Easton Health Care Center

The facility identified a census of 37 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to develop and implement the core elements of antibiotic stewardship to ensure an effective infection prevention and control program including antibiotic stewardship for the residents of the facility. Findings included: - Review of the Infection Control Log for tracking and trending infections from February 2023 through January 2024, lacked evidence of organism identifications, duration of antibiotic prescribed, and the infections treated. The facility was unable to provide evidence of tracking upon request. On 02/28/2 at 10:41 AM, Administrative Nurse E, the facility Infection Preventionist, stated she reviewed the results of any culture and sensitivities but did not track the results. Administrative Nurse E stated she or the charge nurse completed the Mcgeer's and Lobe's criteria after a urine analysis was obtained. The facility's Antibiotic Stewardship Program last reviewed in November 2023 documented it was the policy 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 37 residents. The sample included 12 residents and three Certified Nurse Aides (CNAs) reviewed for in-service training. Based on record review and interview, the facility failed to ensure the four CNA staff reviewed had the required 12 hours of in-service education including the required topics per year. This placed the residents at risk for inadequate care. Findings included: - A review of the facility's in-service records revealed the following: CNA O hired on 06/18/21 had documentation that showed in-services in the past 12 months but lacked any recorded/documented hours of in-service. CNA P hired 09/05/22, had documentation that showed in-services in the past 12 months but lacked any recorded/documented hours of the in-service. CNA Q hired 08/04/20 had documentation that showed in-services the past 12 months but lacked recorded/documented hours. The facility provided the form Annual In-Service Calendar which listed the required in-services for each month and the duration of each training which totaled 42.5 hours annually. On 02/28/24 at 09:00 AM…

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 37 residents. The sample included 12 residents with five reviewed for immunization status. Based on record reviews, and interviews, the facility failed to obtain consent or declinations for influenza (highly contagious viral infection that attacks the lungs, nose, and throat and can be deadly in high-risk groups) vaccination for Resident (R) 22 and R35. The facility also failed to offer or obtain declinations for pneumococcal (type of bacterial infection) vaccination consents, declinations, or administration information for R22, R35, R17, and R32. This placed the residents at increased risk for influenza, pneumonia, and related complications. Findings included: - R22 was admitted to the facility on [DATE]. R22's clinical record lacked documentation the influenza vaccine or pneumococcal vaccine was offered or declined and lacked documentation of a historical administration. Upon request for R22's declination or administration of influenza vaccine or pneumococcal vaccine, 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 identified a census of 37 residents. The sample included 12 residents with two residents reviewed for hospitalization. Based on record review and interviews, the facility failed to provide written notice of transfer with the required information to Resident (R) 139 and/or to their legal representative in a practicable amount of time. The facility also failed to send a notification to the Office of the State Long-Term Care Ombudsman of the facility's transfers and discharges. This deficient practice had the risk of miscommunication between the facility and the residents and possible missed opportunities for healthcare service for these residents. Findings included: - R139's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hypertension (HTN-elevated blood pressure), dementia (a condition characterized by progressive or persistent loss of intellectual…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 37 residents. The sample included 12 residents with two residents reviewed for hospitalization. Based on record review and interviews, the facility failed to provide a bed hold notice when Resident (R) 139 was hospitalized . This deficient practice placed R139 at risk of uninformed choices. Findings included: - R139's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hypertension (HTN-elevated blood pressure), dementia (a condition characterized by progressive or persistent loss of intellectual functioning), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and falls. A review of R139's EMR revealed she was admitted on [DATE]. R139's admission Minimum Data Set (MDS) dated 01/21/24 documented a Brief Interview of Mental Status (BIMS) score of 10 which indicated moderately…

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 37 residents. The sample included 12 residents with one resident reviewed for a baseline care plan. Based on record review and interviews, the facility failed to develop a person-centered baseline care plan to include pressure relieving measures to prevent pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) for Resident (R) 139. This deficient practice placed R139 at risk of impaired care related to uncommunicated care needs. Findings included: - R139's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hypertension (HTN-elevated blood pressure), dementia (a condition characterized by progressive or persistent loss of intellectual functioning), anxiety (mental or emotional reaction characterized by…

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 37 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 30's comprehensive care plan was updated to reflect what services and/or equipment were provided by the hospice within the required seven days after completion og the comprehensive assessment. The facility also failed to update R22's Care Plan to address catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) use and care. This placed these residents at risk of impaired care due to uncommunicated care needs. Findings included: - The electronic medical record (EMR) for R30 documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and dementia (progressive mental disorder characterized by failing memory, and confusion) with mood disturbance. The Significant Change Minimum Data Set (MDS) dated 01/16/24…

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 37 residents. The sample included 12 residents. with two residents reviewed for treatment/services to prevent/heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction) Based on record review and interviews, the facility failed to ensure pressure reducing measures were in place for Resident (R) 139 who developed deep tissue injuries on her bilateral heels. This deficient practice placed R139 at risk of development of pressure ulcers, and of wound worsening. Findings included: - R139's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hypertension (HTN-elevated blood pressure), dementia (a condition characterized by progressive or persistent loss of intellectual functioning), anxiety (mental or emotional…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 37 residents. The sample included 12 residents with three residents reviewed for limited range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension). Based on observation, record review, and interviews, the facility failed to provide ROM to help maintain and prevent a potential decrease in ROM/mobility for Resident (R) 20. This deficient practice placed R20 at risk of loss of ability to perform activities of daily living (ADLs) and worsening or development of contractures (abnormal permanent fixation of a joint or muscle). Findings included: - R20's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of contracture of right and left knees, dementia (a progressive mental disorder characterized by failing memory, and confusion), major depressive disorder (major mood disorder which causes persistent feelings of sadness) and anxiety disorder (mental or emotional reaction characterized by apprehension,…

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

The facility identified a census of 37 residents. The sample included 12 residents with two residents sampled for accidents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 5's fall investigation included a root cause analysis of the fall and failed to ensure that an appropriate intervention was implemented to prevent further falls. These deficient practices placed this resident at risk for additional falls and or injuries. Findings included: - The electronic medical record (EMR) for R5 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), muscle weakness, and a history of repeated falls with fractures of the pelvis (the lower section of bones that connect to the trunk and the legs). The admission Minimum Data Set (MDS) dated 08/15/23 documented R5 had a Brief Interview for Mental Status (BIMS) score of four which indicated severely impaired cognition. R5 required extensive assistance from one staff for activities of daily living (ADLs). R5 had impairment on both sides of her…

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 37 residents. The sample included 12 residents with one resident reviewed for trauma-informed care (treatment or care directed to prevent re-experiencing or reducing the effects of traumatic events). Based on observation, record review, and interviews, the facility failed to identify trauma-based triggers related to Resident (R) 20's posttraumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress) and failed to implement individualized interventions to prevent re-traumatization. These deficient practices placed R20 at risk for decreased psychosocial well-being and ineffective treatment. Findings included: - R20's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of PTSD, contracture (abnormal permanent fixation of a joint or muscle) of right and left knees, dementia (a progressive mental disorder characterized by failing memory, confusion),…

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 37 residents. The sample included 12 residents with two residents sampled for hospice services. Based on observation, record review, and interview, the facility failed to establish a communication process, including how the communication will be documented between the facility and the hospice provider for Resident (R) 32. The facility failed to ensure that R32's written plan of care included both the most recent hospice plan of care and a description of the services furnished by both the facility and hospice. This placed R32 at risk of decline and/or from maintaining the highest practicable physical, mental, and psychosocial well-being. Findings included: - The electronic medical record (EMR) for R30 documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and dementia (progressive mental disorder characterized by failing memory, and confusion) with mood disturbance. The Significant Change Minimum Data Set…

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

The facility identified a census of 37 residents. Based on observation, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to hand hygiene during peri-care and the disinfecting of shared equipment. This deficient practice placed the residents at risk for complications related to infectious diseases. Findings included: - On 02/22/24 at 09:33 AM Certified Nurse Aide (CNA) M and CNA N donned gloves and then transferred Resident (R) 9 into bed with the assistance of a Hoyer lift (total body mechanical lift). CNA M and CNA N removed the lift sling from under R9. CNA M removed R9's slacks, then untaped R9's incontinence brief. CNA M did not change her gloves but proceeded to provide peri-care to R9's peri area. CNA M rolled R9 onto her left side and removed the soiled brief from underneath R9. CNA M provided peri care to R9's rectal area, buttocks, and coccyx (area at the base of the spine) area. Wearing the same soiled gloves, CNA M opened the bedside drawer, removed skin protective cream from the drawer, and applied 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 33 residents. Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for at least eight consecutive hours, seven days a week and failed to designate a full time RN as Director of Nursing to oversee the care provided to the residents. This placed the resident at risk for decreased quality of care. Findings included: - Review of the daily nurse staffing from 11/02/23 through 11/29/23 provided by the facility revealed the following dates which lacked evidence of RN coverage for eight consecutive hours: 11/03/23 - Friday 11/04/23 - Saturday 11/14/23 - Tuesday 11/15/23 - Wednesday 11/18/23 - Saturday 11/21/23 - Tuesday 11/28/23 - Tuesday On 11/29/23 Licensed Nurse (LN) G stated she was aware of two full time nurses and perhaps one as needed (PRN) RN that worked at the building. LN G revealed that there was no Director of Nursing for the facility. On 11/29/23 at 03:16 PM Administrative Nurse E stated she only had two RNs that worked at the facility. There was a third RN, but that RN only worked one day and nothing…

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 33 residents. The sample included three residents reviewed for accidents. Based on record review and interview, the facility failed to evaluate causative factors in order to identify and implement interventions to prevent falls for Resident (R)1, who had multiple falls. This deficient practice placed R1 at risk for continued falls and fall related injury. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab recorded diagnoses of fractured right wrist, muscle weakness, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, and unspecified psychosis (any major mental disorder characterized by a gross impairment in reality perception). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of seven which indicated in moderately impaired…

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

The facility had a census of 38 residents. The facility had one kitchen. Based on observation, interview, and record review the facility failed to store frozen foods under sanitary conditions in the facility kitchen. This deficient practice placed the 38 residents of the facility at risk to receive foods with contamination and/or an unpleasant taste related to freezer burn. Findings included: - On 08/31/22 at 08:00 AM, observation in the facility's kitchen revealed the Leftover freezer contained three unsealed bags of French fries and one unsealed bag of meat patties. On 09/01/22 at 12:10 PM, observation revealed two unsealed bags of French fries and one unsealed bag of burger patties. On 09/01/22 at 12:10 PM, Dietary Staff (DS) BB verified staff were to ensure frozen foods were re-sealed after using a portion of the food from the bags. The facility's Food Safety Requirements policy, dated 01/2022, documented the staff would store food in accordance with professional standards for food service safety. The policy stated staff would store foods in tightly covered containers. 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 had a census of 38 residents and no Covid (highly contagious, potentially life threatening respiratory virus) residents. The sample included 13 residents with two residents on quarantine for Covid. Based on observation, record review, and interview the facility failed to provide a sanitary and comfortable environment to help prevent the development and transmission of communicable disease and infections when staff hung a used gown from a quarantined resident's room on an isolation cart in the hall and cleaned a quarantined resident's room without changing gloves between dirty and clean tasks. The facility further failed to maintain an ongoing infection surveillance program. This placed the 38 residents who resided in the facility at increased risk for infection. Findings included: - On 8/30/22 at 10:00 AM, observation revealed Licensed Nurse (LN) H hung a used isolation gown on an isolation cart outside a quarantine resident's room. LN H verified it was used and stated it should not be there. LN H applied gloves and discarded the gown in the trash can outside 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 had a census of 38 residents. The sample included 13 residents. Based on record review and interview the facility failed to maintain an ongoing infection surveillance program which included antibiotic stewardship. This placed the 38 residents who resided in the facility at increased risk for receiving an infection, and/or negative effects of antibiotic use. Findings included: - The Infection Tracking Binder lacked documentation regarding monitoring and tracking of residents' infections or antibiotic uses, appropriateness or organisms being treated for April, May, June, July and August 2022. On 09/07/22 at 10:40 AM, Administrative Nurse D verified she had not been monitoring or tracking infections. She stated she was new to the Infection Preventionist position, went to a workshop and would be using some ideas she picked up there to start monitoring and tracking. The facility's Antibiotic Stewardship Program Policy, revised on 08/02/22, documented the program would include antibiotic use protocols and a system to monitor antibiotic use. The monitoring should include…

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 38 residents, with three reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on record review and interview, the facility failed to provide the Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN), CMS form 10055, which contained the estimated cost to continue services for skilled services, to the resident or their representative for the three reviewed residents, Resident (R) 27, 30, and 20. This placed the residents at risk for uninformed decisions regarding skilled services. Findings included: - The facility lacked documentation staff provided R27 (or their representative) the ABN form 10055 when the resident's skilled services ended 04/03/22. The facility provided a facility generated form which lacked a cost estimate for continued services. The facility lacked documentation staff provided R30 or their representative) the ABN form 10055 when the resident's skilled services ended 05/16/22. The facility provided a facility generated form which lacked a cost estimate for continued services. 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 38 residents. The sample included 13 residents with five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to care plan Resident (R) 35's fluid restriction. This deficient practice placed R35 at risk for fluid overload (too much fluid in your body). Findings included: - R35's Physician Order Sheet (POS), dated 07/26/22, documented diagnoses of acute kidney failure (kidneys suddenly become unable to filter waste products from your blood), acute and chronic respiratory failure with hypoxia (condition that results in the inability to effectively exchange carbon dioxide and oxygen), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), hypertension (high blood pressure), lymphedema (swelling in an arm or leg caused by a lymphatic system blockage), paroxysmal atrial fibrillation (irregular, often rapid heart rate that commonly…

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 38 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to invite two sampled residents', Resident (R) 5 and R34, (or their representative) to their quarterly care plan conferences and failed to update R8's care plan with a section regarding her facial skin condition. This placed R5 and R34 at risk for not having the right to participate in choosing treatment and options for their care and placed R8 at risk for unmet and/or uncommunicated care needs. Findings included: - R5's Electronic Medical Record (EMR) documented the R5 had diagnoses of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), dementia (progressive mental disorder characterized by failing memory and confusion), and impulse disorder(condition in which a person has trouble controlling emotions or behaviors). R5's Quarterly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 38 residents. The sample included 13 residents with one reviewed for foot care. Based on observation, interview, and record review the facility failed to provide appropriate care and services for Resident (R) 14's feet and or toenails. This deficient practice placed R14 at risk for complication and pain related to his feet. Findings included: - R14's diagnoses included hypertension (high blood pressure), cerebrovascular disease (causes problems with reasoning, planning, judgment, memory and other thought processes), congestive heart failure (heart muscle does not pump blood as well as it should), and atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow). The Quarterly Minimum Data Set (MDS), dated [DATE], documented severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of six. The MDS documented R14 required supervision for eating and extensive assistance of one staff for all other activities of daily living (ADLs).…

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 38 residents. The sample included 13 residents with five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to monitor Resident (R) 35's fluid restriction. This deficient practice placed R35 at risk for fluid overload (too much fluid in your body) and hospitalization for treatment. Findings included: - R35's Physician Order Sheet (POS), dated 07/26/22, documented diagnoses of acute kidney failure (kidneys suddenly become unable to filter waste products from your blood), acute and chronic respiratory failure with hypoxia (condition that results in the inability to effectively exchange carbon dioxide and oxygen), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), hypertension (high blood pressure), lymphedema (swelling in an arm or leg caused by a lymphatic system blockage), paroxysmal atrial fibrillation (irregular,…

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

The facility identified a census of 38 residents. The sample included 13 residents with five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ackowledge and follow up on the Consultant Pharmacist's (CP) medication recommendations and failed to ensrue the CP idenitfied and reported missing behavior documentation for psychotropic (medications which alters mood and thought) medications. This placed R5 at risk for ineffective medication regimen and unnecessary psychotropic medications. Findings included: - Resident (R) 5's Electronic Medical Record (EMR) documented she had diagnoses of hypertension (elevated blood pressure), arthritis (inflammation of a joint characterized by pain, swelling, heat, redness and limitation of movement) of left hand, heart disease, hypokalemia (low level of potassium in the blood) and hypothyroidism (condition characterized by decreased activity of the thyroid gland). R5's Quarterly Minimum Data Set, dated 06/18/22, documented R5 had a Brief Interview for Mental Status (BIMS) of 13, which…

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 38 residents. The sample included 13 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to consistent behavior monitoring for Resident (R) 5 who received several psychotropic medications ( medications which alters mood or thought) including an antipsychotic (class of psychotropic medication primarily used to manage psychosis, principally in schizophrenia but also in a range of other psychotic disorders). This placed the resident at risk for unnecessary psychotropic medication use and related side effects. Findings included: - R5's Electronic Medical Record (ER) documented she had diagnoses of hypertension (elevated blood pressure), arthritis (inflammation of a joint characterized by pain, swelling, heat, redness and limitation of movement) of left hand, heart disease, hypothermia (low level of potassium in the blood) and hypothyroidism (condition characterized by decreased activity of the thyroid gland). R5's Quarterly Minimum Data Set, dated 06/18/22, documented R5…

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.