Medicalodges Eudora

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 48 residents. The sample included 14 residents, with one resident reviewed for physical restraint. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 42 was free of physical restraints when staff placed R42 in a recliner, and raised the footrest though R42 was unable to lower the footrest on her own. This placed the resident in a supine position in the recliner and impeded R42's freedom of movement and mobility. This deficient practice placed R42 at risk for impaired mobility, impaired resident rights and autonomy, and increased risk for restraint-related accidents. Findings Included: - R42's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of [NAME]-[NAME] syndrome (a genetic disorder usually caused by deletion of a part of chromosome 15 passed down by the father), cognitive-communication deficit (trouble reasoning and making decisions while comminating), and aphasia (a condition with disordered or absent…

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 49 residents. The sample included 14 residents with one resident sampled for hospitalization Based on record review and interview the facility failed to provide a written notice of transfer as soon as practicable to Resident (R) 50 or their representative for their facility-initiated transfers. This deficient practice had the risk of miscommunication between the facility and resident/family and possible missed opportunity for healthcare service for R50. Findings included: - The Electronic Medical Record (EMR) for R50 documented diagnoses of falls, 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), atrial fibrillation (rapid, irregular heartbeat), and heart failure. R50's admission Minimum Data Set (MDS) had yet not been completed. R50's Discharge MDS dated 07/07/24 documented she had an unplanned discharge to a short-term acute hospital with a return not anticipated. R50's Care Plan initiated on 07/02/24 directed staff that…

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 49 residents. The sample included 14 residents with one resident sampled for hospitalization. Based on observations, record review, and interview the facility failed to provide a bed hold notice to Resident (R) 50 or their representative when R50 transferred to the hospital. This deficient practice placed R50 at risk for impaired ability to return to the facility or the same room. Findings included: - The Electronic Medical Record (EMR) for R50 documented diagnoses of falls, 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), atrial fibrillation (rapid, irregular heartbeat), and heart failure. R50's admission Minimum Data Set (MDS) had yet not been completed. R50's Discharge MDS dated 07/07/24 documented she had an unplanned discharge to a short-term acute hospital with a return not anticipated. R50's Care Plan initiated on 07/02/24 directed staff that R50 planned to discharge home after the completion of her therapy services.…

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 49 residents. The sample included 14 residents sampled for care plan revision. Based on observation, record review, and interview, the facility failed to ensure staff revised Resident (R)151's Care Plan with staff direction for safe transfers. The facility failed to ensure staff revised R8's plan of care with interventions after a fall. This placed R151 and R8 at risk for impaired care due to uncommunicated care needs. Findings included: - R151's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and intervertebral disc degeneration (the breakdown [degeneration] of one or more of the discs that separate the bones of the spine). R151's admission Minimum Data Set (MDS) dated [DATE] documented she had both long 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 identified a census of 49 residents. The sample included 14 residents with three residents reviewed for positioning. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 151 had interventions in place to avoid a further decrease in range of motion (ROM). This placed the resident at risk for decreased mobility and impaired quality of life. Findings included: - R151's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and intervertebral disc degeneration (the breakdown [degeneration] of one or more of the discs that separate the bones of the spine). R151's admission Minimum Data Set (MDS) dated [DATE] documented she had both long and short-term memory loss. R151 required substantial to maximal staff…

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 49 residents. The sample included 14 residents with five residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure meaningful interventions were implemented for Resident (R) 8 after falls. This deficient practice placed R8 at risk for future falls and possible injuries. Findings included: - R8's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body) affecting the left non-dominate side), transient ischemic attack (TIA- temporary episode of inadequate blood supply to the brain), cerebral infarction (stroke - the 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), dementia (a progressive mental disorder characterized by failing memory, confusion), unsteadiness on his feet, muscle weakness, cognitive-communication deficit, repeated…

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 - R24's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), tardive dyskinesia (abnormal condition characterized by involuntary repetitive movements of the muscles of the face, limbs and trunk), schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), muscle weakness, and dysphagia (swallowing difficulty). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition, but no staff interview was completed. The MDS documented that R24 had a weight loss of five percent or more in the last month or a loss…

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 49 residents. The sample included 14 residents with one person reviewed for side rails. Based on observation, record review, and interviews, the facility failed to attempt the use of alternative measures prior to installing Resident (R) 24's side rail and the facility further failed to complete a side rail safety assessment that acknowledged the presence of a low air loss mattress and the associated risks, prior to installation of the side rails for R24. This deficient practice placed R24 at risk of injury due to unidentified risks from the use of side rails. Findings included: - R24's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), tardive dyskinesia…

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 49 residents. The sample included 14 residents with one resident reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure a communication process was implemented, which included how the communication would be documented between the facility and the hospice provider, and a failed to provide a description of the services, medication, and equipment provided to Resident (R) 20 by hospice. This deficient practice created a risk of missed or delayed services and inadequate end-of-life care for R20. Findings included: - R20's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), aphasia (a condition with disordered or absent language function), muscle weakness, and depressive disorder (a mood disorder…

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 49 residents. The sample included 14 residents with five residents reviewed for immunizations. Based on observation, record review, and interviews, the facility failed to provide Resident (R) 19 with the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial lung infections) as consented. This placed the resident at increased risk for complications related to pneumonia. Findings included: - R19's Electronic Medical Record (EMR) revealed he was eligible and within the required vaccination date range to receive the PCV20 vaccination. A review of the Resident Consent for Influenza, Pneumococcal, and COVID-19 Vaccination form for R19 dated 06/26/23 provided by the facility revealed a signed consent to receive the pneumococcal vaccination. The form indicated R19 was provided educational information related to the PCV 20 vaccination. R19's clinical record lacked evidence R19 received the PCV20 vaccination. Upon request, the facility was unable to provide evidence the PCV20 was administered to R19. On 08/13/24 at 10:22 AM Administrative Nurse…

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

The facility identified a census of 56 residents. Based on observation, record review, and interview, the facility failed to provide Registered Nurse (RN) coverage eight consecutive hours a day, seven days a week. This placed all residents who resided in the facility at risk of lack of assessment and inappropriate care. Findings included: - Review of the August, September, and October 2022 nursing schedule revealed a lack of Registered Nurse coverage for eight consecutive hours a day, on the following dates: 09/04/22 and 09/30/22. On 11/08/22 at 09:45 AM Administrative Staff B verified the facility lacked Registered Nurse coverage on 09/04/22 and 09/30/22. The facility did not provide a policy related to Registered Nurse coverage. The facility failed to provide Registered Nurse coverage eight consecutive hours a day, seven days a week, as required. This placed the residents who resided in the facility at risk of lack of assessment and inappropriate care.

The facility identified a census of 56 residents. Based on record review, and interviews, the facility failed to ensure a staff person was a staff person designated as the Infection Preventionist, who was responsible for the facility's Infection Prevention and Control Program, completed the specialized training in infection prevention and control. This deficient practice placed all residents at risk for lack of identification, tracking/trending, and treatment of infections. Findings included: The facility was unable to provide a policy related to the Infection Preventionist. - On 11/28/22 at 03:44 PM Administrative Nurse D stated the facility did not have a certified Infection Preventionist at this time. Administrative Nurse D stated the facility was in the process of correcting the situation. The facility failed to ensure a staff person was a staff person designated as the Infection Preventionist, who was responsible for the facility's Infection Prevention and Control Program, completed the specialized training in infection prevention and control. This deficient practice placed all…

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 56 residents. The sample included 16 residents. Based on observation, record review and interview the facility failed to secure chemicals in a safe, locked area, and out of reach of the 12 cognitively impaired independently mobile residents. The facility additionally failed to implement R11's anti-rollback device for her wheelchair. This deficient practice placed the affected residents at risk for accidents. Findings Included: On 11/02/22 at 07:08AM an inspection of an unlocked small sink room next to the rear oxygen tank room revealed an open one-gallon bottle of bleach. The label on the bleach read keep out of reach of children, hazardous to humans can cause eye irritation, harmful if swallowed. The sink room had no lock to secure the chemical product. On 11/02/22 at 07:20AM an inspection of the rear spa /bathing room revealed the door propped open and not secured. An inspection of bathroom revealed a cabinet next to the shower area lacked a lock. The cabinet contained an open one-gallon bottle of bleach and tube container of bleach wipes. Both items…

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 56 residents. The facility had one main kitchen. Based on observation, record review and interview the facility failed to ensure that room trays of food were kept at a safe temperature for consumption by residents. Findings included: - On 11/03/22 at 12:11PM Dietary Staff (DS) BB brought the hall tray warmer cart from the kitchen area, for the nursing staff to pass the tray to residents in their rooms. Upon request DS BB checked the food temperature of food items on various trays in the warmer cart. The temperature of the lasagna on the room tray plates revealed to be at 127 degrees Fahrenheit (F). Another plate checked revealed the lasagna internal temperature reading of 123 degrees F. DS BB checked a third room tray plate, which revealed an internal temperature reading of 125 degrees F. On 11/03/22 at 12:15 PM DS BB pushed the room tray cart back to the kitchen to rewarm the room trays to the appropriate serving temperature. At 12:28 PM, after placing the room trays in the warmer oven for 10 minutes, DS BB checked the temperature of the lasagna…

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 69 residents. Based of observations, record review, and interviews, the facility failed to ensure staff were following safe and sanitary infection control practices related to isolation, respiratory equipment, urinary catheters, and personal protective equipment (PPE). This deficient practice placed the residents at risk for preventable infections and illnesses. Findings Included: - On 11/02/22 at 07:02 AM upon entering the facility 2 staff were observed not wearing face coverings in the front hallway. On 11/02/22 at 07:05 AM an inspection of the 200 hallway revealed isolation supplies outside of R3's room, but no signage displayed to indicate if she was on isolation or signage to direct visitors to see nurse before entering room. On 11/02/22 at 07:10 AM during an initial walkthrough of the facility, the back hall linen closet revealed an uncovered clean linen rack with towels, rags, and bed linens items. The linen rack was within five feet of old equipment and a visibly dirty wheelchair. On 11/02/22 at 07:15 AM an inspection of the front hallway…

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 56 residents. The sample included 16 residents which five residents reviewed for immunizations. Based on record review, and interviews, the facility failed to obtain pneumococcal (pneumonia infection that inflames air sacs in one or both lungs which may fill with fluid) vaccination consents, declinations or administration information for Residents (R) 50, R25 and R4 and influenza (highly contagious viral infection that attacks the lungs, nose, and throat and can be deadly in high-risk groups) vaccination consents, declinations or administration information for R36 and R4. This deficient practice placed residents at increased risk for influenza, pneumonia, and related complications. Findings included - Review of the Electronic Medical Record (EMR) for R50, R4, and R25 revealed the clinical record lacked documentation indicating that the three residents listed had been offered, consented, refused, or had received the pneumonia vaccination. Review of the clinical record for R4 and R36 lacked documentation indicating that the two residents listed had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 56 residents. The sample included 16 residents. Based on observation, record review, and interviews, the facility failed to ensure foot pedals were provided for Resident (R) 31's broda chair (specialized wheelchair with the ability to tilt and recline) to prevent her feet from dragging on the floor. This deficient practice placed R31 vulnerable for possible injuries. Findings included: - R31's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of muscle weakness, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Annual Minimum Data Set (MDS) dated [DATE] lacked documentation of a Brief Interview of Mental Status (BIMS) was completed. The MDS documented that R31 required extensive assistance of two staff members for activities of daily living (ADL's). The Quarterly MDS dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 56 residents. The sample included 16 residents with one reviewed for notification of changes. Based on observation, record review, and interviews, the facility failed to notify R11's resident representative and her physician about a skin tear on her upper arm. This deficient practice placed R11 at risk for ineffective treatment and delayed wound care. Findings Included: -The Medical Diagnosis section within R11's Electronic Medical Records (EMR) included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), major depressive disorder (major mood disorder), cognitive communicative deficit, muscle weakness, hypertension (high blood pressure), and edema (swelling resulting from an excessive accumulation of fluid in the body tissues). A review of R11's Quarterly Minimum Data Set (MDS) dated 09/02/22 revealed a Brief Interview for Mental Status score of three, indicating severe cognitive impairment. The MDS indicated she required assistance…

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

The facility identified a census of 56 residents. The sample included 16 residents with one reviewed for transmission of resident assessments. Based on observation, record review, and interviews, The facility failed to electronically transmit R34's Significant Change of Status Minimum Data Set (MDS) within 14 days after completion. This deficient practice placed R34 at risk for delayed treatment and services. Findings Included: - The Medical Diagnosis section within R34's Electronic Medical Records (EMR) included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), major depressive disorder (major mood disorder), hypertension (hi blood pressure), chronic kidney disease, chronic obstructive pulmonary disorder (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and pain in right leg. A review of R34's admission MDS dated 07/05/22 revealed a Brief Mental Status (BIMS) score of six indicating severe cognitive impairment. This MDS was noted to be accepted. On…

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 56 residents. The sample included 16 residents. Based on observation, record review and interview the facility failed to revise a comprehensive person-centered care plan for Resident (R)50 that included interventions to avoid the development of a pressure wound. This deficient practice placed R50 at risk for further skin breakdown and injury. Findings included: The electronic medical record (EMR) for R50 documented diagnoses of hypertension (elevated blood pressure), hemiplegia and hemiparesis following cerebral infarction (paralysis the loss of muscle movement and weakness as the result of a stroke) affecting the right side, diabetes mellitus (DM when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and neuropathy (weakness, numbness and pain from damage to the nerves usually in the hands or feet). The admission Minimum Data Set (MDS) dated [DATE] documented R50 had a Brief Interview for Mental Status (BIMS) score of 12 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 identified a census of 56 residents. The sample included 16 residents with two reviewed for comprehensive care plans. Based on observation, record review, and interviews, the facility failed to provide individualized care plan interventions for R25's bowel and bladder incontinence. This deficient practice placed the resident at risk for complications related to incontinence and increased incontinence -The Medical Diagnosis section within R25's Electronic Medical Records (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), constipation, major depressive disorder (major mood disorder), impulse disorder, dysphagia (swallowing difficulty), and chronic kidney disease. R25 Quarterly Minimum Data Set (MDS) dated 08/01/22 noted a Brief Interview for Mental Status (BIMS) score of 99 indicating severe cognitive impairment, which prevented the test from being completed. The MDS noted she required one-person limited assistance for bed mobility, transfers, and toileting. The MDS indicated that she 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 identified a census of 56 residents. The sample included 16 residents. Based on observation, record review, and interviews, the facility failed to ensure staff provided bathing for one of three residents, who required extensive assistance from staff to complete the care. This deficient practice placed Resident (R) 3 at risk for potential skin breakdown and/or skin complications from not maintaining good personal hygiene and bathing practices. Findings included: - R3's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of hypertension (elevated blood pressure) and anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of five, which indicated severely impaired cognition. The MDS documented R3 required extensive assistance of two staff members for activities of daily living (ADL). The MDS for R3 lacked documentation for…

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

The facility identified a census of 56 residents. The sample included 16 residents with four residents reviewed for quality of care. Based on observations, record reviews, and interviews, the facility failed to follow implement preventative skin interventions for Residents (R)11 and R34. This deficient practice placed the residents at risk preventable skin injuries. Findings Included: - The Medical Diagnosis section within R11's Electronic Medical Records (EMR) included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), major depressive disorder (major mood disorder), cognitive communicative deficit, muscle weakness, hypertension (high blood pressure), and edema (swelling resulting from an excessive accumulation of fluid in the body tissues). A review of R11's Quarterly Minimum Data Set (MDS) dated 09/02/22 revealed a Brief Interview for Mental Status score of three, indicating severe cognitive impairment. The MDS indicated she required assistance from one staff for transfers, dressing, bed mobility, personal hygiene, and toileting. 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 56 residents. The sample included 16 residents, with one resident reviewed for range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension)/mobility. Based on observation, record review, and interviews, the facility failed to ensure staff applied Resident (R) 19's splint and brace as ordered by the physician, which placed R19 at risk for further decrease in ROM. Findings included: - R19's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), dementia (progressive mental disorder characterized by failing memory, confusion), and dysphagia (swallowing difficulty). The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The MDS documented that R19 required extensive assistance of two staff members for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 56 residents. The sample included 16 residents with four residents reviewed for bowel and bladder management. Based on observations, record reviews, and interviews, the facility failed to implement individualized toileting programs for Residents (R)25 and R33. The facility failed to maintain sanitary indwelling urinary catheter care for R34. This deficient practice placed the residents at risk for complications related urinary tract infections. Findings Included: -The Medical Diagnosis section within R25's Electronic Medical Records (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), constipation, major depressive disorder (major mood disorder), impulse disorder, dysphagia (swallowing difficulty), and chronic kidney disease. R25 Quarterly Minimum Data Set (MDS) dated 08/01/22 noted a Brief Interview for Mental Status (BIMS) score of 99 indicating severe cognitive impairment, which prevented the test…

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 56 residents. The sample included 16 residents with two residents reviewed for respiratory care. Based on observations, record reviews, and interviews, the facility failed ensure consistent and hygienic respiratory care and services for Resident (R)11. This deficient practice placed R11 at risk for complications due to respiratory therapy. Findings Included: -The Medical Diagnosis section within R11's Electronic Medical Records (EMR) included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), major depressive disorder (major mood disorder), cognitive communicative deficit, muscle weakness, hypertension (high blood pressure), and edema (swelling resulting from an excessive accumulation of fluid in the body tissues). A review of R11's Quarterly Minimum Data Set (MDS) dated 09/02/22 revealed a Brief Interview for Mental Status (BIMS) score of three indicating severe cognitive impairment. The MDS indicated she required assistance from one staff for transfers, dressing, bed mobility, personal hygiene, 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 identified a census of 56 residents. The sample included 16 residents with one reviewed for competent nursing staff. Based on observation, record review, and interviews, the facility failed to ensure an accurate assessment of R11's skin tear was completed by a licensed nurse. This deficient practice placed R11 at risk for ineffective treatment and delayed wound care. Findings Included: - The Medical Diagnosis section within R11's Electronic Medical Records (EMR) included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), major depressive disorder (major mood disorder), cognitive communicative deficit, muscle weakness, hypertension (high blood pressure), and edema (swelling resulting from an excessive accumulation of fluid in the body tissues). A review of R11's Quarterly Minimum Data Set (MDS) dated 09/02/22 revealed a Brief Interview for Mental Status score of three, indicating severe cognitive impairment. The MDS indicated she required assistance from…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 56 residents. The sample included 16 residents. Five residents were reviewed for medication review. Based on interview, record review, and interview the facility failed to ensure that resident (R)36's prescribed antidepressant (a class of medications used to treat mood disorders and relieve symptoms of depression) medication Prozac and R18's salicylic acid (a medication used to dissolve skin flakes and scales) were available for administration. This placed R36 and R18 at risk for adverse side effects and ineffective treatment. Findings included: The electronic medical record (EMR) for R36 documented diagnoses of major depressive disorder (a major mood disorder, Alzheimer's disease (a progressive mental deterioration characterized by confusion and memory failure), and delirium (sudden severe confusion, disorientation and restlessness). The Significant Change Minimum Data Set (MDS) dated [DATE] documented R36 had a Brief Interview for Mental Status (BIMS) score of three 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 reported a census of 56 resident. Based of observations, record review, and interviews, the facility failed to ensure safe storage and handling of the resident's medications. This deficient practice placed the residents at risk for unnecessary medication and administration errors. Findings Included: - On 11/02/22 at 07:10AM upon entrance to the facility Certified Medication Aid (CMA) T was observed counting medication cards at the medication cart located next to the front nurse's station. CMA T quickly left the cart and went into medication room next to the nurse's station. Inspection of the medication cart revealed that CMA T had left the unsupervised medication cart unlocked. Ten of the resident's medication cards sat on top of the unsecured cart while two residents walked past it in the hallway. CMA T returned to the cart with her face mask on after two minutes and secured the cart. On 11/08/22 at 02:40PM Certified Medication Aid (CMA ) R stated the carts should never be left unattended or have medications left out. On 11/08/22 at 03:10PM Licensed Nurse (LN) H stated…

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 56 residents. The sample included 16 residents. Based on observation, record review, and interviews, the facility failed to ensure a plate guard was provided at meals for Resident (R) 19, which placed her at risk of loss of independence with eating which could cause impaired psychosocial wellbeing. Findings included: - R19's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), dementia (progressive mental disorder characterized by failing memory, confusion), and dysphagia (swallowing difficulty). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The MDS documented that R19 required extensive assistance of two staff members for activities of daily living (ADLs). The Quarterly MDS dated 09/03/22 documented a BIMS score of three, which indicated…

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 49 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to employ a full time certified dietary manager for the 49 residents who resided in the facility and received meals from the facility kitchen. Findings included: -On 04/28/21 at 11:30 AM, observation revealed Dietary Staff (DS) BB served the noon meal. The meal consisted of baked Italian chicken breast, broccoli with cheese sauce, pasta salad, and assorted fruit cup. On 04/28/21 at 11:50 AM, Registered Dietician GG verified the facility did not have a certified dietary manager. On 04/28/21 at 12:30 PM, Administrative Staff A verified the facility did not have a certified dietary manager. Upon request, the facility did not provide a policy regarding Certified Dietary management requirements. The facility failed to employ a full time Certified Dietary Manager, for the 49 residents who resided in the facility who received meals from the facility kitchen, placing the residents at risk for inadequate nutrition.

The facility had a census of 49 residents. Based on observation, interview and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for the 49 residents who received meals from the facility kitchen. Findings included: - On 04/26/21 at 12:50 PM, observation of the facility's kitchen revealed the following: Tile floor throughout kitchen unclean with numerous stained areas, baseboard with gray brownish colored residue. Ceiling above the food prep area with an approximately 3 foot (ft) by 2 ft black and brown stained area. 6 ft by 3 ft dark blue non slip floor mat in front of food service area, unclean with dried substances, black and brown stains. Ceiling above food warmer with approximately 2 ft by 2 ft brown splattered stains. Metal floor of walk in refrigerator with numerous dried food particles under storage racks. On 04/26/21 at 02:15 PM, observation of the refrigerator in the nourishment area off of the main dining room, revealed the following: One large plastic container of lime jello, 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.

The facility had a census of 49 residents. The sample included 13 residents. Based on observation, record review and interview the facility failed to make prompt efforts to resolve grievances of the residents who attend the resident council. Findings included: - On 04/27/21 at 11:03 AM, review of the monthly resident council meeting minutes revealed consistent grievance for the months of January, February and March 2021 regarding the residents not receiving baths or showers as scheduled. On 04/28/21 at 08:05 AM, Activity Staff (AS) Z stated if any grievances were verbalized by the council members, AS Z documented on a facility concern form and it was given to the Director of Nursing and Social Services Director. AS Z verified for the past three months the resident council had a grievance each month regarding not receiving baths as scheduled. On 04/28/21 at 08:45 AM, the Resident Council President verified the consistent grievances for the past three months of residents not receiving baths or showers. Resident Council President verified the facility management was aware 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 - R39's Quarterly MDS, dated 04/09/21, documented the resident had severely impaired cognition, and required extensive assistance of one staff for personal hygiene and bathing. The ADL Care Plan, dated 01/06/21, directed staff to assist the resident with her showers and when she needed or asked for help. The January 2021 Bathing Record documented the resident received a shower on the following days: 01/02/21 01/09/21 (6 days without a shower) 01/19/21 (9 days without a shower). The February 2021 Bathing Record documented the resident received a shower on the following days: 02/02/21 (13 days without a shower) 02/09/21 (6 days without a shower) 02/13/21 02/16/21 02/23/21 (6 days without a shower) 02/27/21 The March 2021 Bathing Record documented the resident received a shower on the following day: 03/30/21 (30 days without a shower). The April 1-28, 2021 Bathing Record documented the resident received a shower on the following days: 04/06/21 (6 days without a shower) 04/13/21 (6 days - and no showers after this…

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 - R30's Quarterly MDS, dated 03/26/21, documented the resident had severely impaired cognition, required extensive assistance of one staff for personal hygiene, and total dependence with bathing. The ADL Care Plan, dated 01/01/21, directed the staff to provide the resident total assistance with personal hygiene, and the resident received a bath on Monday and Thursday. Review of the March 2021 Bathing Record documented the resident received a bath/shower on the following days: 03/04/21 03/22/21 (18 days without a bath/shower). Review of the April 2021 Bathing Record documented the resident received a bath/shower on the following days: 04/01/21 04/12/21 (11 days without a bath/shower) 04/15/21 04/28/21 (13 days without a bath/shower). On 04/27/21 at 10:10 AM, observation revealed the resident seated in her wheelchair in the living room, with eyes closed, and dried brown substance on chin, facial hair on chin, fingernails on both hands jagged with brown substance under nails on both hands, and hair uncombed. On…

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 49 residents. The sample included 13 residents. Based on observation and interview, the facility failed to maintain a clean and sanitary environment for two residents that resided on the south side of the east hallway. Findings included: - On 04/27/21 at 08:00 AM, observation revealed a resident's bathroom toilet on the south side of the east hallway with fecal matter splattered on the toilet rim and inner bowl area. The resident room had two occupants and both residents could use the toilet independently. On 04/28/21 at 08:04 AM, observation revealed the toilet in a resident's room on the south side of the east hallway with fecal matter on the rim and inside the toilet bowl as observed on 04/27/21. On 04/28/21 at 09:59 AM, observation of Resident (R) 7's room revealed the room to be cluttered, had procedure face mask laying on the stand next to the head of the bed, on the copy machine, the overbed table, the recliner and floor. The black refrigerator top next to her recliner had food particles in the top seal door handle. The floor under the resident's bed…

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 49 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide care and services for two of 13 sampled residents, Resident (R) 22 lacked a nursing assessment prior to discharge to the hospital, and R2's skin treatments not completed as physician ordered. Findings included: - R2's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had moderately impaired cognition and required extensive assistance of two staff for dressing, transfers, bed mobility, and toileting. The assessment further documented the resident used ointments other than to his feet. The Skin Breakdown Care Plan, dated 01/11/21, directed staff to contact the physician if the resident had changes in his skin and to monitor for bruises and skin tears. The Pain Care Plan, dated 01/11/21, directed staff to provide medications as ordered, monitor for effectiveness, encourage the use of alternative methods of pain management, and monitor…

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 49 residents. The sample included 13 residents with four reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to document assessments and repositioning for two of four sampled residents, Resident (R) 1 and R36. Findings included: - R1's Physician Order Sheet (POS), dated 04/08/21, documented diagnoses of multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord), bladder dysfunction, abnormal weight loss, and Stage two (partial thickness of loss of dermis (top layer of skin) presenting as a shallow ulcer with a red pink wound bed) pressure ulcer of right buttock. The Annual Minimum Data Set (MDS), dated [DATE], documented R1 had severe cognitive impairment, required extensive assistance of two staff for bed mobility, transfers, dressing 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 49 residents. The sample included 13 residents with five reviewed for bowel and bladder incontinence. Based on observation, interview, and record review the facility failed to document routine care and output for one of five sampled residents, Resident (R) 1. Findings included: -R1's Physician Order Sheet (POS), dated 04/08/21, documented diagnoses of multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord), urinary incontinence, neuromuscular dysfunction of bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), and pressure ulcer (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) to right buttocks. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had severe cognitive impairment, required extensive to total staff assistance for bed mobility, transfers, dressing, toilet use and personal…

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 49 residents. The sample included 13 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to document behaviors related to the use of psychotropic (to treat psychosis (any major mental disorder characterized by a gross impairment in reality testing) medication for one of five sampled residents, Resident (R) 39. Findings included: - R39's Physician Order Sheet (POS), dated 04/08/21, documented diagnoses of depressive episodes (a period characterized by the symptoms of major depressive (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness) disorder), Alzheimer's Disease (progressive mental deterioration characterized by confusion and memory failure), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and hallucinations (sensing things while awake that appear to be real, but the mind…

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.