The Gardens At Aldersgate

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 161 residents. The sample included 34 residents, with three sampled residents reviewed for dignity. Based on observation, record review, and interview, the facility failed to preserve Resident (R) 7's dignity while hospice staff transported him on a shower chair from his room to the shower. The facility failed to ensure R16's dignity while assisting him with dressing, when staff left R16's door open.Findings included:- On 01/06/26 at 07:20 AM, an unidentified hospice staff member pushed R7, whose room was on the Cambridge unit, from his room, seated on a shower chair, down the hallway with a hospital gown tied at the neck. R7's lower extremities, back, and buttocks were exposed as the hospice staff pushed R7 down the hallway. The hospice staff turned R7, seated on the shower chair, around backwards through the double doors that led into the [NAME] Unit. Facility staff Certified Medication Aide (CMA) S, and an unidentified male Certified Nurse Aide (CNA) stood in the hallway…

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 161 residents. The sample included 34 residents, with two reviewed for accommodation of needs for assistive devices. Based on observation, record review, and interview, the facility failed to utilize foot pedals during wheelchair transports for Residents (R) 34 and R33. Findings Included: - On 01/05/26 at 09:15 AM, R34 (A severely cognitively impaired resident) sat in the dining room in the facility's [NAME] Unit. Licensed Nurse (LN) LL walked over to R34 and informed him that he had a phone call at the nurse's station. LN LL proceeded to push R34 to the nurse's station without foot pedals on his wheelchair. R34 placed his feet down several times while in transport.On 01/06/26 at 07:54 AM, R33 (a resident with noted impaired mobility and weakness) wheeled herself into the large common area next to the Sunflower Unit. An unknown staff member walked up to R33 and asked if R33 was tired from wheeling herself. R33 stated Yes, and asked if staff could push her. The unknown staff member…

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 161 residents. The sample included 34 residents. Based on observation, record review, and interview, the facility failed to keep Resident (R) 24's protected health information (PHI) private on a medication cart parked in the main dining room. The facility also failed to provide privacy for R113 during activities of daily living.Findings included:- On 01/05/26 at 10:45 AM, an observation revealed a medication cart parked in the Elmhurst hallway with a laptop computer sitting on the top; the computer screen was unlocked and open with R24's PHI on the screen, visible to all who passed by the medication cart. The information visualized included R24's medications, date of birth , allergy information, and code status. No nursing staff were in view of the medication cart. Licensed Nurse (LN) J exited another room into the hallway.On 01/05/26 at 10:57 AM, Certified Nurse Aide (CNA) M entered R113's room to provide assistance with personal hygiene. CNA M failed to close R113's curtains when providing peri-care, exposing R113's buttocks to the open window. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 161 residents. The sample included 34 residents, with seven reviewed for unnecessary medication. Based on record review and interviews, the facility failed to ensure Resident (R) 9's as-needed clonazepam (antianxiety (a class of medications that calm and relax people) medication had a 14-day stop date.Findings included:- R9's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (high blood pressure), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), retention of urine, end-stage renal disease (ESRD- a terminal disease of the kidneys), and major depressive disorder (major mood disorder…

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 161 residents. The sample included 34 residents, with two residents reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 7 and R90 and their representatives were provided a written notification of transfer, as soon as practicable, upon their transfer to the hospital.Findings included:- R7's Electronic Medical Record (EMR) recorded Discharge Minimum Data Set (MDS) dated 04/28/25, which documented an unplanned discharge to an acute hospital with a return anticipated.R7's Entry MDS dated 05/08/25 documented a re-entry to the facility from an acute hospital.The facility lacked the required written notification of transfer, as soon as practicable, upon his transfer to the hospital between 04/28/25 to 05/08/25.R7's Discharge MDS dated 06/12/25 documented an unplanned discharge to an acute hospital with a return anticipated.R7's Entry MDS dated 06/19/25 documented a re-entry to the facility from an acute hospital.The facility lacked the required written notification of transfer for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 161 residents. The sample included 34 residents, with six residents reviewed for activities of daily living (ADL) care. Based on observation, record review, and interviews, the facility failed to ensure staff assisted Resident (R) 8 with bathing as needed and as scheduled.Findings Included: - R8's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of unstageable (depth of the wound is unknown due to the wound bed being covered by a thick layer of other tissue and pus) pressure ulcer of sacral region (triangular area at the base of the spine), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypertension (elevated blood pressure), and congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid).The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 161 residents. The sample included 34 residents, with two residents reviewed for bowel and bladder incontinence, and a catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). Based on observation, record reviews, and interviews, the facility failed to provide appropriate treatment for Resident (R) 4's indwelling catheter (tube placed in the bladder to drain urine into a collection bag). The facility also failed to ensure R4's drainage bag was not resting on the floor.Findings included:- R4's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of encephalitis (inflammatory condition of the brain), kidney disease (damaged and cannot filter blood effectively, leading to waste buildup), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and hypertension (elevated blood pressure). The Significant Change Minimum…

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 161 residents. The sample included 34 residents, with one resident reviewed for dialysis (a procedure where impurities or wastes are removed from the blood) and end-stage renal disease (ESRD- a terminal disease of the kidneys). Based on observation, record review, and interviews, the facility failed to provide standards of care related to Resident (R) 9's dialysis.Findings included:- R9's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (high blood pressure), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), retention of urine, end-stage renal disease (ESRD- a terminal disease 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 identified a census of 161 residents. The sample included 34 residents, nine medication carts, eight treatment carts, and nine medication rooms. Based on observation, record review, and interviews, the facility failed to properly store medications in two of the eight treatment carts.Findings included:- During the initial tour on 01/05/26 at 07:04 AM, a treatment cart on the Transitional Care Unit was unlocked and unattended in an unlocked storage room. The treatment cart contained medicated ointments and creams.On 01/06/26 at 07:20 AM, an unattended and unlocked treatment cart was on the Sunflower hallway. The treatment cart contained medicated ointments and creams.On 01/05/26 at 07:10 AM, Licensed Nurse (LN) JJ stated they never locked that treatment cart because they did not have a key to unlock the cart. LN JJ stated yes, the cart should be locked.On 01/07/26 at 12:55 PM, Administrative Nurse D stated she would expect all the medication and treatment carts to be locked when not being used.The facility's Medication Storage, dated 01/01/20, documented it is the policy…

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 161 residents. The sample included 34 residents, with five reviewed for immunization status. Based on record reviews and interviews, the facility failed to offer or obtain an informed declination for influenza for Resident (R) 72 and the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial pneumonia infections) vaccination for R72, R16, and R4. Findings included:- Review of R72's clinical record revealed no documented PCV20, and last documented influenza vaccine was 12/14/22. R72's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration or a physician documented contraindication.Review of R16's clinical record revealed the PCV13 was administered on 03/10/13, and the PSV23 was administered on 03/17/17. R16's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration or a physician documented contraindication.Review of R4's clinical record revealed the PCV13 was administered on 01/18/16, and the PSV23…

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 114 residents. The sample included four residents, with one resident reviewed for abuse and neglect. Based on observation, record review, and interview, the facility failed to prevent an episode of staff-to-resident physical abuse of a cognitively Impaired Resident (R) 1. This deficient practice placed R1 at ongoing risk for preventable abuse and mistreatment.Findings included:- The Medical Diagnosis section within R1's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), muscle weakness, repeated falls, and the need for assistance with personal care. R1's Quarterly Minimum Data Set (MDS) completed 07/01/25 indicated a Brief interview for Mental Status (BIMS) score of eight (moderate cognitive impairment). The MDS noted no upper or lower extremity impairments. The MDS noted he used a wheelchair for mobility. The MDS noted he required substantial to maximal assistance with toileting, bathing, transfers, bed mobility, personal hygiene, and dressing. The MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 160 residents. The sample included three residents with three residents reviewed for dementia (a progressive mental disorder characterized by failing memory and confusion) care. Based on observation, record review, and interview the facility failed to develop an individualized dementia treatment plan to address Resident (R)1's dementia-related behaviors to promote his highest practicable quality of life and well-being. This placed R1 at risk for impaired psychosocial well-being and impaired quality of life. Findings included: - R1's Electronic Medical Record (EMR) documented, under the Diagnosis tab, the following diagnoses: metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), Parkinsonism (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), anxiety (mental or…

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

The facility had a census of 148 residents. The sample included 32 residents. Based on record review and interview, the facility failed to ensure six of the six nurse aides reviewed for regular in-service education had completed the in-service as required. This placed the residents at risk for inadequate care. Findings included: - Review of Certified Nurse Aide (CNA) PP, CNA QQ, CNA RR, CNA SS, CNA TT, and Certified Medication Aide (CMA) R's in-service records revealed no completion dates on the documentation of their in-services. On 02/22/24 at 12:00 PM, Administration Staff A verified the facility was unable to verify the dates the in-services were completed. The facility's Required Training, Certification and Continuing Education of Nurse Aides policy, dated 09/11/23, stated the facility would provide at least 12 hours of in-service training annually, documentation would be maintained in the employee's personnel file. The facility failed to ensure CNAs completed the 12 hours of required in-services annually, placing the residents at risk for inadequate care.

The facility had a census of 148 residents. The sample included 32 residents. Based on observation, record review, and interview, the facility failed to store, prepare, and serve food in a sanitary manner for the residents who resided in the facility and received meals from the facility's main kitchen. This placed the residents at risk for foodborne illness. Findings included: - On 02/20/24 at 10:50 AM, observation revealed dietary staff preparing the midday meal. The blades of a box fan in the dishwashing area had light brown debris. The food transportation carts were visibly soiled with liquid staining along with debris attached to the outer walls. The shelving throughout the kitchen that stored pans and bowls had a greasy, sticky film. The cabinets and drawer fronts had peeling paint; they were sticky and had dark debris adhered to them. The cement block partial wall behind the stoves, fryer, and steam oven had paint loss and food/grease spatters along with a dusty, gritty top. The stove top and oven front had dark staining on the doors alone; the backsplash was also not clean.…

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 148 residents. The sample included 32 residents. Based on observation, record review, and interview, the facility's Quality Assessment and Assurance (QAA) program failed to provide good faith efforts to identify multiple issues of concern for the 148 residents, who resided in the facility. This placed all residents at risk for unidentified and ongoing care issues. Findings included: - The facility failed to provide Resident (R)6 dignity related to obtaining blood sugar checks in the dining room with several residents present. Refer to F550. The facility failed to notify the physician of medication refusal for R68. Refer to F580. The facility failed to investigate an unwitnessed fall for cognitively impaired R105 to rule out abuse or neglect. Refer to F610. The facility failed to develop a care plan for R137 who was on a fluid restriction. Refer to F656. The facility failed to revise care plans for three residents, R37, R105, and R128. Refer to F657. The facility failed to provide…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 148 residents. The sample included 32 residents. Based on observation, interview, and record review, the facility failed to date Resident(R)36's insulin (a hormone that allows cells throughout the body to uptake glucose) flex pen when opened and failed to discard R36 ' s insulin flex pen when outdated. The facility further failed to monitor the medication refrigerator temperature for 18 days. This deficient practice placed the affected residents at risk for ineffective medications. Findings included: - On [DATE] at 09:30 AM, observation of the facility's [NAME] neighborhood medication cart revealed the following: R36's Levemir (long-acting insulin) flex pen lacked an open date and discard date. R36 ' s Novolog (fast-acting insulin) date opened [DATE] (expired on [DATE], 28 days). On [DATE] at 09:45 AM, Licensed Nurse (LN) H verified the nurses were to date the flex pens when opened and discard the expired insulin. On [DATE] at 10:00 AM, Nurse Consultant GG verified the nurses should…

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 148 residents. The sample included 32 residents. Based on observation, interview, and record review the facility failed to ensure Covid-19 (highly contagious respiratory virus) isolation protocols were followed. This deficient practice placed the residents at increased risk for COVID-19 infection. Findings included: - Resident (R)204's Electronic Medical Record (EMR) documented a diagnosis of Covid-19. The admission Minimum Data Set (MDS), export-ready, documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The MDS documented that R204 was dependent on staff for activities of daily living (ADL) of dressing and toileting and was in isolation. R204's Covid-19 Care Plan, dated 02/16/24, stated if positive place the resident in isolation. The 02/19/24 care plan update directed strict droplet isolation related to the diagnosis of COVID-19. Staff were to wear personal protective equipment (PPE) which included gloves, gown, and mask when…

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 148 residents. The sample included 32 residents with five residents reviewed for immunizations to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interviews, the facility failed to follow the latest guidance from the Centers for Disease Control and Prevention (CDC) when they failed to offer, obtain an informed declination or a physician-documented contraindication for the pneumococcal PCV 20 vaccination. This deficient practice placed the residents at risk of acquiring, spreading, and experiencing complications from pneumococcal disease. Findings included: - Review of Resident (R)4, R10, R48, R53, and R106's clinical medical records lacked evidence the facility or the resident representative received or signed consent or informed declination for the PCV20. On 02/22/24 at 10:00 AM, Nurse Consultant GG verified the facility had not offered the PCV20 vaccine. The facility ' s Pneumococcal Vaccine: (Series) policy, 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 148. The sample included 32 residents. Based on record review, interview, and observation the facility failed to treat residents with respect, dignity, and privacy during blood glucose testing. This placed the resident at risk for impaired psychosocial well-being. Findings included: - On 02/2/24 at 08:35 AM, observation revealed Licensed Nurse (LN) I obtained Resident (R)6's blood sugar reading using a glucometer (a blood glucose meter monitor device that tests the amount of glucose [sugar] in the blood) from R6's left index finger at the table in the dining room, with three residents at the table with the resident and ten other residents seated in the dining room eating lunch. On 02/22/24 at 10:30 AM, Nurse Consultant GG stated staff should not check residents' blood sugar at the dining room table, staff should take the resident to the room or to a private area. The facility's Residents Dignity policy, dated 01/01/202, documented the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well…

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 148 residents. The sample included 32 residents, with seven reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to notify the physician of Resident (R) 68's behaviors and refusal to take her psychotropic (any drug that affects behavior, mood, thoughts, or perceptions) medications. This placed the resident at risk for impaired care due to delayed physician involvement. Findings included: - The Electronic Medical Record (EMR) documented R68 had diagnoses of dementia without behaviors, depression (abnormal emotional status characterized by exaggerated feelings of sadness, worthlessness, and emptiness), and insomnia (inability to sleep). The Annual MDS, dated 12/06/23, documented R68 had severely impaired cognition and required set-up assistance for eating, toileting, mobility, and transfers. R68 had inattention and disorganized thinking. The MDS further documented R68 had no behaviors and received antidepressant medication. R68's Care Plan, dated 01/30/24, initiated on 10/09/23, documented R68 had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 148 residents. The sample included 32 residents. Based on observation, record review, and interview, the facility failed to complete a full investigation to rule out abuse or neglect after an unwitnessed fall resulting in an injury for cognitively impaired Resident (R) 105. This placed the resident at risk for further injury and unidentified abuse or neglect. Findings included: - The Electronic Medical Record (EMR) for R105 documented diagnoses of dementia without behaviors (a progressive mental disorder characterized by failing memory, confusion), hallucination (sensing things while awake that appear to be real, but the mind created) anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and muscle weakness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R105 had severely impaired cognition. R105 required extensive assistance from two staff for transfers, and toileting, and extensive assistance from one staff for bed…

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 148 residents. The Sample included 32 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for Resident (R) 137's hospice care (specialized care for people near the end of life) and services and physician-ordered fluid restriction, which placed R137 at risk for impaired care due to uncommunicated care needs. Findings included: - R137's Electronic Medical Record (EMR) documented diagnoses of rhabdomyolysis (muscle wasting), atherosclerotic heart disease (thickening or hardening of arteries caused by plaque), pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and heart), essential tremors, type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, asthma (a disorder of narrowed airways that caused…

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 - R128's Electronic Medical Record (EMR) included diagnoses of chronic congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), chronic kidney disease, dependence on renal dialysis, generalized edema (swelling resulting from an excessive accumulation of fluid in the body tissues), acute pulmonary edema (accumulation of extravascular fluid in the lung tissues), anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, schizoaffective (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought) disorder, bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), atrial fibrillation (rapid, irregular heart beat), and presence of a cardiac pacemaker (implanted device to regulate 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 148 residents. The sample included 32 residents with five residents reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide necessary services to maintain good personal hygiene, including bathing for one of the five reviewed for ADLs, Resident (R)61. This placed the resident at risk for poor personal hygiene. Findings included: - R61's Electronic Medical Record (EMR) recorded diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin,) fracture of the left ankle, and low back pain R61's admission Minimum Data Set (MDS), dated [DATE], recorded R61 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS recorded R61 required substantial/max assistance of staff for most ADL and bathing. R61's Care Plan, dated 01/12/24 indicated the R61 required assistance from one staff with ADL care. R61'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 148 residents. The sample included 32 residents with five reviewed for skin issues. Based on observation, interview, and record review the facility failed to implement protective measures for the prevention of skin tears and bruising for Resident (R) 140 who had a large amount of bruising on her forearms. This placed the resident at risk for ongoing skin issues and impaired healing. Findings included: - R140's Electronic Medical Record documented diagnoses of anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues) and human immunodeficiency virus disease (HIV-an infection that attacks the body's immune system). The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R140 required set-up assistance for meals and was dependent on staff for all other activities of daily living (ADL) assistance. The MDS documented R140 received…

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 148 residents. The sample included 32 residents, with nine reviewed for accidents. Based on observation, record review, and interview, the facility failed to evaluate the effectiveness of fall interventions, change or modify the interventions that were ineffective at preventing falls, and failed to follow the plan of care for fall prevention for Resident (R)37. The facility further failed to identify causative factors and implement person-centered interventions for fall prevention for R105. This placed the residents at risk for further falls and injury. Findings included: - The Electronic Medical Record (EMR) for F37 documented diagnoses of vascular dementia without behavioral disturbance (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), repeated falls, hypertension (high blood pressure), and posttraumatic stress…

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 148 residents. The sample included 32 residents with three reviewed for incontinence. Based on observation, interview, and record review the facility failed to help with toileting as care planned for Resident (R) 206. This deficient practice placed R206 at risk for complications related to incontinence including urinary tract infection (UTI). Findings included: - R206's Electronic Medical Record (EMR) documented diagnoses of bacteremia (presence of bacteria in the blood), methicillin-resistant staphylococcus aureus infection (MRSA-a type of bacteria resistant to many antibiotics), abnormal findings in urine, and encephalopathy (a broad term for any brain disease that alters brain function or structure). The admission Minimum Data Set (MDS), dated [DATE], was export-ready and documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS documented R206 required substantial/maximal staff assistance for toileting. R206 was always continent. 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 148 residents. The sample included 32 residents. Based on observation, record review, and interview, the facility failed to monitor Resident (R) 137's physician-ordered fluid restriction. This placed R137 at risk of complications related to fluid overload. Findings included: - R137's Electronic Medical Record (EMR) documented diagnoses of rhabdomyolysis (muscle wasting), atherosclerotic heart disease (thickening or hardening of arteries caused by plaque), pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and heart), essential tremors, type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, asthma (a disorder of narrowed airways that caused wheezing and shortness of breath), and respiratory failure with hypoxia (inadequate supply of oxygen). The Medicare Five…

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 148 residents. The sample included 32 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 128 received care and services for dialysis (a procedure where impurities or wastes were removed from the blood) consistent with professional standards of practice which included ongoing assessments of the resident's condition as well as ongoing communication and collaboration with the dialysis facility. This placed R128 at risk of complications and unmet care needs related to dialysis treatments. Findings included: - R128's Electronic Medical Record (EMR) included diagnoses of chronic congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), chronic kidney disease, dependence on renal dialysis, generalized edema (swelling resulting from an excessive accumulation of fluid in the body tissues), acute pulmonary edema (accumulation of extravascular fluid in the lung tissues), anemia (inadequate…

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 148 residents. The sample included 32 residents. Based on observation, record review, and interview, the facility failed to immediately involve the physician and provide supportive emotional and mental health services to attain Resident (R) 37's highest practicable mental and psychosocial well-being after she made statements of self-harm and/or verbalized feelings of sadness and the desire to die. This placed the resident at risk for unmet mental health care needs. Findings included: - The Electronic Medical Record (EMR) for F37 documented diagnoses of vascular dementia without behavioral disturbance (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), repeated falls, hypertension (high blood pressure), posttraumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), and attention…

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 148 residents. The sample included 32 residents with five reviewed for dementia (progressive mental deterioration characterized by confusion and memory failure) care. Based on observation, record review, and interview, the facility failed to develop and implement an individualized dementia treatment plan for Resident (R) 68, who had dementia and behaviors and failed to provide the necessary dementia care and services to attain or maintain the highest level of practicable physical, mental, and psychosocial wellbeing for R68. This placed the resident at risk for decreased quality of life. Findings included: - The Electronic Medical Record (EMR) documented R68 had diagnoses of dementia without behaviors, depression (abnormal emotional status characterized by exaggerated feelings of sadness, worthlessness, and emptiness), and insomnia (inability to sleep). The Annual MDS, dated 12/06/23, documented R68 had severely impaired cognition and required set-up assistance for eating, toileting, mobility, and transfers. R68 had inattention and disorganized thinking.…

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 148 residents. The sample included 32 residents Based on observation, record review, and interview, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of one sampled resident, Resident (R) 37, who made statements of self-harm. This placed the resident at risk for further decline in her emotional and mental well-being. Findings included: - The Electronic Medical Record (EMR) for F37 documented diagnoses of vascular dementia without behavioral disturbance (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), repeated falls, hypertension (high blood pressure), posttraumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), and attention deficit hyperactivity disorder (ADHD-a chronic…

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 148 residents. The sample included 32 residents, with seven reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist identified and reported the lack of an appropriate indication, or the required physician documentation, for Resident (R)123's use of an antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment in reality) and failed to identify and report the lack of a 14-day stop date or specific duration for R123 and R128's as needed (PRN) antianxiety medication. This placed the residents at risk for unnecessary psychotropic (alerts mood or thoughts) medication side effects. Findings include: - R123's Electronic Medical Record (EMR) recorded diagnoses of dementia (progressive mental deterioration characterized by confusion and memory failure) without behavioral disturbance, anxiety, or mood disturbance. R123's 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 had a census of 148 residents. The sample included 32 residents with seven reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to monitor and provide interventions for bowel management for Resident (R) 45 and R100. This placed the residents at risk for fecal impaction (accumulation of hardened feces in the rectum that the individual was unable to move) and physical decline. Findings included: - The Electronic Medical Record (EMR) for R45 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion) with behavioral disturbances, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), diabetes mellitus (DM-when the body cannot use glucose, not enough sepsis made or the body cannot respond to the insulin), psychosis (any major mental disorder characterized by a gross impairment in reality perception), anxiety (mental or emotional reaction characterized by…

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 - R128's Electronic Medical Record (EMR) included diagnoses of chronic congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), chronic kidney disease, dependence on renal dialysis, generalized edema (swelling resulting from an excessive accumulation of fluid in the body tissues), acute pulmonary edema (accumulation of extravascular fluid in the lung tissues), anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, schizoaffective (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought) disorder, bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), atrial fibrillation (rapid, irregular heart beat), and presence of a cardiac pacemaker (implanted device to regulate 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 135 residents. The sample included 28 residents. Based on observation, record review, and interview, the facility failed to provide accurate reconciliation of controlled drugs at the end of daily work shifts. This placed the residents at risk for misappropriation of medications for two of four medications carts. Findings included: - On 08/15/22 at 03:02 PM observation of the Cambridge Hall medication-controlled substance reconciliation revealed staff lacked documentation for count of controlled medications for 08/10/22 (day shift to evening shift), 08/13/22 (all shifts), and 08/14/22 (day shift to evening shift) day to evening shift (eight times out of a possible 15 shifts worked). On 08/15/22 at 03:35 PM observation of the Elmhurst Hall medication-controlled substance reconciliation revealed staff lacked documentation for count of controlled medications for June 30, 2022 through August 11, 2022 (53 times out of a possible 129 shifts worked). On 08/15/22 at 03:02 PM, during the Cambridge medication cart inspection, Licensed Nurse (LN) G verified the lack…

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 135. The sample included 28 residents. Based on record review, interview and observation the facility failed to treat residents with respect, dignity, and privacy during medication administration. This placed the resident at risk for impaired psychosocial wellbeing. Findings included: - On 08/15/22 at 11:55 AM, observation revealed Licensed Nurse (LN) L obtained Resident (R)52's blood sugar reading using a glucometer (a blood glucose meter monitor device that you test the amount of glucose (sugar) in the blood) from R52's left index finger at the table in the main dining room, with two other resident seated at the table and 13 other residents seated in the dining room eating lunch. On 08/17/22 at 02:30 PM, Administrative Nurse D stated staff should not check residents' blood sugar at the dining room table; they should take the resident to the room or to a private area. The facility's Resident Rights policy date 8/01/2019 documented the facility would inform the resident both orally and in writing in a language that the resident understands of his or her…

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 135 residents. The sample included 28 residents with nine reviewed for nutrition. Based on observation, record review and interview, the facility failed to notify the physician of a significant weight loss for one sampled resident, Residents (R) 16. This placed the resident at risk for continued weight loss. Findings included: - The Physician Order Sheet, dated 06/02/22, recorded R16 had diagnoses rheumatoid arthritis (chronic inflammatory disease that affects joints and organ systems), bipolar disorder (major mental illness that causes people to have severe episodes of high and low moods), schizophrenia (psychotic disorder characterized by gross distortion of reality, fragmented thoughts and impaired language communication), and anxiety (mental health disorder characterized by worry and fear that interferes with daily life). The Annual Minimum Data Set (MDS), dated [DATE], recorded R16 had a Brief Interview for Mental Status score of 15 (cognitively intact) with delusions (untrue…

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 135 residents. The sample included 28 residents, two were reviewed for abuse. Based on observation, record review, and interview the facility failed to report Resident (R) 62's unwitnessed fall with a fracture right elbow and shoulder to the State Agency (SA) as required. This placed the resident at risk for ongoing and/or unidentified abuse or neglect. Findings included: - R62 's physician order sheet, dated 08/15/22, documented the resident had diagnoses of cerebral infarction (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), anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues) and osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk.) The Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status score of three (severely impaired…

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 135 residents. The sample included 28 residents, with four reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide a safe environment when staff failed to implement interventions on Resident(R)107's plan of care aimed to prevent falls. This placed the resident at risk for further falls and injury. Findings included: - The Electronic Medical Record (EMR) for R107 documented diagnoses of dementia (progressive mental disorder characterized by failing memory and confusion), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and dysphagia (swallowing difficulty). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R107 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, and toileting, and limited assistance of two staff for ambulation. The MDS further documented R107 had unsteady balance, 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 had a census of 135 residents. The sample included 28 residents with nine reviewed for nutrition. Based on observation, record review and interview, the facility failed to adequately monitor weights to maintain acceptable parameters of nutritional status for one sampled resident, Residents (R) 16. This placed the resident at risk for continued weight loss. Findings included: - The Physician Order Sheet, dated 06/02/22, recorded R16 had diagnoses rheumatoid arthritis (chronic inflammatory disease that affects joints and organ systems), bipolar disorder (major mental illness that causes people to have severe episodes of high and low moods), schizophrenia (psychotic disorder characterized by gross distortion of reality, fragmented thoughts and impaired language communication), and anxiety (mental health disorder characterized by worry and fear that interferes with daily life). The Annual Minimum Data Set (MDS), dated [DATE], recorded R16 had a Brief Interview for Mental Status score of 15 (cognitively…

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 135 residents. The sample included 28 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed follow up on Consultant Pharmacist (CP) recommendation to obtain a stop date and/or risk versus benefit statement for the continued use of clonazepam (psychotropic medication used for panic disorder or seizures) for Resident (R) 130 and to ensure an appropriate diagnosis for the use of R54's buspirone (antianxiety drug). This placed the residents at risk for inappropriate and unnecessary psychotropic (alters mood or thoughts) medications. Findings included: - R130's Physician Order Sheet (POS), dated 08/05/22, documented diagnoses of bipolar disorder (mental health condition that causes extreme mood swings), post-traumatic stress disorder (psychological reaction occurring after experiencing a highly stressing event), Alzheimer's disease (progressive disease that destroys memory and other important mental functions), 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 135 residents. The sample included 28 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to obtain a stop date and/or risk versus benefit statement for the continued use of clonazepam (psychotropic medication used for panic disorder or seizures) for Resident (R) 130 and failed to ensure an appropriate diagnosis for the use of R54's buspirone (antianxiety drug). This placed the residents at risk for inappropriate and unnecessary psychotropic (alters mood or thoughts) medications. Findings included: - R130's Physician Order Sheet (POS), dated 08/05/22, documented diagnoses of bipolar disorder (mental health condition that causes extreme mood swings), post-traumatic stress disorder (psychological reaction occurring after experiencing a highly stressing event), Alzheimer's disease ( progressive disease that destroys memory and other important mental functions), dementia with Lewy bodies (affects chemicals in 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 135 residents. The sample included 28 residents, with one reviewed for hospice (a type of health care that focused on the terminally ill patient's pain and symptoms and attended to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R) 92. This placed R92 at risk for inappropriate and/or unmet end of life cares. Findings included: - The Electronic Medical Record (EMR) for R92 documented diagnoses of senile degeneration of the brain (the mental deterioration (loss of intellectual ability) and a reduced ability to accurately judge a situation or solve problems), hemiplegia (paralysis of one side of the body), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), 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.