Meridian Rehabilitation And Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an environment free from accident hazards when staff failed to utilize appropriate foot pedals when propelling Resident (R) 2 in his wheelchair causing his feet to not remain safely on the foot pedals during transportation.Findings included:- R2's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion).R2's inaccurate Significant Change Minimum Data Set (MDS), dated [DATE], documented he had a Brief Interview for Mental Status (BIMS) score of one, indicating severe cognitive impairment. The MDS noted R2 was independent with walking with the use of a walker and/or wheelchair.The Activities of Daily Living (ADL) Care Area Assessment (CAA), dated 10/14/25, did not trigger.R2's inaccurate Quarterly MDS, dated [DATE], documented he had a BIMS score of one. The MDS noted R2 was independent with walking with the use of a walker and/or wheelchair.R2'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 Based on interview and record review, the facility failed to ensure Residents (R)28 remained free from unnecessary medications when staff failed to administer as needed (PRN) bowel medication for constipation.Findings included:- R28's Electronic Medical Record (EMR) documented a diagnosis of constipation (difficulty passing stools).R28's Significant Change Minimum Data Set (MDS), dated [DATE], documented he had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS noted he was always incontinent of bowel and had no constipation.R28's Urinary Incontinence/Indwelling Catheter Care Area Assessment (CAA), dated 12/16/25, triggered but lacked an analysis of findings.R28's Quarterly MDS, dated [DATE], documented he had a BIMS score of 11, indicating moderately impaired cognition. The MDS noted he was always incontinent with his bowel.R28's Care Plan, revised 02/23/26, documented R28 had episodes of bowel incontinence and instructed staff to use disposable…

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

The facility reported a census of 96 residents with seven residents reviewed for abuse, neglect, exploitation and/or misappropriation of resident property. Based on observation, interview and record review, the facility failed to send completed investigation reports to the State Agency (SA) within five working days of the alleged incident(s) as required. Findings included: - Review of the facility's notifications to the SA revealed the following:On 04/08/25 incident number 1542136 was reported to the SA. The completed investigation was not submitted within the required five working days nor provided to the surveyor during an on-site visit on 02/02/26.On 07/28/25, incident number 2573926 was reported to the SA. The completed investigation was not submitted within the five working days but was provided to the surveyor during an on-site visit on 02/02/26.On 08/26/25, incident number 2600412 was reported to the SA. The completed investigation was not submitted within the five working days but was provided to the surveyor during an on-site visit on 02/02/26.On 09/02/25, incident number…

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

The facility reported a census of 96 residents. Based on interview and record review, the facility failed to provide direct care staff annual evaluations/performance reviews for five of the five certified nursing assistants sampled, to determine strengths and weaknesses in providing resident care. Findings included: - Review of five Certified Nursing Assistant (CNA) personnel files revealed the following: Review of CNA UU, with hire date of 05/29/19, revealed the lack of an annual review. Review of CNA VV, with hire date of 11/09/21, revealed the lack of an annual review. Review of CNA S, with hire date of 01/12/22, revealed the lack of an annual review. Review of CNA PP, with hire date of 11/16/21, revealed the lack of an annual review. Review of CNA T, with hire date of 12/09/19, revealed the lack of an annual review. On 08/01/24 at 02:25 PM, Administrative staff B reported employee annual reviews should be completed by the Director of nursing. On 08/05/24 at 10:36 AM, Administrative Nurse D reported she thought the Administrator was to complete staff annual reviews. She was not…

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

The facility reported a census of 96 residents. Based on interview and record review, the facility failed to develop, implement, and maintain an in-service training program to ensure staff completed the required 12-hour in-service education for five of the five Certified Nurse Assistants (CNA) sampled, who were employed by the facility for at least one year. This deficient practice placed the residents at risk of decreased quality of care. Findings included: - Review of five Certified Nursing Assistant (CNA) personnel files and in-service training revealed the following: Review of CNA UU, with hire date of 05/29/19, lacked 12 hours of in-service education. Review of CNA VV, with hire date of 11/09/21, lacked 12 hours of in-service education. Review of CNA S, with hire date of 01/12/22, lacked 12 hours of in-service education. Review of CNA PP, with hire date of 11/16/21, lacked 12 hours of in-service education. Review of CNA T, with hire date of 12/09/19, lacked 12 hours of in-service education, as CNA T received 0.5 hour. On 08/05/24 at 10:36 AM, Administrative Nurse D reported she…

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

The facility reported a census of 96 residents. Based on interview and record review, the facility failed to develop, implement, and maintain an effective training program for all staff, which included, at a minimum, training on behavioral health care and services that was appropriate and effective. This failure placed all 96 residents at risk of not reaching their highest practicable well-being. Findings included: - Review of five Certified Nursing Assistant (CNA) personnel files and Course Completion History (computer training) revealed the following: Review of CNA UU, with hire date of 05/29/19, lacked behavioral training. The Alzheimer's Disease and Related Disorders: Behaviors module not started and was due by 04/30/23. No course listed the module for 2024. The Behavioral Health module, not started and was due by 01/31/23, and no course listed for the module in 2024. Review of CNA VV, with hire date of 11/09/21, the Behavioral Health was not started and was due by 01/31/24. Review of CNA S, with hire date of 01/12/22, lacked behavioral health training. The Alzheimer's Disease…

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 Physician Orders dated 04/01/24 revealed the following diagnoses for Resident (R) 81 had diagnoes that included diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and end stage renal disease (a terminal disease because of irreversible damage to vital tissues or organs). The Significant Change Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Review of the functional abilities and goals indicated R 81 required substantial/maximal assistance with bathing. The Quarterly MDS dated 06/12/24 revealed no changes in memory or abilities. Review of the Care Plan dated 05/07/23 regarding Care/Activities of daily living (ADL) preferences indicated R 81 preferred a shower two times a week as tolerated, revised on 12/02/23. The care plan lacked which days/time R81 preferred to have her bath completed per her choice. Review of the bathing sheets for May 2024, indicated R81…

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

The facility reported a census of 96 residents which included 28 residents that smoked. The facility Identified three designated smoking areas of the facility. Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 28 residents that smoked in three of the three designated smoking areas and the service hallway the residents had travel through to the southeast smoking area that was in need of cleaning and/or repairs. Findings Included: - On 07/30/24 at 08:00 AM, on entrance to the facility at the Northeast entrance, noted a stale musty odor prevalent odor throughout the facility during the initial tour. On 07/30/24 at 10:10 AM, Resident (R)54 and R 26, residents of the men's memory care unit (400 hall), were observed smoking on the courtyard adjacent to the locked unit. This area was a designated smoking area which accommodated four residents on the men's memory care unit that smoked. in the facility. Observations revealed the cigarette ashtray/tower was bent over and cracked. There were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 96 residents with 20 residents selected for review. Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) for five of the sampled residents. Resident (R) 28 and R(47) related inaccurate documentation of medications. R (41), R(54) and R(82) related inaccurate documentation on falls. These deficient practices had the potential to lead to uncommunicated need for care and services to meet each individual resident's needs. Findings included: - Review of Resident (R) 28's electronic medical record (EMR), revealed a diagnosis of type II diabetes mellitus (DM- when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. He received hypoglycemic medication (a group of drugs used to help reduce…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 96 residents. The sample of 20 residents included four dependent residents sampled for choices/preferences related to bathing, and two residents reviewed for accident/falls. Based on observation, interview, and record review, the facility failed to review and revise the care plan for four Residents (R)92, R73, R 74, R 81 related to bathing preferences/choices and R 54 and R 41 related to accidents/falls to prevent further falls. Findings included: - Review of Resident (R) 92's undated Physician's Orders, documentation included diagnoses of Spastic hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body) affecting left dominate side, and memory deficit following 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). The admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 96 residents. The sample of 20 residents included five dependent residents sampled for personal hygiene related to bathing, nail care, hair trimming, and facial hair. Based on observation, interview, and record review, the facility failed to ensure necessary services to maintain good personal hygiene for Resident (R)92, 73, 74, 81, and R 82 related to bathing, nail care, hair care and/ or unwanted facial hair. Findings included: - Review of Resident (R) 92's undated Physician's Orders, documentation included diagnoses of spastic hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) affecting left dominate side, and memory deficit following 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). The admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14,…

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

The facility reported a census of 96 residents. Based on observation, interview, and record review, the facility failed to serve food that is palatable, and at a safe and appetizing temperature for the residents of the facility. Findings included: - On 07/30/24 at 07:45 AM, during entrance tour of the facility, observation revealed open metal carts with 10 plus meal trays being served on each of the five units. The plate lacked insulated covers, nor served in closed insulated food service cart. Staff observed serving and setting up individual trays off the open cart one at a time while the remaining meals trays remained in the hallway on the open carts. During resident screening, residents shared concerns related to food which included: 1. On 07/30/24 at 09:58 AM, Resident (R)73, reported sometimes is meal is served an hour late and when he got his meal, the temperature of the food is not good. The food that is supposed to be cold is warm, and the hot foods are cold. 2. On 07/30/24 at 12:16 PM, R 68 reported the food is not acceptable. it is rough, the quality of the food, they…

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

The facility reported a census of 96 residents. Based on observation and interview, the facility failed to provide adequate ventilation in the beauty shop. The facility lacked ventilation to the outside by means of a window, mechanical vent or the combination of to promote good air circulation, as required. Findings included: - On 8/05/24 at 08:00 AM during the initial tour of the facility an assessment of the beauty shop ventilation system revealed the facility lacked an outside ventilation, as required. On 08/05/24 at 08:15 AM, Interview with Administrative Staff A revealed the beautician did not do any certain treatments like perms or bleaching in the beauty shop, so an exhaust fan is not needed. The facility failed to provide a policy regarding beauty shop ventilation as requested on 08/05/24. The facility failed to provide adequate ventilation in the beauty shop to promote good air circulation, as required.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 96 residents, that included 20 residents included in the sample. Based on interview and record review, the facility failed to include Resident (R)61 in the development and planning of the resident's care plan quarterly, which placed R81 at risk of impaired care and autonomy. Findings included: - Resident (R)61's Electronic Medical Record (EMR) documented diagnosis that included acute kidney failure, Human immunodeficiency virus (HIV is a virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases) and muscle weakness. The admission Minimum Data Set(MDS) dated [DATE], documented R61 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R61 had verbal behavioral symptoms four to six days, but less than daily during the look-back period. It was somewhat important to have family, or a close friend involved in discussions about his care. He required staff assistance with activities of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 96 residents. The sample included 20 residents with four residents selected for review related to resident rights to retain and use of their personal possessions. Based on observation, interview , and record review, the facility failed to ensure the resident right to retain and use her personal possessions for Resident (R)63 related to her motorized wheelchair and R 54's missing coat. Findings included: - Review of Resident (R)63's Physician Orders, dated 07/09/24 documentation included diagnoses of diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), cellulitis (skin infection) of left lower limb, chronic obstructive pulmonary disease, (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depressive disorder (a mood disorder that…

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

The facility reported a census of 96 residents with three residents reviewed for Medicare Advance Beneficiary and Medicare Non-Coverage Notices. Based on record review and interview, the facility failed to notify one resident, Resident (R)22, ABN (provides information to beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility before the end of a Medicare covered Party), or a NOMNC (a form given to all Medicare beneficiaries at least two days before the end of a Medicare covered part A stay or when all of Part B therapies are ending), as required. Findings included: - On 07/30/24, Administrative staff A provided a list of discharged Medicare A residents with three residents chosen for review. One Resident, (R)22, identified as discharged from Part A services on 03/23/24, lacked a NOMNC or ABN completed when Medicare Part A services were terminated to let the resident know how many days of the 100 days available remained. The skilled nursing facility (SNF) Beneficiary…

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 96 residents. The sample included 20 residents. Based on observation, interview and record review, the facility failed to provide consistent activities for two residents. Resident (R)41 and R82 were observed not to have received activities on the Memory Care Unit. This deficient practice placed the residents at risk for complications related to decreased psychosocial wellbeing. Findings included: - The 04/14/24 Annual Minimum Data Set (MDS), documented a Brief Interview for Mental Status (BIMS) score of 00, which indicated severely impaired cognition. R41 had a total mood severity score of 00, indicating no depression and there were no behaviors documented. R41 required maximal assistance with activities of daily living, which included toileting, dressing, and bathing. R41 was frequently incontinent of bladder. The resident had no falls. R41 stated it was very important to do her favorite activities in section F activity interview. The Cognition Loss/Dementia Care Area Assessment (CAA) dated 04/14/24, documented R41 was alert with impaired memory…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 96 residents with 20 residents in the sample, that included one resident reviewed for dialysis (procedure where impurities or waste were removed from the blood). Based on observation, interview, and record review, the facility failed to ensure staff obtained vital signs or the dialysis site after Resident (R)81 received dialysis (procedure where impurities or waste were removed from the blood). Findings include: - The Physician Orders dated 04/01/24 revealed the following diagnosis for Resident (R) 81 diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) end stage renal disease (a terminal disease because of irreversible damage to vital tissues or organs). The Significant Change Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. Review of the functional abilities and goals indicated R 81 required substantial/maximal assistance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 96 residents, that included 20 residents included in the sample. The sample included six residents for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure Resident (R)61's medication was available for administration without missed doses. This deficient practice placed R61 at risk of unnecessary complications from not receiving his medication, as ordered by the physician. Findings included: - Resident (R)61's Electronic Medical Record (EMR) documented diagnosis that included Human immunodeficiency virus (HIV is a virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases). The admission Minimum Data Set(MDS) dated [DATE], documented R61 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The care plan, revised on 01/04/24, documented staff were to administer HIV medications as ordered. The physician's orders included…

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 96 residents. The sample included 20 residents. Based on observations, interview and record review, the facility failed to honor a food preference for Resident (R)41. Staff served R 41 pork when documented on her meal ticked as no pork. This deficient practice placed the resident at risk for inadequate care and services. Findings included: - The 04/14/24 Annual Minimum Data Set (MDS), documented a Brief Interview for Mental Status (BIMS) score of 00, which indicated severely impaired cognition. R41 had a total mood severity score of 00, indicating no depression and there were no behaviors documented. R41 required staff to set-up her meals. The Cognition Loss/Dementia Care Area Assessment (CAA) dated 04/14/24, documented R41 alert with impaired memory function. Staff to proceed to care plan with continued assistance with daily decisions and tasks to avoid complications and minimize risks. The Care Plan dated 07/15/24, documented no pork products or shellfish per R41's preference. The Physician's Order documented regular diet, no pork or shellfish…

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 92 residents. The sample included 22 residents. Based on observation, record review, and interview, the facility failed to employ a full time Certified Dietary Manager for the 92 residents who resided in the facility and received their meals from one of one kitchen, which placed the residents at risk not to receive adequate nutrition. Findings included: - On 12/07/22 at 08:35 AM, observation revealed dietary staff cooked and served breakfast. The kitchen staff reported the Dietary Manager was not been present in the kitchen at that time. On 12/12/22 at 01:09 PM, observation revealed Dietary Staff (DS) BB in the kitchen assisting with preparation and serving the midday meal. DS BB verified he was the Dietary Manager; he had enrolled in a Certified Dietary Manager course, but had not completed the Certified Dietary Manager course as of that time. Upon request the facility failed to provide a policy of Certified Dietary Manager. The facility failed to employ a full time Certified Dietary Manager for 92 residents who resided in the facility which placed 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 92 residents. The sample included 22 residents. Based on observation, record review and interview, the facility failed to store, prepare, and serve food under sanitary conditions for meals prepared in the facility's kitchen, which placed the residents at risk of consuming contaminated food. Finding included: - On 10/07/22 at 08:35 AM, observation revealed Dietary Staff (DS) CC present in the kitchen. DS CC had two to three inches of facial hair not contained in a beard guard. DS CC confirmed he had been cooking and serving meals. On 12/12/22 at 01:09 PM observations made during the midday meal preparation and serving revealed: A staff member' s soda can sat on a food prep table across from the three-compartment sink. The three-compartment sink had brown tarry/sticky substance on the plastic plumbing pipes underneath with a clear plastic square full of cloudy water. The three-compartment sink sanitation testing strips had an expiration date of 05/15/22. The floor under the stove/grill lacked floor tile with unfinished floor exposed. The exhaust hood…

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 92 residents. Based on observation, record review, and interview, the facility failed to maintain an effective quality assessment and assurance (QAA) program to develop corrective actions plans and monitor them to correct identified quality deficiencies prior to survey. This deficient practice placed the residents at risk for ineffective care. Findings included: - The facility failed to address repeated concerns in resident council. (Refer to F565) The facility failed to provide a clean, sanitary environment for one of five units in the facility. (Refer to F584) The facility failed to prevent incidents of neglect and resident-to-resident abuse. (Refer to F600) The facility failed to identify and report incidents of resident-to-resident abuse to the State Agency (Refer to F609) The facility failed to investigate incidents of resident-to-resident abuse. (Refer to F610) The facility failed to provide bed hold notification with hospitalization. (Refer to F625) The facility failed to provide consistent assistance for bathing. (Refer to F677) The facility…

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 92 residents. The sample included 22 residents. Based on observation, record review, and interview the facility failed to adhere to infection control practices for COVID-19 (a virus which is characterized mainly by fever and cough, and is capable of progressing to severe symptoms and in some cases causes death especially in older people, and those with underlying health conditions) droplet isolation precautions which placed the residents who resided in the facility at increased risk for contracting COVID-19 infection and 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 12/12/22 at 07:57 AM, observation revealed the facility main entry door with a posted sign 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 92 residents. The sample included 22 residents. Based on observation, record review, and interview, the facility failed to act promptly upon the concerns of 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: - Review of the monthly Resident Council meeting recorded the following: On 12/28/21 the resident council minutes recorded 11 residents in attendance with concerns that hand towels and washcloths were not being passed to the residents and the bed linens not changed. On 01/27/22 the resident minute council minutes recorded 13 residents in attendance with concerns that hand towels and washcloths were not being passed out, beds were not made, and residents were not getting clean ice cups or ice. On 02/15/22 the resident council minutes recorded seven residents in attendance with concerns the residents were only getting ice water once a day or not at all, call lights were not getting answered and staff were reporting they were busy,…

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 92 residents. Thirteen residents resided on the secured female memory care unit. Based on observation, record review, and interview the facility failed to provide housekeeping services to maintain a sanitary and homelike environment for the 13 residents who reside on the memory care unit. This placed the residents at risk for reduced quality of life. Findings included: - On 12/07/22 at 08:29 AM, observation revealed an intense urine odor permeated the seven resident rooms, hall, and dining room on the female memory care unit. Continued observation revealed five residents eating breakfast in the dining room, and the urine odor completely obscured the food aroma. On 12/07/22 at 11:49 AM, observation revealed an intense urine odor continued to permeate the seven resident rooms, hall, and dining room on the female memory care unit. Observation revealed 12 residents eating lunch in the dining room, and the urine odor completely obscured the food aroma. On 12/07/22 at 11:49 AM, Certified Nurse Aide (CNA) Q stated she was aware of the urine odor, not sure what…

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 92 residents. The sample included 22 residents. Based on observation, record review, and interview, the facility failed to monitor medication room refrigerator temperatures of one of two medication rooms, and lock one of five medication carts which placed residents at risk receiving ineffective medication stored in the medication room refrigerator and leave an unattended, unlocked medication cart which placed residents at risk of unintended ingestion/loss of medications. Findings included: - On 12/07/22 at 08:31 AM during initial tour of the medication room located behind the nurse's station near the entrance of the facility, observation revealed a small black refrigerator with a September 2022 temperature log with five temperatures recorded. The temperature log was attached to the refrigerator door, no logs found for October 2022, November 2022, or December 2022. Certified Medication Aide (CMA) PP stated staff should have completed the logs. On 12/07/22 at 10:21 AM observation revealed a medication cart located on the 300-hallway unlocked, and…

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

The facility had a census of 92 residents. The sample included 22 residents. Based on record review and interviews the facility failed to obtain immunization status, provide immunization, or obtain an informed declination for five residents, Resident (R) 13, R34, R33, R81, and R82, with the current Center of Disease Control and Prevention (CDC) influenza (flu) and/or pneumococcal (pneumonia-respiratory illness) immunization which placed the residents at risk for contracting influenza or pneumonia. Findings included: - Upon immunization record review revealed: R13's admission date of 07/12/22, the Electronic Medical Record (EMR) lacked influenza and pneumococcal immunization status and lacked evidence the immunization was offered and/or declined. R33's admission date of 05/09/16 EMR lacked pneumococcal immunization status and lacked evidence the immunization was offered and/or declined. R34's admission date of 11/23/22 EMR lacked pneumococcal immunization status and lacked evidence the immunization was offered and/or declined. R81's admission date of 04/11/22 EMR lacked pneumococcal…

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 92 residents. The sample included 22 residents, with five reviewed for abuse. Based on observation, record review, and interview, the facility failed to prevent an incident of neglect for Resident (R)36, when staff willfully refused to provide R36 the required level of toileting assistance. The facility furtehr failed to prevent resident to resident abuse by Resident (R)194, who had multiple resident to resident altercations.This deficient practice placed the residents at risk for injury and impaired physical and psychosocial well-being. Findings Included: - R36's Electronic Medical Record (EMR) documented diagnoses including a fractured femur (thigh bone) and dementia (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of five, indicating severely impaired decision-making skill. The MDS documented R36 had delusions (belief or altered reality that is…

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 92 residents. The sample included 22 residents. Based on record review and interview, the facility failed to report incidents of resident-to-resident abuse involving Resident (R) 194 to the state agency as required. The placed the residents at risk for ongoing injury and unidentified abuse or mistreatment. Findings Included: - The Electronic Medical Record (EMR) for R194 documented diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dementia (progressive mental disorder characterized by failing memory, confusion), and anxiety (a feeling of worry, nervousness, or unease). The admission Minimum Data Set (MDS), dated [DATE], documented R194 had moderately impaired cognition and was dependent upon two staff for toileting, extensive assistance of two staff for dressing, supervision and set-up assistance for ambulation. R194 was independent with set-up assistance for bed mobility and transfers. The assessment further…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 92 residents. The sample included 22 residents. Based on record review and interview, the facility failed to investigate incidents of resident-to-resident abuse involving Resident (R) 194. This placed the residents at risk for unidentified and ongoing abuse or mistreatment. Findings included: - The Electronic Medical Record (EMR) for R194 documented diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dementia (progressive mental disorder characterized by failing memory, confusion), and anxiety (a feeling of worry, nervousness, or unease). The admission Minimum Data Set (MDS), dated [DATE], documented R194 had moderately impaired cognition and was dependent upon two staff for toileting, extensive assistance of two staff for dressing, supervision and set-up assistance for ambulation. R194 was independent with set-up assistance for bed mobility and transfers. The assessment further documented R194 had no behaviors 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 92 residents. The sample included 22 residents with two reviewed for hospitalization. Based on observation, interview, and record review the facility failed to provide a bed hold notice to Resident (R)51, upon admission to the hospital twice. This deficient practice placed R51 at risk impaired rights to return to her original facility room upon return from the hospital. Findings included: - R51's Electronic Medical Record (EMR) documented diagnoses of pneumonia (severe inflammation of the lungs in which the alveoli (tiny air sacs) are filled with fluid), chronic obstructive pulmonary disease (COPD-chronic inflammatory lung disease that causes obstructed airflow from the lungs), respiratory failure with hypoxia (low levels of oxygen in your body tissues), aspiration pneumonia (when food or liquid is breathed into the airways or lungs, instead of being swallowed), and a pulmonary abscess (pus-filled cavity in the lung surrounded by inflamed tissue and caused by an infection). 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 92 residents. The sample included 22 residents. Based on interview and record review the facility failed to develop a baseline care plan for Resident (R)293's immediate health and safety needs, including dietary, activities of daily living (ADL) assistance, communication barriers, and respiratory. This deficient practice placed R293 at risk for inadequate care and services related to her health and safety. Findings included: - R293's Electronic Medical Record (EMR) documented diagnoses of acute on chronic combined congestive heart failure (condition in which the heart has trouble pumping blood through the body), atrial fibrillation (type of irregular heartbeat), chronic obstructive pulmonary disease (COPD-a group of diseases that cause airflow blockage and breathing-related problems), diabetes mellitus (a group of diseases that affect how the body uses blood sugar (glucose), and hypertension (high blood pressure). The admission Minimum Data Set (MDS), dated [DATE], lacked information…

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 92 residents. The sample included 22 residents. Based on observation, interview and record review the facility failed to develop a comprehensive care plan for Resident (R) 72's diabetic and wound care needs. The facility further failed to develop a care plan for R293's health and safety needs, including dietary, activities of daily living (ADL) assistance, respiratory and communication. This deficient practice placed the residents at risk for inadequate care and services. Findings Included: - The Physician Order Sheet, dated 12/02/22, recorded R72 had diagnoses of diabetes mellitus (disease that affects the body ability to produce or respond to insulin and regulate blood sugar levels), (Parkinson's Disease (progressive disease of the central nervous system marked by tremors, muscular rigidity, and uncontrolled movements), peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and muscle weakness. The Quarterly Minimum Data…

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 92 residents. The sample included 22 residents. Based on observation, interview, and record review the facility failed to review and revise the care plan for Resident (R)51 regarding her use of supplemental oxygen and R34 for dialysis (a process of purifying the blood of a person whose kidneys are not working normally) related care. This deficient practice placed R51 at risk for inadequate care related to her use of oxygen and R34 at risk for inadequate care related to dialysis. Findings included: - R51's Electronic Medical Record (EMR) documented diagnoses of pneumonia (severe inflammation of the lungs in which the alveoli (tiny air sacs) are filled with fluid), chronic obstructive pulmonary disease (COPD-chronic inflammatory lung disease that causes obstructed airflow from the lungs), respiratory failure with hypoxia (low levels of oxygen in your body tissues), aspiration pneumonia (when food or liquid is breathed into the airways or lungs, instead of being swallowed), and 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 92 residents. The sample included 22 residents, with seven reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide consistent bathing services for Resident (R) 16 and R35. This placed the residents at risk for impaired dignity and skin issues. Findings included: - The Electronic Medical Record (EMR) for R16 documented diagnoses of schizophrenia (a psychiatric disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), narcissistic personality (a disorder in which a person has an inflated sense of self importance), and hypertension (high blood pressure). R16's Quarterly Minimum Data Set (MD), dated 08/03/22, documented R16 had intact cognition and required set-up assistance and supervision of transfers, mobility, dressing 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 92 residents. The sample included 22 residents with four reviewed for pressure ulcers (wound to skin and underlying tissue resulting from prolonged pressure on the area). Based on observation, record review and interview, the facility failed to involve the Registered Dietician (RD) for nutritional interventions for one of four sampled residents, Resident (R) 72, who developed a facility acquired pressure ulcer. This placed the resident at risk to worsen his current pressure ulcer or develop more skin issues. Findings included: - The Physician Order Sheet, dated 12/02/22, recorded R72 had diagnoses of Parkinson's Disease (progressive disease of the central nervous system marked by tremors, muscular rigidity, and uncontrolled movements), peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and muscle weakness. The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R72 had a Brief Interview for Mental Status (BIMS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 92 residents. The sample included 22 residents with two reviewed for respiratory treatment. Based on observation, interview, and record review the facility failed to provide adequate respiratory care and services regarding Resident (R)51's use of supplemental oxygen. This deficient practice placed R51 at risk for less than optimal oxygen therapy. Findings included: - R51's Electronic Medical Record (EMR) documented diagnoses of pneumonia (severe inflammation of the lungs in which the alveoli (tiny air sacs) are filled with fluid), chronic obstructive pulmonary disease (COPD-chronic inflammatory lung disease that causes obstructed airflow from the lungs), respiratory failure with hypoxia (low levels of oxygen in your body tissues), aspiration pneumonia (when food or liquid is breathed into the airways or lungs, instead of being swallowed), and a pulmonary abscess (pus-filled cavity in the lung surrounded by inflamed tissue and caused by an infection). 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 had a census of 92 residents. The sample included 22 residents with one reviewed for dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, interview and record review the facility failed to provide care and services for Resident (R) 34 with regard to his dialysis access when staff did not routinely assess the access site and lacked ongoing communication between the dialysis center and facility. This deficient practice placed R34 at risk for avoidable complications related to dialysis. Findings included: - R34's Electronic Medical Record (EMR) documented diagnoses of end stage renal disease (ESRD- medical condition in which a person's kidneys cease functioning on a permanent basis), normocytic anemia (fewer red blood cells than normal), hypertension (high blood pressure), and atrial fibrillation (irregular and often very rapid heart rhythm). The admission 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 92 residents. The sample included 22 residents with six reviewed for accident hazards. Based on observation, record review and interview, the facility failed to complete an assessment for the safe use of side rails for one sampled resident, Residents (R) 33. This placed the resident at risk for entrapment and injuries related to side rail use. Findings included: - The Physician Order Sheet, dated 12/02/22, recorded R33 had diagnoses of alcohol induced dementia (persistent mental disorder marked by memory loss and impair reasoning), major depressive disorder (mental illness characterized by depressed mood and significant loss of interest in life activities), insomnia (problems falling and/or staying asleep), and muscle weakness The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R33 had a Brief Interview for Mental Status (BIMS) score of three (severely impaired cognition) with inattention and disorganized thinking. The MDS recorded R33 was independent with bed mobility and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 92 residents. The sample included 22 residents, with three reviewed for dementia (progressive mental disorder characterized by failing memory, confusion) care. Based on observation, record review, and interview, the facility failed to provide the necessary person-centered dementia care to attain the highest practicable physical, mental, and psychosocial well-being for one sampled resident, Resident (R) 194, who had multiple incidents of behaviors and resident-to-resident altercations. This placed the resident at risk for injury and unmet physical and psychosocial needs. Findings Included: - The Electronic Medical Record (EMR) for R194 documented diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dementia (progressive mental disorder characterized by failing memory, confusion), and anxiety (a feeling of worry, nervousness, or unease). The admission Minimum Data Set (MDS), dated [DATE], documented R194 had 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 92 residents. The sample included 22 residents with five reviewed for unnecessary drugs. Based on observation, interview and record review the facility failed to obtain a copy and act upon the Consultant Pharmacist (CP) recommendations for Resident (R) 36's medication regimen review. This deficient practice placed R36 at risk for medication related issues. Findings included: - R36's Electronic Medical Record (EMR) documented diagnoses including a fractured femur (thigh bone) and dementia (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of five, indicating severely impaired decision-making skill. The MDS documented R36 had delusions (belief or altered reality that is persistently held despite evidence or agreement to the contrary), and no behaviors. The MDS documented R36 required limited assistance of one staff for eating and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 92 residents. The sample included 22 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to notify the physician of elevated blood sugars out of the physician ordered parameters for Resident (R) 72 and failed to complete a physician ordered laboratory test for R36. This placed the residents at risk for adverse side effects and health problems. Findings included: - The Physician Order Sheet, dated 12/02/22, recorded R72 had diagnoses of diabetes mellitus (disease that affects the body ability to produce or respond to insulin and regulate blood sugar levels), Parkinson's disease (progressive disease of the central nervous system marked by tremors, muscular rigidity, and uncontrolled movements), peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and muscle weakness. The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R72 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 92 residents. The sample included 22 residents. Based on observation, interview and record review the facility failed to ensure the resident received drinks consistent with her preferences for Resident (R)86 who requested milk with every meal. This deficient practice placed R86 at risk to not have her rights and choices respected. Findings included: - R86's Electronic Medical Record (EMR) documented diagnoses of hypertension (high blood pressure), gastroesophageal reflux disease (GERD-occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach), and a history of ileus (obstruction of the bowel). The admission Minimum Data Set (MDS), dated [DATE], documented R86 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15. The MDS documented R86 was independent with eating, required extensive assistance of two staff for dressing, toileting, and total staff assistance for bed mobility and transfers. The MDS documented R86 weighed…

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 92 residents. The sample included 22 residents. Based on record review and interviews the facility failed to obtain immunization status, provide immunization, or obtain an informed declination for three of five sampled residents, Resident (R) 13, R34, and R82, for COVID-19 ( highly contagious, potentially fatal respiratory virus) immunization which placed the residents at increased risk for contracting COVID-19. Findings included: - Upon immunization record review revealed: R13's admission date of 07/12/22, the Electronic Medical Record (EMR) lacked COVID-19 immunization status and lacked evidence the immunization was offered and/or declined. R34's admission date of 11/23/22 EMR lacked COVID-19 immunization status and lacked evidence the immunization was offered and/or declined. R82's admission date of 07/13/22 EMR lacked COVID-19 immunization status and lacked evidence the immunization was offered and/or declined. On 12/12/22 at 04:00 PM Administrative Nurse E stated she would like to have the residents' immunization records updated in the EMR within…

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.