Lakehouse Healthcare & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure a level I Pre-admission Screening (PAS) and, if needed, a Level II Pre-admission Screening and Resident Review (PASARR) was completed to screen for mental health needs for 3 of 4 residents (R40, R9, R6) reviewed for PAS. Findings include: R40’s quarterly Minimum Data Set (MDS) dated [DATE], indicated R40 was admitted to the facility on [DATE] and had intact cognition. The MDS indicated R40 was diagnosed with schizophrenia, post-traumatic stress disorder, and a “psychotic disorder”. R40's PAS notice dated 1/21/25, indicated a copy of the PAS was included with this notice, but the PAS was not final until the lead agency sent a final determination to the nursing home. R40's entire medical record was reviewed and lacked evidence that a final determination had been received. During an interview with the director of admissions (DOA) on 8/13/25 at 9:26 a.m., the final PAS was requested, and the DOA confirmed she would review R40’s medical record and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to develop a comprehensive care plan to ensure correct application of a lower extremity brace for 1 of 3 residents (R178) reviewed for the use of a lower extremity brace. Findings include: R178's quarterly Minimum Data Set (MDS) dated [DATE], indicated R178 had severely impaired cognition, a functional limitation in the range of motion of both lower extremities, and required staff assistance with all activities of daily living. R178's diagnosis report dated 5/21/25, indicated R178 had a diagnosis of right-sided weakness following a stroke.R178's Medical Record Attestation Statement Delayed Certification Statement dated 7/2/25, indicated the provider instructed staff to continue to apply the right AFO brace as R178 tolerated. The statement included no further instructions for brace use. R178's care plan dated 7/3/25, order report dated 8/8/25, and tasks dated 8/13/25, were reviewed and did not include R178's use of a right lower extremity…

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 update the plan of care 1 of 1 resident (R154) observed for position and mobility. In addition, the facility failed to revise and update a comprehensive care plan for 1 of 1 resident (R222) who had a history of resident-to-resident incidents. Findings include: R154’s quarterly MDS dated [DATE], identified mild cognitive impairment, used a wheelchair, and had impairments on one side to upper and lower extremities. The MDS lacked identification of an adaptive device such as a brace or ankle-foot orthosis (AFO). R154’s orders from admission through 8/15/25 were reviewed and lacked orders for the use of an adaptive device such as a brace or AFO. R154’s occupational therapy and physical therapy evaluations and treatment plans dated 5/6/23, lacked documentation pertaining to an AFO. R154’s provider visit dated 5/8/23, indicated an initial assessment and plan of care related to a history of stroke, and identified R154’s left side was flaccid and…

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

Based on observation, interview, and document review, the facility failed to ensure routine personal hygiene (i.e., nail care) was completed and provided to reduce the risk of complication (i.e., infection, skin scratches) for 1 of 1 residents (R87) reviewed for activities of daily living (ADLs) and who were dependent on staff for their care. Findings include: R87's annual Minimum Data Set (MDS) assessment, dated 6/14/25, identified R87 had moderately impaired cognition with physical behavioral symptoms (hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurring 1-3 days that do not put resident at significant risk for physical illness or injury and do not significantly interfere with resident's care or participation in activities or social interactions. MDS identified rejection of care was noted 1-3 days during look-back period and there were no changes in behavioral symptoms since last MDS assessment. MDS identified R87 was dependent on staff assistance for shower/bathing needs and required setup/cleanup assistance from staff for personal hygiene needs.…

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 therapeutic recreation assessment was addressed in the electronic medical record (EMR) and care planned to ensure a resident was offered appropriate activities for engagement while at the care facility for 1 of 2 residents (R76) reviewed for activities. Findings include:R76 's admission Minimal Data Set (MDS), dated [DATE], indicated R76 was admitted to the care center on 7/22/25 and was cognitively intact. R76's Activity Interview for Daily and Activity Preferences, dated 7/24/25, included a question How important is it to you to listen to music you like? which indicated R76 answered Very ImportantR76's Therapeutic Rec/Life enrichment Assessment, dated 7/24/25, which had boxes to fill in resident information such as past work experience/professions, religious preferences and current or past interest and hobbies, was left blank with will enter info 7/26/25 typed in to the first blank box of the assessment. A completed paper form…

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 interventions to ensure hearing aids were routinely applied or offered daily for 1 of 1 resident (R20) reviewed who had severe hearing loss. Findings include: R20's quarterly Minimum Data Set (MDS) dated [DATE], identified R20 with intact cognition, did not reject cares, required hearing aids, and diagnoses of paralysis due to a stroke affecting his non dominant side, hepatitis, seizures, anxiety, and depression.R20's care plan (CP) dated 5/1/25, identified HEARING LOSS: Resident has bilateral hearing loss with Goal of Staff to assist res with placement of hearing aids in bilateral ear.During observation and interview with R20 on 8/11/25 at 1:38 p.m., R20 was lying in bed without hearing aids. R20 asked State Surveyor several times to speak louder. R20 stated he did not know where his hearing aids were. R20 stated, I need to have my hearing aids to hear. No one told me where they are.During interview with nursing assistant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure residents had received ordered meals to increase calorie intake and weight per provider orders for 1 of 5 resident (R214) reviewed for nutrition and weight loss.Findings include:R214's comprehensive Minimum Data Set (MDS) assessment dated [DATE], identified R214 had intact cognition with no hallucinations, delusions, behaviors or rejection of care present. R214 was dependent on staff for activities of daily living (ADL's) and needed assistance from staff for set up/clean-up for eating. Pertinent medical diagnoses included traumatic brain dysfunction, quadriplegia (a medical condition described as paralysis of all four limbs), diabetes melilites (DM), osteoporosis, cerebrovascular accident (CVA--a sudden interruption of blood supply to the brain that caused brain cells to be deprived of oxygen and nutrients which led to brain damage, loss of function or death), seizure disorder, and malnutrition. R214 had one, stage three and one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to follow care planned interventions to prevent re-traumatization for 1 of 1 resident (R6) reviewed for trauma informed care who was diagnosed with post-traumatic stress disorder and had identified triggers.Findings include: R6's admission Minimal Data Set (MDS), dated [DATE], identified R6 admitted to the care center on 6/25/25 and had multiple medical conditions including anxiety, major depressive disorder, bipolar, post-traumatic stress disorder (PTSD), schizophrenia and traumatic brain injury. R6's brief interview for mental status (BIMS) assessment, dated 7/1/25, indicated R6 was cognitively intact. R6's trauma history assessment, dated 7/1/25, identified R6 had a history of sexual abuse by males at a young age and could not be in the same room as another male with the door closed. R6's care plan, dated 7/1/25, indicated R6 reported childhood sexual abuse at the hands of two older males, making him distrust the majority of males he has…

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 medication errors were prevented for 2 of 2 residents (R138, R30) observed during medication administration. This resulted in a medication error rate of 7.14% (percent) with two errors out of 28 opportunities. Findings include:R138R138's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of anemia, atrial fibrillation, heart failure, hypertension, hyponatremia, hyperlipidemia, non-Alzheimer's dementia, and malnutrition. The MDS indicated R138 had a feeding tube.R138's provider order dated 5/6/25, indicated R138 required potassium chloride (used to treat and prevent low potassium levels in the body) ER (extended-release) 10 mEq (milliequivalents) via PEG-tube (percutaneous endoscopic gastrostomy tube; a tube passed into the stomach through the abdominal wall) one time a day with instructions to dissolve in water.During observation and interview on 8/13/25 at 8:14 a.m., licensed practical nurse…

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 identified dental concerns (i.e., need for dentures) were acted upon and, if needed, referred to the appropriate resource in a timely manner for 1 of 2 residents (R87) reviewed who voiced dental concerns.R87's annual Minimum Data Set (MDS) assessment, dated 6/14/25, identified R87 had moderately impaired cognition. Further, the MDS identified a section labeled, L0200, along with spaces to record no natural teeth or tooth fragments(s) (edentulous). This was answered, None of the above were present. Further, R87's Clinical Census report, printed 8/14/25, identified R87's current payor source listed as, Medicaid MN.During an interview on 8/11/25 at 1:52 p.m., R87 stated, I don't have any dentures, and I want to wear dentures. R87 explained the facility was supposed to make arrangements for getting her dentures but that was a long time ago. Furthermore, R87 stated he was limited on what he can eat due to not having teeth/dentures.R87's care plan, printed 8/14/25, identified R87 was independent with oral care, had no…

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 2 of 2 resident (R9, R105) received ordered therapeutic diet to maintain or improve their nutritional status.Findings include: R9R9's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R9 had intact cognition with no hallucinations, delusions, behaviors or rejection of care present. R9 was dependent on staff for activities of daily living (ADL's) to include set up assistance for eating. R9's MDS assessment documented height as 76 inches and 171 pounds and was triggered for weight loss. Pertinent medical diagnoses include traumatic brain injury, coronary artery disease (CAD), malnutrition, anxiety, post-traumatic stress disorder (PTSD), and hyponatremia. R9 had one stage four pressure ulcer present upon admission.R9's provider orders indicated on 11/12/24, a therapeutic diet of regular texture, thin consistency, for double portions all meals, cut into bite sized pieces was ordered.R9's Medical Diagnosis list included moderate…

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 personal protective equipment (PPE) was used for 2 of 7 residents (R3, R12) when providing care for residents in enhanced barrier precautions (EBP). Findings include: The CDC article titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 4/2/24, indicated that MDRO transmission in skilled nursing facilities was common and contributed to substantial resident morbidity. EBP is an infection control intervention to reduce transmission of MDROs by using gowns and gloves during high contact resident care activities. The article indicated high-contact activities include providing hygiene, changing briefs, dressing, urinary catheter care, transferring, etc. The article indicated that EBP should be implemented (when contact precautions did not apply) for residents with indwelling medical devices (urinary catheter) or chronic wounds, regardless of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure the physician was notified of a rapid weight gain for resident with diagnosis of Congestive Heart Failure (CHF)(one warning sign of CHF is rapid weight gain which could indicate fluid buildup in the body) and failed to contact physician to receive clarification on orders for 1 of 3 resident (R1) who was admitted to the facility without weight and notification parameters related to CHF diagnosis.Findings Include:R1's admission Minimum Data Set (MDS) assessment dated [DATE] identified an admission of 6/27/25, intact cognition and a medical diagnosis of CHF.R1's physician order dated 6/27/25 identified R1's indicated to weigh R1 for 1 day, then weekly for 4 weeks then monthly.R1's hospital discharge weight was 188 pounds (lbs.) on 6/27/25.R1's recorded daily weights at the facility were as follows:-6/27/25 194 lbs.-6/29/25 192 lbs.-7/2/25 197 lbs. and199 lbs.-7/3/25 197 lbs.-7/4/25 200 lbs.-7/7/25 207 lbs.R1's Nurse Practitioner visit notes dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop and implement a baseline care plan which provided effective and person-centered care direction to meet professional standards of care for 1 of 3 residents (R1) who admitted to the facility with a diagnosis of congested heart failure (CHF). Additionally, the facility failed to implement a baseline care plan within 48 hours of admission for 1 of 3 (R1) reviewed. Findings include:R1's admission Minimum Data Set (MDS) assessment dated [DATE], identified an admission of 6/27/25, intact cognition and a medical diagnosis of congestive heart failure (CHF).R1's physician order dated 6/27/25 identified R1's indicated to weigh R1 for 1 day, then weekly for 4 weeks then monthly.R1's baseline care plan dated 6/30/25, indicated Focus Cardiovascular: the resident has impaired cardia output due to diagnosis of CHF. Interventions listed as:-monitor vital signs and notify MD of significant abnormalities.-Lab work.-Weight monitoring dailyR1's Baseline care plan…

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 comprehensive nursing care to meet acceptable standards of clinical practice for 1 of 3 resident (R1) who was admitted to the facility with a diagnosis of congestive heart failure (CHF) and no clarification for daily weight and notification parameters were requested to ensure adequate medical care. This resulted in a 13-pound (lbs.) weight gain in ten days. Findings include:The National Institute of Health (NIH) (.gov)Nursing ManagementThe nursing care plan for patients with HF should include:Relieving fluid overload symptomsRelieving symptoms of anxiety and fatiguePromoting physical activityIncreasing medication complianceDecreasing adverse effects of treatmentTeaching patients about dietary restrictionsTeaching patient about self-monitoring of symptomsTeaching patients about daily weight monitoring When To Seek HelpPrompt assessment by the medical team is indicated in the following situations:Worsening symptoms of fluid overloadWorsening…

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 change end of life wishes in the medical record to ensure the advanced directive (a written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) was followed for 1 of 3 resident's (R1) reviewed for advanced directives. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment and diagnoses that included acute respiratory failure, diabetes, malnutrition, intellectual disabilities, and adult failure to thrive. R1's care plan dated [DATE], indicated R1 required assistance with all decision making, and was signed by R1's legal guardian and R1's physician. R1's Provider Orders for Life Sustaining Treatment (POLST) form dated [DATE], indicated full code (receive all possible life-saving measures in the event of the event the resident stops breathing or heart stops) and was signed 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 interview and document review the facility failed to accurately document new or changed medication orders for 2 out of 3 residents (R1, R2) reviewed for medical records. R1's seizure medication was changed from tablet form to oral solution, but the tablet form was not discontinued, which resulted in R1 being administered two doses. In addition, R2 did not receive three medications when he returned from a hospitalization resulting in missed doses of medication required for his liver disease and diabetes. Findings include: R1's medication order dated 12/14/24, indicated Levetiracetam 1000 milligram (mg) tablet two times a day. R1's admission Minimum Data Set (MDS) dated [DATE], indicated he had prostate cancer, high blood pressure, diabetes, dementia, impaired cognition related to a stroke and epilepsy. He required staff assistance with all activities of daily living (ADLS). He was admitted for Hospice (end of life care) respite (short stay when their caregiver was unable to care for them) care from…

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 provide ensure that 1 of 3 residents (R1) received treatment in accordance with professional standards of practice. R1 was discharged from the hospital with identified sores on his lower legs and the facility did not provide any cares for three days to his legs. Findings include: R1's care plan dated 8/22/24 indicated R1 had a potential for impaired skin integrity related to decreased mobility, incontinence, anticoagulation therapy, diabetes type II and predisposing disease. R1's interventions were: -Encourage good nutrition and hydration to promote healthier skin dated 8/22/24. -Avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short dated 8/22/24. -Keep skin clean and dry revision date of 10/15/24 -Apply Mepilex border dressing to coccyx area to prevent skin breakdown over body prominences dated 10/23/24. -Wear padded boots when in bed to protect heels from breakdown dated 10/23/24. R1's Minimum Data Set (MDS)…

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 an assessment for self-administration of medications (SAM) was completed for 1 of 3 (R2) residents reviewed for self-administration of medications. Findings include: R2's admission Record dated 6/30/23, indicated R2's diagnoses included chronic obstructive pulmonary disease, respiratory failure with hypercapnia, weakness, essential tremor, gastro-esophageal reflux disease and major depressive disorder. R2's care plan dated 4/21/24 indicated staff to administer medication as ordered/observe for side effects and effectiveness, and assess her ability to safely self-administer medications specified on admission/re-admission, quarterly, review each medication as necessary with the resident. R2's Physician Orders dated 8/23/24 at 3:54 p.m. indicated R2 had been assessed and deemed safe to self-administer ipratropium 0.5 milligram (mg)-albuterol 3 mg/milliliter (ml) nebulization inhaler (medication used to ease breathing) after nursing set up. The physician order lacked evidence of self-administration of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure laundered linens were handled and sorted in a clean, sanitary environment to reduce the risk of contamination for 1 of 1 main washrooms reviewed; failed to ensure staff consistently implemented transmission-based (TBP) and enhanced barrier precautions (EBP) to reduce the risk of infectious spread for 4 of 4 residents (R134, R83, R54 and R2); and failed to ensure general COVID-19 mitigation methods (i.e., masking) were correctly and consistently implemented on units with active infection. These findings have potential for a cumulative effect and, as a result, have potential to affect all 228 residents, staff and visitors within the care center. Findings include: Laundry Room: On 7/30/24 at 8:21 a.m., a tour of the campus main washroom was completed with laundry aide (LA)-A present. The washroom consisted of a large single space with commercial washing machines on one side, and three [NAME] commercial dryers on the opposite. In 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 provide a dignified dining experience for 6 of 6 residents (R18, R15, R53, R142, R208, R386 ) who were seated at the dining room table with other residents who were served meals without being served meals themselves resulting in them waiting for their meals while tablemates dined and for 1 of 1 resident (R386) who was brought to the dining room ungroomed in a hospital gown. In addition, the facility failed to ensure dignity was maintained for 1 of 1 (R164) observed for lack of clothing in bed. Findings include: Dining R203's significant change Minimum Data Set (MDS), dated [DATE], indicated R203 was cognitively intact. During an interview on 7/29/24 at 1:51 p.m., R203 stated food trays would often sit out in a serving cart waiting to be served to residents for over 30 minutes, often causing food to be served cold and past scheduled mealtimes. During observation on 7/31/24 at 7:30 a.m., R53 and R208 were sitting out in the main dining…

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 vinyl floors were clean and in good condition for 2 of 5 resident dining rooms (2nd floor memory care unit and 3rd floor) and 1 of 1 (R134) resident rooms reviewed for environment. Findings include: R134's quarterly Minimum Data Set, dated , 7/20/24 documented R134 with severe impairment of cognitive skills, physical and verbal symptoms directed towards others, had an indwelling catheter. In addition, R134 with diagnoses of Alzheimer's disease, dementia, seizures, depression, anemia, renal insufficiency (decreased kidney function), neurogenic bladder (disruption of the nervous system and the bladder) and obstructive uropathy (difficulty voiding). Also, R134 required extensive assistance of one staff member with bed mobility, eating, toilet use and required setup or clean-up assistance with oral hygiene. R134's Profile in the electronic medical record (EMR) listed family member (FM-A) as Responsible Party, primary Emergency Contact, Power of Attorney, Care Conference Person, Essential Caregiver, Financial Responsibility…

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 care and hygiene (i.e., bathing, nail care, hair combing) was offered and/or completed for 5 of 6 residents (R39, R184, R134, R179, R383) reviewed for activities of daily living (ADLs) and who required staff assistance to complete such care. Findings include: R39 R39's significant change Minimum Data Set (MDS), dated [DATE], identified R39 had moderate cognitive impairment, demonstrated no delusional thinking, and was not diabetic. On 7/29/24 at 2:01 p.m., R39 was observed seated in his electric wheelchair while in his room. R39 had visibly long fingernails present on both hands, and the edge of the nail being multiple millimeters (mm) long on several nails with a dark-colored substance present underneath multiple nail edges. R39 was interviewed and stated the bathing he was provided at the care center was usually inadequate adding, [They] spray you a little bit and call it done. R39 stated the poor bathing…

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 mediations were kept locked or under direct observation of authorized staff in areas where residents, staff and guests could access medications on 3 of 5 resident floors. Findings include: During observation and interview on 7/29/24 at 6:14 p.m., an unattended and unlocked medication cart was observed located along a knee-high wall facing the seventh floor dining room during mealtime. Registered nurse (RN)-A returned to the medication cart and verified it was unlocked and, it should be locked to stop anyone from getting in. During observation and interview on 7/31/24 at 1:10 p.m., an unattended and unlocked medication cart was observed located along a knee wall facing the fifth floor dining room with 12 seated residents in wheelchairs and walkers and two residents in wheelchairs rolling past the cart. During interview with licensed practical nurse (LPN)-B stated he was responsible for the unlocked medication cart and stated, I should always lock the cart when I leave it. Because the residents can get access to it.…

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 food was delivered and served in a timely manner to preserve desired temperatures of food for 3 of 3 residents (R158, R39 and R146) reviewed for dining. This had the potential to affect all residents of facility that received meal trays. Findings include: During survey initial kitchen tour on 7/29/24 at 11:57 a.m., the kitchen supervisor (KS) provided surveyor with printed copy of the document Mealtimes with three columns. First column identified meals and units. The other two columns identified, Dietary Starts: and Cart Arrives on Site: There was notation at bottom of form stating, Note: Meal delivery times may vary by 10 minutes from posted schedule and was documented as below. Meal Times: Cart Arrives on Site BREAKFAST: 2R: 7:15 AM 3G: 7:30 AM 2G: 7:45 AM 7G: 8:00 AM 5G: 8:15 AM 6G: 8:30 AM LUNCH: 2R: 11:15 AM 3G: 11:30 AM 2G: 11:45 AM 7G: 12:00 PM 5G: 12:15 PM 6G: 12:30 PM DINNER: 2R: 4:45 PM 3G: 5:00 PM 2G: 5:15 PM 7G: 5:30…

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 all food items were properly covered when served to residents to reduce and/or prevent the risk of food borne illness. This practice had the potential to affect all residents who received their meals from the kitchen. Findings include: During observation and interview on 7/29/24 at 6:00 p.m., nursing assistant (NA)-N poured beverages into cups and mugs and placed on multiple meal trays which were on an uncovered cart. Uncovered cheesecake desserts were also on the individual meal trays. NA-N wheeled the uncovered cart from the dining room down the hall and passed the meal trays to at least six individuals in their rooms pushing the cart further down the hall between rooms. NA-N stated the beverages came up to the sixth floor in covered pitchers and could be poured into cups in the dining room and taken uncovered to residents' rooms. During observation and interview on 7/31/24 at 9:12 a.m., NA-P wheeled an uncovered cart passing meal trays on the sixth floor which had uncovered bowels of cereal, brown sugar, milk, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to implement an effective pest control program to eliminate bed bugs from the building for 1 of 1 resident (R9) with the potential to affect all 11 residents residing on the odd side of the seventh floor. Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE], indicated R9 had no cognitive deficits and required moderate assistance with transferring, bathing, and toileting hygiene. The pest control company report dated 7/31/24 at 2:15 p.m., indicated R9's original room had been assessed by the pest control company, and a dead bed bug was noted. During an interview on 7/29/24 at 2:09 p.m., R9 stated she was moved from her original room to her current room last week because of a bed bug infestation. R9 stated she was supposed to move back to her old room soon but was scared as she didn't believe that the bed bugs were gone. During an interview and observation on 7/30/24 at 2:55 p.m., R9 was found still residing in the new room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure a self-administration of medications (SAM) assessment was completed to allow a resident to safely self-administer medications for 1 of 1 (R184) residents reviewed for self-administration of medications. Findings include: R184's admission Minimum Data Set (MDS) dated [DATE], indicated R184 had moderate cognitive impairment, didn't have signs of delirium, and didn't refuse cares or medications. The MDS indicated R184 was dependent with showers, lower body dressing, toileting, bed mobility, and transfers. R184 needed substantial assistance with upper body dressing, oral hygiene and eating. R184's Clinical diagnosis record printed 1/31/24, indicated diagnoses of dysphagia (difficulty swallowing) following unspecified cerebrovascular disease (condition that affect blood flow and the blood vessels in the brain), gastrostomy status (surgical procedure that creates an opening in the abdomen and into the stomach, allowing for 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 a written notice of transfer was sent to the office of the Ombudsman for long term care for 2 of 4 residents (R60, R27) reviewed for hospitalization. Findings include: R60 R60's quarterly Minimum Data Set (MDS) dated [DATE] identified R60 with diagnoses of a stroke with paralysis affecting the right dominant side, renal insufficiency, urinary tract infection, diabetes, and an unhealed pressure ulcer to right heel. R60's electronic medical record (EMR) section titled Profile identified primary emergency contact, power of attorney (POA), care conference person, and financial responsibility person as emergency contact (EC)-A. R60's Progress Notes (PN) tab, the notes are listed in vertical columns titled, Effective Date, Type, Note, Care Plan Item or Task, Dept, Shift Report, 24 Hour Report. R60's PN from licensed practical nurse (LPN)-D, dated 4/23/24 at 10:24 p.m. documented, Note Text: Resident send to HCMC ER at 2130. PN on 4/23/24 at 10:28…

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 I Pre-admission Screening and Resident Review (PASARR) was completed prior to admission for 1 of 1 residents (R63). Findings include: R63's significant change Minimum Data Set (MDS) dated [DATE], indicated R63 had intact cognition. R63's medical diagnoses list dated 4/19/24, indicated R63 was diagnosed with generalized anxiety disorder, major depressive disorder, and schizoaffective disorder (a mental health condition that is marked hallucinations, delusions, and mood disorder symptoms, such as depression, mania) R63's PASARR dated 10/12/23, indicated the PAS [PASARR] is not final until the lead agency sends the documentation to the nursing facility. R63's entire medical record was reviewed and lacked evidence a final determination had been received by the county or managed care program as directed by the PAS. During an interview on 7/31/24 at 8:43 a.m., the director of social services (SW)-A stated after reviewing R63's preadmission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure timeliness of person-centered care conferences for 3 of 5 residents (R9, R103, R134) reviewed for care conferences. R9 R9's quarterly Minimum Data Set (MDS) dated [DATE], indicated R9 was admitted on [DATE], and had no cognitive deficits. A review of R9's medical record indicated R9's last care conference was on 2/1/24 and did not demonstrate that a care conference occurred after 2/1/24 or a reason this would not have been practicable for R9. During an interview on 7/29/24 at 2:21 p.m., R9 stated she didn't remember having a care conference with facility staff since the beginning of the year and wished she had been more updated and involved in her care. During an interview on 7/30/24 at 3:04 p.m., social worker (SW)-B stated the social work department had gone through a lot of turnover and there was a backlog of care conferences. SW-B stated after reviewing R9's medical record it looked like R9 should have had a care conference to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to develop proactive interventions to promote appropriate bowel function and decrease the risk for discomfort or further complications for 1 of 1 resident (R9) reviewed for bowel management. In addition, the facility failed to transcribe prescription orders for 1 of 1 (R78) reviewed for non-pressure related skin breakdown. Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE], indicated R9 had no cognitive deficits and required moderate assistance with transferring, bathing, and toileting hygiene. The MDS indicated R9 always had bowel incontinence and a toileting program was not currently being used. R9's medical diagnoses dated 3/22/24, indicated R9 was diagnosed with diabetes, bilateral lower extremity ulcers, respiratory failure, heart failure, kidney disease, and chronic pain syndrome. R9's care plan dated 3/22/24 indicated the resident had bowel incontinence with decreased physical functioning. R9's care plan 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 ensure orders for an audiology referral were acted upon in a timely manner to promote better hearing and quality of life for 1 of 2 residents (R39) reviewed who expressed difficulty with hearing. Findings include: R39's significant change Minimum Data Set (MDS), dated [DATE], identified R39 had moderate cognitive impairment but demonstrated no delusional thinking. Further, the MDS identified R39 had adequate hearing (i.e., no difficulty in normal conversation) and did not use hearing aids. On 7/29/24 at 1:56 p.m., R39 was interviewed. R39 stated his hearing seemed to be getting worse as of late and added, The wax has gotta get cleaned out of my ears. R39 stated nobody from the care center had asked him about his hearing and wished they would so he could get new hearing aides. R39 stated he thought an audiology appointment was set-up with the VA (Veterans Administration) but was not adding, I sure wish they'd get it set up. R39's Nursing Assessment -…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure 1 of 1 residents (R195) with repeated falls had implemented interventions to promote safety and reduce the risk of falls. Findings include: R195's admission minimum data set (MDS), dated [DATE], indicated R195 had diagnoses including cerebral infarct (stoke), hemiplegia (paralysis on one side of the body), and hemiparesis (unable to fully use one side of the body), history of falling with injuries and muscle weakness. Further, R195 required extensive assistance with bed mobility, transfers, and toileting. R195's care plan indicated he was at risk for falls with history of falls related to unsteady gait, cognitive deficits, and syncope. Interventions included R195's call light should be within reach, and to provide a safe environment. R195's physical device assessment, dated 7/25/24, indicated R195 required a perimeter mattress (a mattress that creates a raised edge to decrease falls from bed). Additionally, the medical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to comprehensively reassess to determine what, if any, additional interventions with pain management were needed for 1 of 3 residents (R39); and failed to assessed and develop non-pharmacological interventions to promote comfort for 2 of 3 residents (R69, R131) reviewed for pain management. Findings include: R39 R39's significant change Minimum Data Set (MDS), dated [DATE], identified R39 had moderate cognitive impairment but demonstrated no delusional thinking. The MDS outlined R39 consumed scheduled pain medication and had pain on an almost constant basis during the review period. R39's most recent Pain Interview 23 - V1, dated 6/5/24, identified R39 received schedule pain medication but no as-needed (PRN) or non-pharmacological interventions for pain. The evaluation outlined R39 reported pain almost constantly which occasionally affected his sleep. The pain was listed as being rated, 9, along with Moderate. The evaluation concluded,…

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 direct-care nursing staff were appropriately trained and competent in the use of a external ventilator machine used for 1 of 1 resident (R17) who used the machine on overnight hours and had significant respiratory disease/impairment. Findings include: R17's quarterly Minimum Data Set (MDS), dated [DATE], identified R17 had intact cognition along with several medical conditions including heart failure, Parkinson's Disease, seizure disorder, respiratory failure, and chronic lung disease (i.e., asthma, COPD). On 7/29/24 at 2:31 p.m., R17 was observed seated in an electric wheelchair while in her room with oxygen in place via a nasal cannula. R17 had a hospital-style bed placed next to the wall and adjacent to the bed was a [NAME] Respironics Trilogy 100 machine (a portable, external ventilator) positioned on a vertical stand with a nasal mask (i.e., nasal port with strap to secure around head) attached and draped over the device. 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 consulting pharmacist recommendations were fully addressed or acted upon for 1 of 5 residents (R164) reviewed for unnecessary medications. Findings include: R164's significant change Minimum Data Set (MDS) dated [DATE], indicated R164 had severely impaired cognition. R164's quarterly MDS dated [DATE], indicated R164 did not speak and rarely/never understood verbal content. In addition, R164 was dependent on staff for bed mobility, lower body dressing, and toileting hygiene. R164's medical diagnoses report dated 1/27/23, indicated R164 had dementia without behavioral disturbance, epilepsy, and depression. R164's Order Summary Report dated 3/30/23, included an order dated 3/30/23 for 12.5 milligrams (mg) of quetiapine (an antipsychotic medication) every evening for agitation. The report included an order dated 6/21/24, with no end date for one mg of as-needed lorazepam (a psychotropic medication used to treat seizures) that could be given every…

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 have an indication for use and resident specific target behaviors while taking antipsychotic medications for 1 of 5 residents (R383) reviewed for unnecessary medications. In addition, the facility failed to ensure as-needed antipsychotic medications were limited to 14 days of use or given a specific duration of therapy to ensure necessity and reduce the risk of complication for 1 of 5 residents (R164) reviewed for unnecessary medication use. In addition, the facility failed to ensure an appropriate indication was given for continued antipsychotic medication for 1 of 5 residents (R164) reviewed for unnecessary medication use. Findings include: R383's admission Minimum Data Set (MDS), dated [DATE], indicated R383 was cognitively intact and had received an antipsychotic medication during the seven-day look back period. R383's Orders, dated 7/18/24, indicated an order for Olanzapine (an antipsychotic medication used to treat mental disorders,…

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 medication administration error rate of less than 5 percent (%). Twenty medication administration errors occurred out of 31 opportunities resulting in a 64.52% medication error rate for 2 of 4 residents (R184 and R376). Findings include: R184's admission assessment Minimum Data Set (MDS) dated [DATE], indicated R184 had moderate cognitive impairment, didn't have signs of delirium, and didn't refuse cares or medications. MDS indicated R184 was dependent with showers, lower body dressing, toileting, bed mobility, and transfers. R184 needed substantial assistance with upper body dressing, oral hygiene and eating. R184's Clinical diagnosis record printed 1/31/24, indicated diagnoses of dysphagia (difficulty swallowing) following unspecified cerebrovascular disease (condition that affect blood flow and the blood vessels in the brain), gastrostomy status (surgical procedure that creates an opening in the abdomen and into the stomach,…

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 dental services were provided or offered to promote oral hygiene and reduce the risk of complication (i.e., chewing issues, cavities) for 4 of 4 residents (R39, R50, R134, R179) reviewed for dental services. Findings include: R39 R39's significant change Minimum Data Set (MDS), dated [DATE], identified R39 admitted to the care center in April 2024 and had moderate cognitive impairment but demonstrated no delusional thinking. Further, the MDS section labeled, Section L - Oral/Dental Status, outlined spaces to record if R39 had broken or loose-fitting dentures, abnormal mouth tissue, or obvious tooth cavities but the section was answered, Z. None of the above were present. R39's Census listing, printed 7/31/24, identified R39 current payer source recorded as, Veterans Administration. On 7/29/24 at 1:54 p.m., R39 was observed seated in his wheelchair while in his room. R39 was interviewed, and expressed he had little to no…

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 drinks of preference were offered or served to promote adequate fluid intake and improve meal satisfaction for 1 of 2 residents (R39) reviewed who expressed their preferences of meal items were not honored. Findings include: R39's significant change Minimum Data Set (MDS), dated [DATE], identified R39 had moderate cognitive impairment but demonstrated no delusional thinking during the review period. On 7/29/24 at 1:42 p.m., R39 was observed in his electric wheelchair while in his room. R39 had a meal tray present on his bedside dresser which had a coffee cup filled with coffee and a white Styrofoam cup filled with a dark-red colored juice. R39 expressed multiple complaints about the care center meal service and food quality, and stated he wished they'd serve him milk with meals instead of that red crap as he pointed to the cup on his meal tray. R39 stated he had repeatedly asked for milk with meals but added, I ask them for milk…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure recommended pneumococcal immunizations, as outlined by the Centers for Disease Control (CDC), were offered and/or provided in a timely manner to reduce the risk of severe disease for 2 of 5 residents (R158, R17) reviewed for immunizations. Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/2023, identified several tables with corresponding recommendations when to receive various versions (i.e., PPSV23, PCV13, PCV20) of the pneumococcal vaccine. The graph labeled, Adults 19-[AGE] years old with chronic health conditions ., identified persons who received only a PPSV23 had an option to either get a PCV15 or PCV20 a year after the last PPSV23 dose. The conditions listed including alcoholism and cigarette smoking. Further, The graph labeled, Adults [at or older than] [AGE] years old, outlined persons with a complete series of pneumococcal vaccination (i.e., PCV13 at any age, PPSV23 at or above [AGE] years old) should…

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, interviews, and record review the facility failed to provide interpretive services for 1 of 3 residents (R1) to ensure the resident was fully informed in his primary language the risks and benefits, treatment plan and alternative options to treat diabetes when he ate snacks and refused insulin therapy. Findings included: During observation on 6/5/24 at 10:37 a.m. witness two staff knock on R1's door and enter his room. Observed the two staff standing with R1 in front of his open closet. Unable to understand what R1 told them. One of the staff members was holding a bag of snacks in a plastic bag and left the room. During observation and interview on 6/5/24 at 11:05 a.m., while talking to NP-A in the hallway R1 exited his room and saw writer talking to NP-A. Unable to understand what he was saying he looked at me and pointed at the LPN-C who was holding the bag of sweets and said, show her. He appeared agitated by pacing back and forth and kept looking at me and telling LPN-C show her. LPN-C…

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 interviews and record review the facility failed to use an interpreter during the admission process when the resident's bill of rights was presented for 1 of 3 residents (R1). Staff identified a resident's code status was a factor to let a resident exercise their right to refuse care. Findings included: R1's care plan dated 12/18/23 indicated his preferred language was Somali but he could speak some English. No interventions to improve communication was listed. R1's minimum data set (MDS) dated [DATE], indicated R1 had moderately impaired cognition, cognitive communication deficit (the inability to pay attention to a conversation, stay on topic, and remember the information presented), depression, and rejected cares from staff one to three times a week. Medical history included metabolic encephalopathy (when diabetes caused impaired brain function), diabetes, severe protein calorie malnutrition, adult failure to thrive, dementia with behavioral disturbances. The assessment determined he…

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, interviews, and record review the facility failed to develop a comprehensive care plan to understand cultural practice, medical history, and diabetic goals for 1-3 residents (R1) when he refused to follow a diabetic diet and develop strategies to encourage him to take insulin for elevated blood sugar levels. Findings included: R1's care plan dated 12/18/23, indicated his preferred language was Somali and he could speak some English. The facility failed to identify staff interventions to enhance his understanding the medical provider's current diabetic treatment plan along with strategies to encourage compliance. R1's minimum data set (MDS) dated [DATE], indicated R1 had moderately impaired cognition, depression, and rejected cares from staff one to three times a week. Medical history included cognitive communication deficit (the inability to pay attention to a conversation, stay on topic, and remember the information presented,) metabolic encephalopathy (when diabetes caused impaired brain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to notify the family of one of six residents (R4) reviewed when R4 had an unwitnessed fall, an unrelated injury, and a change in cognition requiring hospitalization. Findings include: R4's care plan dated 12/27/23 indicated R4 was at risk for falls and included interventions to reduce fall risks. Minimum Data Set (MDS), dated [DATE], for R4's admission to the facility indicated he was admitted on [DATE]. R4's functional assessment indicated he required minimal standby assistance with ambulating and did not use a wheelchair or scooter. R4's scored a 12 on his Brief Interview for Mental Status (BIMS), indicating he was moderately cognitively intact. R4's relevant diagnoses included Parkinson's disease, and a surgical encounter for repair of a perforated duodenal ulcer. An Un-witnessed fall report, dated 1/14/24 at 9:30 p.m., indicated R4 was found in the floor of his room after he had been assisted to bed. The report indicated R4 believed he had to get…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident's right to reasonable needs and preferences for 1 of 3 (R1) residents reviewed. R1's remote control for her bed was taken away leaving her dependent on staff for bed mobility. This practice limited R1 in achieving independent functioning and impaired her dignity. R1 was her own decision maker. Finding include: Upon observation and interview on 3/8/24 at 9:37 a.m. R1 was seated in her wheelchair fully dressed and groomed. R1 stated, the staff took her bed remote control away. R1 stated she had never fallen at the facility and was able to use the remote appropriately. Nursing assistant (NA)-A gave R1 her television remote control. R1 turned on her television, changed the channels and used the volume button appropriately. R1 stated she can use the bed remote just as she is able to use the television remote. R1 stated she needed to have the bed remote due to back pain because she liked to lift the head of her bed up and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to document in the resident record the reinserting of an indwelling catheter for 1 of 3 residents (R3) reviewed for urinary incontinence. R3's admission Minimum Data Set (MDS) dated [DATE] indicated R3 had mildly impaired cognition, and an indwelling urinary catheter (a tube inserted into the bladder to drain urine). R3's Diagnoses List indicated diagnoses included left hip fracture, diabetes mellitus type 2, chronic obstructive pulmonary disease (COPD), anemia (low iron), and dysphagia (trouble swallowing). R3's Physician Orders dated 1/4/24 directed to remove the indwelling catheter on 1/4/24, do a post void residual (PVR, a scan of the bladder after voiding to determine the amount of urine remaining in the bladder) every shift, straight cath (tube inserted into the bladder to drain urine that is removed immediately after bladder is drained) if PVR is greater than 350 milliliters (ml), and if straight cathed more than three times, on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to transfer 1 of 3 residents (R1) safely when staff were observed using a two person transfer with gait belt and the resident was assessed and care planned for the use of a mechanical lift transfer. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had severe impaired cognition, moderately impaired vision, minimal difficulty hearing, unclear speech, and no behaviors. R1 had no impairment on upper or lower extremities and used walker and wheelchair for mobility. R1 required partial to moderate assistance with eating meals, oral hygiene, and personal hygiene. R1 required substantial/moderate assistance with toileting and transfers. R1 attended speech therapy from 11/11/23, through 11/16/23, and physical therapy (PT) and occupational therapy (OT) started on 11/11/23. R1's significant change MDS date 12/13/23, identified R1 had impairment on one side of the lower extremities and required substantial/maximal…

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 therapeutic diet per physicians orders were followed for 1 of 3 residents (R1) reviewed for therapeutic diets. Findings include: R1's admission Minimum Data Set, dated [DATE], identified R1 had severe impaired cognition. R1 required partial to moderate assistance with eating meals. R1 required a mechanically altered diet. R1 attended speech therapy from 11/11/23, through 11/16/23. R1's significant change MDS date 12/13/23, identified R1 had impairment on one side of the lower extremities and required substantial/maximal assistance with eating and oral hygiene. R1's medical diagnoses included a mechanically altered diet. R1's care plan dated 12/19/23, identified regular diet, six, Soft and Bite-sized texture. Number two mildly thick consistency. R1's care plan directed staff to monitor/document/report, signs symptoms of dysphagia (difficulty swallowing), pocketing, choking, coughing, drooling, holding food in mouth, several…

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 immediately report (within two hours) an allegation of sexual abuse to the State Agency (SA) for 1 of 4 residents (R2) reviewed for abuse. R2's Face Sheet indicated R2's diagnoses included post traumatic stress disorder (PTSD), and generalized anxiety disorder. R2's admission Minimum Data Set (MDS) dated [DATE] indicated R2 was cognitively intact, and required assistance of two staff for bed mobility, toilet use and transferring, and one staff for personal hygiene and dressing. A Vulnerable Adult Maltreatment Report submitted on 8/1/23 at 3:15 p.m., indicated R2 had reported an incident to her primary care doctor of being raped on 7/7/23. This was reported to the social worker at the facility. R2's care plan dated 7/6/23 indicated R2 could display physical, biological, social, spiritual, emotional, and/or psychological symptoms resulting from actual trauma (history of physical, sexual emotional abuse along with significant loss and financial…

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, document review, and review of facility policy, the facility failed to have an effective system in place to prevent the spread of infection. The facility failed to have a complete water management program that was consistent with the current ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) Guideline, which specifically called for documentation of design and maintenance procedures to protect from the potential exposure of Legionnaire's disease (a serious pneumonia infection) within a healthcare facility. This failure created a potential for 193 of 206 facility residents, who were over the age of 65, to be infected by Legionella. In addition, the facility failed to ensure 2 nursing assistants (NA) appropriately sanitized their hands by using soap during hand washing, prior to serving drinks to residents. The facility also failed to ensure 1 of 1 resident (R- 198) maintained infection control practices when assisting another resident, (R153), 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 observation, interview, and document review, the facility failed to ensure residents were free from potential hazards to ensure their safety for 1 of 1 resident (R11) who was found by facility staff to have a smoking and a sparking electrical power strip in her room. The power strip was not removed after the incident and was still in use at the time of the survey and discovered to have black soot marks on 1 outlet on that power strip. 2 other power strips were observed in the boiler room and fitness room by the Fire Marshall and has the potential to affect all other residents in R11's wing, those residents and staff located near the boiler room, and who used the fitness room. In addition, the facility failed to ensure the safety of 1 of 1 resident (R92) who failed to discard cigarettes in a safe manner inside the building, had a history smoking in unauthorized places, and had a history of burnt clothing as a result of unsafe smoking. Refer also to K741 and K920 for additional information. Findings…

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 serve food that was palatable and at appropriate temperatures to four of 38 residents residing on the 6th and 7th floors (R18, R103, R121, and R123). Foods that were to be served hot were not served at temperatures that met residents' tastes preferences. Findings include: Review of R18's electronic medical record (EMR) revealed a quarterly Minimum Data Set with an Assessment Reference Date (ARD) of 05/02/23, located under the MDS tab. The assessment recorded a Brief Interview for Mental Status (BIMS) score of 15 out of 15 for R18, which indicated the resident was cognitively intact. During an interview on 06/26/23 at 3:07 PM, R18 stated that she eats her meals in her room and the food is cold. Review of R103's EMR revealed a significant change in status MDS with an ARD of 04/13/23, located under the MDS tab. The assessment recorded a BIMS score of 12 out of 15 for R103, which indicated the resident was moderately cognitively impaired. During an interview on 06/26/23 at 1:50 p.m., R103 stated he eats his…

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, document review, and review of the Food and Drug Administration (FDA) Code, the facility failed to assure food was stored, prepared, and served in a sanitary manner. Foods were not dated and /or labeled, covered, and disposed of after expiration. Equipment/surfaces were not clean or were not in good repair. These failures had the potential to increase the risk of food borne illnesses and affect 199 of 206 residents living at the facility who received food from dietary services. Findings include: Review of the, undated, policy titled Food Storage, provided by the facility on 06/29/23, revealed: Dry Storage: All items shall be dated and labeled when needed. (items that have manufacturer expiration dates, will be considered dated.) Items that are fresh for that meal or shift, - i.e., resident meal, resident drhks [drinks] will not need to be individually dated . Opened items will have a date reflecting the date that item was opened on if manufacturer sets open limit. Items will be covered and/or wrapped. Refrigerated Storage: All Foods should be…

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, document review, and review of Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to revise their pneumococcal vaccine policy to reflect current pneumococcal vaccination guidelines. This failure increased the risk for residents to not be vaccinated per current guidelines and contract pneumonia. Findings include: Review of a policy provided by the facility titled Pneumococcal Vaccines, dated 12/2017, indicated All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Both 23-valent pneumococcal polysaccharide (PPSV23®) and 13-valent pneumococcal conjugate (PCV13®) vaccines will be administered routinely in series to all adults >65 years. Adults who are immunocompromised and aged 65 years or older should receive PCV13 followed by PPSV23 at least 1 year after PCV13. Review of the Center of Disease Control (CDC) website titled Pneumococcal Vaccination: Summary of Who and When to Vaccinate, last reviewed 01/24/22, indicated CDC recommends pneumococcal vaccination for all adults 65 years or…

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

Based on interview and document review, the facility failed to honor a resident choice for a private room despite evidence that a private room would promote mental wellbeing for 1 of 1 resident (R191) reviewed for choices. Findings include: R191's quarterly Minimum Data Set (MDS) indicated R191 was cognitively intact and needed extensive assistance with all activities of daily living (ADLs). R191's Medical Diagnosis list, dated 2/10/23, indicated R191 had several medical diagnoses including adjustment disorder with anxiety (an emotional or behavioral reaction to a stressful event or change in a person's life) and depression. R191's progress notes indicated at least three occasions R191 expressed concern over moving to a shared room. On 5/5/23 it was documented by social services R191, expressed concern, stating he does not want to be in a shared room. R191 also expressed concern that he did not feel, medically stable and believed a move may, hinder his mental and physical health. On 5/12/23 it was documented by social services R191 was transferring to rooms on 5/16/23. R191…

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, record review, and document review, the facility failed to notify the medical provider of a significant change in condition for one resident (R-190) of five residents who were reviewed for unnecessary medications. Specifically, the facility failed to notify the medical provider when the resident had an increase in abnormal involuntary movements (AIMS) while taking two antipsychotic medications. Findings include: Review of an undated policy provided by the facility, titled Change in Condition, revealed, Lakehouse Healthcare promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. Review of a policy provided by the facility, titled AIMS Assessment, dated 02/10/16, indicated the facility was to Notify the resident's physician/NP [Nurse Practitioner] of the initial AIMS score, and ongoing if there is a change in the resident's AIMS scores. Review of a document provided by the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to ensure there were physician orders upon admission for all necessary care for one resident (R-565) of 35 sampled residents. The facility failed to ensure that there were PICC (Peripherally inserted central catheter) line dressing orders prior to changing R565's PICC line dressing. Findings include: Review of a policy provided by the facility titled Physician Orders.Patient Care Services, dated 01/03/14, indicated admission Orders from a Discharging Hospital.All signed physician orders, and pertinent medical information documented on the hospital transfer forms will be entered into the resident's EHR [electronic health record] by.licensed nurse. Review of R565's Hospitalist Discharge Summary, dated 06/16/23, which was located under the Misc [Miscellaneous] tab in the electronic medical record (EMR), revealed R565 had septic arthritis of his hip. The discharge summary indicated the resident had surgery and required six weeks…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and document review, the facility failed to provide routine baths and incontinence care to 1 of 1 resident (R92) reviewed for activities of daily living (ADLs). Findings include: R92's significant change Minimum Data Set (MDS), dated [DATE], indicted R92 was cognitively intact and required extensive assistance with transfers, bed mobility, dressing, toileting, and personal hygiene. R92's Care Plan, dated 11/4/22, indicated R92 preferred to take a shower every Thursday morning after breakfast with staff assistance. The care plan further indicated R92 was totally dependent on staff for toilet use, dated 4/15/23, and was to be toileted upon rising, after meals and at bedtime, dated 4/19/22. R92's bathing task in the electronic medical record (EMR) indicated R92 received only one shower during the month of June, occurring on 6/6/23. R92's toileting task in the EMR indicated R92 had been toileted on less than all three shifts, 20 times in the month of June. During an interview on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to provide weekly baths to 1 of 1 resident (R11) reviewed for activities of daily living (ADL). Findings include: R11's quarterly Minimum Data Set (MDS) dated [DATE], indicated R11 had intact cognition, required supervision with eating, and extensive assistance for all other activities of daily living (ADLs). R11's diagnoses included major depression, bipolar disorder, anxiety, suicidal ideations, obesity, overactive bladder, cataracts, hoarding disorder, diabetes, venous insufficiency (decreased circulation to the arms and legs), rectal prolapse, and psoriasis (a skin disease causing itchy, scaly patches). R11's Care Area Assessment (CAA) dated 6/24/22, indicated R11 triggered for visual function, communication, indwelling catheter, and pressure ulcers. R11's care plan undated, indicated R11 had an ADL self-care deficit related to increased pain, venous insufficiency, depression, and diabetes and bowel incontinence related to decreased…

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 individualized activities were provided for 3 of 3 residents (R10, R59 and R 135) reviewed for activities. Findings include: R10 R10's admission Record dated 6/28/23, indicated R10's original admission date was 11/1/2004 with diagnoses of dysphagia (difficulty swallowing) following cerebral infarction, aphasia (a language disorder that affects a person's ability to communicate), hemiplegia (paralysis of one side of the body), and hemiparesis (weakness or the inability to move one side of the body) following cerebral infarction affecting left non-dominant side. R10's quarterly Minimum Data Set (MDS) dated [DATE], indicated R10 had severe cognitive impairment, received enteral feeding via gastric tube, and was totally dependent on staff with all activities of daily living. During documentation review R10's Activity Interview for Daily and Activity Preferences, was last completed on 10/4/21. R10's Therapeutic Rec/Life Enrichment…

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 turn and reposition, and adjust wound treatment and follow physicians orders for a wound consult for 1 of 1 resident (R92) who had a facility acquired Stage II pressure injury (opening in skin caused by pressure that is not in the tissues). R92's significant change Minimum Data Set (MDS), dated [DATE], indicted R92 was cognitively intact and required extensive assistance with transfers, bed mobility, dressing, toileting, and personal hygiene. The MDS further indicated R92 was at risk for pressure injuries. R92's Medical Diagnosis list indicated R92 had a primary medical diagnosis of metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood). R92'S care plan, dated 4/25/23, indicated R92 previously had a Stage II pressure injury to her right buttocks. Interventions included following facility protocols for the prevention of skin breakdown and encouraging R92 to change positions or offload weight.…

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 provide a resident with a limited range of motion with a care planned nursing restorative program and splints for 2 of 2 resident (R49 and R141) reviewed for range of motion. Findings include: R141's quarterly Minimum Data Set (MDS), dated [DATE], indicated R141 needed extensive assistance with all activities of daily living with short-term and long-term memory problems. R141'S Medical Diagnoses list indicated R141 had a primary diagnosis of hemiplegia (one-sided muscle paralysis) and hemiparesis (weakness on one side of the body) following a non-traumatic intracranial hemorrhage affecting the right side (bleeding into the substance of the brain in the absence of trauma or surgery). R141's care plan, dated 6/24/22, indicated R141 was on a nursing maintenance program indicating, do these exercises 1xday for right arm: Move shoulder up, down. Move elbow in, out. Rotate forearm up, down. Bend wrist up, down. x10 each movement. Move slowly,…

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 feeding tube and feeding tube supplies were labeled according to professional standards to avoid the possibility of feeding tube complications and or related infections for 3 of 3 residents (R10, R59 and R135). Findings include: R10's admission Record dated 6/28/23, indicated R10's original admission date was 11/1/2004. Diagnoses included dysphagia (difficulty swallowing) following cerebral infarction (tissue damage related to lack of blood supply to the brain), aphasia (a language disorder that affects a person's ability to communicate), hemiplegia (paralysis of one side of the body), and hemiparesis (weakness or the inability to move one side of the body) following cerebral infarction affecting left non-dominant side. R10's quarterly Minimum Data Set (MDS) dated [DATE], indicated R10 had severe cognitive impairment, received enteral feeding via a gastric (stomach) tube, and was totally dependent on staff for all activities 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 immediate interventions for 1 of 1 resident with repeated suicidal ideation and depression, provide 1:1 supervision until it was determined she was no longer a threat to herself, and perform an immediate safety check of the resident and her surroundings to ensure her safety and mental well-being. Findings include: R137's quarterly Minimum Data Set (MDS), dated [DATE], indicated R137 had moderate cognitive impairment and needed supervision with all activities of daily (ADLs). R137's Medical Diagnosis List indicated R137 had several medical diagnoses including major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and adjustment disorder with mixed disturbance of emotions and conduct (symptoms include behavioral issues such as acting rebellious, destructive, reckless or impulsive), dated 5/26/22, 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, document review and review of the Food and Drug Administration (FDA) warnings (www.fda.gov), the facility failed to ensure one resident (R-190) of five residents reviewed for unnecessary medications had adequate indications for the continued use of two different antipsychotic (Seroquel and Zyprexa) medications. In addition, the facility failed to ensure action was taken in response to possible adverse drug reactions when the resident had an increase in symptoms of abnormal involuntary movements (AIMS) related to taking antipsychotics. Findings include: Review of FDA guidelines titled Highlights of Prescribing Information, dated 1996 and referring to the use of Zyprexa, revealed, Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Zyprexa is not approved for the treatment of patients with dementia-related psychosis. Review of FDA guidelines titled Highlights of Prescribing Information, dated 1997 and referring to the 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 that food preferences were honored for one resident (R-21) of 35 sampled residents. The resident's request and physician orders for a vegetarian diet were not honored. Findings include: Review of R21's Clinical Census, found in the electronic medical record (EMR), under the Clinical tab revealed R21 was admitted on [DATE] with diagnoses including major depressive disorder and adjustment disorder with anxiety. R21's significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/29/23, revealed a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated R21 was severely cognitively impaired. A recent Social Service note, dated 06/27/23, revealed the resident now had a BIMS score of 9 out of 15 which indicated moderate cognitive impairment. Review of Physician Orders, found in the Clinical tab of the EMR and dated 09/05/22, revealed an order for vegetarian diet. Review of the Food…

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 2 of 2 resident (R52, R143) received ordered, therapeutic diets to maintain or improve their nutritional status. Findings include: Centers for Disease Control and Prevention (CDC) (2022), Diabetes indicated keeping blood sugar levels within a healthy target range was important to prevent or delay serious health concerns such as heart and kidney disease. The article indicated a healthy target blood sugar to be 80-130 mg/dL prior to meals and less than 180 mg/dL two hours after the start of a meal. Chronically high blood sugar levels can lead to long-term, serious health problems such as fatigue. R52's significant change Minimum Data Set (MDS) dated [DATE], indicated R52 had moderate cognitive deficits and required supervision for eating and extensive assistance with personal hygiene and dressing. R52's diagnoses included encephalopathy (a group of diseases that affect brain structure and/or function), urinary retention, diabetes,…

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 sanitary and homelike environment for 3 of 3 residents (R10, R59, R135) whose tube feeding poles and equipment had dried tube feeding residue on them. Findings include: R10's admission Record dated 6/28/23, indicated R10 was admitted on [DATE]. Diagnoses included dysphagia (difficulty swallowing) following cerebral infarction (brain tissue damage related to lack of blood flow), aphasia (a language disorder that affects a person's ability to communicate), hemiplegia (paralysis of one side of the body), and hemiparesis (weakness or the inability to move one side of the body) following cerebral infarction affecting left non-dominant side. R10's quarterly Minimum Data Set (MDS) dated [DATE], indicated R10 had severe cognitive impairment, received enteral feeding via gastric tube, and was totally dependent on staff for all activities of daily living. R10's Order Summary Report indicated Enteral Feed order two times a day, Glucerna…

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.