Hilltop Lodge Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 59 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 55, R17, and R54 with sanitary indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag) care and R20 lacked an anchor for catheter tubing. These deficient practices placed the residents at risk for urinary tract infections and catheter related injury. Findings included: - R55's Electronic Medical Record (EMR) documented diagnoses of type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), post hemorrhagic (loss of a large amount of blood in a short period of time) anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), muscle weakness, heart failure, dementia (progressive mental disorder characterized by failing memory, confusion), age related cognitive decline, pain, and the need of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 59 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported Resident (R) 10's had multiple antidepressant (class of medications used to treat mood disorders) medications with a diagnosis of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), R17 lacked blood sugar parameters, R55 lacked an end date for the use of an as needed (PRN) antianxiety (class of medications that calm and relax people), R20's recommended gradual dose reduction of psychotropic (alters mood or thought) medications lacked a physician response, and R38's use of antipsychotic (class of medications used to treat major mental conditions which cause a break from reality) for unapproved diagnosis. The facility also failed to ensure the physicians acknowledged and responded to the CP recommendations. This placed the residents at risk 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 had a census of 59 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 10's antidepressant (class of medications used to treat mood disorders) medications had an approved indication, failed to ensure R55 had an end date for the use of an as needed (PRN) antianxiety (class of medications that calm and relax people), failed to ensure R20's recommended gradual dose reduction of psychotropic (alters mood or thought) medications were addressed, and failed to ensure R38's antipsychotic (class of medications used to treat major mental conditions which cause a break from reality) had an appropriate indication or the required physician documentation. This placed the residents at risk of receiving unnecessary psychotropic medication. Findings included: - R10's Electronic Medical Record (EMR) documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear)…

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 59 residents. The sample included 19 residents with one reviewed for dignity. Based on observation, record review, and interview the facility staff failed to treat Resident (R) 54 with dignity, when staff failed to cover his urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) urine collection bag with a privacy bag leaving the urine visible to other residents and guests in the facility. This placed the resident at risk for impaired dignity. Findings included: - R54's Electronic Medical Record (EMR) documented R54 had a diagnosis of urinary retention (lack of ability to urinate and empty the bladder). R54's Quarterly Minimum Data Set (MDS), dated [DATE], documented R54 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R54 was dependent on staff for toileting hygiene. R54 had an indwelling urinary catheter. R54's Care Plan, revised 01/18/24, documented R54 required partial,…

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 had a census of 59 residents. The sample included 19 residents. Based on observation, record review, and interview the facility failed to provide a safe environment in Resident (R) 37's room, when staff placed crinkled duct tape between the floor carpet seams. This placed the resident at risk of preventable accidents and an unhomelike environment. Findings included: - On 02/27/24 at 09:30 AM, observation revealed in R37's room between the carpet seam had gray duct tape running from the bed to the south wall. Observation revealed that the middle of the duct tape was crinkled up approximately one foot (ft). On 02/28/24 at 10:57 AM, Maintenance Staff (MS) U verified the above finding and stated the flooring needed to be replaced. He said he planned on getting a requisition to the administrator but had not got around to it yet. On 02/28/24 at 04:23 PM, Administrative Nurse D stated she was unaware of the issue with the duct tape on the carpet and said that she would look at it. On 02/29/24 at 09:56 AM, Administrative Nurse D stated the flooring needed to be replaced 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 The facility had a census of 59 residents. The sample included 17 residents. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 11 and R18 remained free of neglect and abuse. This deficient practice placed R11 and R18 at risk for injury and impaired physical and psychological well-being due to abuse, neglect, and/or mistreatment. Findings included: - R11's Electronic Medical Record (EMR) had diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) of the right and left shoulders, chronic kidney disease, congestive heart failure (CHF-a condition with low heart output and the body…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 59 residents. The sample included 17 residents. Based on observation, interview, and record review, the facility failed to report to the State Agency (SA) allegations of verbal and physical abuse and neglect for Resident (R) 11 and R18. This placed the residents at risk for ongoing abuse, neglect and mistreatment. Findings included: - R11's Electronic Medical Record (EMR) had diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) of the right and left shoulders, chronic kidney disease, congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid),…

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 59 residents. The sample included 17 residents. Based on observation, interview, and record review, the facility failed to fully investigate allegations of abuse, neglect and injuries of unknown origin for Resident (R) 11 and R18. This placed the residents at risk of ongoing abuse, neglect and mistreatment. Findings included: - R11's Electronic Medical Record (EMR) had diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) of the right and left shoulders, chronic kidney disease, congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), major…

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 59 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for Resident (R) 55 who had an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag) and use of psychotropic (alters mood or thought) medication, and for R17 and R20's indwelling urinary catheter. This placed the residents at risk for impaired care due to uncommunicated care needs. Findings included: - R55's Electronic Medical Record (EMR) documented diagnoses of type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), post hemorrhagic (loss of a large amount of blood in a short period of time) anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), muscle weakness, heart failure, dementia (progressive mental disorder characterized by failing memory, confusion), age related…

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 59 residents. The sample included 17 residents. Based on observation, interview, and record review the facility failed to revise Resident (R) 19's Care Plan to include interventions related to pressure ulcers (PU-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). This placed the resident at risk for impaired care due to uncommunicated care needs. Findings included: - R19's Electronic Medical Record (EMR) documented diagnoses of cerebrovascular accident (CVA-stroke), hemiplegia and hemiparesis ((weakness and paralysis on one side of the body), dysphagia (swallowing difficulty), and rheumatoid arthritis (chronic inflammatory disease that affected joints and other organ systems). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R19 had a Brief Interview for Mental Status (BIMS) score of zero with short- and long-term memory problems and moderately impaired…

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 59 residents. The sample included 17 residents, with four reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide consistent bathing for Resident (R) 38. This placed R38 at risk for complications related to poor hygiene. Findings included: - The Electronic Medical Record (EMR) for R38 documented diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain) with agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), posttraumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), diabetes mellitus (DM-when the body cannot use glucose, not enough sepsis made or the body cannot respond to the insulin), and depressive disorder (a mood disorder that causes a persistent…

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 59 residents. The sample included 17 residents, with five reviewed for non-pressure skin issues. Based on observation, record review, and interview, the facility failed to provide care and treatment in accordance with professional standards of practice for the care of non-pressure related skin injuries for Resident (R) 18 and R17. This placed the residents at risk for further skin injury and impaired healing. Findings included: - The Electronic Medical Record (EMR) for R18 documented diagnoses of dementia (progressive mental disorder characterized by failing memory, and confusion) without behavioral disturbance, depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), edema (swelling), chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breath), and chronic kidney disease (the kidneys have mild to moderate damage). The Annual Minimum Data Set (MDS), dated [DATE], documented R18…

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 59 residents. The sample included 17 residents with seven reviewed for pressure injuries. Based on observation, record review, and interview, the facility failed to provide interventions to prevent the development of or promote healing for 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) for Resident (R)11 and R19, who had or were at risk for pressure injuries. This placed R11 and R19 at risk for ongoing further pressure injury and related complications. Findings included: - R11's Electronic Medical Record (EMR) had diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort…

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 59 residents. The sample included 17 residents with one reviewed for range of motion (ROM) services. Based on observation, interview, and record review the facility failed to provide ROM services to prevent further loss of mobility and function per the plan of care for Resident (R) 19. This placed the resident at risk for impaired mobility and decreased function. Findings included: - R19's Electronic Medical Record (EMR) documented diagnoses of cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hemiplegia and hemiparesis (weakness and paralysis on one side of the body), dysphagia (swallowing difficulty), and rheumatoid arthritis (chronic inflammatory disease that affected joints and other organ systems). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R19 had a Brief Interview for Mental Status (BIMS) score of zero with short- and long-term…

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 59 residents. The sample included 17 residents, with five reviewed for nutrition. Based on observation, record review, and interview, the facility failed to provide necessary nutritional assessments, notify and seek the involvement of the Registered Dietician (RD), and implement interventions to prevent unintended weight loss for Resident (R) 59, who had known weight loss before admission and continued loss after admission. The facility further failed to ensure that R19, who was on a pureed diet received the full nutritional benefit of what was served during the noon meal. This placed the residents at risk for ongoing weight loss and decline. Findings included: - R59 admitted on [DATE]. The Electronic Medical Record (EMR) for R59 documented diagnoses of anoxic brain injury (brain injury that occurs when the brain is deprived of oxygen for too long), diabetes mellitus (DM-when the body cannot use glucose, not enough sepsis made or the body cannot respond to the insulin), and moderate…

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 59 residents. The sample included 17 residents. Based on observation, interview, and record review, the facility failed to provide Resident (R) 11 with the appropriate treatment and services to attain the highest practicable mental and psychosocial (interrelation of social factors and individual thought and behavior) well-being. This placed the resident at risk for unmet mental health care needs. Findings included: - R11's Electronic Medical Record (EMR) had diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) of the right and left shoulders, chronic kidney disease, congestive heart failure…

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 59 residents. The sample included 17 residents. Based on observation, record review, and observation, the facility failed to obtain blood sugar parameters to ensure adequate monitoring for Resident (R) 17 who received insulin (a hormone that lowers the level of glucose in the blood) which placed the resident at risk of unnecessary medications and complications related to diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). Findings included: - R17's Electronic Medical Record (EMR) included diagnoses of a personal history of urinary tract infections (UTI), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), neuralgia (intermittent along the course of a nerve) and neuritis (inflammation of nerves causing pain), unspecified disorders of the bladder, type two diabetes mellitus, chronic respiratory…

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 had a census of 59 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to provide sanitary indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag) care per the standards practice related to infection prevention for Resident (R) 17, R55, and R54. This placed the affected residents at increased risk for urinary tract infections (UTI) and related complications. Findings included: - On 02/27/24 at 01:47 PM, observation revealed R17 lay in bed and watched TV. The indwelling catheter drainage bag hung on the bedframe at the foot of the bed, without a privacy bag. On 02/28/24 at 07:39 AM, observation revealed R17 lying on his back in the bed. His catheter drainage bag lay directly on the floor, not attached to the bed. Licensed Nurse (LN) H stated the catheter bag should not be lying on the floor and confirmed R17 had a history of UTIs. LN H drained the catheter bag and hooked it to the frame of the bed. On 02/28/24 at 07:45 AM, observation revealed R55 in bed which was low…

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 identified a census of 59 residents with nineteen cognitively impaired residents at risk for abuse, neglect, and exploitation. Based on record review, observation, and interview, the facility failed to implement interventions to protect nineteen cognitively impaired residents during an investigation of resident-to-resident abuse which occurred when Resident (R) 3 unwantedly and inappropriately touched and kissed R2, a cognitively impaired resident unable to consent. This placed the nineteen cognitively impaired residents who were unable to consent to sexual affections at risk for sexual abuse and psychosocial impairment. Findings included: - R3's Electronic Medical Record (EMR) documented R3 had diagnoses of traumatic brain injury (TBI- an injury to the brain caused by an external force), hypertension (high blood pressure), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Quarterly Minimum Data Set (MDS), dated 12/07/23, documented R3 had a Brief Interview for Mental Status score of 15 which indicated intact…

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 identified a census of 59 residents with three residents reviewed for abuse, neglect, and exploitation. Based on record review, observation, and interview, the facility failed to prevent resident-to-resident abuse when Resident (R) 2 was unwantedly kissed on her hand and her mouth by R3. This deficient practice placed R2 at risk for unwanted sexual advances, anxiety, and impaired psychosocial functioning. Findings included: - R2's Electronic Medical Record (EMR) documented R2 had diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) of the right dominant side, aphasia (condition with disordered or absent language function), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Quarterly Minimum Data Set (MDS), dated 12/21/23, documented R2 was rarely or never understood and had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 63 residents. The sample included three residents reviewed for misappropriation and exploitation. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 1 was free from misappropriation when an employee of the facility used R1's money to make purchases for R1 but did not purchase the items and could not produce receipts for the money spent. This deficient practice placed R1 at risk for ongoing misappropriation and exploitation. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The admission Minimum Data Set (MDS), dated [DATE], documented R1…

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 identified census of 66 residents. Based on record review and interview, the facility failed to ensure the staff person designated as the Infection Preventionist, who was responsible for the facility's Infection Prevention and Control Program, completed the specialized training in infection prevention and control. This placed the residents at risk for lack of identification and treatment of infections. Findings included: - On 06/16/22 at 03:29 PM Administrative Nurse E stated she was the facility Infection Preventionist (IP) and was responsible for the Infection Prevention and Control Program. Administrative Nurse E further stated she had completed the course and test but did not have the certificate to verify certification. On 06/16/22 at 03:59 PM Administrative Nurse D stated she knows that Administrative Nurse E had completed her training for the Infection Control Program and thought the facility had her certificate/certification on file. On 06/16/22 04:20 PM Administrative Staff A stated the facility should have the IP certification on file and Administrative Nurse…

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 identified a census of 66 residents. Based on observation, record review, and interviews, the facility failed to perform required food storage equipment checks, store food in a sanitary manner, and ensure kitchen appliances are wiped down daily. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns. Findings Included: During the initial kitchen walk-through on 06/13/22 at 07:15AM. The facility's walk-In freezer unit had water leaking from the freezer unit's cooling unit. The frozen vegetable packages stored on racks directly below the unit had ice from the leaking water An inspection of the reach-in freezer unit at 07:25AM revealed severe frosting inside the freezer. The unit temperature check log was missing checks for 6/10, 611, and 6/12. The unit contained an opened bag of French fries with the melting frost leaking inside of the bag. The freezer also contained packaged hot dogs, mixed vegetables packages, and a Ziplock bag labeled French toast dated 03/14. In a follow-up inspection of the freezer on 06/16/22 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.

The facility identified a census of 66 residents. Based on observation, record review and interview the facility failed to ensure staff followed infection control standard of practice. The facility failed to ensure laundry staff properly covered laundry when being delivered to residents. The facility failed to practice proper hand hygiene while care was provided to a resident. The facility staff failed to doff (remove gloves) after use and applied gel hand sanitizer to gloved hands. This placed the residents at increased risk for infection and transmission of communicable disease. Findings included: - On 06/14/22 at 10:48 AM an unidentified laundry staff pushed an uncovered laundry cart with clean clothes in it down the hallway. On 06/15/22 at 07:55 AM LN I had on a pair of disposable gloves upon returning to the treatment cart. LN I pumped some hand sanitizer on her gloved hands and continued to work. On 06/15/22 at 09:01AM Licensed Nurse (LN) G provided cares to R19. After doffing dirty gloves, LN G failed to sanitize hands before she donned (put on) clean gloves. On 06/16/22 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.

The facility identified a census of 66 residents. The sample included 19 residents with three residents reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 24's urinary catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) drainage bag was placed in a privacy bag. The facility further failed to ensure R27's and R1's right to be treated with respect, dignity, and care during meals. This deficient practice placed the residents at risk for negative psychosocial outcomes and decreased autonomy and dignity. Findings included: - On 06/13/22 at 08:16 AM R1 sat in high back wheelchair in a common area on the north unit. Nursing staff stood next to R1 and assisted her with breakfast. R1 yelled out while nursing staff attempted to assist her with breakfast. R1 attempted to hit or grab the glass from the nursing staff. On 06/13/22 at 01:40 PM R24's catheter bag which lacked a privacy bag, was attached to the frame at the foot of the bed, and was visible from…

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 66 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to develop a care plan with guidance and interventions related to 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) /injury and enteral (within or via the small intestine) feeding for resident (R)44. This deficient practice had the potential to cause a decline in R44's physical, mental, and psychosocial well-being and independence due to uncommunicated care needs. Findings included: - The electronic medical record (EMR) for R44 documented the following diagnoses: quadriplegia (paralysis of the arms, legs and trunk of the body below the level of an associated injury to the spinal cord), and intestinal obstruction. The admission Minimum Data Set (MDS) dated [DATE] documented R44's Brief Interview for Mental Status (BIMS) was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 66 residents. The sample included 19 residents with one resident reviewed for limited range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension). Based on observation, record review, and interviews, the facility failed to implement splints to prevent a potential decrease in ROM/mobility and/or worsening of contractures (abnormal permanent fixation of a joint) for Resident (R) 25, which placed her at risk of loss of ability to perform activities of daily living (ADL's) and development of contractures. Findings included: - R25's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of osteoarthritis (chronic arthritis without inflammation), rheumatoid arthritis (chronic inflammatory disease that affected joints and other organ systems), need for assistance for personal care, and dementia (- progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS) dated [DATE]…

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 - R115's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hypertension (elevated blood pressure), unsteady on his feet, and repeated falls. The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of five which indicated severely impaired cognition. The MDS documented that R115 required extensive of two staff members assistance for activities of daily living (ADL's). The MDS documented R115 had a history of falls prior to admission to the facility. The MDS documented R115 had one injury fall during the look back period. R115's Falls Care Area Assessment (CAA) dated 04/29/22 documented his balance problem as a cause for the injury fall during the look back period. R115 required assistance with ADL's R115's Care Plan dated 04/20/22 documented a non-injury fall, education was given to R115 to use the call light prior to transfers. A Care Plan intervention dated 05/23/22 documented a non-injury fall on 05/20/22 and a sign was placed in…

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 identified a census of 66 residents. The sample included 18 residents with eight reviewed for bowel and bladder manangement. Based on observation, record review, and interviews, the facility failed to develop a bowel/bladder training program or resident specific toileting program for Residents (R)36. This deficient practice placed the residents at risk for complications related to incontinence. -The Medical Diagnosis section within R36's Electronic Medical Records (EMR) included diagnoses of hypertension (high blood pressure), muscle weakness, abnormalities of gait and mobility, need for assistance with personal cares, spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities), major depressive disorder (major mood disorder), and sciatica (a severe pain that radiates from the back into the hip and outer side of the leg). R36's Quarterly Minimum Data Set (MDS) dated 01/19/22 noted a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition. R36's Annual MDS dated 04/20/22 indicated that a BIMS was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 66 residents. The sample included 19 residents which four residents reviewed for activities. Based on observation, record review, and interviews, the facility failed to provide the needed dementia (progressive mental disorder characterized by failing memory, confusion) care and services for Resident (R) 1, which placed her at risk for increased behaviors, confusion. decline in ability to maintain the highest practicable mental and psychosocial well-being. Findings included: - R1's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 99, staff interview was completed and documented severely impaired cognition. The MDS documented that R1 was dependent of one…

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 66. The sample included 18 residents with five residents reviewed for unnecessary medications. Based on observations, interviews, and record reviews, the facility failed to provide reasoning for extended use with an as needed psychotropic medications (a class of medications which affect mood or thoughts) for Resident (R)36. The facility also failed to provide correct diagnosis for antipsychotic medication (class of medications used to treat psychosis and other mental emotional conditions) for R36. This deficient practice placed the residents at risk for ineffective treatment and unnecessary side effects. Findings Included: -The Medical Diagnosis section within R56's Electronic Medical Records (EMR) included diagnoses of hypertension (high blood pressure), muscle weakness, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), vascular dementia (progressive mental disorder characterized by failing memory, confusion), depression (abnormal emotional state characterized by exaggerated feelings of sadness,…

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.