Caretel Inns of Linden

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Code Status was accurately documented and accessible in the medical record Care Plan for one resident (#21) of 1 reviewed for Advance Directives, resulting in the potential for miscommunication of code status which could lead to a lack of appropriate interventions for care.Resident #21 Advance Directives NotesA record review of the Face sheet and electronic medical record indicated Resident #21 was admitted to the facility on [DATE] with diagnoses Dementia mood disturbance with anxiety, and weakness. Per the progress notes, Resident #21 was receiving Hospice services.A review of the Face sheet for Resident #21 identified, Code Status: (Advance Directives)- Code Status: DNR. A review of the Documents section of the electronic medical record identified an assessment form titled, Code Status Form for Resident #21. Do-Not-Resuscitate was checked and further provided, Patient Advocate Consent/Guardian Consent: I authorize that in the event 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 PASARR assessments were completed yearly and posted into the residents' clinical record for two residents (R#7 and R#10) of 3 residents reviewed for coordination of PASSAR and Assessments.Findings Include:On 9/4/25 at 2:30 PM, a review of R7's Pre-admission Screening and Resident Review (PASARR) was conducted. It revealed that R7 did not have one on file for 2025. The last PASARR in R7's File was dated7/3/2024. No other PASSAR Forms were found in R7's Electronic Medical Record. On 09/04/2025 2:58 PM, R10's PASARR was reviewed. An outdated Level I PASARR was found dated 12/20/2021. Another outdated PASSAR Level I and Level II dated August 16, 2024, was found. There was no assessment dated 2025 posted. The social worker (SW) was interviewed on 09/04/25 at 3:00 PM and stated that, according to the facility's policy, the PASARR Assessment must be done within 25 days from admission and then annually. She admitted that she did not have the PASARR…

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 a wound was assessed with appropriate treatment for one resident (R6) and hospice orders were in place for two residents (R60 and R65) of three residents reviewed for quality of care, resulting in missing treatments for a wound and the absence of hospice treatment orders.Findings include: Resident #6 Skin Conditions A record review of the Face sheet and electronic medical record indicated Resident #6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Diabetes, dementia, chronic pain, arthritis, depression, and anxiety. The resident had moderate cognitive decline and needed some assistance with care. On [DATE] at 11:21 AM, Resident #6 was observed sitting on the side of the bed. She had a red, scabbed area on the tip of her nose, and a red, raw area under her lip. The resident said she rubbed them and began rubbing them. On [DATE] at 9:32 AM, Resident #6 was observed resting in bed. She 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 provide appropriate supervision and revise the care plan to prevent falls for one resident (Resident #7) of three residents reviewed for falls and accidents. Findings include:Resident #7 (R7)According to the review of Resident #7's clinical record, on 9/3/2023 at 1:30 PM, R7 was [AGE] years old, admitted to the facility on [DATE], with the primary diagnosis of generalized muscle weakness and difficulty walking, dementia with obsessive compulsive disorders, mixed anxiety disorders, in addition to other diagnoses. and major depressions in addition to other diagnoses.Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 05/15. A score of zero to 07 means that the person has severe cognitive impairment. R7's Section GG of the same assessment date, 7/24/2025, indicated that R7 was dependent on all ADLs (hygiene, showers, and dressing) except for eating. R7 required supervision or touching assistance…

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 consents were signed and behavior monitoring was provided for psychotropic medications for two residents (R13, R60) of two residents sampled for psychotropic medications, resulting in the lack of consents and behavior monitoring.Findings include: Resident #13 R13 is [AGE] years old and admitted the facility most recently on 08/23/2025, with diagnoses that include schizophrenia, major depressive disorder, anxiety disorder and dementia. On 09/05/2025 at 02:35PM, record review revealed that R13 has physician's orders for Fluoxetine 20mg (anti-depressant) and Risperdal 1mg (anti-psychotic). On 09/05/2025 at 02:40PM, record review revealed there was no physician's order for behavior monitoring. Record review also revealed a task (area where the Certified Nursing Assistants chart) titled Behavior Monitoring and Interventions. There were two entries noted, one on 8/18/25 and 8/24/25. No other entries had been made for R13. On 09/05/2025 at 2:42PM, 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 interview and record review the facility failed to ensure resistance patterns of organisms were identified and reviewed in the antibiotic stewardship meeting, resulting in the potential exposure of infection and ineffective antibiotic use for all 52 residents in the facility. Facility Infection Control On 9/09/2025 at 10:48 AM during an interview with IP/Infection Preventionist H, she said she was new to the role. She started in December 2024 and completed the CDC/Center for Disease Control and Preventions Certificate training course for Long Term Care/LTC on 4/6/2025. When asked to review the Infection Surveillance data for the prior year, September 2024 through September 2025, The IP H said she began collecting Infection Surveillance in April 2025, and surveillance prior to that was completed by someone else. During the interview with IP H on 9/9/2025 at 10:48 AM, there was identified Infection Surveillance for July 2025 with line listings, analysis and reporting completed. There was no additional monthly Infection Surveillance for the year with line listings, analysis…

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 residents were 1) Consistently assessed for Influenza and Pneumococcal vaccinations on admission, per Standards of Practice, 2) Provided an educational vaccination information statement for each vaccination, and 3) Documented vaccination information in the residents' medical record, which could potentially affect all residents, including Residents #27, #30, #68 and #70, reviewed for infections, resulting in the potential for exposure to Influenza and Pneumococcal disease, and severe illness. Findings include:FacilityInfection Control On 9/09/2025 at 11:25 AM, during an interview with Infection Preventionist/IP H, she was asked about resident vaccinations for Influenza/FLU and Pneumonia. She said she was currently working with a local pharmacy to implement a vaccination clinic in October 2025 to provide FLU, Pneumonia and Covid vaccinations for the residents. She said resident vaccinations were assessed on admission by the Admissions Coordinator N. The IP H said she thought the residents' received education about 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 residents were 1) Consistently assessed for Covid-19, per Standards of Practice, 2) Provided an educational vaccination information sheet for each vaccination, and 3) Documented vaccination information in the residents' medical record, which could potentially effecting all residents, including Residents #27, #30, #68 and #70, reviewed for vaccinations, resulting in the potential for exposure to Covid-19 and severe illness. FacilityInfection Control On 9/09/2025 at 11:25 AM, during an interview with Infection Preventionist/IP H, she was asked about resident vaccinations for Influenza/FLU and Pneumonia. She said she was currently working with a local pharmacy to implement a vaccination clinic in October 2025 to provide FLU, Pneumonia and Covid vaccinations for the residents. She said resident vaccinations were assessed on admission by the Admissions Coordinator N. The IP H said she thought the residents' received education about the vaccinations via a Vaccine Information Statement/VIS for each specific…

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 Numbers MI00149339 and MI00149518. Based on observation, interview, and record review the facility failed to provide a clean, comfortable and home like environment by failing to ensure that residents' rooms were clean, for two resident's (#1 and #5) and there was enough linen to accommodate residents' needs, resulting in an unclean physical environment, resident dissatisfaction and complaints regarding the lack of cleanliness and linen. Findings Include: Resident #1: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #1 was admitted to the facility on [DATE] with diagnoses: Dementia, Schizophrenia, diabetes, COPD, Cognitive communication deficit, Depression, and a history of falls. Hospice care began 12/16/2024. The MDS assessment dated [DATE] indicated Resident #1 had full cognitive abilities with a Brief Interview for Mental Status score of 14/15 and needed assistance with all care. During a tour of the facility on 1/22/2025 at 9:40 AM,…

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 Number MI00148245. Based on observation, interview, and record review, the facility failed to ensure that the bladder scanner for the entire facility was in good repair to clinically assess residents diagnosed with urinary retention for one resident (Resident #500) of 3 residents reviewed with indwelling catheters, resulting in urinary retention, severe abdominal pain and the likelihood of further complications and delayed urinary care needs. Findings include: Resident #500 (R500): According to the clinical record review on 12/3/24 at 1:30 PM. R500 was discharged to home on [DATE]. R500 was [AGE] years old and admitted to the Administrator on 11/11/24, with the diagnosis of Urinary Retention, Elevated Prostate Specific Antigen (PSA), Chronic Kidney Disease Stage 3, and Chronic Respiratory Failure (CRF) in addition to other diagnoses. Further clinical record review conducted on 12/3/24 at 1:30 PM revealed the following: On 11/16/24 at 1:24 AM, according to the eMar-(electronic…

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 Resident #20: A review of Resident #20's medical record revealed an admission on [DATE] with diagnoses that included dementia, chronic obstructive pulmonary disease, weakness and difficulty in walking. A review of the Minimum Data Set assessment revealed the Resident has severely impaired cognition and needed substantial/maximal assistance with most mobility, upper body and lower body dressing and partial/moderate assistance with oral hygiene. A review of Section B-Hearing, Speech, and Vision, the Resident was documented as makes self-understood with ability to express ideas and wants and understood others with clear comprehension. On 8/21/24 at 10:45 AM, an observation was made in Resident #20's room of Resident #20 lying in bed, with a sheet over her and head of bed slightly elevated. The Resident did not engage in conversation and was able to readjust herself in bed. An observation was made of Resident #20's call light positioned on the floor by her bed and was not secured to the bed or in reach for the…

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

This Citation pertains to Intake Number MI00133932. Based on the interview and record review, the facility failed to maintain an annual-based competencies and education of 12.0 hours for three Certified Nursing Assistants (CNA) reviewed for their annual-based competencies. Findings include: FACILITY Sufficient and Competent Nurse Staffing On 08/22/24 at 01:02 PM, a request for the 12 hours annual competencies was requested from the facility Human Resources office. Three Certified Nursing Assistants (CNA) names were selected for their credentials and yearly competency review. A review of the CNA files revealed: 1. CNA N was hired on 9/12/2013. CNA N's in-service training record did not quantify the number of hours of the in-services and training attended. The topics/lessons were listed dated 9/12/23-9/13/23, but the hours, the competency assessments, and the evaluation were not attached in the checklist. The lessons listed were not validated by the instructor. There was no proof of counter demonstration or post tests on the topics that required testing validation. 2. CNA P was hired…

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 that a medication cart and a treatment cart were secured, ensure proper labeling of medication and ensure that topical treatments were not stored with oral medications, of two medication carts and one medication room reviewed for medication storage and labeling, resulting in the potential of medications administered with decreased efficacy, improper labeling of medications, ingestion of medications and drug diversion. Findings include: On 8/20/24 at 9:10 AM, an observation was made of the treatment cart that was positioned in the 300-hall entrance and dining area entrance, that was unlocked and not under supervision of a nurse. There was no nurse in the vicinity of the treatment cart and no nurse in the 300 hall or in the dining area. A staff member comes by, and they are asked to get the nurse for the 300 hall. Nurse K approached the treatment cart, and the contents were reviewed with the Nurse. The treatment cart included supplies for dressing changes and treatments and prescription topical…

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 Numbers MI00143075 and MI00144896. Based on observation, interview and record review, the facility failed to ensure a safe and sanitary environment in resident care areas and in the kitchen area. This deficient practice has the potential to affect all 55 residents who reside in the building, resulting in the potential for injury, dissatisfaction of living conditions and foodborne illness. Findings include: On 8/21/24 at 10:45 AM, an observation was made in room [ROOM NUMBER] of an open door near Bed B by the window. The door was opened to a furnace and piping that was just inside the door. Housekeeping Staff P was asked about the opened door. The Housekeeping Staff was unsure how long the door had been opened and indicated it should not be left open. Upon pushing on the door, the door did not move and was not able to be shut. The Housekeeping Staff indicated they would call Maintenance Staff. On 8/21/24 at 10:58 AM, the Administrator responded to the Housekeeping Staff request…

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 Number MI00140086. Based on interview and record review, the facility failed to protect Resident #59's right to be free from sexual abuse by Resident #309, resulting in Resident #309 found alone in Resident #59's room with his hand down her pants. Findings Include: Abuse Resident #59: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #59 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Dementia, hypothyroidism and anemia. The MDS dated [DATE] revealed Resident #59 had severe cognitive loss with a Brief Interview for Mental Status (BIMS) score of 1/15. The MDS also indicated the resident needed supervision with mobility. Resident #309: A record review of the Face sheet and MDS assessment indicated Resident #309 was admitted to the facility on [DATE] with diagnoses: history of a stroke, weakness, history of prostate cancer, diabetes, kidney disease, anxiety, depression and hypertension. 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.

This Citation pertains to Intake Number MI00136526. Based on interview, and record review, the facility failed to retain documentation regarding an injury after a fall investigation was completed and that the documentation was retained for one resident (Resident #56) of three residents reviewed for incident report investigations and retention of documentation, resulting in missed opportunities to prevent potential abuse or neglect, implement corrective measures and appropriate interventions and prevent further harm to occur. Findings include: Resident #56 (R56): 08/20/24 03:16 PM, a Facility Reported Incident submitted to the State Agency was reviewed. The surveyor requested the investigation file of R56 reported Fall Incident dated 4/6/2023. The Electronic Medical Record (EMR) Incident/Accident (I/A) Report dated 4/6/23 was incomplete; boxes were not checked, and no pertinent information was entered in the incident report documentation. According to the Fall Incident Report dated 4/6/23 at midnight: Incident Description: Patient observed on the floor by CNA (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 observation, interview and record review, the facility failed to develop and implement a person-centered baseline care plan to guide the care provided to two residents (Resident #307 and Resident #308) of 34 residents reviewed for care plans, resulting in the failure to provide instructions to the staff for effective and person -centered care to promote well-being and provide an appropriate diet for Resident #307 and dialysis catheter care for Resident #308 . Findings Include: Resident #307: Nutrition A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #307 was admitted to the facility on [DATE] with diagnoses: Cancer of the lung, liver and bone; Pulmonary edema, respiratory failure, pneumonia, and glaucoma. On 8/19/2024 at 4:23 PM, during a tour of the facility, Resident #307 was observed lying in bed with family at the bedside. The resident's family said they had to speak with someone from dietary as the resident was unable to chew, and he needed a different…

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 develop and implement a comprehensive resident-centered care plan for Resident #23's use and maintenance of their CPAP machine for one resident (Resident #23) of 15 residents reviewed for comprehensive care planning, resulting in the potential for unmet care needs. Findings include: Resident #23: A review of Resident #23's medical record revealed an admission into the facility on 5/6/24 with diagnoses that included diabetes, weakness, and obstructive sleep apnea. A review of the Minimum Data Set assessment, dated 8/9/24, revealed a Brief Interview of Mental Status score of 12/15 that indicated moderate cognitive impairment and needed supervision or touching assistance with toileting hygiene and most mobility, and partial/moderate assistance with bathing self and lower body dressing. On 8/19/24 at 1:17 PM, an observation was made of Resident #23 sitting in a wheelchair in their room. The Resident was interviewed, answered questions and engaged in conversation. An observation was made of a CPAP (continuous…

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 implement a restorative nursing program for one resident (Resident #25), of three residents reviewed for limited range of motion, resulting in the potential for decline in independence of self-care, physical ability, and overall decreased level of functioning. Findings Include: Resident #25: A review of Resident #25's medical record revealed an admission into the facility on 7/12/19 and re-admission on [DATE] with diagnoses that included kyphosis and scoliosis, bilateral foot drop, weakness, difficulty in walking, chronic pain, muscle wasting and atrophy and need for assistance with personal care. A review of the Minimum Data Assessment revealed the resident was cognitively intact, had impairment on both lower extremities, was independent with eating and oral hygiene, needed partial/moderate assistance with toileting hygiene, bathing, needed substantial/maximal assistance with lower body dressing, and personal hygiene, sit to lying, lying…

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 interventions were enacted to promote nutrition for two residents (Resident #307 and Resident #308) of 4 residents reviewed for food or nutrition, resulting in Resident #307 and Resident #308 lacking timely assessments and monitoring to aid in identification of nutritional needs. Findings Include: Resident #307: Nutrition A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #307 was admitted to the facility on [DATE] with diagnoses: Cancer of the lung, liver and bone; Pulmonary edema, respiratory failure, pneumonia, and glaucoma. On 8/19/2024 at 4:23 PM, during a tour of the facility, Resident #307 was observed lying in bed with family at the bedside. The resident's family said they had to speak with someone from dietary as the resident was unable to chew, and he needed a different textured diet. He had been having difficulty since admission with eating. A review of the Tasks tab in the electronic…

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 physician's orders and facility policy were followed for enteral feeding for one resident (Resident #39) of one resident reviewed for tube feeding, resulting in the resident not receiving the total ordered amount of enteral feeding and a lack of documentation of the amount of enteral feeding infused. Findings include: Resident #39 (R39): Resident #39 is [AGE] years old and most recently admitted to the facility on [DATE] with diagnoses that include dysphagia, cerebral infarction, traumatic brain injury and pressure ulcers. R39 has a brief interview for mental status score (BIMS) of 6, indicating severe cognitive impairment and R39 is currently receiving hospice services. On 08/19/24 at 11:13 AM, observation revealed the enteral feeding pump of R39 infusing at 50ml/hr. On 08/19/24 at 11:20 AM, record review revealed a physician's order for enteral feeding that read, Enteral Feed Order, one time a day, start Osmolite 1.5 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 observation, interview and record review, the facility failed to ensure proper storage, cleaning and labeling of oxygen/respiratory equipment for Resident #9, Resident #23, and Resident #34, of four residents reviewed for oxygen and respiratory care, resulting in the potential of respiratory infection and deterioration in health and wellbeing. Findings include: Resident #23: A review of Resident #23's medical record revealed an admission into the facility on 5/6/24 with diagnoses that included diabetes, weakness, and obstructive sleep apnea. A review of the Minimum Data Set assessment, dated 8/9/24, revealed a Brief Interview of Mental Status score of 12/15 that indicated moderate cognitive impairment and needed supervision or touching assistance with toileting hygiene and most mobility, and partial/moderate assistance with bathing self and lower body dressing. On 8/19/24 at 1:17 PM, an observation was made of Resident #23 sitting in a wheelchair in their room. The Resident was interviewed, answered…

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 assess, monitor, ensure availability of pain medications and provide pain management for one resident (Resident #307) of 2 residents reviewed for pain management, resulting in the resident's verbalizations of unrelieved pain, frustration and helplessness. Findings Include: Resident #307: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #307 was admitted to the facility on [DATE] with diagnoses: Cancer of the lung, liver and bone; Pulmonary edema, respiratory failure, pneumonia, and glaucoma. On 8/19/2024 at 4:23 PM, during a tour of the facility, Resident #307 was observed lying in bed with family at the bedside. The resident's family said he was having pain and was not receiving pain medicine that helped. They said the resident also had a cough and wanted some cough syrup. They said he had pneumonia and received it in the hospital. They said they were told the doctor ordered it, but they were waiting for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure dialysis communication forms were complete and included pre-dialysis and post-dialysis assessment, including location and assessment of the dialysis access site, for one resident (Resident #308) of 2 residents reviewed for Dialysis care, resulting in the potential for a decline in condition and the inability for a prompt response to care needs. Findings Include: Resident #308: Dialysis A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #308 was admitted to the facility on [DATE] with diagnoses: Diabetes, chronic kidney disease, requires renal dialysis, Myelodysplastic syndrome, anemia, heart disease and peripheral vascular disease. On 8/20/2024 at 8:55 AM, Resident #308 was observed lying in bed, awake. He said he received dialysis treatments on Mondays, Wednesdays and Fridays in the afternoon. A review of the physician orders identified the following: Hemodialysis . every M-W-F with chair time 3 pm, start…

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 that clinical staff postings were 1.) Completed and available for review for multiple days from January 2024- August 2024, including the months of January 2024, February 2024 and July 2024 and 2.) The clinical staff posting was accurate, resulting in the inability for residents and visitors to know what clinical staff were working on those days. Findings Include: FACILITY Sufficient and Competent Nurse Staffing On 8/22/2024 at 9:40 AM, during an interview with the Director of Nursing/DON about nurse staffing, she said the Clinical Staff posting document (Staffing Report) was completed daily by the Scheduler D and posted on the wall by the nurses' desk. The document was used to identify how many RN's (Registered Nurses), LPN's (Licensed Practical Nurses) and CAN's (Certified Nursing Assistants) were staffed on that day on each shift. The document identified how many hours were worked for an RN, LPN and CAN's and listed Total Hours per shift) and also included the Date and Resident Census (number 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 ensure that medications were available and administered timely as ordered for two (2) residents, Resident #30 and Resident #103, of nine (9) residents reviewed for medications, resulting in R30 not receiving her Lidocaine 4% Patch topically and R103 was not given her Lantus insulin injection resulting in the potential for adverse reactions or worsening of diabetes condition for R103 and potential for increased in pain and discomfort for R30 related to delayed or interruption of the medication. Findings include: During medication administration observation conducted on 8/20/24 and 8/21/24, There was a total of 32 opportunities observed in halls 100, 200, and 300. Two medication errors were observed out of 32 opportunities. 2 medications were omitted because they were unavailable for the residents. As a result, the facility had a medication error rate of 6.25%. During the medication administration observation conducted on 8/21/24 at 09:00 AM, Nurse Kprepared R30's morning medication due at 10:00 AM. When Nurse…

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 obtain consent for the use of an antipsychotic medication for one resident (Resident #303) of 5 residents reviewed for unnecessary medications, resulting in the potential for unidentified adverse effects and the receipt of an unnecessary medication. Findings Include: Unnecessary Medications, Psychotropic Medications, and Medication Regimen Review Resident #303: A record review of the Face sheet, assessments and progress notes, indicated Resident #303 was readmitted to the facility on [DATE] with diagnoses: Alzheimer's dementia, depression, anxiety, heart failure, atrial fibrillation, anemia, hypothyroidism and a history of falls. The Minimum Data Set (MDS) assessment was not yet completed. A review of the electronic medical record revealed Resident #303 was a prior resident at the facility between 10/23/2023 and 12/21/2023. On 12/21/2023, the resident discharged to an Assisted Living facility. The resident readmitted to the Long Term Care facility on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Number MI00133932. Based on observation, Interview, and record review, the facility failed to ensure a medication error rate of less than five percent (5%) when two medications were omitted for Resident #30 (R30)when the Lidocaine 4% patch was not available and for Resident #103 (R103) when a scheduled Lantus insulin injection was not available from a total of 32 opportunities resulting in a medical administration error rate of 6.25% with the potential for adverse reactions, increased in pain and suffering, and exacerbation of conditions related to omission of the medication or medication not given timely. Findings include: FACILITY Medication administration observation was conducted on 8/20/24 and 8/21/24. A total of 32 opportunities were observed at Halls 100, 200, and 300. Two medication errors were observed out of 32 opportunities, resulting in a 6.25% (over 5%) error rate. During the medication administration observation conducted on 8/21/24 at 09:00 AM, Nurse K prepared…

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 prevent significant medication errors for one resident (Resident #103) of 9 residents reviewed for medication errors, resulting in the potential for serious adverse effects for insulin omission and pain control management as ordered by the physician, and decline or worsening of medical condition. Findings include: Resident 103 (R103): A review of the Electronic Medical Record on 8/21/24 at 11:00 AM revealed that R103 was admitted to the facility on [DATE] with the diagnosis of difficulty in walking with repeated falls, diabetes mellitus, mild protein calorie malnutrition, essential hypertension, and vertebrogenic low back pain in addition to other diagnoses. R103's order for Lantus Solution 100 unit/ ML (Generic: insulin Glargine) was to give 10 units subcutaneously one time daily every day. TAR revealed a schedule to administer at 10:00 AM daily. On 08/21/24 09:29 AM, Nurse K was preparing R103's medication due at 10:00 AM. Nurse K…

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 proper communication and documentation of hospice services for one resident (Resident #39) of two residents reviewed for hospice services, resulting in the absence of progress notes in the medical record. Findings include: Resident #39: Resident #39 is [AGE] years old and most recently admitted to the facility on [DATE] with diagnoses that include dysphagia, cerebral infarction, traumatic brain injury and pressure ulcers. R39 has a brief interview for mental status score (BIMS) of 6, indicating severe cognitive impairment and R39 is currently receiving hospice services. On 08/20/24 at 12:50 PM, record review revealed that the most recent hospice note in the electronic medical record (EMR) was from 06/03/24. R39 admitted to hospice care on 04/23/24. On 08/20/24 at 12:58 PM, an interview was conducted with the medical records (MR) 'C'. MR 'C' was asked when the most recent hospice note was from, for R39. MR 'C' stated the most recent note was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that there was a process for obtaining Resident Code Status: that it was assessed, documented and accessible in the medical record prior to obtaining a physician's order for Code Status for 6 residents (Residents #2, #4, #13, #26, #50 and #112) of 8 residents reviewed for Advance Directives and Code Status, resulting in the potential for the resident's lack of informed knowledge related to options for code status and miscommunication of code status which could lead to a lack of appropriate interventions for care. Findings Include: Resident #2: Advance Directives A chart review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #2 indicated admission to the facility on [DATE] and readmission on [DATE] with diagnoses: Multiple sclerosis, anxiety, depression weakness, glaucoma, retinal detachment, hypertension, chronic sinusitis. The MDS assessment dated [DATE] revealed the resident had mild cognitive loss with a Brief Interview…

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 review and revise care plans with resident changes to ensure that interventions necessary for care and services were provided for 5 resident (Residents #2, #4, #44, #51, and #164) of 23 residents reviewed, resulting in the potential for unmet care needs. Findings Include: Resident #2: Accidents A chart review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #2 indicated admission to the facility on 3/21/2017 and readmission on [DATE] with diagnoses: Multiple sclerosis, anxiety, depression weakness, glaucoma, retinal detachment, hypertension, chronic sinusitis. The MDS assessment dated [DATE] revealed the resident had mild cognitive loss with a Brief Interview for Mental Status (BIMS) score of 12/15 and needed some assistance with all care. A record review of the Incident and Accident Reports, indicated Resident #2 fell in the facility on 3/25/2023 and 6/13/2023. On 6/13/2023 the resident suffered injuries to his scalp and 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility 1) Failed to label medications appropriately, 2) Discard expired medication and medical supplies, and 3) Ensure that a treatment cart that held prescriptions medication for skin and wounds was properly secured, for one of two medication carts, one of one medication rooms and one of two treatment carts reviewed for labeling and storage of medication, resulting in medical procedures being performed with expired medical equipment and the administration of medications with decreased efficacy. Findings include: On [DATE] at 3:45 PM, an observation was made of the 200-hall medication cart with Nurse J. The following observations were made: -Glucose monitor accucheck solution, for monitoring function of the glucose monitor, was not dated with an open date on the bottles of solution. -An open bottle of Dorzolamide eye drops with no date when the bottle was opened. -An open bottle of Timolol eye drops that was not labeled with an open date. -An open bottle…

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 1) Failed to ensure that they provided Covid testing with signs and symptoms of infection for one resident (Resident #56); 2) Failed to ensure that Personal Protective Equipment (PPE) was worn per standards of practice for two residents (Resident #18 and Resident #112); 3) Failed to ensure that surveillance was analyzed, trends were identified and corrective measures were implemented; and 4) Failed to ensure that employee illness was tracked and reported to prevent the spread of infection, resulting in the potential for a serious adverse outcome including infectious illness and death if appropriate Infection Prevention and Control Standards of Practice were not enacted. Findings Include: FACILITY Infection Control On 9/19/23 at 1:21 PM, a Contact precautions sign was on the door of Resident #112's room. A cart with Personal Protective Equipment/PPE was sitting outside the door. The sign said PPE/ a gown and gloves was required on entrance 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 Initial Kitchen Tour: On 9/19/23 at 11:00 AM, the initial tour of the kitchen was conducted with Dietary Manager/Head Chef G. During the tour, the area in the dining room was observed where coffee containers were positioned to dispense coffee on the counter. Near the end of the counter was a fruit fly trap. An observation was made in that area on the wall of three fruit flies with a dead fly in the trap. When asked about issues with fruit flies, the Dietary Manager reported they had issues with drain flies, indicated pest control had been out and indicated the flies were drain flies. Resident #18: A review of Resident #18's medical record revealed an admission into the facility on 9/17/20 and readmission on [DATE] with diagnoses that included adjustment disorder with anxiety, diabetes, heart failure, chronic kidney disease, peripheral vascular disease, and depression. A review of the Minimum Data Set assessment revealed the Resident was cognitively intact and needed extensive assistance with bed mobility,…

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 privacy during dental care for one resident (Resident #8) and assist one resident (Resident #33) with putting laundry away or hung up to be ready for use of three residents reviewed for dignity issues, resulting in feelings of embarrassment, and frustration. Findings include: Resident #8: A review of Resident #8's medical record revealed an admission into the facility on 8/4/14 and re-admission on [DATE] with diagnoses that included hypothyroidism, dementia, depression, stroke, anxiety disorder, and heart disease. A review of Resident #8's Minimum Data Assessment (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11/15 that indicated moderately impaired cognition. On 9/19/23 at 10:42 AM, an observation was made during the initial tour of the facility of Resident #8 sitting in her wheelchair in a common area room that had glass windows and the door was open. Resident #8 was observed to have been…

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 inform the responsible party of the start of a gradual dose reduction (GDR) for the medication Depakote (a medication used to treat seizure disorders, mental/mood conditions and to prevent migraine headaches), the onset of pneumonia, and dental services) for one resident (Resident #33) of 19 residents reviewed for notification of changes/services and care planning, resulting in the lack of communication to develop coordinated care and treatment decisions. Findings include: Resident #33: A review of Resident #33's medical record revealed an admission into the facility on [DATE] and readmitted on [DATE] with diagnoses that included muscle weakness, abnormalities of gait and mobility, obesity, heart disease, mood disorder, depression, and dementia. The Resident's MDS revealed a BIMS score of 10/15 that indicated moderately impaired cognition and needed extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that documentation was in the medical record of discharge summary and physician's order for discharge, and that essential health information was communicated to the hospital upon transfer of one resident (Resident #21) to the emergency room, of three residents reviewed for transfer/discharge, resulting in the potential for lack of communication for the continuation of care. Findings include: Resident #21: A review of Resident #21's medical record revealed an admission into the facility on 3/1/16, re-admission on [DATE] and discharge on [DATE] with diagnoses that included difficulty in walking, weakness, diabetes, chronic obstructive pulmonary disease, anxiety disorder, shortness of breath, heart disease, heart failure, stroke, and low blood pressure. A review of Resident #21's progress notes revealed the following: -Dated 9/2/23 at 8:15 AM, pt (patient) c/o (complained of) chest pn (pain), 1st nitro given 0755. No relief in pain and 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 interview and record review, the facility failed to ensure that one resident (Resident #21) had a written notice of transfer provided to the State Ombudsman and to the Resident/Resident Representative regarding their transfer to the hospital for one resident (Resident #21) of three residents reviewed for transfer/discharge, resulting in the Ombudsman not being informed of the transfer or being able to advocate for the Resident if necessary and the Resident Representative being uninformed of health care status and rational requiring hospital treatment. Findings include: Resident #21: A review of Resident #21's medical record revealed an admission into the facility on 3/1/16, re-admission on [DATE] and discharge on [DATE] with diagnoses that included difficulty in walking, weakness, diabetes, chronic obstructive pulmonary disease, anxiety disorder, shortness of breath, heart disease, heart failure, stroke, and low blood pressure. A review of Resident #21's progress notes revealed the following: -Dated…

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 develop and implement a comprehensive care plan for one resident (Resident #112) of 23 residents reviewed, resulting in Resident #112 lacking a Hospice care plan, which could result in a lack of coordination of care between the facility and Hospice provider. Findings Include: Resident #112: Hospice and End of Life A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #112 was admitted to the facility on [DATE] with diagnoses: Acute respiratory failure, malnutrition, dysphagia, acute kidney failure, hypertension, GERD, hypothyroidism, heart disease, left lower leg wound infection, anxiety, neuropathy and arthritis. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 13/15 and she needed some assistance with all care. The MDS section O revealed Resident #112 was receiving hospice care in the facility. A review of the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that assessment and wound care was consistently provided for pressure ulcers for three residents (Resident #18, Resident #38 and Resident #51) of 4 residents reviewed for pressure ulcers and wounds, resulting in residents not receiving the necessary care and services to aid in preventing pressure ulcers or potential worsening of the wounds. Findings Include: Resident #38: A record review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #38 indicated the resident was admitted to the facility on [DATE] with diagnoses: heart failure, cardiomyopathy, chronic kidney disease, hypertension, atrial fibrillation, diabetes, COPD, dysphagia, anxiety, right lower extremity embolism and thrombosis. The MDS assessment dated [DATE] revealed the resident had mild cognitive loss with a Brief Interview for Mental Status (BIMS) score of 12/15, needed assistance with all care and received oxygen therapy. On [DATE] at 12:48 PM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the appropriate collection of a urine sample for one resident (Resident #32) and ensure that an indwelling urinary catheter securement device was in place for one resident (Resident #51), of six residents reviewed for catheter and urinary tract infections (UTI), resulting in the potential misdiagnosis of a UTI, delay in treatment, worsening of an infection and the potential for irritation, bleeding and pain at the urinary catheter insertion site. Findings include: Resident #32: A review of Resident #32's medical record revealed an admission into the facility on 8/3/18 with a re-admission on [DATE] and 9/22/23 with diagnoses that included muscle weakness, diabetes, obesity, heart disease, open wound to lower leg, and retention of urine. A review of the Minimum Data Set assessment, dated 8/5/23, revealed the Resident was cognitively intact and needed extensive assistance with bed mobility, transfer, dressing and toilet use. A review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that residents received pain medication as ordered prior to wound care for one resident (Resident #51) of 1 resident reviewed for pain, resulting in the potential for increased pain and decreased quality of life. Findings Include: Resident #51: Pain Management A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #51 was admitted to the facility on [DATE] with diagnoses: history of squamous cell skin cancer, weakness, hypertension, enlarged prostate, urinary retention, history of urinary tract infections, depression, anxiety, gout, , history of falls and atrial fibrillation. The resident was transferred to the hospital for blood clots in the urinary catheter tubing and decreased urinary output on 9/14/2023 and readmitted to the facility on [DATE] with a urinary tract infection. The resident had an indwelling urinary catheter (Foley catheter). The MDS assessment dated [DATE] revealed the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that dialysis communication forms were complete and included pre-dialysis and post-dialysis assessment; assess the dialysis access sites and accommodate the resident's medication regimen for one resident (Resident #25) of 1 resident reviewed for Dialysis care, resulting in the potential for a decline in condition and the inability for a prompt response to care needs. Findings Include: Resident #25: Dialysis A record review of the Facesheet and Minimum Data Set (MDS) assessment indicated Resident #25 was admitted to the facility on [DATE] with diagnoses: Diabetes, chronic kidney disease, dependence on renal dialysis, heart disease, hypertension, hypothyroidism, peripheral vascular disease, left and right below the knee amputations, neuropathy, anxiety, depression, and weakness. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 15/15 and the resident needed…

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 Resident #18: A review of Resident #18's medical record revealed an admission into the facility on 9/17/20 and readmission on [DATE] with diagnoses that included adjustment disorder with anxiety, diabetes, heart failure, chronic kidney disease, peripheral vascular disease, and depression. A review of the Minimum Data Set assessment revealed the Resident was cognitively intact and needed extensive assistance with bed mobility, transfers, dressing, personal hygiene, and toileting. Review of the Resident's census revealed the Resident was discharged on 1/31/23 and readmitted on [DATE] and discharged on 2/19/23 and readmitted on [DATE]. A review of Resident #18 wound documentation in the medical record revealed the Resident had an unstageable pressure ulcer to the left heel. The documentation in Wound Rounds, revealed wound site: left heel, Date Identified: 3/31/23; Type: Pressure; Classification: Ulceration; Tissue Types: pale pink Non-granulating-70%, Bright Beefy Red-20%, and Slough white fibrinous-10%; Exudate…

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 appropriate narcotic medication practices including: 1) Nurses not signing the shift-to-shift narcotics count report sheet; 2) Nurses not signing on the narcotics log that they removed narcotics from the narcotics drawer for four residents (Residents #4, #14, #25 and #51) and 3) Discrepancies in narcotics orders/packaging and labeling for four residents (Residents #4, #22, #25 and #112) of 18 residents reviewed for narcotics administration, resulting in the potential for inappropriate access to narcotic medications and residents not receiving medications as ordered. Findings Include: Resident #51: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #51 was admitted to the facility on [DATE] with diagnoses: history of squamous cell skin cancer, weakness, hypertension, enlarged prostate, urinary retention, history of urinary tract infections, depression, anxiety, gout, , history of falls 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.