Sunset Home INC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 39 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 10 had physician-ordered fluid intake, which placed R10 at risk of ongoing urinary tract infections. Findings included: - R10's Electronic Medical Record (EMR) included diagnoses of heart failure, weakness, intellectual disabilities (a significantly below-average score on a test of mental ability or intelligence and limitations in the ability to function in areas of daily life), neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and chronic (persisting for a long period) kidney disease. The Quarterly Minimum Data Set (MDS) dated [DATE], documented R10 had intact cognition, no signs or symptoms of delirium…

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 39 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 10 had physician-ordered fluid intake, which placed R10 at risk of ongoing dehydration and urinary tract infections. Findings included: - R10's Electronic Medical Record (EMR) included diagnoses of heart failure, weakness, intellectual disabilities (a significantly below-average score on a test of mental ability or intelligence and limitations in the ability to function in areas of daily life), neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and chronic (persisting for a long period) kidney disease. The Quarterly Minimum Data Set (MDS) dated [DATE], documented R10 had intact cognition, no signs or symptoms…

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 39 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility's consultant pharmacist failed to notify the director of nursing or R34's physician of the lack of monitoring R34's blood pressure as the physician ordered to monitor the effectiveness of her medication, placing R34 at risk of receiving unnecessary medication. Findings included: - R34's Electronic Medical Record documented diagnoses of hypertension (HTN - elevated blood pressure), transient cerebral ischemic attack (TIA - temporary episode of inadequate blood supply to the brain), and anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R34 received antidepressant (class of medications used to treat mood disorders), diuretic (medication to promote the formation 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 39 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to monitor Resident (R)34's blood pressure as the physician ordered to monitor the effectiveness of her medication. This deficient practice placed R34 at risk of receiving unnecessary medication. Findings included: - R34's Electronic Medical Record documented diagnoses of hypertension (HTN - elevated blood pressure), transient cerebral ischemic attack (TIA - temporary episode of inadequate blood supply to the brain), and anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R34 received antidepressant (class of medications used to treat mood disorders), diuretic (medication to promote the formation and excretion of urine), and opioid (narcotic) medications. 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 36 residents. Based on record review and interview, the facility administration failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for the 36 residents who reside in the facility which placed all residents at risk for decreased health and wellbeing. Findings included: - The facility failed to ensure staff provided cardiopulmonary resuscitation (CPR) to Resident (R) 41, who desired resuscitative measures indicated by his full code status (code status determination for residents who wish to receive CPR). On [DATE] at 05:00 PM, Licensed Nurse (LN) G observed R41 with irregular respirations. At 05:10 PM, LN G checked on R41 again and identified R41 had no pulse or respirations. Without considering R41's code status or initiating CPR, LN G placed a call to R41's representative, who did not answer. LN G then called Administrative Nurse E who informed LN G that R41 was a full code and directed…

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 36 residents. The sample included 15 residents. Based on record review and interview, the facility's Quality Assessment and Assurance (QAA) program failed to provide good faith efforts to identify multiple issues of concern. This placed the residents at risk for decreased quality of care and life. Findings included: - The facility failed to provide mail service on Saturdays. Refer to F576. The facility failed to complete Care Area Assessment Summaries. Refer to F636. The facility failed to develop a comprehensive care plan for accidents. Refer to F656. The facility failed to review and revise care plan for safe transfers. Refer to F657. The facility failed to provide cardiopulmonary resuscitation (CPR) in a timely manner, and failed to maintain a system to verify CPR certifications for licensed staff. Refer to F678. The facility failed to provide safe transfers and accident prevention. Refer to F689. The facility failed to ensure competent nursing staff. Refer to F726. The facility failed to act on recommendation from the Registered Pharmacist. Refer to…

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

The facility had a census of 36 residents. The sample included 15 residents. Based on record review and interview, the facility lacked evidence the required committee members attended the Quality Assessment and Assurance (QAA) Committee quarterly meetings. This placed the residents who resided in the facility at risk for decreased quality of care. Findings included: - On 07/11/23 at 10:30AM, the facility's Quality Assurance Performance Improvement (QAPI) meeting attendance sheets lacked signatures of attendees/committee members on the sheets. The sheets had just a Yes or No placed by the typde name of members who allegedly attended the meetings. On 07/11/23 at 10:30AM, Administrative Staff A stated the facility used to sign in for meetings but they now documented Yes or No if member attended meeting on an electronic form. She confirmed the facility did not document proof or signatures. Upon request the facility did not provide a QAPI policy. The facility failed to retain evidence the required QAA and QAPI members attended meetings at least quarterly which placed residents at risk 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 had a census of 36 residents. The sample included 15 residents. Based on record review and interview the facility failed to provide a sanitary environment to help prevent the development and transmission of communicable disease and infections when the facility failed to develop a water management plan to minimize the risk for development of Legionella (type of bacteria that can cause serious lung infections) or other waterborne pathogens (agents that cause disease or infection) from entering the facility water system. Findings included: - On 07/11/23 at 07:44 AM, when asked to see the facility's water management plan, Maintenance Staff (MS) U stated he had never heard of Legionella disease. On 07/11/23 at 10:11 AM, Administrative Staff A stated she was unaware of any facility system or plan in place for water management to minimize the risk for developing Legionella. Administrative Staff A stated the city tested the city water. Upon request the facility failed to provide a policy regarding Legionella. The facility failed to develop a water management plan for detecting…

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 36 residents. The sample included 15 residents. Based on interview and record review the facility failed to provide an designated and certified Infection Preventionist (IP) to manage and monitor the facility's Infection Prevention and Control Program (IPCP) for the 36 residents who resided in the facility. This placed the residents at risk for infections and health problems. Findings included: - On 07/05/23 at 12:30 PM, Administrative Staff A stated the facility had no certified IP to provide oversight and monitor the facility's IPCP in the facility. Administrative Staff A stated she was enrolled in the IP program but had not completed it. Upon request the facility failed to provide a policy regarding IP. The facility failed to provide an IP who held the required certification to manage and monitor the facility's Infection Prevention and Control Program for the 36 residents who resided in the facility. This placed the residents at risk for infections and health problems.

The facility had a census of 36 residents. The sample included 15 residents. Based on record review and interviews, the facility failed to fully complete comprehensive Minimum Data Set (MDS) assessment Section V, Care Area Assessment Summary (CAA) for Resident (R) 7, R23, R3, R28, and R93 to include an analysis and rationale for care planning decisions. This placed these residents at risk for not accurately reflecting each resident's status and needs to develop an individualized comprehensive plan of care. Findings included: - R7's admission MDS with assessment reference date (ARD) of 01/27/23 Section V Care Area Assessment (CAA) was not completed. R23's Annual MDS with ARD of 11/02/22 Section V CAA was not completed. R3's Annual MDS with ARD of 10/27/22 Section V CAA was not completed. R28's admission MDS with ARD of 02/07/23Section V CAA was not completed. R93's admission MDS with ARD of 06/12/23 Section V CAA was not completed. The Resident Assessment Instrument Manual version 3.0 states, the CAA process provides a framework for guiding the review of triggered areas, 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 36 residents. The sample included 15 residents with one closed record for death reviewed. Based on record review and interview the facility failed to ensure licensed nurses possessed the knowledge and skills to provide cardiopulmonary resuscitation (CPR) for Resident (R) 41, who desired resuscitative measures indicated by his full code status. This placed the full code status residents at risk for receiving inadequate resuscitative measures. Findings included: - R41's Electronic Medical Record (EMR) documented R41 had diagnoses of depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), polyneuropathy (nerve disease, that affects many nerves), and dependence on wheelchair for mobility. R41's Quarterly Minimum Data Set (MDS), dated [DATE], documented R41 had a Brief Interview of Mental Status (BIMS) score 14, which indicated intact cognition. The MDS documented R41 required extensive staff assistance with activities of daily…

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 36 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to assess and record the refrigerator temperatures in the medication room and failed to discard an expired medication in the same refrigerator. This placed the residents who received medications from the refrigerators at risk for receiving less potent or unintended effects from the medications. Findings included: - On 07/06/23 at 02:54 PM, observation in the medication room refrigerator revealed a one-half full box of bisacodyl (laxative )suppositories that expired 03/2023. On 07/06/23 at 02:54 PM, Certified Medication Aide (CMA) S verified the above finding and stated she would discard the suppositories in the trash. CMA S stated night shift was responsible for checking outdates (expiration dates) in the medication room. Review of the medication room refrigerator temperature logs revealed the following: April 2023- lacked documentation on 13 days. May 2023- lacked documentation on 14 days. June 2023- lacked documentation on 14 days.…

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 36 resident. The sample included 15 residents. Based on observation, record review and interview the facility failed to complete a Significant Change Minimum Data Set (MDS) for Resident (R)25 who had a change in activities of daily living (ADL). This placed the resident at risk for unidentified care needs. Findings included: - R25's Electronic Medical Record (EMR) documented he had diagnoses of unspecified dementia with behavioral disturbance (impaired cognition, anxiety, agitation), chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe), convulsions (muscles contract and relax quickly and cause uncontrolled shaking of the body), and Parkinson's disease (a disorder of the central nervous system that affects movement, often causing tremors). R25's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident was severely cognitively impaired. The MDS documented R25 transferred and ambulated independently 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 36 residents. The sample included 15 residents with two reviewed for accidents. Based on observation, record review, and interview the facility failed failed to develop a plan of care with meaningful fall prevention interventions for Resident (R)29 who had two falls. This placed the resident at increased risk for falls and fall-related injury. Findings included: - R29's Electronic Medical Record (EMR) documented R29 had diagnoses of intellectual disability, localized (one area) edema (swelling resulting from an excessive accumulation of fluid in the body tissues), and venous insufficiency (a condition in which the flow of blood through the veins is blocked, causing blood to pool in the legs). R29's Quarterly Minimum Data Set (MDS), dated [DATE], documented R29 had a Brief Interview of Mental Status (BIMS) of 10, which indicated moderately impaired cognition. The MDS documented R29 required extensive staff assistance with activities of daily living (ADLs) except supervision with…

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 36 residents. The sample included 15 residents. Based on observation, record review and interview the facility failed to revise Resident (R) 25's care plan for accidents. This placed the resident at risk for injury related to uncommunicated or unmet care needs. Findings included: - R25's Electronic Medical Record (EMR) documented he had diagnoses of unspecified dementia with behavioral disturbance (impaired cognition, anxiety, agitation), chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe), convulsions (muscles contract and relax quickly and cause uncontrolled shaking of the body), and Parkinson's disease (a disorder of the central nervous system that affects movement, often causing tremors). R25's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident was severely cognitively impaired. The MDS documented R25 transferred and ambulated independently and required minimal assistance with transfers.…

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 36 residents. The sample included 15 residents. Based on observation, record review, and interview the facility failed to provide adequate assistance and safety with transfers for Resident (R) 25 and failed to identify and implement interventions to prevent falls for R29 who had two falls. This placed the residents at risk for future falls and related injury. Findings included: - R25's Electronic Medical Record (EMR) documented he had diagnoses of unspecified dementia with behavioral disturbance (impaired cognition, anxiety, agitation), chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe), convulsions (muscles contract and relax quickly and cause uncontrolled shaking of the body), and Parkinson's disease (a disorder of the central nervous system that affects movement, often causing tremors). R25's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident was severely cognitively impaired. The 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 The facility had a census of 36 residents. The sample included 15 residents, with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to implement a process to acknowledge and respond to the Consultant Pharmacist (CP) recommendation for an appropriate indication for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing) for Resident (R) 25. This deficient practice placed the resident at risk for unnecessary psychotropic (alters mood or thought) medications. Findings included: - R25's Electronic Medical Record (EMR) documented he had diagnoses of unspecified dementia with behavioral disturbance (impaired cognition, anxiety, agitation), chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe), convulsions (muscles contract and relax quickly and cause uncontrolled shaking of the body), and Parkinson'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 had a census of 36 residents. The sample included 15 residents, with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing) for Resident (R) 25's This deficient practice placed the resident at risk for unnecessary psychotropic (alters mood or thought) medications. Findings included: - R25's Electronic Medical Record (EMR) documented he had diagnoses of unspecified dementia with behavioral disturbance (impaired cognition, anxiety, agitation), chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe), convulsions (muscles contract and relax…

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 29 residents. The sample included 12 residents. Based on observation and interview, the facility staff failed to store, distribute, and serve food in accordance with professional standards in 1 of 1 facility kitchens when staff touched a trash can lid, touched other objects, and continued to serve residents with the same contaminated gloves, when staff placed three different types of meat in the same container to thaw, and failed to label ice cream with an expiration date. This placed the 29 residents who resided in the facility and received meals from the facility kitchen at risk for acquiring a food borne illness. Findings included: - 01/04/22 at 08:58 AM, observation revealed in the walk-in refrigerator, in the kitchen, a package of ham slices, a 12 ounce (oz) package of bologna, and a 32 oz package of sliced turkey breast thawing in the same pan. On 01/04/22 at 08:58 AM, observation revealed in the snack refrigerator four strawberry, two chocolate, two vanilla, and two orange containers of ice cream without an expiration date. On 01/05/22 at 11:20…

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

The facility had a census of 29 residents. The sample included 12 residents with four reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on record review and interview, the facility failed to provide form CMS 10055, Advanced Beneficiary Notice (ABN), which included the estimated cost for continued services for skilled services to the resident or their representative for the four residents, Resident (R) 24, R82, R83, and R84. This deficient practice placed all four residents at risk for uninformed decisions and unanticipated costs related to skilled services. Findings included: - The Medicare ABN form informed the beneficiaries that Medicare may not pay for future skilled therapy and did not provide an estimated cost to continue their services. The form included an option for the beneficiary to (1) receive specified services listed, and bill Medicare for an official decision on payment. I understand if Medicare does not pay, I will be responsible for payment, but can appeal to Medicare. (2) receive therapy listed, but do not bill…

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 29 residents. Based on observation, record review, and interview the facility failed to prepare four residents' pureed diets by methods that conserve nutritive value when staff failed to measure ingredients and serving sizes for each residents' plate, placing the residents at risk for nonnutritive food items and inappropriate serving size of each food item. Findings included: - On 01/06/22 at 11:03 AM Dietary Staff (DS) CC stated the facility had four pureed diets of meat. Further observation revealed DS CC placed three 4 ounce (oz) servings of broccoli into a blender container, poured an unmeasured amount of hot water from the dispenser into the blender and blended the ingredients together, to make the consistency of pudding. Observation revealed DS CC poured the unmeasured ingredients onto three divided plates. DS CC placed four (4 oz) chicken fried steaks into a clean blender container, added unmeasured beef broth into the container and blended to consistency of pudding. Further observation revealed DS CC poured the unmeasured pureed chicken fried…

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 29 residents. The sample included 12 residents with six reviewed for activities of daily living (ADLs). Based on observation, record review, and interview the facility failed to provide Resident (R) 7 with the appropriate fitted shoes, placing him at risk for falling. Findings included: - The Electronic Medical Record (EMR), documented R7 had diagnoses of generalized muscle weakness, abnormalities of gait and mobility, and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain). R7's Annual Minimum Data Set (MDS), dated [DATE], documented the resident had short and long term memory problems, independent with ADLs except supervision with eating. R7's MDS documented it was very important to him to choose what clothes to wear. R7's ADL Care Area Assessment (CAA) documented R7 used a cane when ambulating. R7's ADL Care Plan, revised on 10/20/21, documented the resident independent with dressing but may require staff supervision to ensure the task is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 29 residents. The sample included 12 residents with one reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to provide the resident or resident representative with written information regarding the facility bed hold policy, when Resident (R) 8 was transferred to the hospital. This placed R8 at risk for not being permitted to return and resume residence in the nursing facility. Findings included: - R8's Electronic Medical Record (EMS) documented the resident had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance, hallucinations (sensing things while awake that appear to be real, but the mind created), and age related cognitive decline. R8's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) score of two, which indicated severe cognitive impairment. R8's MDS documented the resident required extensive…

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 29 residents. The sample included 12 residents with one reviewed for nutrition. Based on observation, record review, and interviews the facility failed to implement the Registered Dietician's (RD) recommendations for Resident (R) 13, who had a documented weight loss. On 11/19/21 the RD recommended to increase R13's Med Pass 2.0 (a high calorie nutritional supplement) from 60 milliliters (ml) three times daily to 120 ml three daily in response to a 4.11 percent (%) unintended weight loss in 43 days. The facility failed to implement the recommendation until 01/06/22 at which time R13 had a significant weight loss of 11.47 % in three months. Findings included: - R13's Electronic Medical Record (EMR) listed diagnoses of mild cognitive impairment, weakness, frontotemporal dementia (group of brain disorders that primarily affect the frontal and temporal lobes of the brain which are generally associated with personality, behavior and language), and functional dyspepsia (indigestion). R13'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 had a census of 29 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's Consultant Pharmacist failed to report to the Director of Nursing, physician, and medical director the failure to identify an inappropriate diagnosis and monitor behaviors for the use of an antipsychotic medication (class of medications used to treat any major mental disorder characterized by a gross impairment in reality testing and other mental emotional conditions) for one of five sampled residents, Resident (R) 22. This placed R22 at risk for adverse side effects. Findings included: - R22's Physician Order Sheet, dated 12/01/21, recorded the diagnoses of dementia with behavioral disturbance (agitation, wandering, verbal and physical aggression). The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R22 had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. The 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.

The facility had a census of 29 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to identify an inappropriate diagnosis and monitor behaviors for the use of an antipsychotic medication (class of medications used to treat any major mental disorder characterized by a gross impairment in reality testing and other mental emotional conditions) for one of five sampled residents, Resident (R) 22. This placed R22 at risk for adverse side effects. Findings included: - R22's Physician Order Sheet, dated 12/01/21, recorded the diagnoses of dementia with behavioral disturbance, (agitation, wandering, verbal and physical aggression). The Quarterly Minimum Data Set (MDS) , dated 12/10/21, recorded R22 had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. The MDS recorded the resident required moderate assistance with bed mobility and transfers. The MDS further recorded R22 received antipsychotic medication on a daily basis. The Care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 29 residents. The sample included 12 residents with one reviewed for hospice services. Based on observation, record review and interview, the facility failed to establish and document routine communication between the hospice provider and facility staff which included a plan of care available to facility staff directing what services, equipment, and medication were provided to Resident (R) 21, placing him at risk for delayed or inadequate cares due to lack of communication and/or collaberation between facility staff and hospice care providers. Findings included: - R21's Electronic Medical Record (EMR) documented the resident had diagnoses of acute kidney failure (condition when an abrupt reduction in kidneys' ability to filter waste products occurs within a few hours or a few days), occlusion and stenosis of carotid artery (narrowing of the blood vessels (carotid arteries) in the neck restricting the blood flow to brain and head), and bradycardia (slow heart rate). The Quarterly…

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