Brickyard Healthcare - Richmond Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a proper code status order and care plans were in place for 2 of 4 residents reviewed for code status and care plans. (Resident EE & Resident GG) Findings include: 1. The clinical record for Resident EE was reviewed on 11/8/24 at 1:55 p.m. The diagnoses included, but were not limited to, essential tremor, peripheral vascular disease, and chronic respiratory failure. Resident EE had a Physician Orders for Scope and Treatment (POST) form dated 4/29/24. The form indicated Resident EE was a Do Not Resuscitate (DNR). Resident EE had a physician order for DNR status placed on 7/30/24. An Advance Directive care plan, initiated 12/7/23, indicated Resident EE was a full code. During an interview with the Director of Nursing Services (DNS) on 11/8/24 at 1:50 p.m., she indicated Resident EE had a full code care plan because it had not been updated properly. 2. The clinical record for Resident GG was reviewed on 11/8/24 at 12:30 p.m. The diagnoses included,…

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 privacy for residents' medical condition by taking pictures and videos on personal cell phones for 2 of 4 residents reviewed for privacy (Resident KK and Resident W). Findings include: During an interview with Licensed Practical Nurse (LPN) 5 on 11/8/24 at 10:40 a.m., she indicated she had called the on-call Nurse Practitioner (NP) about Resident KK's wound on her leg, and they responded with continuation to monitor the area. LPN 5 indicated she was a new nurse and did not feel comfortable with that. LPN 5 took a picture of the wound on her cell phone and sent it to the Director of Nursing Services (DNS) to get her opinion. LPN 5 indicated she did not send the picture to anyone else and deleted the picture off her phone. During an interview with LPN 4 on 11/8/24 at 2:41 p.m., she indicated she did take a video of Resident W and sent it to the DNS. LPN 4 indicated she was working third shift, and Resident W had a total change in condition. The resident was making a snoring sound, breathing weird, hitting himself,…

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 utilize smoking aprons during smoking for safety of the residents as assessed for 3 of 3 residents reviewed for smoking safety (Resident J, Resident Z and Resident BB). Findings include: 1. During an observation on 11/7/24 at 11:43 a.m., Resident J was outside smoking with other residents and a staff member. Resident J did not have on a smoking apron. During an interview with Resident J on 11/7/24 at 12:00 p.m., he indicated he did not wear a smoking apron when smoking. Resident J indicated the smoking apron was only for residents who drop things and were not safe during smoking. Review of the record of Resident J, on 11/8/24 at 2:18 p.m., indicated the diagnoses included, but were not limited to, chronic respiratory failure, difficulty walking, chronic obstructive pulmonary disease, diabetes, heart failure and dependence on nicotine. The plan of care for Resident J, dated 7/9/24, indicated the resident was at risk for smoking related injury. The interventions included, but were not limited to, provide 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 interview and record review, the facility failed to obtain physician orders to crush medications for 3 of 5 residents reviewed for medication administration. Findings include: 1. The clinical record for Resident L was reviewed on 11/7/2024 at 1:30 p.m. The medical diagnoses included diabetes. During an interview with Resident L, on 11/6/2024 at 1:15 p.m., they indicated they take their medication crushed since they were admitted to the facility. The physician orders did not reflect an active order to crush medications as needed. 2. The clinical record for Resident O was reviewed on 11/7/2024 at 1:40 p.m. The medical diagnoses included diabetes. The physician orders did not reflect an active order to crush medications as needed. 3. The clinical record for Resident P was reviewed on 11/7/2024 at 1:45 p.m. The medical diagnoses included chronic obstructive pulmonary disease. The physician orders did not reflect an active order to crush medications as needed. During a confidential staff interview completed during the survey, the staff member indicated they crush medications…

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 follow-up with monitoring and have an indication for use on a one-time order for Ativan (antianxiety medication) for a resident who was experiencing an acute change in condition for 1 of 3 residents reviewed for change in condition (Resident W). Findings include: During an interview with Licensed Practical Nurse (LPN) 4 on 11/8/24 at 2:41 p.m., she indicated she did take a video of Resident W and sent it to the Director of Nursing Services (DNS). LPN 4 indicated she was working third shift, and Resident W had a total change in condition. The resident was making a snoring sound, breathing weird, hitting himself, banging on his chest, banging on the walls and tore up his bedroom, which was out of character for the resident. LPN 4 indicated she had tried to call the DNS and when she did not answer she video tapped Resident W and sent it to the DNS, on 10/18/24 around 2:30 a.m. LPN 4 indicated she wanted the DNS to understand what a serious situation that was. LPN 4 indicated she did not send the video to anyone else, and 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 interview and record review, the facility failed to ensure an order and care plan were in place for a resident receiving hospice services for 1 of 3 residents reviewed for hospice. (Resident DD) Findings include: The clinical record for Resident DD was reviewed on 11/6/24 at 1:26 p.m. The diagnoses included, but were not limited to, anxiety disorder, diabetes mellitus, and chronic pain syndrome. Resident DD's hospice binder indicated he was placed on hospice on 9/15/24. The clinical record indicated there was not an order for hospice nor a hospice care plan in the Electronic Health Record (EHR). During an interview with the Director of Nursing Services (DNS) on 11/7/24 at 10:29 a.m., they indicated Resident DD's physician put a one-time order in for a hospice services consult for one day only, then the order fell off the EHR after that day, and an order was not put in after that. An interview with the DNS on 11/8/24 at 10:00 a.m., they indicated the facility recently switched over their care plan library for auditing purposes, on 10/28/24, and all of the old care plans were…

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, observations, and record review, the facility failed to ensure Resident 44 had a self-administration of medications assessment completed for 1 of 1 resident reviewed for self-administration of medications. Findings include: The clinical record for Resident 44 was reviewed on 9/11/2024 at 11:20 a.m. The medical diagnoses included chronic respiratory failure and chronic obstructive pulmonary disease. A Quarterly Minimum Data Set (MDS) assessment, dated 8/29/2024, indicated Resident 44 was cognitively intact and did not have behaviors. A self-administration care plan, initiated on 9/10/2024, indicated an intervention of completing a self-administration assessment per the facility's protocol. During an interview and observation, on 9/5/2024 at 11:21 a.m., indicated Resident 44 had two medication nasal sprays. Resident 44 indicated they kept the two medicated nasal sprays on the over-bed table, staff knew about the medicated nasal sprays, and staff told them to just keep the medicated nasal sprays in one spot. During an interview on 9/5/2024 at 11:30 a.m., QMA 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.

Based on observation, interview, and record review, the facility failed to provide fresh water daily for 1 of 1 resident reviewed for hydration. (Resident C) Findings include: During an observation and interview with Resident C on 9/9/24 at 11:30 a.m., the resident had two cups of thickened juice on the bedside table and no water. Resident C indicated she liked juice but would like to have fresh water every day also. During an observation on 9/10/24 at 1:59 p.m., Resident C had a cup of thickened coffee and a cup of thickened juice. The resident did not have any water. During an observation and interview with Resident C on 9/11/24 at 2:52 p.m., the resident had a cup of thickened coffee and juice. The resident did not have any water. Resident C indicated she had not had any water in the last five days. During an observation on 9/12/24 at 1:17 p.m., Resident C had a cup of thickened coffee and a cup of thickened juice. The resident did not have any water. Review of the clinical record of Resident C, on 9/11/24 at 2:15 p.m., indicated the diagnoses included, but were 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.

1. Based on observation, interview, and record review, the facility failed to follow physician orders for obtaining daily and monthly weights for 2 of 2 residents reviewed for weights. (Resident 6 and 44). 2. Based on observation, interview, and record review, the facility failed to have accurate skin assessments, follow physician orders for no brief while in bed, and have heels floated for 1 of 3 residents reviewed for skin. (Resident C) Findings include: 1. The clinical record for Resident 6, reviewed on 9/9/24 at 2:19 p.m., indicated diagnoses included, but were not limited to, schizophrenia, muscle weakness, cognitive communication deficit, diabetes mellitus, and abnormal weight loss. During an observation on 9/9/24 at 11:47 a.m., Resident 6 was lying back in bed. Her legs were uncovered, and they were red and swollen. A quarterly Minimum Data Set (MDS) assessment, dated 7/31/24, indicated Resident 6 was cognitively intact, had limited extremity impairment to both lower extremities, and required a wheelchair for mobility. A physician order, dated 2/23/24, indicated a monthly…

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 don personal protective equipment (PPE) prior to entering the room of a resident in contact isolation for 1 of 2 residents reviewed for transmission-based precautions (TBP). (Resident 36) Findings: The clinical record for Resident 36 was reviewed on 9/6/24 at 11:35 a.m. The diagnoses included, but were not limited to, hypertension, anxiety, and major depressive disorder. The physician's orders indicated contact precautions during care every shift for ringworm, starting 7/5/24. An observation was made on 9/6/24 at 11:40 a.m. There was a sign on Resident 36's door to her room indicating she was in contact precautions and to perform hand hygiene as well as don a gown and gloves prior to entering the room. Certified Nurse Aide (CNA) 11 entered the room at that time with no gown or gloves and shut the door. An interview was conducted with CNA 11, on 9/6/24 at 11:55 a.m., after she exited Resident 36's room. She indicated she cared for Resident 36 with no gown or gloves, because, to her knowledge, Resident 36 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 interview and record review, the facility failed to complete care plan meetings for residents and their representatives for 2 of 3 residents reviewed for care plan meetings (Resident F and Resident D). Findings include: 1. Review of the record for Resident F, on 8/1/24 at 1:23 p.m., indicated the diagnoses included, but were not limited to, cerebral palsy, autistic disorder, seizures, anxiety, depression, adult failure to thrive, and intellectual disabilities. Resident F was admitted on [DATE]. The resident and the resident's representative had two care plan meetings on 1/2/24 and 6/13/24. 2. The clinical record for Resident D was reviewed on 8/2/24 at 12:00 p.m. The diagnoses included, but were not limited to, unspecified intellectual disabilities, essential hypertension, and depression. The clinical record indicated Resident D had a care plan meeting on 12/12/23. No other care plan meetings were documented after that date. A care plan meeting document provided by the Director of Nursing Services…

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 notify a resident's infectious disease physician of lab results, as ordered, and obtain a lab, as ordered by the pharmacy, prior to continuing administration of an antibiotic for 1 of 3 residents reviewed for skin conditions. (Resident E) Findings include: The clinical record for Resident E was reviewed on 8/1/24 at 12:35 p.m. The diagnoses included, but were not limited to, osteomyelitis, type 1 diabetes mellitus, peripheral vascular disease, and peripheral neuropathy. He was admitted to the facility on [DATE] after a hospitalization involving osteomyelitis of the right foot. He was discharged from the facility on 7/19/24. The 5/20/24, ED (emergency department) note from the 5/20/24 through 6/1/24 hospital notes indicated, presenting to ED with pain and bleeding from right foot wounds. Also associated with right calf pain similar to pain when he had his peripheral vascular stent placed one year ago He c/o [complains of] foot wound for past couple 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 interview and record review, the facility failed to ensure a care plan was developed and implemented for seizure-like activities for 1 of 3 residents reviewed for falls. (Resident C) Findings include: The clinical record for Resident C was reviewed on 5-3-24 at 2:35 p.m. His diagnoses included, but were not limited to, unspecified tremor and unspecified convulsions. A nursing note, dated 4-12-24, indicated he had a history of seizure activity. At least three seizure-like activities were documented for Resident C on 4-18-24, and least two more seizure-like activities were documented on 4-20-24. At least one seizure-like activity was associated with a fall. A review of Resident C's clinical record failed to demonstrate any care plan development for care and/or services related to seizure-like activities. This was brought to the attention of the Director of Nursing (DON) on 5-3-24. The DON was informed of the lack of care plans for Resident C related to this resident's seizures or seizure-like activity on 5-3-24 at 4:30 p.m. In an interview with the DON on 5-6-24 at 9:05 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.

Based on observation, interview and record review, the facility failed to ensure adequate staffing was available to provide showers, to toilet and/or change residents, transfer residents who utilized a mechanical lift, and conduct dining services in the main dining room. This had the potential to affect 38 of 55 residents that reside in the facility on the Extended Care Unit (ECU). Findings include: 1. Anonymous interview 1 conducted during the survey from 10/19/23 through 10/23/23, indicated on 10/6/23 there were only 2 Certified Nursing Assistants (CNAs) in the entire facility from 6:00 a.m. until 8:30 a.m. They indicated you cannot expect these aides to take care of 60 people by themselves. Anonymous interview 2 conducted during the survey from 10/19/23 through 10/23/23, indicated there was typically only 1 CNA working on the Transitional Care Unit (TCU) on day and evening shift. It would be helpful to have 2 CNAs. There are times we have found residents inside the nurses' station and there could have been things she [Resident K] got into due to the lack of supervision one 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.

Based on interview and record review, the facility failed to ensure a staff member did not work while experiencing signs and symptoms of a gastrointestinal illness before and during their shift. This had the potential to affect 38 out of 55 residents that reside in the facility. Findings include: An interview conducted with Certified Nursing Assistant (CNA) 10, on 10/19/23 at 4:00 p.m., indicated she had vomited prior to coming to work on 10/14/23. She had thrown up but since she felt better after throwing up, she felt it was okay to come into work. She worked until 11:00 a.m., on 10/14/23, and proceeded to throw up, again. She also had a fever along with the vomiting. An interview conducted with CNA 11, ono 10/19/23 at 4:07 p.m., indicated she was working with CNA 10 on 10/14/23. CNA 10 was vomiting and had a fever while working and ended up leaving around 10:30 a.m. on 10/14/23. The timesheet for CNA 10, dated 10/14/23, indicated they worked day shift (6:00 a.m. to 2:00 p.m.) until 11:03 a.m. on 10/14/23 when they clocked out of work. An interview conducted with the Executive…

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 record review the facility failed report allegations of abuse to the Indiana Department of Health and the Administrator, failed to protect residents after an allegation of abuse for 3 of 13 residents reviewed for abuse (Resident K, Resident Q and Resident R). Findings include: 1.) During an interview with the Administrator on 10/19/23 at 12:40 p.m., indicated on 10/14/23, LPN 19 called and reported that Resident K had a fall. LPN 19 did not report that Resident K reported an allegation of abuse, that CNA 2 had pushed her out of the wheelchair. The Administrator indicated she did not know about the allegation of abuse until 10/16/23 when she came into work and there was a concern form under her door about the allegation. During an interview with CNA 2 on 10/19/23 at 3:15 p.m., indicated on 10/14/23 during the evening time, Resident K was behind the nursing station picking up papers and taking food out of the refrigerator. CNA 2 indicated she asked the resident if she wanted to go to her room and the resident said yes. The resident appeared anxious and…

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

Based on interview and record review the facility failed to treat and assess a resident experiencing emesis and failed to transport a resident with a change in condition to the hospital timely for 1 of 3 residents reviewed for quality of care (Resident C). Finding include: During an interview with LPN 23 on 10/19/23 at 2:00 p.m., indicated on 10/6/23, she was not assigned to care for Resident C, but she had went to check on him and got RN 22 to evaluate him also. RN 21 was his assigned nurse on 10/6/23 and told her she knew something was off with the resident during morning medication pass and was waiting to see what the physician on call wanted to do. During an interview with RN 22 on 10/19/23 at 2:30 p.m., indicated on 10/6/23 she was in morning meeting and someone came down and got her to check on Resident C. RN 2 indicated his oxygen saturation was in the 40's, his eyes were fixed and pinpoint. The resident was having problems breathing and oxygen was placed on the resident and his oxygen saturation came up into the 80's. RN 22 sent the resident to the hospital. During an…

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

Based on interview and record review, the facility failed to ensure oxygen therapy was provided according to physician orders and available for use for 1 of 3 residents reviewed for oxygen therapy. (Resident D) Findings include: The clinical record for Resident D was reviewed on 10/23/23 at 1:58 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), dependence on supplemental oxygen, congestive heart failure, and muscle weakness. A grievance form, dated 10/5/23, indicated the Payroll Coordinator was made aware of a concern from Resident D. The grievance form stated Resident was sent to dialysis w/o [without] oxygen on. Staff asked resident where oxygen was at, resident stated that she went to dialysis w/o [without] it & another staff member rolled her down to room & located concentrator & placed her on that & it was @ [at] 61% - staff member placed oxygen on resident .GRIEVANCE OFFICIAL FOLLOW-UP .DNS [Director of Nursing Services] reminded staff to check A respiratory care plan, revised 10/10/23, indicated Resident D had altered…

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 maintain a sanitary environment for a resident when a supper tray was stored in the resident's dresser and acquired maggots for 1 of 5 residents reviewed for sanitary conditions (Resident E). Finding include: During an interview with Restorative Aide 5 on 10/20/23 at 11:32 a.m., indicated she found a whole meal tray of maggots in Resident E's dresser drawer, the entire plate was covered in maggots. The tray card was dated for 9/22/23 and she found it on 9/26/23. Restorative Aide 5 reported this to everyone in morning meeting including the Administrator and Director Of Nursing (DON). During an interview with the DON on 10/23/23 at 12:02 p.m., indicated there were maggots found on a meal tray in Resident E's dresser. The facility did an investigation and the staff member who had delivered the tray had already been terminated for other reasons. There was no documentation of the incident. Review of the record of Resident E on 10/23/23 at 12:09 p.m., indicated the resident's diagnoses included, but were not limited to, cerebral…

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 dependent resident received assistance and supervision with toileting to where they were later found on the floor of the bathroom, for an unknown period, for 1 of 3 residents reviewed for activities of daily living (ADLs). (Resident D) Findings include: The clinical record for Resident D was reviewed on 10/3/23 at 12:30 p.m. The diagnoses included, but were not limited to, end stage renal disease, malnutrition, dependence on renal dialysis, cognitive communication deficit, peripheral vascular disease, and fluid overload. Resident D was admitted to the facility on [DATE]. An admission minimum data set (MDS) assessment, dated 7/28/23, indicated Resident D was cognitively intact and limited assistance with one staff for toilet use, personal hygiene, dressing, and transfers. An ADL care plan, initiated on 8/2/23, indicated Resident D had an ADL self-care deficit related to impaired mobility. The interventions included, but 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 skin impairments were assessed on a weekly basis, ensure appropriate treatments were initiated timely for a skin impairment, and ensure continued treatment for a skin impairment for 3 of 4 residents reviewed for skin integrity. (Residents B, D and E) Findings include: 1. The clinical record of Resident B was reviewed on 10-3-23 at 10:42 a.m. Her diagnoses included but were not limited to, type 2 diabetes with a history of skin ulcers, morbid obesity, a history of skin infections, high blood pressure, general weakness and a history of bilateral lower extremity cellulitits. Her most recent Minimum Data Set (MDS) assessment, dated 9-1-23, indicated she is cognitively intact, is non-ambulatory, requires extensive assistance of or more persons for bed mobility and personal hygiene care, is dependent of 2 or more persons for transfers, toileting and bathing. This MDS assessment identified Resident B as being at risk for pressure ulcer development, 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 interview and record review, the facility failed to ensure complete documentation of the electronic medication administration records (MAR) and treatment administration records (TAR or ETAR) for 2 of 4 residents reviewed for skin impairment. (Residents B and D) Findings include: 1. The clinical record of Resident B was reviewed on 10-3-23 at 10:42 a.m. Her diagnoses included but were not limited to, type 2 diabetes with a history of skin ulcers, morbid obesity, a history of skin infections, high blood pressure, general weakness and a history of bilateral lower extremity cellulitits. Her most recent Minimum Data Set (MDS) assessment, dated 9-1-23, indicated she is cognitively intact, is non-ambulatory, requires extensive assistance of or more persons for bed mobility and personal hygiene care, is dependent of 2 or more persons for transfers, toileting and bathing. This MDS assessment identified Resident B as being at risk for pressure ulcer development, but currently was without any pressure ulcers or…

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

Based on interview, observation, and record review, the facility failed to ensure Resident D, F, and G had their facial hair shaved per their preference and failed to provide nail care for dependent residents (Resident J and H) for 5 of 9 residents reviewed for activities of daily living (ADL) care. Findings include: 1. The clinical record for Resident D was reviewed on 5/17/2023 at 1:34 p.m. The medical diagnoses included a history of a stroke affecting the left non-dominant side and weakness. A quarterly minimum data set assessment, dated 3/8/2023, indicated that Resident D was cognitively intact and needed extensive assistance from staff with personal hygiene activities of daily living. An observation and interview on 5/16/2023 at 10:43 a.m. with Resident D indicated she was sitting in her wheelchair in the common area with white facial hair on her chin. She indicated she did not like to have facial hair and the staff would shave her, but only on shower days if she asked. An observation of Resident D on 5/17/2023 at 1:30 p.m. indicated she was still in her wheelchair at this time…

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 recommendations were initiated timely for residents with identified weight loss, failed to obtain weights as ordered, and failed to implement weekly weights for a resident identified with significant weight loss for 5 of 8 residents reviewed for nutrition. (Resident 18, 45, F, 22, and 8) Findings include: 1. The clinical record for Resident 18 was reviewed on 5/18/23 at 1:10 p.m. The diagnoses included, but were not limited to, muscle weakness, diabetes mellitus, malnutrition, vascular dementia, and visual hallucinations. A quarterly minimum data set (MDS) assessment, dated 4/13/23, indicated Resident 18 had weight loss and not on a weight loss regimen. A care plan for nutrition, revised 4/18/23, indicated Resident 18 was at risk for malnutrition and swallowing difficulty with a history of weight changes. The interventions included, but were not limited to, house shake daily added on 4/18/23, and weekly weights added on 10/7/22. Another nutrition care plan, revised 4/18/23, indicated Resident 18 had an elevated body…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a system was in place to review pharmacy reviews and potential recommendations for 4 of 5 residents reviewed for unnecessary medications. (Resident 18, Resident E, Resident 25, and Resident 50) Findings include: 1. The clinical record for Resident 18 was reviewed on 5/18/23 at 1:10 p.m. The diagnoses included, but were not limited to, muscle weakness, diabetes mellitus, malnutrition, vascular dementia, and visual hallucinations. A quarterly minimum data set (MDS) assessment, dated 4/13/23, indicated the use of a antipsychotic and antidepressant for the previous 7 day look behind period of the MDS assessment. A physician order, dated 12/14/22, noted the use of Seroquel (antipsychotic medication) 50 milligrams in the morning and 100 milligrams at bedtime for visual hallucinations. A pharmacy review, dated 9/29/22, indicated the clarification for the appropriate use for the medication Seroquel. There was no documentation to show that the…

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

Based on interview and record review, the facility failed to ensure an infection control program that consisted of mapping and tracking infections for 11 of 12 months reviewed. Findings include: The infection control binder was provided by the Area [NAME] President on 5/22/23 at 2:50 p.m. She indicated the facility found the binder in the Clinical Education Coordinator's office. The binder included the following: June of 2022- blank, July of 2022- blank, August of 2022- blank, September of 2022- blank, October of 2022 - blank, November of 2022- blank, December of 2022- blank, January of 2023- blank, February of 2023- Facility mapping with a list of cultures obtained in November and December of 2022, March of 2023- facility mapping with a list of cultures obtained but none referring to lung as marked on the facility map, & April of 2023- facility mapping with a list of cultures obtained. The binder did not reflect the number of infections, where they were acquired, and/or the rate of infection. A document titled Infection Surveillance Monthly Report, dated May of 2023, was provided…

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

Based on observation, interview and record review the facility failed to provide a speciality cup as ordered by the physician, failed to provide a straw to drink with, failed to keep fluids within reach, and failed to provide a whirlpool bath as preferred for 1 of 2 residents reviewed for hydration and 1 of 5 residents reviewed for shower preferences. (Resident 3 and Resident E). Finding include: 1. During an interview with Resident 3's family member on 5/15/23 at 11:57 a.m., indicated when the family visits the resident does not always have fresh water and the resident would not have a straw to drink out of (no speciality cup observed). The family member indicated the resident could not drink without a straw. Resident 49 was observed to have a styrofoam cup with water and a lid, with no straw to drink from. During an observation on 5/16/23 at 3:25 p.m., Resident 3 was laying in bed with a styrofoam cup with a lid on it and no straw (no speciality cup observed). During an observation on 5/18/23 at 10:24 a.m., Resident 3 was laying in bed, the resident's water was out of her reach on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a physical and verbal abuse event was reported to the Administrator and state agency timely for 1 of 4 residents reviewed for abuse. (Resident B) Findings include: The clinical record for Resident B [NAME] reviewed on 5/16/23 at 9:50 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, arthritis, cerebral infarction, muscle weakness, and symptoms and signs involving cognitive functions and awareness. Resident B was admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) assessment, dated 2/23/23, noted Resident B with moderate cognitive impairment, physical behavioral symptoms directed towards others occurred 1-3 days, verbal behavioral symptoms directed towards others occurred 1-3 days, other behavioral symptoms not directed towards others occurred 1-3 days, yes to it interfering with resident's care, yes to significantly intruding on the privacy or activity of others, yes to significant disruption of 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.

Based on interview and record review, the facility failed to ensure the appropriate transfer and discharge paperwork provided to a resident upon transfer to an area hospital was included in the resident's clinical record for 2 of 5 residents reviewed for hospitalization. (Resident H and 50) Findings include: 1. Resident H's record was reviewed on 5/16/23 at 3:51 p.m. and indicated Resident H had diagnoses that included, but were not limited to, a bone infection of the vertebra, sacral and sacrococcygeal region, chronic pain syndrome, neuromuscular dysfunction of bladder, type 2 diabetes mellitus, chronic congestive heart failure, weakness on one side, anxiety, depression, pressure ulcer of sacral region, constipation, and urinary tract infection. Progress notes indicated Resident H was sent to the local hospital on the following dates: - 5/17/2023 at 1:40 p.m.: Resident has been complaining of increased pain. New area on right side of lower butt cheek. Resident has had a bolus of morphine. Is still complaining of pain. Called wound center, wound center has advised that best interest…

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 written bed hold information when a resident was sent to the hospital. This affected 2 of 5 residents reviewed for hospitalization. (Residents H and 50) Findings include: 1. Resident H's record was reviewed on 5/16/23 at 3:51 p.m. and indicated Resident H had diagnoses that included, but were not limited to, a bone infection of the vertebra, sacral and sacrococcygeal region, chronic pain syndrome, neuromuscular dysfunction of bladder, type 2 diabetes mellitus, chronic congestive heart failure, weakness on one side, anxiety, depression, pressure ulcer of sacral region, constipation, and urinary tract infection. Progress notes indicated Resident H was sent to the local hospital on the following dates: - 5/17/2023 at 1:40 p.m.: Resident has been complaining of increased pain. New area on right side of lower butt cheek. Resident has had a bolus of morphine. Is still complaining of pain. Called wound center, wound center has advised that best interest of patient is to send to ER to evaluate.' - 4/14/23 at 8:30 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 interview and record review, the facility failed to ensure accuracy of Minimum Data Set (MDS) assessment regarding to mood and behavior for 1 of 2 residents reviewed for dementia care (Resident B), the use of corrective lenses for 1 of 2 residents reviewed for vision (Resident 26), and complete the pain assessment portion for 1 of 3 residents reviewed for pain (Resident H). Findings include: 1. The clinical record for Resident B was reviewed on 5/16/23 at 9:50 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, arthritis, cerebral infarction, muscle weakness, and symptoms and signs involving cognitive functions and awareness. Resident B was admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) assessment, dated 2/23/23, noted Resident B with moderate cognitive impairment, physical behavioral symptoms directed towards others occurred 1-3 days, verbal behavioral symptoms directed towards others occurred 1-3 days, other behavioral symptoms not directed towards…

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 develop a care plan for Resident E's use of medication to treat her hypothyroidism and failed to develop a care plan for constipation for a resident with a diagnosis of constipation for 2 of 5 residents reviewed for unnecessary medications. (Resident E and Resident H) Findings include: 1. During an interview, on 5/15/23 at 2:55 p.m., Resident H indicated he has always had problems with constipation and said he has gone 10 days sometimes without a bowel movement. Resident H's record was reviewed on 5/16/23 at 3:51 p.m. and indicated Resident H had diagnoses that included, but were not limited to, a bone infection of the vertebra, sacral and sacrococcygeal region, chronic pain syndrome, neuromuscular dysfunction of bladder, type 2 diabetes mellitus, chronic congestive heart failure, weakness on one side, anxiety, depression, pressure ulcer of sacral region, constipation, and urinary tract infection. A Significant Change Minimum Data Set assessment, dated 4/27/23, indicated Resident H was cognitively intact, did not walk, is…

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 discharge summary was completed in full for 1 of 3 closed records reviewed. (Resident 54) Findings include: The clinical record for Resident 54 was reviewed on 5/22/23 at 11:22 a.m. The diagnoses included, but were not limited to, neoplasm of prostate, muscle weakness, hypertension, anxiety disorder, and secondary malignant neoplasm of bone. A Discharge summary, dated [DATE], was not completed in regard to summary of stay, functional mobility, continence, nutrition, activities, skin condition(s), medication information, treatments, community resource guide for any follow-up in regards to Resident 54's care. An interview conducted with Area [NAME] President, on 5/22/23 at 1:46 p.m., indicated Resident 54's discharge was prior to them arriving at the facility. She was not sure why the discharge summary wasn't completed in full. 3.1-36(a)(1) 3.1-36(a)(2) 3.1-36(b)

Based on interview, observation, and record review, the facility failed to ensure Resident D's corrective lenses were in place for 1 of 2 residents reviewed for corrective lenses. Findings included: The clinical record for Resident D was reviewed on 5/17/2023 at 1:34 p.m. The medical diagnoses included a history of a stroke affecting the left non-dominant side and weakness. A quarterly minimum data set assessment, dated 3/8/2023, indicated that Resident D was cognitively intact and needed extensive assistance from staff for dressing and transferring activities of daily living. A vision care plan, dated 6/23/2021, indicated for Resident D to receive assistance with placement and cleaning of her glasses as needed. An observation and interview on 5/16/2023 at 10:43 a.m. with Resident D indicated she was sitting in her wheelchair in the common area and did not have her eyeglasses in place. She indicated the staff had forgotten them in her room that morning and she was unable to propel herself back to get them. An observation of Resident D on 5/16/2023 at 12:03 p.m. indicated she 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.

Based on observation, interview and record review the facility failed to provide an ongoing activity program for 2 of 2 residents reviewed for activities (Resident 11 and Resident 3). Findings include: 1.) During an observation on 5/15/23 at 11:41 a.m., Resident 11 was laying in bed awake, with no TV or radio playing. During an observation on 5/16/23 at 3:28 p.m., Resident 11 was sitting in the common area, not engaging in any type of activity. During an observation on 5/17/23 at 3:41 p.m., Resident 11 was laying in bed awake, there was no TV or radio playing. During an observation on 5/18/23 at 10:22 a.m., Resident 11 was sitting in the common area, not engaging in any type of activity. Review of the record of Resident 11 on 5/18/23 at 3:35 p.m., indicated the resident's diagnoses included, but were not limited to, cerebral palsy, spastic hemiplegia, diabetes, aphasia, profound intellectual disabilities, hypertension and pain. The Annual Minimum Data Set assessment (MDS) for Resident 11, dated 2/19/23, indicated it was very important for the resident to listen to music, be around…

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 follow up and ensure a resident had proper preparation prior to a procedure resulting in the procedure not being able to be completed, failed to complete neurological assessments after a resident fell and hit his head, failed to apply a palm protector as ordered by the physician, apply a rolled towel as ordered by the physician, and failed to obtain weekly weights for congestive heart failure (CHF) for 1 of 7 residents reviewed for accidents, 1 of 4 residents reviewed for quality of care, 1 of 2 residents reviewed for positioning/mobility, and 1 of 8 residents reviewed for nutrition. (Resident 20, Resident 36, Resident J and Resident 35) Findings include: 1. During an interview with Resident 20 on 5/15/23 at 1:16 p.m., indicated she was suppose to have a scope last week and the facility did not follow the appropriate prep work prior to the scope. The resident indicated she went to the hospital to have the procedure done and they sent her back to the facility because she had received medication she was not suppose to of had…

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

Based on interview, observation, and record review, the facility failed to timely follow up on recommendation for the management of Resident F's stage three pressure area and failed to provide pressure relieving boots or float heels for Resident 20's unstageable pressure ulcer to the right heel for 2 of 6 residents reviewed for pressure ulcers. Findings included: 1. The clinical record for Resident F was reviewed on 5/17/2023 at 10:55 a.m. The medical diagnosis stroke and lack of coordination. A minimum data set assessment, dated 3/10/2023, indicated Resident F was cognitively intact, at risk for pressure areas, and had a stage three pressure area. A wound nurse practitioner note, dated 3/23/2023, included the recommendation for imaging, laboratory testing, and a wound culture for Resident F's stage three pressure area to his coccyx. This pressure area measures 1.34 x 0.87 cm (centimeters) x an unmeasurable depth. A wound nurse practitioner note, dated 3/30/2023, included the recommendation for imaging, laboratory testing, and a wound culture for Resident F's stage three pressure…

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

Based on interview, observation, and record review, the facility failed to ensure Resident 23's foot pedals were in place while she was in her wheelchair for 1 of 2 residents reviewed for assistive devices. Findings include: The medical record for Resident 23 was reviewed on 5/15/2023 at 1:20 p.m. The medical diagnoses included autistic disorder and cerebral palsy. An admission Minimum Data Set Assessment, dated 3/21/2023, indicated that Resident 23 was cognitively impaired, utilized a wheelchair, and needed assistance with transferring. An activities of daily living care plan, dated 3/21/2023, indicated that Resident 23 utilized footrests to her wheelchair. An observation on 5/15/2023 at 11:43 a.m. indicated Resident 23 was able to propel herself in her wheelchair with the use of her arms. Her feet hung down and did not contact the floor. She did not have footrests on her wheelchair at this time. An observation on 5/15/2023 at 12:22 p.m. indicated Resident 23 remained in her wheelchair and did not have her footrests in place. An observations on 5/15/2023 at 1:15 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.

Based on observation, interview and record review the facility failed to supervise a resident during meals as instructed by the Speech Therapist, failed to implement fall interventions, and failed to ensure adequate supervision and known whereabouts of a resident for 4 of 7 residents reviewed for accidents (Resident 3, Resident 49, Resident 36 and Resident 23). Findings include: 1. During an observation on 5/18/23 at 12:31 p.m., Resident 3 was laying in bed eating lunch. There was no staff present during this meal observation. Review of the record of Resident 3 on 5/18/23 at 2:00 p.m., indicated the resident's diagnoses included, but were not limited to, hypertensive heart disease, age related osteoporosis, dysphagia, hypertension, dementia, muscle weakness and age related debility. The Speech Therapy discharge summary for Resident 3, dated 10/18/22, indicated the discharge instructions were supervision/full feed during all meals, upright positioning in bed, small bites/sips, extended time between with slow rate. 2a. During an interview with Resident 49's family member on 5/15/23 at…

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

Based on observation, interview, and record review, the facility failed to monitor intake totals for a dependent resident who utilized a gastrostomy tube (a tube that is inserted into the stomach through the abdominal wall for nutrition) and failed to follow up when a resident's residual was less than 100 milliliters per MD orders. This affected 2 of 2 residents reviewed for gastrostomy tubes. (Residents 4 and 14) Findings include: 1. On 5/16/23 at 3:32 p.m., Resident 4 was observed in bed, his eyes were closed and his gastrostomy tube was infusing water at 65 milliliters/hour via a mechanical pump. Resident 4's record was reviewed on 5/17/23 at 2:04 p.m. The record indicated Resident 4 had diagnoses that included, but were not limited to, stroke with paralysis on one side, difficulty speaking, type 2 diabetes mellitus, seizures, and gastrostomy tube. A Quarterly Minimum Data Set assessment, dated 3/15/23, indicated Resident 4 was severely cognitively impaired, required extensive assistance of one for all activities of daily living, was totally dependant on staff for eating, and…

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

Based on interview and record review the facility failed to provide pain management for a resident who had a fall with a fracture and failed to follow up PRN (as needed) pain medicine for a resident who had ineffective pain relief for 2 of 3 resident's reviewed for pain (Resident 36 and Resident E). Finding include: 1. Review of the resident 36 on 5/18/23 at 4:20 p.m., indicated the resident's diagnoses included, but were not limited to, pulmonary fibrosis, protein calorie malnutrition, schizoaffective disorder, profound intellectual disabilities, dysphagia, osteoporosis and polyneuropathy. The progress note for Resident 36, dated 4/5/23 at 3:54 p.m., indicated the resident slipped and complained of right knee pain. A new order was obtained for an x-ray. The progress note for Resident 36, dated 4/5/23 at 6:06 p.m., Resident complained of right knee pain and an x-ray was ordered. The x-ray results indicated a fractured patella (knee). The Nurse Practitioner (NP) progress note for Resident 36, dated 4/6/23 at 12:00 a.m., indicated the resident was seen today for a fall occurring on…

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

Based on interview and record review, the facility failed to ensure complete documentation of pre and/or post dialysis evaluations for 1 of 1 resident reviewed for dialysis. (Resident 28) Findings include: Resident 28's record was reviewed, on 5/17/23 at 3:12 p.m., and indicated Resident 28 had diagnoses that included, but were not limited to, end stage kidney disease, type 2 diabetes mellitus, high blood pressure, and depression. An admission Minimum Data Set Assessment, dated 7/5/22, indicated Resident 28 was cognitively intact, and received hemodialysis. Physician's orders for dialysis care included, but were not limited to: 1. Post Dialysis Assessment. Assess site for s/s (signs and symptoms) of bleeding, infection, post dialysis complications. Notify MD of any abnormal changes. Every Mon, Wed, Fri, started 1/23/23 2. Pre dialysis assessment. Assess site for any s/s of bleeding and infection. Notify MD of any abnormal changes. One time a day every Mon, Wed, Fri for dialysis. Dated: 1/23/2023 3. Dialysis Treatment on (M/W/F) at [Name of Dialysis Center] one time a day every Mon,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure adequate approach of care and implement interventions for a resident with dementia with a history of agitation, anxiety, and combativeness, for 1 of 2 residents reviewed for dementia care. (Resident B) Findings include: The clinical record for Resident B was reviewed on 5/16/23 at 9:50 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, arthritis, cerebral infarction, muscle weakness, and symptoms and signs involving cognitive functions and awareness. Resident B was admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) assessment, dated 2/23/23, noted Resident B with moderate cognitive impairment, physical behavioral symptoms directed towards others occurred 1-3 days, verbal behavioral symptoms directed towards others occurred 1-3 days, other behavioral symptoms not directed towards others occurred 1-3 days, yes to it interfering with resident's care, yes to significantly intruding 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 interview and record review, the facility failed to ensure influenza and pneumococcal immunizations were offered and/or administered for 3 of 5 residents reviewed for immunizations. (Residents H, 29, and 49) Findings include: 1. The clinical record for Resident H was reviewed on 5/19/23 at 9:10 a.m. Resident H was admitted to the facility in December of 2022. No influenza vaccine was documented since admission. The immunizations documentation indicated Resident H received a previous pneumococcal vaccine in 2012. There were no further pneumococcal vaccinations documented since the previous vaccine was administered prior to Resident H turning [AGE] years of age. 2. The clinical record for Resident 29 was reviewed on 5/19/23 at 9:25 a.m. There was no influenza or pneumococcal vaccine documented in Resident 29's clinical record. 3 The clinical record for Resident 49 was reviewed on 5/19/23 at 9:11 a.m. Resident 49 was admitted to the facility on [DATE] with documentation of a pneumococcal vaccine given on…

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