Blumenthal Health and Rehabilitation Center

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 prior to discharge from Medicare Part A skilled services for 2 of 3 residents reviewed for beneficiary protection notification review (Resident #28 and Resident #83).The findings included:1. Resident #28 was admitted to the facility and to Medicare Part A skilled services on 5/22/25.Resident #28's Medicare Part A skilled services ended on 7/2/25. She remained in the facility.Record review revealed there was no documentation Resident #28, or her Responsible Party (RP) were issued a SNF-ABN. During a phone interview with the previous facility Social Worker on 9/11/25 at 12:56 PM she stated it was her job to issue the SNF-ABN. She stated when a resident's Medicare Part A skilled services were about to end, she provided the SNF-ABN to either the resident if they were their own Responsible Party or to the family if they were still going to remain in the facility. The Social Worker 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.

Based on record review, and resident representative and staff interviews, the facility failed to maintain documentation of resolved grievances for 2 of 3 residents (Resident #121 and Resident #170) and evidence of the results of all grievances for 6 of 11 months reviewed (February 2025 to July 2025). Findings included: Review of the facility policy last reviewed on 3/8/24 titled Grievance Policy read in part: The facility must ensure that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent finding or conclusions regarding the resident's concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken by the facility, and the date the written decision was issued.Review of the current facility grievance log for November 2024 through present showed there were no grievances logged between 2/1/25 through 7/31/25.During a phone interview with the previous Social Worker (SW) on 9/11/25 at 12:56 PM who…

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 interviews with staff, family, Nurse Practitioner, Medical Director, and responsible party (RP), the facility failed to protect the residents' right to be from resident- to- resident sexual abuse when a cognitively intact male resident (Resident #5) touched a female resident's (Resident #160's) breasts without her consent and made sexually explicit statements to her that included talking about the size of his penis. In addition, Resident #178 who was a moderately impaired male resident touched a female (Resident #163) between her legs near her vaginal area without her consent. This was for 2 of 4 residents reviewed for resident-to-resident abuse (Resident #160 and Resident #163). The findings included: Resident #160 was admitted to the facility on [DATE]. with diagnoses that included depression and anxiety. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #160's cognition was intact, she had no behaviors and was independent with using her wheelchair.…

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 staff interviews and record reviews, the facility failed to complete annual Minimum Data Set (MDS) assessments within the required 14-day timeframe after the Assessment Reference Date (ARD, the last day of the assessment look-back period) for 2 of 54 residents whose MDS assessments were reviewed (Resident #107 and Resident #126).The findings included: 1. Resident #107 was admitted to the facility on [DATE]. The resident's annual comprehensive Minimum Data Set (MDS) assessment had an Assessment Reference Date (ARD) of 7/30/25. This assessment was signed as completed by the facility's Registered Nurse (RN) MDS Coordinator on 9/3/25. An interview was conducted on 9/10/25 at 3:23 PM with the MDS Coordinator, who was later joined by MDS Nurse #2. During the interview, Resident #107's annual MDS with an ARD of 7/30/25 was reviewed. Upon inquiry, the MDS Coordinator confirmed Resident #107's annual MDS was completed on 9/3/25 and acknowledged this assessment was completed late. An interview was completed 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 staff interviews and record reviews, the facility failed to complete significant change in status Minimum Data Set (MDS) assessments within the required 14-day timeframe after the Assessment Reference Date (ARD, the last day of the assessment look-back period) for 2 of 54 residents whose MDS assessments were reviewed (Resident #14 and Resident #158).The findings included: 1. Resident #14 was admitted to the facility on [DATE]. The resident's significant change in status Minimum Data Set (MDS) assessment had an Assessment Reference Date (ARD) of 6/26/25. This assessment was signed as completed on 8/18/25. An interview was conducted on 9/10/25 at 3:23 PM with the MDS Coordinator, who was later joined by MDS Nurse #2. During the interview, Resident #14's significant change in status MDS with an ARD of 6/26/25 was reviewed. Upon inquiry, the MDS Coordinator confirmed Resident #14's significant change in status MDS was completed on 8/18/25 and acknowledged this assessment was completed late. An interview 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 staff interviews and record reviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the areas of: 1) Activities of Daily Living (Resident #107); 2) Use of an antibiotic medication (Resident #8), and 3) Brief Interview for Mental Status (BIMS) and Pain assessment interview (Resident #48). This occurred for 3 of 54 residents whose MDS assessments were reviewed.The findings included: 1. Resident #107 was admitted to the facility on [DATE]. The resident's cumulative diagnoses included acute respiratory failure with hypoxia (an inadequate supply of oxygen to the tissues) and non-Alzheimer's dementia. The resident's care plan included the following areas of focus, in part:--Long term care: the resident requires assistance with Activities of Daily Living (ADL) related to advanced age, chronic health conditions and is a Hospice patient (Date Initiated: 2/5/25); --The resident is incontinent of bladder and bowels: inability to control bowel and bladder (Date Initiated: 2/5/25).…

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, Resident Representative, and staff interviews, the facility failed to implement a fall mat for fall precautions for 1 of 4 residents reviewed for accidents (Resident #126).The findings included: Resident #126 was readmitted to the facility on [DATE] with diagnoses including dementia and hypertension. The annual Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #126 to be severely cognitively impaired. The MDS documented Resident #126 was dependent on staff for bed mobility. The MDS documented no falls since the previous quarterly MDS completed on 4/2/25. Care plans for Resident #126 last revised on 7/9/25 addressed Resident #126's potential for falling. Interventions included placing a fall mat on the floor on the left side of the bed. Resident #126 was observed on 9/8/25 at 12:03 PM. There was no fall mat on the floor on the left side of the bed. Resident #126 was positioned in the center of the bed, and the bed was in the low position. During 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, resident representative, and staff interviews, the facility failed to revise a care plan for 2 of 54 residents reviewed for care plans (Resident #158 and #28). The findings included: 1. Resident #158 was admitted to the facility 10/18/24 with diagnoses including diabetes and chronic lung disease. The significant change Minimum Data Set (MDS) assessment dated [DATE] documented Resident #158 was cognitively intact and had a condition or chronic disease that resulted in a life expectancy less than 6 months. The MDS documented Resident #158 received Hospice services. A. Review of Resident #158's medical record revealed a physician order dated 8/11/25 that changed Resident #158 full code status (full resuscitative efforts to be made in the event of cardiac arrest) to Do Not Resuscitate status (no resuscitative efforts to be provided in the event of cardiac arrest). This order was evident on Resident #158's face sheet in the electronic medical record.Review of the care plan revealed 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 observation, record review, and resident and staff interviews, the facility failed to provide a record of an activity assessment and provide an ongoing resident centered activities program that included activities to meet the interests of a resident who did not participate in activities outside of his room for 1 of 1 resident reviewed for activities (Resident #3). Resident #3 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting his right dominant side. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #3 was cognitively intact; and his activity preferences included books, music, animals, and being outside. Review of the care plan dated 6/20/25 revealed Resident #3 preferred to participate in self-directed activities such as reading books, watching television programs in his room. The interventions included review with the resident his self-directed preferences, as needed. During an…

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, and record reviews, the facility failed to monitor a resident's vital signs and neurological status (referring to an evaluation of an individual's brain and nervous system functions) after sustaining an unwitnessed fall for 1 of 7 residents reviewed for the provision of care in accordance with professional standards (Resident #8). The findings included:Resident #8 was admitted to the facility on [DATE]. The resident's cumulative diagnoses included respiratory failure with hypoxia (an inadequate supply of oxygen to the tissues), generalized muscle weakness, unsteadiness on feet, and difficulty in walking.A quarterly Minimum Data Set (MDS) assessment dated [DATE] was reviewed for the resident. Resident #8 was assessed as having intact cognition.The resident's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The assessment reported that the resident was understood and could understand others with clear comprehension but did not provide…

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 resident, staff and physician interviews, the facility failed to change a dressing for a peripherally inserted central catheter (PICC- is a type of longer intravenous catheter that goes into a larger vein close to the heart) line as ordered by the provider. The deficient practice occurred for 1 of 1 resident reviewed for parenteral/IV fluids (Resident #112). Findings included:Resident #112 was admitted to the facility on [DATE] with diagnoses of congestive heart failure, diabetes, chronic kidney disease, and cellulitis.Review of physician orders revealed an 8/27/25 order for meropenem (antibiotic) 1 gram intravenously three times a day for infection. An admission Minimum Data Set (MDS) assessment on 8/27/25 noted Resident #112 was cognitively intact. An admission care plan noted focus areas for congestive heart failure, chronic kidney disease, diabetes, falls, cellulitis, antibiotic therapy and central line care.Review of physician orders revealed an 8/28/25 order for 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 observations, record reviews, and staff and family interviews, the facility: failed to obtain an order for oxygen administration (Resident #121 and Resident #131), failed to administer supplemental oxygen at the prescribed rate (Resident #13) and failed to post cautionary signage for oxygen in use (Resident #13). These practices affected 3 of 3 residents reviewed for respiratory services (Residents #121, #131 and #13). The findings included: Resident #131 was admitted to the facility on [DATE]. A review of Resident #131's diagnosis revealed a diagnosis of “other forms of dyspnea.” A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #131 was cognitively intact. The resident was not documented as receiving oxygen during the assessment period. Resident #131's active care plan, last reviewed on 07/29/25, did not include a care plan for oxygen therapy. A review of Resident #131's August 2025 and September 2025 physician orders did not include an order for oxygen therapy. A review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and resident, and staff interviews, the facility failed to provide sufficient nursing staff to provide activity of daily living (ADL) assistance to residents who required extensive to total care with toilet hygiene and eating (Resident #162). This affected 1 of 13 sampled residents. 1. a. Resident #162 was admitted to the facility on [DATE] and had cumulative diagnoses that included dementia, contracture of right and left hands, dysphagia, and aphasia. Resident #162's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated she was barely/rarely understood and her cognitive skills were severely impaired. Resident #162 had functional limitation in range of motion to one side of her upper extremity and to both sides of lower extremities. She was dependent on staff for all ADLs and was always incontinent with bowel and bladder. Resident #162 also had a stage 4 pressure ulcer to her sacrum. An interview with the Ombudsman was conducted on 09/04/25 at 3:44 PM which stated she came 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 review, observations and staff interviews, the facility failed to: discard expired medications on 1 of 3 medication carts observed (Medication Cart #1) and 1 of 2 Medication Rooms (Medication room [ROOM NUMBER]); Failed to remove loose and unsecured pills of various shapes, sizes and colors on 2 of 3 medication carts (Medication Cart #1 and Medication Cart #4); and failed to store medication in accordance with the manufacturer's storage instructions on 1 of 3 medication carts (Medication Cart #1). The findings included:1. An observation was conducted on 09/10/25 at 2:00pm of the Medication (Med) Cart #1 in the presence of Medication Aide (MA) #2. The observation revealed the following medications were stored on the med cart:a. One bubble-pack card containing four 0.4 milligrams (mg) tablets of nitroglycerin (a medication used to prevent and treat chest pain) with no resident identification.An interview was conducted with MA #2 on 09/10/25 at 2:00pm. When asked, MA #2 confirmed that the medication…

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, record review, and staff interviews, the facility failed to implement their infection control policy when they failed to dispose of a soiled brief left on a resident's nightstand after performing incontinence care for 1 of 18 residents reviewed for activities of daily living (Resident #84). The facility also failed to implement their infection control policy regarding handwashing while providing ostomy care for 1 of 2 residents reviewed for ostomies (Resident #9). In addition, the facility failed to implement their infection control policy regarding handwashing and enhanced barrier precautions while providing wound care for 1 of 4 residents reviewed for pressure ulcers (Resident #9). This deficient practice occurred for 2 of 15 staff members observed for infection control practices (Nurse #9 and Nurse Aide #11).The findings included:1. The infection prevention and control sub policy entitled #702 Regulated Medical Waste read in part: The Center maintains a current standard of practice regarding regulated medical waste. Regulated waste is defined as waste…

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 include documentation in the medical record of education regarding the benefits and potential side effects of the Influenza and pneumococcal vaccines and failed to include documentation in the medical record for the acceptance or declination of the vaccinations for 3 of 5 residents reviewed for influenza and pneumonia vaccines (Resident #13, Resident #53, and Resident #132). The findings included: a. Resident #13 was admitted to the facility on [DATE]. A review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #13 was severely cognitively impaired, and the Influenza and Pneumococcal vaccines were not offered. A review of Resident #13's electronic medical record indicated the resident's family had refused the influenza and pneumonia vaccines for Resident #13. There was no information in the medical record that indicated Resident #13, or her family, was provided education regarding the benefits and potential side effects…

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 staff and Wound Nurse Practitioner (NP) interviews, the facility failed to obtain a treatment order for a suspected deep tissue injury when it was first observed which resulted in a delay in the initiation of treatment for 1 of 3 residents reviewed for pressure ulcers (Resident #5). The findings included: Resident #5 was admitted to the facility on [DATE] with diagnoses that included left total knee arthroplasty (surgical procedure to restore or repair a damaged joint) on 11/25/24, type 2 diabetes, chronic kidney disease, osteoarthritis, chronic pain, neuralgia (pain caused by damaged nerve), spondylosis with radiculopathy cervical region (spinal degeneration with nerve root compression of the bones and disks in the neck), hypertension, systemic inflammatory response syndrome (widespread inflammation in the body), hypothyroidism, neuromuscular disorder and obesity. The care plan dated 12/01/24 revealed the resident was at risk for pressure ulcers related to chronic health…

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 staff interviews and record review, the facility failed to: 1) Obtain a provider's order prior to requesting radiology testing (x-ray) be completed for a resident; and 2) Notify the Nurse Practitioner (NP) when the results of the x-ray revealing 4 rib fractures became available. This occurred for 1 of 3 residents (Resident #2) reviewed for accidents. The findings included: Resident #2 was admitted to the facility on [DATE] with cumulative diagnoses which included a history of stroke, generalized muscle weakness, and dementia. The resident's admission Minimum Data Set (MDS) dated [DATE] revealed she had severely impaired cognition. Resident #2 required set-up or clean-up assistance for eating, partial/moderate assistance for bed mobility and walking 10 feet; with substantial/maximum assistance for toileting, bathing, sit to stand, and chair to bed to chair transfers. Resident #2's electronic medical record (EMR) included a Fall Note dated 4/21/25 at 1:00 PM. This note reported Resident #2 had a fall 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.

Based on record review and Administrator interview, the facility failed to report an allegation of neglect to the state agency for 1 of 1 residents reviewed for neglect (Resident #1). Findings included: The Administrator was notified on 1/3/25 at 8:48 AM of an allegation of neglect after Resident #1 sustained a fall on 11/17/24 and did not receive necessary care and services for a fracture. According to the Complaint Intake Unit (CIU), there was no evidence that an initial allegation report was submitted to the state agency until 1/6/25 at 2:15 PM. The Administrator was interviewed on 1/6/25 at 10:08 AM. He revealed that the initial allegation report was not sent to the state agency on 1/3/25 because all parties involved, including the state agency, were aware of the allegation, so he assumed it was not necessary.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure a medical record was accurate regarding post fall documentation. This was for 1 of 5 sampled residents whose medical record was reviewed for documentation (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE]. Review of a 72-hour post fall documentation note dated 11/17/24 at 11:21 AM and completed by Nurse #1 revealed that Resident #1 reported pain in her left hip when the responsible party (RP) arrived at the facility. Review of a 72-hour post fall documentation note dated 11/18/24 at 2:18 PM and completed by Nurse #2 revealed that Resident #1 had a nondisplaced fracture to the left femur and reported a pain level of 4 in the left hip. Review of a 72-hour post fall documentation note dated 11/18/24 at 11:43 PM and completed by the Night Nurse Supervisor revealed that it read the same information from Nurse #1's 72-hour post fall documentation note dated 11/17/24 at 11:21 AM for Resident #1. Review of 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.

Based on record reviews and staff interviews, the facility failed to have licensed nursing coverage 24 hours/day in the facility for 17 out of 120 days reviewed for staffing. The failure to have a licensed nurse in the facility at all times had a high likelihood of impacting every resident in the facility. The findings included: Review of the staffing data submitted by the facility through the CMS (Centers for Medicare and Medicaid Services) Payroll-Based Journal (PBJ) system for quarter 3 (April 1, 2024 through June 30, 2024) indicated there was no licensed nurse coverage 24 hours/day in the facility on 4/6/24, 4/5/24, 4/13/24, 4/14/24, 4/20/24, 4/21/24, 4/27/24, 4/28/24, 5/4/24, 5/5/24, 5/11/24, 5/12/24, 5/18/24, 5/19/24, 5/25/24, 5/26/24 and 5/27/24. The facility was unable to locate the Staff Schedule/Assignment Sheets, timecard reports or payroll reports to review for licensed nursing staff for April through June of 2024. During an interview with the Staff Development Coordinator (SDC) on 10/23/24, she stated she had been in the role of SDC, Infection Preventionist and 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 reviews and staff interviews, the facility failed to provide Registered Nurse (RN) coverage at least 8 consecutive hours per day, 7 days per week for 17 out of 120 days reviewed for staffing. The findings included: Review of the staffing data submitted by the facility through the CMS (Centers for Medicare and Medicaid Services) Payroll-Based Journal (PBJ) system for quarter 3 (April 1, 2024 through June 30, 2024) indicated indicated there was no RN coverage for eight consecutive hours on 4/5/24, 4/6/24, 4/13/24, 4/14/24, 4/20/24, 4/21/24, 4/27/24, 4/28/24, 5/4/24, 5/5/24, 5/11/24, 5/12/24, 5/18/24, 5/19/24, 5/25/24, 5/26/24 and 5/27/24. The facility was unable to locate the Staff Schedule/Assignment Sheets, RN timecard reports, or payroll reports to review for the time period of April 1, 2024 through June 30, 2024. During an interview with the Staff Development Coordinator (SDC) on 10/23/24 at 11:14 AM, she stated she has been in the role of SDC, infection preventionist and the assistant director of nursing since the new company took over in June 2024. She stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews and record reviews, the facility failed to prevent a significant medication error when a nurse failed to administer insulin before a meal as scheduled as specified in the physician's order. This occurred for 1 of 1 sampled resident (Resident #25). The findings included: Resident #25 was admitted to the facility on [DATE]. Her diagnoses included, in part, diabetes mellitus and dementia. A review of the resident's physician's orders included the following: - Humalog Insulin Solution (Insulin Lispro) Inject as per sliding scale (where the dose of insulin administered was dependent on the resident's current blood glucose level): The sliding scale insulin was ordered to be administered before meals and at bedtime as follows: -If the blood glucose was 101 - 150 milligrams (mg)/deciliter (dL), give 2 unit of insulin. -If the blood glucose was 151 - 200 mg/dL, give 3 units of insulin. -If the blood glucose was 201 - 250 mg/dL, give 5 units of insulin. -If the blood glucose was 251…

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's interdisciplinary team failed to assess and document the ability of a resident to self-administer medications for 2 of 2 residents (Resident #6 and Resident #12) who were reviewed for medication self-administration. Findings included: 1. A review of the electronic health record revealed Resident #6 was admitted to the facility on [DATE]. A care plan dated 07/05/24 revealed Resident #6 did not have a care plan to address self-administration of medications. The quarterly Minimum Data Set assessment dated [DATE] revealed Resident #6 was cognitively intact. A review of physician orders dated 09/30/24 for Resident #6 revealed an order for Senna (a stool softener) Oral Tablet 8.6 milligrams (mg). Give 2 tablets by mouth at bedtime for constipation. There was no order discovered for Resident #6 to self-administer medications. Review of Resident #6's 10/20/24 Medication Administration Record (MAR) revealed Nurse #12 had signed off…

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 medical record review and staff interview, the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment for 1 of 2 residents (Residents #15) reviewed for hospice services. Findings included: Resident #15 was admitted to the facility on [DATE] with diagnosis which included malignant neoplasm of the right lung. Resident #15 was admitted to Hospice Services on 4/16/24. A review of the MDS assessments revealed a Significant Change in Status MDS Assessment was not completed after Resident #15 was admitted to hospice services. During an interview on 10/24/24 at 10:35 a.m., the MDS Coordinator revealed she began working at the facility two months ago. She stated she was informed by the Regional MDS Consultant that the facility did not have a MDS Coordinator for over a year; instead, the facility utilized traveling MDS Nurses to complete the MDS' and different facility staff to conduct onsite interviews and observations. After a review of Resident #15's medical record, 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 reviews and staff interviews, the facility failed to accurately code the minimum data set (MDS) assessments in the areas of falls (Resident #42), range of motion (Resident # 59) and failed to assess (Resident #69) and code the MDS assessment for cognition, mood, behavior, functional abilities, bowel and bladder continence, and oral/dental status. This was for 3 of 30 sampled residents reviewed for MDS accuracy. Findings included: 1. Resident #59 was admitted to the facility on [DATE] with the diagnosis which included: hemiplegia and hemiparesis following a cerebrovascular accident affecting the right dominant side and a right-hand contracture. Review of the annual minimum data set (MDS) assessment dated [DATE] indicated Resident #59 was severely, cognitively impaired and had no range of motion impairments of his upper or lower extremities. The review of the Occupational Therapy (OT) Discharge summary dated [DATE] recommended Resident #59 receive a Functional Maintenance Program 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 observations, record reviews and staff interviews, the facility failed to apply the right-hand grip splinting device as recommended by the occupational therapist for 1 of 1 sampled resident (Resident #59) with a contracture of his right hand. Findings included: Resident #59 was admitted to the facility on [DATE] with the diagnosis which included: hemiplegia and hemiparesis following a cerebrovascular accident affecting the right dominant side and a right-hand contracture. Review of the annual Minimum Data Set assessment dated [DATE] indicated Resident #59 was severely cognitively impaired and had no impairments of his upper or lower extremities. The care plan did not include Resident #59's right-hand contracture and the application of a splinting device. The review of the Occupational Therapy (OT) Discharge summary dated [DATE] recommended Resident #59 receive a Functional Maintenance Program for right wrist/hand/finger orthosis in place-using a right grip splint. Nursing education was provided. 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 and Nurse Practitioner interviews, the facility failed to administer oxygen at the physician prescribed rate for 1 of 1 resident sampled for respiratory care (Resident #14). The findings included: Resident #14 was admitted to the facility on [DATE] with diagnoses which included hypoxemia (a low level of oxygen in the blood) and congestive heart failure. A review of Resident #14's quarterly Minimum Data Set (MDS), dated [DATE], revealed she was moderately cognitively impaired and was on oxygen therapy. A review of Resident #14's Physician Orders read, oxygen at 2 liters per minute via nasal cannula and was written on 09/25/24. A review of Resident #14's Care Plan, last revised on 10/14/24, indicated she was at risk for respiratory complications secondary to her supplemental oxygen requirement. Interventions included to administer oxygen as ordered. A review of Resident #14's vital signs revealed an oxygen saturation of 96% on 10/19/24 and 98% on 10/01/24. There were…

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

Based on staff interviews and record review, the facility failed to maintain a complete medical record in the area of diagnoses for 1 of 5 residents (Resident #42) reviewed for unnecessary medications. The findings included: Resident #42 was admitted to the facility 6/14/24 following a fractured pelvis and septic shock resulting in generalized muscle weakness. Review of Resident #42's hospital discharge summary 5/22/24 showed diagnoses schizophrenia and post-traumatic stress disorder (PTSD). Review of Resident #42's electronic medical record cumulative diagnosis face sheet did not include schizophrenia or PTSD. During an interview with the Director of Nursing on 10/24/24 at 11:25 AM, she stated that all residents should have complete and accurate diagnoses in their charts. She stated the MDS Coordinators will be working close with the nursing staff to make sure all charts contain accurate and complete information going forward.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with family, hospice nurse, and facility staff, the facility failed to treat terminal agitation in 1 of 1 (Resident #3) resident reviewed for hospice. The findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses that included late onset Alzheimer's dementia. The resident's medical record included an order for hospice services dated 2/8/2023. Resident #3's discharge Minimum Data Set (MDS) dated [DATE] indicated the resident was severely cognitively impaired and required extensive assistance with activities of daily living and personal hygiene. During the assessment period she received pain medications, both scheduled and as needed. Resident #3 received hospice services during the assessment period. Resident #3's comprehensive care plan was last revised 5/6/2023 and included a focus for hospice services and experiencing a peaceful and dignified death. Interventions included coordinating with the hospice team to ensure residents experienced as little…

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, interviews with staff and the consultant Registered Dietitian (RD), and record review, the facility failed to provide a nourishing evening snack when more than 14 hours elapsed between the provision of a substantial evening meal and breakfast the following day for residents residing on 7 of 7 resident hallways (700 Hall, 200 Hall, 3200 Hall, 300 Hall, 400 Hall, 500 Hall and 600 Hall). The findings included: A review of the facility's Tray Delivery Schedule (updated 10/20/21) indicated the meal cart delivery times were scheduled as follows: --The meal cart for the 700 Hall was scheduled to be delivered at 5:00 PM for Dinner and at 8:00 AM for Breakfast (indicative of a 15-hour time span between the two meals). --The meal cart for the 200 Hall was scheduled to be delivered at 5:25 PM for Dinner and at 8:25 AM for Breakfast (indicative of a 15-hour time span between the two meals). --The meal cart for the 3200 Hall was scheduled to be delivered at 5:35 PM for Dinner and at 8:35 AM for Breakfast (indicative of a 15-hour time span between the two meals). --The meal…

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, interviews with staff and the consultant Registered Dietitian (RD), and record reviews, the facility failed to: 1) Seal, label/date, and/or discard expired food items in 1 of 1 walk-in cooler; 2) Seal and label/date opened food items in 1 of 1 Dry Storage area; 3) Label/date opened food items stored in the kitchen preparation / cooking area; and 4) Label/date opened food items in 1 of 1 Nourishment Room observed (200 Hall). These practices had the potential to affect food served and distributed to all residents. The findings included: 1. An initial tour of the Dietary Department was conducted on 5/21/23 at 10:10 AM and a follow-up observation done with the Dietary Manager on 5/21/23 at 2:23 PM. Observations made of the walk-in cooler identified the following concerns: --A 1/2 (4-inch deep) steam table pan contained 3 plastic container bags piled 6-inches high (over the top of the pan). Both the steam table pan itself and contents of the 3 plastic bags were warm to the touch. The contents…

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 interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint survey dated 6/21/2021 and 8/4/2022, and the complaint survey dated 10/11/2022. This was for nine deficiencies that were cited in the areas of resident rights (F550), formulate advanced directives (F578), safe/clean/homelike environment (F584), accuracy of assessments (F641), care plan timing and revision (F657), treatment and services to prevent/heal pressure ulcers (F686), free from unnecessary psychotropic medications and as needed use (F758), label and store drugs and biologicals (F761), and food procurement (F812). The nine areas were recited on the current recertification and complaint survey of 5/25/2023. The duplicate citations during two federal surveys of record demonstrate a pattern of the facility's inability to sustain an…

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 and interviews with residents and staff, the facility failed to ensure cigarettes were disposed of in a non-combustible container (courtyard), failed to properly label and store personal care equipment in shared bathroom (rooms [ROOM NUMBERS]); failed to repair the linoleum around the base of the toilet (room [ROOM NUMBER]); failed to maintain walls and baseboards in good repair (rooms 602, 605, 606, and 611); failed to repair loose fitting sink faucets (rooms [ROOM NUMBERS]); failed to maintain toilet paper holders in good repair (room [ROOM NUMBER] and 603); failed to maintain properly attached call bell wall sockets (room [ROOM NUMBER]); failed to maintain window blinds in good repair (room [ROOM NUMBER]); maintain night stand in good repair (room [ROOM NUMBER]). This occurred for a courtyard and 7 of 11 rooms reviewed for a clean, safe, and homelike environment. The findings included: 1. An observation was conducted on 5/24/2023 at 11:32 a.m. of the courtyard and it revealed greater…

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 staff interviews and record reviews, the facility failed to offer the opportunity to be vaccinated with the Prevnar 20 (pneumococcal conjugate vaccine (PCV) 20) in accordance with nationally recognized standards for 4 of 5 residents reviewed for pneumococcal immunizations (Resident #58, #53, #70, and #3). Findings include: The Center for Disease Control and the Advisory Committee on Immunization Practices (ACIP) now recommends routine vaccination against pneumococcal infection for all adults aged 65 years or older and 19-64 with certain underlying medical conditions. Beginning June 8, 2021, for persons aged 65 years and older who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown, they should receive 1 dose of PCV15 or 1 dose of PCV20. Review of the facility's immunization policy last revised in 2019 stated that all residents would be offered a pneumococcal vaccine upon admission; brand unspecified. A. Record review revealed Resident #58 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 observation, record review, staff and resident interviews, the facility failed to promote dignity when, 1) a staff member transported a resident (Resident #84) into a public area with the back of their gown open, exposing the backside of the resident and 2) by not shaving a female resident's face (Resident #49) that was dependent on staff for activities of daily living (ADL) care needs. This occurred for 2 of 17 residents reviewed for Dignity and respect. The findings included: 1) Resident #84 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, atrial fibrillation, and a lack of coordination. A review of the quarterly Minimum Data Set assessment dated [DATE] revealed the Resident had no cognitive impairment and required extensive assistance of one staff member with dressing, personal hygiene, and dressing. A review of Resident #84's care plan for 5/4/2023 had a focused area for activities of daily living care needs that included assisting the Resident with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews and medical record reviews, the facility failed to invite a cognitively intact resident to participate in the planning of the resident's care for 2 of 4 residents (Resident #27 and Resident #55) reviewed for participation in care plans. The findings included: 1. Resident #27 was admitted to the facility on [DATE]. Diagnoses included, in part, hypertension and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had intact cognition. During an interview with Resident #27 on 5/22/23 at 11:02 AM, she stated she had not been invited to participate in care plan meetings but would participate in the care plan process if the facility invited her. She added staff had not updated her or involved her on any changes with her medications or treatments. MDS Nurse #3 was interviewed on 5/24/23 at 10:14 AM. She stated that typically, during the month of a resident's MDS assessment, she sent a care plan meeting invitation to the alert and oriented…

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, resident and staff interviews, the facility failed to accurately transcribe the Advance Directive of 1 of the 2 sampled residents reviewed (Resident #13). Findings included: Resident #13 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included: congestive heart failure, schizoaffective disorder, and bipolar disorder. The quarterly Minimum Data Set, dated [DATE] indicated Resident #13 was cognitively intact. The electronic medical records documented Resident #13's advance directive status as Full Code/CPR (cardiopulmonary resuscitation) on the clinical profile and basic information records. Also, included in the resident's electronic record was the Full Code Agreement signed by the resident's responsible representative on [DATE]. Resident #13's portable medical forms, maintained at the nurse's station in the Emergency Book consisted of Resident #13's face sheet which documented the resident's advance directive status as Full Code. The book…

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. Resident #55 was admitted to the facility on [DATE]. Diagnoses included, in part, gastroesophageal reflux disease and coronary artery disease. On 9/28/22, the resident was seen at the facility by the dentist. The comprehensive examination note read, in part, Chief Complaint/Dental Concern: broken and missing teeth. The annual MDS assessment dated [DATE], and completed by MDS Nurse #3, revealed Resident #55 had no dental issues. An observation of Resident #55's mouth was completed with MDS Nurse #1 on 5/23/23 at 1:24 PM. During the observation, MDS Nurse #1 reported the resident had missing and broken teeth. On 5/24/23 at 10:06 AM, an interview was conducted with MDS Nurse #3. She verified she completed the MDS assessment dated [DATE]. She explained when she coded the dental section on the MDS, she looked in Resident #55's mouth before she coded dental status. When she looked in Resident #55's mouth she saw some cavities and missing teeth. She documented her observations on a paper copy of the MDS assessment,…

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 staff interviews and record reviews, the facility failed to develop a baseline care plan within 48 hours of the resident's admission for 2 of 16 newly admitted residents reviewed (Resident #39, Resident #87, and and Resident #98). The findings included: 1. Resident #39 was initially admitted to the facility on [DATE]. Her cumulative diagnoses included diabetes and malnutrition. Resident #39's electronic medical record (EMR) did not include a baseline care plan. On 5/23/23 at 1:25 PM, the facility's Director of Nursing (DON) confirmed Resident #39 did not have a baseline care plan. Further review of Resident #39's EMR revealed a comprehensive, individualized care plan was initiated on 9/6/22 (greater than 48 hours after admission to the facility). The resident's comprehensive care plan included the following areas of focus, in part: --The resident has a diagnosis of diabetes (Start Date 9/6/22); --The resident is at risk for nutritional decline due to a past medical history that included diabetes,…

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 revise the care plan of 1 of 1 sampled resident (Resident #88) reviewed for range of motion and contractures. Findings included: Resident #88 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction and flaccid hemiplegia affecting unspecified side. The annual minimum data set (MDS) dated [DATE] indicated Resident #88 had moderately impaired decision-making skills; unclear speech; and limited range of motion of the upper and lower extremities to one side of his body. The care plan dated 4/21/23 revealed Resident #88 was at risk for falls and injury related to weakness, impaired mobility, incontinence, potential side effects from medication, poor safety awareness and history of falls. Interventions included physical therapist to work with transfers and strengthening. The care plan was not revised to include Resident #88's right hand contractures. During an observation and resident interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interviews, and the Wound Physician interview, the facility failed to follow a physician order for a wound dressing change for 1 of 4 (Resident #569) sample residents reviewed for pressure ulcers. The findings included: Resident #569 had an initial admission date of 1/16/23 and was re-admitted from the hospital to the facility on 2/3/23. His diagnoses included protein-calorie malnutrition and diabetes. Resident #569's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS showed the resident was severely cognitively impaired and had one stage 4 pressure ulcer (a stage 4 pressure ulcer is a full tissue loss with exposed bone, tendon, or muscle). The MDS showed Resident #569 received hospice services. A review of Resident #569's most recent care plan, last reviewed on 5/18/23, included a focus area for pressure ulcer to right heel and a risk for nutritional decline. Interventions included remind to shift weight frequently, refer to wound…

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 consistently provide the functional management program recommended by the occupational therapist for 1 of 1 sampled resident (Resident #88) reviewed for contractures. Findings included: Resident #88 was admitted to the facility on [DATE] with the diagnoses which included cerebral infarction and flaccid hemiplegia affecting unspecified side. The annual minimum data set (MDS) dated [DATE] indicated Resident #88 had moderately, impaired decision-making skills; unclear speech; and limited range of motion of the upper and lower extremities to one side of his body. The care plan dated 4/21/23 revealed Resident #88 was at risk for falls and injury related to weakness, impaired mobility, incontinence, potential side effects from medication, poor safety awareness and history of falls. Interventions included physical therapist to work with transfers and strengthening. During an observation and resident interview on 5/21/23 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 interviews with staff, the consultant pharmacist and Medical Director, and record reviews, the facility failed to limit the use of psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) ordered on an as needed (PRN) basis to 14 days and/or indicate the duration for the PRN order to be extended beyond 14 days, when appropriate. This occurred for 1 of 5 residents (Resident #569) reviewed for unnecessary medications. The findings included: Resident #569 was admitted to the facility on [DATE] with re-entry from a hospital on 2/3/23. His cumulative diagnoses included senile degeneration of the brain. A review of the resident's electronic medical record (EMR) revealed his medication orders dated 2/3/23 included an order for 1 milligram (mg) lorazepam (an antianxiety medication) to be given as one tablet by mouth every 4 hours as needed (PRN) for anxiety. No stop or discontinue date was included in the resident's PRN order for the lorazepam. Lorazepam is…

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 and staff interviews and record review, the facility failed to secure medications for 1 of 1 resident (Resident #88) observed with medications at bedside. Findings included: Resident #88was admitted to the facility on [DATE]. Diagnoses included, in part, aphasia following cerebral infarction and diabetes. The yearly Minimum Data Set assessment dated [DATE] revealed Resident #40 had minimal impaired cognition. An observation of Resident #88's room was completed on 5/21/23 at 11:31 AM. The resident was alert and lying in bed. A bottle of Nystatin powder with his name on it was observed on the resident's bedside table. During an interview with Resident #88 on 5/21/23 at 11:35 AM, he indicated by nodding his head and using a thumbs up sign that the bottle belonged to him and that he used it occasionally when needed. During a record review performed on 5/21/23 there was no self-administer medication assessment found for Resident #88. Med Tech #1 was interviewed on 5/22/23 at 09:35 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, interview with the Dental Practice Administrator, and record review, the facility failed to reschedule a follow up dental care appointment for recommended extractions for 1 of 3 residents (Resident #55) reviewed for dental services. Findings included: Resident #55 was admitted to the facility on [DATE]. Diagnosis included, in part, gastroesophageal reflux disease. On 9/28/22, the resident was seen at the facility by the dentist. The comprehensive examination note read, in part, Diagnosis: Unrestorable teeth, needs extractions-multiple root tips and teeth with advanced bone loss. Patient would like dentures . The note further recommended that prior authorization for dentures be obtained and that extractions were to be performed on the next regularly scheduled visit. A dental visit note dated 1/10/23 revealed Resident #55 was scheduled to be seen by the in-house dental provider for extractions; however, the resident had not felt well on the day of the visit 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.