Kimes Nursing and Rehab LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, record review, and policy review, the facility failed to maintain an infection and prevention and control program designed to help prevent the development and transmission of communicable disease, including COVID-19. This affected 55 of 55 residents residing in the facility.Findings include: Observations on 01/15/26 at 5:00 A.M. revealed a sign on the entrance door to the facility that stated: Staff and visitors, due to current outbreak of COVID-19, N95 mask is required at all times in the facility. Observations on 01/15/26 between 5:01 A.M. and 5:30 A.M. revealed that four of the five staff on night shift (Licensed Practical Nurse (LPN) #73, LPN #105, Certified Nursing Assistant (CNA) #95, and CNA #81) were not wearing any mask in the facility. Interview with LPN #73 on 01/15/26 at 5:01 A.M. at the nursing desk on the skilled unit, confirmed she was not wearing any mask. She stated that she had one resident (Resident #42) on her unit that currently had COVID-19. She…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure residents received showers per their preferred shower schedule. This affected three (#5, #8 and #47) of four residents reviewed for showers. The facility census was 54.Findings include:1. Review of Resident #5's medical record revealed an admission date of 04/26/23 and diagnoses including but not limited to dementia, hypertension, anxiety and depression. Review of Resident #5's quarterly Minimum Data Set, dated [DATE] revealed a Brief Interview for Mental Status score of one (1) indicating the resident had severe cognitive impairment. Further review revealed the resident was dependent on the facility staff for bathing/showering needs.Review of Resident #5's care plan revealed an activities of daily living care plan initiated on 09/16/25 that indicated the resident was dependent on one staff member for assistance with her shower. Further review of the care plan revealed the facility was to assist the resident with a shower twice a week.Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and review of the facility policy review, the facility failed to ensure residents with pressure ulcers received appropriate and timely treatment and services to promote wound healing. This affected two (Residents #22 and #58) of three residents reviewed for pressure ulcers. The facility census was 55 residents. Findings include: 1.Review of the medical record for Resident #22 revealed an admission date of 02/11/25 with diagnoses of congestive heart failure, respiratory failure, diabetes, and stage four kidney disease. Review of readmission notes for Resident #22 dated 03/10/25 revealed the resident returned from the hospital on [DATE] with pressure ulcers to right and left heels. Review of the wound note for Resident #22 dated 04/01/25 revealed the pressure ulcer to the right heel was resolved. Review of the physician's orders for Resident #22 revealed an order dated 05/13/25 to cleanse the left heel with normal saline, apply skin prep, and leave open…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, review of the facility Self-Reported Incident, review of facility witness statements, and review of facility policy, the facility failed to ensure an allegation of physical abuse was reported timely and appropriately. This affected one resident (#39) of the three residents reviewed for abuse during the complaint survey. The facility census was 55. Findings include: Record review for Resident #39 revealed the resident was admitted to the facility on [DATE] and had diagnoses including chronic respiratory failure, dementia with psychotic disturbance, and psychosis. Review of the 5-day Minimum Data Set (MDS) assessment, dated 11/15/24, revealed the resident was rarely/never understood and had long and short term memory problems. Review of the facility Self-Reported Incident (SRI), dated 12/01/24 and timed 11:44 A.M., revealed on 12/01/24 at 11:09 A.M. Activities Director #500 reported to the Administrator an allegation of abuse by Certified Nursing Assistant (CNA) #111…

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 medical records, resident vaccination consent forms and staff interview the facility failed to offer each resident a pneumococcal immunization. This affected four (Residents #10, #36, #37 and #46) of five residents sampled for influenza, pneumococcal and COVID-19 immunization review. The census was 51. Findings include: 1. Review of Resident #10's medical record revealed an admission date of 08/09/21 and diagnoses of atherosclerotic heart disease, diabetes, hypothyroidism, dementia of unspecified severity, anxiety, depression, hypertension and hyperlipidemia. Review of the immunization record revealed Resident #10 received a dose of an unknown type of pneumococcal vaccine on or around 07/10/19. Review of Resident #10's physicians orders revealed no orders for pneumococcal vaccine. Review of the facility form titled Vaccine Administration Record (VAR)/informed Consent for Vaccinations at LTCF Pharmerica revealed a line where the resident or responsible party could indicate if they wished to receive a COVID-19 vaccination, influenza vaccination or other vaccination.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to ensure a resident and or their resident representative was provided a bed-hold notice as required, when the resident was transferred out to the hospital. This affected one (Resident #32) of two residents reviewed for hospitalization. The facility census was 51. Findings include: Review of Resident #32's medical record revealed the resident was admitted to the facility on [DATE]. Her diagnoses included dementia with behavioral disturbances, unspecified intellectual disability, generalized anxiety disorder, restlessness and agitation, and hypernatremia. Her face sheet indicated the resident's sister was listed as her emergency contact #1 and her mother was her emergency contact #2. Review of Resident #32's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was sometimes able to make herself understood and was sometimes able to understand others. She had short and long term memory impairment and her…

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

Based on staff interview and record review the facility failed to to ensure resident Pre-admission Screening and Resident Review (PASARR) documents were accurate regarding resident current conditions and diagnoses. This affected one (Resident #4) of one resident reviewed for PASARR documents. The census was 51. Findings include: Record review of Resident #4 revealed an admission date of 04/26/19 with pertinent diagnoses of: anxiety disorder on 07/30/21, schizoaffective disorder on 01/25/22 dementia, covid 19, type two diabetes mellitus, localized edema, hammer toe, cognitive communication deficit, macular degeneration, sensorineural hearing loss, reduced mobility, vitamin D deficiency, iron deficiency anemia, hypertension, hyperlipidemia, major depressive disorder, hypokalemia, and symbolic dysfunctions. Review of the 08/22/24 Minimum Data Set (MDS) assessment revealed the resident was severely cognitively impaired and used a walker to aid in mobility. The resident required partial moderate assistance to roll left and right, sit to lying, lying to sitting, sit to stand, chair/bed 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 staff interview, and record review the facility failed to develop comprehensive care plans for Resident #36's anticoagulant use and Resident #10's anxiety care plan was not specific and patient centered. This affected two (Resident #10, and #36) of 20 residents reviewed for care plans. The facility census was 51. Findings include: 1. Record review of Resident #36 revealed an admission date of 03/07/24 with pertinent diagnoses of: end stage renal disease, type two diabetes mellitus with diabetic chronic kidney disease, atherosclerotic heart disease of native coronary artery, congestive heart failure, acute embolism and thrombosis of right internal jugular vein, acute and chronic respiratory failure, disorder of kidney and ureter, noninfective gastroenteritis and colitis, hypertension, morbid obesity, disorders of lung, malignant neoplasm of prostate, anemia, polyneuropathy, hypoxemia, acquired absence of left leg above knee, and other malaise. Review of the 09/12/24 Minimum Data Set (MDS) assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure hospice records were available for continuity of care for one resident. This affected one (Resident #109) of one resident reviewed for hospice. Additionally, the facility failed to ensure compression stockings were applied as physician ordered. This affected one resident (#32) of one resident reviewed for edema. The facility census was 51. Findings Include: 1. Review of the medical record for Resident #109 revealed an initial admission date of 09/23/24 with the diagnoses including but not limited to fracture of head and neck of right femur, heart failure, dementia, atrial fibrillation, chronic obstructive pulmonary disease, gout, gastro-esophageal reflux disease and anxiety disorder. Review of the resident's comprehensive admission assessment dated [DATE] revealed the resident had a severe cognitive deficit. The assessment indicated the resident's prognosis was less than six months and the resident received hospice services. Review of the plan…

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 physician ordered pressure reduction devices were implemented as ordered. This affected two residents (#45 and #109) of four residents reviewed for pressure ulcers. The facility census was 51. Findings Include: 1. Review of the medical record for Resident #109 revealed an initial admission date of 09/23/24 with the diagnoses including but not limited to fracture of head and neck of right femur, heart failure, dementia, atrial fibrillation, chronic obstructive pulmonary disease, gout, gastro-esophageal reflux disease and anxiety disorder. Review of the resident's admission nursing assessment dated [DATE] revealed the resident was admitted to the facility with a stage I pressure ulcer to the right outer ankle measuring 2.0 centimeters (cm) by 2.0 cm. The resident also had an abrasion to the right hip measuring 3.0 cm by 0.2 cm and an abrasion to the left buttocks measuring 2.0 cm by 0.2 cm. Review of the resident's Braden scale 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, observation, staff interview, and policy review, the facility failed to ensure fall prevention interventions were implemented as per the plan of care for residents who were at risk for and/ or had a history of falls. This affected two (Resident #33 and #38) of four residents reviewed for falls. The census was 51. Findings include: 1. Review of Resident #33's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included a history of a left hip fracture and a left rib fracture secondary to a fall at home, difficulty walking, muscle weakness, and need for assistance with personal care. His diagnoses list was updated to reflect he had a right hip fracture on 08/19/24, after his admission to the facility. Review of Resident #33's care plans revealed he had an active care plan in place for being at risk for additional falls related to having a history of falls resulting in multiple fractures, a history of waking up through out the night confused and would…

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

Based on record reviews and interviews, the facility failed to ensure a resident with Post Traumatic Stress Disorder (PTSD) was appropriately assessed to identify the cause of the residents PTSD and minimize triggers and/or re-traumatization. This affected one resident (#37) identified by the facility as having PTSD/trauma. The facility census was 51. Findings include: Record review of Resident #37 revealed an admission date of 01/30/23 with pertinent diagnoses of: post traumatic stress disorder chronic 07/12/23, heart failure, morbid obesity, Alzheimer's disease, need for assistance with personal care, repeated falls, unspecified psychosis, hyperlipidemia, paranoid personality disorder, delusional disorders, abnormal posture, cognitive communication deficit, dementia, hypothyroidism, hypertension, tinea unguium, cardiomegaly, mood affective disorder, obstructive sleep apnea,anxiety disorders, major depressive disorder, and nightmare disorder. Review of the 09/11/24 quarterly Minimum Data Set (MDS) assessment revealed the resident was cognitively intact and used a walker to aid 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 observation, record review, policy review, and staff interview the facility failed to follow infection prevention guidelines when they failed to wear appropriate personal protective equipment for enhance barrier precautions when doing would care for Resident #36. This affected one (Resident #36) of five residents reviewed for infection control. The facility census was 51. Findings include: Record review of Resident #36 revealed an admission date of 03/07/24 with pertinent diagnoses of: end stage renal disease, type two diabetes mellitus with diabetic chronic kidney disease, atherosclerotic heart disease of native coronary artery, congestive heart failure, acute embolism and thrombosis of right internal jugular vein, acute and chronic respiratory failure, disorder of kidney and ureter, thrombocytopenia, gout, noninfective gastroenteritis and colitis, hypertension, morbid obesity, disorders of lung, malignant neoplasm of prostate, anemia, polyneuropathy, hypoxemia, acquired absence of left leg above knee, and other malaise. Review of the 09/12/24 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 and interview, the facility failed to ensure one resident (#21) was not treated with an antibiotic prior to the return of the culture and sensitivity (C&S) results. This affected one (Resident #21) of two residents reviewed for urinary tract infection (UTI). The facility census was 51. Findings Include: Review of the medical record for Resident #21 revealed an initial admission date of 02/13/23 with the latest readmission date of 04/07/23 with the diagnoses including but not limited to neurocognitive disorder with Lewy bodies, repeated falls, anxiety disorder, dementia, Alzheimer's disease, mood disorder, hypertension, osteoarthritis, metabolic encephalopathy and osteoporosis. Review of the plan of care dated 03/05/23 revealed the resident had toileting deficits related to dementia, cognitive function fluctuates, short and long term memory deficits, sometimes understood and sometimes understands others, supervision to limited assist with toileting, frequently incontinent of bowel 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.

Based on observation, staff interview, and facility policy review, the facility failed to serve food in a safe and sanitary manner. This affected 46 of 46 residents who utilized the kitchen for meals (Resident #249 received nothing by mouth). The census was 47. Findings Include: Observation on 07/06/23 at 12:36 P.M. revealed [NAME] #163 touching the cornbread from the pan three times with gloves and placed them on the meal plates. Also, she touched one breaded pork chop with the same gloved hand and placed it on the meal plate. In between touching the cornbread and pork chop with the same gloved hands, she touched the counter top, drawer handle for utensils, three different food utensils, multiple plates, and the plate warmer lid to lift it up. Observation on 07/06/23 at 12:44 P.M. revealed [NAME] #163 touching four pork chops with her gloved hand. After touching the pork chops, she took the gloves off, did not wash her hands, and then put a new pair of gloves on. Observation on 07/06/23 at 12:45 P.M. revealed [NAME] #163 touching stuffing after it was served onto the resident'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 review of infection control records and infection control policies and procedures review the facility failed to appropriately monitor resident infections as per infection control policy and procedures for the month of July, August and September of 2022. In addition the facility failed to implement and perform their Legionella Precautionary Maintenance and Inspections per their Legionella Water Management Program. This affected all residents in the facility. The census was 47. Findings Include: 1. Review of the the facility monthly infection control logs from 07/2022 to 07/2023 revealed for the months of 07/2022, 08/2022 and 09/2022 the monthly infection control log form did not include the resident symptoms, indicate if the resident had a chest x-ray or culture done with results , any type of necessary treatments and if the resident required Isolation. Interview on 07/06/23 11:48 AM with Registered Nurse (RN) #142 confirmed the Monthly Infection Log for 07/2022, 08/2022 and 09/2022 was incomplete and did not include the necessary documentation needed to track the residents…

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, review of the facility's shower schedule, resident interview, staff interview, and policy review, the facility failed to ensure a resident's frequency in which they were showered was honored in accordance with their preference. This affected one (Resident #10) of one residents reviewed for choices. Findings include: A review of Resident #10's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included dementia, adult onset diabetes mellitus, major depressive disorder, muscle weakness, difficulty walking, and need for assistance with personal care. A review of Resident #10's baseline care plan initiated on 08/12/21 revealed the resident was indicated not to have a preference at that time regarding bathing activities and staff may choose for her. They indicated showers would be provided two times per week. A review of Resident #10's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, self-reported incident (SRI) review, interview and facility policy review, the facility failed to ensure a thorough investigation was competed for an alleged allegation of abuse. This had the potential to affect all 47 residents residing in the facility and specifically affected Resident #39. Findings Included: Review of the SRI dated 04/01/23 revealed Resident #39 reported Licensed Practical Nurse (LPN) #210, the agency nurse who worked through the night threw something and hit her in the nose with it and woke her up. The SRI indicated the resident was alert and oriented and was emotionally distressed at the moment, but no physical injuries were present. The Administrator immediately reported LPN #210 to the agency and banned the nurse from returning to the facility in any role. The SRI indicated residents were interviewed and statements were being collected from witnesses. Review of the medical record for Resident #39 revealed an initial admission date of 01/30/23 with the diagnoses…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review ,staff interview, policy and procedure review the facility failed to issue a bed hold notification letter to one resident (#47) out of one resident reviewed for hospitalizations. The census was 47. Findings Include: Review of Resident #47's medical record revealed an admission date of 4/28/23 with no cognitive deficits. Diagnoses include atherosclerosis, muscle weakness, surgical aftercare following surgery on the circulatory system, and atherosclerotic heart disease of natives coronary artery without angina pector. Resident #47 was discharged on 05/18/23 to the hospital. Review of Resident #47's medical record nurses progress notes from 05/01/23 to 05/18/23 confirmed resident was discharged to the hospital on [DATE] with no bed hold notification given. Interview on 07/05/23 at 4:09 P.M. with the Administrator verified Resident #47 or the designated resident representative was not issued a Bed Hold Notification Letter when transferred to the hospital . Review of the facility Hold Bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to complete comprehensive assessments as required. This affected three (Residents #9, #250, and #40) of 17 resident assessments reviewed. The census was 47. Findings Include: 1. Record review revealed Resident #9 was admitted to the facility on [DATE]. Her diagnoses were atrial fibrillation, Alzheimer's disease, repeated falls, cognitive communication deficit, muscle weakness, heart failure, generalized anxiety disorder, congestive heart failure, osteoporosis, cerebrovascular disease, kyphosis, anemia, osteoarthritis, atherosclerosis, anemia, chronic kidney disease, major depressive disorder, dermatitis, insomnia, disorder of thyroid, hypertension, delirium, atrial fibrillation, hyperlipidemia, dysphagia. Review of her Minimum Data Set (MDS) assessment, dated 02/22/23, revealed she was cognitively intact. Review of Resident #9 MDS assessments revealed her most recent completed assessment was on 02/22/23. Review of her MDS assessments 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure all resident Pre-admission Screening and Resident Review (PASRR) documents were accurate to resident current conditions and diagnoses. This affected one (Resident #1) of two residents reviewed for PASRR documents. The census was 47. Findings Include: Record review revealed Resident #1 was admitted to the facility on [DATE]. His diagnoses were encephalopathy, type II diabetes, schizoaffective disorder, dementia, acute kidney disease, cognitive communication deficit, peripheral vascular disease, hematuria, depression, edema, hypothyroidism, dysphagia, atrial fibrillation, hydronephrosis, hypo-osmolality and hyponatremia, anxiety disorder, hypertension, hypokalemia, difficulty walking, and hyperlipidemia. Review of his Minimum Data Set (MDS) assessment, dated 05/18/23, revealed he had a severe cognitive impairment. Review of Resident #1's PASRR document, dated 09/17/18, revealed under Section C, the facility indicated he did not 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 medical record review and staff interview, the facility failed to ensure all significant mental health changes were communicated to the state mental health agency. This affected one (Resident #1) of two residents reviewed for PASRR documents. The census was 47. Findings Include: Resident #1 was admitted to the facility on [DATE]. His diagnoses were encephalopathy, type II diabetes, schizoaffective disorder, dementia, acute kidney disease, cognitive communication deficit, peripheral vascular disease, hematuria, depression, edema, hypothyroidism, dysphagia, atrial fibrillation, hydronephrosis, hypo-osmolality and hyponatremia, anxiety disorder, hypertension, hypokalemia, difficulty walking, and hyperlipidemia. Review of his Minimum Data Set (MDS) assessment, dated 05/18/23, revealed he had a severe cognitive impairment. Review of Resident #1 PASRR document, dated 09/17/18, revealed under Section C, the facility indicated he did not have a diagnosis of dementia or Alzheimer's disease. Also, under Section…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure one resident's (#40) hospice continuity of care. This affected one of one resident reviewed for hospice. Findings Included: Review of the medical record for Resident #40 revealed an initial admission date of 02/22/23 with the admitting diagnoses including Alzheimer's disease, anxiety disorder, restlessness and agitation, chronic obstructive pulmonary disease, diabetes mellitus, anemia, insomnia, peripheral vascular disease, chronic kidney disease, hyperlipidemia and depression. Review of the resident's clinical admission assessment dated [DATE] indicated the resident was admitted to the facility with hospice services. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. The assessment indicated the resident received hospice services. Review of the plan of care revealed the resident had no care plan addressing the resident's hospice status. Review of 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, record review and interview, the facility failed to implement the physician ordered off-loading to one resident's (#15) Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also present as an intact or open/ ruptured blister.) pressure ulcer. This affected one of one resident reviewed for pressure ulcers. Findings Included: Review of the medical record for Resident #15 revealed an initial admission date of 08/12/21 with the diagnoses including dementia, altered mental status, adult failure to thrive, nonrheumatic aortic valve insufficiency, cardiac murmur, generalized muscle weakness, schizoaffective disorder, metabolic encephalopathy, dysphagia, hypertension, disorder of kidney and ureter, gastro-esophageal reflux disease, insomnia and presence of cardiac pacemaker. Review of the plan of care dated 09/07/21 revealed the resident was at risk for skin integrity related to diagnoses of dementia with lack of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview, and policy review, the facility failed to ensure fall prevention interventions were implemented for a resident with a known history of falls and considered to be at risk for falls. This affected one (Resident #2) of two residents reviewed for accidents. Findings include: A review of Resident #2's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a fracture of the distal end of her right femur following a fall on 06/09/23, repeated falls, difficulty walking, age related osteoporosis, muscle weakness, muscle wasting and atrophy, need for assistance with personal care, osteoarthritis, hypertension, memory deficit following stroke, and unspecified dementia. A review of Resident #2's fall risk assessment completed on 04/14/23 revealed the resident was assessed to be a moderate risk for falls. Her risk factors included having a history of one to two falls during the past six months, medications that increase the risk for…

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

Based on observation and interview the facility failed to maintain a clean, sanitary homelike environment. This affected one (#40) of 15 sampled residents. Findings Included: On 07/03/23 at 9:57 A.M., observation of Resident #40's room revealed a strong odor of urine. The resident's bed side chair had peeling leather and a rip in the cushion. The resident's wall behind the headboard was also marred. On 07/05/23 at 1:20 P.M., observation of Resident #40 revealed the resident was quiet at bedrest with eyes closed. No signs of incontinence noted, however the resident's room continued to have a strong odor of urine. On 07/05/23 at 10:45 A.M., interview with Registered Nurse (RN) #142 verified the resident's room had a persistent strong odor of urine and the disrepair of the chair and wall. 07/06/23 at 8:00 A.M., observation of Resident #40's room revealed the room continued to have a strong odor of urine.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to ensure medications medications were labeled when opened and discarded when expired. This had the potential to affect seven (Resident #2, #4, #5, #11, #35, #36 and #38) of 22 residents of the south hall. The census was 55. Findings include: Observation of the medication cart on the South Hall medication cart and medication room revealed the following: 1. Lantus Solostar 100 unit/ml for Resident #35 with no date as when it was opened and it had been used. 2. Lantus Solostar 100 unit/ml for Resident #4 with no open date as to when it was opened and it had been used. 3. Symbicort 160-4.5 mcg inhaler for Resident #38 states medication expires in 90 days after opening. There was no date as to when it was opened. 4. One bottle of Geri care extra strength pain relief acetaminophen tablets 1000 tablets 500 mg each expired 08/21. This was verified on [DATE] at 11:12 A.M. with Licensed Practical Nurse (LPN) #8. 5. In the medication room two bottles of Geri…

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

Based on observations, interviews, and policy review, the facility failed to appropriately label and dispose of food items being stored in the facility kitchen. This had the potential to affect all residents residing in the facility who received meals from the kitchen except Resident #32 who was ordered Nothing by Mouth (NPO). The facility census was 55. Findings include: Observation on 09/08/21 at 11:17 A.M. revealed a plastic container of chicken salad and a plastic container with an open package of bologna which had both been opened and used and were labeled with a date opened of 08/31/21. There was an open bag of frozen chicken fritters in the reach in freezer which were not sealed or labeled with the date they were opened. Interview with [NAME] #51 on 09/08/21 at 11:20 A.M. verified the open bag of chicken fritters in the freezer was not sealed or labeled with the date opened. [NAME] #51 verified the chicken salad and bologna had both been opened and used and stated foods were normally thrown out after a week. Review of the facility policy titled Storage of Food, not 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.

Based on observation and staff interview, the facility failed to provide a dignified dining experience for a resident. This affected one (Resident #3) resident of 55 residents observed during dining. The census was 55. Findings include: On 09/07/21 12:17 P.M. observation revealed State Tested Nurses Aide (STNA) #56 standing in front of Resident #3's tray table and feeding her. On 09/07/21 at 12:30 P.M. interview with STNA #56 verified she was standing to feed Resident #3 because she didn't know if she was allowed to sit on the bed and feed her. STNA #56 verified standing and feeding Resident #3 did not provide the resident with a dignified dining experience.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure a new Pre-admission Screening and Resident Review (PASRR) Level I screen was completed for residents who received a new mental illness diagnosis after their admission to the facility and the completion of their initial PASRR Level I screen. This affected two (Resident #43 and #27) of three residents reviewed for PASRR's. Findings include: 1. A review of Resident #27's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included dementia, anxiety, depression, and bipolar disorder. A review of a PASRR Level I screen dated 03/05/19 revealed the resident was screened on that date for indications of a serious mental illness or a developmental disability. The pre-admission screen determination indicated the resident had no indications of a serious mental illness at that time. An in person assessment was not required as a result. Section (D.) of the PASRR assessment required the assessor to identify any indications 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, medical record review, and staff interview, the facility failed to ensure a resident who was unable to complete their oral hygiene received assistance. This affected one (Resident #104) of four residents reviewed for activities of daily living. The census was 55. Findings include: Review of Resident #104's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included dementia, dehydration, schizoaffective disorder, adult failure to thrive and repeated falls. Review of the admission minimum data set (MDS) assessment dated [DATE] revealed cognition was not intact. She required extensive assistance of two or more staff members for bed mobility, transfers, toilet use and personal hygiene and extensive assistance of one staff member for dressing. Observations on 09/07/21 at 11:42 A.M. revealed Resident #104 had a build up of white substance on bottom teeth. On 09/08/21 at 10:27 A.M. Resident #104's bottom teeth continue to have a white substance on them. At 2:30 P.M. her…

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 monitor a skin impairment surrounding Resident #32's gastrostomy tube and did not implement a new order from the wound doctor for the same area. This affected one resident (#32) of five residents reviewed for skin conditions. Findings include: Review of the medical record for Resident #32 revealed an admission date of 07/06/21 with diagnoses including gastrostomy malfunction, stage two pressure ulcer of sacral region, moderate protein-calorie malnutrition, pain, dysphagia, and personal history of malignant neoplasm of tongue. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #32 had intact cognition. The assessment indicated Resident #32 had a stage two pressure ulcer that was present upon admission. Review of the plan of care dated 08/23/21, revealed Resident #32 had skin integrity deficits related to a leaking gastrostomy tube, weakness, recent weight loss, and having admitted with a stage two pressure area, an abrasion…

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, observation and staff interview, the facility failed to ensure pressure reduction interventions were maintained in place. This affected one (Resident #104) of five residents reviewed for pressure ulcers. The census was 55. Findings include: Review of Resident #104's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included dementia, dehydration, schizoaffective disorder, adult failure to thrive and repeated falls. Review of the admission minimum data set (MDS) assessment dated [DATE] revealed cognition was not intact. She required extensive assistance of two or more staff members for bed mobility, transfers, toilet use and personal hygiene and extensive assistance of one staff member for dressing. admission Assessment on 08/12/21 identified a 4.8 cm (centimeter) x 2.7 cm, non blanchable redness to right buttock, a 8 centimeters (cm) by 3.8 cm distal to coccyx non blanchable redness and a 2 cm by 1.8 cm purple area in the center (suspect Deep Tissue…

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 ensure orders were in place for a range of motion program and orthotic device as recommended by the occupational therapist for Resident #29. This affected one (Resident #29) of five residents reviewed for limited range of motion. The facility census was 55. Findings include: Review of the medical record for Resident #29 revealed an admission date of 10/23/17 with diagnoses including depression, dysphagia, cognitive communication deficit, other specific joint derangements of unspecified hand, urinary retention, anxiety, dysphagia, and urinary retention. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #29 had impaired cognition. The resident required extensive assist of two persons for bed mobility dressing, and personal hygiene. She was totally dependent for transfers. The resident had no restorative nursing, no splint or brace. Review of the plan of care dated 08/05/21, revealed Resident #29 had self-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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, policy review, and staff interview, the facility failed to ensure fall interventions were maintained in place. This affected three (Resident #30, Resident #48 and Resident #104) of five residents reviewed for accidents. The census was 55. Findings include: 1. Review of Resident #48's medical record was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, diabetes, adult failure to thrive, epilepsy, hemiplegia and hemiparesis, subarachnoid hemorrhage and aphasia. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed her cognition was intact, she requires extensive assistance with two or more staff members for bed mobility, extensive assistance of one staff member for transfers, dressing, toilet use and personal hygiene. Review of the fall risk evaluation dated 08/06/21 revealed she was at high risk for falls. Review of plan of care dated 07/01/21 revealed an intervention of a pressure alarm to the bed and the chair at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, staff interview, and policy review, the facility failed to ensure a resident admitted with a urinary tract infection (UTI) received the appropriate antibiotic to adequately treat her infection. This affected one (Resident #157) of two residents reviewed for UTI's/ urinary catheters. Findings include: A review of Resident #157's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a UTI. A review of Resident #157's physician's orders revealed she was admitted to the facility with an order to receive Cephalexin (Keflex) 500 milligrams (mg) by mouth (po) twice a day (BID) for seven days. The order indicated the Cephalexin was being used to treat a UTI. There was no order given for a follow up urinalysis to be obtained after the completion of the antibiotic. A review of Resident #157's medication administration record (MAR) for August 2021 revealed the resident received her first dose of Cephalexin 500 mg po on 08/24/21 at 8:30 P.M.…

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, observation, policy review, and staff interview, the facility failed to ensure liquids were maintained within resident reach and the dietician was informed of a 13.9% weight loss. This affected one (Resident #104) of one resident reviewed for hydration and one (Resident #104) of six reviewed for nutrition. The census was 55. Findings include: 1. Review of Resident #104's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included dementia, dehydration, schizoaffective disorder, adult failure to thrive and repeated falls. Review of the admission minimum data set (MDS) assessment dated [DATE] revealed cognition was not intact. She required extensive assistance of two or more staff members for bed mobility, transfers, toilet use and personal hygiene and extensive assistance of one staff member for dressing. The MDS stages pressure area to coccyx as a stage one. Observations on 09/07/21 at 3:14 P.M. revealed Resident #104 was in her recliner with no fluids…

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 administer oxygen and change oxygen tubing as ordered by the physician. This affected two resident (#37 and #38) reviewed for respiratory care. The facility census was 55. Findings include: 1. Record review for Resident #38 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: diabetes mellitus, atrial fibrillation, hypertension, and morbid obesity. This resident had allergies to adhesive tape and tuberculin (TB) solution. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/19/21, revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15. This resident was assessed to require extensive assistance from two staff members with bed mobility, extensive assistance from one staff member for transfers, was independent with set up help only for eating, extensive assist from one staff member with toileting, extensive one assist for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to follow up on pharmacy recommendation in a timely manner. This affected one (Resident #48) of 20 sampled residents. The census was 55. Findings included.: Review of Resident #48's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, diabetes, adult failure to thrive, epilepsy, hemiplegia and hemiparesis, subarachnoid hemorrhage and aphasia. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed her cognition was intact, she requires extensive assistance with two or more staff members for bed mobility, extensive assistance of one staff member for transfers, dressing, toilet use and personal hygiene. Review of Pharmacy review dated 10/13/20 revealed Resident #48 was not receiving antiplatelet therapy despite diabetes mellitus, high blood pressure, and history of CVA. Please review and consider if beneficial/appropriate to add ASA (Aspirin) 81 mg…

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 accurate documentation of oxygen tubing changes in a resident's medical record. This affected one resident (#38) reviewed for respiratory services. Findings include: Record review for Resident #38 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: diabetes mellitus, atrial fibrillation, hypertension, and morbid obesity. This resident had allergies to adhesive tape and tuberculin (TB) solution. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/19/21, revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15. This resident was assessed to require extensive assistance from two staff members with bed mobility, extensive assistance from one staff member for transfers, was independent with set up help only for eating, extensive assist from one staff member with toileting, extensive one for personal hygiene. Review…

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

Based on observation and staff interview, the facility failed to maintain infection control during a dressing change. This affected one (Resident #104) of one resident observed during a dressing change. The census was 55. Findings include: On 09/13/21 12:50 P.M. observation of a dressing change to Resident #104's coccyx by Licensed Practical Nurse (LPN) #24 revealed he washed his hands, gathered his supplies and put on gloves. LPN #24 then removed the old dressing, removed his gloves and washed his hands. The area was pink with granulation tissue. LPN #24 then put on new gloves, cleansed the area with wound cleanser and 4 by 4 gauze. With the same gloves, he applied santyl to the area with Q-tip, then a clean dressing, then removed his gloves and washed his hands. At 1:00 P.M. interview with LPN #24 revealed he had not washed his hands and changed his gloves after cleaning the wound.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, staff interview, and policy review, the facility failed to implement an effective antibiotic stewardship program to ensure a resident admitted with a urinary tract infection (UTI) received the appropriate antibiotic to properly treat her infection. This affected one (Resident #157) of two residents reviewed for UTI's/ urinary catheters. Findings include: A review of Resident #157's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a UTI. A review of Resident #157's physician's orders revealed she was admitted to the facility with an order to receive Cephalexin (Keflex) 500 milligrams (mg) by mouth (po) twice a day (BID) for seven days. The order indicated the Cephalexin was being used to treat a UTI. There was no order given for a follow up urinalysis to be obtained after the completion of the antibiotic. A review of Resident #157's medication administration record (MAR) for August 2021 revealed the resident received her first…

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.