The Villas At The Cedars

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop a care and furnish services according to the providers orders for 1 of 3 residents (R4) reviewed. R4 was ordered to wear compression stocking and an abdominal binder. These services were not being completed. Findings include: R4's physician orders dated 4/17/25 at 9:00 a.m. indicated R4 was to have lymphedema therapy (aims to reduce swelling, alleviate symptoms, and manage symptoms of swelling in the arms and the leg). Wash and apply personal lotion daily. Apply compression compressions in the morning to wear 23/24 hours maximum of 48 years. Compression Xspan (brand name of sock) size 5 toes to just below the knee, 4 extra-long ace wrap from toes to just below the knee in a herring bone (figure 8) pattern. Tubi-grip (elasticated tubular bandage that provides support and compression) from toes to just below the knee-double extra over foot. Remove if painful or irritating. R4's quarterly MDS dated [DATE] indicated R4's BIMS score was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to provide the necessary services recommended by physical therapy to maintain or improve a residents ability to carry out her own activities of daily living for 1 of 3 residents (R4) reviewed. R4 was ordered a functional maintenance program when her physical therapy treatment period ended, and the facility did not initiate the program delaying R4's discharge goals. Based on interview, and record review the facility failed to provide the necessary services recommended by physical therapy to maintain or improve a residents ability to carry out her own activities of daily living for 1 of 3 residents (R4) reviewed. R4 was ordered a functional maintenance program when her physical therapy treatment period ended, and the facility did not initiate the program delaying R4's discharge goals. Findings included: R4's Annual Minimum Data Set (MDS) dated [DATE] indicated R4 had a Brief Inventory of Mental Status (BIMS) score of 15 indicating R4 was cognitively intact.…

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 sufficient nursing staff available at all times to provide nursing services to meet the residents needs for 3 of 3 residents (R1, R2 and R4) reviewed when staff were unavailable to provide necessary care and services according to assessed needs leading to long wait times for incontinence cares.Findings include: The Facility Assessment Tool dated 1/7/25 indicated under staff acuity:-Dressing assistance the facility had 8 independents residents, 67 residents with assistance of 1-2 staff and 1 dependent resident. -Bathing - 4 independent residents, 21 with assistance of 1-2 and 23 dependent residents.Transferring 14 independent residents, 49 residents with assistance of 1-2 staff, 10 dependent residents-Eating - 62 independent residents, 12 residents with assistance of 1-2 and 2 dependent residents.-Toileting - 11 independent residents, 64 residents with assistance of 1-2, and 1 dependent resident.-Mobility - 7 independent residents,…

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 call lights, or another means to request assistance were accessible for 3 of 3 (R2, R5, and R7) residents who were dependent on staff for activities of daily living.Findings include: Upon observation and interview on 7/14/25 at 1:21 p.m. R2 was found in her room seated in her wheelchair with her pants off wearing an incontinent brief. R2 was attempting to get a pair of sweatpants on by herself. R2's bed was in the lowest position, there was a matt on the floor so R2 could not scoot herself in her wheelchair to reach her call light which was placed on her bed wrapped around her 1/4 side rail against the wall. R2 became agitated stating why can't you help me, why can't you help put my pants on? R2 attempted to stand up. The surveyor went to get assistance from registered nurse RN-A at 1:46 p.m. to assist R2. RN-A assisted R2 with getting her pants back on. RN-A left the room and got nursing assistant (NA)-A to assist with getting the…

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

Based on interview and document review, the facility failed to ensure an allegation of potential abuse was reported timely to the administrator and to the State agency (SA) in accordance with established policies and procedures for 1 of 1 residents (R1) who was reviewed for an allegation of abuse. Findings include: A Facility Reported Incident (FRI), dated 6/21/25, at 4:55 p.m., was submitted to the SA which reported an alleged act of abuse towards R1. The report identified nursing assistant (NA)-D reported to the director of nursing (DON), that NA-A handled R1 roughly and [was] being verbally aggressive with [R1]. R1 was agitated by NA-A and attempted to bite NA-A. In response, NA-A held [R1's] arm to [R1's] mouth and said bite yourself. The report indicated this incident occurred 6/20/25, at 5:00 p.m.; however, additionally identified the administrator was updated 6/21/25, at 3:20 p.m. The report identified staff became aware of the incident on 6/20/25, at 3:15 p.m.; however, this date was in error as interviews identified the DON was initially updated on 6/21/25, and the incident…

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 an allegation of potential verbal/ physical abuse was thoroughly investigated and protection was provided when the alleged perpetrator was allowed to continue to work with residents after the allegation was identified for 1 of 1 resident (R1) reviewed for an allegation of abuse. Findings include: A Facility Reported Incident (FRI), dated 6/21/25, at 4:55 p.m., was submitted to the State agency (SA) which reported an alleged act of abuse towards R1. The report identified nursing assistant (NA)-D reported to the director of nursing (DON), that NA-A handled R1 roughly and [was] being verbally aggressive with [R1]. R1 was agitated by NA-A and attempted to bite NA-A. In response, NA-A held [R1's] arm to [R1's] mouth and said bite yourself. The report indicated the incident occurred 6/20/25, at 5:00 p.m.; however, additionally identified the administrator was updated 6/21/25, at 3:20 p.m. The report identified staff became aware of the incident 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 interview and document review, the facility failed to ensure the physician was notified timely of elevated blood sugars and a change condition for 1 of 2 residents (R2) reviewed for change of condition. Findings include: R2's admission Minimum Data Set (MDS) dated [DATE], identified he was admitted to facility on 3/1/25, from an acute care hospital with moderately impaired cognition. He required partial/moderate assistance with personal hygiene and dependent for chair/bed to chair transfers and toileting hygiene. His medical diagnoses included diabetes mellitus (DM) and hyperkalemia (high potassium). R2's provider orders identified: -3/1/25, insulin Aspart (rapid-acting insulin) flex-pen injector 100 unit/ml. Inject 10 units subcutaneously (SQ) with meals for diabetes. -3/1/25, blood sugars before meals and at bedtime for DM. -3/1/25, blood sugar ranges below 75 or greater than 400 update provider. -3/1/25, observe for dehydration, decreased skin turgor, dry mucus membranes, lethargy, fatigue, weakness,…

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 peripherally inserted central catheter (PICC) was appropriately managed based on professional standards of practice and in accordance with physician orders for 1 of 1 resident (R1) reviewed for intravenous (IV) medications. Findings include: R1's face sheet dated 4/3/25, identified diagnoses of cerebral vascular accident (stroke), sequelae of cerebral infarction (complications of stroke on brain and body). R1's hospital Discharge summary dated [DATE], identified R1 had diagnoses that included bacterial endocarditis. Treatment of Ceftriaxone (antibiotic) via PICC. Discharge order for Ceftriaxone 2-gram solution daily. R1's admission Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment. R1 was administered IV antibiotic medication. R1's care plan dated 3/4/25, identified a current infection related to acute bacterial endocarditis (serious infection of the heart lining and valves). Give medications as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow infection control protocols to ensure proper handwashing was implemented for 2 of 4 residents (R1, R2); failed to ensure proper enhanced barrier precautions (EBP) were utilized appropriately for 2 of 2 residents (R1, R3); and failed to disinfect vital sign machine after use for 1 of 1 residents (R1). Findings include Enhanced barrier precautions: refer to an infection control intervention designed to reduce transmission of multi-drug-resistant organism that employs targeted gown and glove use during high contact resident care activities. Gowns and gloves are used as personal protective equipment (PPE). R1 R1's face sheet dated 4/3/25, identified diagnoses of sequelae of cerebral infarction. R1's admission Minimum Data Set (MDS) dated [DATE], identified some cognitive impairment. Used intravenous (IV) medication of antibiotic. R1's care plan dated 2/25/25, EBP related to peripherally inserted central catheter (PICC) line. Staff to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure discharge summary requirements were met for 1 of 3 residents (R1) reviewed for discharge. R1 discharged from the facility against medical advice (AMA), R1's medical record did not include a recapitulation of resident's stay (a concise summary of the resident's stay and course of treatment in the facility) and a final summary of the resident's status at discharge. Findings include: R1 admission Record identified admission on [DATE]. R1's discharge plan assessment, dated 11/25/24 indicated R1 was looking for an assisted living facility after nursing home rehab was completed. R1's Minimum Data Set (MDS), dated [DATE], indicated R1 used a cane for mobility and was diagnosis with non-trauma spinal cord dysfunction, hypertension, hyperlipidemia, anxiety, depression, bipolar disease. Additional diagnoses included history of substance abuse. R1's progress note dated 11/28/24 at 11:23 p.m. indicated R1 was on a leave of absence (LOA), leaving 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 record review the facility failed to report allegations of neglect to the state agency immediately, but not later than two hours for one of one resident (R1) reviewed when R1's change in condition was not assessed, the physician was not notified, and R1's change in condition was not monitored by licensed nurses. R1 began vomiting on [DATE] and died in the facility on [DATE]. Findings include: R1's face sheet indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of schizoaffective disorder. R1's additional diagnoses included esophageal varies with bleeding, dysphagia, cognitive communication deficit, schizophrenia, peptic ulcer without hemorrhage or perforation, and personal history of a traumatic brain injury. R1 died while in the facility on [DATE]. R1's care plan dated [DATE] indicated staff would continue to follow the facility vulnerable adult and abuse reporting policy. R1's brief interview for mental status (BIMS) assessment dated [DATE] indicated R1 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 record review, the facility failed to develop a comprehensive care plan for one of three residents (R1) reviewed when R1 had a history of gastrointestinal bleeds that was not identified on her care plan. Findings include: R1's medical record indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of schizoaffective disorder. R1's additional diagnoses included esophageal varies with bleeding, dysphagia, cognitive communication deficit, schizophrenia, peptic ulcer without hemorrhage or perforation, and personal history of a traumatic brain injury. R1 died while in the facility on [DATE]. R1's brief interview for mental status (BIMS) assessment dated [DATE] indicated R1 had a score of fourteen, which indicated R1 was cognitively intact. R1's provider visit note dated [DATE] indicated R1 was diagnosed with an erosive esophagitis. The visit notes indicated R1 was admitted to the hospital from [DATE] to [DATE] for a gastrointestinal bleed. The visit notes indicated R1 was…

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

Based on observation, interview, and record review the facility failed to ensure personal protection equipment (PPE) was used when sorting dirty laundry. This had the potential to impact all 82 residents who reside in the facility. Findings include: During observation and interview on 9/19/24 at 10.24 a.m., Environmental Service Director (ESD) indicated the laundry aide would take the dirty laundry from the red chute in the laundry room and sort it. He indicated the staff was to wear a gown and gloves when handling dirty laundry. He indicated the gowns are to be hung on the wall in the dirty laundry room. He verified there were no gowns on the wall. Interview with laundry aide (LA) -A and LA- B at 10:35 a.m. they indicated there were no gowns, and there had not been for around a month. LA-B indicated she wears gloves when sorting dirty laundry, but no gowns have been available. Review of undated Contaminated Laundry policy indicated: • Employers must ensure that employees who have contact with contaminated laundry wear appropriate PPE as discussed in the Bloodborne Pathogen Standard…

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 maintain resident privacy and dignity 2 of 3 residents (R46, R11) reviewed for dignity. R46 R46's admission (MDS) dated [DATE], indicated R46 had moderate cognitive impairment and required substantial and/or maximal assistance with most activities of daily living (ADLs), such as hygiene, dressing, and transfers. During observation on 9/18/24 at 7:30 a.m., R46 had their call light on. At 7:32 a.m., the social services designee (SS)-A knocked on R46's door and stated they would let them [the staff] know as they walked out of R46's room. At 7:34 a.m., SS-A stated loudly down the hall to nursing assistant (NA)-A R46 needed a check and change. During interview on 9/18/24 at 8:48 a.m., NA-A stated SS-A always does that when questioned about SS-A's statement in the hall. NA-A stated SS-A should come to staff and tell them what residents' need with a quieter voice. NA-A stated residents needed privacy and did not want other residents to think…

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 1 of 1 resident (R30) to safely administer their own non-oral medications. Findings include: R30's annual Minimum Data Set (MDS) dated [DATE], indicated R30 was cognitively intact and had diagnoses of paraplegia (loss of muscle function in lower half of the body), cataracts (clouding of the lens of the eye), diabetes mellitus (condition which affects how body uses blood sugar), hypertension (high blood pressure), and renal failure (chronic kidney disease; loss of kidney function). R30 required substantial and/or maximal to dependent assistance with activities of daily living (ADLs) such as dressing, toileting hygiene, and rolling left and right and was independent with ADLs such as eating and use of motorized wheelchair. R30's care plan dated 9/12/24, indicated R30 desired to self-administer TUMs (chewable antacid which treats symptoms cause by too much…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure resident use of shared toilet for 1 of 1 resident (R62) reviewed for accommodation of needs. Findings include: R62's quarterly Minimum Data Set (MDS) dated [DATE], indicated R62 had intact cognition and no behaviors or rejection of cares. R62 had limb prosthesis and used a wheelchair. R62 required partial and/or moderate assistance for toileting hygiene and toilet transfers and supervision and/or touching assistance for chair and/or bed-to-chair transfers and walking. The MDS indicated R62 was frequently incontinent of bowel and bladder. R62's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) Worksheet dated 6/14/24, was triggered due to assist needed with activities of daily living (ADLs), such as dressing, hygiene, sitting to standing, and transfers. R62's care plan dated 9/10/24, directed staff to provide R62 with supervision for non-weight bearing transfers, and R62 washed hands and held grab bars but…

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 an enteral feeding pump, tube feeding pole, and supporting legs were cleaned and in sanitary condition for 1 of 2 residents (R11) reviewed for tube feeding. Furthermore, the facility failed to keep the building clean for 1 of 1 bathroom with an unclean exhaust fan and 1 of 1 room with an unclean wall vent and ceiling tiles. Also, the facility failed to keep furniture in good condition for 1 of 2 residents (R30) who had an extended table from a dresser in their room. Findings include: TUBE FEEDING EQUIPEMENT R11's annual Minimum Data Set (MDS) dated [DATE], indicated R11 was in a persistent vegetative state and/or had no discernible consciousness. R11 was dependent on staff for activities of daily living, such as oral and toileting hygiene, dressing, mobility, and transfers, and had impairment on both sides of upper and lower extremities. R11 had diagnoses of quadriplegia (severe or complete loss of motor function in all four…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and observation, the facility failed to ensure a comprehensive and individualized care plan was developed for 1 of 1 resident (R49) reviewed for constipation. Findings include: R49's quarterly Minimum Data Set (MDS) dated [DATE], indicated was cognitively intact, had verbal behaviors and rejection of care, used a walker, and was independent with most activities of daily living (ADLs), such as walking, hygiene, and transfers. R49 was occasionally incontinent of bladder and frequently incontinent of bowel. The MDS indicated R49 had end stage renal disease (medical condition in which a person's kidneys stop functioning on a permanent basis) and diabetes mellitus (condition which affects how body uses blood sugar). R49's care plan dated 9/16/24, lacked information about bowel and bladder incontinence, toileting, or constipation. R49's nursing progress notes indicated the following: -On 8/26/24 at 00:20 [12:20 a.m.], R49 called ambulance for stomach pain and constipation. -On 8/26/24 at 03:09 [3:09…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to comprehensively assess and monitor non-pressure related skin conditions for 1 of 1 resident (R49) reviewed for skin concerns. Findings include: R49's quarterly Minimum Data Set (MDS) dated [DATE], indicated was cognitively intact, had verbal behaviors and rejection of care, used a walker, and was independent with most activities of daily living (ADLs), such as walking, hygiene, and transfers. R49 was occasionally incontinent of bladder and frequently incontinent of bowel. The MDS indicated R49 had end stage renal disease (medical condition in which a person's kidneys stop functioning on a permanent basis) and diabetes mellitus (condition which affects how body uses blood sugar). The MDS did not indicate any behavioral symptoms not directed towards others, such as scratching self. R49 had diabetic foot ulcer, dressings to feet, and nonsurgical dressings to areas other than to feet. R49's care plan dated 9/16/24, direct staff to monitor…

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 routine range of motion for 1 of 2 residents (R11) reviewed for range of motion (ROM). Further, the facility failed to implement a walking program for 1 of 1 resident (R62) reviewed for walking program. Findings include: R11 R11's annual Minimum Data Set (MDS) dated [DATE], indicated R11 was in a persistent vegetative state and/or had no discernible consciousness. R11 was dependent on staff for activities of daily living, such as oral and toileting hygiene, dressing, mobility, and transfers, and had impairment on both sides of upper and lower extremities. R11 had diagnoses of quadriplegia (severe or complete loss of motor function in all four limbs) and epilepsy (brain condition which causes recurring burst of uncontrolled electrical activity and changes in behavior, movements, feelings, and levels of consciousness). The MDS indicated R11 had a feeding tube and no range of motion (for at least 15 minutes a day) in the last seven…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the current pneumococcal vaccination was offered for 1 of 5 residents (R47) reviewed for immunizations. Findings include: Review of R47 record indicated R47 was admitted on [DATE], with diagnosis including metabolic encephalopathy(brain dysfunction caused by a chemical imbalance in the blood that affect the brain) , and dementia Review of R47 record indicated R47's family gave written consent on 3/4/24, for R47 to receive the pneumococcal vaccine per PCP (Primary care provider) order and CDC (Center for Disease Control) guideline. R47's medical record lacked evidence R47 was offered or received the current pneumococcal vaccination. Interview on 9/19/24 at 4:40 p.m., the Director of Nursing (DON) indicated if the consent was signed by the family, the physician would be notified, orders received, and the vaccination would be added to the medical record. The DON verified no orders were received from the physician. The DON indicated she would verify…

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 accurate documentation of medications and treatments when residents were hospitalized for 2 of 3 (R1, R3) residents reviewed for documentation. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact, and required a two person assist for transferring and toileting. R1's Face Sheet undated, indicated R1 had diagnoses of peripheral vascular disease, type II diabetes, personal history of venous thrombosis and embolism. R1's June medication administration record (MAR) had the following omissions: -Hydromorphone Hydrochloride (narcotic pain medication) tablet 4 milligrams (mg). Give 4 milligrams by mouth every 4 hours for pain, start date 6/19/25. On 6/23 at 8:00 p.m., the box was left blank. LPN-D was assigned to R1 for that shift. -Acticoat (silver dressing) dry to incision line Xeroform (occlusive dressing) and the rest, cover with gauze and tape to secure. One time a day for wound. Start date…

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 required information was documented and communicated to a receiving healthcare facility to ensure continuity of care when transferred to the hospital emergently for 1 of 3 residents (R1) reviewed for change in condition. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1's cognition was severely impaired, and diagnosis was dementia. R1 required supervision with bed mobility, transfers, walking, toileting and eating. In addition, R1 required limited assist of one staff member with personal hygiene and dressing, and no mobility device was used. MDS identified R1 did not have a pressure ulcer. R1's nurse practitioner (NP) acute care visit dated 11/10/23, indicated R1 had a sharp decline in condition to include a new pressure sore on sacral area. Nursing reported no oral intake in the past several days and a sharp decline in condition in the last 24 hours. R1 required total assist with activities of daily living…

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 an opportunity to participate in care planning for 4 of 4 residents (R21, R29, R73, R56) reviewed for care conferences. Findings include: R21 R21's quarterly Minimum Data Set (MDS) dated [DATE], indicated she was cognitively intact, independent with bed mobility, transfers, and toileting, and had diagnoses of heart failure, diabetes, lung disease, anxiety, and depression. The MDS indicated there was not an active discharge plan in place for her to return to the community. R21's care plan discharge focus updated 7/20/22, indicated she wished to discharge to the community to live with her mother, and instructed staff to discuss discharge goals and status with resident regularly and update on progress. R21's MHM IDT Care Conference Form V-3 dated 2/9/23, indicated she was working with a relocation worker for transitional service with a goal to discharge back to the community and live with her mother. R21's medical record lacked evidence of…

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

Based on interview and document review the facility failed to ensure resident council concerns were addressed or followed-up on in a timely manner. This had the potential to affect 12 residents who attended the resident council meetings in the previous six months. Findings include: Resident Council notes dated 1/27/23, indicated the following concerns: -The evening shift taking 45 minutes to an hour to answer call lights. -Building not clean. Resident Council notes dated 2/24/23, indicated the following concerns: -Residents waiting too long for medications. -Staff on personal phones while call lights are activated. -Gnats and bugs in the facility. Resident Council notes dated 3/31/23, indicated the following concerns: -Long wait times for meals. -Want educational-style activities that are learning based. -Call light times remain long. -Staff continue to talk on their personal phones. Resident Council notes dated 4/28/23, indicate the following concerns: -Call light wait times. -Ants in the second-floor dining room. -Dirty windows and floors. Resident Council notes dated 5/26/23,…

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 complete a comprehensive fall analysis to determine root cause, develop and implement resident-centric interventions, and monitor for post-fall complications following a fall for 1 of 1 residents (R73) reviewed for falls. In addition, the facility failed to ensure the environment was free from hazards to prevent falls and accidents for 4 of 4 residents (R39, R27, R31, R55) in the locked, memory care unit. Findings include: R73's quarterly MDS dated [DATE], indicated he was moderately cognitively impaired, required extensive assistance of two staff for bed mobility, transfers, and toilet use, was always continent of urine, frequently incontinent of bowel, and not on a toileting program. He had a diagnosis of lung disease. The MDS indicated he did not have any falls since admission or most recent assessment. R73's Medical Diagnosis list included diabetes, weakness, and bilateral below-the-knee leg amputations (BKA). R73's Falls Care Area…

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 resident representatives and/or a provider for 3 of 3 residents (R27, R39, R238) who had a change in condition and/or were involved in incidents resulting in potential or actual harm. Findings include: R27 R27's quarterly Minimum Data Set (MDS) dated [DATE], indicated R27 had severe cognitive deficits and was independent with eating. R27 had diagnoses that included high blood pressure, viral hepatitis C, dementia, behavioral and psychotic disturbance, anxiety, and paranoid schizophrenia. R27's Care Area Assessment (CAA) dated 8/11/22, indicated R27 triggered for cognitive loss/dementia, psychotropic drug use, pressure ulcers, and nutrition. R27's care plan dated 7/20/22, indicated R27 had severely impaired thought processes and needed assistance and supervision with all decision making. Interventions included communicating with R27's family/caregivers regarding R27's capabilities and needs. R27 also had a psychosocial well-being problem…

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 minimize verbal resident-to-resident abuse for 1 of 1 resident (R30) reviewed who was verbally abused by another resident (R58) . Findings include: R30's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R30 was mildly cognitively impaired and identified diagnoses including stroke, depression, post-traumatic stress disorder (PTSD), schizoaffective disorder (a mental health disorder characterized by a combination of symptoms including mood alterations), and anxiety. The MDS also identified R30 as Black or African American and R30 was dependent on staff for transfers, utilized a wheelchair but was unable to self-propel the chair. R30's care plan dated 4/21/23, identified R30 as a vulnerable adult and was at risk for abuse and/ or neglect. The plan directed staff to observed R30 for signs and symptoms of abuse and neglect and report to the facility social services or supervisor for appropriate follow up. R58's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to thoroughly investigate an allegation of resident-to-resident sexual abuse for 1 of 1 residents (R39). Findings include: A Nursing Home Incident Report (NHIR) dated 2/13/23, indicated R39 was seen holding hands with a male resident and entered his room. Upon entering the room, staff witnessed the male resident with his pants down, exposing himself to R39. An Investigation Report dated 2/13/23, indicated staff witnessed R39 and R55 holding hands as they walked down the hall and into R55's room. Upon entry to R55's room, staff saw R55 with his pants down, exposing his genitals to R39. The report indicated R39 was not interviewable. The report indicated R55 reported he was in his bathroom and when he came out, R39 was in his room, although staff witnessed them walk down the hall and into his room together. R55 was placed on a 1:1 for monitoring, although R55 had been on a 1:1 at the time of the occurrence related to previous inappropriate behaviors. 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 level I Pre-admission Screening and Resident Review (PASRR) level I was completed and accurate prior to admission to the facility for 1 of 1 residents (R27). Findings include: R27's quarterly Minimum Data Set (MDS) dated [DATE], indicated R27 had severe cognitive deficits with diagnoses that included borderline intellectual functioning, behavioral and psychotic disturbance, and paranoid schizophrenia. R27's hospital Discharge summary dated [DATE], indicated R27 had the following diagnoses: -6/13/07, paranoid schizophrenia -5/14/07, schizoaffective disorder R27's PASRR dated 7/14/22, indicated the PAS [PASRR] was not final until the lead agency sends the documentation to the nursing facility. In addition, the results indicated R27 did not have a current diagnosis of a mental illness and lacked indication R27 had a diagnosis with paranoid schizophrenia. During an interview on 7/13/23 at 3:30 p.m., the social services representative (SSR) stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to comprehensively assess, update, and implements a care plan for 1 of 1 resident (R55) who continued to have behaviors with no new interventions. Findings include: R55's quarterly Minimum Data Set (MDS) dated [DATE], indicated R55 had severe cognitive deficits and a Patient Health Questionnaire (PHQ-9) score of 19, indicating R55 had major depression that was moderately severe. The MDS also indicated R55 was independent with all activities of daily living (ADLs). R55 had diagnoses that included major depression, dementia without behavioral disturbance, cognitive communication deficit, and adjustment disorder with mixed anxiety. R55's Care Area Assessment (CAA) dated 2/24/23, indicated R55 triggered for delirium, cognitive loss/dementia, communication, and psychotropic drug use. R55's care plan dated 2/13/23, indicated the following behaviors: -12/1/2022: R55 was found with a female resident (R31) in his bed. R55 was already on a 1:1 and 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 provide timely assistance with incontinence cares for 1 of 3 residents (R25) who were dependent upon staff for incontinence cares. Findings include: R25's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R25 had significant cognitive impairment and diagnoses including encephalopathy (brain damage) and hemiparesis (weakness of one side of the body). The MDS indicated R25 required extensive assistance of two staff for bed mobility, transfers, toileting and was unable to ambulate. R25 was always incontinent of bowel and bladder. R25's care plan directed staff to assist R25 to the toilet after a meal for a bowel program as well as to check and change incontinent brief before and after meals and as needed to prevent skin breakdown. An undated, nursing care assignment sheet indicated R25 was to be assisted with toileting every 2-3 hours. The care plan further indicated R25 was on a bowel program that directed staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to comprehensively assess, develop, and implement meaningful and engaging activities for 2 of 2 residents (R27, R39) in the memory care unit. This had the potential to affect all 20 residents residing in the memory care unit. Findings include: R27's annual Minimum Data Set (MDS) dated [DATE], indicated R27 had severe cognitive deficits, was independent with eating, required extensive assistance with all other activities of daily living (ADLs) and was independent with walking. R27's Care Area Assessment (CAA) dated 6/11/23, indicated R27 triggered for cognitive loss/dementia, communication, behaviors, psychotropic drug use, and falls. R27's Customary Routine and Activities assessment dated [DATE], indicated it was very important to R27 to listen to music, be around animals, do her favorite activities, go outside, and to participate in religious activities. It was somewhat important for R27 to do activities in groups. The assessment further…

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, and implement interventions for ongoing and unplanned weight gain for 1 of 1 residents (R27) who had sudden and continued weight gain. Findings include: The Centers for Disease Control and Prevention (CDC) About Adult BMI article dated 6/3/22, indicated a body mass index (BMI) for adults (over the age of 20 years) of 25.0 to 29.9 was categorized as overweight, and a BMI of 30.0 and above was obese. The article also indicated people who were obese were at an increased risk for many disease and health conditions including but not limited to: death, high blood pressure, diabetes, heart disease, stroke, osteoarthritis (a degenerative joint disease), mental illnesses (depression, anxiety) and a low quality of life. R27's quarterly Minimum Data Set (MDS) dated [DATE], indicated R27 had severe cognitive deficits and was independent with eating. R27 had diagnoses that included viral hepatitis C, dementia, anxiety, high blood…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to adequately maintain bed rails to minimize the risk of entrapment for 1 of 1 resident (R73) reviewed who had bed rails attached to their bed. Findings include: R73's quarterly MDS dated [DATE], indicated he was moderately cognitively impaired and required extensive assistance of two staff for bed mobility, transfers, and toilet use. The MDS indicated he did not use bed rails. R73's safety device care plan focus dated 10/7/23, indicated he had bilateral amputation of both legs below the knee and used right and left grab bars (bed rails). It instructed staff to evaluate safety device use quarterly and as needed, including risk/benefits, alternatives, need for ongoing use, and reason for safety device. R73's MHM Bed Mobility Device Evaluation dated 5/12/23, indicated R73 requested bed rails and had ¼ rails in upright position used as grab bars to assist with transfers to maintain independence. A progress note dated 4/3/23, indicated R73 slid…

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 safe, functional environment for 1 of 1 resident (R73) reviewed whose bed did not lock and bed controller did not work. R73's quarterly MDS dated [DATE], indicated he was moderately cognitively impaired, required extensive assistance of two staff for bed mobility, transfers, and toilet use. The MDS indicated he did not have any falls since the most recent assessment. R73's Medical Diagnosis list included bilateral below-the-knee leg amputations (BKA), diabetes, weakness, and lung disease. R73's Falls Care Area assessment dated [DATE], indicated he was at risk for falls due to changes in mobility and medications. A progress note dated 3/3/23, indicated R73 had an unwitnessed fall after attempting to self-transfer. A progress note dated 4/3/23, indicated R73 had an unwitnessed fall and slipped out of bed onto the floor. A progress note dated 4/5/23, indicated R73's fall was reviewed by the interdisciplinary team, and 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 observation, interview, and document review, the facility failed to follow the Centers for Disease Control (CDC) guidelines to prevent and/or minimize the transmission of COVID-19 related to the proper utilization of personal protective equipment (PPE) including facemasks and eye protection. This had the potential to affect 22 residents who resided on the [NAME] neighborhood. Findings include: R8's admission Minimum Data Set (MDS) dated [DATE], indicated R8 had intact cognition and ate independently. R35's quarterly MDS dated [DATE], indicated R35 had intact cognition and ate independently. R91's significant change MDS dated [DATE], indicated R91 had severely impaired cognition and needed extensive assistance with locomotion. On 9/13/21, at 6:21 p.m. dietary aide (DA)-A was observed dishing meals in a satellite kitchen located in the [NAME] neighborhood dining room. A facemask was pulled below DA-A's nose. DA-A delivered soup to R8 who was seated in the dining room. DA-A was within two feet from R8 for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure privacy curtains, resident walls, and fall mats were clean and/or in good repair for 4 of 4 residents (R42, R33, R28, R10) reviewed for environment. Findings include: R42's quarterly Minimum Data Set (MDS) dated [DATE], indicated R42 had a severe cognitive impairment. R42's diagnoses included dementia with behavioral disturbance. On 9/13/21, at 1:36 p.m. R42's privacy curtain was observed to have three circular one inch sized dark brown spots of dried material. Additionally, 20 various sized light brown spots, which were dry, were noted on the privacy curtain. Four areas on the wall, above R42 bed, contained a dried light brown substance. Further, a fall matt which was placed next to R42's bed had a four inch tear which exposed the interior foam. R33's annual MDS dated [DATE], indicated R33 had a severe cognitive impairment. R33's diagnoses included dementia. On 9/13/21, at 3:07 p.m. R33's privacy curtain was observed to have…

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 medication assessment was completed for 1 of 1 resident (R10) who was observed with medications at her bedside. Findings include: R10's quarterly Minimum Data Set (MDS) dated [DATE], indicated R10 had intact cognition and diagnoses which included type II diabetes and visual disturbances. A Physician Order dated 3/26/20, indicated levothyroxine sodium (thyroid medication) tablet 88 micrograms (mcg), give 1 tablet by mouth one time daily During an observation on 9/13/21, at 3:23 p.m. R10 had a plastic medication cup which contained 10 pills. R10 stated the medications were, from the day before. R10 stated she did not take the medications because she was legally blind and was not sure what medications were in the cup. During an observation on 9/15/21, at 7:51 a.m. trained medication assistant (TMA)-B entered R10's room to administer medications and R10 pointed to a medication cup which contained a single…

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 pattern of increased blood glucose levels for 1 of 1 resident (R10) reviewed who received insulin. Findings include: According to the American Diabetes Association (ADA), the recommended blood glucose range (before meals) was 80 - 130 milligrams (mg) per deciliter (dL). R10's quarterly Minimum Data Set (MDS) dated [DATE], indicated R10 had intact cognition and diagnoses of type 2 diabetes mellitus and visual disturbances. R10's Order Summary Report dated 9/16/21, indicated R10 was ordered the following: - Blood glucose check three times daily before meals for diabetes mellitus dated 4/29/21. - R10 was okay to check her own blood glucose and administer Humalog and Lantus insulin under nursing supervision dated 1/10/21. - Humalog 100 units (u)/milliliter (mL). Inject 5 units subcutaneously (injection in fat tissue) with meals for diabetes mellitus unsupervised self-administration. Lantus 100 u/mL. Inject 10 units…

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 comprehensive person-centered care plan to reflect individualized goals for 1 of 4 residents (R38) reviewed for care planning. Findings include: R38's admission Minimum Data Set (MDS) dated [DATE], indicated R38 had a mild cognitive impairment and required one to two person physical assistance with most activities of daily living (ADLs). R38's MDS further indicated R38's diagnoses included dysphagia (difficulty swallowing), right sided hemiplegia/hemiparesis (paralysis/weakness affecting half of the body), and major depressive disorder. The MDS further indicated R38 received occupational and physical therapy. R38's care plan dated 7/21/21, indicated R38, has (SPECIFY) actual/potential for an ADL self-care performance deficit r/t [related to]. 38's goal was documented as, The resident will maintain current level of function in (SPECIFY) through the review date. Interventions included, Monitor/document/report PRN [as needed] any changes, any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure assistance was provided with removing facial hair and dressing and/or bathing was for 2 of 4 residents (R58, R3) reviewed who required staff assistance with activities of daily living (ADL). R58's quarterly Minimum Data Set (MDS) dated [DATE], identified R58 had diagnoses of chronic kidney failure, heart failure, and diabetes. R58 had intact cognition, used a walker for mobility, and required set up assistance with bathing. R58's Active Order Summary dated 9/16/21, indicated R58 received dialysis on Tuesday, Thursday, and Saturday. R58's dialysis dressing was to be removed the day after dialysis. R58's care plan dated 3/25/21, indicated R58 would continue to make daily preferences/choices which were important to him. R58's care plan lacked evidence of bathing preferences. R58's Nursing Assistant task sheet (undated) indicated R58 was scheduled for showers on Saturday evenings and required assistance with bathing. R58's Nursing…

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 removing facial hair for 2 of 2 residents reviewed who were dependent upon staff for hygiene assistance. Findings include: R32's quarterly Minimum Data Set (MDS) dated [DATE], indicated R32 had a moderate cognitive impairment and required extensive assistance with personal hygiene. R32's diagnoses included dementia with behavioral disturbance. R32's care plan revised 9/28/20, indicated, Grooming: limited assist of 1. On 9/13/21, at 1:30 p.m. R32 was observed to have 1/4 inch long hairs across her chin. R32 stated she did not want hair on her chin and needed staff's help to remove it. R32 stated she would like her chin hairs removed daily. R32 was unsure when staff last assisted her with shaving. On 9/14/21, at 1:52 p.m. R32's chin hair remained unchanged. R32 stated staff had not offered to assist her removing the hair. On 9/15/21, at 10:08 a.m. R32's chin hair remained unchanged. During an interview on 9/15/21, at…

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 daily weights were obtained for 2 of 2 residents (R85, R443) reviewed whom had daily weights ordered. Findings include: R85's Face Sheet dated 9/16/21, indicated R85's diagnoses included cerebral infarction (stroke), essential hypertension (high blood pressure), and chronic obstructive pulmonary disease (airflow blockage which causes breathing related issues). R85's admission Minimum Data Set, dated [DATE], indicated R85 was cognitively intact and required extensive assistance with transfers, toileting, and personal hygiene. R85's care plan dated 8/25/21, indicated R85 had congestive heart failure with interventions which included monitoring for edema (swelling) of the legs and feet, periorbital (area around eyes), shortness of breath upon exertion, and weight gain. A Physician Progress Note dated 8/26/21, indicated R85 was admitted to the facility related to bilateral pneumonia and newly diagnosed with congestive heart failure. R85 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure a urinary drainage bag and catheter tubing was kept off the floor to prevent cross contamination and potential infection for 1 of 1 residents (R42) reviewed for catheters. Findings include: R42's quarterly Minimum Data Set (MDS) dated [DATE], indicated R42 had a severe cognitive impairment, an indwelling catheter, and required extensive assistance with toilet use. R42's diagnoses included neuromuscular dysfunction of the bladder, dementia, and multiple sclerosis. R42's care plan dated 2/13/18 indicated, Alteration in urinary elimination r/t [related to] suprapubic catheter. On 9/14/21, at 1:57 p.m. R42 was observed lying in bed. R42's urinary drainage bag was placed on a fall mat next to R42's bed. The fall mat was visibly soiled with three quarter-sized brown spots and gray and brown smudges. At 2:25 p.m. registered nurse (RN)-A observed the urinary drainage bag lying on the fall matt, next to R42's bed, and stated there was 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.