Divine Rehabilitation And Nursing At Canal Pointe

4.Review of the medical record for Resident #48 revealed an admission date of 01/25/23 with diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure, and diabetes mellitus. Review of the MDS assessment for Resident #48 dated 04/01/25, revealed the resident was cognitively intact. Review of the MAR for Resident #48 dated May 2025 revealed medications were administered several hours after the medication was ordered: metoprolol, Entresto, Lasix, Ativan, gabapentin, spironolactone, Macrobid scheduled for 05/04/25 at 9:00 A.M. were given at 11:27 A.M., Macrobid, Colchicine, Eliquis, trazodone scheduled for 05/04/25 at 9:00 P.M. were given at 11:27 P.M., insulin Lispro scheduled for 05/04/25 at 8:00 A.M. was given at 10:46 A.M., Depakote, metoprolol, Entresto, Tamsulosin scheduled for 05/04/25 at 9:00 P.M. were given at 11:24 P.M., insulin Glargine scheduled for 05/05/25 at 9:00 A.M. was given at 11:23 A.M., Gabapentin, Tamsulosin, Entresto, metoprolol, Depakote, trazodone, Eliquis, Colchicine, Macrobid and insulin Glargine scheduled for 05/05/25 at 9:00…

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, interview, menu review and review of the menu spreadsheet, the facility failed to provide food items at the designated portions as written. This affected 101 residents receiving food from the kitchen as three residents (#63, #104 and #106) were ordered nothing-by-mouth (NPO) and seven residents (#9, #10, #24, #54, #74, #95 and #112) were observed to receive alternate meals during the observation. The facility census was 111. Findings include: Review of the menu for week three, dated as Spring/Summer 2025, revealed for lunch on Tuesday (06/03/25), the meal to be served included Polish sausage, potato wedges, sauteed peppers and onions, choice of roll, choice of cookie, milk and coffee/tea. Review of the menu spreadsheet for the lunch meal on 06/03/25 revealed the following portions were to be served: Polish sausage, one each; potato wedges, three ounces; sauteed peppers and onions, four ounces; choice of roll, one each; choice of cookie; one each. The diet extension for mechanical soft diets revealed these residents were to receive a #6-scoop (two thirds of a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of the facility policy, the facility failed to ensure the physician and resident's responsible party were notified when lab draws were not completed according to the physician/certified nurse practitioner (CNP) orders. This affected one (Resident #66) of three residents reviewed for notification. The facility census was 111. Findings include: Record review for Resident #66 revealed an admission date of 04/01/24. Diagnoses included vascular dementia, cerebral infarction, personal history of transient ischemic attack (TIA), and acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was severely cognitively impaired. Review of the care plan dated 04/13/24 revealed Resident #66 had a cerebral vascular accident (CVA/Stroke) related to embolism. Interventions included administering medications as ordered by the physician. Review of the Pharmacy Medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, self-reported incident (SRI) review, interview and facility policy review, the facility failed to prevent resident-to-resident between Residents #48 and #214. This affected two (Residents #48 and #214) of four residents reviewed for abuse. The facility census was 111. Findings Include: 1. Resident #48 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), congestive heart failure, diabetes, heart disease, major depressive disorder, post-traumatic stress disorder (PTSD), a left below the knee amputation, and an internal cardiac defibrillator. Review of the comprehensive quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 was cognitively intact, refused aspects of care daily, and needed no assistance with personal care. Review of SRI tracking number 260710, dated 05/21/25, filed with the State agency for an allegation of physical abuse. Resident #48 and Resident #214 were in the facility's lobby…

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, interview and facility policy review, the facility failed to report an allegation of resident-to-resident sexual abuse to the State agency for one (Resident #58) of four residents reviewed for abuse. The facility census was 111. Findings include: Resident #58 was admitted to the facility on [DATE] with diagnoses of bipolar disorder, major depression disorder, schizophrenia, high blood pressure, and mood disorder. Review of the comprehensive annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 was severely cognitively impaired, had delusions, and had behaviors which significantly interfered with the resident's care and social interaction, significantly intruded on the privacy or activities of others, and had behaviors that significantly disrupted the living environment. Review of the nursing progress notes for Resident #58 revealed on 05/28/25 at 10:56 A.M. Nurse Practitioner (NP) #517, who is the facility's psychiatric NP, evaluated the resident. Resident #58…

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 and record review, the facility failed to monitor Resident #66's daily fluid intake and daily urine output related to a diagnosis of urinary retention requiring the use of an indwelling urinary catheter and discontinuation of the indwelling urinary catheter. This affected one (Resident #66) of two residents reviewed for indwelling catheters. The facility census was 111. Findings include: Record review for Resident #66 revealed an admission date of 04/01/24. Diagnoses included vascular dementia, cerebral infarction, neuromuscular dysfunction of bladder, and retention of urine. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was severely cognitively impaired. Resident #66 had an indwelling urinary catheter and required set up or clean up assistance with personal hygiene. Review of the progress note dated 12/31/24 at 6:19 A.M. revealed Resident #66 was observed coming to the nurse's station to speak with the nurse. Resident #66 then went back towards…

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, record review, and review of the facility policy, the facility failed to ensure Resident #67 received all nutritional interventions recommended by the registered dietitian to treat and prevent significant weight loss. This affected one resident (Resident #67) of three residents reviewed for nutrition. The facility census was 111. Findings include: Record review for Resident #67 revealed an admission date of 06/13/24. Diagnoses included Alzheimer's disease, type one diabetes mellitus, and dysphagia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #67 was severely cognitively impaired. Resident #67 required set up or clean up assistance with meals, had weight loss and was not on a prescribed weight loss regimen. Review of the care plan for Resident #67 dated revised 04/17/25 revealed the resident had nutritional problem or potential nutritional problem related to forgetfulness related to Alzheimer's/dementia. Diagnoses including type one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy, the facility failed to ensure orders were in place for the administration of oxygen and failed to date oxygen tubing as required. This affected one resident (#107) of one resident reviewed for oxygen and had the potential to affect an additional 13 residents (#1, #57, #65, #69, #74, #80, #84, #89, #97, #99, #106, #262 and #311) the facility identified as receiving oxygen in the facility. Facility census was 111. Findings include: Review of Resident #107's medical record revealed an admission date of 04/08/25 and diagnoses including malignant neoplasm of prostate, chronic obstructive pulmonary disease, anxiety and hypertension. Review of an admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #107 was cognitively intact and receiving hospice services. Oxygen was not coded on the MDS assessment. Review of Resident #107's physician's orders as of 06/02/25 revealed no orders were in place relative to oxygen.…

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 and record review the facility failed to obtain communication from the dialysis provider after each dialysis treatment. This affected one resident (Resident #94) of one resident reviewed for dialysis. The facility census was 111. Findings Include: Review of the medical record revealed Resident #94 was admitted to the facility on [DATE] with diagnoses including acute osteomyelitis of the left ankle and foot, diabetes with diabetic neuropathy, end stage renal disease dependent on dialysis, congestive heart failure, high blood pressure, Tourette's disorder, schizophrenia, and anxiety. Review of the physician's orders revealed Resident #94 attended dialysis on Mondays, Wednesdays, and Fridays. The resident was on a fluid restriction of 2000 milliliters (ml) per 12 hour shift. Review of the comprehensive annual Minimum Data Set (MDS) 3.0 , dated 05/20/25, revealed Resident #94 was cognitively intact, received daily insulin medications and diuretics, and received dialysis. Review of the pre and post…

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, interview, and review of the facility policy, the facility failed to ensure a safe environment for Resident #212. This affected one (Resident #212) of one resident reviewed for suicidal ideations. The facility census was 111. Findings include: Record review for Resident #212 revealed an admission date of 05/02/25 and a readmission date of 05/16/25. Diagnoses included anxiety disorder, depression, post-traumatic stress disorder, gender identity disorder, and borderline personality disorder. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #212 was cognitively intact. Resident #212 had little interest or pleasure in doing things, feeling down, depressed or hopeless, feeling bad about herself/himself or a failure or have let herself/himself or her/his family down, and had trouble concentrating on things such as reading the newspaper or watching television. Resident #212 used a manual wheelchair, had no impairments of the upper or…

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, interview and review of the facility policy, the facility failed to ensure blood sugar results were obtained prior to eating the breakfast meal for Resident #72 and failed to prime the insulin pen prior to administering the insulin injection for residents #72 and #19. This affected two (Residents #19 and #72) observed for blood sugar assessments and insulin administration and had the potential to affect an additional 24 (Resident #2, #5, #16, #17, #21, #23, #24, #25, #29, #34, #44, #48, #51, #53, #55, #62, #67, #68, #69, #83, #211, #212, #262, and #311) identified by the facility as requiring a blood sugar assessment prior to meals and or requiring insulin via insulin pen. The facility census was 111. Findings include: 1. Record review for Resident #72 revealed an admission date of 07/27/22. Diagnoses included diabetes mellitus (DM) with diabetic nephropathy. Review of the care plan dated 07/29/24 revealed Resident #72 had diabetes mellitus. Interventions included diabetes…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, pharmacy medical record review and lab requisition review, revealed the facility failed to ensure the physician ordered labs were completed timely for Resident #66. This affected one (Resident #66) of five residents reviewed for unnecessary medications. The facility census was 111. Findings include: Record review for Resident #66 revealed an admission date of 04/01/24. Diagnoses included vascular dementia, cerebral infarction, personal history of transient ischemic attack (TIA), and acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was severely cognitively impaired. Resident #66 did not receive an anticoagulant. Review of the physician orders for Resident #66 revealed an order for Eliquis (anticoagulant) five milligram (mg) tablet, take one tablet by mouth twice daily, ordered on 04/01/24. Interview on 06/09/25 at 10:50 A.M. with Corporate MDS Nurse…

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, record review and review of the facility policy, the facility failed to maintain infection control practices and or ensure personal protective equipment (PPE) was readily available for two residents, Resident #6 and #104 who required enhanced barrier precautions (EBP). This affected two residents (#6 and #104) of two residents reviewed for EBP and had the potential to affect all residents residing at the facility. The facility census was 111. Findings include: 1. Record review for Resident #6 revealed an admission date of 03/05/20. Diagnoses included attention deficit hyperactivity disorder and dementia. Review of the annual Minimum Daa Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 was severely cognitively impaired. Resident #6 had no impairment to the upper or lower extremities, required set up or clean up assistants with eating and bathing. Review of the care plan dated 05/27/25 revealed Resident #6 had cellulitis of the right lower leg related to abrasion on shin.…

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 facility policy review the facility failed to ensure all medications were disposed of in a safe and secure manner. This had the potential to affect an unidentified number of staff and 46 residents (#1, #4, #9, #10, #17, #18, #19, #20, #22, #23, #25, #27, #28, #30, #32, #35, #38, #39, #40, #49, #50, #51, #52, #55, #56, #59, #60, #65, #66, #67, #70, #73, #74, #75, #76, #77, #80, #81, #82, #84, #89, #90, #94, #97, #99, and #100) residing on the third floor of the facility who potentially could have accessed the unsecured medications. The facility census was 101. Findings include: Observation on [DATE] at 1:05 P.M. of the medication room on the third-floor revealed a large sharps disposal container on the counter that was approximately one quarter of the way full of an array of multiple different medications. There was no lid on the sharps container. Interview on [DATE] at 1:10 P.M. with Registered Nurse (RN) #709 verified there was a large sharps disposal container in the…

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

Based on review of the facility Self-Reported Incident (SRI), record reviews and interviews the facility failed to ensure Resident #98 was free from misappropriation. This affected one resident (Resident #98) of three residents reviewed. The census was 103. Findings include: Review of the medical record for Resident #98 revealed an admission date of 04/22/22. Diagnoses included blindness, dementia and adjustment disorder. Review of the SRI on 01/29/24 revealed Resident #98 gave his debit card and personal identification number (PIN) to State Tested Nursing Assistant (STNA) #306 on 01/25/24 to purchase some items for him. On 01/28/24 he reported to Licensed Practical Nurse (LPN) #301 he had not received his debit card or items purchased yet. LPN #301 notified LPN #302, manager on call, who reported it to the Director of Nursing (DON) and the Administrator. A thorough investigation was completed including interviews of residents on his unit, witness statements and education on abuse policy. STNA #306 admitted to having used the resident's debit card and said she had yet to drop off…

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

Based on record review and interview, the facility failed to submit complete and accurate staffing information for the Payroll-Based Journal (PBJ) report to Centers for Medicare and Medicaid Services (CMS) for the third fiscal quarter of 2023. This had the potential to affect all 105 residents in the facility. Findings include: Review of [NAME] PBJ Staffing data report revealed facility triggered for low weekend staffing and one star staffing for Quarter Three of the fiscal year 2023. Interview on 11/30/23 at 10:05 A.M. with Administrator revealed he did research with the corporate/home office and determined this was a reporting error. The hours were not added for some agency nursing staff for that period as well as some nursing managers who worked the weekends, which was not included in the corporate PBJ report sent into CMS. On 11/30/23 at 10:11 A.M. the Administrator sent a follow up email to this surveyor confirming that after additional research the Administrator had found the submitter of the PBJ staffing information submitted to CMS did not include the agency staffing and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the medical record, interview with staff and review of the facility policy, the facility failed to ensure a comfortable water temperature in Resident #75's room and failed to ensure a comfortable temperature in the dining room on floor one. This affected one resident (Resident #75) but had the potential to affect all the resident on the 300 hall unit and affected three residents ( Resident #67, #69 and #74) in the first-floor dining room. The facility census was 105. Findings included: 1. Review of the medical record revealed Resident #75 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, mood disorder. major depressive disorder, pulmonary embolism, convulsions, schizoaffective disorder, bipolar disorder, hypersomnia, hypertension, antisocial personality disorder, hemiplegia and COVID-19. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #75 had intact cognition. Observation on 11/29/23 at 8:30 A.M. revealed the water…

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 store flour in a manner to prevent contamination. This had the potential to affect all 105 residents in the facility. The facility census was 105. All residents receive meals from the kitchen. Findings Included: On 11/27/23 at 9:00 A.M. a tour of the kitchen with the Director of Dining Services (DDS) #69 revealed two styrofoam cups in the flour bin. This was verified by DDS #69 at the time of the kitchen tour. A review of the policy titled, Food Safety Requirements that was undated revealed the definition of contamination is the unintended presence of potentially harmful substances including, but not limited to microorganisms, chemicals, or physical objects. It also revealed that food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of food to the resident. Elements of the process include storage of food in a manner that helps prevent the deterioration or contamination of the food.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review the personnel records for State Tested Nurses Aide (STNA) #70 revealed a hire date of 08/05/22. There was no evidence a tuberculosis test was administered before her hire date for 2023. Review the personnel records for STNA #75 revealed a hire date of 06/09/22. There was no evidence a tuberculosis test was administered before her hire date for 2023. Interview on 11/30/23 at 11:15 A.M. with the Director of Nursing (DON) confirmed the TB tests were not administered timely. Review of the facility policy titled Tuberculosis Risk Assessment Worksheet dated 03/02/23, revealed screening of employees for TB infection on would occur annually. Based on observation, record review, interview and review of facility policy the facility failed to ensure staff washed their hands to prevent possible cross contamination of germs during medication administration for four (Resident #63, Resident #74, Resident #85, and Resident #95) out of six residents observed during medication administration and failed to ensure all…

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, interview, and facilities policy review, the facility failed to follow their policy for abuse in regard to allegations of resident to resident abuse. This affected three residents (Residents #19, #48 and #103) of three reviewed for abuse. The facility census was 105. Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 07/13/15. Diagnoses included cerebral infarction, schizoaffective disorder, anxiety and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. He required partial to moderate assistance for toileting and hygiene and used a wheelchair to ambulate. Review of the skin observation tool dated 10/17/23 and timed 5:30 A.M. revealed the residents' skin was intact. 2. Review the medical record for Resident #48 revealed an admission date of 07/25/23. Diagnoses included dementia, psychotic disorder and diabetes. Review of the quarterly MDS assessment 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 record review, interview, and facilities policy review, the facility failed to thoroughly investigate a witnessed incident of Resident to Resident abuse. This affected three Residents (Residents #19, #48 and #103) of three reviewed for abuse. The facility census was 105. Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 07/13/15. Diagnoses included cerebral infarction, schizoaffective disorder, anxiety and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. He required partial to moderate assistance for toileting and hygiene and used a wheelchair to ambulate. Review of the skin observation tool dated 10/17/23 and timed 5:30 A.M. revealed the residents' skin was intact. 2. Review the medical record for Resident #48 revealed an admission date of 07/25/23. Diagnoses included dementia, psychotic disorder and diabetes. Review of the quarterly MDS assessment dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for one resident (Resident #9) regarding dental status. This affected one resident (Resident #9) of nine reviewed for assessments. The facility census was 105. Findings include: Review of the medical record for Resident #9 revealed an admission date of 07/10/14. Diagnoses included diabetes, dysphagia, heart failure and dementia. Review of the quarterly MDS assessment dated [DATE] revealed the resident was severely cognitively impaired. He required extensive assistance of two people for bed mobility, transfers, dressing, toilet use and hygiene. He required supervision and set up help for eating. He had no broken or missing teeth. Review of the care plan dated 09/29/23 revealed the resident was at risk for oral problems to due some missing teeth. Interventions included a dental consult as needed, monitoring and reporting oral pain as needed and providing the resident with 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 observation, interview, and record review, the facility failed to ensure anti-embolic stockings (stockings used to prevent swelling or blood clots) were applied as ordered. This affected one resident (Resident #77) of three reviewed. The facility census was 105. Findings include: A review of resident records for Resident #77 revealed an admission date of 02/28/22. Pertinent diagnoses included epilepsy, alcohol dependence, alcoholic cirrhosis of liver, neuromuscular dysfunction of bladder, depression, hemiplegia, impulse disorder, cerebral infarction chronic embolism (blood clot), ileostomy, hypertension (high blood pressure) and bipolar disorder. Review of the November 2023 physician's order revealed Resident #77 had orders that included anti-embolic stockings on in the morning and off in the evening. A review of the quarterly Minimum Data Set, dated [DATE] revealed Resident #77 had moderately impaired cognition. On 11/28/23 at 12:00 P.M., an interview with Resident #77 revealed anti-embolic stockings…

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, review of the medical record, and interviews with staff the facility failed to ensure fall intervention were in place for Resident #26. This affected one resident (Resident #26) of six reviewed for accidents. The facility census was 105. Findings included: Review of the medical record revealed Resident #26 was admitted to the facility on [DATE]. Diagnoses alcohol dependence, seizures, chronic obstructive pulmonary disease, heart failure, anemia, psychoactive substance abuse, cerebral infarction, abnormal aortic aneurysm, schizoaffective disorder, peripheral vascular disease, anxiety disorder, depression, dementia, hypertension, COVID-19, mood disorder, and left leg amputation. Review of the annual Minimum Data Set assessment dated [DATE] revealed Resident #26 had moderately impaired cognition and he required limited assistance of one staff member for transfers. He has had no falls. Review of the physician's orders revealed Resident #26 had an order for a mat to the floor dated 10/06/23.…

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, record review, and facilities policy review, the facility failed to ensure pre and post dialysis assessments and vitals and weights were obtained as ordered for one resident (Resident #98). This affected one resident (Resident #98) of one review for dialysis services. The facility census was 105. Findings include: Review of the medical record for Resident #98 revealed an admission date of 08/31/23. Diagnoses included respiratory failure, depression, chronic kidney disease, anemia, diabetes, dementia. and heart failure. Review of the physician's orders for November 2023 revealed an order for pre and post dialysis vitals and weights once per day on Mondays, Wednesdays and Fridays. Review of the quarterly Minimum Data Set assessment (MDS) dated [DATE] revealed the resident was severely cognitively impaired. She required extensive assistance of one person for dressing and hygiene, limited assistance of one person for toileting and supervision of one person for bed mobility and transfers. She 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 review of the medical record, review of the pharmacy recommendation, interview with staff, and review of facilities policy, the facility failed to ensure pharmacy recommendation were addressed and implemented timely. This affected one resident ( Resident #26) of five reviewed for unnecessary medications. The facility census was 105. Findings included: Review of the medical record revealed Resident #26 was admitted to the facility on [DATE]. Diagnoses alcohol dependence, seizures, chronic obstructive pulmonary disease, heart failure, anemia, psychoactive substance abuse, cerebral infarction, abnormal aortic aneurysm, schizoaffective disorder, peripheral vascular disease, anxiety disorder, depression, dementia, hypertension, COVID-19, mood disorder, and left leg amputation. Review of the annual Minimum data set assessment dated [DATE] revealed Resident #26 had moderately impaired cognition and he was administered an anti-psychotic medication seven days a week. Review of the November 2023 physician's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facilities policy review, the facility failed to ensure nonpharmacological interventions were in place prior to administering as needed (prn) pain medication and failed to ensure parameters were in place to determine which type of pain medication to administer. This affected one resident (Resident #53) of six reviewed for unnecessary medications. The facility census was 105. Findings include: Review of the medical record for Resident #53 revealed an admission date of 01/25/23. Diagnoses included chronic obstructive pulmonary disease, heart disease, diabetes, depression, Absence of left leg below knee, hepatitis and generalized muscle weakness. Review of the physicians orders for November 2023 revealed an order for Norco (an opioid medication used to treat moderate to severe pain) 5-235 milligrams (mg) one tablet by mouth (po) every 12 hours prn for pain and Tylenol 1000 mg every eight hours as needed for pain. Review of the quarterly Minimum Data Set (MDS)…

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, interview, and facilities policy review, the facility failed to ensure one resident (Resident #97) had a diagnosis for a prescribed antipsychotic. This affected one resident (Resident #97) of six reviewed for unnecessary medications. The facility census was 105. Findings include: Review of the medical record for Resident #97 revealed an admission date of 10/18/23. Diagnoses included depression, anxiety, substance abuse and cardiac arrest. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. He needed partial to moderate assistance with showering, set up assistance for hygiene and was independent and eating. Review of the physicians orders for November 2023 revealed an order for Zyprexa (an antipsychotic medication) 5 milligrams (mg) once per day for depression. Interview on 11/29/23 at 2:44 PM with the Director of Nursing confirmed the resident did not have an appropriate diagnosis for Zyprexa. Review of the facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and facilities policy review, the facility failed to ensure Resident #63's, Resident #74's and Resident #95's medications were administered as ordered by the physician causing a medication error rate of 45 percent. This affected three ( Resident #63,#74, and #95) out of five residents observed during medications administration. The facility census was 105. Findings include: 1. Resident #63 was admitted on [DATE] with diagnoses including urinary tract infection, acute kidney failure, uropathy, depression, emphysema, gastroesophageal reflux disease, shortness of breath, quadriplegia, high blood pressure, osteoarthritis, pulmonary nodule, anemia, lumbago with sciatica nerve pain, chronic fatigue, alcohol abuse, psychoactive substance use. Resident #63's plan of care initiated on 09/20/23 indicated interventions to administer medications as ordered by the physician to manage his diagnosis of high blood pressure, gastroesophageal reflux disease, symptoms of dehydration…

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 staff interview, the facility failed to store, prepare and serve food under sanitary conditions. This affected all residents in the facility, as there were no residents identified by the facility as receiving nothing by mouth (NPO). The facility census was 101. Findings included: Observations during the kitchen tour with Dietary Manger #600 on 08/16/23 at 10:35 A.M. revealed the following concerns: there were two black, three-tiered carts dirty with food debris and food splashed down the sides of them, the top of the plate warmer was dirty with food debris and dust, two metal carts for the oven pans were dirty with food splashed on them, two drink carts were dirty with dirt and food debris, and three trash cans in the food preparation area with no lids on them. An observation of the walk-in cooler revealed a bag of pepperoni, a quarter of a whole ham wrapped in plastic wrap, a plastic container of shredded cheddar cheese, a plastic container o shredded mozzarella cheese, a plastic container of shredded parmesan cheese, a plastic container of bacon bits and a…

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

Based on the observations and interviews with staff, the facility failed to ensure rooms for Resident #7 and #101 and the shower rooms on the third and fourth floors were maintained in a clean, sanitary manner. This affected two residents ( Resident #7 and #101) of three residents reviewed for physical environment in their rooms, and had the potential to affect all 47 residents (Resident #1, #2, #3, #8, #10, #11,#14, #17, #18, #19, #20, #21, #23, #24, #27, #29, #30, #37, #38, #40, #41, #45, #49, #50, #53. #55, #61, #63, #64, #68, #69, #71, #72, #74, #75, #76, #77, #78, #81, #86, #87, #89, #92, #94, #97, #99 and #100) on the third floor and all 27 residents ( Resident #4, #5, #13, #22, #25, #26, #28, #31, #33, #34, #39, #42, #48, #51, #52, #57, #58, #59, #73, #79, #88, #90, #91, #93, #96, #98, and #101) on the fourth floor where the shower rooms were located for use by those residents. The facility census was 101. Findings included: 1. Observation of the room of Resident #7 on 08/17/23 at 10:10 AM revealed the floor was dirty with dirt buildup around the perimeter of the room. There…

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 review of the medical record, interview with the staff and interview with the family, the facility failed to notify the responsible party/family for Resident #101 with a new order to remove his bed from his room and place his mattress on the floor for safety reasons. This affected one resident ( Resident #101) of three residents reviewed for resident rights. The facility census was 101. Findings included: Review of the medial record revealed Resident #101 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, aphasia, cerebral edema, moderate protein-calorie malnutrition, hemiplegia, pulmonary hypertension, restlessness and agitation and insomnia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #101 had severely impaired cognition. He required total assistance with two staff members for bed mobility, transferring, dressing, toilet use, personal hygiene, and bathing and with one staff member for eating. He was always incontinent of bladder…

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

Based on record review and interview the facility failed to ensure annual performance evaluations and twelve hours of regular in-service education were completed as required for State Tested Nursing Assistants (STNAs). This affected four of four STNA personnel files reviewed and had the potential to affect all 95 residents currently residing in the facility. Findings include: Review of the personnel file for STNA #200 revealed a hire date of 03/17/13 and the last annual performance evaluation was completed on 05/21/20. There was no documentation in the personnel file of a performance evaluation for STNA #200 since 05/21/20, and no documentation of twelve hours of regular in-service education. Review of the personnel file for STNA #201 revealed a hire date of 03/06/18 and the last annual performance evaluation was completed on 05/21/20. There was no documentation in the personnel file of a performance evaluation for STNA #201 since 05/21/20, and no documentation of twelve hours of regular in-service education. Review of the personnel file for STNA #209 revealed a hire date 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 review of the Nursing Home Resident's [NAME] of Rights, medical record review, and interview the facility failed to respect a resident's right to determine when to go to bed. This affected one (Resident #145) of two residents reviewed for choices (18 residents were interviewed regarding choices). Findings include: Review of Resident #145's medical record revealed diagnoses including fusion of the cervical region of the spine and diffuse traumatic brain injury. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #145 was able to make himself understood and was able to understand others. Resident #145 was assessed with moderate cognitive impairment. Resident #145 required extensive assist with transfers. On 08/02/21 at 3:40 P.M., Resident #145 indicated a few days earlier State Tested Nursing Assistant (STNA) #210 refused to assist him to the bedside commode and placed him in bed against his will. On 08/04/21 at 7:07 P.M., STNA #210 verified after lunch one day over the prior…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, policy review and interview, the facility failed to ensure an allegation of abuse was reported. This affected one (Resident #145) of three residents reviewed for abuse. Findings include: Review of Resident #145's medical record revealed diagnoses including fusion of the cervical region of the spine and diffuse traumatic brain injury. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #145 was able to make himself understood and was able to understand others. Resident #145 was assessed with moderate cognitive impairment. Resident #145 required extensive assist with transfers. On 08/02/21 at 3:40 P.M., Resident #145 alleged a few days earlier State Tested Nursing Assistant (STNA) #210 refused to assist him onto the bedside commode and tossed him in bed against his will. Resident #145 indicated he filed a police report because he considered it abusive. Resident #145 stated Licensed Practical Nurse (LPN) #230 was aware. Resident #145 indicated STNA #210…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, and interview the facility failed to ensure one (Resident #145) of four residents reviewed for activities of daily living received bathing assistance. The facility identified 81 residents who required assistance with or who were dependent on staff for bathing. Findings include: Review of Resident #145's medical record revealed diagnoses including fusion of the cervical region of the spine and diffuse traumatic brain injury. An admission Minimum Daily Set (MDS) assessment indicated Resident #145 was able to make himself understood and was moderately cognitively impaired. Resident #145 was dependent on staff for bathing. On 07/14/21, an order was written for showers on Wednesday and Saturday on second shift. Review of bathing records indicated Resident #145 received bed baths on 07/15/21, 07/16/21, 07/24/21 and 07/25/21. On 08/02/21 at 3:49 P.M., Resident #145 stated he had only received one shower since his admission on [DATE]. Resident #145 stated he would prefer 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 observation, medical record review, and interview the facility failed to ensure an activity program was implemented in accordance with a resident's assessment and preferences. This affected one (Resident #59) of two residents reviewed for activities. Findings include: Review of Resident #59's medical record revealed diagnoses including chronic obstructive pulmonary disease, schizoaffective disorder, tracheostomy status, congestive heart failure, and bipolar disorder. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #59 was sometimes able to make herself understood and was sometimes able to understand others. Resident #59 was assessed with short and long term memory problems and severely impaired cognitive skills for daily decision making. The assessment indicated it was very important for Resident #59 to have reading material, listen to music she liked, keep up with the news, do her favorite activities, go outside and get fresh air when weather was good, and participate in…

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 resident interview, medical record review and staff interview the facility failed to ensure physician's orders for foot care were implemented and provided as ordered. This affected one (Resident #36) of one resident reviewed for foot care services. The facility census was 95. Findings include: Interview with Resident #36 on 08/02/21 at 12:51 P.M. revealed no foot care was being completed as ordered by the physician. Review of Resident #36's medical record revealed an admission date of 01/24/18 with diagnosis that included diabetes mellitus type two. Further review of the medical record including physician's orders revealed on 04/08/21 Resident #36 was ordered foot soaks in warm soapy water for 15 minutes for one week. Review of the treatment administration record (TAR) revealed no evidence the foot soak was transcribed onto the TAR and completed as ordered. Interview with Regional Staff #216 on 08/05/21 at 8:45 A.M. verified foot soaks for Resident #36 were not provided as ordered.

Based on observation, resident interview, medical record review and staff interview the facility failed to provide restorative range of motion services as indicated. This affected two (Residents #69 and #76) of three residents reviewed for range of motion. The facility census was 95. Findings include: 1. Observation of Resident #69 on 08/02/21 at 10:15 A.M. identified bilateral contractures to the hands and wrists with no evidence of any type of splint device in place. Continued observations identified no splint devices in place. Review of Resident #69's medical record revealed an admission date of 07/28/16 with diagnoses that include cerebrovascular accident. Further review of the medical record including the State Tested Nurse Aide (STNA) Tasks identified Resident #69 was to receive nursing rehabilitation services including active assist range of motion (AROM) to the bilateral upper extremities including hands, fingers, wrists, elbows and shoulders. Further review of the STNA Tasks for the last 30 days from 07/04/21 to 08/03/21 indicated the AROM assistance was provided only 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 observation, medical record review, staff interview and policy review the facility failed to ensure fall interventions were in place as ordered for one (Resident #62) of four residents reviewed for falls. The facility also failed to ensure monitoring devices were in place as ordered to prevent unwanted exit from the facility for one (Resident #43) of two residents reviewed for supervision. The facility census was 95. Findings include: 1. Review of Resident #62's medical record revealed an admission date of 10/16/18 with diagnoses that include cerebrovascular accident with hemiplegia and hemiparesis. Further review of the medical record revealed a physician's order from 07/27/21 which indicated the use of a low bed for safety following a fall from the resident's bed. Observation of Resident #62 on 08/04/21 at 10:14 A.M. revealed Resident #62 asleep in bed, the bed was observed to be raised approximately two feet off the floor and not in the low position. Interview with Licensed Practical Nurse (LPN) #202…

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, medical record review and interview the facility failed to ensure implementation of physician orders for residents with tracheostomies. This affected two (Residents #20 and #59) of three residents reviewed for respiratory care. The facility identified two residents with tracheostomies. Findings include: 1. Review of Resident #20's medical record revealed diagnoses including acute and chronic respiratory failure, heart failure, anxiety disorder, and tracheostomy {A surgically created opening through the front of the neck and into the windpipe (trachea) into which a tracheostomy tube (trache) is placed to maintain breathing status.} A nursing note dated 06/29/21 at 5:30 P.M. indicated Resident #20 pulled her trache out and the registered nurse was unable to replace it. Resident #20 was sent to the emergency room for trache replacement. Resident #20 had a physician order dated 06/30/21 to keep a spare trache (size 4 uncuffed Shiley) at the bedside. On 07/30/21 at 10:48 A.M., Registered Nurse (RN) #232 confirmed there was no spare trache (size 4 uncuffed Shiley) at…

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

Based on medical record review, observation, policy review, and interview the facility failed to maintain infection control practices during tracheostomy care. This affected one (Resident #59) of one resident observed for tracheostomy care. Findings include: Review of Resident #59's medical record revealed diagnoses including acute respiratory failure with hypoxia (below normal level of oxygen in the blood), chronic obstructive pulmonary disease, obstructive sleep apnea, and tracheostomy (trache) status {A surgically created opening through the front of the neck and into the windpipe (trachea) into which a tracheostomy tube (trache) is placed to maintain breathing status.} A care plan intervention initiated 08/03/21 indicated Resident #59 was to be suctioned as necessary. During observation of trache care on 08/04/21 at 1:20 P.M., Licensed Practical Nurse (LPN) #230 was observed opening a tracheal suctioning kit. A pack of sterile gloves was removed. One glove was donned. The gloved hand was used to reposition flexible tubing lying on the bed and across Resident #59's chest. 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 medical record review and staff interview the facility failed to ensure antibiotic assessments were used to ensure appropriate antibiotic use. This affected one (Resident #62) of five residents reviewed for medications. The facility census was 95. Findings include: Review of Resident #62's medical record revealed an admission date of 10/16/18 with diagnoses that included cerebrovascular accident. Further review of the medical record including medication orders revealed antibiotic orders on 03/20/21 for Levaquin (antibiotic) 500 milligram (mg) every day for five days for a toe infection, 04/15/21 Bactrim DS (antibiotic) one every day for 10 days for a toe infection, 05/04/21 Bactrim DS one every day for 10 days for a toe infection and 05/30/21 gentamicin (antibiotic) 120 mg/100 milliliter (ml) intravenous every eight hours for 14 days for a toe infection. Further review of the medical record found no evidence of any type of assessment completed to determine if antibiotic use was appropriate. Interview with the Director of Nursing on 08/04/21 at 8:50 A.M. verified no…

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