Plaza West Healthcare And Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 130 residents. The sample included 27 residents. Based on observation, record review, and interview, the facility failed to revise the care plan for Resident (R) 117 with interventions to prevent skin tears and failed to [NAME] R78's care plan with interventions to prevent pressure ulcers. This placed the residents at risk of further injury and uncommunicative care needs. Findings included: - The Electronic Medical Record (EMR) for R117 documented diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and epilepsy (brain disorder characterized by repeated seizures). The Annual Minimum Data Set (MDS), dated [DATE], documented R117 had severely impaired cognition. R117 was dependent upon staff for all activities of daily living (ADL). R117 had upper one-side functional impairment and had no…

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 130 residents. The sample included 27 residents, with four sampled residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as the result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to ensure interventions were in place and implemented for Resident (R) 78 to prevent skin breakdown which resulted in an avoidable pressure ulcer development. This deficient practice placed R78 at risk for complications and possible infection-associated pressure wounds. Findings included: - R78 ' s Electronic Medical Record (EMR) documented diagnoses of atrial fibrillation (A-Fib rapid, irregular heartbeat), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), embolism (an obstruction in a blood vessel due to a blood clot or other foreign matter that gets stuck while traveling…

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 130 residents. The sample included 27 residents with two sampled residents reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 346 had a physician's order for supplement oxygen (O2) therapy. The facility failed to ensure staff monitored and documented the effectiveness of R346's supplemental O2. The facility failed to ensure R346's nasal cannula (NC - a thin hollow tube that assists in providing supplemental eO2) was appropriately stored when not used. This deficient practice placed R346 at risk of respiratory complications and possible infection. Findings included: - R346's Electronic Medical Record (EMR) recorded an admission dated 03/01/25 and documented diagnoses of end-stage renal disease (ESRD - when the kidney lose their ability to function and filter waste and excess fluid from the blood), congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), and respiratory failure (inadequate gas exchange by 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 130 residents. The sample included 27 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 295 who received care and services for dialysis (a procedure where impurities or wastes were removed from the blood), was consistent with professional standards of practice, which included ongoing assessments of residents' condition, communication, and collaboration with the dialysis facility. This placed R295 at risk of complications and unmet care needs related to dialysis treatment. Findings included: - The Electronic Medical Record (EMR) for R295 documented diagnoses of fracture (broken bone)of the left tibia (bone of the lower leg), arteriovenous fistula (AV - a surgically created connection between an artery and a vein), dependence on renal (pertaining to kidneys) dialysis, end-stage renal disease, bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational…

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 130 residents. The sample included 27 residents. Based on observation, record review, and interview, the facility failed to provide an accurate reconciliation of controlled drugs during the daily work shift. This placed residents at risk for misappropriation of medication by staff. Findings included: - On 03/17/25 at 08:06 AM, observation of the 400-hall treatment cart revealed the count for controlled medication lacked 03/13/25 and 03/14/25 of the going off-shift signatures, and the 03/15/25 coming on shift staff signature. On 03/17/25 at 08:06 AM, Licensed Nurse (LN) G stated staff should sign at the beginning and end of shifts to ensure the accuracy of the controlled medication count. On 03/17/25 at 08:09 AM, observation of the 400-hall medication cart revealed the count for controlled medication lacked 03/15/25 and 03/16/25 both coming on shifts and going off shift staff signatures. On 03/17/25 at 08:09 AM, Certified Medication Aide (CMA) S stated the count for controlled medications should be signed. On 03/19/25 at 03:15 PM, Administrative Nurse D…

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 130 residents. The sample included 27 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's Consultant Pharmacist (CP) failed to identify and report to facility administration the staff had not notified the physician of out-of-parameter accu-checks (blood glucose monitoring test) for one resident, Resident (R) 29. This placed the resident at risk for physical decline and an ineffective medication regimen. Findings included: - The Electronic Medical Record (EMR) for R29 documented diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), hypertension (high blood pressure), and epilepsy…

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 130 residents. The sample included 27 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to notify the physician for an Accu-check (blood glucose monitoring test) outside of physician-ordered parameters, for one resident, Resident (R) 29. The facility failed to document in the Medication Administration Record (MAR) after administering medication for R295. This placed the residents at risk for adverse effects related to medications. Findings included: - The Electronic Medical Record (EMR) for R29 documented diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), hypertension…

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 130 residents. The sample included 27 residents. Based on observation, record review, and interview, the facility failed to prevent medication administration errors for Resident (R) 29, who received the wrong dosage of a medication supplement for six out of six administrations. This placed the resident at risk for physical decline and other related complications. Findings included: - The Electronic Medical Record (EMR) for R29 documented diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), hypertension (high blood pressure), and epilepsy (epilepsy (brain disorder characterized by repeated seizures). 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.

The facility had a census of 130 residents. The sample included 27 residents. Based on observation, record review, and interview, the facility failed to store and label biologicals as required in one of seven medication carts, when staff failed to place a stop date on R31's Humalog (rapid-acting) Insulin (a hormone that lowers the level of glucose in the blood) Kwik pen (a prefilled, disposable insulin pen). Findings included: - On 03/17/25 at 07:41 AM, on hall 700, 800, and 900 hall treatment cart R31's Humalog insulin Kwik pen lacked an open date. Licensed Nurse (LN) J verified the pen had been opened and stated staff should have placed an open date when they opened it. On 03/19/25 at 03:05 PM, Administrative Nurse D stated she would expect staff to place an open date on an insulin pen when they open it. Upon request, the facility did not provide a policy regarding opening Humalog pens. The facility failed to place an open date on R31's Humalog insulin pen. This placed the residents at risk of receiving an ineffective dose of the medication.

The facility identified a census of 130 residents. The sample included 27 residents, with two residents sampled for hospice care. Based on observation, record review, and interview, the facility failed to ensure there was a collaboration of care between Resident (R) 112's hospice provider and the facility. This placed R112 at risk of inadequate end-of-life care. Findings included: - R112's Electronic Medical Record (EMR) documented diagnoses of malignant neoplasm of the right lung (lung cancer), 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), chronic kidney disease (a condition where the kidneys gradually lose their ability to filter waste products from the blood), and peripheral vascular disease (PVD - slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel). R112's admission Minimum Data Set (MDS) dated 09/28/24 documented she had a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderately…

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 130 residents. The sample included 27 residents. Based on observation, record review, and interview, the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff failed to provide enhanced barrier precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) for Resident (R) 8 and R88. This deficient practice placed the residents at risk for possible exposure to infection for R8 and R88. Findings included: - R8's Electronic Medical Record (EMR) documented that R8 had a diagnosis of dysphagia (swallowing difficulty). R8's Quarterly Minimum Data Set (MDS), dated [DATE], documented that R8 had a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. The MDS documented R8 had a feeding tube. R8's Care Plan, revised 03/03/25,…

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 134 residents. The sample included one resident reviewed for respiratory services. Based on observations, record review, and interviews, the facility failed to provide necessary respiratory care and services for Resident (R) 1. This deficient practice placed R1 at risk for infection and unwarranted physical complications. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), tobacco use, dementia (a progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance, and personal history of pulmonary embolism (an obstruction in a blood vessel due to a blood clot or other foreign matter that gets stuck while traveling through the bloodstream in the lungs). The Annual Minimum Data Set (MDS) dated 08/09/24, documented R1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R1 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 identified a census of 133 residents. Based on record review and interviews, the facility failed to ensure Certified Nurse Aide (CNA) M received the required effective communication training. This deficient practice placed residents at risk for impaired communication. Findings included: - A review of video footage, which included audio and a date and timestamp of 09/18/24 at 01:22 AM, revealed the following interaction between R1 and Certified Nurse Aide (CNA) M: R1 laid in bed on her back with her knees bent, her covers were at her feet. CNA M walked into R1's room and up to R1's bed. CNA M asked R1 what she needed and then placed her hands on her hips while looking down at R1. In a raised voice, CNA M stated to R1 she was not going to do this, it was the second time R1 was on the light, and asked R1 what she needed. Unable to understand or hear R1's response due to the television volume. CNA M grabbed a brief out of R1's closet, closed R1's blinds, moved her bedside table, and then went back to R1's bedside. CNA M asked R1 about what time she goes to dialysis (a…

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

The facility identified a census of 133 residents. Based on record review and interviews, the facility failed to ensure Certified Nurse Aide (CNA) M received the required resident rights training. This deficient practice placed residents at risk for impaired resident rights and loss of dignity. Findings included: - A review of video footage, which included audio and a date and timestamp of 09/18/24 at 01:22 AM, revealed the following interaction between R1 and Certified Nurse Aide (CNA) M: R1 laid in bed on her back with her knees bent, her covers were at her feet. CNA M walked into R1's room and up to R1's bed. CNA M asked R1 what she needed and then placed her hands on her hips while looking down at R1. In a raised voice, CNA M stated to R1 she was not going to do this, it was the second time R1 was on the light, and asked R1 what she needed. Unable to understand or hear R1's response due to the television volume. CNA M grabbed a brief out of R1's closet, closed R1's blinds, moved her bedside table, and then went back to R1's bedside. CNA M asked R1 about what time she goes 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.

The facility identified a census of 133 residents. The sample included three residents. Based on record review and interviews, the facility failed to ensure staff treated Resident (R) 1 with dignity. This deficient practice placed R1 at risk for decreased self-esteem and dignity. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of end-stage renal disease (ESRD-a terminal disease of the kidneys), unsteadiness on feet, cognitive communication deficit, and need for assistance with personal care. The Annual Minimum Data Set (MDS) dated 04/17/24, documented R1 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. R1 required substantial/maximal assistance with toileting hygiene and was independent with transfers. The Quarterly MDS dated 08/22/24, documented R1 had a BIMS score of 12 which indicated moderate cognitive impairment. R1 required dependence on staff for toileting hygiene; partial/moderate assistance with sit-to-stand positioning; and substantial/maximal assistance with chair/bed-to-chair…

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 133 residents. Based on observations, record review, and interviews, the facility failed to ensure staff prevented cross-contamination during incontinence care (lack of voluntary control over urination or defecation) for Resident (R) 2 and failed to disinfect the Hoyer lift (total body mechanical lift) between resident usage. This deficient practice placed the affected residents at risk for infection and related complications. Findings included: - On 09/30/24 at 01:37 PM, Certified Nurse Aide (CNA) O and CNA P entered R2's room with the Hoyer lift. R2 sat in her wheelchair. CNA O positioned the Hoyer lift in front of R2 and CNA P hooked the sling up to the lift. Both CNA O and CNA P donned (put on) gloves. CNA P stood beside R2 while CNA O controlled the lift. They positioned R2 over her bed, lowered R2 down, unhooked the sling, and pulled the Hoyer lift out from under the bed. CNA O tucked the sling under R2 then CNA O and CNA P rolled R2 towards the wall. CNA O pulled out the lift sling and soiled incontinence pad from under R2. CNA P grabbed a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had census of 122 residents. The sample included seven residents with three reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to provide a written notice as soon as practicable for a facility-initiated transfer to Resident (R) 3 and R4, or their representatives, when they were transferred to the hospital. This placed the residents at risk for uninformed care choices. Findings included: - R3's Electronic Medical Record (EMR) documented R3 had diagnoses of pain in left hip, left femur (thigh bone) fracture, and falls. R3's admission Minimum Data Set (MDS) documented R3 had a Brief Interview of Mental Status (BIMS) score of three, which indicated severe impaired cognition. The MDS documented R3 required maximal staff assistance with most activities of daily living (ADLs). R3's Care Plan, revised 12/13/23, instructed staff to anticipate and meet R3's needs, be sure his call light was within reach and respond promptly to all requests for assistance. 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 122 residents. The sample included eight residents. Based on observation, record review, and interview, the facility failed to provide two of three residents reviewed for hospitalization, Resident (R)3 and R4 or their representative, with written information regarding the facility bed hold policy when they were transferred to the hospital. This placed the residents at risk for not being permitted to return and resume residence in the nursing facility. Findings included: - R3's Electronic Medical Record (EMR) documented R3 had diagnoses of pain in left hip, left femur (thigh bone) fracture, and falls. R3's admission Minimum Data Set (MDS) documented R3 had a Brief Interview of Mental Status (BIMS) score of three, which indicated severe impaired cognition. The MDS documented R3 required maximal staff assistance with most activities of daily living (ADLs). R3's Care Plan, revised 12/13/23, instructed staff to anticipate and meet R3's needs, be sure his call light was within reach 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 122 residents. The sample included eight residents with three reviewed for activities of daily living (ADLs). Based on record review and interview, the facility staff failed to provide appropriate ADL care and assistance for Resident (R) 1 when staff left her on the toilet in the shower room unsupervised. This placed R1 at risk or impaired ADL and decreased quality of life. Findings included: - R1's Electronic Medical Record (EMR) documented the resident admitted [DATE]. R1's EMR documented she had diagnoses of unsteadiness on her feet, cognitive communication deficiency and cholecystitis (inflammation of the gallbladder). R1s admission Minimum Data Set (MDS), dated [DATE], documented R1 admitted to the facility from the hospital. R1's Care Plan, dated 08/19/02, documented R1 required maximal staff assistance with toileting The facility's Incident Report, dated 12/02/23, documented Certified Medication Aide (CMA) M assisted R1 to the shower room toilet, gave R1 the call light,…

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 117 residents. The sample included 28 residents. Based on observation, record review, and interview the facility failed to implement a water management program for the Legionella disease (Legionella is a bacterium spread through mist, such as from air-conditioning units for large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease or heavy tobacco use are most at risk of developing a pneumonia caused by legionella). This placed the residents in the facility at risk for infectious disease. Findings Included: - On 10/06/23 at 12:55 PM, Administrative Staff A stated the last maintenance supervisor was fired a few months ago and the facility was unable to locate or retrieve the information regarding the water testing if or when it had been completed and the testing results. Administrative Staff A had the information material for the water management process however lacked documentation the process was completed. The facility's Legionella…

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 117 residents. The sample included 28 residents. Based on observation, record review, and interview, the facility failed to act upon the concerns for the resident council group concerning issues of care and life in the facility. This placed the residents at risk of decreased quality of care and services. Findings included: - Upon record review of the monthly Resident Council meeting recorded the following: In January 2023 the combined household meeting note review recorded concerns of late mealtimes in dining room and for room trays, and cold food. Further concerns logged were staff not answering call lights time, beds not being made, and not enough staff. In February 2023, the meals continued to be late and food was cold; beds not provided with clean linens, trash was not picked up on the weekends, and residents wanted wanting earlier showers. Further concerns logged included lengthy call light response, and not enough staff. In March 2023, the meals continued to be late, rooms were not cleaned properly, staff were yelling to each other and laundry…

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 - R78's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), major depressive disorder (major mood disorder which causes persistent feelings pf sadness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The admission Minimum Data Set (MDS) dated documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R78 required set up assistance of one staff member for activities of daily living (ADLs). The MDS documented R78 required supervision of oversight with her bathing activity during the look back period. The Quarterly MDS dated 07/15/23 documented a BIMS score of 14 which indicated intact cognition. The MDS documented that R78 required supervision of one staff member for ADLs. The MDS documented R78 required physical assistance during bathing look back period. R78'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 had a census of 117 residents. The sample included 27 residents, with 14 reviewed for accidents. Based on observation, record review, and interview, the facility failed to to prevent accidents for two residents, Resident (R) 84 and R115, who both fell out from mechanical lifts. The facility failed to utilize two staff during a full body mechanical lift transfer for R106, and failed to put foot pedals on R328's wheelchair while transporting a resident. These deficient practices placed the residents at risk for increased risk for falls and related injury. Findings included: - The Electronic Medical Record (EMR) documented R84 had diagnoses of chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), retention of urine, diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), venous insufficiency, anemia (inadequate number 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.

The facility had a census of 117 residents. The sample included 28 residents. Based on observation, interview, and record review, the facility failed to label Resident (R)33, R115 and R119s' insulin (hormone which allows cells throughout the body to uptake glucose) flex pens with the date opened and discard date on one medication cart and failed to discard expired stock medication in one medication room. These deficient practices placed the affected resident at risk for ineffective medications. Findings included: - On 08/09/23 at 08:10AM, observation of the medication cart for the 700, 800, and 900 Halls revealed the following: R33's lispro (short acting insulin) flex pen lacked an open date and discard date. R33's glargine (long acting insulin) flex pen lacked a date opened and discard date. R115's lispro flex pen lacked an open date and discard date. R119's lispro flex pen lacked an open date and discard date. On 10/03/23 at 08:20 AM, observation of the 700,800 and 900 Hall medication room revealed the following: One emergency kit (e-kit) in the refrigerator with the expiration…

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 117 residents. The sample included 28 residents. Based on observation, record review, and interview, the facility failed to maintain an environment that promoted dignity for Resident (R) 84, R115, and R31. This deficient practice placed the residents at risk for undignified experience and embarrassment. Findings included: - On 10/03/23 at 12:15 PM observation revealed R84 sat in the dining room in his wheelchair. R84's catheter (tube inserted into the bladder to drain urine) urine drainage bag was fastened to the underside of the seat without a privacy bag. On 10/09/23 at 02:05 PM, Administrative Nurse D verified the catheter urine drainage bag should be covered. The facility's Promoting/Maintaining Resident Dignity policy, dated 01/01/20, documented it was the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, maintains or enhances resident's quality of life by recognizing each resident's individually. The facility failed 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.

The facility had a census of 117 residents. The sample included 28 residents. Based on observation, record review, and interview, the facility failed to include Resident (R) 48 in the development and planning of the resident's care plan, which placed R48 at risk of impaired care and autonomy. Findings included: - R48's Electronic Medical Record (EMR) documented diagnoses of bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), hypertension (elevated blood pressure), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), polyneuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet), muscle weakness, morbid obesity (serious health condition that results in higher body mass), fibromyalgia (condition of musculoskeletal pain, spasms, stiffness, fatigue and severe sleep disturbance) , anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depression (a mood disorder that causes a persistent…

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 117 residents. The sample included 28 residents. Based on observation, record review and interview, the facility failed to ensure Resident (R) 101 was assessed for the ability to safely self-administer nasal spray medication. This placed R101 at risk of improper use of medication and related side effects. Findings included: - R101's Electronic Medical Record documented diagnoses of irritable bowel syndrome (IBS- abnormally increased motility of the small and large intestines), hypertension (high blood pressure), dementia (progressive mental disorder characterized by failing memory, confusion), and overactive bladder (a sudden need to urinate). The admission Minimum Data Set (MDS), dated [DATE], documented R101 had intact cognition and required limited assistance of one staff for bathing, and set up assistance and supervision with personal hygiene. The MDS recorded R101 was independent with set up assistance with bed mobility, transfers, and toileting. R101's Care Plan, dated…

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

The facility had a census of 117 residents. The sample included 28 residents. Based on observation, record review, and interview, the facility failed to support Resident (R) 48's bathing preferences which placed the residents at risk for impaired rights to exercise their autonomy regarding those things that are important in their life. Findings included: - R48's Electronic Medical Record (EMR) documented diagnoses of bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), hypertension (elevated blood pressure), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), polyneuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet), muscle weakness, morbid obesity (serious health condition that results in higher body mass), fibromyalgia (condition of musculoskeletal pain, spasms, stiffness, fatigue and severe sleep disturbance) , anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear),…

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 117 residents. The sample included 28 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for Resident (R) 8's post-traumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress) diagnosis which placed the R8 at risk for uncommunicated care needs. Findings included: - R8's Electronic Medical Record (EMR) documented diagnoses of generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, major depressive disorder (major mood disorder which causes persistent feelings of sadness), epilepsy (brain disorder characterized by repeated seizures), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hemiplegia (weakness and paralysis on one side of the body)following a cerebral infarction…

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

The facility identified a census of 117 residents. The sample included 28 residents. Based on observation, record review, and interviews, the facility failed to consistently provide activities for the 13 residents who lived on Willow, the locked dementia unit. This deficient practice had the risk for a decline in physical, mental, and psychosocial well-being and independence for these residents. Findings included: - Review of the Electronic Medical record (EMR) under Reports for Activity Participation for revealed the following: Resident (R) 7, from 09/17/23 to 10/04/23 (18 days), lacked evidence of activity participation documentation. R106, from 09/12/23 to 10/04/23 (23 days), lacked evidence of activity participation documentation. R327, from 09/14/23 to 10/04/23 (21 days), lacked evidence of activity participation documentation. R328, from 10/01/23 to 10/04/23 (3 days), lacked evidence of activity participation documentation. Observation on 10/03/23 at 10:30 AM Fun Fitness was scheduled as an activity to occur on [NAME] and the residents sat in the common area with the TV on. No…

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 117 residents. The sample included 28 residents. Based on observation, record review, and interview, the facility failed to implement interventions to prevent skin tears and failed to follow the care plan for Resident (R) 47. The facility further failed to monitor daily weights for R7. This placed the residents at risk for further injury and declining health. Findings included: - R47's Electronic Medical Record (EMR) 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), difficulty walking, altered mental status (a change in mental status), and neuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R47 had impaired cognition and required limited assistance of one staff for bed mobility, toileting, personal hygiene, and supervision with set up…

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 117 residents. The sample included 28 residents. Based on observation, record review, and interview, the facility failed to provide footcare to one sampled resident, Resident (32), who had a diagnosis of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) type 2 and required foot care from a licensed nurse. This placed the resident at risk for complications, poor hygiene and injuries. Findings included: - R32's Electronic Medical Record (EMR) documented diagnoses of diabetes mellitus type 2, congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), chronic kidney disease (kidneys are damaged and cannot filter blood the way they should), mild protein calorie malnutrition (a nutritional status in which reduced availability of nutrition's leads to changes in body composition and function), and vitamin D deficiency (when there is not enough vitamin D in the body). 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 117 residents. The sample included 28 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 25 received services and assistance to maintain continence, and/or improve incontinence and failed to manage R84's catheter (tube inserted into the bladder to drain urine) in a sanitary manner. This placed the residents at risk for increased incontinence and urinary tract infections related complications. Findings included: - R25's Electronic Medical Record (EMR) documented diagnoses of chronic kidney disease, unspecified infectious disease, peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), visual loss in both eyes, non-pressure chronic ulcer unspecified part of left lower leg, diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), lymphedema (swelling caused by accumulation of lymph) ,…

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 117 residents. The sample included 28 residents, with one reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to provide necessary respiratory care and services for Resident (R) 30, when staff stored the uncovered nebulizer (turns liquid medication into a mist so that you can inhale it into your lungs) masks on top of the nebulizer machine. This placed the resident at increased risk for respiratory infections and complications. Findings included: - R30's Electronic Medical Record (EMR) documented diagnoses of heart failure (a condition with low hear output and the body becomes congested with fluid), hypertension (high blood pressure) and chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R30 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 117 residents. The sample included 28 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 8 received trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident's which placed the resident at risk for unmet behavioral health care needs. Findings included: - R8's Electronic Medical Record (EMR) documented diagnoses of generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, major depressive disorder (major mood disorder which causes persistent feelings of sadness), epilepsy (brain disorder characterized by repeated seizures), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), hemiplegia (weakness and paralysis on one side of the body)following a cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood…

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 117 residents. The sample included 28 residents. Based on observation, record review, and interview, the facility failed to ensure certified staff possessed the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promoted each resident's rights, physical, mental and psychosocial well-being when a Certified Medication Aide (CMA) did not administer medications as ordered or within acceptable standards of practice This placed the affected resident at risk for decreased quality of care. Findings included: - R101's Electronic Medical Record (EMR) documented diagnoses of irritable bowel syndrome (IBS- abnormally increased motility of the small and large intestines), hypertension (high blood pressure), dementia (progressive mental disorder characterized by failing memory, confusion), and overactive bladder (a sudden need to urinate). The admission Minimum Data Set (MDS), dated [DATE], documented R101 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 117 residents. The sample included 28 residents with two residents reviewed for dementia (progressive mental disorder characterized by failing memory, confusion). Based on observation, record review, and interviews, the facility failed to provide dementia care and services for Resident (R) 327, who had behaviors. This deficient practice placed R327 at risk for increased behaviors, confusion, and decline in ability to maintain the highest practicable mental and psychosocial well-being. Findings included: - R327's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero which indicated severely impaired cognition. The MDS documented that R327 required limited assistance for activities of daily living (ADLs). The MDS lacked a dementia…

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 117 residents. The sample included 28 residents with five reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure R78's as needed psychotropic (affects mood or thought) clonazepam (psychotropic medication used to teat stress or anxiety) had a stop date or a physician ordered specified duration for administration. This deficient practice placed R78 at risk for potential harm and adverse side effects related to unnecessary medications. Findings included: - R78's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), major depressive disorder (major mood disorder which causes persistent feelings pf sadness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The admission Minimum Data Set (MDS) dated documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. 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 117 residents. The sample included 28 residents with three residents reviewed for pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations and Influenza (highly contagious viral disease). Based on record review and interviews, the facility failed to obtain pneumococcal and/or influenza vaccination consent and administer vaccines, or obtain informed declinations for Resident (R) 95, R 115 and R120 after the residents were admitted to the facility. This deficient practice placed the residents at risk to acquire, spread, and experience complications from the pneumococcal and influenza disease. Findings included: - R95's clinical medical record lack evidence the resident or the resident representative received, or signed a consent or informed declination for the pneumococcal and influenza vaccinations upon admission to the facility on [DATE]. R115's clinical medical record lack evidence the resident…

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

The facility had a census of 122 residents. The sample included 25 residents. Based on observation, record review, and interview, the facility failed to hold food at safe temperature to prevent foodborne illness of the 122 residents who received meals from one of one kitchen. This placed the residents at risk for foodborne illness. Findings included: -On 04/19/22 at 11:35 AM observation revealed holding temperature of steam table foods for midday meal taken by Dietary Staff (DS) CC: Enchiladas 140 degrees Fahrenheit (F) Pureed Enchiladas 112 degrees F. Corn 130 degrees F. Pureed corn 112 degrees F. Mashed potatoes 120 degrees F. Pureed beans 112 degrees F. The dietary staff began to plate the food for delivery to the residents. Surveyor notified DS BB the food temperatures were not at correct holding temperature. DS BB alerted facility staff the food could not be served at the current temperature. Staff retrieved items from the steam table and placed them in a convection type oven to reheat. On 04/19/22 at 11:50 AM, the food temperature reading all previous foods temperature rose 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.

The facility had a census of 122 residents. The sample included 25 residents. Based on observation, record review, and interview, the facility failed to store, prepare, and serve food under sanitary conditions for 122 residents who resided in the facility and received meals from the facility kitchen, placing the residents at risk for food borne illness. Findings included: -On 04/18/22 at 07:22 AM, during initial tour of the kitchen observation revealed the walk in freezer had an open box of hash brown patties sitting on the floor of the freezer opened and not dated, a package of tator tots, box of hotdog/sausage links, and a round container of sherbet, open and undated. Further observation revealed the center prep work area with a white charging cord attached to an orange/pink colored cell phone and a black purse with gold chain strap on the lower shelf of a work area next to the serving steam table. On 04/18/22 at 08:17 AM, Dietary Staff (DS)BB verified the food in the walk-in freezer should not be stored on the floor, packages of food items if opened have the date in which 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 -Resident (R) 11 Physician Order Sheet (POS), documented diagnoses of chronic kidney disease, major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R11 had intact cognition, delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), verbal and physical behavioral symptoms directed at others and rejection of care which occurred four to six days of the look back period. The MDS further documented she required limited to extensive assistance of two staff for activities of daily living, received oxygen and respiratory therapy daily. 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 122 residents. The sample included 25 residents of which four were reviewed for dignity. Based on observation, record review and interview the facility failed to treat two of the four residents, Resident (R) 96 and R 13, with respect and dignity when the facility failed to ensure the urine collection bag was covered and not visible to other residents and guests. This placed the residents at risk for impaired dignity. Findings included: - R96's Electronic Medical Record (EMR) recorded a diagnosis of urinary retention (difficulty urinating and completely emptying the bladder). R96's admission Minimum Data Set (MDS), dated [DATE], recorded the resident had intact cognition and a urinary catheter (a tube in the bladder which allows the urine to drain in a collection bag). The Urinary Catheter Care Plan dated 04/01/22 directed the staff to position the catheter bag and tubing below the level of the bladder and away from the entrance door of the room. The care plan directed the staff 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 had a census of 122 residents. The sample included 25 residents, with eight reviewed for bathing. Based on observation, record review, and interview, the facility failed to honor Resident (R) 15's choice to have a female staff member assist her with bathing as care planned. This placed the resident at risk for an undignified and unpleasant bathing experience. Findings included: - The Electronic Medication Record (EMR) reported R15 had diagnoses of dementia (progressive mental disorder characterized by failing memory and confusion), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), hypertension (high blood pressure), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R15's cognition was not assessed and documented the resident required extensive assistance of one staff for bed mobility, transfers, dressing, toileting, personal hygiene, 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 122 residents. The sample included 25 residents. Based on observation, interview, and record review the facility failed to revise the care plan with interventions to prevent further falls when Resident (R)60 fell while attempting to toilet herself. This deficient practice placed R60 at risk for inadequate care. Findings included: - R60 was admitted to the facility after a fall causing a femur (large bone of the upper leg) fracture and surgery. The medical record included diagnoses of anxiety (nervous disorder characterized by a state of excessive uneasiness and apprehension) hemiparesis (partial paralysis affecting only one side of the body) following a stroke, and epilepsy (central nervous system (neurological) disorder in which brain activity becomes abnormal, causing seizures or periods of unusual behavior, sensations and sometimes loss of awareness). The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of eight,…

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 122 residents. The sample included 25 residents, with eight reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide consistent bathing services for two sampled residents, Resident (R) 14 and R15. This placed the residents at risk for complications related to poor hygiene. Findings included: - The Electronic Medical Record (EMR) recorded diagnoses of hypertension (high blood pressure), pain (physical suffering or discomfort by illness or injury), chronic kidney disease (long standing disease of the kidneys leading to renal failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). R14's Quarterly and Five-Day Minimum Data Set (MDS), dated [DATE], documented R14's cognition was not assessed and documented the resident 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 122 residents. The sample included 25 residents with seven residents reviewed for pressure ulcers (PU- injuries to skin and underlying tissue resulting from prolonged pressure on the skin). Based on observation, interview, and record review the facility failed to provide interventions for Resident (R) 57's left foot to prevent the development of a new PU. This deficient practice placed R57 at increased risk for wound related complications including infection and pain. Findings included: - R57's medical record documented diagnoses including hemiparesis (partial paralysis affecting only one side of the body), diabetes mellitus with diabetic polyneuropathy ( a type of nerve damage caused by long-term high blood sugar levels) heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs), and peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). The Significant…

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 122 residents. The sample included 25 residents with 10 reviewed for falls. Based on observation, interview, and record review the facility failed to provide interventions to prevent falls for two of ten sampled residents. Resident (R)60 fell while attempting to toilet herself and R95 fell when staff failed to place his feet on wheelchair footrests while loading into the facility van. This deficient practice placed R60 and R95 at risk for falls and injury. Findings included: - R60 was admitted to the facility after a fall causing a femur (large bone of the upper leg) fracture and surgery. The medical record included diagnoses of anxiety (nervous disorder characterized by a state of excessive uneasiness and apprehension) hemiparesis (partial paralysis affecting only one side of the body) following a stroke, and epilepsy (central nervous system (neurological) disorder in which brain activity becomes abnormal, causing seizures or periods of unusual behavior, sensations and sometimes…

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 - R60 was admitted to the facility after a fall causing a femur (large bone of the upper leg) fracture and surgery. The medical record included diagnoses of anxiety (nervous disorder characterized by a state of excessive uneasiness and apprehension) hemiparesis (partial paralysis affecting only one side of the body) following a stroke, and epilepsy (central nervous system (neurological) disorder in which brain activity becomes abnormal, causing seizures or periods of unusual behavior, sensations and sometimes loss of awareness). The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of eight, indicating moderately impaired decision-making skill. The MDS documented the resident did not walk, required extensive staff assistance for bed mobility, transfers, dressing, toileting, and hygiene. R60 had impaired range of motion (ROM) one upper and one lower extremity, used a wheelchair, had impaired balance with transfers, and was frequently incontinent of urine.…

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 122 residents. The sample included 25 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's Consultant Pharmacist (CP) failed to identify and report multiple episodes of systolic blood pressures outside of physician ordered parameters for Resident (R)15. This place R15 at risk for physical decline and complications related to low blood pressures. Findings included: - The Electronic Medication Record (EMR) reported the resident had diagnoses of dementia (progressive mental disorder characterized by failing memory and confusion), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), hypertension (high blood pressure), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R15's cognition was not assessed and documented the resident required extensive assistance of one…

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 122 residents. The sample included 25 residents, with five reviewed for unnecessary medication. Based on observation, record review, and interview, the facility failed to hold amlodipine (a medication for high blood pressure) when systolic blood pressures were out of parameter for one of five sampled residents, Resident (R) 15. This placed R15 at risk for physical decline and complications related to low blood pressure. Findings included: - The Electronic Medication Record (EMR) reported the resident had diagnoses of dementia (progressive mental disorder characterized by failing memory and confusion), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), hypertension (high blood pressure), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R15's cognition was not assessed and documented the resident required extensive 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.