shaving, and clean clothing and linens for 2 of 4 residents reviewed for ADLs. (Residents 110 and 37) Findings include: 1. Interview with Resident 110 on 8/7/23 at 10:16 a.m., indicated she had not received a shower since being admitted . The record for Resident 110 was reviewed on 8/8/23 at 1:21 p.m. Diagnoses included, but were not limited to, stroke, lack of coordination, and spinal stenosis. The resident was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment, dated 7/26/23, indicated the resident was cognitively intact and she required extensive assistance with bed mobility and transfers. The resident was totally dependent on staff for bathing. A Care Plan, dated 7/24/23, indicated the resident required assistance with ADLs (activities of daily living) including bed mobility, eating,…

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 fall follow-ups and neurological checks were initiated and/or completed following a fall for 1 of 3 residents reviewed for falls. (Resident 213) Finding includes: On 8/8/23 at 1:27 p.m., Resident 213 was observed in bed. There were fall mats noted on the floor on both sides of the bed. Resident 213's record was reviewed on 8/8/23 at 12:58 p.m. Diagnoses included, but were not limited to, fracture of the left femur, dementia without behavioral disturbance, and cognitive communication deficit. The admission 5-Day Minimum Data Set (MDS) assessment, dated 7/3/23, indicated the resident was severely cognitively impaired. She required extensive assist with bed mobility, toilet use, and personal hygiene, and limited assist for transfers. She had impairment in functional range of motion on one side of the lower extremities. A Care Plan, dated 6/29/23, indicated the resident required assistance with Activities of Daily Living (ADLs) including bed mobility, transfers, eating, toileting, and bathing. A Care Plan, dated…

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

Based on record review and interview, the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services to promote healing, related to treatments not completed as ordered and treatment orders not updated timely for 2 of 2 residents reviewed for pressure ulcers. (Residents 49 and 212) Findings include: 1. Resident 49's record was reviewed on 8/9/23 at 11:18 a.m. Diagnoses included, but were not limited to, acute osteomyelitis of the left femur, pressure ulcer of sacral region stage 4, cellulitis of left lower limb, severe protein-calorie malnutrition, pressure ulcer of right hip, and heart failure. The Quarterly Minimum Data Set (MDS) assessment, dated 5/22/23, indicated the resident was cognitively intact for daily decision making. He required extensive assistance with one person physical assist for bed mobility, transfers, dressing, and personal hygiene. He had a functional limitation in range of motion to both lower extremities. He had 4 stage 4 pressure ulcers and 3 unstageable deep tissue injuries present upon admission/entry. 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 a contracture was identified, treated, and monitored, and splints were applied as ordered for 2 of 4 residents reviewed for range of motion (ROM). (Residents 37 and 212). Findings include: 1. On 8/7/23 at 11:08 a.m., Resident 37 was observed in lying in bed. He indicated he thought he would benefit from therapy and had no range of motion in his last two fingers on both hands. The resident was unable to extend those fingers. On 8/8/23 at 1:24 p.m. Resident 37 was noted to be in bed. He still had no range of motion in the last two fingers on his bilateral hands. Interview with RN 1 on 8/10/23 at 10:01 a.m., indicated she worked with the resident often and had not noticed any contractures. Upon observation of the resident at 10:06 a.m., she indicated she would reach out to therapy to get an assessment completed as the fingers were contracted. Resident 37's record was reviewed on 8/10/23 at 9:44 a.m. Diagnoses included, but were not limited to end stage renal disease, dementia, and depressive disorders.…

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

Based on observation, record review, and interview, the facility failed to ensure oxygen was being administered at the correct flow rate for 1 of 1 residents reviewed for oxygen. (Resident 24) Finding includes: On 8/7/23 at 10:03 a.m., Resident 24 was observed sitting in her wheelchair. The resident was wearing oxygen via a nasal cannula with a flow rate set at 2.5 liters. On 8/8/23 at 9:37 a.m., Resident 24 was observed sitting in her wheelchair with the oxygen tubing in her lap. The resident was wearing oxygen via a nasal cannula with a flow rate set at 2.5 liters. The oxygen tubing was not connected to the concentrator. A nursing aide was notified and reconnected the resident's oxygen at 2.5 liters. On 8/8/23 at 1:15 p.m., Resident 24 was observed in the dining hall wearing oxygen via nasal cannula with a flow rate set at 2.5 liters. Resident 24's record was reviewed on 8/8/23 at 12:06 p.m. Diagnoses included, but were not limited to, hyperlipidemia (high cholesterol), hypertension (high blood pressure), non- Alzheimer's dementia, Parkinson's disease, Wernicke's encephalopathy…

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 residents were free of significant medication errors related to timing of insulin administration for 1 of 1 residents reviewed for insulin. (Resident 18) Finding includes: Interview with Resident 18 on 8/7/23 at 2:19 p.m., indicated she did not always receive her insulin on time. The record for Resident 18 was reviewed on 8/8/23 at 1:54 p.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus. The admission Minimum Data Set (MDS) assessment, dated 7/13/23, indicated the resident was cognitively intact and she received insulin injections. A Care Plan, dated 7/20/23, indicated the resident was at risk for complications related to the diagnosis of diabetes mellitus. Interventions included, but were not limited to, administer diabetes medication as ordered by the doctor. Monitor/document side effects and effectiveness. Physician's Orders, dated 7/9/23, indicated the resident was to receive Glargine insulin 30 units subcutaneously one time daily at 8:00 a.m. The resident was also to receive Lispro…

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 specimens for laboratory testing were collected as ordered by the Physician for 1 of 1 residents reviewed for laboratory services (Resident 49). Finding includes: Resident 49's record was reviewed on 8/9/23 at 11:18 a.m. Diagnoses included, but were not limited to, acute osteomyelitis of the left femur, pressure ulcer of sacral region stage 4, cellulitis of left lower limb, pressure ulcer of right hip, and heart failure. The Quarterly Minimum Data Set (MDS) assessment, dated 5/22/23, indicated the resident was cognitively intact for daily decision making. He had 4 stage 4 pressure ulcers that were present upon admission/entry and 3 unstageable deep tissue injuries present upon admission/entry. A Physician's Order, dated 7/27/23, indicated blood urea nitrogen (BUN), creatinine, and glomerular filtration rate (eGFR) draw prior to initiation of antibiotic courses. The Laboratory Report, dated 7/28/23, indicated BUN, creatinine, eGFR were collected on 7/28/23 at 2:35 a.m. and reported on 7/28/23 at 1:02 p.m. A…

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

Based on observation, record review, and interview, the facility failed to ensure infection control guidelines were in place and implemented, including those to prevent and/or contain COVID-19, related to improper cleaning of reusable equipment, improper hand hygiene between glove use, and improper disposal of a lancet for 1 of 6 residents observed during medication pass (Resident 45, LPN 1). Finding includes: On 8/9/23 at 4:20 p.m., LPN 1 was observed checking blood glucose levels of Resident 45. LPN 1 washed her hands and donned clean gloves. She wiped the glucometer down with an alcohol swab and placed the glucometer into a clean glove. She removed her gloves and donned new gloves, without performing hand hygiene in between glove use. She performed the finger stick and obtained the resident's blood glucose reading. She exited the room and placed the used lancet into the regular garbage can. LPN 1 then prepared 30 units of Novolog (an insulin). She retrieved the medication from the cart, donned new gloves without performing hand hygiene first. She wiped the vial with an alcohol…

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 promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy to reduce antibiotic resistance related to a practitioner prescribing antibiotics for wounds without being cultured for 1 of 2 residents reviewed for pressure ulcers. (Resident 49). Finding includes: Resident 49's record was reviewed on 08/09/23 at 11:18 a.m. Diagnoses included, but were not limited to, acute osteomyelitis of the left femur, pressure ulcer of sacral region stage 4, cellulitis of left lower limb, pressure ulcer of right hip, and heart failure. The Quarterly Minimum Data Set (MDS) assessment, dated 5/22/23, indicated the resident was cognitively intact for daily decision making. He had 4 stage 4 pressure ulcers that were present upon admission/entry and 3 unstageable deep tissue injuries present upon admission/entry. Wound Care Notes, dated 7/26/23, indicated a wound culture was completed on 7/19/23, which indicated pathogens were detected in the right hip, left hip, left medial foot, and left lateral foot. The assessment,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure the residents' environment was clean and in good repair related to urine odor and ripped carpet on 2 of 3 units. (Healthcare 2 Unit and TCU Unit) Findings include: During the Environmental Tour with the Director of Maintenance and the Housekeeping Supervisor on 8/11/23 at 9:45 a.m., the following was observed: 1. TCU Unit: In room [ROOM NUMBER], there was a rip in the carpet upon entrance to the room. One resident resided in the room. 2. Healthcare 2 Unit: In room [ROOM NUMBER], the room had a strong urine odor. Two residents resided in the room. Interview with the Maintenance Director and Housekeeping Supervisor at the time, indicated the above was in need of cleaning and/or repair. 3.1-19(f)