Lynwood Manor Healthcare Center

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 66 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality. Findings include: On 07/09/24 at 02:00 P.M., A common area environmental tour was conducted with Director of Maintenance V and Director of Housekeeping and Laundry Services U. The following items were noted: Lobby: The drywall surface was observed (etched, scored, particulate), adjacent to the receptionist desk. The damaged wall surface measured approximately 4-feet-wide by 8-feet-long. B-Hall (North) Soiled Utility Room: The return-air-exhaust ventilation was observed non-functional. Main Dining Room: The two sets of exit door surfaces were observed (etched, scored, particulate). Director of Maintenance V indicated he would have staff repaint the door surfaces as soon as possible. Food Production Kitchen: The exterior surfaces of the two entrance doors were observed (etched, scored, particulate). Director of Maintenance V…

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

Based on interview and record review the facility failed to provide timely financial statements to one Resident (#26)/responsible person of one Resident reviewed for Resident trust fund, resulting in the resident/responsible person being not informed about personal funds. Findings Included: Resident #26 (R26) Review of the medical record revealed R26 was admitted to the facility 05/25/2017 with diagnoses that included Liver cirrhosis (chronic liver damage resulting in liver failure), type 2 diabetes, osteoarthritis right elbow, hepatic failure (liver failure), protein-calorie malnutrition, pain of right shoulder, alcohol dependence, schizoaffective disorder, abnormal gait, muscle weakness, heart disease, heart failure, dementia, gastro-esophageal reflux, depression, hypotension, chronic respiratory failure, history of myocardial infarction (heart attack), hypertension, urinary retention, and chronic viral hepatitis C. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/05/2024, revealed a Brief Interview for Mental Status (BIMS) of 1 (severe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 This citation pertains to intake MI00144424. Based on observation, interview and record review, the facility failed to notify the Physician of a change in tissue appearance for a hot liquid thermal burn for one (Resident #28) of one reviewed. Findings include: Review of the medical record reflected R28 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included multiple sclerosis and unspecified severe protein-calorie malnutrition. The significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/23/24, reflected R28 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was coded for second or third degree burns. During an interview and observation on 07/09/24 at 2:17 PM, R28 reported about three to four months prior, hot coffee fell over and was super hot. He reported having a fourth-degree burn on his leg. He lifted the left leg of his shorts and showed a darkened area, several inches long, on the…

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

Based on interview and record review the facility failed to ensure that the Notice of Medicare Non-Coverage (NOMNC) and a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) for one Resident (#14) out of three reviewed for Beneficiary Notification. Findings Included: Resident #14 (R14) Review of the medical record revealed R14 was admitted to the facility 02/08/2024 with diagnoses that included type 2 diabetes, weakness, difficulty walking, repeated falls, lack of coordination, dysphagia (difficulty swallowing), severe protein-calorie malnutrition, hypertension, hyperlipidemia (high fat content in blood), hypothyroidism (low thyroid hormone), heart disease, depression, chronic obstructive pulmonary disease (COPD), and shortness of breath. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/17/2024, revealed a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. Review of R14's medical record demonstrated that his payment source was changed from Medicare to pending Medicaid on 03/07/2024. 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 observation, interview, and record review the facility failed to provide wound care per physician orders, in one of two residents reviewed for non-pressure wounds (Resident #29), resulting in the likelihood of infection, and delayed wound healing. Findings include: Resident #29 (R29) R29 was observed on Tuesday, 7/09/24 at 10:09 AM, sitting in his room in his wheelchair with dressings on each arm that were heavily saturated with brown drainage and both dressings were dated 7/04/24. R29's Minimum Data Set (MDS), with assessment reference date of 6/28/24, introduced a Brief Interview for Mental Status (BIMS, a brief cognitive screener) score of 15 (13-15 Cognitively Intact). The same MDS indicated he had the diagnoses of heart failure, high blood pressure, end stage renal disease requiring dialysis, lung disease, skin tears, and moisture associated skin damage. In review of R29's physician orders dated 7/01/24, instructions were to cleanse wounds on his left forearm and right elbow with wound cleanser, pat dry, apply Medi honey (aids in promoting moist wound environment 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 observation, interview, and record review, the facility failed to provide restorative ambulation services to maintain mobility, in one of one resident reviewed for mobility (Resident #4), resulting in sadness and fear of loss of ability to walk. Findings Include: Resident #4 (R4) R4 was observed sitting in a wheelchair in her room on 7/09/24 at 12:21 PM and 7/10/24 at 10:25 AM; and during an interview stated she wanted to participate in therapy, but insurance would not cover it. R4 stated she used to be able to walk, staff were supposed to walk with her up and down the hall; but staff did not let her walk outside of her room. R4's Minimum Data Set (MDS) assessment with assessment reference date (ARD) of 6/19/24, revealed she was [AGE] years old, had a Brief Interview for Mental Status (BIMS, short cognitive screener) score of 14 (13-15 Cognitively Intact) and had the diagnoses of traumatic brain injury, history of a stroke with hemiplegia (complete or severe paralysis on one side of the body including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a therapeutic diet to one (Resident #28) of three reviewed for nutrition. Findings include: Review of the medical record reflected R28 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included multiple sclerosis and unspecified severe protein-calorie malnutrition. The significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/23/24, reflected R28 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was coded for second or third degree burns. On 07/09/24 at 2:13 PM, R28 was observed lying in bed. He reported the food was skimpy, referring to the portion sizes he received. R28 reported his current weight was 140 pounds. On 01/01/2024, R28 weighed 167 pounds. On 07/09/2024, R28 weighed 140.2 pounds, which was a 16.05 percent weight loss. A Physician's Order with a start date of 3/18/24 and a revision date of 4/9/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide respiratory treatment in one of two residents reviewed for respiratory services (Resident #22), resulting in the likelihood of decreased quality of sleep, increased risk of stroke, heart disease, and diabetes. Findings include: Resident #22 (R22) On 7/09/24 at 10:28 AM R22 was observed sitting in his wheelchair in his room. A continuous positive airway pressure (CPAP, detects collapse of airway and increases pressure) machine was sitting on a shelf near his bed. R22 stated he did not use his CPAP machine, because it was missing a part. R22's annual Minimum Data Set (MDS) with an assessment reference date of 6/14/24, revealed he was admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS, a short cognitive screener) score of 11 (08-12 Moderate Impairment). The same MDS revealed R22 had the diagnoses of sleep apnea, high blood pressure, Parkinsonism, anxiety, depression, dementia, and seizure disorder.…

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

Based on observation, interview, and record review the facility failed to ensure the medication rate was less than 5% when three medication errors were observed form a total of 26 opportunities for two residents (#58,#60) of five reviewed for medication administration, resulting in a mediation error rate of 11.54%. Findings Included: Resident #58 (R58) Review of R58 medical record demonstrated that she was admitted to the facility 05/07/2024 with diagnoses that included constipation, muscle weakness, repeated falls, dysphagia (difficulty swallowing), anemia (low red blood cells) anxiety, osteoarthritis, atrial fibrillation, gastro-esophageal reflux, insomnia, osteoporosis (weak bones), vitamin D deficiency, hyperlipidemia (high fat in blood), hypoglycemia (low blood sugar), hypertension, and muscle spasms. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/04/2024, revealed a Brief Interview for Mental Status (BIMS) of 13 (cognitively intact) out of 15. Resident #60 (R60) Review of R60 medical record demonstrated that she was admitted 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to honor food preferences for one (Resident #39) of 15 reviewed. Findings include: Review of the medical record reflected R39 admitted to the facility on [DATE], with diagnoses that included dependence on renal dialysis and diabetes. The admission Minimum Data set (MDS), with an Assessment Reference Date (ARD) of 5/23/24, reflected R39 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 07/09/24 at 11:40 AM, R39 was observed seated in a wheelchair, in her room. She reported the facility needed to keep track of the food service. She reported her tray ticket reflected what she could and could not have, as well as dislikes or allergies. Per her report, they highlighted that she could not have peppers, and she had recently been served a meal that had red and green peppers all over it. The peppers aggravated her gallbladder, per her report, and she had not had peppers in 15 to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observation, interview and record review, the facility failed to ensure appropriate assessments for safety using a coffee pot independently and self-administering of medications were completed for one (Resident #9) of three residents reviewed for medication availability resulting in a fire/burn hazard and medication errors. Findings include: Resident #9 (R9) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R9's initial admission date was 1/8/2022 with diagnoses of chronic obstructive pulmonary disease (lung disease), muscle weakness and protein calorie malnutrition. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R9 was cognitively intact (13-15 cognitively intact). During an interview on 2/14/2024 at 2:29 PM, R9 was in his room, walking around. R9 stated, I'm going to make coffee while we talk. R9 proceeded to make coffee and then pulled out an inhaler that was sitting on his bedside table and started using it. After the coffee 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 This citation pertains to intake MI00139686. Based on interview, and record review, the facility failed to monitor residents weights, in one of three residents reviewed for weight loss (Resident #1), resulting in a significant weight loss. Findings include: Resident #1 (R1) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R1 was admitted on [DATE] and expired on [DATE] on Hospice at the facility. R1 was admitted with diagnoses of dysphagia (difficulty swallowing), dementia, gallbladder disease and chronic kidney disease. Brief Interview for Mental Status (BIMS) reflected a score of 11 out of 15 which indicated R1 cognition was moderately impaired (8-12 moderately impaired) Review of the weight monitoring policy with no implementation date or review date under compliance guidelines #5 revealed, Residents with weight loss - monitor weight weekly. Review of R1's chart revealed the following weights: [DATE] -185.8 pounds [DATE] -192.8 pounds [DATE]-168 pounds [DATE]-167 pounds The weights…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from 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 This citation pertain to intake MI00137450. Based on observation, interview, and record review, the facility failed to ensure ongoing communication and collaboration with the dialysis facility in two of three residents reviewed for dialysis services (Resident #7 and #8), resulting in decreased quality of care. Findings include: Resident #8 (R8) R8 was observed lying in her bed on 2/15/24 at 12:32 PM and had a dressing over her fistula on her left arm. In review of R8's electronic medical record (EMR), she was admitted to the facility on [DATE], had discharged from the nursing home to acute care on 2/09/24 and was re-admitted to the facility on [DATE]. R8's Minimum Data Set (MDS) assessment with assessment reference date (ARD) of 2/08/24 revealed she was admitted to the nursing home on [DATE], had a brief interview for mental status (BIMS), a short performance-based cognitive screener, score of 14 (13-15 Cognitively intact). The same MDS indicated R8 had the diagnoses of heart failure, end-stage renal disease…

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

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 70 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 04/12/23 at 08:35 A.M., A comprehensive tour of the food service was conducted with Registered Dietician C. The following items were noted: The Victory 2-door reach-in cooler was observed with moisture dripping into the cooler cavity, adjacent to the interior light assembly. Pooling water was also observed collecting on the reach-in cooler interior flooring surface. Registered Dietician C indicated she would have maintenance make necessary repairs as soon as possible. The Walk-In Cooler refrigeration unit condensate drain line was observed leaking water from the drain funnel connection. The condensate was also observed pooling on the refrigeration unit flooring surface. Registered Dietician C indicated she would contact maintenance for necessary repairs. The Walk-In Freezer was observed with accumulated formed ice droplets…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure binding arbitration agreements complied with all requirements for three (Resident #34, #45, and #53) of three residents reviewed, resulting in the residents and/or representatives to not be informed of their rights. Findings include: On 4/12/23 at 9:12 AM, Nursing Home Administrator (NHA) A reported the facility's arbitration agreement was included in the admission agreement and all new admissions signed the agreement. NHA A reported all 70 facility residents had a signed arbitration agreement. On 4/12/23 at 10:59 AM, NHA A provided a list of all residents who entered a binding arbitration agreement since 9/16/19. The list included 658 residents. On 4/12/23 at 12:43 PM, NHA A reported Case Manager (CM) J was responsible for the facility's binding arbitration agreements. Review of the facility's admission Contract revealed 5. Binding Arbitration .The resident understands that .3. this arbitration provision may be rescinded by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 70 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and plumbing leaks. Findings include: On 04/13/23 at 08:55 A.M., A common area environmental tour was conducted with Director of Maintenance D and Director of Housekeeping and Laundry Services E. The following items were noted: Staff/Visitor Restroom: Eight 12-inch-wide by 12-inch-long vinyl flooring tiles were observed either cracked or severely stained, adjacent to the commode base perimeter. The commode base caulking was also observed cracked, chipped, missing. Director of Maintenance D indicated he would have staff make necessary repairs as soon as possible. A-Wing Soiled Utility Room: The hand sink faucet hot water valve was observed leaking. The valve stem handle was also observed to rotate approximately 270 degrees to stop. North Shower Room: The commode support 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, interview and record review the facility failed to ensure that 1 of 1 (R11) resident reviewed, were treated with respect and dignity by staff resulting in feelings of shame, helplessness and a negative psychosocial outcome. Findings Include: Resident #11 (R11) Review of the medical record reflected R11 was an initial admission to the facility on [DATE]. Diagnoses of Bullous Pemphigoid (autoimmune skin disease, blisters), Idiopathic Orofacial Dystonia (involuntary, forceful contractions of the jaw and tongue, often making it difficult to open or close the mouth), lack of coordination, Schizophrenia, Major Depression and Drug Induced Subacute Dyskinesia (uncontrolled movements in certain muscles). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/28/2023, revealed R11 had a Brief Interview of Mental Status (BIMS) of 12 (mildly impaired) out of 15. Under section G0110, Activities of Daily Living (ADL) Assistance reveals R11 requires extensive assistance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure accurate completion of advance directive information for 2 (Resident #6 and #48) of 3 residents reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time) resulting in the potential for a resident's preferences for medical care to not be followed by the facility. Findings include: Resident #6 Review of the medical record reflected that Resident #6 (R6) was admitted to facility 3/16/23 with diagnoses including history of traumatic brain injury, seizures, left hand contracture, bipolar disorder, major depressive disorder, and anxiety disorder. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/23/23 revealed that R6 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 13 (cognitively intact). Section G of MDS revealed that R6 required supervision after setup for bed mobility, transfers, toilet use, and eating. Review…

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

Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for 2 (Resident #6 and #19) of 19 residents reviewed, resulting in an inaccurate MDS assessment and the potential for unmet care needs. Findings include: Resident #6 Review of the medical record reflected that Resident # 6 (R6) was admitted to facility 3/16/23 with diagnoses including history of traumatic brain injury, left hand contracture, and hemiplegia. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/23/23 revealed that R6 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 13 (cognitively intact). Section G of MDS revealed that R6 required supervision after setup for bed mobility, transfers, toilet use, and eating, and one-person limited assistance with dressing. Section G also indicated that R6 had no impairments in Range of Motion in either the upper or lower extremities. During an observation and interview on 4/10/23 at 12:17 PM, R6 was observed sitting at the edge 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 observation, interview and record review the facility failed to update and revise care plans for three (R1, R2, R12) of 18 reviewed for care plans, resulting in the absence of updated interventions to assist with identified health concerns and the potential for all care needs not being met. Resident #1 (R1) Review of the medical record reflected R1 was an initial admission to the facility on [DATE]. Diagnoses of Anxiety, Depression, age related osteoporosis and abnormalities of gait and mobility. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/28/2023, revealed R1 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Under section G0110, Activities of Daily Living (ADL) revealed R1 required minimal assistance with personal care provided. R1 could propel in her wheelchair independently throughout the facility. Under section D0200, Mood revealed R1 was marked for finding little to no pleasure in doing things, feeling down, feeling bad…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to perform dressing changes as ordered for one (Resident #51) of 18 reviewed for quality of care, resulting in the potential for a worsening wound and infection. Findings include: Review of the medical record revealed Resident #51 (R51) was admitted to the facility on [DATE] with diagnoses that included cellulitis of the right lower limb and non-pressure chronic ulcer of the left foot. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/8/23 revealed R51 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The Physician's Order dated 3/21/23 revealed left foot second toe: cleanse with wound cleanser, pat dry, cover with Band-Aid, change every day and as needed. Review of the podiatry consult dated 3/29/23 revealed Patient needs right big toe dressing change 1 time per day. Remove dressing and clean ulcer with sterile saline. Reapply small gauze square and…

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

Based on observation, interview, and record review, the facility failed to ensure safe storage of smoking materials for 2 (Resident #6 and #25) of 4 residents reviewed for smoking, resulting in the potential for unsafe smoking practices. Findings include: Resident #6 Review of the medical record reflected that Resident # 6 (R6) was admitted to facility 3/16/23 with diagnoses including history of traumatic brain injury, seizures, left hand contracture, bipolar disorder, major depressive disorder, and anxiety disorder. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/23/23 revealed that R6 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 13 (cognitively intact). Section G of MDS revealed that R6 required supervision after setup for bed mobility, transfers, toilet use, and eating. Section J of same MDS revealed that R6 currently used tobacco products. During an observation and interview on 4/10/23 at 11:59 AM, R6 was observed sitting at the edge of her bed with her jacket on as stated that she had just returned from…

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

Based on observation, interview and record review the facility failed to follow infection control protocols related to hand hygiene during medication (med) pass for three of 14 residents, resulting in the potential spread of infection among residents, staff and visitors. Findings include: During an interview and observation on 04/12/23 at 7:38 AM, LPN T & LPN U were passing medications to three residents without the use of hand sanitizer or washing their hands with soap and water before and after administering medications to three difference residents. No observation of a alcohol based hand sanitizer on top of the medication cart. Review of the facilities policy titled, Handwashing/Hand Hygiene, with no date of review. Policy Statement includes This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation breaks down into task. 1) All personnel shall be trained and regularly in-serviced . 2) All personnel shall follow the handwashing/hand hygiene procedures . 3) Hand hygiene products and supplies shall be readily…

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