Autumn Lake Healthcare At Alice Manor

Based on interviews and a review of medical records, it was determined that the facility failed to ensure that residents who require dental services on a routine or emergent basis receive necessary and recommended dental services in a timely manner. This was evident for 2 (#55, #60) of 4 residents reviewed for dental services during the recertification/complaint survey. The findings include: 1) During an interview on 4/24/25, at 2:13 PM, Resident #55 reported that he/she requested dental services but never received them. The resident stated, The facility said my insurance is not covering that service. Resident #55 further indicated that the facility never followed-up on this request. A review of Resident #55's medical records on 4/28/25, at 10:44 AM revealed that there was no dental consultation documentation since the resident's admission in February 2024. In an interview with the Director of Nursing (DON) on 4/28/25, at 11:10 AM, the DON explained that the facility had a contracted dental services team that visited monthly for resident dental care. The team followed residents on…

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 interviews with staff, it was determined that the facility failed to: 1) ensure staff wore appropriate personal protective equipment (PPE) for enhanced barrier precautions while administering medications, and 2) ensure nursing staff use appropriate infection control practices during medication administration. This was evident for 2 (LPN #12 and LPN #16) out of 3 staff members observed during medication administration. It was also determined that the facility failed to 3) maintain isolation precautions as ordered. This was evident for 1 (Resident #16) of 24 residents records reviewed during the recertification/complaint survey process. The findings include: Enhanced Barrier Precautions (EBP) are infection control measures, particularly in nursing homes, that expand the use of personal protective equipment (PPE) like gowns and gloves beyond the standard precautions for anticipated blood and body fluid exposures. This focused approach aims to reduce the transmission of multidrug-resistant organisms (MDROs). A midline (also called a midline catheter) is 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.

Based on staff interview and an investigation of intake #MD00217176 it was determined that the facility staff failed to ensure all nursing staff were educated on the location of the facility's Automated External Defibrillator (AED). This was evident for 3 staff (Staff #23, 24, 25) out of 11 who were interviewed during the recertification/complaint survey. The findings are: An AED is a portable, user-friendly medical device designed to analyze a person's heart rhythm and deliver an electric shock, if necessary, to restore a normal heart rhythm. An investigation of intake #MD00217176 for Resident #94 was conducted on 4/30/25 and 5/1/25. On 4/30/25 from 2:00 PM to 3:00 PM and on 5/1/25 at 7:01 AM survey member conducted interviews with nursing staff related to the AED and their locations. Eleven members of the nursing staff were interviewed and three of them did not know where the AED's were located. Staffing of those interviewed were: 3 Licensed Practical Nurses (all agency), 1 Certified Medication Aide (CMA)(staff), and 7 Geriatric Nursing Assistants (GNA) (6 agency and 1 staff) were…

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

Based on complaint, observation and staff interview, it was determined that the facility staff failed to provide maintenance and housekeeping services to maintain a safe, clean, comfortable and homelike environment for the residents. This was evident for the residents residing on the first floor of the facility during a complaint survey. The findings include: Review of complaint MD00202825 on 11/12/24 revealed an allegation that the facility was very unclean. Observations of the first floor dining and activity room on 11/12/24 at 9 AM revealed a painting and the activity calendar (July 2024) resting on the floor, orange colored buckets with fish aquarium equipment and construction tools and debris, the HVAC units (6) are observed with dust, cobwebs and debris located in the top grates were the heating and air conditioning would exit the unit, and 10 unpackaged brand new chairs stacked in the middle of the room. The large pane windows in the dining/activity room were noted with cobwebs, general dirt and leaves that block the view on the property. In an interview with the facility…

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, interview, and facility document and policy review, the facility failed to report an allegation of abuse to the State Survey Agency immediately, but not later than two hours after an incident occurred for 4 (Residents #28, #37, #39, and #41) of 15 residents reviewed for abuse. Findings included: A facility policy titled, Abuse, Neglect, and Exploitation, reviewed 11/13/2023, revealed, VII. Reporting/Response. A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies (e.g.[exempli gratia, for example], law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. 1. An admission Record revealed the facility admitted Resident #28 on 10/23/2018. According to the admission Record, the resident had a medical history that included diagnoses of schizoaffective disorder…

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 10. Resident #41 A Comprehensive & [and] Extended Care Facilities Self-Report Form, dated 03/09/2022, revealed Resident #41 reported that on 03/08/2022 at 10:00 PM, they were kicked in the back. It was determined Geriatric Nurse Aide (GNA) #22 fit the description given by the resident of the accused staff. The resident later changed their statement to say the incident happened on 03/05/2022, and the aide pushed his knee into the resident's back. The facility's investigative file did not contain any interviews with other residents to determine the extent of the alleged abuse by GNA #22, and no information was provided on the resident census at the time or the mental status assessments of the residents on GNA #22's hall at the time of the incident. During an interview on 11/10/2024 at 11:59 AM, the Administrator stated he did not see any resident interviews for this incident other than the resident making allegations. 11. Resident #41 and Resident #40 A Comprehensive & Extended Care Facilities Self-Report Form,…

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, facility document review, and facility policy review, the facility failed to protect the residents' rights to be free from verbal abuse from staff and sexual abuse from another resident, which affected 3 (Residents #27, #28, and #39) of 15 residents reviewed for abuse. Specifically, Resident #37 sexually abused Resident #39, and Resident #27 and Resident #28 were verbally abused by a staff member. Findings included: A facility policy titled, Abuse, Neglect and Exploitation, reviewed 11/13/2023, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy revealed, 'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. The policy…

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 medical record review and staff interview, it was determined the facility failed to notify the resident's representative(s) in writing of the reason for transfer or discharge, along with the required notification information, in a language and manner they understand and document that notification in the medical record. This was evident for 1 (#18) of 23 residents reviewed for complaints. The findings include: On 11/13/24 at 11:45 AM, a review of Complaint #MD00210696 was conducted. In the complaint, the complainant reported that s/he was not notified when Resident #18 was transferred and admitted to the hospital. On 11/14/2024 at 10:32 AM, a review of Resident #18's medical record revealed the resident was admitted to the facility in September 2022, and, in October 2024, Resident #18 was transferred to the hospital. There was no evidence in the clinical record that the facility staff had provided the resident's representative with written notification of the transfer at the time of transfer or as soon as practicable after the date of transfer out of the facility to 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 medical record review and staff interview it was determined that the facility staff failed to code the resident's status accurately on the Minimum Data Set (MDS) assessment (Resident #8). This was true for 1 of 20 resident complaints reviewed during a complaint survey. The findings include: The facility staff failed to accurately document a residents' medication status on an admission MDS for Resident #8. The MDS is a federally mandated assessment tool that helps nursing home staff members gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. A review of Resident #8's closed medical record on 11/13/24 at 10 AM revealed that an admission MDS was completed on 05/29/23. The MDS coded the resident under Section M0210 (unhealed pressure ulcers) as yes. However, a review of the nursing and physician assessments did not reveal Resident #8 had any healing…

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 reviews of a complaint, a closed medical record and staff interview, it was determined that the facility staff failed to initiate a care plan for a resident with a history of substance abuse disorder. This was evident for 1 (Resident #24) of 20 residents reviewed during a complaint survey. The findings include: Review of complaint MD00203494 on 11/19/2024 revealed allegation that Resident #16 was sent to the hospital on [DATE] with a change in condition. While Resident #16 was being evaluated in the emergency room, Resident #16 was identified as have received Methadone. Methadone is administered to treat moderate to severe pain. Methadone can also treat narcotic drug addiction. Resident #16 was a roommate to Resident #24 in March 2024. Review of Resident #24's closed medical record on 11/19/24 at 11 AM revealed diagnoses including a cerebrovascular accident, seizures, alcohol dependence and substance abuse disorder. Resident #24 was receiving the medication Methadone for substance abuse disorder. Upon…

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 compliant, reviews of a closed clinical record and administrative records, and staff interviews, it was determined that the facility failed to ensure that a resident received services to promote healing of a surgical wound. This was found evident in 1 (Resident #14) out of 2 Residents reviewed for wound care during a complaint survey. The finding include: A wound vacuum, also known as a vacuum-assisted closure (VAC) or negative-pressure wound therapy, is a medical device that uses suction to help wounds heal. Review of complaint MD00202563 on 11/12/24 at 11 AM revealed an allegation that Resident #14 was admitted to the facility on [DATE] with an abdominal surgical wound that was to have a wound-vac applied upon admission. The wound-vac was not applied on 01/03/24. Review of Resident #14's closed medical record on 11/12/24 revealed a nursing note, dated 01/04/24 at 10:30 PM indicating Resident #14 called 911 to be transported back to the hospital because the facility had not obtained a wound-vac and 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 compliant, reviews of a closed clinical record and administrative records, and staff interviews, it was determined that the facility failed to ensure that a resident received services to promote healing of a pressure ulcer. This was found evident in 1 (Resident #6) out of 2 Residents reviewed for pressure ulcers during a complaint survey. The finding include: A pressure ulcer (also known as pressure sore or decubitus ulcer) is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according to their severity from Stage I (area of persistent redness), Stage II (superficial loss of skin such as an abrasion, blister, or shallow crater), Stage III (full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), and Stage IV (full thickness skin loss with extensive damage to muscle, bone, or tendon). Review of complaint MD00188407 on 11/12/24 at 11 AM revealed an allegation that Resident #6 developed bed sores on his/her buttock area. A review of Resident #6's closed clinical record on…

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, interview, and facility policy review, the facility failed to investigate a fall, determine root cause, and implement interventions to prevent further falls for 1 (Resident #40) of 1 resident reviewed for accidents. Findings included: A facility policy titled, Falls and Fall Risk, Managing, revised 02/2018, indicated, After a fall: - If a resident has just fallen or is found on the floor without a witness to the event, nursing staff will record vital signs and evaluate for possible injuries to the head, neck, spine, and extremities. - An incident report must be completed for resident falls. The incident report form should be completed by the nursing supervisor/charge nurse on duty at the time and submitted to the Director of Nursing Services. The policy revealed, The nursing staff will begin to try to identify possible or likely causes of the incident. They will refer to resident-specific evidence including medical history, known functional impairment, etc. [et cetera; and so forth]. An admission Record indicated the facility admitted Resident #40 on…

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 medical record review, observation and interview with resident and facility staff, it was determined that the facility failed to provide appropriate interventions for a resident with identified history of trauma. This was evident for 1 (#19) of 23 residents reviewed for complaints. The findings include: On 11/13/24 at 10:58 AM, a review of complaint # MD00211446 revealed the complainant reported that in October 2024, during a visit with Resident #19, in response to interactions with Resident #19, the complainant alleges s/he encountered unprofessional and inappropriate conduct from facility staff related to his/her interactions with Resident #19. On 11/14/24 at 2:07 PM, a review of Resident #19's electronic medical record (EMR) was conducted. The medical record documented that Resident #19 had medically complex conditions with multiple diagnosis which included Parkinson's, Schizophrenia, and depression and resided in the facility for long term care following admission to the facility in May 2023 until the beginning of September 2024, when the resident was admitted to 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 medical record review and staff interview It was determined that the facility failed to ensure that a resident's medication regimen was free from an unnecessary psychotropic medication failing to ensure that a psychotropic medication prescribed as needed was limited to 14 days. This was evident for 1 (#17) of 23 residents reviewed for complaints. The findings include: As needed (PRN) orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. On 11/12/24 at 10:33 AM, a review of complaint #MD00210287 was conducted. In the complaint, the complainant expressed concerns with how Resident #17's medication prescribed. On 11/12/24 at 12:36 PM, a review of Resident #17's November 2024 Medication Administration Record (MAR) revealed a 6/10/24 order for Ativan (Lorazepam) Injection Solution, inject 2 milligrams (MG) intramuscularly (IM)…

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 reviews of a closed medical record and staff interview, it was determined that the facility staff obtained a laboratory specimen on a resident without a physician's order. This was evident for 1 (Resident #14) of 20 complaints reviewed during a complaint survey. The findings include: A review of Resident #14's closed medical record on [DATE] at 10 am, revealed a laboratory result, dated [DATE] at 9:33 am, that indicated Resident #14's TSH and Free T4 levels were within normal limits. Further review of Resident #14's closed medical record indicated that Resident #14 was readmitted to the facility on [DATE] and Resident #14's physician instructed the nursing staff to obtain a TSH level on [DATE] to measure Resident #14's Thyroid function (TSH). The facility laboratory staff obtained a blood specimen on [DATE] and reported on [DATE] that Resident #14's TSH level was 59.35 (normal 0.45 - 4.50) Resident #14's physician was notified and Resident #14's thyroid medication was adjusted. Resident #14's 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.

Based on review of medical records and interview with staff, it was determined that the facility failed to have an effective system in place to 1) ensure that drug regimen reviews were done for all residents at least monthly, 2) ensure tht pharmacist recommendations were acted upon timely from identified irregularities during the monthly pharmacy review and 3) have evidence that drug regimen reviews were completed, addressed and acted on by the physician. This was evident for 4 (#32, #31, #54, #9) out of the 5 residents reviewed for medication regimen review during the annual survey but affected all residents in the facility. The findings include: 1) A record review was conducted for Resident #32 on 6/7/21 at 12:33 PM. Documentation of the monthly drug regimen reviews were not found in Resident #32's medical record. An interview was conducted with the Director of Nursing (DON) on 6/9/21 at 8:23 AM. The DON stated the pharmacist was doing monthly reviews remotely and would send the report to the DON and Assistant Director of Nursing (ADON). The pharmacy reviews/ recommendations would…

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 staff interview, it was determined the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was observed on 1 of 2 nursing units during the annual survey. The findings include: On 6/11/21 at 12:01 PM, an environmental tour was conducted with the Director of Maintenance and the following observations that had been made during the survey were brought to his attention: The right and left wheelchair armrests were missing from the wheelchairs in room [ROOM NUMBER]-1 and room [ROOM NUMBER]. The right wheelchair armrest was missing from the wheelchair in room [ROOM NUMBER]-2, room [ROOM NUMBER]-1 and room [ROOM NUMBER]. The left wheelchair armrest was missing on the wheelchair in room [ROOM NUMBER]-2. The vinyl covering on the right wheelchair armrest in room [ROOM NUMBER]-2 was split on the back panel with yellow foam exposed. The following observations were made while on tour with the Maintenance…

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 medical record review and staff interview it was determined that the facility failed to document that information was provided to the acute care facility when a resident was transferred there emergently. This was evident for 2 (#229, #129) of 5 residents reviewed for transfer to an acute care facility. The findings include: 1a) Review of Resident #229's medical record on 6/8/21 at 7:55 AM revealed a nursing note dated 10/11/20 at 18:47 which documented that Resident #229 was found face down, lying in the hallway, bleeding with a deep laceration to the right side of the nose. Resident #229 was transferred to an acute care facility for treatment. 1b) Continued review of Resident #229's medical record revealed a change in condition note dated 10/12/20 at 6:50 AM which documented that Resident #229 was face down on the floor with a hematoma on the forehead. Resident #229 was sent out to an acute care facility. 1c) Further review of the medical record for Resident #229 revealed a change in condition note dated 11/10/20 at 17:27 documenting that Resident #229 complained of pain…

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 medical record review and staff interview, it was determined that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was identified for 2 (#229, #233) of 5 residents reviewed for hospitalization during the annual survey. The findings include. 1a ) Review of Resident #229's medical record on 6/8/21 at 7:55 AM revealed a nursing note dated 10/11/20 at 18:47 which documented that Resident #229 was found face down, lying in the hallway, bleeding with a deep laceration to the right side of the nose. Resident #229 was transferred to an acute care facility for treatment. 1b) Continued review of Resident #229's medical record revealed a change in condition note dated 10/12/20 at 6:50 AM which documented that Resident #229 was face down on the floor with a hematoma on the forehead. Resident #229 was sent out to an acute care facility. 1c) Further review of the medical record for Resident #229 revealed a change in condition note dated 11/10/20 at 17:27 documenting that Resident #229 complained of pain in the upper left…

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 medical record review and staff interview, it was determined the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#32) of 5 residents reviewed for unnecessary medications and 2 (#232, #233) of 5 residents reviewed for hospitalization during the annual survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) Review of Resident # 32's medical record on 6/7/21 at 12:33 PM revealed a quarterly MDS with an assessment reference date (ARD) of 3/29/21 that failed to capture diagnoses of depression, osteoporosis, anemia, GERD (Gastroesophageal reflux disease) and insomnia in Section I, Active…

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 5). This surveyor interviewed Resident #65 on 6/3/21 at 12:57 PM. The resident stated that he/she was not consulted with plan of care changes. A review of Resident #65's clinical record on 6/11/21 revealed that the resident had a care plan meeting on 2/3/21, but the resident was not invited. The Assistant Director of Nursing and Social worker were interviewed on 6/11/21 at 1:06 PM. She confirmed that the invitations sent to the responsible party and the resident were not in the chart. It was not evident that the resident was invited. The Administrator, Director of Nursing, and ADON were informed of the findings on 6/11/21 at 1:30 PM. Based on medical record review and staff interview, it was determined the facility staff 1) failed to review and revise the interdisciplinary care plans after MDS assessments and 2) failed to ensure that care plan meetings were held with the interdisciplinary team and residents/or resident responsible party. This was evident for 6 (#32, #46, #232, #233, #65, #1 ) of 60 residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, and observation, it was determined that the facility staff failed to ensure food was served in a palatable manner. This was evident for 2 (#30, #329) out of 3 residents reviewed for complaints about food. The findings include: 1. During the initial tour of the facility Resident #30 was interviewed on 6/3/21 at 1:40 PM and stated that the food tastes terrible. A test tray was obtained on 6/9/21 at 12:56 PM. Temperatures were taken to evaluate the palatability. The pork chops were 84 degrees F (Fahrenheit), the mashed potatoes were 114F, and the kale was 131F. A temperature of 130 degrees or above would indicate that hot food is served at level of palatability. The Administrator (Staff #4), Director of Nursing (Staff #3), and Assistant Director of Nursing (Staff #2) were informed of the findings on 6/11/21 at 1:30 PM. 2) During an interview for the facility's annual survey on June 4, 2021 at 9:50 AM, Resident #329 complained about the quality of the food served 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 administrative record review, medical record review, observation and interviews with facility staff, it was determined the facility 1) failed to document in the resident medical record that pain medication was refused when offered to a resident for their complaints of pain 2) failed to provide the correct Advanced Beneficiary Notice to residents who received Medicare Part A services, 3) failed to protect resident medical information, 4) failed to accurately document when a treatment was or was not done and 5) failed to timely write a progress note. This was found to be evident for 7 ( #179, #331, #332, #333, #132, #32, #229) 60 residents reviewed and for 9 resident room numbers of 60 residents reviewed during the annual survey The findings include: 1) On 6/8/21, complaint # MD00164919 was reviewed for multiple concerns. One of the concerns was resident # 179's transfer to an acute care hospital on 3/5/21 for chronic back pain. Review of the medical record on 6/8/21, and a pain assessment done on 3/5/21,…

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 and interviews with facility staff, it was determined that the facility failed to adhere to infection control practices and guidelines to prevent the transmission and spread of germs and microorganisms in the facility. This was found to be evident during the facility's annual Medicare/Medicaid survey. The findings include: 1) On 6/3/21 at 9:33 AM, Staff # 10 was observed leaving Resident #181's room without wearing a gown or eye protection. Resident #118 was newly admitted without verification of their COVID status. The door was open and there were no Transmission Based Precautions (TBP) signs posted on the door. Staff # 10 did not wear a gown or eye protection while inside of the resident room while they were providing services to the resident. An interview was conducted with the ADON, on 6/3/21 at 10:00 AM, and she stated that the resident was admitted to the facility 2 days ago and the facility was awaiting documentation of the resident Covid Vaccination status to be brought in by 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 clinical record review and staff interview, it was determined that the facility staff failed to ensure that a PASARR was completed for the residents (Resident #31). This was evident for 1 out of 2 residents reviewed for PASARR compliance. The findings are: Residents are required to have a Preadmission Screening and Resident Review (PASARR) completed as part of the admission process. A PASARR is federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. A review of Resident #31's clinical record on 6/4/21 and 6/11/21 revealed that the PASARR was not in the clinical record. The Assistant Director of Nursing (ADON) and the social worker were interviewed on 6/11/21 at 1:06 PM. They said it was not in the clinical record because it was pulled for the survey team. They said they would provide a binder with all of the PASARR's in them. The PASARR provided was completed on 12/17/20. It was reviewed and Section C was incomplete. The Administrator (Staff #4), Director of Nursing (Staff #3), and the ADON (Staff #2) were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined that facility staff failed to develop and initiate a comprehensive, for a resident that was resident centered and specific to the resident's needs. This was evident for 1 (#32) of 5 residents reviewed for mobility and 1 (#79) of 16 residents reviewed in relation to complaints during an annual survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Resident #32's medical record was…

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

Based on clinical record review and staff interview, it was determined that the facility staff failed to ensure that activities of daily living (ADL's) were provided to residents who needed assistance (Resident #31). This was evident for 1 out of 4 residents reviewed for ADL care. The findings are: During the tour of the facility on 6/4/21 at 8:09 AM, Resident #31 was observed to have long fingernails on both hands. Resident #31 was observed again on 6/10/21 at 12:36 PM to have long fingernails. The Administrator (Staff #4), Director of Nursing (Staff #3), and the Assistant Director of Nursing (Staff #2) were informed of the findings on 6/11/21 at 1:30 PM.

Based on observation, record review and staff interview, it was determined that facility staff failed to provide care and treatment to Resident #32 in accordance with physician's orders and then signed off that the treatment was performed. This was evident for 1 (#32) of 5 residents reviewed for mobility. The findings include: Observation was made, on 6/3/21 at 9:54 AM, of Resident #32 lying on his/her right side with his/her feet on the bottom sheet and nothing under the heels. A second observation was made with a second surveyor present on 6/3/21 at 2:02 PM of Resident #32 lying on the right side with feet crossed and on the bottom sheet. The heels were not offloaded. Subsequent observations were made on 6/4/21 at 7:15 AM, on 6/4/21 at 1:45 PM and on 6/7/21 at 11:05 AM of Resident #32 lying in bed, partially on the right side and the feet were not offloaded. On each day, 6/3, 6/4 and 6/7/21 the assigned nurse signed off on Resident #32's June 2021 Treatment Administration Record (TAR) that the feet were offloaded. Review of Resident #32's June 2021 physician's orders documented,…

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

Based on record review, observation and interview, it was determined the facility staff failed to provide the necessary treatment and services to promote healing and prevent infection to an existing pressure ulcer for Resident #46. This was evident for 1 (#46) of 4 residents reviewed for pressure ulcers during the annual survey. The findings include: Medical record review for Resident #46, on 6/7/21 at 7:23 AM, revealed a weekly skin evaluation with documentation that Resident #46 had a Stage 3 wound to the right buttock with a date of onset of 4/14/21. The skin evaluation documented treatment was in progress. Pressure ulcers are injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin. They can happen to anyone, but usually affect people confined to bed or who sit in a chair or wheelchair for long periods of time or have compromised nutrition. Pressure ulcers most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips, and tailbone and can develop over hours or days. At stage 3, there is full-thickness 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 observation, record review and staff interview, it was determined that the facility failed to ensure that residents with limited range of motion received the appropriate treatment and services to prevent further decline in range of motion. This was evident for 2 (#46, #233) of 5 residents reviewed for positioning and mobility during the annual survey. The findings include: 1) Observation was made, on 6/3/21 at 9:43 AM, of Resident #46 lying in bed with bilateral elbows bent to the chest with the hands up by the shoulders, which were contracted. Resident #46 did not have anything in the palms of the hand and was not wearing any type of hand or arm splint. Resident #46 was observed again on 6/3/21, 6/4/21, 6/7/21 and 6/9/21. Resident #46 was not wearing any type of splints or anything in palms of hands. The surveyor observed a container of arm and hand splints in the resident's closet. Review of Resident #46's medical record on 6/7/21 at 7:40 AM revealed a care plan, has ADL (activities of daily living) self-care performance r/t impaired mobility, central cord syndrome with…

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

Based on medical record review and staff interviews, it was determined that the facility staff failed to ensure resident receiving antipsychotic medication had a gradual dose reduction (GDR) review conducted by licensed pharmacist. This was evident for 1(#9) out 5 residents reviewed for unnecessary medications during the survey. The findings include: Risperidone is an antipsychotic mood stabilizer medication prescribed for treatment of acute manic or mixed episodes associated with bipolar disorder. www.medicinenet.com A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to anti-psychotic, anti-depressant, anti-anxiety, and hypnotic medications. On 6/8/21 at 1:18 PM, Resident #9 was selected for Unnecessary Meds, Psychotropic Meds, and Med Regimen Review during the investigation phase of survey. Medical record review on 6/10/21 revealed that Resident #9 was admitted to the facility with a history of Dementia, Parkinson Disease, Schizoaffective Disorders, history of fall and chronic…

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 medical record review and interview, the facility failed to provide medically ordered routine dental care to a resident (Resident #1). This was evident in 1 of 60 residents reviewed during the facility's annual survey. The findings include: Review of Resident #1's medical records revealed the resident was admitted to the facility on [DATE] with the diagnosis of Dementia. Resident #1's Brief Interview of Mental Status (BIMS) score was unable to be calculated due to the resident's inability to answer questions in a coherent manner. The BIMS score is an assessment used by long term care facilities to determine how well the brain is functioning or cognition level. Because Resident #1 was unable to be scored on the BIMS test, the facility found it necessary to require a resident representative to assist the resident in making medical and/or financial decisions. Further review of Resident #1's medical records revealed that on February 10, 2021 the resident was ordered to have a dental consultation because 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 observation and staff interview, it was determined the facility failed to equip and maintain secure handrails on 2 of 2 nursing units observed during the annual survey. The findings include: On 6/11/21 at 12:01 PM, an environmental tour was conducted with the Director of Maintenance and the following observations of handrails, that had been made during the survey, were brought to his attention: A hand rail was missing approximately 2 feet in length in the hallway outside of room [ROOM NUMBER]. The Maintenance Director stated it was from where the previous maintenance staff took out the water fountain. The current Maintenance Director has been in his position since December 2020. The hand rail end cap was missing on the handrail outside of room [ROOM NUMBER], at the corner of the hall that was diagonal to the nurse's station on the second floor. The hand rail end cap was missing outside of room [ROOM NUMBER] and on the corner across from the first floor nursing station. There was a missing hand rail next…

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 review of facility employee's training files and staff interview, it was determined that the facility failed to ensure that all employees received mandatory abuse prevention training. This was evident for 1 out 5 employee's human resource records reviewed during the survey. The finding includes: Facility must provide abuse training to all staff (which includes for the purposes of the training guidance), all facility staff, (direct and indirect care and auxiliary functions) contractors, and volunteers. On 6/10/21 at 9:30 a.m, review of staff member # 12's facility training transcripts revealed this staff member was employed in year 2008 and signed the pledge against abuse policy. Continued record review revealed no evidence that this staff received additional annual or semiannual abuse training from the facility, which is a federal employee requirement for all staff providing direct and indirect resident care for nursing home residents. On 6/7/21 at 10:00 a.m., surveyor conducted interview with ADON who was unable to provide staff members training manuscript to verify…

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 staff interview, the facility staff failed to store linen in an appropriate manner to prevent the spread of infection. This practice was observed on an outside location of the building during the survey process. The findings include: On 9/6/18 at approximately 9:00 AM, the surveyor noted that on the third-floor balcony, outside of the facility's building, there were two rolling racks full of clothing hanging on the racks. Some of the clothes had fallen to the bottom of the rack. Along with the racks of clothing there was a large tiered linen rack with the flaps completely open. On the linen cart was clean folded linen open to the air. The Assistant Director of Nursing (ADON) was informed. At 10:15 AM The Corporate Nurse, the Director of Nursing (DON), ADON and staff #9 were on the balcony observing the contents and began removing the items. At approximately 10:30 AM the facility Administrator was interviewed and acknowledged being aware that the clothing and linen had been removed from the laundry room. It is the facility's responsible to protect its…

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 the facility staff failed to maintain dignity for Resident #24 while bathing the resident in the resident's bedroom. This was evident for 1 out of 30 residents investigated during the survey process. The findings include: On September 3, 2018 around 10:00 AM, while interviewing residents during the first part of the survey, this writer went to Resident #24 and 25's bedroom door which was closed. The writer knocked on the bedroom door, asking for Resident #25, whose bed is by the window of the room. Staff person #10 answered, come in, you can come in. Upon entrance into the bedroom the writer observed Resident #24 in the first bed near the door. The resident was completely unclothed, exposed to the writer. The Geriatric Nursing Assistant (GNA) was bathing the resident without having pulled the privacy curtain around the resident. The writer stated to the GNA, doesn't the resident have a privacy curtain, noticing the privacy curtain behind the GNA. The GNA stated, oh, I'm sorry. Residents have a right to receive services from the facility that when performed,…

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 medication cart observations and staff interviews it was determined the facility staff failed to ensure that the medical records were kept in a confidential manner. This was evident in 1 out of 3 medication carts. The findings include: On 9/4/18 at 10:55 A.M. on the second-floor long term care 200-Unit the surveyor observed on top of the unattended medication cart, the nursing second floor nursing shift to shift report document exposed and was not kept in a confidential manner. This document is used by the facilities nursing staff for assigned nursing task preformed during the nurses shift on assigned residents. On this shift to shift report the surveyor was able to view the resident's names, room numbers for rooms 316A through 233B and vital signs that were visible for public access. The residents' room assignment and personal information was available to be viewed by any observer. On the same day on 9/4/18 at 11:26 A.M., the surveyor interviewed the Certified Medication Aide (CMA), staff member #1, who replied, I was providing care to another resident and forgot to turn…

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 staff interview, it was determined the facility failed to ensure that glucose test strips and medications used for treatments were properly labeled. This was evident in 2 of 13 storage areas inspected during the survey. The findings include: On 9/11/18 beginning at 1:30 PM, an inspection of areas used to store medications and medical supplies was initiated. This included inspection of 2 medication storage rooms, 1 clean utility room, 4 nurses' medication carts, 4 carts used by Certified Medicine Aides (CMAs), and 2 treatment carts. In the first-floor nurses' medication cart #2, a vial of Glucocard Vital Glucose Test Strips was observed not marked with the date when opened or the discard date. On the side of the vial it stated, Use within 90 days (3 months) of first opening. Once the vial has been opened and test strips have been exposed to air, a gradual process of deterioration begins. It is a minimal standard of nursing practice to label items with the date when opened or the discard date if opening the item changes the expiration date. In the first-floor…

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

Based on meal service observations and staff interviews it was determined that the facility staff: 1) failed to demonstrate appropriate hand hygiene practices during meal service involving residents on the 200 Nursing Unit. This was evident for one 1 out of 3 units, and 2) failed to install plumbing in a manner that ensures that food contact equipment is not contaminated in case of a sewage blockage. The findings include: 1) On 9/4/18 at 11:50 AM during a meal observation of the lunch tray service on the 200 Nursing Unit, Geriatric Nursing Assistant's (GNA's) #5, #6, #7, and #8 was observed touching uniformed clothing with hands without washing hands or sanitizing hands before pulling and serving lunch trays from the food cart and delivered the breakfast trays to resident's Rooms #218, 221, 219, 206, 202 and 201. 2) On 9/12/18 at 12:30 PM during the lunch meal observation in the main dining room, the surveyor observed Geriatric Nursing Assistant (GNA) #4 touching and pulling his/her nursing uniform top down over their nursing uniform pants and continued pulling resident's lunch…

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.