Aberdeen Rehabilitation and Skilled Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain complete and accurate medical records for two (R3 and R12) of 15 residents reviewed for medical records, resulting in resident's pharmacy recommendations being unclear and not maintained in the resident's Electronic Health Record (EHR) with the potential for miscommunication of pharmacy recommendations, physician's orders, and an unclear picture of the resident's health care status. Findings include: R3: According to R3's Electronic Health Record (EHR) the resident admitted to the facility with multiple diagnoses that included Intellectual Disabilities and altered Mental Status. The Pharmacist's Drug Reviews dated 5/6/24 and 7/2/24 indicated there were pharmacy recommendations and documented; Please take the following action described below. There was no further documentation to describe the recommendation of action from the Pharmacist. On 8/28/24 at approximately 1:00 PM the Director of Nursing (DON) was asked where the Pharmacist's…

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

Based on observation, interview, and record review the facility failed to practice proper infection control techniques for one (R4) of one resident reviewed with enhanced barrier precautions, resulting in the potential for widespread infection. Findings include: 08/28/24 at 2:15 PM, R4 was observed to be returned to bed for brief changed and wound care. Registered Nurse, (RN) O and Certified Nursing Assistant, (CNA) S were observed to perform care on R4 without wearing a gown. Review of R4 Electronic Medical Record, (EMR) noted an admission date to the facility on 2/16/24 with a pertinent diagnosis of Stage II to buttocks. R4's Brief Interview of Mental Status, (BIMS) score was 14/15 (intact cognition). 08/28/24 at 2:25 PM, RN O was interviewed and acknowledged staff should have been wearing a gown. Unit Manager, UM R was interviewed and added there was a sign on the door and the staff should have been wearing a gown when performing change of brief as well as wound care.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00138801. Based on interview and record review, the facility failed to seek timely medical evaluation of an injury of unknown origin for one resident (R102), out of three residents reviewed for falls, resulting in the potential for delay in the provision of resident care needs. Findings include: The State Agency received a complaint that the resident fell, and the facility failed to seek timely medical evaluation and treatment. A review of Resident #102's (R102) clinical record documented an admission date of 1/18/2020. R102's diagnoses included Alzheimer's Disease, Atrial Fibrillation, and Diabetes Mellitus-Type 2. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. A review of R102's care plans documented resident was at risk for falls due to muscle weakness and diagnosis of dementia with a start date of 7/20/2023. A review of nursing notes documented the following: - Date/time: 8/3/2023 at 4:48 AM: Resident was pleasant and cooperative 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.

Based on observation, interview and record review the facility failed to promptly make good faith attempts to resolve grievances for members of the Resident Council resulting in the potential for frustration and unmet care needs. Findings include: During a Resident Council meeting on 08/08/23 at 1:35 PM, six of six residents reported they did not know how to file a grievance or that it was an option to file a grievance. Resident Council participants reported communication in the building was poor. They reported if a concern was voiced, it was not addressed. Five of the six residents responded when asked about staffing and call light response time. Four of the five residents who participated in the discussion expressed concerns with staffing and extended call light response times. The Resident Council participants reported waiting up to one hour for staff to respond to their call lights. They reported staff seemed rushed and did not have time to stop and ask if the residents needed anything. One participant expressed there had been an ongoing concern with not receiving restorative…

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 #16 (R16) According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] Resident 16 (R16) was an [AGE] year old male admitted to the facility with diagnoses that included heart peripheral vascular disease and diabetes. Review of MDS reflected R16 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status. Further review of the medical record including the monthly Physician orders reflected R16 was started on an anti-anxiety medication on as as needed basis on April 28, 2023 with no stop date. Review of R16's care plan dated 7/13/23 reflected R16's problem for the care plan was a diagnosis of anxiety with a goal of stabilize/improve mood and approaches were 1. appropriate referrals 2. encourage activities of interest. 3 explain all procedures of care calmly. 4. identify possible stressors to resident that need to be eliminated . 5. maintain medications as ordered. 6. Offer support and encouragement as needed. On 08/08/23 at 09:06 AM, during an interview 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 This citation pertains to Intakes MI00132462 and MI00135054. Based on observation, interview, and record review, the facility failed maintain sufficient staff for one (Resident #2) and Resident Council, resulting in extended call light response times and the potential for unmet care needs. Findings include: Review of the Resident Council minutes revealed on 2/21/21, 5/30/23, and 6/27/23, the Resident Council expressed concerns with call light response times. During a Resident Council meeting on 08/08/23 at 1:35 PM, five of the six residents responded when asked about staffing and call light response time. Four of the five residents who participated in the discussion expressed concerns with staffing and extended call light response times. The Resident Council participants reported waiting up to one hour for staff to respond to their call lights. They reported staff seemed rushed and did not have time to stop and ask if the residents needed anything. Resident #2 (R2) Review of the medical record revealed R2…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the physician received, reviewed and acted upon identified medication regimen irregularities for four residents (Resident #9, 16, 17, and 35) of five reviewed for unnecessary medications, resulting in the potential for unnecessary medications and adverse reactions. Resident #16 (R16) According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] Resident 16 (R16) was an [AGE] year old male admitted to the facility with diagnoses that included heart peripheral vascular disease and diabetes. Review of MDS reflected R16 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status. Further review of the medical record including the Pharmacy reviews and revealed the Pharmacist had found irregularities and had made recommendations for the Physician on 5/07/23, 06/01/23 and 07/05/23 . Resident #17 (R17) According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] Resident 17 (R17) was 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 dispose of expired medications in one of two medication carts and two of two medication rooms reviewed, resulting in the potential for decreased medication efficacy and adverse side effects in a current facility census of 34 residents. Findings include: On 8/8/23 at 8:49 AM, Station 3 Medication Room was reviewed in the presence of Director of Nursing (DON) B. During the review, it was noted that the medication refrigerator within the medication room contained a Tuberculin Purified Protein Derivative box with a handwritten open date of 7/6/23. An open, undated Tuberculin vial was noted within the box. DON B confirmed the 7/6/23 open date indicated on the box, stated that Tuberculin was good for thirty days after opening, and therefore would have expired on 8/5/23 and would be disposed of immediately. Station 1 Medication Room was reviewed, also in the presence of DON B, immediately following Station 3 review with a second Tuberculin Purified Protein Derivative box with a handwritten open date of 7/6/23 and an open, undated…

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 accurate completion of advance directive information for 3 (Resident #23, #27, and #35) of 4 residents reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility. Findings include: Resident #27 Review of the medical record revealed that Resident #27 (R27) was admitted to the facility 11/21/2017 with diagnoses including major depressive disorder, pain, and difficulty in walking. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/13/23 revealed that R27 had clear speech, was understood by others, and was able to understand others. Section C of the same MDS revealed that R27 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 12 (moderately impaired cognition). In an observation and interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation Pertains To Intake #MI00135054 Based on observation, interview and record review the facility failed to develop and operationalize an abuse policy consistent with regulations for three (Resident #'s 1, 9 and 23) of five reviewed, resulting in allegations of abuse to go unreported to the State Agency, not thoroughly investigated and the potential for further abuse allegations not be reported. Findings include: Resident #9 According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] reflected Resident 9 (R9) was a [AGE] year old male admitted [DATE] with diagnosis that included Parkinson's disease and depression. Further review of the MDS reflected R9 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status. On 08/09/23 at 09:00 AM, R 9 was interviewed in his room, R 9 was observed sitting in his recliner. R9 was engaging and articulate when queried about former facility employee Licensed Practical Nurse (LPN) D, R9 winced and made a grimaced facial…

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 #MI00135054 Based on observation, interview, and record review, the facility failed to report allegations of abuse for three (Resident #1, #9 and #23) of 5 reviewed, resulting in allegations of abuse that were not reported to the State Agency and the potential for further allegations of abuse to go unreported. Findings include: Resident #9 According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] reflected Resident 9 (R9) was a [AGE] year old male admitted [DATE] with diagnosis that included Parkinson's disease and depression. Further review of the MDS reflected R9 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status. On 08/09/23 at 09:00 AM, R 9 was interviewed in his room, R 9 was observed sitting in his recliner. R9 was engaging and articulate when queried about former facility employee Licensed Practical Nurse (LPN) D, R9 winced and made a grimaced facial expression. R9 further reported LPN D was not very nice, he had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation Pertains To Intake #MI000135054 Based on observation, interview and record review, the facility failed to ensure the protection of residents and thoroughly investigate allegations of abuse for one (Resident #9) of 5 reviewed for abuse, resulting in the potential for further abuse to occur and allegations of abuse not being thoroughly investigated. Resident #9 According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] reflected Resident 9 (R9) was a [AGE] year old male admitted [DATE] with diagnosis that included Parkinson's disease and depression. Further review of the MDS reflected R9 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status. On 08/09/23 at 09:00 AM, R9 was interviewed in his room, R9 was observed sitting in his recliner. R9 was engaging and articulate when queried about former facility employee Licensed Practical Nurse (LPN) D, R9 winced and made a grimaced facial expression. R9 further reported LPN D was not very nice, he had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the resident and/or resident's representative a written reason of transfer to a hospital for 2 (Resident #9 and #23) of 2 residents reviewed for transfer/discharge, resulting in the potential of residents and/or family being un-informed of the reason for transfer. Findings include: Resident #9 Review of the medical record reflected that Resident #9 (R9) was readmitted to facility 4/28/23 with diagnoses including syncope and collapse, muscle weakness, Parkinson's Disease, and pulmonary fibrosis. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) Of 6/7/23 reflected that R9 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 14 (cognitively intact). Review of the Discharge MDS dated [DATE] reflected that R9 had an unplanned discharge to an acute care hospital and that his return to the facility was anticipated. In an observation and interview on 8/07/23 at 10:10 AM, R9 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 notify the resident and/or resident's representative of the facility's policy for bed hold for two (Resident #9 and Resident #26) of two reviewed resulting in the potential of residents and/or representatives to be uninformed of the bed hold policy. Findings include: Resident #26 (R26) Review of the medical record revealed R26 admitted to the facility on [DATE] with diagnoses that included muscle weakness, cellulitis, protein-calorie malnutrition, convulsions, anxiety, pressure ulcer, hypotension, diabetes, and seizures. Review of the progress note dated 7/4/23 revealed R26 was transferred to the hospital for a blood transfusion. There was no documentation that a bed hold policy was provided upon transfer. In an interview on 08/08/23 at 11:20 AM, Director of Nursing (DON) B reported R26 did not receive a bed hold notice because the transfer was an emergency. Resident #9 (R9) Review of the medical record reflected that Resident #9 (R9) 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 complete a comprehensive assessment for one (Resident #139) of 12 reviewed, resulting in the potential for unmet care needs. Findings include: Review of the medical record revealed Resident #139 (R139) admitted to the facility on [DATE] with diagnoses that included heart failure, hypertension, diabetes, Parkinson's Disease, stage 4 pressure ulcer, and osteomyelitis of vertebra sacral and sacrococcygeal region. On 8/8/23 at 7:25 AM, R139 was observed asleep in bed with a wound vac in place. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/30/23 revealed the MDS was in process, incomplete, and not submitted. R139 did not have a completed MDS assessment since admission. In a telephone interview on 8/8/23 at 3:27 PM, MDS Coordinator M reported she had completely missed R139's comprehensive admission MDS. MDS Coordinator M reported R139's MDS was due by 5/6/23.

Based on observation, interview, and record review the facility failed to revise the care plan for one residents (#23) of 12 residents reviewed for care plan timing and revision resulting in the potential for residents that use language other than English to have unmet care needs. Findings included: Resident #23 (R23) Review of the medical record revealed R23 was admitted to the facility 08/21/2016 with diagnoses that included Alzheimer's disease, muscle weakness, dementia, psychotic disturbances, mood disturbance, anxiety, disc degeneration of the lumbar region, pain, spondylosis (wear and tear of spinal disk) of cervical region, insomnia, hyperkalemia (high potassium), osteoarthritis, and constipation. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/16/2023, revealed R23 Brief Interview of Mental Status (BIMS) was dashed out because resident cognition could not be assessed. During observation and attempted interview on 08/07/2023 at 10:08 a.m. R23 was observed lying in bed. R23 did not respond to verbal questions. During a telephone 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.

Based on observation, interview, and record review the facility failed to provide interpretive services for one resident (#23) of one resident reviewed for language resulting in the potential for resident that use language other than English to have unmet care needs. Findings Included: Resident #23 (R23) Review of the medical record revealed R23 was admitted to the facility 08/21/2016 with diagnoses that included Alzheimer's disease, muscle weakness, dementia, psychotic disturbances, mood disturbance, anxiety, disc degeneration of the lumbar region, pain, spondylosis (wear and tear of spinal disk) of cervical region, insomnia, hyperkalemia (high potassium), osteoarthritis, and constipation. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/16/2023, revealed R23 Brief Interview of Mental Status (BIMS) was dashed out because resident cognition could not be assessed. During observation and attempted interview on 08/07/2023 at 10:08 a.m. R23 was observed lying in bed. R23 did not respond to verbal questions. During a telephone interview on 08/07/2023…

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 Intakes MI00134426 and MI00136854. Based on observation, interview, and record review the facility failed to provide assistance with activities of daily living (ADLs) for three (Resident #139, #188, #238) of four reviewed, resulting in unmet care needs and the potential for a decline in emotional and physical health. Findings include: Resident #139 (R139) Review of the medical record revealed Resident #139 (R139) admitted to the facility on [DATE] with diagnoses that included heart failure, hypertension, diabetes, Parkinson's Disease, stage 4 pressure ulcer, and osteomyelitis of vertebra sacral and sacrococcygeal region. R139 did not have a Minimum Data Set (MDS) assessment completed since admission. Review of the Physician's Order dated 4/24/23 revealed EATING: Feeding assistance. The Physician's Order dated 4/25/23 revealed Diet Order: Regular, thin liquids as tolerated; provide feeding assistance with meals. Review of the Nutritional assessment dated [DATE] revealed Requires feeding…

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 #11 According to the clinical record including the Minimum Data Set (MDS) dated [DATE] , Resident 11 (R11) was a [AGE] year old male admitted to the facility with multiple medical issues including a diagnoses of traumatic brain injury. Review of the MDS reflected R11 scored 12 out of 15 on the Brief Interview for Mental (BIMS). Section G of the MDS reflected R11 required extensive assistance from two staff persons for bed mobility and transfers, for dressing and eating R11 coded as requiring extensive assistance from one staff person. Section G 0400 of the MDS reflected upper extremity impairment and bilateral impairment for lower extremity. Review of R11's Physician order dated 04/05/23 reflected Restorative (3x/wk ) [3 times a week] AROM (active range of motion) exes (exercises) of BUE/BLE (bilateral upper and lower extremities) 10 reps x 1 set. Gentle stretch of BIL (bilateral) hamstrings, as tolerated. Review of the Restorative Nursing Care Plan dated 4/05/23 revealed R11 was to have restorative…

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 a therapeutic diet that considers the residents clinical conditional condition for one resident (#189) of three residents reviewed for proper diet requirements resulting in the potential of clinical complications for those residents with a clinical condition. Findings Included: Resident #189 (R189) Review of the medical record revealed R189 was admitted to the facility 07/13/2023 with diagnoses that included diabetes, hypertension, end stage renal disease, chronic obstructive pulmonary disease (COPD), muscle weakness, epistaxis, diarrhea, kidney transplant, asthma, constipation, arthritis, angina pectoris, atherosclerotic heart disease, breast cancer, hypothyroidism, hypertension, bipolar disorder, and kidney failure. During observation and interview on 08/08/2023 at 07:39 R189 was observed standing in the doorway of her room. Resident appeared well groomed. R189 explained that she received hemodialysis three times per week and demonstrated a dressing on her left arm that covered her dialysis port.…

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 assure safe and appropriate use of bed rail assist bars for one resident (#23) of one resident reviewed for bed safety resulting in the potential for entrapment, injury, or death. Findings Included: Resident #23 (R23) Review of the medical record revealed R23 was admitted to the facility 08/21/2016 with diagnoses that included Alzheimer's disease, muscle weakness, dementia, psychotic disturbances, mood disturbance, anxiety, disc degeneration of the lumbar region, pain, spondylosis (wear and tear of spinal disk) of cervical region, insomnia, hyperkalemia (high potassium), osteoarthritis, and constipation. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/16/2023, revealed R23 Brief Interview of Mental Status (BIMS) was dashed out because resident cognition could not be assessed. During observation and attempted interview on 08/07/2023 at 10:08 a.m. R23 was observed lying in bed. R23 did not respond to verbal questions. R23's left side of the bed was pushed up against the wall…

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 as needed psychotopic medication was not prescribed for longer than 14 days for one resident (#16) of 5 reviewed for unnecessary medications, resulting in the potential for unnecessary psychotropic medications and adverse reactions. According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] Resident 16 (R16) was an [AGE] year old male admitted to the facility with diagnoses that included heart peripheral vascular disease and diabetes. Review of MDS reflected R16 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status. Review of monthly Physician orders reflected an anti-anxiety medication was ordered on 4/28/23 on an as needed basis, the Physician order did not have a stop date. On 08/08/23 at 09:06 AM, during an interview with Social Worker/Activity Director C, she reported she worked with the psychiatric group that comes to the facility and Nursing staff. When further questioned about stop…

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 error rate of less than five percent when two medication errors were observed from a total of twenty-eight opportunities for two residents (Resident #16 and #17) of five reviewed for medication administration, resulting in a medication error rate of 7.14% and the potential for reduced efficacy of medications and increased risk of adverse reactions/side effects. Findings include: Resident #17 (R17) Review of the medical record revealed that Resident #17 (R17) was readmitted to facility on 6/16/23 with diagnoses including diabetes mellitus. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/20/23 revealed that R17 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 13 (cognitively intact). Section N, of the same MDS, revealed that R17 had received insulin injections on 3 of the days since her 6/16/23 facility readmission. Further review of R17's medical record revealed an order dated 6/21/23 for Novolog FlexPen Insulin four times…

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 administer pneumococcal immunizations in accordance with the Center for Disease Control and Prevention (CDC) recommendations for two residents (#1, #23) of five residents reviewed resulting in the potential for server illness and complications from pneumococcal disease Findings Included: Resident #1 (R1) Review of the medical record revealed R1 admitted to the facility on [DATE] with diagnoses that included muscle weakness, hemiplegia and hemiparesis, osteoarthritis, insomnia, anxiety, and pseudobulbar affect. The Minimum Data Set (MDS) with an Assessment Reference Date of 7/9/23 revealed R1 scored 6 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). Review of R1's medical record demonstrated that she had received pneumococcal vaccination, PCV13, on 10/11/2017. No documentation of PCV20 or PPS23 vaccinations were offered or provided to resident R1. According to CDC (Center for Disease Control and…

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

Based on observation, interview, and record review the facility failed to ensure monitoring and inspection of resident bed frames and mattress for one resident (#23) of one resident reviewed for bed safety resulting in the potential for entrapment, injury, or death. Findings Included: Resident #23 (R23) Review of the medical record revealed R23 was admitted to the facility 08/21/2016 with diagnoses that included Alzheimer's disease, muscle weakness, dementia, psychotic disturbances, mood disturbance, anxiety, disc degeneration of the lumbar region, pain, spondylosis (wear and tear of spinal disk) of cervical region, insomnia, hyperkalemia (high potassium), osteoarthritis, and constipation. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/16/2023, revealed R23 Brief Interview of Mental Status (BIMS) was dashed out because resident cognition could not be assessed. During observation and attempted interview on 08/07/2023 at 10:08 a.m. R23 was observed lying in bed. R23 did not respond to verbal questions. R23's left side of the bed was pushed up…

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.