Richmond Healthcare & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 47 residents. The sample included 12 residents, with two residents reviewed for accommodation of needs. Based on observation, record review, and interviews, the facility failed to provide wheelchair foot pedals for Resident (R) 16's wheelchair while pushing her in the hall. This placed R16 at an increased risk for preventable falls and injuries. Findings included: - R16's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin was made, or the body cannot respond to the insulin), sleep apnea (a disorder of sleep characterized by periods without respirations), asthma (a disorder of narrowed airways that causes wheezing and shortness of breath), muscle weakness,…

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 47 residents. The sample included 12 residents, with one resident reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide written notification of the reason and location for the facility-initiated transfer for Resident (R ) 7. This deficient practice placed R7 at risk of delayed care or uncommunicated care needs. Findings Included: - The Medical Diagnosis section within R7's Electronic Medical Records (EMR) included diagnoses of muscle weakness, type two diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), repeated falls, insomnia (difficulty sleeping), and dysphagia (difficulty swallowing). R7's Annual Minimum Data Set (MDS) completed 01/07/25 noted a Brief Interview for Mental Status (BIMS) score of nine indicating mild cognitive impairment. The MDS noted she had bilateral upper and lower extremity impairment. The MDS noted she required total…

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 47 residents. The sample included 12 residents, with one resident reviewed for hospitalization. Based on observations, interviews, and record review, the facility failed to provide a copy of the facility bed hold policy to Resident (R) 7 and/or their representative, with a written notice specifying the duration and cost of the bed hold, at the time of R7's transfer to the hospital. This placed the resident at risk for impaired rights. Findings Included: - The Medical Diagnosis section within R7's Electronic Medical Records (EMR) included diagnoses of muscle weakness, type two diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), repeated falls, insomnia (difficulty sleeping), and dysphagia (difficulty swallowing). R7's Annual Minimum Data Set (MDS) completed 01/07/25 noted a Brief Interview for Mental Status (BIMS) score of nine indicating mild cognitive impairment. The MDS noted she had bilateral…

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 47 residents. The sample included 12 residents, with 12 residents whose Minimum Data Set (MDS) were reviewed. Based on observation, record review, and interviews, the facility failed to complete an accurate MDS assessment for Resident (R) 35's status regarding admission to hospice services. This deficient practice placed R35 at risk for inappropriate care planning and care needs. Findings included: - R35's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and major depressive disorder (major mood disorder that causes persistent feelings of sadness). The Significant Change MDS dated 11/26/24 documented a Brief Interview of Mental Status (BIMS) score of five which indicated severely impaired cognition. The MDS documented R35 was dependent on staff assistance for her activities of daily living (ADL). R35's MDS lacked indication she…

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 47 residents. The sample included 12 residents, with one resident reviewed for activities of daily living (ADL) care. Based on observation, record review, and interviews, the facility failed to ensure staff assisted Resident (R) 16 with grooming and face shaving. This deficient practice placed R16 at risk for impaired dignity, comfort, and a further decline in ADLs. Findings Included: - R16's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), sleep apnea (a disorder of sleep characterized by periods without respirations), asthma (a disorder of narrowed airways that causes wheezing and shortness of breath), muscle…

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 47 residents. The sample included 12 residents, with one resident reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to follow a physician's order for weekly weights to monitor Resident (R) 17 for fluid overload. This deficient practice placed R17 at risk for delay in treatment related to fluid overload and untreated illness. Findings included: - R17's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 47 residents. The sample included 12 residents, with 5 reviewed for accidents. Based on observations, record reviews, and interviews, the facility failed to ensure a safe care environment related to the following Residents (R) 29, R33, and R32. This deficient practice placed the residents at risk for preventable accidents and injuries. Findings Included: - The Medical Diagnosis section within R29's Electronic Medical Records (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), type two diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), cognitive-communication disorder (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), weakness, and history of falls. R29's Quarterly Minimum Data Set (MDS) completed 02/03/25 noted a Brief Interview for Mental Status (BIMS) score of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 47 residents. The sample included 12 residents, with one resident reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 15's nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) mask and nasal cannula were stored in a sanitary manner. This placed R15 at an increased risk for respiratory infection and complications. Findings included: - R15's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), major depressive disorder (major mood disorder that causes persistent feelings of sadness), myocardial infarction (heart attack), rhabdomyolysis (breakdown of damaged skeletal tissue), bipolar disorder (a major mental illness that causes people to have episodes of severe high 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 identified a census of 47 residents. The sample included 12 residents, with four reviewed for dementia (a progressive mental disorder characterized by failing memory, and confusion) care. Based on interviews, record reviews, and observations, the facility failed to provide dementia-related care services for Resident (R) 91 to promote the resident's highest practicable level of well-being. This deficient practice placed R91 at risk for decreased quality of life, isolation, and impaired dignity. Findings Included: - The Medical Diagnosis section within R91's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), thrombocytopenia (abnormally low number of platelets, the parts of the blood that help blood to clot, sometimes associated with abnormal bleeding), kidney disease (damage to the kidneys that impairs their…

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 47 residents. The sample included 12 residents, with three residents reviewed for hospice (a type of health care that focuses 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) 15. This placed the resident at risk for inappropriate end-of-life care. Finding Included: - R15's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), major depressive disorder (major mood disorder that causes persistent feelings of sadness), myocardial infarction…

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 45 residents with 22 residents selected for review, including 19 sampled for unnecessary medications. Based on record review and interview, the facility failed to ensure 19 residents, Resident (R) 3, R4, R5, R6, R8, R9, R11, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, and R25 received their physician ordered medication scheduled on 04/08/24 during the 06:00 PM to 09:00 PM medication pass. Findings included: - The facility incident summary for the medication errors on 04/08/24, revealed on 04/08/24 at 06:00 PM, Administrative Nurse D was working as a charge nurse when Certified Medication Aide (CMA) R stated she needed to leave. Administrative Nurse D misunderstood CMA R thinking CMA R told her she had given all but one resident their medication. On 04/09/24 at 05:30 PM, Administrative Nurse D received a call from CMA S asking who administered medication last evening, in which she responded CMA R had. CMA S informed Administrative Nurse D several residents had not received their medication. Administrative Nurse D discovered CMA R had given…

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 45 residents with 22 residents selected for review, including 19 sampled for unnecessary medications. Based on record review and interview, the facility failed to ensure 10 residents, Resident (R) 3, R4, R5, R6, R17, R20, R21, R22, R24, and R25 received their physician ordered psychotropic (alters mood or thought) medication scheduled on 04/08/24 during the 06:00 PM to 09:00 PM medication pass. Findings included: - The facility incident summary for the medication errors on 04/08/24, revealed on 04/08/24 at 06:00 PM, Administrative Nurse D was working as a charge nurse when Certified Medication Aide (CMA) R stated she needed to leave. Administrative Nurse D misunderstood CMA R thinking CMA R told her she had given all but one resident their medication. On 04/09/24 at 05:30 PM, Administrative Nurse D received a call from CMA S asking who administered medication last evening, in which she responded CMA R had. CMA S informed Administrative Nurse D several residents had not received their medication. Administrative Nurse D discovered CMA R had given 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 reported a census of 43 residents. Based on observation, interview, and record review, the facility failed to maintain a clean, sanitary kitchen for food storage, preparation, and serving to the residents of the facility. Findings included: - During the initial tour of the kitchen on 04/25/23 at 07:37 AM, revealed the following areas of concern: 1. Two 14-inch skillets lacked the non-stick cooking surface, making the skillets uncleanable. 2. The reach-in refrigerator had food debris littered across on the bottom. 3. The reach-in refrigerator had an opened five pound (lb) container of cottage cheese, which lacked an open date. 4. The inside of the microwave had splattered, dried on food on the inside surfaces. 5. Three knives had gnawed, rubber handles, making them uncleanable. On 04/25/23 at 07:37 AM, Dietary staff BB confirmed the areas of concern needed to be addressed. The facility lacked a cleaning schedule. The facility failed to maintain a clean, sanitary kitchen for food storage, preparation and serving to all of the residents of the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 43 residents with 14 residents sampled, including two residents reviewed for hospitalization. Based on interview and record review, the facility failed to provide one of the two reviewed, Resident (R)24 and/or their representative, with a written notice specifying the duration and cost of the bed hold policy, at the time of the resident's transfer to the hospital. Findings included: - Review of Resident (R)24's electronic medical record (EMR) revealed the resident had a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. Review of the Cognitive Loss/Dementia Care Area Assessment (CAA), dated 04/05/23, documented staff would anticipate the resident's needs. The quarterly MDS, dated 01/03/23, documented the resident had a BIMS score of six,…

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 - Resident (R)18's Physician Orders, dated 04/25/23, documentation included diagnoses of hemiplegia (paralysis of one side of the body)and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following a cerebral vascular event (CVA- damage to the brain from the interruption of its blood supply which affecting left non dominate side), muscle weakness, and hypertension (high blood pressure). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 13 indicating cognitively intact. He required extensive assistance of staff for bed mobility, transfer, locomotion, and walking did not occur. His balance during transition was not steady, and he could only stabilize with staff assistance. The resident had functional limitation in his range of motion with his upper and lower extremity on one side of his body. He used a wheelchair (w/c) as an assistive mobility device. He did not experience 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 43 residents with 14 residents sampled, including three residents reviewed for Activity of Daily Living (ADL). Based on observation, interview and record review, the facility failed to provide appropriate care to one dependent Resident (R)29, regarding hair care. Findings included: - Review of Resident (R)29's electronic medical record (EMR), revealed diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and Schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought). The significant change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, indicating severe cognitive impairment. She required supervision of one staff for personal hygiene. The Activity of Daily Living Functional/Rehabilitation Potential (ADL) Care Area Assessment (CAA), dated 08/26/22, documented the resident…

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 43 residents with 14 residents sampled. Based on observation, interview, and record review, revealed the facility failed to complete adequate neurological checks (checks for disorders of the central nervous system) for one Resident (R)24, following a fall which resulted in a head injury. Findings included: - Review of Resident (R)24's electronic medical record (EMR), revealed a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. Her balance was not stable, and she was only able to stabilize with staff assistance. She had one non-injury fall since her prior assessment. The Falls Care Area Assessment (CAA), dated 04/05/23, documented staff would anticipate the needs of the resident. The quarterly MDS, dated 01/03/23, documented the resident had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 43 residents with 14 residents sampled, including six residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to implement appropriate interventions following falls for three dependent Residents (R)14, R 18 and R 28. Findings included: - Review of Resident (R)14's electronic medical record (EMR), revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. The resident required extensive assistance of one staff for bed mobility, transfers, toilet use, dressing and personal hygiene and limited assistance of one staff for walking in his room. His balance was not steady, and he was only able to stabilize with staff assistance. He used a walker and a wheelchair and had no falls since admission. The Falls Care Area…

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 43 residents with 14 residents sampled including one resident reviewed for bowel and bladder. Based on observation, interview and record review, revealed the facility failed to toilet one Resident (R)24 timely in order to achieve or maintain as much normal bladder function as possible. Findings included: - Review of Resident (R)24's electronic medical record (EMR) revealed a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. He required extensive assistance of two staff for toileting and was always incontinent of bladder (inability to hold urine). The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 04/05/23, documented the resident used incontinence briefs for urinary incontinence. The quarterly 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 43 residents. The 14 sampled residents included six reviewed for unnecessary medications. Based on observation, interview and record review the facility failed to ensure the staff administered the resident's antidepressant medications as ordered by the physician for one of the six residents reviewed, (R)32. Findings included: - Review of resident (R)32's physician orders, dated 04/16/23, revealed diagnoses which included depression (abnormal emotional state characterized by exaggerated feeling of sadness, worthlessness, emptiness, and hopelessness), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and psychosis (major mental disorder characterized by a gross impairment in reality testing). Review of the admission Minimum Data Set, (MDS), dated [DATE], documentation included the resident's Brief Interview for Mental Status, score of 15, indicating cognitively intact. He was feeling tired or having little energy. He…

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 48 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions to prevent the spread of food borne illnesses to the residents of the facility. Findings included: - An environmental tour of the kitchen, on 09/30/21 at 11:34 AM, noted the following areas of concern: 1) The bottom of the toaster had a large build-up of crumbs. 2) The empty coffee pot contained two live flies. 3) Five cutting boards were deeply gouged and not easily sanitized. 4) The juice machine in the dining room had a sticky build-up on the four nozzles and congealed juice in the spill tray. 5) One storage rack, in the dry storage room, had a build-up of grease substance. 6) The dry storage room had one case of cake mix (6-5 pound (lb) bags) and 18 cans of vegetables resting directly on the floor. On 09/30/21 at 11:49 AM, Dietary staff BB stated, the supplies in the storage room should not be left on the floor. The items had been on the floor since the food delivery on 09/28/21. On 10/04/21 at 11:27…

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 48 residents with 16 selected for review. Based on observation, interview and record review, the facility failed to review and revise the care plan for one sampled resident (R)37, with interventions for dementia (progressive mental disorder characterized by failing memory, confusion) care strategies when the resident frequently yelled/screamed out. Findings included: - Review of R37's Physician Order Sheet, dated 09/27/21, revealed diagnosis included Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure,) anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear,) and psychosis (any major mental disorder characterized by a gross impairment testing). Review of the Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with severely impaired cognitive function, with a mood score of 18 indicating moderately severe depression. The resident had verbal behaviors directed…

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 48 residents with 16 selected for review which included one resident selected for review for activities. Based on observation, interview and record review, the facility failed to provide activities for the one sampled dependent resident (R)37 with dementia. Findings included: - Review of R37's Physician Order Sheet, dated 09/27/21, revealed diagnosis included Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure,) anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear,) and psychosis (any major mental disorder characterized by a gross impairment testing). Review of the Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with severely impaired cognitive function, with a mood score of 18 indicating moderately severe depression. The resident was unable to indicate her preferences and the facility staff did not indicate her preferences for activities. The resident…

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 48 residents with 16 residents sampled, including three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to place foot pedals on the wheelchair of one of the three sampled residents, Resident (R)7, when being propelled by staff, to prevent accidents. Findings included: - The electronic medical record (EMR) for Resident (R)7, under the Med Diagnosis tab, revealed the resident had a diagnosis of dementia progressive mental disorder characterized by failing memory, confusion). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. She required supervision with setup help only for locomotion on the unit with the use of a wheelchair. She had no impairment in functional range of motion (ROM). The Activities of Daily Living Functional/Rehabilitation Potential (ADL) Care Area Assessment (CAA), dated 11/20/20,…

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 48 residents with 16 selected for review which included one resident selected for review for dementia. Based on observation, interview and record review, the facility failed to provide appropriate treatment and care services for the one sampled resident (R)37 with dementia who frequently yelled out. Findings included: - Review of R37's Physician Order Sheet, dated 09/27/21, revealed diagnosis included Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure,) anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear,) and psychosis (any major mental disorder characterized by a gross impairment testing). Review of the Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with severely impaired cognitive function, with a mood score of 18 indicating moderately severe depression. The resident had verbal behaviors directed toward others daily. The resident was dependent 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.