Pinecrest Medical Care Facility

Based on interview and record review, the facility failed to provide written transfer notification to the resident and resident's representative including reason, effective dates, and the location to which the resident was being transferred for one Resident (R39), of two residents reviewed for transfers out of the facility. Findings include: All times are recorded in Eastern Daylight Time (EDT) unless otherwise noted. Resident #39 (R39) The medical record for R39 revealed a transfer to the hospital on 7/9/23. The medical record did not indicate a written notification of transfer was given to R39 or sent to her representative. During an interview on 7/25/24 at 10:58 AM, Administrative Staff C stated she did not send written notifications of hospitalization stays to any residents or their representatives. She was not aware this was required. Staff C stated the previous person in her position had retired. The facility policy titled Transfer and Discharge dated 7/2024 was provided and read in part: 12. Emergency Transfers/Discharges - initiated by the facility for medical reasons to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to develop comprehensive care plans for two Residents (R41 and R54) of 17 residents reviewed for care planning. This deficient practice resulted in the lack of care plan goals and interventions, with the potential for unmet needs. Findings include: All times are recorded in Eastern Daylight Time (EDT) unless otherwise noted. Resident #54 (R54) R54 was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure, congestive heart failure, diabetes, major depressive disorder, panic disorder, anxiety disorder, dementia and multiple fracture history. On 7/22/24 the facility presented a matrix with all residents listed which included conditions and concerns. R54 was listed as End of Life Care/Comfort Care/ Palliative Care. The Electronic Medical Record (EMR) reflected weights of: 7/22/24 187.0 pounds 6/24/24 199.0 pounds 4/22/24 220.0 pounds 1/22/24 232.0 pounds These weights indicated a 6% weight loss in one month, a 9%…

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

Based on observation, interview, and record review, the facility failed to provide medication administration to meet professional standards 1.) administer antibiotics according to physician order and 2.) flush peripherally inserted central catheter (PICC) for one Resident #32 of four residents reviewed for medication administration. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise specified. Resident #32 (R32) Review of R32's physician order, dated 6/27/24, revealed an order for vancomycin 750 mg (milligrams) / 150 ml (milliliters), intravenously one time a day for sepsis until 8/6/24. On 7/23/24 at 7:50 AM, medication administration was observed with Licensed Practical Nurse (LPN) R for R32. LPN R accessed R32's PICC line using a 10 ml (milliliter) syringe filled with normal saline solution. LPN R failed to check for a blood return prior to administering the saline solution into the PICC line. R32's PICC line dressing was observed dated 7/10/24 indicating when the last time the dressing was changed. On 7/23/24 at 8:10 AM, an interview 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 meet the nutritional needs and preferences for two Residents (R29 and R54) of 3 residents reviewed for nutrition. This deficient practice resulted in residents not receiving prescribed diet, food preferences, experiencing thirst, and potential risk for physical decline. Findings include: All times are in Eastern Daylight Time (EDT) unless otherwise noted. Resident #29 (R29) R29 was admitted to the facility on [DATE] with diagnoses including dysphasia (difficulty swallowing) , spasms of the esophagus, dementia, heart failure and stroke with left side paralysis. The Electronic Medical Record (EMR) revealed the physician diet Order Summary: Start dated 11/1/23, Regular diet Pureed texture, Nectar/Mildly Thick consistency . texture varies per DPOA (Durable Power of Attorney) sm (small) portions, gravy w/pureed meat, extra gravy on side, super cereal at B(breakfast), super spuds L (lunch); magic cup thawed or yogurt as dessert, nectar water…

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 nurse aides completed required dementia training and demonstrated the skills and techniques necessary to care for residents for three contracted Certified Nurse Assistants (CNAs F, AA and BB) of three contract nursing staff reviewed for competency evaluation, resulting in the potential for unmet physical and psychosocial needs for all 63 residents residing in the facility. Findings include: All times recorded in Eastern Daylight Time (EDT), unless otherwise noted. A review of CNA F's competency evaluation as provided by Human Resources Director, Staff Z on 7/24/2024 at 3:36 p.m., revealed a Skills Checklist by [contract company], dated 5/03/2024. Further review of the Skills Checklist, revealed the checklist to be a self-evaluation completed by CNA F indicating how frequently she performed tasks and how proficient she felt at the listed tasks. Further review of the documents provided by Staff Z revealed no further evaluation of CNA F's skills. Review of CNA F's education roster titled Core Mandatory Exam - Nursing,…

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

Based on observation, interview, and record review, the facility failed to ensure a medication administration error rate of less than five percent, with three errors identified out of 30 opportunities, affecting two Residents (R30 and R32) of four residents observed for medication administration, resulting in a medication error rate of 10.00 percent. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise specified. On 7/23/24 at 7:50 AM, medication administration was observed with Licensed Practical Nurse (LPN) R for R30. LPN R was observed dispensing one torsemide 20 mg tab. LPN R was asked how many she dispensed and replied, One. That is how many he gets. After medications were verified, LPN R was made aware R30 had a recent order change related to drug amount for torsemide dispensed by pharmacy. Prior orders for R30 were to dispense one 40 mg tab and current supply was 20 mg. Review of R30's physician order, dated 7/12/24, revealed the current order for torsemide 20 mg, was to give 2 tablets by mouth one time a day for edema. On 7/24/24 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 provide adaptive dining equipment for two Residents (R22 & R29) of three residents reviewed for adaptive dining equipment needs. This deficient practice resulted in increased difficulty with food consumption and independent eating with the potential for decreased food/fluid intake and risk for weight loss. Findings include: All times are in Eastern Daylight Time (EDT) unless otherwise noted. Resident #22 (R22) On 7/22/24 at approximately 1:20 PM, the lunch meal was observed for R22. The meal tray card indicated Colored Plates be provided. R22 had her meal served on a white plate. During an interview on 7/22/24 at 1:49 PM, when asked for the purpose of the colored plates, Dietary aide (Staff) J explained they were used for those residents who were visually challenged. During an interview on 7/22/24 at 3:07 PM, R22 stated, I need colored plates. I am legally blind. R22 said they did not get one today. The Electronic Medical Record (EMR)…

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 maintain a complete infection control program, including an outbreak line listing and surveillance mapping during an RSV (contageous respiratory illness) outbreak in the facility that had the potential to affect all 65 vulnerable residents in the facility. This deficient practice resulted in the potential for sustained spread of RSV within the facility resident population. Findings include: During an interview on 1/16/24 at 1:23 p.m., Infection Preventionist (IP) F and Registered Nurse (RN) Supervisor G were asked for the outbreak line listing and surveillance tracking map for the RSV outbreak in the facility. (IP) F said a line listing for the RSV had not been completed, nor had there been any surveillance mapping to identify RSV illness as it occurred in affected individuals. IP F stated, We did have an outbreak of RSV . [Resident R1] on 12/22/23 was suspected of having RSV. When asked for the name of the Resident with the first case of RSV in the facility, IP F stated, Give me just a second, as she looked through her…

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 deficiency pertains to Intakes MI00134358, MI00132367, and MI00131319. Based on observation, interview, and record review, the facility failed to ensure sufficient staff to provide nursing related services, assure resident safety, and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, based on resident acuity and diagnoses of the resident population. This deficient practice resulted in unmet resident care needs and inadequate supervision to prevent and respond to resident needs. Findings include: All times noted are Eastern Daylight Savings Times (EDST) unless otherwise noted. Observation during breakfast on 7/19/23 at 8:58 a.m., found 10 residents seated in the dining room without nursing supervision while the meal trays were consumed. Two Dietary Aides (Staff); U and V, were present in the kitchen who prepared and delivered the individual meal trays to each resident. During an interview on 7/19/23 at 9:00 a.m., Staff U and V were asked if any…

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

This deficiency pertains to Intakes: MI00134358, MI00132367, MI00131319. Based on observation, interview, and record review, the facility failed to perform annual licensed nurse and nurse aide competency evaluations and ensure licensed nursing staff and certified nurse aides (CNAs) had the specific competencies, skill sets, and techniques necessary to care for two Residents (R4 and R42] of four residents reviewed for pressure ulcer and catheter care. This deficient practice resulted in improper catheter and wound care technique and the potential for worsening of condition for both residents and had the potential to affect all facility residents. Findings include: All times noted are Eastern Daylight Savings Times (EDST) unless otherwise noted. Resident R4 During a catheter care observation for R4 on 7/21/23 at 10:36 a.m., CNA LL began catheter care with cleansing of the catheter tubing. CNA LL held the tubing, approximately one inch from the urethral opening, and cleansed downward four times. The tubing near the urethra was never cleansed. The tubing was rinsed, and CNA LL took 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 This deficiency pertains to MI00134358, MI00132367, MI00131319. Based on observation, interview, and record review, the facility failed to ensure a Registered Nurse (RN) was designated and served as the Director of Nursing (DON) on a full-time basis. This deficient practice resulted in the inability to provide in-person supervision over the activities of the Nursing Department. This deficiency had the ability to affect all 68 facility residents. Findings include: All times noted are Eastern Daylight Savings Times (EDST) unless otherwise noted. During a telephone interview on 7/19/23 at 8:31 p.m., Staff CCC was asked about the absence of the DON in the building. Staff CCC stated, Our DON has been working from home, but I know she is getting paid, because she calls in to the morning meeting. She has been working from home since March. You can't expect the survey to succeed when she has been working from home since March . [The DON] has the DON (work) cell phone and we have to call her and notify her if someone…

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 deficiency pertains to Intakes MI000134358, MI00132367, and MI00131319. Based on interview and record review, the facility failed to complete performance reviews of all nurse aide at least once every 12 months. This deficient practice resulted in the potential for quality-of-care concerns related to lack of training to meet the Certified Nurse Aide (CNA's) performance-based education needs. This deficient practice has the potential to affect all 68 vulnerable residents in the facility. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted. During an interview on 7/26/23 at 7:52 a.m., Administrative Staff T was asked for performance reviews for five staff members pulled yesterday for review. Staff T stated, We don't have any (performance reviews). The managers of the department are responsible for the department performance reviews - such as the DON (Director of Nursing) for nurses. (With) all the changes and the instability in the nursing level, there is nobody to perform them because the DON is working from home. Administrative staff…

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

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety as evidenced by failing to label, date, and store food to ensure it was kept free from contamination and failed to properly clean areas with a potential to contaminate food during preparation. This deficient practice had the potential to result in food borne illness among any or all 39 residents in the facility. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise specified. During the initial tour of the kitchen with Certified Dietary Manager (CDM) N and CDM O on 07/18/23 at 11:45 AM, the walk-in freezer was observed with partially used, re-sealed, bags of broccoli, breaded fish, mixed vegetables, spinach, and asparagus, which were not dated when opened and had no use by date. CDM N stated these partially used frozen food items should be dated. CDM O agreed each item should be dated after opening. The satellite kitchens were observed with CDM O. The refrigerator in 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 deficiency pertains to Intake MI00132367. Based on interview and record review, the facility failed to implement their abuse policy to screen potential employees for a history of abuse by completion of reference checks for four recent hires ( Staff BB, JJ, OO, and PP) out of five staff reviewed for reference checks. This deficient practice resulted in the potential for individuals with a history of abuse to be employeed by the facility which had the potential to affect all 68 facility residents. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted. Review of Staff OO's Employment Application on 7/25/23 at 2:27 p.m., revealed no reference checks were completed prior to starting employment with the facility. When asked if reference checks were available for Staff OO, Administrative (Staff) Z said no reference checks were performed. Staff Z said the reference checks were not being completed by the Director of Nursing (DON) who was responsible for the decision to hire the nursing staff employees. Staff Z said her job description did not…

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 #15 (R15) Injury of unknown origin facility reported incident dated 8/30/22: Review of R15's face sheet, dated 8/30/22, reveal R15 was a [AGE] year-old female resident admitted to the facility on [DATE] with medical diagnoses including anxiety, severe intellectual disability, schizophrenia, and diabetes mellitus. Review of handwritten notes from a communication notebook between facility staff, dated 8/28/22 and timed 11p [11:00 PM] author unknown, read in part, [R15] yelled out on and off all night long. Slapped herself a few times. Left foot is hanging weird - she can't put pressure on it. Review of handwritten notes from communication notebook between facility staff, dated 8/28/22 and timed 3-7 [3:00 PM - 7:00 PM] author LPN C, read in part, .tried to transfer self to bed and was sit (sic) on floor next to w/c [wheelchair]. Looked like [R15] may attempted to transfer into bed but didn't make it. 2-person pivot with gait belt, no grimacing - stood up without issue and pivoted into bed. Note: Indicating…

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 deficient practice pertains to Intakes: MI00132367, MI00134358, MI00136498, MI00134726, MI136473 and MI00137019. Based on observation, interview, and record review, the facility failed to ensure thorough investigations were completed for allegations of abuse including injuries of unknown origin for four Residents (R9, R29, R15, and R50) out of 21 residents reviewed for abuse. This deficient practice resulted in the potential for continuation of abuse. Findings include: All times noted are Eastern Daylight Savings Times (EDST) unless otherwise noted. Resident R9 Review of the Facility Reported Incident (FRI), dated 5/1/23, revealed the following, in part: On May 1, 2023, at approximately 5:15pm, it was reported to me [Director of Nursing (DON)], by the RN (Registered Nurse) Supervisor, that an aide, [Certified Nurse Aide (CNA) Y], swore at a resident while trying to pick (R9) up off the floor. A witness reported that while (CNA Y) was trying to get (R9) back into her chair, she heard (CNA Y) say, 'sh*t 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 This deficiency pertains to Intake MI00132367. Based on observation, interview, and record review, the facility failed to ensure facility staff were trained and knowledgeable of the location of Cardiopulmonary Resuscitation (CPR) equipment for basic life support for residents with a full-code status. This deficient practice resulted in the potential for the delay or inability to perform CPR as a life-saving measure for facility residents. Findings include: All times noted are Eastern Daylight Savings Times (EDST) unless otherwise noted. During a telephone interview on [DATE] at approximately 8:00 p.m., Confidential Staff CCC was asked about CPR equipment in the facility. Staff CCC stated, We don't have emergency crash carts, but I am pretty sure they bought some and they have been sitting in the basement for some time. We don't have any crash carts on the floor. All of our (CPR and emergency supply) stuff is really spread out about the building. I don't even know if we have a code policy. We have our oxygen…

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 #9 (R9) On 7/20/23 at 8:20 AM, an observation was made on the 600 hall of Certified Nurse Aide (CNA) VV assisting R9 in her wheelchair. CNA VV was pushing R9 down the 600 hall from room [ROOM NUMBER] down to the nursing station area (approximately 50 feet in distance). R9's feet were dragging on the floor below her as she sat in her wheelchair. CNA seen Surveyor witness R9 being pushed without foot pedals and immediately went to R9's room [room [ROOM NUMBER]] retrieved the foot pedals and placed them on R9's wheelchair. Review of R9's care plan, date printed 7/21/23, read in part, .I can't complete my cares on my own and need assistance of one to two staff to help me with my activities of daily living .I need my aides to .Whenever needed, use a regular wheelchair (one with a cushion, slip pads and foot pedals) . Resident #268 (R268) On 7/20/23 at 9:38 AM, an observation was made of the 600 hall of CNA VV assisting R268 in her wheelchair. CNA VV was observed pushing R268 on the 600 hall from room [ROOM…

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 expired medications were removed from one medication cart out of four medication carts and one medication storage room out of three medication storage rooms reviewed for medication storage. This deficient practice resulted in the administration of expired insulin, the potential for decrease in potency of insulin, and medication errors. Finding include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise specified. On 7/20/23 at 7:45 AM, an observation was made of the 500/600 hall medication cart. The 500/600 medication cart was found to have the following expired medications: a. Insulin lispro 100u (unit)/ml (milliliters), date opened 6/28/23 and expired date 7/19/23, and belonged to Resident #5 (R5); b. Insulin lispro 100u /ml, date opened 6/17/23 and expired date 7/15/23, and belonged to Resident 15 (R15); c. Insulin glargine 100u /ml, date opened 6/29/23 and expired date 7/20/23, and belonged to 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.

This deficiency pertains to Intakes MI00132367 and MI00134358. Based on observation, interview, and record review, the facility failed to provide respect and dignity during dining for three Residents (R9, R29, and R49) of 21 sample residents reviewed for dining. This deficient practice resulted in the potential for decreased meal consumption and dissatisfaction with dining assistance provided by facility staff. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted. Resident #29 (R29) During breakfast observation on 7/19/23 at 9:07 a.m., Resident (R29) took one fork full of eggs and had great difficulty getting the eggs from the plate to their mouth. R29 picked up a half slice of toast and took a bite and then picked up a bite of eggs with a fork, but dropped the eggs onto their lap. R29 attempted to pick up the egg from his lap, unsuccessfully. R29 balanced the half-slice of toast, held in the left hand with the fork held in their right hand, supporting the toast. R29 took another bite of toast. R29 continued to try and eat the toast with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on interview and record review, the facility failed to obtain consent for psychoactive medication for one Resident (#51) of five residents reviewed for psychoactive medications. This deficient practice resulted in Resident #51 (R51)and their Responsible Party not being informed of potential medication side effects/adverse reactions. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise specified. A review of R51's electronic medical records (EMR) indicated an admission into the facility on 8/31/21 with diagnoses including major depressive disorder, unspecified dementia, and congestive heart failure. A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed R51 had severely impaired cognition with a score of 3/15 on the Brief Interview for Mental Status (BIMS) assessment. The medical record documented R51 had an appointed responsible party for health care and financial decisions. A review of R51's 'Physician Orders' for July 2023 indicated…

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 facilitate resident self-determination related to dining location preference for one Resident (R3) of one resident reviewed for resident choices. This deficient practice resulted in frustration, anger, dissatisfaction with care, and feelings of helplessness when resident choices were not honored. Findings include: All times are Eastern Daylight Savings Time (EDST) unless otherwise noted. During an interview on 7/18/23 at approximately 1:10 p.m., R3 was asked about any concerns with nursing care. R3 stated, One nurse won't even talk to me. She will not say one word to me. [Staff AA] is the nurse. [Staff AA] makes me go to breakfast every day I am here (and she is here) - even if I don't want to. During an observation and interview on 7/21/23 at 8:35 a.m., when asked about the location of breakfast the previous day, R3 stated, [Staff AA] made me go to breakfast yesterday (in the dining room) and I did not want to go to breakfast. I want to watch TV while I am eating my breakfast. I never want to go to…

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

This deficiency pertains to Intake MI00136498. Based on interview and record review, the facility failed to protect the residents' right to be free from verbal abuse and neglect by Staff for one Resident (R9), out of eight residents reviewed for abuse. This deficient practice resulted in the potential for fear, humiliation, and feelings of helplessness when R9 was verbally disparaged following a fall from a chair. Findings include: All times noted are Eastern Daylight Savings Times (EDST) unless otherwise noted. Review of the Facility Reported Incident (FRI), dated 5/1/23, revealed the following, in part: On May 1, 2023, at approximately 5:15 p.m., it was reported to me [Director of Nursing (DON)], by the RN Supervisor, that an aide, [Certified Nurse Aide (CNA) Y], swore at a resident while trying to pick her (R9) up off the floor. A witness reported that while he was trying to get her back into her chair, she heard him (CNA Y) say, 'sh*t and G*d d*mn you' to the resident . Review of R9's Minimum Data Set (MDS) assessment, dated 6/20/23, revealed R9 had active diagnoses that…

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 completely assess and establish a baseline care plan within 48 hours that included measurable goals and interventions for one Resident (#58) of two sampled residents reviewed for development of baseline care plans. This deficient practice resulted in the facility's failure to address priority risk factors and individual needs. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise specified. The first plan of care for R58 was presented on 07/20/23 at 3:52 PM by Staff T who stated it was started on 1/2/23. A baseline care plan was not written within 48 hours of the admission on [DATE] and did not mention plans to keep R58 safe using the knowledge of R58's previous daily habits of leaving his home. According to the electronic medical record (EMR), Resident #58 (R58) was admitted to the facility on [DATE], with a primary diagnosis of Alzheimer's disease. A review of the Minimum Data Set (MDS) assessment for R58,…

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 an effective means of communication for one Resident (#50) of two residents reviewed for communication. This deficient practice resulted in Resident #50 struggling to communicate her basic needs, which resulted in feelings of frustration. Findings include: Resident #50 (R50) Review of the Minimum Data Set (MDS) assessment, dated 5/16/23, revealed R50 was admitted to the facility on [DATE], with diagnoses including fracture (unspecified), dementia, and urinary tract infection. The assessment revealed R50 required extensive two-person assistance for bed mobility, transfers, dressing, and toileting, and could feed herself with set-up only. The Brief Interview for Mental (BIMS) assessment revealed a score of 3/15, which indicated R50 had severe cognitive impairment. The sensory assessment revealed R50 had clear speech, and was usually understood, and was sometimes able to understand others, had no vision impairment and wore hearing…

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 appropriate catheter care to prevent urinary tract infections for one Resident (R4) of one resident reviewed for catheter care. This deficient practice resulted in the potential for cross-contamination of feces and increased risk of urinary tract infection. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted. During a catheter care observation for R4 on 7/21/23 at 10:36 a.m., CNA LL began catheter care with cleansing of the catheter tubing. CNA LL held the tubing, approximately one inch from the urethral opening, and cleansed downward four times. The tubing near the urethra was never cleansed. The tubing was rinsed, and CNA LL took the towel that was draped over R4's body to dry the catheter tubing with the same dirty gloves. CNA LL then used a new, wet washcloth to cleanse the right and left creases between the pubic area and the inner thigh. CNA LL wiped downward three times in the left and right thigh crease, finding brown feces on the white washcloth…

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 the provision of trauma-informed care to mitigate triggers that may cause re-traumatization for one Resident (R3) of one resident reviewed for trauma-informed care. This deficient practice resulted in increased anxiety, flashbacks, and feelings of re-traumatization. Findings include: All times are Eastern Daylight Savings Time (EDST) unless otherwise noted. During an interview on 7/18/23 at approximately 1:10 p.m., R3 stated, This morning and all this week so far, and I have told them, and told them, and told them - I don't like men washing me up. The man put me on the bedpan, he gave me my bath this morning. Back when I was sixteen, I was [sexually assaulted], and it brings the anxiety back up. I know he won't [sexually assault] me but there is always the chance that he would. I have told them several times that I don't want a man. I have asked them to get someone else, and they say - 'He is the only one we got. It is him or nobody.' I can't do it myself. Review of R3's Minimum Data Set (MDS) assessment, 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.

Based on interview, and record review, the facility failed to evaluate the use of antipsychotic medication for potential adverse consequences at least quarterly, if not more often for three Residents (#9, #36 and #51) of five sampled residents reviewed for unnecessary medications. This deficient practice resulted in the facility's failure to determine the potential for reducing or discontinuing psychoactive medications based on therapeutic goals and any adverse effects or functional impairment. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise specified. Resident #9 (R9) The facility electronic medical records (EMR) for R9 revealed the most recent admission date of 12/29/20 with current diagnoses which included anxiety disorder, major depressive disorder, recurrent, schizophrenia, unspecified, and drug induced subacute dyskinesia (unusual movements that a person cannot control). Current Physician ordered psychotropic medications included Seroquel, Lexapro, Trazadone, and Lorazepam. The EMR contained Abnormal Involuntary Movement Scale (AIMS)…

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 radiology services in a timely manner and professional standards of practice after an unwitnessed fall for one Resident (R15) out of one resident reviewed for radiology services. This deficient practice resulted in the delay of medical treatment, diagnosis, and pain control for two fractures. Finding include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise specified. According to the Facility Reported Incident (FRI), dated 8/30/22, read in part, .Registered Nurse [RN S] was called into the locked unit to assess [R15's] leg, left lower extremity swollen (which she does have 2+ edema to that extremity) and bruising noted to ankle, resident was unable to move foot/toes and foot drop noted. RN called physician and order to send out to hospital for evaluation . Review of R15's face sheet, dated 8/30/22, reveal R15 was a [AGE] year-old female resident admitted to the facility on [DATE] with medical diagnoses including…

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