Southview Acres Healthcare Center

Based on interviews and document review the facility failed to thoroughly investigate an allegation of abuse for 1 of 3 residents (R1) reviewed for abuse. In addition, the facility failed to protect 1 of 3 residents (R1) while the investigation was conducted. Findings include: On 6/17/25 at 5:47 p.m., a Brief Interview for Mental Status (BIMS) was conducted. Summary score was 12 and indicated moderate impaired cognition. R1's care plan dated 6/24/25, identified at risk for falls related to restless leg syndrome (RLS), CVA, altered mental status, and lace of safety awareness. Noted to have uncontrolled movement of legs that pulled him out of bed. Staff were instructed to assist him with ambulation, transfers, utilizing therapy recommendations and encourage him to spend time in central location for increased supervision. He made statements and accusations which were unsubstantiated, unfounded and untrue. Family and friend reported this was not new behavior. Staff were directed to provide refused care at an alternative time per his preference, listen to his accusations/complaints and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure proper enhanced barrier precautions (EBP), glove use, and hand hygiene was performed during incontinence care for 1 of 3 (R1) residents reviewed for incontinence care. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 needed extensive assistance with personal hygiene and had a suprapubic catheter (tube inserted into the bladder through an incision in the lower abdomen). R1's EBP signage undated, indicated staff needed to wear gloves and gown when providing high-contact resident care activities such as changing linens, providing hygiene, or changing brief. During an observation on 3/26/25 at 10:43 a.m., nursing assistant (NA)-A and NA-B were observed sanitizing hands and placing on gloves prior to going into R1's room. R1 had a sign indicating he was on EBPs and a bin of personal protective equipment (PPE) was outside the entrance of his door. NA-A and NA-B entered R1's room to assist him with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to assess and, if able, implement interventions to ensure privacy was maintained during provision of wound care for 1 of 1 resident (R108) reviewed who expressed being claustrophobic and not wanting their doorway closed to public view. In addition, the facility failed to ensure resident' identifiable personal care information was kept secured and out of public view when stored on 1 of 1 mobile medication carts. This had potential to affect 1 of 1 residents and 14 residents (R53, R21, R74, F85, R82, R65, R7, R38, R103, R147, R154, R116, R102 and R128) of the second floor whose information was listed on an exposed care sheet. Findings include: PRIVACY WITH CARE: R108's quarterly Minimum Data Set (MDS), dated [DATE], identified a section to record R108's cognitive screening (i.e., BIMS). However, this was dashed as, Not Assessed [See F638]. On 1/6/25 at 2:04 p.m., R108's room was observed from the public hallway with her room door being left…

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 comprehensive care-planning process (i.e., meeting) was implemented to ensure continuity of care and promote participation in care-planning for 1 of 2 residents (R222) reviewed for participation in care-planning. Findings include: R222's admission Minimum Data Set (MDS), dated [DATE], identified R222 admitted to the care center on 11/22/24 and had intact cognition. The MDS outlined R222 had symptoms of depression along with several medical conditions including heart failure, diabetes mellitus, and arthritis. The MDS outlined R222's goal was a return to the community and an active discharge plan was in place. The MDS identified what, if any, Care Area Assessments (CAA) had been triggered due to R222's MDS responses for further evaluation. These CAA(s) included activities of daily living (ADL) function, urinary incontinence, falls, and nutritional status. Further, the MDS' care plan decisions were signed as completed on 12/3/24; and the final…

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 quarterly Minimum Data Set (MDS) was completed in a timely and/or comprehensive manner to facilitate accurate evaluation of resident' conditions for 2 of 3 residents (R50, R108) reviewed for MDS accuracy. Findings include: R50 The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2023, identified the RAI process (i.e., MDS) was completed to help evaluate resident' strengths and areas for care-planning. The manual listed all types of assessments to be completed along with corresponding timeframe's for them via a graph labeled, RAI OBRA-required Assessment Summary. This directed a quarterly MDS should be completed (i.e., signed) within, ARD + 14 calendar days. R50's significant change MDS, dated [DATE], identified R50 had severe cognitive impairment, demonstrated hallucinations, and was on hospice. R50's electronic medical record listed a section labeled, MDS, 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, observation and document review, the facility failed to ensure comprehensive care plans were developed and maintained to facilitate person-centered care for 2 of 2 (R142, R139) residents reviewed for care planning. R142 R142's quarterly Minimum Data Set (MDS) dated [DATE], indicated R142 was cognitively intact, had no behaviors, did not refuse cares, needed set-up for oral hygiene and eating, and required maximal assistance with mobility and all activities of daily living (ADL). The MDS also indicated R142 had no pressure ulcers. R142's Clinical Diagnosis report printed on 1/8/24, indicated R142 had diagnoses of encounter for orthopedic aftercare following surgical amputation, type II diabetes (a condition in which the pancreas doesn't make enough insulin causing the body to have trouble controlling blood sugar and using it for energy), local infection of the skin and subcutaneous tissue, atherosclerotic heart disease (damage or disease in the heart's major blood vessels), essential…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure routine personal hygiene cares (i.e., nail care) was completed to reduce the risk of complication (i.e., scratches, infection) for 1 of 3 residents (R47) reviewed for activities of daily living (ADL) and whom was dependent on staff for their nail care. Findings include: R47's admission Minimum Data Set (MDS), dated [DATE], identified R47 had severe cognitive impairment and demonstrated no rejection of care behaviors during the review period. Further, the MDS outlined R47 was dependent on staff for bathing, and required supervision or touching assistance with personal hygiene (i.e., shaving, combing hair). R47's most recent Weekly Bath Audit 020919 - V9, dated 1/2/25, identified R47 received a bed bath. The audit listed, Was nail care rendered? which was answered, 1. Yes. The audit also listed, Are nail beds clear of debris? which was answered, 1. Yes. Further, the audit outlined, Patient has scratches on his left side of his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and document review, the facility failed to comprehensively reassess and, if needed or able, develop interventions to ensure activities-of-interest were advertised, offered and/or provided for 1 of 2 residents (R222) reviewed for activities and whom resided on the short-term unit (i.e., TCU). Findings include: R222's admission Minimum Data Set (MDS), dated [DATE], identified R222 had intact cognition and demonstrated no delusional thinking. The MDS outlined several questions with a response of importance to R222, including having reading materials, keeping up with the news, and doing her favorite activities. These were all coded with a response of, Somewhat important, or, Very important. R222's Therapeutic Recreation/Activity Evaluation, dated 11/27/24, identified R222's background information along with a section labeled, Recreation Interest/Needs, which contained checkmarks placed next to applicable items. These outlined R222 liked activities in groups, independently, in her room or day…

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, care plan, and implement interventions to prevent recurrent pressure ulcers for 2 of 2 resident (R39 and R142) who had a history of pressure ulcers. Findings include: R142 The Centers for Medicare (CMS) State Operations Manual (SOM) Appendix PP, dated 8/8/2024, identified definitions for pressure ulcer care and treatment. This included, Avoidable, being outlined as, . the resident developed a pressure ulcer/injury, and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors, define and implement interventions that are consistent with resident needs . monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. In addition, the guidance provided several stages of injury definition which included, Stage II Pressure Ulcer: Partial-thickness skin loss with exposed dermis . presenting as a shallow open ulcer. Adipose…

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 bladder and bowel incontinence was comprehensively assessed and interventions developed to promote continence for 2 of 2 resident (R142, R139) reviewed for incontinence cares. Findings include: R142 R142's quarterly Minimum Data Set (MDS) dated [DATE], indicated R142 was cognitively intact, had no behaviors, did not refuse cares, needed set-up for oral hygiene and eating, and required maximal assistance with mobility and all activities of daily living (ADL). The MDS outlined R142 was always incontinent of bowel. A trial of toileting program (e.g., scheduled toileting) had not been attempted since admission to this facility. Furthermore, the toileting program and bowel pattern section of the MDS was left blank. R142's Clinical Diagnosis report printed on 1/8/24 indicated, resident had diagnoses of encounter for orthopedic aftercare following surgical amputation, type II diabetes (a condition in which the pancreas doesn't make…

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 antibiotic without an end date was monitored and evaluated for the appropriateness of its continued use for 1 of 1 residents (R107) reviewed for antibiotic administration. Findings include: R107's quarterly Minimum Data Set (MDS) dated [DATE], indicated R107 had intact cognition, no wound infection, and had a hip fracture. The MDS indicated R107 was taking an antibiotic. R107's order summary dated 12/6/24, indicated R107 was taking 500 milligrams (mg) of cephalexin (an antibiotic) four times a day for infections starting on 12/6/24 with no end date. R107's hospital note dated 12/6/24, indicated R107 was admitted to the hospital on [DATE], had a planned hip surgery, and was discharged back to the facility on [DATE]. The note indicated R107 was to follow up with the orthopedic trauma clinic in two weeks but could call the office before that time with any additional questions or concerns. R107's hospital discharge orders dated 12/6/24,…

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 order for laboratory services was followed through and completed for 1 of 1 resident (R145) reviewed for laboratory services who had Clostridium difficile (C. diff; bacteria which can cause diarrhea, abdominal pain and cramping, fever, nausea, and dehydration.) Findings include: R145's significant change Minimum Data Set (MDS), dated [DATE], indicated R145 was admitted to the facility on [DATE], was cognitively intact and required substantial/maximum assistance with toileting and partial to moderate assistance with personal hygiene. R145's Orders contained two orders to test for C-diff, one dated 12/16/24 and another dated 12/31/24. On 12/17/24, it was documented in R145's progress notes, Collected stool specimen, called lab for pick up today. On 12/30/24, it was documented in R145's progress notes that R145 continued to report having 4-9 stools daily. On 12/30/24, it was documented in R145's progress notes that the lab informed that…

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 the ordered drink consistency for 1 of 1 residents (R82) reviewed for dining. Findings include: R82's admission Minimum Data Set (MDS) dated [DATE], indicated R82 had intact cognition with diagnoses of heart failure, kidney disease, and malnutrition. The MDS indicated R82 required setup help with eating. R82's progress note dated 12/31/24 at 1:07 p.m., indicated R82 had declined in status upon hospital return and the speech therapist recommended a diet change to a pureed texted and nectar thick liquids. R82's care plan dated 1/3/25, indicated R82 had a diagnosis of dysphagia and a 12/24 diagnosis of Respiratory Syncytial Virus (RSV) and pneumonia. R82's order summary report dated 1/6/25, indicated R82 was on a mechanical soft (soft easy to chew and swallow foods) textured diet with all liquids thickened to a nectar consistency. R82's Speech Therapy Treatment Encounter Note dated 1/7/25, indicated R82 was being seen by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to follow infection control standards of practice for the cleaning of hard surfaces in the resident room for 1 of 1 residents (R39) on enhanced barrier precautions (EBP) reviewed for infection control practices. Findings include: According to the Centers for Disease Control (CDC) March 19, 2024, article titled Healthcare-Associated Infections (HAIs), the cleaning of patient care areas includes, Potential for exposure to pathogens: High touch surfaces (e.g., bed rails) require more frequent and rigorous environmental cleaning than low-touch surfaces (e.g., walls). The CDC article titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) dated 4/2/24, indicated MDRO transmission in skilled nursing facilities was common and contributed to substantial resident morbidity. EBP is an infection control intervention to reduce transmission of MDROs by using gowns and gloves during high…

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 a resident was treated in a dignified manner when he received a haircut from a nursing assistant (NA)-B without permission for 1 of 3 residents reviewed for dignity. Findings include: R3's significant change Minimum Data Set (MDS) dated [DATE], indicated R3 was severely cognitively impaired. R3's Diagnoses List printed 1/30/24, included chronic obstructive pulmonary disease (COPD) and Parkinson's Disease. On 1/29/24 at 3:56 p.m., licensed practical nurse (LPN)-A stated an NA cut R3's hair. LPN-A stated NAs often cut residents' hair when family permission was obtained. LPN-A stated R3's family was upset about the haircut, because both family member (FM)-A and R3 thought it was too short. On 1/30/24 at 8:18 a.m., FM-B stated when FM-A visited R3 last week, R3 had a haircut that was a buzz cut and was much shorter than R3 preferred to wear, or had ever worn. FM-B stated when she saw a photo of the haircut, she felt sad for R2 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 interview and document review, the facility failed to provide the opportunity to participate in the care planning process, be included in the decisions about care, treatment and/or interventions in the required quarterly time frame for 1 of 3 resident (R3) reviewed for care planning. Findings include: R3's significant change Minimum Data Set (MDS) dated [DATE] indicated R3 was severely cognitively impaired, and indicated R3 was admitted to the facility on [DATE]. R3's diagnoses printed 1/30/24, included chronic obstructive pulmonary disease (COPD) and Parkinson's Disease. R3 was admitted in October, 2022. R3 did not have an initial care conference. R3's first care conference was held seven months after admission on [DATE], and family did attend. R3's only other care conference was 12/13/23. R3's progress notes lacked mention of additional care conferences. On 1/30/24 at 8:18 a.m., family member (FM)-B stated she did not know how to get care information about R3. FM-stated there was one care conference…

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 non-English speaking resident was provided with appropriate interpretive services for 1 of 3 residents (R1). In addition, the facility failed to reevaluate the effectiveness of the services offered, allowing them to be fully informed about their health status in an emergent situation. Findings include: R1's Face Sheet identified R1 had diagnoses that included anoxic brain damage, nuclear cataract, unspecified hearing loss in the left ear, repeated falls, and syncope and collapse. R1's admission assessment dated [DATE], identified R1 was a Cantonese speaker and required the use of an interpreter. R1 had moderate difficulty with ability to hear and no hearing aids or appliances are normally used. admission summery identifies R1's family member (FM)-A was available and helped with admission assessment and was available anytime to help with interpreting task. FM-A informed facility staff resident was hard of hearing and IPad interpretation might…

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 complete a thorough investigation regarding a fall for 1 of 1 residents (R1) reviewed for falls. Findings include: Vulnerable adult maltreatment report submitted to the State Agency dated 1/8/24, identified R1 was discharged from hospital on [DATE] and admitted to transitional care unit (TCU). R1 was readmitted to hospital on [DATE] . R1 was diagnosed with subdural hematoma, subarachnoid hemorrhage, parietal skull fracture, deep tissue injury to left heal, pressure injury to the coccyx. None of these conditions were present at the time of discharge on [DATE]. R1's face sheet identified R1 had diagnoses that included Anoxic brain damage, nuclear cataract, unspecified hearing loss in the left ear, repeated falls, and syncope and collapse. R1's care plan dated 12/28/23, identified R1 spoke Cantonese and required and interpreter. Interventions included R1 unable to use interpreter iPad due to hearing. Son was able to interpret for resident. R1's abuse…

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 comprehensive care plans including a toileting plan of care, a pressure sore plan of care, and a skin integrity plan of care for 3 of 3 residents (R1, R4, R5) reviewed for comprehensive care planning. Findings include R1's face sheet identified R1 had diagnoses that included Anoxic brain damage, nuclear cataract, unspecified hearing loss in the left ear, repeated falls, and syncope and collapse. R1's minimum data set (MDS) dated [DATE], identified R1 as preferred language of Chinese, R1 wanted or needed an interpreter to communicate with a doctor or health care staff. Brief interview for mental status (BIMS) was not completed. R1 required substantial to maximum assist for toileting. R1 had not had a trial of a toileting program and R1 was frequently incontinent of bladder and always incontinent of bowel. A toileting program was not being used to manage the residents continence R1's bowel and bladder program screener dated 12/19/23, R1 never…

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 impaired skin integrity and initiate and evaluate appropriate interventions for 1 of 1 residents (R5) reviewed for non-pressure related skin injuries. Findings include: R5's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R5 was admitted to the facility on [DATE] with medical diagnoses including articular cartilage disorder of right hip (damage to the cartilage cushioning the hip joint), tendency to fall, weakness, intellectual disabilities, atherosclerosis (buildup of fatty plaques in arteries) polyosteoarthritis, anemia, heart failure, type 2 diabetes with hyperglycemia (elevated blood sugar levels), chronic obstructive pulmonary disease, and malnutrition. R5's Brief Interview for Mental Status (BIMS) score was 8, indicating moderate cognitive impairment. R5 utilized a walker and ambulated independently, was independent with mobility in bed and transfers from bed to chair, required moderate assistance with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to perform comprehensive skin assessments and provide interventions for pressure ulcer prevention and treatment for 2 of 3 residents (R4, R1) reviewed for pressure ulcers. Findings include R4's face sheet noted medical diagnoses that included severe protein-calorie malnutrition, adult failure to thrive, hypotension (low blood pressure), anemia (low amount of healthy red blood cells), and Wernicke's encephalopathy (a degenerative brain disorder related to lack of vitamin B). R4's face sheet identified R4 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) was not completed as R4 was still in the initial assessment period. R4's Braden Scale for Predicting Pressure Sore Risk dated 12/31/23, was a score of 12 indicating R4 was at high risk for developing pressure sores. A provider order placed 12/31/23 indicated staff were to monitor R4's sacral dressing every shift and consult the as needed order to replace the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure a community-use available glucometer was properly cleaned and disinfected between patient' use for 1 of 1 resident (R107) observed to have their blood glucose checked with the device. This had potential to affect 12 of 12 residents identified to reside on the 200 East Unit and have diabetes mellitus. In addition, the facility failed to ensure medical supplies with potential for blood-borne cross contamination were appropriately stored away from patient living areas for 1 of 1 resident (R44); and failed to ensure posted transmission-based precautions were consistently implemented to reduce to risk of infectious spread for 1 of 1 resident (R18) identified to be on such precautions. This had potential to affect 25 of 25 residents identified to reside on the same unit. Findings include: An email correspondance from the director of nursing (DON) dated 11/20/23 at 1:11 p.m., indicated 12 residents on the 200 East Unit were diagnosed…

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' responsible parties were notified in a timely manner with abnormal lab values and corresponding medical treatment being implemented for 1 of 2 residents (R173); and with the development of a skin ulcer which required medical care and treatment for 1 of 2 residents (R49) reviewed for notification of change. Findings include: A Vulnerable Adult Maltreatment Report, dated 2/14/23, identified a report had been submitted for R173 which alleged multiple care-related concerns. These included an allegation R173 had a change in condition, with abnormal laboratory values (i.e., elevated potassium, failing kidneys) and new medications (i.e., Lasix; a diuretic) being started to address. However, the allegation outlined R173's family or responsible party was not notified of these until later when R173 had to be hospitalized for continued treatment. R173's significant change in status Minimum Data Set (MDS), dated [DATE], identified…

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 significant change in status assessment (SCSA) was completed within required timeframe to help facilitate timely person-centered careplanning for 1 of 2 residents (R144) reviewed for Minimum Data Set (MDS) accuracy. Findings include: The Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) 3.0 User's Manual, dated October 2023, indicated a significant change in status assessment (SCSA) was required when various criteria were met. The manual directed the MDS completion date must be no later than 14 days from the assessment reference date (ARD) (ARD + 14 calendar days) and no later than 14 days after the determination the criteria for an SCSA were met. R144's SCSA MDS, dated [DATE], identified R144 had intact cognition, required supervision to limited assistance with activities of daily living (ADLs), and had no current pressure injuries. However, R144's electronic medical record (EMR) Minimum Data Set (MDS…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to develop a comprehensive care plan, including with resident-specific interventions, to meet the known and identified behavioral expressions and needs for 1 of 1 resident (R78) reviewed with cognitive impairment who, at times, refused personal care. Findings include: R78's admission Minimum Data Set (MDS), dated [DATE], identified R78 had intact cognition, demonstrated several indicators of depression (i.e., feeling down, poor appetite or overeating), but demonstrated no rejection of care behaviors. Further, the MDS outlined R78 had traumatic brain dysfunction and it was somewhat important for her to be able to choose her bathing method (i.e., shower vs bath). On 11/27/23 at 1:55 p.m., R78 was interviewed, and stated she had been at the nursing home for several weeks and had only received a couple baths which was really weird. R78 stated they would like to get, at minimum, a sponge bath more regularly but added a full tub bath helps feel like I…

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 routine bathing was offered or provided to promote good hygiene for 1 of 5 residents (R78) reviewed for activities of daily living (ADLs) and who was dependent on staff for their cares. Findings include: R78's admission Minimum Data Set (MDS), dated [DATE], identified R78 had intact cognition, demonstrated no rejection of care behaviors, and required substantial assistance to complete mobility and self-care activities of daily living (ADLs). R78's care plan, dated 11/2/23, identified R78 admitted to the nursing home on [DATE], and had several self care needs. The care plan outlined several interventions for R78 including, BATHING/SHOWERING: The patient requires maximum assistance with dressing, and, PERSONAL HYGIENE/ORAL CARE: The resident requires maximum assist X 1. However, the care plan lacked any evidence for when or how (i.e., frequency, type) R78's bathing would be completed; nor did the care plan outline any refusal of care behaviors.…

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 care plan interventions for 2 or 2 residents (R73, R83) reviewed for falls. Findings include: R73's quarterly Minimum Data Set (MDS) dated [DATE], documented R73 with intact cognition and required support with setup for bed mobility, transfers, walking in her room and corridor, and all assistance with daily living (ADL's). Also, R73 had no limitations in upper and lower extremity range of motion. In addition, R73 had diagnoses of osteoarthritis and anxiety. In addition, the facility failed to ensure safe management of diabetic testing supplies for R44. R73 R73's Resident Fall Risk assessment dated [DATE], indicated R73 had no falls in previous three months and a normal gait. R73's electronic medical record (EMR) failed to indicate subsequent falls assessments. R73's progress note (PN) dated 11/2/23, indicated R73 had an unwitnessed fall on 11/2/23 with no injury. R73's PN dated 11/16/23, indicated R73 had an unwitnessed fall…

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 non-pharmacological interventions were care planned, attempted, and recorded before the administration of as-needed (PRN) psychotropic medication to reduce the risk of complication for 1 of 1 residents (R38) reviewed for unnecessary medication use. Findings include: R38's significant change Minimum Data Set (MDS) dated [DATE], indicated R38 had severely impaired cognition and was diagnosed with dementia, anxiety, and depression. R38's care plan dated 9/15/23, indicated R38 required extensive assistance with personal hygiene, bed mobility, toilet use, and dressing. R38's care plan indicated that R38 had impaired cognitive function, thought processes, and decision-making. The care plan indicated R38 had a communication problem related to cognitive loss and confusion and staff were to anticipate his needs. The care plan indicated R38 was partially dependent on staff for meeting his emotional, intellectual, and social needs related 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 recommended pneumococcal vaccinations, as outlined by the Centers for Disease Control (CDC), were offered and provided in a timely manner for 2 of 5 residents (R18, R140) reviewed for immunizations. Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer PCV20 who had received PCV13 at any age and PPSV23 at or after [AGE] years old. R18's quarterly Minimum Data Set (MDS), dated [DATE], identified R18 had severe cognitive impairment and several medical conditions including heart failure, dementia, and malnutrition. Further, under Section O - Special Treatments and Programs, the MDS outlined R18's pneumococcal vaccinations were up to date. R18'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 The facility failed to thoroughly investigate a resident's ability to consent to consensual sexual activities for 2 of 2 residents (R3 and R4) reviewed for an allegation of abuse when the residents had impaired cognition, impaired communication, and required extensive assistance for all their activities of daily living (ADLS.) The findings included: R3's care plan dated 2/24/23 indicated she had an elevated risk for falling. R3's care plan dated 5/30/23, indicated R3 needed assistance from staff to meet all of her emotional, intellectual, physical, and social needs related to her mental and physical disabilities. R3's care plan dated 6/22/23, indicated R3 had impaired; cognition, thought process, and the ability to make decisions. Her SLUMS (test to evaluate memory, attention span, orientation, level of awareness and the ability to organize thoughts and regulate emotions) test score was 7 out of 30 indicating she had dementia (loss of ability; to think, remember, reason, or control emotions.) Based on their…

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.