Emerald Pointe Health And Rehab Ctr

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, review of camera footage, employee statement review and policy review, the facility failed to provide care and services, including appropriate supervision levels, to prevent resident neglect. This affected one resident (Resident #10) of three residents reviewed for neglect. The facility census was 58. Findings included: Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, muscle weakness, osteoporosis, vertigo, anxiety, and restlessness and agitation. Review of Resident #10's care plan, dated 05/23/23, revealed the resident was at risk for alteration in comfort with interventions including to reposition the resident for comfort. Further review revealed the resident was at risk for falls related to weakness, poor safety awareness, osteoporosis, glaucoma, vertigo,…

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, review of camera footage, employee statement review, self-reported incident review, and policy review, the facility failed to report an allegation of resident neglect to the state survey agency This affected one (Resident #10) of three residents reviewed for neglect. The facility census was 58 Findings include: Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, muscle weakness, osteoporosis, vertigo, anxiety, and restlessness and agitation. Review of Resident #10's care plan, dated 05/23/23, revealed the resident was at risk for alteration in comfort with interventions including to reposition the resident for comfort. Further review revealed the resident was at risk for falls related to weakness, poor safety awareness, osteoporosis, glaucoma, vertigo, and anxiety with interventions including to encourage and remind the resident to ask for assistance and to monitor/anticipate/intervene…

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 a medication error report and the facility's related investigation, resident interview, staff interview, review of employee personnel files, and policy review, the facility failed to have competent nurse staffing to ensure medications were administered to residents to meet professional standards of nursing. This affected two residents (#41 and #44) of four residents reviewed. Findings include: 1 a.) Review of Resident #44's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included congestive heart failure (CHF), chronic ischemic heart disease, hypertension (HTN), and atrial fibrillation. Review of Resident #44's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. She was not known to have displayed any behaviors or reject care during the seven days of the assessment period. Review of Resident #44's physician's orders revealed she received the following…

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

Based on interview and record review, the facility failed to ensure bathing and showers were provided as requested. This affected one resident (#14) of three residents reviewed for showers. The census was 58. Findings include: Review of Resident #14's record revealed a 10/29/20 admission with diagnoses including Alzheimer's disease, hypertension, gastroesophageal reflux disease, depressive disorder, vitamin D deficiency, pruritus, chronic pain syndrome, peripheral vascular disease, anxiety disorder, dementia, and cough. Review of the 01/04/24 quarterly Minimum Data Set Assessment revealed the resident was independent for daily decision making, dependent of two or more for shower/bathing, and resident does none of the effort to complete activity. Interview on 02/26/24 at 1:35 P.M. with Resident #14 revealed she was to get a shower every Monday. She said it has been two weeks and they have not asked her if she wanted a shower. Review of shower sheets included the resident received one shower in January 2024 on 01/24/24, with no refusals noted. In February 2024 the resident had 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 record review, policy review, and interview, the facility failed to ensure resident representatives and physician were notified of changes in treatment and condition. This affected two residents (#59, #61) of three residents reviewed for notification. The census was 58. Findings include: 1. Record review of Residents #61 revealed a 09/09/22 admission with diagnoses including unspecified dementia, proximal atrial fibrillation, atherosclerotic heart disease, sick sinus syndrome, chronic kidney disease stage four, psoriasis, hypertension, hyperlipidemia, aortic aneurysm, peripheral vascular disease, anemia in chronic kidney disease, major depressive disorder, Anxiety, Gastroesophageal reflux disease, hemiplegia, gout, constipation, angina pectoris, overactive bladder, insomnia, Hydronephrosis, chronic pain syndrome, vitamin D deficiency, macular degeneration, cough, puritis, shortness of breath, hyperglycemia, old myocardial infarction, personal history of neoplasm with the breast, personal history of pulmonary embolism and dry eye syndrome. Review of the quarterly 01/15/24…

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

Based on record review and interview, the facility failed to ensure a plan of care was in place related to a blister from spilled coffee. This affected one resident (#15) of three residents reviewed for skin conditions. The census was 58. Findings include: Review of Resident #15's medical record revealed a 07/01/18 admission with diagnoses including type two diabetes mellitus without complications, chronic obstructive pulmonary disease, unspecified, diastolic congestive heart failure, atherosclerotic heart disease, essential primary hypertension, rheumatoid arthritis, hyperlipidemia, arthritis, iron deficiency anemia, morbid severe obesity, hypokalemia, Gastroesophageal reflux disease without esophagitis,allergic rhinitis, adjustment disorders with depressed mood, vitamin D deficiency, encounter for orthopedic aftercare following a surgical amputation, muscle weakness, and a personal history of Covid. Review of a quarterly 01/09/24 Minimum Data Set Assessment indicated the resident was independent for daily decision making, with lower extremity impairment on one side, Interview 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.

Based on record review and interview, the facility failed to ensure timely intervention for a resident with nausea and vomiting. This affected one resident (#61) of three residents reviewed for change in condition. The census was 58. Findings include: Record review of Residents #61 revealed a 09/09/22 admission with diagnoses including unspecified dementia, proximal atrial fibrillation, atherosclerotic heart disease, sick sinus syndrome, chronic kidney disease stage four, psoriasis, hypertension, hyperlipidemia, aortic aneurysm, peripheral vascular disease, anemia in chronic kidney disease, major depressive disorder, Anxiety, Gastroesophageal reflux disease, hemiplegia, gout, constipation, angina pectoris, overactive bladder, insomnia, Hydronephrosis, chronic pain syndrome, vitamin D deficiency, macular degeneration, cough, puritis, shortness of breath, hyperglycemia, old myocardial infarction, personal history of neoplasm with the breast, personal history of pulmonary embolism and dry eye syndrome. Review of the quarterly 01/15/24 Minimum Data Set Assessment included the resident…

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

Based on observation, record review, and interview, the facility failed to ensure pressure reduction measures were in place as ordered. This affected two residents (#4, #15) of three residents reviewed for skin impairment. Findings include: 1. Record review of Resident #4 revealed a 01/24/24 admission with diagnoses including hemiplegia,hemiparesis following cerebral infarct affecting left non dominate side, protein calorie malnutrition, muscle weakness, dysphasia, muscle wasting and atrophy, proximal atrial fibrillation, tremor, hypercalcemia, gastrointestinal hemorrhage, pulmonary hypertension, major depressive disorder, hypertension, iron deficiency, anemia, hyperlipidemia, heart failure, pain, nausea and vomiting, urine retention, and benign prosthetic hyperplasia. Review of a 01/31/24 admission Minimum Data Set Assessment (MDS) revealed the resident was independent for daily decision making, had upper extremity impairment on one side, and required maximum assist for turning and rolling in bed. Review of a 02/15/24 Pressure Skin Grid revealed a right heel unstageable (full…

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, and interview, the facility failed to ensure accurate medical records. This affected two residents (#4, #15) of three residents reviewed for skin impairment. Findings include: 1. Record review of Resident #4 revealed a 01/24/24 admission with diagnoses including hemiplegia,hemiparesis following cerebral infarct affecting left non dominate side, protein calorie malnutrition, muscle weakness, dysphasia, muscle wasting and atrophy, proximal atrial fibrillation, tremor, hypercalcemia, gastrointestinal hemorrhage, pulmonary hypertension, major depressive disorder, hypertension, iron deficiency, anemia, hyperlipidemia, heart failure, pain, nausea and vomiting, urine retention, and benign prosthetic hyperplasia. Review of a 01/31/24 admission Minimum Data Set Assessment (MDS) revealed the resident was independent for daily decision making, had upper extremity impairment on one side, and required maximum assist for turning and rolling in bed. Review of a 02/15/24 Pressure Skin Grid revealed a right heel unstageable (full thickness tissue loss where the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, in room camera video review, resident interview, staff interview, and facility education review, the facility failed to ensure Resident #63 received a dignified experience during a meal service and during incontinence care. This affected one resident (#63) of three residents reviewed for dignity. Findings include: A review of Resident #63's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Down's Syndrome, senile degeneration of the brain, muscle weakness, depression, and anxiety disorder. A review of Resident #63's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had unclear speech and was sometimes able to make herself understood. She was sometimes able to understand others. Her vision was moderately impaired without the use of any corrective lenses. She had short and long term memory impairment and her cognitive skills for daily decision making was severely impaired. She was known to have hallucinations, physical…

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 videos from an in room camera, resident interview, staff interview, and review of facility education information, the facility failed to ensure a resident was transferred in a safe and orderly manner. This affected one resident (#63) of three residents reviewed. Findings include: A review of Resident #63's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Down's Syndrome, senile degeneration of the brain, muscle weakness, depression, and anxiety disorder. A review of Resident #63's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had unclear speech and was sometimes able to make herself understood. She was sometimes able to understand others. Her vision was moderately impaired without the use of any corrective lenses. She had short and long term memory impairment and her cognitive skills for daily decision making was severely impaired. She was known to have hallucinations, physical behaviors directed 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 in room camera video review, staff interview, and policy review, the facility failed to ensure appropriate infection control practices were followed during feeding assistance and with the provision of incontinence care. This affected one resident (#63) of three residents reviewed. Findings include: A review of in room camera videos from Resident #63's room revealed there were nine separate videos that lasted between 14 seconds to one minute and 27 seconds in length. Six of the nine videos (videos #1, #2, #3, #4, #6, and #9) involved feeding assistance that was provided to Resident #63 by State Tested Nursing Assistant #16. Two of the nine videos were of Resident #63 receiving incontinence care as provided by State Tested Nurse Aide (STNA) #45 and #68. Of the six videos that showed Resident #63 being assisted with her meal, five of the videos (video #1, #2, #4, #6, and #9) had identified infection control concerns. STNA #16 was observed in those videos to be seated on the resident's bed assisting her with her meal. The aide was observed to wipe her nose with the outside 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.

Based on observation, interview, and facility policy review the facility failed to store foods properly to prevent spoilage and/or contamination. This had the potential to affect 51 residents receiving food from the kitchen. The facility identified one resident (Resident #155) as receiving nothing by mouth. The facility census was 52. Findings included: Observation on 04/10/23 at 8:15 A.M. of the kitchen revealed the following items in the walk-in refrigerator which were opened and not dated: one large bag of mixed green salad, one squeeze bag of whipped cream, and a partial ham wrapped in aluminum foil. There was also one resealable plastic bag of hot dogs, dated 04/08/23, with the seal not completely closed. Observation on 04/10/23 at 8:23 A.M. of the following items in the reach in the dining refrigerator which were opened and not dated: one large container of International Delight Amaretto coffee creamer which was one-half full. Observation on 04/10/23 at 8:25 A.M. of the cooks' reach in refrigerator revealed the following items, opened, and not labeled or dated: a five-gallon…

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 the Preadmission Screening and Resident Review (PASARR) Identification Screen was accurate. This affected one resident (Resident #3) of one resident reviewed for PASARR. The facility census was 52. Findings included: Review of Resident #3's medical record revealed an admission date of 04/18/10. Additional diagnoses were added including generalized anxiety entered 05/15/12, major depressive disorder recurrent, unspecified entered 08/25/15, and unspecified psychosis not due to substance or known physiological condition entered 08/25/15. Review of Resident #3's significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively impaired and had active diagnoses including anxiety disorder, depression and a psychotic disorder (other than schizophrenia). Review of Resident #3's PASARR dated 03/16/23 revealed in Section E: Indications of serious mental illness, the diagnoses of mood disorder was marked with an X.…

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, interview, and facility policy review the facility failed to ensure care planning conferences were conducted quarterly. This affected one Resident (Resident #27) of one resident reviewed for care planning. The facility census was 52. Findings included: Review of Resident #27's medical record revealed an initial admission date of 12/22/20 with diagnoses including fibromyalgia, major depressive disorder, anxiety disorder, hyperlipidemia, and muscle weakness. Review of Resident #27's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/15/23, revealed she was moderate cognitive impairment. Review of Resident #27's care conferences revealed care conferences were conducted on 09/23/21, 10/28/21, 05/19/22, 08/18/22 and 02/23/23 Review of Resident #27's progress notes revealed she declined a care planning conference on 11/28/22 and had a care planning conference scheduled 02/22/23. There was no documentation to confirm the care planning conference scheduled for 02/22/23 occurred. Interview on 04/10/23 at 11:20 A.M. with Resident #27 revealed she did not…

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 residents were assisted with activities of daily living. This affected one resident (Resident #35) of two residents reviewed for activities of daily living (ADL). The facility census was 52. Findings included: Review of Resident #35's medical record revealed an initial admission date of 07/17/18 and readmission on [DATE] with diagnoses including Alzheimer's disease, type two diabetes, essential hypertension, and muscle weakness. Review of Resident #35's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/18/23, revealed she was cognitively impaired and needed limited assistance of one person with personal hygiene. Review of Resident #35's current care plan revealed she required assistance with ADLs and may be at risk of developing complications associated with decreased ADL self-performance (weakness, pain, impaired cognition, wheelchair for mobility and non-ambulatory). Interventions included resident can groom (nails, shave,…

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, interview and policy review, the facility failed to properly store nebulizer masks for two residents (Resident #3 and Resident #9) and failed to change oxygen tubing weekly for one resident (Resident #14). This affected three residents (Resident #3, #9 and #14) of four residents reviewed for respiratory care. The facility census was 52. Findings include: Record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of congestive heart failure, pneumonia, and unspecified cough. Review of current medication orders revealed Resident #9 was ordered Albuterol Sulfate inhalation solution 2.5 milligrams per three milliliters four times per day via nebulizer for unspecified cough. Observation of Resident #9, on 04/10/23 at 11:31 A.M., revealed the resident was in their room, seated in a wheelchair and receiving two liters of oxygen via nasal cannula. A nebulizer machine (used to administer breathing treatments) was sitting on a nightstand. 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 interview and record review the facility failed to ensure antibiotics were discontinued per physician orders. This affected one resident (Resident #15) of six residents reviewed for unnecessary medication use. The facility census was 52. Findings included: Review of Resident #15's medical record revealed an admission date of 09/09/22 with diagnoses including unspecified dementia, atherosclerotic heart disease of native coronary artery, chronic kidney disease - stage four, essential hypertension, and hemiplegia affecting the left nondominant side. Review of Resident #15's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/25/23, revealed she was not cognitively intact and during the assessment period, received one day of an antibiotic. Review of Resident #15's progress note dated 01/24/23 at 2:58 P.M. revealed a urinalysis result was reviewed by the physician and ampicillin 500 milligrams (mg) bid (twice a day) for three days was ordered. The progress note was entered by Registered Nurse (RN) #163. Review of Resident #15's physician orders revealed an order dated…

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

Based on record review and interview, the facility failed to provide an appropriate diagnosis for a resident receiving an antipsychotic medication. This affected one resident (Resident #48) of six residents reviewed for unnecessary medications. The facility census was 52. Findings include: Review of the medical record for Resident #48 revealed an admission date of 0/19/22. Diagnoses included Alzheimer's disease, dementia with psychotic disturbance, hypertension, muscle weakness, and severe protein-calorie malnutrition. Review of the Minimum Data Set (MDS) assessment, dated 01/26/23, indicated Resident #48's Brief Interview for Mental Status (BIMS) score was 04, which indicated severely impaired cognition. The resident did not have any hallucinations, delusions, physical or verbal behaviors, or rejection of care. Review of a psychiatric nurse practitioner progress note, dated 02/06/23, revealed the resident did not have behaviors or paranoia. Review of a physician progress note, dated 02/25/23, revealed the resident denied depression, anxiety, or nervousness. Review of a physician…

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

Based on observation and interview the facility failed to ensure outside garbage was contained in a receptacle. This had the potential to affect all 52 residents residing in the facility. Findings included: Observation on 04/11/23 at 11:25 A.M. with Dietary Supervisor (DS) #102 revealed two garbage dumpsters in the back corner of the facility parking lot. Each dumpster had two lids which could be moved to create an approximate six-inch gap between them. There was a large amount of garbage observed on the ground. The garbage started around six feet from the dumpsters and went down the hill into the woods approximately 20 yards. An interview at the time of the observation with DS #102 revealed she believed raccoons got in the dumpsters and took out items. She stated the garbage down the bank into the woods was from raccoons and the garbage had been down the bank and into the woods for quite a long time. Interview on 04/11/23 at 1:55 P.M. with the Administrator verified garbage should be in the dumpsters and not scattered down the hill.

Based on observation, record review, interview and facility policy review the facility failed to ensure the appropriate transmission based precautions were posted for a resident in isolation. This affected one resident (Resident #36) of one resident reviewed for transmission based precautions. The facility census was 52. Findings include: Review of Resident #36's medical record revealed an initial admission date of 05/04/21 with diagnoses including Guillain-Barre syndrome (a rapid- onset muscle weakness caused by the body's immune system damaging the peripheral nervous system), type two diabetes mellitus without complications, essential hypertension, hyperlipidemia, and muscle weakness. Review of Resident #36's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/09/23, revealed he was cognitively intact. Review of Resident #36's physician order dated 03/31/23 to 04/10/23 revealed he was on contact isolation for Methicillin Resistance Staphylococcus Aureus (MRSA) (a staph bacteria that has become resistant to many of the antibiotics used to treat ordinary staph infections 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 record review, interview, Loeb's Minimum Criteria for Initiating Antibiotic Therapy review and facility policy review the facility failed to ensure residents met the minimum criteria for initiating antibiotic use. This affected one resident (Resident #15) of six residents reviewed for unnecessary medication use. The facility census was 52. Findings included: Review of Resident #15's medical record revealed an admission date of 09/09/22 with diagnoses including unspecified dementia, atherosclerotic heart disease of native coronary artery, chronic kidney disease - stage four, essential hypertension, and hemiplegia affecting the left nondominant side. Review of Resident #15's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/25/23, revealed she was not cognitively intact and during the assessment period, received one day of an antibiotic. Review of Resident #15's progress note dated 01/24/23 at 2:58 P.M. revealed a urinalysis result was reviewed by the physician and ampicillin 500 milligrams (mg) bid (twice a day) for three days was ordered. The progress note 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 observation, record review, review of the facility assessment and interview the facility failed to ensure adequate staffing levels to provide timely care and services including assistance with activities of daily living, individualized activity programs, and weekend activities. This affected 12 (Residents #9, #36, #34, #151, #26, #2, #27, #42, #5, #14, #28 and #44) and had the potential to affect all 48 residents currently residing in the facility. Findings include: 1. Resident #9 was admitted to the facility on [DATE] with diagnoses including dementia, muscle weakness, chronic pain, osteoporosis, and cerebral infarction. Review of Resident #9's Minimum Data Set assessment (MDS) dated [DATE] revealed the resident required extensive assistance of one person for bathing. Review of Resident #9's self-care deficit plan of care revealed interventions included to bathe per the resident's preference and to see the bathing schedule. Review of Resident #9's current shower schedule and bathing preference revealed…

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

Based on record review, policy review, and interview, the facility failed to develop a sustainable plan of correction to correct staffing deficiencies identified and cited during previous survey activity exited 04/12/21. This had the potential to affect all 48 residents currently residing in the facility. Findings include: Review of survey activity Statement of Deficiencies from a previous survey with an exit date of 04/12/21 revealed deficient practices were identified with staffing and activities of daily living. During the current survey, deficient practices were identified with staffing and activities of daily living. Review of the facility's Quality Assurance Performance Improvement (QAPI) policy, dated 11/28/17, revealed the QAPI program would address performance improvement processes and a system for tracking performance to ensure improvements were realized and sustained. The Administrator was responsible for ensuring the QAPI program was sustained during transitions of leadership and staffing, the QAPI program was adequately resourced, including ensuring staff time,…

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 shower schedule, review of bathing preferences, review of the facilities shower preference and shower documentation process, and interviews the facility failed to ensure dependent residents were provided showers per their schedule/preference. This affected eight (Resident #5, #14, #28, #34, #36, #41, #44, and #151) of nine reviewed for bathing/showers. The current census was 48. Findings include: 1. Resident #9 was admitted to the facility on [DATE] with diagnoses including dementia, muscle weakness, chronic pain, osteoporosis, and cerebral infarction. Review of Resident #9's Minimum Data Set (MDS) dated [DATE] revealed the resident required extensive assistance of one person for bathing. Review of Resident #9's self-care deficit plan of care revealed her intervention included to bathe per the resident's preference and to see bathing schedule. Review of Resident #9's current shower schedule and bathing preference revealed Resident #9 requested showers twice weekly…

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 activity schedule, review of the facility assessment, and interviews the facility failed to timely comprehensively assess resident preferences for activities and failed to provide activities on the weekend per preferences. This affected four (Residents #2, #26, #27, and #42) and had the potential to affect all 48 residents currently residing in the facility. Findings include: 1. Resident #26 was admitted to the facility on [DATE] with diagnoses including stroke, diabetes, major depressive disorder, aphasia, hemiplegia, dysphagia, and difficulty walking. Review of Resident #26's plan of care revealed no evidence of an activity plan of care. Review of Resident #26's activity assessments revealed no evidence of an activity assessment was completed. Review of Resident #26's admission Minimum Data Set (MDS) dated [DATE] revealed no evidence the activities and preference section F was completed. Review of Resident #26's activity documentation dated April 01, 2021 to May 19, 2021…

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 policy review the facility failed to ensure prescription drugs were dated when opened and properly stored in their original packaging. This affected three residents (Resident #1, #13 and #16) whose medications were found opened and not dated and had the potential to affect all 48 residents currently residing in the facility. Findings include: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease, hypertension, and vitamin d deficiency. Review of Resident #1's [DATE] physician orders revealed an order for Fluticasone propionate suspension 50 micrograms to be administered one spray in each nostril one time a day for nasal congestion. Observation on [DATE] at 2:06 P.M. of the 400 hall medication cart with Registered Nurse (RN) #62 revealed Resident #1's Fluticasone nasal spray was opened, but was not labeled with the date it was opened. Interview on [DATE] at 2:10 P.M. RN #62 confirmed than nasal spray was open and should have…

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

Based on observation, interview, record review, and policy review the facility failed to ensure Resident #200's urinary catheter bag was covered to maintain dignity. This affected one out of two residents reviewed for urinary catheters (Resident #14 and Resident #200). The facility census was 48. Findings include: Medical record review for Resident #200 revealed an admission date of 05/12/21 with diagnoses that included acute kidney failure, hypertension, and chronic ischemic heart disease. Review of Resident #200's May 2021 physician's orders revealed an order for an indwelling urinary (Foley) Catheter to gravity drainage related to intractable pain. Observations on 05/17/21 at 10:38 A.M. and 05/18/21 at 8:37 A.M. revealed Resident #200's bedroom door was open and the resident's Foley catheter drainage bag and tubing were exposed and visible from the hallway. Interview on 05/18/21 at 8:56 A.M. Director of Nursing (DON) #35 confirmed that Resident #200's catheter bag and tubing was exposed and visible from the hallway. Review of the facility's admission packet which contained…

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 Resident #24, who had indicators of serious mental illness, had a pre-admission screening and resident review (PASARR) completed to determine whether the resident qualified for Level II services. This affected one (Resident #24) of one reviewed for PASARR. Findings include: Record review revealed Resident #24 was admitted to the facility on [DATE]. The resident's current mental health diagnoses include schizoaffective disorder, psychosis, major depressive disorder, anxiety, and mental disorder. Review of Resident #24's problematic manner plan of care revealed risk related to inappropriate behaviors as evidence by easily angered, irritable, unstable mood, cures at staff and family members at times, anxiousness, and repetitive concerns. The resident demonstrated difficulty adjusting to change in routine, attempted to manipulate staff/family members, and had a poor appetite at times. The resident stated feelings of sadness, little interest in group…

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, medical record review, and policy review the facility failed to ensure Resident #32 received treatments per her physician's orders and Resident #28's skin intervention were in place. This affected two of three residents reviewed for skin conditions (Residents #24, #28 and #32). The facility census was 48. Findings include: 1. Medical record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, diabetes mellitus type two, and dementia. Review of Resident #32's quarterly Minimum Data Set (MDS) dated [DATE] revealed she required extensive assistance of one person for bed mobility and two person extensive assistance for transfers. Review of the facility provided skin grid documentation, dated 05/17/21, revealed Resident #32 had Moisture Associated Skin Damage (MASD) that was first noted on 05/05/21. Review of Resident #32's May 2021 physician's orders revealed an order from 05/06/21 to 05/10/21 for zinc oxide to buttocks every six…

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, interviews, and policy review the facility failed to ensure pressure ulcer treatments were administered per physician orders. This affected one (Resident #26) of two residents reviewed for pressure ulcers. The facility census was 48. Findings include: Resident #26 was admitted to the facility on [DATE] with diagnoses including osteomyelitis, cerebral infarction, Parkinsonism, type two diabetes, hemiplegia and hemiparesis, and muscle weakness. Review of Resident #26's orders and Medication Administration Records (MAR) dated 04/2021 to 05/2021 revealed to apply zinc to right upper buttocks every six hours and as needed. There were 38 times the zinc was not signed off as administered per the orders. Review of Resident #26's alteration in skin integrity plan of care revealed the resident had pressure areas on the left heel, the right buttocks, and on the right heel. The intervention included to provide treatments per physician orders. Review of Certified Nurse Practitioner (CNP) wound notes…

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 provide range of motion services to two (Residents #14 and #24) of 16 residents observed for and/or interviewed regarding range of motion. The facility identified eight residents with contractures. Findings include: 1. Review of Resident #14's medical record revealed diagnoses included quadriplegia (paralysis of all four limbs), muscle spasms, and chronic pain syndrome. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact and was able to make herself understood. The MDS indicated Resident #14 had functional limitation in range of motion (ROM) to both upper and both lower extremities. There were no orders, no care plan, and no record of any ROM services. On 05/17/21 at 11:45 A.M. Resident #14 verified she had limitations in ROM of all her joints due to quadriplegia. Resident #14 reported she did not get ROM services provided, even during hands on care. On 05/18/21 at 5:16 P.M. State…

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 interview the facility failed to ensure catheter care for a resident in accordance with the plan of care and physician's orders. This affected one (Resident #14) of two residents reviewed for urinary catheters. The facility identified eight residents with indwelling urinary catheters. Findings include: During an interview on 05/17/21 at 11:39 A.M. Resident #14 reported she had an indwelling urinary catheter since March of 2020. Upon inquiry about catheter care, Resident #14 stated she did not receive routine catheter care. Catheter care was provided during showers once or twice a week. Resident #14 indicated she was very prone to urinary tract infections, especially since the catheter was initiated. Review of Resident #14's medical record revealed diagnoses including quadriplegia (paralysis of all four limbs) and neuromuscular dysfunction of the bladder. On 12/04/20, a physician's order was written for Foley catheter care every shift and as necessary. A plan of care initiated…

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, medical record review, and policy review the facility failed to ensure proper infection control procedures were followed during catheter care for Resident #200. This affected one of two residents reviewed for the use of indwelling urinary catheters (Resident #200 and #14). The facility census was 48. Findings include: Resident #200 was admitted to the facility on [DATE] with diagnoses including acute kidney failure, hypertension, and chronic ischemic heart disease. Review of Resident #200's May 2021 physician orders revealed an order for an indwelling urinary catheter (Foley) to gravity drainage related to intractable pain, and for catheter care every shift. Observation on 05/19/21 at 2:45 P.M. of catheter care for Resident #200 revealed State Tested Nursing Assistant (STNA) #16 gathered supplies, washed her hands, and donned gloves. The Director of Nursing (DON) was present and helped position the resident. STNA #16 began by cleaning the tubing of the catheter from the point 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, review of the infection control log, review of antibiotic stewardship log, review of Loeb and McGeer criteria, interviews, and policy review the facility failed to ensure appropriate use of antibiotics. This affect two (Resident #18 and #19) of four reviewed for infections. The facility census was 48. Findings include: 1. Closed record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including urinary tract infection (UTI) and benign prostatic hyperplasia with lower urinary tract symptoms. Review of Resident #18's progress note dated 03/31/21 revealed the resident continued to have gross hematuria (blood in the urine). The resident denied urinary pain or discomfort. Review of Resident #18's progress notes dated 04/03/21 revealed the resident returned from the emergency room with an order for Bactrim DS (antibiotic) to be given twice daily for 10 days for hematuria. Review of Resident #18's urine culture report dated 04/03/21 revealed there was no growth.…

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 policy review the facility failed to ensure residents received pneumococcal immunizations timely. This affected two (Residents #151 and #200) of five residents reviewed for immunizations. The facility census was 48. Findings include: 1. Resident #151 was admitted to the facility on [DATE] with diagnoses including hypertension and cough. Review of Resident #151's updated consents revealed the resident and physician had signed consents for pneumococcal consent. Review of Resident #151's medical record revealed no evidence the resident had received the pneumococcal vaccine. 2. Resident #200 was admitted to the facility on [DATE] with diagnoses including heart disease, kidney failure, and shortness of breath. Review of Resident #200's consents dated 05/13/21 revealed the resident representative had signed consent for the pneumococcal vaccine. Review of Resident #200's medical record revealed no evidence the resident had received the pneumococcal vaccine. Interview on 05/19/21…

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.