The Laurels of Bedford

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide an effective bowel management program for one (Resident #64) of one reviewed, resulting in the potential for constipation.Review of the clinical record revealed R64 was admitted into the facility on 7/1/25 with diagnoses that included: muscle weakness and difficulty walking. According to the Minimum Data Set (MDS) assessment dated [DATE], R64 scored 11/15 on the Brief Interview for Mental Status exam (which indicated moderately impaired cognition).On 9/16/25 at 12:41 PM R64 was observed lying on his side in bed. R64's lunch tray was observed on his tray table with only a few bites gone. R64 reported that he didn't want to eat more because the food made him constipated. He further reported that he had suffered from constipation for about a month. When asked if he was receiving medication to help, he reported not to his knowledge.A review of R64's task log (documentation of residents' bowel movements) for the past 30 days, 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 This citation pertains to Intake #MI00149504 Based on interviews and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act 42CFR483.12(c) Findings include Resident #1 (R1) Review of the medical record reflected R1 was an initial admission to the facility on [DATE]. Diagnoses of unspecified fracture of upper end of left humerus, subsequent encounter for fracture with routine healing, difficulty with walking, Type 2 Diabetes Mellitus, and history of falling. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/22/2024, revealed R1 had a Brief Interview of Mental Status (BIMS) of 11 out of 0 to 15 being (moderate cognitive impairment). Under section G0100, Activities of Daily Living (ADL) Assistance reveals R1 needs set up assistance for meals and oral hygiene. R1 requires substantial to maximum assistance with showers, toileting, and getting dressed. During…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake #MI00149504 Based on interview and record review the facility failed to thoroughly investigate allegations of abuse for one of two residents (R1, R9) reviewed for abuse from a total sample of nine; resulting in known allegations of abuse to go uninvestigated and the potential for abuse to occur with no intervention or protection. Findings include: Resident #1 (R1) Review of the medical record reflected R1 was an initial admission to the facility on [DATE]. Diagnoses of unspecified fracture of upper end of left humerus, subsequent encounter for fracture with routine healing, difficulty with walking, Type 2 Diabetes Mellitus, and history of falling. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/22/2024, revealed R1 had a Brief Interview of Mental Status (BIMS) of 11 out of 0 to 15 being (moderate cognitive impairment). Under section G0100, Activities of Daily Living (ADL) Assistance reveals R1 needs set up assistance for meals and oral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to provide sufficient staffing related to Dietary Services effecting 107 residents, resulting in the increased likelihood for delayed meal preparation and delivery service. Findings include: On 09/11/24 at 09:05 A.M., A comprehensive tour of the food service was conducted with Dietary Manager P. The following items were noted: Dietary Manager Q and Dietary [NAME] R from another regional corporate facility were observed assisting facility staff with the Breakfast Meal preparation and delivery service protocol. On 09/11/24 at 09:14 A.M., An interview was conducted with Dietary Manager P regarding current facility staffing levels. Dietary Manager P stated: We are currently down one Dietary [NAME] and two Dietary Aides (one AM and one PM). Review of the meal schedule provided by the facility revealed lunch service in the main dining room was scheduled for 11:45 AM. An observation on 09/10/24 at 11:55 AM in the main dining room revealed one Certified 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to: (1) clean and maintain food service equipment, (2) clean food production kitchen flooring surfaces, (3) properly store and label food products, and (4) effectively date mark potentially hazardous ready-to-eat food products effecting 107 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and resident foodborne illness. Findings include: On 09/11/24 at 09:05 A.M., A comprehensive tour of the food service was conducted with Dietary Manager P. The following items were noted: The flooring surface was observed soiled with accumulated and encrusted (dust, dirt, grease) residue. The wall/floor junctures, corners, and entrance door frame cavities were also observed soiled with accumulated and encrusted dust, dirt, and grime. The entrance door exterior surface between the Main Dining Room and Food Production Kitchen was observed soiled with accumulated and encrusted dust/dirt/grime. The emergency eye…

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 provide palatable food products for seven of seven reviewed (R4, R29, R72, R84, R85, R99, and R169) effecting 107 residents, resulting in the increased likelihood for decreased resident food acceptance and nutritional decline. Findings include: On 09/11/24 at 12:29 P.M., Lunch meal food trays were observed leaving the food production kitchen, within a stainless steel non-insulated transport cart. On 09/11/24 at 12:30 P.M., Lunch meal food trays were observed arriving to the 100 Hall, within a stainless steel non-insulated transport cart. On 09/11/24 at 12:35 P.M., Food products were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following food product temperatures were recorded for Resident #29's lunch meal food tray: Chicken Teriyaki - 120.8 degrees Fahrenheit* Fluffy Steamed [NAME] - 122.0 degrees Fahrenheit* Asian Blend Vegetables - 131.5 degrees Fahrenheit* Dinner Roll substituted for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 107 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality. Findings include: On 09/12/24 at 09:20 A.M., A common area environmental tour was conducted with Director of Maintenance T and Director of Housekeeping and Laundry Services S. The following items were noted: Beauty Shop: The desk fan was observed soiled with accumulated dust/dirt deposits. Director of Housekeeping and Laundry Services S indicated she would have staff thoroughly clean and sanitize the desk fan as soon as possible. 100 Hall Shower Room: Two return-air-ventilation grills were observed heavily soiled with accumulated dust and dirt deposits. Ambulance Entrance/Exit Door: The door sweep was observed worn and torn, exposing an open space between the door slab and threshold plate. The damaged door sweep measured approximately 12-inches-long,…

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 accurate advance directive (legal documents that allow a person to identify decisions about end-of-life care ahead of time) information was in place for one resident (#1) of one resident reviewed for advance directives from a total sample of 22 residents. Findings Included: Resident #1 (R1) Review of the medical record revealed R1 was admitted to the facility 04/01/2017 with diagnoses that included Huntington's Disease (an inherited condition in which nerve cells in the brain break down over time), ulcerative colitis, left and right thigh muscle contractures, anxiety, adult failure to thrive, contracture of right hand, dysphagia (difficulty swallowing), cognitive communication deficient, aphonia (loss of ability to speak), Tourette's Disorder (a neurological disorder that causes people to have tics, which are sudden, repetitive, and involuntary movements or sounds), dementia, epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), moderate intellectual…

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 a Preadmission/Annual Resident Review (PAS/ARR) was completed after the 30-day exemption period and failed to notify the State mental health authority for one (Resident #97) of two reviewed. Findings include: Review of the medical record revealed Resident #97 (R97) was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, anxiety, bipolar disorder, post-traumatic stress disorder, and schizophrenia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/10/24 revealed R97 scored 15 out of 15 (cognitive intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the DCH 3877 PASARR Level I screening revealed R97 was marked as hospital exemption discharge. Review of the Mental Illness/Intellectual Disability/Related Condition Exemption Criteria Certification Level II Screening revealed R97 was marked as a hospital exempted discharge and was likely to require less…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure proper communication/documentation of Hospice services provided to one resident (#45) of one resident reviewed for Hospice services, resulting in a lack of coordination of comprehensive services and care provided. Findings Included: Resident #45 (R45) Review of the medical record revealed R45 was admitted to the facility 10/10/2018 with diagnoses that included protein-calorie malnutrition, palliative care (a specialized medical are that helps people with serious illness manage symptoms and stress while improving quality of life), disorder of the bladder, anxiety, disorder of bone density and structure, neuromuscular dysfunction of the bladder, depression, muscle wasting and atrophy, polyneuropathy (disease that affects multiple peripheral nerves throughout the body, causing weakness, numbness, and burning pain), anemia (low red blood cells), multiple sclerosis, hyperlipidemia (high fat content in blood), over active bladder. 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 ensure infection control practices for Foley catheters were maintained for two residents (Resident #98 and 17), and infection control surveillance was thoroughly conducted, resulting in the potential for the spread of infections to all 104 residents who resided at the facility. Findings Included: Record review of an infection control surveillance line listing log (list of all infections in the facility) for the month of May 2023 revealed the facility had 33 infections with 10 of the infections being catheter acquired, and 23 being healthcare associated infections. Further review of a June 2023 surveillance log revealed the facility had 46 total infections with 12 being catheter acquired, and 28 being healthcare associated infections. In an interview on 7/12/2023 at 1:02 PM, Registered Nurse (RN) G, who was the Infection Control Nurse, was asked what process was used to identify the root cause of the clusters in the infections for May 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 interview and record review, the facility failed to ensure the timely completion of Minimum Data Set (MDS) assessments for four (Resident #16, #20 #68, #112) of 22 reviewed for MDS, resulting in late MDS assessments and the potential for further late assessments. Findings include: Resident #12 (R112) According to the clinical record including the Minimum Data Set (MDS) with an assessment reference date of 02/20/23, R112 was a [AGE] year old female admitted on [DATE] with diagnoses that included heart failure, major depression and anxiety. R112 scored 15 out of 15 on the brief Interview for Mental Status. R112's MDS assessment was not completed until 03/17/23. Resident #20 (R20): Review of the medical record reflected R20 was admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included unspecified fracture of lower end of right radius and ulna, muscle weakness, history of falling and Parkinson's Disease. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date…

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 the accurate coding of Minimum Data Set (MDS) assessments for six (Resident #5, #16, #28, #53, #61 and #68) of 22 reviewed for MDS, resulting in the potential for inaccurate care plans and unmet care needs. Findings include: Resident #53 (R53): Review of the medical record reflected R53 admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included major depressive disorder and schizoaffective disorder, bipolar type and depressive type. The quarterly MDS, with an Assessment Reference Date (ARD) of 5/8/23, reflected all areas of Section C (Cognitive Patterns) were marked as not being assessed or no information available on 5/31/23. Section D (Mood) and Section E (Behavior) of the same MDS were marked as not assessed on 5/31/23. Section Q (Participation in Assessment and Goal Setting) was marked as not assessed on 5/31/23. The MDS was completed on 6/2/23. Review of R53's medical record reflected an OBRA Level II…

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 resident food stored in the 400 unit refrigerator, where 10 residents resided, had refrigerator temperatures documented, the expiration dates of food, and resident's names documented on food items, resulting in the potential for food borne illnesses. Findings Included: In an observation on 7/13/2023 at 1:05 PM, with Licensed Practical Nurse (LPN) S in the 400 hall resident food refrigerator revealed that the refrigerator temperature was not recorded for the dates of 7/11 and 7/12/2023. Additionally, the resident food refrigerator did not have a thermometer in it, and therefore the temperature of the refrigerator on inspection was not able to be determined. It was also observed in the resident food refrigerator on the 400 hall a container that had two slices of cheese cake in it was opened, had no resident's name, no date of expiration, or when opened recorded on the container. A bottle that contained a drink was also observed to be opened, and had no resident's name, or date that it was opened recorded…

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 advanced written notice prior to a room change for one Residents (#68), of two residents reviewed for room changes. This deficient practice resulted in the potential for increased anxiety, misunderstanding of the reasons for the room change, and the lack of opportunity for resident to ask questions or express concerns. Findings include: Resident #68 (R68) Review of the medical record reflected R68 admitted to the facility on [DATE] with diagnoses that included personal history of traumatic brain injury, abnormal posture, major depressive disorder, and dysphagia (difficulty swallowing). The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/10/23, reflected all areas of Section C (Cognitive Patterns) were marked as not being assessed or no information available on 5/5/23. In an observation and interview on 07/10/23 at 1:04 PM, R68 was seated in his wheelchair watching television in his room. R68 reported…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation Pertains To Intake #'s MI00136714 and MI00136757 Based on observation, interview and record review, the facility failed to ensure the protection of residents and thoroughly investigate allegations of abuse for three (Resident #110, R#111 and #112) of four reviewed for abuse, resulting in the potential for further abuse to occur and allegations of abuse not being thoroughly investigated. Findings include: Resident #110 According to the clinical record including the Minimum Data Set (MDS) [DATE] R110 was a [AGE] year old female admitted to the facility on [DATE] with diagnosis that included end stage renal disease, heart failure and anxiety. R110 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Of note, On February 6, 2023, R110 was sent to the hospital after a medical emergency while at dialysis and never returned to the facility. Resident #111 According to the medical record including the Minimum Data Set (MDS) dated [DATE], Resident 111 (R111) was a [AGE]…

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 necessary information was communicated/provided to the receiving facility upon discharge for two (Resident #75 and #107) of two reviewed for hospital transfer, resulting in the potential for unmet care needs and/or residents to not receive the necessary services to ensure a safe and effective transition of care. Findings include. Resident #75 (R75) Review of the medical record reflected R75 was an initial admission to the facility on [DATE]. Diagnoses of renal disease, diabetes, high blood pressure and depression. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/04/2023, revealed R75 did not have a Brief Interview of Mental Status (BIMS), screening for Sections C for cognitive pattern and section D for mood. These sections were left blank. Record review revealed R75 was hospitalized from [DATE] through 04/17/23 for Acute Kidney Injury (AKI), UTI ruled out. During an interview on 07/12/23 at 11:10 AM, Minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00136858. Based on interview and record review, the facility failed to provide a written notice of transfer or discharge for one (Resident #11) of three reviewed for transfer/discharge, resulting in the potential for the Resident not being informed of the reason for transfer and their appeal rights. Findings include: Review of the medical record reflected R11 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included anxiety, major depressive disorder, hemiplegia/hemiparesis following cerebral infarction and diabetes. R11 did not reside in the facility at the time of the survey. A Progress Note for 6/29/23 at 10:15 PM reflected R11 was transferred to another facility [psychiatric facility] and report was called to the receiving Registered Nurse (RN). During an interview on 07/13/23 at 8:38 AM, Director of Nursing (DON) B reported the discharge (transfer) process was to send a face sheet, code status, medication administration record (MAR) and Power…

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 MI00136858. Based on interview and record review, the facility failed to provide a bed hold policy upon transfer for one (Resident #11) of three reviewed for transfer/discharge, resulting in the potential for the Resident not being informed of the facility's bed hold policy. Findings include: Review of the medical record reflected R11 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included anxiety, major depressive disorder, hemiplegia/hemiparesis following cerebral infarction and diabetes. R11 did not reside in the facility at the time of the survey. A Progress Note for 6/29/23 at 10:15 PM reflected R11 was transferred to another facility [psychiatric facility] and report was called to the receiving Registered Nurse (RN). During an interview on 07/13/23 at 8:38 AM, Director of Nursing (DON) B reported the discharge (transfer) process was to send a face sheet, code status, medication administration record (MAR) and Power of Attorney paperwork, if…

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 complete quarterly Minimum Data Set (MDS) assessments timely for two (Resident #53 and #61) of 22 reviewed for MDS assessments, resulting in the potential for unrecognized and unmet care needs in a current facility census of 104 residents. Findings include: Resident #53 (R53): Review of the medical record reflected R53 admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included major depressive disorder and schizoaffective disorder, bipolar type and depressive type. The quarterly MDS, with an Assessment Reference Date (ARD) of 5/8/23, reflected all areas of Section C (Cognitive Patterns) were marked as not being assessed or no information available on 5/31/23. Section D (Mood) and Section E (Behavior) of the same MDS were marked as not assessed on 5/31/23. Section Q (Participation in Assessment and Goal Setting) was marked as not assessed on 5/31/23. The same MDS was completed on 6/2/23, which was more than 14 days after…

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 develop and implement a comprehensive Care Plan for one (Resident #108) of 22 reviewed, resulting in the potential for unmet care needs. Findings Include: Resident #108 Review of the medical record reflected Resident #108 (R108) admitted to the facility on [DATE] with diagnoses that included heart failure, atrial fibrillation (irregular heart rate) and type two diabetes mellitus. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/13/23, reflected R108 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R108 was no longer admitted to the facility. Review of R108's medication list revealed she was admitted to the facility on Warfarin (an anticoagulant medication), with a start date of 4/11/23. Review of R108's Care Plan revealed R108 did not have an anticoagulant care plan initiated for the duration of her admission at the facility. In an interview 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 observation, interview and record review, the facility failed to revise a Care Plan for one resident (Resident #20) and failed to ensure one resident (Resident #82) had Care Conferences resulting in the potential for unmet needs. Findings include: Resident #82 Review of the medical record reflected Resident #82 (R82) admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease, muscle weakness, and anemia. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/19/23, reflected R98 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS revealed R82 required supervision to ambulate and use the toilet. In an observation and interview on 7/10/23 at 12:46 PM, R82 was in his room, seated in a wheelchair. R82 appeared to understand and answer questions without difficulty. R82 reported that he lived about a mile from the facility. R82 expressed that he does not want to be at 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 observation, interview and record review, the facility failed to effectively implement discharge planning for one of two residents (Resident #82) reviewed for discharge planning according to resident specific goals resulting in frustration. Findings include: Resident #82 Review of the medical record reflected Resident #82 (R82) admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease, muscle weakness, and anemia. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/19/23, reflected R98 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS revealed R82 required supervision to ambulate and use the toilet. In an observation and interview on 7/10/23 at 12:46 PM, R82 was in his room, seated in a wheelchair. R82 appeared to understand and answer questions without difficulty. R82 reported that he lived about a mile from the facility. R82 expressed that he does not want to be at 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 record review the facility failed to ensure one out of four residents (Resident #47), who had a Foley catheter (tube inserted into the bladder to drain urine), was appropraitley assessed for the need to continue or discontinue the use of the catheter, resulting in the potential for complication and/or infections. Findings Include: On 7/11/2023 at 11:04 AM, Resident #47 (R47) was observed to have a Foley catheter in place. R47 was asked if she knew why she had the catheter. R47 stated no and wanted the catheter removed. Review of R47's medical diagnosis revealed R47 had a neuromuscular dysfunction (lack of bladder control) of the bladder. Record review of a progress note dated 4/26/2022 revealed, Note Text: Guests indwelling catheter will remain in place r/t (related to) dx (diagnosis) of neurogenic bladder. Continue with current plan of care. Review of R47's care plans that were in place revealed, (R47) is at risk for urinary tract infection and catheter-related trauma r/t indwelling foley catheter . Guest has dx of neuromuscular dysfunction 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 provide medically related social services pertaining to discharge planning and room changes (Resident #68) and care conferences (Resident #82) for two of 22 reviewed, resulting in the potential for residents not to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #68 Review of the medical record reflected R68 admitted to the facility on [DATE] with diagnoses that included personal history of traumatic brain injury, abnormal posture, major depressive disorder, and dysphagia (difficulty swallowing). The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/10/23, reflected all areas of Section C (Cognitive Patterns) were marked as not being assessed or no information available on 5/5/23. In an observation and interview on 07/10/23 at 1:04 PM, R68 was seated in his wheelchair watching television in his room. R68 reported that he had resided at 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 interview and record review, the facility failed to ensure timely follow-up for identified pharmacy medication regimen review irregularities for one (Resident #61) of five reviewed for unnecessary medications, resulting in the potential for unnecessary medications and adverse reactions. Findings include: Review of the medical record reflected Resident #61 (R61) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included bipolar disorder, dementia, schizophrenia, anxiety disorder, delusional disorders and major depressive disorder. The Quarterly MDS, with an ARD of 4/29/23, reflected Sections C (Cognitive Patterns), D (Mood) and Q (Participation in Assessment and Goal Setting) were not assessed, as marked on 5/9/23. Section E was not assessed for behavioral symptoms, rejection of care or wandering. R61's Physician's Orders reflected trazodone (medication used to treat depression) was decreased from 50 milligrams (mg) at bedtime to 25 mg at bedtime, with a start date of 9/21/22.…

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 one out of five residents (Resident #60) had an indication for the use of an antibiotic, resulting in the potential for the over use of antibiotics. Findings Included: Resident #60 Per the facility face sheet R60 was admitted to the facility on [DATE]. Review of a urinalysis (urine test to identify infections) dated 7/10/2023, revealed R60 was potentially positive for an urinary tract infection (UIT). Review of an urine culture and sensitivity (C&S) (second part of urine test that reveals what organism was causing the infection, and what antibiotic would will be effective for treating the UTI) revealed that the results were completed on 7/11/2023, and indicated mixed flora (meaning the sample had been contaminated and a new sample was required). Therefore, no organism nor antibiotic was identified on the C&S report. Record review of Physician's orders dated 7/11/2023, revealed that Cephalexin (antibiotic) Capsule 500 MG (milligrams) was ordered…

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 the medication regimen was free of unnecessary psychotropic medications for one (Resident #61) of five reviewed for unnecessary medications, resulting in the potential for unnecessary medications and adverse reactions. Findings include: Review of the medical record reflected Resident #61 (R61) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included bipolar disorder, dementia, schizophrenia, anxiety disorder, delusional disorders and major depressive disorder. The Quarterly MDS, with an ARD of 4/29/23, reflected Sections C (Cognitive Patterns), D (Mood) and Q (Participation in Assessment and Goal Setting) were not assessed, as marked on 5/9/23. Section E was not assessed for behavioral symptoms, rejection of care or wandering. R61's Physician's Orders reflected trazodone (medication used to treat depression) was decreased from 50 milligrams (mg) at bedtime to 25 mg at bedtime, with a start date of 9/21/22. The 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.

Based on observation, interview, and record review the facility failed to ensure expired medications were disposed of, and a refrigerator for medication storage had temperatures documented, resulting in the potential for administration of expired and/or ineffective medications. Finding Included: During a medication storage observation on 7/13/2023 at 2:13 PM, with Licensed Practical Nurse (LPN) Son the 400 rehab hall, it was revealed that the refrigerator where medications were stored did not had the temperature documented for the date of 7/12/23. Further observation with LPN S of the same refrigerator revealed two boxes of influenza vaccination were stored in the refrigerator with other medication, and each box contained 10 pre-filled syringes that had expired on 6/30/2023. In an interview on 7/13/2023 at 2:22 PM, Director of Nursing (DON) B stated that her expectation was that the nurses passing the medications check and toss the expired medications, and that the Unit Managers go through the medication storage weekly and check for expired meds. Per the facility policy 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.