Brookdale Rosehill

The facility reported a census of 76. Based on observations, record review, and interviews, the facility failed to adequately address and resolve recurring issues reported by the Resident Council. This deficient practice placed the residents at risk for decreased psychosocial wellbeing and impaired quality of life. Findings included: - A review of the facility's Resident Council Minutes from 12/2022 through 11/2023 indicated the council had recurring concerns with call light response times. The Resident Council Minutes for 01/2023 noted under new business concerns over call light response time. The form did not list actions taken or resolutions provided. No other issues were reported on the minutes. The Resident Council Minutes for 02/2023 noted under old business the previous call light concern was resolved and noted no other new/old concerns. No other issues were reported on the minutes. The Resident Council Minutes for 03/2023 noted long call light waits under new business concerns. The form did not list actions taken or resolutions provided. No other issues were reported on the…

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

The facility identified a census of 76 residents. The sample include 18 residents. Based on observation, record review, and interviews, the facility failed to implement a system to allow residents and/or their representative to file grievances anonymously. This deficient practice placed the residents at risk for decreased psychosocial wellbeing. Finding Included: - On 12/18/23 at 07:05AM an inspection of the facility revealed no designated grievance drop -box or alternative system available accessible to the residents and visitors of the facility to allow submission of grievances anonymously On 12/18/23 at 02:00PM, the Resident Council members reported they were not aware if the facility provided a way to complete an anonymous grievance. The council reported Social Services X was responsible for complaints or grievances. The council stated they would contact staff or social services. On 12/19/23 at 12:30PM Certified Nurses Aid (CNA) O reported she was not aware of an anonymous way the residents could report grievances other than giving staff the forms directly. She stated she was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 76 residents. The sample included 18 residents. Based on interview and record review, the facility failed to establish and maintain a system to ensure nursing staff maintained current cardiopulmonary resuscitation (CPR- a life-saving medical procedure that consists of chest compressions to allow oxygenated blood to circulate to vital organs, such as the brain and heart and artificial ventilation) certification for healthcare providers. This deficient practice placed all residents who desired CPR at risk for inadequate resuscitative measures. Findings included: - On [DATE] Licensed Nurse (LN) K's CPR certification had an issue date of [DATE] and a renew (expiration) date of 10/2023. On [DATE] at 03:43 PM Administrative Staff A stated LN K was a newer nurse and had previously worked at the facility as a Certified Nurse Aide. Administrative Staff A stated that LN K's CPR certification expired at the end of October. Administrative Staff A stated the facility had had 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.

The facility identified a census of 76 residents. The sample include 18 residents. Based on observation, record review, and interviews, the facility failed to provide consistent weekend activities. This deficient practice placed the affected residents at risk for decreased psychosocial wellbeing and boredom. Findings included: - A review of the facility's Activity Calendar for September, October, and November 2023 was completed. The review revealed two consistent activities of movie matinee and activities connection as shown for both Saturday and Sundays. The calendar indicated church services were provided Sunday mornings. The calendar indicated the activity B-fit was provided by the therapy department on weekends. On 12/18/23 at 02:05PM, Resident Council members reported activities minimally occurred on weekends compare to the weekdays. The council reported due to the low staffing in the facility and limited activities provided, the resident usually watched television or wheeled themselves around to see each other. The council reported the facility did provide an Activities…

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 76 resident. The facility had three medication storage rooms and five medication carts. Based on observation, record review and interview, the facility failed to ensure safe and secure storage of medications and biologicals. This deficient practice created a risk for adverse side effects and ineffective medication administration. Findings included: - On 12/14/23 at 09:25 AM the medication cart on the 300 hallway was left unsecured and unlocked in an area where residents were present. Licensed Nurse (LN) J came running out of a resident's room in the 300 hall when she realized she left the medication cart unlocked. On 12/14/23 at 09:45 AM the treatment cart in the 400 hall was left unsecured and unlocked. On 12/14/23 at 09:25 AM LN J stated the medication and treatment carts should be secured when not in use. On 12/19/23 at 03:16 PM Administrative Nurse D stated that the medication cart, medication room, and treatment carts should all be securely locked when staff was not using them. The facility policy Storage and Expiration of Medications,…

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 76 residents. The sample included 18 residents with one resident reviewed for dignity. Based on observation, interview and record review, the facility failed to ensure a dignified care environment for Resident (R) 47 related to her incontinence management. This deficient practice placed R47 at risk unnecessary embarrassment and decreased psychosocial wellbeing. Findings included: - On 12/14/23 at 02:05 PM an inspection of R47's room revealed a heavy urine smell. R47's room floor had a wet substance leading around the room and into the restroom. Parts of R47's floor had a dried / sticky substance covering it. On 12/18/23 at 12:34 PM R47 was in her room standing next to the closet in her room. R47 had a pair of white pants on the floor next to her recliner. R47 stated she just changed her pants and was going to lunch. R47 had a pile of clothing in her laundry basket. She reported she could do most things for herself but needed staff assistance from time to time. Staff were not in the room to assist her changing. R47 smelled of urine as she went to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 76 residents. The sample included 18 residents with two residents reviewed for transfers. Based on observation, record review and interview, the facility failed to provide written notification of facility-initiated transfers with the required information to Resident R165 or their family/durable power of attorney (DPOA) in a practicable amount of time. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare service for R165. Findings included: - The electronic medical record (EMR) for R165 documented diagnoses of chronic obstructive pulmonary disease (COPD - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), chronic respiratory failure (a condition when your body does not have enough oxygen), and dependence on supplemental oxygen. The admission Minimum Data Set (MDS) dated 09/26/23 for R165 documented a Brief Interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 76 residents. The sample included 18 residents. Based on observation, interview, and record review the facility failed to provide a copy of the Bed Hold notice to Resident (R)63, or her representative, upon discharge to a hospital in November 2023. This deficient practice placed R63 at risk to not be allowed to return to their same room upon discharge from the hospital. Findings included: - R63's Electronic Medical Record documented diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), muscle weakness, difficulty walking and reduced mobility. R63's Entry Tracker documented she admitted on [DATE]. R63's Care Plan with an initiated date of 10/31/23 documented R63 had an activities of daily living (ADLs) self-care performance deficit. An eINTERACT SBAR Summary for Providers note dated 11/02/23, documented R63 had an unwitnessed fall in her room. The note…

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 76 residents. The sample included 18 residents with one resident reviewed for baseline care plan. Based on observation, record review, and interviews, the facility failed to develop a person-centered baseline care plan to include an indwelling catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) for Resident (R) 115. This deficient practice placed R115 at risk of impaired care related to uncommunicated care needs. Findings included: - R115's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of weakness, disorder of kidney and ureter (duct that urine passes from the kidney to the bladder), femur (thigh bone) fracture (broken bone) of left leg, and encounter for fitting and adjustment of urinary device. The admission Minimum Data Set (MDS) was in progress. R115's Care Area Assessment (CAA) was in progress. R115's Baseline Care Plan dated 12/10/23 documented staff would 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 identified a census of 76 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to provide adequate care and services for activities of daily living (ADL) when staff failed to provide supervision with eating during meals for Resident (R)43. This deficient practice placed R43 at risk for complication related to aspiration (inhaling liquid or food into the lungs) and decline of overall abilities. Findings included: - The electronic medical record (EMR) for R43 documented diagnoses of hemiplegia (paralysis of one side of the body), dysphagia (difficulty swallowing), cerebral infarction (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), aphasia (condition with disordered or absent language function), and hemiparesis (muscular weakness of one half of the body). R43 Quarterly Minimum Data Set (MDS) completed 11/16/23 noted a Brief Interview for Mental Status (BIMS) assessment could not be completed due to severe…

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 76 residents. The sample included 18 residents with four reviewed for activities of daily living (ADL). Based on observation, record review, and interviews, The facility failed to provide consistent bathing opportunities for Residents (R)19, R13, and R37. This deficient practice placed the residents at risk for complications related to hygiene and infections and impaired psychosocial wellbeing. Findings included: - The electronic medical record (EMR) for R19 documented diagnoses of type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), irritable bowel syndrome (IBS- abnormally increased motility of the small and large intestines), chronic kidney disease, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). R19 Significant Change 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 identified a census of 76 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure staff physician ordered daily weights were obtained and monitored for Resident (R) 164 who had congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid). The facility also failed to ensure staff applied R52's thrombo-embolic deterrent (TED - a stocking that helps prevent blood clots and swelling in your legs) hose. This deficient practice placed R164 at risk for unwanted weight/fluid gain and R52 at risk for swelling and possible complications. Findings included: - The electronic medical record (EMR) for R164 documented diagnoses of hypertension (elevated blood pressure), atrial fibrillation (rapid, irregular heartbeat), and CHF. The admission Minimum Data Set (MDS) dated 11/24/23 documented R164 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. R164 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY - The Diagnoses tab of R34's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), injury of lumber spinal cord, and difficulty in walking. The Quarterly Minimum Data Set (MDS) dated 11/14/23, documented R34 had a Brief Interview for Mental Status (BIMS) score of nine which indicated moderate cognitive impairment. The MDS documented R34 used a wheelchair and required substantial assistance from staff for bathing and toileting. The MDS further documented R34 was dependent on staff to transition from seated to lying or lying to seated position and for chair to bed transfers. The Pressure Ulcer/Injury Potential Care Area Assessment (CAA) dated 10/28/23, documented R34 was at risk for skin breakdown due to weakness, decreased mobility, and incontinence. R34's Care Plan with an initiated date of 11/23/23, documented R34 had potential for impairment to skin integrity due to weakness, decreased mobility, pain, 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 identified a census of 76 residents. The sample included 18 residents with five reviewed for bowel and bladder management and/or urinary catheter (tube inserted into the bladder to drain urine). Based on interviews, observations, and record review, the facility failed to identify changes in Resident (R) 47's bowel and bladder incontinence patterns and implement individualized toileting interventions. The facility additionally failed to ensure R115's indwelling catheter had an appropriate indication and physician's order to provide catheter and related care. This deficient practice placed both residents at risk for complications related to bladder management and incontinence. Findings included: - The electronic medical record (EMR) for R47 documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), cerebral infarction (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), type two diabetes mellitus (DM-when the body cannot use…

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 76 residents. The sample included 18 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) recommendations for physician documented rationale for the continued use of the antipsychotic medication (class of medications used to treat major mental conditions which cause a break from reality testing) for Resident (R) 37 were addressed by the physician. This deficient practice placed R37 at risk for unnecessary psychotropic medication and related complications. Findings included: - R37's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia (progressive mental disorder characterized by failing memory, confusion), and anxiety…

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 76 residents. The sample included 18 residents with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to ensure dosing instructions for Voltaren (topical pain reliever medication) gel for Resident (R) 52. This deficient practice R52 at risk for unnecessary medication use and physical complications for the affected resident. Findings included: - R52's Electronic Medical Record (EMR) from the Diagnoses 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 made or the body cannot respond to the insulin), and osteomyelitis (local or generalized infection of the bone and bone marrow). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that…

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 76 residents. The sample included 18 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure an appropriate indication or documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefit for the continued use of antipsychotic (class of medications used to treat major mental conditions which cause a break from reality testing) for Resident (R)115 and R37. This deficient practice placed these residents at risk for unnecessary psychotropic medication and related complications. Findings included: - R115's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of weakness, disorder of kidney and ureter (duct that urine passes from the kidney to the bladder), femur (thigh bone) fracture (broken bone) of left leg, and encounter for fitting and adjustment of urinary device. The admission…

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 76 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to ensure physician ordered laboratory test results for Resident (R) 37 were included the clinical record. This deficient practice could result in unnecessary tests and delayed treatment. Findings included: - R37's Electronic Medical Record (EMR) under the Orders tab revealed physician order: Complete Blood Count (CBC) laboratory test to be obtained monthly per physician order. Notify the physician of results dated 04/27/23. R37's EMR lacked laboratory tests obtained on 08/25/23, 09/25/23 and 10/25/23. On 12/19/23 at 03:15 PM Administrative Nurse D stated outside laboratory obtained the lab tests ordered by the physician. Administrative Nurse D stated the results were faxed to the facility and the physician was notified of the results, then the nurse would initial and dated the results. Administrative Nurse D stated the laboratory results were then sent to medical records, and scanned into the results are then scanned into the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 76 residents. The sample included 18 residents with five reviewed for influenza (highly contagious viral infection) and pneumococcal (type of bacterial infection) immunizations. Based on record review and interviews, the facility failed to provide pneumococcal vaccinations or informed refusals for Residents (R)13 and provide influenza vaccinations or informed refusals for R53. This deficient practice placed the residents at risk for complication related to infectious diseases. Findings included: - R13's clinical record lacked evidence indicating she or her representative was offered, consented, refused, or had received the pneumonia vaccination since her admission in 2019. R53's clinical record lacked evidence indicating she or her representative was offered, consented, refused, or had received the Influenza vaccination since her admission on [DATE]. On 12/19/23 at 02:23PM Administrative Nurse F stated she recently took over from the previous infection preventionist and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 70 residents. The sample included 19 residents with three reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide bathing services for one sampled resident, Resident (R) 62. This placed the resident at risk for poor hygiene. Findings included: - The Electronic Medical Record (EMR) for R62 recorded diagnoses of femur fracture (broken thighbone), osteoarthritis (the breakdown of joint cartilage [flexible connective tissue] causing pain and stiffness), and hypertension (high blood pressure). R62's admission Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, toileting and ambulation. The MDS further documented R62 required extensive assistance of one staff for bathing. The ADL Care Plan, dated 01/21/22, directed staff to provide R62 with a sponge bath when a full bath or shower could not be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 70 residents. The sample included 19 residents. Based on observation, interview, and record review, the facility failed to provide supervision and assistance for one of four residents reviewed for accidents, Resident (R) 230 who was at risk for falls. This placed R230 at risk of injury. Findings included: - R230's Physician Order Sheet, dated 01/27/22, documented diagnoses of chronic obstructive pulmonary disease (COPD-progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), heart failure, dependence on supplemental oxygen, chronic pain, dyspnea (difficulty breathing), encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition), repeated falls, lack of coordination, difficulty in walking, and urinary tract infection. The admission Minimum Data Set (MDS), dated [DATE], documented R230 had moderately impaired cognition, required supervision and limited assistance of one staff…

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 70 residents. The sample included 19 residents, with one reviewed for urostomy (an artificial opening in an organ of the body) care. Based on observation, record review, and interview, the facility failed to provide urostomy care for one sampled resident, Resident (R) 178. This placed the resident at risk for inappropriate care and unecessary complications. Findings included: - The Electronic Medical Record (EMR) documented R178 had diagnoses of hypertension (high blood pressure), cellulitis (inflammation of the deepest layer of the connective tissue), and pain. R178's admission Minimum Data Set (MDS), dated [DATE] was in progress. The Urostomy Care Plan, dated 02/07/22, directed staff to change the appliance (bag) as needed, cleanse with soap and water, pat dry, apply skin prep (an antimicrobial skin cleanser), and appliance. The Urostomy Care Plan further directed staff to maintain universal precautions when providing resident care. The Urostomy Care Plan lacked documentation 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 70 residents. The sample included 19 residents, with three reviewed for hydration. Based on observation, record review, and interview, the facility failed to monitor hydration status for one sampled resident, Resident (R) 69, who was on a physician ordered fluid restriction, and failed to establish a fluid restriction as ordered for R176. This placed the residents at risk for dehydration or fluid overload. Findings included: - The Electronic Medical Record (EMR), documented R69 had diagnoses of chronic kidney disease stage two (minor kidney damage), cirrhosis of the liver (liver damage), atrial fibrillation (irregular, rapid heart rate), hypertension (high blood pressure), and congestive heart failure (the heart doesn't pump blood as well as it should). R69's admission Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition and required extensive assistance of two staff for bed mobility and transfers and independent with eating. The Urinary Tract Infection…

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 70 residents. The sample included 19 residents, with three reviewed for pain. Based on observation, record review, and interview, the facility failed to ensure that pain management was provided to one sampled resident, Resident (R) 62. This placed the resident at risk for pain and discomfort. Findings included: - The Electronic Medical Record (EMR) for R62 recorded diagnoses of femur fracture (broken thighbone), osteoarthritis (the breakdown of joint cartilage [flexible connective tissue] causing pain and stiffness), and hypertension (high blood pressure). R62's admission Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, and toileting. The MDS further documented the resident had frequent pain and received pain medication. The Pain Care Plan, dated 02/02/22, directed staff to administer pain medication as ordered, anticipate R62's need for pain relief, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 70 residents. The sample included 19 residents with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to hold insulin (a hormone which regulates the amount of sugar in the blood) for Resident (R) 40 when blood sugars were lower than the physician ordered parameter, did not provide interventions when R22 had five days without a bowel movement, and did not hold blood pressure medication for R69 when blood pressures were out of the physician ordered parameters. This deficient practice placed three of six residents at risk for adverse side effects from medications. Findings included: - R40's Physician Order Sheet (POS), dated 02/09/22, documented a diagnosis of diabetes mellitus (an impairment in the way the body regulates and uses sugar as a fuel). The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 11, indicating 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.