Meadowbrook Health & Rehabilitation

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 1 of 11 newly admitted residents reviewed (Resident #119).The findings included: Resident #119 was initially admitted to the facility on [DATE]. She was discharged home with a family member on 11/12/25. The resident had a second admission to the facility on [DATE]. Her cumulative diagnoses included emphysema, a history of a cerebral infarction (a type of stroke) and repeated falls. Resident #119's electronic medical record (EMR) included a Nursing re-admission Assessment Tool completed by Nurse #3 and dated 12/13/25. This document included information on the resident's mental and physical health, a pain tool, Braden Scale, Patient Record of Tuberculosis Screening, Fall Risk/Medication, Smoking Safety Screen, Device / Air Mattress Safety Observation, and an Elopement Evaluation. Further review of Resident #119's EMR revealed there was no baseline care plan completed 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, staff interviews and record review, the facility failed to obtain a provider's diet order for a resident after her admission to the facility. This occurred for 1 of 11 newly admitted residents reviewed (Resident #119).The findings included: Resident #119 was initially admitted to the facility on [DATE]. The resident's diet order (dated 10/15/25) was a Regular diet with mechanical soft textures and regular, thin liquids. On 10/22/25, Med Pass 2.0 (a high calorie, high protein nutritional supplement) was added to her diet order as 120 milliliters (ml) to be given at bedtime daily. Resident #119 was discharged to her home with a family member on 11/12/25. Resident #119 was hospitalized from [DATE] to 12/12/25. Her hospital Inpatient Discharge summary dated [DATE] included Diet and Nourishment Orders for a pureed diet with thin liquids. The resident was admitted a second time to the facility on [DATE]. Her cumulative diagnoses included emphysema, a history of cerebral infarction (a type 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 observations, record review, and staff interviews, the facility failed to maintain a urinary catheter drainage bag off the floor to prevent the risk of infection for 1 of 1 resident reviewed for indwelling urinary catheter (Resident #8). The findings included:Resident #8 was admitted to the facility on [DATE] with diagnoses which included neuromuscular dysfunction of the bladder. Review of Resident #8's significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #8's cognition was severely impaired and was totally dependent for most activities of daily living (ADL). The MDS further revealed Resident #8 was coded for having an indwelling urinary catheter.Review of Resident #8's physician orders revealed an order dated 12/09/25 for an indwelling urinary catheter for neurogenic bladder with urinary retention.Review of Resident #8's care plan revised on 12/16/25 revealed the resident was readmitted to the facility from the hospital with a catheter for neurogenic bladder with urinary retention.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews with staff, the facility failed to enter a physician's order for oxygen delivery for 1 of 1 resident reviewed for respiratory care (Resident #101).The findings included: Resident #101 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, tobacco use, and anemia. On 12/15/25 at 3:55 PM Resident #101 was observed asleep in bed and wearing oxygen via nasal cannula at 3 Liters/minute (L/min) connected to portable oxygen next to her bed. The resident did not show any signs of discomfort or difficulty breathing. Review of the nurse progress note date 12/15/25 2:52 PM progress note revealed Nurse #8 notified the provider that Resident #101 had abnormal vital signs: blood pressure 159/101, pulse 104, and oxygen saturation level of 64% on room air. A normal oxygen saturation level is at, or above, 90%. Nurse #8 documented she was ordered to start Resident #101 on 2L/min of oxygen. Nurse #8 wrote that she communicated 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 observations, staff interviews, and record reviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 26 opportunities, resulting in a medication error rate of 7.6% for 2 of 6 residents (Resident #35 and Resident #105) observed during the medication administration. The findings included: 1. On [DATE] at 8:16 AM, Medication Aide (Med Aide) #1 was observed as she prepared and administered fifteen (15) medications to Resident #35. A review of Resident #35's current orders revealed a medication order was initiated on [DATE] for 200 - 25 micrograms (mcg) per actuation of Breo Ellipta aerosol powder to be given as one puff by mouth one time a day for shortness of breath / wheezing. Breo Ellipta is an inhaled medication used for the management of chronic obstructive pulmonary disease (COPD) and/or asthma. Resident #35's Breo Ellipta was scheduled for administration at 8:00 AM once daily in accordance with the physician's orders. This medication 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, and staff, Resident, Pharmacy Consultant and Nurse Practitioner interviews, the facility failed to administer pain medication as ordered for 1 of 3 residents (Resident #2) reviewed for pain management. Findings included: Review of Resident #2's hospital record indicated she had a right ankle Computed Tomography (CT) Scan on 12/23/2024 which showed a new minimally displaced fracture involving the right ankle and a knee x-ray that showed a mildly displaced fracture involving the distal femur which forms the knee joint. The hospital record also indicated Resident #2 had surgical repair of the right ankle on 1/25/2025. Resident #2 was admitted to the facility on [DATE] with fractures to her left knee and right ankle. An admission Minimum Data Set assessment dated [DATE] indicated Resident #2 was cognitively intact and had moderate pain frequently. A Physician's Order dated 1/8/2025 at 8:00 pm indicated Resident #2 should receive Oxycodone Hydrochloride (a narcotic pain…

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 Nurse Practitioner interviews, the facility failed to ensure a resident was transported to a scheduled urologist appointment on 1/2/2025 to have their suprapubic indwelling urinary catheter changed. The deficient practice occurred for 1 of 1 resident reviewed for medical related social services (Resident #3). Findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses of diabetes, obstructive uropathy and chronic kidney disease. Resident #3's quarterly Minimum Data Set assessment dated [DATE] indicated she was severely cognitively impaired and required an indwelling urinary catheter. A Visit Summary from the Urologist dated 12/2/2024 stated Resident #3 was scheduled for a 31-day suprapubic catheter change at the urologist's office on 1/2/2025. There was no evidence in the medical record that Resident #3 attended the urology appointment scheduled for 1/2/2025. During an interview with the Appointment Coordinator on 1/29/2025 at 3:40 pm he stated he…

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, Nurse Practitioner, Pharmacy Consultant, and resident interviews, the facility failed to ensure 1 of 1 resident (Resident #2) had pain medication available that was ordered on admission to the facility. Findings included: Review of Resident #2's hospital record indicated she had a right ankle Computed Tomography (CT) Scan on 12/23/2024 which showed a new minimally displaced fracture involving the right ankle and a knee x-ray that showed a mildly displaced fracture involving the distal femur which forms the knee joint. The hospital record also indicated Resident #2 had surgical repair of the right ankle on 1/25/2025. Resident #2 was admitted to the facility on [DATE] with fractures of her left knee and right ankle. A Physician's Order dated 1/8/2025 at 8:00 pm indicated Resident #2 should receive Oxycodone Hydrochloride (a narcotic pain medication) 10 milligrams (mg) two times a day for pain beginning 1/8/2026 and would be discontinued on 1/10/2025. Resident #2's 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 observations and staff interviews, the facility failed to repair a sink drain and pipe which resulted in the kitchen having a large amount of water in the floor which had the potential to be hazardous for staff. Also observed in the kitchen were multiple ceiling vents that were dusty and dirty, and four bags of cereal not labeled or stored properly. These practices had the potential to affect food served to residents. Findings included: An observation conducted on 09/24/23 at 10:35 AM revealed Dietary Aide (DA) #1 pulled the lever to drain the sink, but the water did not drain properly and ran across the kitchen floor resulting in a large area of standing water. Dietary Aide #1 turned the sink back on and the pipe running under the sink was leaking water continuously. Observations of ceiling vents above the dry station and stove area were observed to be dusty and dirty. Also observed next to the tea and coffee station were four bags of unlabeled cereal that were folded and not clipped or stored properly. An interview conducted with DA #1 on 09/24/24 at 10:45 AM revealed the…

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

Based on observations and staff interviews the facility failed to remove loose garbage and debris from around 2 of 2 trash receptacles located outdoors behind the kitchen. This practice had the potential to impact sanitary conditions and attract pests/rodents. The findings included: An observation of the outdoor trash receptacle area on 9/24/24 at 4:30 PM revealed masks, water bottles, debris, gloves, and a bag of trash on the ground. The facility staff break area was located off from the trash receptacle area which also was observed with food wrappers and drink bottles on the ground. An observation of the outdoor trash receptacle area on 09/25/24 at 12:15 PM revealed masks, water bottles, debris, gloves, and a bag of trash on the ground. The facility staff break area was located off from the trash receptacle area which also was observed with food wrappers and drink bottles on the ground. An observation of the outdoor trash receptacle area on 09/26/24 at 7:35 AM revealed plastic drink bottles, gloves, masks, debris, and two bags of trash ripped open around the dumpster area. 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 interviews the facility failed to complete smoking assessment for 2 of 3 residents reviewed or smoking (Resident # 67 and Resident #91). The findings included: a. Resident #67 was admitted to the facility on [DATE] which included heart failure and diabetes. Review of Resident #67's annual Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. The MDS further revealed the resident was coded for smoking. Review of Resident #67's care plan revised on 08/14/24 revealed the resident was a smoker. The goal was for Resident #67 would not suffer injury from unsafe smoking practices through the review date. Interventions included the resident could smoke unsupervised. Review of Resident #67's medical record revealed the resident did not receive a quarterly smoking assessment from 04/07/23 until 7/24/24. The smoking assessment completed in 7/24/24 indicated Resident #67 was an unsupervised smoker. b. Resident #91 was admitted to the facility on [DATE]. 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 staff, Nurse Practitioner (NP) interviews and record review, the facility failed to notify a residents Responsible Party (RP) for refusals of his prescribed insulin. This was for 1 (Resident #1) of 3 residents reviewed for notification. The findings included: Resident #1 was admitted on [DATE] with a diagnoses of Diabetes Mellitus (DM), Blindness, Schizophrenia and Bipolar Disorder. Review of Resident #1's undated admission Record (face sheet) read his sister was his designated RP and emergency contact. Review of Resident #1's November 2023 insulin orders included the following: *Humalog insulin sliding scale: Inject as per sliding scale subcutaneously before meals for Diabetes: if 201 - 250 = 1 unit; 251 - 300 = 2 units; 301 - 350 = 3 units; 351 - 400 = 4 units; 401+ = 5 units If blood glucose greater than 400, give 5 units and call the Physician, *Solostar insulin: Inject 14 units subcutaneously two times a day at 8:00 AM and 8:00 PM *Humalog insulin: Inject 14 units subcutaneously before meals.…

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 develop a comprehensive care plan in the area of resident's refusal of medications. This was for 1 (Resident #1) of 3 residents reviewed for comprehensive care planning. The findings included: Resident #1 was admitted on [DATE] with a diagnosis of Diabetes Mellitus (DM). Review of Resident #1's August 2023 Medication Administration Record (MAR) and a nursing note dated 8/10/23 at 12:43 PM read he refused in lunch time dose of his prescribed insulin. Another nursing note dated 8/16/23 at 11:50 PM read he refused his 8:00 PM prescribed dose of insulin. Review of Resident #1's October 2023 MAR and a nursing note dated 10/18/23 at 12:28 AM read he refused his 8:00 PM prescribed dose of insulin. Review of Resident #1's November 2023 MAR and nursing notes dated 11/18/23 at 10:13 PM , 11/19/23 at 9:44 PM and 11/24/23 at 12:12 PM, he refused his prescribed dose of insulin. His quarterly Minimum Data Set (MDS) dated [DATE] indicated he was cognitively…

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's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented effective procedures and monitor the interventions that the committee put into place following a complaint investigation dated 9/3/21 for two deficiencies in the area of comprehensive care planning at F656 and notification of changes at F580. Also, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented effective procedures and monitor the interventions that the committee put into place following the recertification survey dated 5/6/22 for one deficiency in the area of notification of changes at F580. The continued failure of the facility during three federal surveys of record showed a pattern of the facility's inability to sustain an effective QAPI program. Findings included. This tag is cross referenced to: F656- Based on staff interviews and record review, the facility failed to develop a comprehensive care plan in the area of resident's refusal of medications. This was for 1…

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 ensure dietary staff contained facial hair for staff members with beards serving residents food for the preparation of resident's lunch meal trays. The result of the failure to contain facial hair during meal tray preparation and serving had the potential to affect all residents in the facility who would receive a lunch meal tray, and 138 of 139 residents received meal trays. Findings included: On 4/3/2023at 11:35 am an observation of the dietary staff preparing and serving the lunch meal trays for residents revealed the dietary staff failed to contain facial hair for staff with beards, during the observation: The Dietary Manager was preparing trays for plates and handling the plates after the cook served food onto the plates with his facial hair not contained. The Dietary Manager had a full beard and mustache that was approximately 2-inches long. Dietary Aide #1 did not have his facial hair contained throughout the observations. Dietary Aide #1 was handling uncovered lunch meal plates and placing condiments on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, the facility's Quality Assurance and Performance Improvement committee (QAPI) failed to maintain implemented procedures and monitor these interventions the committee put into place in following the complaint investigation of 11/9/2021, the recertification survey of 05/06/22, the complaint investigation of 11/17/2022, and the complaint investigation of 3/2/2023. This was for 4 re-cited deficiencies, E0001, F655, F696, and F812, which were originally cited on 5/6/2022, 1 re-cited deficiency F584 originally cited on 11/9/2021 and 11/17/2022, and 1 re-cited deficiency F677 originally cited on 3/2/2023. The continued failure of the facility during the 4 federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance and Performance Improvement Program. The findings included: This tag is cross referred to: 1. E0001: Based on record review and staff interview, the facility failed to provide a facility 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, staff interviews, the facility failed to maintain a clean safe and homelike environment by the failure to cover fluorescent tube lighting in 1 of 18 rooms (room [ROOM NUMBER]), failed to secure television cable outlet covers and electrical outlet covers in 4 of 33 resident rooms (rooms 107, 320, 326 and 333), failed to maintain window blinds that were in disrepair with missing and bent slats in 2 of 18 rooms (rooms 109 & 116), failed to provide a window blind in 1 of 18 rooms (room [ROOM NUMBER]), failed to maintain intact sheetrock and clean walls for 1 of 18 rooms (room [ROOM NUMBER]) failed to maintain resident cabinetry in 2 of 18 rooms (room [ROOM NUMBER] bed 2 & room [ROOM NUMBER] bed 1), failed to maintain the interior bathroom cabinet where residents' belongings were stored which was rusted and peeling in 1 of 18 rooms (room [ROOM NUMBER]), failed to repair a leaky bathroom sink 1 of 30 rooms (room [ROOM NUMBER]), failed to secure a bathroom handrail 1 of 30 rooms,…

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, resident and staff interviews, the facility failed to provide palatable food for 2 of 4 residents (Resident #51 and Resident #107). Resident #51 was upset because he received gravy without sausage, and his oatmeal was served on his meal plate without a bowl and without sugar or butter. Resident #107 received gravy without sausage and could not eat her oatmeal because it was served on her meal plate without a bowl and without sugar or butter. Findings included: 1. A. Resident #51 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease and dementia. An annual Minimum Data Set assessment dated [DATE] indicated Resident #51 was moderately cognitively impaired and was able to feed himself with set up of his meals. The assessment further indicated Resident #51 had no significant weight loss. The facility's menu for Wednesday, 4/5/2023, indicated the residents would be served sausage and gravy, oatmeal, and fruit. On 4/5/2023 at 8:46 am an observation 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 and staff interviews the facility failed to implement their abuse policy in the areas of reporting allegations of abuse to the state regulatory agency within the required timeframe for 1 of 5 abuse allegation reports reviewed for reporting alleged violations. (Resident #128, #52). The findings included: Review of the facility policy revised on 10/22/22 titled Abuse-Neglect and Exploitation, read in part: Section VII. Reporting/Response: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later that 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.…

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 provide nail care for one of 26 residents (Resident # 69) who was dependent on staff for nail care. The findings included: Resident #69 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease, and major depressive disorder. A review of the quarterly Minimum Data Set (MDS) dated [DATE] coded Resident #69 as being cognitively intact, had no rejections of care and required extensive assistance of one staff member to complete personal hygiene. A review of Resident #69's care plan revised on 3/23/23, included a focused area for self-care needs. The intervention included checking nail length, trim and clean nails on bath day as necessary and report any changes to the nurse. The care plan did not include any refusals for resident care. An observation was completed on 4/3/23 at 11:03 AM of Resident #69 who was lying in bed with a jacket on and covered with sheets, his hands were on top 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, observations, and staff, resident and Nurse Practitioner interviews the facility failed to manage a resident's pain for 1 of 2 residents (Resident #74) reviewed for pain. Findings included: Resident #74 was admitted to the facility on [DATE] with diagnosis of arthritis. Resident #74's Physician's Orders indicated he had an order for Oxycodone HCI 10 milligrams 1 tablet by mouth every 12 hours as needed for severe pain dated [DATE] for 14 days. Resident #74's physician's orders did not include any other medications for pain. The admission Minimum Data Set assessment dated [DATE] indicated Resident #74 was cognitively intact. The assessment further indicated Resident #74 rated his pain at 5 on a scale of 1 to 10, and stated his pain was occasional. A Care Plan dated [DATE] stated Resident #74 would maintain acceptable level of comfort, but the interventions did not include pharmacological or nonpharmacological interventions for pain. A Physician's Order written [DATE] indicated Resident #74…

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 documentation in the medical record regarding vaccination status, education on the benefits and potential side effects before being offered the COVID vaccination or refusal for 1 of 5 residents (#47) reviewed for infection control. The findings included: Resident #47 was admitted to the facility on [DATE]. A Minimum Data Set assessment dated [DATE] indicated Resident #47 had moderate cognitive impairment. A review of the immunizations section of Resident #47's electronic medical record, indicated no documentation related to COVID-19 vaccinations. During a telephone interview on 4/10/23 at 1:32 PM the Assistant Director of Nursing (ADON)/ Infection Preventionist indicated she started working at the facility in February 2023 and the previous Infection Preventionist records were incomplete, whereas some staff entered documentation into the immunizations tab of the medical record and some staff did not. She further indicated she was unable…

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.