Autumn Lake Healthcare At Ruxton

Based on observation, interview and record review it was determined the facility failed to ensure effective management of pest control. This was evident for all floors of the facility during surveyor review of environment during the facility's recertification survey.The findings include: On this surveyor's initial tour of the facility's kitchen the surveyor's observations on 2/18/26 at 7:49AM included the lower tier of a two tier food preparation table located across from the two compartment sink which was observed to have numerous dark rod shaped pellets approximately the size of a grain of rice, scattered on it's surface in addition to food debris and areas of yellow sticky liquid matter next to a bag of corn starch and next to containers which held flour, sugar, white rice, and thickener powder were observed. On 2/18/26 at 7:52AM the surveyor conducted an interview and dual observation of the concerns with FSD #12 and inquired as to if the facility kitchen had pest concerns at present. FSD #12 stated to the surveyor during the interview: We have had a problem in the building with…

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

Based on observation, interview and record review it was determined the facility failed to ensure a Resident (#97) had the capability of safe self administration of a medication and failed to ensure the interdisciplinary team was aware of the Resident's self administration of the medication. This was evident for 1 (#97) out of 2 Residents reviewed for quality of care during the facility's recertification survey. The findings include: On 2/19/26 at 10:05AM the surveyor conducted an interview with Resident #97 and observed them retrieve a bottle of magnesium citrate from the drawer which had a prescription label on it. Resident #97 showed the bottle to this surveyor and informed this surveyor that they needed more of the medication and that they had asked Licensed Practical Nurse Supervisor (LPNS) #9 for more of it three to four weeks ago and were told that they would get it but had not yet been given it. Resident #97 explained to this surveyor that they keep the medication for emergencies for a problem with constipation. On 2/19/26 at 10:09AM the surveyor conducted an interview with…

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

Based on resident interview, staff interview, and clinical record review it was determined that the facility staff failed to ensure a resident received showers according to personal preference. This was evident for 1 (Resident #104) out of 1 resident reviewed for preference in shower schedule.The findings include: During observation of Resident #104's wound dressing change on 2/20/26 at 2:50 PM the resident stated that he/she was supposed to get two showers twice a week in the evening but doesn't always get one. Staff #15 who was doing the dressing change offered that the resident was supposed to get showers on the 3-11 shifts. Resident said he/she wanted showers on the 7-3 shift and has told nursing staff that he/she wants showers on day shift because he/she wants the showers before wound dressings are changed not after. The resident said even if the old dressing got wet it would have to come off anyway so getting wet would not matter. The resident then stated that they did not get a shower on Tuesday, 2/17/26.This surveyor interviewed the Director of Nursing (DON) on 2/24/26 at…

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

Based on resident interview and staff interview, it was determined that the facility staff failed to provide a resident with a quarterly statement for a personal funds account. This was evident for 1 (#104) out of 2 residents reviewed for a personal funds account.The findings include:During the initial tour of the facility on 2/18/26 this surveyor interviewed Resident #104 at 2:51 PM. Resident #104 informed the surveyor that they do not get a quarterly statement telling them how much is in their personal funds account. Staff #18 was interviewed on 2/25/26 at 2:59 PM. This surveyor requested a copy of the quarterly statements provided to Resident #104 and signed by the resident indicating that the resident received the statements.The quarterly statements with signatures were not provided to the survey team at the exit conference. This surveyor's business card was provided to Staff #18 at the exit conference so that the facility staff could email copies to this surveyor. Copies were provided via email on 3/2/26 at 10:38 AM but they were not signed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews with resident's and facility staff, it was determined the facility failed to ensure Resident's room furniture and the resident's environment was clean and well maintained for residents residing in the facility . This was evident during the surveyor's initial tour of the facility for two Resident rooms (#208, and #210) located on the second floor, observations of Resident # 19 Room and for Room # 309 during the facility's recertification survey.The findings include:1.On 2/18/26 at 9:02AM the surveyor observed Resident room [ROOM NUMBER] at which time the nightstand furniture was found to be in disrepair with wood located at the base of one of the nightstand observed to be broken in half with areas present in which the wood stain was worn off. A white substance was observed smeared across the front of one of the nightstand drawers. Further observation of the furniture in Resident room [ROOM NUMBER] revealed a wooden dresser with multiple worn and chipped areas in which the wood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with staff and a resident representative, it was determined that the facility failed to follow the grievance process for a resident and resident representative. This was evident for 1 (Resident #180) of 2 residents reviewed for grievances during the annual recertification and complaint survey.The findings include:A grievance is a formal or informal, written or oral complaint by a resident or resident representative regarding care, treatment, staff behavior, or quality of life. Facility staff are responsible for making prompt efforts to resolve (facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance) a grievance and to keep the resident/resident representative informed of the progress towards a resolution.On 2/24/2026 at 3:45PM, a review of Resident #180's Complaint/Grievance Forms filed by the resident representative included:1/17/2025-Failure to ensure nurses and aides have appropriate competencies: Requested…

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 the facility failed to ensure Resident #4's personal funds was appropriately managed. This was evident for 1 out of 2 Residents reviewed for personal funds during the facility's recertification survey.The findings include:On 02/18/2026 at 2:15PM the surveyor conducted an interview of Resident #4 who expressed to the surveyor that they had sought Social Security for themself and learned that they had been approved for disability benefit, and in approximately October or November of 2025 they had received a check that came in their mail which was in their own name and made payable to only them. Resident #4 stated to the surveyor: The Administrator took my check, it was for $19,780.00 and then s/he supposedly put $2000.00 in an account for me, I don't get a statement or anything. During the interview Resident #4 continued to express to the surveyor that they did not understand why the check was taken from them when it was payable to their name, and was not made payable to the facility. Resident #4 stated they had wished to use 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 record reviews and interviews, the facility failed to provide written information regarding transfers to the hospital and discharge to; the resident and/or the resident's responsible party (RP), and the local Ombudsman. This was evident for 6 (# 94, # 181, # 179, # 12, #140, # 7) of 6 residents reviewed for transfer / discharge.The findings include: 1.On 2/18/26 at 2:45 PM a medical record review was conducted and upon review it was revealed Resident # 94 was transferred to the hospital on [DATE]. The resident has cognitive impairment and is not their own RP. At this time the survey team requested documentation of the written notification of the hospital transfer documentation and bed hold policy that was provided to the resident responsible party. The facility provided 2 documents to the survey team for Resident # 94. Review of the first page titled, Notice of Acute Emergent Discharge or Transfer Form had a listed reason for resident # 94 hospital transfer. There was no area on the form for 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 record review and interview it was determined the facility failed to ensure resident minimum data set assessments were completed timely. This was evident for 2 out of 2 Residents (#34 and #17) reviewed for the Resident Assessment task during the facility's recertification survey.The findings include:1.) On 2/25/26 at 11:49AM the surveyor conducted an interview of Minimum Data Set Coordinator RN (MDSC-RN) #20 and reviewed Resident #34's minimum data set assessment record with them. MDSC-RN #20 reported to the surveyor during the interview that Resident #34's annual minimum data set assessment with an assessment reference date of 1/10/26 was completed, however, It is already late, we signed it on 2/10/26. During the interview, MDSC-RN #20 indicated that the assessment was to have been completed within fourteen days from the assessment reference date of 1/10/26 and additionally stated: We usually make sure it is completed, but I can't remember why we missed this one, it was not within the fourteen day timeframe. On 2/25/26 at 12:01PM MDSC-RN #20 reported to the survey team…

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

Based on observation and interviews with staff, it was determined that the facility failed to administer medication according to professional standards of practice. This was evident for 1 (Resident #126) out of 7 residents observed for medication administration during the annual recertification survey.The findings include: House Stock medications are a supply of commonly used non-prescription (OTC-over the counter) medications, not assigned to a specific resident. On 2/24/2026 at 9:30AM, the Surveyor observed Registered Nurse (RN) #24 preparing medications for Resident #126. RN #24 retrieved Vitamin B-1 100mg from a medication bottle with a pharmacy label with another resident's name on it. The Surveyor expressed the concern that Resident #126's name was not on the medication bottle and another resident's name was on the medication. RN #24 stated that the medication is a house stock medication and is the same medication, route of administration, and dosage that Resident #126 is ordered for. RN #24 stated they don't know why the pharmacy labeled the house stock medication bottle with…

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

Based on record review and interview, the facility failed to Ensure a resident had their wound dressing changed according to physician's order for 1 (#104) of 1 resident wound dressing observation, and to ensure medications were administered as ordered by the physician for 1 (#140) of 1 resident reviewed for medication administration. The findings were evident during the facility's annual Medicare/Medicaid survey.The findings include: 1.) This surveyor observed Resident #104's wound dressing on the resident's left leg on 2/18/26 at 2:20 PM. The dressing was dated 2/17/26 which told the observer that was when the dressing was put on the resident's leg. This surveyor observed on 2/20/26 at 2:50 PM the wound dressing being changed. The nurse (Staff #15) doing the wound dressing change showed this surveyor the dressing prior to removing the dressing and treating the leg. The old dressing that was being removed had a date of 2/17/26 on it. Staff #15 confirmed the date and that she was the one who put the dressing on the resident's leg on 2/17/26. The date indicated that the dressing had…

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

Based on medical record review and interviews with facility staff it was determined the facility failed to ensure that a resident was kept safe and free from accidents after observing the resident to be in distress. This was found to be evident for 1 (Resident #2) of 5 residents reviewed for accidents and observations made during the facility's annual Medicare/Medicaid survey.The findings include:Resident # 2 has the following but not limited diagnosis; Tracheostomy (opening in the neck leading to windpipe to help a person breathe), Epilepsy (convulsions) and Gastrostomy (opening through the stomach for insertion of a feeding tube). An interview was conducted with resident # 2 family member on 2/18/26 at 1:15PM and the family member stated that they were concerned about a fall that the resident had in March of last year and asked how this was possible considering the resident status. During a medical record review on 2/20/26 at 9:35AM of the change in condition/concurrent review form dated 3/5/25, it revealed the following summary regarding resident # 2: Around 8:45 AM nurse 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 resident interview, staff interview, observation, and clinical record review it was determined that the facility failed to ensure a resident's pain management was adequately addressed. This was evident for 1 (#104) out of 1 resident being reviewed for wound care.The findings include:This surveyor observed Resident #104 having a wound dressing changed on 2/20/26 at 2:50 PM by a nurse (Staff #15). While the nurse was changing the resident's dressing, Resident #104 stated that he/she asked for some pain medication at 2:30 PM but did not get any before wound care started. Staff #15 interjected and said she was doing another resident's dressing change so she could not give him/her any pain medication before she started. She asked the resident if they were in pain and the resident replied that they are in pain all of the time. She said she would give him/her pain medication as soon as she finished. The resident said that was acceptable.A review of Resident #104's clinical record on 2/24/26 revealed that the primary physician ordered on 2/4/26 Oxycodone 15 mg by mouth every 4…

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

Based on clinical record review and staff interview, it was determined that the facility staff failed to ensure a pain medication was administered according to the physician's order. This was evident for 1 (#104) out 1 resident reviewed for pain medication.The findings are:A review of Resident #104's clinical record on 2/24/26 revealed that the primary physician ordered on 2/4/26 Oxycodone 15 mg by mouth every 4 hours as needed for pain 5-10 on a 1-10 scale. A review of the Medication Administration Record revealed that: on 2/6/26 at 8:25 PM the resident's pain level was 4 but medication was administered, on 2/10/26 at 10:37 AM and 5:55 PM the resident's pain level was 4 but medication was administered, on 2/11/26 at 1:50 AM the resident's pain level was 4 but medication was administered, on 2/13/26 at 9:17 PM the resident's pain level was 4 but medication was administered, on 2/14/26 at 1:30 AM and 6:05 AM the resident's pain level was 4 but medication was administered, and on 2/15/26 at 4:33 PM and 8:55 PM the resident's pain level was 4 but medication was administered.Pain…

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

Based on clinical record review, observation, and staff interview, it was determined that the facility staff failed to ensure a resident received routine and follow-up dental care. This was evident for 2 residents (#9 and # 180) out of 2 residents reviewed for dental care during the facility's annual Medicare/Medicaid survey.The findings include:1.During the initial tour of the facility on 2/18/26 at 8:31 AM Resident #9 was observed to have few if any teeth. A review of the clinical record on 2/20/26 revealed that the resident has not had a dental consult in over a year. The resident was required to receive, but not limited to, an annual inspection of the mouth and jaw for signs of disease as well as a diagnosis of any dental disease. The Director of Nursing (DON) was interviewed on the morning of 2/24/26. This surveyor informed her of the finding and asked if she could provide evidence that the resident has either gone to the dentist or has had a dentist assess the resident at the facility. The DON was interviewed on 2/24/26 at 12:00 PM. She confirmed that she could not find a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to maintain medical records in accordance with the accepted professional standards and practices for complete and accurate records. This was evident in 3 (#94, #97, #165) of the 51 residents' records reviewed. The findings include: 1) During observation rounds conducted on [DATE] at 1:46 PM Resident # 94 was observed and the resident complained to this surveyor of experiencing pain. The resident stated that pain has been ongoing for approximately two weeks. The nurse (Staff #23) who was at the nurse station at this time was made aware of the resident's pain concerns and assessed the resident. During medical record review on the same date, it was revealed the resident has an order for Morphine Sulfate Concentrate (give 0.25 ml(milliliter) every 4 hours PRN (as needed). Resident #94 received morphine on [DATE] at the following times: 0446, 0943, and 1429. There was no documentation on the medication administration record that the resident's pain level was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment for residents on 2 of 2 units observed (Somerset and Arcadia Memory Care). This had the potential to affect all residents residing on these units.The findings include: 1. Somerset Unit During observation rounds on 2/18/26 at approximately 9:00 a.m., the following concerns were identified: room [ROOM NUMBER]: Dirty clothing was observed on top of the resident's bedside table. The room had a strong odor resembling urine. The central supply cart on the unit was noted to have a large dark stain on the side. room [ROOM NUMBER]: Clothing was observed piled in the corner of the resident's room between both closets. The bathroom contained a dark yellow sticky substance and an odor resembling urine. room [ROOM NUMBER]: The dresser drawer was hanging off the track, and chipping wood was observed behind the resident's headboard. room [ROOM NUMBER]: A…

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

Based on resident interviews, record reviews and staff interviews, it was determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice. This was evident for 1 resident (Resident #1) receiving medications late.The findings include: On 10/07/2025 at 2:40 PM, Resident #1 was interviewed. During the interview, Resident #1 stated that he/she has received medications several hours late.On 10/07/2025 at 3:37 PM, the surveyor reviewed the resident's records. The resident record review revealed that Resident #1's Medication Admin Audit Report indicated that the resident received the following morning medications late on 10/2/25: 1. Metamucil 4 in 1 Fiber Oral Packet (Psyllium), for bowel regimen, was scheduled for 9:00 AM and was administered at 11:37 AM; 2. Lasix Oral Tablet 20 mg (Furosemide), for edema, was scheduled for 9:00 AM and was administered at 11:37 AM; 3. Buspirone HCl Oral Tablet 30 mg (Buspirone HCl), for anxiety, was scheduled for 9:00 AM and was administered at 11:37 AM;4. Lamotrigine ER Oral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program, failed to seal gaps in the walls, and prevent rodents from entering residents rooms for six residents (R20, R18, R6, R15, R16, and R14) residing on the third floor. The facility census was 164. Findings include: Review of facility policy titled Physical Environment Quality dated 12-23-2022 documented it was the facility policy to provide a safe, functional and comfortable environment for residents, staff and the public. Observations of the facility first floor, second floor and third floor on 2/11/2024 from 9:10 AM through 12:45 PM, showed no mice traps were placed in residents ' rooms, workstations, or breakrooms. During an interview on 2/11/2025 at 10:10 AM, Registered Nurse (RN)21 stated he saw a mouse on the third floor a few weeks ago. 1. Record Review of the quarterly Minimum Data Set assessment (MDS) dated [DATE], revealed R20 had a Brief Interview of Mental Status (BIMS) score of 15…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to provide respiratory care in accordance with professional standards for four of four residents (Residents (R) 18, R22, R120 and R357) reviewed for respiratory care out of 32 sampled residents. This failure had the potential for the residents to be subjected to contaminated respiratory equipment and to not receive proper airflow. Findings include: Review of the facility's policy titled, Oxygen Administration, dated 01/27/23, documented . (5.a) follow the manufacturer recommendations for the frequency of cleaning equipment filters . (5, e.) keep delivery devices covered in plastic bag when not in use. A copy of the manufacturer guidelines was not provided by the facility. 1. Review of R18's undated admission Record located under the Profile tab of the electronic medical record (EMR), revealed R18 was admitted on [DATE] with diagnoses which included pneumonia due to other specified infectious organisms and chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to ensure residents received appropriate supervision during medication administration for three of 161 residents (Resident (R) 122, 97, and 103) reviewed during initial tour. This failure could result in unwarranted medication side effects and mismanaged medical conditions. Findings include: Review of the facility's policy titled, Medication Administration, implemented 12/14/22, revealed Observe resident consumption of medication. Review of the facility's policy titled, Medication Storage, implemented 12/14/22, revealed During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. Review of R122's undated admission Record located in the Profile tab of the electronic medical record (EMR) revealed R122 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, unspecified, type 2 diabetes mellitus…

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 interview, record review, and policy review, the facility failed to ensure a grievance was adequately documented and investigated to ensure satisfactory resolution for one of 32 sampled residents (Resident (R) 97). This failure had the potential to cause dissatisfaction with care, feelings of helplessness, and fear for R97. Findings include: Review of R97's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed s/he was admitted to the facility on [DATE]. Review of R97's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 09/12/24 and located in the MDS tab of the EMR, revealed the facility assessed the resident to have a Brief interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. S/he did not exhibit any mood or behavioral symptoms. Review of R97's Care Plan, dated 11/07/23 and located in the Care Plan tab of the EMR, revealed, Problematic manner in which resident acts characterized…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and policy review, the facility failed to ensure an ongoing program of meaningful activities was designed for one of one resident (Resident (R) 113) reviewed for activities out 32 sampled residents. This failure had the potential to contribute to feelings of boredom, depression, loneliness, or helplessness for R113. Findings include: Review of R113's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed s/he was admitted to the facility on [DATE] with diagnoses which included dementia, anxiety, and insomnia. Review of R113's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 08/15/24 and located in the MDS tab of the EMR, revealed the facility assessed the resident to have a Brief Interview for Mental Status score of zero out of 15 which indicated the resident was severely cognitively impaired. S/he did not exhibit any mood symptoms but wandered daily. R113 was dependent on staff for all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and policy review, the facility failed to ensure a splint was applied to address a hand contracture for one of five residents (Resident (R) 71) reviewed for limited range of motion out of 32 sampled residents. This failure had the potential to lead to increased contracture, pain, or skin breakdown for the resident. Findings include: Review of R71's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed s/he was admitted to the facility on [DATE] and had diagnoses which included stroke with resulting hemiplegia and hemiparesis on the left side, muscle spasm, muscle weakness, and vascular dementia. Review of R71's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 07/21/24 and located in the MDS tab of the EMR, revealed the facility assessed the resident to have a Brief Interview for Mental Status Score (BIMS) of 15 out of 15 which indicated the resident was cognitively intact. S/he did not exhibit…

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, interviews, and policy review, the facility failed to ensure appropriate personal protective equipment (PPE) was worn for two of four sample residents (Resident (R) 107 and R205) reviewed for transmission-based or enhanced barrier precautions out of 32 sampled residents. These failures have the potential to contribute to spread of infection among staff and residents. Findings include: 1. Review of R107's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed s/he was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of gastritis and diarrhea. Review of R107's EMR under the Orders tab indicated a new diagnosis of recurring clostridium difficile (c-diff - an infection that causes diarrhea and colitis and forms spores that are highly transmissible), was added on 04/03/24 and revealed an order, dated 04/03/24, for contact isolation due to reoccurring c-didf [sic]. The orders also indicated R107 received an oral…

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, resident interview and staff interviews, it was determined that the facility failed to ensure interventions for a care plan focus were revised with interventions to address residents' medication refusals. This was evident for 1 (#MD00209998) of 1 complaint reviewed. 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. It should be revised to reflect the resident's plan of care. The findings include: Review of Resident #2 ' s medical record revealed that she/he had a past medical history schizophrenia (a mental illness which affects thinking, behavior, and emotions), bipolar type (causes extreme mood swings), and type 2 diabetes (a health condition when the body does not produce enough insulin which regulates blood sugar level). On 9/25/24 at 5:13 AM, a review of complaint #MD00209998 revealed an allegation that Resident #2 called 911 on the night of 9/16/24 from the facility because he/she had not received insulin all day. On 09/25/24 at 8:48 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 record review and interview it was determined that facility staff failed to ensure the safety of a Resident by not providing adequate supervision as evidenced by the fact that the Resident fell and was found on the floor 5 times in a 4-month period and making rounds. This was evident for 1 (# MD00210090) of 1 complaint reviewed. 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. The findings include: A complaint #MD 00210090 alleged that Resident #1 fell on 9/19/24 around 2 a.m. and was left on the floor for hours crying for help. The roommate could not get anyone and subsequently the police had to come in to assist the resident around 5 a.m. This Resident was admitted to the facility, on 12/19/23, with the diagnosis of delirium, right-side stroke, osteoarthritis, depression, and heart failure. Record review, on 9/25/24 at 8:58 a.m., of nurse Staff #6 ' s progress note, dated 9/10/24 at 7:11 a.m., revealed that Resident #1 was found on the floor mat at the Resident ' s…

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 review of a complaint, interviews, and documentation review, it was determined the facility failed to have an effective pest control program as evidenced by numerous reports and observation of mice throughout the facility. This had the potential to affect all residents in the facility. The findings include: On 9/13/24 at 11:15 AM a review of complaint MD00209294 alleged that there was an infestation of mice running throughout the facility, and even getting up on some of the patient's beds. I know for sure that the third-floor manager is aware and that admissions is aware. It's not fair to the residents or the families to have that additional worry or fear. On 9/13/24 at 11:39 AM the complainant was interviewed and stated there were mice and she had to set traps in her mother's room. The complainant stated she spoke to the Nursing Home Administrator (NHA) about it, and he stated that it will take time. On 9/13/24 at 12:32 PM Resident #36 was interviewed and stated he/she saw a mouse the other night. On…

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

Based on record review and interview it was determined the facility failed to report allegations of abuse within 2 hours of the allegation and an injury of unknown origin within 24 hours to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 3(#10, #8, #2) residents involved in 14 facility reported incidents reviewed during a complaint survey. The findings include: 1) On 9/18/24 at 9:24 AM a review of facility reported incident MD00186088 revealed Resident #10 made a statement to his/her spouse that the person who drew his/her blood, smacked [him/her] in the head. There was no date of the incident on the report. There was no investigation provided to the surveyor to determine the date of the incident. Review of the intake report for MD00186088 the received date was 11/28/22. The facility did not supply the surveyor with email confirmations as to when the report was sent in and when the final report was sent in. On 9/16/24 at 10:46 AM an interview was conducted with the Director of Nursing (DON) who stated she couldn't find the investigation. 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 review of facility administrative records, facility investigations, and staff interview, it was determined the facility failed to thoroughly investigate incidents of alleged abuse, neglect, and misappropriation of property. This was evident for 4 (#10, #8, #2, #30) residents involved in 14 facility reported incidents reviewed during a complaint survey. The findings include: 1) On 9/18/24 at 9:24 AM a review of facility reported incident MD00186088 revealed Resident #10 made a statement to his/her spouse that the person who drew his/her blood, smacked [him/her] in the head. There was no date of the incident on the report. There was no investigation provided to the surveyor to determine the date of incident. There was no evidence that staff were interviewed and that the incident was investigated. On 9/16/24 at 10:46 AM an interview was conducted with the Director of Nursing (DON) who stated she couldn't find the investigation. On 9/17/24 at 9:24 AM an interview was conducted with the NHA who stated that he could not find the file or investigation related to this 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 the review of a complaint, medical record review and interview with staff, it was determined that the facility failed to timely implement wound care orders for a resident with a scrotal ulcer. This was evident for 1 (Resident #35) of 28 complaints reviewed during a complaint survey. The findings include: On 9/17/24 at 8:00 AM a review of complaint MD00177503 revealed concern about being notified that Resident #35 had a pressure ulcer on the sacrum on 9/28/21. On 9/17/24 at 8:00 AM a review of Resident #35's medical record revealed Resident #35 was admitted to the facility in July 2021 with diagnoses that included a urinary tract infection, obstructive and reflux uropathy, anemia, dementia, and Downs syndrome. Resident #35 was admitted with a foley catheter for the obstructive and reflux uropathy. Obstructive uropathy occurs when urine cannot drain through the urinary tract. Urine backs up into the kidney and causes it to become swollen. Reflux nephropathy is a condition in which the kidneys are damaged by the backward flow of urine into the kidney. A foley catheter is a…

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

Based on medical record review, policy review, and interview, it was determined the facility staff failed to ensure the physician wrote, dated, and signed progress notes at each resident's visit. This was evident for 1 (Resident #24) of 28 complaints reviewed during a complaint survey. The findings include: On 9/16/24 at 11:37 AM Resident #24's medical record was reviewed and revealed a 2/21/24 physician's note. Review of the note revealed the physician signed the note on 2/29/24. Continued review of Resident #24's medical record revealed a 2/28/24 note that was signed by the physician on 3/7/24. A 3/6/24 physician's note was signed by the physician on 3/19/24. A 3/8/24 physician's note was signed on 3/19/24 and a 3/13/24 physician's note was signed by the physician on 3/19/24. On 9/17/24 at 10:40 AM the Physician Visits Policy, that was given to the surveyor by the Nursing Home Administrator (NHA) documented, Policy Explanation and Compliance Guidelines, letter f. remind the physician to date and sign all orders and write a progress note. Number 2. documented, The physician should…

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 review of complaint MD00977840, interviews, and medical record review, it was determined the facility failed to ensure that pain and anxiety medications were available to a resident. This was evident for 1 (#18) of 28 complaints reviewed during a complaint survey. The findings include: On 9/13/24 at 12:14 PM complaint MD00197840 was reviewed and alleged that the facility often ran out of Resident #18's medications and that at times the resident would be verbally abusive towards the nursing staff when his/her medications were not given. The complainant reported that the resident would often call 911 when he/she was not given his/her medication. On 9/13/24 at 12:26 PM an interview was conducted with Resident #18 who was asked if he/she had any concerns. Resident #18 stated he/she had issues with pain medication being available and it made him/her mad. The resident did admit that in the past he/she would call 911 about his/her pain medications. On 9/17/24 at 2:24 PM Resident #18's medical record was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with family and facility staff, it was determined that the facility failed to ensure medical records were complete, accurate and up to date related to residents' status in the facility. This was evident during the review of 2 of 38 (#22 and #24) residents reviewed during a complaint survey. The findings include: 1. Review on 9/13/24 at 10:26 AM of the medical record for Resident #22 revealed a discharge to the hospital on [DATE]. According to the resident's family, when called on 9/16/24 at 12:54 PM, s/he passed away on 1/3/24. Further review of Resident #22's medical record revealed that on 1/9/24 an initial activity assessment was completed and uploaded into Resident #22's medical record. This concern was brought to the attention of the DON on 9/16/24. She followed up with the activity director who stated that she had the information on paper, but it was not uploaded into the computer and available for others to review until 1/9/24. The DON stated that she educated…

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, the facility staff failed to honor a resident's choices (Resident #157) ,the facility staff failed to provide showers to Resident (#24), the facility nursing staff failed to 1. know what days of the week a resident was to receive a shower and 2. follow a resident's choice to receive a shower as indicated in the medical record for Resident (#101). This was evident for 3 of 9 residents reviewed for choices during this survey. The findings include: 1. The facility staff failed to honor a resident's choices (Resident #157). On 7/9/19 at 9:04 AM during the initial interview process Resident #157 complained that we (residents) haven't been on an outside trip since December 2018 because the Administrator says she doesn't have enough geriatric nursing assistants to send one with us. Resident #157 says the lack of monthly outside trips is distressing. On 7/15/19 at 8:40 AM the Director of Nursing confirmed there had been no outside activities since December 2018. On 7/15/19 at 12:30 PM during an interview with the Activities Director (#13) it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was evident for 14 resident rooms and 1 shower room and 1 resident lounge. The findings include: 1. On 7/9/19 at 11:45 AM during an environmental tour of the Somerset Unit rooms 305-330 with the Unit Manager the following issues were confirmed. room [ROOM NUMBER]: Bathroom airflow vent was covered with debris and the bathroom had pungent odors. The first bed had brown stains on the privacy curtain. room [ROOM NUMBER]: Broken overbed light cord, 3 telephone outlets pulled from wall and on floor, telephone on the floor, 3 drawer chest covered with spills and had a used bowl and spoon on top, floor by the bed covered with sticky spills. Heat/Air conditioning unit had personal items and plants piled on top covering the vents and stained privacy curtain. room [ROOM NUMBER]: Both boxes on wall of universal…

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

Based on medical record review, observation and interview, it was determined the facility failed to maintain the environment for Residents (#16 and #67) free from potential accidents. This was evident for 2 of 2 resident selected for review of accidents and 2 of 67 residents selected for review during the annual survey process. The findings include: The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. MDS assessments contain standardized questions about several elements of functional and cognitive status and mobility, Behavioral symptoms - a number of items about behavioral symptoms common in dementia, Psychosocial functioning - resident participation in activities and resident preferences, Symptoms and geriatric syndromes - for example pain, continence, falls, nutritional status, activities of daily living and many others 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 record review, observation and interview, it was determined the facility staff failed to administer dietary supplements to Residents (#115, #16, #136, #105, #148, #17, #147 and #117) and failed to obtain weekly weights on (Resident #148) as ordered. This was evident for 8 out of 14 residents selected for review of nutrition and 8 out of 67 residents selected for review during the annual survey. The findings include: Surveyor observation of the second-floor nursing station on 7/10/19 at 12:34 PM revealed the presence of a black plastic container. Inside the plastic container were supplements for residents to be delivered and administered at 10:00 AM. The container contained no ice or any mechanism to keep the items cold. As of 2:00 PM, the supplements had not been delivered to the residents as ordered. 1 A. The facility staff failed to administer a supplement to a resident as ordered. Medical record for Resident #115 revealed on 1/10/19 the dietician ordered: honey thick liquids 3 times a day between meals for hydration. Honey-thick liquids - are slightly thicker, less…

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 of medication pass and interview, it was determined the facility staff failed to obtain a medication error rate less than 5% (Residents #77, and #368). This includes 2 out of 4 residents observed for medication pass, 5 errors out of 27 opportunities with a medication error rate of 18.52%. The findings include: The facility uses an Electronic Medical Record (EMR) for the administration and documentation of medications for administration to the residents. The physician's orders for the medications are entered the EMR with the times of medication administration. During medication observation, the computer will display yellow for the medication to be administered in that time frame. Any medication outside the time frame of administration will be gray. When gray, the facility staff is not able to document administration since it is not in the ordered time frame. Medications must be given within a ½ hour of the time that is listed on the medication log. This means that you have ½ hour before the medication is due, and ½ hour after it is due to administer the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined the facility staff failed to ensure that medications were properly secured, thoroughly labeled with residents' name, and dated when the medication was open. This was evident for 2 of 6 medication carts observed during the annual survey process. The findings include: Observation of the medication carts and treatment carts on [NAME] Ridge on 7/11/19 at 8:00 AM revealed the following: 1. Artificial tears had no date to indicate when it was open on Treatment cart #1 on main hall. Artificial tears are eye drops used to lubricate dry eyes and help maintain moisture on the outer surface of your eyes. 2. Timolol eye drops had no date to indicate when it was open on Treatment cart #1 on main hall. Timolol eye drops medication is used to treat high pressure inside the eye due to glaucoma. 3. Lantus insulin had no date to indicate when it was open on Treatment cart #1 on main hall. Insulin is a hormone that works by lowering levels of glucose (sugar) in the blood. 4.…

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 Residents (#23 and #148) with the most dignified existence. This was evident for 2 of 8 residents reviewed for dignity during the survey process and 2 of 67 residents selected for review. The findings include: 1. The facility staff failed to provide Resident with breakfast in a timely manner. Surveyor's observation revealed Resident #23's breakfast in the room on 7/10/19 at 8:00 AM; however, staff failed to feed resident until 8:20 AM and roommate noted to be eating while Resident #23 was not eating or being fed. Surveyor observation of Resident #23 on 7/17/19 at 8:15 AM revealed the resident's breakfast already in the room, note on the bedside table. The resident's roommate was eating breakfast. Further observation revealed the facility staff failed to feed Resident #23 until 8:40 AM, at least 25 minutes after the tray had been noted to be sitting in the resident's room. Interview with the Director of Nursing on 7/18/19 at 1:30 PM confirmed the facility staff failed to provide Resident #23…

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

Based on resident complaint and observation, it was determined that the facility failed to have the facility complaint/compliment forms readily available to wheelchair dependent Resident (#18) and the facility failed to ensure that Residents (#9 and #145) had access to their nurse call button. This was evident for 3 of 3 resident's reviewed for accommodation of needs during this survey. The findings include: 1. The facility failed to have the facility complaint/compliment forms readily available to wheelchair dependent residents. In an interview with Resident #18 on 7/9/2019 at 11:36 AM, Resident #18 stated that s/he is unable to walk and requires the use of his/her wheelchair to move through the facility. Resident #18 stated s/he was unable to reach the complaint/compliment forms that were located outside of the Director of Nurses office. Resident #18 stated s/he likes to write down complaints and compliments to be addressed by the facility administration. Resident #18 also stated that besides the complaint/compliment forms being unreachable, the submission mail box was also to…

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

Based on resident complaint, reviews of administrative records including a resident's personal funds records, individual resident account statements, transaction reports, transaction receipts, and staff interview, it was determined the facility staff failed to maintain a system that ensures a full and complete accounting of a resident's personal monies entrusted to this facility. This was evident for 1 (Resident #18) of 2 residents reviewed for personal property during an annual recertification survey. The findings include: In an interview with Resident #18 on 7/9/19 at 11:38 AM, Resident #18 complained that the facility does not keep an accurate account of his/her resident fund account monies. Resident #18 stated he/she facility takes out monies in one lump sum and I never truly know how much is in my account. In an interview with the business office manager on 7/12/19 at 12:00 PM, the facility business office manager stated Resident #18 has an interest baring funds account here at the facility. The facility business office manager also stated that Resident #18 does use 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 resident complaint, review of a medical record review and staff interview, it was determined the facility staff failed to immediately notify a resident's physician regarding the resident's refusal of taking his/her anti-seizure medications. This was evident for 1 (Resident #117) of 2 residents reviewed for notification during an annual recertification survey. The findings include: In an interview with Resident #117 on 7/11/19 at 9:40 AM, Resident #117 stated that s/he does not like to take her anti-seizure medication because it makes him/her feel different. Resident #117 stated that s/he had a seizure in which s/he had to go and be admitted to the hospital. Reviews of Resident #117's medical record on 7/11/19 revealed medication records that indicated Resident #117 had 53 opportunities to take his/her anti-seizure medication and 19 refusals in May 2019. Review of Resident #117's nursing progress notes revealed the nursing staff only contacted Resident #117's physician 5 times. On 5/17/19 Resident #117 was observed having a seizure and was sent to the hospital at that time.…

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 provide the resident and their representative with a summary of the baseline care plan within 48 hours of admission to the facility. This was evident for 1 (Resident #366) of 4 resident reviewed for care plan participation and 1 of 67 residents reviewed during an annual recertification 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. Review of Resident #366's medical record on 7/9/19 revealed Resident #366 was admitted to the facility on [DATE]. Review of the medical record failed to reveal documentation that a copy of the baseline care plan was provided to Resident #366 or Resident #366's responsible party within 48 hours after admission. An interview with the Facility Staff #25 on 7/9/19 at 10:00 AM confirmed the facility staff did not supply Resident #366 nor his/her responsible party…

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 the medical record and interviews with staff, it was determined that the facility staff failed to develop a comprehensive activities care plan for residents (#316, #20). The facility failed to follow the care plan to provide eating assistance for a resident (#157). This was evident for 3 of 67 residents reviewed during the annual survey. The findings include: A care plan is a written guideline of care based on the individual resident's needs developed by an interdisciplinary team which includes nursing, rehabilitation staff, and dietary that communicates to other health care professionals. A written care plan decreases the risk of incomplete, incorrect or inaccurate care. 1. During interview with the Activities Director on 7/15/19 at 12:30 PM it was confirmed that an activity care plan had not been developed for Resident #20. 2. On 7/16/19 at 11:50 AM during an interview with the Director of Nursing it was confirmed that the facility had not developed an activities care plan for Resident #316. 3. Observation on 7/9/19 at 12:05 PM of Resident #157,who is totally…

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 failed to implement a comprehensive care plan for the use of an anticoagulant medication for a resident (#117) and the facility staff failed to implement interventions for Resident (#16) as noted on a care plan. This was evident for 2 of 5 residents reviewed for care planning during an annual recertification 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. The facility failed to implement a comprehensive care plan for the use of an anticoagulant medication for a resident. Review of Resident #117's medical record on 7/11/19 revealed that Resident #117 has a history of severe anemia. Further review revealed Resident #117 was receiving the anticoagulant, Eliquis 2.5 mg, orally, twice a day for a cardiac arrhythmia. A review of Resident #117's care plans failed to reveal a care plan for anticoagulant therapy. 2. The facility staff failed to implement interventions for Resident #16 as…

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 obtain a podiatry consultation as ordered for Resident (#24), the facility staff failed to initiate a medication and a Iodosorb dressing in a timley manner for Resident (#135) and the facility staff failed to administer medications in a timely manner per physician's orders for Resident (#91). This was evident for 3 of 67 residents reviewed during the annual survey process. The findings include: 1. The facility staff failed to obtain a podiatry consultation as ordered for Resident (#24). Medical record review for Resident #24 revealed on 4/25/19 the physician ordered: podiatry consultation. Podiatry is the treatment of disorders of the foot and ankle. It is the branch of medicine that deals almost exclusively with the foot and ankle. Podiatry includes the treatment of minor ailments, such as ingrown toenails, but can also include surgeries to improve chronic conditions such as bunions or foot pain. Further record review revealed the facility staff failed to obtain the podiatry consultation as…

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 resident complaint, reviews of a medical record, and staff interview, it was determined that the facility staff failed to follow up with an audiologist office since March 2019 to obtain a resident's hearing aids for Resident (#39) and failed to obtain an ophthalmology consultation as ordered by the physician for Resident (#148). This was evident for 2 of 8 residents reviewed for vision/hearing during an annual recertification survey. The findings include: In an interview with Resident #39 on 7/10/19 at 10:40 AM, Resident #39 stated that the facility was to provide him/her with hearing aids. Resident #39 stated s/he was seen by an audiologist who recommended that Resident #39 should be fitted for bilateral hearing aids in March 2019. Review of Resident #39's medical record revealed a hearing difficulty care plan that listed the following nursing interventions: Demonstrate understanding by completing task when requested, attempt to minimize excess noise, gain individual's attention before beginning to converse, when talking to patient, use gestures and simple sentences while…

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 provide ambulatory services to Resident (#23) to maintain mobility. This was evident for 1 of 2 residents selected for range of motion during the survey process and 1 of 67 residents selected for review during the annual survey process. The findings include: Medical record review for Resident #23 revealed on 4/15/19 the physician ordered: Physical Therapy (PT) evaluation and treat for strengthening and walking. PT is the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery. Further record review revealed Resident #23 received PT services and was discharged from PT services on 5/17/19. At that time, record review revealed: Therapy Discharge Communication which indicated: request resident to be walked to the toilet upon waking up, within 1 hour after meals and upon resident request; however, there is no evidence the facility staff became aware of this request and failed to ambulate the resident as noted in…

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

Based on a review of the clinical records and staff interview it was determined that the facility staff failed to document the administered of pain medication and failed to assess the need for pain medication and thoroughly monitor the effectiveness. This was true for Resident (#135), 1 out of the 7 residents reviewed for pain management during an annual recertification survey. The findings include: Pain is often regarded as the fifth vital sign regarding healthcare because it is accepted now in healthcare that pain, like other vital signs, is an objective sensation rather than subjective. As a result, nurses are trained and expected to assess pain. A component of pain assessment-focusing on words to describe pain, intensity, location, duration, and aggravating or alleviating factors. It is the expectation the facility staff assess pain prior to and after the administration of pain medication to determine the need of the medication and the effectiveness of the medication. Medical record review of Resident #135's clinical record revealed on 6/13/19 the resident's primary physician…

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

Based on staff interview and documentation review it was determined that facility staff failed to provide evidence that the facility's Geriatric Nursing Assistant (GNA), have been deemed competent to provide resident care independently. This is true for 1 GNA (Staff #22) employed by this facility. Findings include: On 7/15/19 Review of the employee files for GNA staff #22 revealed that she/he failed the skill portion of the NNAAP Exam. The NNAAP Exam consists of two components: a written or oral portion and a skills demonstration portion. Each candidate must successfully complete both components of the exam before a state can add their name to the state nurse aide registry. CNA (certified nursing assistant) who fails the NNAAP examination may continue to work in the GNA role, provided the register nurse in staff development develops an action plan to assist the CNA in the areas of deficiency. The action plan would specifically address the area of testing where the CNA was unsuccessful, i.e. written or clinical application of skills. This action plan would be use by all licensed…

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 consultant pharmacist failed to conduct a thorough medical record review to identify and bring to the facility staff's attention Resident (#100) receiving Nystatin cream for 2 months and the facility failed to conduct thorough medication regimen reviews and identify that Resident (#72) was receiving an antipsychotic.This was evident for 2 of 6 residents selected for review of un-necessary medications and 2 of 67 residents selected for review during the annual survey. The findings include: 1. The consultant pharmacist failed to conduct a thorough medical record review to identify and bring to the facility staff's attention Resident (#100) receiving Nystatin cream for 2 months Medical record review for Resident #100 revealed on 5/6/19 the physician ordered: Nystatin cream 100000 units under breast, 2 times a day for rash. Nystatin is an antifungal medication. Nystatin prevents fungus from growing on your skin. Nystatin topical (for the skin) is used to treat skin infections caused by yeast. The use of nystatin to be…

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 ensure Resident (#100) was free from an un-necessary medication. This was evident for 1 of 6 residents reviewed for un-necessary medication and 1 of 67 residents reviewed during the annual survey process. The findings include: Medical record review for Resident #100 revealed on 5/6/19 the physician ordered: Nystatin cream 100000 units under breast, 2 times a day for rash. Nystatin is an antifungal medication. Nystatin prevents fungus from growing on your skin. Nystatin topical (for the skin) is used to treat skin infections caused by yeast. The use of nystatin to be applied to the skin and is usually is applied twice a day for no longer than 2 weeks. Review of the Medication Administration Record revealed the facility staff documented the administration of the Nystatin cream from 5/7/19 to 5/31/19, 6/1/19-6/30/19 and from 7/1/19 to 7/12/19 at 9:00 AM and 5:00 PM (2 months). Interview with the Director of Nursing on 7/18/19 at 1:30 PM confirmed the facility staff failed to ensure 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 upon staff interview and medical record review it was determined the facility staff failed to obtain a dental consultation as ordered for Resident (#5). This was evident for 1 of 4 residents selected for review of dental services and 1 of 67 resident selected for review during the annual survey. The findings include: Medical record review for Resident #5 revealed on 1/17/19 the physician ordered: dental consultation related to ill-fitting dentures. Further record review revealed the facility staff failed to obtain the dental consultation as ordered. Interview with the Director of Nursing on 7/18/19 at 1:30 PM confirmed the facility staff failed to obtain a dental consultation for Resident #5 as ordered by the physician.

Based on observation and interviews of facility staff, it was determined that food service employees failed to ensure that sanitary practices were followed, equipment was maintained and safe food handling practices were followed to reduce the risk of foodborne illness. This deficient practice has the potential to affect all residents. The findings include: On 7/9/2019 at 8:25 AM a tour of the facility's main kitchen was conducted with Regional Kitchen Manager (Staff #7) and the facility's Food Service Manager (Staff #8). Observation of the dish drying rack revealed wet stacked baking pans and steam table pans. Paper towels for hand drying were observed stacked inside a wire basket beside hand sinks and not stored inside paper towel dispensers to protect from splashes and contamination. Sanitizer test strips were not available at the 3 compartment sink to test sanitizer strength and had to be brought over by the Food Service Manager (Staff #8) who stated that the test strips could not be stored at the sink because they would fall in. The tile wall between the 3 compartment sink 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 review and interview, it was determined the facility staff failed to maintain medical records in the most accurate form for Residents(#157, #158 ). This was evident for 2 of 67 residents reviewed in the annual survey. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1. Resident #157 was observed on 7/9/19 at 12:05 PM trying to open and consume his/her physician ordered nutritional supplement. A review of the medical record revealed the consumption of the ordered nutritional supplement is documented on the Geriatric Nursing Assistant's (GNA) Task list. The GNA checks either accepted, resident not available or refused the nutritional supplement. When interviewed, the Director of Nursing (DON) on 7/15/19 at 12:50 PM stated if the resident takes 2 sips or 50% or 100% of the nutritional supplement…

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 that the facility staff failed to provide a safe, sanitary environment to prevent the development and transmission of disease and infection by failing to post an isolation sign on Resident's (#135 and #367) door and to have the necessary equipment to alert visitors, residents, and staff to see the nurse before entering the room. This was true for 2 out of 3 residents selected for review during the annual survey process. The findings include: On 7/8/19 at 10:00 AM, an observation outside Resident's #135 and #367 rooms revealed there was no signage to indicate to stop and see a nurse before entering the rooms and no necessary equipment/isolation cart to alert visitors, residents, and staff. An isolation cart contained items necessary to prevent transmission of disease such as, isolation gowns, masks, and gloves. No one entering without previous knowledge would be alerted that isolation was expected. On 7/11/19, medical record review for Resident #135 revealed on 6/13/2019, the physician ordered Contact Isolation 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.

Based on observation, staff interview and record review it was determined that the facility failed to maintain kitchen equipment in safe operating condition. This deficient practice has the potential to affect all residents. The findings include: On 7/9/2019 at 8:25 AM observation of the facility's kitchen revealed a non-operational hand sink covered in a clear plastic bag located on the kitchen's tray line. This was the closest hand sink available to the 3 staff working on the tray line at the time of observation. Interview with the Regional Kitchen Manager (Staff #7) and Food Service Manager (Staff #8) confirmed that the sink had not been operational for multiple weeks. On 7/12/2019 at 7:26 AM the Administrator (Staff #1) stated that the hand sink was out of order due to a collapsed drain pipe. Documentation was provided showing repair requests dating back to 3/21/2019. The Administrator (Staff #1) stated that the drain pipe was damaged when a plumber's snake pierced the pipe walls and that the facility is scheduled to have it repaired this month. Documentation review confirmed a…

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