The Villas At Richfield

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure a resident's preferred activities for individual entertainment were available for 1 of 1 resident (R16) reviewed for activities.Finding include:R16's Minimum Data Set (MDS) assessment dated [DATE], identified R16 had cognitive impairment and displayed no delusional thinking, with some rejection of cares. R16 was dependent on facility staff for upper and lower body dressing, putting on and removing shoes, and transferring from bed to chair.R16's Evaluation and Social History dated 8/19/24, indicated R16 had no visual or auditory deficits that would impact activity participation, enjoys time with her children, music, and game shows. R16's specific preference to music is old rhythm and blues. Further, R16 was willing to try new activities, actively engages in structured activities of choice, and actively engages in independent activity of choice.R16's care plan dated 11/14/24, indicated R16 had generalized anxiety, major depressive…

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 bruises were adequately assessed and monitored for 1 of 1 resident (R92), failed to ensure non-pressure wounds had timely assessment and documentation for 1 of 3 residents (R92), and furthermore failed to implement and/or clarify a wound order after a hospitalization for 1 of 3 residents (R2) reviewed for non-pressure related wounds.Findings include: R92's admission Minimum Data Set (MDS) assessment, dated 6/11/25, indicated intact cognition, did not have delusions or hallucinations, physical, verbal, or other behavioral symptoms, and did not reject care. Further, R92 was dependent on staff for toileting hygiene, lower body dressing, and required substantial to maximal assistance with upper body dressing, personal hygiene, and showering and bathing. R92's diagnoses included cancer, wound infection, diabetes, arthritis, was morbidly obese with a body mass index of 50.0 to 59.9. Furthermore, R92 was at risk for developing pressure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to appropriately assess and help maintain range of motion and prevent possible contracture who had limited functional movement in the right hand for 1 of 2 residents (R16) reviewed for range of motion (ROM). Findings include:R16's Minimum Data Set (MDS) assessment dated [DATE], identified R16 had cognitive impairment and displayed no delusional thinking, with some rejection of cares. Further, R16 required moderate assistance to eat and perform oral hygiene.During observation and interview on 6/23/25 at 3:51 p.m., R16 was resting in bed and her daughter held up R16's right hand and stated she was concerned R16's hand and fingers were becoming more contracted; stating R16 is no longer able to hold silverware or brush her teeth on her own. R16 could previously do those things. During observation on 6/24/25 at 12:40 p.m., R16 had food present and was attempting to feed self. R16 was unable to use the silverware, instead R16 was picking up 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 interview and document review, the facility failed to ensure timely reassessment after administration of as needed narcotic medication for 1 of 2 residents (R296) reviewed for pain.Findings include: R296's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R296 had intact cognition and diagnoses of hypertension, cirrhosis (scarring of liver caused by many diseases and conditions which includes alcohol use disorder), gastro-esophageal reflux disease (condition in which stomach contents move up into the esophagus), viral hepatitis (infection which causes liver inflammation and damage), diabetes mellitus, fracture, anxiety disorder, depression, and chronic obstructive pulmonary disease (condition caused by damage to airways and other parts of the lung). R296 received as needed pain medications. The MDS indicated R296 had pain almost constantly and the pain occasionally effected sleep and interfered with therapy activities and day-to-day activities. R296's care plan, indicated R296 had chronic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to comprehensively assess past trauma and implement individualized care plan interventions utilizing a trauma-informed approach for 1 of 1 (R19) resident reviewed who had post-traumatic stress disorder (PTSD).Findings include:R19's Minimum Data Set (MDS) dated [DATE], identified intact cognition, was independent with eating, dressing, toileting, and walking. Diagnosis included depression, schizophrenia, and post-traumatic stress disorder (PTSD). The Care Area Assessment Summary of the MDS for psychosocial well-being was not completed.R19's provider's history and physical note dated 10/9/23 indicated R19 had a diagnosis of schizophrenia, depression, and suicidal ideation. Further, R19 had PTSD due to religious persecution, starvation, and violence suffered in the Sudan; further being complicated by increased life stressors, unspecified psychosis, and alcohol use disorder.Initial review of R19's care plan dated 10/10/23, the focus lacked individualized…

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 the ensure residents were free from unnecessary medications for 1 of 2 residents (R25) reviewed for diuretic use. Findings include: R25's admission Minimum Data Set (MDS) assessment, dated 5/21/25, indicated R25 was cognitively intact with no behaviors or delirium. R25 had range of motion to one side of her upper body and required partial to moderate assistance with activities of daily living. R25 received diuretic medication. R25's diagnosis list included chronic respiratory failure, essential hypertension (high blood pressure), chronic kidney disease, and chronic diastolic congestive heart failure (CHF-heart disease that causes buildup of fluid in the body). R25's care plans included diuretic therapy related to hypertension and congestive heart failure. Interventions included administer medication as ordered and potential side effects that included dizziness, postural hypotension (drop in blood pressure with position changes), fatigue, 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 ensure medical records were complete and accurately documented for 2 of 2 residents (R92, R25) reviewed. Findings include: For additional details please see F684 and F757. R92's admission Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, did not have delusions or hallucinations, physical, verbal, or other behavioral symptoms, and did not reject care. R92's diagnoses included cancer, wound infection, diabetes, and arthritis. Furthermore, R92 was at risk for developing pressure injuries, had surgical wounds, and took an anticoagulant (blood thinner). During observation and interview on 6/23/25 between 2:14 p.m., and 2:17 p.m., R92 had bruises bilaterally to the back of her upper arms. R92's right arm had a bruise approximately the size of a grapefruit and the bruise located on R92's left arm went from R92's arm pit area to her elbow and was purple towards the elbow and a faded yellow color on the upper part 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 proper placement of catheter bag for 1 of 1 resident (R2) reviewed for catheter use.Findings include: R2's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R2 had severe cognitive impairment, no behaviors or rejections of care, and required substantial/maximal to dependent assistance with activities or daily living. R2's diagnoses included peripheral vascular disease, neurogenic bladder, diabetes mellitus, dementia, anxiety, and depression. R2 had an indwelling catheter, was always incontinent of bowel, and was at risk for pressure ulcers. R2's care plan printed, indicated R2 had a suprapubic catheter. Staff were to provide assistance with peri-cares in the morning, at bedtime, and as needed, monitor for signs/symptoms of UTI, monitor catheter output, provide catheter care per policy, change catheter per policy, apply protect cream after each incontinent episode, encourage only and nutritional intake, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure alleged violations of an injury of unknown origin that resulted in suspicion of serious bodily injury were immediately reported, no later than 2 hours, to the State Agency (SA) and administrator for 1 of 1 resident (R2) reviewed for abuse. Findings include: R2's Medicare 5-Day Minimum Data Set (MDS) dated [DATE], indicated R2 had moderate cognitive impairment. R2's provider progress note by physician's assistant (PA)-A dated 2/19/25 no time indicated, indicated R2 was seen to discuss discharge planning to return home. R2's left wrist was noted to be bruised and swollen with tenderness to palpation, with no reported falls and injuries. The provider ordered an X-Ray for the left wrist. The progress notes lacked information about a staff discovery of R2's swollen wrist. On 3/12/25 at 10:11 a.m., during an interview, social worker (SW)-A stated he was not aware of R2's wrist injury however, confirmed any injury of unknown origin should have been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to thoroughly investigate an injury of unknown origin for 1 of 3 residents (R2), (R2 had a swollen, bruised, tender right wrist with no known related injuries or accidents) reviewed for abuse. Findings include: R2's Medicare 5-Day Minimum Data Set (MDS) dated [DATE], indicated R2 had moderate cognitive impairment. R2's provider progress note by physician's assistant (PA)A dated 2/19/25 no time identified, indicated R2 was seen to discuss discharge planning to return home. R2's left wrist was noted to be bruised and swollen with tenderness to palpation, with no reported falls and injuries. The provider ordered an X-Ray for the left wrist. On 3/12/25 at 10:11 a.m., during an interview, social worker (SW)-A stated he was not aware of R2's wrist injury however, confirmed any injury of unknown origin should have been investigated, and was not aware if it had been investigated. On 3/12/25 at 3:48 p.m., during an interview, director of nursing (DON) stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure adequate and required information was communicated and documented to a receiving healthcare facility to provide continuity of care for 1 of 3 residents (R2) reviewed for discharge. Findings include: R2's Medicare 5-Day Minimum Data Set (MDS) dated [DATE], indicated R2 had moderate cognitive impairment, an indwelling catheter (used to drain urine from the bladder), a history of stroke and renal insufficiency (kidneys were not fully functioning). R2's care plan printed 3/12/25, lacked indication R2 had a catheter. R2's diagnoses list printed 3/11/25, indicated chronic kidney disease and neuromuscular dysfunction of the bladder. R2's hospital Discharge summary dated [DATE], indicated R2 arrived to the hospital on 1/20/25, with urinary retention that was relieved with a catheter. R2's provider progress notes dated 1/29/25, indicated R2 had a catheter in the hospital for urinary retention. R2's progress notes dated 2/1/25, indicated R2 had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to comprehensively assess, develop a plan of care, and provide interventions for 1 or 1 resident (R2) reviewed for catheter care. In addition, the facility failed to notify a provider for further direction when staff were unable to re-insert the catheter. Findings include: R2's Medicare 5-Day Minimum Data Set (MDS) dated [DATE], indicated R2 had moderate cognitive impairment, an indwelling catheter, a history of stroke, and renal insufficiency (kidneys were not fully functioning). R2's diagnoses list printed 3/11/25, indicated chronic kidney disease and neuromuscular dysfunction of the bladder. R2's care plan printed 3/12/25, lacked indication R2 had a catheter. R2's hospital Discharge summary dated [DATE], indicated R2 arrived to the hospital on 1/20/25, with urinary retention that was relieved with a catheter and discharged to the facility on 1/28/25, with the catheter. R2's provider progress notes dated 1/29/25, indicated R2 had a catheter 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 interview and document review, the facility failed to develop a care plan to address diabetic management for 1 of 3 residents (R4) reviewed for nursing services. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4 was cognitively intact with diagnoses of Type 2 diabetes (insulin resistance often developed in adulthood), and required insulin injections 7 of 7 days in the 7-day assessment look-back period. R1's Physician Orders dated 10/14/24, indicated R4 was prescribed Glargine insulin (a long-acting insulin often administered at bedtime to patients with Type 2 Diabetes) 100 units (u)/ per milliliter (ml), 56 units injected subcutaneously (subq., under the skin) one time a day. R1's care plan printed 11/15/24, lacked a care focus area for diabetic management and corresponding interventions. R1's Physician Orders dated 10/15/24, indicated R4 was prescribed Humalog insulin (a short-acting insulin, generally used with long-acting insulin, to cover insulin needs for meals…

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

Based on observation, interview, and document review, the facility failed to ensure food and beverages stored in the refrigerators, were labeled, dated and discarded properly. This deficient practice had the potential to affect 87 residents who received food and beverages from the refrigerators. Findings include: On 8/19/24 at 12:45 p.m., during the final tour of the kitchen area with the dietary manager(DM), the following concerns were identified.: Kitchen Freezer: -six veggie burgers in an opened plastic bag without notation of a date. Kitchen refrigerator: -large plastic container 1/2 full of Asian salad dressing with black crusty substance around the lid without any notation of the date it had been opened. -plastic carton ¾ full of thickened milk without notation of a date it was opened and a manufacturer's best by date of 3/4/24. -large container ½ full of Orange Marmalade without notation of a date it had been opened. -large plastic container ¾ full of Blue Cheese salad dressing with black crusty particles inside the container without any notation of the date it had been…

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 promote dignity while utilizing a mechanical lift sling for extended periods of time for 1 of 3 residents (R13) reviewed for dignity and who was dependent on staff for activities of daily living (ADL's) and required the use of a mechanical lift for transfers. Findings include: R13's quarterly Minimum Data Set (MDS) dated [DATE], identified R13 had moderate cognitive impairment and diagnoses which included: moderate intellectual disabilities, and Parkinsonism (movement symptoms related to Parkinson's disease). Indicated R13 was dependent on staff for chair/bed transfers, dressing, and personal hygiene. R13's Care Area Assessment (CAA) dated 3/18/24, identified R13 needed assistance with ADL's and had decreased mobility and cognition secondary to schizoaffective disorder (mental health condition with symptoms such as hallucinations, delusions, and mood disorders), failure to thrive, and moderate intellectual disabilities. R13 required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure medications were administered safely for 3 of 3 residents (R79, R74, R354) who had medications left at the bedside and had not been assessed as safe to self-administer those medications. Findings include: R79 R79's significant change in status Minimum Data Set (MDS) dated [DATE], identified R79 was cognitively intact, and had diagnoses which included: cancer, hypertension and diabetes mellitus. Identified R79 was independent with eating, bed mobility, and transfers, and required partial/moderate assistance with dressing. R79's care plan revised 8/7/24, identified R79 was receiving hospice services, and was independent with dressing, personal hygiene, and transfers. R79's care plan lacked instructions for self administration of medications. During an observation on 8/19/24 at 1:29 p.m., R79 was lying in her bed. Next to her bed was a bedside stand with two boxes of antibiotic and pain relief cream and a small tube of antibiotic…

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 housekeeping services for a clean environment for 4 of 4 residents (R79, R2, R81, R19) with a shared bathroom. Findings include: R79's Face Sheet, dated 8/21/24, identified R79 had diagnoses which included; malignant neoplasm of temporal lobe, depression, and diabetes mellitus. R79's care plan revised 8/7/24, identified R79 was independent with a walker for ambulation, transfers, and required assistance of one with toileting. R2's Face Sheet dated 8/21/24, identified R2 had diagnoses which included: Alzheimer's disease, diabetes mellitus, and delusional disorders. R2's care plan revised 6/5/24, identified R2 required two staff for assistance with transfers, wheelchair use for mobility, and required assistance of one with toileting. R81's Face Sheet dated 8/21/24, identified R81 had diagnoses which included: malignant neoplasm of unspecified site of right female breast, muscle weakness, and fracture of unspecified part of neck of the left femur, subsequent encounter for closed fracture with routine…

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 a care conference for 1 of 1 residents (R68) to review and revise care plan with the interdisciplinary team (IDT), who was reviewed for care planning. R68's quarterly Minimum Data Set (MDS) dated [DATE], identified R68 was cognitively intact and had diagnoses which included: malnutrition, anxiety and depression. R68's care plan revised 7/26/24, identified R68 was a vulnerable adult, was at risk for harm related to suicidal thoughts and had started working with relocation services to assist with finding housing. R68 was independent with transfers, ambulation, dressing, bathing, and personal hygiene. R68's Care Conference Form dated 4/1/24, identified it was a quarterly care conference, and resident and family was involved in plan of care. Review of R68's medical record lacked documentation of a care conference completed after R68's quarterly MDS dated [DATE], was completed. During an interview on 8/19/24 at 2:40 p.m., R68 stated had not been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to provide assistance with personal hygiene for 2 of 5 residents( R30, R12). In addition the facility failed to provide assistance with dressing for 1 of 5 residents (R66) reviewed for activities of daily living (ADL)'s. Findings include: R30 R30's quarterly Minimum Data Set (MDS) dated [DATE], identified R30 had intact cognition and diagnoses which included hypertension, (elevated blood pressure), Renal insufficiency, and Diabetes Mellitus (DM). Identified R30 required physical assistance from staff with personal hygiene. R30's current care plan dated 7/23/23, indicated R30 had deficits with ADL's related to weakness, chronic pain and obesity. R30 required assistance with personal hygiene. R30's Comprehensive Care Area Assessment (CAA) dated 8/15/23, identified R30 had a self care deficit and required assistance with personal hygiene which included shaving facial hair. During an observation on 8/19/24 at 2:37 p.m., R30 was lying in bed 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 appropriate donning/doffing of personal protective equipment (PPE) practices to prevent the spread of infection for 1 of 1 residents (R26) observed for enhanced barrier precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). Findings include: Review of Centers for Disease Control and Prevention(CDC) guidance dated 4/1/24, Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) indicated Examples of high-contact resident care activities requiring gown and glove use for EBP included: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care: any skin opening requiring a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure call lights were accessible for 1 of 1 residents (R27) who were reviewed for call light accessibility. Findings include: R27's quarterly Minimum Data Set (MDS) dated [DATE], indicated R27 was cognitively impaired and had diagnoses of depression and schizophrenia (a serious mental health condition). Identified R27 was dependent on staff for activities of daily living (ADL) and mobility. R27's care plan dated 7/19/23, lacked documentation of the use or placement of R27's call light. During an observation on 8/20/24 at 12:18 p.m., R27 was sitting in his wheelchair watching television. R27's call light was laying on a pillow on the nightstand table behind R27. R27 was not able to move his wheelchair or turn around independently to reach his call light off of the nightstand table. During an observation on 8/20/24 at 12:28 p.m., R27 remained in the same position as above. R27's call light remained laying on a pillow on the nightstand…

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 care and services to promote dignity for 2 of 3 residents (R1, R4) who required assistance with activities of daily living (ADLs) and reported feeling embarrassed by their hygiene appearance. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], identified intact cognition and no behaviors. R1 had impaired strength bilaterally lower extremities, dependent on staff for toileting hygiene, all transfers, and placement of footwear. R1 required partial to moderate assistance to go from sitting on edge of bed to lying and substantial to maximum assistance for personal hygiene. R1's care plan dated 4/23/24, identified ADL's self-care performance deficit related to paraplegia, MS, depression, and anxiety and directed staff to provide total assistance with all personal hygiene. R1's [NAME] care sheet dated 5/30/24, identified R1 required total assistance with all personal hygiene care, assist of one for bathing, and explain…

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 administer and discharge/assess timely a nebulizer treatment according to standards of for 1 of 1 resident (R2) who was left alone during administration of a nebulizer treatment for administration (15 minutes) and an additional 105 minutes following the treatment. Findings include: R2's annual Minimum Data Set (MDS) dated [DATE], identified R2 was cognitively intact with no behaviors. R2 had diagnoses of traumatic spinal cord injury, seizure disorder, quadria pelagic (paralysis that affects all four limbs and torso from neck down), and depression. R2 had impairment of bilaterally lower extremities, and dependent on staff for toileting hygiene, shower/bathing, clothing and shoes placed on, personal hygiene, sit to lying and lying to sit. R2 required substantial to maximum assistance required to roll left and roll right. R2 was dependent on staff for be to chair transfers, unable to walk, and had a motorized wheelchair. R2's physician orders indicated:…

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 appropriate emergency equipment in the room and have complete tracheostomy care orders for 1 of 1 resident (R6) reviewed for respiratory care. Findings include: R6's Face Sheet dated 3/7/24 indicated diagnoses which included cerebral infarction (stroke), acute respiratory failure with hypoxia (low oxygen), severe protein calorie malnutrition, type II diabetes, gastroesophageal reflux disease, malignant neoplasm of colon and encephalopathy. R6's 5-day Medicare Minimum Data Set (MDS) dated [DATE], indicated R6 had severe cognitive impairment and was completely dependent for all activities of daily living. R6's History and Physical dated 2/26/24, indicated he had a tracheostomy (surgical opening directly into the trachea) and feeding tube placed on 11/16/24. R6's Order Summary active from 2/27/24 to 3/6/24 directed: -Suction deep laryngeal 2 times daily -Weekly vital signs -May use oxygen per tracheostomy as needed -3 liters 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 record review the facility failed to develop and implement a comprehensive care plan for 3 of 3 residents reviewed for comprehensive care plans when residents did not comply with their care planned smoking interventions. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], noted R1 had moderately impaired cognition, required the assistance for bed mobility, transfers, bathing, dressing and is non-ambulatory. R1's diagnoses included encephalopathy (a disease that alters brain function), hemiplegia, dysphagia, and weakness. R1's smoking evaluation dated 10/18/23, noted R1 identified as a smoker but was deemed unsafe to store/handle his own cigarette and lighter due to cognitive loss, dexterity problems, inability to light his own cigarette and noted cigarette ashes on his clothing. R1's care plan initiated on 10/24/23, noted R1 was a smoker but was not a safe smoker, unable to store/handle his own cigarettes and lighter, and that he will not smoke at 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.