Meadowbrook Rehabilitation Hospital

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 109 residents. The sample included 22 residents, with two residents reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 16 received services and treatment for his right-hand contracture (abnormal permanent fixation of a joint or muscle) to prevent an avoidable reduction of range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension). Findings included:- R16's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), muscle weakness, contracture of right hand, hemiparesis/hemiplegia (weakness and paralysis on one side of the body), and cerebrovascular accident (CVA- stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Annual 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 109 residents. The sample included 22 residents, with six residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) recommendations had been reviewed and addressed by the physician within 30 days for Residents (R) 15 and R9. The facility also failed to ensure the CP had identified and reported the physician-ordered laboratory tests had not been followed for R15 and R9. Findings included:- R15's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of major depressive disorder (major mood disorder that causes persistent feelings of sadness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), epilepsy (brain disorder characterized by repeated seizures), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), and dementia (a progressive mental 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 102 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to ensure staff immediately reported staff-to-resident abuse for R1 on 10/31/24. This deficient practice placed R1 at risk for further abuse. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebrovascular disease (CVA-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) affecting the right dominant side, cognitive communication deficit, speech and language deficits following cerebrovascular disease and generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Annual Minimum Data Set (MDS) dated 03/22/24, documented R1 had a Brief Interview for Mental Status (BIMS) score of 99 which indicated R1 was unable…

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 100 residents. The sample included 20 residents. Based on observation, interview and record review, the facility failed to ensure its certified nurse aides (CNA) received 12 hours in-services annually as required. This deficient practice placed the 100 residents of the facility at risk for inadequate care. Findings included: - The facility provided a list of CNAs who had worked at the facility for more than one year and the in-service records for those staff The facility lacked evidence that any of the aides had the required 12 hours of in-services for 2023. On 01/24/24 at 11:10 AM, Administrative Nurse D verified the facility had not provided the required 12 hours of in-services annually for their CNA staff. The facility's Required Training, Certification and Continuing Education of Nurse Aides policy, dated 01/09/24, stated it was the policy of the facility to comply with State and Federal regulation and requirements pertaining to training, certification, and continuing education of its nurse aides. The policy stated the facility would provide at least…

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 100 residents. The sample included 20 residents. Based on observation, record review, and interview, the facility failed to promote and provide dignity for Resident (R) 28, who had an uncovered urinary catheter (insertion of a catheter into the bladder to drain the urine) bag. The facility further failed to promote dignity and respect during dining for the 15 residents seated in the dining room when staff discussed their personal issues and looked at their cell phones when assisting residents in eating the meal. These deficient practices placed the residents at risk for an undignified experience and impaired quality of life. Findings included: - On 01/22/24 at 05:10 PM, observation revealed R28 sat in a Broda chair (specialized wheelchair with the ability to tilt and recline) at the dining table. Further observation revealed an uncovered urinary catheter bag hung on the side of R28's chair with clear yellow urine. On 01/23/24 at 11:50 PM, observation revealed R28 sat in a Broda chair at the dining table. An uncovered urinary catheter bag hung on the side…

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 100 residents. The sample included 20 residents. Based on observation, record review, and interview the facility failed to provide activities of daily living (ADL)care and assistance to Resident (R) 28, R38, R18, and R61. This deficient practice placed the residents at risk for poor hygiene and impaired dignity. Findings included: - R28's Electronic Medical Record (EMR) documented R28 had diagnoses of urinary retention (lack of ability to urinate and empty the bladder), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and psychotic disturbance (any major mental disorder characterized by a gross impairment in reality perception). The Quarterly Minimum Data Set (MDS), dated 12/30/23, documented the resident had a Brief Interview for Mental Status (BIMS) score of four indicating severely impaired cognition. The MDS further documented R28 required moderate staff assistance with dressing, grooming, 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 100 residents. The sample included 20 residents. Based on observation, interview, and record review, the facility failed to complete competency assessments for staff to ensure staff possessed the skills and abilities necessary to provide care to facility residents. This placed the residents who used mechanical lifts at risk for impaired care and decreased quality of life. Findings included: - The facility lacked documentation of any skills competency checks for any Licensed Nurse (LN) staff or Certified Nurse Aides (CNA) for 2023. On [DATE] at 07:48 AM, Resident (R) 70, an alert and oriented resident, stated a CNA used a sit-to-stand lift to transfer him. R70 stated while he was in the lift, the battery died. The CNA was unaware of the emergency release button to let R70 safely sit back down, so the CNA left R70 standing up, in the lift and left the room. R70 stated he yelled for help as he was starting to fall. A review of R76's medical record revealed on [DATE], staff were…

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 100 residents. The sample included 20 residents. Based on observation, interview, and record review, the facility failed to discard outdated medication in one of two medication rooms. This placed the residents at risk of ineffective medications. Findings included: - On [DATE] at 01:40 PM, observation in the medication room located on the 800 hall of the South campus building revealed expired Pneumovax (a vaccine which helps protect against 20 types of pneumococcal bacteria) vials (small glass container), dated [DATE]. On [DATE] at 01:40 PM, Licensed Nurse (LN) I verified the above finding. The facility's Medication Storage Policy, revised documented the medication rooms would be routinely inspected by the facility designee for discontinued, outdated, defective or deteriorated medications with worn, illegible, or missing labels. The facility failed to discard two expired Pneumovax vaccination vials. This placed the residents at risk of receiving ineffective medications.

The facility had a census of 100 residents. The sample included 20 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, in one of two kitchens. This placed the residents who received their meals from the facility's south kitchen at risk for foodborne illness. Findings included: - On 01/22/24 at 12:30 PM, observation in the kitchen revealed the following: The two-door dietary refrigerator had nine uncovered, undated, unlabeled cinnamon rolls on the top left corner shelf and the middle shelf had 27 unlabeled, undated peanut butter sandwich halves. The silver one-door upright freezer located by the oven had an unlabeled, undated, half-full three-gallon container of cookies and cream ice cream. The three-door fresh produce refrigerator had an unlabeled, undated Zip-lock bag with three red peppers and two heads of cabbage that had a black substance on them, The two-door frozen produce upright freezer had an unlabeled, undated, unsealed box 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 100 residents. The sample included 20 residents with five residents reviewed for immunizations to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interview, the facility failed to follow the latest guidance from the Centers for Disease Control and Prevention (CDC) when they failed to offer, obtain an informed declination, or a physician documented contraindication for pneumococcal PCV20 vaccination. This deficient practice placed the residents at risk to acquire, spread, and experience complications from the pneumococcal disease. Findings included: - Review of Resident (R) 11. R26, R31, R38, and R44's clinical medical records lacked evidence of a consent, informed declination, or physician documented contraindication for the current pneumococcal vaccine PCV20. On 01/25/24 at 09:51 AM, Administrative Nurse E stated he has discussed the PVC20 vaccine with residents and had plans to take information regarding PCV20 to 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 100 residents. The sample included 20 residents. Based on observation, record review, and interview the facility failed to ensure one of two kitchens' plate warmer was in safe and operable condition. This placed the residents who received their meals from the south kitchen at risk of receiving cold food. Findings included: - On 01/24/24 at 11:50 AM, observation revealed in the kitchen the plate warmer was not working. On 01/23/24 at 01:55 PM, Certified Dietary Manager (CDM) BB verified the plate warmer was not working and stated it had not been working for some time. CDM BB said every time dietary staff plugged it in, everything plugged in along that wall would short out. CDM BB stated he had reported it to maintenance. On 01/25/24 at 07:52 AM, Maintenance Staff (MS) U stated he was unaware of the issue with the plate warmer. MS U stated staff should report all maintenance issues through the Technology Enhanced Learning System (TELS) on the computer, or if unable to run the TELS system, staff should report issues directly to him. On 01/25/24 at 11:45 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 had a census of 100 residents. The sample included 20 residents. Based on observation, record review, and interview, the facility failed to accommodate one resident's, Resident (R) 61's preferences when staff delivered R61's meal trays with the other facility room trays even though R61's representative would not be coming until later to feed the resident. This placed the resident at risk for impaired nutrition as well as decreased quality of life. Findings included: - The Electronic Medical Record (EMR) for R61 documented diagnoses of cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hemiparesis/hemiplegia (weakness and paralysis on one side of the body), weakness, and other lack of coordination. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R61 had severely impaired cognition and was dependent upon two staff for eating, bed mobility, transfers,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 100 residents. The sample included 20 residents. Based on observation, record review, and interview, the facility failed to report to the State Agency (SA) within the required timeframe Resident, (R)96's black eye received from an unknown origin. This placed the resident at risk for further injury and unidentified abuse or mistreatment. Findings included: - The Electronic Medical Record (EMR for R96 documented diagnoses of congenital (from birth) deformities of the hip, severe protein-calorie malnutrition (inadequate intake of food occurring in the absence of significant inflammation, injury, or another condition that elicits a systemic inflammatory response), muscle weakness, abnormalities of gait and mobility, lack of coordination, adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration depressive symptoms, impaired immune function, and low cholesterol), cognitive-communication deficit, and tremors…

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 100 residents. The sample included 20 residents. Based on observation, record review, and interview, the facility failed to thoroughly investigate an injury of unknown origin for one resident, Resident (R) 96, who had a black eye. This placed the resident at risk for further injury and unidentified abuse or mistreatment. Findings included: - The Electronic Medical Record (EMR for R96 documented diagnoses of congenital (from birth) deformities of the hip, severe protein-calorie malnutrition (inadequate intake of food occurring in the absence of significant inflammation, injury, or another condition that elicits a systemic inflammatory response), muscle weakness, abnormalities of gait and mobility, lack of coordination, adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration depressive symptoms, impaired immune function, and low cholesterol), cognitive-communication deficit, and tremors (involuntary…

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 100 residents. The sample included 20 residents with three reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to notify the State Long Term Care (LTC) Ombudsman (a person who advocates for residents of nursing homes), as required, of Resident (R) 76's discharge from the facility. This placed the resident at risk for impaired rights and/or advocate involvement. Findings included: - R76 's Electronic Medical Record (EMR) documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), sepsis (a life-threatening systemic reaction that develops due to infections which cause inflammation throughout the entire body), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid) and atrial fibrillation (rapid, irregular heart beat). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview…

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 100 residents. The sample included 20 residents with three reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to provide Resident (R) 76 and/or the resident's representative with the facility Bed Hold upon a facility-initiated discharge/transfer to the hospital. This placed the resident at risk for impaired rights. Findings included: - R76 's Electronic Medical Record (EMR) documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), sepsis (a life-threatening systemic reaction that develops due to infections which cause inflammation throughout the entire body), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid) and atrial fibrillation (rapid, irregular heart beat). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating…

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 100 residents. The sample included 20 residents. Based on observation, record review, and interview, the facility failed to develop a care plan for Resident (R) 96, who had tremors. This placed the resident at risk for unmet care needs. Findings included: - The Electronic Medical Record (EMR for R96 documented diagnoses of congenital (from birth) deformities of the hip, severe protein-calorie malnutrition (inadequate intake of food occurring in the absence of significant inflammation, injury, or another condition that elicits a systemic inflammatory response), muscle weakness, abnormalities of gait and mobility, lack of coordination, adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration depressive symptoms, impaired immune function, and low cholesterol), cognitive-communication deficit, and tremors (involuntary quivering movement). The admission Minimum Data Set (MDS), dated [DATE], documented R96 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 100 residents. The sample included 20 residents. Based on observation, record review, and interview, the facility failed to revise a care plan with effective person-centered interventions for one resident, Resident (R) 18, who had falls related to toileting and failed to revise a care plan for R61, who no longer had enhanced barrier precautions. This placed the residents at risk for further injury and unmet care needs. Findings included: - The Electronic Medical Record (EMR) for R18 had diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body), a history of urinary tract infections (an infection in any part of the urinary system), and mixed incontinence (involuntary leakage of urine associated with urgency and also with exertion, effort, sneezing, or coughing). The Annual Minimum Data Set (MDS), dated [DATE], documented R18 had severely impaired cognition, and was dependent upon staff for toileting, transfers, and bed mobility. R18 required substantial to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 100 residents. The sample included 20 residents, with one reviewed for restorative therapy. Based on observation, record review, and interview, the facility failed to provide one sampled resident, Resident (R) 61, restorative therapy as care planned. This placed the resident at risk for a decline in mobility and function. Findings included: - The Electronic Medical Record (EMR) for R61 documented diagnoses of cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hemiparesis/hemiplegia (weakness and paralysis on one side of the body), weakness, and other lack of coordination. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R61 had severely impaired cognition and was dependent upon two staff for bed mobility, transfers, toileting, and dressing. R61 had upper and lower functional impairment on one side and did not ambulate. The Significant Change…

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 100 residents. The sample included 20 residents. with two reviewed for accidents. Based on observation, record review, and interview, the facility failed to implement the fall prevention interventions for Resident (R) 18, who had falls related to toileting, and failed to provide padded bed rails for R96, who had tremors and hit the bed rails which resulted in bruising. This deficient practice placed the resident's at risk for injury. Findings included: - The Electronic Medical Record (EMR) for R18 had diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body), a history of urinary tract infections (an infection in any part of the urinary system), and mixed incontinence (involuntary leakage of urine associated with urgency and also with exertion, effort, sneezing, or coughing). The Annual Minimum Data Set (MDS), dated [DATE], documented R18 had severely impaired cognition, and was dependent upon staff for toileting, transfers, and bed mobility. R18 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 had a census of 100 residents. The sample included 20 residents. Based on observation, interview, and record review, the facility failed to provide the physician-ordered residual checks and water flushes for Resident (R) 14's feeding tube (tube for introducing high-calorie fluids into the stomach). This deficient practice placed R14 at risk for aspiration (inhaling liquid or food into the lungs) and inadequate hydration. Findings included: - R14 's Electronic Medical Record (EMR) documented diagnoses of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), dysphagia (swallowing difficulty) following cerebral infarction (stroke), and Type 2 Diabetes Mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 100 residents. The sample included 20 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported Resident (R) 18's blood pressures outside of physician-ordered parameters. This deficient practice placed R18 at risk for unnecessary medication side effects. Findings included: - The Electronic Medical Record (EMR) for R18 had diagnoses of hypertension (high blood pressure), hemiparesis/hemiplegia (weakness and paralysis on one side of the body), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time). The Annual Minimum…

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 100 residents. The sample included 20 residents, with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to hold metoprolol (a blood pressure medication) when blood pressures were out of parameters for one resident, Resident (R) 18. This placed R18 at risk for physical decline and medications complications. Findings included: - The Electronic Medical Record (EMR) for R18 had diagnoses of hypertension (high blood pressure), hemiparesis/hemiplegia (weakness and paralysis on one side of the body), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) , and mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time). The Annual 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 100 residents. The sample included 20 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review, the facility failed to obtain a physician rationale and risk versus benefit explanation for the continued use of risperidone (antipsychotic medications used to treat major mental conditions that cause a break from reality) for Resident (R) 31. This deficient practice placed the resident at risk of receiving unnecessary antipsychotic drugs. Findings included: - R31 's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) paranoid personality disorder (when someone distrusts others for no perceived reason at all), and delusional disorder (type of mental health condition in which a person can't tell what's real from what's imagined). The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score 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 identified a census of 39 residents. Based on observation, record review, and interviews, the facility failed to perform required cooking equipment checks, store food in a sanitary manner, and ensure kitchen appliances are wiped down daily. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns. Finding Include: -During the initial inspection of the kitchen on 03/14/22 at 07:10AM the facility's dishwasher sanitation log from 12/2021 through 03/2022 had missing sanitation documentation on 24 occasions (12/22, 12/23, 12/24, 12/25, 12/26, 12/27, 12/28, 12/29, 12/30, 12/31, 2/11, 2/12, 2/13, 2/14, 2/15, 2/16, 2/17, 2/18, 2/19, 2/25, 2/26, 2/27, 2/28, and 2/29). A review of the walk-in refrigerator's temperature revealed missing temperature checks on 24 occasions (12/1, 12/2, 12/15, 12/19, 12/20, 12/21, 12/22, 12/23, 12/24, 12/25, 12/26, 12/27, 12/28, 12/29, 12/30, 12/31, 1/15, 1/22, 1/23, 1/24, 1/29, 1/30, 1/31, and 2/28). A review of the facility's walk-in freezer's temperature log revealed missing temperature checks…

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 39 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to provide care and services to maintain Resident (R) 16's highest level of function, by not maintaining urostomy (diversion of urine away from a diseased or defective bladder through a surgically created opening, or stoma, on the skin) supplies. This placed the resident at risk for physical discomfort, and negative psychosocial impact. Findings included: - R16 's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of need for assistance with personal care, acute transverse myelitis in demyelinating disease of the central nervous system (inflammation of the spinal cord, the part of the nervous system which send message from brain to the nerves and also the sensory information back to the brain), and neuromuscular dysfunction of bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system). The Annual Minimum…

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 39 residents. The sample included 12 residents. One resident, (R)27, was sampled for the accuracy of assessments. Based on observation, record review and interview the facility failed to ensure that R27 received an accurate Minimum Data Set (MDS) assessment when the facility incorrectly coded an antipsychotic (a class of medications used to treat psychosis and other mental emotional conditions) as an antidepressant (class of medication s used to treat mood disorders). Findings included: - R27's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion). The admission MDS dated 02/10/22 documented a Brief Interview of Mental Status (BIMS) score of 99. A staff interview documented short- and long-term memory problems with moderately impaired decision making. The MDS documented that R27 required extensive assistance of one staff member for activities of daily living (ADL's). 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 39 residents. The sample included 12 residents. Based on observations, record reviews, and interviews, the facility failed to revise the comprehensive care plan to include antipsychotic medication (class of medications used to treat psychosis [any major mental disorder characterized by a gross impairment in reality testing]) use and antibiotic therapy (class of medication used to treat bacterial infections) for aspiration pneumonia (an inflammatory condition of the lungs caused by inhaling foreign material or vomit) for Resident (R) 27, which had the potential for alteration of continuous care among nursing home staff, that could result in adverse consequences related to safety, adverse side effects or injury. Findings included: - R27's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 39 residents. The sample included 12 residents with six residents reviewed for activities of daily living (ADLs) cares. Based on observation, record review, and interview, the facility failed to ensure bathing was provided for one resident who required assistance from staff to complete the care. This deficient practice placed resident (R)27 at risk for potential skin breakdown and/or skin complications from not maintaining good personal hygiene and bathing practices. Findings included: - R27's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 99. A staff interview documented short- and long-term memory problems with moderately impaired decision making. The MDS documented R27 required extensive assistance of one staff member for activities of daily living…

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 39 resident. The sample included 12 residents. One resident, (R) 40, was sampled for the prevention of decline in range of motion (ROM). Based on observation, record review, and interview the facility failed to ensure staff applied R40's splint and brace as ordered by the physician, which placed r40 at risk for further decrease in ROM. Findings included: - The electronic medical record (EMR) for R40 documented diagnoses of hemiplegia and hemiparesis following a cerebral infarction affecting the left side (paralysis and weakness for the left side due to a stroke), neoplasm of the peripheral nerves and autonomic nervous system (growths in or near the strands of nerves that transmit signals from the brain to rest of your body). The Annual Minimum Data Set (MDS) dated [DATE] documented R40 had a Brief Interview for Mental Status (BIMS) score of nine which indicated moderately impaired cognition. She required total assistance of two staff to complete her activities of daily living…

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 39 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to ensure the physician documented a clinical indication for antipsychotic medication (class of medications used to treat psychosis [any major mental disorder characterized by a gross impairment in reality testing]) use as recommended by the Consultant Pharmacist (CP) for Resident (R) 27, which had the potential of unnecessary psychotropic (altering mood or thoughts) medication administration thus leading to possible harmful side effects. Findings included: - R27's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 99. A staff interview documented short- and long-term memory problems with moderately impaired decision making. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 39 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to ensure an appropriate diagnosis for antipsychotic medication (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment in reality testing) for Resident (R) 27, which had the potential of unnecessary psychotropic (altering mood or thoughts) medication administration thus leading to possible harmful side effects. Findings included: - R27's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 99. A staff interview documented short- and long-term memory problems with moderately impaired decision making. The MDS documented R27 required extensive assistance of one staff member for activities 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 identified a census of 39 residents. The sample included 12 residents with 12 reviewed for infection control. Based on observation, record review, and interviews, the facility failed to identify and implement transmission-based precautions and personal protective equipment (PPE) for Resident (R) 22 and R23 and failed to ensure adequate hand hygiene during peri-care for R22. This deficient practice placed the residents at risk for complications related infectious pathogens. Findings Include: -On 03/10/22 at R23's Lab Report indicated his urine culture tested positive for methicillin-resistant staphylococcus aureus infection (MRSA- drug resistant contagious bacteria). On 03/14/22 at R22's Lab Report indicated his urine culture tested positive for MRSA. On 03/15/22 at 10:15AM an observation of R22's and R23's shared room and surrounding area/door failed to provide an isolation cart or sign outside his room directing staff and visitors to check with nursing before entering due to the presence of MRSA. The area contained no biohazard bags for waste or laundry preventing it…

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.