The Emeralds At Grand Rapids LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN; CMS-10055) to 1 of 3 residents (R54) reviewed whose Medicare Part A coverage ended while in the facility. Findings included: R54's Notice of Medicare Non-Coverage (CMS-10123) dated 10/15/24, indicated R54's last day of skilled services was on 10/15/24 due to going on hospice services. The form was signed by R54 and dated 10/15/24. In addition, R54's medical record lacked evidence the required CMS-10055 had been reviewed and/or provided to R54 prior to their Medicare Part A coverage ending. R54's Census List indicated a payer change occurred on 10/16/24, to hospice private pay. R54's progress notes from 10/9/24 to 10/17/24, indicated R54 was a resident of the facility until discharge on [DATE]. During an interview on 3/27/25 at 8:01 a.m., the business office manager (BOM) stated she was responsible to give the residents the CMS 10123 and 10055 forms to the residents 3 days prior…

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 perform prescribed dressing changes to a pressure ulcer as ordered for 1 of 3 residents (R27) reviewed for pressure ulcers. Findings include: R27's annual Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition. Diagnoses included anemia, coronary artery disease and renal failure. R27 was at risk for pressure ulcers and had an unhealed unstageable pressure ulcer. R27's Medication Administration Record (MAR) dated 3/25, indicated orders were present from 3/7/25 to 3/20/25 to cleanse pressure ulcer with vashe. Loosely fill wound with vashe damped packing strip, ensure filling in tunnel and undermining. Leave out tail for easy removal. Cover with bordered foam dressing. Change twice daily and as needed. R27's MAR dated 3/25 lacked documentation dressing changes were completed on the following days: - Day shift 3/9/25, 3/13/25, 3/14/25, 3/16/25 through 3/18/25, and 3/20/25 - Evening shift 3/8/25 through 3/10/25, 3/14/25 through 3/16/25…

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 consistently monitor dialysis access site for 1 of 1 resident (R27) reviewed for dialysis care. Findings include: R27's annual Minimum Data Set (MDS) dated [DATE], indicated intact cognition. Diagnoses included anemia, end stage renal disease and diabetes. The MDS indicated R27 was on dialysis. R27's care plan dated 9/25/24, indicated R27 had a dialysis port to the right chest. The care plan lacked information related to R27's arteriovenous dialysis fistula in the right arm. R27's Order Summary report dated 2/6/24, indicated orders which included dialysis-monitor chest port post dialysis, dialysis-no IV. Blood draws, blood pressures on right arm. Fistula incision care and monitor dialysis site for bleeding. The order summary lacked to monitor the fistula bruit and thrill (swish sound coming from fistula indicating normal function) from fistula. Provider progress note dated 2/18/25, indicated R27 had right upper extremity fistula placed for dialysis on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure licensed staff were educated and competent in the administration of intravenous medications (IV) and/or the management and care of peripherally inserted central catheters (PICC) [a long thin tube inserted into a vein on the inside of the upper arm that extends into a larger vein leading to the heart for medication, blood, and nutrition administration] for 1 of 1 residents (R200) reviewed for PICC line care and management. This deficient practice had the potential to impact all residents at the facility who had IV/PICC access and/or received medications through IV/PICC access. Findings include: R200's admission Minimum Data Set (MDS) dated [DATE], indicated R200 was cognitively intact with the diagnoses of congestive heart failure, diabetes, and respiratory failure. R200's careplan initiated on 2/18/25, did not include R200's PICC line nor did it include goals and interventions for care of R200's PICC line. The Order Summary Current…

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 make sure pharmacy recommendations were addressed timely for 2 of 5 residents (R28, R33) reviewed for unnecessary medications. Findings include R28's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition, and diagnoses included heart failure, hypertension, and renal failure. R28's order summary report dated 12/12/24, indicated R28 was started on Quetiapine Fumarate oral tablet 25 milligrams (mg) one time daily by mouth for a diagnosis of other specified anxiety disorders. R28's Consultant Pharmacist Medication Regimen (PMR) Review dated 2/13/25, recommended the facility address the diagnosis for Quetiapine Fumarate. The PMR indicated CMS guidance for antipsychotic utilization in nursing facilities required an FDA approved diagnosis in chart to use the medication which other specified anxiety was not. The form had not been addressed or signed as completed. During interview on 3/27/25 at 10:43 a.m., the consultant pharmacist (CP)…

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 have an appropriate diagnosis for use of medication for 1 of 5 residents (R28) reviewed for unnecessary medications. Findings include R28's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition, and diagnoses included heart failure, hypertension, renal failure and post kidney transplant. R28's order summary report dated 12/12/24, indicated R28 was on Tacrolimus Oral 1mg capsule, take one by mouth every 12 hours for health maintenance. During interview on 3/27/25 at 10:43 a.m., the consultant pharmacist (CP) stated medications appropriate for a diagnoses of health maintenance included several different vitamins and minerals that a resident took as a preventative or maintenance dosing program. The CP stated Tacrolimus was an antirejection drug for patients who have received a transplant. The CP reviewed R28's chart and indicated R28 had a history of post kidney transplant and post kidney transplant would have been the appropriate…

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 have an appropriate diagnosis for use of an antipsychotic for 1 of 5 residents (R28) reviewed for unnecessary medications. In addition, the facility failed to complete orthostatic blood pressure (series of blood pressures taken while lying, sitting, and standing) monitoring for an antipsychotic medication for 1 of 1 residents (R33). Findings include R28's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition, and diagnoses included heart failure, hypertension, and renal failure. R28's order summary report dated 12/12/24, indicated R28 was started on Quetiapine Fumarate oral tablet 25 milligrams (mg) one time daily by mouth for a diagnosis of other specified anxiety disorders. R28's Consultant Pharmacist Medication Regimen (PMR) Review dated 2/13/25, recommended the facility address the diagnosis for Quetiapine Fumarate. The PMR indicated CMS guidance for antipsychotic utilization in nursing facilities required an FDA approved…

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 properly labeled with direction for use for 1 of 1 resident (R13). Findings include: R13's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R13 had intact cognition. Diagnoses included heart failure, hypertension, and renal insufficiency. R13's Order Summary Report dated 3/29/24, indicated R13 had ordered Diclofenac sodium topical gel, apply 2gms topically to shoulders, upper and mid back 4 times a day. During an observation of R13's room on 3/24/25 at 3:17 p.m., a box with a tube of diclofenac cream was noted on the shelf to the right of the bed. The box and the tube lacked any kind of label with resident name, medication dosage or times to administer. During an interview on 3/24/25 at 3:17 p.m., R13 stated the staff utilize the diclofenac cream on her back and just leave it on the shelf so it would be available when they needed it. During a second observation of R13's room on 3/25/25 at 2:06…

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, interviews, and documentation review the facility failed to properly provide maintenance to maintain bed wheel locks to prevent bed from moving during transfers for 1 of 3 residents (R2) resident reviewed for falls. Findings include: User-Service Manual for Joern's Bed Frames Easy-Care Bed dated 2020, identified to keep bed from rolling in the lowest position, press down on the locking lever to lock casters. The standard caster set comes with two locking casters placed at opposing corners of bed. Possible injury: before leaving the bed unattended, check that the lock feature was in locked position. Never leave an unlocked bed unattended. The Easy-Care Bed contained various parts that wear from normal use. R2's Fall Review Evaluation dated 10/2/24, identified at risk for falls. R2's displayed agitated behavior (verbally/physically abusive, socially inappropriate such as screams, disrobes, and self-abusive), unable to walk even when assisted by staff, and required hands-on assistance to move…

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 physician orders to obtain a Basic Metabolic Panel (BMP), and Urine Analysis (UA)/Urine Culture (UC) with susceptibility and sensitivity, timely for 1 of 3 residents (R1) reviewed, who was diagnosed with a urinary tract infection (UTI) Findings include: R1's significant change Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included vascular dementia, anxiety and R1 had severely impaired cognition. R1's progress note dated 6/3/24, revealed R1 was evaluated by the physician related to nursing requested resident to be seen regarding her agitation, behaviors, and multiple falls. Resident had fallen 7 times since her admission. Resident is disoriented to place and time. Physician discussed with family who stated resident smelt like urine and her room smelled of strong urine. Further, family reported resident frequently would get a urinary tract infection (UTI) and exhibited behaviors and more confusion when she had a UTI. New…

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 provide adequate supervision for 1 of 3 residents (R1) reviewed, who was cognitively impaired and able to leave the building without staff's knowledge into the courtyard which resulted in a fall and being able to exit the secured area. In addition, the facility failed to implement fall interventions for 1 of 3 residents (R1), who was at high risk for falls. Findings include: R1's significant change Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included vascular dementia, anxiety and R1 had severely impaired cognition. Further, MDS indicated R1 had two or more falls with no injury and one fall with injury. R1's care plan as of 6/18/24, indicated R1 had an alteration in cognition related to dementia and R1's daughter assists with decision making. R1 had a history of consistent wandering, pacing, agitation, restlessness/anxiousness, hallucinations, and history of eloping the facility. Due to these behaviors, R1 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 interview and document review, the facility failed to ensure discharge summary requirements were met, which included a recapitulation of resident's stay (a concise summary of the resident's stay and course of treatment in the facility) and a final summary of the resident's status at discharge, as well as communicating resident's condition upon discharge with receiving the facility for 1 of 1 residents (R1) reviewed. Findings include: R1's discharge Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included encounter for orthopedic aftercare following surgical amputation, and type 2 diabetes. Further MDS identified R1 had two or more falls with no injury and one fall with injury since previous assessment. Review of R1's Progress Notes revealed the following: -On 3/15/24, R1 was in bed and self-transferred to wheelchair. R1 did not press call light for assistance. R1 hit her head on the base of the table stand causing a 2 cm laceration to right forehead. R1 required first aid including…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure injuries following a fall were monitored for healing for 1 of 3 residents (R1) reviewed. Findings include: R1's discharge Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included encounter for orthopedic aftercare following surgical amputation, and type 2 diabetes. Further MDS identified R1 had two or more falls with no injury and one fall with injury since previous assessment. R1's Incident Review and Analysis dated 3/18/24, indicated R1 was found on floor on 3/15/24, after R1 had attempted to stand up from bed and fell forward. R1 had hit left forehead on the metal part of the bedside table causing bleeding and a 2-centimeter (cm) laceration. R1 had a new right below the knee amputation and thought she could stand independently. Review of R1's Progress Notes revealed the following: -On 3/15/24, R1 was in bed and self-transferred to wheelchair. R1 did not press call light for assistance. R1 hit her head on the base of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to ensure 1 of 1 residents (R1) was re-assessed for supervision with eating following a diet change order. Findings include: R1's admission Record indicated she admitted to the facility on [DATE], with diagnosis that included dysphagia (difficulty swallowing). R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment. The MDS indicated R1 required supervision or touching assistance to eat and identified a mechanically altered diet. R1's care plan updated 1/17/24, indicated Diet: mechanical soft diet, nectar thick liquids, no straws. Per speech therapy close supervision at meals. Remind R1 to clear between cheek/lip and teeth with tongue. R1 demonstrated good tongue range but low motivation/awareness to clear on her own. R1's care plan was updated to resolved on 3/20/24, following surveyor inquiry. R1's Speech Therapy SLP (Speech and language pathologists) Evaluation and Plan of Treatment dated 12/22/23, identified 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 interview and document review, the facility failed to ensure the resident [NAME] of Rights were provided in writing and ongoing for residents of the facility for 5 of 5 residents (R7, R15, R26, R43, R50) interviewed during resident meeting. This deficient practice had the potential to affect all 54 residents residing in the facility. Findings include: R7 quarterly Minimum Data Set (MDS) dated [DATE], identified R7 had no cognitive impairment. R15 admission MDS dated [DATE], identified R15 had no cognitive impairment. R26 admission MDS dated [DATE], identified R26 had no cognitive impairment. R43 significant change MDS dated [DATE], identified R43 had no cognitive impairment. R50 significant change MDS dated [DATE], identified R50 was cognitively intact. On 1/9/24 at 10:02 am, R7, R15, R26, R43, and R50 stated they knew what the Residents' [NAME] of Rights was and on admit was told to read the rights but was not provided a copy. On 01/09/24 04:29 p.m., the social services designee (SDD) stated admission…

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 have a process to assess, offer and provide the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits of the pneumococcal vaccine for 4 of 5 residents (R7, R13, R14, R24) reviewed for immunizations. This had the potential to affect all residents who were eligible for the pneumococcal booster. Findings include: R7's quarterly Minimum Data Set (MDS) dated [DATE], identified R7 was [AGE] years old and had diagnoses of type 2 diabetes mellitus and heart failure. R7's immunization record undated, identified R7 received the pneumococcal polysaccharide vaccine (PPSV23) on 6/10/14, and received the pneumococcal conjugated vaccine (PCV-13) on 11/22/16. R7's medical record did not include evidence R7 or R7's representative received education regarding pneumococcal vaccine booster and there was no indication R7 was offered the pneumococcal vaccine per CDC guidance. R13's admission MDS dated [DATE], identified R13 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 document review the facility failed to ensure preventative maintenance and weight calibration was conducted on three scales. This had the opportunity to affect 29 residents at the facility who are routinely weighed with these scales. Findings include: On 1/9/24 at 3:20 p.m., the director of maintenance (DOM) stated there was no scheduled preventative maintenance or scheduled weight calibration for the three wheelchair scales in the facility. The DOM stated there were no records of weight calibration conducted on the scales. The DOM stated the importance of accurate weights was residents' care and well-being. On 1/10/24 at 9:41 a.m., licensed practical nurse (LPN)-A stated the maintenance department conducts preventative maintenance on the wheelchair scales on a regular basis. On 1/10/24 at 11:35 a.m., a Detecto scale technical support representative stated preventative maintenance and weight calibration should be conducted according to the Detecto preventative maintenance…

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 clothing (other than a hospital type gown) was offered or provided for 1 of 3 residents (R205) reviewed for dignity. In addition, the facility failed to ensure bathing was offered or provided for 1 of 3 residents (R5) reviewed for dignity. The facility also failed to ensure a Medicare notification of non-coverage for therapy was delivered in a private and dignified manor for 1 of 3 residents (R42) reviewed for resident rights. Findings include: R205: R205's admission Minimum Data Set (MDS) dated [DATE], identified R205 had moderate cognition, exhibited no rejection of care, and required assistance with ADL's including dressing, bed mobility, wheelchair locomotion and transfers. R205's diagnoses included right femur fracture and left tibia fracture. R205's care plan dated 1/4/24, identified a self-care deficit related to weakness. Interventions included assistance with ADL's including personal hygiene, dressing, and locomotion.…

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 self-administration of medications were assessed for safety and care planned accordingly to reduce the risk of an adverse event for 1 of 1 residents R31 reviewed for self-administration of medication. Findings include: R31's quarterly Minimum Data Set (MDS) dated [DATE], identified R31 had diagnoses of chronic respiratory failure (an absence of enough oxygen in the tissues to sustain bodily functions), dependence on respirator, right heart failure (chronic condition in which the heart doesn't pump blood as well as it should), morbid obesity, type 2 diabetes mellitus, hypertension and had a tracheostomy (an opening in the trachea [windpipe] from the outside to allow air and oxygen to reach the lungs). In addition, R31's MDS identified R31 was cognitively intact. R31's current physician order report undated, identified an order for miconazole nitrate powder 2% apply to itching or other topically as needed. Self-Administration of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure 1 of 1 resident (R23) had access to their call light. Findings include: R23's Minimum Data Set (MDS) dated [DATE], indicated R23 had severe cognitive impairment with the diagnoses of heart failure, end stage renal disease, and dementia. R23's care plan intervention dated 12/6/23, listed under fall risk, instructed staff to place call light within reach when in bed. During an observation on 1/7/24 at 2:51 p.m., R23 was in their room seated in a recliner. R23's call light was out of reach on the floor between the night stand and bed. During an observation on 1/8/24 at 4:09 p.m., R23 was in bed. The call light was on top of R23's bed covers. During an observation on 1/9/24 at 8:06 a.m., R23 was in their room in a recliner. R23's call light was out of reach on the floor between R23's bed and nightstand. Licensed practical nurse (LPN)-A entered R23's room, placed a clothing cover up on R23 for breakfast, and then left the room without…

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 correctly code Minimum Data Set (MDS) Section L. Oral/Dental Status to ensure dental issues were addressed in the plan of care for 1 of 1 resident (R12) reviewed for MDS accuracy. Findings include: R12's significant change MDS dated [DATE], identified R12 was cognitively intact with diagnoses of end stage renal disease and diabetes. R12's admission MDS dated [DATE], and significant change MDS dated [DATE], Section L. Oral /Dental Status both indicated R12 did not have any broken, cracked, or chipped teeth, dental pain, or other dental abnormalities. R12's undated, care plan did not include dental concerns or dental interventions related to R12's impaired dental status. The Teeth/Dentures section of R12's admission record dated 9/19/23, indicated R12 had their own teeth with no dentures or partials. The dental section did not identify broken teeth, any dental issues, nor was the unable to assess option selected to indicate R12's teeth…

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 provide quarterly care conferences for 1 of 4 residents (R17) reviewed for care planning. Findings include: R17's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R17 was cognitively intact. Diagnoses included depression, psychotic disorder, and schizophrenia. Review of R17's care conference forms and progress notes identified care conferences were held on 11/8/23, and 2/3/23. There was no other documentation of care conferences for R17. On 1/4/24 at 2:46 p.m., R17 stated there had not been a care conference in 2023, other than 11/23, and possibly a second one but she could not recall the date. During an interview on 1/9/24 at 11:26 a.m., licensed practical nurse (LPN)-A stated care conferences were held every quarter while the resident was in the facility. The care conference was needed to discuss the treatment plan for the resident and to ensure the resident's wishes were taken into account when updating the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure routine bathing was offered or provided to promote good hygiene for 1 of 5 residents (R5) reviewed for activities of daily living (ADLs) and who was dependent on staff for their cares. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], identified R5 was cognitively intact, demonstrated no rejection of care behaviors, and required substantial assistance with ADL's including showering/bathing, and transfers. R5's care plan, revision date 12/21/23, identified R5 would be dressed, groomed, and bathed per facility policy and would accept assistance with self cares. The plan identified R5 required assistance with personal hygiene, showering/bathing and transfers. However, the plan lacked any evidence for when or how (i.e., frequency, type) R5's bathing would be completed; nor did the plan outline any refusal of care behaviors. On 1/7/23 at 2:27 p.m., R5 stated she was scheduled for baths twice weekly on Tuesday 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 appropriately position 1 of 3 residents (R24) reviewed for pressure ulcers. Findings include: R24's quarterly Minimum Data Set (MDS) dated [DATE], identified R24 had diagnoses that included enterocolitis due to Clostridium difficile (C. diff), quadriplegia (severe form of paralysis that affects all four limbs and the torso), acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), chronic heart failure (condition in which the heart doesn't pump blood as well as it should), Methicillin resistant Staphylococcus aureus (MRSA) infection, and had a colostomy (opening in the large intestine to facilitate removal of feces from the body). R24's MDS further identified he was cognitively intact, required extensive assistance with activities of daily living (ADLs), and was at risk for pressure ulcers. R24's current physician order report undated, did not include the use of any adaptive…

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 follow care plan interventions for 1 of 2 residents (R33) reviewed for smoking. Findings include: R33's quarterly Minimum Data Set (MDS) dated [DATE], identified R33's diagnoses included spastic quadriplegic cerebral palsy (condition that affects movement and posture), dysphagia (condition with difficulty in swallowing food or liquid), emphysema (lung disease which results in shortness of breath), abnormal involuntary movements, and speech disturbances. In addition, R33's MDS identified him as cognitively intact and required total staff assistance for all activities of daily living (ADLs). R33's care plan dated 10/18/23, identified R33 was at risk for accidents related to safe smoking and required extensive staff assistance to smoke. R33's interventions included: -wearing a smoking apron -staff directed to assist resident by placing cigarette in resident's mouth using an extension holder -staff to light cigarette -staff to supervise…

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 tracheostomy cares were followed for 1 of 1 resident (R31) reviewed for tracheostomy (an opening in the trachea [windpipe] from the outside to allow air and oxygen to reach the lungs) care. In addition, the facility failed to ensure oxygen use parameters were followed and oxygen tubing was changed in a timely manner for 1 of 2 residents (R31) reviewed for respiratory care. Findings include: R31's quarterly Minimum Data Set (MDS) dated [DATE], identified R31 had diagnoses which included chronic respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), dependence on respirator (ventilator) status, diabetes mellitus, and anxiety. R31's MDS also identified he was cognitively intact and he received oxygen therapy, suctioning, tracheostomy care, and non-invasive mechanical ventilator. R31's care plan dated 12/56/23, identified R31 had a tracheostomy with a goal of having no signs or…

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 dialysis assessments and treatments were completed as ordered and documented per policy for 2 of 2 residents (R43 and R12) reviewed for dialysis care. Findings include: R43: R43's significant change Minimum Data Set (MDS) dated [DATE], indicated R43 was cognitively intact, and diagnoses included diabetes and end stage renal disease. R43 currently received dialysis. R43's care plan dated 1/11/24, informed staff R43 was at risk for complications related to dialysis and the interventions instructed staff to call 911 for uncontrolled bleeding, and provide treatment and dressing per protocol. R43's Order Summary dated 1/11/24, included the following orders: modified renal diet, check blood glucose before meals, complete dialysis communication Tuesday, Wednesday, and Saturday (Tue-Thu-Sat), dialysis Tue-Thu-Sat remember to send a snack, daily weight, dialysis vital signs one time a day after dialysis, and monitor dialysis site 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 consultant pharmacist recommendations were addressed for 1 of 5 residents (R31) reviewed for unnecessary medications. Findings include: R31's quarterly Minimum Data Set (MDS) dated [DATE], indicated R31's diagnoses included type 2 diabetes mellitus, anxiety disorder, morbid obesity. R31 had intact cognition, independent with most activities of daily living (ADLs) needed assistance with toileting hygiene. R31's care plan dated 12/7/23, directed staff to monitor for skin breakdown for signs/symptoms of infection. Report signs/symptoms to medical doctor (MD). Care plan further directed staff to document on skin condition and keep MD informed of changes. R31's Order Listing Report identified the following: 10/25/23, miconazole nitrate powder 2% (medication for itching) apply to itching or other topically as needed for stasis dermatitis (condition of skin changes due to insufficient blood return). A Consultant Pharmacist Communication to the…

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

Based on observation and interview, the facility failed to ensure medications were dated when opened in 3 of 3 med carts reviewed for medication storage. This had the opportunity to affect five residents (R51, R46, R14, R35, R6). Findings include: During an observation on 1/11/24 at 11:10a.m., of the wing 100 medication cart revealed R51's Timolol eye drops were opened without being labeled with the date opened. During an observation on 1/11/23 at 11:18 a.m., of the wing 300 medication cart revealed R46's Derm Otic Oil (ear drops) were opened without being labeled with the date opened. R14's inhaler was opened without being labeled with the date it was opened. During an observation on 1/11/24 at 11:27a.m., of the wing 200 medication cart revealed R35's Incruse Ellipta inhaler and R6's Refresh eye drops were labeled without being labeled with the date they were opened. During an interview on 1/11/24 at 11:32 a.m., the director of nursing (DON) stated medications should be labeled with the date they were opened to ensure the medication is safe and effective for the residents. 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 interview, observation, and document review, the facility failed to coordinate necessary dental services for 1 of 1 resident (R12) reviewed for dental services. Findings include: R12's significant change Minimum Data Set (MDS) dated [DATE], identified R12 was cognitively intact with diagnoses of end stage renal disease and diabetes. Section GG0130. Self-Care letter I. indicated R12 required assistance to perform oral hygiene. R12's admission MDS dated [DATE], and significant change MDS dated [DATE], Section L. Oral /Dental Status both indicated R12 did not have any broken, cracked, or chipped teeth, dental pain, or other dental abnormalities. R12's undated, care plan focus areas identified potential for altered nutrition and self-care deficit related to weakness, but did not include dental concerns or dental interventions related to R12's impaired dental status. During an interview on 1/7/24 at 7:24 p.m., it was noted that R12 was missing several teeth in the front of his mouth. R12 stated they had…

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 proper hand hygiene and glove use practices were maintained for 1 of 3 residents (R24) observed during wound care. Findings include: R24's quarterly Minimum Data Set (MDS) dated [DATE], identified R24's diagnoses included enterocolitis due to clostridium difficile (inflammation of the colon caused by bacteria Clostridium difficile, it can cause severe damage to the colon and can even be fatal), depression, colostomy status (an opening from the colon or large intestine through the abdomen), and quadriplegia (paralysis that affects all a person's limbs and body from the neck down). In addition, R24's MDS identified R24 was cognitively intact and required assistance with activities of daily living. R24's MDS further identified he was at risk for pressure ulcers and had one stage two, three stage four, and one unstageable pressure ulcer(s). R24's care plan dated 12/19/23, identified R24 had a current infection extended-spectrum…

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 protect facility residents from potential abuse when they allowed an alleged perpetrator (AP) (licensed practical nurse (LPN)-A) to work after an allegation of misappropriation of resident property (drug diversion). This had the potential to affect all seven residents who resided on Wing 3, who were ordered opioid (narcotic/pain) medication(s). Findings include: A facility reported incident (FRI), submitted 11/16/23 at 5:49 p.m., identified an incident occurred on 11/15/23 at 2:00 a.m. R1 reported to staff when LPN-A administered him his 2:00 a.m. oxycodone (opioid) medication the pill lacked an overall taste (not the normal bitter taste), and he experienced increased pain on those nights. R1 indicated similar incidents were present for 'awhile,' but he was unable to provide a direct timeline; however, reported he noticed increased pain over the last couple days. Further, he explained when he received his 2:00 a.m. medications he would sleep a couple…

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 allegations of misappropriation of resident property to the State Agency (SA) within 24 hours of the allegation for 1 of 3 residents (R1) reviewed for drug diversion. Findings include: A facility reported incident (FRI), submitted 11/16/23 at 5:49 p.m., identified an incident occurred on 11/15/23 at 2:00 a.m. R1 reported to staff when licensed practical nurse (LPN)-A administered him his 2:00 a.m. oxycodone (opioid) medication the pill lacked an overall taste (not the normal bitter taste), and he experienced increased pain on those nights. R1 indicated similar incidents were present for awhile, but he was unable to provide a direct timeline; however, reported he noticed increased pain over the last couple days. Further, he explained when he received his 2:00 a.m. medications he would sleep a couple hours and wake up in extreme pain. The FRI identified alleged non-fiduciary financial exploitation related to medication theft. R1's Minimum Data…

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 elopement to state agency (SA) for 1 of 1 residents (R1) who eloped from the facility without staff knowledge. Findings include: R1's admission Record indicated he admitted to the facility on [DATE] with a diagnosis that included: Syncope, epilepsy, history of traumatic brain injury (TBI) and repeated falls. R1's Elopement Risk Evaluation dated 9/28/23, identified a habit/history of wandering or attempts to leave the unit or building, pacing or agitated behavior and indicated he was ambulatory. The evaluation indicated R1 was at risk for elopement and identified the use of a WanderGuard. R1's Brief Interview for Mental Status dated 9/30/23, identified a score of six which indicated severe cognitive impairment. R1's facility Progress Note dated 9/30/23, 2:33 p.m. indicated R1 was found on the side of the highway headed south. A younger guy and his female friend brought resident back to the facility. R1 did not have a WanderGuard due to not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to thoroughly investigate an elopement for 1 of 1 residents (R1) who left the facility without staff knowledge and was found by two strangers on the highway. Findings include: R1's admission Record indicated he admitted to the facility on [DATE], with diagnosis that included: Syncope, epilepsy, history of traumatic brain injury (TBI) and repeated falls. R1's Elopement Risk Evaluation dated 9/28/23, identified a habit/history of wandering or attempts to leave the unit or building, pacing or agitated behavior and indicated he was ambulatory. The evaluation indicated R1 was at risk for elopement and identified the use of a WanderGuard. R1's Brief Interview for Mental Status dated 9/30/23, identified a score of six which indicated severe cognitive impairment. R1's facility Progress Note dated 9/30/23, 2:33 p.m. indicated R1 was found on the side of the highway headed south. A younger guy and his female friend brought resident back to the facility. R1 did not…

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