Woodbury Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to provide routine care conferences to allow for resident/ family participation and interdisciplinary review, and update, if necessary, of the care plan for 1 of 1 resident (R50) reviewed for care conferences. Findings include:R 50's quarterly Minimum Data Set (MDS) dated [DATE] severely cognitively impaired, unable to communicate clearly, and understand others. R50 had the following diagnoses: major depressive disorder, Alzheimer's, unspecified psychosis not due to a substance or known physiological condition, unspecified dementia, psychotic disturbance, mood disturbance, and anxiety.R50's electronic medical record (EMR) indicated R50 had a care conference on 6/24/25, EMR indicated the last documented care conference for R50 was 10/7/24.During an interview on 7/21/25 at 6:28 p.m., R50's family member (FM)-A stated the facility were doing care conferences quarterly then it changed. FM-A stated it was explained to them the social worker left 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, observation, and document review, the facility failed to ensure symptoms of constipation were acted upon and assessed to determine what, if any interventions were needed to promote appropriate bowel management for 1 of 1 resident (R4). Findings include:R4's Optional State Assessment (OSA) dated 7/8/25, indicated R4 did not reject care, required extensive assistance with bed mobility and toilet use, and was not on a urinary or bowel toileting program.R4's Medical Diagnosis form indicated the following diagnoses: hemiplegia (paralysis of one side of the body) affecting the left nondominant side, diabetes mellitus (DM), muscle weakness, chronic idiopathic (without a known cause) constipation.R4's care plan dated 10/3/24 indicated R4 had a self care deficit due to a stroke and required substantial to maximal assist of one for personal hygiene. R4's care plan dated 7/17/25 indicated R4 refused to get out of bed due to refusing the mechanical lift. R4's care plan dated 10/14/24, indicated R4 had frequent incontinence of bowel and bladder and interventions indicated 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 record review the facility failed to assess trauma history and identify potential triggers for 1 of 1 residents (R8) with post-traumatic stress disorder (PTSD). Findings include:R8's quarterly Minimum Data Set, dated [DATE], indicated R8 was cognitively intact and had diagnoses of anxiety, depression and PTSD. R8's trauma screening assessment dated [DATE], indicated R8 had experienced a traumatic event, and a referral was made for a counselor or therapist. The assessment lacked information of the traumatic event and lacked assessment of anything that may trigger R8's trauma experience.R8's care plan dated 11/7/24, indicated R8 had experienced trauma/PTSD and referred staff to Associated Clinic of Psychology (ACP)notes. R8's care plan lacked identification of triggers for R8's PTSD. Interventions included therapy referral if indicated, chaplain visits as requested, consistent staffing if able, validate feelings and approach calmly. R8's ACP progress note dated 3/25/25, indicated R8 received…

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 Number of residents sampled:2Number of residents cited:2Findings include:R11's quarterly Minimum Data Set (MDS) dated [DATE], indicated R11 was cognitively intact and had diagnoses of anxiety and depression. R11's care plan revised 12/15/24, indicated R11 had a psychosocial well-being problem related to depression and anxiety. Interventions included to encourage R11 to verbalize feelings, perceptions and fears and help identify precipitating factors of stressors.R11's medical record lacked indication follow up was completed after a behavioral outburst by R105. R105's admission MDS dated [DATE], indicated R105 was cognitively intact and had diagnoses of adjustment disorder with mixed disturbances and conduct and heart failure. R105's nursing progress note dated 6/17/25 at 8:48 p.m., indicated R105 had loud and disruptive behaviors for over 4 hours. The note indicated other residents were visibly upset from the behavior. A message was left for the nurse manager. R105's nursing progress note dated 7/19/25 at 9:51…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure call lights were within reach and accessible for 1 of 3 residents (R1), who was dependent on staff for care. Findings include: R1's care plan revised 12/23/24, identified a focus that R1 had potential for/actual communication problem with difficulty expressing ideas, understanding others related to speech is clear. Intervention identified to ensure/provide a safe environment: Call light in reach, adequate low glare light, bed at appropriate height and wheels locked, and avoid isolation. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had diagnoses of encounter for palliative care, anxiety, depression, and chronic pain syndrome. R1's cognition was moderately impaired and required substantial to maximum assist for toileting hygiene, dressing and bed mobility. During an observation and interview on 4/28/25 at 12:15 p.m., R1's room on the third floor was the last room on the left at the end of the hallway furthest…

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 Enhanced Barrier Precautions (EBP)- (an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities,) were implemented or followed for management of a non-pressure skin wound to reduce the risk of infection to others for 1 of 1 resident (R1). Further the facility failed to implement hand hygiene for 1 of 1 resident (R1) observed during incontinence care and transfer. Findings included: R1's care plan revised 1/28/25, identified a focus that R1 had a disease/condition requiring precautions-wounds with drainage, history of Methicillin Resistant Staphylococcus Aureus (MRSA)-(caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections). Interventions dated 8/8/24, identified to bag and transport used linen according to facility protocol,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to promote dignity for 6 of 6 residents (R1, R23, R28, R31, R47, R58) reviewed for resident rights when name labels were observed on the outside of clothing. Additionally, the facility failed to ensure a dignified home-like environment was provided during dining services in 1 of 2 dining rooms reviewed. Findings include: Clothing Labels R1's annual Minimum Data Set (MDS) dated [DATE], indicated R1 had severely impaired cognition and required moderate assistance with lower body dressing. R23's quarterly MDS dated [DATE], indicated R23 had severely impaired cognition and was dependent on staff for dressing. R28's annual MDS dated [DATE], indicated R28 had severely impaired cognition and required maximal assistance with lower body dressing. R31's quarterly MDS dated [DATE], indicated R31 had severely impaired cognition and required maximal assistance with lower body dressing. R47's quarterly MDS dated [DATE], indicated R47 had severely…

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 self-administration of medications was comprehensively assessed for 1 of 1 residents (R75) with medication found at the bedside. Findings include: R75's quarterly Minimum Data Set (MDS) dated [DATE], indicated R75 had intact cognition and was diagnosed with diabetes, a stroke, and hypertension. The MDS indicated R75 was dependent on staff for bed mobility, transferring, and toileting. R75's Order Summary Report dated 6/13/24, indicated R75 had an order for two tablets of 500 milligrams (mg) of chewable calcium carbonate (antacid), every six hours as needed. R75's care plan dated 2/7/24, indicated R75 was dependent on staff for all activities of daily living. The care plan indicated that R75 was to be fully upright and supervised while eating and given medications one at a time with sips of water. The care plan did not address the self-administration of medication. R75's Medication Administration Record (MAR) dated 6/1/24-…

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 a comprehensive, person-centered care plan was developed and readily available to promote continuity of care for 2 of 3 residents (R61, R199) reviewed for care planning. Findings include: R61's admission Minimum Data Set (MDS), dated [DATE], identified R61 had intact cognition and was admitted to the care center on 6/3/24 from the acute care hospital. The MDS outlined R61 needed physical assistance for most activities of daily living (ADLs) and had multiple medical conditions including fractures, neurogenic bladder, and multiple sclerosis (MS). Further, the MDS outlined multiple Care Area Assessments (CAAs; items to have an in-depth review completed) were triggered for R61 including ADL Functional/Rehab, Urinary Incontinence and Indwelling Catheter, Falls, and Pressure Ulcer. On 6/24/24 at 1:07 p.m., R61 was interviewed. R61 explained they admitted to the care center several weeks prior after being hospitalized for a leg fracture. R61 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 ensure bathing care was consistently provided or recorded for 1 of 2 residents (R61) reviewed for activities of daily living (ADLs) and who was dependent on staff assistance for bathing. Findings include: R61's admission Minimum Data Set (MDS), dated [DATE], identified R61 had intact cognition and admitted to the care center on 6/3/24 from the acute care hospital. Further, the MDS recorded R61 demonstrated no delusional thinking and required substantial and/or maximum assistance with showering and/or bathing. R61's care plan, printed 6/25/24, identified R61 resided on the transitional care unit (TCU) and listed a focus, [Preferred Name] has an ADL Self Care Performance Deficit r/t [related to] [blank], with no goal statement associated. The care plan directed an intervention which read, SHOWER/BATHE SELF: requires partial/moderate assistance of # staff to complete, and, TUB/SHOWER TRANSFER: dependent on assistance of # 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 observation, interview and document review, the facility failed to comprehensively assess and, if needed, develope interventions to promote a proactive bowel management program to promote comfort and reduce the risk of complication (i.e., impaction, constipation) for 1 of 1 residents (R61); and failed to comprehensively assess and, if needed, develop or implement interventions to promote good posture and positioning while in bed for 1 of 1 resident (R26) observed who leaned significant to the side while in bed. Findings include: Bowel Management: R61's admission Minimum Data Set (MDS), dated [DATE], identified R61 had intact cognition and was dependent on staff for toilet hygiene and transfers. The MDS outlined a section labeled, H0600. Bowel Patterns, with spacing to record if constipation was present. This was answered, No. Further, the MDS identified R61 consumed multiple medications during the review period including opioids (i.e., narcotics). R61's initial Comprehensive Nursing Data Collection -…

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 passive range of motion and palm protector to prevent possible contracture for one of one residents (R38) reviewed for range of motion (ROM) who had limited functional movement of their hands. Findings include: R38's admission Minimum Data Set (MDS), dated [DATE], indicated R38 was on hospice with Alzheimer's dementia, had severe cognitive impairment and required substantial/maximum assistance with eating, toileting and personal hygiene and was dependent on staff for showers and dressing. R38's Therapy Recommendations and discharge instructions, dated [DATE], indicated R38 was to wear a palm protector at all times, provided hand hygiene and gentle PROM. The form indicated R38 was tolerating both the palm protector and the PROM. R38's sectioned labeled Tasks in the electronic medical record (EMR), for the month of June 2024, indicated a Functional Maintenance Program for a right palm protector at all times to be removed for hand…

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 urology orders for catheterization were clarified; and failed to ensure the use of an in-dwelling Foley catheter was comprehensively assessed or care-planned to promote continuity of care for 1 of 1 resident (R20) reviewed for catheter use. Findings include: R20's quarterly Minimum Data Set (MDS), dated [DATE], identified R20 had intact cognition. The MDS outlined a section labeled, H0100, which identified R20 did not use an indwelling catheter. On 6/24/24 at 4:53 p.m., R20 was observed seated in her wheelchair. R20 had a urinary drainage bag attached to her right leg (i.e., leg bag) which was visible at the bottom of her pant leg. The bag had visible, light-yellow colored urine present with a slight cloudy appearance. R20 was interviewed and verified she used a catheter, however, when asked the rationale just shrugged her shoulders and voiced aloud, Don't know. R20 stated it had been placed at the clinic and reiterated they were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure proper cleaning of a non-invasive ventilation machine to reduce the risk of complications (i.e., respiratory infection) for 1 of 1 residents (R40) observed for non-invasive ventilation machine use. Findings include: The ResMed AirFit F20 Full Face Mask User Guide dated 12/20, indicated the mask should be disassembled, rinsed, cleaned with a soft brush until dirt was removed, cleaned with warm water and a mild detergent, rinsed and air dried daily or after each use. The guide indicated the headgear should be cleaned with warm water and mild detergent and then rinsed and air-dried weekly. The ResMed AirCurve 10 User Guide dated 4/21, indicated the non-invasive ventilation machine should be cleaned weekly including washing the water tub and air tubing with warm water and mild detergent and wiping the machine's exterior with a dry cloth. The guide recommended regular cleaning of the tubing, water tub, and mask for optimal therapy and…

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

Based on observation, interview, and document review the facility failed to comprehensively assess past trauma and develop a comprehensive person-centered care plan with goals and interventions utilizing a trauma-informed approach including monitoring of PTSD (post-traumatic stress disorder) for 1 of 1 (R39) residents reviewed for trauma-informed care. Findings include: R39's quarterly Minimum Data Set (MDS) assessment dated , 6/6/24, indicated R39 diagnoses included: PTSD, adjustment disorder with mixed anxiety and depressed mood (a mental health condition with symptoms of depression and anxiety), borderline personality disorder (a mental health disorder that is characterized by unstable mood and behavior) and depression. R39 had intact cognition. R39's Trauma Screening, dated 12/20/23, identified R39 identified experiencing a traumatic event. The document identified through questions with radio-button answered yes that R39 experienced nightmares or thought about event when you did not want to; will go out of the way to avoid situations that reminded R39 of the event; been 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 consultant pharmacist recommendations were acted upon timely, and an appropriate rationale was recorded for not implementing recommendations for 1 of 5 residents (R38) reviewed for unnecessary medication use. Findings include: R38's admission Minimum Data Set (MDS), dated [DATE], indicated R38 was admitted to the facility on [DATE], (was signed onto hospice three days later on 4/18/24) and had severe cognitive impairment. R38's Diagnoses list, dated 4/15/24, indicated R38 had several medical diagnoses including dementia with agitation, generalized anxiety, and major depressive disorder. R38's physician orders, dated 4/19/24, indicated an order for prochlorperazine maleate 10 milligrams (mg) by mouth every six hours as needed for nausea and vomiting (an antipsychotic medication used to treat schizophrenia and anxiety which can also be used to treat severe nausea and vomiting) and an order for lorazepam (medication used to treat anxiety and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure a scheduled antifungal medication without an end date was evaluated for the appropriateness of its continued use for 1 of 5 residents (R40) reviewed for unnecessary medications. Findings include: R40's significant change Minimum Data Set (MDS) dated [DATE], indicated R40 had intact cognition and was diagnosed with heart failure, respiratory failure, and debility. R40 was dependent on staff to complete bathing, toileting hygiene, and transfers. R40's Order Summary Report dated 3/26/24, indicated R40 had an order starting on 3/26/24 with no end date for nystatin (an antifungal medication) powder application to the groin folds two times a day for a rash. R40's Medication Administration Report (MAR) dated 3/26/24- 6/26/24, indicated R40 had received twice daily applications of nystatin powder during this period except for seven incidents where a three was coded indicating drug refused. R40's Body Audits dated 5/2/24, 5/9/24, 5/16/24, 5/23/24,…

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 care plan and document resident specific target behaviors for 1 of 5 residents (R38) who was prescribed scheduled antipsychotic medication. Further, the facility failed to ensure that as-needed (PRN) psychotropic medications were limited to 14 days of use or the practitioner documented both a specific order duration and the rationale for extending the PRN psychotropic order, to ensure the medications continued necessity and reduce the risk of complication for 1 of 5 residents (R69) reviewed for unnecessary medication use. Findings include: R38's admission Minimum Data Set (MDS), dated [DATE], indicated R38 had severe cognitive impairment and was dependent on staff for activities of daily living (ADLs). R38's physician order, dated 4/15/24, indicated R38 had an order for quetiapine fumarate (an antipsychotic medication used to treat anxiety and agitation) 100 milligrams (mg) by mouth two times a day for Alzheimer's dementia with agitation. R38'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 interview and document review, the facility failed to report to the state agency immediately, within 2 hours, an allegations of verbal abuse for one of one (R1) residents reviewed. R1's hospital discharge paperwork dated 8/28/23, indicated R1 was discharged to the facility for supportive care following a coronary artery bypass graft (CABG) surgery. A handwritten complaint from R1 written 8/31/23 indicated a facility employee had entered her room unannounced and when R1 attempted to speak with the employee, he had told her to shut up. MDS admission assessment dated [DATE] indicated R1's diagnoses included non-ST elevation myocardial infarction, coronary artery disease, and the presence of bypass grafts. R1's Brief Interview for Mental Status (BIMS) was 12 out of 15, and indicated she was moderately cognitively impaired. During and interview on 9/15/23 at 10:53 a.m., family member (FM)-A stated R1 had called him the morning of 8/31/23 very upset about an interaction with a laundry aide. FM-A stated R1…

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 the west hallway shower room was kept clean, sanitary and in good repair, which had the potential to affect all 22 residents who utilized the west shower room. Additionally, the facility failed to provide maintenance services for 2 of 2 (R11, R295) residents whom had broken door handles and latches. Findings include: R11's significant change Minimum Data Set (MDS) dated [DATE], identified intact cognition, a diagnosis of medically complex conditions related to colon cancer, rejection of care 1-3 days in the seven day look back period, and one-person physical assist was provided for bathing along with extensive staff assistance provided for transfers, hygiene and dressing. During an interview on 8/7/23 at 12:50 p.m., R24 stated the common shower room she used in the hallway was disgusting. During an observation on 8/7/23 at 12:52 p.m., the shower room was observed to have an approximate four by four-foot area for showering with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure a self-administration of medications assessment was completed to allow residents to safely administer their own medications for 1 of 1 resident (R25) observed with medications at bedside. Findings include: R25's quarterly MInimum Data Set (MDS) dated [DATE], indicated R25 had intact cognition and diagnoses of congenital malformations of intestinal fixation (the intestines are not in the correct position in the abdomen), right upper quadrant pain, and unspecified abdominal pain. It further indicated, R2 was independent with all activities of daily living (ADL) except eating which required supervision, had a feeding tube, received 26-50% of calories and 501 cubic centimeters (cc) or more fluids through TF. R25's physician's orders dated 8/5/23, indicated tube feeding Osmolite 1.5 at 50 millileters (ml)/hour (hr). If patient is able to eat small meals frequently throughout the day, then infuse TF overnight only from 8:00 p.m.-8:00…

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's needs were assessed appropriately for 1 of 1 resident (R58) when a staff answered a call light and immediately turned it off without assessing or addressing the resident's needs. Findings include: R58's quarterly Minimum Data Set (MDS) dated [DATE], indicated R58 was cognitively impaired, required 2-person physical assist for bed mobility, transfers, and toilet use. R58 required 1-person physical assist with all other activities of daily living (ADLs) and could always make self understood with verbal and non-verbal expression. R58's diagnoses included dementia, dysphagia, and anxiety. R58's communication care area assessment (CAA) dated 3/7/23, indicated R58 had difficulty putting sentences together. R58's care plan (CP) dated 6/14/23, indicated R58 had cognitive loss and directed staff to use communication techniques that facilitate optimal interaction and to identify self, face when speaking, and make eye contact.…

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 assistive devices were maintained and provided for 1 of 1 resident (R24) reviewed for hearing aid assistance. Findings include: R24's quarterly Minimum Data Set (MDS) dated [DATE], identified adequate hearing, moderately impaired cognition, diagnoses of medical complex condition related to diabetes mellitus, and staff provided supervision for hygiene and dressing. R24's hearing evaluation clinical note dated 5/31/23, identified R24 reported difficulty hearing and was a good candidate for amplification. Bilateral rechargeable hearing aids for both ears were recommended/chosen and both R24 and her family member approved to proceed. R24's Annual Comprehensive Nursing Home visit notes dated 8/4/23, identified R24 received hearing aids today and reported they helped with hearing. R24's care plan dated 7/2/23, identified deficits in memory/recall ability, judgement and decision making related to dementia. Interventions 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 ensure interventions were used consistently for 1 of 2 residents (R36) at risk for pressure ulcers (PU) when an air mattress was unplugged for several days and not used. Findings include: R36's quarterly Minimum Data Set (MDS) dated [DATE], indicated R36 was cognitively impaired and required 1-person physical assistance with bed mobility and most activities of daily living (ADLs). The MDS indicated R36 was at risk for developing PUs and had a stage II PU (partial-thickness skin loss with exposed dermis) upon admission to the facility. R36's diagnoses included fractured vertebra, dementia, and muscle weakness. R36's skin care area assessment (CAA) dated 3/30/23, indicated R36 was at risk for developing PU's and interventions would be added to R36's care plan (CP) to minimize risk and avoid complications. R36's CP dated 7/6/23, indicated R36 had potential for impairment to skin integrity related to decreased mobility, incontinence, and a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure an expired medication was discarded and replaced before administration for 1 of 2 residents (R30) reviewed for insulin administration. Findings include: R30's quarterly Minimum Data Set (MDS) dated [DATE], identified Intact cognition, extensive assist of one staff provided for hygiene, a diagnosis of diabetes mellitus, and insulin given seven out of seven days in the lookback period. R30's care plan identified he had diabetes mellitus type II with a history of complications and a goal for insulin daily. R30's Medication Administration Record (MAR) dated [DATE] through [DATE], identified an order for Humalog (insulin lispro) inject five units subcutaneously before meals for diabetes (three times daily). Humalog (lispro insulin) manufacturer's instructions dated 2012, identified used cartridges or prefilled pens should be discarded after 28 days, even if insulin remained. During an observation on [DATE] at 10:57 a.m., trained…

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 insulin stored in the medication cart was labeled with an expiration date for 2 of 4 residents (R57 and R145) reviewed for medication storage. Findings include: R57's admission Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition, extensive assist of one staff was provided for hygiene, a diagnosis of diabetes mellitus and insulin was given seven out of seven days in the look back period. R57's Medication Administration Record (MAR) dated [DATE] through [DATE], identified an order for Novolog (insulin aspart) inject 15 units subcutaneously at bedtime for diabetes. R145's admission MDS was not yet completed due to being a new admission. R145's face sheet identified an admission date of [DATE], and a diagnosis of diabetes mellitus type II. R145's MAR dated [DATE] through [DATE], identified an order for insulin Lantus inject 15 units subcutaneously at bedtime for diabetes. During an observation and interview…

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 dental services were provided for 1 of 1 resident (R50) reviewed for dental services. Findings include: R50's quarterly Minimum Data Set (MDS) dated [DATE], indicated R50 had moderate cognitive impairment and required 2-person physical assistance for most activities of daily living (ADLs). R50's diagnoses included dementia, schizophrenia, and abnormal weight loss. R50's care plan (CP) dated 6/6/23, indicated R50 had oral/dental health problem related to partial dentures with an intervention of coordinate arrangements for dental care, transportation as needed/as ordered. R50's Oral/Dental Assessment Form (O/DAF) dated 5/24/23, indicated R50 had obvious missing teeth, no teeth/dentures on upper and missing posterior teeth on lower. The O/DAF indicated, recommended treatment included routine, non-urgent dental care to replace upper denture and provide new lower partial. R50's provider order dated 1/25/23, indicated R50 could be seen…

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 contact precautions (measures intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment) for clostridioides difficile (C. diff), (a germ that can cause symptoms ranging from diarrhea to life-threatening colon inflammation) were implemented for 3 of 3 residents (R81, R106, R20). Findings include: R81's admission Minimum Data Set (MDS) dated [DATE], indicated moderate cognitive impairment, required extensive assistance with most activities of daily living (ADLs) including toileting, and was frequently incontinent of stool. R81's Medical Diagnosis form in the electronic medical record (EMR), indicated the following diagnoses: arthritis due to other bacteria to right knee, sepsis, bacterial infection unspecified. R81's medication administration record (MAR) dated August 2023, indicated R81 finished vancomycin (an antibiotic) 125 milligram…

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.