Kenwood View Healthcare And Rehabilitation Center

The facility had a census of 60 residents. The sample included 17 residents. Based on observation, record review, and interview the facility failed to prepare, store, and serve food in accordance with professional standards for food service safety for the 60 residents who resided in the facility and received their food from the facility kitchen, when facility failed to ensure clean and sanitary food prep areas. The facility staff failed to change gloves after touching her glasses, other objects, then picked up bread with the same contaminated gloves. The facility kitchen staff failed to order enough food for the noon meal and the facility staff failed to complete refrigerator logs. This placed the 60 residents at risk for foodborne illness. Findings included: - On 05/01/23 at 07:17 AM, observation in the kitchen revealed the following: The refrigerator located in the kitchen had a plastic bag with four hamburger patties with an expiration date 04/18/23. The silver, three door freezer located in the dry storage room had an open bag of chicken patties, without a label or date. The…

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

The facility had a census of 70 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility's Quality Assessment and Assurance (QAA) program failed to provide good faith efforts to identify multiple issues of concerns for the 60 residents, who resided in the facility. Findings included: - The facility failed to provide Resident (R)9 dignity related to odorous dressing changes, and R34 for dirty clothes two days in a row. Refer to F550. The facility failed to resolve resident grievance's in a timely manner. Refer to F565. The facility failed to provide R28, R47, and R56 a cost estimate for further services related to skilled services. Refer to F582. The facility failed to protect R35 from misappropriation of property and exploitation. Refer to F602. The facility failed to report a fall with injury for R36. Refer to F609. The facility failed to thoroughly investigate R12's skin tear and R36's fall with injury. Refer to F610. The facility failed to revise care plans for five residents. Refer to F657. The facility failed to provide…

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 60 residents. Based on observation, interview, and record review the facility failed to provide proper infection control when using the same glucometer without disinfecting it between residents, delivering linens throughout the facility in an uncovered cart, during urinary catheter care, while providing oxygen therapy, and filling resident's used water mugs with ice while holding the used mug inside the ice bin. This deficient practice placed the residents of the facility at risk for infections. Findings included: - On 05/01/23 at 12:02 PM, observation revealed Certified Nurse Aide (CNA) Q handled a resident's used water mug and put fresh ice in it from the open ice machine in the dining room. CNA Q held the soiled mug over the ice while filling it and a few pieces of ice flew from the cup to the clean ice in the bin. Continued observation revealed CNA Q served four other residents their beverages, without first changing her gloves. On 05/01/23 at 02:55 PM, observation revealed laundry staff pushed an uncovered cart of clean linen, down the west hall. On…

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

The facility had a census of 60 residents. Based on observation, interview, and record review the facility failed to ensure essential equipment in the kitchen was maintained in safe operating condition with two ovens and the plate warmer out of service. Findings included: - On 05/03/23 at 10:57 AM, observation in the facility kitchen revealed Dietary Staff (DS) DD pointed to the two ovens below a hood and stated they did not work right. DS DD stated the last administrator was supposed to have a company come and look at them because the pilot light does not stay lit, and a gas odor drifted out. On 05/03/23 at 02:00PM, DS EE stated the plate warmer did not work and had not been working for about three months. On 05/03/23 at 02:05 PM, DS CC verified the findings listed above and stated the former administrator called a company to come fix the ovens, but he did not know if the current administrator was aware of them not working or the plate warmer not working. On 05/04/23 at 11:43 AM, Administrative Staff A stated she was unaware the two ovens and the plate warmer were not working, and…

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

The facility had a census of 60 residents. The sample included 17 residents. Based on observation, record review, and interview the facility failed to act promptly, investigate, and resolve grievances and recommendations of six resident council members (Resident (R)14, R13, R15, R29, R42 and R212). This placed the five resident council members at risk for depression from unsolved concerns. Findings included: - Review of the Resident Council Minutes from 08/30/22 to 03/06/23 revealed the members had concerns regarding snacks not being offered, running out of food, request for different food items to be served, missing resident clothing, not receiving scheduled showers, and rooms not being cleaned. The resident council minutes lacked documentation regarding the above concerns being acted upon and resolved. Review of the Grievance Log from 08/30/23 to 05/01/23 revealed a lack of documentation regarding grievances from resident council members or resolution of them. On 05/02/23 at 10:25 AM, observation revealed R14, R13, R42, R212, R15, and R29 attended the resident council meeting with…

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 60 residents. Based on observation, interview, and record review the facility failed to date one insulin pen when opened and monitor refrigerator temperatures for two of two medication rooms. This deficient practice placed Resident (R) 26 at risk to receive outdated insulin and residents to receive temperature compromised medications. Findings included: - On 05/01/23 at 08:56 AM, observation revealed the thermometer in the east medication room had a solid red line up to 28 degrees Fahrenheit (F) with more small red lines past that. The temperature log for the refrigerator was dated April and only had a temperature recorded on the first two days. On 05/01/23 at 09:00 AM, observation revealed the east nurse's treatment cart held one undated insulin pen for R26. On 05/01/23 at 09:00 AM, Licensed Nurse (LN) J verified the lack of temperature monitoring in the east medication room and the undated insulin pen in the east treatment cart. 05/03/23 07:51 AM, Administrative Nurse D verified staff were to monitor and document refrigerator temperatures for the…

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

The facility had a census of 60 residents. Based on observation, record review, and interview the facility kitchen staff failed to provide food prepared by methods that conserve nutritive value, flavor and appearance, when dietary staff failed to follow a recipe while preparing four residents' pureed diets. This deficient practice placed the four residents at risk for impaired nutrition. Findings included: - On 05/03/23 at 11:12 AM, observation during pureed food preparation revealed Dietary Staff (DS) DD, overlooked and assisted by Dietary Manager (DM) CC, stated the facility had four pureed diets, but she was preparing five because she always made extra in case one resident would like more. DS BB placed an unmeasured amount of cooked peas (used the line towards the top of the steam table pan as guidance for measurement) blended. DM CC retrieved a clean blender container and placed an unmeasured amount of cooked tri color pasta in it, then added an unmeasured amount of chicken base broth and blended. Further observation revealed DS DD and DM CC had not followed a recipe for the…

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

The facility had a census of 60 residents. Based on observation, record review, and interview the facility failed to ensure no more than a 14-hour lapse between a substantial evening meal and breakfast the following day, when staff failed to provide the 60 residents who resided in the facility a nourishing snack at bedtime. This placed the residents at risk for impaired nutrition. Findings included: - On 05/01/23 at 11:00 AM, Dietary Manager (DM) CC stated resident meal times were breakfast at 7:30 AM, lunch at 11:30 AM, and supper at 04:30 PM. On 05/02/23 at 10:25 AM, during resident council meeting, Resident (R) 13, R14, R15, R29, R42, and R212 stated the facility did not pass bedtime snacks and if residents requested a snack sometimes they received one, but most of the time the kitchen was out. On 05/02/23 at 02:17 PM, Certified Dietary Aide (CNA) M stated staff did not deliver snacks, the kitchen staff brought down a snack tray and placed it in the nourishment refrigerator for bedtime snacks. CNA M stated if a resident requested a snack, the staff would give them one. CNA M…

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 Electronic Medical Record (EMR) for R34 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), need for assistance with personal care, other symptoms and signs involving cognitive functions and awareness, and other symptoms and signs involving appearance and behavior. R34's Quarterly Minimum Data Set (MDS), dated [DATE], documented R34 had severely impaired cognition, and required extensive assistance of two staff for personal hygiene, toileting, dressing, transfers, and bed mobility. The MDS further documented R34 required extensive assistance of one staff for eating. The Care Plan, dated 03/16/23, initiated on 09/03/20, documented R34 could eat independently after set up, preferred to wear a clothing protector, the staff were to anticipate and meet the resident's needs, and remind R34 the importance of hygiene. On 05/01/23 at 12:11 PM, observation revealed R34 sat at the dining table eating the noon meal with a knife.…

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 60 residents, with three reviewed for Center for Medicare and Medicated Services (CMS) Beneficiary Liability notices. Based on record review and interview, the facility failed to provide CMS Form 10055, Advanced Beneficiary Notice (ABN), which included the estimated cost to continue services for skilled services to the resident or their representative for three resident:, Resident (R) 28, R47, and R56. This deficient practice placed all three residents at risk for unanticipated costs related to skilled services. Findings included: - The Medicare ABN form informed the beneficiaries Medicare may not pay for future skilled therapy and did not provide an estimated cost to continue their services. The form included options for the beneficiary to (1) receive specified services listed, and bill Medicare for an official decision on payment. I understand if Medicare does not pay, I will be responsible for payment, but can appeal to Medicare. (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for payment of services. (3) I do 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 had a census of 60 residents. The sample included one resident reviewed for exploitation. Based on observation, interview, and record review the facility failed to ensure Resident (R) 35 was free from staff misappropriation of her money when an employee of the facility used R35's credit card for unauthorized purchases. This deficient practice placed R35 at risk of exploitation. Findings included: - R35's Electronic Medical Record documented diagnoses of diabetes (chronic condition that affects the way the body processes blood sugar (glucose), tobacco use, history of stroke, and cognitive communication deficit. The admission Minimum Data Set (MDS), dated [DATE], documented R35 had short and long-term memory problems with severely impaired decision making. The MDS documented R35 required limited assistance of one staff for hygiene, dressing, locomotion, extensive staff assistance for bed mobility, transfers, eating, and total staff assistance for toileting. The Grievance Form, dated 04/28/23,…

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 60 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to report to the state agency an unwitnessed fall with injury for Resident (R)36 who went outside without supervision, fell, and sustained a hematoma (a solid swelling of clotted blood within the tissues) on her forehead. This placed the resident at risk for further injury and unidentified abuse and mistreatment. Findings included: - The Electronic Medical Record (EMR) for R36 recorded diagnoses of Alzheimer disease (a progressive mental deterioration characterized by confusion and memory failure), muscle weakness, anxiety (a feeling of worry, nervousness, or unease about something), and abnormality of gait. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R36 had severely impaired cognition, required extensive assistance of two staff for transfers, and extensive assistance of one staff for bed mobility, dressing, toileting, and personal hygiene. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 60 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to thoroughly investigate two sampled residents, Resident (R) 12, who received a skin tear to his forearm, and R36, who had a fall with injury. This placed the residents at risk for further injury and unidentified abuse or mistreatment. Findings included: - The Electronic Medical Record (EMR) for R12 documented diagnoses of traumatic brain injury (an injury that affects how the brain works), unsteadiness on feet, impulse disorder (urges and behaviors that are excessive and/or harmful to oneself or others), and muscle weakness. R12's Annual Minimum Data Set (MDS), dated [DATE], documented R12 had intact cognition and required extensive assistance of two staff for toileting, personal hygiene, extensive assistance of one staff for dressing. The assessment further documented R12 had no skin issues. The Care Plan, dated 03/30/23, documented a potential for skin tears…

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 60 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to revise care plans for five sampled residents, Resident (R)12's care plan for a skin tear, R36 who had 2 falls, R54 who had a facility acquired pressure ulcer, R9 who had venous ulcers (a shallow wound that develops on the lower leg when the leg veins fail to return blood back toward the heart normally) to her lower legs, and R25 for dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). This placed the residents at risk for unmet care needs. Findings included: - The Electronic Medical Record (EMR) for R12 documented diagnoses of traumatic brain injury (an injury that affects how the brain works), unsteadiness on feet, impulse disorder (urges and behaviors that are excessive and/or harmful to oneself or others), and muscle weakness. R12's Annual Minimum Data Set…

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 60 residents. The sample included 17 residents with one reviewed for transfer/discharge. Based on observation, record review, and interview the facility failed to implement discharge planning when Resident (R) 45 requested to return to the community. This placed the resident at risk for impaired psychosocial wellbeing. Findings included: - R45's Electronic Medical Record (EMR) documented he had diagnoses of rheumatoid arthritis (chronic inflammatory disease that affected), weakness, and abnormalities of gait and mobility. R45's Quarterly Minimum Data Set (MDS), dated [DATE], documented R9 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented the resident required staff supervision with activities of daily living (ADLs), balance steady at all times, and used a walker for mobility. The MDS documented an active discharge planning had not occurred for R9 to return to the community. R45's ADL Care Plan, revised 02/09/23, documented…

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 60 residents, the sample included 17 residents, with two reviewed for activities of daily living (ADL). Based of observation, record review, and interview, the facility failed to provide appropriate cares to include grooming for Resident (R) 34, observed wearing dirty clothes for two out of four days on survey, and failed to assist R34 during meal service as he ate his meal with a knife only. This placed the resident at risk for poor hygiene and injury while eating with the knife. Findings included: - The Electronic Medical Record (EMR) for R34 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), need for assistance with personal care, other symptoms and signs involving cognitive functions and awareness, and other symptoms and signs involving appearance and behavior. R34's Quarterly Minimum Data Set (MDS), dated [DATE], documented R34 had severely impaired cognition, and required extensive…

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 60 residents. The sample included 17 residents with one reviewed for positioning and two reviewed for skin issues. Based on observation, record review, and interview the facility staff failed to provide care and treatment in accordance with professional standards of practice when staff failed to monitor and provide care for Resident (R)9's venous ulcers (a shallow wound that develops on the lower leg when the leg veins fail to return blood back toward the heart normally) and staff failed to complete weekly skin assessments, and failed to change her lower legs dressing, when the odiferous serosanguinous drainage seeped through her to her outer dressing. Staff further failed to provide instructions for staff on how to care for R12's skin tear and/or to monitor her skin tear. Staff failed to reposition R44 when she leaned over to the right without support. This placed the residents at risk for inappropriate care. Findings included: - R9's Electronic Medical Record EMR documented R9 had…

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

The facility had a census of 60 residents. The sample included 17 residents, with one reviewed for hearing loss. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 45 received proper treatment and assistive devices to maintain his hearing ability when staff failed to follow up on R45's request to see an audiologist (physician who checks hearing loss). This placed the resident at risk for impaired communication. Findings included: - R45's Electronic Medical Record(EMR) documented the resident had a diagnose of hearing loss. R45's Quarterly Minimum Data Set (MDS) documented the resident had adequate hearing and wore no hearing device. R45's Communication Care Plan, revised 02/09/23, instructed staff to anticipate and meet R45's needs, be conscious of his position when in groups, activities, dining room to promote proper communication with others, allow R45 time to respond, repeat as necessary, do not rush, request clarification from him to ensure understanding, face him when speaking, make eye contact with him , turn off the television/radio…

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 60 residents. The sample included 17 residents with one reviewed for dialysis. Based on observation, interview, and record review the facility failed to provide physician ordered care and services related to dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). This deficient practice placed Resident (R) 25 at risk for complications related to dialysis. Findings included: - R25's Electronic Medical Record documented diagnoses of dependence on renal dialysis, diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose), congestive heart failure (chronic condition in which the heart doesn't pump blood as well as it should), atrial fibrillation (irregular, often rapid heart rate), blindness in right eye and low vision in left eye, and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong…

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 60 residents. The sample included 17 residents, with one reviewed for Post-Traumatic Stress Disorder (PTSD -psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress, such as natural disaster, military combat, serious automobile accident, airplane crash or physical torture). Based on observation, record review, and interview the facility failed to provide Resident (R)16 the appropriate treatment and services to attain her highest practicable mental and psychosocial (interrelation of social factors and individual thought and behavior) well-being, when staff failed to provide R16 with behavioral health services for PTSD. This placed the resident at risk for unmet mental health care needs. Findings included: - R16's Electronic Medical Record (EMR) documented the R16 had diagnoses of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), major…

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 60 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to identify and provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of one sampled resident, Resident (R) 43, who had behaviors. This placed the resident at risk for further decline of their emotional and mental well-being. Findings included: - The Electronic Medical Record (EMR) documented R43 had diagnoses of anxiety (a feeling of worry, nervousness, or unease), psychosis due to unknown substance (a severe mental condition in which thought and emotions are so effective that contact is lost with external reality), intermittent explosive disorder (repeated, sudden episodes of impulsive, aggressive, violent behavior or angry verbal outbursts in which you react grossly out of proportion to the situation), depression (abnormal emotional state characterized by exaggerated feelings of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 60 residents. The sample included 17 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to place a stop date on Resident (R) 16's as needed (PRN) Ativan (class of medications that calm and relax people with excessive anxiety, nervousness, or tension). This placed the resident at risk for unnecessary medications and related complications. Findings included: - R16's Electronic Medical Record (EMR) documented R16 had diagnoses of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), major depressive disorder (major mood disorder), schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought) symptoms, such as sensing things while awake that appear to be real, but the mind created…

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 59 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve foods in a sanitary manner for the 42 residents who received food from the facility kitchen and in the dining room. Findings included: - On 11/09/21 at 08:00 AM, observation in the facility's kitchen revealed the three-door refrigerator contained the following items. a gallon sized bag with 1/2 a ham-undated a gallon sized bag with ham chunks-undated a gallon sized bag with uncooked roast dated 11/01/21 On 11/10/21 at 11:00 AM, observation revealed the refrigerator and freezer Temperature Logs missing temperatures for the days of 11/06, 11/07, 11/08/21. Further observation revealed the stove with black, baked on food particles inside the oven, various food particles on the bottom of the three-door refrigerator and three door freezer. Continued observation revealed dried brown liquid on the wall above the trash can. On 11/10/21 at 12:00 PM, observation revealed Dietary Staff (DS) DD used her gloved hands to touch the food on numerous 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 - R46's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had moderately impaired cognition and required extensive assistance of one staff for dressing and limited assistance of one staff for toileting and personal hygiene. The ADL Care Area Assessment (CAA), dated 07/09/21, documented R46 was at risk for further decline in ADLs, falls, immobility, refused therapy and remained at a functional baseline. The ADL Care Plan, dated 08/13/21, directed staff to monitor, report a decline in abilities to assist with ADLs, and to provide assistance as needed. On 11/10/21 at 09:45 AM, observation revealed Certified Nurse Aide (CNA) M assisted the resident to the bathroom, pulled the resident's pants down and dried feces (waste material from the bowel) was hanging from the resident's perineum (area between the genitals and the anus). CNA M changed the resident soiled incontinence product, pants and shirt, stood the resident up and stated the resident performed her own personal hygiene. Further…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 59 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to provide reasonable accommodation of resident needs for one sampled Resident (R) 40, regarding a wheelchair footrest needing repaired or replaced. Findings included: - The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score nine, which indicated moderately impaired cognition. The MDS documented the resident required extensive assistance with activities of daily living (ADLs) except supervision with locomotion off unit and eating. The MDS documented the resident used a walker and wheelchair for mobility. The ADL Care Plan, revised on 10/27/21, documented the resident required staff assistance with ADLs except supervision with eating. The care plan documented the resident used a wheelchair and walker for mobility. On 11/09/21 at 11:04 AM, observation revealed the residents high back…

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 59 residents. The sample included 15 residents with three sampled for Medicare Part A Liability Notices. Based on record review and interview, the facility failed to provide one of three sampled residents (or their representative) the Advance Beneficiary Notices (ABN), forms 10055 and 10123 for discharge from skilled services, Resident (R) 37. Findings included: - The Medicare Advanced Beneficiary Notice (ABN) informed the beneficiary that Medicare may not pay future skilled therapy services and provided a cost estimate of continued services. The form included option for the beneficiary to (1) receive specified therapy listed, and bill Medicare for an official decision on payment. I understand if Medicare does not pay, I am responsible for payment, but can appeal Medicare. (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for services. (3) I do not want the listed therapy services. The Notice of Medicare Non-Coverage (NOMNC) Form CMS-10123, and the Detailed Explanation of Non-Coverage which explained the appeals process.…

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 59 residents. The sample included 15 residents with four reviewed for accidents. Based on observation, interview and record review the facility failed to review and revise the care plan to prevent further falls for one sampled Resident (R) 36. Findings included: - R36's diagnoses included dementia (group of symptoms that affects memory, thinking and interferes with daily life), myelodysplastic syndrome (group of disorders resulting from poorly formed or dysfunctional blood cells. This causes tiredness, difficulty in breathing, pale skin, frequent infections, easy bruising and bleeding), osteoporosis (condition when bone strength weakens and is susceptible to fracture), and polyneuropathy (condition in which a person's peripheral nerves are damaged and affects the nerves in your skin, muscles, and organs). R36's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 59 residents. The sample included 15 residents, with seven reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide the necessary services to maintain grooming, and personal hygiene for two sampled residents, Resident (R) 9, R46, and failed to provide bathing for R22. Findings included: - R46's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had moderately impaired cognition and required extensive assistance of one staff for dressing and limited assistance of one staff for toileting and personal hygiene. The ADL Care Area Assessment (CAA), dated 07/09/21, documented R46 was at risk for further decline in ADLs, falls, immobility, refused therapy and remained at a functional baseline. The ADL Care Plan, dated 08/13/21, directed staff to monitor, report a decline in abilities to assist with ADLs, and to provide assistance as needed. On 11/10/21 at 09:45 AM, observation revealed Certified…

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 59 residents. The sample included 15 residents with four reviewed for accidents. Based on observation, interview and record review, the facility failed to implement interventions to prevent falls for Resident (R)36. This placed R36 at increased risk for falls and injuries related to falls. Findings included: - R36's diagnoses included dementia (group of symptoms that affects memory, thinking and interferes with daily life), myelodysplastic syndrome (group of disorders resulting from poorly formed or dysfunctional blood cells. This causes tiredness, difficulty in breathing, pale skin, frequent infections, easy bruising and bleeding), osteoporosis (condition when bone strength weakens and is susceptible to fracture), and polyneuropathy (condition in which a person's peripheral nerves are damaged and affects the nerves in your skin, muscles, and organs). R36's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 12 which indicated…

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 59 residents. The sample included 15 residents, with five reviewed for nutrition. Based on observation, interview and record review, the facility failed to provide Resident (R) 21, who had a history of weight loss, her breakfast meal and physician ordered supplement with meals on a consistent basis. This placed R21 at risk for further weight loss and complications related to decreased nutrition. The facility failed to provide the correct diet to R33, who received a regular diet and had a physician order pureed diet. This placed R33 at risk for choking and aspiration. Findings included: - R21's Physician Order Sheet, dated 10/08/21, documented the resident had a diagnosis of protein calorie malnutrition. The admission Minimum Data Set Assessment (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score 10, which indicated moderately impaired cognition. The MDS documented the resident required extensive staff assistance with activities of daily…

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 59 residents. The sample included 15 residents with one reviewed for feeding tube (medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation) care and services. Based on observation, interview, and record review the facility failed to ensure competent nursing practice during the administration of medications via the feeding tube for sampled Resident (R) 34. Findings included: - R34's Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status score of 11, indicating moderately impaired cognition. The MDS documented the resident required extensive assistance of one staff for eating, weighed 181 pounds, and received 51% or more of his total calories through tube feeding. The MDS documented the resident received antidepressive (drug to mitigate depression) and opioid (narcotic pain drugs) medications. The Tube Feeding Care Plan, dated 10/06/21, 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 had a census of 59 residents. The sample included 15 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's Consultant Pharmacist failed to identify and report to the Director of Nursing, facility medical director, and physician an inappropriate diagnosis for the use of an antipsychotic medication (class of medications used to treat any major mental disorder characterized by a gross impairment in reality testing and other mental emotional conditions) for one of five sampled residents, Resident (R) 53. Findings included: - R53's Medicare Five Day Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. MDS further documented R53 received an antipsychotic medication routinely. The Psychotropic Drug Use Care Area Assessment (CAA), dated 11/02/21, documented the resident had a diagnosis of dementia with behavioral…

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 59 residents. The sample included 15 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to identify an inappropriate diagnosis for the use of an antipsychotic medication (class of medications used to treat any major mental disorder characterized by a gross impairment in reality testing and other mental emotional conditions) for one of five sampled residents, Resident (R) 53. Findings included: - The Medicare Five Day Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of ten which indicated moderately impaired cognition. MDS further documented R53 received an antipsychotic medication routinely. The Psychotropic Drug Use Care Area Assessment (CAA), dated 11/02/21, documented the resident had a diagnosis of dementia with behavioral disturbances (progressive mental disorder characterized by failing memory, confusion, with increased agitation)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.