Orchard Hill Rehabilitation And Healthcare Center

Based on review of medical records and interviews with facility staff, it was determined the facility failed to order and implement the treatment of a Stage 3 pressure ulcer timely. This was evident for 1 (Resident #1) out of 1 residents reviewed for pressure ulcers during the during the facility 's annual recertification survey.The findings include:A pressure ulcer also known as pressure sore, bed sore, or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying skin. Pressure ulcers are staged according to their severity from Stage I (area of persistent redness), Stage II (partial thickness loss of skin presenting as a shallow open ulcer), Stage III (full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with exposed tendon, muscle or bone) to Unstageable (the depth of tissue damage cannot be determined due to the presence of slough or eschar (both are types of dead skin that prevent healing). Consistent care is essential for treating and preventing pressure…

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, observations, and interviews, it was determined that the facility failed to provide additional nourishment for a resident as ordered by a physician. This was found to be evident in 1 (Resident #55) of 40 residents reviewed during the recertification survey.The findings include:Magic Cups most commonly refer to high-calorie, nutrient-dense frozen nutritional desserts often used in health settings.During an interview on 4/16/2026 at 10:43 AM, Resident #55 stated that their meals are often missing items they expect to receive.Resident #55's medical record was reviewed on 4/20/2026 at 12:30 PM. The resident was admitted on [DATE] and had a diet order placed by a physician on 4/2/2026 that stated, Magic Cup with meals for risk of malnutrition or equivalent 4 oz. TID and Health shakes with meals for risk of malnutrition 4 oz. TID.On 4/21/2026 at 8:56 AM, Resident #55's breakfast meal was observed. No Magic Cup or health shake were observed on the meal tray and the resident's meal ticket…

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

Based on review of medical records and interviews with facility staff, it was determined the facility failed to ensure that a resident's primary care provider(s) assessed and monitored his/her pressure ulcer. This was evident for 1 (Resident #1) out of 1 residents reviewed for pressure ulcers during the facility 's annual recertification survey.The findings include:A pressure ulcer also known as pressure sore, bed sore, or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying skin. Pressure ulcers are staged according to their severity from Stage I (area of persistent redness), Stage II (partial thickness loss of skin presenting as a shallow open ulcer), Stage III (full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with exposed tendon, muscle or bone) to Unstageable (the depth of tissue damage cannot be determined due to the presence of slough or eschar (both are types of dead skin that prevent healing). Consistent care is essential for treating 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 and staff interview, it was determined that the facility failed to ensure that the pharmacist performed an accurate medication regimen review and identify a medication without a matching diagnosis. This is evident for 1 (Resident #2) of 2 residents reviewed for medication regimen review.The findings include:On 04/20/2026 at 11:05 AM, a review of the electronic medical record for Resident #2 revealed an order for Lorazepam Injection 1 mg intramuscularly every 24 hours as needed for breakthrough seizures for a duration of 6 months. The order was written by Staff #17 on 02/13/26. Review of Resident #2's documented medical diagnoses revealed no documented diagnosis of seizures and no evidence of seizure activity to support the use of this medication. Monthly medication regimen reviews completed on 02/27/26 and 03/29/26 documented No medication irregularities noted at this time. The pharmacist failed to identify or report that the medication lacked a documented supporting diagnosis.On 04/23/2026 at 10:27 AM, during an interview with Staff #17, the surveyor shared…

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 staff interview, it was determined that the facility failed to ensure medications were ordered with an adequate indication and supporting diagnosis and failed to ensure appropriate parameters for a psychotropic medication ordered on an as-needed basis, resulting in an unnecessary medication. This is evident for 1 (Resident #2) of 2 residents reviewed for unnecessary medications.The findings include: Lorazepam is a benzodiazepine psychotropic medication commonly used for anxiety, agitation, or acute seizure activity, but it carries risks such as sedation, respiratory depression, and dependence, and requires clear clinical justification. Levetiracetam (Keppra) is an anticonvulsant used to prevent or control seizures and should be supported by a documented seizure disorder or related neurological condition.On 04/20/2026 at 11:05 AM, during review of Resident #2's electronic medical record it was revealed the resident was ordered Lorazepam Injection 1 mg intramuscularly every 24 hours as needed for breakthrough seizures for a duration of 6 months. This order…

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 medical record review, it was determined that the facility failed to maintain and document accurate medical records. This was found to be evident in 1 (Resident #44) of 1 resident reviewed for dialysis during the recertification survey.The findings include:On Thursday, 4/16/2026 at 11:08 AM, Resident #44 was interviewed after returning from hemodialysis (HD) and stated that they receive HD 3 times a week on Tuesdays, Thursdays, and Saturdays at 6:00 AM.Resident #44's medical records were reviewed on 4/20/2026 at 8:20 AM and showed that the resident was admitted to the facility on [DATE]. Review of Resident 44's active medical orders revealed an order placed on 1/9/2026 that stated, Dialysis on [NAME] M, W, F as per schedule, every day shift every Mon, Wed, Fri. A nephrology consult dated 4/16/2026 was reviewed that stated under assessment and plan, ESRD on hemodialysis, dialyzes T/Th/Sat via tunneled catheter with stable post-HD returns, continue T/Th/Sat HD.Resident #44's Treatment…

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

Based on interviews with facility staff, review of employee files, and review of pertinent documentation, it was determined that the facility failed to ensure the nurses' aides had continuing education that included dementia management training and addressed areas of weakness as determined in nurse aides' performance reviews. This was found to be evident for 2 (GNA #44 and GNA #45) of 5 GNA employee files reviewed during the facility's recertification survey. The findings include:Performance reviews are to be completed for each GNA at least every 12 months to identify specific, in-service education based on the outcome of those individual performance reviews. Relias is an online training provider that offers continuing education (CE) for healthcare, senior care, and disabilities professionals. Relias's CE library covers a wide range of topics and is accredited by many national and state licensing boards. Relias's courses are designed to help healthcare workers improve patient care, grow, and provide high-quality care.On 4/22/26 at 7:55 AM in an interview with the Director of Nursing…

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 staff interview, it was determined the facility failed to provide documentation that allegations of neglect were thoroughly investigated. This was evident for 1 (#3) of 5 residents reviewed for facility reported incidents reviewed during a complaint survey.The findings include: On 1/20/26 at 9:47 AM a review of facility reported incident 2697242 was conducted and revealed the facility's Regional Director received a call about potential neglect for Resident #3 after the resident had been sent to the hospital. Review of the facility's investigation revealed a summary that documented the Director of Nursing (DON) had interviewed nursing staff that had provided care to Resident #3 for the 72 hours prior to transfer to the hospital. Review of the facility's investigation revealed the geriatric nursing assistant (GNA) that provided care for Resident #3 the morning of transfer to the hospital was interviewed and wrote a statement that was included in the packet. There were no further statements or interviews of staff from the previous 72 hours.…

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 interview and observed smell of resident's room, the facility failed to provide bedpan or change resident as requested. This was evident for 1 out of 1 resident reviewed.The findings include: On 1/20/26 at 11 am Resident #6 was heard outside of their room requesting to be changed. There were two nurses observed outside the room. Staff # 4 was the resident's assigned nurse. Staff # 4 stated to resident, you just put on your call bell, give us a chance to get there. Resident #6 continued to call out for help. There was a strong odor of urine coming from the resident's room. During the interview with resident Resident # 6 at the time of the observation, they complained about not being changed on a timely basis. Resident # 6 stated the last time I was changed was in the middle of the night and its now 11 am and I haven't been changed. Surveyor interviewed Resident #6 later in the day at 1PM and resident stated they were changed about 1 hour later or about 12 noon. The Director of Nursing was made aware of the observation and said, ok.

Based on observation, medical record review, and interview, it was determined the facility failed to provide respiratory services in accordance with professional standards of practice. This was evident for 1 (#3) of 9 residents reviewed during a complaint survey.The findings include: On 1/20/26 at 11:30 AM observation was made of Resident #3 lying in bed. Resident #3 was receiving oxygen via nasal cannula. Observation was made of the oxygen concentrator that was sitting next to the bed. The setting of the amount of oxygen being delivered was 4 L (liters) per minute. There was no date written on the humidification water bottle or the oxygen tubing. The date would have indicated when the humidification water bottle was opened and when the oxygen tubing was applied.Review of Resident #3's medical record revealed a 1/18/26 physician's order for oxygen to be administered at 2L/min.On 1/20/26 at 11:41 AM the Director of Nursing (DON) accompanied the surveyor in Resident #3's room. The DON confirmed the oxygen was set at 4L/min. The DON stated she would check with the nurse and review 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 medical record review, the facility failed to make an appointment for Resident # 6. that was to see an outside physician. This was evident for 1 out of 1 resident reviewed.The Findings include:Medical record review on 1/20/26 for Resident #6 revealed that on 11/23/25 the Doctor for Resident #6 requested the resident get an appointment to see a gynecologist for symptoms and possible infection. The request was sent over to Staff # 5 who arranges appointments and transportation for residents that need to go out of the facility. Staff # 5 could not make an appointment for resident because all gynecologist that facility uses would not accept the resident because the large stretcher needed by resident that would not fit through the office door. Staff member # 5 stated in her interview on 1/20/26 at 11 AM, that resident's daughter makes all the appointments. Resident #6's daughter stated in an interview on 1/20/26 at 12:30PM that she was unaware that resident needed an appointment with gynecologist and she would be able to get an appointment. Per interview with DON…

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 complaints, interviews, and documentation review it was determined that the facility failed to have sufficient nursing staff to meet the needs of the residents. This was evident for 6 of 9 complaints submitted to the Office of Health Care Quality (OHCQ), the regulatory agency, multiple staff and resident interviews, observation of staffing boards, and review of staffing schedules. This deficient practice had the potential to affect all residents.The findings include: 1) Six out of nine complaints that the Office of Health Care Quality (OHCQ) received and reviewed on this survey alleged the facility did not have sufficient nursing staff to provide essential care to the residents that resided at the facility. Complaints consisted of nursing care delayed and inadequate, waiting hours to be cleaned after a bowel movement, left lying in feces and lying in bed wet, residents not receiving showers, not being turned in bed, and not receiving basic hygiene. 2) Interviews of residents and complainants revealed their concerns that the facility was short-staffed: On 10/14/25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to notify the Resident's physician when the Resident's BiPap was not administered (Resident #5). This was evident for 1 of 16 residents reviewed during a complaint survey.The findings include:Review of Resident #5's medical record on 10/14/25 revealed the Resident was admitted to the facility in September 2024 with a diagnosis to include acute and chronic respiratory failure with hypercapnia. Hypercapnia is a condition characterized by an excessive amount of carbon dioxide in the blood, often resulting from respiratory issues like chronic obstructive pulmonary disease (COPD) or hypoventilation. Further review of Resident #5's medical record revealed the Resident was discharged to the hospital on 9/9/25 and returned to the facility on [DATE]. Review of the hospital Discharge summary dated [DATE] states: Patient has a history of respiratory failure and CO2 (carbon dioxide) retention. Using a BiPap is critical. Review of Resident #5's physician…

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

Based on review of facility reported incidents, record review, and interview, it was determined the facility failed to report an injury of unknown origin within 2 hours to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 1 (#11) of 4 residents reviewed for 4 facility reported incidents during a complaint survey.The findings include: On 10/16/25 at 7:19 AM a review of facility reported incident 2566844 was conducted and revealed Resident #11 had a displaced fracture of the right hip. Review of Resident #11's medical record revealed Resident #11 had a history that included dementia, failure to thrive, and multiple contractures. On 7/15/25 on the 3:00 PM to 11:00 PM shift, Resident #11 complained about right foot pain. Resident #11 was also observed with right foot swelling. The physician was notified and ordered for the right leg to be elevated on a pillow. On 7/16/25 the physician ordered an x-ray and doppler study. On 7/16/2025 at 11:12 PM, Resident #11's X-ray result of the right hip showed that there was a displaced fracture laterally. The MDS…

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

Based on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#11) of 4 residents reviewed for 4 facility reported incidents during a complaint survey.The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. On 10/16/25 at 7:19 AM a review of facility reported incident 2566844 was conducted and revealed Resident #11 had a displaced fracture of the right hip. Review of Resident #11's medical record revealed a 7/16/25 physician's order for an x-ray and doppler study. On 7/16/2025 at 11:12 PM, Resident #11's X-ray result of the right hip documented there was 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 medical record review and interview, it was determined that the facility failed to have a process in place to ensure that a baseline care plan was provided to the resident's representative within 48 hours of admission to the facility (Resident #3). This was evident for 1 of 16 residents reviewed during a complaint survey. The findings include: The baseline care plan is given to residents and their representatives within 48 hours of their admission and details a variety of components of the care that the facility intends to provide to that resident. In addition to the baseline care plan, residents are also expected to receive a list of their admission medications. This allows residents and their representatives to be more informed about the care that they receive. During interview with Resident #3's representative (RP) on 10/14/25 at 9:06 AM, the RP stated he/she was never given a baseline care plan or had a meeting with the facility staff to discuss admission to the facility within the first 48 hours of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation, medical record review and interview, it was determined the facility failed to follow professional standards of practice when administering medications (Resident #5). This was evident for 1 of 16 residents reviewed during a complaint survey. The findings include:The 6 rights of medication administration are the right patient, the right drug, the right does, the right route of administration, the right time, and the correct documentation. Review of Resident #5's medical record on 10/14/25 revealed the Resident was admitted to the facility in September 2024 with a diagnosis to include end stage renal disease and dependence on renal dialysis. The facility staff assessed the Resident on 7/13/25 to have a BIMS (Brief Interview for Mental Status) of 15 out of 15 indicating the Resident's cognition is intact.Review of facility documentation on 10/15/25 revealed a written statement from Staff #22 on 8/7/25 that stated: 8/5/25 1st day without a preceptor as night shift…

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 complaint review, medical record review and interview, it was determined the facility staff failed to provide needed activities of daily living (ADL) for residents totally dependent on bathing assistance (Resident #3, #13). This was evident for 2 of 16 residents reviewed during a complaint survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) Review of complaint 2594969 regarding Resident #3 not receiving showers for the first month and half since admission to the facility even though the Resident's representative asked the facility staff to give the Resident showers. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to provide treatment and care in accordance with professional standards of practice (Resident #5 and #11). This was evident for 2 of 16 residents reviewed during a complaint survey. The findings include: 1) Review of Resident #5's medical record on 10/14/25 revealed the Resident was admitted to the facility in September 2024 with a diagnosis to include end stage renal disease and dependence on renal dialysis. Further review of Resident #5's medical record revealed the Resident was discharged to the hospital on 9/9/25 and returned to the facility on [DATE]. Review of the hospital Discharge summary dated [DATE] states: Please note this is critical for the patient to take Midodrine 1 hour prior to hemodialysis. Usually patient's dialysis is scheduled at 6:00 in the morning, therefore the first does of midodrine should be given at 5 AM. Midodrine is a medication used to treat low blood pressure (hypotension). Further review of Resident #5'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 medical record review and staff interview, it was determined the facility failed to provide treatment/services to prevent/heal pressures ulcers. This was evident for 1 (#12) of 3 residents reviewed for pressure ulcers during a complaint survey.The findings include: A pressure ulcer, also known as pressure sore or decubitus ulcer, is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed). On 10/14/25 at 9:30 AM a review of Resident #12's medical record revealed…

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 facility staff failed to keep medication carts locked when unattended and discard medications/biologicals when expired. This was evident on 1 of 3 nursing units observed during random observations made during a complaint survey. The findings include: On [DATE] at 8:14 AM observation was made of an unlocked and unattended medication cart sitting outside of room [ROOM NUMBER]. The nurse was in the room and could not be visualized from the hallway. Staff #5 came out of the room and asked the surveyor what she was doing. The surveyor informed Staff #5 that the medication cart was left unlocked and unattended and that she could not be visualized from the hallway.The surveyor opened the top drawer of the medication cart and observed an opened 20 ml. vial of sterile water. There was no date opened on the bottle of sterile water. Also observed in the top right section of the first drawer was an insulin pen for Resident #14. The insulin was opened 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards (Resident #6 and #12). This was evident for 2 of 16 residents reviewed during a complaint survey.The findings include. A medical record is the official documentation of 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) Review of Resident #6's medical record on 10/14/25 revealed the Resident was admitted to the facility in June 2025 with diagnosis to include Multiple Sclerosis. Further review of Resident #6's medical record revealed the Resident has a Stage IV pressure ulcer of the sacrum and is currently receiving hospice services. Review of Resident #6's August, September and October 2025 Treatment Administration Records (TARs) revealed…

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

Based on observation and interview it was determined the facility failed to: 1) ensure food items were labeled, 2) ensure food items were discarded appropriately, 3) ensure the freezer was maintained free from ice accumulation, 4) ensure the device utilized for dispensing of juice was not stored on the kitchen floor, 5) ensure safe storage of cleaning chemicals and 6) ensure consistent required temperature levels for dishwashing sanitization. These deficient practices have the potential to affect all facility residents. On 3/10/25 beginning at 8:00 AM the surveyor conducted an initial tour of the facility's kitchen. On 3/10/25 at 8:12 AM the surveyor observed a metal container in the reach in refrigerator with the following label present: Monday Sauces/Gravies Homemade prep/opened on 3/3/25 1:25 PM, use by 3/5/25 1:25 PM. Further observation of the contents of the metal container revealed a white, lumpy, and crusty appearance of the gravy. On 3/10/25 at 8:13 AM the surveyor observed 10 unlabeled side item containers present within the reach-in refrigerator. Upon further observation…

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

Based on a review of the resident medical records and interview with facility staff, it was determined that the facility failed to ensure that drug records were maintained in a manner that allowed for reconciliation of dispensed and administered medication. This was evident for 4 (Resident #14, #31, #52, and #100) out of 4 residents reviewed for administration of narcotic medication during this recertification/complaint survey. The findings include: Oxycodone is narcotic medication used to treat moderate to severe pain. It is at high risk for addiction and dependence. It can cause respiratory distress and death when taken in high doses or when combined with other substances, especially alcohol or other illicit drugs such as heroin and cocaine. A controlled medication utilization record (known as a count sheet) is a form to record controlled medication dispense. It documents the details for each use of any controlled substance amount removed from its original containers, including date, time, the dose given, the signature of the nurse administering medication, the amount remaining,…

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

Based on observation and interview, it was determined the facility failed to ensure the kitchen steam table was maintained in safe operating condition. This was evident for one out of one steam tables observed to be in operation during the surveyor's initial tour of the facility's kitchen during the recertification/complaint survey. The findings include: During the surveyor's initial tour of the facility's kitchen on 3/10/25 at 8:04 AM the surveyor observed the steam table which was holding food had two out of six indicator lights (utilized to indicate to staff that the steam wells are on and ready for use) which were inoperable and four out of six knobs (to control the temperature levels of the steam wells used to maintain food temperatures) which were missing. On 3/10/25 at 8:05 AM the surveyor shared their concern and conducted an interview with [NAME] #38 who stated the following information regarding the steam table conditions: It's been like that for years. On 3/10/25 at 8:26 AM the surveyor conducted an interview and dual observation of concerns with Certified Dietary Manager…

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 facility staff, it was determined that the facility failed to provide residents with information to formulate an advanced directive and ensure that a current copy of residents' advanced directives was in the residents' medical record. This was evident for 1 (Resident #56) of 3 residents reviewed for advanced directives during the recertification/complaint survey. The findings include: An advance directive is a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. It is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. On 3/10/25 at 11:44 AM the Director of Nursing (DON) confirmed and verified that the facility does not have paper charts for the residents. On 3/10/25 at 1:52 PM 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 with facility staff, it was determined that the facility staff failed to notify a provider and/or resident representative of a significant weight loss for a resident. This was evident for 1 (Resident #113) of 47 residents reviewed for the facility's recertification/complaint survey. The findings include: On 3/10/25 at 2:56 PM a review of Resident #113's medical record revealed the following weights: 3/5/2025 11:29 134.4 Lbs (pounds) Mechanical Lift ADON (Manual) 2/5/2025 15:40 164.0 Lbs (pounds) Mechanical Lift ADON (Manual) In the weights section of the resident's medical record, the electronic medical record had flagged and documented (written between these two weights) that there was a significant weight loss over 30 days. On 3/13/25 at 9:54 AM in an interview with the ADON when asked if the physician and/or resident representative (RP) was notified of the Resident #133's significant weight loss, she stated, no, there was no documentation observed that the physician or RP was notified of his/her weight loss. The Regional Dietician #20 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, resident interview, and staff interview it was determined that the facility staff failed to ensure showers maintained proper temperatures. This was evident for 1 out of 4 nursing units observed during the recertification/complaint survey. The findings include: Resident #100 was interviewed on 03/10/25 at 11:51 AM. Resident stated that the shower room for unit 2 doesn't have hot water so few showers are taken. During the tour of the facility with the Maintenance Director (Staff #31) on 3/17/25 at 11:17 AM he used his thermometer and checked the water temperature. It was observed that the water from the hand sprayer was 88.8 degrees Fahrenheit (F). Staff #31 then turned on the shower and the temperature was the same. He left the water running and we continued with checking the shower rooms on the other units. After verifying the other shower rooms had hot water Staff #31 rechecked the water in the Unit 2 shower room and it was still in the 80's. Staff #31 went to the resident rooms on either side of the shower room and the water in each room registered as 106F.…

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 facility reported incident, record review and interview it was determined the facility failed to ensure a resident (#120) was free from misappropriation of their personal funds. This was evident for 1 out of 2 facility reported incidents (#MD00212032) reviewed for misappropriation/personal property during the facility's recertification/complaint survey. The findings include: On 3/10/25 at 9:00AM the surveyor began review of a facility reported incident (#MD00212032) which was submitted by the facility to the Office of Health Care Quality on 11/14/24 which involved a family member of Resident #120 who notified the facility on 11/14/24 of unusual financial transactions which had occurred on the resident's personal bank account on 10/10/24 for $250.00 and 10/21/24 for $15.00. Review of facility reported incident #MD00212032 revealed the allegations were verified by the facility regarding the misappropriation of Resident #120's funds by Geriatric Nursing Assistant (GNA) #35. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of a facility reported incident, record review and interview it was determined the facility failed to ensure the implementation of the abuse, neglect, exploitation and misappropriation policy and procedures. This was evident for 1 out of 2 facility reported incidents (#MD00212032) reviewed for misappropriation/personal property during the facility's recertification/complaint survey. The findings include: On 3/10/25 at 9:00AM the surveyor began review of a facility reported incident (#MD00212032) which was submitted by the facility to the Office of Health Care Quality on 11/14/24 which involved a family member of Resident #120 who notified the facility on 11/14/24 of unusual financial transactions which had occurred on the resident's personal bank account on 10/10/24 for $250.00 and 10/21/24 for $15.00. Review of facility reported incident #MD00212032 revealed the allegations were verified by the facility regarding the misappropriation of Resident #120's funds by Geriatric Nursing Assistant (GNA)…

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 facility staff, it was determined that the facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days of the resident's enrollment and discontinuation in hospice. This was evident for 1 (Resident #33) of 2 residents reviewed for hospice during the recertification/complaint survey. The findings include: The MDS is a federally mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. The information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. A Significant Change in Status Assessment (SCSA) is required when a resident enrolls in a hospice program and when a resident receiving hospice services discontinues those services. Completion of the SCSA ensures a more thorough review of factors related to the identified decline(s) or improvements in a resident's condition and ensures 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 interview with residents, review of medical records and interview with facility staff, it was determined that the facility failed to hold care plan meetings of the interdisciplinary team for residents at the time of the quarterly revision of the Minimum Data Set (MDS). This was evident for 3 (Resident #55, Resident #104, Resident #37) of 28 residents reviewed for care plan during this recertification/complaint survey. The findings include: Minimum Data Set (MDS) is a core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. The data elements (also referred to as items) in the MDS standardize communication about resident problems and conditions within nursing homes, between nursing homes, and between nursing homes and outside agencies. MDS assessments need to be accurate to ensure each resident receives the care they need. Care plans are developed for residents to guide 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 observation, interview, and medical record review it was determined the facility failed to ensure medical orders were followed for the provision of thickened liquids. This was evident for 1 (Resident #46) out of 1 residents reviewed for hydration during the facility's recertification/complaint survey. The findings include: On 3/12/25 at 12:22PM the surveyor conducted an observation of Resident #46 who was observed laying in bed asleep at meal time with a covered meal tray which included beverages on it which was sitting in front of them on the over bed table positioned over their bed. The contents of the tray appeared to be unopened and not yet consumed by the resident. On 3/14/25 at 10:50AM the surveyor observed a cup of thin water sitting on the nightstand furniture next to Resident #46 which appeared to be untouched with straw paper still present on part of the straw. On 3/14/25 at 1:20PM the surveyor observed Resident #46 in bed sleeping after meal time with a cup of thin water at their bedside on their nightstand furniture. On 3/17/25 at 9:03AM the surveyor reviewed…

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 and resident interviews, it was determined that the facility failed to monitor/access residents related to potentially leading to smoking accidents. This was evident in 5 (Resident # 37, #44, #61, #93, and #100) of 5 residents reviewed for smoking during this recertification/complaint survey. The findings include: a) On 3/12/25 at 7:16 AM, a review of Resident #61's medical records revealed that on 2/25/25 a social worker (Staff # 11) wrote in a progress note, Resident was caught in the courtyard by the Activities Director smoking outside of the scheduled smoking times. Writer wrote up a smoking behavioral contract for this infarction and issued it to the Resident. On 3/12/24 at 12:03 PM, the surveyor interviewed with Staff #11. She said that on 2/25/25 the activity director found four residents (Resident #37, #44, #61, and #100) were smoking in the courtyard when it was not the facility's scheduled smoking hours. Staff #11 said, I don't know how they had their smoking material. They supposed not to have them. She also stated that she 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical records and interview with facility staff, it was determined that the facility failed to monitor and timely address a significant weight loss for a resident. This was evident for 1 (Resident #113) of 3 residents reviewed for nutrition during the recertification/complaint survey. The findings include: Resident #113's medical record was reviewed on 3/10/25 at 2:56 PM. The review revealed the resident was admitted to the facility on [DATE] and all of the weights obtained by the facility for the resident were as follows: - 3/5/2025: 134.4 lbs (pounds) - 2/12/2025: 165.0 lbs - 2/5/2025: 164.0 lbs - 1/24/2025: 164.0 lbs - 1/22/2025: 163.0 lbs The above weights reflected that the resident experienced a 29 lb (18%) significant weight loss between 2/5/2025 and 3/5/2025. On 3/12/25 at 11:13 AM review of Resident #113's medical record revealed a Nutritional Risk assessment dated [DATE] as follows: - Section A Weight status; loss or gain- Comments: Per resident's son, his/her UBW (usual body…

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 residents and staff, it was determined that the facility staff failed to obtain/monitor pre and post-dialysis body weights. This is evident for 1 (Resident # 220) of the 1 resident reviewed for dialysis services during the recertification/complaint survey. The findings include: Hemodialysis is a treatment that filters wastes and water from the blood, as the kidneys did when they were healthy. It helps control blood pressure and balance essential minerals, such as potassium, sodium, and calcium, in patients' bodies. During an interview with Resident #220 on 3/10/25 at 8:12 AM, the resident reported that he/she transferred to the hospital on 1/19/25 due to shortness of breath. Also,the resident claimed that he/she still had some discomfort with breathing and edema. On 3/12/25 at 7:30 AM, a review of Resident #220's discharge summary from the hospital dated 1/25/25 showed that the resident was admitted to the hospital due to respiratory failure with hypoxia (Hypoxia is a condition in which there is an inadequate supply of oxygen to the…

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

Based on observation it was determined that the facility staff failed to post staffing information in an easily accessible location. This was evident for 4 out of the 7 days of the recertification/complaint survey. The findings are: The survey team observed upon entrance and subsequent tours of the facility that the facility staff had not posted the nurse staffing information for the facility in an easily accessible location. The team then observed on March 14, 2025, that a sign with the nurse staffing information was placed on a table in the reception area adjacent to St Patrick's Day decorations. The survey team informed the facility of the citation at the exit conference.

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 ensure medications are kept in a secure location. This was evident for 1 out of the 4 nursing units observed during the recertification/complaint survey. The findings include: During the tour of the facility on 3/10/25 at 8:09 AM an unlocked medication cart was observed on Unit Two between rooms [ROOM NUMBERS]. There were no residents in the hallway at this time. Three facility staff members walked past the medication cart during the observation period and not one locked the cart. At 8:22 AM, the Director of Nursing (DON) walked up to the medication cart, opened the controlled substance logbook, and pushed in the lock. This surveyor walked up to the DON, informed her that I had been standing in the hallway, and that the medication cart had been unlocked for almost 15 minutes. She confirmed it was unlocked when she went up to the cart.

Based on observation, review of medical records, and interviews with residents and staff, it was determined that the facility failed to ensure that residents received necessary and/or recommended dental services in a timely manner. This was evident for 1 (Resident #61) of 2 residents reviewed for dental services during the recertification/complaint survey. The findings include: During an interview with Resident #61 on 3/10/25 at 12:29 PM, the resident reported that he/she had broken teeth that still retained roots. The resident said, I need oral surgery to remove this remaining piece. But the staff canceled my appointment. On 3/13/25 at 11:33 AM, the surveyor reviewed Resident #61's medical records. The review revealed that the dental consultation was placed on 4/24/24; the consultation form included a copy of an X-ray that showed a broken tooth. Further review of medical records revealed that Resident #61 was seen by [name of contracted dental group] on 6/11/24. On that day, the dentist documented that Patient has retained roots 11 & 12 that are partially embedded in gingiva 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 review of medical records and interview with facility staff, it was determined that the facility failed to 1) ensure contracted services for wound care were timely documented in the medical record and 2) failed to ensure the resident's medical record was no longer accessible by a provider once that provider was no longer involved in the care of the resident. This was evident for 3 (Resident #121, #119, #270) of 47 residents reviewed during the facility's recertification/complaint survey. The findings include: 1) A review of Resident #121's clinical record on 3/12/25 at 2:41 PM revealed that on 3/6/25 the Certified Registered Nurse Practitioner (CRNP #34) wrote a note for a wound care visit that was done on 11/20/24. The resident was seen on wound care rounds for the evaluation of wounds on the right foot. The Director of Nursing (DON) was shown the note on 3/12/25 and informed it was written for a wound care consult that occurred almost four months earlier. She replied that she did not recognize who CRNP #34 was. She then added that she would look into it. 2) On 3/14/25 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 review of the facility records and interview with facility staff, it was determined that the facility failed to monitor and track antibiotic usage. This was evident by 1) the delayed start of the antibiotic and 2) a resident receiving an extra dose. This was found to be true for 1 (Resident #94) out of 3 residents reviewed for antibiotic use during the recertification/complaint survey. The findings include: 1) As part of the investigation into Urinary tract infection, the surveyor reviewed Resident #94's medical record on 3/17/25 at 7:30 AM. The review revealed that the resident's urine test on 2/24/25 resulted in a positive for infection, and the provider prescribed oral Augmentin 875/125mg (antibiotic) twice a day for five days on 2/26/25. Further review of Resident #94's Medication Administration Record (MAR) for February 2025 revealed that the afternoon dose scheduled at 9 PM for Augmentin 875/125mg was signed by a nurse, then the order was discontinued at 11:16 PM on 2/26/25. The new order (the same indication, dose, duration, and frequency) was placed with a starting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to administer medications and treatments as ordered by the physician (Resident #5, #22, #47, #56). This was evident for 4 of 61 residents reviewed during a complaint survey. The findings include: 1. The facility staff failed to administer pain medication timely for Resident #5. Review of Resident #5's medical record on 10/10/24 for a complaint regarding timely administration of pain medication in March 2022 revealed the Resident was admitted to the facility on [DATE] with diagnosis to include malignant neoplasm of endometrium. A malignant neoplasm of the endometrium, also known as endometrial cancer, is a type of cancer that occurs when cells in the lining of the uterus grow out of control. Further review of Resident #5's medical record revealed the Resident was ordered to receive A) Morphine Sulfate 30 mg every 12 hours for pain and B) Gabapentin 300 mg three times a day for peripheral neuropathy. Gabapentin is a medication used to treat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to notify the resident's physician and/or resident's representative when the resident had a change in condition (Resident #9 and #47). This was evident for 2 of 38 complaint residents reviewed during a complaint survey. The findings include: 1. Review of Resident #47's medical record on 10/16/24 revealed the Resident was admitted to the facility on [DATE] from the hospital with diagnosis to include chronic respiratory failure and status post lung transplant. Review of the hospital Discharge summary dated [DATE] revealed the Resident was on BiPAP for his/her chronic respiratory failure. BiPAP, or bilevel positive airway pressure, is a noninvasive ventilator that helps people breathe when they have medical problems that make it difficult. Review of Resident #47's October 2024 TAR revealed the facility staff did not document the Resident was administered the BiPAP on 10/4 and 10/6/23. Further review of Resident #47's medical record revealed 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 review of a facility reported incident, medical record review, and staff interview, it was determined the facility failed to protect a resident from inappropriate sexual contact from a geriatric nursing assistance (GNA) (Resident #21). This was evident for 1 of 39 facility reported incidents reviewed during a complaint survey. The findings include: On 10/10/24 at 1:21 PM a review of facility reported incident MD00187475 revealed on 1/7/23 at 6:00 AM the facility's previous Director of Nursing (DON), Staff #52 received a telephone call that a GNA was found by staff engaged in a sexual act with Resident #21, an alert and oriented resident. Police were notified and the GNA was sent home. Review of the facility's investigation revealed GNA #58 was from a staffing agency. The facility documented that Resident #21 discussed the situation with them and stated GNA #58 came in to provide care and made the sexual advances. Resident #21 stated he/she was not upset it happened. Resident #21 stated 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.

Based on reviews of facility reported incidents with documentation and interview, it was determined the facility failed to report allegations of abuse within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 3 (#17, #3, #10) of 39 facility reported incidents reviewed during a complaint survey. The findings include: 1) On 10/15/24 at 9:43 AM a review of facility reported incident MD00183680 was conducted and revealed Resident #17 told the MDS nurse on 9/20/22 at 11:15 AM that he/she was hit in the leg that morning by a GNA while getting ready for dialysis. The MDS nurse report it to the NHA, and an initial facility report was sent to OHCQ at 12:36 PM. Review of the facility's investigation revealed an email from GNA #54 that documented Resident #17 wanted to speak to a supervisor because he/she wanted someone else to take care of him/her. When GNA #54 told Resident #17 who the supervisor was the resident started screaming, shouting, and crying. GNA #54 documented in the email that because of the loud noise 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 documentation review and interview, it was determined the facility failed to thoroughly investigate allegations of abuse, neglect, exploitation or mistreatment for residents (Resident #3, #6, #10 and #43). This was evident for 4 of 39 residents reviewed for facility reported incidents during an annual survey. The findings include: Upon entry to the facility on [DATE] a list of facility reported incidents was provided to administration. At that time the request was for all investigations to be provided to the surveyors. 1. On 10/10/24 review of facility reported incident MD00182429 revealed Resident #6's emergency contact emailed the facility on 3/9/22 with allegations of neglect of the Resident. On 10/15/24 at 11:10 AM the Director of Nursing (DON) stated she could not find the investigation for facility reported incident MD00182429. Interview with the DON on 10/16/24 at 8:24 AM confirmed the facility does not have the email with the list of grievances, interview with the Resident, emergency contact or…

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

Based on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 2 (#59, #24) of 61 residents reviewed during a complaint survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On 10/10/24 at 11:54 AM Resident #59's medical record was reviewed and revealed Resident #59 sustained a fracture of the proximal phalanx of the fifth toe according to an x-ray report dated 7/30/24. Review of the Discharge Return Anticipated MDS with an assessment reference date (ARD) of 7/31/24 failed to capture the fracture in Section I, diagnosis. On 10/10/24 at 1:10 PM 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 review of a facility reported incident, record review, and staff interview it was determined that facility staff failed to update care plans when there were changes in resident needs and failed to have evidence of care plan meetings. This was evident for 2 (#10, #4) of 61 residents reviewed during a complaint 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) On 10/16/24 at 8:02 AM a review of facility reported incident MD00196462 alleged that on 9/1/23 Resident #10 was slapped by staff while being provided with ADL (activities of daily living) care. Review of the facility's investigation revealed staff interviews that Resident #10 was agitated with the staff who were attempting to change the resident, and the resident kicked and punched at the GNA (geriatric nursing assistant). On 10/16/24 at 9:20 AM an interview was conducted with Licensed Practical Nurse (LPN) #13 about Resident #10's behaviors. LPN #13 was asked what she did when…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers (Resident #22). This is evident for 1 of 3 residents reviewed for pressure ulcers during a complaint survey. The findings included: A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and / or eschar in the wound bed). Review of Resident #22's medical record on 10/15/24 revealed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to provide respiratory care treatment for residents (Resident #47 and #4). This was evident for 2 of 3 residents reviewed for respiratory care services. The findings include: 1.Review of Resident #47's medical record on 10/16/24 revealed the Resident was admitted to the facility on [DATE] from the hospital with diagnosis to include chronic respiratory failure and status post lung transplant. Review of the hospital Discharge summary dated [DATE] revealed the Resident was on BiPAP for his/her chronic respiratory failure. BiPAP, or bilevel positive airway pressure, is a noninvasive ventilator that helps people breathe when they have medical problems that make it difficult. Review of the Resident's physician orders and September 2024 TAR (Treatment Administration Record) revealed the Resident's Bipap was not ordered and documented as administered until 9/29/23, 4 days after admission. Review of Resident #47's October 2024 TAR revealed 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 interview, the facility failed to ensure a resident's drug regimen was free from an unnecessary drug (Resident #47). This was evident for 1 of XX residents reviewed during a complaint survey. The findings include: Review of Resident #47's medical record on 10/16/24 revealed the Resident was admitted to the facility on [DATE] from the hospital. Review of the hospital Discharge summary dated [DATE] revealed the Resident was to receive Metoprolol 25 mg two times daily, Please do not take on the morning of dialysis days. Review of the Resident's medical record revealed the Resident went to dialysis on Tuesdays, Thursdays and Saturdays. Metoprolol is a medication that is used to lower blood pressure and heart rate. Further review of the Resident's medical record revealed the Resident received Metoprolol on the following days that the Resident also received dialysis: 9/28, 9/30, 10/3, and 10/5/23. Interview with the Director of Nursing on 10/16/24 at 12:30 PM confirmed the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and interview, the facility staff failed to obtain outside services for residents in a timely manner (Resident #27). This was evident for 1 of 61 residents reviewed during a complaint survey. The findings include: 1. During interview with Resident #27 on 10/17/24 at 12:30 PM, the Resident stated the facility never got me the splints for my foot drop. Observation of the Resident at that time revealed the Resident had heel protector boots but no foot drop splints in place. Review of Resident #27's medical record on 10/17/24 revealed the Resident was readmitted to the facility on [DATE] with diagnosis to include muscle wasting and atrophy of right lower leg and tibia fracture of left leg. Further review of Resident #27's medical record revealed the Resident went to a vascular specialist on 6/18/24 and at the time the vascular specialist recommended foot drop splints. The Resident went to the Specialist on 7/12/24 for complaints pain feet and ankles and pain in both legs.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on administrative and medical record reviews and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards (Resident #9 and #22). This was evident for 2 of 61 residents reviewed during a complaint survey. The findings include. A medical record is the official documentation of 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. Review of Resident #22's medical record on 10/15/24 revealed the Resident was admitted to the facility on [DATE] from the hospital with an unstageable right heel pressure ulcer, a left below the knee amputation surgical wound, and right leg and foot arterial wounds. Further review of Resident #22's medical record revealed the Resident was seen by the Wound Nurse Practitioner on 1/4 and 1/17/23 but 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 resident and staff interview, it was determined that the facility staff failed to maintain the resident call bell system in working order. This was evident for 1 of 14 resident rooms on the Unit 3 nursing unit which affected 2 (#10, #35) of 37 residents that resided on Unit 3 during a complaint survey. The findings include: On 10/16/24 at 8:54 AM observation was made in Resident #10 and Resident #35's room of small handheld bells sitting on the over the bed tray tables. On 10/16/24 at 8:58 AM Resident #35 was interviewed and was asked about the handheld bell. Resident #35 stated, you can ring it, but they don't come. Resident #35 was asked how long the call bell had not been working. Resident #35 stated, over a week, at least 10 days. Maintenance was waiting for a part; he said that on Monday. On 10/16/24 at 8:58 AM the surveyor rang the handheld bell. The surveyor rang the bell again at 9:08 AM. There was no nursing staff that came to the resident's room. At 9:15 AM the surveyor rang…

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 of the facility's kitchen food services, and staff interview it was determined that the facility failed to maintain food service equipment in a manner that ensures sanitary food service operations. This was identified while observing the facility's dish washing machine in operation. The findings include. Observation of the facility's dish washing machine on 6/22/21 at 2:30 PM revealed that the lunch time dish washing was nearly completed. Observation of the wash temperature gauge revealed that the wash temperature did not go above 141 degrees Fahrenheit (F). The Certified Dietary Manager (staff #11) joined the surveyor and confirmed that the wash cycle water temperature was not at the correct temperature for proper dishware sanitation. As the dietary staff continued to run racks of dishes or empty dish racks into the dish washing machine, the temperature gauge for the wash cycle went down to 138 degrees Fahrenheit. Review of the dishwasher temperature log at 2:35 PM revealed that there was not any recording of the dishwashing water temperatures for the lunch…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview it was determined that the facility staff failed to promote self determination for Residents (#67, #69, # 112 and #113). This was evident for 4 of 10 residents reviewed for choices and 4 of 58 residents reviewed during the survey process. The findings include: 1. Facility staff failed to provide showers as scheduled and per Resident #67's request. During interview with Resident #67 on 6/16/21 at 10:00 AM, the resident stated he/she was not receiving showers as he/she would like. Review of Resident #67's medical record on 6/21/21 revealed the resident was admitted to the facility on [DATE]. Further review of the resident's medical record revealed the facility conducted an assessment of the resident on 5/10/21 and coded the resident as total dependence on staff with one person physical assist for bathing. Review of Resident #67's electronic medical record revealed the resident was scheduled for showers on Tuesday and Fridays. Review of showers documented as given 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 facility documentation and interview, the facility staff failed to provide evidence that the facility had purchased a surety bond to assure the security of all the residents' personal funds deposited with the facility. This was evident during the investigation of facility tasks during an annual survey. The findings include: On 6/29/21 at 12:00 PM the Business Office Manager provided the surveyor a list of all residents' personal funds held with the facility including a total of $87, 928.11. At that time the surveyor requested evidence of a surety bond purchased by the facility. Surety bond is an agreement between the principal (the facility), the surety (the insurance company), and the obligee (depending on State law, either the resident or the State acting on behalf of the resident), wherein the facility and the insurance company agree to compensate the resident (or the State on behalf of the resident) for any loss of residents' funds that the facility holds, safeguards, manages, and accounts for. The Business Office Manager provided the surveyor an email dated 10/14/20…

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 staff interview it was determined that the facility failed staff to provide residents and/or their representative (RP) with the proper paper documentation of the facilities bed hold policy (Resident #29, #40, #57, #82 and #89). This was evident for 5 out of 5 residents reviewed for discharge during the annual survey. The findings include: A bed hold policy is written information to the resident or resident representative that specifies the duration that the resident is permitted to return and resume residence in the nursing facility. It is given before a nursing facility transfers a resident to a hospital or the resident goes out on therapeutic leave. 1. On 6/24/21 a medical record review for Resident #29 was done and it revealed the resident was transferred to the hospital on 9/12/20 and again on 6/11/21. Further review of the resident medical record on the same date did not find written documentation of the facility's bed hold policy was provided to the resident and/or the RP. 2. An interview was conducted with the Unit Manager (staff #4) on 6/21/21 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview it was determined the facility staff failed to ensure the care plan meeting occurred to review and revise the care plan after the quarterly Minimum Data Set assessment (Residents #1, #13) and the facility staff failed to review and revise care plans for Residents ( #89 and #53) to reflect accurate and appropriate interventions. This was evident for 4 of 6 residents selected for review of care planning and 5 of 58 residents selected for review 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…

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 resident medical records and interviews with residents and facility staff, it was determined that the facility failed to ensure that residents received treatment and care to promote the highest practable well being as evidenced: by failures to follow physician orders, to follow up on dieticians' recommendations and abnormal labs, and to adequately assess residents for fall risks. This was evident for 6 of 58 residents (Residents #38, #80, #210, #260, #470, and #472) that were reviewed during the survey. The findings include: 1. The facility staff failed to schedule a neurology consultation for Resident #38 as ordered by the physician. Medical record review for Resident #38 on 6/29/21 at 8:45 AM revealed on 1/23/21 the physician ordered: please schedule the patient with neurologist for migraines. Neurology is the branch of medicine concerned with the study and treatment of disorders of the nervous system. Migraine is a neurological condition that can cause multiple symptoms. It is frequently…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility staff failed to obtain weights as ordered by the physician in a timely manner for Residents (#53, #57); failed to provide Resident #69 with supplement as ordered; failed to hold milk for Resident #210 as recommended by dietician ;failed to ensure Resident #213 received foods of preference and failed to provide Resident #261 with a therapeutic diet. This was evident for 6 of 8 residents reviewed for Nutrition and 6 of 58 residents selected for review during the survey process. The findings include: 1. The facility staff failed obtain a weight for Resident #53 in a timely manner. Medical record review for Resident #53 on 6/25/21 at 9:00 AM revealed the facility staff documented the resident's weight on: 2/2/21 as 174.4 lbs. 3/5/21 as 167.2 lbs. 5/6/21 as 195.5 lbs.- an increase of 28.3 lbs in 2 months and 5/27/21 as 204 lbs- another increase of 8.5 lbs. Further record review revealed staff #30 assessed the resident on 5/13/21 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, it was determined the facility staff failed to address Consultant Pharmacy Drug Regimen Review in a timely manner for Residents (#29, #38, #53, #80, #82 and #98). This was evident for 6 of 6 residents reviewed for unnecessary medication and 6 of 58 residents selected for review during the survey sample. The findings include: 1. The facility failed to ensure that monthly medication regimen reviews were conducted by the pharmacy to identify any irregularities in the resident medication regimen. for Resident #29. A medical record review was conducted on 6/24/21 at 8:50 AM for Resident #29. Upon review it revealed the resident has a list of current medications prescribed by the physician. One of the medications reviewed for Resident #29 for unnecessary medications is Buspirone HCL. The resident is prescribed Buspirone HCL 10 mg one time a day and Buspirone HCL 5 mg at bedtime for Anxiety. A pharmacy regimen review is conducted monthly by the pharmacy to identify if there are any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility staff failed to maintain medical records in the most accurate form for residents (Resident #38, #82, #84,# 89, #212, #213, #312, #460 and #463). This was evident for 9 of 58 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. The facility staff failed to obtain the complete consultation report as requested by the physician for Resident #38. Medical record review on 6/28/21 at 9:30 AM for Resident #38 revealed on 6/7/21 the physician reviewed a Neurology consultation for the resident. Review of the consultation revealed the consultation Final Report was 4 pages; however, the medical record only had 3 pages of that consultation. 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, review of employee health records and interview; the facility staff failed to: 1.) thoroughly screen for immunity to diseases and failed to offer the Hepatitis B vaccine to those newly hired employees (Employee #38, #39, #40, #41, #42). This is evident for 5 of 5 newly hired employees and 1 out of 58 residents reviewed during an annual survey; and 2.) failed to follow standard infection control practices regarding the food tray for Resident #35. This was evident for 1 of 1 breakfast tray observed. The findings include: 1. The facility staff failed to thoroughly screen for immunity for diseases Measles is an infection of the respiratory system caused by a virus. Measles is spread through respiration contact with fluids from an infected person's nose and mouth, either directly or through aerosol transmission, and is highly contagious. Mumps is a contagious disease that leads to painful swelling of the salivary glands. The mumps are caused by a virus. The virus is spread from person-to-person…

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, it was determined the facility staff failed to provide an environment to promote the highest dignity to Resident #213. This was evident for 1 of 1 resident reviewed for dignity and 1 of 58 residents reviewed during the survey sample. The findings include: 1 A. The facility staff failed to provide Resident #213 breakfast tray with the utmost dignity. This surveyor arrived at Unit 4 on 6/22/21 at 8:05 AM. Upon observation, Resident #35's (roommate to Resident #213) breakfast tray was noted in the room. Upon further observation, it was noted that the food carts were at each end of the hall; however, it was also noted no staff actively serving trays. The surveyor interviewed Resident #213 if breakfast was served, and the resident confirmed that no breakfast had been served to her/him and no was tray noted in the room for Resident #213. It was also noted that the Geriatric Nursing Assistants removing dirty trays (trays that had been in residents' room 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 notify Resident #69's Responsible Party (RP) when a medication was discontinued. This was evident for 1 of 1 resident reviewed for notification of change and 1 of 58 resident reviewed during the annual survey process. The findings include: Interview with the Resident #69's responsible party on 6/21/21 at 8:50 AM revealed that she is not always notified of changes in the resident's condition. Medical record review for Resident #69 on 6/22/21 at 12:00 PM revealed on 8/7/20 the physician order: discontinue Plavix 75 milligrams. Plavix is a brand-name prescription drug. Plavix is an antiplatelet medication. It prevents the platelets from clumping together into blood clots. Further record review and interview with the Director of Nursing (DON) on 6/ 22/21 at 1:30 PM revealed the facility staff failed to notify the RP for Resident #69 of the discontinuation of the Plavix. Interview with the Nursing Home Administrator, DON and Corporate Nurse on 6/30/21 at 2:00 PM were notified of the concerns…

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, staff interview, and review of administrative records, it was determined that the facility failed to provide written notification to residents when the facility determined that a resident no longer qualified for Medicare part A skilled services. This is identified for 2 (Residents #89, and #106) of 2 residents reviewed that remained in the facility after termination of skilled services. The findings include. At the initation of the survey on 6/16/21, the facility was requested to provide a list of Medicare beneficiaries who were discharged from a Medicare covered Part A stay with benefit days remaining in the past 6 months prior to the survey. The facility provided a computerized list of all residents discharged from the facility. The facility was asked to provide another list. The 2nd list only included 20 residents and none of the residents on the list had remained in the facility upon termination of Medicare skilled service. An interview was conducted with the Short term Social…

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 on 6/25/21 at 11:49 AM, the facility staff failed to replace ripped and torn screens in rooms 209, 211, 213, and 215. This was evident for 4 out of 15 rooms observed for ripped screens. The findings include: On 6/25/21 at 12:03 PM this writer spoke with the Maintenance Director, Staff #29, the Administrator was present and stated to him the screens in the windows of rooms 209, 211, 213, and 215 were ripped and need replacing. Further observation revealed that there are other windows in the facility where the screens have been repaired with screening material, but could use replacement, as well. The Maintenance Director returned a short time later with the Administrator on 6/25/21 at 12:49 PM and stated that he would do an audit of all the rooms and replace any damaged screens.

Based on medical record review it was determined the facility staff failed to notify the Office of Health Care Quality (OHCQ) of an injury of unknown origin to Resident #69. This was evident for 1 of 58 residents selected for review during the annual survey process. The findings include: The purpose of the reportable events is to ensure the health, safety, and welfare of residents in nursing homes. A reportable event is an allegation or actual occurrence of an incident that adversely affects or has the potential to negatively affect the welfare of an individual. The purpose of a thorough investigation is first to determine if abuse of the resident has occurred. It is the expectation that any injury of unknown occurrence be investigated by the facility and be reported to the appropriate agency within 24 hours and the conclusion of the investigation to be reported in 5 days to the appropriate agency (OHCQ). Medical record review for Resident #69 on 6/22/21 at 11:30 AM revealed that on 9/29/20 the resident was noted to have a lump-like swelling with purplish discoloration on the right…

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

Based on medical record review and staff interview it was determined that the facility failed to document that information was provided to the acute care facility when a resident was transferred there emergently. This was evident for 1 (Resident #40) of 6 residents reviewed for hospitalization and 1 of 58 residents reviewed during the annual survey. The findings include: Resident #40's medical record was reviewed on 6/21/21at 8:30 AM. Review of the Census tab in the electronic health record (EHR) revealed that billing was stopped on 6/17/21. Review of the progress notes and the evaluations tab did not reveal any information as to why billing was stopped. There was not any type of progress note nor an evaluation to indicate that the resident was sent out of the facility. An interview with the Unit Manager (staff #4) on 6/21/21 at 2:18 PM confirmed that the resident was sent to the hospital on 6/17/21. She was informed that there was not any documentation in the medical record to indicate that Resident #40 was transferred out on 6/17/21. She reviewed the chart and confirmed that there…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with staff it was determined that the facility failed to ensure that the resident, and/or their responsible party (RP), received written notification of a transfer to the hospital, including appeal rights and ombudsman contact information (Residents #29 #40, #57, #82 and #89). This was found to be evident for 5 out of 5 residents reviewed for hospitalization during an annual survey. The findings include: 1. Resident #29's medical record was reviewed on 6/24/21 at 8:41 AM and it revealed the resident was transferred to the hospital on 6/11/21 for urinary retention with abdominal pain and on 9/12/20 for dark emesis (vomiting) and shortness of breath. Further record review on the same date failed to reveal the resident and/or RP was notified in writing of the reason for the transfer. An interview was conducted with the Director of Nursing on 6/24/21 at 2:30 PM and she was asked to provide documentation that the residents and/or RP were notified in writing of the transfer…

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

Based on medical record review and staff interview, it was determined that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was exemplified for 2 (#40, #89) of 6 residents reviewed for hospitalization during the annual survey and 2 of 58 residents selected for review during the annual survey. The findings include. 1. Resident #40's medical record was reviewed on 6/21/21at 8:30 AM. Review of the Census tab in the electronic health record (EHR) revealed that billing was stopped on 6/17/21. Review of the progress notes and the evaluations tab did not reveal any information as to why billing was stopped. There was not any type of progress note or and evaluation to indicate that the resident was sent out of the facility. An interview with the Unit Manager (staff #4) on 6/21/21 at 2:18 PM confirmed that the resident was sent to the hospital on 6/17/21. Staff #4 was asked questions to how are resident informed of the facilities bed hold policy and how are residents informed in writing of a facility initiated discharge. Staff…

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 accurately code the resident's status on the Minimum Data Set (MDS) assessment (Resident #1, #54 and #111). This was evident for 3 out of 58 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. Care Area Assessments (CAAs) are part of this process, and provide the foundation upon which a resident's individual care plan is formulated. MDS assessments are completed for all residents in certified nursing homes, regardless of source of payment for the individual resident. MDS assessments are required for residents on admission to the nursing facility, periodically, and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview it was determined that facility staff failed to develop and implement comprehensive care plans for residents (Resident #1 and #260). This was evident for 2 of 6 residents reveiwed for care plans and 2 of 58 residents selected for review during an annual survey. The findings include: A care plan is an outline of nursing care showing all the resident's needs and the ways of meeting the needs. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the individual's specific needs. It is a dynamic document initiated at admission and subject to continuous reassessment and change by the nursing staff caring for the resident. The care plan typically includes nursing and medical diagnoses, nursing interventions, and outcomes to ensure consistency of care. 1. The facility staff failed to develop and implement a care plan to manage a resident's dental care. Review of Resident…

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

Based on medical record review and observation, it was determined the facility staff failed to provide nursing care within the standards of practice for Residents #84 and #210. This was evident for 2 of 58 residents reviewed during the survey process. The findings include: 1 A. The facility staff failed to lubricate a suppository prior to insertion for Resident #84. Medical record review for Resident #84 on 6/25/21 at 8:00 AM revealed on 4/26/21 at 5:00 PM the physician ordered: Anusol-HC Suppository 25 milligrams, insert 1 suppository rectally two times a day for Hemorrhoid. Anusol Suppositories help to relieve the swelling, itch and irritation of internal piles (hemorrhoids) and anal itching. Observation of medication administration on 6/23/21 at 8:42 AM revealed facility staff nurse #34 administered Anusol suppository; however, failed to apply lubricant prior to administration. Dip the tip of the suppository in water, or apply a small amount of water-based lubricant, such as K-Y Jelly prior to insertion of the suppository. A lubricant helps the suppository more easily slide 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 review of a closed medical record and staff interview, it was determined that the facility staff failed to provide a resident with a completed discharge summary (Resident #112). This was evident for 1 of 3 residents reviewed for closed records during an annual survey. The findings include: Review of Resident #112's closed medical record on 6/21/21 revealed that Resident #112 was discharged from the facility on 4/5/21. Resident #112's electronic medical record and paper record failed to reveal a completed discharge summary from Resident #112's attending physician that included: a recapitulation of the resident's stay, a final summary of the resident's status, reconciliation of all pre-discharge medications with the post discharge medications, and a post discharge plan of care. An interview with the Director of Nursing on 6/25/21 at 9:23 AM confirmed that Resident #112's record did not include a completed discharge summary.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and interview it was determined the facility staff failed to provide thorough grooming and personal hygiene services for (Residents #1, #69, #80, #212). This is evident for 4 of 9 residents reviewed for activities of daily living (ADL) care and 4 of 58 residents selected for review during the annual survey process. 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 section of the MDS is: Functional Abilities and Goals. Some of the components assessed in the Functional Abilities and Goals of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers (Resident #67, #77 and #260). This is evident for 3 of 5 residents reviewed for pressure ulcers and 3 of 58 residents reviewed during an annual survey. The findings included: A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and / or eschar in the wound bed). A deep tissue injury (DTI) is a unique…

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 interview with a resident, it was determined that the facility failed to provide safety equipment for a resident that smokes. This was identified for Resident #70 during 1 of 3 smoking observations and 1 of 58 residents selected for review during the annual survey. The findings include: During the initiation of the survey as requested the facility provided a list of residents that smoke, the designated smoking times, and a list of resident that require a smoking apron for safety. Resident #70 was identified to wear a smoking apron when smoking. On 6/17/21 Resident #70 was observed during the 9 AM resident smoking time to not be wearing a smoking apron safety device. The resident was interviewed as she/he was smoking. The resident indicated she/he had graduated from using a smoking apron as she/he was no longer in a wheelchair. Review of Resident #70's medical record on 6/17/21 at 11:50 AM revealed a care plan related to the resident smoking safely. One of the two written goals was; I will utilize my safety equipment appropriately…

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 thoroughly assess and intervene when Resident #53 was noted with a decrease in urinary continence. This was evident for 1 of 3 resident selected for review of urinary continence and 1 of 58 residents selected for review during the annual survey. The findings include: The Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Categories of MDS (Minimum Data Set) are: Cognitive patterns, Communication and hearing patterns, Vision patterns, Physical functioning and structural problems which includes the assessment of range of motion, Continence, Psychosocial well-being, Mood and behavior patterns, Activity pursuit patterns, Disease diagnosis, Other health conditions, Oral/nutritional status, Oral/dental status, Skin condition, Medication use and Treatments and procedures. At the end of the MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to administer pain medication to newly admitted residents in a timely manner (Resident #261 and #470). This was evident for 2 out of 2 residents reviewed for pain management and 2 of 58 residents reviewed during an annual survey. The findings include: 1. During interview with Resident #261 on 6/16/21 at 11:53 AM, the resident stated when he/she was admitted to the facility from the hospital around 8:00 PM, he/she didn't receive pain medication until the next day around 3:00 PM even though he/she had requested pain medication. Review of Resident #261's medical record on 6/21/21 revealed the resident was admitted to the facility on [DATE] at approximately 8:15 PM from the hospital with a diagnosis to include chronic pain syndrome. Review of the resident's Medication Administration Record for June 2021 revealed the facility staff first documented they administered Oxycodone 10 mg to the resident was 6/12/21 at 7:14 PM, almost 24 hours after 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 medical record review, it was determined the facility failed to maintain enough nursing staff to meet resident care needs in a timely manner for residents. This deficient practice has the potential to affect all residents in the facility. The findings include: During investigation of multiple complaints from residents and residents' families regarding staffing at the facility, the surveyor interviewed the Resident Council President (#40) and the resident's roommate (#106) on 6/23/21 at 12:15 PM. At that time Resident #40 and #106 both stated it takes too long for the facility staff to answer call bells. Resident #40 stated he/she had recently been readmitted from the hospital and uses a BiPAP machine. A BiPAP machine is a non-invasive form of therapy for patients suffering from sleep apnea. Resident #40 stated he/she put on his/her call bell last night at 10:40 PM because his/her BiPAP didn't seem to be working correctly and it took until 12:30 AM (1 hour and 40 minutes) for the staff to answer. During interview with Resident #106 at that time, he/she…

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 that Resident #80 was free from unnecessary medications. This was evident for 1 of 5 residents selected for review of unnecessary medications and 1 of 58 residents selected for review during the annual survey process. The findings include: 1 A. The facility staff failed to hold a blood pressure medication as ordered by the physician for Resident #80. Medical record review for Resident #80 on 6/29/21 at 12:30 PM revealed on 6/1/21 the physician ordered: Cozaar 50 milligrams by mouth at bedtime for high blood pressure. Administer the medication if the blood pressure is greater than 140/90. Cozaar is a medicine used to treat the symptoms of high blood pressure. Review of the Medication Administration Record (MAR) revealed the facility staff documented the resident's blood pressure as 123/67 on 6/4/21 at 9:00 PM and 122/76 on 6/5/21 at 9:00 PM; however, failed to hold the medication as ordered. 1 B. The facility staff failed to administer pain medication in accordance with the parameters set by the…

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

Based on record review and observation of medication administration, it was determined the facility staff failed to maintain an error rate below 5%. Observation of medication administration resulted in an error rate of 12.9%. This was evident for 2 of 3 (#210 and #84) residents observed and 4 of 31 opportunities for error. The findings include: Error #1: The facility staff failed to administer a medication until surveyor intervention. Medical record review for Resident #210 on 6/22/21 at 10:00 AM revealed on 5/18/2021 the physician ordered: Cholecalciferol Tablet, give 5000 IU (international units) by mouth one time a day for supplement. Cholecalciferol is vitamin D3. Vitamin D helps the body absorb calcium. Cholecalciferol is used as a dietary supplement in people who do not get enough Vitamin D in their diets to maintain adequate health. Observation of medication administration on 6/21/21 at 9:14 AM revealed facility staff #35 failed to administer the medication until surveyor intervention. Staff #35 had completed administering medications to Resident #210 and had proceeded 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 upon observation, staff interview and medical record review it was determined that facility staff failed to assist a resident in obtaining routine and emergency dental care (Resident #1 and #69). This was evident for 2 of 2 residents reviewed for dental and 2 of 58 residents reviewed during an annual survey. The findings include: 1. Observation of Resident #1 on 6/28/21 at 11:46 AM revealed the resident to have upper dentures with the top middle tooth broken and the 2 teeth to the right of the middle tooth broken. Further observation of the resident revealed the resident did not have lower dentures. Review of Resident #1's medical record on 6/28/21 revealed the resident was admitted to the facility on [DATE]. Further review of the medical record revealed as of 6/28/21 the resident has not received any dental services for broken and missing dentures. Interview with the Director of Nursing on 6/29/21 at 11:05 AM confirmed the facility staff failed to obtain a dental consult for the resident. Following…

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.