Hearthstone Health And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to implement Enhanced Barrier Precautions (EBP), Transmission Base-Precautions (TBP), and provide care in a manner to prevent cross contamination for 2 of 31 sampled residents (Resident (R) 40 and R15) reviewed for infection control. These failures placed all residents of the facility at risk for the transmission and spread of infections.Findings include: 1. Review of R40's Face Sheet, located under the Profile tab in the electronic medical record (EMR) indicated the resident was admitted to the facility on [DATE] with a diagnosis of neuromuscular dysfunction of the bladder. During an observation on 03/02/2026 at 9:55 AM, a sign posted outside R40's room indicated that R40 was on Enhanced Barrier Precautions. The signage directed staff to perform hand hygiene before and after entering the room. Staff were to don (put on) gloves and gowns prior to entering the room to provide direct care to R40. Continued observation revealed an isolation cart outside of R40's room that contained yellow…

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 clinical record review, interview and document review, the facility failed to: 1) perform nursing pre and post dialysis assessments and 2) access and maintain completed dialysis communication transfer forms in collaboration with the dialysis provider for 6 of 6 sampled residents on dialysis (Resident # 9, #20, #151, #51, #61, and #60). The deficient practice potentially placed the residents at risk for improper coordination of care between the facility and the dialysis provider. Findings include: Resident #9 Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including end stage renal disease, type two diabetes mellitus without complications, and heart failure. Physician orders for Resident #9 documented the following: -05/31/2024: Hemodialysis: Monday-Wednesday-Friday. Special instructions; Vital signs (VS) after each session. Send/receive communication form with patient. Medical Records scan upon return, every day shift, every Monday, Wednesday, and Friday.…

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 interview, clinical record review, and document review, the facility failed to ensure a Licensed Practical Nurse (LPN) spoke about a resident in a respectful manner and treated a resident with dignity for 1 of 3 residents sampled related to facility reported incidents (FRI) (Resident #251). This deficient practice had the potential to cause a resident to experience psychosocial harm or mental anguish because of not being treated with respect. Findings include: Resident #251 Resident #251 was admitted to the facility on [DATE], with diagnoses including cognitive communication deficit, anxiety disorder, unspecified, and sepsis due to methicillin susceptible staphylococcus aureus. A FRI, dated 01/28/2025, documented an LPN1 had entered the room of Resident #251 to hang the resident's intravenous (IV) antibiotic. The LPN1 had dropped the IV spike (the sharp end of an IV tube used to puncture an IV bag) into the garbage can and was going to continue to use the IV tubing. Resident #251 had noted to the LPN1…

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 interview, clinical record review, and interview, the facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) assessment for 1 of 3 closed records sampled residents (Resident #99). This deficient practice had the potential to deprive the resident of necessary needs and services relative to their current health management needs upon discharge home. Findings include: Resident #99 Resident #99 was admitted to the facility on [DATE], and discharged on 12/18/2024, with diagnoses including encounter for surgical aftercare following surgery on the digestive system, cognitive communication deficit, prediabetes, and other abnormalities of gait and mobility. A Nursing Progress Note dated 12/18/2024, documented the resident was discharged home with all medications and belongings. A discharge MDS assessment dated [DATE], Section A - Discharge Status, documented the resident was discharged short-term to the hospital. On 02/25/2025 at 12:46 PM, the MDS Coordinator explained the MDS assessments 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and document review, the facility failed to ensure: 1) a resident's behaviors of threatening staff members with physical and sexual violence were care planned for 1 of 22 sampled residents (Resident #78). This deficient practice had the potential to result in staff working with the resident being unaware of the resident's behaviors and the resident's behaviors worsening or escalating with no interventions in place, 2) edema and the use of diuretic medications were care planned for 1 of 22 sampled residents (Resident #83). This deficient practice had the potential to result in staff working with the resident to be unaware of the need to monitor the resident for edema, provide medications (diuretic) as indicated, and monitor for adverse side effects of the medication. Findings include: Resident #78 Resident # 78 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including alcohol dependence with alcohol-induced persisting…

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 interview, clinical record review, and document review the facility failed to ensure a medication ordered for edema was entered into a resident's order set and Medication Administration Record (MAR) for 1 of 22 sampled residents (Resident #83). This deficient practice resulted in the resident not receiving the medication and continuing to have edema and discomfort and the potential to result in an exacerbation of chronic illnesses. Findings include: Resident #83 Resident #83 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD) and acute on chronic diastolic (congestive) heart failure (CHF), and pain, unspecified. The resident's diagnoses list did not include a diagnosis for edema. On 02/24/2025 at 2:37 PM, Resident #83 complained of edema to bilateral lower extremities (BLE). Resident #83 verbalized the resident was not being provided medication for edema. Resident #83 had notable edema to the resident's BLE. A Provider Visit note dated…

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, interview, clinical record review, and document review the facility failed to ensure a resident's pain was managed, a physician was notified when pain medication was not effective and/or the resident's pain exceeded the parameters of the medication ordered for 1 of 22 sampled residents (Resident #83). This deficient practice could have the potential for unrelieved pain, discomfort, and inadequate pain management. Resident #83 Resident #83 was admitted to the facility on [DATE], with diagnoses including pain, unspecified, pain in left hip, cellulitis of left upper limb, restless leg syndrome, pain in left hip, and pain in right hip. A physician's order dated 04/19/2024, documented acetaminophen tablet 325 milligrams (mg). Give one tablet by mouth every four hours as needed for mild pain/headache not to exceed three grams per day. Resident #83's Medication Administration Record (MAR) for February 2025, documented the resident was administered one tablet of acetaminophen 325 mg for pain levels…

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 interview and personnel record review, the facility failed to ensure a Certified Nursing Assistant (CNA) had an annual performance evaluation completed timely for 2 of 2 CNAs employed greater than one year, sampled for personnel record review (Employee #7, and #8). Findings include: Employee #7 Employee #7 was hired on 01/01/2024, as a CNA. Employee #7's personnel record lacked documented evidence an annual performance review had been conducted by the employee's anniversary date of 01/01/2025. Employee #8 Employee #8 was hired on 01/01/2024, as a CNA. Employee #8's personnel record documented an annual performance review had been conducted on 02/25/2025, 55 days after the employee's anniversary date of 01/01/2025. On 02/25/2025 at 12:56 PM, the Human Resources Manager confirmed Employee's #7 did not have an annual performance evaluation for 2025 and Employee #8's annual performance evaluation for 2025 was completed late. The Human Resources Manager verbalized all CNAs were required to have an evaluation every year by the hire anniversary date and they were to be completed…

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, interview, clinical record review, and document review, the facility failed to ensure a resident's behaviors of threatening staff members with physical and sexual violence were monitored per facility policy for 1 of 22 sampled residents (Resident #78). This deficient practice had the potential to result in a resident's behaviors worsening or escalating with no monitoring in place. Findings include: Resident #78 Resident # 78 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including alcohol dependence with alcohol-induced persisting dementia, schizoaffective disorder, unspecified, and hallucinations, unspecified. A Nursing Progress Note, dated 01/06/2025, documented the resident used profane language toward the Licensed Practical Nurse (LPN) and called the LPN derogatory names. The resident told the LPN to get on the LPN's knees and perform a sexual act for the resident and apologize to the resident until the resident was tired of the LPN. The resident yelled…

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, document review, and interview the facility failed to demonstrate effective administration by not ensuring pre and post dialysis assessments, documentation of the assessments, and communication with the dialysis center were completed and correctly documented. This deficient practice resulted in a substandard quality of care. On 03/03/2025 at 1:13 PM, the Executive Director confirmed the facility lacked a process to ensure pre and post dialysis assessments, documentation of the assessments, and communication with the dialysis center was completed and correctly documented on the facility's Dialysis Communication Record. The Executive Director explained it was important the process was followed to ensure continuity of care between the facility and the dialysis center. On 02/27/2025 at 3:02 PM, the Executive Director verbalized not understanding why the deficient practice was a substandard quality of care. It was explained to the Executive Director the scope and severity of the deficient practice included all of the facility's dialysis patients and was a systemic…

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 interview, clinical record review, and document review, the facility failed to ensure a resident's medical record was complete for 6 of 6 sampled residents (Resident #9, #20, #151, #61, #51, and #60), and to accurately document monitoring of a resident with significant weight loss for 1 of 22 sampled residents (Resident #1). The deficient practice had the potential for the resident to experience health risks associated with additional unknown weight loss. Findings include: Resident #9 Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including end stage renal disease, type two diabetes mellitus without complications, and heart failure. A physician's order dated 05/31/2024, documented Hemodialysis: Monday-Wednesday-Friday. Special instructions; Vital signs (VS) after each session. Send/receive communication form with patient. Medical Records scan upon return, every day shift, every Monday, Wednesday, and Friday. A physician's order dated 06/04/2024, documented…

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 interview and document review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify the facility lacked a process to ensure 1) pre and post dialysis assessments, documentation of the assessments, and communication with the dialysis center were completed and correctly documented, and 2) medical records were completed and filed in a manner allowing the facility to easily locate the records and ensure the records were not misfiled and/or lost. This deficient practice resulted in a substandard quality of care related to the facility's dialysis process and keeping of medical records. Findings include: Dialysis On 03/03/2025 at 1:13 PM, the Executive Director confirmed the QAPI committee had not identified the lack of a process to ensure pre and post dialysis assessments, documentation of the assessments, and communication with the dialysis center was completed and correctly documented on the facility's Dialysis Communication Record. The Executive Director explained it was important the process was followed to ensure continuity of care…

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 personnel record review, interview and document review, the facility failed to ensure resident rights training was completed by staff upon hire for 2 of 16 sampled employees (Employee #13 and #15). Findings include: Employee #13 Employee #13 was hired as a Licensed Practical Nurse with a start date on 05/07/2024. Employee #13's personnel record lacked documented evidence of resident rights training. Employee #15 Employee #15 was hired as a Certified Nursing Assistant with a start date on 01/08/2025. Employee #15's personnel record lacked documented evidence of resident rights training. On 03/03/2025 at 12:22 PM, the Executive Director verbalized all staff were required to take resident rights training upon hire and confirmed Employee #13 and #15 did not receive resident rights training upon hire. The facility policy titled In Service Training Program, last revised April 2024, documented all personnel must participate in regularly scheduled in-service training classes including patient rights and civil rights.

Based on interview and document review, the facility failed to ensure facility staff received training on the facility's quality assurance and performance improvement (QAPI) program for 8 of 16 sampled employees (Employee #1, #3, #4, #7, #8, #9, #13, and #16). Findings include: Employee #1 Employee #1 was hired as the Executive Director with a start date on 01/01/2024. Employee #1's personnel record documented QAPI training dated 01/14/2024 and lacked documented evidence of annual QAPI training for 2025. Employee #3 Employee #3 was hired as the Activity Director with a start date on 01/01/2024. Employee #3's personnel record documented QAPI training dated 01/14/2024 and lacked documented evidence of annual QAPI training for 2025. Employee #4 Employee #4 was hired as the Registered Dietitian with a start date on 01/01/2024. Employee #4's personnel record documented QAPI training dated 01/15/2024 and lacked documented evidence of annual QAPI training for 2025. Employee #7 Employee #7 was hired as a Certified Nursing Assistant (CNA) with a start date on 01/01/2024. Employee #7'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.

Based on personnel record review, interview and document review, the facility failed to ensure facility staff received compliance and ethics training for 6 of 16 sampled employees (Employee #1, #3, #4, #6, #7, and #8). Findings include: Employee #1 Employee #1 was hired as the Executive Director with a start date on 01/01/2024. Employee #1's personnel record documented compliance and ethics training dated 01/10/2024 and lacked documented evidence of annual training for 2025. Employee #3 Employee #3 was hired as the Activity Director with a start date on 01/01/2024. Employee #3's personnel record documented compliance and ethics training dated 01/10/2024 and lacked documented evidence of annual training for 2025. Employee #4 Employee #4 was hired as the Registered Dietitian with a start date on 01/01/2024. Employee #4's personnel record documented compliance and ethics training dated 01/14/2024 and lacked documented evidence of annual training for 2025. Employee #6 Employee #6 was hired as the Dietary Supervisor with a start date on 01/01/2024. Employee #6's personnel record…

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, interview, clinical record review, and document review the facility failed to obtain to obtain an informed consent for a psychoactive medication prior to the administration of the medication for 2 of 5 residents reviewed for unnecessary medications (Resident #49 and #62). Findings include: Resident #49 Resident #49 was admitted to the facility on [DATE], with a diagnosis of anxiety disorder, unspecified and urticaria, unspecified. Resident #49's physician's orders documented the following: -Start date 07/27/23, Hydroxyzine hydrochloride (HCL) tablet 25 milligrams (mg), oral, as needed for itching, diagnosis anxiety disorder unspecified, three times a day as needed. Discontinued 08/08/23. -Start date 08/08/23, Hydroxyzine HCL tablet 25 mg, oral, as needed for itching, diagnosis anxiety disorder unspecified, three times a day as needed. Discontinued 08/25/23. Resident #49's clinical record lacked informed consent for Hydroxyzine HCl. On 03/21/24 at 11:27 AM, the Administrator confirmed 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 Resident #67 Resident #67 was admitted to the facility on [DATE], with a diagnoses including traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, subsequent encounter, anxiety, and depression. A physician's order dated 12/27/23, documented Resident #67 may not go out on pass. Resident #77 Resident #77 was admitted to the facility on [DATE], with diagnoses including type two diabetes mellitus with foot ulcer, localized edema and other acute osteomyelitis, right ankle and foot. A physician's order dated 12/29/23, documented Resident #77 may not go out on pass. Resident #42 Resident #42 was admitted to the facility on [DATE], with a diagnosis of unspecified fracture of right femur, subsequent encounter for closed fracture with routine healing. A physician's order dated 12/30/23, documented Resident #42 may not go out on pass. Resident #6 Resident #6 was admitted to the facility on [DATE], with a diagnosis of chronic respiratory failure with hypoxia. A physician's order dated…

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, clinical record review, interview, and document review the facility failed to ensure 1) the Minimum Data Set (MDS) Coordinator, in charge of the facility's Restorative Nursing Program (RNP), had the knowledge and skills needed to manage the program and ensure all residents in need of RNP services were included in the program and 2) a nurse was trained to access resident care plans in the Electronic Medical Record (EMR) after the facility underwent a change of ownership with a new EMR program. Findings include: Restorative Nursing Program On 03/21/24, during the afternoon, the facility provided a list of 41 residents identified by the facility as requiring assistance from the RNP, 38 of 41 residents listed remained in the facility and 3 of 41 residents listed had been discharged from the facility. Review of the facility's list of residents receiving Restorative Nursing Assistant (RNA) services via the RNP lacked documented evidence 25 of the 38 residents identified received RNA services.…

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

Based on observation and interview, the facility failed to ensure the outside receptacles were sealed (lid closed) and free of debris on the surrounding pavement. Findings include: On 03/18/24 at 9:10 AM, a garbage receptacle (GR1) outside was surrounded on left side and back with debris including disposable gloves, a used rag, and pieces of plastic. There was an unknown residual substance on the ground underneath the front side of GR1. The Dietary Manager (DM) verbalized GR1 was leaking. The DM explained maintenance was responsible for keeping trash areas clean. On 03/19/24 at 2:45 PM, an empty can was used to prop open an outside garbage receptacle (GR2). On 03/19/24 at 3:17 PM, the DM verbalized there were signs on the outside garbage receptacles reminding staff to close the lids because too many people used the garbage receptacles. The DM explained garbage receptacles must remain closed to prevent the smells from attracting vermin. On 03/19/24 at 3:17 PM, GR1 was open. On 03/19/24 at 3:17 PM, the DM confirmed GR1 was open and verbalized GR1 should not have been open. The DM…

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 document review and interview, the facility failed to demonstrate effective and knowledgeable administration by not ensuring the facility's Minimum Data Set (MDS) Coordinator, in charge of the facility's Restorative Nursing Program (RNP) had the skills and knowledge necessary to manage RNP services and ensure residents identified to be in need of restorative services were included the facility's RNP. Findings Include: On 03/21/24, during the afternoon, the facility provided a list of 41 residents identified by the facility as requiring assistance from the RNP, 38 of 41 residents listed remained in the facility and 3 of 41 residents listed had been discharged from the facility. Review of the facility's list of residents receiving Restorative Nursing Assistant (RNA) services via the RNP lacked documented evidence 25 of the 38 residents identified received RNA services. Clinical record review identified an additional seven residents had orders to receive RNA services via the RNP and lacked documented…

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, clinical record review, interview and document review the facility failed to ensure 1) enhanced barrier precautions (EBP) were implemented for 24 of 24 residents reviewed with wounds and indwelling medical devices (Resident #110, #7, #55, #93, #516, #413, #161, #26, #19, #25, #18, #42, #76, #462, #74, #111, #22, #3, #84, #514, #260, #96, #45, and #39), 2) appropriate personal protective equipment (PPE) was worn by staff entering resident rooms with transmission-based precautions (TBP) signs in place, and 3) hand hygiene was performed between glove changes for 1 of 21 sampled residents (Resident #26) with the potential to effect the entire census. Findings include: Enhanced Barrier Precautions Resident #110 Resident #110 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of cutaneous abscess of abdominal wall. A physician's order dated 03/07/24, with a start date of 03/08/24, documented wound treatment: pack right abdominal drain site with iodoform, cover 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 observation, clinical record review, interview, and document review the facility failed to ensure services provided met professional standards of quality of care by not ensuring 1) 25 of 38 residents identified by the facility as needing restorative aide assistance were included in the facility's Restorative Nursing Program (RNP) (Resident #61, #36, #49, #82, #1, #80, #63, #32, #67, #77, #42, #66, #90, #6, #53, #20, #60, #14, #43, #30, #54, #52, #58, #74, and #35) and 2) Residents with orders for Restorative Nursing Assistant (RNA) services were included in the RNP for 7 of 97 residents residing in the facility (Resident #50, #13, #44, #86, #23, #511, and #10). The failure to ensure the residents were included in the RNP placed the residents at risk of increased weakness, a decrease in independence, and/or not meeting the residents' maximum potential of physical, mental, and psychosocial wellbeing. Findings include: Residents identified as not receiving RNA services On 03/21/24, during the afternoon,…

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, interview, and document review the facility failed to protect privacy for 11 of 54 residents residing in the facility's A-Wing (Resident #110, #461, #76, #35, #260, #26, #57, #7, #45, #111 and #89), and failed to ensure resident rights to personal privacy was maintained by not covering a resident's urinary catheter collection bag containing urine for 1 of 21 sampled residents (Resident #76) Findings include: On 03/21/24 at 12:03 PM, the A-wing treatment cart was in the main hub of the facility's A-wing. The treatment cart was unlocked and unattended and contained prescription medications. The pharmacy labels attached to medications included the residents name, the name of the medication, and what the medication was being used for. Additionally, the labels were attached to manufacturer labeled products which further identified the type of medication and what the medication was used for. Resident #110 Resident #110 was admitted to the facility on [DATE] and readmitted 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 clinical record review, interview, and document review the facility failed to ensure 1) a resident was kept safe from verbal abuse by a staff member for 1 of 21 sampled residents (Resident #412) and 2) a resident was kept safe from physical and verbal abuse by another resident for 1 of 21 sampled residents (Resident #62). Findings include: Resident #412 Resident #412 was admitted to the facility on [DATE], with diagnoses including malignant neoplasm of colon, unspecified, secondary malignant neoplasm of unspecified lung, neoplasm related pain acute/chronic, type II diabetes mellitus, and other ascites. FRI#NV00070749 documented on 03/20/24, the allegation a staff member cursed at Resident #412. A physician's order dated 03/20/24 documented a hospice consult for remaining in the facility related to metastatic colon cancer. A Social Services Progress note dated 03/11/24, documented Resident #412's physician informed the resident of a terminal diagnosis related to cancer. A Social Services Progress note…

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, clinical record review, interview, and document review the facility failed to ensure 1 of 21 sampled residents (Resident #72) and 1 of 3 closed record sampled residents (Resident #79) and the Residents' Representatives received written notification of transfer or discharge. Findings include: Resident #72 Resident #72 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including osteomyelitis of vertebra, thoracic region, acute and chronic respiratory failure with hypoxia, and age-related cognitive decline. Resident #72's Minimum Data Set 3.0 (MDS) assessments, Section A, documented Resident #72 was admitted to and discharged from the facility as follows: -admitted to the facility on [DATE], and discharged on 01/07/24 to a short term general hospital. -readmitted to the facility on [DATE], and discharged on 01/26/24 to a short term general hospital. -readmitted to the facility on [DATE], and discharged on 02/09/24 to a short term general hospital. -readmitted to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review, and document review, the facility failed to provide a bed hold policy notification upon transfer to a hospital for 1 of 21 sampled residents (Resident #72) and 1 of 3 closed record sampled residents (Resident #79) and to the Residents' Representatives. Findings include: Resident #72 Resident #72 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including osteomyelitis of vertebra, thoracic region, acute and chronic respiratory failure with hypoxia, and age-related cognitive decline. Resident #72's Minimum Data Set 3.0 (MDS) assessments, Section A, documented Resident #72 was admitted to and discharged from the facility as follows: -admitted to the facility on [DATE], and discharged on 01/07/24 to a short term general hospital. -readmitted to the facility on [DATE], and discharged on 01/26/24 to a short term general hospital. -readmitted to the facility on [DATE], and discharged on 02/09/24 to a short term general hospital.…

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 interview, clinical record review, and document review the facility failed to ensure a baseline care plan was developed to address pain management for 1 of 21 sampled residents (Resident #462). Findings include: Resident #462 Resident #462 was admitted to the facility on [DATE], with diagnoses including fracture of condylar process of right mandible, subsequent encounter for fracture with routine healing, fracture of condylar process of left mandible, subsequent encounter for fracture with routine healing, and unspecified fracture of upper end of right humerus, subsequent encounter for fracture with routine healing. Resident #462's physician's orders documented: -Monitor level of pain using 0-10 scale every shift, start date 03/05/24. -Non-pharmacological interventions for pain every shift: 1-repositioning, 2-dim light/quiet environment, 3-relaxation, 4-distraction, 5-music, 6-massage, start date 03/05/24. -oxycodone hydrochloride (hcl) oral solution 5 milligrams (mg) per 5 milliliters (ml), give 10ml…

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, interview, clinical record review, and document review the facility failed to ensure the Comprehensive Care Plan for 1 of 21 sampled residents (Resident #75) included care plans related to communication and Restorative Nursing Aide (RNA) services. Finding include: Resident #75 Resident #75 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, cognitive communication deficit, mixed receptive-expressive language disorder, aphasia, and cognitive social or emotional deficit following cerebral infarction, and other abnormalities of gait and mobility. 03/18/24 at 1:31 PM, during an interview with Resident #75, it was noted the resident had difficulties speaking. The resident's words were jumbled and incomprehensible. At times the resident attempted to talk slower and was able to say a few words, mostly numbers. A communication device including a picture board was not noted to be present in 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, interview and document review the facility failed to ensure staff performed hand hygiene and followed enhanced barrier precautions while providing wound care to 1 of 21 sampled residents (Resident #26). Findings include: Resident #26 Resident #26 was admitted to the facility on [DATE], with diagnoses including aftercare following explanation of hip joint prosthesis and unspecified open wound, left hip, subsequent encounter. On 03/20/24 at 9:08 AM, during a wound care observation, a Licensed Practical Nurse (LPN) removed a soiled dressing from Resident #26's left hip. The LPN removed the gloves worn during soiled dressing removal and donned a new pair of gloves. The LPN did not perform hand hygiene between changing gloves. On 03/20/24 at 9:10 AM, the LPN packed Resident #26's wound with iodoform packing strip, applied zinc paste to the surrounding area, and removed the gloves worn during packing and application of the zinc paste. The LPN donned a new pair of gloves and did not perform hand…

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, interview, clinical record review, and document review the facility failed to ensure restorative nursing assistance (RNA) was provided to a resident in accordance with therapy recommendations for 1 of 21 sampled residents (Resident #75). The failure to provide RNA services had the potential for the resident to have a decline in muscle tone and development of contractures. Finding include: Resident #75 Resident #75 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, cognitive communication deficit, mixed receptive-expressive language disorder, and other abnormalities of gait and mobility. On 03/18/24 at 1:36 PM, Resident #75 was resting in bed, the resident's right upper extremity (RUE) was weak and flaccid in appearance. A sign indicating the resident was to wear an arm brace 4-5 hours a day was located on the wall by the resident's bed. Resident #75 was not able to effectively verbalize how…

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, interview, clinical record review, and document review the facility failed to ensure a resident's pain was managed and a physician was notified when pain medication was not effective for 1 of 21 sampled residents (Resident #462). Findings include: Resident #462 Resident #462 was admitted to the facility on [DATE], with diagnoses including fracture of condylar process of right mandible, subsequent encounter for fracture with routine healing, fracture of condylar process of left mandible, subsequent encounter for fracture with routine healing, and unspecified fracture of upper end of right humerus, subsequent encounter for fracture with routine healing. On 03/19/24 at 8:15 AM, Resident #462 was in bed and complained of pain in the right shoulder. Resident #462 verbalized the resident asked facility staff for pain medication at 7:00 AM and staff had not returned. Resident was tearful and stated I'm in so much pain. On 03/20/24 at 10:07 AM, a Certified Nursing Assistant (CNA) verbalized signs…

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 clinical record review, interview and document review the facility failed to maintain completed dialysis communication transfer forms for 1 of 21 sampled residents (Resident #23). Findings include: Resident #23 Resident #23 was admitted to the facility on [DATE], with diagnoses including end stage renal disease and dependence on renal dialysis. A physician's order dated 12/27/23, documented Resident #23 was to receive dialysis treatment at a dialysis center, every Tuesday, Thursday, and Saturday. To send and receive the communication form with patient. Medical Records to scan upon return. Resident #23's clinical record lacked documented evidence of a completed dialysis communication transfer form for the following dates: -01/04/24, Thursday -01/23/24, Tuesday -02/17/24, Saturday On 03/21/24 at 2:10 PM, the Director of Nursing (DON), confirmed Resident #23's clinical record lacked the completed dialysis communication transfer forms for the above dates. The DON verbalized the nursing staff should have…

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, clinical record review, interview, and document review the facility failed to ensure controlled substance logs were correctly completed to provide accurate reconciliation of controlled medications for 3 of 21 sampled residents (Resident #161, #60, and #73). Findings include: Resident #161 Resident #161 was admitted to the facility on [DATE], with diagnoses including fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, multiple fractures of ribs, unspecified side, subsequent encounter for fracture with routine healing, and chest pain, unspecified. A physician's order dated 03/11/24, documented oxycodone hydrochloride (HCL) 10 mg milligram tablets, give one tablet by mouth every four hours as needed for moderate to severe pain. A physician's order dated 03/12/24, documented oxycodone HCL 10 mg tablets, give two tablets by mouth every four hours as needed for moderate to seer pain. On 03/20/24 at 9:53 AM, the B100 hall Narcotics Log…

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 interview, clinical record review, and document review, the facility failed to ensure a resident was not administered a pain medication without the physician specified pain level reached per physician's order resulting in a resident receiving oxycodone hydrochloride (HCL) unnecessarily for 1 of 5 sample residents reviewed for unnecessary medications (Resident #49). Findings include: Resident #49 Resident #49 was admitted to the facility on [DATE], with a diagnosis of acute pain due to trauma. A care plan initiated on 02/15/24, documented a focus on acute/chronic pain with interventions and tasks including administering analgesia medication as per orders. Give half an hour before treatments or care. A physician's order dated 12/30/23, documented oxycodone HCL capsule five milligrams (mg) give one capsule by mouth every eight hours as needed for severe pain (seven through ten) do not give for pain less than seven. The January 2024 Medication Administration Record (MAR) for Resident #49 dated 03/20/24,…

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, interview, clinical record review, and document review the facility failed to ensure 1) temperatures were monitored and documented for 1 of 2 medication storage rooms including the medication refrigerator and freezer, 2) a cup of medication was not pre-poured and stored in a medication cart for 1 of 21 sampled residents (Resident #410), 3) a medication cart was not left unsecured and unattended and 4) a treatment cart containing medications was not left unsecured and unattended. Findings include: Temperatures The temperature log for the B Wing medication room and the B Wing medication refrigerator and freezer for the month of October 2023, lacked documented evidence the temperature of the medication room, the medication refrigerator, and the medication freezer were monitored as follows: -A temperature was not recorded for the medication room during the AM shift on 10/26 - 10/29, and 10/31/23. -A temperature was not recorded for the medication room during the PM shift on 10/25 - 10/29, 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 interview, observation, clinical record review, and document review, the facility failed to ensure a resident was interviewed for food preferences within 71-hours of admission per facility policy for 1 of 21 sampled residents (Resident #514). Findings include: Resident #514 Resident #514 was admitted to the facility on [DATE], with a diagnosis of cellulitis of the left lower limb. A physician's order dated 03/13/24, documented a regular diet, regular texture, thin liquid consistency. On 03/18/24 at 11:49 AM, Resident #514 verbalized the resident had not met with anyone regarding food preferences since being admitted to the facility. The resident verbalized not being aware of an option for alternate menus, but you get what you get. On 03/19/24 at 1:47 PM, the resident verbalized being served lunch for the day, but not knowing what lunch was. The resident explained lunch looked like a mix between lasagna and a burrito and the meal was too spicy. On 03/20/24 at 4:08 PM, the Dietary Manager (DM) verbalized…

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 clinical record review, interview and document review, the facility failed to complete the Treatment Administration Record (TAR) for the treatment of a wound for 1 of 21 sampled residents (Resident #7), and the Medication Administration Records (MAR) for the administration of insulin for 1 of 21 sampled residents (Resident #84). Findings include: Resident #7 Resident #7 was admitted to the facility on [DATE], with a diagnosis of unspecified open wound, left thigh, subsequent encounter. A physician's order dated 02/22/24, documented wound treatment, cleanse left posterior thigh gently with no rinse soap, pat dry, cleanse with saline, pat dry. Apply Silver alginate to wound bed and cover with dressing. Change daily and PRN, every day shift for wound treatment. Resident #7's TAR for March 2024, lacked documented evidence the wound treatment had been administered per the physician's order on 03/04/24, 03/07/24, 03/08/24 and 03/12/24. On 03/21/24 at 2:07 PM, the Director of Nursing (DON), confirmed 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 clinical record review, interview, and document review the facility failed to ensure 1 of 5 residents sampled for vaccinations (Resident #75) was screened for eligibility to receive a pneumococcal vaccine, education regarding the vaccine was provided to the resident and/or the resident representative, and the vaccine was offered and either administered or declined. Findings include: Resident #75 Resident #75 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, heart failure, unspecified and atherosclerotic heart disease of native coronary artery without angina pectoris. Resident #75's clinical record lacked documented evidence the resident was screened for eligibility to receive the pneumococcal vaccine, education regarding the vaccine was provided to Resident #75 and/or the resident's representative, and the vaccine was offered and either administered or declined. On 03/21/24 at 3:57 PM, the Director 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 observation, interview, and document review, the facility failed to document training needed for all staff. Findings include: Resident #49 Resident #49 was admitted to the facility on [DATE] with a diagnosis of anxiety disorder, unspecified and major depressive disorder, recurrent severe without psychotic features. On 03/19/24 at 12:39 PM, Resident #49 was in bed yelling state you're f , you guys are useless. A Licensed Practical Nurse entered Resident #49's room and asked if the resident needed to yell. The resident replied the resident did not need to yell, and the LPN informed the resident the state agents left the building. On 03/19/24 at 12:47 PM, Resident #49 yelled for a Certified Nursing Assistant (CNA) to bring ice water. Ice water, ice water. The resident's call light was not on. A care plan initiated 02/15/24, documented a focus on anti-anxiety medication use with interventions and tasks to monitor and document side effects including hostility, rage and aggressive or impulsive behavior. 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 interview, clinical record review, and document review, the facility failed to ensure a resident was treated with respect and dignity by facility staff during discharge planning conversations for 1 of 9 sampled residents (Resident #4). Findings include: Resident #4 Resident #4 was admitted to the facility on [DATE], with diagnoses including pain, unspecified, diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified, and other stimulant use, unspecified with stimulant induced anxiety disorder. A Facility Reported Incident (FRI) documented on 12/15/23, Resident #4 had reported a Case Manager (CM) had called the resident stupid. On 01/24/24 at 11:44 AM, the CM verbalized the CM had been in the room with a Discharge Planner and was trying to assist the resident with a discharge plan. The CM verbalized the CM had made a remark regarding the resident's barriers to discharging home with family. The CM verbalized the CM had been frustrated from the lack of cooperation between 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 clinical record review, interview, and document review, the facility failed to protect a resident's quality of life when the facility-initiated life saving measures during a Code Blue (medical emergency), to include chest compressions, for a resident with a Do Not Resuscitate (DNR) order for 1 of 20 sampled residents (Resident #2). This was a result of not honoring a resident's choice regarding the resident's plan of care resulting in psychosocial harm when the resident's life was prolonged by two days. Cross reference with Immediate Jeopardy tag F 684. The facility's pervasive disregard for resident's choice in code status was identified during an audit to remove the Immediate Jeopardy resulted in 7 of 22 residents' records not accurately reflect or complete the documentation staff were trained to refer to for the resident's code status (Resident #25, #35, #40, #49, #56, #9 and #57). Findings include: Resident #2 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including…

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 interview, clinical record review and document review, the facility failed to ensure a resident was free from misappropriation of property when a Certified Nursing Assistant (CNA) asked for money from a resident and failed to pay the money back to the resident for 1 of 20 sampled residents (Resident #4). Findings include: Resident #4 Resident #4 was admitted to the facility on [DATE], with diagnoses including other acute osteomyelitis, right ankle and foot, other specified disorders of teeth and supporting structures and non-pressure chronic ulcer of other part of right foot tissue, unspecified. A Facility Reported Incident (FRI) dated 09/28/23, documented Resident #4 had reported to the facility a CNA had asked the resident for money. The resident provided money to buy tacos and the change was not returned and a couple of days later the CNA asked the resident for money and the resident gave the CNA ten dollars. An investigation by the facility on 09/29/23, documented another resident had also 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 observation, clinical record review, document review, and interview, the facility failed to update a resident's care plan to address hearing loss and use of a hearing device for 1 of 20 sampled residents (Resident #3), resident exhibiting resistance to care for 1 of 20 sampled residents (Resident #8) and resident's pathological left femur fracture following surgery for 1 of 20 sampled residents (Resident #9). Resident #3 Resident #3 was admitted to the facility on [DATE], with diagnosis including presence of other specified devices. A Nursing Progress Note dated 08/30/23, documented the resident was able to make needs known and was hard of hearing. Resident #3's care plan initiated on 08/09/23, lacked documented evidence the resident had a hearing deficit and used a hearing device. On 11/13/23 at 2:52 PM, a Registered Nurse (RN) verbalized the resident wore hearing aids and believed the condition should be care planned. The RN confirmed the resident did not have a care plan for hearing loss and the use…

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 clinical record review, document review and interview, the facility failed to ensure the facility staff properly operated a resident lift with two persons to prevent an injury to a resident for 1 of 20 sampled residents (Resident #5). Findings include: Resident #5 Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including hemiplegia and hemiparesis following other cerebrovascular disease affecting left dominate side and vascular dementia, moderate, with mood disturbance. A Minimum Data Set 3.0 (MDS) Section G dated 07/04/23, documented Resident #5's functional status for bed mobility and transfer support was extensive assist, two persons assist. A Minimum Data Set 3.0 (MDS) Section GG dated 10/04/23, documented Resident #5's functional abilities and goals for sitting to lying and bed to chair transfer as substantial and maximum assist. A Nursing Progress Note dated 09/16/23 at 9:02 PM, documented Resident #5 had a purple bruise below the resident's left…

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

Based on observation, and interview, the facility failed to ensure food delivered to residents in a dining area were properly covered and not exposed prior to the residents' consumption, potentially affecting 111 of 111 residents. Findings include: On 11/06/23 at 11:37 AM, a resident's food tray was sitting unsupervised in the B200 Wing dining area. The plate of food was covered and a fruit cup was uncovered sitting on the food tray. The Food Services Director (FSD) presented to the dining area and lifted the food cover off the plate to take the temperature of the entrée. The FSD verbalized the resident had been sleeping during lunch service and was going to eat the meal in the resident's room. The FSD verbalized the meal was covered when delivered to the dining areas in the closed cart but the additional items on the tray were not. On 11/06/23 at 11:42 AM, the FSD confirmed the resident's fruit cup was uncovered and unsupervised sitting in the dining room. The FSD confirmed the food should be covered at all times until ready to be eaten by the resident.

Based on observation, interview, and document review, the facility failed to ensure resident information was not visible on an unattended computer screen facing a public area for 17 of 17 residents residing in a unit. Findings include: On 11/12/23 at 10:30 AM, a computer screen on a medication cart, facing the common area, was open to a screen with a resident list of the A300 Medication Administration Record (MAR). The screen was unattended. On 11/12/23 at 10:32 AM, a resident passed by the unattended screen in a wheelchair. On 11/12/23 at 10:35 AM, a resident sat in a wheelchair near the unattended screen. On 11/12/23 at 10:37 AM, a Registered Nurse (RN) returned to the medication cart. The RN confirmed the computer screen contained resident information that was visible to anyone entering the A300 unit. The RN verbalized the RN should have locked the computer screen before leaving the medication cart. On 11/15/23 at 4:02 PM, the Director of Nursing verbalized the computer screens should not have resident information visible when they were unattended by staff. The facility policy…

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.