Autumn Care of Nash

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to treat a resident in a dignified and respectful manner when Resident #86 requested toileting assistance from Nurse Aide (NA) #1 to use the bed pan for a bowel movement and the NA told the resident to have a bowel movement in his brief. A reasonable person expects to be assisted with toileting needs by their caregiver and would have experienced embarrassment when told to have a bowel movement in their brief rather than be assisted with toileting needs as requested. This deficient practice affected 1 of 3 residents reviewed for dignity (Resident #86). Findings included:Resident #86 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #86 was cognitively intact. He had no behaviors and was dependent on staff for toileting and transfers. Resident #86 was coded as continent of bowel and bladder. Review of the facility's investigation documentation completed by the Administrator revealed…

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, resident, and Medical Director interviews, the facility failed to notify the physician of a significant change when the resident's feeding tube site was identified by staff as visibly irritated, leaking, and caused the resident pain when touched for 1 of 1 sampled resident reviewed for feeding tube care (Resident #64). Findings included: Resident #64 was readmitted to the facility on [DATE] with diagnoses that included gastrostomy status (an artificial opening into the stomach through the abdomen wall to provide nutritional support). Review of Resident #64's physician orders revealed that on 4/5/25 a new order was initiated for nurses to clean the gastronomy tube (g-tube) site with normal saline and then apply a calcium alginate cover with split gauze twice daily until healed. Resident #64's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #64 was moderately cognitively impaired and she had a feeding tube. Review of the treatment…

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 and resident interviews, Pharmacy Manager and Medical Director interviews, the facility failed to protect the resident's right to be free from misappropriation of narcotic medication for 2 of 3 residents reviewed for misappropriation of property (Resident #96 and Resident #18). The findings included:The facility's Abuse, Neglect, and Exploitation policy last revised on 7/11/24 revealed it was the facility's policy to report all allegations to the Administrator/Abuse Coordinator. The policy further read that the Administrator/Abuse Coordinator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in this policy. The policy defined misappropriation as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without consent. a. Resident #96 was admitted to the facility on [DATE] with diagnoses which included joint replacement surgery. Resident #96…

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 care plan for 1 of 5 residents reviewed for psychotropic medications (Resident #2).The findings included:Resident #2 was admitted to the facility on [DATE] with diagnoses that included vascular dementia.Review of a physician's order dated 7/9/25 revealed an order for Olanzapine 2.5 milligrams (MG), take 1 tablet by mouth at bedtime. (Olanzapine is an antipsychotic medication used to treat mental health conditions and regulate your mood, behaviors and thoughts)The Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 had severe cognitive impairment and received antipsychotic medication on a routine basis.Review of Resident #2 's Comprehensive Care Plan dated 10/29/24 and revised 7/11/25 contained no information or interventions regarding antipsychotic medications.An interview conducted with the MDS nurse on 7/24/25 at 10:00 AM. The nurse was observed to review Resident #2's care plan and stated it must have been…

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, Pharmacy Manager, and Medical Director interviews, the facility failed to have effective systems in place for the inventory of controlled substances which resulted in a narcotic medication being ordered for a resident that did not have a physician order and the medication being diverted from the facility for 1 of 3 residents reviewed for misappropriation of resident's property (Resident #96). The findings included:Review of the Inventory Control of Controlled Substances Policy last revised 8/01/24, read in part a facility representative should regularly check the inventory records to reconcile inventory. The policy further noted this process should include current and discontinued inventory of controlled substances to the log used in the facility's-controlled medication inventory system.Resident #96 was admitted to the facility on [DATE] with diagnoses which included joint replacement surgery. Resident #96 discharged from the facility on 3/03/25.Resident #96 had a physician…

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 an accurate medication administration record for 1 of 5 residents reviewed for medication administration (Resident #36).The findings included:Resident #36 was admitted to the facility on [DATE] with diagnoses that included seizures.1a. Review of a physician order dated 5/1/24 revealed Lamotrigine 200 milligrams (mg) was to be administered two times a day for seizures. (Lamotrigine is an anticonvulsant medication used to treat and prevent seizures)Review of Resident #36's June Medication Administration Record (MAR) revealed no documentation of Resident #36's receiving her 8:00 PM dose of Lamotrigine on 6/2/25, 6/4/25, 6/10/25, 6/11/25, 6/12/25, 6/17/25, and 6/18/25.1b. Review of a physician order dated 5/1/24 revealed Phenobarbital 60 mg was to be given at bedtime for seizures. (Phenobarbital is a barbiturate derivative medication used to treat seizures)Review of Resident #36's June MAR revealed no documentation of Resident #36'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 record review, and staff and Medical Doctor interviews, the facility failed to enter a physician's order into the electronic medical record and document the administration of a medication for 1 of 4 residents reviewed for medication administration documentation (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] for surgical aftercare following surgery on the digestive system. Documentation in a nursing progress note dated 5/8/2025 at 12:59 PM written by Nurse #1 revealed Resident #1 was observed vomiting, the physician was notified, and an order was obtained for ondansetron (a medication used to prevent nausea and vomiting) 4 milligrams (mg) every 6 hours as needed. There was no documentation in the electronic medical record of a physician's order for ondansetron or documentation on the medication administration record (MAR) of its administration ondansetron for Resident #1 during the resident's stay at the facility. Nurse #1 was interviewed on 5/21/2025 at 11:36 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 observations, record review, and staff interviews the facility failed to maintain dignity when a resident had an uncovered urinary drainage bag with urine visible for public view from the hallway. The reasonable person concept was applied as individuals have the expectation of being treated with dignity and would not want their urine visible to visitors, staff, and other residents. This deficient practice was for 1 of 3 residents reviewed for dignity. (Resident #213) The findings included: Resident #213 was admitted to the facility on [DATE] with the diagnosis of urinary retention. An admission Minimum Data Set assessment dated [DATE] revealed the Resident was severely cognitively impaired, required substantial to maximum assistance from staff to complete activities of daily living, was incontinent of bowel, and was coded as having a urinary catheter. An observation of Resident #213 occurred on 6/10/24 at 9:45am. Resident #213 was observed in her room, in bed with her urinary drainage bag uncovered 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 interviews with staff and record review the facility failed to complete a baseline care plan within 48 hours of admission to address the immediate needs for 1 of 3 newly admitted residents reviewed (Resident #213). The findings included: Resident #213 was admitted to the facility on [DATE] with diagnoses that included diabetes, atrial fibrillation, and muscle weakness. An admission Minimum Data Set assessment dated [DATE] revealed the Resident was severely cognitively impaired, required substantial to maximum assistance from staff to complete activities of daily living, was incontinent of bowel and bladder, and was coded as having a urinary catheter. A review of Resident #213's medical record revealed the 48-hour baseline care plan was completed on 6/10/24. An interview was completed on 6/11/24 with the Director of Nursing (DON). The DON indicated it was the receiving nurse's responsibility to initiate the baseline care plan within 48 hours to meet the Resident's immediate needs. The DON stated 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 and staff interview the facility failed to implement a comprehensive care plan for 1 of 1 resident who received renal dialysis (Resident #43). The findings included: Resident #43 was admitted to the facility on [DATE] with diagnoses of end stage renal disease, renal dialysis, and diabetes mellitus. Review of the annual Minimum Data Set, dated [DATE] revealed that Resident #43 was mildly cognitively impaired, required set up assistance with eating and was coded for receiving dialysis. Review of the physician order dated 12/21/21 revealed an order for Novasource renal, one time a day for weight loss. Review of the physician order dated 1/25/23 revealed an order for fluid restriction 1,200 cubic centimeters (cc) every day. Dietary to give 840cc q day. Nursing to give 660 cc q day. Nursing 1st shift to give-270cc, nursing 2nd shift to give 270cc, 3rd shift to give-120cc. Review of the physician's order dated 2/8/22 revealed Resident #43 had a diet order as renal diet, regular texture. Review…

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 ensure a resident receiving dialysis had a physician's order for 1 of 1 sampled resident reviewed for receiving dialysis. (Resident #43). The findings included: Resident #43 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of end stage renal disease, and renal dialysis. Resident #43's care plan dated 11/27/20 noted he was on hemodialysis related to diagnoses of end stage renal disease. Staff were to provide diet as ordered, if resident has dialysis shunt, palpate for distal thrill and auscultate for bruit, monitor for bleeding, hemorrhage, sepsis, monitor skin around vascular access for, redness. Report to physician/Dialysis center: fever, chills, hypotension. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed the resident as having moderately impaired cognition. The MDS coded Resident #43 as receiving dialysis. Resident #43's medical record was reviewed and revealed there was no physician order 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.