Bywood East Health Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to immediately report an allegation of sexual abuse to the state agency (SA) for 1 of 1 resident (R1, R2) when R2 was found engaged in a sexual act with R1 without staff's knowledge of R2's consent. Findings include: R2's admission minimum data set (MDS) dated [DATE], indicated R2 was cognitive impaired. R2's Care Plan dated 8/19/25, indicated R2 had potential for abuse, neglect and/or exploitation related to vulnerable adult status. R1's admission MDS dated [DATE], indicated R1 was cognitively intact. A Facility Reported Incident (FRI) dated 8/14/25 at 1:40 p.m., indicated on 8/13/25 at 7:31 p.m., writer received a call that R2 and R1 were found to be engaging in a sexual act. Writer was told R1 offered R2 a cigarette in exchange for sex. This morning at approximately 11:30 a.m. writer went to go speak with resident (R2) and she stated nothing happed and she was okay and had no memory of the incident, she was her normal routine, had a BIMs of 5…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to thoroughly investigate a resident-to-resident abuse allegation for 2 of 2 residents (R3 and R4) and a resident-to-resident sexual assault allegation for 2 of 2 residents (R1, R2) to determine incident details, interview all parties involved, appropriately assess and identify interventions to reduce likelihood of future abuse. Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE], indicated R3 had bipolar disorder, alcohol dependance, post-traumatic stress disorder (PTSD) and was cognitively intact. R4's quarterly MDS dated [DATE], indicated R4 was cognitively intact with disorganized thinking and had no behaviors. A Facility Reported Incident dated 8/14/25 at 10:45 p.m., indicated R3 and R4 engaged in a verbal altercation on the smoking patio. Staff were able to separate them and R3 went back into the building to his room on the third floor. Several minutes later R3 returned to the smoking patio and R4 was seen on the ground where R3…

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, document review and interview, the facility failed to comprehensively develop and implement a resident centered care plan for 1 of 1 resident (R2) who was at risk of abuse and interventions were not identified to address the root cause of that risk and decrease the likelihood of abuse re-occurring. Findings include: R2's Care Plan dated 8/19/25, indicated R2 was admitted on [DATE], had Alzheimer's Disease with early onset, nicotine dependance, and verbal behavioral symptoms directed towards others. R2's Progress Notes admission date (7/21/25) to 8/20/25, indicated:-7/22/25, out of bed multiples times asking for cigarettes-7/23/25, she was up and out with her cigarettes-7/24/25, R2 comes to writer to get cigarettes, explanation given that she only receives one once an hour, she often comes early. -7/24/25, R2 asks for cigarettes but gets one each hour.-7/25/25. Resident in and out of room requesting cigarette before one hour completion.-7/26/25, Resident is constantly asking for cigarette…

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 laundry was handled and transported in a way to prevent the spread of infection to the extent possible. This had the possible to affect all 70 residents residing in the facility. Findings include: During interview and observation on 4/15/25 at 8:06 a.m., the head of maintenance (HOM) stated an outside company laundered the facility's linens and the facility washed the resident personal laundry. The laundry room did not have gowns hanging for use and the HOM confirmed staff did not wear gowns, only gloves and a mask, when handling resident dirty laundry. The facility's linens were brought up to the floors for resident use in large, uncovered bins. Personal laundry was brought up to the floors in uncovered, metal hanging carts. The HOM confirmed clean laundry was not covered when brought up to the floors. On 4/14/25 at 1:24 p.m., the second floor unit was toured and room [ROOM NUMBER] (unoccupied) was found with an open door to the…

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

Based on observation, interview, and document review, the facility failed to ensure food was reheated to an appropriate temperature to reduce the risk of foodborne illness for 12 residents who ingested the food item. Findings include: Captain Ken's Bag Heating Protocol, indicated the chicken pot pie filling was to reach a temperature of 165 degrees Fahrenheit (F). The Facility's temperature log dated 4/14/25 through 4/20/25, indicated the temperature of the chicken and dumplings was 170 F on 4/16/25 for the lunch service. During an observation on 4/16/25 at 10:43 a.m., cook (C)-A took out multiple bags of chicken pot pie filling (confirmed in a later interview) from the steam cooker, cut the tops off the bags, and mixed the item into a large metal container. C-A was not observed to take the temperature of the item. During an observation and interview on 4/16/25 at 10:45 a.m., as C-A was observed to continue prepping food for the lunch meal service, temperature logs were found and indicated the chicken and dumplings temperature was taken at 170 degrees. C-A was observed to take the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure voiced allegations of potential verbal and/or mental abuse were reported to the administrator and State agency (SA) in a timely manner for 3 of 4 residents (R21, R26, R55) reviewed who reported potential allegations of abuse. Findings include: R21 R21's quarterly Minimum Data Set (MDS), dated [DATE], identified R21 had intact cognition but demonstrated delusional thinking during the review period. On 4/14/25 at 12:51 p.m., R21 was interviewed in their shared room with the doorway partially open at her request. R21's roommate was not present, however, a bed and personal belongings were present on their side of the privacy curtain. R21 stated she felt abused by her roommate and expressed the roommate often called her derogatory names and swore at her. R21 added, [Roommate] calls me a slut, and says, F [expletive] you [to me]. R21 named the roommate by name and expressed they had lived together for at least a couple months. R21 stated she wasn't…

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 voiced allegations of potential verbal and/or mental abuse were acted upon, investigated, and if needed, adequate protection provided to ensure safety and well-being for 3 of 4 residents (R21, R26, R55) reviewed who reported potential allegations of abuse. Findings include: R21 R21's quarterly Minimum Data Set (MDS), dated [DATE], identified R21 had intact cognition but demonstrated delusional thinking during the review period. On 4/14/25 at 12:51 p.m., R21 was interviewed in their shared room with the doorway partially open at her request. R21's roommate was not present, however, a bed and personal belongings were present on their side of the privacy curtain. R21 stated she felt abused by her roommate and expressed the roommate often called her derogatory names and swears at her. R21 added, [Roommate] calls me a slut, and says, F [expletive] you [to me]. R21 named the roommate by name and expressed they had lived together for at least a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded with consumed medications to promote continuity of care and ensure accurate care-planning for 2 of 5 residents (R25, R4) reviewed for MDS accuracy. Findings include: The Centers for Medicare & Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2023, identified a purpose to offer clear guidance on how to use (i.e., code) the RAI which was divided in multiple sections. The manual outlined, Section N: Medications, which directed an intent to record the number of days during the review period a type of various medications, including hypoglycemic and antipsychotics, were administered to the resident. The manual outlined consumption of these high-risk medications could have potential for side effects which . can adversely affect health, safety, and quality of life. The manual outlined, N0415 B1. Antianxiety: Check if an anxiolytic medication was taken by…

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 resident care plans were comprehensive and up to date to ensure continuity of care for 3 of 3 residents (R55, R57 and R65) reviewed for comprehensive care plans. Findings include: R55 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 Enhanced Barrier Protection (EBP) were defined as, . expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing . MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities . residents with wounds and indwelling medical devices are at especially high risk of both acquisition of…

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 ongoing, comprehensive discharge planning to a lower level of care for 1 of 1 residents (R52) who wished to be discharged from the nursing home. Findings include: R52's quarterly Minimum Data Set (MDS) dated [DATE], indicated active discharge planning was occurring for the resident to return to another facility but, a referral had not been made to a Local Contact Agency (LCA) and discharge was expected to be more than three months away. The MDS indicated R52 had intact cognition. R52's care plan revised on 1/8/24, indicated R52 had a discharge plan to move into an assisted living facility. The discharge care plan solely included the following two interventions: discharge criteria would be completed upon admission and reviewed quarterly, annually, and as needed, and nursing would get discharge orders and staff would follow through when discharge was pending. R52's progress note dated 2/15/24 at 2:53 p.m., indicated the outside care coordinator…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to comprehensively assess and develop interventions to promote acceptance with bathing and/or personal hygiene cares for 1 of 2 residents (R24) reviewed who appeared disheveled and had a pattern of refusing cares. Findings include: R24's quarterly Minimum Data Set (MDS), dated [DATE], identified R24's long-term and short-term memory was impaired. The MDS outlined R24 had both physical and verbal behaviors recorded, however, had no rejection of care behaviors during the review period. Further, the MDS identified R27 needed substantial assistance with bathing, however, was independent with personal hygiene. On 4/14/25 at 12:33 p.m., R24 was observed seated on his bedside while in his room. R24 was dressed in gray-colored sweatpants along with a thick winter coat, and his hair appeared greasy along with him having a visible brown-colored substance over both his hands. R24 stated, I dunno, when asked about it and expressed he was not sure what…

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 repeated complaints of pleuritic and/or gastrointestinal distress (i.e., heartburn) were assessed and acted upon to determine what, if any, proactive interventions were needed to promote comfort and prevent complication for 1 of 1 resident (R5) reviewed who complained of heart pain. Findings include: R5's quarterly Minimum Data Set (MDS), dated [DATE], identified R5 had moderate cognitive impairment and several medical conditions including non-traumatic brain dysfunction, heart failure, and schizophrenia. Further, the MDS outlined consumed multiple medications including an anticoagulant (i.e., blood thinner). On 4/14/25 at 2:32 p.m., R5 was observed seated in a chair on the second floor unit. A medication cup was present on the arm of the chair which was approximately 1/2 full of a white colored liquid. R5 was asked by the surveyor if she had any pain to which R5 just repeatedly kept saying aloud, Just my heart. R5 stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure voiced complaints of difficulty hearing were acted upon, assessed, and if needed, treatment started or referred to audiology to promote quality of life for 1 of 1 resident (R24) reviewed who was hard of hearing (HOH). Findings include: R24's quarterly Minimum Data Set (MDS), dated [DATE], identified R24's long-term and short-term memory was impaired. Further, the MDS outlined R24's hearing was recorded as, 0. Adequate [no difficulty in normal conversation, social interaction, listening to TV], and R24 did not use hearing aids. R24's care plan, printed 4/15/25, identified R24's actual or potential problems and care needs along with corresponding goals and interventions. The care plan outlined, [R24] has potential/actual alteration in communication related to being hard of hearing and needing hearing aids, with a last revised date recorded, 07/11/2022. The care plan directed to minimize background noise, speak with increased volume…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to ensure a resident who had multiple incidents of smoking indoors was reassessed for safe smoking for 1 of 2 residents (R32) reviewed for smoking. Findings include: R32's annual Minimum Data Set (MDS) dated [DATE], indicated R32 was cognitively intact and independent with activities of daily living. R32's most recent smoking assessment, dated 2/27/25, indicated R23 smokes only in designated areas and was deemed a safe smoker. R32's progress notes indicated R32 had at least three incidents of smoking indoors in the past 6-7 months: - On 9/30/24 it was documented R32 violated the facility's smoking policy by smoking in her room. R32 stated she would not smoke in the facility and signed the Smoking Policy. - On 4/9/25 it was documented R32 was caught smoking in her room. R32 was again educated on the risks and consequences of smoking in her room with oxygen being used in the room next to her. - On 4/14/25 it was documented staff informed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure a physician visit was completed in a timely manner (i.e., every 60 to 70 days) to promote continuity of care and reduce the risk of disease complication for 1 of 5 residents (R5) reviewed for unnecessary medication use. Findings include: R5's quarterly Minimum Data Set (MDS), dated [DATE], identified R5 had moderate cognitive impairment and several medical conditions including non-traumatic brain dysfunction, heart failure, and schizophrenia. Further, the MDS outlined consumed multiple medications including antipsychotic and anticoagulant (i.e., blood thinner) medications. On 4/14/25 at 2:32 p.m., R5 was observed seated in a chair on the second floor unit. A medication cup was present on the arm of the chair which was approximately 1/2 full of a white colored liquid. R5 was asked by the surveyor if she had any pain to which R5 just repeatedly kept saying aloud, Just my heart. R5 stated the pain just started that day. At this…

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 implemented appropriate and manufacturer-directed steps to prevent post-administration complication (i.e., thrush) of a steroid-infused inhaler for 1 of 1 residents (R4) observed to receive inhaled medication during the recertification survey. Findings include: R4's quarterly Minimum Data Set (MDS), dated [DATE], identified R4 had moderate cognitive impairment; along with multiple medical conditions including (history of) pneumonia and asthma. On 4/16/25 at 7:20 a.m., medication set-up and administration was observed with trained medication aide (TMA)-A who removed R4's medications from a mobile cart stationed in the hallway. R4 was seated next to the cart and TMA-A removed two inhalers from the cart to provide to R4. These were handed to the surveyor for review and included a metered-dose inhaler labeled mometasone furoate (Asmanex) HFA 200 mcg/act (micrograms/actuation) with an attached pharmacy label which directed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure consulting pharmacist recommendations for standard-of-care laboratory monitoring with a consumed cardiac glycoside medication were acted upon and addressed in a timely manner for 1 of 5 residents (R5) reviewed for unnecessary medication use. Findings include: R5's quarterly Minimum Data Set (MDS), dated [DATE], identified R5 had moderate cognitive impairment and several medical conditions including non-traumatic brain dysfunction, heart failure, and schizophrenia. Further, the MDS outlined consumed multiple medications including antipsychotic and anticoagulant (i.e., blood thinner) medications. R5's Medication Administration Record (MAR), dated 4/2025, identified all of her consumed medications and recorded treatments for the period. The orders included, Digox[in] . 125 MCG [micrograms] . one time a day related to CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE, with a listed start date recorded, 03/03/2025. The medication was recorded as being…

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 consumed cardiac glycoside medication was appropriately monitored in accordance with the standard-of-care laboratory testing to help reduce the risk of medication toxicity for 1 of 5 residents (R5) reviewed for unnecessary medication use. Findings include: A Cleveland Clinic feature titled, Digoxin, dated 4/2023, identified the medication was used to help with certain heart issues. The feature outlined, Various factors affect how much of the drug your body absorbs and excretes. Digoxin levels that are too high can be life-threatening. The feature outlined the medical provider will check a patient's digoxin level adding, You'll need to have a provider check your digoxin level regularly. They'll tell you how often you need to do this. The medication side effects listed included upset stomach, dizziness, and heart block. Further, the article identified a normal digoxin level range of, 0.5 to 2 ng/ml [nanograms/milliliter], 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 implement the current standards of vaccinations regarding pneumonia for 1 of 5 residents (R22) over [AGE] years old whose vaccinations histories were reviewed. Findings include: The Center for Disease Control and Prevention (CDC) identified on the PneumoRecs VaxAdvisor Application, revised 12/11/24 to reflect a change in age guidance, advised for patients over [AGE] years of age, Give at least one does of the PCV15, PCV20, or PCV21 at least one year after the last does of PPSV23. R22's face sheet, printed 4/16/25, indicated R22 was [AGE] years old at the time of survey, was cognitively intact and was initially admitted to the care center on 9/15/23. R22's Immunizations listed in her electronic medical record (EMR) indicated R22 received the PPSV23 (Pneumovax 23) on 6/30/11. No other pneumococcal vaccines were listed in R22's EMR. According to the CDC, R22 should receive at least one does of the PCV15, PCV20, or PCV21 at least one year after the last…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to comprehensively assess and appropriately transfer a resident off the floor after an unwitnessed fall with potential head injury for 1 of 1 resident (R2) reviewed for falls. Findings include: R2's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R2 had diagnoses including a personal history of traumatic brain injury. R2 utilized a manual wheelchair independently and required supervision or touching assistance for transfers. R2's progress note dated 3/16/25, indicated R2 was involved in an altercation with another resident, R1, at 8:08 a.m. R2 was coming out of the elevator, R1 wanted to enter the elevator and started dragging R2's out. R1 grabbed R2's wheelchair which flipped him [R2] backward and R2 fell and hit the back of his head on the floor of the elevator. Progress note identified on assessment, no apparent redness, injury or bump noted at this time, included a set of vital signs, and noted R2 complained of pain…

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 Performance Improvement (QAPI) adequately addressed and monitored a known rodent (mouse) infestation that had the ability to affect all 68 residents residing in the facility. Findings include: During interview on 10/09/24, at 12:00 p.m. R4 stated there is mice on second floor where she lives and she sees them all of the time. You really need to check this out while you are here. During observation and interview on 10/09/24, at 12:08 p.m. trained medical assistant (TMA)-A stated R3 takes her lunch trays to her room and sometimes buys snacks to feed the mice in her room. During observation TMA-A walked to R3's room and opened her door, and a mouse was observed to run behind her night stand against her wall next to R3's bed. TMA-A further stated he thinks the mice sometimes come up on her bed. An observation on 10/9/24, at 11:00 a.m. of R3's room revealed a pile of food on top of a large tortilla shell consisting 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 implement effective and timely pest control measures to reduce and/or eliminate a mouse infestation in the facility. This had potential to affect all 68 residents whom resided in the facility. Findings include: During interview on 10/09/24, at 12:00 p.m. R4 stated there is mice on second floor where she lives and see's them all of the time and you really need to check this out while you are here. During observation and interview on 10/09/24, at 12:08 p.m. to follow up on R4's comment, on second floor trained medical assistant (TMA)-A stated R3 takes her lunch trays to her room and sometimes buys snacks to feed the mice in her room. During observation TMA-A walked to R3's room and opened her door, and a mouse was observed to run behind her night stand against her wall next to R3's bed. TMA-A further stated he thinks the mice sometimes come up on her bed. An observation on 10/9/24, at 11:00 a.m. of R3's room revealed a pile of food on top…

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 timely notification to a provider/guardian for a missing resident for 1 of 1 residents (R1), who was sent to appointment without an escort and was missing for seven hours at the hospital until family member (FM)-A found him lost and confused looking for his room. Findings include: R1's Significant Change Minimum Data Set (MDS) dated [DATE], indicated R1 had a non-traumatic brain dysfunction, diabetes, asthma, anxiety, and Schizophrenia. R1's MDS further indicated independent with Activities of Daily Living, ambulate independently, and had acute on-set mental status change with disorganized thinking. R1's Care Plan, dated 9/18/24, indicated R1 had cognitive impairment, was not safe in the community, and could not leave the facility without an escort. R1 was at risk for falls due to impaired cognition, received psychotropic medication, and had a history of substance abuse. R1's progress notes identified on: 1) 9/18/24 at 7:30 p.m.: The resident…

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 exercise reasonable care for the protection of the resident's property from loss or theft and ensure a lock box was provided for personal property and/or monies for 1 of 1 resident (R1) who had loss of property after removing $50.00 from his account. R1had recent traumatic brain injury and no recollection where the money went. The facility also failed to investigate where the missing money went or implement safety measures to protect resident property from potential loss or theft. Findings include: R1's significant change minimum data set (MDS dated [DATE], indicated R1 had a non-traumatic brain dysfunction, diabetes mellitus asthma, anxiety, and Schizophrenia. R1's MDS further indicated independence in activities in daily living ambulates independently, had acute on-set mental status change with disorganized thinking. R1's Care Plan, dated 9/18/24, indicated R1 had cognitive impairment, received psychotropic medication, and had a history of substance…

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 timely report an allegation of missing resident for 1 of 1 resident (R1) who had a traumatic brain injury was cognitively impaired went missing from the facility and was later found on the local hospital grounds. Findings include: In a Wandering and Elopement Risk Assessment, dated 9/17/24, R1 was identified to be at risk for elopement, resident is not safe in the community and cannot leave the facility without an escort. R1 has a recent diagnosis of traumatic brain injury, diabetes, schizoaffective disorder (serious mental disorder), seizure disorder, psychoactive (illicit drug) substance abuse, and opioid abuse. R1 ambulated independently and scored a 99 on his brief interview for mental status (BIM)s, dated 9/17/24, indicating unable to complete. R1's Significant Change Minimum Data Set (MDS) dated [DATE], indicated R1 had a non-traumatic brain dysfunction, diabetes, asthma, anxiety, and Schizophrenia. R1's MDS further indicated independent with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to provide timely notification to a provider for change in condition related to falls, or treatment after falls for 3 of 3 residents (R1, R5, R6) reviewed for change in condition. Findings include: R1's diagnoses list dated 9/6/24, indicated R1 admitted to the facility on [DATE] with diagnoses of schizophrenia, anxiety, depression, diabetes, drug induced subacute dyskinesia (involuntary muscle movement), and orthostatic hypotension (a sudden drop in blood pressure when standing from a seated or lying position with feelings of dizziness or feeling faint). R1's annual Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition, and supervision with set-up assistance for bed mobility, transfers, eating, and toileting. R1's progress notes dated 8/12/24 at 10:48 p.m., indicated R1 fell near the elevator, and could not state how he fell, but R1 reported hitting his head, with a reddened area noted on the left side of the forehead. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure allegations of verbal abuse were reported immediately (within two hours) to the State Agency (SA) for 2 of 3 residents (R1, R3) reviewed for abuse. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 was cognitively intact and had no behaviors. On 6/20/24 at 4:40 p.m., a progress note indicated the director of nursing (DON) talked with R1 regarding an incident with a staff member. R1 didn't want police notified, and felt safe in the facility. R3's quarterly Minimum Data Set (MDS) dated [DATE], identified R3 had mild cognitive impairment. On 6/23/24 at 5:50 p.m., a progress note indicated R3 reported that nursing assistant (NA-A) called her a crazy bitch and said, f . you to R3. The Nursing Home Incident Report dated 6/21/24, indicated the staff to resident incident between R1 and maintenance worker (M)-A occurred on 6/19/24 at 2:36 p.m The facility reported the incident on 6/21/24 at 2:16 p.m. nearly 48 hours…

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 54 of 72 residents with personal funds accounts (including R1, R2, R4, R5, R6, R8) with the facility had access (and/or awareness of access) to their funds as soon as possible to meet their individualized needs, after hours, and on weekends. Findings include: State Agency (SA) report dated 4/9/24 at 1:47 p.m. indicated family member (FM)-A was concerned as R1 was not receiving his monthly income since the facility had taken over as payee for R1. FM-A indicated she had called to speak to someone at the facility and they had hung up on her. R1 was needing his money to buy things and was stressed as he did not know where his money was. Staff at the facility informed FM-A they could see R1 had over $600.00 dollars available. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment. R1's admission record dated 4/12/24 at 1:04 p.m. indicated R1 had a guardian in place. R2's annual MDS dated [DATE], indicated R2 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to provide quarterly statements for resident personal fund accounts for 54 of 72 residents (including R2, R3, R4, R5, R6, R7, and R9) residents reviewed for personal fund accounts. R2's annual Minimum Data Set (MDS) dated [DATE], indicated R2 was cognitively intact. On 4/11/24 at 8:28 a.m., stated she does not remember getting a statement of her resident fund account but she would like that. R3's annual Minimum Data Set (MDS) dated [DATE], indicated R5 was cognitively intact. On 4/11/24 at 8:41 a.m., R3 stated he had not gotten any statements from the facility and did not know how much money he has in the facility. R4's annual MDS dated [DATE], indicated R4 was cognitively intact. On 4/11/24 at 9:35 a.m., R4 indicated she had never gotten a statement for her funds in the facility that she could remember. R5's annual MDS dated [DATE], indicated R5 was moderately cognitively impaired. On 4/11/24 at 11:52 a.m., R5 stated he was not aware if he had any…

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 Performance Improvement (QAPI) adequately addressed and monitored a known rodent (mouse) infestation that had the ability to affect all 72 residents residing in the facility. Findings include: R36's quarterly MDS dated [DATE], indicated R36 had intact cognition. During interview with R36 on 3/5/24 at 2:50 p.m., R36 stated, yes, I have concerns with mice keep running back and forth [pointing to wall baseboard along head of bed]. R36 stated, I told staff about it and they gave me a trap. R62's quarterly MDS dated [DATE], identified R62 with intact cognition. During interview with R62 on 3/4/24 at 8:49 a.m., R62 stated the care center had an issue with pests and rodents adding, There's mice all the time [here]. R62 stated he often heard noises around the room, including amongst his personal items, which then moved or would disappear when he tried to locate the source and believed these to be mice running around the…

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

Based on interview and document review the facility failed to ensure an infection prevention and control surveillance system was created and implemented to identify, track, and analyze all resident infections to prevent the spread of communicable diseases and infectious organisms. In addition, the facility failed to have the infection control program reviewed annually. This had the potential to affect all 72 residents, staff and visitors in the facility. Findings include: During interview and document review with director of nursing (DON) and infection control preventionist (ICP) on 3/6/24 at 3:50 p.m., a review of the infection surveillance program lacked monitoring data, documentation, and follow-up of infections. DON displayed a spreadsheet that had been established with no data on it and a review of the facility infection surveillance program demonstrated there was no data collection tool completed to document infections, provide analysis and identify infections and infection risks. DON stated he was working with ICP to fill it in with data regarding surveillance. The ICP stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to implement effective and timely pest control measures to reduce and/or eliminate a mouse infestation in the facility. This had potential to affect all 72 residents whom resided in the facility. Findings include: A off-site Vulnerable Adult Maltreatment Report, dated 6/2023, identified several concerns with care at the care care center including, There are also mice running around everywhere at Facility. [Resident] is afraid they are going to crawl in bed with [resident] due to them running under [their] bed. An additional Vulnerable Adult Maltreatment Report, dated 8/2023, identified the reporter had concerns for health and safety of the resident population adding, There is a mice, flies and mold infestation at [the care center]. The report added, Reporter noticed mice was running around and flies when reporter looked at kitchen of Bywood East Health Care Nursing Home . [resident] is concerned with mice running around . this is a disease…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and document review, the facility failed to provide the opportunity for 4 of 4 residents (R17, R28, R42, R48) reviewed to participate in care planning and care conferences. Findings include: R17 R17's quarterly Minimum Data Set (MDS) dated [DATE], indicated R17's Brief Interview for Mental Status was left blank. The MDS indicated he was diagnosed with diabetes, depression, and a psychotic disorder. R17's Care Plan Revision/ Review report dated 12/14/23, indicated R17's care plan was revised/ reviewed for activities, dietary, and nursing needs but did not indicate that R17 attended or was invited to this meeting. R17's Brief Interview for Mental Status report dated 2/26/24, indicated that R17 had intact cognition with a score of 15/15. R17's medical record was reviewed and lacked evidence that R17 was invited or attended the care conference held on 12/14/23. During an interview on 3/4/24 at 7:52 a.m., R17 stated he did not recall attending or receiving an invitation to a care conference. R28…

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

Based on observation and interview, the facility failed to ensure resident records that contained private, medical, and personal information were not accessible to unauthorized personnel. Findings include: During observation and interview on 3/5/24 at 8:13 a.m., a 2nd floor nursing station laptop was left open with patient identifying information including a medication list was observed. No staff were present with ambulatory residents walking past it. The facility administrator exited a staff room adjacent to the unattended laptop and stated, this [pointing the open laptop] should not be visible to anyone for HIPPA [health information portability privacy act] reasons. During interview with trained medication aide (TMA)-A on 3/5/24 at 8:32 a.m., TMA-A stated she was responsible for the unattended laptop and stated, I should have closed or turned on the screen saver [before leaving the laptop]. TMA-A stated, the information is private and should not be left unattended. During observation and interview on 3/6/24 at 12:59 p.m., a 2nd floor nursing station laptop was left open 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 a Level II Pre-admission Screening and Resident Review (PASARR) was completed, retained in the medical record, and readily available to ensure continuity of care with mental health needs for one of two residents (R52) reviewed for PASARR. Findings include: R52's quarterly Minimum Data Set (MDS), dated [DATE], indicated R52 was cognitively intact and admitted to the facility on [DATE]. R52's Medical Diagnoses list, printed 3/7/23, indicated R52 was admitted to the facility with a primary diagnosis of schizoaffective disorder, bipolar type (a mental health condition including symptoms of schizophrenia and mood disorders, such as depression or bipolar disorder) and secondary diagnoses of depression, unspecified mood disorder and bipolar disorder ( a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration that can make it difficult to carry out day-to-day tasks.) The Medical Diagnoses list did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to follow standards of practice related to medication administration for 1 of 1 resident (R228) reviewed for medication administration. Findings include: According to the National Institute of Health article titled, Nursing Rights of Medication Administration, last updated September 4, 2023, [the nurse is] the final person to check to see that the medication is correctly prescribed and dispensed before administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration. The five traditional rights in the traditional sequence include: Right patient .Right drug .Right route .Right time .Right dose. R228's admission assessment dated [DATE], identified R228 with an admission to the facility on 2/15/24 and with intact cognition. In addition, R228 had diagnoses of heart failure, cirrhosis (liver disease), diabetes, anxiety, manic depression, and chronic obstructive pulmonary disease (a 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 observation, interview, and document review, the facility failed to ensure routine personal cares, including bathing and nail care, were offered or provided to maintain a dignified appearance and reduce the risk of complication (i.e., infection, skin impairments) for 1 of 1 resident (R20) reviewed who was legally blind. Findings include: R20's most recent Brief Interview for Mental Status (3.0 BIMS), dated 2/28/24, identified R20 had intact cognition. R20's annual Minimum Data Set (MDS), dated [DATE], identified R20 demonstrated no rejection of care behaviors, had diabetes mellitus, and required no help for personal hygiene cares but substantial assistance with bathing. However, the spaces to recorded R20's cognition were left blank and not completed. On 3/4/24 at 8:29 a.m., R20 was observed standing upright in his shared room. R20 was dressed in a black-colored sweatshirt which had visible, white-colored dried substance on the front. R20 also had long fingernails present on both hands, with some nails…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to comprehensively assess and implement new fall interventions for a resident with multiple falls to attempt to limit falls for 1 of 1 resident (R66) reviewed for falls. Additionally, the facility failed to accurately assess a resident observed with multiple burn holes in their clothing for safe smoking practices for 1 of 4 residents (R4) reviewed for smoking. Findings include: Falls: R66 R66's quarterly Minimum Data Set, dated [DATE], indicated R66 was independent with all activities of daily living, non-ambulatory and had two or more falls since admission without serious injury. R66 refused cognitive testing, however appeared to be cognitively intact during interviews. R66's Medical Diagnoses list, printed 3/7/24, indicated R66 was admitted to the facility on [DATE] with a primary diagnosis of unspecified paraplegia (Complete paralysis of the lower half of the body including both legs, often caused by damage to the spinal cord.) R66'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 therapeutic diets as prescribed by the physician for 1 of 1 (R48) residents reviewed for diet restrictions. Findings include: R48's admission record, dated 3/7/24, identified R48 admitted to the facility on [DATE]. Diagnoses included type 2 diabetes mellitus without complications (diabetes), heart failure, hypertension (high blood pressure), and hyperlipidemia (high cholesterol). R48's quarterly Minimum Data Set (MDS), dated [DATE], identified intact cognition and independence with eating. R48's care plan, dated 3/7/24, identified R48 under nutrition at risk for long and short-term complications related to alteration in blood glucose: type 2 diabetes. Goal: [R48] will have no hypoglycemic episodes [low blood sugar] through review dates; maintain weight through review date. Interventions: monitor blood glucose as ordered by MD, provide with oral medication(s) and/or insulin per DO [doctor order]; order labs per DO to monitor treatment; educate…

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 for 2 of 2 residents (R57, R67) were clearly explained in a form and manner that they understood prior to entering into the binding arbitration agreements. Findings include: R57's annual Minimum Data Set (MDS) dated [DATE], identified R57 admitted to facility on 4/27/22 and had intact cognition. Review of R57's signed Bywood East Health Care Arbitration Agreement dated 5/2/22, indicated, Resident and Bywood East Health Care 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 Bywood East Health Care. Review of the agreement did not include evidence the binding arbitration agreement was explained in a form, manner and language that the resident or his or her representative understands. During interview with R57 on 3/6/24 at 9:11 a.m., R57 unable to recall signing admission paperwork informing him that he was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to accurately assess 6 of 8 residents (R1, R2, R3, R4, R6, and R7) reviewed when their cognition and depression was not assessed on the minimum data set (MDS). Findings include: R1's Minimum Data Set (MDS) a standardized assessment tool that measures health status in nursing home residents) dated 9/29/23, did not indicate R1's cognition, or depression test findings. R1 had a diagnosis of bipolar disease, dementia, chronic pain, panic attacks, heart disease, weakness, and poor nutritional intake. R1's MDS dated [DATE], indicated she had normal cognition and minimal depression. R2's MDS dated [DATE], indicated she had normal cognition and no depression. R2's diagnosis included dementia with behavioral issues, a mood disorder, lung disease, diabetes, and depression. R2's MDS dated [DATE], did not indicate his cognition and depression test results. R3's MDS dated [DATE], indicated mild cognitive impairment and minimal depression. R3's diagnosis included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to develop and implement behavioral health comprehensive person-centered care plans providing care and services for 6 of 8 residents (R1, R2, R3, R4, R6, and R7) reviewed when their cognition and depression was not assessed, and recommendations from resident's psychologist were not added to the resident's care plans. Findings include: R1's care plan intervention dated 1/25/22, indicated her depression would be monitored per facility policy. In addition, staff were ordered to observe her for any mood or behavior changes. R1's Minimum Data Set (MDS [a standardized assessment tool that measures health status in nursing home residents]) dated 9/29/23, did not indicate R1's cognition, or depression test findings. She had Bipolar disease, dementia, chronic pain, panic attacks, heart disease, weakness, and poor nutritional intake. R1's Associated Clinic of Psychology (ACP) note dated 11/28/23, directed staff to encourage her to spend more time in common spaces…

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 track behavior charting for resident to resident altercations for 4 of 8 residents (R1, R2, R3, and R4) reviewed when incidents occurred but not documented on the nursing assistant (NA) target behavior charting required to determine the residents' overall response to care plan interventions and meeting their behavior goals. Findings include: R1's MDS dated [DATE], identified she had normal cognition, minimal depression, bipolar disease, dementia, chronic pain, panic attacks, heart disease, weakness, and poor nutritional intake. R1's nursing note dated 1/8/24 at 9:51 p.m., indicated she was in a physical fight with another resident, and she was satisfied how she beat her up. R1's NA behavior charting regarding yelling or hitting others dated 12/24/23 through 1/22/24, did not indicate the 1/8/24, incident when she fought R2. R2's MDS dated [DATE], indicated her cognitive status and depression score was not assessed. He had dementia with behavioral…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure 1 of 1 residents (R1) was free from the use of manual restraint when staff held onto her wheelchair restraining her movement. Findings include: R1's Diagnoses List undated indicated R1's diagnoses included schizoaffective disorder (a mental disorder with both schizophrenia and mood disorder symptoms), nicotine dependence, and alcohol dependence with intoxication. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition, and utilized a wheelchair. On 8/20/23 at 4:15 a.m., a progress note written by registered nurse (RN)-A indicated, Around 2:25 a.m., (R1) came to the first floor and pulled on the medication cart, and was able to open it because it was not shut enough. Then the writer noticed she was hiding something in her clothes. The writer asked R1 what she had taken from the cart and R1 replied, I'm just curious about what's inside. When the writer went out of the office to see what she took from the cart, R1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to notify a resident representative timely of an incident that occurred for 1 of 8 residents (R10) reviewed for notification of change. Findings include: R10's Diagnoses List undated indicated R10 had degenerative disease of the nervous system, schizophrenia, developmental disorder of scholastic skills, history of traumatic brain injury, unspecified dementia, and mild cognitive impairment. R10's Face Sheet indicated an appointed guardian as his emergency contact. R10's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R10 had a memory problem, severely impaired cognitive skills for daily decision-making skills. R10 displayed inattention and disorganized thinking continuously. R10 did not have verbal or physical aggression behaviors, did not reject care, or wander. R10 did not walk was independent with locomotion in his room and around the building in his wheelchair. R10's care plan dated 2/12/22, indicated R10 had alteration in…

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.