Advena Living At Fountainview

The facility had a census of 42 residents. Based on record review and interview, the facility failed to ensure the staff person designated as the Infection Preventionist, who was responsible for the facility's Infection Prevention and Control Program, completed the specialized training in infection prevention and control. This placed the residents at risk for lack of identification and treatment of infections. Findings included: - On 01/19/23 at 01:20 PM, Administrative Nurse E stated she was responsible for the Infection Prevention and Control Program and lacked certification as an Infection Preventionist. Administrative Nurse E stated she had completed most of or all the training modules but had not taken the test or received the certification. The Surveillance for Infections policy, dated October 2021 documented the Infection Preventionist will conduct ongoing surveillance for Healthcare- Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission -based precautions…

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 42 residents. Based on observation, interview, and record review the facility failed to ensure drugs were in locked storage when unattended by licensed staff. This deficient practice placed residents at risk for missing or tampered with medications. Findings included: - On 01/17/23 at 03:01 PM, observation revealed the facility's medication cart on the 100-hall unlocked and no nursing staff in sight. The drawers of medications were accessible. At 03:05 PM, Certified Medication Aide (CMA) S verified she had left the cart unlocked when she went to assist a resident in their room. On 01/19/23 at 04:10 PM, observation of the medication cart on the 100 hall revealed the cart unlocked and medication accessible with no licensed staff in sight of the cart. Administrative Staff A locked the cart as he went past. On 01/19/23 at 04:10 PM, Administrative Staff A verified staff were to lock the medication cart when leaving the area or when out of sight of the cart. The facility's Storage of Medications policy, dated 10/2021, documented drugs and biologicals are…

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 42 residents. The sample included 12 residents of which five were reviewed for immunization status. Based on record review and interview, the facility failed to offer and provide and/or obtain informed refusals for influenza and pneumococcal vaccinations and failed to offer and provide the residents and/or their representative the current years Vaccine Information Statement (VIS-information sheets produced by the CDC [Centers for Disease Control and Prevention] that explained both the benefits and risk of vaccine to vaccine recipients for Resident (R)5, R10, R17, R29 and R35. This placed the affected residents at increased risk for illness and infection. Findings included: - R5's clinical record lacked evidence the current year Vaccine Information Statement form was provided to the resident and/or resident's representative, or an informed refusal was obtained. R10's clinical record lacked evidence the current year Vaccine Information Statement form was provided to the resident and/or resident's representative or an informed refusal was obtained. R17's…

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 42 residents. The sample included 13 residents with five reviewed for activities of daily living (ADL). Based on observation, interview, and record review, the facility failed to provide dignity during dining for Resident (R) 28 who was brought to the dining room disheveled and then left unassisted while he dropped food all down the front of his shirt. This placed R28 at risk for impaired dignity and decreased psychosocial wellbeing. Findings included: - R28's Electronic Medical Record (EMR) recorded diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), history of cerebrovascular accident (CVA- stroke-sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) and depression (mood disorder characterized by persistent sadness). The Quarterly Minimum Data Set (MDS) dated [DATE] recorded R28 had a Brief interview for Mental Status (BIMS) score of four which…

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

The facility had a census of 42 residents. The sample included 12 residents. Based on record review and interview, the facility failed to provide three sampled residents, Resident (R)13, R16 and R146 (or their representative) the completed Skilled Nursing Facility Advanced Beneficiary Notices (ABN) form 10055, (CMS) Centers for Medicare and Medicare Services which placed them at risk to make uninformed decisions about their skilled care Findings included: - The Medicare ABN form 10055 informed the beneficiary that Medicare may not pay for future skilled therapy services. The form included an option for the beneficiary to receive specific services listed, and bill Medicare for an official decision on payment. The form stated 1) I understand if Medicare does not pay, I will be responsible for payment, but can make an appeal to Medicare, (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for services, (3) I do not want the listed services. The facility provided R13 the completed form 10055, which estimated the cost for the services to be able to make an…

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 42 residents. The sample included 13 residents with one reviewed for hospitalization. Based on observation, interviews, and record review, the facility failed to provide Resident (R) 19 with a bed hold notice upon discharge to the hospital. This placed the resident at risk for impaired rights to return to the facility and in the same room as previously resided. Findings included: - R19's Electronic Medical Record (EMR) recorded diagnoses of hypertension (HTN-high blood pressure), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and depression (mood disorder characterized by feelings of persistent sadness). The Quarterly Minimum Data Set (MDS) dated [DATE] recorded R19 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment. R19 required extensive assistance of one staff for most activities of daily living (ADL). R19 used a wheelchair for mobility and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 42 residents. The sample included 13 residents with two reviewed for urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) use. Based on observation, interview, and record review the facility failed to develop a baseline care plan in a timely manner for Resident 93's urinary catheter and R194's activities of daily living (ADL) , hospice and end of life cares. This deficient practice placed at risk for unmet and uncommunicated care needs. Findings included: - R93 was admitted to the facility 01/16/23, with a diagnosis of malignant neoplasm (cancer) of the lung. The Baseline Care Plan, dated 01/18/23, lacked catheter care information. The Physician Order, dated 01/17/23, directed staff to place an indwelling urinary catheter due to resident decline, change every 30 days and as needed (prn). The Progress Note, dated 01/17/23 at 06:19 PM, documented the nurse placed a 18 french, 30 milliliter (ml), indwelling catheter via sterile procedure and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 42 residents. The sample included 12 residents, with two reviewed for indwelling urinary catheters (tube inserted directly into the bladder to drain urine). Based on observations, interview and record review, the facility failed to develop a care plan for Resident (R) 15's indwelling catheter as well as need for assistance with activities of daily living. This placed R15 at risk for uncommunicated and unmet care needs. Findings included: - R15's Electronic Medical Record (EMR) recorded diagnoses of pain, heart failure, neuromuscular dysfunction (lack of bladder control due to brain, spinal cord or nerve problems) of bladder and urinary tract infection. The admission Minimum Data Set (MDS), dated [DATE], recorded R15 had intact cognition, required extensive assistance of one staff for activities of daily living (ADL), had an indwelling urinary catheter and was always incontinent of bowel. The Urinary Incontinence/Indwelling Catheter Care Area Assessment (CAA), dated 11/28/22,…

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 42 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observations, interview and record review, the facility failed to revise the care plan to include Resident (R)38 and R32's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment in reality testing medication which included targeted behavior and side effects) medication, and failed to revise R19s care plan with her change in mobility status. This placed the affected residents at risk for inadequate care or uncommunicated care needs. Findings included: - R38's Electronic Medical Record (EMR) recorded diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure.) R38's admission Minimum Data Set (MDS), dated [DATE], recorded R38 had Brief Interview for Mental Status (BIMS) score of eight which indicated moderate cognition impairment. The MDS recorded R38 required limited assistance 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 42 residents. The sample included 13 residents with one reviewed for discharge. Based on interviews, and record review, the facility failed to establish a discharge plan with goals for Resident (R) 42. This placed R42 at risk for uncommunicated care needs and inappropriate discharge. Findings Included: - R42's Electronic Medical Record (EMR) recorded diagnoses of diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), right femur (thigh bone) fracture, and depression (mood disorder characterized by feelings of persistent sadness). R42's admission Minimum Data Set (MDS) dated [DATE] recorded R42had a Brief Interview for mental Status (BIMS) score of 15 which indicated he was cognitively intact. He required supervision with set up help for activities of daily living (ADL). The MDS recorded R42 was at risk for…

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 42 residents. The sample included 13 residents with one reviewed for discharge. Based on interviews, and record review, the facility failed to complete a recapitulation of Resident (R) 42 stay at the facility. This placed R42 at risk for uncommunicated care needs and missed health care opportunities. Findings Included: - R42's Electronic Medical Record (EMR) recorded diagnoses of diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and depression (mood disorder characterized by feelings of persistent sadness). R42's admission Minimum Data Set (MDS) dated [DATE] recorded R42had a Brief Interview for mental Status (BIMS) score of 15 which indicated he was cognitively intact. He required supervision with set up help for activities of daily living (ADL). The MDS recorded R42 was at risk for pressure injuries,…

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 42 residents. The sample included 13 residents with five reviewed for activities od daily living (ADL). Based on observation interview, and record review the facility failed to provide Resident (R) 28 with the requires personal hygiene and dressing assistance he required. The facility further failed to provide consistent bathing per resident preferences for R28, R35, and R38. This placed the affected residents at risk for impaired dignity increased risk for skin issues and other complications. Findings included: - R28's Electronic Medical Record (EMR) recorded diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), history of cerebrovascular accident (CVA, stroke-CVA) (stroke) - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) and depression (mood disorder characterized by persistent sadness). The Quarterly Minimum Data Set (MDS) dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 42 residents. The sample included 13 residents with five reviewed for activities of daily living (ADL). Based on observation, interviews, and record review, the facility failed to ensure appropriate wheelchair positioning for Resident (R) 19 whose feet dangled in an unsupported, dependent position while she sat in her wheelchair. This placed R19 at increased risk for medical complications and/or injuries. Findings included: - R19s' Electronic Medical Record (EMR) recorded diagnoses of hypertension (HTN-high blood pressure), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and depression (mood disorder characterized by feelings of persistent sadness). The Quarterly Minimum Data Set (MDS) dated [DATE] recorded R19 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment. R19 required extensive assistance of one staff for most activities of daily living (ADL).…

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 42 residents. The sample included 13 residents with seven reviewed for accidents and/or falls. Based on observation, record review, and interviews the facility failed to ensure interventions identified to prevent falls were implemented for Resident (R)35 and failed to identify and implement interventions to prevent further falls for R36. This placed the residents at risk for further falls and fall related injuries. Findings included: - R35's Electronic Medical Record (EMR) recorded diagnoses of renal insufficiency (kidney failure) diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), dementia (progressive mental disorder characterized by failing memory, confusion), hip fracture, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and depression (mood disorder characterized by persistent sadness). The Quarterly Minimum Data Set (MDS) dated [DATE] recorded R35…

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 42 residents. The sample included 13 residents with five reviewed for unnecessary medication. Based on observation, interviews, and record review, the facility failed to act upon the recommendations of the Consultant Pharmacist (CP) to monitor and report abnormal findings when Resident (R) 19's blood glucose levels were outside acceptable parameters and failure to administer R19's as needed (PRN) insulin (medication used to lower blood glucose levels) for elevated blood glucose levels. This placed the affected residents at risk for medical complications related to the medication regimen. Findings included: - R19s' Electronic Medical Record (EMR) recorded diagnoses of hypertension (HTN-high blood pressure), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and depression (mood disorder characterized by feelings of persistent sadness). The Quarterly Minimum Data Set (MDS) dated [DATE] recorded R19 had a Brief…

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 42 residents. The sample included 13 residents with five reviewed for unnecessary medication. Based on observation, interviews, and record review, the facility failed to monitor and report abnormal findings when Residnet (R) 19's blood glucose levels were outside ordered parameters and further failed to administer R19's as needed (PRN) insulin (medication used to lower blood glucose levels) for elevated blood glucose levels. The facility further failed to monitor bowel movements for R35 and R36. This placed the affected residents at risk for medical complications related to the medication regimen. Findings included: - R19s' Electronic Medical Record (EMR) recorded diagnoses of hypertension (HTN-high blood pressure), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and depression (mood disorder characterized by feelings of persistent sadness). The Quarterly Minimum Data Set (MDS) dated [DATE] recorded R19…

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 42 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observations, interview and record review, the facility failed to ensure an appropriate indication for Resident (R)38's, and R32's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment in reality testing)medication, failed to ensure a 14- day stop date for R17's received as needed (PRN) psychotropic (an antianxiety medication that calm and relax people with excessive restlessness) that lacked a 14 day stop date or rationale for use. This placed the affected residents at risk for unintended affects related to psychotropic drug medications. Findings include: - R38's Electronic Medical Record (EMR) recorded diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure.) R 38's admission Minimum Data Set (MDS), dated [DATE], recorded R38 had a Brief Interview for Mental Status (BIMS)…

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 42 residents. The sample included 12 residents with two reviewed for hospice. Based on observation, interviews, and record review, the facility failed to ensure collaboration with the hospice provider to establish a plan for Resident (R)194's care and included shared information regarding R194's care needs, medication and equipment provided by hospice as well as the frequency of nursing visits and nursing care provided by hospice. This placed R194 at risk for uncommunciated or unmet care needs related to end of life cares. Findings included : - R194's Electronic Medical Record (EMR) recorded diagnoses of respiratory failure and dementia (progressive mental disorder characterized by failing memory and confusion). The admission Minimum Data Set (MDS), dated [DATE], documented R194 had severe cognitive impairment, required limited to extensive assistance with activities of daily living (ADL), and had medically complex conditions. The MDS further documented R194 had condition or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 41 residents. The sample contained 14 residents, with five residents reviewed for COVID-19 vaccinations. Based on interview and record review, the facility failed to follow instruction by the legal representative, for refusal of the COVID 19 vaccination for one Resident (R) 5 of the five sampled residents. The facility administered R5 the COVID-19 vaccine and then failed to timely notify the resident's legal representative of the failure to follow the instructions provided. Findings included: - The signed Physician Order Sheet (POS), dated 06/01/21, documented R5's diagnoses included dementia (progressive mental disorder characterized by failing memory, confusion). An annual Minimum Data Set (MDS), dated [DATE], documented the resident Brief Interview for Mental Status (BIMS) score was 4, indicating severe cognitive impairment. A signed POS, dated 01/20/21, permitted R5 to receive the COVID-19 vaccination if asymptomatic of infection. A document in R5's Electronic Medical Record…

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 41 residents. The sample contained 14 residents. Based on observation, interview, and record review, the facility failed to review and revise the plan of cares for two of the sampled residents. This included, Resident (R)1 with failure to include appropriate interventions following falls to prevent further falls and for R1 and R2 who used wheelchairs without foot pedals, propelled by staff, and with their feet touching the floor. Findings included: - The signed Physician Order Sheet (POS), dated 06/01/21 documented R1's diagnoses included 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). A significant change Minimum Data Set (MDS), dated [DATE], documented R1 had short and long term memory loss, used a wheelchair, and had two or more non-injury falls since the last assessment 13 days prior.…

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 41, the 14 sampled residents included two sampled for discharge. Based on interview and record review, the facility failed to develop a discharge summary that included a recapitulation of the residents stay, a final summary of the residents' status at the time of discharge, for one of the two residents, Resident (R) 39. Findings included: - Review of Resident (R)39's, Physician Orders, dated, 04/01/21 documented the resident admitted to the facility on [DATE], with the following diagnoses: traumatic brain injury, epileptic seizures (violent involuntary series of contractions of a group of muscles), and hemiplegia (paralysis of one side of the body.) The admission Minimum Data Set, (MDS) dated [DATE], revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS). R39 required total dependence with two plus person assistance with activities of daily living. R39 expected to remain in the facility. Per record review, the nurses note dated 04/14/21 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 41, the sample of 14 included six residents for review regarding Activities of Daily Living (ADL). Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain adequate personal hygiene, related to bathing, for one of the six residents, Resident (R)8. Findings included: - The signed Physician Order Sheet (POS), dated 06/01/21, documented R8's diagnoses included a healing fracture of his right thigh. An admission Minimum Data Set (MDS), dated [DATE], documented R8's Brief Interview for Mental Status (BIMS) score was 12, indicating moderate cognitive impairment. He required physical help of one staff for part of bathing. The (ADL)Functional/ Rehabilitation Potential Care Area Assessment (CAA), dated 04/15/21, documented R8 had no dementia diagnosis, and required supervision to limited assistance with his activities of daily living (ADL) functioning. R8's ADL care plan, dated 05/12/21, instructed staff to offer him a shower…

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 41 residents. The sample contained 14 residents, with three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure safety for two of the three sampled residents including, failure to implement planned interventions to prevent further falls for Resident (R)1, and failure to use wheelchair foot pedals when propelling chairs for two cognitively impaired residents, R1 and R5, placing them at risk for falls/accidents. Findings included: - The signed Physician Order Sheet (POS), dated 06/01/21 documented R1's diagnoses included 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). A significant change Minimum Data Set (MDS), dated [DATE], documented R1 had short and long term memory loss, used a wheelchair, and had two or more non-injury…

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 41 residents, with 14 sampled for review which included five residents reviewed for unnecessary medication monitoring. Based on interview and record review, the facility failed to adequately monitor one of the five residents reviewed, Resident (R)30's orders for notification to the physician when the resident's blood sugar was out of the ordered parameters. Finding included: - The Order Summary Report, dated 06/01/21 included a diagnosis of diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). A physician order with a start date of 01/08/21, instructed staff to complete a fasting accucheck daily and notify the physician if the resident's blood glucose was less than 50 or greater than 300. The Licensed Nurse Medication Administration Record (MAR) dated 04/01/21 though 04/30/21, revealed R30 had blood sugar levels out of parameters on three different occasions. On 04/24/21 his blood sugar was 346, on 04/25/21 his blood sugar was 317, and on 04/26/21 his blood sugar was 358.…

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.