Matthews Memorial Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure:1. EBP were utilized for 1 (Resident #57) of 3 residents reviewed for pressure ulcers;2. Staff performed proper hand hygiene while feeding residents; 3. Staff followed proper infection prevention and control practices during transport of soiled linens; and4. Staff followed proper infection prevention and control practices while laundering resident clothing.Findings: 1. Review of a facility policy on 12/02/2025 at 2:26 p.m. titled Enhanced Barrier Precautions, with a revision date of 03/2024 revealed in part.Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing home. Enhanced Barrier Precautions involve gown and glove use…

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

Based on record review and interview, the facility failed to ensure services were provided to meet professional standards of practice for 1 (#3 of 3 (Resident #1, Resident #2, and Resident #3) sampled residents and 1 (Resident #R1) of 1 random resident. The facility failed to:1. Ensure Resident #3's physician was notified of and immediately responded to the request of an antibiotic for a tooth abscess; and 2. Ensure Resident #R1's received wound care as ordered by the physician. Findings:Resident #3Review of the facility policy with a review/revision date of for Physician Orders read as. It is the policy of this community that all physician orders shall be implemented timely and carried out in a professional manner. When new or revised orders are requested due to consultant recommendations, the attending physician or nurse practitioner, clinical nurse specialist, or physician assistant shall be documented in the resident clinic record. Additional follow-up may be needed until a response was received. Review of the medical record for Resident #3 revealed an admit date of 11/30/2023,…

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 record review and interview the facility failed to immediately inform the resident, consult the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) resident records reviewed for falls. Findings: Review of a facility policy with a revision date of 09/2017 and titled Change in Resident Medical Status revealed the following in part . A change in medical status is defined as any physical, psychological and/or medical deviation as compared to the resident's status as noted in the initial assessment. These changes may include: a fall and/or injury . A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s), when there is - 1. An accident involving 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.

Based on interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 2 (Resident #27 and Resident #64) of 29 sampled residents reviewed for quality of care. Findings: Patient #27 Review of Resident #27's Electronic Health Record revealed an admit date of 07/03/2024 with the following diagnoses including Type 2 DM with Neuropathy and long term use of Insulin. Review of Resident #27's 09/2024 Physician Orders revealed the following including: 07/03/2024 - Insulin Glargine Soln Pen-Injector 100U/ml inject 15U q HS 07/03/2024 - HGBA1C q 3 months (Sept, Dec, Mar, June) 07/18/2024 - Accuchecks BID notify MD if CBG <60 or >300 Review of Resident #27's 09/2024 Electronic Medication Administration Record revealed Capillary Blood Sugars above 300 on the following dates and times: 09/05/2024 at 6:00 a.m. - 301 09/06/2024 at 6:00 a.m. - 330 09/08/2024 at 6:00 a.m. - 324 Review of Resident #27's 09/2024 Nurse Notes revealed no documentation that the Physician was notified concerning capillary blood…

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

Based on record review and interview, the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice and the comprehensive person-centered care plan for 2 (#4, #64) of 2 residents reviewed for pain. The facility failed to ensure Resident #4 and #64, who reported pain, received medication or interventions to alleviate pain. Findings: Review of the facility's policy titled Pain Screen and Management with a revision date of 12/2023 revealed in part . 1. All residents have the right to treatment for pain. 2. The resident's statements are the most valid measurement of pain. 3. A pain scale is used whereby the resident describes his/her pain and amount of pain relief. Chronic Pain Management: Documentation requirements for Chronic Pain Management focus on the following: E-MAR documentation Use of as needed (PRN) medication Review and revision of care plan as appropriate Resident #4 Resident #4's medical record revealed an admit date of 05/31/2017 with diagnoses that included .Chronic Pain Syndrome,…

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.

Based on interview and record review, the Facility failed to provide pharmaceutical services that assure the accurate reconciliation of controlled medications to meet the needs of each Resident by failing to ensure at each shift change a physical inventory of controlled medications were conducted by two licensed clinicians. Findings: Review of the Facility's policy and procedure titled Controlled Substances with a revision date of 11/2017, read in part .A controlled drug count is to be done at the beginning of each shift by the outgoing and the on-coming medication nurses. Telephone Interview on 09/09/2024 at 11:00 a.m. with S10 Agency LPN revealed on 09/08/2024 she reported to work for 7:00 a.m. S10 Agency LPN confirmed she did not reconcile narcotics with the off going nurse or any other nurse and she should have. Interview on 09/09/2024 at 1:15 p.m. with S9 Agency LPN revealed she worked the 11:00 p.m. to 7:00 a.m. shift on 09/07/2024. S9 Agency LPN revealed S10 Agency LPN was the on-coming nurse for 7:00 a.m. on 09/08/2024. S9 Agency LPN confirmed she did not reconcile…

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 observations, interviews and record review the facility failed to ensure snacks are served at times in accordance with resident's needs, preferences and requests. The facility failed to provide snacks for residents outside of scheduled meal service times. The facility failed to ensure that Residents meals were distributed in a timely manner. Findings. Interviews on 09/08/2024 at 2:00 p.m. with residents during the Resident Council meeting revealed snacks were not being provided and were not available at all times. Residents in the council meeting stated they would ask for snacks and the nurse would tell them dietary did not leave any out for them. Residents stated snacks were labeled with residents names on them, and if your name was not on a snack you did not get a snack. Observation on 09/08/2024 at 9:44 a.m. of meal service on Hall X revealed staff were distributing breakfast trays. Interview on 09/08/2024 at 10:35 a.m. with Resident #236 revealed he was admitted to the facility on [DATE]. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Residents who are unable to carry out ADLS (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene for 2 (#2 and #82) of 2 (#2 and #82) Residents reviewed for ADL's. The facility failed to ensure Resident's (#2 and #82) were shaved. Findings: Review of the facility's policy with a revision date of 08/24, titled Resident Quality of Care revealed the following: . 2. The policy of the facility is to establish a minimum acceptable level of daily care which shall include and involve the maximum utilization of the resident's capabilities; while providing the necessary assistance to accomplish the following: .C. At the time of the bath, all residents shall also receive .nail care .shave . Resident #2 Record review revealed Resident #2 was admitted to the facility on [DATE] with the following diagnosis that included Cerebral Infarction Unspecified, Paraplegia, Cognitive Communication…

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.

Based on record review, observation, and interview the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing and to prevent infection for 1 (#188) of 2 (#2, #188) residents reviewed for pressure ulcers. The facility failed to ensure Resident #188's wounds were accurately assessed and documented weekly. Findings: Review of the facility's policy titled Pressure Ulcer Prevention and Treatment Interventions Guidelines last revised on 10/2022 revealed in part . 1. Weekly body audits are to be performed by a Licensed Nurse on designated day. 2. If a pressure ulcer is present initiate the weekly documentation. Review of Resident #188's medical record revealed an admit date of 11/03/2021 with diagnoses that included .Paraplegia, Pressure Ulcer of Sacral Region, Pressure Ulcer of Left Buttock-stage 4, Pressure Ulcer of Right Buttock-Stage 4, and Acquired Absence of Right Leg above Knee. Review of Resident #188's Quarterly MDS with an ARD of 05/06/2024 revealed a BIMS score 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.

Based on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #54) of 1 sampled residents reviewed for respiratory care. The facility failed to ensure respiratory equipment was properly labeled and stored. Findings: Review of Resident #54's Clinical Record revealed an admit date of 02/01/2024 with diagnoses that included in part .Hypertensive Heart Failure with Heart Failure, Gastrostomy Status, and Chronic Respiratory Failure with Hypoxia. Review of Resident #54's Care Plan with a Review date of 10/01/2024 revealed in part .At risk for Shortness of Breath, Resident has a diagnosis of Acute Respiratory Failure, with interventions that included: Oxygen as ordered. Observation and interview on 09/08/2024 at 11:12 a.m. revealed Resident #54's Nebulizer mask was uncovered and undated lying on his over bed table. Resident #54's oxygen tubing was uncovered and undated lying on top of the oxygen concentrator beside his bed. Resident #54 revealed he wore oxygen daily and received nebulizer treatments…

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.

Based on interview and record review the facility failed to immediately consult with the physician, and notify the resident's representative when a resident experienced a fall for 1 Resident (#1) of 3 (Resident#1, Resident #2, Resident #3) sampled residents. Findings: Review of the Facility's Policy titled Change in Resident Medical Status with a revision date of 09/17 read in part: A change in medical status is defined as physical, psychological and/or medical deviation as compared to the resident's status as noted on the initial assessment. These changes may include: a fall and/or injury . A facility must immediately inform the resident; consult with the resident's physician; and or notify, consistent with his or her authority, the resident representative(s), when there is 1. An accident involving the resident which results in injury and has the potential for requiring physician intervention. Review of the facility's incident report dated 04/05/2024, revealed action taken: On 04/05/2024 at 9:15 p.m., Resident #1's physician was contacted. The report revealed the name of Resident…

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

Based on interview and record review, the facility failed to ensure prompt efforts were made by the facility to resolve a grievance filed by a resident's Responsible Party, for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. Findings: Review of the facility's policy/procedure titled, Grievances-Residents, last revised in 10/2023, revealed, in part . The facility shall make prompt efforts to resolve the grievances. The Administrator and his/her designees will conduct an impartial investigation of the allegations .will discuss the findings and recommendations within five (5) work days of receiving the complaint, with the complainant. Review of an electronic grievance complaint dated 04/08/2024, revealed an electronic complaint was registered by the DON. Resident #1's RP stated she was not notified of a fall that Resident #1 sustained on 04/05/2024. Findings of conclusion: Resident did in fact have a fall on 04/05/2024, and S3 LPN did not notify the RP of the fall. Corrective action taken: DON verbally counseled S3 LPN regarding policy to notify RP…

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.

Based on record review and interview the facility failed to ensure a resident received services in accordance with professional standards. The facility failed to ensure physician's orders were followed for wound care for 1 (#2) of 1 sampled resident reviewed for wound care. Findings: Review of the facility's Physician Orders policy read in part . It is the policy of this facility that all physician's orders will be implemented timely and carried out in a professional manner. Review of Resident #2's clinical record revealed an admit date of 01/27/2017 with diagnoses that included: Peripheral Vascular Disease, Lymphedema, Chronic Venous Hypertension with ulcers to bilateral lower extremities, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus with Diabetic Neuropathy, and Unspecified Atherosclerosis of native arteries of extremities to bilateral legs. Review of Resident #2's Quarterly MDS assessment with ARD of 09/14/2023 revealed Resident #2 had a BIMS score of 15, indicating cognitively intact. Review of Resident #2's 10/2023 Physician's Orders read in part . 10/19/2023…

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.

Based on observation and interview the facility failed to maintain a clean, comfortable, and homelike environment by failing to ensure resident's shower rooms were clean, sanitary, and in good repair for 2 (Hall X and Hall Y) of 2 (Hall X and Hall Y) shower rooms observed. The facility failed to ensure medication carts were clean and sanitary for 2 of 3 medication carts observed for medication storage. The facility failed to ensure residents' assistive devices were maintained in good working condition for 1(Resident #19) of a sample size of 31 Residents. The facility failed to maintain the air conditioner units in sanitary condition in 2 (Room A and Room B) of 2 (Room A and Room B) rooms observed for air conditioner filter status. The facility failed to ensure that the designated smoking area was maintained in a clean, safe, and comfortable environment for all smokers in the facility. Findings. 1. Observation on 10/03/2023 at 7:55 a.m. of the shower room on Hall X revealed trash and debris scattered on the floor upon entry. An opened, cluttered cabinet containing trash and bath…

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.

Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide shaving, and nail care to dependent residents for 4 (Resident #2, Resident #19, Resident #56 & Resident #78) of 31 sampled residents. Findings: Review of the facility policy titled: Quality of Care, revealed in part: Each resident shall receive optimal care to attain and/or maintain the highest possible mental and physical functional status as determined by the comprehensive assessment and person-centered plan of care. 2 b a full bath at least 3 times weekly. 2 c. all residents shall also receive if applicable; nail care, shave, and oral care. Resident #2 Review of Resident #2's EHR (Electronic Health Record) revealed an admission date of 11/17/2021 with diagnoses which included Epileptic Seizure, Cerebral Vascular Accident, Chronic Obstructive Pulmonary Disease, Essential (primary) hypertension and Atherosclerosis…

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.

Based on record review and interview, the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by: 1. Failing to answer or respond to call light in a timely manner for 5 (#6, #9, #17, #18, #34) residents out of a total sample of 31, 2. Failing to provide incontinent care for residents who require assistance in a timely manner for 2 (#17 and #42) out of a total sample of 31, 3. Failing to honor resident's preferences for bedtime for 1 (#18) out of 31, 4. Failing to bathe residents who require assistance for 2 (#31 and #51) out of a total sample of 31, and 5. Failing to round or check in on residents who require assistance every two hours for 1 (#6) out of a total sample of 31. Findings: Resident Council Interviews conducted on 10/02/2023 at 1:00 p.m. during the facility Resident Council Meeting revealed 13 residents in attendance out of a total facility census of 86. Three residents including Resident # 6 (BIMS of 15, cognitively intact) 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.

Based on observation and interview the facility failed to ensure that food was stored in accordance with professional standards for food service. This deficient practice had the potential to affect the 82 residents that received meals prepared by the kitchen. Findings: Observation on 10/02/2023 at 9:00 a.m. of the facility's dry storage room accompanied by S9 Dietary Manager revealed the following items on shelves for use: (1) unopened gallon jug of dijon honey mustard dressing with an expiration date of 08/17/2023 and (1) opened gallon jug of soy sauce with an expiration date of 09/30/2022. S9 Dietary Manager confirmed findings at the time of observation. Observation on 10/02/2023 at 9:10 a.m. of the facility's walk in cooler accompanied by S9 Dietary Manager revealed (1) 64 ounce package of low fat vanilla yogurt on the shelf for use with an expiration date of 09/24/2023. Findings confirmed with S9 Dietary Manager at the time of observation. Observation on 10/02/2023 at 9:15 a.m. of facility's upright cooler revealed the following items on the shelves for use: (1) 5lb. opened 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 Based on record review and interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (#3) of 2 (#3, #238) residents reviewed for hospice. The facility failed to collaborate with Resident #3's hospice provider in order to honor the resident's choices regarding end of life care. Findings: Resident #3 Review of Resident #3's medical record revealed an admit date of [DATE] with diagnoses that included, in part, Cerebral Infarction, Dysphagia, Dementia, and Epilepsy. Review of Resident #3's physician's orders revealed an order dated [DATE] to admit to hospice. Review of the physician's orders for Resident #3 revealed an order dated [DATE] which read Full Code. Review of Resident #3's admission MDS with an ARD of [DATE] revealed a BIMS score of 3 which indicated the resident had severe cognitive impairment. Review of the MDS revealed Resident #3 was totally…

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 observation, record review and interview, the facility failed to ensure 1 (Resident #57) of 1 sampled residents reviewed for pressure ulcers, received the necessary treatment and services to prevent and promote wound healing. The facility failed to ensure staff applied Resident #57's heel protectors as ordered. Findings: Review of the facility policy titled: Prevention and Treatment of Skin Issues, revealed in part . It is the policy to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventive measures; and to provide appropriate treatment modalities for wounds according to industry standards of care. The following may be utilized according to risk areas and resident need: pressure reducing/relieving/redistributing mattress to each resident bed in facility, pressure relieving devices in chair, bed rail, arm and leg protectors, positioning devices, moisture barriers, heel protectors or suspension boots,…

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 record reviews and interviews, the facility failed to ensure that 4 (#2, #3, #4, and #5) out of 5 sampled residents who required dialysis (#1, #2, #3, #4, #5) residents, received such services, consistent with professional standards of practice as evidenced by failing to ensure there was ongoing communication, coordination and collaboration between the nursing home and the dialysis staff. Findings: Resident #2 Review of Resident #2's medical record revealed an admit date of 06/22/2023 with diagnoses that included in part .Non-displaced fracture of the left femur, Encounter for orthopedic aftercare, ESRD, Dependence on renal dialysis, and Heart failure. Review of Resident #2's current physician's order revealed an order for the resident to receive dialysis three days per week on Monday, Wednesday, and Friday. Review of Resident #2's Dialysis communication sheets for the month of July 2023 revealed only two completed dialysis communication sheets. In an interview on 08/01/2023 at 4:12 p.m., S2 DON…

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 record review and interview the facility failed to thoroughly investigate an allegation of misappropriation of funds/exploitation for 1 (#6) of 6 (#1, #2, #3, #4, #5, and #6) sampled residents reviewed for abuse. Findings: Resident #6 Review of Resident #6's medical record revealed an admit date of 07/04/2023, with diagnoses that included in part .Quadriplegia, Major Depressive Disorder, Restlessness and Agitation, Schizophrenia, and Pressure Ulcer of sacral region, Stage 4. Review of Resident #6's admission MDS with an ARD of 07/14/2023 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Review of the MDS revealed Resident #6 was totally dependent on two person physical assist with bed mobility, transferring, and toilet use. Resident #6 required limited assistance by one person with eating. In an interview on 08/02/2023 at 4:45 p.m., Resident #6 stated that on 07/19/2023, a staff member stole $1,900 from him out of his friend/RP's (Responsible Party) car. Resident #6…

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 record review and interview, the facility failed to implement the plan of care to meet the needs of 1 (#3) of 6 (#1, #2, #3, #4, #5, #6) sampled residents. The facility failed to complete Resident #3's daily wound care as per physician's orders. Findings: Review of Resident #3's Electronic Health Record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included in part . End Stage Renal Disease, Type 2 Diabetes Mellitus, Unspecified Severe Protein Calorie Malnutrition, Dependence on Renal Dialysis, Pressure Ulcer of Sacral Region-Stage 4, Urinary Tract Infection, Infections of Central Nervous System, and Drop Foot- Left and Right. Review of Resident #3's Quarterly MDS with an ARD of 05/02/2023 revealed in part . Resident #3 had BIMS of 15 (Cognitively intact) and was totally dependent on staff for transfers, toileting, and bathing. Resident #3 required extensive, 1 person physical assist for personal hygiene. Resident #3 had 1 pressure ulcer-stage 4. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Residents who are unable to carry out ADLS (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene for 2 (#3 and #4) of 6 (#1, #2, #3, #4, #5, #6) sampled residents. The facility failed to ensure Resident's (#3, #4) received a bath on their scheduled bath days. Findings: Review of the facility policy titled: Bathing read in part . Bathing- General Principals: To cleanse the body and promote skin health. Document in the clinical record. Resident #3 Review of Resident #3's Electronic Health Record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included in part . End Stage Renal Disease, Type 2 Diabetes Mellitus, Unspecified Severe Protein Calorie Malnutrition, Dependence on Renal Dialysis, Pressure Ulcer of Sacral Region-Stage 4, Urinary Tract Infection, Infections of Central Nervous System, and Drop Foot- Left and Right. Review of Resident #3's Quarterly 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.

Based on record review and interview, the facility failed to ensure nursing staff had appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 (#1) of 6 (#1, #2, #3, #4, #5, #6) sampled residents. This was evidenced by a licensed practical nurse administering a medication to treat low blood pressure to Resident #1 with an elevated systolic blood pressure. Findings: Review of Resident #1's medical record revealed an admit date of 06/07/2023 with diagnoses that included in part .Hypotension, Hemiplegia following Cerebral Infarction, ESRD, and Dependence on Renal Dialysis. Review of Resident #1's MDS with an ARD of 07/03/2023 revealed a BIMS score of 12, which indicated the resident had mildly impaired cognition. Review of the MDS revealed Resident #1 required extensive assistance by two persons with bed mobility and toilet use and was totally dependent on two persons with transferring. Review of Resident #1's physician'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.