Meadow Park Rehabilitation And Healthcare Center

Based on medical record review and interviews it was determined that the facility staff failed to ensure a resident's medical record was accurate. This deficient practice was evident for 1 (#217) in 2 medical records reviewed for accuracy during the recertification survey. The findings include: On 06/11/25 at 12:19 PM a review of Resident #217's electronic medical record revealed the resident had a diagnosis of a complete traumatic amputation of the left lower leg. On 06/12/25 at 10:13 AM a review of Resident #217's skin assessment revealed the resident had a left heel wound. On 06/18/25 at 11:25 PM during an interview with the Administrator, the surveyor reported it was documented in the resident's electronic medical record that the resident had a complete traumatic amputation of the left lower leg, but it was documented on the wound progress report that the resident had a left heel wound. On 06/18/25 at 1:46 PM during an interview with the Administrator the surveyor asked who is responsible for ensuring the residents' diagnoses are entered correctly in the electronic medical…

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 it was determined the facility staff failed to maintain infection control practices as evidenced by staff not maintaining a resident's oxygen tubing and disposing of waste according to professional standards. This was evident in 1 of the 3 residents observed for infection control practices (Resident #60). The finding includes: On 06/07/22 at 9:44 am during an interview with Resident #60 the surveyor noticed the resident was not wearing her oxygen tubing. Under further inspection, the surveyor noticed the oxygen tubing was on the floor under the resident's bed. The surveyor made RN #17 the resident's assigned nurse aware. On 06/07/22 at 09:50 am RN #17 came into the resident's room and observed the resident's oxygen tubing on the floor under the bed. After surveyor intervention, the resident was provided a new oxygen tubing that was applied to the nasal passages.

Based on observation and interview, the facility failed to maintain the dignity of residents by leaving Resident #45's face soiled with food after the resident was assisted with a meal and neglecting to cover a residents urinary collection bag. This was evident for 2 of 22 residents reviewed during the facility's annual survey (Residents #49 and #159). 1.) The facility staff failed to treat a resident with respect and dignity by failing to cleanse Resident #49's face after feeding him/her breakfast. During observations rounds on 6/7/22 at 9:45 am AM Resident #45 was observed with eggs on the right side of his/her face. A review of Resident #45's medical record on 6/7/22 at 10:00 AM, revealed the resident is totally dependent on staff for care. During an interview with Registered Nurse (RN) #8 on 6/7/22 at 10:15 AM, s/he stated, the resident had been fed earlier and the GNA assigned to the resident should have cleaned his/her face prior to leaving the room. The findings were verified by RN #8. 2.) The facility staff failed to treat a resident with respect and dignity by failing 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 observation and interview, the facility failed to accommodate the needs of a resident by failing to ensure a resident's call bell was in reach when needed (Residents #9 and Resident #51). This was evident in 2 of 22 residents reviewed during the facility's annual survey. The findings include: A call bell is a bedside button tethered to the wall in the resident's room, which directs signals to the nursing station; a call light usually indicates that the patient has a need or perceived need requiring attention from the nurse or geriatric nursing assistant (GNA) on duty. 1. On 6/5/2022 at 9:50 a.m. Resident #9 was observed lying in bed, when asked about the location of his/her call bell, the Resident #9 looked around for the device. The device was observed on the floor next to the right side of the resident's bed. On 6/5/2022 at 9:50 a.m. GNA #24 was interviewed the GNA verified the surveyors observation and the location of Resident #9's call bell. 2. On 6/5/2022 at 10:15 a.m. Resident #51 was observed lying in bed. The resident's call bell was located inside the first drawer…

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

Based on observations and interviews it was determined the facility failed to provide a homelike environment as evidenced by residents having stained linen and soiled equipment in residents' rooms. This was evident for 1 of 4 residents assessed for a clean and comfortable homelike environment (Residents #29). The finding includes: On 06/07/22 at 11:02 am the surveyor observed Resident #29 in bed receiving enteral nutrition (nutrition provided through a tube contacted to the stomach). The enteral feeding pump was attached to an intravenous pole, which had dried enteral feeding on the base. While attempting to interview Resident #69 in his/her room on 06/07/22 at 11:24 am, the surveyor observed stained linen on the resident's bed, this observation was made after the linen was changed. During an interview with GNA #30 on 06/07/22 at 11:30 am he/she stated most of the linens have stains on them. GNA #30 retrieved another fitted sheet; however, that sheet stained as well. On 06/10/22 at 10:15 am in an interview, Unit Manager #23, he reported the staff was supposed to clean up the enteral…

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 administrative record review and interviews with facility staff it was determined the facility failed to complete an investigation into allegations of abuse. This was found to be evident for 4 of 11 complaints reviewed during the facility's annual Medicare/Medicaid survey (Residents # 366, 367, 368, and # 370). The findings include 1. On 6/7/22 at 10:00 a.m. the survey team requested documentation of the facility's investigations into allegations of abuse. A review of the facility's investigations revealed the following: On 11/21/2021 Resident #360 made an allegation of abuse. A review the facility's investigation revealed the file contained Resident #face sheet and a facility self-reporting form. There were no interview statements from staff or residents or resident assessments. On 7/16/2021 Resident #367 made an allegtion of abuse. A review the facility's investigation revealed a copy of the resident's face sheet, a facility self-reporting form, and typed interview statements from 4 staff (a Nurse Practitioner, a OTA, a Nurse, and a GNA). There were no resident interviews…

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 it was determined the facility staff failed to complete a Notice of Transfer when a resident was sent to the hospital. This was evident in 1 of 1 (Resident #37) resident records reviewed for transfer documentation. The findings include: On 06/16/22 at 10:40 am while reviewing Resident#37 electronic medical record, the surveyor noticed there no documentation of a Notice of Transfer for review when the resident was sent to the hospital on [DATE]. The surveyor spoke with the Director of Nursing (DON), Staff #3, and requested a copy of the document. On 06/17/22 at 9:45 am the DON, Staff#3 made the surveyor aware there was not a transfer summary.

Based on medical record review and staff interview, it was determined the facility staff failed to ensure comprehensive Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 of 4 (#23) residents reviewed for dialysis during the revisit 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. On 8/26/22 at 11:40 AM a review of Resident #23's medical record revealed a physician's order, pre and post dialysis weight on Mon, Wed, Fri. two times a day every Mon, Wed, Fri. that was written on 8/14/22. A 8/17/22 at 11:00 AM progress note documented, patient came back from Dialysis, vitals stable. Dialysis is a procedure to remove waste products and…

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

Based on observation, record review, and interview, it was determined the facility failed to ensure that a resident's care plan intervention was implemented for making sure the call bell was within reach when needed. This was evident for 1 of 3 (#9) residents reviewed for access to the call bell during the revisit survey. The findings include: A call bell is a bedside button or cord attached to the wall in the resident's room, which allows the resident to alert a nurse or other healthcare staff member remotely of their need for help. The use of a nurse call bell system is designed to contribute to ensuring resident safety and allows residents in healthcare setting to alert staff remotely of their need for help. Immobile residents can use the nurse call bell to communicate with staff for any type of assistance. On 8/25/2022 at 1:20 PM, Resident #9 was observed lying in bed. When asked to use her/his call bell, Resident #9 looked around for the device but could not find it. The call bell was observed dangling on the floor and attached to the left upper side of the resident's 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.

The facility's staff failed to provide the necessary services to maintain personal hygiene for 2 of 12 residents reviewed during this annual survey (Resident #49 and #79). The findings include: 1. During observations rounds on 6/7/22 at 9:45 am AM Resident #45 was observed with eggs on the right side of his/her face. A review of the resident's medical record on 6/7/22 at 10:00 AM, revealed the resident is totally dependent on staff for care. During an interview with the Registered Nurse (RN) #8 on 6/7/22 at 10:15 AM, s/he stated, the resident had been feed earlier and the GNA assigned to the resident should have cleaned his/her face prior to leaving the room. The findings were verified by RN #8. 2. The surveyor conducted an interview with a member of Resident #79's family on 6/10/22 at 1:30 pm. The family member complained that assigned facility failed to provide personal care to the resident for most of the day. On 6/10/22 at 1:44 pm the surveyor observed Resident #79 dressed in nightclothes. Resident #79 was interviewed on 6/10/22 at 1:44 pm the resident stated, I asked staff 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 record review, observations and interview, the facility staff failed to follow a physician's orders by not consistently weighing , and for failing to follow physician orders for the administration of oxygen therapy. This was evident for 2 out of 22 residents reviewed during an annual survey (Residents #61 and #66). The findings include: 1. On 6/5/2022 at 1:00 p.m. a review of Resident #66's medical record revealed an order on 4/15/2022 at 6:51 p.m. for Resident #66 to receive Oxygen (O2) at 2 liters per nasal cannula. On 6/6/2022 at 9:30 a.m. a review of medical record revealed an order for weights every two (2) weeks on Monday from 12/14/2020-4/15/2022. The following weights were documented 5/31/2021 (221.6 lbs.), 9/20/2021 (220 lbs.), 2/21/2021 221.5 lbs.), 3/7/2021 (219 lbs.), 4/4/2022 (186 lbs.), no other weights were documented after 4/4/2022. An oxygen concentrator is a device that concentrates the oxygen from a gas supply to provide supplemental oxygen, as a medical treatment. On 6/5/2022 at 2:00 p.m. observation of Resident # 66's, Oxygen per nasal cannula, 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.

Based on medical record review, observation and interview it was determined that the facility failed to ensure a supplement was administered to a resident as ordered. This was found to be evident for 1 out 8 of residents (Resident #49) reviewed during medication order reconciliation. The findings include: During observation rounds on 6/7/22 at 9:45 am Resident #49 was noted with a Magic Cup nourishment on his/her bedside table. The nourishment was dated 6/6/22 HS (hour of sleep). A review of Resident #49's medical record on 6/7/22 at 10:00 am revealed a physician order dated 11/29/21 for Magic Cup three times a day for weight loss with breakfast, lunch, and dinner. A review of the Medication Administration Record on 6/7/22 at 10:15 am revealed the Magic Cup was signed off as being administered at 1700 (5:00 pm) and the resident had consumed 100% of the nourishment. During interview with Registered Nurse (RN) #8 on 6/7/22 at 10:15 am she stated the nourishment comes from the kitchen and must be documented every meal. Surveyor then reviewed the concern that the documentation reveals…

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 the facility staff failed to ensure that pharmacist recommendations were acted upon and documented in the resident's medical record. This was evident for 2 of 3 (#13, #15) residents reviewed for drug regimen review. The findings include: Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. 1) Resident #13's medical record was reviewed on 8/26/2022 at 9:50 AM and revealed the resident was admitted to the facility on [DATE]. Monthly medication regimen review was not readily found in Resident #13's medical record. At 10:25 AM on 8/26/2022, the Director of Nursing (DON) was asked 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 and interviews it was determined that the facility failed to properly label and store residents' medications in accordance with currently accepted professional principles. This was observed in 2 of the 2 medication storage rooms within the facility. The findings include: On [DATE] at 9:21 am while checking the second-floor medication storage room the surveyor noted the following observations: Acetaminophen Suppositories in the refrigerator without a patient label, stored Hydrocortisone Suppositories for Resident #37 that expired on [DATE], and Hydrocortisone AC suppositories that expired on [DATE]. Also, there was an open and un-dated insulin pen for a resident who was no longer in the facility in a bag labeled with name for of a third discharged resident's name. There were four large bags of medications for residents who were no longer at the facility. On [DATE] 10:02 during an interview with Unit Manager #23 she made the surveyor aware the staff is supposed to medications of discharged…

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.

The facility failed to provide laboratory services to residents (Resident #79). This was evident for 1 of 1 resident investigated for laboratory services in the facility's annual survey. The findings include: On 6/6/22 at 1:30 pm, the surveyor conducted a family interview with the family of Resident #79. A family member alleged that the facility failed to provide laboratory results for ordered laboratory tests in the month of May 2022. The surveyor reviewed Resident #79's medical record on 6/6/22 at 3:00 pm. The review revealed that laboratory test were pending from 5/18/22. The surveyor interviewed the Director of Nursing on 06/10/22 at 9:21 am regarding the process for requesting laboratory test. The Director of Nursing explained that the provider issues orders for laboratory work. The facility request laboratory staff to draw blood work through the interface with the laboratory provider. The Director of Nursing admitted that the facility staff did not know how to properly order laboratory staff to draw resident blood work. The Director of Nursing stated that the staff 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.

The facility failed to maintain updated and accurate records including there facility matrix, a record of medical orders for treatment (Resident #75), and emergency contact information for residents (#356). This deficient practice has the potential to affect all residents. The finding include: 1. On 6/5/22 at 8:30 am, the survey team leader requested a matrix of all current residents. The facility matrix is used to identify pertinent care categories for newly admitted residents in the last 30 days and all other residents. The Administrator provided a copy of the facility matrix on 6/5/22 at 11:00 am. On 6/6/22 at 7:30 am, the survey team reconciled the facility's matrix with their observation from the tour the previous day and determined that the matrix did not align with their observations. On 6/6/22 at 10:00 am, the survey Team Leader informed the Administrator that the matrix was inaccurate. On 6/7/22 at 10:00 am, the Administrator provided an updated matrix. 2. A review of Resident #75's medical records on 6/8/22 at 2:11 pm revealed the resident receives dialysis through a third…

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 interview with the facility staff it was determined that the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the resident's status as evidenced by failure to: 1a) assess the resident's Functional Status; b) Bowel and Bladder status; c) Medication Usage for antipsychotic gradual dose reduction and 2) Medication usage for antibiotic use. This was found to be evident for 2 out of 32 residents (Resident #28 and #57) reviewed during the investigative stage of the survey. The findings include: The Minimum Data Set (MDS) is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. The MDS provides a comprehensive assessment of the resident's functional capabilities and helps nursing home staff identify health problems. It is designed to collect the minimum amount of data to guide care planning and monitoring for residents in long-term care settings. MDS assessments need to be accurate to ensure each resident receives the care they need. 1a) On 4/10/19…

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 interview it was determined that the facility failed to consistently ensure an interdisciplinary team, which included the resident, unit nurse manager, a geriatric nursing assistant and the physician or nurse practitioner contributed to the resident's care plan and failed to ensure care plans were updated and revised as needed as evidenced by failure to update care plans in relation to: 1) the use of a urinary catheter; 2) development of a pressure ulcer and the need for intravenous hydration. This was found to be evident for 2 out of 32 residents (Resident #28, #90) reviewed for care planning during the investigative stage of the survey. The findings include: 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. 1) During an interview with Resident #28 on 4/10/19 the surveyor asked why he/she had a Foley catheter also call urethral catheter. The resident replied, I don't think I can go to the bathroom without it, the resident also revealed that one…

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, interview and observation it was determined that the facility failed to provide care in accordance with professional standards of practice as evidenced by the failure to: 1a) ensure nursing assessments were completed as ordered by physician; 1b) provide physician ordered flushes of a intravenous line to maintain patency 1c) complete dressing changes as ordered to an intravenous line; 1d) address possible swallowing issues; 2a) to ensure an antibiotic to treat a wound infection was administered as needed; 2b) to ensure dressing changes for a chronic non-pressure wound were completed as needed; 2c) to ensure blood sugars were monitored as ordered; and 2d) to administer insulin as ordered; 3) to administer pain medication available in the interim box; 4) to ensure assessment and accurate documentation of resident respiratory status and oxygen usage and 5) to maintain and complete incident reports and investigations into falls; 6) update a hospice care plan to reflect discontinuation of hospice services. This was found to be evident for 6 out of 32…

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 records review and interview with the facility staff, the facility failed to ensure when a resident was verbalizing feelings of depression the facility clarified which behavioral health recommendations to follow when two treating behavioral health physicians wrote conflicting orders for the resident. This was true for 1 out of 1 resident (Resident #28) reviewed in the investigation portion of the survey. The findings include: On 4/17/19 Resident #28's medical records were reviewed and revealed that the resident was admitted to the facility in June 2018 for rehabilitation and with diagnoses which included anxiety disorder, and major depression. Review of a note dated June 2018 from Behavioral Health Psychiatrist (Staff #38) services revealed: Thought Content: Negative about her/his-self, Mood: Depressive. Medical intervention; Increase Zoloft (medication used to treat depression) to 150 mg (milligram) daily. In August 2018 the Psychiatrist Staff #38 followed up on resident's depression. It revealed the following: Reports feeling sad, and depressed. Medication…

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 interview with staff it was determined that the facility failed to identify that the wrong dosage of medication was being discontinued which caused the resident to receive a lower dose of a medication that was being used to treat continued depression. This was evident for 1 out of 7 residents (Resident #28) reviewed for unnecessary medication review. The findings include: Resident #28's medical records were reviewed on 4/17/19 and revealed that the resident was admitted to the facility in June 2018 for rehabilitation and diagnoses that included anxiety disorder and major depression. In June 2019 the resident was examined by psychiatrist (Staff #38), and documentation review of the visit revealed that the resident was having negative thoughts about his/herself and was feeling depressed. The physician increased the resident Zoloft (medication used to treat depression) to 150 milligram (mg) every day. The Psychiatrist #38 followed-up with the resident in August 2018. The resident revealed to the psychiatrist he/she was still having feelings of sadness…

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 resident council meeting minutes and interview with residents and facility staff, it was determined the facility failed to give adequate responses to grievances that were presented by the resident council. This was found to be evident during a resident council meeting, and a review of the resident council meeting minutes that was completed during the facility's annual Medicare/Medicaid survey. The findings include: Resident Council is a group of residents that meets regularly the on behalf of all residents in the facility to discuss and offer suggestions about facility policies and procedures affecting residents' care, treatment, and quality of life. Facility staff are required to consider residents' views and act upon grievances and recommendations. Facility staff must consider these recommendations and attempt to accommodate them, to the extent practicable. The survey team conducted a resident council meeting on 4/10/19 at 2:30 PM. There were six residents (Resident's #18, #63, #72, #74, #101 and #110) in attendance and represented the first and second floor, of…

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

Based on administrative record review, medical record review and interviews with facility staff it was determined the facility failed to notify the resident representative of a treatment change for a resident with a pressure ulcer. This was found to be evident for 1 of 7 complaints (Resident #164) reviewed during the facility's annual Medicare/Medicaid survey. The findings include: Complaint # MD00134417 was reviewed on 4/9/19 through 4/15/19 during the facility's annual Medicare/ Medicaid survey. Resident #164's family alleged the facility did not notify the family of a pressure ulcer or change in the resident condition. Upon medical record review on 4/10/19, it was noted that Resident #164 was admitted to the facility with a pressure ulcer to the coccyx (buttock) area. In an interview with the complainant on 4/11/19 at 3:24 PM, s/he stated that the family was unaware of the resident pressure ulcer and that the resident did not have one when admitted to the facility. The complainant went on to say that when the family visited Resident #164, they saw the facility staff treating 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 interviews with facility staff and residents, it was determined the facility failed to ensure that residents can submit grievances without fear of reprisal. This was found to be evident for 1 of 6 residents (Resident #101) that attended the resident council meeting conducted during the facility's annual Medicare/Medicaid survey. The findings include: The state surveyors conducted a resident council meeting on 4/10/19 at 2:30 PM. There were six residents who attended the meeting. The question was asked, can you file a grievance without fear that someone will get back at you? All the residents responded, no. The residents stated that the staff display attitudes if you complain about them. The residents explained the call bells will be ignored, and the staff will delay bringing them their water. One of the residents went on to explain that s/he complained to a male nurse on one occasion and when s/he requested a gown the GNA came into the room and slung the gown at him/her. The resident was unable to provide a name of the GNA. The Administrator was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with staff it was determined that the facility failed to have a system in place to ensure the resident, or their responsible party, received written notification of a transfer to the hospital, including appeal rights and ombudsman contact information. This was found to be evident for 2 out of 3 residents reviewed for hospitalization (Resident #30 and #164). The findings include: 1) On 4/15/19 review of Resident #30's medical record revealed the resident had been originally admitted to the facility in 2018. The resident was discharged from the facility to the hospital in January 2019. Further review of the medical record failed to reveal any documentation that a notice regarding the transfer had been provided to the resident or the resident's responsible party. On 4/15/19 at 5:26 PM the Administrator confirmed that they currently do not have a process in place to provide the required transfer information. The concern regarding the failure to have a system in place 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 medical record review and interview it was determined that the facility failed to ensure the development of a baseline care plan that included instructions needed to provide effective and person centered care within 48 hours of admission. This was found to be evident for 1 out of the 32 residents (Resident #172) reviewed during the investigative portion of the survey. The findings include: On 4/12/19 review of Resident #172's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included kidney failure, dementia, heart failure, diabetes and a history of falling. Further review revealed a physician order, dated 4/9/19 for swallowing precautions which included providing oral care before and after meals, remaining upright for 30 minutes after eating and to provide small bites of food and small sips of liquid. On 4/12/19 review of the care plan section of the electronic health record revealed a plan, initiated 4/10/19, addressing nutritional problem or potential…

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 interview it was determined that the facility to ensure comprehensive care plans were developed for residents as evidenced by failure to address: 1) a non-pressure chronic ulcer; and 2) the use of an indwelling Foley urinary catheter 3) revision of a care plan after treatment discontinuation. This was found to be evident for 3 out of 32 residents (Resident #171, #266 and #83) reviewed during the investigative portion of the survey. The findings include: 1) Review of Resident #171's medical record revealed the resident was admitted in March 2019 with a diagnoses that included, but not limited to, diabetes, high blood pressure and a non-pressure chronic ulcer (wound) of the left lower leg which had an infection. Review of the primary care physician's admission note revealed a plan to address the resident's left leg cellulitis (skin infection) by continuing doxycyline 100 mg twice a day for 2 more weeks. The resident was seen by the wound physician on 3/26/19, review of the note from this visit revealed a plan for daily silvadene dressings. 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, medical record review and interviews with facility staff it was determined the facility failed to provide individualized activities for residents and failed to assist resident's to group activities. This was found to be evident for 3 out of 3 residents (Resident #315, #4 and #71) reviewed for activities during the facility's annual Medicare/ Medicaid survey. The findings include: 1) Observations were made on 4/10/19 at 12:26 PM, 4/11/19 at 11:00 AM and 4/12/19 at 1:45 PM and Resident #315 was in his/her room. There were no activities observed taking place with the resident. An interview was conducted with Activity Representative (#18) on 4/17/19 at 10:10 AM and s/he was made aware Resident #315 was observed multiple times and was not involved in activities. Staff #18 stated there is a book that is kept on the unit that has specific one on one activities done with each resident. On 4/17/19 at 11:45 AM Staff #18 submitted a book that contained a form titled Activity Attendance Log. Review of the activity log revealed that there were no activities documented 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 medical record review and interview it was determined that the facility failed to ensure safety precautions were communicated to staff providing care for a resident. This was found to be evident for 1 out of 6 residents (Resident #172) reviewed for accidents during the survey. The findings include: On 4/12/19 review of Resident #172's medical record revealed diagnoses that included kidney failure, dementia, heart failure, diabetes and a history of falling. Further review revealed a physician order, dated 4/9/19 for swallowing precautions which included providing oral care before and after meals, remaining upright for 30 minutes after eating and to provide small bites of food and small sips of liquid. On 4/12/19 review of the care plans revealed a plan, initiated 4/10/19, addressing nutritional problem or potential nutritional problem r/t therapeutic diet; altered consistency diet; abnormal nutrition-related labs (elevated HgbA1c), diuretic therapy; dysphagia (difficulty swallowing); dx of CHF…

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 it was determined that the facility failed to ensure supplements were administered to residents as ordered. This was found to be evident for 3 out of 32 residents (Resident #71, #30 and #165). The findings include: 1) On 4/12/19 review of Resident #71's medical record revealed the resident was admitted in March 2019 after a hospitalization for a fracture. Review of the 3/8/19 Nutrition Risk Assessment revealed a recommendation: Ensure Plus BID [twice a day] for additional 700 calories and 26 grams of protein. A corresponding physician order for the Ensure Plus two times a day was also found but had been discontinued. A 4/4/19 dietician note revealed the resident had a significant weight loss over the past month and recommended an increase in the Ensure Plus to three times a day. A corresponding physician order for the Ensure Plus three times a day was also found. Further review of the medical record failed to reveal any documentation that either nursing or geriatric nursing assistants (GNA) had been administering 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 interview with staff it was determined that the facility failed to ensure pain medication was administered in a timely manner. This was found to be evident for 1 out of 4 residents (Resident #167) reviewed for pain management. The findings include: On 4/17/19 review of Resident #167's medical records revealed the resident was admitted to the facility in November 2018 for rehabilitation and with diagnoses that included lumbar radiculopathy (a painful condition that happens when a nerve in your lumbar spine (lower back) is pinched or irritated) and leg pain. Further review of the medical records revealed that the resident arrived at the facility approximately 8:00 PM and a pain assessment was completed at that time. It revealed the intensity of the pain was moderate. Further review of the pain assessment revealed that on a score of 1-5 the pain level was at a 4. Review of the emergency medication supply list revealed that it contains oxycodone 15 milligram. It further revealed that the pharmacy must be contacted for authorization number prior 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 interviews with residents, review of resident council meeting minutes and interviews with facility staff it was determined the facility failed to have adequate staff to ensure that response to call lights were timely and that staff provided care assistance requested by the resident in a timely manner. This was found to be evident for 6 out of 6 resident council members (Resident # 18, #63, #72, #74, #101 and #110) interviewed during the survey. The findings include: Review of resident council meeting minutes on 4/10/19 revealed concerns from residents of call lights not being answered as follows: -The meeting minutes for July 25, 2018 revealed residents reported call lights are not being answered between 2-5 AM. -The meeting minutes for August 15, 2018 revealed call lights are not being answered and that there was a 2 hour wait for call bell response during the day. -The meeting minutes for October 17, 2018 revealed that on 11-7 shift staff are not answering call bells in a timely manner. -The meeting minutes for November 6, 2018 revealed residents complained there was not…

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 employee files and interviews it was determined that the facility failed to ensure skills competency was demonstrated by newly hired nurses and geriatric nursing assistants (GNA) prior to being allowed to work independently with residents. This was found to be evident for 3 out of 3 GNAs (#15, #16, and #17) and 2 out of 2 nurses (#34 and #32) reviewed for new hire skills competency during the survey. The findings include: 1) On 4/16/19 review of GNA #15, #16, and #17's employee files revealed all three had been hired between 1/27/19 and 2/17/19. Further review of the employee files failed to reveal any documentation of a skills evaluation having been conducted after hire. On 4/16/19 at 1:01 PM the Administrator confirmed that there was no official system in place to assess the GNAs competency prior to being allowed to work independently with residents. The Administrator later presented with blank skills checklist forms for nurses and GNAs that could be used. 2) Review of complaint MD00135012 revealed Resident #165's nurse on 12/21/18 was Nurse…

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

Based on review of employee information and interview it was determined that the facility failed to ensure annual evaluations were being completed for nursing staff. This was found to be evident for all nursing and geriatric nursing assistants (GNA) having worked at the facility for more than a year and has the potential to affect all residents. The findings include: On 4/17/19 a review of a list of current nursing and GNA staff revealed many staff with a hire date of 2017 or before. At 10:19 AM the Corporate Regional Director of Operations (#37) reported that when [name of current corporate owners] took over they rehired the staff but maintained their years of service from the original hire date. The regional director went on to confirm that no annual evaluations had been completed because we haven't observed for a year. Surveyor then addressed the concern with the regional director and the Administrator that they were operating under the same provider number as the previous owners, have many of the same staff and the regulation requires an annual evaluation of the GNAs.

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 ensure pharmacist recommendations resulting from identified irregularities during the monthly pharmacy review were addressed and acted on by the physician as evidenced by failure to address recommendation for gradual dose reduction and failure to identify missed lab test for diabetes monitoring and failure to include required components in the medication regime review policy. This was found to be evident for 2 out of the 5 residents (Resident #28 and #20) sampled for medication regimen review during the investigative stage of the survey. The findings include: 1) On 4/17/19 Resident #28's medical records were reviewed and revealed that on July 26, 2018, September 20, 2018 and October 24, 2018, a pharmacist completed the required monthly medication review. This review found irregularities with the resident medication and recommendations were made. The July 2018 pharmacy recommendation revealed: 1. Please attempt a gradual dose reduction if…

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 interview with facility staff it was determined that the facility staff failed to adequately monitor the use of antipsychotic medications used to treat a resident's behavior. This was evident for 1 out of 5 residents (Resident #28) reviewed for unnecessary psychotropic medications. The findings include: Antipsychotics should only be used in accordance with relevant current standards of practice and for specific target behaviors that present a danger to self or others. On 4/17/19 Resident #28's medical records were reviewed. This review revealed a physician order for Clonazepam, Seroquel, Risperdal, Trazadone and Zoloft. Further review of the physician orders reveal that the resident was taking Clonazepam for anxiety, Trazadone and Zoloft for depression and the physician wrote Seroquel and Risperdal for personality disorder. Review of the medication administration records (MAR) reveal generalized behaviors not individualized or specific to the resident identified behaviors. On 4/17/19 during an interview with Nurse (#21) the surveyor asked her if…

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, interview and observation it was determined that the facility failed to ensure medications were secured and accounted for as evidenced by observation of a physician prescribed antibiotic cream being stored in a resident's dresser drawer and nursing staff failure to sign off the administration of a narcotic on the Medication Administration Record (MAR) and the Controlled Substances Record. This was found to be evident during a dressing change observation (Resident #171) and an observation of narcotic count between shifts and has the potential to affect all residents. The findings include: 1) Review of Resident #171's medical record revealed the resident was admitted in March 2019 with a diagnoses that included but not limited to diabetes, high blood pressure and a non-pressure chronic ulcer [wound] of the left lower leg which had an infection. On 4/12/19 during a dressing change observation the resident reported that there was medicated lotion in the dresser drawer. Surveyor observed the nurse remove a bag with a tube of Mupirocin Ointment from 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 observations it was determined the facility failed to consistently maintain a sanitary environment in the kitchen based on 2 random observations. This has the potential to affect any resident who consumes food from the kitchen. The findings include: Observation on 4/9/19 at 8:28 AM of the Kitchen Staff #13 was observed with her hair out of the hair net while preparing food on the tray line. She was made aware that her hair was out during the tray line and asked someone else to tuck her hair up. Surveyor notified the Kitchen General Manager (Staff #4) at 8:30 AM on 4/9/19 of the observations. On 4/11/19 at 8:00 AM surveyor entered kitchen to request a test tray. The kitchen general manager (#4) was observed at the tray line with no hair net on. He was asked where his hair net was. He proceeded to his office, placed his hat on and stated that he was just checking on a few orders. At 1:46 PM on 4/11/19 the combined observations from 4/9/19 and 4/11/19 of the dietary staff and the Kitchen General Manager #4 were reviewed with the Kitchen General Manager #4 again 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interviews with facility staff it was determined the facility failed to provide services from an outside source to a resident with a pressure ulcer that required ongoing care and treatment. This was found to be evident for 1 of 7 complaints (Resident #164) reviewed during the facility's annual Medicare/Medicaid survey. The findings include: Review of intake #MD00134417 in which the family alleged the resident acquired a stage 2 pressure ulcer to buttocks and the facility did not notify the family of the wound or change in condition. Medical record review conducted on 4/9/19 revealed a nurse admission assessment completed on 11/14/18 for Resident #164 indicated a pressure area to coccyx (bottom portion of the spine below the sacrum). Review of wound documentation forms presented to the survey team failed to have measurements of the wound that was identified upon the resident's admission. Further review of wound documentation forms revealed that on 11/27/18 measurements obtained…

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 interview with staff it was determined that the facility failed to ensure documentation of specialist assessments were available in the medical record for review by other health care professionals. This was found to be evident for 3 out of the 32 residents (Resident #165, #171 and #20) reviewed during the investigative portion of the survey. The findings include: 1) Review of Resident #165's medical record revealed a psych nurse practitioner (NP) (Staff #25) note, dated 11/27/18 that revealed the resident was refusing antidepressant medications and that the nurse practitioner intended to follow-up with the resident the following week to re-evaluate if patient will agree to anti-depressants. Further review of the medical record revealed a nursing note, dated 12/12/18 at 12:16 AM that revealed the following: resident seen by the psych practitioner today and the resident is to start zoloft 50 mg po [by mouth] daily for depression. A corresponding physician order dated 12/12/18 was also found. Review of the Medication Administration Record (MAR)…

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.