Life Care Center Of Rochester

Based on record review and interview, the facility failed to provide a transfer and discharge form for 3 of 3 residents reviewed for hospitalization. (Residents 16, 2 and 44) Findings include: 1. A record review for Resident 16 was completed on 9/17/2024 at 1:36 P.M. Diagnoses included, but were not limited to: paraplegia, pressure ulcer sacral region, schizoaffective disorder, pressure ulcer left hip, neuromuscular dysfunction of bladder, unspecified psychosis and presence of urogenital implants. An Annual Minimum Data Set (MDS) assessment, dated 7/11/2024, indicated Resident 16 was cognitively intact, and he received antipsychotic medication. He had four stage 4 pressure ulcers and had an indwelling bladder catheter. A Nursing Progress Note, dated 3/27/2024 at 1:09 P.M., indicated Resident 16 had exhibited an increase in delusional behavior and a referral was made to the neuropsychiatric hospital. Resident 16 agreed he needed more assistance with psychiatric services due to his mind was racing. Resident 16 was accepted for admission, and his guardian was informed of the pending…

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

Based on record review and interview, the facility failed to provide a bed hold form for 3 of 3 residents reviewed for hospitalization. (Residents 16, 2, and 44) Findings include: 1. A record review for Resident 16 was completed on 9/17/2024 at 1:36 P.M. Diagnoses included, but were not limited to: paraplegia, pressure ulcer sacral region, schizoaffective disorder, pressure ulcer left hip, neuromuscular dysfunction of bladder, unspecified psychosis, and presence of urogenital implants. An Annual Minimum Data Set (MDS) assessment, dated 7/11/2024, indicated Resident 16 was cognitively intact, and he received antipsychotic medication. He had four stage 4 pressure ulcers and had an indwelling bladder catheter. A Nursing Progress Note, dated 3/27/2024 at 1:09 P.M., indicated Resident 16 had exhibited an increase in delusional behavior and a referral was made to the neuropsychiatric hospital. Resident 16 agreed he needed more assistance with psychiatric services due to his mind was racing. Resident 16 was accepted for admission, and his guardian was informed of the pending admission. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted timely for 2 of 2 resident assessments reviewed. (Resident 20 & 47) Findings include: 1. The record for Resident 47 was reviewed on 9/19/2024. Resident 47 was admitted on [DATE]. A Quarterly Minimum Data Set (MDS) assessment, dated 8/5/2024, was not locked and transmitted until 9/17/2024, which was over 120 days from the admission MDS assessment that was transmitted. 2. The record for Resident 20 was reviewed on 9/19/2024. Resident 20 was admitted on [DATE]. A Quarterly MDS assessment, dated 5/12/2024, was not transmitted and accepted until 9/17/2024. The accepted date was over 120 days from the last assessment that was transmitted. During an interview, on 9/19/2024 at 11:20 A.M., the MDS Coordinator indicated the next assessments due were listed on her schedule and that the MDS assessment in question had been transmitted. She indicated she completed the schedule for the MDS assessments and it…

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

Based on observation, record review and interview, the facility failed to develop comprehensive person-centered care plans for a resident with edema (Resident 29) and a resident with a history of itching (Resident 34) for 2 of 20 residents reviewed. Findings include: 1. During an observation, on 9/16/2024 at 10:59 A.M., Resident 29 had +1 pitting edema (swelling with a slight indentation in the skin that was barely visible after pressure was applied) to his bilateral lower legs. During an observation, on 9/18/2024 at 10:59 A.M., Resident 29 was noted to have +1 pitting edema to his bilateral lower legs. The record for Resident 29 was reviewed on 9/18/2024 at 10:17 A.M. Diagnoses included but were not limited to: chronic venous idiopathic hypertension, congenital malformation syndrome, muscle weakness, sleep apnea, chronic obstructive pulmonary disease, hypertension and generalized edema. The record lacked a person-centered care plan for the resident's edema. During an interview, on 9/19/2024 at 11:17 A.M., the MDS Coordinator indicated she updated and completed the care plans along…

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 timely notification of a change in condition and provide timely treatment for 2 of 3 residents reviewed for hospitalization and insulin usage. (Resident 2 and 16) Findings include: 1. During an interview with Resident 2, on 9/17/2024 at 10:34 A.M., she indicated she had been hospitalized four times for pneumonia recently. A record review for Resident 2 was completed on 9/18/2024 at 2:20 P.M. Diagnoses included, but were not limited to: diabetes mellitus type 2 with neuropathy, emphysema, atrial fibrillation, and paranoid personality disorder. A Significant Change Minimum Data Set (MDS) assessment, dated 7/31/2024, indicated Resident 2 was cognitively intact and had a diagnosis of respiratory failure and chronic lung disease. The assessment indicated her primary medical categories were debility and cardiorespiratory conditions. A Nursing Progress Note, dated 7/10/2024 at 8:48 A.M., indicated Resident 2's vital signs included a blood pressure of 96/43, an irregular heart rate of 94-97 beats per minute and oxygen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to store respiratory equipment in a sanitary manor for 3 of 3 residents reviewed for oxygen therapy. (Resident 36, 44 & 154) Findings include: 1. During an observation, on 9/16/2024 at 2:48 P.M., Resident 36's equalizer tubing was dated 8/2020/24 and unbagged. Resident 36's current Physician's Orders included: change and date nebulizer tubing weekly every day shift on Tuesdays. During an interview, on 9/18/2024 at 2:17 P.M., Resident 36 indicated the nebulizer tubing was never in a bag. 2. During an observation, on 9/16/2024 at 10:13 A.M., Resident 44's nebulizer mask was lying on a bedside table with the respiratory bag, dated 8/20/2024, and the tracheostomy suction tip was observed with the outer wrapper, undated, with the suction tip outside the wrapper. During an observation, on 9/16/2024 at 1:58 P.M., the suction tip was missing from the suctioning tubing, but the suctioning tubing was open to air. During an observation, on 9/17/1024 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 discontinued medications were removed from a medication room and failed to ensure a medication refrigerator was free from a large build up of ice for 1 of 2 medication rooms observed. (Skilled hall medication room) Finding includes: During an observation of the South/Skilled hall medication room, on 9/19/2024 at 9:23 A.M. with RN 2, the following was observed: a plastic bag with the following medications, along with a hand written list, dated 6/12/2024, of the following medications 30 Haldol 5 mg (milligram) tablets (antipsychotic); 70 Hydrocodone 10/325 mg tablets (narcotic); 45 Lorazepam 0.5 mg tablets; liquid Morphine Sulfate (narcotic); 2 Fentanyl 20 mcg (micrograms) and 3 25 mcg patches (narcotic). The freezer section of the medication refrigerator had a large build up of ice. During an interview, on 9/19/2024 at 9:25 A.M., RN 2 indicated the medications that had been discontinued ahsould have been desgtroyed and the medication refrigerator should not have had an ice build up. On 9/19/2024 at 10:00…

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 staff change gloves and complete hand hygiene when providing perineal care for 1 of 1 residents reviewed for incontinence needs. (Resident 7) Finding includes: During an observation on, 9/17/2024 at 9:06 A.M., CNA 3 was observed to provide incontinence care for Resident 7. She donned gloves and removed the dirty brief from the resident. CNA 3 put the dirty brief and the dirty wipes she had used on the floor mat next to the resident. With her dirty gloves still on, she went into the bathroom to obtain a trash bag. She placed the wet brief and the wipes into the trash bag. CNA 3 then went to the closet and got a pair of clean pants without changing her contaminated gloves. CNA 3 then put the residents pants on, and repositioned the resident on the floor mat. CNA 3 rubbed the residents back and then moved a pillow under her head. During an interview, on 9/17/2024 at 9:13 A.M., CNA 3 indicated she should have removed her gloves and washed her hands after cleaning the resident's perineal area. On 9/19/2024…

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

Based on observation, record review, and interviews, the facility failed to ensure the menu was followed for 54 of 54 residents who consumed food in the facility. Finding includes: During an observation of the noon meal service in the kitchen and dining and resident halls, conducted on 2/19/2024 between 11:30 A.M. - 12:55 P.M., the following was observed: Cook 4 utilized a 3 ounce scoop to serve all the residents Dijon potatoes, except for two residents receiving pureed food. Cook 4 served two residents a pureed diet. There were only pureed hamburger steak and gravy and pureed Dijon potatoes on the plate. In addition, the two residents received a container of chocolate ice cream and beverages. The residents did not receive a dinner roll or a vegetable. Cook 4 served eight residents a mechanical soft diet, but they did not receive any dinner roll. Review of the facility menu for the day, provided by the Food Service Supervisor on 2/19/2024 at 1:00 P.M., indicated staff should have utilized a #8 (4 ounce) scoop for the Dijon potatoes for all residents, a #16 (2 ounce scoop) for pureed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure a sanitary and comfortable environment was maintained in 1 of 4 halls observed for environment. (Central Hall) Findings include: During an initial tour, on 2/19/2024 from 9:20 A.M. to 9:34 A.M., the following items were observed on the Central Hall: - room [ROOM NUMBER] had brown and yellow stains in the bathroom with a strong urine smell. - Rooms 203-204's shared bathroom had stained flooring, and a strong urine smell. - room [ROOM NUMBER]-212's shared bathroom had stained flooring with a slimy black substance along the wooden cove wall base. The wooden cove wall base had black stains. A liquid substance was seen around the toilet to the cove wall base. The drywall above the cove wall base was wavy in appearance. - Rooms 216-217's shared bathroom had stained flooring, debris on floor and a strong urine odor. - Rooms 220-221's shared bathroom had stained flooring, and odor of urine. - Rooms 222-223's shared bathroom had stained…

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

Based on record review and interview, the facility failed to prevent a misappropriation of resident property for 1 of 1 resident's reviewed for misappropriation of property. (Resident B) Finding includes: A Reportable Incident, dated 10/5/2023, indicated .Description added- 10/5/2023 Allegation of fraudulent use of a debit card Immediate Action Taken- Staff member suspended, law enforcement notified. MD and family aware. Family canceled debit card. Preventative Measures Taken: Type of preventative measures added: 10/5/2023 Investigation initiated. Employee suspended pending investigation. Interviews being conducted with all residents for any concerns. Abuse inservice started A 5-day Follow up, dated 10/11/2023, indicated . Investigation was initiated by Executive Director into [Name of Resident] family's concern with unauthorized online activity on his back account with [Name of Bank]. Resident is his own responsible party with a BIMS (Brief Interview for Mental Status) score of 15- cognition intact. The Executive Director did speak with Deputy [Name of Deputy] during 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 record review and interview, the facility failed to notify a State agency of an attempted suicide for 1 of 4 reportable incidents reviewed. (Resident B) Finding includes: A clinical record review was completed on 11/15/2023 at 8:50 A.M. Resident B was admitted on [DATE] with diagnoses included, but were not limited to: hemiplegia, hemiparesis following cerebral infarct, epilepsy, anxiety, and psychosis not due to a substance or known physiological condition. An admission Note, dated 6/16/2023, from (Name of hospital) indicated Resident B was seen in ER (Emergency Room) and admitted because resident threatened to kill himself by wrapping a ligature around his neck. On arrival to emergency department, he denied any suicidality. A care plan, dated 6/23/2023, indicated the resident used antidepressant medication r/t (related to) depression and was at risk of adverse reactions. Interventions included but were not limited to: Observe for and report PRN adverse reactions to antidepressant therapy; suicidal…

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

Based on record review and interview, the facility failed to follow the physician's orders for reporting laboratory results timely, and providing oral medications as prescribed for 1 of 3 residents reviewed. (Resident D) Finding includes: A record review was completed, on 11/16/2023 at 8:30 A.M. Resident D had intact cognition and was his own Power of Attorney (POA). Resident D's diagnoses included, but were not limited to: Psoriasis, latent tuberculosis, and Type 1 diabetes mellitus. A Physician's order, dated 5/12/2023, indicated to obtain the following labs: comprehensive metabolic panel, complete blood count with differential, Hepatitis A, Hepatitis B, Hepatitis C, and QuantiFERON Gold test on the next lab day. A Health Status Note, dated 5/25/2023 at 3:52 P.M., indicated the nurse had called [Name of Hospital Lab] to inquire about Resident D's CBC, CMP, Quantiferon Gold, Hepatitis A, B, and C lab results. It was at that time the nurse was informed that the labs would be drawn the next day on the normal lab draw day at the facility. A Health Status Note, dated 5/26/2023,…

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, observation and interview, the facility failed to act on a residents' statements of wanting to die, and failed to ensure environmental hazards were removed from a resident's room after a suicide attempt for 1 of 1 resident's reviewed for accidents. (Resident 2) Finding includes: A clinical record review was completed on 11/15/2023 at 8:50 A.M. Resident 2 was admitted on [DATE] with diagnoses included, but were not limited to: hemiplegia, hemiparesis following cerebral infarct, epilepsy, anxiety, and psychosis not due to a substance or known physiological condition. An admission Note, dated 6/16/2023, from (name of hospital) indicated Resident 2 was seen in ER (Emergency Room) and admitted because resident threatened to kill himself by wrapping a ligature around his neck. On arrival to emergency department, he denied any suicidality. A PASSAR (Pre-admission Screening and Resident Review) Level II outcome, dated 6/21/2023, indicated .we learned you were admitted to the hospital 6/16/2023…

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

Based on record review and interview, the facility failed to report a positive QuantiFERON Gold test (Tuberculosis skin test) to the Indiana Department of Health for 1 of 1 resident reviewed for reportable diseases. (Resident D) Finding includes: A Health Status Note, dated 5//31/2023, indicated the lab called with a positive Tuberculosis (TB). NP (Nurse Practitioner) at facility and made aware. Resident D indicated, he had a chest X-ray for this situation in April 2023, and voiced several years ago having a positive PPD (Purified Protein Derivative) then having a chest X-ray done resulting in a negative result. A Health Status Note, dated 6/2/2023, indicated a Chest X-ray was required related to a positive TB result. A Health Status Note, dated 6/3/2023, indicated: Chest X-ray results received. No tuberculosis seen. NP notified. A Progress Note, dated 6/7/2023, from the Dermatologist indicated that Resident D had a positive tuberculosis skin test and was referred to Infectious Disease for treatment of tuberculosis. An Infectious Disease Progress Note, dated 9/7/2023, indicated the…

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

Based on observation and interview, the facility failed to provide a cleanly kitchen environment with proper sanitation for 1 of 1 kitchens. This deficient practice had the potential to affect 55 of 55 residents who ate their meals in the kitchen. Findings include: On 6/15/2023 at 7:52 A.M., during the initial tour of the kitchen, the following was observed: - A bottle of 409 spray cleaner with Lawry's seasoning salt and a bucket of puree bread mix was observed on the bottom shelf of a three-tiered cart by the steam table. - The stovetop had food debris on top and three of the six wells had significant debris. The outside oven, convection oven, and knife holder had food debris visible. - The stainless-steel storage drawers with ladles, spoons, and spatulas in the first drawer, scoops in the second drawer, and whisks, large utensils and miscellaneous in the third drawer, had visible rust in the drawers. There were no coverings in the drawers. - A stainless steel six-drawer counter containing paper products of lids, souffle cups, bowl lids, condiment cups, cupcake liners, hand mixer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure a functional, sanitary and comfortable environment was maintained in 2 of 4 halls observed for environment.(South Hall and Central Hall) Findings include: During an environmental tour, on 6/22/2023 at 11:35 A.M., with the Maintenance Director the following items were observed on the South Hall: - room [ROOM NUMBER] The entry room door had gouged unpainted areas. Dark brown spots were on the floor by bed 1. A headboard was off the bed. the bathroom doors were scratched and had missing paint, the floor was stained and had wet floor tiles under the toilet with a strong urine smell. - room [ROOM NUMBER] had gouged doors, walls, floors with black marks in the entrance to the room. - room [ROOM NUMBER]'s entry door had gouges and missing paint. - room [ROOM NUMBER] the doors to the room and the bathroom had gouges with missing paint. The floor in the bathroom had black marks along the bathroom entrance. - room [ROOM NUMBER]'s entry door…

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, record review and observation, the facility failed to prevent a resident's right to be free from mental and physical abuse for 2 of 3 residents reviewed for abuse. ( Resident 53 and 12) Findings include: 1. During an interview, on 6/15/2023 at 12:27 P.M., employee 4 indicated she had been assigned to 1:1 care for a combative resident, Resident 53, and staff had been threatening the resident. Employee 4 indicated the aides and nurses were threatening. Employee 4 indicated, when the resident would try to go behind the nurses' station to get food, the staff would say do you want me to get the lotion? Employee 4 indicated this is a known trigger for him, and he would do anything to not have lotion applied to him, I believe he had sensory issues. When getting report, I was told if he doesn't listen threaten him with lotion. There was a chair with lotion outside his door in case someone needed to grab the lotion and show him to get him to cooperate. During an interview, on 6/15/2023 at 3:00 P.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 record review and interview, the facility failed to ensure resident care plan meetings were held timely for 1 of 20 residents reviewed for care plan meetings. (Resident 33) Finding includes: During an initial interview with Resident 33 on 6/15/2023 at 12:09 P.M., she indicated that she was unsure if care plan meetings had occurred. She indicated her granddaughter worked at the facility. On 6/19/2023 a clinical record review was completed. Diagnoses included, but were not limited to: Diabetes Mellitus type 2, chronic kidney disease, and hearing loss. An Annual Minimum Data Set (MDS) Assessment on 5/31/2023, indicated Resident 33 was cognitively intact. A review of the Progress Notes indicated no entries for care plan meetings were documented. There were no documents in the electronic medical record that indicated a care plan meeting had occurred in the past year. During an interview on 6/20/2023 at 10:27 A.M., the Social Service Director indicated that a progress note would be placed when the care plan meeting occurred, and she had a binder that the care plan meeting notes…

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, record review and observation, the facility failed to ensure a physician's order had been followed for a resident who used a pacemaker monitoring device for 1 of 1 residents reviewed for a heart device. (Resident 11) Finding includes: During an interview, on 6/19/2023 at 10:08 A.M., Resident 11's daughter indicated the staff didn't plug in the pacemaker monitoring device that resident 11's Cardiologist supplied to transmit data from the pacemaker. A record review, was completed on 6/19/2023 at 2:30 P.M. Diagnoses included, but not limited to: heart failure, unspecified atrial fibrillation, and hypertension. A physician's order, dated 3/31/2023, indicated to make sure pacemaker monitoring device is plugged in and functioning every shift. A care plan, dated 9/20/2022 and current through 6/21/2023, indicated Resident 11 had a pacemaker related to heart failure and atrial fibrillation and is at risk for mechanical failure. Interventions included, but were not limited to: nursing staff should check pacemaker monitoring device to ensure it is working properly, dated…

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

Based on observation, record review and interview, the facility failed to prevent a resident from developing 2 new deep tissue injuries in 1 of 1 resident reviewed for pressure ulcers. (Resident 25) Finding includes: During an observation, on 6/17/2023 at 9:53 A.M., Resident 25 was observed lying in bed with pressure relieving boots at the end of the bed. A record review was completed on 6/20/2023 at 5:34 A.M. Resident 25's diagnoses included, but were not limited to heart failure, anxiety, depression, diabetes, dementia, psychotic disorder, and Schizophrenia. An Annual MDS (Minimum Data Set) Assessment, dated 3/31/2023, indicated the resident had hallucinations and delusions. Required extensive assist of 2 staff for bed mobility, transfers, toilet use and dressing and supervision of 1 staff for eating and had no pressure ulcers. Current physician orders for Resident 25 included: apply skin prep to bilateral heels every shift, float heels while in bed every shift for preventative. Weekly skin assessment: complete skin integrity data collection tool every Saturday. 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, record review, and observation, the facility failed to ensure nursing staff were competent in using a pacemaker monitoring device for 1 of 1 residents reviewed who required mechanical device monitoring. (Resident 11) Finding includes: During an interview, on 6/19/2023 at 10:08 A.M., Resident 11's daughter indicated the staff didn't plug in the pacemaker monitoring device the Cardiologist supplied to transmit data from the pacemaker. A record review, completed on 6/19/2023 at 2:30 P.M. Resident 11's diagnoses included, but not limited to, heart failure, unspecified atrial fibrillation, and hypertension. A physician's order, dated 3/31/2023, indicated to make sure pacemaker monitoring device is plugged in and functioning every shift. A care plan, dated 9/20/2022 and current through 6/21/23, indicated Resident 11 had a pacemaker related to heart failure and atrial fibrillation and is at risk for mechanical failure. Interventions included but were not limited to nursing staff should check pacemaker monitoring device to ensure it is working properly, dated 3/31/2023.…

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

Based on observation, record review and interview, the facility failed to ensure medication carts were free from loose pills, failed to date medication when opened and failed to ensure the freezer section of a medication refrigerator was free from ice buildup in 3 of 3 medication storage areas observed. (Central Hall medication cart, Skilled Hall medication cart and South Hall Medication room) Findings include: 1. During a medication storage audit, on 6/17/2023 at 10:45 A.M., with LPN 20 on the Central East medication cart, the following was observed: 5 loose pills and 3 pieces of a white pill were observed in two of the med cart drawers. During an interview, on 6/17/2023 at 10:46 A.M., LPN 20 indicated the loose pills should not be in the cart. 2. During a medication storage audit, on 6/17/2023 at 10:50 A.M., with LPN 20 on the Central Hall medication cart, the following was observed: - A packaged Loperamide ( anit-diarrhea) pill in the drawer and an opened and undated bottle of Lactulose (laxative and ammonia reducer). During an interview, on 6/17/2023 at 11:00 A.M., LPN 20…

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