Autumn Lake Healthcare At Cherry Lane

Based on observations, interviews and record reviews it was determined that the facility failed to store food in a manner that maintains professional standards of food service safety. This was evident in the Kitchen and in 2 (2A/B and 1A/B) of 4 Nutrition Rooms in the facility. This practice had the potential to affect all residents that eat food prepared by the facility's kitchen and that store food in nutrition rooms. The findings include:1. During the initial tour of the Kitchen with [NAME] #1 on 7/30/25 at 8:43 AM there were food products found open in the walk-in freezer with no label showing opening or expiration dates. The following foods were identified as being opened and unlabeled: An opened bag of chocolate chip cookies An opened bag of Charbroil Pattie for Salisbury An opened Bag of Salisbury steaks An opened bag of Tilapia Fillets An additional bag of Salisbury steaks/burgers An opened bag of Frozen Cookie Dough During an interview with [NAME] #1 on 7/30/25 at 8:58 AM he reported the items found were supposed to be labeled after opening with dates showing an opening 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 medical record reviews, interviews and observations it was determined that the facility failed to ensure medical records were complete, readily assessable and organized. This was evident for 2 (Resident #163 and #137) of 2 residents reviewed for medical record storage.The findings include:During an interview with the complainant for Complaint #337031 on 7/31/25 at 5:07 PM he/she reported that the facility had not obtained weights daily as had been ordered for Resident #163.During a review of the Electronic Medical Record (EMR) on 8/01/25 at 11:52 AM for Resident #163 it was discovered that there was a doctor's order from 1/30/25 to 2/12/25 for weights to be done daily which stated, Weigh at same time every day and call MD if increases more than 2 lbs/day or 5 lbs/5 days, every night shift. Further review of the medical records for Resident #163 revealed three weights were documented in the EMR, they were obtained on 1/30/25, 2/03/25 and 2/12/25. The Treatment Administration Record (TAR) showed the weight order was signed off as completed every day from 1/30/25 - 2/11/25…

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

Based on observation, interviews and record review, it was determined that the facility failed to ensure appropriate infection control practices. This was evident for 1 (Resident #16) of 59 residents reviewed for infection control during the recertification survey.The findings include:On 07/30/25 at 11:39 AM during initial rounds the surveyor observed a pair of sneaker-like black shoes on the bedside table of Resident #16. The inner soles of the shoes were marked with the resident 's name. Next to the shoes, was an unopened 4oz container of apple juice.While the surveyor was in the room, GNA #10 came into the resident's room to provide care. The surveyor interviewed GNA #10 and enquired about the black shoes. GNA #10 stated that she received training on infection control and that she was not responsible for the shoes on the bedside table. GNA #10 in referring to the shoes stated, I did not put it there, I met it there. Later at 11:45 AM on 07/30/25, Charge Nurse #9 entered the room and was interviewed by the surveyor. Charge Nurse #9 stated that the shoes should have been placed in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews it was determined that the facility failed to screen and offer vaccinations to residents. This was evident for 2 (Residents #20 and #138) out of 5 residents screened for immunizations.The Findings include: During a medical record review on 08/12/2025 at 3:46 PM it was discovered that Resident #20 had been admitted on [DATE] and was offered the Pneumonia Vaccination which he/she refused. Resident #20 was still a resident in the facility and there was no documentation that Resident #20 was reoffered the Pneumonia vaccine. During additional medical record review on 8/12/25 at 3:59 PM it was revealed that Resident #138 was offered and refused the pneumonia vaccine on 8/31/2018. Resident #138 was still a resident in the facility and had no documentation of additional Pneumonia vaccines being offered. During an interview with the Infection Preventionist (IP) on 8/13/2025 at 8:06 AM he reported we would offer it again this year if you refused last year. He reported…

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 surveyor observation and staff interview it was determined the facility staff failed to keep the building clean, neat, attractive and in good repair. This was evident on both floors of the facility. The findings include. An environmental tour was conducted with the maintenance director (staff #16) on 7/21/23 at 9 AM. The maintenance director was informed of the accumulated environmental concerns by multiple members of the survey team during the initial days of the survey beginning on 7/10/23. The following observations were confirmed by the Maintenance director. In room [ROOM NUMBER] bathroom, revealed vinyl cove/base molding separating from wall along the left wall, a browned stained ceiling tile near the ventilation fan and a rust stained metal suspended ceiling strip above the sink. In room [ROOM NUMBER] bathroom, revealed a hole in the bottom of the wall to the right of the sink area measured approximately 10 inches long, 3 to 4 inches deep extending down under the cove molding area and appeared…

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 and record review it was determined the facility failed to perform a thorough investigation of an allegation of abuse. This was evident for 4 (Resident #253, #1, #175, and #71) out of 6 residents reviewed for abuse. The findings include: 1) Resident #253 relayed to the surveyor on 7/11/23 at 12:02 PM an allegation of abuse in which they had reported that an Occupational Therapist was swinging the cane at me (approximately) last Thursday (7/6/23) and the facility reported to my family that I was threatening the staff. On 7/17/23 at 12:01 PM, PTA (Staff #28), stated in an interview with surveyors regarding the alleged incident on 7/7/23: We had to pull him/her back in the chair. We snugged him/her back in the chair by the gait belt. He/she wants to walk. On 7/21/23 at 12:00 PM, the facility ' s incident self report form was reviewed by surveyors. The report indicated that, on 7/14/23 at approximately 3:47 PM, the facility began investigating an allegation that Resident #253 had been abused during a therapy session on or around 7/6/23. The facility documented that…

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

Based on a review of a complaint intake, medical record review, and staff interview it was determined that the facility failed to document the reason leading up to a transfer of a resident to the hospital in the medical record including a reason for the transfer. This was evident for 1 (Resident #160) of 6 residents reviewed for hospitalization. The findings include: On 7/25/23 complaint intake, MD00140476 was reviewed related to resident #160. Based on a review of the complaint the resident had a fall, and busted his/her head and was transported to the emergency room. A review of resident #160's closed medical record on 7/25/23 did not reveal any evaluations or progress notes indicating the resident had a fall and was transferred to the hospital. Review of the closed paper medical record on 7/25/23 revealed Hospital discharge instructions with the resident's name time stamped/prepared on 4/17/19 at 4:13 AM. The local hospital's discharge instructions indicated resident #160 had a fall from standing and a laceration to scalp. On 7/26/23 the assistant director of nursing (ADON) 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 staff interview it was determined the facility staff failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 4 (Residents #105, 119, 106, and 160) of 6 residents reviewed for Notice requirements before transfer/discharge. The findings include: 1) Review of the medical record for Resident #105 on 7/28/2023 at 10:07 AM revealed that Resident #105 was transferred to an acute care facility on the following dates: 2/8/2022 for left hip acute fracture, on 10/29/2022 for change in mental status, on 4/12/2023 for unwitnessed fall, and on 7/13/2023 for change in mental status and hypotension (low blood pressure). However, there was no documentation and/or evidence in the record indicating that the facility staff notified the resident/resident's representative (RP) in writing of the reason for the transfer/discharge to the acute care facility on the above dates/times the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, it was determined that the facility failed to failed to develop and implement comprehensive, Resident-centered care plans for residents residing in the facility. This was evident for 5 (Resident #71, #252, #177, #93, and #399) of 33 resident care plans reviewed during the survey. The findings include: 1) A review of Resident #71's physicians orders on 7/18/23 at 1:51 PM revealed an order dated 6/23/23 for OT (Occupational Therapy) Clarification; RNP (Registered Nurse Practitioner) order; Resting hand splint to be worn on L [left] hand 8hrs [hours] on, during the day, assessing for redness, skin tears, and maintaining palmar hygiene and nail hygiene. This order was discontinued on 7/18/23. On 7/19/23 at 9:14 AM, the resident's care plan was reviewed and revealed that there was no focused care plan problem listed for the hand splint ordered on 6/23/23. In an interview with the Rehabilitation Director (Staff #27), on 7/24/23 at 12:56 PM, Staff #27 stated that when OT…

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, interviews, and observations it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 8 (Resident #69, #148, #43, #253, #31, #50, #71, #72) of 83 residents reviewed during the survey. The findings include: 1) On 7/24/2023 at 1:11 PM, Review of order summary report for Resident #69 revealed two separate medication orders for Bactroban: - Bactroban External Ointment 2 % (Mupirocin) Apply to face topically one time a day for wound care. Order date 6/26/2023 and discontinued on 7/19/2023. - Left Cheek/Face Wound- Apply Bactroban and leave open to air twice a day. every day and evening shift order date 6/6/2023 and discontinued on 7/19/2023. On 7/24/2023 at 2:15 PM, Review of Medication Administration Record (MAR) and Treatment Administration Record (TAR) for June and July 2023 was completed. Staff documentation revealed duplicate medication (Bactroban) application to the resident's face from 6/27/2023 through 7/19/2023: MAR application noted one time a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, it was determined that the facility staff failed to maintain the resident call system in working order. This was evident for 2 (Unit 2C and Unit 1B) of 4 nursing units observed during the annual survey. The findings include: 1) 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. During an initial observation of the 2C unit on 7/10/2023 at 10:00AM, the surveyor observed the following: On 7/10/2023 at 10:11 AM, Resident #39 was observed lying in bed watching TV. When asked to use her/his call bell, Resident #39 looked around but could not find the device.…

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 and documentation review, it was determined the facility failed to ensure a training program was set up and in place for their staff to be educated on Abuse, neglect, and exploitation, and resident abuse prevention. This was evident for 5 (Staff #14, #35, #36, #37, #38) out of 5 staff training records and 1 (Staff #30) of 1 nurse aide reviewed for nurse aide abuse training. The findings include: 1) On 07/20/23 at 12:59 PM, an interview was conducted with Assistant Director of Nursing (ADON), an educator. The ADON stated that all nursing staff must complete the annual mandatory competency packet, which was filed on the competency binder. A review of annual competency packet binder on 07/20/23 at 01:30 PM revealed that the form contained several categories of nursing skills quizzes, including resident Abuse, neglect prevention & bill of rights: the section had ten printed statements and staff supposed to answer true or false. Also, each staff's competency packet was stapled with post-tests of other training ( hand hygiene, dementia care, infection control, HIPPA,…

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 that the facility staff failed to treat a resident in a dignified manner by leaving two urinals that contained urine hanging on the bedrail. This was evident for 1 (Resident #17) of 83 residents reviewed during the annual survey. The findings include: During an observation of Resident #17 on 7/11/2023 at 9:54 AM, the surveyor observed the resident sitting in their wheelchair by the left side of the bed and watching TV. Surveyor observed two urinals hanging on the resident's right upper bed rail (one was completely full of yellow colored urine and the other urinal was 1/4 full). When asked if the resident had used the urinals prior to breakfast, s/he said yes. Resident #17 stated that s/he had used the urinals a couple of hours ago. Observed on the floor by the foot of the resident's bed was dirty linen and a hamper full of dirty laundry with fruit flies/gnats on them. Resident stated, they don't do nothing for me. On 7/11/2023 at 10:20 AM, Resident #17's nurse, Licensed Practical Nurse (LPN #6) and the 2nd floor Unit…

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, it was determined the facility failed to accommodate the needs of a resident by failing to ensure the call bell was in reach when needed. This was evident for 1 (#39) of 83 residents reviewed during the 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 7/10/2023 at 10:11 AM, Resident #39 was observed lying in bed watching TV. When asked to use her/his call bell, Resident #39 looked around but could not find the device. The call bell was observed behind the resident's head of bed and out of reach. Resident # 39 attempted to get it twice and was unable to reach it both times. S/he gave up trying 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 and medical record review it was determined that the facility failed to have a process in place to ensure residents receive written notice of room changes. This was evident for 3 (Residents #250, #144, and #251) out of 3 residents who had expressed their concern regarding room changes during the recertification survey. The findings include: 1.)During an interview with Resident #144 on 7/10/23 at 9:58 AM, they expressed their concern that they had been moved to their room all of a sudden, and with no reason for it 2.) On 7/10/23 at 9:58 AM, during the interview with Resident #144, Resident #251, (the roommate of Resident #144) verbalized not having received any advance notice of him/her receiving a roommate . 3.) During an interview with Resident #250 on 7/12/23 at 2:28 PM, they reported that they were moved to another room with no advance notice. When the resident asked facility staff for a reason why, he/she reported that staff tiptoed around the reason why. On 7/24/23 at 8:43 AM, review of the medical records revealed that no documentation could be found of the…

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

Based on medical record review, staff interview, and review of administrative records, it was determined that the facility failed to provide written notification to residents when the facility determined that a resident no longer qualified for Medicare part A skilled services. This is identified for 2 (Residents #126, and #134) of 2 residents reviewed that remained in the facility after termination of Medicare part A services. The findings include. Notification to residents regarding the end of their Medicare coverage is required to be minimally 48 hours prior to the scheduled effective date that coverage will end, therefore, affording them an opportunity to appeal the decision or to prepare for discharge. In addition, CMS is very specific in the form that is required to be used for the notification of the non-coverage of Medicare services. The SNFABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage) provides information to residents/beneficiaries that services may no longer be covered by Medicare and addresses the resident's liability for payment should they…

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 Interviews, review of the medical record, and observation, it was determined the facility failed to properly recognize and address a resident grievance. This was evident for 1 (Resident #253) out of 1 resident who was reviewed for grievances. The findings include: During the surveyor's initial tour on 7/10/23 at 9:48 AM, Resident #253, admitted to the facility on [DATE], reported the following concerns about the therapy department: a concern that therapy staff did not always treat them with respect and dignity; a concern with their rehabilitation plan of care; and a concern that they were not able to walk in therapy because therapy required them to have an AFO (device utilized in therapy to maintain a natural foot position) which was located at his/her personal home. Resident #253 was asked by the surveyor if they had attended an interdisciplinary care plan meeting, and they stated they had not. On 7/10/23, no documentation of a care planning meeting could be found on the medical record. On 7/11/23 at…

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

Based on observation record review and staff interview, it was determined that the facility failed to adequately assess and complete the Minimum Data Set (MDS) for a resident with impaired speech. This was evident for 1 (Resident #13) of 7 residents assessed for communication and sensory and 1 (Resident #50) of 6 residents reviewed for abuse during an annual survey. The Findings include: 1) 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 7/10/23 at 10:24 AM, observation of Resident #13 revealed that resident had trouble with expression. Resident was asked to state name and birthday. Resident #13 Stated her name and birthday but was very hard to understand. Review of the quarterly Minimum…

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

Based on medical record review, resident, and staff interview, it was determined that the facility staff failed to revise and update a comprehensive care plan for a resident with a suprapubic catheter. This was evident for 1 (#18) of 83 residents reviewed during 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. A suprapubic catheter is a hollow flexible tube that is used to drain urine from the bladder. It is inserted into the bladder through a cut in the belly, a few inches below the navel (belly button). Medical record review was conducted for Resident #18 on 7/31/2023 at 12:11 PM. Resident #18 was originally admitted to the facility in January 2019 with diagnoses that included but not limited to paraplegia, retention of urine, neuromuscular dysfunction of bladder, and chronic kidney disease. Review of order summary report on 7/31/2023 at 12:33 PM revealed the following active orders: - Irrigate suprapubic catheter with 60cc of Sterile water…

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 a complaint, medical record review, and interview it was determined that the facility failed to ensure 1) staff followed physician orders as evidenced by failure to monitor a resident's blood sugars, 2) failed to ensure right orders for treatment were put in and documented on, 3) failed to document and rotate the site of subcutaneous injection, 4) failed to manage a resident with dehydration, and 5) failed to respond to a resident's concern with swallowing difficulties. This was evident for 5 Residents (#91, #76, #148, #163, and #253) of 83 residents reviewed during the survey. The findings include: The hemoglobin A1C (HbA1c or HgA1c) test is a simple blood test that measures your average blood sugar levels over the past 3 months. It's one of the commonly used tests to diagnose prediabetes and diabetes and is also the main test to help you and your health care team manage your diabetes. It is an important blood test that gives a good indication of how well your diabetes is being controlled (normal level…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and observation it was determined that the facility failed to properly identify, document, and monitor a resident's pressure ulcer. This was evident for 1 (Resident #71) of 6 residents reviewed for positioning and mobility. The findings include: A pressure ulcer is skin breakdown caused by pressure, usually over a bony prominence, but can also be caused by pressure from a medical device. Pressure ulcers are categorized using numbers for stages, a stage 1 being the most superficial type, and stage 4 being the deepest. A contracture is a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and ultimately causes rigidity, joint deformities, and a total loss of movement around the joint. Splints are used to prevent further tightening of contractures but may increase the risk of developing skin breakdown. On 7/10/23 at 1:10 PM a record review revealed that Resident #71, who was admitted to the facility on [DATE], had a history 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 medical record review and staff interview, it was determined that the facility failed to have a system to monitor and respond to changes in residents' weights and notify the physician when residents' weight loss was identified. This was evident for 3 (Resident #158, #144, and #251) of 6 residents reviewed for nutrition during this survey. The findings include: 1) A review of complaints, MD00166589 and MD 00156901, was conducted on 07/19/23 at 11:20 AM. The complainants reported that Resident #158 had concerns about his/her care, including losing weights. Further review of Resident #158's medical record revealed he/she had admitted to the facility in June 2020 with diagnosed chronic obstructive pulmonary disease, heart failure, morbid (severe) obesity, paraplegia, and colostomy. Also, the resident repeated discharge to the hospital and re-admission to the facility several times: discharge (d/c) on 6/26/20 due to profuse sweating, readmit on 6/28/20, d/c on 7/14/20 due to gastrostomy tube malfunction,…

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 records review and interview with staff, it was determined the facility failed to: 1) provide a BiPAP Machine mask to a resident requiring it, 2) properly label and date an oxygen tubing when changed and follow the physician's order for the administration of oxygen, and 3) properly document the administration of oxygen. This was evidence 3 (Resident #168, #93, and #50) of 5 residents reviewed for Respiratory care. The findings include: 1) BiPAP (Bilevel positive airway pressure) is a machine. It's a form of noninvasive ventilation that providers might use someone can breathe on their own but aren't getting enough oxygen or can't get rid of carbon dioxide. Choosing a suitable size mask for a resident is a critical step to use of a BiPAP machine. On 08/01/23 at 12:46 PM, the surveyor reviewed a complaint, MD00189465. The complainant reported Resident #168 did not receive respiratory care with BiPAP because the facility failed to offer an accurate size of mask for BiPAP. Further review of Resident…

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

Based on interview, observation, and medical record review, it was determined the facility failed to administer pain medication in a timely manner and according to physicians ' orders. This was evident in 1 (Resident #46) out of 2 residents who were reviewed for pain during the recertification survey. The findings include: On 7/11/23 at 9:50 AM, Resident #46 was observed by surveyors to be sitting in their wheelchair at the entrance to their room, looking out into the hallway, at which time surveyors conducted an interview. Resident #46 reported to surveyors during the interview that they requested Tylenol for knee pain that they rated as a 5 (moderate pain on a scale of 0 to 10) and were told by the nurse that it would be brought at 9 AM with other morning medications. The resident discussed needing the pain medication to relieve the pain she/he was having and so that she/he could more fully participate in therapy. On 7/11/23 at 9:52 AM, Licensed Practical Nurse (LPN) #52, entered the room with surveyors present to administer the pain medication. Therapy staff then arrived…

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

Based on observation, interview, and record review, it was determined the facility failed to ensure that residents did not receive medications without adequate indications for their use. This finding was evident for 2 of 6 residents reviewed for unnecessary meds. (#72 and #50). 1. Albuterol is an inhaled, quick acting medication used to relieve shortness of breath caused by bronchospasm and is often ordered on a short term or as needed basis. Bronchospasm is anb abnormal contraction of the smooth muscles of the lungs, resulting in an acute narrowing and obstruction of the respiratory airway. A cough with generalized wheezing usually indicates this condition. Bronchospasm is a chief characteristic of asthma and bronchitis. Resident #72 was admitted to the facility in August 2018. The admission History and Physical done by the resident's attending physician, Staff #22, was dated 8/23/18 and indicated that the resident had no concerns with his/her respiratory system, no history of respiratory problems, and no active respiratory diagnosis. On 7/10/23 at 11:12 AM, an initial observation…

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.

x Based on interview and review of the facility records, it was determined that the facility failed to monitor and track antibiotic usage and resistance data. This was evident by 1) the duration of antibiotic use was not completed due to changing to a different salt form*, 2) a resident's antibiotic was prescribed without indication, and 3) the facility antibiotic stewardship program failed to document essential elements for antibiotic use. This was found to be true on 2 (Resident #69 and #399) out of 5 residents reviewed for antibiotic use and antibiotic stewardship program review during the annual survey. The findings include: *Salt form: Over 50% of all drug molecules used in medicine exist as salts, most frequently as the hydrochloride, sodium, or sulfate salts. Drugs are often formed as a weak acid or base, but this drug form is not always optimal for dissolution or absorption into your body.) Doxycycline hyclate vs Monohydrate: The antibiotic component (doxycyline) is the same in both medications, but the salt forms (hyclate and monohydrate) are different. These salt forms…

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 a review of a complaint intake, 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 1 (Resident #160) of 6 residents reviewed for hospitalization during the annual survey. The findings include: On 7/25/23 complaint intake, MD00140476 was reviewed related to resident #160. Based on a review of the complaint the resident had a fall, and busted his/her head and was transported to the emergency room. A review of resident #160's closed medical record on 7/25/23 did not reveal any evaluations or progress notes indicating the resident had a fall and was transferred to the hospital. Review of the closed paper medical record on 7/25/23 revealed Hospital discharge instructions with the resident's name time stamped/prepared on 4/17/19 at 4:13 AM. The local hospital's discharge instructions indicated resident #160 had a fall from standing and a laceration to scalp. On 7/26/23 the assistant director of nursing (ADON) was shown the hospital…

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 a review of a complaint intake, medical record review, and staff interview it was determined the facility failed to notify the resident/resident representative in writing of the bed hold policy upon transfer of a resident to an acute care facility. This was evident for 1 (#160) of 6 residents reviewed for hospitalization during the annual survey. Findings include: The bed-hold policy describes the facility's policy of holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. On 7/25/23 complaint intake, MD00140476 was reviewed related to resident #160. Based on a review of the complaint the resident had a fall, and busted his/her head and was transported to the emergency room. A review of resident #160's closed medical record on 7/25/23 did not reveal any evaluations or progress notes indicating the resident had a fall and was transferred to the hospital. Review of the closed paper medical record on 7/25/23 revealed Hospital discharge instructions with the resident's name time stamped/prepared on 4/17/19…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of medical records and interviews, it was determined that the facility failed to ensure resident's Ileostomy care. This was evident for 1 (Resident #148) of 2 residents reviewed for ostomy care during the annual survey. The findings include: An ostomy is a surgery that makes a temporary or permanent opening in the skin called a stoma. A stoma is a pathway from an internal organ to the outside of your abdomen. An ileostomy is a stoma constructed by bringing the end or loop of the small intestine out onto the surface of the skin or the surgical procedure which creates this opening. Intestinal waste passes out of the Ileostomy and is collected in an external ostomy system which is placed next to the opening. On 08/02/23 at 11:27 AM, the surveyor reviewed a complaint of MD00182706. The complainant reported that the facility's nursing staff did not use the correct supplies for ileostomy bags and skin prep pads for Resident #148's care. Also, the complainant insisted that these incorrect supplies…

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 of Room # 250 and during an interview with Resident # 31, the facility failed to the patch the wall in the back of bed C in room [ROOM NUMBER]. This was observed for 1 out of 37 rooms. The findings include: On 1/22/19 at 2:01 PM this surveyor interviewed Resident # 31. During an observation of the room, a patch of drywall was missing from the back of bed C. On 1/23/19 the area was shown to the Director of Support Services. Staff # 4 stated that he will patch the dry wall, right away. The Directof of Nursing (DON) and the Administrator were informed.

Based on medical record review and staff interviews it was determined the facility staff failed to conduct a comprehensive assessment when a significant weight gain occurred in Resident #104's condition. This was evident for 1 of 3 residents reviewed for change in condition during the survey process. The findings include: Medical record review revealed that Resident #104 was admitted to the facility with a medical diagnosis that included but not limited to Arthritis due to Bacteria of knee and shoulder for rehabilitation and antibiotic therapy. Review of the skilled nursing assessment revealed that staff documented weights for Resident #104 on 1/20/19 of 177.5 lbs. On 1/21/19 skilled nursing assessment staff documented a weight of 194.0 lbs. for Resident #104 which is a change in weight of 16.5 lbs. in 24 hours. On 1/25/19 at 2:30 P.M. the surveyor conducted a staff interview with the Director of Nursing (DON) who verified that the fluctuation of weight involving Resident #104 was not addressed according to the care and treatment policy. The Administrator, Director of Nursing 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 is was determined that the facility failed to revise and update the care plan that addressed a resident's after change in condition. This was evident 1 out of 37 resident's involving Resident #104 during the survey process. The finding includes: The 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. Medical record review revealed that Resident #104 was admitted to the facility with diagnoses which included but not limited to Arthritis due to Bacteria of knee and shoulder for rehabilitation, antibiotic therapy and other chronic health conditions that require ongoing treatment. Continued record review revealed that on 1/21/19 staff documented on the skilled nursing assessment that Resident # 104 weighed 194 lbs. On 1/20/19 staff documented on the skilled nursing assessment that Resident #104's weight was 177.5 lbs., a change in condition. Medical record review revealed a dietary and weight care plan with initiation dates of 12/24/18…

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 interviews the facility staff failed to label a vaccine vial with the date when opened. This was evident for 1 out of 2 medication rooms observed during the survey process. The findings include: On 01/28/19 around 01:29 PM, 2 medication rooms were surveyed. The 2A/2B medication room had a vial of Tuberculin Vaccine that was opened but not dated. Tuberculin should be discarded if it has been opened for more than 30 days or the expiration date has passed. Without a date of when opened there is no way to determine how old the vaccine would be.