Hamilton Pointe Health And Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the residents' families for 2 of 3 residents reviewed for notification of changes. A resident's family was not notified of a change in the resident's physical condition and a resident's fall. (Resident F, Resident M)Findings include: 1. On 7/30/25 at 2:37 P.M., Resident F's clinical record was reviewed. Diagnoses included but were not limited to hypertension and acute respiratory failure. The Current admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact. Resident F needs supervision for transferring, setting up for eating, partial assistance with hygiene, and substantial/maximum assistance of 2 for toileting and dressing. Current physician orders included, but were not limited to, Tylenol Extra Strength Oral Tablet (pain relief) 500 Milligrams (MG). Give 1 tablet by mouth three times a day for Shoulder pain dated 7/24/25. The Current Fall Risk Care Plan dated 7/1/25 indicated the resident was at…

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

Based on observation, interview, and record review, the facility failed to revise a resident's plan of care to reflect current interventions for 1 of 3 residents reviewed for accidents. A resident's falls care plan was not updated to reflect implementation of a call don't fall sign. (Resident 2)Finding includes:On 7/31/25 at 9:15 A.M., Resident 2's clinical record was reviewed. Diagnosis included, but was not limited to, fracture to right humerus. The most recent quarterly Minimum Data Set (MDS) assessment, dated 7/7/25, indicated mild cognitive impairment, and no falls since the prior assessment. A current risk for falls care plan, last revised on 7/30/25, lacked an intervention for a call don't fall sign in the resident's room. A progress note on 6/13/25 at 10:02 A.M. indicated Resident 2 fell, but did not remember how it happened. An immediate intervention was a call don't fall sign in place. An IDT note on 6/16/25 at 8:49 A.M. indicated the resident had fallen on 6/13/25, and would evaluate upon return from hospital for any new interventions. On 7/31/25 at 2:00 P.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, interview, and record review, the facility failed to ensure a resident with an indwelling urinary catheter received appropriate services and treatment related to catheter placement for 1 of 3 residents reviewed for catheter use. A resident with an indwelling urinary catheter received the wrong size catheter. (Resident B)Finding includes:On 7/31/25 at 8:50 A.M., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, ulcerative colitis, anxiety, and depression. The most recent quarterly Minimum Data Set (MDS) assessment, dated 7/17/25, indicated no cognitive impairment, and use of an indwelling urinary catheter. Resident 10 was dependent on staff for bed mobility and toileting.Current physician orders included, but were not limited to:Foley catheter: 16 French (size of catheter)/30cc (milliliter) balloon, dated 3/14/25.Foley catheter: change catheter as needed 16 French/30cc balloon every 8 hours as needed for maintaining catheter, dated 3/14/25.An indwelling catheter care plan, created 3/17/25, indicated, but was not limited 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 interview and record review, the facility failed to ensure accurate documentation for 1 of 2 residents reviewed for change of condition, and 1 of 2 residents reviewed for urinary tract infections (UTI) or catheter. (Resident B, Resident 21)Findings include:1. On 7/31/25 at 8:50 A.M., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, ulcerative colitis, anxiety, and depression. The most recent quarterly Minimum Data Set (MDS) assessment, dated 7/17/25, indicated no cognitive impairment and use of an indwelling urinary catheter. Resident B was dependent on staff for bed mobility and toileting.Current physician orders included, but were not limited to:Foley catheter: 16 French (size of catheter)/30cc (milliliter) balloon, dated 3/14/25.An indwelling catheter care plan, created 3/17/25, indicated, but was not limited to, an intervention to change the catheter system when clinically indicated or ordered, dated 3/17/25.A progress note on 7/3/25 at 5:15 P.M. 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 observation, interview, and record review, the facility failed to ensure infection control practices were maintained and Personal Protective Equipment (PPE) was worn entering isolation rooms for 3 of 7 halls observed. (300 Hall, 500 Hall, 900 Hall ). Findings include: 1. On 2/27/25 at 8:20 a.m., Activity Staff 2 was observed to enter room [ROOM NUMBER] to pass out activity calendars, standing and speaking with the residents before leaving the room. room [ROOM NUMBER] had a sign posted on the door that indicated droplet precautions, wear gloves and gown upon entering room, wear a surgical mask (N-95 mask if available) upon entering the room, goggle or face shield to be worn if performing aerosol respiratory treatments, hand hygiene before and after patient or environment contact, with soap and water or alcohol-based hand sanitizer. PPE was available at the entrance. Activity Staff 2 did not don PPE upon entering the room. Activity Staff 2 was observed to enter non isolation rooms [ROOM NUMBERS] to pass…

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 food was served in a sanitary manner in accordance with professional standards for food service safety for 2 of 2 observations of the kitchen, 1 of 1 observations of meal service. Gloves were not changed, bare hands touched plates, fingers were licked, floors soiled. (Kitchen) Findings include: 1. On 2/25/25 at 9:30 a.m., the kitchen floor was observed to have debris along the walls, behind and under tables, equipment, racks, and in the dry panty. The same was observed on 2/27/25 at 10:10 a.m. 2. On 2/25/25 at 9:25 a.m., Dietary Aide 2 was observed with gloved hands to be standing at a table preparing 6 plates of salad. Dietary Aide 2 left the food prep table, walked to the walk in refrigerator carrying a food container, went in and back out, obtained a cutting board and walked to the food prep table and laid it down. Dietary Aide 2 picked up a food container containing tomatoes, covered it with plastic wrap, walked to the food scale, weighed the tomatoes, touching the screen of the scale with gloved…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a newly admitted resident had immediate orders for pressure wounds for 1 of 3 residents reviewed for pressure wounds. (Resident B) Finding included: On 12/9/24 at 9:44 a.m., Resident B indicated he was admitted to the facility in June of 2024, and had pressure wounds on admission to his buttock. On 12/9/24 at 10:10 a.m., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, anemia, unspecified, unspecified protein-calorie malnutrition, paraplegia, complete, pressure ulcer of right buttock stage IV (4), type 2 diabetes mellitus with unspecified complications, colostomy status, other acute osteomyelitis, right femur, other acute osteomyelitis right ankle and foot, peripheral vascular disease, pressure ulcer left hip, unstageable, pressure ulcer of right buttock, unstageable. Resident B was admitted to the facility on [DATE]. An admission MDS (Minimum Data Set) assessment dated [DATE], indicated Resident B's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the privacy of residents was respected for 6 of 6 random observations and 1 of 1 insulin administrations observed. Staff did not knock on doors when entering, and left the door open when administering injections. (Resident D, Resident 45, Resident 37, Resident 6, Resident 7, Resident S, Resident 150) Findings include: 1. On 5/31/24 at 10:33 A.M., Registered Nurse (RN) 57 was observed to enter Resident 7's room without knocking. 2. On 5/31/24 at 10:35 A.M., RN 57 was observed to enter Resident S's room without knocking. 3. On 5/31/24 at 10:37 A.M., RN 57 was observed to enter Resident 150's room without knocking. 4. On 6/3/24 at 7:10 A.M., Qualified Medication Aide (QMA) 23 was observed to enter room [ROOM NUMBER] without knocking. From the hallway, QMA 23 was observed to administer two injections into Resident 45's abdomen. 5. On 6/3/24 at 7:16 A.M., QMA 23 was observed to enter Resident 37's room without knocking. 6. On 6/3/24 at…

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

Based on observation, interview, and record review, the facility failed to ensure residents who self administered medications were assessed for ability to self administer those medications for 4 of 4 random observations. Medications were observed in rooms where the resident lacked a self administration of medication assessment. (Resident 7, Resident S, Resident 150, Resident 6) Findings include: 1. On 5/30/24 at 9:39 A.M., Resident 7 was observed lying in bed with a box of throat lozenges lying at the foot of the bed. The box had a pharmacy label with the resident's name on it. On 5/31/24 at 9:41 A.M., Resident 7's clinical record was reviewed. Diagnosis included, but were not limited to, dementia, anxiety, depression, and psychotic disorder. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 5/7/24, indicated a moderate cognitive impairment, and verbal behaviors directed toward others. Resident 7 required substantial to maximum assistance with transfers and bathing, and partial to moderate assistance with bed mobility. Current physician orders included, but were not…

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

Based on observation, interview, and record review, the facility failed to ensure that food was served at palatable temperatures for 1 of 1 trays tested for temperature. (400 Hall) Finding includes: On 5/29/24 at 8:30 A.M., Resident 40 indicated the food was not hot all the time. On 5/29/24 at 2:40 P.M., Resident 6 indicated the food was cold and didn't taste good. On 5/30/24 at 10:47 A.M., Resident 31 indicated the food was not hot all the time. On 5/31/24 at 2:40 P.M., during a Resident Council meeting which consisted of 15 people, the following statement was made about the food temperatures: the food stayed on trays too long while coming down the halls (making the food cold by the time it reached the resident). On 6/3/24 at 10:44 A.M., [NAME] 28 checked the temperatures of the lunch food items that were on the holding table ready to be served. On 6/3/24 at 11:10 A.M., kitchen staff started plating the food. On 6/3/24 at 11:56 A.M., the lunch cart was delivered to the 400 hall and left in the hallway. Staff were not notified of its arrival. On 6/3/24 at 12:01 P.M., staff started…

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 store and prepare food under sanitary conditions during 3 of 3 kitchen observations. Food was left open to air, expired food was not disposed of from the refrigerator, and gloves were not used according to professional standards. (Kitchen, Main Dining Room, [NAME] 21) Findings include: 1. On 5/28/24 at 8:15 A.M., the full kitchen tour with the Dietary Manager indicated the following: In the reach-in freezer, the following items were observed: Slice of orange melon open to air in a tray not labeled or dated 5 small ice cream containers tipped over with the lids half on and half off In the walk-in freezer, the following items were observed: 3 french fries were scattered on the shelves open to air 1 bag of mixed vegetables open to air In the walk-in refrigerator, the following items were observed: 1 broken egg in an egg crate with whole eggs Rice with a use by date of Sunday 5/25/24 1 boiled egg on the floor Bag of grapes open to air with no label or date Container of boiled eggs in liquid open to air Cup of…

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

Based on observation, interview, and record review, the facility failed to ensure a safe, sanitary, and comfortable environment to help prevent the development and transmission of infection for 6 of 6 random observations. Resident care items were observed uncovered in bathrooms, and staff did not sanitize hands entering or exiting rooms with enhanced barrier precautions as indicated. (Resident 37, Resident D, Resident 7, Resident 46, Resident 20) Findings include: 1. On 5/30/24 at 9:38 A.M., Resident 7's bathroom was observed with four uncovered washbasins on the floor. On 6/5/24 at 8:30 A.M., the same was observed. 2. On 5/30/24 at 9:14 A.M., Resident 46's bathroom was observed with an uncovered washbasin in the sink. 3. On 5/30/24 at 10:10 A.M., Resident 20's bathroom was observed with an uncovered toothbrush on the back of the sink. On 6/5/24 at 8:29 A.M., the same was observed. 4. On 6/3/24 at 7:16 A.M., Qualified Medication Aide (QMA) 23 was observed to attempt to administer medications to Resident 37. QMA 23 entered and exited Resident 37's room without sanitizing or washing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide an environment free of pests based on 8 (eight) random observations of gnats during the survey. (800 Nursing Hall, Kitchen, 300 Nursing Hall, Nurses Station, Dining Room, Resident room [ROOM NUMBER], ADON (Assist Director of Nursing) Office, and Nursing Manger Office) Findings include: 1. On 5/29/24 at 3:05 P.M., during a random observation a gnat was observed flying in a resident's room. 2. On 5/31/24 at 10:05 A.M. during a random observation gnats were observed flying in a Nursing Manager Office. 3. On 6/3/24 at 10:27 A.M., during a random observation in the ADON's office, several gnats were observed flying about in the room. 4. On 5/29/24 at 9:16 A.M., Resident 84 indicated she had a problem with gnats in her room. At that time, gnats were observed in her room. 5. On 5/29/24 at 2:39 P.M., gnats were observed in Resident 6's room. 6. On 6/3/24 at 11:32 A.M., gnats were observed in the main dining room. 7. On 6/3/24 at 11:53…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the MDS (Minimum Data Set) Assessment was completed accurately for 2 of 5 residents reviewed for unnecessary medications. (Resident 6, Resident 7) Findings include: 1. On 5/30/24 at 2:31 P.M., Resident 6's clinical record was reviewed. Diagnosis included, but was not limited to, malignant neoplasm of descending colon. The most recent Annual MDS (Minimum Data Set) Assessment, dated 4/28/24, indicated Resident 6 was cognitively intact and did not receive an opioid during the 7-day lookback period. Physician orders included, but were not limited to: fentanyl (an opioid medication) patch 12 MCG/HR (micrograms per hour) - Apply 1 patch transdermally every 72 hours for pain and remove per schedule, dated 11/3/23. oxycodone-acetaminophen (an opioid medication) tablet 5-325 MG (milligrams) - Give 1 tablet by mouth three times a day for pain and give 1 tablet by mouth as needed for pain may have up to two additional doses daily. PRN (as needed) dose may…

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

Based on interview and record review, the facility failed to ensure physician orders were followed for 2 of 2 residents reviewed for nutrition. (Resident 55 and Resident S) Findings include: 1. On 5/31/24 at 12:22 P.M., Resident 55's clinical record was reviewed. Diagnoses included, but were not limited to, dementia and epilepsy. The most recent Annual MDS (Minimum Data Set) Assessment, dated 4/18/24, indicated Resident 55 was moderately cognitively intact, required setup assistance from staff for eating, had a feeding tube, had an unplanned weight loss, and was receiving a mechanically altered diet. Physician orders included, but were not limited to: Weekly weights for trending weight loss one time a day every Saturday for trending weight loss, dated 2/17/24. 2-Cal HN (liquid nutritional supplement) 300 mL (milliliters) bolus (administer full amount at once) four times a day, dated 5/23/24- current. 2-Cal HN 300 mL bolus four times a day, dated 5/2/24-5/23/24. Jevity 1.5 (liquid nutritional supplement) 300 mL bolus feeding four times a day before meals and at bedtime, 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 interview and record review, the facility failed to provide care by thorough assessment of a resident prior to narcotic medication administration and implementation of a person centered care plan for the use of narcotics, and a care plan that reflected accurate resuscitative measures for 1 of 2 residents reviewed for expiration in the facility. (Resident P) Findings include: On [DATE] at 9:15 A.M., Resident P's clinical record was reviewed. Diagnoses included, but were not limited to, asthma and atrial fibrillation. The most recent quarterly MDS (Minimum Data Set) Assessment, dated [DATE], indicated Resident P was cognitively intact and was receiving opioid pain medication during the seven day lookback period. Physician orders included, but were not limited to: Do not resuscitate, dated [DATE]. Observe for side effects (Narcotic pain medication), dated [DATE]. Ipratropium-albuterol (medication to improve breathing) inhalation solution 0.5-2.5(3) mg/mL (milligram per milliter) one inhalation inhale…

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 post fall assessments were completed and care plans were updated to prevent falls for 2 of 4 residents reviewed for accidents. (Resident 40, Resident 83) Findings include: 1. On 5/30/24 at 2:18 P.M., Resident 40 was observed in bed. There was one set of non-skid strips near her bed. On 5/30/24 at 1:26 P.M., Resident 40's clinical record was reviewed. Diagnoses included, but were not limited to, vascular dementia, fracture of fifth metacarpal bone right hand, and history of falling. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 5/16/24, indicated Resident 40 had moderate cognitive impairment, required supervision of staff for sit to stand transfers and toileting, partial to moderate assistance of staff for bathing, and had one fall with no injury since the prior assessment. A fall risk assessment, dated 3/15/24, indicated Resident 40 was at low risk for falls. A current falls care plan, revised 1/22/24, indicated the resident was at risk for falls. The interventions 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, interview, and record review, the facility failed to ensure pain management consistent with professional standards of practice, care plans, and the resident's goals and preferences were provided for 2 of 2 residents reviewed for pain management. A resident was not monitored for side effects of narcotic pain medication resulting in an overdose, pain medication was not given as prescribed, and a resident's preference for non-pharmacological pain relief was not honored. (Resident T, Resident 6) Findings include: 1. On 5/30/24 at 9:52 A.M., Resident T indicated she had arthritis and gout, and was in constant pain. She indicated she received medications for pain, but it did not help much. On 5/31/24 at 9:46 A.M., Resident T's clinical record was reviewed. Diagnosis included, but were not limited to, anxiety and leg pain. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 4/5/24, indicated no cognitive impairment, and no behaviors. Resident T required supervision with bed mobility and toileting, and partial to moderate assistance with bathing.…

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 it was free of a medication error rate of greater than 5 percent (%) for 2 of 3 residents (Resident 6, Resident 17) observed during medication pass. Three medication errors were observed during 25 opportunities for error in medication administration. This resulted in a medication error rate of 12%. Findings include: 1. On 6/3/24 at 6:50 A.M., LPN 19 was observed to administer medications to Resident 17. LPN 19 put two chewable tablets of calcium carbonate 500mg (milligram) into the same medication cup as the other medications, and administered them all to the resident to swallow them. LPN 19 then removed a patch from the resident's back with bare hands, and applied a new patch (rivastigmine 4.6/24) also with bare hands. On 6/5/24 at 10:10 A.M., Resident 17's clinical record was reviewed. Diagnosis included, but were not limited to, dementia. Current physician orders included, but were not limited to: Calcium Carbonate tablet chewable 500mg, give 2 tablets by mouth one time a day, dated 11/3/23.…

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 observation, interview and record review, the facility failed to ensure accurate documentation for 1 of 1 residents observed for a glucometer reading, and 1 of 3 residents reviewed for falls. A blood glucose was documented incorrectly, and post-fall assessments were not completed following a fall. (Resident 6, Resident 86) Findings include: 1. On 6/3/24 at 11:15 A.M., Licensed Practical Nurse (LPN) 19 was observed to perform a glucose reading on Resident 6. LPN 19 performed a fingerstick, and obtained a reading of 177. On 6/3/24 at 2:00 P.M., a blood sugar summary for Resident 6 was provided and indicated a blood sugar of 175 on 6/3/24 at 11:20 A.M. On 6/4/24 at 9:15 A.M., Registered Nurse (RN) 31 indicated blood sugar readings should be documented accurately. 2. On 5/30/24 at 2:59 P.M., Resident 86's clinical record was reviewed. Diagnoses included, but were not limited to, hemiplegia and hemiparesis following a cerebral infarction affecting right dominant side, aphasia following cerebral infarction, and muscle weakness. The current admitting MDS (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 and record review, the facility failed to ensure the necessary care and services were provided for 2 of 2 residents reviewed for dialysis services. Post assessments were not done and medications were not given as ordered. (Resident B, Resident C) Findings include: 1. On 8/28/23 at 8:59 a.m., Resident B indicated he received dialysis services three times a week. On 8/28/23 at 9:35 a.m., Resident B's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus without complications, chronic kidney disease unspecified, end stage renal failure, dependence on renal dialysis. An admission MDS (Minimum Data Set) assessment, dated 7/21/23, indicated Resident B's cognition was intact, they were receiving dialysis services. Care plans were reviewed and included, but were not limited to: I have end stage kidney disease requiring dialysis, date initiated 7/20/23. August 2023 physicians orders were reviewed and included, but were not limited to: Dialysis at (name of facility) Tue, Thurs, Sat at 11 am, order date 7/18/23. Pre and post nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to revise comprehensive care plans for 1 of 3 residents reviewed for nutrition, 1 of 31 residents reviewed for advanced directives, and 2 of 6 residents reviewed for care planning. Care plans were not updated to reflect correct code status, when an antibiotic was completed, when a resident resolved a urinary tract infection, and was not updated to reflect a significant weight loss. (Resident 88, Resident 353, Resident 4, Resident 63) Finding includes: 1. On [DATE] at 1:02 p.m., Resident 88 indicated she has had a weight loss and was trying to increase her eating. On [DATE] at 9:03 a.m., Resident 88's record was reviewed. Resident 88's diagnosis included, but were not limited to, COVID-19, muscle weakness. A quarterly MDS (Minimum Data Set), assessment, dated [DATE], indicated Resident 88's cognition was intact. The MDS was marked for weight loss, not on prescribed wt loss regimen, loss of 5% or more in the last month or loss of 10% or more in last 6…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to properly prevent and/or contain COVID-19 for 3 of 33 residents reviewed for infection control, and 1 of 6 residents observed for care. (Resident 23, Resident 39, Resident 31, Resident 4) Findings include: On 11/21/22 at 10:00 A.M., The Centers for Disease Control and Prevention (CDC) COVID Data Tracker for [NAME] County was accessed. The county transmission level was moderate. 1. On 11/21/22 at 10:32 a.m., CNA 1 was observed to don a gown and face shield and enter room [ROOM NUMBER] where Resident 23, and Resident 39, were in transmission based precautions due to COVID-19. CNA 1 had on a surgical mask. A sign that indicated droplet precautions was observed on the door. On 11/21/22 at 10:40 a.m., CNA 1 indicated they were supposed to put on a blue gown, face shield, go in the room and put on gloves. CNA 1 pointed to the N95 masks that were on the door and indicated they were supposed to put on a COVID mask. 2. On 11/14/22 at 8:45 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to notify a resident's family related to the need to alter treatment in 1 of 4 residents reviewed for falls. A resident's family was not notified of a delay for a STAT (immediate) X-Ray order following a fall that resulted in a hip fracture.(Resident G) Findings include: On 11/21/22 at 1:42 P.M., Resident G's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, history of falling, and presence of left artificial hip joint. An MDS (minimum data set) Assessment was not available due to the resident being admitted to the facility on [DATE] and discharging 7/10/22. A physician narrative progress note, dated 7/7/22, indicated Resident G was pleasantly confused and the provider was unable to assess the resident's cognition. Nursing notes were reviewed and indicated the following: On 7/8/22, the resident was found at 11:20 A.M. on the floor of her bedroom by her wheelchair. Resident G showed no signs of pain and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide transfer/discharge notice to the resident upon transfer to the ER (emergency room) for 2 of 6 residents reviewed for hospitalizations. Residents were not provided with transfer/discharge notice. (Residents 20, Resident 91) Findings include: 1. On 11/16/22 at 1:44 P.M., Resident 20's clinical record was reviewed. Diagnosis included, but were not limited to, cellulitis of right lower limb, cellulitis of left lower limb, and chronic venous hypertension with ulcer of lower extremity. The most recent admission MDS (minimum data set) Assessment, dated 10/26/22, indicated Resident 20 was cognitively intact. A hospital discharge note indicated Resident 20 had been hospitalization from 11/7/22 to 11/9/22 for right lower extremity cellulitis, mild hypokalemia, mild hypomagnesemia, hypertension, hyperlipidemia, and diabetes mellitus. Resident 20's clinical record lacked information that the notice of transfer or discharge form was provided to the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide Bed Hold notice to resident upon transfer to the ER (emergency room) for 2 of 6 residents reviewed for hospitalizations. Residents were not provided with Bed Hold notice. (Residents 20, Resident 91 ) Findings include: 1. On 11/16/22 at 1:44 P.M., Resident 20's clinical record was reviewed. Diagnosis included, but were not limited to, cellulitis of right lower limb, cellulitis of left lower limb, and chronic venous hypertension with ulcer of lower extremity. The most recent admission MDS (minimum data set) Assessment, dated 10/26/22, indicated Resident 20 was cognitively intact. A hospital discharge note indicated Resident 20 had been hospitalization from 11/7/22 to 11/9/22 for right lower extremity cellulitis, mild hypokalemia, mild hypomagnesemia, hypertension, hyperlipidemia, and diabetes mellitus. Resident 20's clinical record lacked information that a bed hold policy was provided to the resident on 11/7/22. During an interview on 11/21/22…

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 observation, interview, and record review, the facility failed to ensure a resident received care consistent with professional standards of practice to prevent pressure ulcers in 1 of 2 residents reviewed for pressure ulcers. A resident dependent on staff developed a stage II pressure ulcer on the left buttock. (Resident 4) Findings include: On 11/14/22 at 9:52 A.M., Resident 4 was observed laying in her bed unable to reach her Breathcall (call light that the resident blows into to alert staff) call light. At that time, the resident indicated that if she can't reach her call light she has to wait on the staff to come back into her room. On 11/15/22 at 9:23 A.M., Resident 4 was observed laying in her bed unable to reach her call light. The call light was observed to have a mouthpiece and was bent up towards the head of the bed. The mouthpiece was pointed down at mattress level. On 11/16/22 at 9:07 A.M., Resident 4 was observed laying in her bed with her call light out of reach. The mouthpiece of the call light was pointed towards the chair on the right side of the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper supervision was provided to prevent accident hazards for 1 of 5 residents reviewed for accidents. A resident was observed to carry a box cutter that staff was unaware he had in his possession. A medication cart was observed to be unlocked. (Resident 57, Hall 400) Findings include: 1. On 11/14/22 at 9:40 A.M., Resident 57 was observed in his room, sitting in his wheelchair, putting butter on some bread. At that time, the resident pulled a box cutter out of his front shirt pocket that he indicated he kept on his person to open snacks and boxes that he had in his room. On 11/17/22 at 11:14 A.M., Resident 57's clinical record was reviewed. Diagnoses included, but were not limited to, macular degeneration of right eye, monoplegia of upper limb affecting left nondominant side, anxiety disorder, history of traumatic brain injury, depressive disorder, and unspecified mood (affective) disorder. The most recent quarterly MDS (minimum…

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 safety of residents during the administration of oxygen therapy by not changing oxygen tubing weekly for 2 of 2 residents. (Resident 28, Resident 77) Findings include: 1. On [DATE] at 8:47 A.M., Resident 77 was observed to be lying in bed with oxygen on. The oxygen tubing and humidification bottle were not dated. On [DATE] at 8:30 A.M., Resident 77 was observed wearing oxygen with the tubing and water humidification bottle not dated. On [DATE] at 7:33 A.M., Resident 77 was observed wearing oxygen with the tubing and water humidification bottle not dated. On [DATE] at 8:40 A.M., Resident 77's clinical record was reviewed. Diagnosis included but not limited to, nondisplaced interotrancheric fracture of the left femur, history of falls, and essential hypertension. The most recent MDS (minimum data set) assessment dated [DATE] included a cognition status considered moderately impaired. Physician's orders included, but were not…

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

Based on interview, and record review, the facility failed to ensure the necessary care and services were provided for 1 of 1 residents reviewed for dialysis. A resident's weights were not taken as ordered. (Resident 15). Finding includes: On 11/16/22 at 1:03 p.m., Resident 15's clinical record was reviewed. Resident 15 had diagnoses that included, not limited to, unspecified diabetes mellitus, end stage renal disease, dependence on dialysis. An annual MDS (Minimum Data Set) assessment, dated 8/12/22, indicated Resident 15's cognition was intact. Care plans were reviewed and included, not limited to: I have end stage kidney disease requiring dialysis and experience Hypotension, itching and nausea at times. Interventions included, not limited to, I will participate in my dialysis as scheduled three times weekly. Mon. Wed. Fri ., My weights and vital signs will be obtained as ordered and monitored. Date Initiated: 10/30/2017. November physicians order were reviewed and included, but not limited to, daily weight on M/W/F, order date 6/24/22. The November EMAR (Electronic Medication…

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

Based on interview and record review, the facility failed to provide contraindications for gradual dose reduction trials for residents on psychotropic medications for 2 of 5 residents reviewed for unnecessary medications. (Resident 54, Resident 67) Findings include: 1. On 11/16/22 at 1:00 P.M., Resident 54's clinical record was reviewed. Diagnosis included, but were not limited to, unspecified dementia, psychotic disturbance, mood disturbance, anxiety, major depressive disorder, and anxiety disorder. The most recent quarterly MDS (minimum data set) Assessment, dated 8/20/22, indicated Resident 54 was cognitively impaired. A Pharmacist note, dated 7/27/22, recommended a gradual dose reduction of risperidone 0.25 mg bid (twice a day), ordered 3/28/22. The physician failed to provide a contraindication why a gradual dose reduction should not be attempted. 2. Resident 67's clinical record was reviewed on 11/16/22 at 12:20 P.M. The most recent annual Minimum Data Set (MDS) Assessment, dated 8/31/22, indicated the resident was mildly cognitively impaired. Diagnoses included, but were not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to obtain radiology services as ordered by the physician for 1 of 1 resident needing STAT(immediate) X-Ray procedures. A resident with a recent left hip replacement due to left hip fracture from a fall, fell and did not receive STAT radiologic images timely. (Resident G) Findings include: On 11/21/22 at 1:42 P.M., Resident G's clinical record was reviewed. Diagnoses included, but were not limited to, dementia, history of falling, and presence of left artificial hip joint. An MDS (minimum data set) Assessment was not available due to the resident being admitted to the facility on [DATE] and discharging 7/10/22. A physician narrative progress note, dated 7/7/22, indicated Resident G was pleasantly confused and the provider was unable to assess the resident's cognition. Nursing notes were reviewed and indicated the following: On 7/8/22, the resident was found at 11:20 A.M. on the floor of her bedroom by her wheelchair. Resident G showed no signs…

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.