Heritage Gardens Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 50 residents. The sample included three residents reviewed for accidents. Based on record review and interview, the facility failed to provide adequate supervision and failed to identify and implement interventions to address elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff) risk and attempts for Resident (R)1, who had exit seeking behavior and actual attempts to elope from the facility. This placed the resident at risk for elopement and other preventable accident hazards. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab, recorded diagnoses of schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), hypertension (elevated blood pressure), reduced mobility, and dementia (progressive mental disorder characterized by failing memory, confusion). The admission 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 52 residents. Based on observation, record review, and interviews, the facility failed to post the pertinent state agencies and advocacy groups in a manner that was accessible and clearly visible to residents and/or their representatives. This placed the residents at risk for impaired access to resident advocacy groups and agencies. Findings included: - On 09/18/23 at 11:54 AM the facility had the state agencies and advocacy group contact information posted in the main dining room but not at wheelchair height. The height of the posting was aproximately five feet. The posting text was too small to discern the contact information, right to file a complaint with the state agency and the relevant phone numbers in order to do that. There was a large table against the wall in front of the posting which prevented residents and visitors from approaching the postings in order to see more clearly. On 09/19/23 at 10:06 AM Resident (R) 3 and R11 stated the state agency and advocacy information was difficult to read where it was posted and it was a bit high.…

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 52 residents. The sample included 15 residents and five Certified Nurse Aide's (CNA) were reviewed for performance evaluations and required in-service training. Based on record review and interview, the facility failed to ensure three of the five CNA staff reviewed had received yearly performance evaluations and had the required 12 hours of in-service education per year. This placed the residents at risk for inadequate care. Findings included: - Review of the facility's in-service records revealed CNA M, CNA O, and CNA P lacked the required 12 hours of yearly in-service education. The facility was unable to provide yearly performance evaluations for the following CNAs: CNA M hire date of 05/25/22. CNA O hire date of 09/15/21. CNA P hire date of 05/12/22. On 09/19/23 at 12:49 PM Administrative Nurse D stated that she did not have the performance evaluations for CNA M, CNA O, and CNA P. She stated that they were paper copies and that she was unable to locate them. She further stated that she provided all of the in-service education that she had available…

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 52 residents. Based on observation, record review, and interviews, the facility to ensure staff practiced standard infection control practices regarding appropriate hand hygiene during wound care. The facility also failed to ensure staff disinfected resident's items after dirty items were placed on bedside table where the resident ate her meals. The facility failed to ensure the Infection Preventionist tracked and trended infections within the facility. This had the potential to increase the residents' risk for transmission of infectious disease. Findings included: - On 09/20/23 at 07:32 AM Licensed Nurse (LN) H entered Resident (R) 34's room to obtain a blood glucose level. LN H washed hands and donned gloves, placed a clean barrier onto R34's bedside table next her bed. LN H dropped the lancet onto the floor. She picked the dirty lancet up off the floor and placed the dirty lancet onto the bedside table next to clean barrier. LN H doffed gloves and obtained a new lancet, hand sanitized, then donned new gloves and obtained R34's blood glucose. LN…

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 52 residents. The sample include 15 residents. Based on observation, record review, and interviews, the facility failed to promote a safe, homelike environment. This deficient practice had the potential for decreased psychosocial well-being and impaired safety and comfort for the affected residents. Findings Included: - On 09/18/23 at 07:05AM walkthrough of the facility revealed a heavy urine smell in the southwest hall and the southeast hallway. On 09/18/23 at 09:23AM an inspection of Resident (R)27's bathroom revealed missing tiles around her toilet. On 09/19/23 at 11:00AM Maintenance Staff U was on the secured unit fixing the wall tiles in the unit. She stated the facility was getting around to completing some minor repairs around the facility. An inspection of the facility's front hallways near the main entrance from 09/18/23 through 09/20/23 revealed ongoing loud beeping from the Call Light system. On 09/19/23 at 09:00AM R29 stated the noise from the call light system did get annoying after hearing them beep all day. She stated staff would…

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 52 residents. The sample included 15 residents with five residents reviewed for accidents and/or hazards. Based on observation, record review, and interview the facility failed to secure rooms containing hazardous materials to keep out of reach of 12 cognitively impaired /independently mobile residents. This deficient practice placed the 12 residents at risk for preventable injuries and accidents. Findings Included: - On 09/18/23 at 07:34AM, an inspection of an unsecured utility closet in the north-east hall revealed a sprayer bottle of Shurguard Plus cleaning solution in the lower cabinet. The bottle contained the warning, Keep out of reach of children, hazardous to humans can cause eye irritation, harmful if swallowed. On 09/20/23 at 01:43PM Certified Nurses Aid (CNA) N stated all chemical products and cleaning solutions should be securely locked out of reach for the residents. On 09/20/23 at 03:00PM Administrative Nurse D stated staff were expected ensure hazardous chemicals and items were kept out of reach of the residents. She stated the utility…

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 52 residents. The sample included 15 residents with two residents reviewed for dignity. Based on observation, interview and record review, the facility failed to ensure a dignified care environment for Resident (R)1. This deficient practice placed R1 at risk unnecessary embarrassment and decreased psychosocial wellbeing. Findings Included: - The Medical Diagnosis section within R1's Electronic Medical Records (EMR) included diagnoses of schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), major depressive disorder (major mood disorder), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and insomnia (difficulty sleeping). R1's Annual Minimum Data Set (MDS) completed 07/02/23 noted a Brief Interview for Mental Status (BIMS) score of nine indicating moderate cognitive impairment. The MDS indicated a history of wandering behaviors. The MDS indicated she required supervision when walking on…

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

The facility identified a census of 52 residents with 15 residents included in the sample. The facility identified 26 residents who discharged from Medicare Part A services. Based on interview and record review the facility failed to issue CMS (Center for Medicare/Medicaid Services) Skilled Nursing Facility Advance Beneficiary Notification (SNF ABN) form 10055 (the form used to notify Medicare A participants of potential financial liability when a Medicare Part A episode ends) for Resident (R) 11 and failed to ensure the SNF ABN form 10055 and the Notification of Medicare Non-Coverage (NOMNC- the form used to notify Medicare A participants of their rights to appeal and the last covered date of service) form 10123 was provided within the required timeframes for R16. This failure placed the residents at risk for decreased autonomy and impaired right to appeal. Findings included: - Review of R11's Electronic Medical Record (EMR) documented the Medicare Part A episode began on 06/05/23 and ended on 07/02/23. R11 remained in the facility for custodial care. The facility did not issue 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 identified a census of 52 residents. The sample included 15 residents with five residents reviewed for care planning. Based on observation, record review, and interviews, the facility failed identify the level of care assistance needed for activities of daily living (ADLs) on Resident (R)44's care plan. This deficient practice placed R44 at risk for ineffective treatment and preventable accidents due to uncommunicated care needs. Findings Included: - The Medical Diagnosis section within R44's Electronic Medical Records (EMR) included diagnoses of hypertension (high blood pressure), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), congestive heart failure (a condition with low heart output and the body becomes congested with fluid), type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), morbid obesity (severely overweight), and blistering of the left and right heels. R44's admission Minimum Data Set (MDS) completed 08/26/23 noted 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 identified a census of 52 residents. The sample included 15 residents with five residents reviewed for activities of daily living (ADLs). Based on observation, record review, and interviews, the facility failed to provide consistent bathing opportunities for Resident (R)44 and R33. This deficient practice placed both residents at risk for infections and skin breakdown. Findings Included: - The Medical Diagnosis section within R44's Electronic Medical Records (EMR) included diagnoses of hypertension (high blood pressure), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), congestive heart failure (a condition with low heart output and the body becomes congested with fluid), type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), morbid obesity (severely overweight), and blistering of the left and right heels. R44's admission Minimum Data Set (MDS) completed 08/26/23 noted a Brief Interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 52 residents. The sample included 15 residents with two residents reviewed for treatment/services to prevent/heal pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to implement preventive measures to prevent possible skin breakdown for Resident (R) 33 who was at risk for development of pressure ulcers. The facility failed to ensure weekly wound assessments were completed for R4 who had a pressure ulcer. These deficient practices placed these residents at risk of development or worsening pressure ulcers. Findings included: - R33's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), congestive heart failure (CHF-a condition with low heart output and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 52 residents. The sample included 15 residents with three residents reviewed for increase/prevent decrease in range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension). Based on observation, record review, and interviews, the facility failed to provide services to prevent a potential decrease in ROM/mobility and/or development of contractures (abnormal fixation of a joint or muscle) for Resident (R) 19 when staff failed to provide his left-hand splint to prevent contractures. The deficient practices placed the resident at risk of loss of ability to perform activities of daily living (ADLs) and development or worsening of contractures. Findings included: - The electronic medical record (EMR) for R19 documented a diagnosis dementia (progressive mental disorder characterized by failing memory, confusion), traumatic brain injury (TBI - sudden injury that causes damage to the brain and affects how the brain works), limitation of…

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

The facility identified a census of 52 residents. The sample included 15 residents with three reviewed for bowel and bladder management. Based on observation, record review, and interviews, the facility failed to implement individualized interventions to improve/maintain R44's bowel and bladder incontinence. This deficient practice placed R44 at risk for complications related to incontinence. Findings Included: -The Medical Diagnosis section within R44's Electronic Medical Records (EMR) included diagnoses of hypertension (high blood pressure), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), congestive heart failure (a condition with low heart output and the body becomes congested with fluid), type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), morbid obesity (severely overweight), and blistering of the left and right heels. R44's admission Minimum Data Set (MDS) completed 08/26/23 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact…

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 52 residents. The sample included 15 residents with two residents reviewed for dementia (progressive mental disorder characterized by failing memory, confusion) care services. Based on observation, record review, and interviews, the facility failed to provide dementia care and services for Resident (R)27's dementia related behaviors. This deficient practiced placed the residents at risk for unmet care needs to maintain their highest practicable level of functioning. Findings Included: -The Medical Diagnosis section within R27's Electronic Medical Records (EMR) included diagnoses of dementia, visual hallucinations (sensing things while awake that appear to be real, but the mind created), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and major depressive disorder (major mood disorder). R27's Quarterly Minimum Data Set (MDS) completed 07/02/23 noted a Brief Interview for Mental Status (BIMS) score of two indicating severe cognitive impairment. The MDS indicated hallucinations,…

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 44 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility staff failed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections, when staff failed to conduct a complete COVID (acute respiratory infection) screening process for visitors and staff prior to entering the facility. The facility failed to utilize aseptic (free from contamination caused by harmful bacteria, viruses, or other microorganisms) technique when providing tracheotomy (trach-opening though the neck into the trachea through which an indwelling tube may be inserted) care failed to ensure staff performed appropriate hand hygiene when provided care to R13, R16 and R27. This placed the residents at increased risk for infections. Findings included: - On 01/24/22 at 07:30 AM Transportation Aide MM asked the COVID screening questions and assessed temperatures of the survey team. Transportation Aid MM failed to disinfectant the thermometer between individual use after it made…

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 44 residents. The sample included 17 residents. Based on observation, interview, and record review, the facility failed to have a surety bond or otherwise provide satisfactory assurance to guarentee the security of all personal funds of the residents deposited with the facility. This placed the residents at risk for impaired psychosocial well-being and loss of personal funds. Findings included: - On 01/26/22 at 11:30 AM, review of the facility's Surety Bond for personal fund accounts revealed the amount coverage was $20,000.00. On 01/26/22 at 11:30 AM, review of the 37 residents' personal fund accounts revealed a total of $36,071.14. On 01/26/22 at 11:30 AM, Administrative Staff B verified the surety bond was not large enough to insure all of the resident funds. The facility's Surety Bond Requirements policy, dated 12/01/20, documented the facility must purchase a surety bond or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of the residents deposited with the facility. The surety bond must be…

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 44 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to provide personal privacy for phone calls for residents in the Special Care Unit (SCU) who did not have a personal phone. This placed the residents at risk for lack of privacy during phone calls. Findings included: - [DATE] at 09:05 AM, observation revealed Resident (R) 40 in the nurse's office of the SCU talking loudly on the office phone with the Social Security Administration. R40 verified his personal information on the phone while three residents and a surveyor sat in chairs in the hall just outside the office. The nurse was in the office with him but did not shut the door for privacy. The facility's Grievance Log lacked documentation of any phone privacy grievance. On [DATE] at 09:34 AM, R38 stated the nurse had to be in the room when residents made phone calls as the phone was in the nurse's office. On [DATE] at 12:47 PM, R40 stated he did not have 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.

The facility had a census of 44 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to provide a safe, clean, homelike atmosphere in the Special Care Unit (SCU- a special care unit for memory related issues is specifically designed to accommodate the unique needs of dementia patients) and the two shower rooms on the main halls of the facility. This placed the residents at risk for an non-homelike environment. Findings included: - On 01/24/22 at 09:10 AM, observation revealed the following: A reddish colored recliner in the SCU living room with a large tear in the upholstery of the head rest area with the inner foam revealed. The shower room had two tiles falling away from the wall behind the toilet. The grout between the wall tiles of the shower were discolored and/or stained a brownish color approximately three feet up the wall from the floor. The seat belt for the whirlpool was frayed along it's length. Resident (R) 17's wheelchair arms had damaged arm coverings with the inside foam visible. The seat had a four-inch…

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 44 residents. The sample included 17 with two reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide an environment free of accident hazards for Resident (R) 23 when the facilty failed to secure a wobbly grab bar on her bed. The facility failed to ensure a safe, accident free environment when staff left an unlocked treatment cart containing medications unsupervised and left medications unsupervised at the bedside of R14 on the south hall. These deficient practices placed residents at risk for accidents. Findings included: - The Physician Order Sheet (POS), dated 01/18/22, for R23 documented diagnoses of autism (serious developmental disorder that impairs the ability to communicate and interact), depression ( mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) with anxiety (intense, excessive, and persistent worry and fear about everyday…

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 44 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to date Resident (R) 22, R15, R35 and R17's insulin (medication that lowers the level of glucose [a type of sugar] in the blood) vials when they were opened in one of two medication carts. The facility failed to ensure medication carts did not contain expired medications. The facility also failed to lock an unsupervised treatment carts. This placed the residents at risk for receiving an ineffective insulin medication and risk due to unintended access to unsupervised medications. Findings included: - On 01/24/22 at 08:23 AM, observation of a medication cart on the main side of the facility revealed R22 had two vials of Lantus (slow acting insulin), R15 had one vial of Novolog (fast acting insulin), and one vial of Levimer (long acting insulin), and R35 had 2 vials of Admelog (fast-acting mealtime insulin that works to control blood sugar when you eat) insulinwhich lacked a date when they were opened and/or discard date. On 01/24/22 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 44 residents. The sample included 17 residents. Based on observation, interview, and record review, the facility failed to ensure staff treated three residents who required assistance with dignity during meals, Resident (R) 17, R37, and R16. The facility failed to provide R16 with his meal at the same time as other residents at his table. This placed the residents at risk for an undignified experience. Findings included: - On 01/25/22 at 12:12 PM, observation revealed R17 sat at the dining table with Certified Nurse Aide (CNA) O standing over him assisting R17 with a few bites of his meal. At 12:14 PM, CNA M cued R17 to eat and placed food onto his spoon for him while standing beside his chair. On 01/26/22 at 07:35 AM, observation revealed R17 at the dining table in his wheelchair while CNA O stood over him to assist with bites of food. Further observation revealed R37 sat at another dining table and CNA O walked back and forth between R17 and R37 to assist each one with their meal. Observation revealed no available chair in the dining room for CNA O to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 44 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to notify Resident (R) 34 that she was getting a new roommate. This placed the resident at risk for impaired psychosocial well-being. Findings included: - The Electronic Medical Record (EMR) for R34 recorded diagnoses of heart failure (the heart doesn't pump blood as well as it should), diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired), atrial fibrillation (rapid, irregular heart beat), debility (physical weakness), and constipation (difficulty in emptying the bowels). R34's Five Day Minimum Data Set (MDS), dated [DATE], documented R34 had intact cognition and required extensive assistance of two staff for bed mobility, transfers only occurred once or twice with the assistance of two staff, and limited assistance of one staff for personal hygiene. The Activities Care Plan, dated 12/15/21, documented the resident 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.

The facility had a census of 44 residents. The sample included 17 residents with three reviewed for Beneficiary Liability Notices. Based on interview and record review, the facility failed to ensure Resident (R)17 and R5 received notice of the discontinuation of Medicare Part A services in a timely manner and failed to ensure R5's notice contained the appropriate appeal information. This placed the residents at risk to make uninformed decisions about their skilled services. Findings included: - The Medicare Advanced Beneficiary Notice (ABN) form 10055 informed the beneficiary that Medicare may not pay future skilled therapy services and provided a cost estimate of continued services. The form included option for the beneficiary to (1) receive specified therapy listed, and bill Medicare for an official decision on payment. I understand if Medicare does not pay, I am responsible for payment, but can appeal Medicare. (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for services. (3) I do not want the listed therapy services. The Notice of Medicare…

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 44 residents. The sample included 17 residents, with one reviewed for dental. Based on observation, record review, and interview, the facility failed to accurately assess one of 17 sampled residents on the Minimum Data Set (MDS), Resident (R) 34. This placed the resident at risk for an inaccurate care plan. Findings included: - The Electronic Medical Record (EMR) for R34 recorded diagnoses of heart failure (the heart doesn't pump blood as well as it should), diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired), atrial fibrillation (rapid, irregular heart beat), debility (physical weakness), and constipation (difficulty in emptying the bowels). R34's Five Day Minimum Data Set (MDS), dated [DATE], documented R34 had intact cognition and required extensive assistance of two staff for bed mobility, transfers only occurred once or twice with the assistance of two staff, and limited assistance of one staff for personal hygiene. The MDS further…

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 44 residents. The sample included 17 residents, with one reviewed for constipation. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan that included Resident (R) 34's history of constipation (difficulty in emptying the bowels) and interventions to prevent constipation. This placed the resident at risk for complications related to constipation including impaction (the condition of being or process of becoming impacted, especially of feces in the intestine). Findings included: - The Electronic Medical Record (EMR) documented R34 had diagnoses of constipation, diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired), and debility (physical weakness). R34's Quarterly Minimum Data Set (MDS), dated [DATE], documented R34 had an onset of mental changes and required extensive assistance of two staff for bed mobility, transfers, dressing, and toileting. The assessment further documented 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 44 residents. The sample included 17 residents with two reviewed for accidents. Based on observation, record review, and interview, the facility failed to review and revise R17's care plan to include the transfer assistance required, placing R17 at risk for injury during transfers. Findings included: - R17's Physician Order Sheet (POS), dated 01/17/22, documented diagnoses of contracture (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), muscle weakness, hemiplegia (paralysis on one side of the body) affecting right dominant side, and major recurrent depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R17 had short- and long-term memory problems with severely impaired decision making. The MDS documented R17 required supervision…

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 44 residents. The sample included 17 residents, with one resident sampled for constipation. Based on observation, record review, and interview, the facility failed to provide interventions for lack of bowel movements for one sampled resident, who had a history of impaction (the condition of being or process of becoming impacted, especially of feces in the intestine) and constipation (difficulty in emptying the bowels), Resident, (R) 34. This placed the resident at risk for impaction. Findings included: - The Electronic Medical Record (EMR) documented R34 had diagnoses of constipation, diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired), and debility (physical weakness). R34's Quarterly Minimum Data Set (MDS), dated [DATE], documented R34 had an onset of mental changes and required extensive assistance of two staff for bed mobility, transfers, dressing, and toileting. The assessment further documented the resident was always incontinent 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 44 residents. The sample included 17 residents with two reviewed for restorative services. Based on observation, record review, and interview, the facility failed to provide range of motion for Resident (R) 16, who had contracted (abnormal permanent fixation of a joint) left hand fingers. This placed the resident at risk for further decrease in range of motion. Findings included: - R16's Electronic Medical Record (EMR) documented the resident had diagnoses of generalized muscle weakness , limitation of activities due to disability, and lack of coordination (the ability to use different parts of the body together smoothly and efficiently). R16's Quarterly Minimum Data Set (MDS), dated [DATE], documented R16 had short and long term memory problems and severely impaired cognition. The MDS documented R16 required total staff assistance with eating and extensive staff assistance with the rest of activities of daily living (ADLs). The MDS documented R16 had functional limitation in range…

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 44 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being for Resident (R) 20. This placed R20 at risk for decline. Findings included: - The Electronic Medical Record (EMR) for R20 recorded diagnoses of psychosis (any major mental disorder characterized by a gross impairment in reality testing), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and obsessive-compulsive disorder (anxiety disorder characterized by recurrent and persistent thoughts, ideas and feelings of obsessions severe to cause marked by distress, consumes considerable time or significantly interfere with the resident's occupational, social or interpersonal functioning). R20's Annual Minimum Data Set (MDS), dated [DATE], documented the resident had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 44 residents. The sample included 17 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to monitor and provide interventions for bowel management for one sampled resident, Resident (R) 36. This placed the resident at risk for complication related to constipation. Findings included: - The Electronic Medical Record for R36 recorded diagnoses of constipation (difficulty in emptying the bowels), dementia (progressive mental disorder characterized by failing memory and confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R36's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had severely impaired cognition and required extensive assistance of one staff for bed mobility, dressing, toileting, and personal hygiene. The MDS further documented the resident's bowel incontinence was not rated. The Medication Care Plan, dated…

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

The facility had a census of 44 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 32's and R21's medication administration was free from significant errors when staff crushed extended release medications prior to administration. This placed both residents at risk for unecessary complications related to immediate release of a medication intended for extended release. Findings included: - On 01/25/22 at 08:02 AM, observation during medication administration revealed Certified Medication Aide (CMA) R crushed R32's metoprolol succinate (medication used to treat chest pain, heart failure, and high blood pressure) extended release (ER), 50 milligram (mg) tablet. When asked about crushing the ER medication, CMA R looked at R32's electronic medication administration record (EMAR) and stated there was no warning on the screen stating do not crush or on the individual prepackaged medication plastic packets. CMA R mixed the crushed metoprolol succinate ER with the other medications she had crushed 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.