Mountain View Manor Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with staff, the facility failed to protect resident rights to be free from misappropriation of controlled medication for 1 of 7 residents reviewed for misappropriation of resident property (Resident #276). The findings included: Review of the facilities Abuse, Neglect and Exploitation policy and procedure which was last reviewed on 4/4/25 revealed that the facility stated residents had the right to be free from misappropriation of property. Resident #276 was admitted to the facility on [DATE] with diagnosis that included depression, anxiety disorder and dementia. Review of the quarterly minimum data set (MDS) dated [DATE] revealed that Resident #276 was severely cognitively impaired. Review of the physician's order dated 10/16/24 revealed Resident #276 had an order to receive 0.5 milligrams (MG) of lorazepam (a medication used to treat anxiety) every 6 hours as needed for anxiety for 14 Days. Review of the facilities investigation dated 10/26/24 revealed at 9:00 PM 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 record review and staff interviews, the facility failed to implement their abuse policy and procedure by not maintaining evidence of an investigation into misappropriation of property and not immediately reporting an allegation of abuse to the Administrator/designee and not notifying local law enforcement or Adult Protective Services of allegations of abuse or misappropriation of property for 3 of 5 abuse investigations reviewed (Residents #12, #24, #27, #43, #223, #222). The findings included: Review of the facilities Abuse, Neglect and Exploitation policy and procedure which was last reviewed on [DATE]. The administrator will be immediately notified by staff if abuse, neglect, mistreatment, misappropriation and or exploitation is alleged or suspected. Staff will document the investigation findings including any recommendations of corrective action and such documentation will be retained as part of the investigation file. a. Review of the initial allegation report submitted by the facility to the State…

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 record review, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of oxygen use for 1 of 3 residents reviewed for respiratory care (Resident #272). The findings included: Resident #272 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia (a condition in which there is an inadequate supply of oxygen to the body's tissues). A review of Resident #272's physician orders revealed an order dated 04/13/25 for oxygen to be administered continuously via nasal cannula at 3 liters per minute, may titrate to keep oxygen (O2) saturation greater than 90%. A review of the admission Minimum Data Set, dated [DATE] revealed Resident #272 was not coded for oxygen use. An observation on 04/14/25 at 11:56 AM revealed Resident #272 sitting in his wheelchair by his bed with oxygen being administered via nasal cannula by an oxygen concentrator.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to develop a baseline care plan within 48 hours of a resident's admission (Resident #272) and ensure a baseline care plan addressed insulin use for a resident with diabetes (Resident #73) for 2 of 4 residents reviewed for respiratory care and self-administration of medications. The findings included: 1. Resident #272 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure with hypoxia (a condition in which there is an inadequate supply of oxygen to the body's tissues). A review of Resident #272's medical record revealed no baseline care plan had been developed for him within 48 hours of admission. On 04/17/25 at 9:16 AM an interview with the Admission/Discharge Nurse revealed she was responsible for completing baseline care plans, but if a resident was admitted over the weekend the nurse on the hall admitting the resident was responsible for completing it. An interview on 04/17/25 at 10:14 AM with the 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 observations, record review, and resident and staff interviews, the facility failed to provide showers as scheduled to a resident dependent on staff assistance for bathing for 1 of 4 residents reviewed for activities of daily living (Resident #2). Findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (trouble breathing), heart failure, and anxiety disorder. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #2 with intact cognition and was dependent on staff assistance with showering/bathing and transfers. She displayed no behaviors and did not reject care during the MDS assessment period. A review of Resident #2's comprehensive care plans last reviewed/revised on 03/13/25 revealed she had an activities of daily living self-care performance deficit related to deconditioning, COPD and heart failure. Interventions included dependence on staff with showering twice weekly and as necessary. Review of 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 observations, record review, and staff interviews, the facility failed to post cautionary and safety signage outside a resident's room that indicated the use of oxygen for 1 of 3 residents reviewed for respiratory care (Resident #272). The findings included: Resident #272 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia (a condition in which there is an inadequate supply of oxygen to the body's tissues). A review of Resident #272's physician orders revealed an order dated 04/13/25 for oxygen to be administered continuously via nasal cannula at 3 liters per minute, may titrate to keep oxygen (O2) saturation greater than 90%. A review of the admission Minimum Data Set (MDS) dated [DATE] indicated Resident #272 exhibited no behavior or rejection of care and was not coded for oxygen use. An observation on 04/14/25 at 11:56 AM revealed Resident #272 sitting in his wheelchair by his bed with oxygen being…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews, the facility failed to secure medications stored at the bedside for 1 of 1 resident reviewed for medication storage (Resident #73). Findings included: Resident #73 was admitted to the facility 04/07/25 with a diagnosis including costochondritis (inflammation of the cartilage that connects a rib to the breastbone). Review of the baseline care plan dated 04/08/25 revealed Resident #73 was cognitively intact. Review of the medical record revealed Resident #73 was assessed for self-administration of medication on 04/08/25. The assessment indicated Resident #73 was not approved for self-administration of medications and may not keep medications at the bedside. Review of Resident #73's Physician orders revealed an order dated 04/09/25 for Diclofenac Sodium gel 1% (anti-inflammatory medication) apply to left chest wall twice a day for 14 days. Resident #73's admission Minimum Data Set (MDS) assessment dated [DATE] was in progress. An observation of Resident…

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 observations, record review, staff interviews, and review of the facility's policies and procedures, the facility staff failed to follow infection control procedures when Nurse #1 did not don a gown while administering Resident #51's tube feeding for 1 of 5 staff members observed for infection control practices. The findings included: Review of the facility's undated policy for Enhanced Barrier Precautions revealed that gowns and gloves should be worn when performing high contact resident care activities such as device care or use with central lines, urinary catheters, feeding tubes, tracheostomies or ventilators. An observation on 04/16/25 at 11:59 AM of Nurse #1 entering Resident #51's room that had a sign on the door for Enhanced Barrier Precautions which instructed staff to don gloves and gown. Nurse #1 entered the room and informed Resident #51 she was going administer his tube feed, washed her hands, and applied clean gloves. Nurse #1 proceeded to attach the tube extension set to the gastrostomy tube (feeding tube surgically inserted into the stomach) and administered…

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 record review and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the areas of Preadmission Screening and Resident Review (PASRR), falls, pressure ulcer, skin and ulcer treatments, tobacco use, gradual dose reduction, and respiratory treatments for 7 of 24 sampled residents (Residents #8, #42, #39, #1, #19, #26, and #29). Findings included: 1. Resident #8 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, anxiety, depression, and post-traumatic stress disorder. A PASRR Level II Determination Notification letter dated 01/08/21 revealed Resident #8 had a Level II PASRR with no expiration date. a. The annual MDS assessment dated [DATE] indicated Resident #8 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or other related conditions. b. The significant change MDS assessment dated [DATE] indicated Resident #8 was not currently considered by the state…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews with the Medical Doctor and staff the facility failed to set the alternating pressure air mattress at the correct setting based on the resident's weight for 3 of 4 residents reviewed for pressure ulcers (Resident #39, #24, and #1). Findings included: 1. Resident #39 was admitted to the facility on [DATE]. Resident #39's current diagnoses included adult failure to thrive, a sacral stage 3 pressure ulcer (full-thickness loss of skin) and right buttock stage 3 pressure ulcer. A physician's order with an active date 09/20/23 was for the placement of an air mattress to the bed and indicated it was for wound healing and preventative measure. The physician orders included check the placement of the air mattress daily at bedtime. The care plan revised on 10/03/23 identified Resident #39 had the potential and actual skin impairment involving the sacrum and right gluteal fold related to impaired mobility. Interventions included an air mattress to the bed and indicated it…

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 and staff interviews the facility failed to cover and date an open food item in 1 of 1 walk-in freezer; ensure food items were labeled and dated in 2 of 2 nourishment rooms (A/B Hall and C/D Hall); and maintain a clean refrigerator and freezer in 1 of 2 nourishment rooms (C/D Hall). These practices had the potential to affect food served to residents. Findings included: 1. An initial tour of the walk-in freezer on 01/22/24 at 10:37 AM revealed a box of hamburger patties open to air with no open date. An interview with the Assistant Dietary Manager on 01/22/24 at 10:37 AM revealed the hamburger patties should be covered and dated when they were opened. He stated it was the responsibility of the person that opened the item to date it and cover it, so it was not left open to air. The Assistant Dietary Manager stated he was not sure why the hamburger patties were not covered and dated. A telephone interview with the Dietary Manager on 01/25/24 at 9:25 AM revealed all food in the freezer should be covered, labeled, and dated when opened. She stated it was 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 observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint investigation survey completed on 07/15/22. This was for one repeat deficiency originally cited in the area of infection prevention and control that was subsequently recited on the current recertification and complaint investigation survey of 01/26/24. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. The findings included: This tag is cross referenced to: F 880: Based on observations, record review, and staff interviews, the facility failed to ensure staff implemented their infection control policy for Personal Protective Equipment (PPE) and hand hygiene when Nurse Aide (NA) #2, the Admissions Director, the Maintenance Director, and Nurse #4 failed to don N-95 facemasks and/or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews, the facility failed to ensure staff implemented their infection control policy for Personal Protective Equipment (PPE) and hand hygiene when Nurse Aide (NA) #2, the Admissions Director, the Maintenance Director, and Nurse #4 failed to don N-95 facemasks and/or goggles upon entering and/or removing N-95 facemasks and sanitizing goggles upon exiting 3 of 3 resident rooms on special droplet contact precautions for COVID-19 (Rooms 106, 141 and 159); when Nurse #3 failed to perform hand hygiene after removing dirty gloves and before donning clean gloves during wound care for 1 of 3 residents reviewed for pressure ulcers (Resident #29); and when the Nursing Consultant and NA #3 failed to assist 3 of 3 residents with hand hygiene before meals for 2 of 2 dining observations (Residents #21, #46, and #229). These failures occurred during a COVID-19 outbreak at the facility. Findings included: The facility's policy, Transmission-based Precautions (Special Droplet…

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 record review and staff interview the facility failed to include documentation in the medical record of education on the benefits, and possible side effects of the influenza vaccination and document refusal or acceptance of the influenza vaccination for 3 of 5 residents (Resident #17, Resident #19, Resident #55) reviewed for immunizations. The findings included: Record review of the following residents' immunizations and consents revealed in part: 1a. Resident #17 was admitted on [DATE] with the quarterly minimum data set (MDS) revealing she was severely cognitively impaired and was administered the flu vaccine on 10/9/23 with the only flu consent signed by the resident's Responsible Party (RP) was dated 7/25/17. 1b. Resident #55 was admitted on [DATE] with the quarterly minimum data set (MDS) revealing she was cognitively intact and was administered the flu vaccine on 10/9/23 with the only flu consent signed by the resident was dated 6/20/22. 1c. Resident #19 was admitted on [DATE] with the quarterly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews with residents and staff the facility failed to obtain physician orders and assess the ability to safely use medications observed at the bedside for 2 of 3 residents reviewed for self-administered medications (Resident #35 and #46). Findings included: 1. Resident #35 was admitted to the facility on [DATE] with diagnoses including gastro-esophageal reflux disease (GERD). The admission Minimum Data Set (MDS) dated [DATE] assessed Resident #35 was cognitively intact with the ability to communicate needs and understood others. The comprehensive care plan initiated on 12/23/23 did not address the abilities of Resident #35 to self-administer medication. A review of the medical records revealed no self-administer assessment was completed for Resident #35 to safely administer medications. During an observation and interview on 01/22/24 at 2:35 PM Resident #35 was observed resting in bed and placed on the overbed table within arm's reach was a bottle of calcium carbonate…

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 2. Record review of the undated North Carolina Medicaid Uniform Screening Tool (NC MUST) inquiry document revealed Resident #48 had a Level I PASRR effective 02/22/23. There were no requests for an updated PASRR evaluation submitted or completed since 02/22/23. Resident #48 was admitted to the facility on [DATE] with diagnosis that included bipolar disorder and unspecified dementia mild without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the admission minimum data set (MDS) dated [DATE] revealed Resident #48 had not been evaluated by Level II PASRR and determined to have a serious mental illness, intellectual disability or other related condition. Resident #48 received antipsychotic medication on a routine basis. An interview on 01/24/24 at 3:59 PM with the Social Worker revealed she was new to the role and was being transitioned into taking over the PASRR process. She explained the Bookkeeper currently completed PASARR requests. A telephone interview on 01/25/24 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to request a Preadmission Screening and Resident Review (PASRR) re-evaluation after a significant change in physical or mental status for 1 of 4 sampled residents reviewed for PASRR (Resident #8). Findings included: Resident #8 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, anxiety, depression, and post-traumatic stress disorder. A PASRR Level II determination notification letter dated 01/08/21 revealed Resident #8 had a Level II PASRR with no expiration date. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was not considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or other related conditions. During an interview on 01/24/24, the Social Worker (SW) revealed she was still learning the PASRR process to take over once she gained access to NC MUST and did not know to request a PASRR re-evaluation when 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 record review and staff interview the facility failed to create a comprehensive care plan related to smoking for 1of 2 residents (Resident #74) reviewed for smoking. The findings included: Resident #74 was admitted to the facility on [DATE] with diagnosis that included nicotine dependence on cigarettes. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #74 was cognitively intact with no behaviors. Resident #74 had shortness of breath and current use of tobacco. Review of the comprehensive care plan dated 11/16/23 revealed that there was no care plan related to smoking. Review of the facilities smoking policy revealed in part: The registered nurse completing the initial smoking assessment will complete an Immediate Needs Care Plan to address the resident's smoking safety. The plan of care will be reviewed by the interdisciplinary team (IDT) and updated once a quarter or more frequently as warranted by the resident's condition. Review of the Smoking Evaluation dated 10/31/23…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews with staff the facility failed to provide nail care for 1 of 1 dependent resident reviewed for activities of daily living (Resident #24). Findings included: Resident #24 was admitted to the facility on [DATE]. Resident #24's current diagnoses included dementia. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #24's cognition as severely impaired and dependent on staff for bathing and personal hygiene. The care plan, revised on 01/08/24, identified Resident #24 as having a self-care deficit related to fatigue and impaired balance. Interventions included check nail length, trim and clean on bath days, and as necessary. During an observation on 01/22/24 at 12:03 PM the fingernails of Resident #24 appeared jagged and dirty. The left thumb nail was long and extended approximately 2-centimeters (cm) past the tip of thumb and had a buildup of thick black colored debris underneath the nail. Review of the Nurse Aide (NA) activities of daily living…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff, Registered Dietician (RD), and Medical Director (MD) interviews the facility failed to address weight loss for 1 of 3 residents reviewed for nutrition (Resident #29). Findings included: Resident #29 was admitted to the facility 04/23/21 with diagnoses including anemia and diabetes. Review of Resident #29's physician orders revealed an order dated 04/24/21 for furosemide (a diuretic) 20 milligrams (mg) once a day for fluid retention. Review of Resident #29's weights are as follows: 09/03/23 207 pounds 09/25/23 191 pounds 10/02/23 188.5 pounds 10/04/23 191 pounds 10/23/23 190 pounds 11/02/23 190 pounds 12/04/23 191 pounds 01/04/24 176 pounds 01/15/24 175 pounds The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 was moderately cognitively impaired and was dependent on staff assistance for eating. The MDS indicated Resident #29 had a stage 2 pressure ulcer (partial skin loss with exposed dermis) that was not present on admission and was not receiving…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews the facility failed to attempt alternatives, review the risks and benefits, and obtain informed consent from the resident's Responsible Party (RP) prior to use of bed rails; comprehensively assess the risk of entrapment after the placement of an alternating pressure air mattress; and accurately assess the continued need for bed rails for 2 of 6 residents reviewed for bed rail use (Resident #1 and Resident #24). Findings included: 1. Resident #1 was admitted to the facility 04/28/13 with diagnoses including stroke, hemiplegia (paralysis on one side of the body), aphasia (a language disorder that affects a person's communication ability), contracture to the right hand (a disorder that affects normal movement), and non-Alzheimer's dementia. Resident #1 had a physician order dated 07/24/23 to check placement of air mattress daily on night shift. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was rarely or 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 observation, record review, resident and staff interviews, the facility failed to provide drinks consistent with the resident's preference for 1 of 1 sampled resident (Resident #55). Findings included: Resident #55 was admitted to the facility on [DATE]. A physician's diet order dated 06/01/22 for Resident #55 noted a regular diet, regular texture and regular liquids. The quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #55 with intact cognition and requiring setup or cleanup assistance only with eating and drinking. During an interview on 01/24/23 at 9:53 AM, Resident #55 revealed there was a soft drink dispenser out in the main dining room for everyone to access but the sweet tea ran out frequently, most recently yesterday at lunch and two times last week. She explained when the sweet tea ran out dietary didn't have any more and she was offered unsweet tea with a sugar packet, but it didn't taste the same because the sugar didn't dissolve completely. Resident #55 explained…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews with the Registered Dietitian and staff the facility failed to follow the physician's diet order for double portions of protein with meals for 1 of 3 residents reviewed for nutrition (Resident #39). Findings included: Resident #39 was admitted to the facility on [DATE]. Resident #39's current diagnoses included adult failure to thrive, a sacral stage 3 pressure ulcer (full-thickness loss of skin) and right buttock stage 3 pressure ulcer. Review of the quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #39 was cognitively intact and required supervision with eating. Resident #39 weighed 113 pounds with known weight loss and not on a regimen to lose weight. The MDS identified a stage 4 pressure ulcer (full-thickness skin loss). The Registered Dietitian (RD) progress note dated 01/03/24 revealed Resident #39 was encouraged to consume as much protein as possible to increase wound healing and recommended double protein of meat at meals. Review of 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.