Autumn Lake Healthcare At Birch Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, it was determined that the facility failed to investigate allegations of abuse. This was evident for one (Resident #50) out of three investigated for Abuse. The findings include: Resident #50 has medical conditions that include a traumatic brain injury, anxiety, depression, a seizure disorder, problems with thinking and memory (cognitive impairment). On 6/4/25 at around 10:15 AM, the surveyor reviewed complaint MD00216414. The complaint stated that Resident #50 had been taken to the local hospital's emergency room following an episode in which the resident was combative. While there, the resident told a nurse that s/he had been hit and punched by staff at [NAME] Lake Birch Manor. The hospital staff examined [the resident] and found two small bruises-one under the left eye and one on the middle-left side of [their] back. On 6/06/25 at 4:17 PM, the surveyor reviewed the progress notes for Resident #50. The notes showed that the resident had been readmitted to the facility on…

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

Based on medical record review and interview it was determined that the facility failed to provide written notice of the bed hold policy and transfer to the resident's responsible party; and failed to ensure all required information was included in the forms currently being used to provide notification of transfer and bed hold. This was found to be evident for one (Resident #76) out of four residents reviewed for hospitalization during the survey. The findings include: On 6/5/25 review of Resident #76's medical record revealed the resident was not capable to make health care decisions and a Responsible Representative was identified for the resident. On 6/9/25 the resident was sent to the hospital via emergency medical services. Review of the Change in Condition Review form, dated 6/9/25 revealed the Responsible Representative was not present at time of discharge but that the Bed Hold Policy and the Reason for Transfer/Discharge was sent to the Representative. This form was signed by nurse (Staff #20). On 6/10/25 at 3:13 PM when asked how the Bed Hold and Transfer Notice were sent to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately documented. This was evident for 1 (#94) out of 2 Residents reviewed for dental care. The findings include: The Minimum Data Set (MDS) is an assessment of the Resident that provides the facility with the necessary information to develop a care plan, deliver appropriate care and services to the Resident, and modify the care plan based on the Resident's status. 1a) An observation on 6/4/25 at 11:13 AM showed that Resident #94 was edentulous (had no teeth). The Resident stated at that time that s/he wore complete dentures. However, they were left at home. A review of Resident #94's record contained a Nursing admission assessment completed on 1/12/25. The assessment recorded that Resident #94 had no natural teeth. However, a continued review of Resident #94's MDS assessment dated [DATE] showed an answer NO to the statement No natural teeth or tooth…

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 ensure staff provided medication as ordered. This was found to be evident for one (Resident #59) out of five residents reviewed for unnecessary medication. The findings include: Review of Resident #59's medical record revealed the resident had an order, in effect from 9/19/23 until it was changed on 5/23/25, for Lorazepam (also known as Ativan) 0.5 mg tablet three times a day related to anxiety disorder. Review of the resident's Medication Administration Record for April 2025 revealed documentation that indicated it was administered to the resident as ordered every day in April. Review of the Controlled Drug Administration Record for the Lorazepam 0.5 mg tablets revealed on 4/28/25 at 2:00 PM the last tablet of a supply of 30 was removed. This indicated there were no tablets left in the supply for this resident. Further review of the Controlled Drug Administration Record for the Lorazepam 0.5 mg tablets revealed a new 30 tablet supply was received at the facility on 4/29/25 and the first…

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 that the facility failed to have an order to monitor a resident's air mattress. This was found to be evident for one (Resident #76) of four residents reviewed for pressure ulcer care and prevention. The findings include: Review of Resident #76's medical record revealed the resident resided at the facility for more than a year and was totally dependent on staff for activities of daily living such as dressing, eating, transferring from bed to wheelchair and mobility. On 6/5/25 at 9:36 AM surveyor observed, with Nurse #29, the resident in bed. An air mattress control was observed at the foot of the bed but no lights were on and it was noted to be unplugged. When surveyor asked if the air mattress was being used, the nurse indicated it was and proceeded to plug in the mattress and it began to inflate. Surveyor observed it was set at 240 lbs and the nurse confirmed this observation. The nurse went on to report that the resident required total care and was unable to wheel self when in the wheelchair. On 6/5/25 at 1:00 PM…

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

Based on observations, interviews and record review, it was determined that the facility failed to provide necessary respiratory care consistent with professional standards of practice for tracheostomy residents. This was evident for one (Resident #109) of two residents reviewed for respiratory care during this survey. The findings include: A tracheostomy is a surgical opening created through the neck into the trachea (windpipe) to allow breathing to occur. A breathing tube is usually placed through this opening to provide an airway and to remove secretions from the lungs. The nose and mouth naturally filter out harmful pollutants, irritants and germs. However, a tracheostomy provides direct access into the lungs requiring strict infection control measures during care. Care for tracheostomy residents can only be performed by licensed and trained personnel. On 6/5/25 at 9:05 AM Resident #109 was observed in bed. The head of bed was raised at approximately 30-45 degrees. The resident had shortness of breath with audible breath sounds. Oxygen was observed and set at 3.5 liters per…

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 reviews and interviews, it was determined that the facility failed to provide routine dental services to a Medicaid funded residents. This was evident in 1 (Resident #71) of 1 resident reviewed for dental care. The findings include: Resident #71 was admitted into the facility in early 2023. The resident's medical record indicated his/her cognitive pattern as severely impaired. On 6/4/25 at 1:06 PM, Resident #71's responsible party (RP) was interviewed. During the interview, the RP reported dental concerns and that the resident had not seen a dentist. The RP stated, when I've asked about that (Dental services) in the past, they (Facility staff) said we would have to sign him/her up for that. I'm not sure of the status, I have not gotten any update about dental care or seeing a dentist. A review of Resident #71's medical record was conducted on 6/6/25 at 9:49 AM. The review revealed a comprehensive assessment with a reference date of 2/22/23, where section L coded the resident with obvious or likely cavity or broken natural teeth; and mouth or facial pain, discomfort…

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

Based on observations, record review, and interviews, it was determined that the facility failed to ensure that residents were served meals according to a predetermined menu that incorporated the residents' preferences. This deficient practice has the potential to affect all residents. The findings include: 1) An observation of Lunch on the first-floor unit on 6/4/25 at 12:54 PM showed that Resident #24 was eating in the dining room. The Resident's tray contained pork chops, buttered corn, roasted potatoes, 1 slice of bread, chilled pears, 1 packet diet sugar, 1 packet pepper, 1 packet salt and a cup of coffee. However, the Resident's meal ticket read Smothered pork chops, buttered corn, [NAME] roasted potatoes, 1 slice bread, 1 packet margarine, chilled pears, 1 package sugar, 1 package pepper, 1 package salt, 8 oz of whole milk, and 6 oz of coffee. Resident #24 reported not getting any milk or butter. Staff #14, a Geriatric nurse aid, was present and confirmed that Resident #24 did not receive milk or butter on his/her lunch tray. 2) Resident #96 was observed eating lunch in the…

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

Based on observations and interviews, it was determined that the facility failed to store food in accordance with professional standards. This was evident in 1 out of 3 units observed during the recertification survey. The findings include: An observation of the 2nd-floor unit nourishment room refrigerator on 6/4/25 at 10:13 AM, with staff #12, a Geriatric nurse aid present, showed 4 cups of Jello with an expiration date of 4/24/25. Staff stated they were expired, looked watery, and then disposed of them. In an interview on 6/4/25 at 2:44 PM with staff #13, the unit manager showed that she checked the refrigerator every morning; however, she missed the Jellos. In an interview on 6/11/25 at 7:43 AM, the Director of Nursing was made aware of the concern and stated that he had been informed by staff.

1) Review of Resident #59's medical record revealed the resident had resided at the facility for more than a year. The resident was seen regularly by a primary care physician and a nurse practitioner in addition to a pain management nurse practitioner. a. A review of a note written by physician (Staff #30) for a visit on 4/25/25 revealed the visit was a monthly follow-up for ongoing management of dementia with behavioral disturbance, mood disorder, chronic pain and kidney disease. The section titled Plan included the following: Lorazepam 0.5 mg TID [three times a day] PRN [as needed] for anxiety. This Lorazepam (also known as Ativan) order indicated the resident was to receive the medication only when the resident was experiencing symptoms of anxiety and staff would be expected to document the symptoms and the effectiveness of the medication. Review of the physician orders revealed the resident had an order, in effect at the time the 4/25/25 note was written, for Lorazepam 0.5 mg tablet three times a day related to anxiety disorder. This order was originally written 9/19/23. Review…

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

Based on interview and record review, it was determined that the facility failed to ensure the development and ongoing implementation of a facility-wide, data-driven Quality Assurance and Performance Improvement (QAPI) program that included at least one current Performance Improvement Project (PIP) in the past 12 months. The findings include: On 06/04/25, the facility provided a copy of its QAPI policy upon entrance for review. The QAPI policy in reference to PIP determination for the facility states, areas for improvement are identified by routinely and systematically assessing quality of care and service, and include high risk, high volume, and problem prone areas. Consideration will be given to the incidence, prevalence, and severity of the problem, especially those that affect health outcomes, resident safety, autonomy, choice quality of life, and care coordination. During an interview on 06/11/25 at 10:49 AM, the Nursing Home Administrator (NHA) confirmed that she was responsible for QAPI at the facility and was asked if there was a PIP the facility had completed within 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 interview and record review, it was determined that the facility failed to ensure the Infection Preventionist (IP) attended the Quality Assurance and Performance Improvement (QAPI) committee meetings. The findings include: On 06/05/25 at 11:55 AM, the Nursing Home Administrator (NHA) provided QAPI meeting attendance records for six months, covering December 2024 through May 2025. Review of these records revealed that for the months of December 2024, January 2025, and February 2025, the Director of Nursing (DON) signed the attendance sheets as the IP. On 06/11/25 at 10:12 AM, the NHA stated that the DON was not a certified IP nurse, nor was certified in December 2024, January 2025, or February 2025. On 06/11/25 at 11:01 AM, the NHA was asked to provide QAPI attendance records for June 2024 through November 2024 for further evidence of IP attendance. During the exit conference, the NHA provided a QAPI attendance record for October 2024 which also lacked evidence of a qualified IP nurse in attendance.

Based on record review, observation, and interviews it was determined that the facility failed to ensure that critical medical equipment was plugged into generator power supplied outlets. This was evident for one (Resident #102) out of two residents reviewed for respiratory care. The findings include: Resident #102 has a history of a traumatic brain injury and chronic respiratory failure. The resident has a tracheostomy (trach) and required a continuous supply of oxygen. A tracheostomy is a surgical procedure where a hole is made in the neck and into the windpipe (trachea) to help air reach the lungs. On 6/05/25 at 1:00 PM, the surveyor reviewed the medical record for Resident #102. A nursing progress note dated 2/16/25 stated the following: We had a brief power outage. Another nurse and I switched the resident's equipment to the emergency power outlet. Further review of Resident #102's medical record revealed that the resident had orders for the following medical treatments: *Suction trach every shift and as needed every shift for Respiratory Failure *Suction trach every shift 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.

F584 - §483.10(i) Safe Environment S/S: E Regulation: §483.10(i) mandates a safe, clean, comfortable, and homelike environment, which includes exercising reasonable care for the protection of residents' property from loss or theft. This requirement obligates the facility to document and secure residents' belongings through an inventory system upon admission, during the resident's stay, and at discharge, with a signed acknowledgment by the resident or their representative. F584 - Honor the resident's right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. NOTE - TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during a complaint survey, the facility failed to ensure the protection of residents' personal property for 2 (Residents #61 and #55) of 12 residents reviewed. Specifically, the facility did not adhere to its own policy requiring an inventory and tracking process for resident belongings upon admission and discharge…

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 F609: Reporting S/S= D Based on observation, record review and interviews during a complaint survey, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source were reported immediately, but not later than two hours to the state survey agency (Office of HealthCare Quality) for 2 (Residents #5 and #33) of 12 reportable incidents reviewed. Specifically, when Resident #33 was observed with an injury of an unknown origin on 1/4/22, it was not reported to the state survey agency until 1/6/22 and when Resident #5 was observed with injuries of an unknown origin on 10/9/24, the facility did not report the injury. The findings include: The Policy and Procedure titled Abuse, Neglect and Exploitation last revised 11/13/23 documented in pertinent part it was the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit…

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 resident and staff interview, it was determined the facility failed to provide the resident or resident representative with a summary of their baseline care plan on admission. This was evident for 2 (#224, #63) of 2 residents reviewed for care plans, 2 (#45, #228) of 5 residents reviewed for hospitalization, and 1 (#227) of 1 residents reviewed for hospice The findings include: A baseline care plan must be prepared for all residents within 48 hours of a resident's admission. Its purpose is to provide the minimum healthcare information necessary to properly care for a resident until a comprehensive care plan can be completed for the resident. The baseline care plan, along with a copy of their medications, is given to the resident and details a variety of components of the care that the facility intends to provide to that resident. This allows residents and their representatives to be more informed about the care that they receive. 1) On 6/2/21 at 10:53 AM, during an interview, Resident #224 indicated he/she was not familiar with a care plan. On…

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

Based on medical record review and observation, it was determined the facility staff failed to review and revise care plans for Resident #27 to reflect accurate and appropriate interventions for (elevated cholesterol) and the facility staff failed to provide the interventions as indicated on the care plans (suction at the bedside, floating of bilateral heels at all times and pillows between skin to skin) for Resident #27. This was evident for 1 of 3 residents selected for review of care plan participation during the annual survey process. The findings include: The Minimum Data Set (MDS) is part of a federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process entails a comprehensive, standardized assessment of each resident's functional capabilities and health needs. Assessments are conducted by trained nursing home clinicians on all patients at admission and discharge, in addition to other time intervals (e.g., quarterly, annually, and when residents experience a significant change in status). By 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and interview with facility staff, it was determined that the facility failed to 1. void a resident's MOLST form when an updated MOLST form was completed (#45, #228, #227, #224) 2. transcribe a medication from a physician order correctly (#19) and 3. have documentation that pharmacy consults were completed and on the chart. (#31) This was evident for 6 of 55 residents reviewed during the annual survey. The findings include: A MOLST (Maryland Medical Order for Life Sustaining Treatment) form documents a person's wishes for cardiopulmonary resuscitation (CPR) and other life-sustaining treatment and includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding CPR and other life-sustaining treatment options. The practitioner (physician or nurse practitioner) completes, signs, and dates the form, and the form kept with other active medical orders in the resident's medical record. If an updated MOLST form is completed, all older 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 random observation of interactions between activity staff and a resident, it was determined that facility staff failed to interact with a resident in a respectful manner by speakling loudly but not changing her position to bend down when speaking so that the resident, who was seated in a chair, was able to better understand/hear what she/he was saying to them. The findings include: During initial tour and observations on 6/1/2021 at 11:33 AM, staff #16, later identified as an activites staff member, was observed telling Resident #40 loudly to go to the dining room. Staff # 16 was heard to repeat herself while increasing her tone of voice and told the resident you have to go to the dining room. Staff was a tall employee and did not attempt to bend down to the resident, who was seated in a chair, talk closer to his/her ear, or approach the resident face to face at eye level before speaking to them. After repeating herself 3 times with no response from the resident, staff #16 shook her head and walked away. Resident #40 was heard stating to the staff as s/he walked away,…

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 the facility staff failed to notify the physician of a sudden weight gain for Resident #60. This was evident for 1 of 6 residents reviewed for nutrition and 1 of 55 residents reviewed during the annual survey. The findings include: Medical record review for Resident #60 on 6/1/21 at 12:30 PM revealed the facility staff documented the resident's weight on 12/1/21 as 137 lbs (the resident's normal weight range). On 1/15/21, the facility staff documented the resident's weight as 143.6 lbs., on 2/1/21 the documented weight as 144.4 lbs., 3/5/21 the weight as 150.6 lbs., 3/31/21 the weight as 152.4 and 4/7/21 the weight as 156.7 lbs. Further record review and interview with the corporate nurse on 6/2/21 at 11:30 AM revealed the resident's baseline weight was in the high 130's. Further record review revealed that, on 4/12/21 at 11:25 AM, the dietitian documented: the following : weight however is with fluid retention to feet ( bilateral) per resident observation - will re - request notification to the physician for this issue…

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 document timely notification to a resident or representative (RP) regarding notification and explanation of their rights regarding a pending discharge from Medicare. This was evident in 1 of 3 (#66), residents reviewed regarding liability notices.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 wish to continue receiving the skilled services. The NOMNC (Notice 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 the review of a facility reported incident involving a fall, observations, and medical record review, it was determined that the facility failed to provide privacy for a resident during activities of daily living (ADL) care. The findings include: Review of the medical record for Resident #10 on 6/2/2021 revealed diagnoses including a history of a traumatic brain injury, lack of coordination, generalized muscle weakness and anxiety disorder. A change in condition was also noted to occur on 1/24/2021 during the review period where Resident #10 had a fall , according to the nurse practitioner notes in the medical record. On 6/7/2021 at 9:23 AM, further review of the medical record for Resident #10 revealed a care plan for high risk for falls, initiated on 5/23/2014. A progress care plan note was entered as a late entry on 1/26/2021 stating that On 1/24/2021, the aide reported that the resident was holding on to the dresser while standing for a diaper change and suddenly let go of the dresser . subsequently resident had a fall with injury to his/her back and legs. Census review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation throughout the annual recertification survey, it was determined that the facility staff failed to maintain a sanitary, orderly, and comfortable interior. This was evident for resident rooms, the dining room and activity room. The findings include: A tour of the environment of care was conducted on June 7, 2021, in response to team discussions of prior findings during a building tour and with the Maintenance Director. Based on this tour, there was evidence of unattended maintenance needs. The following is a summation of those finding: 1. Wall damage to every room on the 1st floor of the facility. In the residents rooms, some effort of repair using wall compound was noted, but the application was rough and incomplete, plus the area of repair was never filled in, sanded, and painted as necessary to restore the damaged wall. 2. Missing ceiling tile in the hallway outside room [ROOM NUMBER]. 3. Base board molding missing from the wall near the bathroom in room [ROOM NUMBER] and the base…

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

Based on medical record review and staff interview, it was determined that the facility failed to document the transfer of a resident in the medical record including the reason for the transfer and information provided to the receiving provider to ensure a sae and effective transition of care. This was evident for 1 (#45) of 2 residents reviewed for hospitalization. The findings include: On 6/4/21 at 9:11 AM, a review of Resident #45's medical record was conducted. The census report in the resident's EMR (electronic medical record) included documentation that Resident #45 was initially admitted to the facility in March 2021, transferred out to the hospital 5/22/21 and transferred back into the facility on 5/28/21. On 5/22/21 at 7:55 AM, in a progress note, the nurse documented that Resident #45 was feeling sick and had vomited, and noted that a message was sent to the physician. There was no further documentation found in the medical record to indicate the response of the physician or details regarding the resident's transfer to the hospital. There was no change in condition…

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

Based on medical record review and staff interview, it was determined that the facility staff failed to notify the Office of the State Long-Term Care Ombudsman in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 2 (#228, #45) of 5 residents reviewed for hospitalization. The findings include: 1) On 6/2/21 at 2:16 PM, a review of Resident #228's medical record was conducted. The census report in the resident's EMR (electronic medical record) detailed documentation that resident #228 was initially admitted to the facility in March 2021and that, since their initial admission, Resident #228 was transferred to the hospital on 3/28/21, 4/16/21, 5/8/21 and 5/15/21. The medical record did show documentation that Resident #228 was admitted to the hospital following each hospital transfer and readmitted to the facility following each hospitalization. Continued review of the medical record failed to reveal evidence that the Ombudsman had been notified when the resident was transferred to the hospital. 2) On 6/4/21 at 9:11 AM, a review 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 medical record review and staff interview, it was determined the facility failed to orient, prepare and document a resident's preparation for a transfer to the hospital. This was evident for 2 of (#45, and #80) of 5 residents reviewed for hospitalization. The findings include: 1. On 6/4/21 at 9:11 AM, a review of Resident #45's medical record was conducted. The census report in the EMR (electronic medical record) documented that Resident #45 was initially admitted to the facility in March 2021 and, since his/her initial admission, Resident #45 was transfered out to the hospital on 4/10/21, 5/7/21 and 5/22/21 and later readmitted to the facility. 1.1 On 4/10/21 at 12:46 AM, in a progress note, the nurse documented that Resident #45 was transferred to the emergency room via ambulance for persistent nausea and vomiting. There was no documentation found in the medical record that Resident #45 was oriented and prepared for the transfer in a manner that the resident could understand and there was no documentation of the resident's understanding of the transfer in the 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 observation, medical record review and staff interview, it was determined that the facility failed to develop and implement comprehensive person-centered care plans. This was evident for 1 (#228) of 5 residents reviewed for hospitalization. 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. On 6/2/21 at 2:16 PM, a review of Resident #228's medical record was conducted and revealed documentation that Resident #228's went to the hospital on 3/28/21 and returned on 3/29/21. On 3/28/21 at 6:41 PM, in a Change of Condition Evaluation note, the nurse documented that Resident #228's sustained a seizure (a sudden, uncontrolled electrical disturbance in the brain that can cause changes in behavior, movements, or feelings) and indicated the resident was transferred to the hospital. On 3/30/21, in a progress note, the CRNP (Certified Registered Nurse Practitioner) documented that Resident #228 was sent to the hospital on 3/28/21 for a witnessed seizure. On…

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

Based on observation and interview, it was determined the facility staff failed to provide thorough grooming and personal hygiene services for (Resident #59). This is evident for 1 of 2 residents selected for review during an annual survey. The findings include: The Long-Term Care Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status which forms the foundation of the comprehensive assessment for all residents of long-term care facilities certified to participate in Medicare or Medicaid. The MDS contains items that measure physical, psychological, and psycho-social functioning. The items in the MDS give a multidimensional view of the patient's functional capacities and can be used to present a nursing home's profile. One of the sections of the MDS is: Functional Abilities and Goals. Some of the components assessed in the Functional Abilities and Goals of the MDS is bed mobility, transfers, dressing, eating toileting and personal hygiene. Surveyor observed Resident #59 on 6/2/21 at 9 AM withfinger nails on both hands extremely long 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, interview and observation, it was determined the facility staff failed to provide care to Residents (#42 and #60) in order to promote the highest practicable well-being. This was evident for 1 of 4 residents selected for review of medication pass and 1 of 26 opportunities for error and 1 of 55 residents selected for review during the annual survey. The findings include: 1. The facility staff failed to administer medications as ordered by the physician for Resident #42. Medical record review for Resident #42 on 6/3/21 at 10:00 AM revealed: On 10/10/20, the physician ordered: Torsemide Tablet 100 milligrams (mgs.), give 1 tablet by mouth one time a day for CHF. On 2/19/21 the physician ordered: Torsemide 100 mg, 2 tablets every day for CHF (an increase in the medication dose). On 12/5/20, the physician ordered: Metolazone 5 milligrams (mgs) by mouth, 30 minutes before Torsamide. Torsemide is used to reduce extra fluid in the body (edema) caused by conditions such as heart failure. This can lessen symptoms such as shortness of breath and swelling in the arms,…

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 and observation, it was determined the facility staff failed to apply hand splint and knee brace as ordered for Resident #27. This was evident for 1 of 1 residents selected for review of limited motion during the annual survey process. The findings include: 1 A. The facility staff failed to apply a hand splint for Resident #27 as ordered. Medical record review for Resident #27 on 6/8/21 at 9:00 AM revealed on 4/24/21 the physician, in collaboration with occupational therapy, ordered: resident to wear left resting hand splint order which is to be worn daily between 8 AM-2 PM, check skin prior to and after application of the splint. Further review of medical record revealed on 4/26/2021 at 3:19 PM by the Rehabilitation staff: Inservice provided to staff regarding the application of the left hand resting splint. Hand splints aid in healing by keeping the hands from contracting (bending), thus preventing deformities from developing. Surveyor observation of Resident #27 on 6/1/21 at 11:18 AM, 6/2/21 at 11:51 AM and 6/8/21 at 10:43 AM revealed the resident in bed;…

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

Based on medical record review and observation, it was determined the facility staff failed to provide Resident #2 with ice cream consistently and failed to provide Resident #2 with chicken/tuna sandwiches on lunch tray as indicted on the meal tray ticket and failed to obtain a weight as ordered, failed to provide a blue adaptative mug with a handle and failed to provide a morning snack for Resident #31. This was evident for 2 of 6 residents selected for review of nutrition 2 of 7 residents selected for review of food during the annual survey. The findings include: 1. The facility staff failed to provide Resident #2 with the foods as indicated on the meal ticket. Surveyor observation of the meal ticket that accompanied the trays for Resident #2 revealed: ice cream with tray and chicken/tuna sandwich x 2. The meal tray ticket is generated in the kitchen and indicates any special dietary needs or request that is to accompany the food tray to the resident. Surveyor observation of Resident #2's tray on: 6/2/21 at 12:14 PM revealed that the facility staff failed to provide 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.

Based on medical record review, it was determined the facility staff failed to ensure residents (#27, #31 and #35) were free from unnecessary medications. This was evident for 1 of 5 residents selected for review of unnecessary medication review and 2 of 55 residents selected for review during the annual survey. The findings include: 1. The facility staff failed to hold a blood pressure medication as ordered when the blood pressure was below the parameter. Medical record review for Resident # 27 on 6/8/21 at 11:00 AM revealed that, on 3/29/21, the physician ordered: Metoprolol Tartrate Tablet 50 milligrams (mgs.) give 1 tablet via PEG-Tube two times a day for high blood pressure, hold if SBP (systolic blood pressure, top number is less than) <110 or pulse <60. PEG stands for percutaneous endoscopic gastrostomy, a procedure in which a flexible feeding tube is placed through the abdominal wall and into the stomach. PEG allows nutrition, fluids and/or medications to be put directly into the stomach, bypassing the mouth and esophagus. Metoprolol is used with or without other medications…

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 staff failed to date medications upon opening them and removed expired medications. This was found to be evident for 2 out of 3 medication carts reviewed during the facility's annual Medicare/Medicaid survey. The findings include: Surveyor observation of the medication cart #1 on the first floor on 6/9/21 at 9:50 AM revealed: A floor stock bottle of Geri Mox (Mylanta antacid type medication) opened and dated 1/21/21. A bottle of floor stock Mintox (an antacid type of medication) opened with no open date, and A bottle of Keppra ( a seizure medication) for Resident #5- opened and no open date. Review of medication cart #2 on the first floor revealed the following observations: Bottle of Carafate (stomach/ulcer medication) for Resident #31- opened and not dated and Bottle of Potassium Chloride for Resident #21-opened and not dated. Of note, all bottles were noted to be sticky. The Nursing Home Administrator, Interim Director of Nursing and Corporate Nurse was made aware of all concerns on 6/9/21 at 1:00 PM at exit conference.

Based on medical record review and observation, it was determined the facility failed to ensure that a resident noted with a lactose intolerance did not receive milk on the food tray (Resident #2). This was evident for 1 of 7 residents selected for review of food and 1 of 6 residents selected for review of nutrition during the survey process. The findings include: Surveyor observation of Resident's meal ticket from the kitchen revealed: no milk. The meal ticket accompanies the resident's food tray from the kitchen with any specific dietary needs or requests. Surveyor observation of Resident #2's breakfast trays on: 6/2/21 at 8:36 AM and 6/3/21 at 7:55 AM revealed the resident was served milk. Further review of the resident's medical record revealed Resident #2 was lactose intolerant. Interview with the Nursing Home Administrator, Interim Director of Nursing and Corporate Nurse on 6/9/21 at 1:00 PM were notified of the dietary concerns for Resident #2.

Based on review of pertinent facility documents and interview with facility staff, it was determined that the facility failed to have an updated facility assessment to include information relevant to the needs of the residents the facility serves. The findings include: Review of the facility assessment, on 6/9/2021 on 10:30 AM, revealed that the facility failed have an updated annual facility assessment. Interview with staff #11 at 10:37 AM revealed that the currently reviewed assessment was from November of 2019 and the facility is unable to find one more current. Further review of the provided facility assessment failed to reveal any information related to the numerical staffing needs of the facility based on the facility assessment to ensure enough qualified staff are available to meet each resident's needs. Additionally, during the annual survey, it was noted that the facility had a significant number of bariatric patients 10 of the current 74 residents in house were noted as requiring specialized bariatric equipment. According to the facility assessment, there was nothing…

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 failed to have adequate ventilation in resident bathrooms. This was evident for 1 resident bathroom observed on the 1st floor of the facility. The findings include: Observation of resident room/bathroom on 06/07/21 12:52 PM revealed that the exhaust fan was not operational in Rooms 101. The bathrooms had a lingering smell of feces due to the lack of airflow. The Environmental Director confirmed that the lack of airflow and was caused by the exhaust fan not properly secure to the ceiling. The Administrator was made aware of these findings on 6/9/2021 during the exit conference.

Based on a review of a self reported incident submitted by the facility, it was determined that staff #23 had not received training, although permitted to work in the facility. This was true for 1 out 1 employee reviewed for allegations of abuse. The findings include: A review of Staff #23's employee file on 6/9/21 at 10:00 AM, revealed that Staff #23 was hired in the facility 9/20. Further review of the employee file failed to reveal any evidence that staff #23 had the required training prior to working at the facility. It is the expectation that all staff be trained/educated in: Abuse and Neglect, Resident Rights, HIPPA, Caring for the person with Dementia: Behavior and Communication and Customer Service prior to working in the facility with the residents. Interview with the Nursing Home Administrator on 6/9/21 at 11:30 AM revealed that the facility did not employ a Human Resource staff personnel at that time. It was further noted that staff #23 worked from 9/20 till 3/15/21 with no evidence of any training. (The staff was terminated 3/15/21 when 2 no call, no shows occurred and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and resident and staff interview, it was determined the facility failed to develop a base line care plan within 48 hours of a resident's admission. This was evident but not limited to 3 of 31 residents in the final sample. (#109, #83, #92) 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) Review of resident #83's medical record during the survey revealed resident was admitted to the facility on [DATE]. Upon an introductory interview of resident #83 on 7/26/18 at 9:35 AM revealed that this resident had not received a copy of a baseline care plan or of any care plan. The survey team was informed that the 48-hour baseline care plan will be found in the assessment portion of the electronic medical record. Upon review of the 48 hour Baseline Care Plan Assessment, it was revealed that the facility did not provide the minimum healthcare information necessary 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.

3) Observations of resident #13, on 7/26/18, revealed resident lying in bed with noted bilateral hand contractures. (A contracture is a condition of shortening and hardening of muscles, tendons or other tissue which often leads to deformity and rigidity of joints.) The resident was not noted to have any type of hand and or arm splints applied to hand contractures. Review of the physicians' orders revealed an order, written on 1/26/18, as Bilateral resting hand splints to be worn 6 hrs.on/6 hrs. off as tolerated per 24 hr. period. Skin checks to be performed when splints are removed. Monitor for positioning during wear time. Additional orders related to contractions were written as Increase Bivalve cast to left arm 1 hour per day (until 6 hours) or as much as tolerated until next appointment every shift. And a second order was written on 4/14/18 as Begin with 30 minutes wear trails on left arm bivalve cast. If patient tolerates well, please increase duration of wear time to 30 minutes per day. One time per day. Review of a quarterly assessment, dated 4/29/18, revealed that 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 observation, medical record review and staff interview, it was determined the facility failed to evaluate resident care plans. This was evident for 6 (#43, #44, #70, # 93, #111, #91) of 45 residents investigated during the annual 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) Observation was made, on 7/26/18 at 9:19 AM, of Resident #43. Resident #43 appeared to be wheezing. Review of Resident #43's July 2018 Medication Administration Record (MAR) documented that the resident had just received a breathing treatment. Review of Resident #43's medical record revealed a care plan has altered respiratory status/Difficulty Breathing r/t decreased lung compliance, aspiration. A care plan evaluation was not found in the medical record. Review of Resident #43's care plan has limited physical mobility r/t contractures, cognitive deficit and has potential impairment to skin integrity did not have evaluations in the medical record. Staff #8…

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 4. The facility failed to maintain a medical record in the most complete and accurate form for resident #30. Melatonin is a dietary supplement use to promote a normal sleep pattern. Ambein is used to treat insomnia. Review of the Resident # 30's medical record, on 8/2/18 at 9AM, revealed the resident was admitted to the facility on [DATE]. A care plan was initiated on 4/27/18 for insomnia. According to the care plan, the resident was receiving Ambien for Insomnia. Continued review of the medical record revealed the resident was ordered Melatonin for Insomnia not Ambien. During interview with the Unit Manager on 8/3/18 at 9:30AM, he/she stated the Ambien was entered in error. Based on medical record review and staff interview, it was determined the facility failed to keep complete and accurate medical records. This was evident for 4 (#43, #262, #73, #41, #30 ) of 45 residents investigated during the annual survey. The findings include: 1) Observation was made of Resident #43 on 7/26/18 at 9:13 AM. Resident #43…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, it was determined the facility failed to monitor a reach-in freezer to assure safe storage of ice cream in the freezer. This was evident during a follow-up tour of the kitchen. The findings include: On 8/1/18 at 11:40 AM, observation of the [NAME] and [NAME] ice cream freezer did not reveal a thermometer in the freezer. The Food Service Manager (staff #7) was asked for the freezer temperature logs. The Food Service Manager indicated that they were not monitoring the freezer temperatures. He indicated that there had been an issue with the freezer cover. There was a noted buildup of frost/ice on the walls of the ice cream freezer.

Based on medical record review and staff interview, it was determined the facility failed to notify the physician of a significant weight loss. This was evident for 2 (#73, #81) of 4 residents reviewed for nutrition. The findings include: 1) Review of the medical record for Resident #73, on 7/27/18, revealed the resident weighed 154.0 pounds (lbs.) on 6/15/18, and 2 weeks later ,weighed 141.0 lbs., which was a 13-pound weight loss. Further review of the medical record revealed that the physician, dietician and responsible party were not notified of the significant weight loss by the nursing staff. The physician did not see the resident until 7/23/18 and the dietician did not see the resident until 7/24/18. Failure to notify the physician promptly delays any interventions the physician may have wanted to put into place to prevent further decline in weight. 2) Review of the medical record for Resident #81 revealed an admission weight on 3/19/18 of 266 lbs. The resident's 7/24/18 weight was 229 lbs. A 4/19/18 physician's visit documented that the resident had weight loss, likely…

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 staff interview, it was determined the facility failed to provide housekeeping and maintenance services to keep the resident's environment clean and in good repair. This was evident on 3 of 3 nursing units. The findings include: The following environmental concerns were observed during the survey: room [ROOM NUMBER]: One of the window blind slats on the right side of the window was broken and missing. room [ROOM NUMBER]B: The laminate on the over the bed tray table was chipped on the corner, approximately 3 inches around the corner, with particle board exposed, and the footboard was cracked and loose on the right side. The cracked edges were sharp. There were multiple brown and black stains on the privacy curtain. In the bathroom that 2 of the 4 roommates used, a was urinal hanging on the grab rail which was 3/4 full of urine with a strong urine odor. The toilet was filled with urine and toilet paper, which made the bathroom and room smell of urine. There were spackle marks on the walls…

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

Based on medical record review and staff interview, it was determined that the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 5 (#29, #90, #103, #70, # 97) of 45 residents reviewed. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) Review of the medical record for Resident #29 revealed a progress note, dated 5/2/18 at 23:30, which stated, Patient admitted to hospice. Family members were at bed side. Review of the MDS, with an assessment reference date (ARD) of 5/10/18, failed to capture Hospice services in section O0100 during the previous 14 days. On 8/1/18 at 11:08 AM, the MDS Coordinator confirmed 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 surveyor observation, review of the medical record, hospital records and interviews with staff, it was determined that the facility staff failed to provide quality of care and services in accordance with the resident's goals for care and professional standards of practice to meet each resident's physical, mental and psychosocial needs. This was evident for 2 (#97 and #91) of 56 residents reviewed. The findings include: 1) On 7/26/18 at 9:25 AM, Resident #97 was observed resting in his/her bed. The resident had a nebulizer mask in place over his/her nose and mouth and was receiving a nebulizer (breathing) treatment. The surveyor also observed that the resident had a nasal oxygen cannula in place under the nebulizer mask and in the resident's nostrils. The other end of the oxygen tubing was connected to an oxygen concentrator (a machine that concentrates oxygen from the room air and delivers it to the resident). The concentrator was set to deliver 4 liters of oxygen per minute. The oxygen tubing was not labeled to indicate when it was removed from its packaging and put into…

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

Based on medical record review and staff interview, it was determined that the facility failed to ensure that each resident's drug regimen was free from psychotropic drugs. This was evident for 1 (#70) of 5 residents reviewed for unnecessary medications. The findings include: Resident #70's medical record was reviewed on 8/3/18 and the August 2018 physician's orders revealed documentation regarding the antipsychotic medication Quetiapine Fumarate (Seroquel) 25 mg, give 0.5 tablet by mouth two times a day for depression (12.5 mg). Resident #70 also received the medication Sertraline (Zoloft) 50 mg. every day for depression and Trazodone 50 mg. two times a day for major depressive disorder. Review of physician progress notes revealed a note, dated 7/26/18 at 16:15, which documented dementia-stable without any recent falls or agitation, Mood disorder-well controlled without medication side effects and Insomnia-well controlled with trazodone. A 6/20/18 at 12:54 physician's progress documented dementia-stable cognitive status without any major falls or injuries, mood disorder-controlled…

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, staff interview, and facility documentation review, it was determined that the facility failed to 1) ensure that medication and treatment carts were locked when unattended, 2) failed to discard medications after the expiration date and 3) failed to date medications once opened. This was evident for 2 of 3 nursing unit hallway observed, of 2 medication carts observed and on 1 of 2 nursing units observed. The findings include: 1) Observation was made, on 7/26/18 at 11:31 AM, of a treatment cart sitting in the hallway on the third-floor secured unit, outside of room [ROOM NUMBER], unlocked and unattended. The surveyor opened the treatment cart and observed scissors in the top drawer along with bandages, skin staple removers, and steri strips. Observed in the second and third drawers were creams and ointments and wound dressings in the fourth drawer. The third-floor secured unit consists of residents with dementia and behavioral problems. Staff #9 was told about the treatment cart on 7/26/18 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.

Review of the Dishwasher Checklist for the month of May revealed that the facility failed the monitor the water temperatures and chlorine sanitation levels for the last 11 days for the month of May. At 11:50 AM, the food service manager (staff#7) was asked to show how they test for proper chemical sanitation. The food service manager obtained the vial of chorine test strips and ran a plate pellet through the dishwasher and placed the test strip into a small puddle of water remaining on the plate pellet. The food service manager revealed a 0 level of sanitation. The food service manager had utilized another test strip and got the same result of 0 chlorine sanitation level. The food service manager then replaced the chlorine sanitation bottle with a new bottle of chlorine sanitizer. A plate cover was placed into a rack and ran through the dishwashing machine and the food service manager recorded a reading of 100 parts per million on the chlorine test strip. The dishwashing machine is a ADC 44. Per manufacture guidelines…

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 and interviews with staff, it was determined that the facility staff failed to implement the facility developed POC (plan of correction) from the annual survey (2017). Quality Assurance (QA) encompasses all managerial, administrative, clinical, and environmental services. It is an organizational structure, processes, and procedures designed to ensure that care practices are consistently applied and is responsible for identifying quality concerns and developing and implementing plans of action to correct these quality concerns and measure the outcomes of the process over time. The findings include: The facility staff failed to implement the facility developed plan of correction from the annual survey year (2017). On 8/2/18 at 2PM and 8/3/18 at 10AM, the surveyor reviewed the annual survey results from 2017 and found that the facility developed plan of correction was not followed. The facility had repeat deficiencies under the following F tags; F553, F580, F584, F610, F641, F642, F656, F684, F692, F744, F756, F757, F758, F761, F812, F842, F868, F908.…

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

Based on review of facility documentation and interview with staff, it was determined that the facility failed to have a system to monitor antibiotic use. This has the potential to affect all residents. The evidence includes: During a review of facility infection prevention logs that took place with the Infection Preventionist at 8/2/2018 at 1:45 PM, no evidence was found of a system to monitor current use of antibiotics in the facility. This was confirmed by one of the corporate nurses on 8/2/2018 at 2:15 PM. This concern was reviewed with the Director of Nursing and corporate staff during survey exit.

Based on resident and staff interview and medical record review, it was determined the facility failed to include the resident and the resident's representative in the development and implementation of the resident's person-centered care plan after a significant change assessment by failing to have a care plan meeting to review the updated care plan. This was evident for 1 (#29) of 4 residents reviewed for care plan meetings.The findings include: An interview was conducted with Resident #29 on 7/26/18 at 11:51 AM, and the resident was asked if he/she was involved in care plan meetings. Resident #29's daughter was in the room at the time and told the surveyor it has been quite some time since we went to a care plan meeting. It has been longer than 3 months. Review of Resident #29's paper medical record revealed a care plan sign in sheet which documented that the last care plan meeting was 4/12/18. Staff #6 stated that, after the significant change assessment was done on 8/2/18 at 3:26 PM, a care plan meeting should have been held in May, however, it was missed, and the resident was…

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

Based on observation, staff interview and medical record review, it was determined that the facility staff failed to ensure access to the nurse call bell for a resident who was totally dependent on nursing staff for daily care due to impaired mobility. This was evident for 1 (#43) of 45 residents investigated during the annual survey. The findings include: Observation was made, on 7/26/18 at 9:19 AM, of Resident #43 lying in bed. The call light cord was observed lying on the floor. While the surveyor was in the room, Staff #2 walked in the room and said, oh your call bell is on floor. Staff #2 picked the call bell cord up and put it in the resident's hand. The surveyor asked if the resident was capable of using the call bell and Staff #2 stated we are working with her to use the call bell. Review of Resident #43's care plan Resident #43 is a Moderate risk for falls r/t (related to) contractures, cognitive memory loss, which was revised on 5/16/18, stated Be sure Resident #43's call light is within reach and encourage Resident #43 to use it for assistance as needed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident observation, review of the medical record and interview with staff, it was determined that the facility staff failed to notify the resident and/or the resident's representative before a room change. This was evident for 1 of 56 residents reviewed. The findings include: A review of Resident #97's medical record on 7/30/18 at 10:13 AM revealed a progress note indicating that the resident was moved from room [ROOM NUMBER] to a room on the 3rd floor on 7/23/18. On 7/30/18, the surveyor observed Resident #97 on the second floor. Further review of the record revealed a Social Services progress note, dated 7/27/18, which indicated that the resident was notified, and his/her representative was called and notified that Resident #97 would be moved back to the second floor that day. No evidence was found to indicate that the resident, his/her representative or the resident's new room-mates were notified in writing of either room change. During an interview, on 7/30/18 at 2:10 PM, Staff #8 confirmed 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 record review, interview the resident, and the facility staff, it was revealed the facility failed to provide quarterly statements (Resident #66). This is evident for 1 of 1 residents selected for review. The findings include: The facility failed to provide quarterly statements of personal funds for resident #66. Resident #66 is non-verbal and uses a dry erase board to communicate. During an initial interview by surveyor on 7/27/18 at 7:38am, resident (#66) wrote, they said I don't have any money. When asked if he/she receives quarterly statements from the facility, the resident wrote no. On 08/03/18 10:06 AM, during interview with the business office manager, he/she stated the resident was receiving the quarterly statements and that the residents' POA was also receiving them, he/she also stated each party had signed for them. At 10:15AM on 8/3/18, this surveyor requested a copy of the signed quarterly statements, since the resident stated he/she does not receive them. Approx. 11:15AM, this writer had not received the requested documents and went to the residents' room. The…

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

Based on medical record review and staff interview, it was determined the facility failed to report an injury of unknown origin to the State Survey Agency. This was evident for 2 (#73, #111) of 15 residents reviewed for abuse. The findings include: Review of Resident #73's progress notes on 8/1/18 revealed a 5/31/18 at 14:40 note which stated, staff observed bruise to the left upper eye of the res (resident), upon assessment res denied pain upon palpation, skin surrounding the bruised area is intact with no skin tear observed, notified POA/dr. Staff #14 was asked on 8/1/18 at 3:35 PM if the incident was reported to the Office of Heath Care Quality (OHCQ) as an injury of unknown origin and the reply was no, it was not because it was his behavior. He would put his head down on the hand rails in the hall. Review of the emergency room documentation of 6/1/18 at 16:23 revealed documentation of the chief complaint and history of present illness which stated, presents to the emergency department for altered level of consciousness for the past 24 hours. Patient is from [nursing facility]…

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

Based on medical record review and staff interview, it was determined the facility failed to thoroughly investigate an injury of unknown origin and report it to the to the State Survey Agency within 5 working days of the incident. This was evident for 1 (#73) of 15 residents reviewed for abuse. The findings include: Review of Resident #73's progress notes on 8/1/18 revealed a 5/31/18 at 14:40 note which stated, staff observed bruise to the left upper eye of the res, upon assessment res denied pain upon palpation, skin surrounding the bruised area is intact with no skin tear observed, notified POA/dr. Staff #14 was asked on 8/1/18 at 3:35 PM if the incident was reported to the Office of Heath Care Quality (OHCQ) as an injury of unknown origin and the reply was no, it was not because it was his behavior. He would put his head down on the hand rails in the hall. Review of the emergency room record of 6/1/18 at 16:23 revealed documentation of the chief complaint and history of present illness which stated, presents to the emergency department for altered level of consciousness for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined that the facility failed to document the emergent discharge of a resident in the medical record including the reason for the transfer and information provided to the receiving provider to ensure a safe and effective transition of care. This was evident for 2 (#73, #262) of 13 residents reviewed for hospitalization. The findings include. 1) Review of Resident #73's medical record on 8/2/18 revealed documentation that the resident stayed in bed during the shift and was unable to stand. The physician was notified and ordered to send the resident to the emergency room for evaluation. There was no documentation found in the medical record regarding the transfer of the resident to the emergency room. There was no change in condition assessment which would have described the resident's condition and what interventions were done for the resident. Staff #28 was interviewed on 8/2/18 at 2:32 PM, and asked what the procedure was when sending a 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 4) Review of the medical record for resident #13 on 7/30/18 revealed the resident was sent to the hospital for pneumonia and septic shock on 6/18/18. Further review of the medical record failed to produce written evidence that the responsible party was notified in writing of the transfer. 5) Review of the medical record for resident #108 revealed that resident #108 was transferred to the hospital on 6/10/18. Continued review of the medical record did not reveal evidence that the resident or resident's responsible party was notified in writing of the transfer. Interview of the Administrative team on 8/1/18 at 4:45 PM confirmed that the facility has not been providing the written documentation as per the regulatory requirement. Based on medical record review and staff interview, it was determined the facility 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 8 (#24, #44, #73, #13, #108, #111, #91,…

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 orient, prepare and document a resident's preparation for a transfer to the hospital. This is identified for 2 (#73, #108) of 13 residents reviewed for hospitalization. The findings include. 1) Review of Resident #73's medical record on 8/22/18 documented that the resident stayed in bed during the shift and was unable to stand. The physician was notified and ordered to send the resident to the emergency room for evaluation. Review of the documented not in the resident's medical record did not reveal any information that the resident had received an explanation as to why he/she was going to the emergency room and the potential response of the resident's understanding. Staff #28 confirmed the above findings on 8/2/18 at 2:32 PM. 2) Resident #108's medical record review revealed that this resident was sent to the hospital on 6/10/18. The nursing note was written as The resident was sent to [NAME] Hospital 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 staff interview, it was determined the facility staff failed to ensure that a discharge Minimum Data Set (MDS) assessment was completed, encoded and electronically transmitted to the CMS System. This was evident for 1 (#1) of 4 residents reviewed for resident assessments for a discharge during the annual survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. Review of the medical record for Resident #1, on 8/1/18, revealed the resident was admitted to the facility on [DATE], and discharged from the facility on 3/31/18. The only MDS Assessment in the electronic system…

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 a discharge Minimum Data Set (MDS) assessment was completed and signed by a registered nurse. This was evident for 1 (#1) of 4 residents reviewed that had been discharged from the facility. 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. Review of the medical record for Resident #1 on 8/1/18 revealed that the resident was admitted to the facility on [DATE] and discharged from the facility on 3/31/18. The only MDS Assessment in the electronic system was the admission assessment with an…

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

Based on medical record review and staff interview, it was determined that the facility staff failed to provide an activities program to meet the needs and preferences of the residents, and failed to develop a resident centered care plan related to activities with achievable goals and measurable objectives. This was evident for 2 (#70, #103) of 4 residents reviewed for dementia care. 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) Resident #70's care plans were reviewed and there was no care plan found for activities that would have addressed the resident's customary routines, interests, preferences and personal choices. Review of the Activity interview for daily and activity preferences that was completed on 3/22/18, after admission to the facility, documented that the resident thought it was somewhat important to choose what clothes to wear, listen to favorite music, be around animals such as pets, keep up with the news, do favorite activities 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, medical record review, and staff interview, it was determined that the facility failed to ensure that residents with a limited range of motion received the appropriate treatment and services to prevent further decline in range of motion. This was evident for 2 (#43,#13 ) of 4 residents reviewed for mobility. The findings include: Observation was made, of Resident #43 on 7/26/18 at 9:13 AM. Resident #43 was lying in bed with both legs contracted inward at the knees, with feet next to buttocks. Both hands were contracted with hands in fists. The resident did not have hand splints on hands, and both legs were directly on the fitted sheet of the mattress. There were no heel protectors. Observation was made at that time of the resident's nightstand with a green crate sitting on top of the nightstand. The hand splints were in the green crate. Resident #43 was observed again, on 7/26/18 at 11:18 AM, lying in bed after morning care. The resident was not wearing hand splints, legs were not elevated on pillows and there were no heel protectors applied. On 7/26/18 at 1:50…

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

Based on medical record review and staff interview, it was determined the facility failed to keep a resident's environment free from accident hazards. This was evident for 1 (#81, #92) of 5 residents reviewed for accidents. The findings include: 1) Review of the medical record for Resident #81 revealed a Change in Condition note related to a fall on 7/10/18 at 14:44. The note stated, beauty shop chair not fitting in properly. The note continued resident was witnessed on the floor at the beauty shop at 2 PM. Staff #22 stated on 7/31/18 at 1:53 PM, they had cleaned, and the chair was moved up against the wall. The resident walked in the room and sat in the chair that was up against the wall. When he/she sat in the chair, the chair tipped sideways and the whole top of the chair was broke and not in the hydraulic part. He said he was ok. That was the first time the chair was moved so that the room could be deep cleaned. The room has not been cleaned like that in 1 to 1 1/2 years. Staff #22 continued to say that when the chair was moved the top section of the chair was picked up and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined that the facility staff failed to conduct an in-depth assessment for a resident's urinary incontinence. This was evident for 1 (#81) of 2 residents reviewed for bladder incontinence. The findings include: Review of Resident #81's medical record, on 7/31/8 at 3:28 PM, revealed a care plan has bladder incontinence r/t dementia that was initiated on 6/27/18. The goal was will remain free from skin breakdown due to incontinence and brief use through the review date. The interventions included encourage fluids during the day to promote prompted voiding responses; check as required for incontinence; wash, rinse and dry perineum; change clothing PRN after incontinence episodes; toilet resident before and/or after breakfast, lunch, dinner, at HS and PRN. The care plan was not updated to include the intervention to apply incontinence briefs that were in use daily. Interview of Staff #16 on 7/31/18 at 10:23 AM revealed the resident is continent during…

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 failed to 1) timely assess a resident with weight loss, 2) immediately notify the physician, dietician and family of unplanned significant weight loss and 3) failed to revise a care plan for nutrition when weight loss was recognized. Failure of the facility staff to immediately assess and notify the physician and dietician of weight loss delayed interventions that the physician could have put in place at the first sign of weight loss. This was evident for 1 (#73) of 3 residents reviewed for nutrition. The findings include: Review of the medical record for Resident #73 on 7/27/18 revealed that the resident has had a gradual weight loss since admission on [DATE]. Resident #73's weight on admission was 166 lbs. One month later, the weight was 157 lbs. on 5/7/18. Resident #73's weight on 6/15/18 was 154.0 pounds (lbs.) and 2 weeks later 6/29/18 Resident #73's weight was 141.0 lbs., which was a 13-pound weight loss in 2 weeks. Further…

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

Based on observation, medical record review, and staff interview, it was determined that the physician reviewed a resident's plan of care which included treatments, and signed off that the treatment was appropriate for the resident. This was evident for 1 (#44) of 2 residents reviewed for bladder incontinence. The findings include: Resident #44 on observed on 7/26/18 at 9:39 AM lying in a geriatric chair. The resident was non-verbal. The resident was wearing bilateral heel protectors and had a wedge/pillow in between the legs. Review of Resident #44's medical record revealed that the resident was started on Hospice care 7/10/18 after recent hospitalizations, and the family felt the resident would be more comfortable with palliative care. The resident was total care for all aspects of daily living. Review of Resident #44's care plans revealed a care plan functional bladder incontinence r/t dementia and impaired mobility. The goal was will remain free from skin breakdown due to incontinence and brief use. The intervention on the care plan was to check for incontinence and wash…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview it was determined that the facility staff failed to provide a resident centered dementia treatment and services plan by failing to create and implement resident centered care plans with achievable goals, measurable objectives and evaluations related to daily activities. This was evident for 2 (#70, #103) of 4 residents reviewed for dementia care. 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) Review of the medical record for Resident #70 on 8/3/18 revealed that the resident had a BIMS (Brief Interview of Mental Status) of 3 on the most recent MDS, with an assessment reference date of 6/21/18. A BIMS coded between 0 and 7 indicate severe cognitive impairment, scores between 8 and 12 indicate moderate impairment while scores above 13 shows little to no impairment. The evaluation is used to detect cognitive impairment and is a quick…

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

Based on medical record review and staff interview, it was determined that the facility pharmacist failed to identify and report irregularities in the resident's drug regimen to the physician, facility's medical director and the director of nursing. This was evident for 2 (#70, #107) of 5 residents reviewed for unnecessary medications. The findings include: 1) Review of the medical record for Resident #70 on 8/3/18 revealed August 2018 physician's orders for the antipsychotic medication Seroquel, 12.5 mg two times a day, for depression. Pharmacy reviews dated 3/29/18, 4/16/18, 5/17/18, and 6/19/18 revealed that no irregularities were noted. It was not until 7/26/18 that the pharmacist noted the diagnosis of depression for the Seroquel, which was not a supporting diagnosis for the antipsychotic medication. Reviewed with Staff #8, on 8/3/18 at 6:45 AM, who confirmed the finding. 2) The facility's consulting pharmacist failed to identify an excessive Tylenol order for Resident #107. Resident #107 was ordered 650 mg of as-needed Tylenol with an order to not exceed 3000 mg of Tylenol per…

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 record and interview with facility staff, it was determined that the facility ordered and administered an excessive amount of Tylenol to Resident #107. This was true for 2 of 6 residents reviewed for pain medication regimen. The findings include: Resident #107 was ordered 650 mg of as-needed Tylenol, with an order to not exceed 3000 mg of Tylenol per day, despite the resident already having a scheduled order for 2600 mg of Tylenol per day. Furthermore, this as-needed Tylenol was administered to the resident, exceeding the ordered daily maximum of 3000 mg. Tylenol (acetaminophen) is an over the counter pain medication that is metabolized in the liver. Excessive doses of Tylenol can lead to liver damage. Although the recommended daily limit for adults is considered to be 4000 mg, older adults may metabolize through their liver more slowly and should not exceed a lower dose. Resident #107's medical record was reviewed on 8/1/2018 at 8:30 AM. The resident was first ordered Tylenol on 6/22/2018 at 1600. The Tylenol order was Tylenol Tablet 325 MG…

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 that the facility staff failed to maintain the resident call system in working order. This was evident for 2 of 32 resident call light observations. The findings include: On 7/26/18 at 1:34 PM, during an observation of room [ROOM NUMBER], the surveyor attempted to activate the call light for bed A. The call light located in the hallway above the door did not light. The surveyor observed the call light panel at the nurses' station, which was not activated. The surveyor pressed the reset button on the wall panel in the residents' room and attempted to activate the call bell a second time without success. The surveyor then attempted to activate the call button for bed B and again, neither the light above the room door, nor the call light panel at the nurses' station activated. Staff #14 was present and confirmed that the call system was not functioning for either bed in room [ROOM NUMBER].