Lincoln Park Manor INC

The facility had a census of 32 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to employ a full time certified dietary manager for the 32 residents who resided in the facility and received meals form the facility kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 12/14/23, review of the noon meal consisted of enchiladas, refried beans, whole kernel corn, garlic bread, and apple pie. On 12/14/23 at 11:20AM, observation revealed Dietary Staff BB in the kitchen overseeing the preparation of the noon meal. On 12/13/23 at 08:1AM, Dietary Staff BB verified she was not a certified dietary manager. Dietary Staff BB stated she had not started the certified dietary manager classes. On 12/14/23 at 2:00PM, Administrative Staff A verified Dietary Staff BB had no dietary manager certification. 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 32 residents who…

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 32 residents. The sample included 14 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 for the 32 residents who received their meals from the facility's kitchens when staff stored uncovered hamburger in two freezers. Kitchen staff failed to defrost the chest freezer and clean the outside of a chest and upright freezer. Kitchen staff failed to ensure the dishwasher sanitizing test strips were still effective. This placed the 32 residents at risk for foodborne illness. Findings included: - On 12/13/23 at 08:15 AM, observation in the kitchen revealed the following: The inside of the white chest freezer, located in the dry storage room, had approximately one-quarter inch ice buildup, 13 uncovered quarter-pound hamburger patties, and seven slider hamburgers in an unsealed zip-lock bag. The outside of the white chest freezer and upright freezer, located in the dry storage room, had numerous different size areas 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 32 residents. Based on observation, interview and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (YR) 2023 Quarter 2 and 3 indicated the facility did not have licensed nurse coverage 24 hours a day, seven days a week on multiple days, (Quarter 2: 5 dates, Quarter 3: 6 dates) Review of the facility licensed nurse payroll data for the dates listed on the PBJ revealed a licensed nurse on duty for 24 hours a day seven days a week. On 12/13/23 at 08:00 AM, observation revealed a licensed nurse on duty in the facility. On 12/14/23 at 12:30 PM, Administrative Staff B stated the facility's corporate office completed the PBJ report and would have access to the staff schedule from the computer. On 12/18/23 at 08:00 AM, Administrative Staff B stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 32 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to include two sampled residents, Resident (R) 1 and R14, in the development and planning of the residents' care plan. This placed the residents at risk of impaired care and decreased autonomy. Findings included: - The Electronic Medical Record (EMR) for R1 documented diagnoses of diabetes mellitus type 2 (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), dementia with other behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), auditory hallucinations (sensing things while awake that appear to be real, but the mind created), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), migraines ( a recurrent, throbbing headache that typically affects one side of the head and is often accompanied by nausea and disturbed vision),…

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 32 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 1 had a physician's order and was assessed for the ability to safely self-administer medications left at the bed side. This placed R1 at risk for improper use of medication and related side effects. Findings included: - The Electronic Medical Record (EMR) for R1 documented diagnoses of diabetes mellitus type 2 (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), dementia with other behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), auditory hallucinations (sensing things while awake that appear to be real, but the mind created) , anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), migraines (a recurrent, throbbing headache that typically affects one side of the head and is often accompanied by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had census of 32 residents. The sample included 14 residents with one reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to provide a written notice for a facility-initiated transfer to Resident (R32) or her representative within a practicable time when R32 was transferred to the hospital. This placed the resident at risk for uninformed care choices. Findings included: - R32's Electronic Medical Record (EMR) documented R32 had diagnoses of heart failure, hypoxemia (abnormal deficiency in the concentration of oxygen in arterial blood) and edema (swelling resulting from an excessive accumulation of fluid in the body tissues). R32's admission Minimum Data Set (MDS), dated [DATE], documented R32's Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS documented R32 required extensive staff assistance with most activities of daily living (ADLs). R32's Care Area Assessment (CAA) did not trigger for hydration/fluid…

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 32 residents. The sample included 14 residents. Based on record review and interview, the facility failed to provide Resident (R)32 or his representative with written information regarding the facility bed hold policy when R32 was transferred to the hospital. This placed R32 at risk for not being permitted to return and resume residence in the nursing facility. Findings included: - R32's Electronic Medical Record (EMR) documented R32 had diagnoses of heart failure, hypoxemia (abnormal deficiency in the concentration of oxygen in arterial blood) and edema (swelling resulting from an excessive accumulation of fluid in the body tissues). R32's admission Minimum Data Set (MDS), dated [DATE], documented R32's Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS documented R32 required extensive staff assistance with most activities of daily living (ADLs). R32's Care Area Assessment (CAA) did not trigger for hydration/fluid maintenance. R32's Care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 32 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to revise the care plan for Resident (R) 30 to include the Black Box Warning (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration) for risperidone (antipsychotic medication) for staff direction to monitor for side effects from the antipsychotic medication. This placed the residents at risk due to uncommunicated care needs and adverse side effects. Findings included: - The Electronic Medical Record (EMR) for R30 documented diagnoses of frontotemporal neurocognitive disorder (occurs when nerve cells in the frontal and temporal lobes of the brain are lost), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), expressive language disorder (caused by brain damage sustained from neurological conditions), and abnormalities of gait and mobility. The Significant Change-5 Day…

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 32 residents. The sample included 14 residents, with five reviewed for falls, Based on observation, record review, and interview, the facility failed to evaluate effectiveness of fall interventions and change or modify the interventions which were ineffective at preventing falls for Resident (R) 19. This placed the resident at risk for further falls and injury. Findings included: - The Electronic Medical Record (EMR) for R19 documented diagnoses of weakness, epilepsy (a brain disorder characterized by repeated seizures), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), transient ischemic attack (TIA- temporary episode of inadequate blood supply to the brain), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and pain. The Quarterly- 5 Day Medicare Minimum Data Set (MD, dated 12/29/23, documented R19 had intact cognition and required supervision and one staff assistance for dressing, toileting, and personal hygiene. R19 required supervision 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 32 residents. The sample included 14 residents with one reviewed for hydration. Based on observation, record review, and interview, the facility nursing staff failed to consistently monitor Resident (R) 32's fluid intake related to a physician-ordered fluid restriction. This placed R32 at risk for fluid overload. Findings included: - R32's Electronic Medical Record (EMR) documented R32 had diagnoses of heart failure, hypoxemia (abnormal deficiency in the concentration of oxygen in arterial blood) and edema (swelling resulting from an excessive accumulation of fluid in the body tissues). R32's admission Minimum Data Set (MDS), dated [DATE], documented R32's Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS documented R32 required extensive staff assistance with most activities of daily living (ADLs). R32's Care Plan, revised on 09/13/23, documented R32 received a 2000 cubic centimeter (cc) fluid restriction and instructed dietary to provide…

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 32 residents. The sample included 14 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist identified and reported that Resident (R) 26's as needed (PRN) Xanax (a sedative used for anxiety and panic disorder) lacked a 14-day stop date or specified duration which included a physician rationale. This placed the resident at risk for inappropriate use of medications. Findings included: - The Electronic Medical Record (EMR) for R26 recorded diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and restlessness and agitation. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R26 had severely impaired cognition and was independent with dressing, toileting, eating, and oral care. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 32 residents. The sample included 14 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to identify Resident (R) 30's allergy medication, Benadryl, with psychotropic (alters mood or thoughts) properties being used to treat anxiety and failed to apply the required 14-day stop date or obtain a specified duration for use with a physician rationale as required for as needed (PRN) psychotropic medications. The facility further failed to ensure an appropriate indication for R30's risperidone (an antipsychotic) or the required physician documentation and failed to ensure R30's PRN lorazepam (an antianxiety medication) had a physician's rationale for the extended use. The facility also failed to ensure R26's PRN Xanax (a sedative used for anxiety and panic disorder) had a 14-day stop date as required. This placed the residents at risk for unnecessary psychotropic medications and related complications. Findings…

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 32 residents. The sample had 14 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed ensure a medications error rate of less than five percent (%) when staff incorrectly administered medications to Resident (R)1. This placed the resident at risk for improper use of medication and related side effects and resulted in a medication error rate of 27 %. Findings included: - The Electronic Medical Record (EMR) for R1 documented diagnoses of diabetes mellitus type 2 (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), dementia with other behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), auditory hallucinations (sensing things while awake that appear to be real, but the mind created) , anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), migraines (a recurrent,…

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 32 residents. The sample included 14 residents, with one reviewed for hospice (a type of health care that focused on the terminally ill patient's pain and symptoms and attended to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R) 26. This placed R26 at risk for inappropriate and/or unmet end of life cares. Findings included: - R26's Electronic Medical Record (EMR) recorded diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and restlessness and agitation. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R26 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.

The facility had a census of 32 residents. The sample included 14 residents with one reviewed for bladder and bowel incontinence. Based on observation, record review, and interview, the facility staff failed exercise appropriate hand hygiene when providing Resident (R)31 incontinent and catheter (tube inserted directly into the bladder to drain urine) cares. This placed the resident at risk for infection. Findings included: - R31's Electronic Medical Record (EMR) documented R31 had diagnoses reflux uropathy (condition when urine flows backwards into your kidneys (two bean-shaped organs found on the left and right sides of the body) and urine retention (lack of ability to urinate and empty the bladder). R31's admission Minimum Data Set (MDS) documented R31 had short term memory problems and modified independent cognitive skills for daily decision making. The MDS documented R31 required limited staff assistance with most activities of daily living (ADLs), had an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag), and was frequently…

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 32 residents. The sample included 13 residents reviewed for care plan. Based on observation, interview and record review, the facility failed to revise and update Resident (R)29, R22, R30 and R31s' care plan with interventions aimed to prevent falls and fall related injuries. This placed the residents at risk for ineffective care and monitoring. Findings included: - The electronic medical record (EMR) for R29 documented diagnoses of restless leg syndrome (a condition that causes an uncontrollable urge to move the legs, usually because of an uncomfortable sensation), history of stress fracture (a crack in the bone due to repetitive pressure), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), and artificial left knee joint (a procedure that involves cutting away of damage cartilage and bone). The Annual Minimum Data Set (MDS) dated [DATE] documented R29 had a Brief Interview for Mental Status (BIMS) of six 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 32 residents. The sample included 13 residents with nine reviewed for accidents. Based on observation, record review, and interview, the facility failed to complete a root cause analysis to identify causative factors and failed to implement meaningful, resident centered interventions for five sampled residents, Resident (R) 22, R30, R31, and R29, who were at risk and had falls. This placed the residents at increased risk for falls and fall related injury. Findings included: - The Electronic Medical Record (EMR) documented R22 had diagnoses of type 2 diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), hypertension (high blood pressure), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness. The Quarterly Minimum Data Set (MDS), dated…

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

The facility identified a census of 32 residents. Based on observation, record review and interview, the facility failed to ensure staff followed infection control standard of practice. The facility failed to practice proper hand hygiene while serving residents their meals in the dining room. The facility failed to provide a clean barrier under the glucometer (instrument used to calculate blood glucose) while obtaining blood glucose reading. The facility failed to ensure staff sanitized the facility glucometer after each use. The facility failed to properly store the scoop for the ice chest in a sanitary manner. This placed the residents at risk for increased infection and transmission of communicable disease. Findings included: - On 05/23/22 at 11:10 AM Dietary Staff CC and Dietary Staff DD donned a hairnet and gloves as they came out of the kitchen area carrying trays with the plates and bowls of food on them to serve to residents. Gloves were not removed after serving food from the tray. On 05/23/22 at 11:14 AM Dietary Staff CC walked out of the kitchen with the same gloves 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 had a census of 32 residents. The sample included 13 residents, with four reviewed for neglect. Based on observation, record review, and interview, the facility failed to ensure Resident (R)22 remained free from neglect when staff failed to provide the necessary care and services during a transfer as directed by R22's plan of care. This deficient practice placed R22 at risk for injury and impaired physical and psychosocial well-being. Findings included: - The Electronic Medical Record (EMR) documented R22 had diagnoses of type 2 diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), hypertension (high blood pressure), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness. R22's Quarterly Minimum Data Set (MDS), dated [DATE], documented R22 had moderately…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 32 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility staff failed to report an injury of unknown origin to administration staff for one sampled resident, Resident (R) 30, who had a bruise with swelling on top of her forehead. This placed the resident at risk for further injury and unidentified abuse or mistreatment. Findings included: - The Electronic Medical Record (EMR) documented R30 had diagnoses of hypertension (high blood pressure), dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), and type 2 diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R30 had moderately impaired cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS further documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 32 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to investigate an injury of unknown origin for one sampled resident, Resident (R) 30, who had a bruise with swelling on top of her forehead. This placed the resident at risk for further injury and unidentified abuse or mistreatment. Findings included: - The Electronic Medical Record (EMR) documented R 30 had diagnoses of hypertension (high blood pressure), dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), and type 2 diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R30 had moderately impaired cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS further documented R30 had unsteady…

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 32 residents. The sample included 13 residents. One resident (R)9 was reviewed for transfer and discharge. Based on record review and interview, the facility failed to provide written notice of discharge when R9 was discharged to an acute care facility. Findings included: - The electronic medical record for R9 documented diagnoses of pneumonia (inflammation of the lungs), chronic obstructive pulmonary disease (COPD-a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), hemiplegia and hemiparesis following cerebral infarction affecting left dominant side (muscular weakness of one half of the body and paralysis of one side of the body following a stroke), and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). The Annual Minimum Data Set (MDS) dated [DATE] documented R9 had a Brief Interview for Mental Status (BIMS) score of eight which indicated a…

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 32 residents. The sample included 13 residents, with one reviewed for change of condition. Based on observation, record review, and interview, the facility failed to follow up with care in a timely period consistent with standards of nursing care after Resident (R) 31 developed increased weakness in her right arm. This placed R31, who had a history of a stroke at increased risk for physical decline and delay in treatment. Findings included: - The Electronic Medical Record (EMR) documented diagnoses of vascular dementia without behavioral disturbance (problems with reasoning, planning, judgement, memory and other thought processes caused by impaired blood supply to the brain), cerebrovascular disease (an area of the brain is temporarily or permanently affected by bleeding of one or more of the cerebral blood vessels) and cerebral infarction (CVA-occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). R31's 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 32 residents. The sample included 13 residents. Based on observations, record review and interview, the facility failed to ensure resident (R)9 and R4's oxygen (O2) tubing was dated and stored in a plastic bag when not in use. This deficient practice left R9 and R4 at risk for respiratory complication and increased risk for bacteria formation. Findings included: - The electronic medical record for R9 documented diagnoses of pneumonia (inflammation of the lungs), chronic obstructive pulmonary disease (COPD-a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), hemiplegia and hemiparesis following cerebral infarction affecting left dominant side (muscular weakness of one half of the body and paralysis of one side of the body following a stroke), and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). The Annual Minimum Data Set (MDS) dated [DATE]…

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 32 residents. The sample included 13 residents, with five reviewed for unnecessary medications. Based on observations, record review, and interview, the facility's failed to ensure the Consultant Pharmacist (CP)followed up with monthly with recommendations to change R31's inappropriate diagnosis for the Seroquel (antipsychotic medication) [medication used to treat psychosis and other mental emotional conditions]). The facility further failed to ensure staff followed up on the CP recommendation from June 2021. This deficient practice placed R31 at risk for adverse side effects related to antipsychotic use. Finding included: - The Electronic Medical Record (EMR) documented diagnoses of vascular dementia without behavioral disturbance (problems with reasoning, planning, judgement, memory and other thought processes caused by impaired blood supply to the brain), anxiety (a feeling of worry, nervousness, or unease), cerebrovascular disease (an area of the brain is temporarily or…

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 32 residents. The sample included 13 residents, with five residents' reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to provide interventions for lack of bowel movements for one sampled resident, Resident (R) 31, who had a history of constipation (difficulty in emptying the bowels) This placed the resident at risk for complications related to constipation. Findings included: - The Electronic Medical Record (EMR) documented R31 had diagnoses of constipation, congestive heart failure (a condition with low heart output and the body becomes congested with fluid), and hypertension (high blood pressure). R31's Annual Minimum Data Set (MDS), dated [DATE], documented the resident had moderately impaired cognition and required extensive assistance of one staff for bed mobility, transfer, dressing, toileting, and personal hygiene. The MDS documented the resident was always continent of bowel. R31's EMR lacked documentation a Bladder…

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 32 residents. The sample included 13 residents, with five reviewed for unnecessary medications. Based on observations, record review, and interview, the facility failed to ensure an appropriate diagnosis for Resident (R) 31's Seroquel (antipsychotic medication [medication used to treat psychosis and other mental emotional conditions]). placing R31 at risk for adverse side effects. Finding included: - The Electronic Medical Record (EMR) documented R31 had diagnoses of vascular dementia without behavioral disturbance (problems with reasoning, planning, judgement, memory and other thought processes caused by impaired blood supply to the brain), anxiety (a feeling of worry, nervousness, or unease), cerebrovascular disease (an area of the brain is temporarily or permanently affected by bleeding of one or more of the cerebral blood vessels), altered mental status (changes in cognition, mood, or behavior), and depression (a mood disorder that causes a persistent feeling of sadness and 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.