Laurels Peak Health Care, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and document review the facility failed to accurately document a resident's verbal and physical abuse towards staff, and rejection of cares for 1 of 3 residents (R2) reviewed when the Minimum Data Set (MDS) indicated the resident did not have any behaviors or rejection of cares during an evaluation period over seven days. The nursing progress notes for the same period documented daily rejections of care and yelling at staff when they tried to provide hygiene and incontinent care. Findings include: R2's nursing progress notes during the evaluation period dated from 2/27/25 through 3/6/25, indicated she refused the following: medication, walk, brush her hair, change soiled clothing, and bed linen, shower, and housekeeping services. R2's annual MDS dated [DATE], indicated she had moderate impaired cognition and dementia. She was unable to move the right side of her body or communicate her thoughts and feelings after a stroke leading to worsening anxiety and depression. She required 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.

The facility failed to develop and revise a person centered behavior care plan, document the risk verse benefit associated with refusing care, identify root cause analysis, and determine what triggered her anxiety and agitation, and provide ordered psychiatric follow up care for 1 of 3 residents (R2) reviewed, when she was found to have maggots on her body because she refused to accept help to change soiled clothing and bed linen, and let housekeeping clean her room. Findings include: R2's initial admission care plan dated 2/10/23, indicated cognition deficit, unable to communicate her thoughts and needs, history of refusing care and becoming agitated when approached. She required the assistance from one person to dress, bath, incontinent care and brush her hair. Mood and behavior interventions included being alert to any changes in her mood, monitor and document her behaviors, and give medication as ordered by the doctor. The interventions were renewed during quarterly and annual assessments and no other interventions were developed. R2's care plan dated 9/8/23, indicated her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to clarify medication orders for 1 of 3 residents (R3) reviewed for medication errors. Findings include: R3's undated Face Sheet indicated diagnoses of malignant neoplasm of prostate (prostate cancer), permanent atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular beating of the heart), and diabetes. R3's Medicare Part A Discharge Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition, and had diagnoses of cancer, end stage renal disease (ESRD), and diabetes. R1 received anticoagulants (blood thinners). R3's progress note dated 3/29/25 at 2:11 a.m., indicated R3 was sent to the emergency department (ED) via ambulance for gross hematuria. R3's progress note dated 3/29/25 at 11:36 a.m., indicated R3 returned to facility around 9:40 a.m. R3 was tired and if there was blood in his urine, to give it a few hours and push water to try to flush his bladder. If urine was to remain significantly bloody or if he developed…

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 observations, interview and documents review the facility failed to ensure enhanced barrier precautions (EBP-where gown and gloves used for high contact resident care activities) was used for 2 of 2 resident (R3 and R5). Findings include: R3's admission Minimum Data Set (MDS) dated [DATE], identified diagnoses of malignant neoplasm (cancer) of the brain with intact cognition. R3 had an unstageable area covered with slough and/or eschar (dead tissue/cells, usually black in color). During an observation and interview on 3/5/25 at 1:10 p.m., R3 was in bed and nursing assistants (NA)-R and NA-N were performing peri care for urine incontinence. Neither NA had put on a gown, but did have gloves on. NA-R and NA-H both assisted R3 by lowering her pants and then unsecured the brief. NA-R performed peri care and removed soiled brief and placed in trash can and removed her gloves. NA-R did not perform hand hygiene before putting on clean gloves and placed new brief and applied barrier cream to the buttocks. NA-R…

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 observation, the facility failed to ensure all residents were consistently offered and provided a nutrient and/or calorie-substantive snack after the dinner meal and before bedtime for 19 of 19 residents (R43, R2, R5, R37, R39, R34, R16, R25, R10, R29, R7, R19, R42, R6, R31, R99, R22, R202, R4) who voiced a concern. This had the potential to affect all 51 residents who resided in the facility. Findings include: Record review for R43, R2, R5, R37, R39, R34, R16, R25, R10, R29, R7, R19, R42, R6, R31, R99, R22, R202, R4 Minimum Data Set (MDS) indicated: 1. R43's significant change MDS dated [DATE], indicated intact cognition and diagnosis included diabetes. 2. R2's quarterly MDS dated [DATE], indicated intact cognition and diagnosis included chronic obstructive pulmonary disease (COPD). 3. R5's quarterly MDS dated [DATE], indicated intact cognition and diagnosis included epilepsy. 4. R37's quarterly MDS dated [DATE], indicated intact cognition and diagnosis included diabetes. 5. R39's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to consistently monitor and assess a resident for potential complications related to dialysis treatment post treatment, failed to monitor fluid restrictions, failed to notify the provider of refusal of dialysis, and failure to complete dialysis treatment and monitor daily weights per order for 1 of 1 resident (R99) reviewed for dialysis. Findings include: R99's facesheet printed on 8/21/24, included diagnoses of diabetes type 2, peripheral vascular disease (slow progressive disorder of blood vessels outside the heart), end stage renal disease (kidneys no longer work to meet the needs of the body), edema (swelling) and cellulitis (bacterial skin infection) of lower limb. R22's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R99 had intact cognition, end stage renal disease (ESRD), had 2 venous/arterial ulcers present and was receiving hemodialysis (a machine filters wastes, salts and fluid from the blood). 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 label insulin pens with opened and expiration dates for 3 of 3 residents (R10, R253, and R24). Further, the facility failed to label an insulin pen with clear, concise, and viewable resident identification for 1 of 1 resident (R10). Finally, the facility failed to dispose of expired eye drop medication for 1 of 1 resident (R4). Findings include: On 8/20/24 at 1:14 p.m., observation of medication storage with licensed practical nurse (LPN)-A, identified insulin pens for (R10, R253, and R24) were not labeled with the opened and expiration dates. Each insulin pen included the label to document the opened and expiration dates, however, it was left blank. During the same observation, a Novolog insulin pen for R10 was not labeled with clear, concise, and viewable resident information. The only resident identifier noted on the R10's Novolog insulin pen was a handwritten resident room number in permanent marker. Prednisolone-Bromfenac Ophthalmic Suspension 1-0.0075% eye drops for R4 was observed to not be discarded…

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 a clean field, use clean supplies and scissors when performing wound care treatments to reduce the risk and/or prevent infections for 1 of 1 resident (R99) whose treatments were observed for venous ulcer wound care and treatment. Findings include: R99's face sheet, printed 8/21/24, included diagnoses of diabetes type 2, peripheral vascular disease (slow progressive disorder of blood vessels outside the heart), end stage renal disease (kidneys no longer work to meet the needs of the body), edema (swelling) and cellulitis (bacterial skin infection) of lower limb. R22's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R99 had intact cognition, end stage renal disease (ESRD), had 2 venous and arterial ulcers present and was receiving hemodialysis (a machine filters wastes, salts and fluid from the blood). R22's physician orders dated 8/16/24, included: -Check bilateral lower extremities (BLE), if drainage is…

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 the kitchen ceiling tiles, tracks, lights and kitchen ceiling vents were kept in a clean and sanitary manner and free of dust and debris. This had the potential to affect all 51 residents residing in the facility. Findings include: During an observation and interview on 8/19/24 at 11:50 a.m., with the dietary manger (DM)-A, the ceiling tiles, ceiling tracks, overhead lights and ceiling vents observed in the kitchen was covered with thick dark fuzzy material. The vents were in operation. When asked who was responsible for cleaning the kitchen vents, lights and ceiling tiles and tracks, the DM-A stated she was not sure but thought maybe it was maintenance. DM-A stated kitchen staff clean the kitchen per the cleaning book which staff document when complete, but the ceiling isn't part of what is listed in the book. DM-A added they currently do not have a maintenance person for the facility as the last one left awhile ago. Review of kitchen cleaning book did not include the vents, lights or ceiling tiles…

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 physician orders related to weight gain, and monitor and assess edema (a condition characterized by an excess of watery fluid collecting in the cavities or tissues of the body) for 1 of 1 resident (R2) reviewed for fluid overload. Findings include R2's face sheet dated 6/7/24, identified R2 had diagnoses that included congestive heart failure. R2's physician orders included the following -2000 mL (milliliters) fluid restriction, 1080 mL for dietary and 920 mL for nursing (start date 12/16/23). -Compression stockings on in the morning (AM) and off at night (HS) (start date 1/2/24). -Daily weights. Update provider if weight gain of greater than two pounds in one day or five pounds in one week in the am for hypertensive heart disease (start date 3/1/24). R2's care plan dated 9/5/23, identified a goal to follow fluid restriction with the restriction of 2000mL of fluid per day with 1080mL from dietary and 920mL from nursing. R2's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to provide sufficient staffing to ensure residents received care and assistance as needed. These deficient practices had the potential to affect all 48 residents who resided in the facility. Findings include: Refer to F561: The facility failed to ensure a resident's morning routine preferences, mealtime and location, and clothing preferences were honored for 1 of 3 residents (R16) who voiced concerns about choices. Refer to F677: The facility failed to provide nail care and grooming for 3 of 6 residents (R2, R10, R103) who were dependent upon staff for assistance with grooming and personal hygiene Refer to F689: The facility failed to ensure adequate supervision during meals for 1 of 3 residents (R16) reviewed who required supervision. Room Tray Delivery: R14's quarterly minimum data set (MDS) assessment dated [DATE], identified R14 as having moderate cognitive impairment. R14 had clear speech, was able to understand and was understood.…

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 Quality Assessment and Assurance (QAA)/Quality Assurance and Performance Improvement (QAPI) committee was effective in implementing appropriate and sustained action plans to correct deficiencies identified during a previous survey. This resulted in repeat deficiencies identified during current survey. This deficient practice had the potential to affect all 48 residents residing in the facility. Findings include: During an interview on 9/29/23 at 1:30 p.m., reviewed findings from previous survey with the regional director of operations (RDO)-A and the assistant director of nursing (ADON) who also facilitated QAPI meetings, and compared them to findings from current survey. Of the seven citations from the previous survey, four would be repeat citations. The repeat deficiencies included: 1. Providing residents and/or the resident representatives with a quarterly statement of personal funds. 2. ADL care for dependent residents 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 observation, interview, and document review the facility failed to maintain a system to analyze monthly surveillance data for trends and patterns to reduce the spread of illness, infections, control transmission of infections and communicable diseases present in the facility, failed to implement measures to prevent the spread of infection when the facility failed to ensure personal protective equipment (PPE) of N95 masks were worn, and failed to wear appropriate PPE when sorting and handling soiled laundry. This had the potential to affect all 48 residents who resided in the facility. Findings include: Hand Hygiene: During entrance conference on 9/25/23 at 11:55 a.m., was informed by the director of nursing (DON) four residents were in transmission based precautions (TBP) for Covid-19. On 9/25/23 at 1:08 p.m., dietary aide (DA)-A entered R16's room with meal tray and provided set up assistance with the meal. R16 was not provided or offered hand hygiene from DA-A. On 9/25/23 at 1:37 p.m., NA-H delivered…

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 maintain a clean, safe, and homelike environment when carpet in resident hallways and resident room (R20) were observed to be stained and soiled, and baseboard heat registers in resident rooms (R199, R41, R34) were in disrepair. In addition, facility failed to ensure kitchen ceiling tiles and vents were maintained in a clean and sanitary manner. This had the potential to affect all 48 residents who resided in the facility. Findings include: During an observation on 9/25/23 at 12:38 p.m., in room [ROOM NUMBER], the cover of the metal baseboard heat register was bent forward with metal protruding outward from the register approximately one to two inches. During an observation on 9/25/23 at 1:41 p.m., in room [ROOM NUMBER], the cover on the baseboard heat register was completely off on one side. During an observation and interview on 9/25/23 at 3:39 p.m., in room [ROOM NUMBER], observed the cover of the baseboard heat register almost all the way off. R34…

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 mail was delivered to residents on Saturdays. This had the potential to affect all residents in the facility who received personal mail, including but not limited to 4 of 4 residents (R11, R20, R23, R40), at the resident council meeting, who verbally confirmed not receiving mail on Saturdays. Findings include: On 9/26/23 at 2:30 p.m. to 3:00 p.m., a resident council interview was held with R4, R8, R11, R18, R20, R23, R27, R29, R40, R102, who routinely attended resident council meetings. When asked if they received their mail on Saturdays, R11 stated they did not, adding mail was put at the front desk and left there, mail was not delivered to any residents' rooms. R20, R23, and R40 verified mail was not delivered on Saturdays. All other residents in attendance did not indicate they received mail or not on Saturdays. During an interview on 9/27/23 at 1:07 p.m., social services (SS)-A confirmed residents did not always receive mail on Saturdays due to staffing, stated receptionist managed receiving/delivery 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 and interview, the facility failed to ensure meals were served in a timely manner for 5 of 5 residents (R25, R45, R100, R28, R16) reviewed for dining. This deficient practice had the potential to affect all 48 residents residing within the facility. Findings include: R25's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R25 was cognitively intact and required supervision of one for eating. During an observation on 9/25/23 at 12:53 p.m., in R25's room on the 200 wing, observed R25's breakfast tray still setting on his overbed table. R25, who ate in is room, stated he had not received his lunch yet. During an observation on 9/25/23 at 1:14 p.m., observed dietary aide (DA)-A deliver lunch trays to the 200 wing. Observed DA-A take a tray into R25's room and bring a different tray out of the room. DA-A acknowledged resident lunch trays had been delivered late, stating he and other DA's were in training. Dietary director (DD)-L who was also in the hallway, stated they had 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 interview and record review, the facility failed to ensure a resident's morning routine preferences, mealtime and location, and clothing preferences were honored for 1 of 3 residents (R16) who voiced concerns about choices. Findings include: R16's quarterly Minimum Data Set (MDS) dated [DATE], identified moderate impaired cognition no rejection of care, required one person physical assist with bed mobility, dressing, personal hygiene, two person physical assist with transfers and toilet use, and no setup or physical help from staff with eating, utilized a wheelchair, diagnoses included hemiplegia following cerebral infraction affecting left nondominant side (paralysis of the left side following a stroke), anxiety disorder, and dysphagia (swallowing difficulties). R16's significant change in status MDS dated [DATE], indicated somewhat important to choose what clothes to wear, choose between a tub bath, shower, bed bath or sponge bath, to do things with groups of people, and do favorite activities. R16's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to provide quarterly statements for resident personal fund accounts for 1 of 1 resident (R31) who indicated she hadn't been notified of account balance. Findings include: R31's quarterly Minimum Data Set (MDS) dated [DATE] indicated R31 was admitted to facility on 1/25/23, had intact cognition, understands and was understood. During an interview on 9/25/23 at 12:02 p.m., R31 indicated did not receive a quarterly statement of personal fund account balance, unaware how much money was in account. While interviewed on 9/28/23 at 9:41 a.m., family member (FM)-F, also known as R31's power of attorney (POA), indicated had never received any type of statements from facility, including statement of R31's personal fund balance, unaware of account balance at time. During an interview on 9/28/23 at 9:45 a.m., receptionist (R)-E indicated management of resident personal fund accounts, stated she hand delivered quarterly statements to residents in charge of self,…

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 adequate and required information was documented and communicated to a receiving healthcare facility to ensure continuity of care for 1 of 2 residents (R14) reviewed for hospitalization, had transferred to hospital emergently. Finding include: R14 was admitted to the facility on [DATE]. R14's diagnoses listed on face sheet received on 9/27/23, included: hemiplegia and hemiparesis (paralysis of one side of body) following cerebral infarction (stroke), type 2 diabetes mellitus ((DM) abnormal blood sugar), osteomyelitis (bone infection), severe calorie-protein malnutrition, methicillin resistant staphylococcus aureus (type of infection), congestive heart failure (CHF), chronic kidney disease (CKD), major depressive disorder (mood disorder), chronic viral hepatitis C (infection of liver causing swelling), neuromuscular (nerve/muscle) dysfunction of bladder, dementia (brain impairment), anxiety, and chronic pain. R14's quarterly minimum data set…

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 complete a significant change Minimum Data Set (MDS) assessment after resident (R14) had a decline in functional ability for eating, dressing, and personal hygiene, 1 of 9 residents (R41) reviewed for activities of daily living (ADLs). In addition, R14 was noted to have a significant change in cognition and significant change in weight loss Findings include: R14 was admitted to the facility on [DATE]. R14's diagnoses listed on face sheet received on 9/27/23, included: hemiplegia and hemiparesis (paralysis of one side of body) following cerebral infarction (stroke), type 2 diabetes mellitus ((DM) abnormal blood sugar), osteomyelitis (bone infection), severe calorie-protein malnutrition, methicillin resistant staphylococcus aureus (type of infection), congestive heart failure (CHF), chronic kidney disease (CKD), major depressive disorder (mood disorder), chronic viral hepatitis C (infection of liver causing swelling), neuromuscular…

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 nail care and grooming for 3 of 6 residents (R2, R10, R103) who were dependent upon staff for assistance with grooming and personal hygiene. Findings include: R2's significant change in status Minimum Data Set (MDS) assessment dated [DATE], indicated R2 was cognitively intact, no rejection of care, extensive assist of two-person physical assist with bed mobility, transfers, toilet use, one person physical assist with dressing, personal hygiene, setup help with eating, indicated bathing activity did not occur, and utilized a wheelchair and diagnoses included: debility, cardiorespiratory conditions, acute and chronic respiratory failure with hypoxia, arthritis, anxiety disorder, schizophrenia, and chronic lung disease. R2's Care Area Assessment (CAA) Summary dated [DATE], indicated R2 triggered for activity of daily living (ADL) functional r/t (related to) need for assistance with ADLs and a BIMS of 14 (cognitively intact), had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to timely identify and provide care/services of skin condition for 1 of 4 residents (R41) reviewed for quality of care, whom had an open skin lesion. Findings include: R41's face sheet printed on 9/28/23, indicated diagnoses of type 2 diabetes mellitus ((DM) abnormal blood sugar), glaucoma (abnormal vision), age related cognitive decline, and dermatitis (inflammation of skin). R41's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R41 had intact cognition and moderate visual impairment, extensive assistance by 1 staff for personal hygiene, and had no skin concerns. R41's provider orders printed on 9/28/23, indicated licensed nursing to complete weekly skin inspection in the evening every Sunday. R41's plan of care received on 10/3/23, instructed staff to monitor skin integrity daily during cares, complete weekly skin inspection by nurse, and assist with personal hygiene- requires extensive assist of 1. R41's weekly 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 observation, interview and document review, the facility failed to ensure adequate supervision during meals for 1 of 3 residents (R16) reviewed who required supervision. In addition, the facility failed to ensure safe smoking interventions for 1 of 1 resident (R6) reviewed for smoking. In addition, the facility failed to ensure appropriate intervention were implemented for falls for 1 of 1 resident (R41) reviewed for falls. Findings include: Supervision during meals: R16's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified moderate impaired cognition, no rejection of care, required one person physical assist with bed mobility, dressing, personal hygiene, two person physical assist with transfers and toilet use, and no setup or physical help from staff with eating, utilized a wheelchair, no swallowing complaints, diagnoses included hemiplegia following cerebral infraction affecting left non-dominant side (paralysis of the left side following a stroke), hypertension (high blood…

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 PRN (as needed) psychotropic medication orders which extended beyond 14 days, included the duration of the order for 2 of 2 residents (R12, R26) reviewed for unnecessary medications. Findings include: R12's face sheet printed on 9/29/23, included diagnoses of social phobia, PTSD (post-traumatic stress disorder) and depression. R12's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R12 was cognitively intact, had no behaviors and required extensive assistance of one staff for most ADL's (activities of daily living). R12's significant change care area assessment (CAA) dated 3/8/23, indicated R12 triggered for psychotropic drug use due to daily use of antidepressant and anti-anxiety medications. R12 had PRN clonazepam available for anxiety that he had taken three times in the look back period. R12's care plan dated 1/2/20, indicated the potential for psychotropic drug ADR's (adverse drug reaction) due to daily use 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 follow-up and dental services were provided for 1 of 1 resident (R10) reviewed for dental services, who had broken/chipped teeth in poor condition. Findings include: R10's significant change in status Minimum Data Set (MDS) assessment dated [DATE], indicated R10 was cognitively intact, no rejection of care, one person physical assist with bed mobility, transfers, walk in room, dressing, toilet use, personal hygiene, setup help with eating, and indicated bathing support required one person physical assist, and utilized a wheelchair and walker; diagnoses included coronary artery disease, heart failure, renal insufficiency, chronic lung disease, respiratory failure; obvious or likely cavity or broken natural teeth, mouth or facility pain, and discomfort or difficulty with chewing, R10's Care Area Assessment (CAA) Summary dated 7/20/23, indicated R10 had his own teeth with several missing in poor overall condition, difficulty with…

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