Camelot Rehabilitation At Magnolia Park

Based on observations, and interview, the facility failed to store food in accordance with professional standards for food service, and ensure sanitary conditions were maintained in the kitchen as evidenced by: 1. opened food items in the walk in cooler not labeled with the date and time; and 2. expired foods in the dry storage area. This deficient practice had the potential to affect the 116 residents who consumed food from the kitchen. Findings: On 02/02/2025, a review of the facility's policy titled, Food Receiving and Storage, with a last revision date of July 2014, last reviewed date of 10/30/2024, revealed in part . Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: .6. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in-first out system. 7. All food stored in the refrigerator or freezer will be covered, labeled and dated (use by date) . On 02/02/2025 at 8:30 AM, a tour 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 Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure proper PPE (Personal Protective Equipment) was worn while proving care for 3 (#53, #95, #118) out of 36 sampled residents. Findings: Resident #95 On 02/04/2025, a review of the facility's policy titled, Enhanced Barrier Precautions Cheat Sheet with a last reviewed date of 10/30/2024 read in part, Examples of Enhanced-Based Precaution Residents: Wounds-includes .pressure ulcers .indwelling medical devices .feeding tubes .Enhanced-Based Precautions are indicated during: .changing briefs or assisting with toileting .Implementation: gowns and gloves are used during high-contact sessions . Review of Resident #95's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, congestive heart…

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 the MDS (Minimum Data Set) was coded accurately for use of Bipap (Bilevel Positive Airway Pressure) for 1 (#19) resident of 5 (#19, #41, #78, #95 and #112) residents investigated for respiratory care. Resident #19 Review of Resident #19's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, Type 2 Diabetes Mellitus with unspecified complications, Major Depressive Disorder and other, Sleep Apnea. Review of Resident #19's current physician's orders read, RCU (Respiratory Care Unit): Bipap (Bilevel Positive Airway Pressure) S/T (Spontaneous/Timed) 16/12 RR (Respiration Rate) = 12 @ 21% at HS (Hour of Sleep) six times a day. Review of Resident #19's care plan read in part, Focus: The resident has Bipap related to sleep apnea. Review of Resident #19's MAR/TAR (Medication Administration Record/Treatment Administration Record) for November 2024 revealed Resident #19 used a Bipap nightly as…

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, observations and interviews, the facility failed to provide appropriate and sufficient services, treatment, and care according to standards of professional practice for 1 (#3) of 4 (#3, #38, #62, and #78) residents that were reviewed for urinary catheter or UTI (urinary tract infection). The facility failed to ensure Resident #3's urinary catheter drainage tubing was properly secured off of the floor. Findings: Resident #3 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Obstructive and Reflux Uropathy, Bladder Neck Obstruction. Review of Resident #3 Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed in Section GG Chair/bed-to-chair transfer that Resident #3 was coded as 3, indicating that the resident required partial/moderate assistance. On 02/02/2025 at 9:55 AM, an observation was conducted of Resident #3 in his room. The resident had a urinary catheter drainage bag laying on the floor roughly one foot away from the right…

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 the resident's respiratory equipment was stored properly for 2 (Resident #19 and Resident #41) out of 5 (Resident #19, #41, #78, #95 and #112) 36 sampled residents reviewed for respiratory care. On 02/04/2025 review of the facility's policy titled Departmental (Respiratory Therapy) - Prevention Infection with a review date of 10/30/2024 read in part, Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: 7. Store the circuit in plastic bag marked with date and resident's name, between uses. On 02/04/2025 at 4:17 PM, S2DON (Director of Nursing) confirmed that this is the policy used for proper storage of all respiratory equipment. Resident #19 Review of Resident #19's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, Type 2 Diabetes Mellitus with Unspecified Complications, Major Depressive Disorder and Other, Sleep Apnea. Review 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 observations and interview, the facility failed to ensure staffing information posted daily was current and in a prominent place readily accessible to residents and visitors. The facility's census was 133. Findings: On 02/04/2025 at 2:00 PM, an observation was made of staffing data sheets filed in a closed binder. The binder was set in a window at the nurses' station directly across the hall from the administrative offices. The hall was not in a pathway frequently used by residents or visitors. The staffing sheets for 02/03/2025 and 02/04/2025 were not in the binder. On 02/04/2025 at 2:09 PM, an interview was conducted with S7ASADMIN (Assistant Administrator). She confirmed that staffing data sheets for 02/03/2025 and 02/04/2025 were not in the binder and staffing sheets that are in a closed binder are not readily accessible to residents or visitors.

Based on observation and interview the facility failed to ensure hallway hand rails were securely affixed to the walls on 1 (Hall W) of 6 (Hall U, Hall V, Hall W, Hall X, Hall Y, and Hall Z) hallways observed in the facility. This failed practice had the potential to affect all mobile residents that reside on Hall W. Findings: Review of a facility policy on 02/04/2025 at 12:38 PM titled, Maintenance Service with a revision date of 12/2009 revealed the following in part . 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of the maintenance personnel include . a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. Maintaining the building in good repair and free from hazards. 9. Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned . Observations made on 02/02/2025 at 9:52 AM, 02/02/2025 at 11:20 AM, 02/02/2025 at 12:10 PM, and 02/02/2025 at 12:15 PM…

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 interviews and record reviews, the facility failed to ensure that services were provided as outlined in the comprehensive plan of care for 2 (#28 and #63) out of 45 sampled residents by failing to ensure that: 1. Resident #28 had appropriate interventions for ADL (Activities of Daily Living) self-care related to Amputation. 2. Resident #63's physician orders were followed. Findings: 1. Resident #28 was admitted to the facility on [DATE] with Diagnoses which included, but were not limited to, End Stage Renal Disease, Dependence on Renal Dialysis, Type Two Diabetes, Acquired Absence of left leg above the knee, and Acquired Absence of Right Leg Below the Knee. A review of the resident's care plan revealed that he was care planned on 01/29/2024 for ADL self-care performance deficit r/t (related to) amputation, with the following interventions in part: 1) Bathing: Resident is independent with bathing. No assistance required. 2) Bed mobility: Resident is independent with bed mobility. No assistance required.…

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 store food in accordance with professional standards for food service and failed to ensure sanitary conditions were maintained in the kitchen by failing to: 1. Ensure compromised cans in the dry storage room were disposed; 2. Failed to ensure food products were discarded on or before the expiration date; 3. Failed to ensure the kitchen was maintained in sanitary condition. Findings: An observation was made on 01/29/2024 at 08: 36 a.m. of the facility's walk-in pantry with S5FKS (Kitchen Supervisor) which included: -Five compromised dented cans which included: 1 can of slice beets, 2 cans of Mandarin, 1 can of apple slices, and 1 can of cream style corn) -Three expired loaves of bread with expiration date of 01/20/2024 -Two expired loaves of bread with expiration date of 01/27/2024 -Scoops stored in plastic Ziploc bags that had dried food particles on it -Old and dried food matter was observed on the wall above the food preparation table. On 1/29/2024 at 8:36 a.m., an interview was conducted with S5KS. She confirmed the cans…

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 assess 2 residents (#56 and #70) out of 45 sampled residents for self-administration of medications. Findings: Review of the facility's policy titled Self- Administration of Medications read in part .Residents have the right to self - administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so .4. The resident must sign the Consent for Administration of Medication Form regarding and agree to abide by the restrictions for handling and storage of medication according to one of the following plans. 5. Any bedside medications will meet all the required labeling specifications and guidelines required of any medications in the facility .9. The nursing staff will routinely check self- administered medications and will remove expired, discontinued, or recalled medications. Resident #56: Resident #56 was admitted to the facility on [DATE] with Diagnoses which included, but…

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 investigate and take corrective actions for a grievance made by 1 (#56) out of a total sample of 45 residents. Findings: A review of the facility's policy titled Resident Grievances/Complaints, Recording and Investigating read in part: Policy Statement. All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance(s). Resident #56 was admitted to the facility on [DATE] with Diagnoses which included, but were not limited to, Type 2 Diabetes Mellitus with other circulatory Complications and Long Term Use of Aspirin. A review of the resident's quarterly MDS (Minimum Data Set) dated 11/17/2023 revealed she had a BIMS (Brief Interview for Mental Status) of 15, indicating her cognition was intact. On 01/29/2024 at 9:19 a.m., an observation and interview was conducted with Resident #56 in her room. The resident stated she washed her underclothes herself because sometimes when her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the assessment accurately reflected the status of 2 (#130 and #14) residents out of a total of 45 sampled residents by failing to ensure that: 1. Resident #130 was coded correctly for weight loss on discharge assessment. 2. Resident #14 was coded correctly for discharge on discharge assessment. Findings: 1. Review of Resident #130's electronic health record revealed she was admitted on [DATE] with diagnoses that included Morbid Obesity, Cellulitis of Left Lower Limb, Cellulitis of Right Lower Limb, Anxiety Disorder and Edema, Unspecified. Review of Resident #130's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/29/2023 Section A - Identification Information, A2105 Discharge Status was coded as 04 indicating she was discharged to Short-Term General Hospital. Further review of Resident #130's electronic health records nurses notes dated 11/29/2023 at 15:35 (3:35 p.m.) read in part, Resident dc'd (discharged ) home in stable…

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 that a resident who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 1 (Resident #129) of 2 (Resident #129 and Resident #183) investigated for activities of daily living out of a sample of 45. Findings: Review of Resident #129's electronic health record revealed she was admitted on [DATE] with diagnoses that included, Displaced Supracondylar Fracture without Intracondylar Extension of Lower End of Left Femur, Subsequent Encounter for Closed Fracture with Routing Healing, Difficulty in Walking, and Contusion of the Left Hip. Review of Resident #129's admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 01/09/2024 Section C - Cognitive Patterns C0500 BIMS (Brief Interview for Mental Status) Summary revealed a score of 13 indicating she was cognitively intact. Further review of Resident #129's MDS Section GG - Functional Abilities and Goals, E. Shower/Bathe…

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 RN (Registered Nurse) was on duty for 8 consecutive hours per day for 7 days per week. Findings: Review of the facility's PBJ (Payroll Based Journal) Staffing Data Report for FY (Fiscal Year) Quarter 4 2023 (July 1 - September 31) revealed a trigger for One Star Staffing Rating. Review of the Time Card Report for the PBJ time period Quarter 4 2023 (July 1 - September 31) revealed the following: On 07/09/2023, S7ADON (Assistant Director of Nursing) clocked in for 6.22 hours. On 07/29/2023, S7ADON clocked in for 7.93 hours. On 08/27/2023, S7ADON clocked in at 7:56 a.m. and clocked out at 4:25 p.m. total of 7.98 hours and S8RN clocked in at 7:52 a.m. and clocked out at 3:53 p.m. total of 7.52 hours. On 09/09/2023, S4MDS (Minimum Data Set) Registered Nurse clocked in for 2.21 hours. On 09/10/2023, S4MDS clocked in for 2.38 hours. On 09/23/2023, S7ADON clocked in for 5.95 hours. On 01/30/2024 at 4:20 p.m., an interview was conducted with S2DON (Director of Nursing). S2DON stated that there must be 8 hour consecutive RN…

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, interviews, and record review, the facility failed to ensure that pharmaceutical services provided to meet the needs of each resident were consistent with state and federal requirements and reflect current standards of practice for 1 (#2) of 3 residents (#1, #2, and #483) observed during medication pass. This had the potential to affect all the residents residing in the facility. The facility census was 122. Findings: A review of the facility's policy titled Administering Oral Medications, read in part: Steps in the Procedure .7. Check the expiration date on the medication. Return any expired Medications to the pharmacy. On 01/30/2024 at 7:51 a.m., an observation was conducted of S10LPN (Licensed Practical Nurse) during D1 medication pass on HallW. An observation of Resident #2's Metformin (Anti-diabetic medication) blister pack revealed an expiration date of 12/13/2023. Further review revealed it was sent by the pharmacy on 12/30/2023. There were two pills remaining out of the packet of 30 pills. S10LPN confirmed that the medication was expired and stated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a homelike environment for 1 (#1) out of 6 residents (#1, #24, #109, #110, #112 and #129) investigated for environment, by failing to ensure that the resident's wheelchair and wheelchair pad were cleaned. This had the potential to affect all residents in the facility who used a wheelchair. The Facility's census was 122. Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease and Major Depressive Disorder. Review of Resident #1's quarterly MDS with an ARD (Assessment Reference Date) of 11/08/2023, revealed in section C that he had a BIMS (Basic Interview of Mental Status) of 15, indicating that his cognition was intact. Further review revealed in section GG that the resident used a wheelchair. On 01/29/2024 at 8:52 a.m., an observation and interview was conducted with Resident #1 in his room. The resident's wheelchair was at his bedside. There was moderate dust…

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 interviews, the facility failed to update the facility wide assessment as evidenced by failing to: 1. Identify the resident population acuity levels, specifically ventilator dependent residents and residents requiring tracheostomy care 2. Include facility staff competencies regarding mechanical ventilator alarms 3. Include Respiratory Therapy Director or Respiratory Therapists as facility resources needed to provide competent support and care for the facility's resident population daily and during emergencies 4. Include how respiratory therapists were staffed on the mechanical ventilator and tracheostomy unit 5. Update the facility wide electronic medical record system to reflect the current system used This deficient practice had the potential to affect the 135 residents who resided in the facility. Findings: A review of the facility's policy and procedure titled, Facility Assessment, read in part: A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day…

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 develop and implement a comprehensive plan of care for 3 (#1 #2, and #4) residents out of a total sample of 4 residents as evidenced by: 1. Failing to implement a tracheostomy/ventilator plan of care for residents #1 and #4 and 2. Failing to implement physician's orders to obtain vital signs for resident #2. Findings: A review of the facility's policy titled, Care Plans, Comprehensive Person-Centered read in part: A comprehensive, person-centered care plan that includes measureable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .8. The comprehensive, person-centered care plan will .b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Resident # 1: Review of Resident # 1's record revealed he was re-admitted to the facility on [DATE] with the following pertinent…

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 that residents with a urinary catheter had a privacy bag or covering over their urinary catheter collection bag to promote dignity for 2 (#1 and #4) of 4 (#1, #2, #3, and #4) sampled residents. Findings: Review of the facility's policy, Quality of Life - Dignity read in part . Policy Statement: Each resident shall be care for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Policy Interpretation and Implementation .11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: a. Helping the resident keep urinary catheter bags contained and private. Resident # 1: Review of Resident # 1's record revealed he was admitted to the facility on [DATE] with the following pertinent diagnoses: Other Cerebral Infarction (Stroke), Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Unspecified Side,…

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 policy review, record review, and interview, the facility failed to ensure each resident's plan of care and clinical record accurately reflected their advanced directives for 1 (#4) out of 4 sampled residents (#1, #2, #3 and #4). Findings: Review of the facility's policy, Advance Directives revealed, in part, the following: Policy Interpretation and Implementation . 10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. Resident #4: Review of Resident #4's health record revealed that he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Cerebral Infarction, Chronic Respiratory Failure with Hypercapnia, and Tracheostomy Status. Review of Resident #4's physician's orders revealed an order dated [DATE] that read: DNR (Do Not Resuscitate). Review of Resident #4's care plan revealed a focus of Resident/Responsible Party (RP) has elected a DNR status with an intervention of to ensure…

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, observation and interviews, the facility failed to maintain accurately documented medical records in accordance with accepted professional standards and practices. The facility failed to ensure Resident # 1's EHR (Electronic Health Record) tracheostomy supplies were accurately documented for 1 (#1) out of 4 (#1-#4) sampled residents. Findings: Review of Resident # 1's record revealed he was re-admitted to the facility on [DATE] with the following pertinent diagnoses: Other Cerebral Infarction (Stroke), Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Unspecified Side, Aphasia Following Cerebral Infarction, Dysphagia Following Cerebral Infarction, Acute Respiratory Failure with Hypoxia, Pneumonitis Due to Inhalation of Food and Vomit, Tracheostomy Status and Bed Confinement Status. Review of November 2023 physician's orders revealed an order dated 11/13/2023 RCU (Respiratory Care Unit): Change trach (tracheostomy) every month and prn (as needed) for airway maintenance #8…

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 a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene by failing to provide bathing on 08/18/2023, 08/19/2023, 08/23/2023, 08/25/2023, 08/28/2023, and 08/29/2023 for 1 (#3) of 2 (#2 and 3) residents who were dependent on staff for bathing, out of 3 (#1-3) sampled residents. Findings: Resident #3 was admitted to the facility on [DATE] with diagnoses that included Tracheostomy, Dysphagia following Cerebral Infarction, Amyotrophic Lateral Sclerosis, Cerebral Infarct, Acute Respiratory Failure with Hypoxia, Myocardial Infarction, Severe Protein-Calorie Malnutrition, Pneumonia, Gastrostomy, Neuromuscular Dysfunction of Bladder, Parkinson's disease, and Metabolic Encephalopathy. A review of Resident #3's MDS (Minimum Data Set) assessment dated [DATE] revealed that his BIMS (Brief Interview of Mental Status) score was 09, indicating that he was moderately impaired for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that residents who require urostomy services, receive such care consistent with professional standards of practice as evidenced by the facility failing to assess a new Suprapubic catheter insertion site and failing to change the dressing to the Suprapubic catheter site from 08/21/2023 until the resident was discharged on 08/31/2023, for 1 (#3) of 3 (#1-3) sampled residents, out of a census of 135. Findings: Resident #3 was admitted to the facility on [DATE] with diagnoses including Neuromuscular Dysfunction of Bladder, Parkinson's disease, Amyotrophic Lateral Sclerosis, Cerebral Infarct, Acute Respiratory Failure with Hypoxia, and Metabolic Encephalopathy. A review of the facility's admission assessment dated [DATE] revealed that he was incontinent of his bladder, and had a Foley catheter in place upon admission. A review of Resident #3's Physician Telephone Orders revealed on order dated 08/18/2023 for: Suprapubic cath insertion on 08/21/2023.…

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.