Life Care Center Of Andover

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 96 residents. The sample included 20 residents, with four reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on interviews, observations, and record reviews, the facility failed to ensure staff set the appropriate weight for Resident (R) 245's low air-loss mattresses (specialized air mattress used to reduce pressure on the body) and failed to ensure R55's low air-loss mattress was plugged in and functioning. This deficient practice placed both residents at risk for complications related to skin breakdown and pressure ulcers. Findings Included: - The Medical Diagnosis section within R245's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), major depressive disorder (major mood disorder), end-stage renal failure (kidney failure), and 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 The facility identified a census of 96 residents. The sample included 20 residents with four residents reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)55 was provided services and treatment to prevent worsening of contractures (abnormal permanent fixation of a joint or muscle) in his left hand. This deficient practice placed R55 at risk for discomfort and decreased range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension). Findings included: - R55's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of spastic quadriplegic cerebral palsy (a progressive disorder of movement, muscle tone, or posture caused by injury or abnormal development in the immature brain, most often before birth), protein-calorie malnutrition (inadequate intake of protein and calories which may cause wasting of muscle and tissue), muscle spasms, muscle weakness, need for assistance…

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 The facility reported a census of 96 residents with 20 residents sampled. Based on observation, interview, and record review the facility failed to provide timely incontinenct care to Resident (R) 81, to prevent an incontinence episode during the lunchtime meal in the dining room, which left a puddle of urine on the floor by the resident. This failure placed the resident at risk for potetial negative psychosocial well-being, due to embarassment and frustration. The facility staff also failed to ensure they educated R10 regarding keeping the urinary catheter bag below the level fo the bladder, in order to prevent the potential infection control issue, which could lead to urinary tract infections. Findings included: - The Medical Diagnosis section within R10's Electronic Medical Records (EMR) included diagnoses of general anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), obstructive uropathy (blockage in the urinary tract), benign prostatic hyperplasia…

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 The facility identified a census of 96 residents. The sample included 20 residents, with three sample residents reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 4 had her physician-ordered supplemental oxygen on as ordered. The facility failed to ensure R4's nasal cannula (NC - a thin hollow tube that assists in providing supplemental oxygen) was appropriately stored when not used. The facility failed to ensure R43's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) mask was stored appropirately when not in use. This deficient practice placed R4 and R43 at risk of respiratory complications and possible infection. Findings included: - R4's Electronic Medical Record (EMR) documented diagnoses of respiratory failure (a condition where the lungs are unable to adequately perform their primary function of gas exchange), chronic obstructive…

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 The facility identified a census of 96 residents. The sample included 20 residents, with one resident reviewed for trauma informed care (treatment or care directed to prevent re-experiencing or reducing the effects of traumatic events). Based on observation, record review, and interviews, the facility failed to identify trauma-based triggers related to Resident (R) 24's post-traumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress) and failed to implement individualized interventions to prevent re-traumatization. These deficient practices placed R24 at risk for decreased psychosocial well-being and ineffective treatment. Findings included: - R24's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of PTSD, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), anxiety (mental or emotional…

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 The facility identified a census of 96 residents. The sample included 20 residents with two reviewed for bed rails. Based on observation, record review, and interviews, the facility failed to ensure that Residents (R) 15 and R55 had a safety assessment for the use of side rails that acknowledged the risks of their low air-loss mattress. This deficient practice placed both residents at risk for uninformed decisions and impaired safety related to the risks associated with the use of side rails. Findings Included: - The Medical Diagnosis section within R15's Electronic Medical Records (EMR) included diagnoses of type two diabetes (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), major depressive disorder (major mood disorder), morbid obesity (severely overweight), general anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and schizoaffective disorder (a mental disorder characterized by gross…

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 The facility identified a census of 95 residents. The sample included 20 residents, with one resident reviewed for trauma informed care (treatment or care directed to prevent re-experiencing or reducing the effects of traumatic events). Based on observation, record review, and interviews, the facility failed to identify and provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for Resident (R) 24, who has a history of posttraumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). This deficient practice placed R24 at risk for further decline of her emotional and mental wellbeing. Findings included: - R24's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of PTSD, cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety…

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 The facility reported a census of 93 residents. The sample of 22 residents included 10 residents sampled for personal hygiene related to grooming, bathing, nail care, and shaving. Based on observation, interview, and record review the facility failed to ensure necessary services to maintain good personal hygiene for the nine of the 10 sampled residents, including Resident (R)45, R73, R 25, R 59, R 64, R 4, R 8, R 19, and R 22. Findings included: - Review of Resident (R) 45's Physician's Orders, dated 10/04/23 documentation included diagnoses of bipolar disorder (mental health condition that causes extreme mood swings that include emotional highs [mania or hypomania] and lows [depression]), muscle weakness, and nicotine dependence. The admission Minimum Data Set, (MDS) dated [DATE], documented the resident's Brief Interview for Mental Status, (BIMS) score of 15, indicating cognitively intact. He did not exhibit behaviors or reject cares. He required supervision of staff for activities of daily living (ADL).…

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.

The facility reported a census of 93 residents. Based on interview and record review, the facility failed to ensure sufficient qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being. Findings included: - Review of the Facility Assessment, updated 06/23/23, documented the facility would base the staffing plan on resident population and the needs of residents' care and support. The facility assessment did not specify the required amount of staff required for resident care. Review of the Fiscal Year (FY) Quarter 4 2022 (July 1 through September 30), Quarter 2, 2023 (January 1 through March 31) and Quarter 3, 2023 (April 1 through June 30) of the Payroll Based Journal (PBJ) revealed the facility had excessively low weekend staffing. On 10/16/23 at 09:09 AM, Resident #38 stated he would wait hours for the Certified Nurse Aides (CNA) to answer his call light. The facility needed more staff. On 10/16/23 at 10:49 AM, Resident…

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

The facility reported a census of 93 residents. Based on observation, interview and record review, the facility failed to have Registered Nurse (RN) coverage for at least eight continuous hours on 07/22/23, 07/23/23, 08/05/23, 08/06/23, 08/19/23, 08/23/23, 09/12/23, 09/24/23, 09/30/23, 10/08/23, 10/14/23 and 10/15/23, as required. The facility may permit the DON to serve as a charge nurse only when the facility had an average daily occupancy of 60 or fewer residents. This placed the residents in the facility at risk for unsupervised nursing care and services. Findings included: - Review of the Daily Staff Postings from 07/01/23 through 10/17/23, revealed the facility had greater than 60 residents on all days. Review of the nursing schedules for 07/01/23 through 10/17/23, revealed the facility did not have the required eight consecutive hours of Registered Nurse (RN) coverage, as required, on 07/22/23, 07/23/23, 08/05/23, 08/06/23, 08/19/23, 08/23/23, 09/12/23, 09/24/23, 09/30/23, 10/08/23, 10/14/23 and 10/15/23. On 10/18/23 at 11:13 AM, Consultant staff GG stated Administrative…

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.

The facility reported a census of 93 residents. Based on interview and record review, the facility failed to complete an annual performance review at least once every 12 months for two of the five Certified Nurse Aides (CNA) reviewed, CNA P and CNA Q, to ensure adequate appropriate cares and services provided to the residents of the facility. Findings included: - Review of five employee personnel files, employed by the facility for greater than one year, revealed the following concerns: Review of Certified Nurse Aide (CNA) P, hired 08/13/04, lacked an annual performance review in her personnel file. Review of CNA Q, hired 11/15/21, lacked an annual performance review in her personnel file. On 10/17/23 at 04:10 PM, Administrative Nurse D stated the annual staff evaluations had not all been completed. The facility policy for Performance Evaluations, reviewed 12/05/22, included: Annual performance reviews shall be completed annually to all staff members. The facility failed to complete an annual performance review for these two CNAs, employed by the facility for greater than one year,…

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.

The facility reported a census of 93 residents. Based on observation, interview, and record review the facility failed to prepare, store, and serve food under sanitary conditions, to the residents of the facility. Findings Included: - On 10/16/23 at 02:42 PM, the following concerns were identified during the initial tour of the kitchen with Dietary Staff BB: 1. Five cup cake pans, with 24 cup capacity, sat stacked together ready for use. The pans inside held a brown substance in contact in the edges which would contact the food when used. 2. The refrigerator contained an open to air sliced turkey package which lacked a date to indicate when it was opened. 3. The refrigerator contained an open to air package of sliced ham in the unsealed package. On 10/16/23 at 02:52 PM, Dietary Staff BB confirmed the above findings. She stated the brown substance was on the baking surface of the pans and could be in direct contact with the food. Additionally, she stated the opened packages of meat in the refrigerator should be sealed and labeled with the date open to prevent the spread of food borne…

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.

The facility reported a census of 93 residents. Based on observation, interview and record review, the facility failed to maintain a quality assurance committee that developed and implemented appropriate plans of action to correct identified infractions of resident rights, nursing services, food and nutritional services, pharmacy services, comprehensive resident centered care plans, infection control, physical environment, and quality of life and quality of care concerns for all residents. Findings included: - On 10/18/23 at 01:04 PM, Administrative staff A stated the quality assurance (QA) committee met almost every month on 09/20/23, 08/16/23, 07/12/23, 06/14/23, 03/08/23, 02/08/23, 01/18/23, 12/14/22, 11/09/22 and 10/12/22. 1. Failure to provide quality of life for residents as evidenced by the following: a) Refer to F677. The facility failed to show respect and dignity to one Resident (R)4, by failing to ensure the resident had appropriate clothing to wear, rather than hospital-type gowns. b) Refer to F679. The facility failed to provide an ongoing program of appropriate…

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.

The facility reported a census of 93 residents. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program with the failure of staff to perform proper transportation of soiled linen and hand hygiene when appropriate and failure of the staff to clean resident transfer equipment between resident use. This deficient practice has the potential to negatively affect every resident in the facility. Findings include: - On 10/18/23 at 08:25 AM, CNA M exited a resident's room with a full body mechanical lift (a device used to transfer a person who is unable or incapable of sitting or standing) on the 100 hallway and transported the full body mechanical lift to the 300 hall and entered a different resident's room without sanitizing the full body mechanical lift. On 10/18/23 at 08:35 AM, CNA M stated that the lifts were supposed to be sanitized after each resident use. On 10/18/23 at 09:03 AM Certified Nurse Aide (CNA) M and CNA MM carried clean linen and clean supplies into multiple rooms while carrying clean linens against their…

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.

The facility reported a census of 39 residents. Based on observation and interview, the facility failed to provide a safe, functional, and sanitary environment in the kitchen. Findings included: - On 10/16/23 02:42 PM, during initial tour of the kitchen with Dietary Staff BB, identified an eight foot by 4 inch open slated iron grate surrounding by 28 ceramic tiles in the food prep area. The tiles were not level with the grate and posed a trip hazard. Dietary staff BB confirmed the findings and report she was concerned staff may trip and fall while working in the food prep area. On 10/17/23 at 11:24 AM, Dietary Staff CC confirmed the findings and stated he had to be careful not to trip on the uneven surface while preparing food. On 10/17/23 at 11:30 AM, Dietary Staff BB stated the floor need to have maintenance repair it, so the surfaces were even and not a trip hazard. She stated she had mentioned her concern but was not aware of a plan to repair the floor. The facility lacked a policy to address maintenance and repair related to the kitchen. The facility failed to provide a safe,…

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.

The facility reported a census of 93 residents. Based on observation, interview, and record review, the facility failed to ensure all residents were free from accident hazards regarding several residents not having access to their call lights while in their beds. Findings included: - During an initial tour of the facility on 10/16/23 at 08:30 AM, the following areas of concern were noted: 1. Resident #195's call light was on the floor underneath her bed, out of her reach. 2. Resident #22's call light was on the floor underneath her bed, out of her reach. 3. Resident #54's call light was on the floor underneath her bed, out of her reach. 4. Resident #8's call light was on the floor underneath his bed, out of his reach. 5. Resident #19's call light was on the floor underneath his roommates' bed, out of his reach. 6. Resident #33's call light was on the floor underneath her bed, out of her reach. 7. Resident #68's call light was coiled on the floor, out of his reach. On 10/17/23 at 04:13 PM, Consultant staff GG stated the resident's call lights should always be within their reach while…

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.

The facility reported a census of 93 residents. Based on observation, interview, and record review, the facility failed to maintain a clean, comfortable and homelike environment, regarding concerns in the clean utility closet on one of four resident halls. Findings included: - During an environmental tour on 10/18/23 at 10:10 AM with Housekeeping/Maintenance Staff U, the following areas of concern were noted in the clean utility closet on one resident hall: 1. There was one unopened box of 96 COVID-19 tests, stored directly on the floor. 2. There was one opened box of 90 COVID-19 tests, stored directly on the floor. Random trash had been thrown into the open box on top of the testing supplies. 3. There was one unopened box of 72 briefs, stored directly on the floor. 4. There was one opened box of 16 briefs, stored directly on the floor. 5. The hand washing sink in the clean utility closet contained random pieces of trash. On 10/18/23 at 10:10 AM, Housekeeping/Maintenance staff U stated the boxes should not be stored directly on the floor and should not contain trash. The facility…

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.

The facility census totaled 93 residents on four halls with a commons area where residents gather for meals and activities and with a medication cart and a nurse treatment cart for each hallway. Based on observation, interview, and record review, the facility failed to provide a safe environment for 21 residents by the failure to ensure a medication cart used by the facility remained locked when not in direct line of vision of the nurse and medication aide passing medications from their carts. Findings included: - On 10/16/23 at 12:08 PM, a medication cart was left unlocked and unattended in the 300 hallway. On 10/16/23 at 12:11 PM, Licensed Nurse (LN) I stated that the medication cart was assigned to her and confirmed that it was left unattended and unlocked. LN I further confirmed that the cart serviced 21 residents and contained prescription medications such as metoprolol (Lopressor - a medication to lower blood pressure and heart rate), amlodipine (Norvasc - a medication to lower blood pressure), bupropion (Wellbutrin - an antidepressant [class of medications used to treat mood…

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 The facility reported a census of 93 residents with 22 residents sampled, including two residents reviewed for dignity. Based on observation, interview, and record review, the facility failed to show respect and dignity to one Resident (R)4, by failing to ensure the resident had appropriate clothing to wear, rather than hospital-type gowns. Findings included: - Review of Resident (R)4's electronic medical record (EMR) revealed a diagnosis of major depressive disorder (MDD--a significant mental illness). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. It was somewhat important for her to choose which clothing to wear and she required extensive assistance of one staff for dressing. The Activity for Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 09/26/23, documented the resident required extensive assistance with all her ADL's. The care plan for ADL's, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 93 residents. The sample included 22 residents with four reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to provide a bed hold notice to two residents, Resident (R)25 and R46, or their representative when the residents were sent and admitted to the hospital. This deficient practice placed R25 and R46 at risk to not be allowed to return to their former rooms at the facility. Findings include: - The Electronic Health Records (EHR) documented that R46 had the following diagnoses: type 1 diabetes mellitus ( DM1 - a chronic metabolic disorder characterized by persistent high blood glucose when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), chronic kidney disease, chronic pancreatitis (a condition characterized by inflammation of the pancreas that can be accompanied by severe pain with nausea and vomiting), and chronic respiratory failure (a condition in which respiratory function 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 - R33's physician orders dated [DATE] revealed the following diagnoses: dementia (progressive mental disorder characterized by failing memory, confusion), heart failure (heart muscle doesn't pump blood as well as it should), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Significant Change in Status Minimum Data Set (MDS) dated [DATE], revealed the resident had severe cognitive impairment with memory problems and severely impaired decision-making ability. The resident had shortness of air with all activity and required the use of oxygen (O2). The resident had a terminal diagnosis and received hospice services. The Quarterly MDS dated [DATE], revealed no significant changes in cognition. The resident received hospice services and use of O2. Review of the Activities of Daily Living (ADL)Functional/rehabilitation Potential Care Area Assessment (CAA) dated [DATE] revealed the resident required extensive to total staff assistance with ADL's 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY - Review of Resident (R) 25's Physician's Orders, dated 10/04/23 documentation included diagnoses of morbid obesity (severely overweight), type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), protein calorie malnutrition, heart failure, chronic kidney disease (CKD), coronary artery disease (CAD- abnormal condition that may affect the flow of oxygen to the heart), abnormalities of gait and mobility, chronic ulceration (wound) of the left foot, needed assistance for personal care, dependence on wheelchair, and with left and right buttock wounds. The admission Minimum Data Set, (MDS) dated [DATE], documented the resident's Brief Interview for Mental Status, (BIMS) score of 15, indicating cognitively intact. She did not exhibit behaviors nor reject care. She required extensive assistance of staff for bed mobility, and personal hygiene. She had a formal clinical skin assessment which indicated she was at risk for developing 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 93 residents with 22 residents sampled, including one resident reviewed for activities. Based on observation, interview and record review, the facility failed to provide an ongoing program of appropriate activities for one Resident (R)4. Findings included: - Review of Resident (R)4's electronic medical record (EMR) revealed a diagnosis of major depressive disorder (MDD-a major mental illness). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. It was somewhat important for her to be around animals, go outside when the weather was nice and to do her favorite activities. The Activity Care Area Assessment (CAA), dated 09/26/23, documented the resident was a recent admission and showed limited interest in facility activities. The care plan for activities, completed 09/23/23, instructed staff the resident was dependent on staff for meeting her emotional, intellectual,…

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 The facility reported a census of 93 residents with 22 residents selected for review, which included four residents reviewed for pressure ulcers. Based on observation, record review, and interview, the facility failed to reposition one Resident (R67), with a high risk for development of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) over two hours and 15 minutes. In addition, the facility failed to implement interventions to prevent further development of pressure areas for R85. Findings include: - The Electronic Health Record (EHR) revealed Resident (R)67 had a diagnosis that included anoxic brain damage (brain damage as a result of lack of oxygen flow to the brain), quadriplegia (paralysis of the arms, legs and trunk of the body below the level of an associated injury to the brain or spinal cord) and soft tissue disorders related to pressure of right ankle and foot. 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 The facility reported a census of 93 residents with 22 residents sampled, including one resident reviewed for restorative services. Based on observation, interview, and record review, the facility failed to provide restorative services for Resident (R)22, to maintain or prevent decline in range of motion (ROM) ability. Findings included: - Review of Resident (R)22's electronic medical record (EMR) revealed a diagnosis of contracture (permanent fixture of a joint) to her left hand. The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. She had limited range of motion (ROM) on one side of her upper extremity and received no restorative cares during the assessment period. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 05/26/23, documented the resident required assistance with all ADL's due to contractures. The Quarterly MDS, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 93 residents with 22 residents included in the sample, that included one resident reviewed for respiratory services. Based on observation, interview, and record review the facility failed to ensure one Resident (R) 33's oxygen (O2) tubing dated to ensure safe oxygen treatment and failed to document in the clinical records, when the resident required use of the O2, identified by staff that the resident required the O2 continuously. Findings included: - R33's physician orders dated 08/23/23 revealed the following diagnoses: dementia (progressive mental disorder characterized by failing memory, confusion), heart failure (heart muscle doesn't pump blood as well as it should), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Significant Change in Status Minimum Data Set (MDS) dated [DATE], revealed the resident had severe cognitive impairment with memory problems and severely impaired decision-making ability. The resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 93 residents with 22 residents sampled, that included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure the consultant pharmacist identified and reported the lack of an appropriate/ timely Abnormal Involuntary Movement Scale ([AIMS] a clinical outcome measure used to assess abnormal movements in people with tardive dyskinesia [abnormal condition characterized by involuntary repetitive movements of the muscles of the face, limbs, and trunk]) for Resident (R)55, who received an antipsychotic (class of medication used to treat psychosis) medication. Findings included: - Review of Resident (R)55's electronic medical record (EMR) documented a diagnosis of paranoid schizophrenia (a type of schizophrenia accompanied by paranoia, which means having delusions of persecution, grandiosity, or jealousy and hallucinations, such as hearing voices). The Annual Minimum Data Set (MDS), dated [DATE], documented…

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 The facility reported a census of 93 residents with 22 residents sampled. Based on observation, interview, and record review, the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for one Resident (R)55, who takes an antipsychotic (medication which treats psychosis) medication. Findings included: - Review of Resident (R)55's electronic medical record (EMR) documented a diagnosis of paranoid schizophrenia (a type of schizophrenia accompanied by paranoia, which means having delusions of persecution, grandiosity, or jealousy and hallucinations, such as hearing voices). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She received an antipsychotic (medication used to treat psychosis) seven days of the seven-day assessment period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 06/23/23, documented the resident received antipsychotic medications. The Quarterly…

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.

The facility reported a census of 93 residents. Based on observation, interview, and record review, the facility failed to ensure the use of recipes reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy, also failure to prepare adequate nutritional food in accordance with the menus/follow recipes for the residents of the facility. Findings included: - On 10/17/2023 at 11:24 AM, Dietary Staff CC identified eight residents in the facility which received pureed diets. He stated that he followed the recipes for preparation of the menu food items. On 10/17/23 at 11:34 AM, Dietary staff CC confirmed the menu for the meal included Salisbury steak, macaroni cheese, green beans, steamed rice, dinner rolls, and cheesecake. Dietary Staff CC proceeded to place Salisbury steak in a blender without weighing or counting the meat servings. He added water to the content of the blender to gain his desired consistency. Upon inquiry Dietary Staff CC indicated he did not know what the recipe called for because the recipe documented 13.34 as…

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.

The facility reported a census of 93 residents. Based on interview and record review, the facility failed to ensure two Residents (R)89 and R 11 acknowledged receipt of the 2022-2023 vaccination information, related to influenzas or pneumococcal (vaccines designed to prevent pneumonia or influenza) vaccination. In addition, the facility failed to ensure R11 acknowledged receipt related to COVID-19 vaccination information to make informed declination decisions as required. Findings included: - Review of the Electronic Health Record (EHR) for Resident (R) 89 lacked documentation of the 2022 influenza vaccine or declination of the vaccine. It further lacked documentation of any pneumococcal vaccine or declination of the vaccine (s). Review of R11's EHR lacked documentation of 2022-2023 influenza vaccine or declination of the vaccine. It further lacked documentation of any pneumococcal vaccine or declination of vaccines. R 11's EHR also lacked any record of the COVID vaccine or Booster ever been given with no declination of the vaccine. On 10/18/23 at 01:00 PM, Administrative Nurse D…

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 The facility reported a census of 75 residents with 20 residents sampled, including 11 residents reviewed for Activities of Daily Living (ADL). Based on interview, record review, and observation the facility failed to provide appropriate bathing opportunities to 10 of the 11 residents including; Residents (R)35, R 177, R 9, R 44, R 62, R 57, R 128, R 16, R 30, and R43 to ensure personal hygiene needs are met. Findings included: - The Physician Order Sheet (POS), dated 01/06/22, documented Resident (R)35 had a diagnosis of morbid obesity (a serious health condition that can interfere with basic physical functions such as breathing or walking). The significant change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She had no rejection of care and required physical help in part of bathing of two staff. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 75 residents. The 20 residents selected for review included five residents reviewed for quality of care including three residents for non-pressure wounds and one with alignment positioning. Based on observation, interview and record review, the facility failed to provide non-pressure wound care to two residents (R)30 and R57 and failed to provide assessment and timely treatment for non-pressure skin wounds for R177. Furthermore, the facility failed to provide alignment positioning for the one resident R25, who sat in the wheelchair with feet handing behind the foot pedals and above the floor without any support. Findings included: - Review of resident (R)57's Physician Order Sheet, dated 01/06/22, revealed diagnoses included lower extremity fracture with open wound to the left ankle with Methicillin-resistant Staphylococcus aureus (MRSA- a type of bacteria resistant to many antibiotics), diabetes (when the body cannot use glucose, not enough insulin made or the body cannot…

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 The facility reported a census of 75 residents with 20 residents sampled, including two residents sampled for dignity. Based on interview, record review, and observation, the facility failed to ensure Resident (R)25 was treated with respect and dignity, when sitting in the commons area with drool down the front of his face and clothing and staff failure to stop and clean him off. Findings included: - The Physician Order Sheet (POS), dated 01/06/22, documented Resident (R)25 had a diagnosis of quadriplegia (paralysis of the arms, legs and trunk of the body below the level of an associated injury to the spinal cord). The significant change Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severe impairment. The resident required extensive assistance of one staff for personal hygiene and had functional limitation in his range of motion (ROM) on both sides of his upper and lower extremities (arms and legs). The Activity of Daily Living (ADL) Functional/Rehabilitation…

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 The facility reported a census of 75 residents with 20 selected for review. Based on observation, interview and record review, the facility failed to review and revise one sampled resident's (R) 30's care plan for interventions for pressure relieving devices for a preventative boot which the resident often refused and staff failed to identify the failure and implement an effective interventnion for the resident's diabetic heel ulcer. Findings included: - Review of resident (R)30's Physician Order Sheet, dated 01/06/22, revealed diagnoses included heart failure, diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), major depressive disorder, osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), hemiparesis ( muscular weakness of one half of the body), cerebral vascular accident (stroke) peripheral vascular disease (abnormal condition affecting the blood vessels) and chronic ulcer to the left heel. The Quarterly…

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 The facility reported a census of 75 residents with 20 residents sampled, including three residents sampled for activities. Based on observation, record review, and interview, the facility failed to provide an ongoing program of individualized activities for one of the three residents, Resident (R)25. Findings included: - The Physician Order Sheet (POS), dated 01/06/22, documented the resident had a diagnosis of quadriplegia (paralysis of the arms, legs and trunk of the body below the level of an associated injury to the spinal cord). Review of the significant change Minimum Data Set (MDS), dated [DATE], documented the resident had a staff assessment for cognition which revealed severe cognitive impairment. It was very important for the resident to listen to music he liked and somewhat important to do things with groups of people. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 08/12/21, documented the resident had a communication deficit related to memory problems and a history of 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 The facility reported a census of 75 residents with 20 selected for review which included one resident reviewed for restorative services. Based on observation, interview and record review, the facility failed to provide restorative services to ensure one resident (R)34 received restorative services to her bilateral foot (drop- extended) contractures with proper wheelchair positioning devices and bed device to enhance anatomical joint alignment as much as possible to prevent further decline. Findings included: - Review of resident (R)34's Physician Order Sheet, dated 01/06/22, revealed diagnoses included cerebral vascular accident(stroke), hemiplegia (paralysis of one side of the body), schizoaffective disorder (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought) and contracture (abnormal permanent fixation of a joint) of right and left hands and knees. The Quarterly Minimum Data Set, (MDS), dated [DATE] assessed the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 75 residents with 20 residents sampled, including two residents reviewed for accidents. Based on observation, interview and record review, the facility failed to ensure staff safe transports for one of the two, dependent Resident (R)17 while in her wheelchair to prevent accidents. Findings included: - The Physician Order Sheet (POS), dated 01/06/22, documented Resident (R)17 had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severe impairment. She required extensive assistance of two staff for locomotion in the facility and the use of a wheelchair. She had no impairment in functional range of motion (ROM). The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 03/23/21, did not trigger. The quarterly MDS, dated 11/19/21, documented the resident had a Brief Interview for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 75 residents with 20 selected for review, which included three residents reviewed for urinary catheters. Based on observation, interview and record review, the facility failed to provide proper catheter care and services for the three sampled residents (R)30, R43 and R35 to prevent pulling trauma and infection. Findings included: - Review of resident (R)30's Physician Order Sheet, dated 01/06/22, revealed diagnoses included heart failure, diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), major depressive disorder, osteoarthritis(degenerative changes to one or many joints characterized by swelling and pain) hemiparesis,( muscular weakness of one half of the body), cerebral vascular accident (stroke) peripheral vascular disease ( abnormal condition affecting the blood vessels)and neurogenic bladder(dysfunction of the urinary bladder caused by a lesion of the nervous system.) The Quarterly Minimum Data Set (MDS), dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 75 residents 20 selected for review, which included five residents reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure the consistent administration for one of the five residents, Resident (R) 30 antibiotic therapy following lack of intravenous site, which created a significant medication error for this resident with pneumonia. Findings included: - Review of resident (R)30's Physician Order Sheet, dated 01/06/22, revealed diagnoses included heart failure, diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), major depressive disorder, osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), hemiparesis (muscular weakness of one half of the body), cerebral vascular accident (stroke), peripheral vascular disease (abnormal condition affecting the blood vessels) and chronic ulcer to the left heel. The Quarterly Minimum…

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