The Gardens at Cedarwood

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and policy review, the facility failed to ensure monthly Medication Regimen Review (MRR) recommendations made by the pharmacy consultant were addressed timely and maintained as part of the permanent medical record for three Residents (#21, #9, and #19), out of 5 residents selected for an unnecessary medication review. Specifically, the facility failed: 1. To ensure facility wide recommendations were addressed timely and maintained as part of the medical record; 2. For Resident #21, to ensure the January, February, and March 2024 consultant pharmacist recommendations were acted upon timely and to ensure the January, February, March, and April 2024 consultant pharmacist recommendations were maintained as part of the permanent medical record; 3. For Resident #9, to ensure the April 2024 consultant pharmacist recommendations were maintained as part of the permanent medical record and acted upon timely for Abnormal Involuntary Movement Scale (AIMS) testing to be completed; and 4.…

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 policy review, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed: 1. For Resident #50, to ensure the medications were administered under direct supervision and not left at the bedside; 2. To ensure medication and treatment carts on Unit One were locked when not in direct supervision of the licensed nurse; and 3. Ensure safe storage of medications and biologicals according to current standards of practice in 2 of 2 observed medication carts. Findings include: Review of the facility's policy titled Medication Administration-General Guidelines, dated as effective January 2024, indicated but was not limited to the following: -Medications are administered only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications. -Medications are administered in accordance with…

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, policy review, and interview, the facility failed to provide education, assess for eligibility, and offer pneumococcal vaccinations per facility policy and the Centers for Disease Control and Prevention (CDC) recommendations for three Residents (#9, #13, and #34), out of a total sample of five residents reviewed for immunizations. Findings include: Review of the facility's policy titled Pneumococcal Vaccine, updated May 2023, indicated but was not limited to the following: -It is the policy of this facility to offer and administer pneumococcal Vaccine to eligible individuals who consent for vaccination. -Vaccination for adults ages 19 through [AGE] years old with certain chronic medical conditions or risk factors. The CDC [Centers for Disease Control and Prevention] recommends vaccination for those with any of these conditions and risk factors: -Chronic lung disease, including chronic obstructive pulmonary disease, emphysema, and asthma. -Residents will be screened for needing vaccine,…

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 the Beneficiary Protection Notification Review, interview, and policy review the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), Form CMS-10055 and the Notice of Medicare Non-Coverage (NOMNC), Form CMS 10123, were provided timely and explained to the resident/resident representative for two Residents (#19 and #49), out of three sampled residents. Specifically, the facility failed to issue the SNF ABN and failed to issue and explain the NOMNC timely ensuring the Resident/Resident representative understood the appeal process. Findings include: Review of the facility's policy titled Advance Beneficiary Notices, dated as last revised 3/4/24, indicated but was not limited to the following: -It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage. -The current Center for Medicare and Medicaid Services (CMS) approved version of the forms shall be used. a. For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), Form CMS-10055.…

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, policy review, and interview, the facility failed to ensure staff developed and implemented a baseline care plan within 48 hours of the resident's admission, which included the instructions needed to provide effective and person-centered care to the resident and provide the resident and/or their representative with a summary of the baseline care plan for two Residents (#52 and #109), out of a total sample of 15 residents. Specifically, the facility failed: 1. For Resident #52, to provide him/her a written summary of the baseline care plan by completion of the comprehensive care plan and document receipt of the information within the Resident's clinical record; and 2. For Resident #109, to develop a baseline care plan for Post-Traumatic Stress Disorder (PTSD- mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations). Findings include: Review of the facility's policy titled The Baseline Care Plan, last reviewed December…

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, record review, and policy review, the facility failed to implement interventions on the Falls Care Plan for one Resident (#21), out of a total sample of 15 residents to meet the resident's physical, psychosocial and functional needs. Findings include: Review of the facility's policy titled Comprehensive Care Plans, dated as last revised 3/4/24, indicated but was not limited to the following: -It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. -The comprehensive care plan will describe, at minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. -Qualified staff responsible for carrying out interventions specified in the care plan. Review of the facility'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.

Based on observations, interviews, record review, and policy review, the facility failed to ensure activity of daily living (ADL) care was provided to maintain good personal grooming for one Resident (#46), out of a total sample of 15 residents. Specifically, the facility failed to ensure nail care was performed for Resident #46. Findings include: Review of the facility's policy titled Nail Care, last revised 3/4/24, indicated but not limited to: - The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health. - Routine cleaning and inspection of nails will be provided during activities of daily living (ADL) care on an ongoing basis. - Routine nail care, to include trimming and filing, will be provided/offered on a regular schedule and as needed based on resident need and preference. - Principles of nail care: nails should be kept smooth to avoid skin injury; each resident will have his/her own nail care equipment (e.g., clippers, emery boards, files, etc.); equipment will not be shared between residents. -…

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, record review and policy review, the facility failed to provide indwelling catheter (a flexible tube inserted into the bladder to drain urine outside of the body) care and management consistent with professional standards for three Residents (#34, #160, and #16), out of a total sample of 15 residents. Specifically, the facility failed: 1. For Resident #34, to ensure the Foley catheter was assessed for removal as soon as possible or determine a clinical condition related to Foley catheter placement on admission to the facility; 2. For Resident #160, to ensure orders were in place for the Foley catheter and Foley catheter care, and to ensure the Foley catheter bag was hung at an appropriate level, below the bladder to discourage backflow of urine which helps prevent urinary tract infections (UTIs); and 3. For Resident #15, to ensure the catheter bag was hung at an appropriate level, below the bladder, to discourage backflow of urine which helps to prevent UTIs. Findings include: Review of the facility's policy titled Appropriate Use Indwelling…

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, interview, and policy review, the facility failed to ensure one Resident (#109), out of a sample of 15 residents, received culturally competent, trauma-informed care accounting for resident experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. Specifically, the facility failed to assess Resident #109 and identify triggers of trauma to prevent potential re-traumatization. Findings include: Review of the facility's policy titled Trauma Informed Care, dated as last revised 3/4/24, indicated but was not limited to the following: -It is the policy of this facility to provide care and services which address the needs of trauma survivors by minimizing triggers and/or re-traumatization. -DEFINITIONS: Trauma results from an event or series of events, or circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental,…

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, policy review, and interview, the facility failed to ensure for one Resident (#15), out of a sample of 15 residents, that their as needed (PRN) psychotropic medication, Lorazepam (antianxiety), was re-evaluated 14 days after the medication was prescribed to ensure it was beneficial and necessary for the Resident in accordance with the standard of practice. Findings include: Review of the facility's policy titled Psychotropic Medication Treatment in Long Term Care (LTC), dated January 2021, indicated but was not limited to the following: -It is the policy to abide by state and federal regulations when requesting consent and administering medications. -Pharmacy Consultant will perform monthly medication regimen reviews. These reviews will identify existing irregularities regarding indications for use, dose, duration, and the potential for, or existence of adverse consequences or other irregularities. Any identified concerns must be reported to the attending physician and the Director of Nurses (DON). Resident #1 was admitted to the facility in June 2019 with…

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 records reviewed and interviews, for one of three sampled residents (Resident #1), who had a been diagnosed with a deep vein thrombosis (DVT), with new orders from the Nurse Practitioner for an anticoagulant medication to be started, the Facility failed to ensure nursing notified Resident #1's Physician, when his/her medication was unavailable to be administered in accordance with his/her Physician orders, as a result Resident #1 did not receive his/her first scheduled dose, he/she was transferred to the Hospital Emergency Department (ED) for evaluation and was admitted . Findings include: The Facility Policy, titled Change in Resident's Condition or Status and Notification, date reviewed June 2022, indicated the following: -to ensure that the resident and/or his/her representative, and his/her attending Physician/Physician extender are notified of changes in the resident's medical/mental condition and/or status -the RN Nurse Supervisor/Charge Nurse will notify the resident's attending Physician, Physician extender or on-call Physician when there has been a significant…

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

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a been diagnosed with a deep vein thrombosis (blood clot, DVT), with new orders from the Nurse Practitioner for an anticoagulant (blood thinner) medication to be administered, the Facility failed to ensure nursing notified the correct Pharmacy in order to obtain Resident #1's medication in a timely manner, as a result Resident #1 did not receive his/her first scheduled dose as ordered and he/she was transferred to the Hospital for evaluation. Findings include: The Pharmacy Policy, titled Provider Pharmacy Requirements, effective date January 01, 2021, indicated the following: -that regular and reliable pharmaceutical service is available to provide residents with prescription and nonprescription medications, services, and related equipment and supplies. -providing routine and timely pharmacy services as contracted, and emergency pharmacy service 24 hours per day, seven days per week -emergency or stat (immediately) medications are available for administration no more than four (4)…

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, policy review, and document review, the facility failed to ensure the dish machine temperatures were monitored to ensure the machine was reaching temperatures to clean and sanitize the dishes as required per the manufacturer. Findings include: Review of the facility's policy titled Dish Machine, dated May 2020, indicated but was not limited to the following: - all staff will receive training consistent with manufacturer recommendation for dish machine use - high temp machines must reach water temperatures in accordance with manufacturer specifications for wash and rinse - dietary staff will record dish machine temperatures on a log after each meal service Review of the facility provided CMA Dish Machine owner's manual, Revision 2.08.A, undated, indicated but was not limited to the following: - the CMA-180 is a hot water sanitizing single rack dish machine - the wash temperatures should cycle at a minimum of 155 degrees Fahrenheit (F) - the rinse/sanitation cycle should reach a minimum of 180 degrees F Review of the Dishwasher Temperature Monitoring…

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 4. Resident #4 was admitted to the facility in April 2019. Review of the medical record for Resident #4 included a Physician's Interim Order, dated 1/12/23 to collect a stool specimen to rule out c-difficile (c-diff) (a bacterial infection in the colon). The interim order was observed in the medical record on 1/12/23 at 4:00 P.M. Review of the Nursing Progress note, dated 1/12/23, indicated Resident #4 had a foul smelling bowel movement overnight and that morning. The note indicated the Nurse Practioner had been in earlier that afternoon and ordered for a stool collection sample to be sent out to rule out a c-diff infection and parasites. On 1/12/23 at 4:00 P.M., the surveyor observed the room of Resident #4 to not have any precaution signs or a precaution cart to provide supplies to care for the Resident with a possible infection. On 1/13/23 at 8:58 A.M., the surveyor observed the room of Resident #4 to not have any precaution signs or a precaution cart. During an interview on 1/13/23 at 9:00 A.M., the Nursing…

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 document review, the facility failed to resolve concerns brought forward during Resident Council meetings. Findings include: Review of the Resident Council Meeting Minutes and Concern Forms for January 2022 through December 2022 identified the following unresolved concerns: 1/20/22: transportation for bus trips was noted to be a resident concern and documents indicate residents can shop online (no additional information or resolution was provided). 2/17/22: bus trips continue to be on hold related to transportation issues and documents indicate families can bring in items or residents can online shop (no additional information or resolution was provided). 3/24/22: bus trips continue to be on hold related to transportation issues and documents indicate families can bring in items or residents can online shop (no additional information or resolution was provided). 4/26/22: bus trips continue to be on hold related to transportation issues and documents indicate families can bring in items or residents can online shop (no additional information or resolution was…

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, the facility failed to ensure that residents had a homelike environment. Findings include: On 1/13/23 at 11:45 A.M., the surveyors conducted an environmental tour of the first and second floor units and observed the following: -The first-floor resident hallway, lower half of the wall was dusty and contained dried liquid drip stains. -room [ROOM NUMBER], on the right side of the room, the wall wainscoting was scraped revealing wood beneath. There were multiple wires hanging loosely from the lower wall. The floor had a large yellow tint. The linoleum tile floor had a couple of gouges revealing the subfloor. -room [ROOM NUMBER], the linoleum tile floor had gouges and wear revealing the subfloor beneath. -The first floor back activity room contained a maroon upholstered armchair that was stained with dark spots, faded, distressed and sunken in at the arm rests. The legs of the chair were scraped showing a darker color beneath. -room [ROOM NUMBER], the baseboard heater cover was scraped 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, interview, and policy review, the facility failed for seven Residents (#7, #9, #13, #16, #19, #47, and #159) to address and resolve voiced grievances regarding the television reception at the facility. Findings include: Review of the facility's policy titled Grievances/Concerns, dated 12/6/21, indicated but was not limited to the following: - grievances/concerns may be submitted orally or in writing - the person receiving the grievance orally will submit a grievance form on the resident's behalf - the grievance/concern investigation will be initiated upon receipt and a written resolution will be made available to the administrator within five working days - the administrator will review the findings and the resident will be informed of the actions taken within 10 working days of the grievance being made During an interview on 1/10/23 at 11:23 A.M., the surveyor observed Resident #7 to have the television (TV) on and the picture was snowy and difficult to see. Resident #7 said the TV reception is poor and he/she has complained about it in the past and has been…

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, interviews, policy review, and record review, the facility failed to follow professional standards of practice for three Residents (#32, #4 and #29), in a total sample of 14 residents. Specifically, the facility failed: 1. For Resident #32, to follow physician's orders to change a dressing for a suprapubic catheter (tube inserted in the belly to drain the bladder); 2. For Resident #4, a. To implement the bowel protocol, b. To follow hospital recommendations for bowel medications following a fecal impaction, and c. To accurately follow physician's orders for bowel regimen medications; and 3. For Resident #29, to ensure a pacemaker was monitored per the professional standards of practice. Findings include: 1. Resident #32 was admitted to the facility in August 2022 with a diagnosis of urinary retention. Review of the medical record indicated Resident #32 had an indwelling Foley catheter until 12/30/22 when surgery was conducted to insert a suprapubic catheter. Review of the paper 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, medical record review, and maintenance record review, the facility failed to ensure the resident environment remained as free from accidents and hazards as possible. Specifically, the facility failed to: 1. Implement interventions to reduce the potential for a resident to resident altercation between Resident #26 and Resident #38; and 2. Ensure water temperatures were maintained at safe and comfortable levels in resident bathrooms. Findings include: 1. Resident #26 was admitted to the facility in September 2016 with a diagnosis of adjustment disorder. Review of the Minimum Data Set (MDS) assessment, dated 12/21/22, indicated Resident #26 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he/she was cognitively intact. Resident #38 was admitted to the facility in April 2021 with a diagnosis of dementia. Review of the MDS assessment, dated 12/14/22, indicated Resident #38 scored an 11 out of 15 on the BIMS, indicating he/she had moderately impaired…

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

Based on interview and record review, the facility failed for seven Residents (#9, #25, #4, #48, #29, #35, and #57) to maintain a medical record that was accurate and complete, out of a total sample of 14 residents and three closed records. Specifically, the facility failed to: 1. Identify and correct a sudden documented change in wound classification for Resident #9; 2. Ensure consultant information was available in the medical record for Resident #25; 3. Ensure Physician Progress Notes were readily accessible for Residents #4, #48, #29, and #35; 4. Maintain complete and accurate activities of daily living (ADL) documentation for Resident #35; and 5. Reflect the accurate code status for Resident #57. Findings include: During an interview on 1/12/23 at 3:58 P.M., the Director of Nurses (DON) said the facility does not have a policy regarding medical records. 1. Resident #9 was admitted to the facility in July 2019 with diagnoses including Protein-calorie malnutrition, adult failure to thrive, and muscle weakness. Review of the medical record indicated Resident #9 developed a shear…

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, document review, and interview, the facility failed to implement an antibiotic stewardship program to determine if antibiotics were prescribed for the appropriate diagnosis by ensuring cultures were obtained prior to the start of an antibiotic. Findings include: Review of the Facility Assessment, dated 8/18/2017 with an Addendum for the Infection Control Program, included but was not limited to: -Infection Control Preventionist (ICP) chairs the antibiotic stewardship program. Line listings, trending and tracking of infections and precautions. Review of the facility binder titled Infection Control Line Listing indicated that infections and the corresponding antibiotics prescribed to treat the infections were listed for the months of January 2022 through January 2023. Review of the facility Line Listing, dated January/February 2022, indicated six residents received antibiotics and did not meet the McGeer's criteria (no culture was obtained) for that infection. The line listing culture date, culture site, culture result, and comments section were left blank 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, staff interview, and policy review, the facility failed to document the recapitulation of the Resident's stay that included pre- and post-discharge medications for two Residents (#57 and #58) of two closed records reviewed. Findings include: Review of the facility's policy titled Discharge Summary and Plan, last revised September 2012, included but was not limited to: -When the facility anticipates a resident's discharge to a private residence, another nursing care facility a discharge summary and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment. -The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of a resident's status at the time of the discharge in accordance with established regulations. 1. Resident #57 was admitted to the facility in October 2022 for short term rehabilitation following a hospitalization for urinary tract infection and a fall. Review of 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 observation, interview, and record review, the facility failed to ensure that one Resident (#24) received the proper treatment to maintain hearing abilities, out of a total sample of 14 residents. Findings include: Resident #24 was admitted to the facility in September 2021 with medical diagnoses including difficulty hearing. Review of the Minimum Data Set (MDS) assessment, dated 12/2/22, indicated Resident #42 has severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 03 out of 15 and indicated Resident #24 had moderate hearing difficulty and did not have hearing aids. Review of the January 2023 Physician's Orders indicated bilateral hearing aids, supplies labeled in case in room. Resident can manage them independently. Document inserting them in the morning, and removing them in the afternoon, as needed for prevention. Review of the clinical record failed to indicate that the hearing aids were provided for self-applying to the Resident, as instructed. Further review of the clinical record failed to indicate that nursing staff 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 Based on observation, interview, and policy review, the facility failed to safely store medications on two of two units. Specifically, the facility failed to: 1. Maintain a temperature log that reflected a minimum of daily temperature checks in the first-floor medication room; and 2. Ensure medication carts were secured when not in view of the licensed nurse. Findings include: Review of the facility's policy titled Medication Storage in the Facility, dated September 2013, indicated but was not limited to the following: - medications requiring refrigeration are kept in a refrigerator at temperatures between 36 and 46 degrees Fahrenheit (F) - the facility should maintain a temperature log in the storage area to record temperatures at least once a day - medication supply is only accessible to licensed nursing personnel or those with authorized access - medication carts are kept locked when not in attendance of persons with authorized access 1. On 1/12/23 at 10:37 A.M., the surveyor observed the first-floor…

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 interviews, policy review, and record review, the facility failed to assist a Resident (#35) in obtaining recommended dental services, in a total sample of 14 residents. Findings include: Resident #35 was admitted to the facility in May 2022. Review of the Minimum Data Set (MDS) assessment, dated 10/26/22, indicated Resident #35 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the Resident was cognitively intact. Review of the medical record for Resident #35 indicated the Resident was responsible for his/her own healthcare decision making. During an interview on 1/10/23 at 1:40 P.M., the Resident said that he/she needed a full upper plate (dental). The Resident said he/she had been seen by the dentist but had not heard what the plan was for follow-up. Review of the medical record indicated the following: -The contracted dental provider's Dental Progress Note, dated 9/22/22, listed the chief complaint as: wants removable partial denture with a treatment plan of extractions and refer to oral surgeon. -The Dental Visit Referral Report…

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 provide a sanitary environment for one Resident (#9), out of a total sample of 14 residents. Specifically, the facility failed to ensure the wheelchair for Resident #9 was clean and sanitary. Findings include: During an interview with observation on 1/10/23 at 2:30 P.M., the surveyor observed Resident #9 sitting in his/her wheelchair with dried beige substance on the left wheel, backrest, crossbars, and left handle. Resident #9 said they did not think the wheelchair gets cleaned and said the staff do not wipe up spills when they occur. During an interview with observation on 1/11/23 at 8:09 A.M., the surveyor observed Resident #9 sitting in his/her wheelchair in their room. The wheelchair had a dried beige substance stuck to the backrest, left handle, splattered throughout the left wheel and on the lower crossbars. Resident #9 said it has been a long time since anyone has cleaned his/her wheelchair and it is embarrassing to have it in the condition it is in. During an interview on 1/11/23 at 10:18 A.M., Certified Nurse…

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.