Episcopal Church Home The Gardens

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure a system to reduce the risk of significant medication errors for transdermal opioid patches for 1 of 3 residents (R1) reviewed for medication administration. R1 was ordered by her hospice agency to have a transdermal opioid patch (narcotic medicated patch that slowly releases the medication into the body) placed on her skin every seven days. On two occasions the nursing staff failed to remove the old patch from her skin when the new patch was placed on her.Findings include: R1's hospice care plan dated 5/28/25 indicated buprenorphine (Butrans) 5 micrograms per hour (mcg/hr.) patch (an opioid patch used to treat opioid use disorder but also used for pain management) was to be applied once every week. Remove old patch prior to new patch application for chronic pain. R1's facility providers order dated 5/29/25 indicated Butrans transdermal patch 5 mcg/hr. Apply 1 patch transdermal one time a day every seven days for pain. The facility's order did…

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 establish a communication process between the facility and the hospice provider to ensure that the needs of a resident were addressed and met for 1 of 3 residents (R1) reviewed for hospice services. R1 did not receive the necessary care and services when she had the same medication error occur twice. In addition, the facility failed to have a designated member of the interdisciplinary team who was responsible to work with hospice to ensure residents receiving hospice services needs were met.Findings include: R1's hospice care plan dated 5/28/25 indicated buprenorphine (Butrans) 5 micrograms per hour (mcg/hr.) patch (an opioid patch used to treat opioid use disorder but also used for pain management) was to be applied once every week. Remove old patch prior to new patch application for chronic pain. R1's facility providers order dated 5/29/25 indicated Butrans transdermal patch 5 mcg/hr. Apply 1 patch transdermal (on the skin) one time 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 record review the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as a part of the regular maintenance program to identify areas of possible entrapment for 3 of 3 residents (R1, R2, and R3) reviewed. The bed manufacturer guidelines indicated to visually inspect the bed and accessories monthly and indicated to follow the FDA guidance.Findings include: Recommendations for Health Care Providers Using Adult Portable Bed rails dated 2/27/2023 retrieved on 8/14/25 from https://www.fda.gov/medical-devices/general-hospital-devices-and-supplies/hospital-beds indicated, when evaluating the safe use of a hospital bed, component or accessory, manufacturers and caregivers should recognize that the risk for entrapment may increase if a hospital bed system is used for purposes, or used in a care setting, not intended by the manufacturer. Evaluating the dimensional limits of gaps in hospital beds may be one component of a bed safety program which…

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 an allegation of abuse was reported immediately to the state agency and administrator of the facility, but not later than two hours after the allegation is made for 1 of 3 residents (R1) reviewed for abuse. R1 reported to multiple staff members the care she received was rough causing pain, staff yelled at her, and a staff member heard another staff member yelling at R1. Findings include: The facilities grievance log dated 1/1/25 - 5/16/25 did not indicate any grievances about R1. R1's re-admission Minimum Data Set (MDS) dated [DATE] indicated R1's Brief Inventory of Mental Status (BIMS) score indicated a 99 meaning unable to complete. R1 was dependent upon staff for toileting hygiene, bathing, lower body dressing, and moving from a lying to a sitting position on the side of her bed. R1's pertinent diagnoses were hypovolemia (deficiency of volume of blood in the body), cirrhosis of the liver (scar tissue in the liver), unspecified dementia,…

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 revise the care plan for 1 of 3 residents (R2) who were reviewed for falls. Findings include: R2's face sheet dated 3/27/25, identified diagnosis of Parkinson's disease, dementia, and kidney disease. R2's quarterly Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment, maximum assistance for bed mobility, dependent for transfers, and two or more falls since admission without injury. R2's fall focus care plan dated 11/13/24, identified at risk for falls. Goal of will not sustain serious injury. Interventions added as followed: -11/13/24 to place call light within reach and encourage to use it -12/11/24 ensure R2's phone is close to her bed where can be easily reached. -12/23/24 R2 sometimes wakes up confused and agitated, she will scream and attempt to get out of bed on her own, staff to provided reassurance and redirection until calmed. -12/26/24 R2 sometimes wakes up confused and attempts to climb out of bed,…

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 a skin tear (a traumatic wound that occurs when the top layer of skin separates from the underlying layers) for 1 of 1 resident (R3) reviewed for injury of unknown origin. Findings include: R3's face sheet dated 3/26/25, identified diagnoses of heart failure (condition in which heart doesn't pump blood as well as it should), chronic obstructive pulmonary disease (a common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), and peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs). R3's care plan dated 1/22/25, identified R3 had actual impairment to skin integrity related to a healing skin tear on right upper arm. No other areas of skin impairment were identified. R3's admission nursing assessment dated [DATE], identified skin tear on right forearm measuring 3.2…

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 have a process in place to monitor refrigerator, dishwasher and breakfast food temperatures in all six unit kitchens in the care facility. In addition the facility failed to ensure opened food and beverage containers were dated to prevent unsafe consumption by residents. This had the ability to affect all 55 residents residing in the care facility. Findings include: During interview and observation on 9/9/24 at 11:45 a.m., the registered dietician (RD) stated there was one central kitchen where lunch and dinner were cooked, and each resident floor (two through seven) had their own full kitchen. Breakfast was cooked to order for each resident on the floors and lunch and dinner were kept warm in a steamer on the floors. Each floor had an industrial refrigerator, one unit residential type refrigerator and a high temperature dishwasher. During observation the second-floor kitchen lacked any temperature logs for the industrial and unit refrigerators and the dishwasher. The industrial refrigerator was showing two…

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 the facility failed to ensure proper use of gloves while providing personal cares for 1 of 1 resident (R35) observed for personal cares. In addition, the facility failed to sanitize a standing lift sling shared by residents for 2 of 2 residents (R35 and R9) observed for infection control practices. Findings include: Hand Hygiene R35's quarterly Minimum Assessment Data (MDS) dated [DATE], indicated R35 had moderate cognitive impairment, needed setup to eat, supervision with oral hygiene, and was dependent with bathing, toileting, dressing, bed mobility and transfers. R35's clinical diagnoses record printed 9/12/24, indicated diagnoses of epileptic syndrome (a unique combination of symptoms or by the location in the brain where the seizures originate), malignant neoplasm of the frontal lobe (brain cancer), essential hypertension(abnormally high blood pressure that's not the result of a medical condition), pain, unspecified dementia, type…

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 unqualified staff did not administer as needed (PRN) medication used for skin rash for 1 of 1 resident (R1) reviewed for qualified staffing. Findings include, R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact, and had diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels), peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) , hypertension (high blood pressure), and diabetes. R1's Clinical Diagnoses record printed 9/12/24, indicated diagnoses of local infection of the skin and subcutaneous tissue (under the skin), and irritant contact dermatitis (a skin rash caused by contact with a certain substance) due to fecal and urinary incontinence. R1's Clinical Orders record printed 9/12/24, included an order for Nystatin powder (used to treat fungal or yeast infections) 100,000 unit/gm (gram) topical…

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 assistance with personal hygiene for 2 of 2 residents (R6, R44 ) reviewed for activities of daily living (ADLs) for dependent residents. Findings include: R6 R6's annual Minimum Data Set (MDS) dated [DATE], identified severe impairment of cognition, diagnoses of Alzheimer's and heart failure, and R6 required extensive assistance with ADL's. In addition, R6 did not display rejection of cares. R6's Care Area Assessment (CAA) identified triggers for delirium, cognitive loss/dementia, functional abilities, psychosocial well-being, mood state, and psychotropic drug use (medications used to treat mental health disorders). R6's care plan (CP) dated 8/2/22, and revised 8/21/23 identified, PERSONAL HYGIENE/ORAL CARE: I require limited to extensive assist of 1 staff for personal hygiene and oral care. R6's nursing assistant (NAR) task form in the electronic medical record (EMR) for dates of 8/12/24 to 9/9/24 identified, PERSONAL HYGIENE:…

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 assess and implement interventions to assist a resident, who was unable to maintain positioning for 1 of 1 resident (R40) reviewed for positioning. Findings include: R40's quarterly Minimum Data Set (MDS) indicated R40 was admitted to the care facility on 4/4/22, had severe cognitive impairment, and was dependent on staff for activities of daily living (ADLs). The MDS further indicated R40 had 2 or more falls with injury since the last assessment. R40's Diagnoses list, printed 9/12/24, indicated R40 had several medical diagnoses including Parkinson's Disease, vascular dementia, and legal blindness. R40's care plan, printed on 9/12/24 lacked interventions to address R40's positioning. During observation on 9/9/24 at 1:21 p.m., R40 was in the common area in a black, high back wheelchair. R40 was leaning over at her waist to the right with her right arm hanging over the side of the wheelchair arm. An unnamed nurse approached R40 to ask if she needed toileting, R40 stated no. The unnamed nurse did not attempt to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to implement, and care plan, new and appropriate fall interventions to prevent falls for 2 of 2 residents (R40 and R51) reviewed for falls. Findings include: R40 R40's quarterly Minimum Data Set (MDS), dated [DATE], indicated R40 was admitted to the care facility on 4/4/22, had severe cognitive impairment, and was dependent on staff for activities of daily living (ADLs). The MDS further indicated R40 had 2 or more falls with injury since the last assessment. R40's Diagnoses list, printed 9/12/24, indicated R40 had several medical diagnoses including Parkinson's Disease, vascular dementia and legal blindness. R40's past two fall assessments, dated 4/27/24 and 7/27/24, indicated R40 has at risk for falls. R40's care plan, dated 4/5/22 and revised on 8/2/24, indicated R40 had behaviors where I try to stand up, wander and occasionally grab at staff during cares. However, the care plan problem lacked any new interventions since 4/5/22. R40's care…

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 monitor orthostatic blood pressures during the use of an antipsychotic medication (used to manage delusions, hallucinations, paranoia, or disordered thought) for 1 of 5 residents (R51) reviewed for antipsychotic medications. Findings include: R51: R51's annual Minimum Data Set (MDS) dated [DATE], identified admission to facility on 7/26/23, intact cognition, independence with ambulation, standing and transfers and was taking antipsychotics (medications prescribed for mood disorders). R51's Care Area Assessment (CAA) dated 7/22/24, identified care plan triggers for delirium, cognitive loss/dementia, communication, functioning abilities, psychosocial well-being, mood state, behavioral symptoms, falls, and psychotropic drug use. R51's Medical Diagnoses downloaded from electronic medical record (EMR) on 9/10/24, identified R51 with dementia (group of symptoms affecting memory, thinking and social abilities), bipolar (mental health condition…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure mediations were safely and securely stored for 1 of 1 resident (R38) reviewed for medication storage. Findings include: R38's quarterly Minimum Data Set (MDS) dated [DATE], indicated R38 had moderate cognitive impairment, was dependent with dressing, toileting, bathing, transfers, but ate independently. The MDS indicated the following diagnoses, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), diabetes (a group of diseases that result in too much sugar in the blood), anxiety, depression, and hyperlipidemia (a condition in which there are high levels of fat particles in the blood). R38's care plan printed 9/12/24, indicated R38 was unable to ambulate, transferred with assist of staff and a standing lift, and used a manual wheelchair with brake extenders. The care plan also indicated R38 had poor safety awareness, and impaired cognitive function related to mild cognitive…

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 care plan for one of one resident (R3) reviewed for care plans when interventions were not put into the care plan following a care conference that led to a fall. Findings include: R3 was admitted to the facility on [DATE] with a primary diagnosis of dementia. Additional diagnoses included osteoarthritis, abnormalities of gait and mobility, pain, muscle weakness, morbid obesity, difficulty walking, reduced mobility, Alzheimer's Disease, fecal urgency, urinary incontinence, and incontinence of feces. R3's care plan dated [DATE] indicated R3 was at high risk for falls related to cognitive impairment, difficulty remembering to use walker, and incontinence. Interventions placed included making sure the call light is within reach, encourage the use of her call light for assistance, and evaluate and treat pain as needed. R3's Fall Risk Evaluation dated [DATE] indicated R3 had a history of falls. The evaluation indicated R3's predisposing fall risks…

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 appropriate personal protective equipment (PPE) was utilized to prevent the spread of infection when rinsing contaminated laundry. Furthermore, the facility failed to transport clean laundry in a manner which ensured protection from dust and soil. This had the potential to impact all 60 residents who reside in the facility. Findings include: R51's annual Minimum Data Set (MDS) dated [DATE], indicated R51 was cognitively intact and had diagnoses of heart disease and diabetes. R10's quarterly MDS dated [DATE], indicated R10 had cognitive impairment and diagnosis of dementia. An observation on 7/31/23 at 9:03 a.m., a white laundry basket was on the floor outside of R51's room. The laundry basket contained two small piles of clean folded clothes and the clothes were not covered. R51 stated that's a job for me to do later and indicated his clean clothes needed to be put away. An observation on 8/1/23 at 9:03 a.m., a white laundry…

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 (SAM) was completed to allow residents to safely administer their own medications for 1 of 1 resident (R14) observed with medications at bedside. Findings inclued: R14's annual Minimum Data Set (MDS) dated [DATE], indicated R14 had intact cognition and diagnoses of mild intermittent asthma, heart disease , and chronic kidney disease. It further indicated R6 required extensive assistance with all activities of daily living (ADL) except walking in room/corridor in which she required limited assistance. R14's medical record lacked a doctor's order to be able to self administer her medication. R14's Self Administration of Medications assessment dated [DATE], indicated R14 had no desire to self administer medications. During observation and interview on [DATE] at 12:09 p.m., R14 was sitting in her recliner with her bedside table next to her. On the bedside table she had 2 albuterol…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to maintain sanitary equipment for 1 of 1 residents (R45) reviewed for environmental cleanliness. Findings include: R45's quarterly Minimum Data Set (MDS) dated [DATE], indicated R45 had severe cognitive impairment and diagnosis of stroke. R45's MDS further indicated R45 had a mechanically altered diet and required tube feedings. An observation on 7/31/23 at 7:09 a.m., R45 was in bed. Next to R45's bed was a pole with a pump that was used to administer R45's tube feeding. On the bottom feet of the pole were small and large drops of a tan/brown dry substance. In between the feet of the pole the same substance was on the carpet. An observation on 8/1/23 at 4:11 p.m., R45 was sitting in her wheelchair. R45's tube feeding pole was up towards the head of the bed. The same tan/brown dry substance was on the feet of the pole. When interviewed on 8/2/23 at 7:49 a.m., housekeeper (HSK)-A was not sure if equipment was cleaned by the housekeeping…

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 report a fall with major injury for 2 of 5 residents (R6, R27) reviewed for accidents. Findings include: R6's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of congestive heart failure (CHF), unspecified fall, abnormalities of gait and mobility, low back pain, and history of falling. It further indicated R6 was independent with all activities of daily living (ADL), occasionally incontinent of bladder, frequently incontinent of bowel, had a previous fall history prior to admission, and had received an antidepressant 7/7 and a diurectic 6/7 days in the look back period. R6's Care Plan dated 4/28/23, included R6 was at high risk for falls related to a history of impaired mobility, diabetes, dementia, CHF, a history of falls, and a recent fall on 5/16/23. It further included interventions to anticipate and meet the resident's needs, ensure his call light was within reach and encourage him to use it for assistance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to maintain a walking program for 1 of 1 residents (R25) reviewed for restorative rehabilitation. Findings include: R25's annual Minimum Data Set (MDS) dated [DATE], indicated R25 was cognitively intact and had diagnoses of stroke and dementia. R25's MDS further indicated R25 required assist of one for walking. R25's assistance of daily living (ADL) care area assessment (CAA) dated 7/12/23, indicated R25 was unsteady with transitions, required staff assistance to stabilize, and required limited assistance with transfers and ambulation. R25's care plan revised 5/20/22, indicated R25 had limited physical mobility related to a fall with fractures, weakness and history of stroke. R25's care plan further indicated R25 required assistance of 1 person, gait belt, and walker for mobility. R25's nursing assistant care sheet revised 8/2/23, indicated R25 had a restorative nursing program and required ambulation with assist of one staff, gait belt…

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 monitor, assess, and ensure provider wound care orders were followed for 1 of 1 resident (R51) who had facility acquired pressure ulcers. Findings include: R51's annual Minimum Data Set (MDS) dated [DATE], indicated R51 was cognitively intact and had diagnoses of peripheral vascular disease (PVD, poor blood flow to extremities), diabetes, and stage 2 pressure ulcers (a shallow wound with skin loss and pink or red base). R51's pressure injury care area assessment (CAA) dated 5/3/23, indicated R51 was at risk for worsening pressure ulcers related to limited to extensive assist with mobility, limited range of motion to left lower extremity, stage 2 pressure injury and history of diabetes, PVDs and right below the knee amputation. R51's care plan revised 6/23/23, indicated R51 had history of pressure injuries related to decreased mobility and impaired circulation. R51's care plan instructed staff to assess, measure, and record wounds…

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 antibiotic medication was properly labeled and secured for 1 of 1 residents (R38) reviewed for antibiotic use. Findings include: R38's significant change Minimum Data Set (MDS) dated [DATE], indicated R38 was cognitively intact and had diagnoses of multiple sclerosis (disease that disrupts the nerve signals between brain and body), enlarged prostrate and urine retention. R38's provider order dated 5/17/23, indicated R38 required gentamicin (antibiotic) 200 milligrams/liter bladder irrigation on Monday, Wednesday, and Friday for prophylactic urinary tract infection. When observed on 8/2/23 at 3:21 p.m., licensed practical nurse (LPN)- B entered R38's room to administer R38's antibiotic medication. LPN-B entered R38's room and asked R38 if he was ready for the medication and R38 replied yes. LPN-B then retrieved a graduate cylinder with a 60 milliliter (ml) syringe containing clear liquid inside of it that was placed on top 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.