Cambridge Place

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 77 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to revise the care plan for one sampled resident, Resident (R) 47, which included interventions for antihypertensive (a class of medication used to treat high blood pressure) medications. This placed the residents at risk for physical decline, other related complications, and at risk for unnecessary medications.Findings included:- The Electronic Medical Record (EMR) for R47 had diagnoses of pulmonary hypertension (high blood pressure in the arteries of the lungs), atrial fibrillation (rapid, irregular heartbeat), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and dementia with behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion).The Quarterly Minimum Data Set (MDS) dated [DATE], documented R47 had moderately impaired cognition. R47 required partial assistance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 77 residents. The sample included 18 residents, with one reviewed for hydration. Based on observation, record review, and interview, the facility failed to consistently monitor Resident (R) 70's physician-ordered fluid restriction. This placed the resident at risk of complications related to fluid overload.Findings included:- The Electronic Medical Record (EMR) for R70 documented diagnoses of chronic kidney disease, stage 4 (a progressive, long term condition where the kidneys gradually lose their ability to filter waste and excess fluid from the blood), peripheral autonomic neuropathy (a disorder of the peripheral nerves that control automatic bodily functions), edema (swelling, resulting from an excessive accumulation of fluid in the body tissues), and hypo osmolality (when there is an abnormally low concentration of solutes in the blood, often caused by too much water in the body).The Quarterly Minimum Data Set (MDS), dated [DATE], documented R70 had intact cognition. R70 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 77 residents. The sample included 18 residents, with two reviewed for dialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood). Based on observation, record review, and interview, the facility failed to ensure ongoing fluid restriction implementation for Resident (R) 4, who received dialysis treatment. This placed the resident at risk for complications and health decline.Findings included:- R4's Electronic Medical Record (EMR) recorded diagnoses of end stage renal disease (ESRD- a terminal disease of the kidneys), 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), and hemiplegia (paralysis of one side of the body).R4's admission Minimum Data Set (MDS), dated [DATE], recorded R4 had a Brief Interview for Mental Status (BIMS) score of six, which indicated severe cognitive…

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 77 residents. The sample included 18 residents, with one reviewed for hydration. Based on observation, record review, and interview, the facility failed to hold blood pressure medication per the physician's ordered parameters for one resident, Resident (R) 47. This placed R47 at risk of low blood pressure and pulse side effects, and at risk of receiving unnecessary medication.Findings included:- The Electronic Medical Record (EMR) for R47 had diagnoses of pulmonary hypertension (high blood pressure in the arteries of the lungs), atrial fibrillation (rapid, irregular heartbeat), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and dementia with behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion). The Quarterly Minimum Data Set (MDS) dated [DATE], documented R47 had moderately impaired cognition. R47 required partial assistance with oral hygiene, toileting hygiene, upper body…

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 77 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff failed to provide enhanced barrier precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) for Resident (R) 13. The facility staff failed to don (put on) gloves when emptying R13's urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag). The facility staff also failed to wear gloves when picking up an uncovered urinary catheter bag from the floor. This deficient practice placed the residents at risk for possible exposure to infection.Findings included:- On 08/24/25 at 09:30 AM, observation revealed no EBP signage outside R13's door, but personal protective equipment (PPE) was on the inside of R13's room door. On 08/24/25 at 02:50 PM,…

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 79 residents. The sample included two kitchens and 18 residents. Based on observation, record review, and interview the facility failed to provide the services of a full time certified dietary manager for the 79 residents who resided in the facility and received their meals from the kitchen. Findings included: - On 12/06/23, review of the noon meal consisted of roast beef, buttered noodles, seasoned squash, dinner roll, and assorted deserts. On 12/06 /23 at 10:56 AM, observation revealed Dietary Staff BB in the kitchen overseeing the preparation of the noon meal. On 08/29/23 at 04:25 PM, Dietary Staff BB verified she was not a certified dietary manager. Dietary Staff BB stated she had completed the course, failed the test and had to wait six months to repeat the class. On 12/6/23 at 12:30 PM, Administrative Staff A verified Dietary Staff BB had no dietary manager certification. On 12/07/23 at 12/05/23 at 8:30 AM, observation revealed dietary staff in the kitchen prepared the breakfast meal. On 12/07/23 at 09:10 AM, Dietary Staff BB verified she worked at…

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 79 residents. The sample included 18 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 all the residents who received their meals from the facility's two kitchens. This placed all residents at risk for food borne illness. Findings included: - On 12/05/23 at 08:27AM observation in the first of two kitchens revealed the following: The walk-in refrigerator had a cracked eggshell, an approximately one-half inch(in) by three in. wide piece of plastic wrap on the floor, and numerous different size pieces of paper underneath the bottom shelf. The white chest freezer had approximately one-quarter in. of ice around all the inside and had numerous different sized, dried brown, liquid stains on the bottom. The counter ice machine located at the entrance to the kitchen had numerous different size brown specks of food particle in and around the tray. On 12/06/23 at 10:22 AM, observation revealed in the kitchen 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 79 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 (FY) 2023 Quarter 1 indicated the facility did not have licensed nurse coverage 24 hours a day, seven days a week on multiple (5) dates. Review of the facility licensed nurse payroll data for the dates listed on the PBJ revealed a licensed nurse was on duty for 24 hours a day seven days a week. On 12/06/23 at 08:30AM, observation revealed a registered nurse on duty in the facility. On 12/07/23 at 01:00PM, Administrative Staff (AS) A verified the facility did not send in the correct data to CMS for payroll-based data. The facility's Reporting Payroll Based Data Journal policy, dated 12/01/2019, states complete, and accurate direct care staffing…

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 79 residents. The sample included 18 residents. Based on observation, interview, and record review the facility failed to provide infection control measures for residents' oxygen tubing when not in use and failed to implement a surveillance plan for water borne pathogens. This deficient practice placed the residents of the facility at risk for infections. Findings included: - Upon request, the facility was unable to provide evidence the facility assessed risks and implemented a surveillance plan to identify and prevent Legionella (prevent Legionella disease (Legionella is a bacterium which can cause pneumonia in vulnerable populations) and other opportunistic waterborne pathogens. On 12/05/23 at 08:45 AM, observation in R32's room revealed her uncovered oxygen tubing coiled up on the oxygen canister with the nasal canula touching the back of the tubing. On 12/05/23 at 10:48 AM, observation revealed R25's oxygen tank on her wheelchair in the hall with the unbagged/uncovered nasal cannula draped on the seat back. On 12/06/23 at 07:37 AM, observation…

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 79 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to ensure one of two kitchens walk-in freezer was in safe operating condition, when the freezer door continued to build up with ice and fail to completely shut. This placed the residents of one of two buildings who received their meals from that kitchen at risk for foodborne illness. Findings included: - On 12/05/23 at 8:27AM, observation in the kitchen revealed the walk-in freezer door had ice buildup on the frame of the door and would not stay closed. On 12/06/23 at 11:59 AM, Dietary Staff (DS) BB verified the walk-in freezer door had ice buildup on it for about six months, she had notified maintenance, but nothing got done. On 12/6/23 at 12:30PM, Administrative Staff A stated she was aware of the problem with the walk-in freezer door not closing due to ice buildup. The facility's Preventative Maintenance Program Policy, revised 10/25/19, documented the maintenance director was responsible for developing and maintain a schedule 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 had a census of 79 residents. The sample included 18 residents with one reviewed for abuse. Based on observation, record review, and interview the facility failed to ensure staff identified and reported allegations of potential abuse to the administrator of the facility immediately. This placed the residents at risk for ongoing abuse and/or mistreatment. Findings included: - R69's Electronic Health Record (EHR) revealed diagnosis of dementia (progressive mental disorder characterized by falling memory, confusion,) major depressive disorder (major mood disorder which causes persistent feelings of sadness,) hypertension (elevated blood pressure.) R69's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R69 had severely impaired cognition. The MDS recorded she required limited assistance of one staff assistance for transfers and activities of daily living (ADL.) The MDS further documented R69 had no falls and no skin issues. R69's Quarterly MDS, dated 10/06/23, recorded R69 had severely impaired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 79 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to investigate Resident (R)69's unwitnessed fall in the bathroom which resulted in swelling and bruising. This deficient practice placed R69 at risk for unidentified and continued abuse, neglect and/or mistreatment. Findings included: - R69's Electronic Health Record (EHR) revealed diagnosis of dementia (progressive mental disorder characterized by falling memory, confusion), major depressive disorder (major mood disorder which causes persistent feelings of sadness) and hypertension (elevated blood pressure). R69's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R69 had severely impaired cognition. The MDS recorded she required limited assistance of one staff assistance for transfers and activities of daily living (ADL.) The MDS further documented R69 had no falls and no skin issues. R69's Quarterly MDS, dated 10/06/23, recorded R69 had severely impaired…

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

The facility had a census of 79 residents. The sample included 18 residents with one reviewed for discharge to the hospital. Based on observation, interview, and record review, the facility failed to notify the ombudsman of the facility-initiated discharge of Resident (R) 81, placing R81 at risk for discharges without oversight of the ombudsman office. Findings included: - R81's Electronic Medical Record documented he was admitted to the facility 09/27/23 with diagnoses of atrial fibrillation (rapid irregular heartbeat), hypertension (high blood pressure), left femur (thigh bone) fracture, and anxiety disorder (mental disorder characterized by apprehension, uncertainty and irrational fear). R81's Care Plan, dated 10/02/23, directed staff to ensure the call light was within reach and encourage R81 to use it for assistance as needed. Engage the resident in active conversation. The Progress Note to the physician, dated 10/03/23 at 04:30 PM, stated R81 said he would have better acceptance of being in the nursing home if he could visit home, sit on the porch, and see the dogs. The note…

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 79 residents. The sample included 18 residents with one reviewed for respiratory care. Based on observation, interview, and record review the facility failed to develop and implement a baseline care plan for Resident (R) 25's use of supplemental oxygen. This deficient practice placed R25 at risk for respiratory complications related to uncommunicated care needs. Findings included: - R25's Electronic Medical Record documented diagnoses including chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing)), obstructive sleep apnea (disorder in which a person frequently stops breathing during his or her sleep), and congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid). The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS…

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

The facility had a census of 79 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to review and revise Resident (R) 284's Care Plan with effective interventions for staff to follow when R284 had behaviors. This placed R284 at risk for unmet care needs. Findings included: - R284's Electronic Medical Record (EMR) documented R284 had diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), major depressive disorder (major mood disorder which causes persistent feelings of sadness), and dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance. R284's admission Minimum Data Set (MDS) documented it was in progress. R284's Care Plan, revised on 12/06/23, documented R284 had behaviors of yelling out and asking staff to take a gun and shoot me or just kill me or take me outside and let me lay there and die. R284's Care Plan lacked interventions for staff to follow when R284 had these behaviors. The Nurse's Note, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 79 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility staff failed to provide necessary services for one of four residents reviewed for activities of daily living (ADLs), when Resident (R) 74 requested staff assistance with repositioning and they told her she would have to wait, then did not return until 41 minutes later to assist her. This placed R74 at risk for impaired mobility and decreased comfort. Findings included: - R74's Electronic Medical Record (EMR) documented R74 had diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), carcinoma (cancer) in right breast, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), major depressive disorder (major mood disorder which causes persistent feelings pf sadness), and chronic pain.…

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 79 residents, The sample included 18 residents with one reviewed for range of motion (ROM). Based on observation, interview, and record review, the facility failed to provide neck stretching exercises for Resident (R) 15 to prevent further decline in her neck range of motion as discussed during her quarterly care plan meeting. This placed the resident at risk for decreased or impaired comfort. Findings included: - R15's Electronic Medical Record documented diagnoses of contracture (abnormal permanent fixation of a joint or muscle) of left shoulder muscle, acquired deformity of neck, contracture of left forearm muscle, osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, shuffling gait, muscle rigidity and weakness). The Quarterly 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 79 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to provide an environment free from accident hazards when Resident (R) 67's bedrail exceeded the acceptable safety dimension to prevent entrapment. This placed the resident at risk for accidents and preventable injury. Findings included: - R67's diagnoses from the Electronic Medical Record (EMR) included neuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), atrial fibrillation (rapid, irregular heart beat), and pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and in the heart). R67's admission Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 14,…

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 79 residents, The sample included 18 residents with one reviewed for respiratory care. Based on observation, interview, and record review, the facility failed to provide Resident (R) 25's supplemental oxygen at the physician ordered rate through the nasal canula and with the use of a non-invasive ventilator. This deficient practice placed R25 at risk for complications resulting from the incorrect rate of oxygen administered. Findings included: - R25's Electronic Medical Record documented diagnoses including chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing)), obstructive sleep apnea (disorder in which a person frequently stops breathing during his or her sleep), and congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid). The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental…

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 79 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to assess the actual bedrail prior to use to assure safety for Resident (R) 67. This placed the resident at risk for injury. Findings included: - R67's diagnoses from the Electronic Medical Record (EMR) included neuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), atrial fibrillation (rapid, irregular heart beat), and pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and in the heart). R67's admission Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating cognitively intact cognition. The MDS documented R67 required extensive assistance of two…

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 79 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed provide adequate medically related social services to meet Resident (R) 284's mental and behavioral health needs. This placed the resident at risk for decreased quality of care and life. Findings included: - R284's Electronic Medical Record (EMR) documented R284 had diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), major depressive disorder (major mood disorder which causes persistent feelings of sadness), and dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance. R284's admission Minimum Data Set (MDS) documented it was in progress. R284's Care Plan, revised on 12/06/23, documented R284 had behaviors of yelling out and asking staff to take a gun and shoot me or just kill me or take me outside and let me lay there and die. R284's Care Plan lacked interventions for staff to follow when R284 had these behaviors. 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 79 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to discard Resident (R)32's outdated insulin (hormone which allows cells throughout the body to uptake glucose) flex pen. This deficient practice placed the affected resident at risk for ineffective medications. Findings included: - On [DATE] at 10:45AM, observation revealed R32's Lantus (long-acting insulin) flex pen had an open date of [DATE] (31 days) and lacked a discard date. On [DATE] at 10:50 AM, Licensed Nurse (LN) H verified the nurses were to date the flex pens when opened and discard the insulin pen when expired. On [DATE] at 01:30 PM, Administrative Nurse E verified the nurses should label and date the flex pens with the resident's name and discard expired and/or outdated pens. According to www.Medlineplus.gov, Lantus pens can be used within 28 days of opening, but after that time they must be discarded. The facility's Labeling of Medication 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 79 residents. The sample included 18 residents with two reviewed for hospice (a type of health care that focused on the terminally ill patient's pain and symptoms and attending 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)46. This placed R46 at risk for inappropriate end of life cares. Findings included: - R46's Electronic Health Record (EHR) revealed diagnosis of chronic obstructive pulmonary disease (COPD - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), rheumatoid arthritis (chronic inflammatory disease that affects joints…

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 42 residents with seven residents reviewed for restorative therapy. Based on record review, observation, and interview, the facility failed to provide Resident (R) 1, R2, R3, and R4. with the restorative therapy services to maintain or improve mobility with the maximum practicable independence. The deficient practice placed R1, R2, R3, and R4 at risk for an avoidable decline in range of motion and mobility. Findings included: - R1 had diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), muscle wasting and atrophy (wasting or decrease in size of a part of the body), and unsteadiness of feet. R1 had a Brief Interview for Mental Status (BIMS) score of nine which indicated moderate cognitive impairment. R1 required supervision with set up help only for bed mobility, transfer, ambulation, locomotion, eating and personal hygiene. R1 require one staff limited assistance for dressing, toileting, and bathing. Staff were directed to provide R1 with restorative nursing services: active range of motion (AROM),…

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 77 residents. The sample included 18 residents. Based on observation, record review and interview, the facility failed to correctly prepare a pureed diet for three residents. This placed the residents at risk for not receiving adequate nutrition and choking. Findings included: - On 03/15/22 at 11:40 AM, observation revealed Dietary Staff (DS) BB (Dietary Manager) prepared a pureed diet. DS BB placed three slices, approximately three ounces (oz) of pork loin into a blender. DS BB blended the pork loin, added some of the meat broth (not measured), and emptied the pork into a storage bowl in the warming well. Further observation revealed DS BB placed three, 1/2 cup servings of spinach into a blender with some spinach juice (not measured), blended the spinach to the correct texture, emptied the spinach into the storage bowl, and placed into the warming well. Continued observation revealed DS BB place three 2 by 2-inch slices of butterscotch cookie bars and some milk (not measured) into a blender, blended the dessert, placed into three separate bowls, 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.

The facility had a census of 77 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to prepare, store, distribute, and serve food under sanitary conditions for the 77 residents in the facility, who received their meals from one of the two facility kitchens. This placed the residents at risk for foodborne illness. Findings included: - On 03/14/22 at 9:00 AM, during initial tour, observation revealed the following: One - 16-inch Oscillating table fan located on the cabinet top blowing air on the food preparation table. The metal fan mesh cover had gray fuzzy substance covering the metal and the three fan blades. Six - 12 inches x 3 foot fluorescent lights, located above the food preparation area, with the plastic light covers covered with a brownish gray fuzzy substance. Two - 4 foot x 3 foot ceiling mounted heater and air conditioning units, located on each side of the range hood and blowing air directly across the food preparation area. The air vent grills covered with a brown greasy/sticky substance and gray fuzzy…

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 77 residents. The sample included 18 residents. Based on observation, interview and record review, the facility failed to use a proper disinfection agent on the facility's multi use glucometer (an instrument which measures the amount of glucose (sugar) in your blood). This placed the residents in one of two facility buildings at risk for blood borne pathogens (any organism that can produce disease) when staff obtained blood sugar tests of residents. Findings included: - On 03/16/22 at 11:41 AM, observation revealed Licensed Nurse (LN) I obtained a blood sugar test from Resident (R) 173. After checking the blood sugar, she laid the glucometer on top of the medication cart and went on to do other things. Further observation revealed LN I used Clorox wipes with ammonium chloride, not bleach, to disinfect the glucometer. On 03/16/22 at 11:45 AM, LN I stated the two facility Evencare G2 glucometers were used for any resident needing accuchecks and stated if she needed to use the glucometer for another person she would clean it with Clorox wipes. The facility…

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 - R22's Physician Order Sheet (POS), dated 01/20/22, documented diagnoses of long-term use of anticoagulant (commonly known as blood thinner), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), presence of cardiac pacemaker (implanted device to regulate the beating of the heart) pulmonary hypertension (high blood pressure that affects the arteries in the lungs and heart), and atrial fibrillation (rapid, irregular heart beat). The admission Minimum Data Set (MDS), dated [DATE], documented R22 had intact cognition, required extensive assistance of one staff for activities of daily living (ADLs), had no skin ulcers, and received an anticoagulant and diuretic (medication to promote the formation and excretion of urine) daily. The Pressure Ulcer/Injury Care Area Assessments (CAA), dated 12/12/21, documented the resident was at risk for the potential development of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony…

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 77 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for Resident (R) 22 placing the resident at risk for improper care and continued skin injury. Findings included: - R22's Physician Order Sheet (POS), dated 01/20/22, documented diagnoses of long-term use of anticoagulant (commonly known as blood thinner), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), presence of cardiac pacemaker (implanted device to regulate the beating of the heart) pulmonary hypertension (high blood pressure that affects the arteries in the lungs and heart), and atrial fibrillation (rapid, irregular heart beat). The admission Minimum Data Set (MDS), dated [DATE], documented R22 had intact cognition, required extensive assistance of one staff for activities of daily living (ADLs), had no skin ulcers, and received an anticoagulant and diuretic…

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 77 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to complete the weekly skin assessment to document Resident (R) 22's skin condition which developed on 03/11/22. This placed the resident at risk for further skin issues. Findings included: - R22's Physician Order Sheet (POS), dated 01/20/22, documented diagnoses of long-term use of anticoagulant (commonly known as blood thinner), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), presence of cardiac pacemaker (implanted device to regulate the beating of the heart) pulmonary hypertension (high blood pressure that affects the arteries in the lungs and heart), and atrial fibrillation (rapid, irregular heart beat). The admission Minimum Data Set (MDS), dated [DATE], documented R22 had intact cognition, required extensive assistance of one staff for activities of daily living (ADLs), had no skin ulcers, 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 77 residents. The sample included 18 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure the Consultant Pharmacist's recommendations were addressed by the facility and physician for a 14 day stop date or physician's rationale for extended use for PRN (as needed) psychotropic medication (medications that affect a person's mental state) for Resident (R) 21 and provide an appropriate diagnosis for an antipsychotic medication (medication used to treat major emotional conditions and mental illness) for R4. This placed the residents at risk to receive unnecessary psychotropic medications and adverse medication side effects. Findings included: - The Physician Order Sheet, dated 03/03/22, recorded R21 had diagnoses of depression (mental health disorder characterized by a persistent depressed mood, causing impairment of daily life), and anxiety (mental health disorder characterized by worry and fear that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY - R4's Physician Order Sheet (POS), dated 03/11/22, documented diagnoses of Parkinson's disease (disorder of the central nervous system that affects movement), major depressive disorder, single episode (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and dementia (group of thinking and social symptoms that interferes with daily functioning). R4's Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition, and a mood score of one. The MDS documented R4 was independent with eating and required extensive staff assistance for all other activities of daily living (ADLs). The MDS documented R4 received antipsychotic medications (medication used to treat major emotional conditions and mental illness) seven days of the lookback period. The MDS documented the physician stated a gradual dose reduction (GDR) of the antipsychotic was…

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 77 residents. The sample included 18 residents with two reviewed for hospice (a type of health care that focused on the terminally ill patient's pain and symptoms and attending 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) 40 and R25. This placed R40 and R25 at risk for inappropriate end of life cares. Findings included: - R40's Physician Order Sheet, dated 02/10/22, revealed diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion.) R40's Quarterly Change Minimum Data Set (MDS), dated [DATE], recorded R40 had severely impaired…

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