Care One At Lexington

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and observation, the facility failed to ensure accurate documentation of the clinical record for three Residents (#17, #52, #392) of 37 sampled residents. Specifically: 1. For Resident #52, the facility documented compression stocking were applied when they were not. 2. For Resident #17, the facility documented heel protectors were applied when they were not. 3. For Resident #392, the facility failed to ensure nursing obtained a physician's order for a lidocaine (topical prescription medicated patch used for pain) patch that included the location, and the facility failed to ensure that nursing consistently documented the location where the lidocaine patch was applied. 1. Resident #52 was admitted to the facility in November 2022, and has active diagnoses which include congestive heart failure, bilateral leg edema and dementia. Review of Resident #52's Minimum Data Set assessment dated [DATE], indicated he/she was dependent on staff for all lower body dressing and putting…

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 observation, the facility failed to follow infection control procedures. Specifically: 1. The facility failed to ensure 2 of 2 nurses cleaned blood glucose meters according to infection control practices. 2. The facility failed to ensure staff wore complete personal protective equipment in rooms designated as requiring enhanced barrier precautions. 3. The facility failed to ensure staff conducted proper handwashing and glove use. 4. The facility failed to ensure it used unexpired hand sanitizer. Review of the facility policy, Blood Glucose Monitoring, dated as revised [DATE], indicated: Disinfect the meter before and after each use, or when the monitor is visibly soiled as follows: - Use Super Sani-Cloth Germicidal Disposable Wipe (or other commercially prepared pre-moistened wipe which meets CDC guidelines) to wipe down the meter using caution not to get liquid in the test strip and key code ports of the meter - If blood is visibly present on the meter, a 2nd Sani-Cloth…

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 observation, the facility failed to ensure it had secured hallway handrails on the [NAME] and Minuteman units. Findings include:Minuteman Unit On 12/27/24 at approximately 9:15 A.M., the surveyor observed: - Handrail end cap detached from rod and metal not secure, located in the hallway near rooms 223-224. On 12/27/24 at approximately 9:37 A.M., the surveyor observed: - Handrail end cap detached and no longer attached to the abutting the wall, located in hallway near room [ROOM NUMBER]. [NAME] Unit On 12/30/24 at approximately 8:58 A.M., the surveyor observed: - Handrail end cap detached and no longer attached to the abutting wall. Another end cap was missing and metal screws were exposed located, located near the sprinkler room. -Handrail end cap detached, and not attached to the wall, located in the hallway near the dining room. During an interview with Maintenance Staff #1 on 12/30/24 at 9:03 A.M., he said staff will report broken handrails to us verbally or by using the online TELS…

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 a dignified dining experience for one Resident (46) out of a total sample of 37 residents. Findings include: The facility policy titled Dignity, revision date February 2021, indicated the following: - Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. - Residents are treated with dignity and respect at all times. - Individual needs and preferences of the resident are identified through the assessment process. - When assisting with care, residents are supported in exercising their rights. For example, residents are: Provided with a dignified dining experience. Resident #46 was admitted to the facility in October 2019 and has diagnoses that include Cerebral Palsy (condition that affects movement and posture), Parkinson's disease, muscle weakness, tremors, lack of coordination, feeding difficulties, and dysphagia. Review of the most recent Minimum Data Set (MDS) assessment,…

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 accurately complete the Minimum Data Set (MDS) assessment for two Residents (#4 and #139) out of a total sample of 37 residents. Findings include: 1. Resident #4 was admitted to the facility in July 2019 with diagnoses including dementia, bipolar disorder, and anxiety disorder. Review of the facility document titled Documentation Survey Report v2 (where Certified Nurse's Aides document level of assist provided each shift and where that level of assist required by residents, is used to complete the MDS), dated [DATE] indicated that Resident #4 required the following: - Eating: substantial/maximum assist. - Oral hygiene: maximum assist/dependent. - Upper body dressing: maximum assist/dependent. Review of the MDS dated [DATE] indicated the following; - Eating: supervision/touching assistance. - Oral hygiene: partial/moderate assistance. - Upper body dressing: partial/moderate assistance. Review of the facility document titled Documentation Survey 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and observation, the facility failed to ensure care plan implementation for four (Resident #52, #17, 442, and #46) of 37 sampled residents. Specifically: 1. For Resident #52, the facility failed to implement the physician order for compression stockings. 2. For Resident #17, the facility failed to implement the physician order for heel protectors. 3. For Resident #442, the facility failed to develop a care plan for eating assistance. 4. For Resident #46, the facility failed to develop a comprehensive falls care plan. Findings include: 1. Resident #52 was admitted to the facility in November 2022, and has active diagnoses which include chronic congestive heart failure, bilateral leg edema and dementia. Review of Resident #52's Minimum Data Set assessment dated [DATE], indicated he/she was dependent on staff for all lower body dressing and putting on/taking off footwear. The Resident had a Brief Interview for Mental Status Score of 3, indicating severe cognitive impairment. Review…

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, record review and interview, the facility failed to meet professional standards of practice for one Resident (#392) out of a total of 37 sampled residents. Specifically, for Resident #392 the facility failed to ensure nursing clarified a physician's order for ascorbic acid extended release (ER) oral capsule. In addition, from 12/15/24 through 12/26/24, nursing staff documented they administered the medication 25 times. Findings include: Review of the facility policy titled Administering Medications, dated as revised 5/16/24, indicated that medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 8. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician…

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 assistance with activities of daily living (ADL's) for one Resident (#442) out of a total sample of 37 residents. Specifically, for Resident #442 the facility failed to ensure the Resident received necessary services to maintain good nutrition. Findings Include: Review of the facility policy, titled Activities of Daily Living (ADL), Supporting, revised March 2018, indicated, but was not limited to, the following: - Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: - Dining (meals and snacks). - The resident's response to interventions will be monitored, evaluated and revised as appropriate. Resident #442 was admitted to the facility in November 2024 with diagnoses of cerebral palsy and malnutrition. Review of the Minimum Data Set (MDS), dated [DATE],…

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 treatment and care in accordance with professional standards of practice for one Resident (#29) out of a total sample of 37 residents. Specially, the facility failed to obtain wound care orders for five days after Resident #29's wound vac (negative pressure wound vacuum, which is a medical device that uses suction to help a wound heal by gently pulling fluid out of it and keeping the edges of the wound together) was placed on hold because the wound was worsening. Finding include: Review of the facility policy titled Medication and Treatment Order, dated as revised July 2016, indicated that orders for medications and treatments will be consistent with principles of safe and effective order writing. 1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. 2. Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for two Residents (#441 and #119) out of a total of 37 sampled Residents. Specifically: 1. For Resident #441, the facility failed to place an order for treatment or monitoring for a known pressure injury on admission. 2. For Resident #119, the facility failed to ensure nursing consistently implemented physician's orders for air mattress settings. Findings include: Review of the facility policy titled Pressure Ulcer/Skin Breakdown - Clinical Protocol, revised March 2014, indicated, but was not limited to, the following: - The physician will authorize pertinent orders related to wound treatments, including wound cleansing and debridement approaches, dressing (occlusive, absorptive, etc.), and application of topical agents if indicated…

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

Based on observation, interview, and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for one Resident (#43), out of a total sample of 37 residents. Specifically, for Resident #43, the facility failed to ensure that they maintained Resident #43's tracheostomy (a surgically created opening in the neck to provide an airway for breathing) and associated respiratory equipment in a clean and sanitary manner to prevent potential contamination and the spread of infection. Findings include: Resident #43 was admitted to the facility in November 2024 with diagnoses including malignant neoplasm of the mouth, dysphagia, and chronic obstructive pulmonary disease (COPD). Review of the most recent Minimum Data Set (MDS) assessment, dated 12/2/24, indicated that Resident #43 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS indicated Resident #43 required tracheostomy care. On 12/26/24 at 9:46 A.M., the surveyor observed Resident #43'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 observation, record review, and interview, the facility failed to ensure nursing was competent and had the required skill set to provide necessary care for residents' needs. Specifically: 1. For Resident #391, the facility failed to ensure that nursing was (a) competent to use an insulin pen-injector and (b) competent to administer enoxaparin according to manufacturer's guidelines. 2. For Resident #131, the facility failed to ensure that nursing was competent to accurately measure the external catheter length of a CVC (central venous catheter) and PICC (peripherally inserted central line). 3. The facility failed to ensure agency licensed nursing staff were trained and demonstrated competency related to medication administration techniques. Findings include: According to the Board of Registration in Nursing, 244 CMR 9.00: Standards of Conduct, a competency is defined as the application of knowledge and the use of affective, cognitive, and psychomotor skills required for the role of a nurse licensed by…

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

Based on record review and interviews, the facility failed to provide routine medications to one Resident (#122) out of a total sample of 37 residents. Specifically, for Resident #122, the facility failed to provide modafinil (a non-amphetamine central nervous system stimulant with wakefulness-promoting properties. It is used in the treatment of conditions which cause excessive daytime sleepiness) as ordered by the physician. Findings include: Review of the facility policy titled, Unavailable Medications, dated as revised February 2019, indicated medications used by residents in the nursing facility may be unavailable for dispensing from the pharmacy on occasion. This situation may be due to the pharmacy being temporarily out of stock of a particular product, a drug recall, manufacturer's shortage of an ingredient, or the situation may be permanent because the drug is no longer being made. The facility must make every effort to ensure that medications are available to meet the needs of each resident. A. The pharmacy staff shall: 1. Call or notify nursing staff that the ordered…

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 recommendations from the Monthly Medication Reviews (MMR) conducted by the consultant pharmacist were addressed by the facility in a timely manner for two Residents (#14 and #29) out of a total sample of 37 Residents. Specifically, 1. For Resident #14, the facility failed to address the pharmacist recommendations. 2. For Resident #29, the facility failed to implement the consultant pharmacist's recommendations once approved by the attending physician. Finding Include: Review of the facility policy, Medication Regime Reviews, dated as revised May 2019, indicated the consultant pharmacist reviews the medication regimen of each resident at least monthly. 1. The consultant pharmacist performs a monthly medication review (MMR) for every resident in the facility receiving medication. 2. Medication regimen reviews are done upon admission (or as close to admission as possible) and at least monthly thereafter, or more frequently if indicated. 3. Reviews for short-stay individuals (those who are expected to stay for 30 days…

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, record review and interviews, the facility failed to ensure that two Residents (#29 and #391) were free from significant medication errors out of a total sample of 37 residents. Specifically: 1. For Resident #29, nursing staff failed to administer insulin in accordance with the physician's order. 2. For Resident #391, nursing staff failed to prime (prepare insulin for injection) the insulin pen injector resulting in an inaccurate dose of insulin administered. Findings include: Review of the facility policy, Nursing Care of the Older Adult with Diabetes Mellitus, dated as revised November 2020, indicated it provided an overview of diabetes in the older adult, its symptoms and complications, and the principles of glucose monitoring. The policy indicated that for further diabetes education and guidelines, refer to the provider orders and instructions as well as the American Diabetes Association, Standards of Medical Care in Diabetes. Symptoms Associated with Diabetes: 1. Hyperglycemia. Uncontrolled diabetes from lack of insulin or inadequate insulin results in…

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 policy review, the facility failed to ensure: 1. Medications were properly stored in one of four medication carts and 2. Treatment carts were attended while unlocked, and 3. Medications were labeled, and dated once opened, according to manufacturer's guidelines in one out of four medication storage areas. Findings include: Review of the facility policy titled Medication Labeling and Storage dated revised February 2023 indicated that the facility stores all medications and biologicals in locked compartments. Further review failed to indicate that medications cannot be pre-poured and stored, and un-labeled in the medication cart. 1. On 12/30/24 at 9:43 A.M., the surveyor observed the [NAME] Unit medication cart contained an un-labeled medication cup containing 10 pills. During an interview on 12/30/24 at 9:43 A.M., Nurse #2 said that she ran out of an over-the-counter medication and had to go get it from med storage. Nurse #2 said she put the medication cup in the top drawer…

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 ensure laboratory services were provided for one Resident (#14) out of a sample of 37 residents. Specifically, the facility failed to ensure it obtained Resident #14's Depakote (medication used to treat mood and behavior) serum drug level, per the physician's order. Finding Include: Review of the facility policy, Lab and Diagnostic Test Results - Clinical Protocol, dated as Revised November 2018, indicated: 1. The physician will identify, and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for tests. 3. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility. Resident #14 was admitted to the facility in January 2012 with diagnoses including major depression and traumatic brain injury. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/17/24, indicated that Resident #14 had moderate cognitive impairment as evidenced by a Brief Interview for 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff provided food that accommodated the allergies, intolerances, and preferences of one Resident (#442) out of a total sample of 37 residents. Specifically, the facility failed to ensure that Resident #442, who had an active diagnosis of celiac disease (a chronic autoimmune disorder, triggered by the consumption of gluten, that damages the small intestine and prevents the body from absorbing nutrients from food) was not served food containing gluten (a protein found in some grains, including wheat) despite gluten being listed as an allergen in the Resident's medical record. Findings include: Review of the facility policy, titled Food Allergies and Intolerances, revised August 2017, indicated, but was not limited to, the following: - Residents with food allergies and/or intolerances are identified upon admission and offered food substitutions of similar appeal and nutritional value. Steps are taken to prevent resident exposure to…

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, policy reviews and interviews, the facility failed to ensure advanced directives were obtained for one Resident (#177) upon admission and when his/her health care proxy was activated to ensure the Resident's end of life wishes were honored, out of a total of 32 residents sampled. Specifically, Resident #177's wishes to be a DNR (Do Not Resuscitate) were not enforced at his/her time of death. Findings include: Review of the policy titled 'Advance Directives', dated as revised [DATE], indicated the following: -The resident has the right to formulate an advanced directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. -Do Not Resuscitate (DNR) indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, healthcare proxy, or representative (sponsor) has directed that no cardio pulmonary resuscitation (CPR) or other life sustaining treatments or methods are to…

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, records reviewed and interviews, the facility failed to provide professional standards of practice for one Resident (#287), out of a total sample of 32 residents. Specifically for Resident #287, staff failed to obtain weights in accordance with the physician's orders. Findings include: Resident #287 was admitted to the facility in September 2023 with diagnoses including diastolic congestive heart failure and other abnormalities of breathing. Review of the Minimum Data Set (MDS), dated [DATE] indicated the Resident #287 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of Resident #287 medical record indicated the following: -Physician order dated 9/30/23: Daily weight- call for weight gain greater than 3 pounds for 2 consecutive nights. Every day shift for congestive heart failure. -Review of nutrition risk care plan indicated an intervention date created 10/3/23 for weights as ordered. Review of the weight record did not indicate 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 observations, record review and interview the facility failed to provide assistance with grooming for one Resident (#47), out of a sample of 32 residents. Findings include: Review of the facility's policy titled 'Dignity', dated February 2021, indicated: 5. When assisting with care, residents are supported in exercising their rights. For example, residents are: a. groomed as they wish to be groomed (hairstyles, nails, facial hair, etc.) Resident #47 was admitted to the facility in November of 2023 and has diagnoses that include, but not limited to, spinal stenosis, covid-19, toxic encephalopathy, visual loss both eyes, dysphagia, and chronic kidney disease. Review of the Minimum Data Set assessment, dated 11/24/23, indicated Resident #47 scored a 4 out of 15 on the Brief Interview for Mental Status exam, indicating severe cognitive impairment and required partial/moderate assistance with personal hygiene. Further, the MDS did not indicate Resident #47 exhibited behaviors or resisted care. On 1/8/24 at…

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 records reviewed the facility failed to ensure that treatment and care was provided in accordance with professional standards of quality for one Resident (#28) out of 32 sampled residents. Specifically, the facility failed to obtain two physician orders to treat skin conditions for Resident #28. Findings include: Review of the facility policy titled 'Skin Tears - Abrasions and Minor Breaks, Care of', reviewed 3/4/19, indicated the following: -The purpose of this procedure is to guide the prevention and treatment of abrasions, skin tears, and minor breaks in the skin. 1. Obtain a physician's order as needed. Document physician notification in the medical record. 2. Review the resident's care plan, current orders, and diagnoses to determine the resident needs. 18. Apply the ordered dressing and secure with tape or bordered dressing per order. Resident #28 was admitted to the facility in March 2021 with diagnoses including dementia and a skin condition that causes large, fluid filled blisters. Review of the Minimum Data Set (MDS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to follow up on a recommendation for hearing aides for one Resident (#59) out of a total sample of 32 residents. Findings include: Resident #59 was admitted in January 2023 with diagnoses including hypertension. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #59 scored a 13 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. During an interview on 1/8/24 at 11:17 A.M., Resident #59 said that he/she has been missing his/her hearing aides for a month now and it is affecting him/her. Resident #59 said he/she is unsure why it is taking so long to get hearing aides. Review of the audiology note, dated 11/20/23, indicated a recommendation for hearing aides and a medical consult to obtain medical clearance for hearing aides. During an interview on 1/9/24 at 8:38 A.M., Unit Manager #3 said that she faxed over the physician approval to the audiology company in early December and was still…

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, record reviews and interview the facility failed to ensure weights were obtained for one Resident (#47), resulting in the delay of identifying a weight loss, assessing the weight loss, and implementing interventions to prevent further weight loss, out of a total sample of 32 residents. Findings include: Review of the facility's policy titled 'Weight Assessment and Intervention', dated as revised March 2022, indicated the following: -Policy Statement: Resident weights are monitored for undesirable or unintended weight loss or gain. -Weight Assessment: 1. Residents are weighed upon admission and at intervals established by the interdisciplinary teams such as: weekly for four weeks, then monthly unless otherwise indicated (i.e., residents on hospice) or as ordered. 2. Weights will be recorded in each resident's medical record. 6. Weights are reviewed monthly to follow individual weight trend over time. Negative trends are evaluated to determine significant unplanned or undesired weight loss. Resident #47 was admitted to the facility in November of 2023 and has…

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 a plan of care was developed for Trauma-Informed Care for one Resident (#7), who was admitted with the diagnosis of post-traumatic stress disorder (PTSD), out of a total sample of 32 residents. Findings include: Review of facility policy titled 'Trauma-Informed and Culturally Competent Care', revised August 2022, indicated the following but not limited to: -To guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice. -To address the needs of trauma survivors by minimizing triggers and/or re-traumatization. -Develop individualized care plans that address past trauma in collaboration with the residents and family, as appropriate. Resident #7 was admitted to the facility in October 2023 with diagnoses including post-traumatic stress disorder (PTSD). Review of Resident #7 Minimum Data Set (MDS), dated [DATE], indicated the Resident scored a 13 out of a possible 15 on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, policy review and interviews, the facility failed to ensure medications with short expiration dates were dated when opened and expired or outdated medications were not available for administration. Findings include: Review of policy titled 'Medication Labeling and Storage' revised 2/2023, indicated the following but not limited to: -If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. -Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly. 1.) During an inspection of the [NAME] Unit team two medication cart on 1/9/24 at 12:07 P.M., the following medications were available for administration: -Insulin Humulin N kwik pen unopened with directions to refrigerate until use. -One inhaler fluticasone…

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, record review, policy review and interviews, the facility failed to complete a physical therapy evaluation as recommended by the physician for one Resident (#70) out of a total sample of 32 residents. Findings include: Resident #70 was admitted to the facility in December 2017 with diagnoses including stroke. Review of Resident #70's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15 which indicated he/she had moderate cognitive impairment. The MDS also indicated Resident #70 requires substantial assistance from staff for all functional tasks. During interviews on 1/8/24 at 8:04 A.M., and 1/11/24 at 8:31 A.M., Resident #70 said he/she has pain in his/her left foot at times. The surveyor observed Resident #70's left foot. The big toe was bent underneath the second, third and fourth toe and the Resident was unable to move his/her toe on his/her own. The ankle was in a dorsiflexed position…

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 maintain an accurate medical records for one Resident (#109) out of a total sample of 32 residents. Specifically, for Resident #109, the facility documented that the Resident was receiving enteral tube feeding when he/she was no longer receiving tube feeding. Findings include: Resident #109 was admitted to the facility in July 2023 with diagnoses including dysphagia (difficulty swallowing) and muscle weakness. Review of Resident #109's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 13 out of a possible 15 indicating that he/she is cognitively intact. Further review of the MDS indicated that Resident #109 requires supervision/touching assist when eating. The surveyor made the following observations: -On 1/8/24 at 8:16 A.M., Resident #109 was eating breakfast in his/her bed alone. -On 1/9/24 at 8:23 A.M., Resident #109 was eating breakfast in his/her bed…

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