Melrose Healthcare

Based on resident group meeting, interview and test tray results, the facility failed to ensure foods provided to the residents were prepared by methods that conserve palatability and are at appetizing temperatures on four of four units. Findings include: The facility was unable to provide a policy regarding food temperature palatability. During the initial Resident screening process, numerous residents voiced concerns and displeasure about the overall food quality, temperature, and variety they are provided. During the resident council group meeting on 4/8/25, at 11:05 A.M., 10 out of 16 participating residents complained that the food is always cold and does not taste good. On 4/8/25, the surveyors conducted test tray audits during lunch on all units of the facility, the results were as followed: On the first floor A-unit side, the meal cart arrived on the unit at 12:00 P.M., the surveyor received the tray at 12:12 P.M., the following was recorded: - Stuffed shell pasta with cheese was 120 degrees Fahrenheit and was warm, not hot. - Salad was 79 degrees Fahrenheit and room…

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 properly follow food handling practices to prevent the risk of foodborne illness in accordance with professional standards for food service safety. Findings include: The surveyor made the following observations during the lunch trayline on 4/8/25: - At 11:38 A.M., the cook began trayline service, the cook had a visible beard approximately one-inch long and was not wearing a beard net. - At 11:41 A.M., a diet aide removed disposable gloves and then touched her pants with her bare hands, then touched the oven knobs and then put on a new pair of disposable gloves without washing her hands, thus contaminating her gloves. At 11:44 A.M., the diet aide removed her disposable gloves and used oven mits to remove a tray from the oven. She then put on new disposable gloves without washing her hands, contaminating the gloves. The diet aide then put on new gloves and directly touched bread, contaminating the bread. - At 11:59 A.M., the cook left the tray line, opened a door to leave the kitchen and got a new box of disposable gloves 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 and interviews, the facility failed to obtain consent for the use of psychotropic medication for one Resident (#8) out of a total sample of 23 residents. Findings include: Review of the facility policy titled, Psychotropic Medication, dated 7/2023, indicated the following: -A written informed consent from the resident (or legally authorized individual in the case of competency) is required for administration of psychotropic medication. -The interdisciplinary team assesses and monitors the appropriateness, effectiveness, and side effects associated with psychotropic medications for each resident via resident care plan review period the resident, and one indicated, the family or responsible person, will be included in this process prior to the administration of dose. Resident #8 was admitted to the facility in August 2019 with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, mood disturbance, anxiety. Review of Resident #8's most recent Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure a Roger's treatment plan (a judge and legal guardian decide when an antipsychotic medication can be administered) was valid and kept up to date for one Resident (#8) out of a total of 23 sampled Residents. Findings include: Resident #8 was admitted to the facility in [DATE] with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, mood disturbance, anxiety. Review of Resident #8's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident score a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS) which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #8 was dependent on staff for self-care tasks. Review of Resident #8's medical record indicated the Resident has active physician orders for two antipsychotic medications. Review of Resident #8's medical record indicated a Roger's treatment plan that expired on [DATE]. When asked, 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, record review and interviews, the facility failed to file a grievance for one Resident (#80), out of 23 total sampled residents. Specifically, the facility failed to ensure staff filed a grievance on behalf of Resident #80, who complained that his/her pants were missing. Findings include: Review of the facility policy titled 'Grievances, revised February 2024, indicated: - If a resident, and/or health care representative, or another interested family member of a resident has a complaint, a staff member will inform the person of the grievance process and assist the resident, or person acting on the resident's behalf, to file a written grievance with the facility using the Grievance form as needed. - Grievances may be submitted orally or in writing. Note: If a grievance is submitted orally, the facility employee taking the grievance must write it up on the grievance report form. - The Administrator will document receipt of all grievances on the Grievance Log. Resident #80 was admitted to the facility in February 2024 with diagnoses including hypertension and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to provide treatment and care in accordance with professional standards of practice for two Residents (#20, and #9), out of a total sample of 23 residents. Specifically, 1. For Resident #20, the facility failed to ensure his/her pacemaker checks were completed. 2. For Resident #9, the failed ensure six bilateral foot wounds were assessed and measured weekly. Findings include: 1. Review of the facility policy titled, Care of a Resident with a Pacemaker, dated 3/18, indicated the following: -2. When the resident's pacemaker is monitored by the Physician, document the date and results of the pacemaker surveillance, including: a. How the resident's pacemaker was monitored (phone, office, internet); 1. Resident #20 was admitted to the facility in October 2024 with diagnoses that included dementia, presence of cardiac pacemaker, heart failure, asthma, and type 2 diabetes. Review of Resident #20's most recent Minimum Data Set (MDS) assessment, dated…

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 ensure that the resident environment remained free of accident hazards for two Residents (#149 and #88) out of a total sample of 23 residents. Specifically: 1. For Resident #149, the facility failed to implement fall interventions after a fall. 2. For Resident #88, the facility failed to ensure that the Resident was wearing a smoking apron as indicated in the medical record while the Resident was smoking. Findings include: 1. Resident #149 was admitted to the facility in January 2025 with diagnoses of falls resulting in a vertebral fracture and dementia. Review of Resident #149's most recent Minimum Data Set (MDS) indicated the Resident was unable to complete the Brief Interview for Mental Status (BIMS) and the staff had assessed him/her to have moderate cognitive impairment. The MDS also indicated Resident #149 required substantial to maximal assistance with self-care and mobility tasks. Review of the incident report dated 2/2/25…

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 acceptable parameters of nutritional status for one Resident (#12) out of a total sample of 23 residents. Specifically, the facility failed to a. obtain weekly weights to monitor the weight for Resident #12 as ordered and b. provide the dietary supplements as indicated by the Registered Dietitian. Findings include: Review of the facility policy titled Weight Management, dated and revised April 2019, indicated the following: - Weights will be obtained weekly X 4 after admission. Subsequent weights will be monthly, unless physician's orders or the resident's condition warrants more frequently as determined by the Interdisciplinary Team (IDT). - If a resident refuses weighing or circumstances prevent weighing the resident, the IDT will document the reason in the resident's medical record and care plan. Make attempt to weigh resident at another time. Resident #12 was admitted to the facility in January 2019 with diagnoses including…

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, policy review, and record review, the facility failed to provide respiratory care services in accordance with professional standards of practice two Residents (#92, and #13) out of a total sample of 23 residents. Specifically: 1. For Resident #92, the facility failed to ensure oxygen was set to the level prescribed by the physician and maintain a clean filter on the oxygen concentrator; and 2. For Resident #13, the facility failed to ensure oxygen was set to the level prescribed by the physician. Findings include: Review of the facility policy titled, Oxygen Administration, dated 1/2024, indicated the following: -Steps in procedure: 6. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. - Preparation: Verify that there is a physician's order in place. Review the physician's orders or facility protocol for oxygen administration. 1. Resident #92 was admitted to the facility in August 2024 with diagnoses…

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 interviews, the facility failed to provide care and services consistent with professional standards of practice for one Resident (#13) who required renal dialysis (a life sustaining treatment that helps the body remove extra fluids and waste products from the blood when the kidneys are not able to) out of a total sample of 23 residents. Specifically, for Resident #13, the facility failed to ensure nursing staff documented they obtained blood pressures from his/her arm with the AV fistula (arteriovenous fistula, is when an artery and vein connect directly, allowing blood to flow. This term is interchangeably used with AV shunt.). Findings include: Review of the facility policy titled Hemodialysis Access Care, dated and revised November 2017, indicated the following: - Guidelines: Steps in the procedure: 4. To prevent infection and/or clotting: Do not use access arm to take blood pressure. Resident #13 was admitted to the facility in January 2025 with diagnoses including end stage renal…

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 comprehensive person-centered plan of care was developed for Trauma-Informed Care for two Residents (#57 and #88), who were admitted with the diagnosis of Post-Traumatic Stress Disorder (PTSD), out of a total sample of 23 residents. Findings include: Review of the facility policy titled Trauma Informed Care, dated October 2019, indicated: To guide staff in appropriate and compassionate care specific to individuals who have experienced trauma. Trauma-informed care is culturally sensitive and person-centered. Reduce or eliminate unnecessary stimuli. 1. Resident #57 was admitted to the facility in July 2023 with diagnoses that included Post Traumatic Stress Disorder, dementia, frontotemporal neurocognitive disorder, and depression. Review of Resident #57's most recent Minimum Data Set (MDS) assessment, dated 3/27/25, indicated he/she scored a 00 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairments. Further…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure one Resident (#8) was free from unnecessary psychotropic medications, out of a total sample of 23 residents. Findings include: Review of the facility policy titled, Psychotropic Medication, dated 7/2023, indicated the following: -To administer and monitor the effects of psychotropic medications when prescribed. Psychotropic medications will be prescribed at the lowest possible dosage and are subject to gradual dose reduction and re-review as needed. -Dosage is appropriate for the resident and is not in excess of the suggested daily dosage maximum, unless specifically documented by the attending physician. -The interdisciplinary team assesses and monitors the appropriateness, effectiveness, and side effects associated with psychotropic medications for each resident via resident care plan review period the resident, and one indicated, the family or responsible person, will be included in this process prior to the administration of dose. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to follow the recommendations of the dentist to ensure a referral was made to the oral surgeon for one Resident (#92) out of a total sample of 23 residents. Findings include: Resident #92 was admitted to the facility in August 2024 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #92's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15, which indicated he/she is cognitively intact. The MDS also indicated Resident #93 required partial to moderate assistance with functional daily tasks. During an interview on 4/6/25 at 9:34 A.M., Resident #92 said he/she has been waiting to see the dentist. The Resident said he/she was supposed to have teeth pulled and have dentures made and no one from the facility has discussed this with him/her. Resident #92 was observed to have several small, broken and brown teeth…

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 provide the prescribed, therapeutic diet for two Residents (#12, #4) out of a total sample of 23 Residents. Specifically: 1. For Resident #12, the facility failed to ensure the Resident was receiving Nectar Thickened Liquids as ordered. 2. For Resident #4, the facility failed to ensure that the Resident was receiving a Dysphagia Mechanical Soft diet and Nectar Thick Liquids as ordered. Findings include: 1. Resident #12 was admitted to the facility in January 2019 with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease dysphasia and Barrett's Esophagus without dysplasia. Review of Resident #12's most recent Minimum Data Set Assessment (MDS) indicated that the Resident has a Brief Interview for Mental Status score of 15 out of 15 indicting intact cognition. Further review of the MDS indicated that the Resident requires partial/moderate assistance with eating. The surveyor made the following observations: -…

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 accurately document in the medical record for one Resident (#9) out of 23 total sampled residents. Specifically, for Resident #9, the facility failed to document presence of six bilateral foot wounds in weekly skin evaluations. Findings include: Resident #9 was admitted to the facility in November 2024 with diagnoses including diabetes and mild cognitive impairment. Review of the Minimum Data Set (MDS) assessment, dated 1/23/25, indicated Resident #9 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 4 out of 15. This MDS indicated Resident #9 had two unstageable pressure ulcers. This MDS also indicated Resident #9 was unable to walk and was dependent on staff for turning in bed, hygiene, and transferred. Review of Resident #9's entire plan of care related to skin, revised 3/24/25, indicated the Resident had left and right heel arterial ulcers. The entire plan of care failed to indicate the Resident had any other wounds. On 4/7/25 at 10:36 A.M., the surveyor…

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 and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Specifically, for Resident #9, the facility failed to ensure staff performed hand hygiene before applying and after removing gloves during wound care. Findings include: Review of the facility policy titled 'Handwashing/Hand Hygiene', revised July 2024, indicated, but was not limited to the following: - Policy: The facility considers hand hygiene the primary means to prevent the spread of infections. 6. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: e. Before donning (applying) gloves. i. After handling used dressings, contaminated equipment, etc. j. After removing gloves. 8. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.…

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

Based on observation and interview, the facility failed to ensure residents on 3 of 3 units had access to the use of a telephone where calls can be made without being overheard. Findings include: During the Resident Group Interview on 4/2/24 at 2:00 P.M., all participating residents said that staff are unable to provide a telephone in private for Residents to make calls. Residents reported that the facility used to have a portable phone but now any residents who do not own their own cell phone, can only use the phone at the nurses station, where anyone can hear their conversations. Residents said this occurs on all units. On 4/3/24 at 8:18 A.M., the surveyors observed Resident #16 at the nurses station on the 2nd floor making a phone call. Resident #16 said that he/she used to be able to have the conversations with his/her family on a portable phone in his/her room but did not know where the portable phone went. On 4/3/24 at 10:13 A.M. the surveyor observed a resident at the nurses station on the 2nd floor making a phone call while staff and residents were in the area and could…

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 ensure resident centered care plans were developed and/or implemented for two Residents (#47, and #53) out of a total sample of 20 Residents. Specifically the facility failed to; 1.) develop a vision, communication and fall risk care plan for Resident #47, 2.) develop a pacemaker care plan for Resident #53. Findings include: A review of the facility's policy titled Care Plans, comprehensive Person-centered dated January 2024, indicated the following: -A comprehensive, person-centered care plan will be developed for each resident. The care plan will include objectives that meet the resident's physical, psychosocial, and functional needs is developed for each resident. Comprehensive care plan development includes: a. the Interdisciplinary Team (IDT) in conjunction with the resident and his/her family or legal representative, may assist with the development of a comprehensive care plan for each resident. b. the care plan interventions are…

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, and policy review, the facility failed to ensure staff stored all drugs and biologicals in accordance with accepted professional standards of practice. Specifically, 1. The facility failed to properly secure medications and medication carts on two of four units. 2. The facility failed to ensure medications were labeled and stored according to manufacturer's guidelines in two of four medication carts. Findings include: Review of facility policy titled Storage of Medications, revised 1/2024, indicated: -The facility shall store drugs and biologicals in a safe, secure, and orderly manner. 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use. 1.) The surveyor made the following observations of medication carts left unlocked, unattended, and out of line of vision: -On 4/1/24 at 8:39 A.M., the surveyor…

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, policy review, and interview, the facility failed to store and prepare food in accordance with professional standards for food service safety. Findings include: Review of the facility policy titled, Food and Supply Storage, dated June 2018, indicated the following: - Food, non-food items, and supplies used in food preparation and service shall be stored in such a manner as to maintain safety and sanitation of food or supply for human consumption as outlined in the Federal Drug Administration Food Code, state regulations, and city county/health codes. - Discard food that exceeds their use by date or expiration date, is damaged, is spoiled, has the time and temperature danger zone requirements, or incorrectly stored such that it is unsafe or its safety is uncertain. During an initial tour of the kitchen on 4/1/24 at 7:05 A.M., the following was observed: *A container of cool whip that was opened and undated. The Top of the container was not fully secured and was loosely on the container. *A container of coleslaw with a discard date of 3/27/24. *A container 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 record review and interviews, the facility failed to obtain consents for psychotropic medications explaining the risks and benefits of treatment, prior to administering psychotropic medication for two Residents (#47 and #76) out of a sample of 20 Residents. Findings include: A review of the facility's policy titled Psychotropic Medication, dated July 2023, indicated the following: -To administer and monitor the effects of psychotropic mediations when prescribed. The interdisciplinary team assesses and monitors the appropriateness, effectiveness, and side effects associated with psychotropic medications for each resident via resident care plan review. The resident, and when indicated, the family or responsible person, will be included in this process prior to the administration of dose. Psychotropic medication management includes: a. a physician's order and an appropriate diagnosis is required for psychotropic medications. b. a written informed consent from the resident (or legally authorized individual…

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 advanced directives related to guardianships were valid and in place for two Residents, (#16 and #12) out of a total of 20 sampled Residents. Specifically: 1.) For Resident #16, the facility failed to ensure an established Guardianship was reviewed and renewed annually per court order, and; 2.) For Resident #12, the facility failed to establish a health care agent/representative when his/her activated health care proxy was no longer reachable or involved in his/her care. Findings include: 1. Resident #16 was admitted to the facility in June 2009 with diagnoses including schizoaffective disorder, syncope, and bipolar disorder. Review of his/her most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #16 scored 9 out of a possible 15 on the Brief Interview for Mental Status Exam, (BIMS), indicating moderate cognitive impairment. Review of the clinical record indicated Resident #16 had an established [NAME] Guardianship, (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, policy review and interviews, the facility failed to ensure one Resident (#31) was free from involuntary seclusion, out of a total sample of 20 Residents. Findings include: Review of the facility policy titled, Abuse: Prohibition, dated December 2017, indicated the following: -Each resident has the right to be free from verbal, sexual, physical and mental abuse, neglect, corporal punishment, involuntary seclusion, and misappropriation of their property. Every resident in the facility will be treated with respect and dignity at all times. -Involuntary seclusion: the separation of a resident from other residents or from his/her room or confinement to his/her room (with or without roommates) against the resident's will, or the will of the resident's legal representative. Resident #31 was admitted to the facility in February 2024 with diagnoses including stroke with paralysis on right side and abnormalities of gait and mobility. Review of Resident #31's most recent Minimum Data…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, policy review and interviews, the facility failed to ensure one Resident (#31) was free from restraints out of a total sample of 20 residents. Specifically, the facility failed to identify and assess the use of a pillow under a fitted sheet as a potential restraint for Resident #31. Findings include: Review of the facility policy titled, Use of Restraints, dated 1/2024, indicated the following: -Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. -Physical restraints are defined as any manual method, physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. -The definition of a…

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

Based on observations, interviews, record review, and policy review, the facility to ensure that services provided met professional standards for one Resident (#13), out of 20 total sampled Residents. Specifically, the facility failed to implement a daily wound dressing according to the physician's order for five days. Findings include: Review of the facility policy titled Medication and Treatment Orders, last revised April 2018, indicated: -Orders for medications and treatments will be consistent with regulatory standards. Review of the facility policy titled Dressings, Dry/Clean, revised April 2018, indicated: -Verify that there is a physician's order for this procedure. Resident #13 was admitted to the facility in December 2022 with diagnoses that included peripheral vascular disease and obesity. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/21/24, indicated that Resident #13 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. This MDS indicated Resident #13 had an open lesion on his/her foot.…

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 provide assistance with meals for two Residents (#379 and #30) out of a total sample of 20 residents. Findings include: Review of the facility policy titled, Activities of Daily Living (ADLs), Supporting, dated September 2019, indicated the following: -Residents will be provided with care, treatment and services as appropriate to maintain or improve as able their ability to carry out activities of daily living (ADLs). -Residents who are unable to carry out activities of daily living independently will receive the services necessary for activities of daily living. -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 (melas and snacks). 1. Resident #379 was admitted to the facility in October 2023 with diagnoses including pneumonitis due 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, record review, policy review and interviews, the facility failed to provide an activity program for three Residents (#31, #38 and #47) out of a total sample of 20 residents. Findings include: Review of the facility policy titled, Activity Evaluation, dated April 2019, indicated the following: -In order to promote the physical, mental and psychosocial well-being of residents, an activity evaluation is conducted and maintained for each resident at least quarterly and with any change of condition that could affect his/her participation in planned activities. -Each residence activities care plan relates to his/her comprehensive assessment and reflects his/her individual needs. -The activity evaluation is used to develop individual activities care plan (Separate from or as part of the comprehensive care plan) that will allow the resident to participate in activities of his/her choice and interest. 1. Resident #31 was admitted to the facility in February 2024 with diagnoses including stroke 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 an interview, the facility failed to follow up on a referral for ophthalmology services for one Resident (#12) out of a total of 20 sampled Residents. Findings include: Resident #12 was admitted to the facility in February 2016 with diagnoses including Wernicke's encephalon, chronic obstructive pulmonary disease, and alcohol dependence. Review of Resident #12's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated he/she scored 8 out of a possible 15 on the Brief Interview for Mental Status Exam, indicating severe cognitive impairment. The MDS also indicated he/she requires physical assistance from staff with bathing, dressing and toileting. During an interview on 4/1/24 at 7:59 A.M., Resident #12 said he/she wants to be seen by an eye doctor and wants glasses. Review of Resident #12's optometry notes indicated: - 11/8/23: Assessment: Glaucoma suspect, Cataract nuclear, [right] eye. Plan: Cataract surgery recommended. Referral: ophthalmology consult. - 3/8/24: 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.

Based on observations, record review and interviews, the facility failed to ensure respiratory care was provided consistent with professional standards of care for one Resident (#4) out of a sample of 20 residents. Specifically for Resident #4, the facility to ensure oxygen was administered in accordance with the physician's orders. Findings Include: Review of facility policy titled Oxygen Administration, revised January 2024, indicated to review the physician's orders for oxygen administration and to evaluate oxygen saturation. Resident #4 was admitted to the facility in March 2018 with diagnoses including chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and weakness. Review of Resident #4's most recent Minimum Data Set (MDS) assessment, dated 3/7/24, indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating that Resident #4 is cognitively intact. The MDS assessment failed to indicate the use of oxygen. On 4/1/24 at 7:52 A.M., the surveyor observed Resident #4 lying in 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure services consistent with professional standards of practice related to hemodialysis (the process of cleansing the blood by passing it through a special machine, necessary when the kidneys are unable to filter the blood) were provided for one Resident (#65) out of a total sample of 20 residents. Specifically, for Resident #65 the facility failed to ensure: 1. That a plan of care was developed for his/her AV (aterio-venous) Fistula (dialysis access site). 2. That emergency supplies were at the bedside in accordance with the physician's orders. Findings Include: Review of facility policy titled Hemodialysis Access Care, revised November 2017, indicated: care of an AV Fistula includes but is not limited to checking the patency of the site at regular intervals by checking for bruit and thrill (to ensure blood flow through the access site), and monitoring the site for bleeding. Resident #65 was admitted to the facility in November 2023…

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

Based on Record review and interviews the facility failed to act upon irregularities identified in the pharmacist's Medication Regimen Review (MRR) for one Resident (#76) out of a sample of 20 residents. Findings include: Resident #76 was admitted to the facility in March 2024 with diagnoses that included end stage renal disease, anxiety and left leg above the knee amputation. Review of Resident #76 most recent Minimum Data Set (MDS) assessment, dated 3/10/24, indicated he/she was unable to participate in the Brief Interview for Mental Status Exam and was assessed by staff as being severely cognitively impaired. Review of Resident #76's physician's orders, dated 3/19/24, indicated Ativan (a psychotropic medication used to treat anxiety) 0.5 milligrams every four hours as needed. Review of Resident #76's medical record indicated a pharmacist recommendation dated 3/18/24 with the following recommendation regarding physician's orders for Ativan as needed: PRN [as needed] orders for psychotropic medications are limited to 14 days. If the prescribing practitioner believes it is…

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

Based on record review and interviews the facility failed to ensure that PRN [as needed] ordered psychotropic drugs were limited to 14 days for one Resident (#76) out of a total sample of 20 residents. Specifically, for Resident #76 the facility failed to ensure a 14 day stop date for a PRN Ativan (a psychotropic medication used to treat anxiety) order. Findings Include: Resident #76 was admitted to the facility in March 2024 with diagnoses that included end stage renal disease, anxiety and left leg above the knee amputation. Review of Resident #76 most recent Minimum Data Set (MDS) assessment, dated 3/10/24, indicated he/she was unable to participate in the Brief Interview for Mental Status Exam and was assessed by staff as being severely cognitively impaired. Review of Resident #76's physician's orders, dated 3/19/24, indicated: Ativan 0.5 milligrams every four hours as needed. The Ativan order failed to indicate a stop date for the medication. Review of Resident #76's March and April 2024 Medication Administration Record indicated that PRN Ativan had been administered on 3/22/24.…

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 reviews, policy review and interviews, the facility failed to maintain accurate medical records for three Residents (#31, #13, and #76) out of a total sample of 20 Residents. Specifically: 1) For Resident #31, the facility inaccurately documented the Resident had been transferred out of bed. 2) For Resident #13, the facility documented a daily wound dressing as completed, when it was not completed according to the physician's order for five days; and 3) For Resident #76 the facility failed to accurately document skin assessments on the weekly skin evaluation. Findings include: 1. Resident #31 was admitted to the facility in February 2024 with diagnoses including stroke with paralysis on right side and abnormalities of gait and mobility. Review of Resident #31's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15, which indicated he/she had moderate cognitive impairment. The MDS also…

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 and interview, the facility failed to maintain a comfortable home like environment on 2 of 2 Resident units. Findings include: During observations on 2/5/23 at 8:16 A.M., the surveyor observed the following on the 2nd floor nursing unit: room [ROOM NUMBER] Bathroom: There was a hole in the wall above the sink. The water faucet on the left was stuck in the on position but no water was coming out. room [ROOM NUMBER]: There was no functional heat system. The Residents had to be moved out of the room as the outdoor temperatures had been below 0 degrees Fahrenheit. During an interview with the Maintenance Director on 2/6/23 at 2:44 P.M., he said that he was not aware that the heat was not working in room [ROOM NUMBER]. During observations on 2/7/23 at 7:49 A.M., the surveyor observed the following: room [ROOM NUMBER]: There were gouges on the bathroom door. The thermostat on the wall was missing a plate cover. There were patches of plaster without paint on the wall behind the door and the overbed…

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 provide a dignified existence for 5 Residents (#49, #44, #10, #1 and #36) out of a total sample of 24 Residents. Findings include: Review of the facility policy titled Resident Rights and dated as last revised November 2017 indicated that all employees shall treat residents with kindness, respect and dignity. 1. For Resident #49 the facility failed to assist with eating in a dignified manner. Resident #49 was admitted to the facility in February 2020 with diagnoses including schizoaffective disorder, bipolar disorder and metabolic encephalopathy. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #49 requires an extensive assist with eating. On 2/5/23, at 8:57 A.M., the surveyor observed Resident #49 lying in bed with a meal tray on an over the bed table at the end of Resident #49's bed. During an interview on 2/5/23, at 8:57 A.M. Resident #49 said he/she was very hungry. On 2/5/23, 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, record review and interview, the facility failed to ensure 4 Residents (#19, #34 #49 and #44) were free from restraints out of a total sample of 24 residents. Specifically for Residents # 19, #34, #49 and #44 the facility failed to assess the use of 1/2 siderails as a potential restraint. Findings include: Review of the facility policy titled 'Use of Restraints' and dated as last revised 11/2019, indicated: *Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. *Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily *If the device restricts a resident from changing position or place it is considered a restraint. *Prior to placing a device that could act as a restraint, a pre-restraining assessment will be completed. Review of the facility's Proper Use of Side Rails…

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 interviews, the facility failed to develop and implement the plans of care for 5 Residents (#46, #1,#36, #42, and #61), out of a total of 24 sampled Residents. Findings include: 1.) For Resident #46, the facility failed to implement physician's orders regarding the use of ace wraps his/her edema. Resident #46 was admitted to the facility in May 2020 with diagnoses including hemiplegia and hemiparesis affecting the left non-dominant side. Review of his/her most recent Minimum Data Set Assessment (MDS) completed on 11/24/22 indicated a score of 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. During an observation on 2/5/23 at 8:16 A.M., Resident #46 was observed in bed with kerlix (gauze rolls used for wound care) wrapped around his/her legs with socks on to hold the kerlix in place. Resident #46 told the surveyor that he/she is supposed to have ace wraps on both his/her legs every morning. During an observation on 2/6/23…

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 obtain consent for the use of siderails prior to their installation for 4 sampled Residents (#44, #19, #34 and #49) out of a total of 24 sampled Residents. Findings include: Review of the facility's Proper Use of Side Rails Policy, with a revised date of 4/4/19 indicated: *Before the use of side rails, the staff shall inform the resident and/or legal representative about the benefits and potential hazards associated with siderails. Observations throughout the survey revealed that the siderails the facility uses act as a 1/4 siderail when in the up position. The 1/4 side siderails in the down position acts as a 1/2 siderail as the rail remained above the mattress. 1. Resident #44 was admitted to the facility in December 2022 with diagnoses including Alzheimer's disease, falling and anxiety. Review of his/her most recent Minimum Data Set, dated [DATE] indicated he/she is severely cognitively impaired and is totally dependent on staff 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 observation and interview the facility failed to 1. store medications securely for 1 Resident (#2) and 2. label medications appropriately in 1 of 1 medication rooms and 2 of 2 medication carts. Findings include: 1. Resident #2 was admitted to the facility in May 2017 with diagnoses including asthma, schizoeffective disorder and anxiety disorder. Review of the most recent Minimum Data Set assessment dated [DATE], indicated that Resident #2 scored a 15 out of 15 on the Brief Interview for Mental Status exam indicating that Resident #2 is cognitively intact. Further review indicated Resident #2 requires supervision for activities of daily living. Review of the doctor's orders dated February 2023 indicated an order for ProAir HFA Aerosol Solution 108 (90 base) MCG/ACT (albuterol Sulfate HFA) 2 puffs inhale orally every 4 hours as needed for SOB/WHEEZE. Further review indicated an order for Flovent HFA Aerosol 220 MCG/ACT (Fluticasone Propionate HFA) 2 puffs inhale orally two times a day, rinse mouth out…

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 to maintain proper sanitation practices related to 1.) food storage, and 2.) food handling. Findings include: 1) Review of the facility policy titled, Food and Supply Storage, revised June 2018 indicated the following: *Food, non-food items, and supplies used in food preparation and services shall be stored in such a manner as to maintain safety and sanitation of the food or supply for human consumption as outlined in the Federal Drug Administration Food Code, state regulations, and city/county health codes. *Food and food supplies are stored to minimize exposure to splash, dust, or other contamination. *Refrigerated Time/Temperature Control for Safety (TCS), ready to eat foods (foods which are especially susceptible to encourage the growth of bacteria that can cause sickness if consumed, such as Eggs, Dairy, Meat products, and cooked vegetables) prepared on site that is held longer than 24 hours should be properly labeled with the common name, the preparation date (day 1), and use by date (maximum 7 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 interview, the facility failed to maintain an accurate medical record for 4 Residents (#49, #1, #36, and #64) out of a total sample of 24 Residents. Findings include: 1. Resident #49 was admitted to the facility in February 2020 with diagnoses including schizoaffective disorder, bipolar disorder and metabolic encephalopathy. On 2/5/23, at 7:50 A.M., the surveyor observed Resident #49 lying in bed with a dry protective dressing on his/her left upper arm. During an interview on 2/5/23, at 7:50 A.M.,Resident #49 said that the dressing on his/her left upper arm was because of dialysis. Review of the doctor's orders dated February 2023 indicated that Resident #49 receives dialysis Tuesdays, Thursdays and Saturdays. Further review indicated 2 different orders for checking the function of the arteriovenous (AV) fistula created for Resident #49 to receive dialysis. 1. AV Fistula: X Brachial R check thrill and bruit each shift. Document + if present, - if not present every shift. 2. Check bruit and thrill on left arm notify NP/MD with changes 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.

Based on observations and interviews, the facility failed to wear Personal Protective Equipment (PPE) appropriately to prevent the potential spread of infection on 2 out of 3 units. Findings include: On 2/5/23, at 8:00 A.M., the surveyor observed Certified Nurse's Aide (CNA) #5 in the hallway of the first floor unit with her mask beneath her nose standing next to and talking to another CNA. On 2/6/23 at 7:59 A.M., the surveyor observed a CNA walking down the hallway on the second floor, wearing gloves and holding bag of soiled linen. The surveyor then observed the CNA to open the door to the soiled linen cute, remove her gloves in the hallway and without performing hand hygiene entered the dining area. On 2/7/23, at 8:17 A.M., the surveyor observed a CNA walking down hallway on the second floor wearing gloves and carrying dirty linen. On 2/07/23, at 11:25 A.M., the surveyor and the Infection Control Nurse, observed Certified nurse's Aide #5 walking down the hallway on the first floor with 2 gloves on carrying a clean shirt and a protective brief. The surveyor also observed CNA #5…

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 interviews the facility failed to ensure that one Resident (#2D) out of a total sample of 16 residents, whose right to be informed of, and participate in his/her treatment plan, was not honored when his/her activated Health Care Agent, declined the administration of an antidepressant and antipsychotic medication and despite the Health Care Agent signed a refusal, the facility continued to administer the antidepressant and antipsychotic medication. Findings include: Review of the facility policy titled, Psychoactive Medication, dated as revised April 2018, indicated: - an informed consent from the resident or legally authorized individual in the case of resident incompetence is required for administration of psychoactive medications. Resident #2D was admitted to the facility in February 2023 with diagnoses including cognitive impairment, dementia and glaucoma. Review of the Minimum Data Set Assessment (MDS) dated [DATE], indicated that Resident #2D was rarely understood.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure 1 Resident (#2) was assessed for the ability to self administer medications out of a total sample of 24 Residents. Findings include: Review of the facility policy titled 'Safety and Supervision of Residents', dated as last revised April 2018, indicated that 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. Further review indicated that the staff and practitioner will periodically (for example, during quarterly MDS reviews) reevaluate a Resident's ability to continue to self-administer medications. Resident #2 was admitted to the facility in May 2017 with diagnoses including asthma, schizoaffective disorder and anxiety disorder. Review of the most recent Minimum Data Set assessment dated [DATE], indicated that Resident #2 scored a 15 out of 15 on the Brief Interview for Mental Status exam indicating that Resident #2…

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 complete a significant change Minimum Data Set assessment for 1 Resident (#1) out of a total sample of 24 Residents. Finding include: Resident #1 was admitted in October 2004 with diagnoses including multiple sclerosis, dysphagia and obstructive uropathy. Review of Resident #1's significant change in status Minimum Data Set assessment, dated 12/14/22, indicated he/she was not receiving hospice care. Review of the physician's order, dated 10/6/22, indicated hospice consult evaluation and treatment. Review of long term care status form, dated 10/11/22, indicated Resident #1 was admitted to hospice services. Review of the Nursing Note, dated 10/11/22, indicated Resident #1 signed onto hospice services. During an interview on 2/7/23 at 10:49 A.M., the Director of Clinical Reimbursement said that Resident #1's significant change in status MDS was not completed. The Director of Clinical Reimbursement said that the assessment should have been completed within 14 days of his/her change in status.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 Resident (#1) out of a total sample of 24 Residents. Specifically, for Resident #1, the facility failed to accurately code a) hospice services and b) antibiotic use. Findings include: Resident #1 was admitted in October 2004 with diagnoses including multiple sclerosis, dysphagia and obstructive uropathy. Review of Resident #1's significant change in status Minimum Data Set (MDS) assessment, dated 12/14/22, indicated he/she was not receiving hospice services and he/she received an antibiotic for 7 days. a) Review of the MDS dated [DATE], indicated he/she was not receiving hospice services. Review of the physician's order dated 10/6/22 indicated a hospice consult evaluation and treatment. Review of the long term care status form, dated 10/11/22 indicated Resident #1 was admitted to hospice services. Review of the nursing note, dated 10/11/22, indicated Resident #1 signed onto…

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 revise the plan of care for 2 Residents (#34 and #1) out of a total sample of 24 Residents. Findings include: 1. For Resident #34 the facility failed to revise a care plan for the level of assistance Resident #34 requires with eating. Resident #34 was admitted to the facility in June 2015 with diagnoses including quadriplegia, stroke and dementia. Review of the most recent Minimum Data Set (MDS) dated [DATE], indicated that Resident #34 scored an 9 out of 15 on the Brief interview for Mental Status exam indicating Resident #34 has moderate cognitive impairment. Further review indicated that Resident #34 requires continual supervision with one person physical assist for eating. Review of the current care plan with the Focus of ADL (Activities of Daily Living) Function, Eating; (intervention dated 2/2/22) - varies from continual supervision to total assist-resident is non-compliant with diet texture; provide education. On 2/5/23, at 8:57…

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 provide the required supervision of activities of daily living (ADLs) for one Resident #10 out of a sample of 24 Residents. Findings include: Review of the facility policy titled Activities of Daily Living (ADLs), Supporting revised September 2019 indicated 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). Resident #10 was admitted to the facility in June 2020 with diagnoses including dysphagia and dementia. The most recent minimum data set (MDS) dated [DATE] indicated a brief interview for mental status (BIMS) score of 4 out of a possible 15 indicating severe impairment. During an observation on 2/5/23 at 8:32 A.M., the surveyor observed Resident #10 in his/her room alone, eating his/her breakfast meal. During an…

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 provide assistance with grooming for 2 Residents (#32 and #5) out of a total sample of 24 Residents. Findings include: Review of the facility policy titled Activities of Daily Living, dated as revised September 2019, indicated the following: *Appropriate care and services will be provided for residents who are unable to carry out activities of daily living independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care). 1. Resident #32 was admitted in March 2020 with diagnoses including diabetes. Review of the Minimum Data Set (MDS) dated [DATE] indicated Resident #32 scored a 14 out of a possible 15 on the Brief Interview for Mental Status (BIMS), which indicated the Resident is cognitively intact. The MDS also indicated that Resident #32 requires one person physical assistance for personal hygiene. During an…

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 reviewed and interviews, for 1 of 24 sampled Residents (#36), the facility failed to ensure nursing provided care and services that met professional standards of practice, related to monitoring and identifying changes in skin. Specifically, when nursing did not complete comprehensive weekly skin assessments and there was no documentation to support when a pressure injury developed to Resident #36's left heel. Findings include: Resident #36 was admitted to the facility in February 2022 with diagnoses including dementia, dysphagia and post-traumatic stress disorder. Review of Resident #36's quarterly Minimum Data Set assessment dated , 11/2/22, indicated that he/she did not have behaviors, he/she required assistance for bed mobility and dressing, and had a history of weight loss. Review the physician's order, dated 2/10/22, indicated for nursing to conduct a weekly skin check every evening on Thursdays. Review of the medical record indicated that on 10/6/22 nursing completed a comprehensive skin…

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 complete a fall evaluation for one (Resident #10) out of a sample of 24 Residents. Findings include: Review of the facility policy titled Falls and fall risk, managing last revised April 2018 indicated the following: *A fall is defined as unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force. A fall without injury is still a fall, unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. *If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. Resident #10 was admitted to the facility in June 2020 with diagnoses including paranoid schizophrenia, and dementia. Review of Resident #10's Minimum Data Set (MDS) completed on 10/26/22 indicated he/she scored 4 out of a…

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

Based on interview, record review, and policy review, the facility failed to ensure for 2 Residents (#13 and #49) out of a sample of 2 Residents receiving dialysis care and services, were consistent with professional standards of practice. Specifically, the facility failed to ensure ongoing communication and collaboration with the dialysis center. Findings include: Review of the facility policy titled End-Stage Renal Disease, Care of a Resident with' dated as last revised 11/2017, indicated that residents with end stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Further review indicated that the contracted ESRD and the facility will agree on how information will be exchanged between the facilities to manage all aspects of the resident's care. 1. Resident #13 was admitted to the facility in January of 2018 with diagnoses including end stage renal disease, anemia, severe protein-calorie malnutrition and paranoid schizophrenia. Review of the medical record indicated that Resident #13 receives dialysis services every Tuesday, Thursday and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that pharmacy recommendations were reviewed and addressed by the attending physician for 1 sampled Resident (#44) out of a total of 24 sampled Residents. Findings include: Resident #44 was admitted to the facility in December 2022 with diagnoses including Alzheimer's disease, falling and anxiety. Review of his/her most recent Minimum Data Set, dated [DATE] indicated he/she is severely cognitively impaired and is totally dependent on staff for bathing, dressing and eating. Review of the monthly pharmacist recommendation to Resident #44's physician for the month of January 2023 indicated the following: Resident #44 is currently ordered for the following PRN psychotropic Medication: Lorazepam Concentrate: 2 MG/ML - .5 mg sublingually every 4 hours as needed for increased anxiety Please review this PRN order and consider if d/c is appropriate or document continued need for therapy and specify stop date. There was no indication in the clinical record…

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 an as needed (PRN) anti-anxiety medication was limited to 14 day use for 1 sampled Resident (#44) out of a total of 24 sampled Residents. Findings include: Resident #44 was admitted to the facility in December 2022 with diagnoses including Alzheimer's disease, falling and anxiety. Review of his/her most recent Minimum Data Set, dated [DATE] indicated he/she is severely cognitively impaired and is totally dependent on staff for bathing, dressing and eating. Review of Resident #44's physician's orders indicated the following: record indicated an order for Lorazepam Concentrate, 2 MG/ML/ give .5 mg sublingually every 4 hours as needed for increased anxiety, 12/29/22. (An anti anxiety medication). Review of Resident #44's Medication Administration Records dated December 2022, January 2023 and February 2023 indicated Resident #44 received 9 doses of Lorazepam. During an interview with Corporate Nurse #1, the Director of Nursing, and the Administrator…

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 it was free from a medication error rate of greater than 5 percent. Two of five nurses observed made 3 errors in 33 opportunities on one of three units resulting in a medication error rate of 9.09%. These errors impacted 2 Residents (#11 and #7) out of 6 residents observed. Finding include: Review of the facility policy titled , Administering Medications dated as revised 2/2020, indicated medications will be administered in a safe and timely manner, and as prescribed. -Medications will be administered in accordance with prescriber order, including any required time frame. -Medications are administered within one hour before or after their prescribed times. *During the medication administration pass on the C- Unit on 2/5/23 at 10:28 A.M., the surveyor observed Nurse #4 prepare medications for Resident #11 including: - clonazepam 0.5 milligrams (mg), 1 tablet - tramadol 50 mg, 1 tablet Review of Resident #11's active physician's orders, dated 6/17/21, indicated: -tramadol tablet 50 mg, administer 50 mg 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.