Woodlyn Heights Healthcare Center

Based on observation, interview and document review, the facility failed to ensure pharmacist recommendations were acted upon timely for 1 of 5 residents (R9) reviewed for unnecessary medication use.Findings include:R9's Pharmacist's Recommendation to Prescriber and Residents reviewed with No Recommendation, dated July 2025 to December 2025, were reviewed and identified the following:7/18/25: no recommendations8/17/25: Seroquel an antipsychotic medication needs appropriate diagnosis. This was signed by provider 8/20/25.9/23/25: recommendation was to consider a trial discontinuation of the agents to reduce poly-pharmacy as receiving risperidone 0.5mg twice a day and Seroquel three times a day. Prescriber responded on 12/18/25 to change Seroquel to twice a day and plant to d/c (discontinue) if possible.10/20/25: no recommendations12/16/25: recommending gradual dose reduction. Provider responded GDR being completed.The November 2025 Pharmacist Recommendation to Prescriber was not provided.During an interview on 12/31/25 at 11:42 a.m., director of nursing (DON) stated she believes she…

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 recommended pneumococcal vaccinations, as outlined by the Centers for Disease Control (CDC), were offered and/or provided in a timely manner to reduce the risk of severe disease for 1 of 5 residents (R4) reviewed for immunizations. Also, the facility failed to document shared clinical decision making for 2 of 5 residents (R16, R27) identified as needing or being offered an updated pneumococcal immunization per CDC's Recommendation of Adult Immunizations Schedule for Ages 19 Years or Older, United States, 2025, Revised October 7, 2025.Findings include:During interview and record review with director of nursing (DON) on 12/30/25 at 11:12 a.m., DON reviewed electronic medical records (EMR's) and verified the following:R4's date of birth was 2/9/53, and the EMR lacked information on pneumococcal immunization status. DON stated they expected the facility to have documentation to support him being offered or having declined the vaccine.R16's date 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 staff were offered, and or provided education regarding the benefits and potential risks associated with COVID-19 vaccination for 3 of 3 staff (LPN-A, LPN-B, HSK-A) reviewed for COVID-19 vaccinations. Findings include:Review of Centers for Disease Control and Prevention (CDC) Clinical Guidance for COVID-19 Vaccination, updated 7/11/25, indicated the CDC recommended an updated COVID-19 vaccine for most adults ages 18 years and older, including people who live and work in long-term care (LTC) settings, get one dose of an updated COVID-19 vaccine. People 65 years and older who live and work in LTC settings should receive 2 doses of an updated COVID-19 vaccine, spaced 6 months apart.During an interview on 1/9/24 at 11:38 a.m., human resources director (HR)-F stated the facility did not have any documentation of COVID-19 vaccine being offered or education provided for licensed practical nurse (LPN)-A; LPN-B or housekeeper (HSK)-A.During an interview on 1/9/25 at 1:20 p.m., director of nursing (DON) stated she was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to assess potential signs of constipation to determine what, if any, interventions were needed to promote comfort and reduce the risk of complication (i.e., impaction) for 1 of 1 residents (R15); failed to comprehensively assess and develop interventions to ensure a consistent nursing approach with a developed, non-pressure skin condition for 1 of 2 (R5); and failed to ensure orders for a peripherally inserted central catheter (i.e. PICC line) were clarified and the line was managed in accordance with professional standards of care for 1 of 1 residents (R28) reviewed who had a PICC. Findings include: BOWEL MANAGEMENT: R15's quarterly Minimum Data Set (MDS), dated [DATE], identified R15 had moderate cognitive impairment but demonstrated no delusional thinking. Further, the MDS outlined R15 was totally incontinent of bowel and consumed multiple medications including both psychotropic and narcotic medications. On 12/2/24 at 3:07 p.m., R15 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 meals were served in a warm, palatable manner to promote quality of life and nutritional intake for 4 of 4 residents (R5, R15, R32, R112) reviewed for dining. This had the potential to affect 35 residents identified to reside on the units with cold food complaints. Findings include: During an observation on 12/5/24 at 7:45 a.m., tall metal meal carts and a plastic cart were observed in the main kitchen with trays placed to have a small bowl of hot cereal covered with a disposable plastic cover sitting on (approximately) every tray. Cook-A (C)-A was observed plating pancakes and sausage patties to each tray. At 8:06 a.m., the 300/400-unit meal carts left the main kitchen. During an observation and interview at 12/3/24 at 8:10 a.m., after the four meal trays were passed from the plastic cart to residents on the 400 hallway, the pancake was measured to be at 108 degrees Fahrenheit and the oatmeal was measured at 119 degrees…

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

Based on observation, interview, and document review, the facility failed to ensure monitoring and timely removal of facility food stored in refrigerators and freezers was completed to reduce the risk of foodborne illness. This had the potential to affect approximately 10 residents who regularly consumed deli sandwiches from the facility kitchen. Findings include: During the initial tour with the dietary director (DD) at 12/2/24 at 11:37 a.m., the following foods were found in walk-in cooler in the first-floor kitchen: -Two opened plastic bags of sliced ham dated 11/4/24. -Two opened undated bags of sliced turkey. -An unopened bag of sliced turkey with an expiration date of 11/23/24 that appeared fully thawed. During an interview on 12/2/24 at 11:49 a.m., the DD stated the deli meat was quickly used so she did not expect dietary staff to date it. The DD stated she thought the bag of sliced turkey dated 11/23/24 had come from the freezer and when asked about the process to ensure thawed food was not kept past the date when it was safe to consume, was not able to answer. During a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure staff consistently implemented enhanced barrier precautions (EBP) in accordance with Centers for Disease Control (CDC) guidelines to reduce the risk of infection spread for 3 of 4 residents (R4, R12 and R28) whom resided on different wings of the care center. 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…

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 2 residents (R112) reviewed for Physician Orders for Life Sustaining Treatment (POLST) had the correct code status (i.e., full code, DNR) information outlined within the medical record. This could cause R112 to receive resuscitation efforts (i.e., CPR) against his wishes. Findings include: R112's Medical Diagnosis listing, printed [DATE], identified R112's medical history and diagnoses. This identified R112 had a history of suicidal ideation, opioid use, sleep apnea, diabetes mellitus, and acute kidney failure. R112's PointClickCare (electronic medical record) displayed demographic information (i.e., room number, date of birth , allergies) along the top with a banner-like field. This identified R112 admitted to the care center on [DATE], and included a section labeled, Code Status, which directed, Advanced Directives [click-able link] Code Status: Full code. The link, when clicked, brought up another click-able link to a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure privacy was maintained during the provision of personal cares for 1 of 1 resident (R4) observed to be receiving peri-care with their window blinds open to the outside parking lot. Findings include: R4's admission Minimum Data Set (MDS), dated [DATE], identified R4 had intact cognition and demonstrated no delusional thinking. On 12/4/24 at approximately 7:05 a.m., R4 was observed laying in her bed from the parking lot with her room lights on, and the window blinds pulled up approximately three-quarters (i.e., 3/4) of the window height. R4's window was at ground-floor level and a single female staff member was observed dressed in dark-blue colored scrubs and assisting R4 whose legs and peri-area were exposed and visible from the sidewalk leading up to the main entrance of the care center. The staff member had gloves on and was observed wiping R4 with a cloth on her peri-area. At 7:09 a.m., the surveyor knocked and opened R4's room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to clean and maintain a resident's wheelchair for 1 of 1 residents (R39) reviewed for safe, clean and homelike environment. Findings include: R39's quarterly Minimum Data Set (MDS) dated [DATE], indicated R39 was cognitively intact and had no delusions, no hallucinations, or behaviors. The quarterly MDS also indicated R39 was dependent with dressing, toileting, and personal hygiene and indicted R39 needed moderate assist with oral hygiene and was independent eating. R39's clinical diagnosis report printed on 12/5/24, indicated diagnoses of cerebral palsy (a congenital disorder of movement, muscle tone, or posture), essential hypertension (high blood pressure) , functional quadriplegia (a condition that causes a person to be unable to move due to a severe disability from another medical condition), and constipation. R39's care plan printed on 12/5/24, indicated R39 independently used a motorized tilt wheelchair for locomotion. During…

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

Based on observation, interview, and document review the facility failed to ensure nails were trimmed and cleaned for 1 of 1 resident (R9) who was dependent upon staff for cares. Findings include: R9's quarterly Minimum Data Set (MDS) indicated R9 was cognitively intact, had no behaviors and did not refuse personal cares. R9's Clinical Diagnosis report printed 12/5/24, indicated diagnoses of post-polio syndrome (a condition that causes gradual muscle weakness and atrophy), morbid obesity (a disorder involving excessive body fat that increases the risk of health problems), Type 2 diabetes mellitus (a condition in which the pancreas doesn't make enough insulin causing the body to have trouble controlling blood sugar and using it for energy), candidiasis of skin and nails(a fungal infection caused by an imbalance of healthy bacteria and yeast in the body) , functional quadriplegia (a condition that causes a person to be unable to move due to a severe disability from another medical condition), essential hypertension (abnormally high blood pressure that's not the result of a medical…

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 reassess after repeated refusals of a range of motion (ROM) program and, if needed, develop interventions to reduce the risk of mobility loss for 2 of 3 resident (R9 and R39) reviewed for ROM. Findings include: R9 R9's quarterly Minimum Data Set (MDS) indicated R9 was cognitively intact, had no behaviors and did not refuse personal cares. R9's Clinical Diagnosis Report printed 12/5/24, indicated diagnoses of post-polio syndrome (a condition that causes gradual muscle weakness and atrophy), morbid obesity (a disorder involving excessive body fat that increases the risk of health problems), Type 2 diabetes mellitus (a condition in which the pancreas doesn't make enough insulin causing the body to have trouble controlling blood sugar and using it for energy), candidiasis of skin and nails (a fungal infection caused by an imbalance of healthy bacteria and yeast in the body) , functional quadriplegia (a condition that causes 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 comprehensively assess and, if needed, develop interventions to promote safety and reduce the risk of injury or impairment for 1 of 1 resident (R16) reviewed who had been attempting to order alcohol from a mobile delivery service (i.e., DoorDash). Findings include: R16's admission Minimum Data Set (MDS), dated [DATE], identified R16 had intact cognition, demonstrated no delusional thinking or hallucinations, and had several medication conditions including asthma, a history of seizure disorder, and diabetes mellitus. R16's progress note, dated 11/13/24, identified an entry at 9:03 p.m. which read, Someone was here to deliver an order to a resident while in the room . the person who delivered that her card was expired. while [sic] he was on his way out, I observed that he had a bottle of Liquor; I made the order nurse [sic] witness it . will update social services and her to be searched [sic] every shift. In addition, a subsequent note, dated 11/30/24,…

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 comprehensively assess a resident who had significant weight gain at the care facility (37%) in less than 1 year, and failed to care plan appropriate interventions to assist with weight loss goals for 1 of 2 residents (R51) reviewed for nutrition status. Findings include: R51's quarterly Minimum Data Set (MDS), dated [DATE] indicated R51 was admitted to the care facility on 1/29/24, was cognitively intact and independent with most activities of daily living (ADLs). R51's Diagnoses List, dated 1/29/24, indicated R51 had several medical diagnoses including unspecified personality disorder, generalized anxiety disorder and major depressive disorder. The Diagnoses List also indicated a diagnosis of prediabetes, dated 11/12/24. R51's weights documented in the electronic medical record (EMR) indicated R51 was admitted to the care facility weighing 210.6 pounds and his most current weight, dated 11/17/24, was 288.9 pounds, indicating a weight gain of 78.3…

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 attempt a gradual dose reduction (GDR) or document a clinical rationale for not attempting for 1 of 5 residents (R51) reviewed for unnecessary medications. Findings include: R51's quarterly Minimum Data Set (MDS), dated [DATE], indicated R51 was admitted to the care facility on 1/29/24, was cognitively intact and independent with most activities of daily living (ADLs). R51's Diagnoses List, dated 1/29/24, indicated R51 had several medical diagnoses including unspecified personality disorder, generalized anxiety disorder and major depressive disorder. R51's Orders, dated 1/29/24, indicated R51 had the following psychotropic medications; aripiprazole (an atypical antipsychotic indicated for schizophrenia, bipolar disorder, major depressive disorder, irritability associated with autism, and Tourette's) 2 milligrams (mg) by mouth one time a day for anxiety depression and duloxetine (an antidepressant medication) 60 mg two times a day for anxiety and…

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

Based on observation, interview and document review, the facility failed to ensure narcotic and controlled substance reconciliation was completed in accordance with established policies and procedures to reduce the risk of diversion and/or theft on 2 of 3 medication carts reviewed. This had the potential to affect 6 residents identified to have controlled substances in these carts which were reviewed during a facility-reported incident investigation for possible drug diversion. Findings include: The facility's Controlled Substances policy dated 10/19/22, indicated the narcotic records would be reconciled by a physical count of the remaining narcotic supply at the change of each shift by the oncoming and outgoing licensed nurse/designee. The policy indicated after the supply was counted and justified, each nurse would record the date and his/her signature verifying the count was correct. During an interview and observation on 11/26/24 at 9:25 a.m., the 500-hall medication cart was reviewed with registered nurse (RN)-B. The mobile cart was locked with a physical key, along with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a homelike environment to two out of two residents (R2, R3) reviewed for environment. R4 had been playing his music loudly and R2 and R3 had complaints of not being able to hear their music or their televisions. Findings Include: During an observation in the 600 hallway on 7/15/24 at 11:01 a.m., R4 had his door to his room open and loud explicit music playing. This explicit music could be heard from the front entrance of the facility as well as in the other hallways. During an observation in the 600 hallway on 7/15/24 at 12:28 p.m., R4 had his door to his room open and loud music playing. This music could be heard from the front entrance of the facility as well as in the other hallways. R2's medical records printed on 7/16/24 indicated R2 was admitted to the facility on [DATE] with a primary diagnosis of cerebral palsy. R2's additional diagnoses included polyneuropathy, major depressive disorder, and mild intellectual disabilities. R2's brief…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop a comprehensive care plan to meet the residents medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment for one of one resident (R1) reviewed for care plans. R1 was on dialysis, used tube feeding to get his nutrients, and had respiratory concerns, and activities of daily living and those care areas were not addressed on his care plan. Findings include: R1's medical records printed on 7/15/24 indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of sepsis. R1's additional diagnoses included nondisplaced fracture of olecranon process without intraarticular extension of right ulna, hypokalemia, falls, a kidney transplant recipient, presence of a cardiac pacemaker, anemia, gastro-esophageal reflux disease, other mechanical complication of surgically create arteriovenous fistula, moderate protein-calorie malnutrition, bronchiectasis, dysphagia, end-stage renal disease, congestive heart…

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 monitor and assess the hydration status for one of one resident (R1) reviewed for hydration. R1 had an order for tube feedings with direction to adjust the free water flushes pending hydration status one time a day and facility staff were not monitoring or assessing R1's hydration status. Findings include: R1's medical record printed on 7/15/24 indicated R1 was admitted to the facility on [DATE] due to sepsis. R1's additional diagnoses included hypokalemia, moderate protein-calorie malnutrition, bronchiectasis, dysphagic, chronic obstructive pulmonary disease (COPD), gout, and lymphedema. R1's hospital discharge papers dated 5/22/24 indicated R1 had a gastrostomy-jejunostomy placed on 5/18/24. The record indicated R1 was on tube feedings with an oral diet. The record indicated R1 was on a Novasource Renal diet administered at one hundred twenty milliliters (mL) per hour for nine hours. The record indicated R1 was to receive thirty mL before and after…

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 assess a resident before and after dialysis for one of one resident (R1) reviewed for dialysis. Findings include: R1's medical record printed on 7/15/24 indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of sepsis. R1's additional diagnoses included a kidney transplant recipient, anemia in chronic kidney disease, end stage renal disease, and dependence on renal dialysis. R1's treatment administration record (TAR) dated 5/29/24 indicated nursing was to complete a pre-and-post dialysis assessment before dialysis and on return from dialysis on Mondays, Wednesdays, and Fridays. The pre-dialysis assessment included vital signs, level of consciousness, if the resident had experienced any muscle cramping, itching, discomfort, or pain, and if there was a thrill and bruit noted. The post-dialysis assessment included vital signs, if the resident had experienced any dizziness, nausea, vomiting, fatigue, chills, shaking, muscle weakness, skin…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a medical record was accurately document vital signs and assessments for one of one resident (R1) reviewed for medical records. R1's treatment administration record (TAR) indicated R1 was to have a pre-and-post dialysis assessment done three days a week and all but three of those assessments were not completed. R1's vital signs were documented while he was not in the facility. Findings include: R1's medical record indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of sepsis. R1's additional diagnoses included bronchiectasis, dysphagia, obstructive sleep apnea, and chronic obstructive pulmonary disease (COPD). R1 was discharged from the facility on [DATE]. R1's hospital Discharge summary dated [DATE] indicated R1 was inpatient from [DATE] to [DATE]. R1's admitting diagnosis was respiratory failure with hypoxia, including acute kidney injury, delirium, pneumonia, two-time renal transplant, hypertensive heart and chronic…

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 offer a neutral and fair arbitration process by ensuring both the resident or his or her representative, and the facility agree on the selection of a neutral arbitrator, and that the venue is convenient to both parties for 11 of 17 residents (R1, R2, R4, R5, R15, R17, R22, R28, R42, R47, and R48) reviewed for binding arbitration. Findings include: Review of document titled Residents with Arbitration Agreements provided by facility on 3/11/24, documented R1, R2, R4, R5, R15, R17, R22, R28, R42, R47, and R48 with signed binding arbitration agreements with the facility. Review of R1, R2, R4, R5, R15, R17, R22, R28, R42, R47, and R48 Arbitration Agreements indicated, The arbitration shall be administered by the American Health Lawyers Association (AHLA) in accordance with its Rules of Procedure. In addition, The Arbitration will be conducted at a site selected by Facility. R47's quarterly MDS dated [DATE], indicated R47 had intact cognition and diagnoses…

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 community use glucometers were properly cleaned and disinfected between patient use for 4 of 4 residents (R10, R47, R42, R35) to have their blood glucose checked with the devices. This had the potential to affect 25 of 69 identified in the facility with orders to obtain blood glucose monitoring. In addition, the facility failed to ensure a wound vac machine was kept off the floor for 1 of 1 residents (R176) reviewed for wound care. Glucometer disinfecting between residents Per manufacturer's instruction for use of Even Care G3 Blood Glucose Monitoring System in the Cleaning and Disinfecting section highlighted the EVENCARE G3 Meter should be cleaned and disinfected between each patient and to avoid wetting the meter test strip port. The document further indicated, the approved and recommended Environmental Protection Agency (EPA) direction included using Medline Micro-Kill+ (Trademark) Disinfecting wipes. According to Medline…

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 2 of 2 residents (R10, R27) reviewed for the ability to self-administer medications (SAM). Findings include: R27's quarterly Minimum Data Set (MDS) dated [DATE], indicated R27 was cognitively intact and had no issues with mood or behavior. MDS indicated R27 needed assistance to set up her meals, supervision with showers, and was independent with dressing, toileting, bathing, and transfers. R27's Medical Diagnosis report printed 3/13/24, indicated diagnoses of multiple sclerosis (a disease in which the immune system eats away the protective covering of nerves, disrupting the communication between the brain and the body), unspecified psychosis (a mental disorder characterized by a disconnection from reality), polyneuropathy (simultaneous malfunction of many peripheral nerves throughout the body), generalized anxiety, idiopathic chronic gout (a condition caused by too much uric acid in the body which causes swelling and pain around…

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 a Level II Pre-admission Screening and Resident Review (PASARR) was conducted, documented, and retained to ensure mental health needs were appropriately addressed or provided for 2 of 2 residents (R4, R27) reviewed for PASARR. Findings include: R4 R4's annual Minimum Data Set (MDS) dated [DATE], identified R4 with admission to facility on 3/10/21 and diagnoses of bipolar disorder (a mental health condition that causes extreme mood swings between emotional highs and lows), depression, diabetes, and delusional disorder. R4's initial Pre-admission Screening (PAS) results and attached letter from Senior Linkage Line, dated 3/10/21, indicated The Senior Linkage Line forwarded the PAS to the county/managed care organization for processing. The PAS is not final until the lead agency sends documentation to the nursing facility. The letter went on to list a lead agency and phone number for the facility to follow up with. R4's entire medical record 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 appropriate infection control techniques were implemented during wound care for 2 of 2 residents (R11, R49) who were reviewed for wound care. In addition, the facility failed to comprehensively assess, monitor, and provide necessary care for 1 of 1 residents (R2) with a intrathecal baclofen pump. Findings include: R11 R11's quarterly Minimum Data Set (MDS) dated [DATE], identified R11 with intact cognition, diagnoses of diabetes, chronic kidney disease, chronic obstructive pulmonary disease (debilitating lung disease[COPD]), lymphedema (condition that results in swelling of the leg or arm due to blockage in the lymphatic system which is part of the immune system), anxiety, depression, and cellulitis of right lower leg (potentially serious bacterial skin infection). In addition, R11 on oxygen. R11's Diagnosis List, printed 3/14/24, identified R11 with non-pressure chronic ulcer of right lower leg with fat layer exposed, and history…

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 assistance for hearing appliances for 1 of 1 (R17) residents reviewed who had bilateral hearing aides. Findings include: R17's quarterly Minimum Data Set (MDS) dated [DATE], indicated R17 admitted to the facility on [DATE], and had moderate cognitive impairment, diagnoses of Parkinson's (progressive disorder that affects the nervous system and parts of the body controlled by the nerves), encephalopathy (brain disorder that affects its function), chronic pain, anxiety, dementia, diabetes and depression. In addition, R17 received hospice services. R17's Care Area Assessment (CAA) dated 5/22/23, indicated R17 triggered for communication impairment. R17's care plan (CP) dated 1/7/22, indicated, [R17] had impaired hearing compensated well with use of bilateral hearing aides. CP intervention include, [R17] requires the following hearing appliances: (hearing aides bilateral). R17's [NAME] with print date of 3/12/24, informed care staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure oxygen therapy was appropriately administered as well as provide Continuous Positive Airway Pressure ([CPAP]- ventilation machine that administers air via an external device at a predetermined level of pressure) therapy for 1 of 1 residents (R47) reviewed for respiratory care. Findings include: R47's quarterly Minimum Data Set (MDS) dated [DATE], indicated R47 had intact cognition with no behaviors present. The MDS indicated that R47 received oxygen therapy but did not use a CPAP. The MDS indicated R47 required staff assistance for bathing, dressing, and bed mobility. The facility Standing Orders for Skilled Nursing Facilities dated 1/17/22, indicated that nursing staff could initiate and titrate supplemental oxygen from one to four liters per nasal canula (NC) as needed for dyspnea (shortness of breath), hypoxia (oxygen saturation less than 88 percent), or acute angina (chest pain) to keep oxygen saturations at greater than 88…

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 provide appropriate side effect monitoring with psychotropic medication consumption for 1 of 5 residents (R24) reviewed for unnecessary medication use. Findings include: R24's quarterly Minimum Data Set (MDS) dated [DATE], indicated R24 had severe cognitive impairment and was dependent on assistance with activities for daily living (ADLs). The MDS included diagnoses of hypertension (high blood pressure), epilepsy (seizure disorder) and renal insufficiency/renal failure/end-stage renal disease (kidneys no longer adequately filtering waste from the blood). The MDS indicated R24 had hallucinations, delusions and no physical or verbal aggression. R24's physician note, dated 2/7/24, included the following diagnoses; personal history of traumatic brain injury (TBI), chronic kidney disease, major depressive disorder recurrent severe with psychotic symptoms, restlessness and agitation, unspecified fall, hypertensive heart disease without heart failure 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 interview and document review the facility failed to ensure 1 of 1 residents (R27) reviewed for medication errors were free of significant medication errors whenwhen R27 didn't receive ordered metoprolol (medication to treat high blood pressure and control heart rate) for 30 days and in addition, R27 didn't receive ordered atorvastatin (medication to treat high blood cholesterol) between 2/13/24 and 3/13/24. Findings include: R27's quarterly Minimum Data Set (MDS) dated [DATE], indicated R27 was cognitively intact and had no issues with mood or behavior. MDS indicated R27 needed assistance to set up her meals, supervision with showers, and was independent with dressing, toileting, bathing, and transfers. R27's Medical Diagnosis report printed 3/13/24, indicated diagnoses of multiple sclerosis (a disease in which the immune system eats away the protective covering of nerves, disrupting the communication between the brain and the body), unspecified psychosis (a mental disorder characterized by a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure dental needs were appropriately acted upon for 1 of 1 residents (R47) reviewed for dental care. Findings include: R47's quarterly Minimum Data Set (MDS) dated [DATE], indicated R47 had intact cognition with no behaviors present. The MDS indicated R47 was diagnosed with heart failure, diabetes, and depression and required setup assistance with oral hygiene. R47's dental progress note dated 1/4/24, indicated that the doctor of dental surgery (DDS) recommended that R47 have five teeth extracted prior to moving forward with a partial denture. R47's dental General Referral dated 1/4/24, indicated that the DDS recommended R47 to see an oral surgeon for extraction of five teeth related to fractured teeth/ root tips that were not restorable. The note also indicated that these teeth were causing R47 pain. R47's progress note dated 2/27/24 at 5:33 p.m., indicated that R47 had obvious or likely cavity or broken natural teeth. R47's 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 maintain accurate medical records to ensure accurate medication lists, nurse/licensed professional monitoring and interventions were implemented for 2 of 2 residents (R2 and R27) reviewed. Findings include, R27's quarterly Minimum Data Set (MDS) dated [DATE] indicated R27 was cognitively intact and had no issues with mood or behavior. MDS indicated R27 needed assistance to set up her meals, supervision with showers, and was independent with dressing, toileting, bathing, and transfers. R27's Medical Diagnosis report printed 3/13/24 indicated diagnoses of multiple sclerosis (a disease in which the immune system eats away the protective covering of nerves, disrupting the communication between the brain and the body), unspecified psychosis (a mental disorder characterized by a disconnection from reality), polyneuropathy (simultaneous malfunction of many peripheral nerves throughout the body), generalized anxiety, idiopathic chronic gout (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 binding arbitration agreements were clearly communicated in a form and manner that they understood prior to signing the forms for of 2 of 2 residents (R2, R47) reviewed for binding arbitration agreements. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 had intact cognition and diagnoses of multiple sclerosis (A disease that affects central nervous system creating difficulty with sending brain signals to the rest of the body [MS]). Review of R2's signed Arbitration Agreement dated 2/3/22 indicated, Resident and Facility will not be able to bring or start a lawsuit in any court and are giving-up all rights to a jury trial to decide any disputes that Resident may have against Facility or Facility may have against Resident. During interview with R2 on 3/14/23 at 8:45 a.m., R2 was unable to recall signing admission paperwork informing her that she was not required to enter into the binding arbitration agreement as…

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 have a system in place to record accurate narcotic reconciliation to be able to account for all controlled substances for a 1 of 3 residents (R1) reviewed. The facility failed to identify prompt identification of loss or potential diversion of a controlled medication or determine the extent of loss for thirty morphine tablets ordered for R1. Findings include: Upon observation on 3/4/24 at 2:35 p.m. a pharmacy receipt for R1's morphine delivery on 2/16/24 was not found in the facility receipt bin on the wall. The bin had a pile of receipts dated from 1/29/24 - 3/5/24. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 had a Brief Inventory of Mental Status (BIMs) score of 10 indicating cognitive impairment. R1 required moderate assistance of one staff member for dressing and hygiene. R1's pertinent diagnoses was metabolic encephalopathy (an imbalance of or reduced oxygen to the brain). R1's physician order dated 2/15/24…

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 records review, the facility failed to thoroughly assess pain and implement orders for pain management for 1 of 1 resident (R2) reviewed who was suffering from headaches and prescribed tramadol. Findings include: R2's admission Minimum Data Set (MDS) dated [DATE], showed an admission date of 7/17/23. The MDS indicated R2 had moderate cognitive impairment, with active diagnoses including fractures and other multiple traumas, cancer, hypertension, and dementia. The MDS also indicated R2 was frequently in moderate pain and receiving pain medications. R2's care plan identified R2's alteration in thought processes as evidenced by deficits in memory/recall ability, judgment, decision making, and thought processes. The care plan directed staff to observe, document, and report to medical practitioner any changes in cognitive function. The care plan indicated R2 had potential for actual communication problem with difficulty expressing ideas/wants. The care plan indicated R2's preference 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.