Pittsburg Care And Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 52 residents with 16 sampled for review. Based on observation, interview, and record review, the facility failed to complete an accurate Minimum Data Set (MDS) for one Resident (R) 25, regarding opioid medications (a powerful pain-reducing medication). Findings included: - Review of Resident (R) 25's Electronic Medical Record (EMR) revealed a diagnosis of chronic pain (pain which persists for a long period). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She received scheduled and as needed (PRN) medication and reported occasional pain which affected her sleep and day to day activities. She reported the worse pain in the past five days was a four on the one to ten pain scale. The MDS inaccurately documented the resident did not receive opioid medication (a powerful pain-reducing medication). The Pain Care Area Assessment (CAA), dated 12/22/23, 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 reported a census of 52 residents with 16 sampled, including four residents reviewed for accident hazards. Based on observation, interview, and record review the facility failed to ensure fall interventions were maintained for Resident (R)13. This placed the resident at increased risk for further falls, injury, and pain. Findings included: - Review of Resident (R)13's Electronic Medical Record revealed diagnoses that included Huntington's disease (rare abnormal hereditary condition characterized by progressive mental deterioration; a disabling central nervous system movement disorder), major depressive disorder (major mood disorder), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of four, which indicated severe cognitive impairment. The resident had two or more nonmajor injury falls since the prior assessment. 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 reported a census of 52 residents with 16 residents sampled, including five residents reviewed for unnecessary medications. Based on interview and record review, the facility failed to ensure one Resident (R) 25 remained free from unnecessary medications related to the failure to administer as needed (PRN) medications for lack of bowel movements (BM) for longer than three days. Findings included: - Review of Resident (R) 25's Electronic Medical Record (EMR) revealed a diagnosis of constipation (inability to pass stool). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She was dependent on staff for toileting needs, had no behaviors, and rejected cares one to three days of the assessment period. She was occasionally incontinent of bowel and had no constipation. The Behavioral Symptoms Care Area Assessment (CAA), dated 12/22/23, documented the resident would frequently refuse bowel…

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

The facility reported a census of 68 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions for the residents of the facility. Findings included: - During the initial tour of the kitchen on 09/12/22 at 10:10 AM, Dietary Staff EE was cleaning the refrigerator in the kitchen using a sanitizing solution. Testing of the cleaning solution, at that time, revealed 0 ppm result when checked with a test strip. The liquid sanitizing solution the staff used to sanitize the refrigerator lacked any actual sanitizing solution in the water. On 09/12/22 at 10:12 AM, Dietary Staff EE stated the solution should be between 150-200 ppm and she had made the cleaning solution five to 10 minutes prior to this testing. Dietary Staff EE stated she checks the cleaning solution twice during her shift. Dietary staff EE made a new solution which tested at 400-500 ppm. On 09/14/22 at 11:34 AM, Dietary Staff EE was placing the pureed cake from the mixer into a bowl upon entry into the kitchen to observe pureed diet meal prep.…

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

The facility reported a census of 68 residents. Based on observation, interview and record review, the facility failed to maintain an effective quality assurance committee that identified, developed and implemented appropriate intervention plans of action in a timely manner to ensure the residents received adequate needed quality care from the facility. Findings included: - Interview, on 09/15/22 at 01:41 PM, with Administrative Staff A, revealed the facility Quality Assurance Committee met monthly and the last meeting was on 09/2021. Administrative Staff A revealed the committee identified concerns with pressure ulcers, restorative and therapy communication issues, maintenance and housekeeping issues, and food temperatures. However, these areas were not corrected with the QAA interventions as the resurvey included these areas and others as reflected below: 1.) Refer to F 561: The facility failed to provide individual choices for the one sampled dependent Resident (R)55 related to his preferences for clothing selection 2.) Refer to F F677: The facility failed to ensure three of the…

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

The facility reported a census of 68 residents. Based on observation, interview and record review the facility failed to handle, store, process and transport linens to prevent the spread of infection for the residents of the facility. Findings included: - On the laundry tour, on 09/15/22 at 07:58 AM, with Maintenance/Laundry Director staff U, explained that the laundry staff had not arrived for work so the laundry tour would in effect demonstrate how the laundry was left by the laundry staff the previous evening. The tour with maintenance/Housekeeping Director U revealed the following concerns: 1. The washing machine was full of clothes. 2. The vinyl floor throughout the laundry was heavily soiled. 3. The soiled laundry room had four plastic bags of soiled laundry directly on the floor. 4. The soiled laundry sorting area with three uncovered barrels of soiled laundry had linen spilling over the sides of the barrels. 5. The laundry room walls in the clean linen processing area had loose peeling sheet rock with multiple holes in the sheet rock, which created an unsanitizable surface.…

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

The facility reported a census of 68 residents. Based on observation, interview, and record review, the facility failed to provide necessary housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior in resident areas including rooms, bathrooms and in a shower room. Findings included: - A brief tour of resident rooms and care areas beginning on 09/15/22 at 09:13 AM, revealed the following areas of concern: Five bathrooms with caulking missing/cracked/dirty around the toilets. Two rooms with gaps in the tile and debris present in the gaps. Five resident bathrooms with dirty floors. Two bathrooms with a dirty toilet. One room with an approximate 6 inch by 6 inch, hole in the wall. Five rooms with chipped paint to the doorways. One room with peeling wall paint. One room with a wash basin and bedpan stored directly on the floor. One room with a urinal dated 07/26/22, stored in a bag, with yellow liquid at the bottom of the bag. One of the shower rooms had rust-colored caulking around the toilet, a slow drip from the sink, the toilet had water running…

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 Medical Diagnosis tab located in the electronic medical record (EMR), for Resident (R)20, included diagnoses of a 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) stage four (full thickness tissue loss with exposed bone, tendon or muscle) of the sacral (area of the lower back near the spine) region, morbid obesity (a disorder involving excessive body fat, body mass index [BMI] greater than 40), and lymphedema (swelling caused by accumulation of lymph [a fluid that flows through the lymphatic system]). The admission Minimum Data Set (MDS) dated [DATE], assessed R20 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. She required supervision and setup for eating and drinking. R20's height was 60 inches and she weighed 263 pounds and did not/was not known if she had any weight loss greater than five percent in the last month or greater than…

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 reported a census of 68 residents with 22 selected for review including nine residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as result of pressure, pressure in combination with shear and/or friction). Based on observation, interview, and record review, the facility failed to provide treatment to Resident (R)43 in a timely manner to a pressure ulcer on the coccyx (the area below the sacrum commonly known as the tailbone), failed to ensure a dressing was in place and the air mattress settings were correct for R20 who had a stage four (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer of the sacral (area of the lower back near the spine) region, failed to ensure R11's who admitted with a stage four sacral wound and acquired an unstageable pressure area due to eschar to both heels that the air mattress was at the appropriate setting. Additionally, the facility failed to implement interventions 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 reported a census of 66 residents with 22 selected for review, which included five residents reviewed for dialysis. Based on observation, interview, and record review, the facility failed to coordinate dialysis (a process that filters wastes and fluids from the body when the kidneys fail) care of pre and post weight assessments and details of the dialysis sessions with the dialysis provider as required for five of the five residents reviewed, 02 Resident (R)53, R41, R118, and R262. Findings included: - Review of Resident (R)50's Physician Order Sheet, dated 08/09/22, revealed diagnoses included end stage renal (kidney) disease and diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with normal cognition, and received dialysis. The Care Plan, revised 08/25/22, instructed staff the resident received dialysis on Mondays, Wednesdays and Fridays. Staff to monitor…

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

The facility reported a census of 68 residents. Based on observation, interview, and record review, the facility failed to provide necessary housekeeping and maintenance services to the facility kitchen areas, to maintain a sanitary, orderly, and comfortable interior for the residents of the facility. Findings included: - The initial tour of the kitchen on 09/12/22 at 10:03 AM, revealed the following items/areas of concern: 1. The door frame and the inside of the door entering the kitchen had areas of chipped paint. 2. Under the counter of the dishwashing area near the entry door lacked cove base and the strip of cove base under the dishwasher pipes was loose. 3. The wall below the dishwasher had a large area of chipped paint. 4. The ice machine drain hoses were in the drain and the drain lacked a cover. On 09/14/22 at 03:03 PM, the kitchen tour revealed the following concerns: 1. The ceiling by the light above the microwave area had a crack approximately one-and-a-half feet long. 2. The light cover near the dishwasher had dead insects/debris in it. 3. The cove base was missing in…

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

The facility reported a census of 68 residents. Based on observation, interview, and record review, the facility failed to maintain an effective pest control program, for the residents of the facility, with the presence of flies in various areas of the facility. Findings included: - The pest control Service Inspection Report dated 06/24/22 revealed the facility reported no issues. The fly lights were checked, and glue boards replaced as needed. The kitchen drains were dusted, and an application of an aerosol fly bait were applied to multiple areas for small fly control. The pest control Service Inspection Report dated 07/29/22 revealed the facility reported no issues. The fly light glue boards were replaced as needed and an application of an aerosol fly bait to multiple areas of the kitchen for small fly control. The pest control Service Inspection Report dated 08/25/22 revealed all fly light glue boards were replaced as needed and applied an aerosol fly bait to the dish sink area in the kitchen for small fly control. On 09/14/22 at 11:34 PM, observation in the kitchen food areas…

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 reported a census of 68 residents with 22 sampled which included one resident reviewed for choices. Based on observation, interview, and record review, the facility failed to provide individual choices for the one sampled dependent Resident (R)55 related to his preferences for clothing selection. Findings included: - Review of the resident's (R)55's, Physician Orders, dated 08/03/2022, revealed diagnoses which included, obstructive pulmonary disease, severe sepsis, acute kidney failure, abnormal results of liver function, pneumonia, cellulitis of right lower limb, type 2 diabetes mellitus with hyperglycemia, and morbid obesity. The admission Minimum Data Set (MDS) dated [DATE], documented the Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact. He required extensive assistance of staff for bed mobility, dressing, personal hygiene, and was totally dependent on staff for transfers. The resident weighed 453 pounds. He reported it was very important to select his…

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 reported a census of 68 residents, with 22 sampled. Based on observation, interview, and record review, the facility failed to accurately complete a Comprehensive Assessment, and Quarterly Assessment, respectively related to the use of a Continuous Positive Air Pressure (CPAP) machine for one sampled Resident (R)55. Findings included: - Review of the resident's (R) 55's, Physician Orders, dated 08/03/2022, revealed diagnoses which included, chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The admission Minimum Data Set (MDS) dated [DATE], documented the Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact. He exhibited difficulty breathing and/or was short of breath (SOB) on exertion, when sitting at rest, and when lying flat. The MDS lacked documentation of the resident's use of a CPAP machine. The Quarterly MDS, dated 08/15/22, lacked any…

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 reported a census of 68 residents with 22 selected for review. Based on observation, interview and record review, the facility failed to develop comprehensive person-centered care plans for one of the sampled residents, Resident (R)30 with range of motion impairments and the lack of a restorative program. Findings included: - Review of Resident (R)30's Physician's Order Sheet, dated 07/28/22, revealed diagnoses included 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), muscle weakness, and chronic kidney disease. The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with severely impaired cognitive status, and was totally dependent on two staff for bed mobility and transfers. The resident had bilateral (both) impairment of upper and lower extremities. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment(CAA), dated 07/24/22 did not trigger…

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 reported a census of 68 residents with 22 selected for review including four residents reviewed for activities of daily living (ADL's). Based on observation, interview, and record review, the facility failed to ensure three of the sampled residents, Resident (R)4, R39, and R46, who required staff assistance, received appropriate personal hygiene assistance for cleaning and trimming of their fingernails. Findings included: - The Medical Diagnosis tab located in the electronic medical record (EMR) for Resident (R)4 included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), cerebral infarction (stroke - damage to tissues in the brain due to a loss of oxygen to the area), and diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). The Quarterly Minimum Data Set (MDS) dated [DATE] for R4 assessed him with a short-term and a long-term memory problem, impaired decision making, and he did not…

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 reported a census of 68 residents with 22 selected for review which included one resident selected for review of hospice services. Based on observation, interview and record review, the facility failed to coordinate care between hospice services and the facility to ensure the resident's advance directive for no resuscitative measures determined and carried out. Findings included: - Review of Resident (R)113's Physician Order Sheet, dated [DATE], revealed diagnoses that included malignant neoplasm (tumor) of the lung, adult failure to thrive and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain.) The resident admitted to the facility on [DATE] with an order for hospice services. The admission Minimum Data Set (MDS), dated [DATE], assessed the resident with severely impaired cognitive status with altered level of consciousness. The resident required extensive assistance of two staff for bed mobility with no impairment in functional range of motion in 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 reported a census of 68 resident with 22 selected for review, which included four residents reviewed for accidents. Based on observation, interview and record review, the facility failed to ensure safe transfer techniques for one resident (R) 34 of the four residents reviewed. Findings included: - Review of Resident (R)34's Physician Order Sheet, dated 08/02/22, revealed diagnoses included Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and dysphagia (swallowing difficulty). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with severe cognitive deficit, constant inattention and altered level of consciousness. The resident was dependent on two staff for bed mobility and transfers. The resident had impairment in functional range of motion on one side of her upper and lower extremities. The Falls Care Area Assessment (CAA), dated 02/21/22, assessed the resident required staff assistance for stabilization. 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 reported a census of 68 residents with 22 selected for review including two residents reviewed for urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). Based on observation, interview, and record review, the facility failed to ensure one of the two residents, Resident (R)20's catheter drainage bag remained below bladder level and failed to drain the catheter bag in a sanitary manner to prevent urinary tract infection. Findings included: - The Medical Diagnosis tab located in the electronic record (EMR) for Resident (R)20 included diagnoses of infection and inflammatory reaction due to indwelling urethral catheter, overactive bladder, and a 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) stage four (full thickness tissue loss with exposed bone, tendon or muscle) of the sacral (area of the lower back near the spine)…

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 reported a census of 68 residents, with 22 sampled, which included one resident sampled for respiratory care. Based on observation, interview, and record review, the facility failed to provide appropriate respiratory care to maintain respiratory equipment to prevent the spread of infection, for the one sampled Resident (R) 55. Findings included: - Resident (R) 55's Physician Orders, dated 08/03/2022, revealed diagnoses which included, chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The admission Minimum Data Set (MDS) dated [DATE], documented the Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact. The resident required extensive assistance of staff for bed mobility. He exhibited difficulty breathing and/or was short of breath (SOB) on exertion, when sitting at rest, and when lying flat. The MDS lacked documentation of the use of a Continuous…

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 reported a census of 68 residents with 22 selected for review. Based on record review and interview the facility failed to notify the physician for one of the residents, Resident (R)20, when she experienced a significant weight loss. Findings included: - The Medical Diagnosis tab located in the electronic medical record (EMR), for Resident (R)20, included diagnoses of a 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) stage four (full thickness tissue loss with exposed bone, tendon or muscle) of the sacral (area of the lower back near the spine) region, morbid obesity (a disorder involving excessive body fat, body mass index [BMI] greater than 40), and lymphedema (swelling caused by accumulation of lymph [a fluid that flows through the lymphatic system). The admission Minimum Data Set (MDS) dated [DATE], assessed R20 with a Brief Interview of Mental Status (BIMS) score…

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

The facility reported a census of 68 residents. The sample of 22 residents included six residents reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of multiple medications as ordered by the physician, for one resident of the six sampled residents; (R)60 related to pain medication and medications to treat gastrointestinal acid reflux (indigestion/heartburn). Findings included: - Review of the resident's (R)'s, Physician Orders, dated 08/03/22, revealed diagnoses which included fracture around right hip joint, hematemesis (person vomits blood due to internal bleeding), gastroesophageal reflux disease (backflow of stomach contents to the esophagus), peripheral vascular disease (a blood circulation disorder that causes the blood vessels outside of the heart and brain to narrow which typically causes pain), fracture of right foot metatarsal bone(s) (broken bones in the forefoot), cellulitis (skin infection) left lower limb, and fracture of the right…

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

The facility reported a census of 68 residents which included five residents reviewed for influenza and pneumococcal vaccines. Based on interview and record review the facility failed to ensure two of the five residents (R24 and R 12) or their representatives received information/education for the benefits, risks, or medical contraindications regarding pneumococcal immunization. Findings included - On 09/14/22 review of Resident (R) 24 and (R) 12's immunization records revealed the medical records lacked evidence of pneumococcal education provided, prior to consent or refusal of the pneumococcal vaccination. On 09/14/22 at 01:24 PM, Administrative Nurse E verified the above findings related to immunization. She stated the resident and/or their representative should be provided with education regarding the benefit verses the risks of the pneumococcal vaccine prior to deciding to receive or refuse the vaccine. She agreed the facility lacked evidence the facility provided education to R24 and R12 and/or their representatives prior to their giving consent or refusing the vaccine, as…

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.