Havenwood Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure the correct administration of insulin per physician orders for 1 of 3 residents (R1) who received 20 units of Novolog (rapid acting used to lower blood sugar levels onset in 15 minutes) instead of the physician ordered Lantus (long-acting onset 3 to 4 hours and duration of 24 hours). Findings included: R1's annual Minimum Data Set (MDS) dated [DATE], identified intact cognition with no behaviors. Her diagnoses include diabetes mellitus (DM) and received insulin injections 7 out of 7 days a week. R1's care plan dated 9/18/25, identified a potential for alteration in nutrition related to obesity, diabetes, and chronic pain. Staff were directed to offer snacks two times a day. Medicate as ordered. Follow diabetic protocols. Monitor continuous glucose monitoring (CGM) as ordered. Monitor for signs and symptoms of hypoglycemia/hyperglycemia (low blood/high blood sugars). R1's physician orders identified: -Start date 3/21/25, bedside glucose…

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 document review, the facility failed to ensure medications were secured at all times in 1 of 3 medication carts used. This had the potential to affect 20 residents whose medications were stored in medication cart. Additionally, the facility failed to ensure medication was labeled with clear and unaltered administration instructions to prevent potential error for 1 of 3 residents (R4) observed to receive medication.Findings include:R4's admission Minimum Data Set (MDS) dated [DATE], diagnosis: multiple sclerosis (MS) (a chronic autoimmune disease affects the central nervous system damaging the protective covering of nerve fibers with symptoms of muscle weakness, spasms or stiffness, and problems with balance and coordination). R4's provider order dated 9/6/25, identified: -Baclofen (muscle relaxant) tablet 20 milligrams (mg); amount 1 1/2 tabs (30mg); oral twice a day 7:00 a.m. and 9:00 p.m. -Baclofen tablet 20 mg 1 tablet oral twice a day 12:00 p.m. and 5:00 p.m. Special…

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 document review the facility failed to report an allegation of neglect of care to the state agency (SA) for 1 of 3 residents (R1) reviewed who alleged neglect of care.R1's Resident Face Sheet indicated she admitted to the facility on [DATE]. R1's diagnosis included atrial fibrillation, adult failure to thrive and hypertension. R1's Individual Resident Care Plan dated 6/19/25, indicated she required assistance with repositioning, toileting and wheelchair mobility and displayed no behaviors. R1's Progress Note dated 6/22/25, indicated R1's family spoke with nurse regarding R1's condition. R1's family insisted R1 be sent to the emergency department because they felt facility's care of R1 was poor. R1 had not been eating or drinking much and refusing to take her medications. Family asked for boxes to pack up R1's belongings and said they would not be bringing R1 back to the facility. R1's Progress Note dated 6/23/25, indicated social services designee (SSD) called and spoke with R1's family…

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 document review the facility failed to utilize assistance devices (transfer belt) and provide a hazard free environment as care planned for 3 of 4 residents (R1, R3, R4) reviewed for falls. Findings include: R1's Resident Face Sheet indicated she admitted to the facility 8/21/24, with diagnosis that included fracture of left scapula, weakness, moderate dementia and back pain. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and indicated she had upper extremity impairments to one side. The MDS indicated R1 required substantial to maximal assistance to transfer and stand and indicated ambulation was not attempted due to medical condition or safety concerns. R1's MDS indicated she had sustained two or more falls since the prior assessment with no injury and two or more falls with minor injury. R1's care plan dated 6/5/25, identified a risk for falls and decreased physical mobility related to left shoulder injury, muscle weakness and inability 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, and interview, the facility failed to have a system in place to ensure water temperatures were maintained a comfortable temperature for 2 of 13 residents (R22 ,R45) who resided on Maple Lane unit reviewed for complaints of cold-water temperatures. This had the potential to affect all 13 residents residing who resided on Maple Lane unit. Findings include: R22's annual Minimum Data Set (MDS) dated [DATE], identified R22 had severe cognitive impairment and was dependent on staff for bathing, dressing and grooming. R45's quarterly MDS dated [DATE], identified R45 had moderate cognitive impairment and was independent with dressing and grooming and required supervision with bathing. During interview on 2/10/25, at 1:45 p.m. family member (FM)-H stated R22 did not have hot water in his room. Staff had to take R22 to another wing in the facility for his showers as there wasn't any hot water on the wing R22 resided. FM-H felt it was terrible the residents had to wash up in cold water and were carted…

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 document review, the facility failed to ensure flooring was maintained in a safe manner for 1 of 1 resident (R49) reviewed for environment. Findings include: R49's quarterly Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment and had non-Alzheimer's dementia. During observation on 2/11/25 at 8:42 a.m., the floor in R49's room had a black substance built up on the seams between the flooring tiles in the room which covered approximately 50 percent of the floor. When walking on the black substance between the seams would stick to your shoes. During an interview on 2/12/25 at 11:44 a.m., housekeepers (HSK)-A and HSK-B stated R49's room was cleaned about three days a week and included sweeping and mopping the floor. They stated the stuff coming up between the tiles was sticky and not sure if it was cleanable. HSK-A and HSK-B stated sometimes they can get a little bit of it to come off, but within a couple of days more sticky stuff would come up through 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 document review, the facility failed to accurately code a significant weight loss on the Minimum Data Set (MDS) for 1 of 3 residents (R30) reviewed for nutrition Findings include: R30's quarterly MDS dated [DATE], identified R30 had a severe cognitive impairment and diagnoses t included diabetes, hemiplegia (paralysis on one side of the body), hemiparesis (weakness on one side of the body), chronic kidney disease, dysphasia (difficulty swallowing food or liquids) and aphasia (a comprehension and communication (reading, speaking, or writing) disorder resulting from damage or injury to the specific area in the brain). R30's weight was 153 pounds (lbs.) and R30 had no loss of 5% or more in the last month or loss of 10% or more in last 6 months. R30's medical records identified the following weights: - 7/14/24 172.5 lbs. - 1/3/25 153.3 lbs. Which is a 11.13 percent decrease in weight in 180 days. R30's Mini Nutrition assessment dated [DATE], identified the registered dietician would continue…

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 document review, the facility failed to develop a baseline care plan to ensure immediate resident needs were identified and addressed for 1 of 4 residents (R211) whom were newly admitted . Findings include: R211's Discharge summary dated [DATE], identified R211 was hospitalized for acute blood loss anemia and acute knee pain due to gout. R211's bleeding resolved and was restarted on anticoagulant medications as well as gout medications to treat his left knee pain. R211's progress note dated 1/24/25, identified R21 arrived at the facility to be admitted . R21 had a foley catheter in place, which would remain until his urology appointment in March. R21 had experienced a lot of falls at home prior to admission and would need assist of one and walker with ambulation. On 2/11/25, at 8:14 a.m. R211 was observed sitting in a recliner watching television in his room. The door to the room was open and R211's foley catheter bag was visible attached to the side of his recliner. R211'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed identify enhanced barrier precautions (EBP) interventions for 1 of 1 resident (R18) reviewed with a surgical wound. Findings include: R18's admission minimum data set (MDS) dated [DATE], identified R18 was admitted on [DATE], was cognitively intact and was receiving surgical wound care. R18's orders report dated 1/24/25, identified staff were to monitor R18's dressing placement and for signs and symptoms of infection such as increased redness, warmth, swelling, drainage, or generalized fever over 101. Staff were to notify the charge nurse so they could notify the provider. R18's care plan revised 2/12/25, identified R18 recently had a hip replacement and required staff to complete dressing changes and monitor and report any signs or symptoms of infection. The plan further identified R18 required assist of one staff for transfers, toileting and dressing. However, the plan failed to address R18's need for EBP. During observation on 2/10/25 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 interview and document review, the facility failed to revise and update a comprehensive care plan for 1 of 3 residents (R10) reviewed for weight loss. Findings include: R10's quarterly minimum data set (MDS) dated [DATE], identified R10 was cognitively intact and required set-up assistance for eating, and had a weight loss that was not a physician-prescribed weight-loss regimen. R10's progress notes, identified the following: - 10/16/24, registered dietician (RD)-A identified R10 weighed 115 lbs. and had been drinking a nutritional supplement daily. RD-A's recommendations included staff to offer and provide high calorie, high protein shakes. - 11/5/24 RD-A identified R10's weight had been stable for one week and recommendations included high caloric foods per patient request and continue to follow up and monitor weights. - 11/12/24 RD-A identified staff were to provide alternate meals upon request, offer high calorie/high protein shakes, food items to help promote weight gain, and to monitor intake and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure a bed was kept in the low position to prevent falls for 1 of 2 residents (R40) reviewed for falls. Findings include: R40's Falls Risk assessment dated [DATE], identified R40 was at high risk for falls. R40's quarterly Minimum Data Set (MDS) dated [DATE], identified R40 had moderate cognitive impairment and a diagnosis of unspecified convulsions. R40 required substantial/maximal assistance to roll left and right. R40's care plan revised 12/19/24, identified R40 had decreased physical mobility with potential for falls related to lower extremity weakness, impaired mobility related to general muscle weakness and poor coordination manifested by inability to transfer, wheel self, turn and reposition self, sit up, lie down or get feet and legs into bed independently. R40 was unable to ambulate. The care plan directed to follow fall interventions as listed in nursing orders. R40's nursing order dated 2/6/25, identified R40's fall…

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 document review, the facility failed to comprehensively assess and implement interventions to prevent weight loss for 1 of 3 residents (R30); and failed to implement assessess nutrition interventions to prevent further weight loss for 1 of 3 residents (R10) reviewed for nutrition. Findings include: R30: R30's quarterly MDS dated [DATE], identified R30 had severe cognitive impairment and diagnoses included diabetes, hemiplegia (paralysis on one side of the body), hemiparesis (weakness on one side of the body), chronic kidney disease, dysphasia (difficulty swallowing food or liquids) and aphasia (a comprehension and communication (reading, speaking, or writing) disorder resulting from damage or injury to the specific area in the brain). R30's weight was 153 pounds (lbs) and R30 had no loss of 5% or more in the last month or loss of 10% or more in last 6 months. R30's Mini Nutrition assessment dated [DATE], identified the registered dietician would continue R30's current plan 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 interview and document review, the facility failed to ensure a complete medical record was maintained to include the physician reviewed orders, treatments and care plans during routine visits for 1 of 2 residents (R7) reviewed during medication administration. Findings include: R7's undated Resident Face Sheet identified admission date 6/13/24. Diagnoses included epilepsy, diabetes, pain, autistic disorder, fibromyalgia and chronic kidney disease. R7's Physician Order Report dated 10/7/24 to 1/7/25, lacked complete orders. The signed physician order report identified 12 ordered medications on page one and two of the documents. Of the 12 orders, only nine were legible as the document had faded and incomplete printed areas over the pages. R7's activities of daily living (ADL) order with start date 8/15/20, appeared to order a non-pharmaceutical intervention for pain, however, was illegible as the scanning was faded and incomplete in areas. Pages three and four of the order report were not available. When interviewed on 2/12/25, at 11:52 a.m. the medical records staff member…

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 document review, the facility failed to ensure long term residents received routine physician visits every 60 days as required for 2 of 2 residents (R7, R39) reviewed during medication administration. Findings include: R7: R7's quarterly Minimum Data Set (MDS) dated [DATE], identified R7 had intact cognition. Diagnoses included epilepsy, diabetes, pain, autistic disorder, polyneuropathy, fibromyalgia, conduct disorder, and chronic kidney disease. R7's medical record identified R7 had physician visits for his primary care on 7/26/24 and 1/8/25. R7's medical record lacked documentation of routine 60 day visits for 165 days, from 7/26/24 to 1/8/25. During interview on 2/12/25, at 11:52 a.m. the medical record staff (MR)-F stated she was only able to find documentation of physician visits July 25, 2024 and January 8, 2024. It appeared a visit had been scheduled in September and November 2024, however the visits were not completed or billed. MR-F thought they must have been canceled for some…

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 document review, the facility failed to comprehensively assess and implement interventions for identified behaviors for 1 of 3 residents (R17) reviewed for dementia care. Findings include: R39's quarterly Minimum Data Set (MDS) dated [DATE], identified R39 had a severe cognitive impairment, R39 used antipsychotic medication daily and exhibited no hallucinations, delusions or behaviors during the assessment period and had a diagnosis of dementia. R39's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 8/21/24, identfiied R38 was unable to complete BIMS interview. R39 was at risk for alteration in thought process with potential for anxiety, falls, and decreased mobility related to cognitive decline secondary to unspecified dementia.Would proceed to anticpate R39 needs and intervene when making poor decisions. R39's care plan revised 11/26/24, identified R39 had alteration in thought process with potential for anxiety related dementia and nursing home placement manifested by impaired…

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 document review, the facility failed to ensure as needed medication from facility standing orders were transcribed and administered appropriately to reduce the risk of complications for 1 of 1 resident (R56) reviewed for loose stools. Findings include: R56's admission Minimum Data Set (MDS) dated [DATE], identified R56 had mild cognitive impairment and was continent of both bowel and bladder with no constipation present. A diagnosis of diarrhea was included. R56's Medication Administration Record (MAR) dated 2/1/25 to 2/10/25, identified loperamide (an antidiarrheal) OTC (over the counter) medication was added on 2/5/25. Instructions were for loperamide 2 milligrams (mg) to be administered four times per day for diarrhea. Special instructions instructed to give 2 mg of the medication after each loose stool, not to exceed 8 mg in a 24-hour period. The medication was scheduled to be given every day at 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. Staff initialed the medication…

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 document review, the facility failed to ensure consulting pharmacist recommendations were acted upon, addressed, and documented in the medical record for 1 of 5 residents (R51) reviewed for unnecessary medication use. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], identified R5 had intact cognition. Diagnoses included paroxysmal atrial fibrillation, heart disease, and secondary hypertension. R5's Physician Order Report signed 10/9/24, identified R5's current medication regimen with their corresponding start dates and included the following: Eliquis (an anticoagulant) 2.5 milligrams (mg) two times per day, aspirin (reduces the formation of blood clots) 81 mg every day, and Diltiazem (to prevent chest pain) 120 mg every day. R5's Consultant Pharmacist's Medication Review dated August 2024, identified R5's medication regimen had been reviewed by the consulting pharmacist (CP) and listed an irregularity regarding the medication Diltiazem. The CP comment included…

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 document review, the facility failed to provide a face-to-face provider evaluation for continued use of a as needed (PRN) psychotropic medication for 1 of 2 residents (R39) reviewed for mood/behavior. Findings include: R39's quarterly Minimum Data Set (MDS) dated [DATE], identified R39 had severe cognitive impairment. R39 used antipsychotic medication daily and exhibited no hallucinations, delusions or behaviors during the assessment period. R39 had a diagnosis of dementia. R39's Physician order dated 1/21/25, identified Zyprexa (olanzapine) (an antipsychotic medication) 2.5 milligram (mg) tablets. Give 2.5 mg by mouth once a day as needed. Used for behaviors. Add note when given. Okay to stand until next face to face visit. R39's electronic medication administration record (EMAR) dated January 2025, identified R39 received Zyprexa 2. 5mg PRN on the following days; - On 1/23/25 at 2:36 a.m. for other - On 1/25/25 at 4:13 p.m. for behavior issues yelling at table R39's EMAR dated February…

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 document review, the facility failed to implement enhanced barrier precautions (EBP) for 1 of 1 resident (R211) reviewed for catheter care; and 1 of 1 resident (R18) reviewed with a surgical wound. Findings include: A CDC Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) manual, dated 7/2022, identified MDRO transmission within a nursing home was common and contributed to substantial resident morbidity and mortality. The feature outlined EBP were defined as, . expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing . MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities . residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The feature…

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 document review the facility failed to notify the physician of a change in condition for 1 of 3 residents (R1) who was sleeping more than usual, not eating and not taking medications. Findings include: R1's Resident Face Sheet identified diagnosis that included dementia with behavioral disturbance, depression, hypertensive kidney disease, open wound and agitation. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated she displayed no rejection of care behaviors during the basement period. The MDS indicated R1 was able to eat independently after set up and weighed 116 pounds. R1's care plan dated 3/25/24, identified a self care deficit related to dementia and decreased physical mobility. The care plan indicated R1 did not ambulate and required assist of two staff for transfers. The care plan identified an alteration in nutrition related to a poor appetite at times, pain and cognitive dysfunction. The care plan indicated R1 was able to feed…

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 document review, the facility failed to identify and assess for a change of condition for 1 of 3 residents (R1) who began sleeping more, missing medications due to sleep and not drinking/eating regularly. Additionally, R1's family member had to voice concerns regarding deteriorating health condition for initiation of hospital transfer. Findings include: R1's Resident Face Sheet identified diagnosis that included dementia with behavioral disturbance, depression, hypertensive kidney disease, open wound and agitation. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated she displayed no rejection of care behaviors during the basement period. The MDS indicated R1 was able to eat independently after set up and weighed 116 pounds. R1's care plan dated 3/25/24, identified a self care deficit related to dementia and decreased physical mobility. The care plan indicated R1 did not ambulate and required assist of two staff for transfers. The care…

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 document review the facility failed to assess the use of a wedge cushion used to keep a resident (R1) in bed as a potential restraint for 1 of 3 residents reviewed for rights. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment. The MDS indicated R1 had two or more falls since the last assessment date and did not use restraints. R1's care area assessment (CAA) dated 12/6/23, identified multiple falls and indicated after medication adjustments R1 was more alert and moved around more. The CAA indicated R1 was restless and liked to fidget with things. The CAA identified fall interventions that included a contour mattress, low bed against the wall and a wedge cushion to position in bed. R1's care plan dated 3/18/24, identified decreased physical mobility with potential for falls. The care plan identified general weakness, poor coordination, restlessness and impulsive behaviors. The care plan indicated R1 was unable to turn…

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 document review, the facility failed to ensure nutrient and/or calorie substantive snacks were offered and readily available for 3 of 6 residents (R6, R50, R308) who voiced concern at a resident council meeting. This had the potential to affect all residents residing at the facility. In addition, the facility failed to prevent a greater than 14-hour lapse between dinner and breakfast meals and without offering a snack in the evening. Findings include: During a resident council meeting on 4/3/24 at 2:00 p.m., the following residents stated concerns with recent changes to the snack cart: R6, whose quarterly Minimum Data Set (MDS) dated [DATE] identified intact cognition, stated the facility hardly ever comes around with snacks. They used to, but the cart went away. R308, whose admission MDS dated [DATE] identified moderately impaired cognition, added they didn't come around at all with the snack cart. R50, whose quarterly MDS dated [DATE] identified moderately impaired…

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 document review, the facility failed to ensure allegations of abuse were reported for 1 of 6 residents (R28) reviewed for abuse. This had the potential to affect residents who he provided care for. Findings include: R28's significant change Minimum Data Set (MDS) dated [DATE], identified R28 had diagnoses which included anxiety, depression, bipolar disorder, and secondary Parkinsonism (when symptoms similar to Parkinson disease are caused by certain medicines, a different nervous system disorder or another illness). In addition, R28's MDS identified she was cognitively intact, was understood by others and was able to understand others, and further identified she had no rejections of care, delusions, or hallucinations. R28's care plan dated 4/20/20, identified R28 as a vulnerable adult, one of the listed interventions was to invite designated family to care conferences, encourage family and resident to voice question or concerns. During an interview on 4/1/24 at 3:32 p.m., R28 stated there…

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 document review, the facility failed to ensure allegations of abuse were investigated for 1 of 6 residents (R28) reviewed for abuse. This had the potential to affect residents who he provided care for. Findings include: R28's significant change Minimum Data Set (MDS) dated [DATE], identified R28 had diagnoses which included anxiety, depression, bipolar disorder, and secondary Parkinsonism (when symptoms similar to Parkinson disease are caused by certain medicines, a different nervous system disorder or another illness). In addition, R28's MDS identified she was cognitively intact, was understood by others and was able to understand others and further identified she had no rejections of care, delusions, or hallucinations. R28's care plan dated 4/20/20, identified R28 as a vulnerable adult, one of the listed interventions was to invite designated family to care conferences, encourage family and resident to voice question or concerns. During an interview on 4/1/24 at 3:32 p.m., R28 stated…

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 document review and interview the facility failed to verify nurse aide registration for 1 of 5 nursing assistants (NA-A) prior to allowing the individual to serve as a nurse aide and work directly with residents in the facility after the 4 month training period. This had the potential to affect residents who he provided care for. Findings include: Review of NA-A's personnel file identified date of hire as 10/23/23, and placed on an investigatory suspension on 4/1/24. No verification of NA-A nursing assistant certification was located in the personnel file. A search of the nursing assistant registry revealed he was not currently registered. During an interview on 4/5/24 at 9:22 a.m., the administrator stated NA-A took his nursing assistant skills test on 12/22/23, but did not take his knowledge test related to a communication misunderstanding between the testing site and the facility. NA-A showed the facility proof of passing the skills test after the testing date. The administrator stated it was an expectation that after the four month training period a nursing assistant…

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 document review, the facility failed to ensure nursing staff observed medication administration for 1 of 1 residents (R30) observed to self-administer a nebulizer treatment who was not assessed to be able to do so. Findings include: R30's quarterly Minimum Data Set (MDS) dated [DATE], identified R30's diagnoses included aphasia (a language disorder caused by damage in a specific area of the brain that controls language expression and comprehension), asthma, anxiety, depression, and morbid obesity. R30's MDS identified her as severely cognitively impaired, with behaviors (verbal/vocal symptoms, disruptive sounds), rarely/never was understood, and rarely understood others. R30's current Physician Order Report dated 4/5/24, identified R30 had an order for albuterol sulfate solution (used to treat wheezing and shortness of breath caused by breathing problems such as asthma) for nebulization 2.5 milligrams (mg) per 3 milliliters (ml) for inhalation for moderate persistent asthma…

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 document review, the facility failed to ensure conflicting directives for emergency care and treatment were clarified to ensure resident wishes would be implemented correctly in an emergent situation for 1 of 15 residents (R28) reviewed for advanced directives. Finding include: R28's significant change Minimum Data Set (MDS) dated [DATE], identified R28 had diagnoses which included anxiety, depression, bipolar disorder, and secondary Parkinsonism (when symptoms similar to Parkinson disease are caused by certain medicines, a different nervous system disorder or another illness). In addition, R28's MDS identified she was cognitively intact, was understood by others and was able to understand others and further identified she had no rejections of care, delusions, or hallucinations. On [DATE] at 12:36 p.m., R28's electronic medical record (EMR) identified her as do not resuscitate (DNR) on her face sheet. On [DATE] at 12:37 p.m., a review of R28's Uniform Code Level Directions for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure the long term care ombudsman was notified of resident transfers for 1 of 2 residents (R26) reviewed for hospitalization. Findings include: R26's quarterly Minimum Data Set (MDS) dated [DATE], identified R26 had diagnoses which included dementia, hemiplegia (paralysis on one side of the body), seizure disorder, and depression. R26's MDS identified she was cognitively intact. R26's progress notes revealed the following: -11/16/23, identified R26 was sent to the hospital at approximately 7:05 p.m -1/13/24, identified R26 was sent to the hospital at approximately 4:15 p.m R26's medical record lacked evidence notification was sent to the state ombudsman's office regarding the transfers to the hospital. An email communication from the ombudsman dated 4/4/24, indicated the ombudsman's office had not received any communications regarding hospitalizations since 4/2021. During an interview on 4/4/24 at 1:56 p.m., social worker (SW)-A stated the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to provide the resident or their representative a written bed hold notice for 1 of 2 residents (R26) reviewed for hospitalization. Findings include: R26's quarterly Minimum Data Set (MDS) dated [DATE], identified R26 had diagnoses which included dementia, hemiplegia (paralysis on one side of the body), seizure disorder, and depression. R26's MDS identified she was cognitively intact. R26's progress notes revealed the following: -11/16/23, identified R26 was sent to the hospital at approximately 7:05 p.m -1/13/24, identified R26 was sent to the hospital at approximately 4:15 p.m R26's medical record lacked evidence written notification was given to the resident or the resident's representative for either hospitalization. During an interview on 4/4/24 at 12:46 p.m., nurse consultant (NC)-A stated residents would sign a bed hold on admission to designate if they would want their bed held in the future. During an interview on 4/4/24 at 1:38 p.m., social…

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 document review the facility failed to ensure residents who were at risk for pressure ulcers were repositioned timely as directed by the residents care plan for 1 of 2 residents (R30) reviewed for pressure ulcers. Findings include: R30's quarterly Minimum Data Set (MDS) dated [DATE], identified R30's diagnoses included aphasia (a language disorder caused by damage in a specific area of the brain that controls language expression and comprehension), asthma, anxiety, depression, and morbid obesity. R30's MDS identified her as severely cognitively impaired, with behaviors (verbal/vocal symptoms, disruptive sounds), rarely/never was understood, and rarely understood others. In addition, R30's MDS identified she was at risk for pressure ulcers and was always incontinent of bowel and bladder. R30's care plan dated 11/29/21, identified R30 had an alteration in elimination. Interventions included to check for incontinence every two to three hours. R30's care plan indicated R30 was 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 document review, the facility failed to ensure nebulizer and tubing were changed in a timely manner for 1 of 1 residents (R30) reviewed for respiratory care. Findings include: R30's quarterly Minimum Data Set (MDS) dated [DATE], identified R30's diagnoses included aphasia (a language disorder caused by damage in a specific area of the brain that controls language expression and comprehension), asthma, anxiety, depression, and morbid obesity. R30's MDS identified her as severely cognitively impaired, with behaviors (verbal/vocal symptoms, disruptive sounds), rarely/never was understood, and rarely understood others. In addition, R30's MDS identified she was receiving oxygen therapy. R30's care plan dated 11/29/21, did not address respiratory care and/or nebulizer treatments. R30's Physician Order report dated 3/5/24-4/5/24, did not address care and changing of nebulizer and tubing. R30's medical record lacked direction and/or documentation for nebulizer and tubing changes.…

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 document review, the facility failed to ensure medications were administered in accordance with physician orders for 2 of 6 residents (R30, R39) observed to receive medication. A total of two errors out of 27 opportunities were identified resulting in a facility error rate of seven percent. Findings include: R30: R30's quarterly Minimum Data Set (MDS) dated [DATE], identified R30's diagnoses included aphasia (a language disorder caused by damage in a specific area of the brain that controls language expression and comprehension), asthma, anxiety, depression, and morbid obesity. R30's MDS identified her as severely cognitively impaired, with behaviors (verbal/vocal symptoms, disruptive sounds), rarely/never was understood, and rarely understood others. R30's current Physician Order Report dated 4/5/24, identified R30 had an order for albuterol sulfate solution (used to treat wheezing and shortness of breath caused by breathing problems such as asthma) for nebulization 2.5…

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 medications with a shortened expiration period were labeled with an opened-on date and failed to ensure expired medications were disposed for one of two medication carts in the facility. This practice had the potential to affect all residents with medications stored in the facility. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and a diagnosis of multiple sclerosis. R2's provider orders dated 5/6/22, identified an order for Flonase Allergy Relief, one spray to each nostril two times per day related allergic rhinitis. R13's quarterly MDS dated [DATE], identified moderately intact cognition and a diagnosis of chronic obstructive pulmonary disease (COPD). R13's provider orders dated 5/3/23, identified an order for albuterol sulfate inhaler 90 micrograms (mcg) per actuation. Gve one to two puffs every four to six hours as needed for shortness of breath. During an observation on 4/5/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to assess 1 of 3 residents (R4) reviewed for nursing care assessment. While receiving assistance with a transfer, staff heard an audible tear which was not assessed by nursing staff on duty at the time of the incident. Findings include: R4's quarterly Minimum Data Set, dated [DATE], identified severe cognitive impairment and indicated she required total assistance from two staff to complete bed mobility and transfers. R4's care plan dated 4/11/23, identified impaired physical mobility related to Multiple Sclerosis, obesity and an inability to transfer. The care plan directed staff to provide assistance from two staff for bed mobility and provide total assistance from two staff for transfers using a bariatric ceiling lift. A report to the state agency (SA) dated 6/22/23, indicated on the morning of 6/22/23, nursing staff reported to unit manager that R4 appeared to have some swelling and increased pain to her right shoulder. Unit manager assessed R4 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.