Cedar Hills Center for Nursing and Rehabilitation

Based on observations and staff interviews, the facility failed to ensure the side doors to trash dumpsters remained closed, failed to contain waste in dumpsters with lids or coverings and failed to maintain a clean garbage area free from litter for 2 of 2 trash dumpsters and 1 of 1 construction container. These practices had the potential to attract pests and rodents.Upon arrival into the parking area of the facility an observation of the dumpster area on 2/9/26 at 9:15 a.m., revealed a long/large open to air construction-type container overflowing with bags of trash with some of the bags on the ground next to one side of building of the facility. There was no covering/tarp over the container or trash bags. On 2/11/26 at 12:07 p.m., accompanied by the Regional Food Service Consultant, an observation of the facility's dumpster area was completed. The large/long open-to-air construction-type container remained in the same condition with an overflow of bags of trash. There were two trash dumpsters surrounded by an unlocked, gated fence located in the back of the parking lot. The doors…

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 facility policy review, record review and staff interviews, the facility failed to implement an antibiotic stewardship program to monitor antibiotic usage in the facility. This practice had the potential to affect 87 of 87 residents in the facility.The findings included:Review of the facility's policy titled, Antibiotic Stewardship Program, effective date 12/2025 revealed the following: The Antibiotic Stewardship Program purpose is to optimize the overall infection prevention program by the treatment of infections while reducing the adverse events associated with antibiotic use. The Infection Preventionist utilizes expertise and data to form strategies to improve antibiotic use to include tracking of antibiotic starts, monitoring adherence to evidence based published criteria during the evaluation and management of treated infections and reviewing antibiotic resistance patterns in the facility to understand which infections are caused by resistant organisms. A review was conducted of the pharmacy services antibiotic user tracking sheets for the months of November 2025,…

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 develop a baseline care plan within 48 hours of admission for 9 of 30 residents reviewed for baseline care plan (Residents #30, #105, #106, #110, #6, #109, #82, #99, and #72).Findings included: 1. Resident #30 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included paraplegia and neuromuscular dysfunction of bladder. A review of the medical record revealed no documented evidence that a baseline care plan was completed for Resident #30. Attempts made to contact the Nurse who admitted Resident #30 were unsuccessful. An interview was conducted on 02/13/26 at 8:45 am with the Unit Manager (UM). She was not aware that a baseline care plan was not completed for Resident #30. The UM attempted to locate the baseline care plan without success and confirmed it had not been completed. She stated that the baseline care plan should have been completed no later than 48 hours after the resident was admitted to the facility.…

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 and staff interviews, the facility failed to remove loose and unsecured pills of various shapes, sizes and colors on 2 of 4 medication carts observed (Hall 300 Medication Cart #1 and Medication Cart #2).The findings included:a. An observation was conducted on 02/11/26 at 10:35 am of Medication Cart #2 on Hall 300 in the presence of Nurse #4. The observation revealed the following medications were stored in the medication cart:-One small round pink unmarked tablet found in the first drawer of the medication cart.-One small round yellow unmarked tablet found in the first drawer of the medication cart.-One medium round brown unmarked tablet found in the second drawer of the medication cart. -One small oblong white unmarked tablet found in the second drawer of the medication cart.-One small round pink tablet with marking E found in the second drawer of the medication cart-One small round bright yellow unmarked tablet found in the third drawer of the medication cart.-One half of a round white unmarked tablet found in the third drawer of the medication cart.-One…

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 maintain vaccination consents or declination decisions in the residents' medical record and failed to maintain a record of education of the benefits and potential side effects for the influenza and pneumococcal immunizations for 5 of 5 residents reviewed for immunizations (Resident #21, Resident #20, Resident #9, Resident #72 and Resident #33). The findings included:Findings included:a. Resident #21 was admitted to the facility on [DATE].Review of Resident #21's Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. Further review of the MDS revealed Resident #21was not offered the influenza vaccine and was offered but declined the pneumococcal vaccine.An interview was conducted with Resident #21 on 02/12/26 at 8:57 am and she indicated she could not recall if she was offered the influenza or pneumococcal vaccines. Review of the medical record revealed Resident #21 declined to have the pneumococcal vaccine. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview and staff interviews the facility failed to treat a resident in a dignified and respectful manner when Nurse Aide #7 and Nurse Aide #8 were delayed in responding to a resident's call for assistance and told the resident to stop using her call light causing the resident to be upset and mad. The deficient practice affected 1 of 3 residents reviewed for dignity (Resident #82).Findings included:Resident #82 was admitted to the facility on [DATE] with diagnoses that included fracture of left hand, fracture of left radius, muscle weakness, and anxiety. Resident #82 transferred to the hospital on 2/9/26. The admission comprehensive Minimum Data Set (MDS) assessment for Resident #82 dated 1/29/26 revealed she was cognitively intact, had no behaviors, and required assistance of staff with toileting, bed mobility, and transfers. She was coded to use a wheelchair for mobility. A grievance reporting form was initiated by the Social Worker on 2/5/26 and stated C.N.A's (Certified…

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 inform and provide written information to a resident regarding the residents' right to accept or refuse medical/surgical treatment and to formulate an advanced directive for 1 of 33 sampled residents reviewed for advanced directives (Residents #105). Findings included: Resident #105 was admitted to the facility on [DATE]. The nursing admission assessment dated [DATE] indicated Resident #105 was cognitively intact. There was no documentation in Resident #105's medical record indicating the resident was informed of his right to accept or decline medical or surgical treatment prior to making an advance directive decision and/or an advance directive formulated for code status. During an interview on 2/11/26 at 11:36 AM, Resident #105 indicated she had not received any paperwork or education on advanced directives and/or been informed of her right to accept or refuse medical/surgical treatment. Resident #105 stated she wanted to be resuscitated if…

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 provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) form 10555 (liability notice that informs Medicare Part A beneficiaries of potential Medicare non-coverage before providing custodial care or items that are usually paid for by Medicare) prior to discharge from Medicare Part A skilled services for 2 of 3 residents reviewed for beneficiary protection notification review (Resident #116 and Resident #117).The findings included:1. Resident #116 was admitted to the facility on [DATE]. He was admitted to Medicare Part A skilled services on 11/6/25.Resident #116's Medicare Part A skilled services ended on 11/28/25. He remained in the facility.Record review revealed there was no documentation Resident #116, or his responsible party were issued a CMS SNF-ABN form 10555 prior to discharge from Part A Medicare services. During an interview with the facility Social Worker on 2/12/26 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 develop a comprehensive care plan in the areas of activities of daily living and activities (Resident #13), and discharge goal (Resident #4) for 2 of 30 residents whose care plans were reviewed (Resident #13 and Resident #4). The findings included:1. Resident #13 was admitted to the facility on [DATE] with diagnoses that included neurocognitive disorder with Lewy bodies and muscle weakness.A significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #13 was cognitively impaired, was dependent on staff for personal hygiene, bathing, and toileting and felt it was somewhat important to be included in group activities.A review of Resident #13's comprehensive care plan revised on 12/29/25 revealed that no care plan had been developed for activities of daily living (ADL) or activities.An interview was conducted with MDS Coordinator #1 on 2/12/26 at 9:34 AM. The MDS Coordinator #1 indicated per the MDS assessment, Resident #13…

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, and interview of the staff, residents, and a family member, the facility failed to provide dependent residents nail care (Residents #8 and #10) and facial hair care (Resident #10). The deficient practice affected 2 of 10 residents reviewed for activities of daily living (Residents #8 and #10). Findings included:1. Resident #8 was admitted on [DATE] with a diagnosis of non-Alzheimer's dementia. The quarterly Minimum Data Set, dated [DATE] documented that Resident #8's cognition was moderately impaired. The resident was dependent for bathing, dressing and personal care, and was incontinent of bowel and bladder. The active diagnoses were dementia, anxiety, and muscle weakness. The care plan for Resident #8 dated 12/27/25 documented a self-care deficit due to weakness. The resident required assistance with personal care, including clean and trim nails. On 2/09/26 at 11:51 am, an observation and interview were conducted. Resident #8's 10 fingernails were approximately 1/2 inch…

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, observation, and interview of staff, the physician assistant, and the wound nurse practitioner, the facility failed to change the pressure ulcer dressing as ordered (Resident #30). The deficient practice affected 1 of 5 residents reviewed for pressure ulcers. The findings included:Resident #30 was admitted to the facility on [DATE] with diagnosis which included spina bifida with hydrocephalus, paraplegia, and stage 4 pressure ulcer to the sacrum.The care plan initiated on 08/14/25 revealed Resident #30 had a stage 4 pressure ulcer to the sacral area and a potential for pressure ulcer development related to crushing injury, impaired mobility, spina bifida. The goal was Resident #30's pressure ulcer would show signs of healing and remain free from infection. Interventions included administer medication as ordered, administer treatments as ordered, monitor for effectiveness, educate the resident/family/caregiver as to the causes of skin breakdown, and follow facility policies/protocols for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, physician assistant, and staff interviews the facility failed to obtain ordered urine analysis and culture sensitivity specimen for 1 of 2 residents. (Resident #30) The facility failed to empty the urinary catheter bag as ordered to maintain free urine flow through an indwelling catheter and failed to keep stool away from urinary catheter and the meatus to prevent urinary tract infections for 1 of 2 resident reviewed for urinary catheter care. (Resident #30)1a. Resident #30 was admitted to the facility on [DATE] with diagnosis which included spina bifida with hydrocephalus, paraplegia, neuromuscular dysfunction of bladder, and urinary tract infection.The care plan initiated on 08/14/25 revealed Resident #30 had a urinary catheter related to neurogenic bladder. The goal was Resident #30 would show no signs or symptoms of urinary tract infection. The interventions included monitor and document intake and output per facility policy, monitor for signs and symptoms of discomfort with urination…

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 and Physician Assistant interviews, the facility failed to obtain an ordered clostridium difficile test result for a Resident experiencing abdominal tenderness and loose stools (clostridium difficile is a bacterium which can cause diarrhea, abdominal pain and bowel inflammation). The deficient practice occurred on three separate occasions for 1 of 3 residents reviewed for laboratory services (Resident #98).Findings included:Resident #98 was admitted on [DATE] from the hospital setting after diagnoses of declining functional status and pulmonary embolism, with past medical history of vaginal and rectal bleeding secondary to anticoagulant use, past clostridium difficile infection, right hip osteoarthritis, depression, anxiety, obstructive sleep apnea and generalized weakness. A provider note dated 12/29/25 at 8:15 AM indicated Resident #98's physical exam revealed abdominal tenderness with palpation and an order was placed for stool testing to rule out possible clostridium…

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 reviews, and staff interviews, the facility failed to implement infection control policies and procedures for enhanced barrier precautions when Nurse Aide (NA) #1 failed to don a gown when starting to provide incontinence care to Resident #105 who had a sacral wound and required surveyor intervention for 1 of 7 staff members observed for infection control practices (NA #1). Findings included:The facility's enhanced barrier precautions last revised in 12/2025, documented it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmissions of multidrug-resistant organisms.An observation of Resident #105's room door and the hallway immediately outside the room on 02/11/26 at 9:25 AM and at 11:24 AM revealed Resident #105's door did not have enhanced barrier precaution signage posted, and there was no personal protective equipment (PPE) available outside of Resident #105's room.On 02/11/26 at 11:34 AM, an observation was made of Nurse Aide (NA) #1 performing incontinence care on Resident #105. NA #1 had donned…

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 record review, and staff and resident interviews the facility failed to provide resolution of Resident Council Meeting grievances for 5 of 6 monthly Resident Council Meetings. The Resident Council had repeated concerns regarding coffee not being served before breakfast and clothes not coming back from laundry (5/28/24, 06/25/24, 07/30/24, 08/27/24, and 09/24/24). On 05/28/24 the Resident Council Meeting Minutes noted a dietary concern that coffee was not being served or made before breakfast. The Resident Council Follow-Up form attached to the 05/28/24 Resident Council Meeting Minutes did not demonstrate the facility's response to grievances voiced during the Resident Council. On 06/25/24 the Resident Council Meeting Minutes noted a dietary concern that coffee was not being served or made before breakfast. The Resident Council Follow-Up form attached to the 06/25/24 Resident Council Meeting Minutes did not demonstrate the facility's response to grievances voiced during the Resident Council. On 07/30/24 the Resident Council Meeting Minutes noted a housekeeping concern 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 record review, staff interview, Corporate Nurse Consultant and Physician interview the facility failed to follow physician orders to obtain a monthly weight (lbs.) for 1 of 3 residents (Resident #50) reviewed for nutrition. The findings included: Resident #50 was admitted to the facility on [DATE] with a diagnosis that included hypertension, depression and fractures. Resident #50's physician order dated 2/26/24 stated monthly weight every Monday for monitoring. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 was cognitively intact. Resident #50 had no upper body impairment and 1 lower extremity impairment. The MDS further indicated Resident #50's height was 71 inches, and his weight was left blank. Weight loss 5% or more and weight gain was not assessed. Review of Resident #50 quarterly MDS assessment dated [DATE] indicated he was cognitively intact. Resident #50 had no upper body impairment and 1 lower extremity impairment. The MDS further indicated Resident #50's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, resident interview, and staff interviews, the facility failed to provide privacy for a catheter bag and activities of daily living (ADL) care for 2 of 2 residents (Resident #14 and Resident #55) reviewed for personal privacy. The findings included: 1. Resident #14 was admitted to the facility on [DATE] and resided in room [ROOM NUMBER]with diagnoses which included obstructive uropathy, urinary tract infection, and muscle weakness. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact for decision making and was dependent for toilet use. The MDS further revealed Resident #14 was coded for an indwelling catheter and was incontinent for bowels. An observation and interview conducted with Resident #14 on 11/04/24 at 12:20 PM revealed Resident #14 did not have a privacy curtain near the resident's door which allowed him to be viewed from the hallway. Resident #14 indicated staff did not attempt to block the doorway entrance 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 record reviews and staff interviews, the facility failed to permit Resident #336 to remain in the facility and initiated the resident's discharge when she returned later than expected from a leave of absence. The resident returned to the facility on 2/12/24 and was informed by staff she was not allowed to remain in the facility due to her being gone from the facility over 24 hours. Additionally, the facility failed to provide written documentation which stated the reason the facility could not meet the resident's needs for 1 of 3 residents reviewed for discharge. (Resident 336). The findings included: Resident #336 was initially admitted to the facility on [DATE] with diagnoses which included chronic pain, opioid dependence, intentional self-harm by other firearm discharge and anxiety. Review of Resident #336's admission Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact and was independent with activities of daily living. Review of a late entry progress note completed 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 record reviews, staff interviews, and physician interview, the facility failed to provide a safe and orderly discharge for 1 of 3 residents (Resident # 336) reviewed for discharge. On 2/11/24 at 12:30 pm Resident #336 signed out of the facility on leave of absence with an expected return time of 9:30 pm. Due to transportation issues, Resident #336 was not able to return to the facility until 2/12/24 and was informed that she had been discharged and therefore could not remain in the facility. Resident #336 was not provided with discharge instructions or prescriptions, and the discharge location was not verified. This resulted in Resident #336 going to the hospital to get her medications refilled. Resident #336 remained in the hospital under observation until she was readmitted to the facility on [DATE]. The findings included: Resident #336 was initially admitted to the facility on [DATE] with diagnoses which included chronic pain, opioid dependence, intentional self-harm by other firearm discharge 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 record review, staff interview and physician interview, the facility failed to comprehensively assess a resident in the area of weights for 1 of 3 residents (Resident #50) reviewed for nutrition. The findings included: Resident #50 was admitted to the facility on [DATE]. Resident #50's physician order dated 2/26/24 stated monthly weight every Monday for monitoring. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 was cognitively intact. The MDS indicated Resident #50's height was 71 inches, and his weight was left blank. Weight loss 5% or more was not assessed and weight gain was identified as not assessed. Review of Resident #50 quarterly MDS assessment dated [DATE] indicated he was cognitively intact. The MDS indicated Resident #50's height was 71 inches, and his weight was left blank. Weight loss 5% or more was not assessed and weight gain was identified as not assessed. Review of Resident #50's care plan created 10/14/23 and revised on 9/25/24 stated he had…

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 reviews, resident and staff interviews, the facility failed to provide restorative range of motion and the application of the splinting devices as recommended by the occupational therapist for 1 of 2 sampled resident (Resident #48) reviewed for limited range of motion. Findings included: Resident #48 was admitted to the facility on [DATE] with diagnoses which included: hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting the left non-dominant side and a left-hand contracture. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #48 was cognitively intact and had range of motion impairments of one side of her upper and lower extremities. The care plan dated 9/16/24 revealed Resident #48 required assistance with her activities of daily living (ADL). Interventions included physical, occupational and speech therapies were to evaluate and treat as indicated/ordered. Review of the occupational therapy Discharge summary dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident, staff, and physician interviews, the facility failed to ensure a resident receiving dialysis services had a physician's order for dialysis services, a care plan and failed to monitor after dialysis treatments. This was for 1 of 1 resident reviewed for dialysis (Resident #64). The findings included: Record review of the hospital history and physical dated 5/27/24 as the orders for dialysis, revealed right sided permacath access (a flexible tube that's inserted into a blood vessel in the neck or upper chest to provide dialysis treatment), hemodialysis every Monday, Wednesday and Friday. Record review of the hospital Discharge summary dated [DATE] revealed Resident #64 had permacath and to return to the dialysis schedule of Monday, Wednesday and Friday. Resident #64 was admitted to the facility on [DATE] with diagnoses including end-stage renal disease and dependence on renal dialysis. Resident #64's admission assessment dated [DATE] completed by the Unit Manager revealed no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, North Carolina (NC) Nurse Aide (NA) Registry Representative and staff interviews, the facility administration failed to have effective systems in place to identify when a nurse aide had an expired registry listing with the NC Nurse Aide Registry for 1 of 5 employees reviewed for sufficient nurse staffing (NA #4). The findings included: Nurse Aide (NA) #4 was hired by the facility on [DATE]. Review of NA #4's personnel file revealed NA #4's registry listing expired on [DATE]. Review of the NC Nurse Aide Registry online portal revealed NA #4's original test date was [DATE] with a listing expiration date of [DATE]. A telephone interview was completed with NC Nurse Aide Registry representative on [DATE] at 10:22 AM. The NC Nurse Aide Registry representative confirmed that NA #4's registry listing expired on [DATE]. Review of the nursing schedules from [DATE] to [DATE] revealed that NA #4 worked the following days: [DATE], [DATE] and [DATE]. NA #4 was assigned to the 300-hall from 7:00 AM 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 observations, resident, and staff interviews, the facility failed to provide a privacy curtain for 2 of 14 rooms on the 200-hall reviewed for privacy (room [ROOM NUMBER] and room [ROOM NUMBER]). The findings included: 1.Resident #14 was admitted to the facility on [DATE] and resided in room [ROOM NUMBER]. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact for decision making. An observation and interview conducted with Resident #14 on 11/04/24 at 12:20 PM revealed Resident #14 did not have a privacy curtain that blocked him from the doorway. The resident shared a room with another resident. Resident #14 further revealed he had not had a privacy curtain since admission. Resident #14 stated he had expressed to nursing staff that he would like a curtain so he could not be seen from the hallway if someone was to open the door during care. An observation and interview with Nurse Aide (NA) #8 on 11/5/24 at 10:15 AM revealed Resident #14 had not had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff, Pharmacist, Nurse Practitioner, and Resident interviews the facility failed to administer antiseizure medication and pain medication for 2 of 3 residents (Resident #8 and Resident #9) reviewed for providing pharmaceutical services to meet residents' needs. administration. Resident #8 did not receive her antiseizure medication on 7/15/2024 and 7/16/2024, and Resident #9 was admitted with a left total knee replacement and did not receive pain medication when admitted to the facility. Findings included: 1. Resident #8 was admitted to the facility on [DATE] with diagnoses malignant neoplasm to the brain resulting in seizures and brain necrosis due to radiation therapy. Resident #8's Physician's orders included an order written 7/15/2024 for Lamotrigine 200 milligrams twice daily; Lamotrigine 25 milligrams (2 tablets) at bedtime for seizures; and Levetiracetam 1000 milligrams (2 tablets) two times a day for seizures. Resident #8's Medication Administration Record (MAR) for 7/2024 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, Nurse Practitioner, and staff interviews the facility failed to report the results of a urinalysis received on 8/8/2024 to the Nurse Practitioner until 8/12/2024, failed to report pain and distention of the lower abdomen to the Nurse Practitioner on 8/5/2024, and failed to report being unable to flush a urinary catheter for 1 of 1 Resident (Resident #1) reviewed for urinary catheter care. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses of end stage renal disease, neuropathic bladder, and Parkinson's disease. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was cognitively intact and had a urinary catheter in place. Resident #1's Physician's Orders indicated he had a Urinalysis with Culture if indicated ordered 8/5/2024 due to discolored urine. Review of a urinalysis laboratory result obtained 8/8/2024 indicated Resident #2 had a mixed flora and collection of a new urinary sample was suggested by 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 record review, observations, and staff interviews the facility failed to report an allegation of abuse to Adult Protective Services for 1 of 3 residents (Resident #6) who alleged staff to resident abuse which occurred on 7/25/2024 and was reported to the Administrator on 7/26/2024 but was not reported to Adult Protective Services until 8/1/2024. Findings included: The facility's Abuse, Neglect and Exploitation Policy reviewed on 1/1/2024 stated the facility would report all alleged violations to the Adult Protective Services and all other required agencies with 24 hours if the event that caused the allegation did not result in abuse or serious bodily injury. Resident #6 was admitted to the facility on [DATE] with diagnoses of hemiplegia and epilepsy. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #6 was severely cognitively impaired and required total assistance with bed mobility and transfers. According to the facility's investigation dated 7/26/2024 at 2:45 pm a Family…

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 resident, Responsible Party, and Nurse Practitioner interviews the facility failed to have a Urinalysis with Culture sample collected on 8/5/2024 tested at the laboratory that same day. The Urinalysis with Culture was not completed and reported to the facility until 8/8/24. In addition, the facility failed to follow through on 8/8/24 when the laboratory suggested a new urine sample when the results for the 8/5/24 indicated the sample was contaminated. The deficient practice occurred for 1 of 1 resident (Resident #1) reviewed for suprapubic catheter care. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses of end stage renal disease, neurogenic bladder which required a suprapubic catheter, and Parkinson's disease. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was cognitively intact and had a urinary catheter in place. A Nurse Practitioner's Progress Note dated 8/7/2024 indicated she saw Resident #1 on 8/5/2024 in 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 record review, observations and staff, Pharmacy Consultant and Nurse Practitioner interviews the facility failed to administer pain medication as ordered for 1 of 3 residents (Resident #9) reviewed for pain management. Findings included: Resident #9 was admitted to the facility on [DATE] with diagnoses of left knee replacement. A Physician's Order dated 8/28/2024 at 6:45 pm indicated Resident #9 should receive Oxycodone/Acetaminophen 5/325 milligrams, a narcotic pain medication, for pain every 4 hours for pain rated at 4 or more on a pain scale of 1 to 10. An admission Minimum Data Set (MDS) had not been completed for Resident #9. A late entry note written on 8/29/2024 at 5:25 am by Nurse #6 indicated Resident #9 arrived at the facility 8/28/24 at 5:45 pm with an incision to his left knee which was covered with a bandage. His vital signs were normal, he was alert and oriented with some confusion, and he was resting. A progress note written by Nurse #7 on 8/28/24 at 9:34 pm indicated Resident #9 reported…

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 have pain medication available as ordered by the Nurse Practitioner on admission to the facility and provide nursing staff access to the electronic emergency backup medication storage for 1 of 3 residents reviewed for pain management (Resident #9). Findings included: Resident #9 was admitted to the facility on [DATE] with diagnosis of left knee replacement. A Physician's Order dated 8/28/2024 at 6:45 pm indicated Resident #9's admission medication orders included Oxycodone/Acetaminophen 5/325 milligrams, a narcotic pain medication, which was ordered every 4 hours as needed for pain rated at 4 or more on a scale of 1 to 10. A Nurse's Progress Note written 8/28/2024 at 9:34 pm written by Nurse #7 stated Resident #9 reported his pain was a 6 on a scale of 1 to 10 and he was experiencing muscle spasms to his left lower leg. An interview was conducted by phone on 9/17/2024 at 12:52 pm with Nurse #6 and she stated she worked on the 3:00 pm to 11:00 pm…

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 interviews, and staff interviews, the facility failed to place residents' call lights (Resident #12, #19, #15 and #40) within reach to allow for the residents to request staff assistance. This was for 4 of 4 residents reviewed for accommodation of needs. The findings included: 1) Resident #12 was admitted to the facility on [DATE] with diagnoses that included Vascular Dementia, anxiety disorder, orthostatic hypertension, osteoarthritis, and hearing loss. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #12's cognition was severely impaired. She had no behavior and no rejection of care. She required extensive assistance of 1 for bed mobility, dressing, toilet use, and personal hygiene. She had functional limitation with range of motion on one side of her lower extremities. Resident #12's active care plan, last revised on 04/14/23, indicated she was at risk for falls due to a history of falls and decreased mobility. The interventions…

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 interviews, and staff interviews, the facility failed to provide nail care for dependent residents (Resident #15, #19, and #40) and failed to wash a dependent residents (Resident #64) hair. This was for 4 of 12 residents reviewed for activities of daily living (ADL). The findings included: 1. Resident #15 was admitted to the facility on [DATE] with diagnosis that included Vascular Dementia with psychotic disturbance, history of falls, and type 2 diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #15's cognition was severely impaired. He had no behavior and no rejection of care. He required extensive assistance of 2 for personal hygiene. Resident #15 ' s active care plan, last revised on 08/21/23, indicated he had an ADL self-care performance deficit related to cognitive impairment, weakness and debility. The interventions included for staff to check nail length, trim and clean on bath day and as necessary. Report any changes 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, resident interview, family interview, staff interviews and record review, the facility failed to provide a lunchtime meal to a dialysis resident on 11/02/23, 11/04/23, 11/07/23, 11/09/23, 11/11/23, 11/14/23 and 11/16/23 for 1 of 1residents reviewed for dialysis (Resident #185). Findings included: Resident #185 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease and dependence on dialysis. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #185 cognition was not assessed, and staff assessment indicated his memory was ok. The MDS documented Resident #185 was able to understand others and was understood. In an interview with Resident #185 on 11/12/23 at 5:06 pm and he stated, he had not gotten a breakfast meal either at the facility or bag to go since his admission on [DATE]. He reported he went to dialysis on Tuesday, Thursday, and Saturday. He explained his chair time at dialysis was 6:15 am and he was usually…

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 record review and staff interviews the facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours a day, for 16 of 30 days (10/13,10/18,10/19,10/20, 10/23. 10/24, 10/27, 10/28, 10/29, 11/01, 11/02, 11/06, 11/07, 11/10, 11/11, and 11/12)) reviewed for staffing. Findings included: Review of the daily staffing sheets from 10/12/23 through 11/12/23 revealed there was no RN scheduled for the following days, 10/13, 10/18, 10/19, 10/20, 10/23, 10/24, 10/27, 10/28, 10/29, 11/1, 11/2, 11/6, 11/7, 11/10, 11/11, and 11/12. During an interview with the Scheduler on 11/16/23 at 3:00pm who indicated she had only been doing this job for 6 weeks. She revealed that she had no knowledge of not being able to count the Director of Nursing (DON) as the RN on staff if no other RN was not present. Scheduler acknowledge many days of no RN. The Administrator was interviewed on 11/16/23 at 4:58pm. The Administrator acknowledged the days the facility did not have an RN scheduled but she stated the DON was present and she had been the RN for that day. However, 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 record review, observation and staff interviews, the facility failed to remove expired medications and failed to remove loose pills from 1 of 2 medication carts reviewed and failed to remove expired medications from 1 of 2 medication storage rooms reviewed (300B medication cart and 200 hall medication storage room). Findings included: 1a. An observation of the 300B medication cart was conducted on 11/14/2023 at 1:30pm in the presence of Nurse #1 and Medication Aide (MA) #3 revealed the following medications as expired, that were in the medication cart and available for use: - One bottle of Milk of Magnesia liquid that expired September 2023. - One bottle of Multivitamin liquid that expired July 2023. MA #3 indicated that the two medications in the 300B medication cart were expired, and he was unaware that the medications had expired. Nurse #1 indicated that the two medications on the 300B medication cart were expired and indicated that both medications must be removed from the medication cart. Nurse #1 further indicated that night shift nurses were responsible for checking…

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 test tray observation, record reviews, and interviews with residents and staff the facility failed to serve food that was palatable and at temperatures acceptable to 5 of 8 residents reviewed for food palatability (Resident #1, Resident #3, Resident #22, Resident #26, and Resident #38). This practice had the potential to affect other residents. Findings included: a. Resident #1 was admitted to the facility on [DATE]. Resident #1 resided on the 100 hall. A review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact and independent with eating after assistance with meal set up. During an interview with Resident #1 on 11/12/23 at 4:32pm she indicated she had concerns with all her meals being cold. Resident #1 alleged the food was unappealing because the food was often undercooked or overcooked. A second interview was conducted with Resident #1 on 11/15/23 at 1:15 pm, Resident #1 indicated that lunch was cold today. Resident #1 indicated that the pork loin, mashed potatoes…

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, resident and staff interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor intervention the committee put in place following a complaint survey conducted on 12/17/20. This was evident for 1 deficiency that was cited in the area Comprehensive Resident Centered Care Plan (Develop/Implement Comprehensive Care Plan) and on the current recertification and complaint survey conducted on 11/17/23. The facility's Quality Assessment and Assurance (QAA) Committee also failed to maintain implemented procedures and monitor intervention the committee put in place following a complaint survey conducted on 1/28/21. This was evident for 1 deficiency that was cited in the area of Quality of Care and on the current recertification and complaint survey on 11/17/23. The QAA additionally failed to maintain implemented procedures and monitor interventions the committee put in place following recertification and complaint…

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 3. Resident #54 was initially admitted to the facility on [DATE] with diagnoses that included diabetes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #54 received one injection of insulin during the last seven days looked at for the 9/23/23 assessment. Review of the Medications Administration Record (MAR) for September 2023 showed Resident #54 received dulaglutide (once a week injection used to improve blood sugar) an injection of 0.75 milligram (mg) subcutaneously (under the skin, between the skin and muscle) on 9/21/23. Review of the MAR for September 2023 showed Resident #54 received insulin lispro (fast acting injectable insulin) on the following days: 9/16/23, 9/17/23, 9/18/23, 9/20/23, 9/21/23, and 9/22/23. An interview was conducted on 11/16/23 at 12:45 P.M. with the MDS Nurse #2 . MDS Nurse #2 reviewed the quarterly MDS and confirmed it was inaccurate. MDS Nurse #2 stated when she looked at Resident #54's MAR she only saw the medication dulaglutide and did not…

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, observations and staff interviews, the facility failed to develop an individualized and comprehensive care plan or interventions after falls (Resident #15), for a resident at risk for pressure ulcers and urinary incontinence (Resident #78) and failed to care plan a wanderguard (Resident #14). This was for 3 of 20 residents whose care plans were reviewed. The findings included: 1. Resident #15 was admitted to the facility on [DATE] with diagnosis that included Vascular Dementia with psychotic disturbance and history of falls. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #15's cognition was severely impaired. He had no behavior and no rejection of care. He required extensive assistance of 2 for bed mobility, dressing, and personal hygiene. He had 2 or more falls with no injuries. Resident #15 ' s active care plan, last revised on 08/21/23, included a focus for Resident #15 being at risk for falls related to impaired mobility, lower extremity amputee, 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 observations, record review, resident, and staff interview the facility failed to obtain a physician's order and perform dressing changes for a skin tear to a Resident's left upper arm for 1 of 1 resident reviewed for skin condition (Resident #78). The findings included: Resident #78 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, history of cerebral infarction, and chronic pain. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #78 was cognitively intact and needed extensive assistance with 1-person physical assist with bed mobility, 1-person physical assist with transfers, supervision with setup help with eating, and supervision with 1-person physical assist with toilet use. A review of progress note written on 11/08/23 at 10:28 am read in part, Resident found on floor in resident's bathroom laying in front of toilet with both knees bent. Resident wearing nonskid socks at time of incident. Resident assessed for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and record review the facility failed to identify the root cause for six falls and implement effective interventions to prevent six falls (Resident #15). This was for 1 of 7 residents reviewed for accidents. The findings included: Resident #15 was admitted to the facility on [DATE] with diagnosis that included Vascular Dementia with psychotic disturbance and history of falls. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #15's cognition was severely impaired. He had no behavior and no rejection of care. He required extensive assistance of 2 for bed mobility, dressing, and personal hygiene. He had 2 or more falls with no injuries. Resident #15 ' s active care plan, last revised on 08/21/23, included a focus for Resident #15 being at risk for falls related to impaired mobility, lower extremity amputee, and the use of psychotropic medications. (Initiated: 01/14/23). The interventions (Initiated: 01/14/23) included for staff to be sure…

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 reviews, interviews with staff and interview with the Pharmacist Consultant, the facility failed to have a medication error rate of less than 5% as evidenced by 3 medication errors out of 26 opportunities, resulting in a medication error rate of 11.54% for 2 of 3 residents (Resident #45 and Resident #11) observed during the medication administration observation. The findings included: 1. a. Resident #45 was admitted to the facility on [DATE]. Her cumulative diagnosis included Chronic Obstructive Pulmonary Disease (COPD). A review of Resident #45 active Physician Orders included a current order for Advair Diskus Aerosol Powder Breath Activated 250-50 MCG/DOSE, 1 inhalation inhale orally one time a day for SOB (initiated 11/10/23). Advair Diskus Aerosol is an inhaled medication containing a combination of two medications, fluticasone (a corticosteroid) and Salmeterol (a long-acting bronchodilator). Used to treat Chronic Obstructive Pulmonary Disease (COPD). On 11/15/23 at 8:22 AM,…

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.