Clearwater Nursing & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to provide infection control practices for Resident (R)16, when staff left her nebulizer mouthpiece (a device that changes liquid medication into a mist easily inhaled into the lungs) on the bed and left her BIPAP (-Bilevel Positive Airway Pressure is a noninvasive ventilation device that helps patients breathe by delivering two levels of air pressure: higher during inhalation and lower during exhalation) tubing, that was unattached from the oxygen concentrator (medical device that separates nitrogen from the air around you so you can breathe up to 95% pure oxygen), directly on the floor. Findings included:- R16's Electronic Medical Record (EMR) documented diagnoses of chronic obstructive pulmonary disease (COPD-a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and pleural effusion (abnormal accumulation of fluid in the lungs).The Quarterly Minimum Data Set (MDS),…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure staff possessed the skills and competencies required when Licensed Nurse (LN) G failed to prime a Humalog (rapid-acting hormone that lowers the level of glucose in your blood) Kwik Pen (a pre-filled, disposable insulin injection device). prior to administration to Resident (R)19. Findings included:- On 06/02/2026 at 10:13 AM, R19 ambulated in the hall with a walker. LN G asked R19 if she was ready to receive her insulin, and R19 replied yes and entered her room. LN G followed her in with a plastic container that held a Humalog, 100 UNIT/milliliter (ml) [NAME] Pen, LN G clicked up seven units of insulin in the pen, then, without priming the pen (a procedure which removes the air from the needle and cartridge that may collect during normal use, ensuring that the pen is working correctly), administered the insulin in R19's left arm. LN G verified she had not primed the insulin and stated she was unaware she was supposed to. Upon…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to label Resident (R)6 insulin (a hormone that lowers the level of glucose in the blood) flex pens when initially opened for use and when expired and failed to discard R43's insulin flex pen that had expired. This deficient practice placed the affected residents at risk for ineffective medications. Findings included:- On [DATE] at 08:30 AM, observation of the facility's treatment cart revealed the following:R6's Humalog (fast-acting insulin) FlexPen was not labeled with an open date or an expired date.R43's Lantus (long-acting insulin) flex pen was labeled with an opened date of [DATE] and an expired date of [DATE]. On [DATE] at 08:15 AM, Administrative Nurse D verified the nurses should label and date the insulin flex pens with the date opened and discard the expired insulin flex pens. Medlineplus.gov directs open, unrefrigerated Humalog and Lantus can be used within 28 days; after that time, they must be discarded. The facility's…

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

Based on observation, record review, and interview, the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff failed to change gloves and wash hands during incontinence care for Resident (R) 42. Staff also failed to store R12's breathing treatment mask and tubing in a sanitary manner. Findings included:1. On 06/01/26 at 10:00 AM, observation revealed R42 rested in bed on his back. Certified Nurse Aide (CNA) N and CNA O donned a gown and applied gloves and entered R42's room. R42 reported to the CNAs that he needed incontinence care due to having a bowel movement. CNA O gathered supplies, while CNA N pulled down the resident's pants and instructed him to turn onto his left side. Further observation revealed CNA N pulled down the brief in the back to reveal a moderate amount of stool covering the backside and his wound dressing area. CNA N removed the brief and dressing and provided peri-care to R42's buttock area, then instructed R42 to turn on his back. Further observation…

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 40 residents. The sample of seven residents included three residents reviewed for social/medically related social services. Based on observation, interview, and record review, the facility failed to provide care in a respectful and dignified manner for a dependent, cognitively impaired Resident (R)7 when staff shaved his beard off. Findings included:- R7's Electronic Health Record (EHR) documented diagnoses which included dementia (a progressive mental disorder characterized by failing memory and confusion) with psychotic (characterized by a gross impairment in reality and/or perception) disturbances, and failure to thrive. The 02/27/26 Entry Minimum Data Set (MDS) documented R7 admitted to the facility on [DATE]. R7's Discharge Return Anticipated MDS, dated 03/01/26, documented the resident was transferred to the hospital on [DATE]. R7's Baseline Care Plan, initiated on 02/27/28 and updated 02/28/26, informed staff that the resident had poor communication and comprehension. 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 had a census of 40 residents. Based on observation, interview, and record review, the facility failed to provide supervision, treatment, services, and physical well-being for Resident (R) 2, who had dementia (a progressive mental disorder characterized by failing memory and confusion) with intrusive wandering behaviors by going into R6, R4, R3, and R5's rooms uninvited. Findings included:R2's Electronic Medical Record (EMR) documented diagnoses of dementia, hypertension (high blood pressure), and unspecified protein-calorie malnutrition. R2's Quarterly Minimum Data Set (MDS), dated [DATE], documented that R2 had severe cognitive impairment, physical behavioral symptoms directed toward others, which occurred one to three days of the look back period, and wandered four to six days of the look back period. R2 used a wheelchair for mobility, was dependent with toileting, showering, and putting on and taking off footwear, required substantial/maximal assistance with upper and lower body dressing, lying…

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 40 residents. The sample included three residents reviewed for medications. Based on observation, record review, and interview, the facility failed to prevent significant medication errors for Resident (R) 1 who did not receive medications as ordered Additionally, the facility failed to notify the physician of the error. Findings included:- R1's Electronic Medical Records (EMR), documented diagnoses which included wound infection, osteomyelitis (local or generalized infection of the bone and bone marrow), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), renal failure (inability of the kidneys to excrete wastes, concentrate urine, and conserve electrolytes), and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). R1's 02/24/26 Medicare -5 Day Minimum Data Set (MDS) documented R1 had a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. R1 had an infection of the foot and a diabetic ulcer. R1 took…

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 47 residents; the sample included 10 residents with three residents sampled for accommodation of preferences. Based on observation, interview, and record review the facility failed to ensure staff acknowledged and implemented Resident (R)6's preferences related to receiving his medications after his meals. Findings included:- R6's undated Physician Orders, in the Electronic Health Record (EHR) included diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) with hyperglycemia (elevated blood sugar content in the blood), long term use of insulin (hormone replacement medication that regulates blood sugar), 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), chest pain, hypertension (high blood pressure), myocardial infarction (heart attack), atrial fibrillation (irregular heart…

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 47 residents. The sample included 10 residents, with six residents reviewed for abuse. Based on interview, and record review, the facility failed submit a completed investigation for allegations of resident-to-resident abuse to the State Agency within five working days as required for allegations involving Resident (R) 1 and R2 on 06/21/25 and R1 and R3 on 06/28/25.Findings Included:- The facility provided an initial report to the SA for a resident-to-resident involving R1 and R2 in Incident KS00196132 and for R1 and R3 in Incident KS00196270.R1's Progress Note on 06/21/25 at 03:08 AM documented staff witnessed R1 in the dining room with a female resident [R2]. The noted recorded staff witnessed both residents slapping each other on the arms, R1 grabbed the female resident's arm, and staff immediately intervened and separated the residents.R1's Progress Note on 06/28/25 at 11:03 AM, documented staff notified R1's representative that staff observed R1 touching a female resident in the genital area and R1 would be monitored on a one-to-one basis. 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.

The facility reported a census of 47 residents. The sample included 10 residents, with six residents reviewed for abuse. Based on interview, and record review, the facility failed to thoroughly investigate allegations of abuse for allegations involving Resident (R) 1 and R2 on 06/21/25 and R1 and R3 on 06/28/25.Findings Included:- The facility provided an initial report to the SA for a resident-to-resident involving R1 and R2 in Incident KS00196132 and for R1 and R3 in Incident KS00196270.R1's Progress Note on 06/21/25 at 03:08 AM documented staff witnessed R1 in the dining room with a female resident [R2]. The noted recorded staff witnessed both residents slapping each other on the arms, R1 grabbed the female resident's arm, and staff immediately intervened and separated the residents.The facility could not provide an investigation related to the 06/21/25 incident.R1's Progress Note on 06/28/25 at 11:03 AM, documented staff notified R1's representative that staff observed R1 touching a female resident in the genital area and R1 would be monitored on a one-to-one basis. The note…

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 43 residents. Based on observation, interview and record review, the facility failed to maintain a clean, comfortable and homelike environment throughout the facility for all residents of the facility, regarding four Residents (R)7, R 26, R 35 and R 145, who had no means to control the temperature of their rooms. Findings included: - During an environmental tour on 05/28/24 at 12:56 PM, four Residents (R)7, R26, R35 and R145, rooms were noted to have blankets laying over their vents. Additionally, the door to R145's room was being held open with a gait belt (a wide belt, usually made from canvas threads or rigid plastic, used to help transfer or stabilize a resident during activity) that was tied to the doorknob and to a handle on a dresser drawer. On 05/28/24 at 12:56 PM, Resident (R)26 stated he had to cover the vent to his room because he was unable to control the temperature of his room. A resident in a neighboring room had the thermostat in their room and it was too warm for R 26. On 05/29/24 at 08:30 AM, an observation of R135's room revealed…

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 43 residents. Based on interview and record review the facility failed to ensure adequate staffing to meet the needs of the residents of the facility. In 2023 the facility lacked 8-hour Registered Nurse (RN) coverage for 29 days, as reported by the facility. In 2023 the facility lacked 24-hour Licensed Nurse (LN) coverage for 127 days, about 35% of the year. This deficient practice affected all residents in the facility. (See the citations found on current recertification survey to include 4 IJ, harm, and subsequent Substandard Quality of Care.) Finding included: - During the annual survey, which began on 05/28/24, several residents reported issues involving lack of staff (Res ID and time of interview withheld for anonymity): 1. Staff do not respond to call lights promptly and said regularly they are not answered for over 45 minutes. 2. Staff do not answer call lights for 20-30 minutes on any shift and stated weekend staffing was slower. 3. Staff can be slow to respond and said they waited for 45 minutes for staff assistance with toileting. Review…

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 43 residents. Based on observations, interviews, and record review the facility failed to ensure 8-hour Registered Nurse coverage each day, as required, in order to meet the needs of the residents. This failure had the potential to negatively affect all residents in the facility and placed them at risk for decreased quality of life, treatment, and care. Finding included: - During the annual survey, which began on 05/28/24, several residents reported issues involving lack of staff. Review of the 2023 facility reported PBJ data revealed the following infraction dates representing dates the facility reported lack of required 8-hour Registered Nurse coverage in the facility: January: 3 days (16, 23, 29). February: 5 days (1, 5, 9, 25, 26). March: 3 days (4, 18, 25). April 2023: 6 days (2, 8, 15, 16, 29, 30). May 2023: 5 days (6, 7, 13, 14, 27). July 2023: 1 days (2). August 2023: 2 days (20, 27). November 2023: 4 days (16, 17, 23, 24). Of the 2023 8-hour RN infraction dates revealed: 2 on Monday, 1 on Wednesday, 12 on Saturday, and 13 on Sunday. Lack 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.

The facility reported a census of 43 residents. Based on observation, interview, and record review, the facility failed to serve the residents of the facility food, which was palatable, attractive, and served at the appropriate temperature. Findings included: - During an interview with Resident (R) 26 on 05/28/24 at 12:50 PM, the resident stated when staff delivered his meals to his room, the food was always cold. On 05/30/24 at 01:07 PM, the survey team requested a sample meal tray and Dietary Staff O delivered the meal tray. The vegetables on the meal tray were measured by Dietary Staff O and measured 122 degrees Fahrenheit (F), which was below the required serving temperature of 135 degrees F. On 05/30/24 at 01:07 PM, the survey team tasted the meal tray for palatability and determined that the vegetables were not palatable. Dietary Staff O also tasted and confirmed the vegetables were not palatable due to temperature and should be served at the appropriate temperature. The facility lacked a policy for palatable foods. The facility failed to serve the residents of 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 reported a census of 43 residents. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne illness. This deficient practice had the potential to negatively affect all the residents of the facility. Findings included: - During an initial tour of the kitchen on 05/28/24 at 08:20 AM, with Dietary Staff O, the following areas of concern were noted: 1. The main kitchen refrigerator contained three large, opened containers of sour cream which all lacked an open date. 2. The main kitchen refrigerator contained a small package of spoiled lettuce, wrapped in plastic wrap, with a date of 05/14/24. 3. The main kitchen refrigerator contained two large, opened containers of salad dressings which lacked an open date. 4. The main kitchen refrigerator contained a large container of cheese-pimento salad which lacked an open date. 5. The main kitchen refrigerator contained a small plastic bag with an unknown meat product which lacked…

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 43 residents. Based on observation, interview and record review, the facility failed to properly dispose of garbage and refuse by not ensuring the dumpster lid was always closed. Findings included: - On 05/28/24 at 08:20 AM, observation revealed the lid to the dumpster, used for garbage and refuse, contained a cover that sat in the open position on the back of the dumpster. On 05/28/24 at 08:20 AM, Dietary staff O stated she was unaware the dumpsters were part of the kitchen staff's responsibilities to ensure that they remained closed. On 06/06/24 at 01:50 PM, Administrative Nurse B stated that the expectation was for the lid on the dumpster to be in the closed position at all times and stated that she was aware of the regulatory requirement. The facility lacked a policy for ensuring the dumpsters lid was closed at all times. The facility failed to properly dispose of garbage and refuse by not ensuring the dumpster lid was closed at all times.

The facility identified a census of 43 residents. Based on observations, record reviews, and interviews the facility failed to put in place an effective administration who ensured the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident who resided at the facility. This deficient practice placed the residents at risk for decreased quality of care, quality of treatment, and sense of well-being. Findings included: - The facility failed to ensure an effective quality assessment and performance improvement (QAPI) program as evidenced by the number of deficient practices, elevated scope and severity, and substandard quality of care found onsite as followed. The facility failed to treat each resident with dignity, respect, and in a manner and environment that promoted the enhancement of resident's quality of life when the facility utilized Styrofoam containers for seven residents in their rooms for their meal trays. 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 reported a census of 43 residents. Based on observation, interview, and record review the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e. Payroll Base Journal (PBJ), related to licensed nursing staffing information, when the facility failed to accurately report Registered Nurse (RN) coverage on 29 dates between January 1, 2023 and 09/30/23. Findings Included: - Review of the Payroll Base Journal (PBJ) Staffing Data Report for fiscal year (FY), Quarter 2 2023 (January 1-March 31) revealed a lack of Registered Nurse (RN) coverage for eight hours every 24 hours on the following dates: On 01/16 Monday (MO), On 01/23, MO, On 01/29, Sunday (SU), On 02/01, Wednesday (WE), On 02/05, SU, On 02/09, Thursday (TH), On 02/25, Saturday (SA), On 02/26, SU On 03/04, SA On 03/18, SA On 03/25, SA Review of the PBJ for FY, Quarter 3, 2023 (April 1- June 30),…

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 43 residents. Based on the observations, interview, and record review obtained on the current survey IKSC11 and its numerous findings of deficient practice including 5 Immediate Jeopardy citations which constituted Substandard Quality of Care, and with several of the deficient practice areas noted as repeat citations from the prior survey, the facility failed to demonstrate an effective Quality Assurance and Performance Improvement (QAPI) program. This failure affected all 43 residents of the facility and placed them at risk for a decreased quality of life, decreased quality of care, and continued resident to resident abuse. (See all citations associated with IKSC11). Findings Included: - During the first day of the onsite recertification survey, 05/28/24, the surveyors discovered 4 Immediate Jeopardy (IJ) concerns which were not identified by the facility. The surveyors issued IJ templates to the facility for hazardous hot water temperatures (See finding at F689), for lack of preventing continued resident-to-resident abuse (See finding at F600),…

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 43 residents. Based on interview, observations, and record review, the facility failed to maintain an effective infection control program when laundry services failed to maintain a closed clean linen cart while delivering laundry, and further failed to maintain enhanced barrier precautions (infection control interventions designed to reduce transmission of resistant organisms which employs targeted gown and glove use during high contact cares) (EBP) when providing cares to a resident with a chronic wound. Findings included: - On 05/30/24 at 08:33 AM, observation revealed Laundry Aide X push a laundry cart down a hallway with the cover down, raised the cover, and delivered the laundry items to a resident's room, exited the room, performed hand hygiene. Laundry Aide X then delivered linens to a second resident's room and left the laundry cart in the hallway with a raised cover. Laundry Aide X stated they were unsure of whether or not linen carts were required to be covered when…

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 43 residents. Based on observation, interview, and record review, the facility failed to ensure dignity in resident dining when the facility served seven residents their meals in Styrofoam containers, due to a lack of plates, cups, and flatware, for residents who chose to eat in their room. Findings included: - On 05/30/24 at 09:02 AM, observation revealed dietary staff delivered a multi-tiered cart with Styrofoam containers of food to each hall. The Certified Nurse Aides (CNAs) on each hall then delivered each tray with styrofoam containers to the seven residents who chose to dine in their room. On 06/03/24 at 10:00 AM, Dietary Manager O stated that Styrofoam containers were used to deliver meals to the room prior to her hire, and she was in the process of ordering more plates, cups, and silverware to be able to provide actual plates and flatware to the residents who chose to eat in their rooms. Dietary Manager O stated there was an unknown supply chain problem with her supplier and they were having trouble obtaining enough plates for all of 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 census totaled 43 residents with 15 residents included in the sample. Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) for five sampled residents. Resident (R)1, related to hospice and medications on the Care Area Assessment (CAA), R30 related to accidents not addressed on the CAA, R32, related to dialysis and nutrition not addressed on the CAA, and R39, related to medications not addressed on section N on the MDS. These deficient practices had the potential to lead to uncommunicated need for care and services to meet each individual residents' needs. Findings included: - R1's electronic medical record (EMR) revealed the following diagnoses that included chronic atrial fibrillation (rapid, irregular heart beat), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), violent behavior, major depressive disorder (major mood disorder which causes persistent feelings pf…

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 - Resident (R) 3's Electronic Health Record (EHR) revealed diagnoses that included a pressure ulcer of right heel stage three (full thickness pressure injury extending through the skin into the tissue below), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and muscle weakness. The admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. R3 required maximal assistance with activities of daily living (ADL's lower dressing). Total dependence for transfers and toileting. Partial to moderate assistance with wheelchair mobility, bed mobility, personal hygiene, bathing, and upper body dressing. R3 was incontinent of bowel and bladder. The Quarterly MDS dated 03/29/24, documented a BIMS of 15. No changes in ADL's. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 01/02/24, documented the resident required assistance with functional…

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 43 residents with 15 residents sampled. Based on observation, interview, and record review, the facility failed to ensure the right of R22's representative to be informed of changes, when the resident had an increase in behaviors and staff placed R22 on one-to-one observation due to his behaviors. Findings included: - Review of Resident (R)22's Electronic Medical Record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion) with behaviors. The Significant Change Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed R22 had severe cognitive impairment. The resident was independent with ambulation. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 02/16/24, documented the resident had cognitive loss related to dementia. The Behavioral CAA, dated 02/16/24, documented the resident had behavioral symptoms related to daily wandering. The Quarterly MDS, dated 05/17/24, 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 43 residents with 15 residents included in the sample. Based on observation, interview, and record review, the facility failed to recognize a significant change in a resident's physical condition and perform a comprehensive Minimum Data Set (MDS) assessment within the required 14-day period. This deficient practice had the potential to lead to uncommunicated needs and placed the resident at risk of further deterioration of his physical, mental, and psychosocial well-being. (Resident (R) 30) Findings included: - R30's Electronic Health Record (EHR) included diagnoses of diabetes mellitus type 2 (DM2- when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), metabolic encephalopathy (condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), dementia (a progressive mental disorder characterized by failing memory, confusion), repeated falls, pain in [the] left hip…

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 43. The sample included 15 residents. Based on observation, record review, and interviews, the facility failed to revise the fall care plan with interventions for three residents. Resident (R)16, R24 and R30. This deficient practice placed all three residents at risk for impaired ability to achieve and/or maintain their highest practicable level of physical and emotional wellbeing due to uncommunicated care needs. Findings included: - R16's Electronic Health Record (EHR) revealed diagnoses of intermittent explosive disorder, bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), dementia (progressive mental disorder characterized by failing memory, confusion), and sexual dysfunction. The Significant Change Minimum Data Set (MDS) dated [DATE], documented staff completed an interview to determine the resident's cognition, which indicated he had moderately impaired cognition. No behaviors were noted on the assessment. R16 required…

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 43 residents with 15 residents included in the sample. Based on observation, interview, and record review, the facility failed to provide appropriate and timely Activities of Daily Living (ADLs) for one resident regarding untrimmed facial hair for one Resident (R)17. Findings included: - R17's Electronic Medical Record (EMR) revealed diagnoses that included acute and subacute infective endocarditis (inflammation of the muscles of the heart), and dysphagia (swallowing difficulty) following cerebral infarction (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). The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 08, indicating moderately impaired cognitive impairment. The resident required assistance of one staff with daily cares. The Activities of Daily Living (ADL Functional/ Rehabilitation Care Area Assessment (CAA)…

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 totaled 43 residents, with 15 included in the sample, and one resident reviewed for Hospice care. Based on observation, interview, and record review the facility failed to provide treatment and care in accordance with professional standards with the failure to coordinate resident care with hospice services. Findings included: - R1's electronic medical record (EMR) revealed the following diagnoses that included chronic atrial fibrillation (rapid, irregular heart beat), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and intermittent explosive disorder, delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue) hypertension (elevated blood pressure), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and hypothyroidism (condition characterized by decreased activity of the thyroid gland). The admission 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 identified a census of 43 residents, which included 15 residents sampled, and one resident reviewed for Dialysis. Based on interview, observation, and record review, the facility failed to develop a comprehensive person-centered care plan for Resident (R)32's related to hemodialysis (a procedure where impurities or wastes were removed from the blood) the resident received three times a week. This deficient practice had the potential to lead to uncommunicated needs regarding dialysis care which could lead to negative impacts on the resident's physical, mental and psychosocial well-being. Findings included: - R32's Electronic Health Record (EHR) included diagnoses of diabetes mellitus type 2 (DM2- when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), anemia (a condition without enough healthy red blood cells to carry adequate oxygen to body tissues), stage four chronic kidney disease (CKD - a disease characterized by progressive damage and loss 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 reported a census of 43 residents, with 15 residents in the sample, that included one resident reviewed for treatment/services/mental and psychosocial concerns. Based on observation, interview, and record review the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for Resident (R)39, who had a history of personal trauma and a diagnosis of post-traumatic stress disorder. This placed the resident at risk for impaired quality of life due to untreated and ongoing mental health concerns. Findings included: - Resident (R)39's Electronic Health Record (EHR) revealed diagnoses that included metabolic encephalopathy (broad term for any brain disease that alters brain function or structure), post-traumatic stress disorder (PTSD a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback 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 census totaled 43 residents with 15 residents included in the sample, that included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to follow up on pharmacy recommendations in a timely manner for one Resident (R)1, regarding as needed lorazepam (a medication used for severe agitation) to obtain a new prescription every 14 days, to minimize or prevent adverse consequences related to medication therapy. Findings include: - R1's electronic medical record (EMR) revealed the following diagnoses that included chronic atrial fibrillation (rapid, irregular heart beat), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), violent behavior, major depressive disorder (major mood disorder which causes persistent feelings pf sadness), intermittent explosive disorder, delusional disorder (untrue persistent belief or perception held by a person although evidence shows it 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 census totaled 43 residents with 15 residents included in the sample, that included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure two Residents (R) 1, regarding as needed lorazepam (a medication used for severe agitation) and R24, regarding failure to monitor the use of an antipsychotic medication (medication used to treat psychosis). Findings include: - R1's Electronic Medical Record (EMR) revealed the following diagnoses that included chronic atrial fibrillation (rapid, irregular heart beat), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), violent behavior, major depressive disorder (major mood disorder which causes persistent feelings pf sadness), intermittent explosive disorder, delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue) and personality disorder. The admission Minimum Data…

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 44 residents. Based on observation, interview, and policy review, the facility failed to store, prepare, and serve food under sanitary conditions for the residents of the facility. Findings included: - During the initial tour of the kitchen on 11/01/22 at 08:20 AM Dietary Staff BB stated that items in dry storage were to be used or discarded within 30 days after opening. Bulk storage of sugar and flower were usable for 60 days after opening. Items in the refrigerator were usable for 30 days after opening. Items in the freezer were usable for 60 days after opening. States that staff has been instructed to write the date received or opened on all food packages. An observation of the kitchen 11/01/22 at 08:22 AM revealed the following areas/items with concerns: 1. Eight hardened plastic cutting boards of various sizes all had deep gouges in the surface. One cutting board had dried food adhered to the surface. 2. A covered tub of cornbread muffins, on a wire rack in the kitchen, lacked a date. 3. In the side-by-side refrigerator in the kitchen Dietary…

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 44, with 12 residents sampled. Based on observation, interview, and record review the facility failed to verify Resident (R)195's advanced directives (a legal document in which a person specified what actions should be taken for their health, which may or may not include a do not resuscitate [DNR-decision whether or not to withhold medical intervention in the even the resident's heart stops] order), Findings included: - Review of the Physician Orders in R195's Electronic Health Records (EHR) on 11/01/22 at 03:00 PM documented no DNR order. Further review of the resident's EHR home screen lacked any information regarding advanced directives or R195's DNR status. Review of the scanned documents in the EHR revealed a DNR order signed by R195's Durable Power of Attorney (DPOA) and witness but lacked a signature from the resident's physician. An interview with R195's DPOA on 11/02/22 at 02:20 PM, revealed the resident had a DNR and provided an unsigned paper copy of the DNR. An interview on 11/08/22 at 01:25 PM with Social Services Designee (SSD) X…

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 44 residents. The sample of 12 included two residents sampled for hospitalization. Based on observation, interview and record review, the facility failed to send a copy of the facility-initiated hospitalization transfer/discharge notice to the representative of the Office of the State Long- Term Care Ombudsman as required the two sampled residents, Resident (R)44 and R18 who discharged to the hospital. Findings included: - The Progress Notes dated 05/08/22 for R 44 revealed the resident went to the hospital for complaint of right wrist pain due to fall in the dining room. R44's medical record revealed the resident discharged to an Assisted Living facility, on 10/01/22 at 09:16 AM On 11/3/22 at 04:00 PM, interview with Social Service Staff X confirmed she did not transmit the resident's hospitalization notice to the Ombudsman from 09/01/22 to 10/19/22. Interview, on 11/3/22 at 04:42 PM, with Administrative Staff A indicated the SSD had not been aware that notification to the Ombudsman needed to be transported monthly which includes hospitalization…

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 44 with 12 residents sampled for review. Based on observation, interview, and record review the facility failed to complete a comprehensive assessment of the resident's functional capacity, within 14 days of admission, for one of the sampled residents Resident (R)145, to ensure the resident received required care assistance by the staff. Findings included: Resident (R )145's Electronic Health Record) (EHR) revealed the resident admitted to the facility on [DATE], with diagnoses including aphasia, diastolic heart failure, COPD, GERD, MDD, and seizures. Further review of the EHR for the resident's Minimum Data Set Assessment, (MDS), revealed the admission of 10/14/22 and as of 11/1/22, staff failed to start a comprehensive admission assessment MDS for this resident. The areas on the form contained N/A indicating not applicable. The EHR documented that the resident had allergies listed as no known drug allergies and also had Black Box Warning (BBW) included per Federal Drug…

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 44 residents with 12 selected for review. Based on interview and record review the facility failed to develop a baseline care plan within 48 hours of admission to the facility to include the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care, for two of the 12 sampled Resident (R) 145 and R195, to ensure person centered cares provided by staff to the residents. Findings Include: - R145's pertinent diagnoses from the Electronic Health Record (EHR) documented: heart failure (a condition with low heart output and the body becomes congested with fluid), Chronic Obstructive Pulmonary Disease (COPD progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and seizures (violent involuntary series of contractions of a group of muscles). The resident admitted to the facility on [DATE]. On 11/02/22 at 09:09 AM staff enter R145's room and using…

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 43 residents with 12 residents included in the sample, and one resident reviewed for discharge. Based on interview and record review the facility failed to document a recapitulation summary of the one sampled resident's stay upon discharge, Resident R 42. Findings included: - The Physician Orders dated 08/04/22 revealed the following diagnoses: chronic pain (persisting for a long period, often for the remainder of a person's life) and chronic obstructive pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The admission Minimal Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) with a score of 15 indicated intact cognition. R42 required the following assistance with Activities of Daily Living (ADL) total dependence with two or more person for bed mobility and transfers. Dressing, toilet use, and personal hygiene required total dependence with one person's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 44 residents. The 12 residents selected for review included two reviewed for personal hygiene care needs. Based on observation, interview, and record review the facility failed to provide necessary services to maintain good grooming for the two sampled Residents (R) 145 and R25. Findings Include: - R145's pertinent diagnoses from the Electronic Health Record (EHR) documented: heart failure (a condition with low heart output and the body becomes congested with fluid), Chronic Obstructive Pulmonary Disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and seizures (violent involuntary series of contractions of a group of muscles). As of 11/01/22 the staff failed to start the admission Minimum Data Set (MDS) for R145. As of 11/01/22 the staff failed to document the Care Plan for R145. The EHR documented R145 admitted to the facility on [DATE]. The shower record in the EHR revealed staff assisted…

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 44 residents with 12 residents in the sample. Based on observation, interviews, and record review the facility failed to monitor with weekly wound assessments as ordered for one sampled Resident R 18's, decubitus ulcer on the right and left ischial area (a bone that makes up the bottom of the pelvis). Findings included: - Review of the Physician Orders dated 08/15/22 revealed the following diagnoses: agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), chronic pain syndrome (persisting for a long period, often for the remainder of a person's lifetime), depression (abnormal emotional state characterized by exaggerated feeling of sadness and emptiness), paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk). Review of the admission Minimum Data Set dated 01/10/22 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The Activities of Daily Living (ADL) indicated R18 required total dependence with bed mobility, transfer 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.

The facility census was 44. The 12 residents sampled included one for smoking safety. Based on observation, interview, and record review, the facility failed to ensure the one sampled Resident (R)32, remained as safe as possible from smoking accident hazards. Findings included: - R32's pertinent diagnoses from the Electronic Health Record (EHR) documented: schizoaffective disorder, bipolar type (a psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought with severe high and low moods). The 07/22/22 Quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The resident required physical assistance of two or more persons for all activities of daily living (ADLs) except eating. The 10/27/21 Annual MDS documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident required physical assistance of two or more persons for all activities of daily living (ADLs) except eating. The 08/01/22 Care Plan…

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 44 residents with 12 sampled including one reviewed for respiratory care. Based on observation, interview, and record review the facility failed to ensure oxygen tubing stored in a sanitary manner for the one sampled Resident (R) 145, to prevent respiratory infections. Findings included: - R145's pertinent diagnoses from the Electronic Health Record (EHR) documented: heart failure (a condition with low heart output and the body becomes congested with fluid), Chronic Obstructive Pulmonary Disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and seizures (violent involuntary series of contractions of a group of muscles). The EHR documented that R145 used oxygen. The EHR lacked instructions to change the oxygen tubing on a weekly basis. An observation on 11/02/22 at 09:09 AM, revealed R145 sitting up in her wheelchair. R145's oxygen (O2) tubing was coiled directly on the floor with the cannula hanging over the concentrator. Both the humidifier water bottle and 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.

The facility census totaled 44 residents, with 12 residents sampled, including five for unnecessary medications. Based on interview, and record review the facility failed to ensure adequate follow up on the consultant pharmacist recommendations related to medications for one of the five sampled residents, Resident (R) 26. This failure placed the resident at risk for adverse effects related to medication use. Findings include: - The Electronic Health Record (EHR) documented R26 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), urinary incontinence (involuntary passage of urine), and major depressive disorder (major mood disorder). The 12/11/21 Annual Minimum Data Set (MDS), documented a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. R26 had verbal behaviors towards others that interfered with care and activities, as well as disrupted privacy of others and the living environment. The assessment documented the use of an antidepressant medication daily in the seven-day look back…

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.