Daughters Of Miriam Center For Nursing & Rehabilit

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure a dignified dining experience for Resident #62, Resident #13, Resident #52 and Resident #24. This affected four residents (#62, #13, #52 and #24) out of 12 residents observed eating their meals in the secured unit dining room. The facility census was 166. Findings include: 1. Review of the medical record revealed Resident #62 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including severe dementia with behaviors, hemiplegia (one sided paralysis) and hemiparesis (weakness on one side) following a cerebral infarction (stroke) affecting the left non-dominant side, dysphagia (difficulty swallowing), and osteoarthritis. Resident #62 had medical conditions including weakness with abnormal gait and mobility, used a wheelchair for mobility, and needed assistance with personal care. A review of the Resident #62's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated she was rarely or never understood. A 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.

Based on observation, interview, and recipe review, the facility failed to ensure appropriate puree preparation techniques were followed. This had the potential to affect 17 Residents (#17, #37, #42, #53, #62, #63, #74, #79, #80, #86, #88, #98, #105, #106, #113, #132, and #326) the facility identified as requiring a puree textured diet. The facility census was 166. Findings include: Observation on 10/30/24 from 10:19 A.M. to 10:55 A.M. of puree preparation by [NAME] #684 revealed preparation of puree cake, Brussels sprouts, sweet potatoes, and tomato soup. Dietary Director (DD) #813 and Dietary Manager (DM) #836 were also present for observation. [NAME] #684 did not refer to any recipes or diet manual during the preparation. [NAME] #684 indicated he was looking for a pudding like consistency. [NAME] #684 was noted to add large amounts of water and thickener (a powdered substance used to alter the texture of foods and beverages to allow for safe swallowing) to the Brussels sprouts, sweet potatoes, and tomato soup. After completing the puree preparation [NAME] #684 was observed to add…

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, medical record reivew, and facility policy review, the facility failed to ensure the physician was notified in a timely manner for a change in condition for Resident #162 and for Resident #126. This affected two Residents (#126 and #162) of two reviewed for notification of change. The facility census was 166. Findings include: 1. Review of the closed medical record for Resident #162 revealed an admission date of [DATE] and discharge date of [DATE]. Diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), malignant neoplasm of bronchus or lung, atherosclerotic heart disease, essential hypertension, generalized muscle weakness, difficulty in walking, repeated falls, and history of fractures including right femur, left tibia, T9-T10 (thoracic spine) vertebra, and right clavicle. Review of the plan of care initiated on [DATE] revealed Resident #162 was at risk for falls related to history of falls with fracture and weakness. Interventions included Dycem…

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 with staff the facility failed to follow-up with grievances involving Resident #167 in a timely manner. This affected one resident (#167) of three residents reviewed for grievances. The census was 166. Findings include: Review of the closed medical record for Resident #167 revealed an admission date of 12/16/19 and a discharge date of 01/19/24. Diagnoses included heart failure, dysphagia and dementia without behavioral disturbance. Review of the concern log revealed an entry on 01/04/24 from the family of Resident #167 regarding issues including missing dentures and request for medical records. The notes indicated the team met with the family regarding concerns and gave a consent to be seen by the dentist for replacement dentures. It stated the Administrator discussed replacement options. Review of the email dated 01/08/24 at 1:30 P.M. from the son to the Administrator revealed the son typed he had left five voicemails in the past ten days for Medical Records department. He was asking for a response by the next day. Review of the email dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure Resident #62, Resident #108 and Resident #79 were assisted with eating their meal. This affected three residents (#62, #108 and #79) out of seven residents reviewed for activity of daily living (ADL) assistance. The facility census was 166. Findings include: 1. Resident #62 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including severe dementia with behaviors, hemiplegia (one sided paralysis) and hemiparesis (weakness on one side) following a cerebral infarction (stroke) affecting the left non-dominant side, dysphagia (difficulty swallowing), osteoarthritis, and hyperlipidemia (high cholesterol). Resident #62 had medical conditions including weakness with abnormal gait and mobility, used a wheelchair for mobility, and needed assistance with personal care. A review of the Resident #62's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated she was rarely or never understood. Resident #62's physician order…

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, resident interview, staff interview, and review of the medical record, the facility failed to ensure residents received prescribed treatments or application of appliances as prescribed to maintain or prevent a decline in range of motion (ROM). This affected one resident (Resident #27) of one resident reviewed for ROM/mobility. The facility census was 166. Findings include: Review of the medical record for Resident #27 revealed an admission date of 01/07/24 with diagnoses including chronic obstructive pulmonary disease (COPD), depression, primary hypertension, osteoarthritis, muscle weakness, pain in left shoulder, and hemiplegia or hemiparesis following a cerebral infarction affecting the left non-dominant side. Review of the annual Minimum Data Set (MDS) 3.0 assessment completed on 10/13/24 revealed Resident #27 had intact cognition and no behaviors or rejection of care. Further review of the MDS revealed Resident #27 had impaired range of motion (ROM) on one side of her upper and lower…

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, medical record review, and review of facility policy, the facility failed to ensure appropriate care and services were in place for Resident #111's enteral feeding tube. This affected one resident (Resident #111) of one reviewed for tube feeding concerns. The facility identified eleven residents ( #46, #63, #66, #79, #97, #98, #110, #111, #128, #137, and #148) who received enteral tube feedings. The facility census was 166. Findings include: Review of the medical record for Resident #111 revealed an initial admission date of 12/20/23 and a facility re-entry date of 01/31/24. Diagnoses included hypertensive urgency, hematuria, altered mental status, benign prostatic hyperplasia, oropharyngeal phase dysphagia, type two diabetes mellitus with diabetic neuropathy, unspecified dementia, pure red cell aplasia, vesicointestinal fistula, flaccid neuropathic bladder, stage three chronic kidney disease, acquired absence of the right and left leg above the knee, and attention to gastrostomy. Review of the quarterly Minimum Data Set (MDS) 3.0 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 medical record reviews, staff interviews, and review of facility policy, the facility failed to provide appropriate assessments and monitoring to ensure residents were free from complications before and after dialysis treatments. This affected three residents (Resident #50, Resident #126, and Resident #314) of three residents reviewed for dialysis. The facility identified three residents (#50, #126 and #314) as receiving dialysis. The facility census was 166. Findings include: 1. Review of the medical record for Resident #126 revealed an admission date of 08/15/24. Diagnoses included end stage renal disease, diabetes mellitus type one, and dependence on renal dialysis. Review of the significant change Minimum Data Set (MDS) 3.0 assessment completed on 10/08/24 revealed Resident #126 had intact cognition and required substantial to maximal assistance with chair to bed, toilet, and shower transfers. Further review of the MDS revealed Resident #126 was on dialysis. Review of the physician orders 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure staff administered Resident #107's insulin as ordered by the physician. This affected one resident (#107) out of four residents observed for medication administration. The facility census was 166. Findings include: Review of the medical record revealed Resident #107 was re-admitted on [DATE] with diagnoses including diabetes mellitus, and long term use of insulin. Resident #107's physician order dated 09/23/24 indicated to administer 21 units of Insulin Glargine Solution 100 units per milliliter (u/ml) subcutaneously (SQ) one time a day for diabetes mellitus. There were no parameters for holding the insulin medication in the order. An observation on 10/29/24 at 8:25 A.M. of Licensed Practical Nurse (LPN) #763 administering medications to Resident #107 revealed a failure to administer the Insulin Glargine Solution medication as ordered by the physician. The following medications were administered during the observation: Aspirin 81…

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, review of the facility's fall investigations, and interview, the facility failed to ensure documentation was complete and accurate for Resident #15, #19 and #50. This affected three residents (#15, #19, and #50) of 43 records reviewed. The facility census was 166. Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 04/29/18 with diagnoses including age-related osteoporosis, presence of left artificial shoulder joint, major depressive disorder, presence of right artificial hip joint, hypothyroidism, and a history of falling. Review of the facility's fall investigation dated 10/03/24 at 11:40 P.M. revealed Resident #19 had an unwitnessed fall while self-ambulating, complained of six out of ten pain to the right side, was administered acetaminophen and an ice pack, and was sent to the hospital around 1:40 A.M. on 10/04/24, two hours after the fall occurred. There was no witness statement for Licensed Practical Nurse (LPN) #791, who wrote a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of facility policy and interview the facility failed to maintain infection control standards during care for Resident #107 during medication administration and Resident #111 during gastronomy tube site care. This affected one resident (#107) out of four residents reviewed for medications administration and one resident (#111) out of one resident reviewed for tube feeding. The facility census was 166. Findings include: 1. Resident #107 was re-admitted on [DATE] with diagnoses including heart failure, iron deficiency anemia, diabetes mellitus, high white blood cell count, lung cancer, Alzheimer's dementia, aortic valve stenosis, fractured right femur, high blood pressure, leiomyoma of uterus (uterine fibroids), vascular dementia, cerebral vascular disease with transient ischemic attack (TIA) and stroke, high cholesterol, lymphoma, and long term use of insulin. An observation 10/29/24 at 8:25 A.M. of Licensed Practical Nurse (LPN) #763 administering medications to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and review of facility policy, the facility failed to ensure medications were stored in a secure location at all times. This had the potential to affect 40 residents (#1, #6, #7, #10, #12, #13, #15, #16, #19, #22, #24, #27, #30, #36, #37, #46, #51, #60, #62, #65, #67, #69, #77, #79, #85, #88, #91, #99, #103, #105, #106, #107, #110, #118, #119, #123, #130, #132, #147, and #148) residing on [NAME] three unit. The facility census was 150. Findings include: On 09/09/24 at 10:05 A.M., an observation of the [NAME] three unit revealed a medication cart was unattended and unlocked in the hallway between Resident #7's room and Resident #107's room. At the time of observation, there was one resident ambulating in the hallway with a walker and one family member present in the hallway. On 09/09/24 at 10:10 A.M., upon returning to the medication cart, Licensed Practical Nurse (LPN) #700 confirmed the medication cart was left unattended and unlocked in the hallway. LPN #700 further…

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, observations, and interview the facility failed to maintain standard infection control protocol when administrating medications. This affected one (Resident #137) of one resident reviewed for medication administration. Findings include: Review of medical record for Resident #137 revealed an admission date of 07/17/24. Diagnoses included acute kidney failure, spastic quadriplegic cerebral palsy, and neuromuscular dysfunction of the bladder. The resident had impaired cognition. A random observation on 09/09/24 at 9:31 A.M. revealed Licensed Practical Nurse (LPN) # 515 administering medications for Resident #137. LPN #515 placed three of 13 medications from medication cards into her bare hand. Interview during observations LPN#515 stated medications should be placed into the medication cup, not a bare hand. Review of the facility policy titled Administering Oral Medications, dated 2010 revealed staff were directed not to touch medications with their hands and to place all medications into a medication cup.

Based on observation, interview, and medical record review, the facility failed to provide wound treatment according to physician orders. This affected one (#67) of three residents reviewed for wound care. The facility census was 161. Findings Include: Review of Resident #67's medical record revealed an admission date of 06/01/22. Diagnoses included hemiplegia, right heart failure, and unspecified malnutrition. Review of a wound physician assessment, dated 01/03/24, revealed Resident #67 had moisture associated skin damage (MASD) to the buttocks, which had improved since its development on 12/27/23, and measured 3 centimeters (cm) by 1.5 cm with a depth of 0.2 cm. The assessment called for a treatment of honey alginate (a mesh dressing mixed with honey gel) covered by a foam dressing to be changed daily. Review of a physician order dated 12/27/23 confirmed there was an active order in place for this treatment. Observation of wound care for Resident #67 by Licensed Practical Nurse (LPN) #501 on 01/09/24 at 10:45 A.M. revealed she performed the dressing care by washing the wound with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed medical record review, staff interview and review of a fall investigation, the facility failed to provide appropriate monitoring during personal care to prevent a fall. This affected one (#114) of three residents reviewed for falls. The facility census was 161. Findings Include: Review of Resident #114's medical record revealed an admission date of [DATE]. Diagnoses included encephalopathy, chronic kidney disease, and unspecified dementia. Resident #114 was admitted to hospice on [DATE] and expired in the facility on [DATE]. Review of the Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #114 was severely cognitively impaired, was dependent on staff for toileting assistance, and needed substantial assistance with turning in bed. Review of a plan of care focus area, revised [DATE], revealed Resident #114 had an activities of daily living (ADLs) self-performance deficit related to impaired mobility. Interventions included extensive one to two person staff assistance with 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.

Based on observation, record review, facility policy review and interview the facility failed to ensure all food items were properly stored and served in a manner to prevent contamination, spoilage and/or food borne illness. This had the potential to affect 141 of 141 residents who received meal trays from the kitchen. The facility identified one resident (#108) who received nothing by mouth (NPO status). The facility census was 142. Findings include: 1. On 10/16/23 at 9:30 A.M. an initial tour of kitchen was conducted with Dietary General Manager (DGM) #944. There were seven half-gallon containers of whole milk noted in the dairy refrigerator that had a sell by date of 10/09/23. There were four large dry storage bins containing potato flakes, sugar, flour and breadcrumbs. Each bin had a scoop inside of it. On 10/16/23 at 9:50 A.M. DGM #944 verified the sell by date on the seven half gallons of whole milk was 10/09/23. DGM #944 also verified the scoops inside of the storage bins containing potato flakes, sugar, flour and breadcrumbs. Review of the policy titled Food Storage 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, review of facility policy, observation and interview, the facility failed to ensure all residents were treated with dignity and respect. This affected four residents (#49, #52, #255 and #268) of 142 residents observed for right to dignity and respect. The facility census was 142. Findings include: 1. Review of the medical record for Resident #255 revealed he was admitted to the facility on [DATE] with diagnoses including encephalopathy, paroxysmal atrial fibrillation, and urinary tract infection. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #255 had a Brief Interview for Mental Status (BIMS) score of 9 indicating short-term and long-term cognition impairment. Resident #255 was dependent to maximal assistance by staff for activities of daily living (ADL). Review of the care plan dated 10/18/23 revealed Resident #255 had an ADL self-care performance deficit and had incontinence of bowel and bladder. Interventions included to maintain and/or…

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

Based on observation and interview the failed to ensure meals were served at a palatable temperature. This had the potential to affect 39 residents (#8, #12, #19, #21, #23, #27, #28, #29, #31, #31, #34, #35, #36, #39, #45, #46, #53, #69, #72, #77, #81, #82, #84, #86, #88, #89, #90, #97, #98, #100, #102, #104, #109, #114, #117, #123, #125, #128, and #129) of 39 residents who resided on unit MY2 on the second floor. The facility census was 142. Findings include: Observation of a test tray on 10/18/23 at 6:12 P.M. of the dinner meal with Dietary Manager (DM) #969 revealed the temperature of the salisbury steak was 116.2 degrees Fahrenheit (F), mashed potatoes was 112.6 degrees F, mixed vegetables was 107.3 degrees F, and the chicken barley soup was 145.4 degrees F. The Salisbury steak, mashed potatoes, and mixed veggies tasted very good but was cold to taste. During the observation DM #969 declined to taste the meal but verified the temperatures. Interviews on 10/18/23 between 6:23 P.M. and 6:27 P.M. with Residents #39 and #82 stated the meal was cold when they received it. 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 meals were served in a timely manner according to the designated meal times for the facility. This had the potential to affect 39 residents (#8, #12, #19, #21, #23, #27, #28, #29, #31, #31, #34, #35, #36, #39, #45, #46, #53, #69, #72, #77, #81, #82, #84, #86, #88, #89, #90, #97, #98, #100, #102, #104, #109, #114, #117, #123, #125, #128, and #129) of 39 residents who resided on unit MY2 on the second floor. The facility census was 142. Findings include: Review of the mealtimes revealed breakfast was at 8:30 A.M., lunch 12:30 P.M., and dinner 5:30 P.M. Observation on 10/16/23 at 1:06 P.M. revealed lunch trays were still being plated in a common kitchen for delivery to the resident rooms on the second floor MY2 unit. Observation on 10/17/23 at 9:47 A.M. of breakfast trays for the second floor MY2 unit resident rooms revealed trays were still being delivered and Resident #35, who was not interviewable, did not get her tray until 9:47 A.M. Interview on 10/18/23 at 10:46 A.M. with Dietary Manager (DM) #944…

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, facility policy review, review of the Centers for Disease Control (CDC) Considerations for Preventing Spread of COVID-19, and interview the facility failed to maintain proper infection control practices/procedures to prevent the spread of infection including COVID-19. This had the potential to affect eight residents (#17, #64, #80, #136, #259, #262, #263 and #265) who resided on the same unit as Resident #261 who was in isolation for COVID-19. The facility census was 142. Findings include: Review of Resident #261's medical record revealed an admission date of 10/13/23. Diagnoses included COVID-19 and lung cancer. Review of the current physician orders for October 2023 revealed Resident #261 was on isolation precautions for all care and services related to being positive for COVID-19. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/13/23, revealed the assessment was in progress. Review of the care plan dated 10/15/23 revealed no interventions related to COVID-19. Observation on 10/17/23 at 7:01 A.M. revealed State Tested Nursing…

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 obtain signed authorization with a witness not connected to the facility to open resident accounts. This affected two residents (#36 and #121) of five residents reviewed for personal resident fund accounts. The facility census was 142. Findings include: On 10/23/23 at 1:30 PM a review of personal resident funds was conducted with Resident Banker (RB) #763 and the Administrator. Review of the personal resident fund account for Resident #36 revealed a balance of $1737.34. There was not an authorization for the facility to open and manage resident funds. This was verified by an interview with RB #763 and the Administrator at the time of the review. Review of the personal resident fund account for Resident #121 revealed a balance of negative $46.00. There was not an authorization for the facility to open and manage resident funds. This was verified by an interview with RB #763 and the Administrator at the time of the review.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure a complete and accurate care plans had been established for Resident #11. This affected one resident (#11) of 29 residents reviewed for care plans. The facility census was 142. Findings include: Review of the medical record revealed Resident #11 was admitted on [DATE]. Diagnoses included multiple sclerosis, Alzheimer's Disease with late onset dementia, anemia, neuromuscular dysfunction of bladder, age-related osteoporosis, depression, hypothyroidism, osteogenesis, presence of urogenital implants, history of COVID-19, and retention of urine. Review of Resident #11's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had intact cognition and had a foley catheter for bladder elimination. Review of Resident #11's care plan dated 09/12/23 did not include foley catheter care. Review of physician orders for October 2023 revealed no orders for foley catheter care. Interview on 10/24/23 at 10:26 A.M. with the Director of Nursing…

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, facility policy review and interview the facility failed to administer insulin per physician order and complete blood sugar testing related to the administration of insulin for Resident #66. This affected one resident (#66) of five residents reviewed for medication administration. In addition, based on observation, interview and record review, the facility failed to ensure adequate care and treatment of a burn-related wound for Resident #90. This affected one resident (#90) of five residents reviewed for wound care. The facility census was 142. Findings include: 1. Review of the medical record revealed Resident #66 was admitted on [DATE] with a diagnosis including type two diabetes mellitus (DM). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment date 10/02/23 revealed Resident #66 had intact cognition. Review of the physician orders dated October 2023 revealed an order for glargine subcutaneous (SQ) solution pen-injector 100 unit/Milliliter (U/ml) (Insulin Glargine) inject 12…

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, policy review and interview the facility failed to provide adequate care and services to identify, assess and/or provide treatments to promote healing of a pressure ulcer for Resident #19 and Resident #99. This affected two residents (#19 and #99) of five residents reviewed for wound care and/or pressure ulcers. The facility census was 142. Findings include: 1. Review of Resident #19's medical records revealed an admission date of 03/11/22. Diagnoses included stage four pressure ulcer ( full thickness loss of tissue exposing bone, muscle or tendon) of the sacrum (tailbone), muscle weakness, and difficulty walking. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 had impaired cognition. Resident #19 required extensive assistance with bed mobility, toileting and personal hygiene and total dependence for transfers. Review of progress notes dated 08/26/23 to 08/27/23 revealed Resident #19 was identified as having an open area to the coccyx,…

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, resident interview, staff interview, and policy review, the facility failed to utilize proper transfer technique for Resident #258 and Resident #19, and failed to ensure fall interventions were implemented to mitigate fall risks for Resident #126. This affected three residents (#258, #19 and #126) of four residents reviewed for accidents/hazards. The facility census was 142. Findings include: 1. Review of the medical record for Resident #258 revealed she was admitted to the facility on [DATE] with diagnoses including displaced intertrochanteric fracture of right femur, muscle weakness, and difficulty in walking. Review of the Five day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating she was alert ad oriented to person, place, and time. Resident #258 was maximal assist for Activities of Daily Living (ADLs). Review of the care plan dated 10/05/23 revealed Resident #258 had an ADL 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 observation, record review, policy review and interview the facility failed to timely collect a urine specimen for suspicion of a urinary tract infection for Resident #19 and failed to ensure physician's orders were in place for Foley catheter care for Resident #11. This affected two residents (#11 and #19) of three residents reviewed for Foley catheter care. The facility census was 142. Findings include: 1. Review of Resident #19's medical records revealed an admission date of 03/11/22. Diagnoses included neuromuscular bladder, difficulty walking and muscle weakness. Review of the care plan dated 09/28/23 revealed Resident #19 was on antibiotic therapy related to frequent urinary tract infections. Interventions included administer antibiotics as ordered. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 had impaired cognition. Resident #19 required extensive assistance with toileting and personal hygiene. Resident #19 was incontinent of bowel and bladder. 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.

Based on observation and interview the facility failed to ensure medications were not left unattended at the residents bedside. This affected three residents (#69, #84 and #129) of 142 residents observed for medication storage. The facility census was 142. Findings include: 1. Observation on 10/17/23 at 8:38 A.M. revealed Resident #129 was in bed in her room with a medication cup containing one white pill and one brownish colored pill, a medication cup with an orange colored liquid medication, a medication cup with a red colored liquid medication and a medication cup with a clear liquid medication. Resident #129 was not interviewable. 2. Observation on 10/17/23 at 8:40 A.M. revealed Resident #84 was in his room standing next to his bedside table and Resident #84 had a medication cup with several medications inside. Upon entering Resident #84's room Licensed Practical Nurse (LPN) #959 entered and stated Resident #84 knows to take his meds, I was just coming back to check if he did. 3. Observation on 10/17/23 at 8:43 A.M. revealed Resident #69 was sleeping in bed, he had a medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure adaptive equipment was provided with meals. This affected one resident (#40) of five residents reviewed for nutrition. The facility census was 142. Findings include: Review of the medical record for Resident #40 revealed an admission date of 09/30/21. Diagnoses included dysphagia, muscle weakness, and hemiplegia and hemiparesis following a stroke affecting the left non-dominant side. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 had intact cognition. Review of the physician orders for October 2023 revealed the resident had a diet order for regular diet, pureed texture, and regular (thin) consistency diet. Review of the plan of care revised on 09/12/23 for nutrition revealed the resident received a mechanical altered diet due to dysphagia and received built-up utensils. Observation on 10/16/23 at 1:11 P.M. of Resident #40 in bed eating lunch revealed the resident's tray ticket read…

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

Based on observation and interview the facility failed to ensure food was served in a sanitary manner. This affected three residents (#39, #49, and #276) in the small dining room on the 100 unit and had the potential to affect 52 residents (Residents #1, #39, #40, #49, #50, #80, #81, #82, #114, #135, #136, #144, #145, #151, #164, #166, #178, #180, #182, #185, #190, #194,#195, #212, #214, #215, #216, #220, #274, #275, #276, #277, #278, #279, #280, #281, #282, #283, #284, #285, #286, #287, #288, #289, #290, #291, #292, #293, #294, #296, #297, and #298) currently residing on the first floor. The facility census was 244. Findings include: 1. Observation on 03/02/20 at 12:35 P.M. of the noon meal in the small dining room on the 100 unit revealed the tray line server, Dietary Aide (DA) #250, dropped an empty package from a sanitizer wipe he'd used to clean the thermometer onto the floor. With his gloved hands, he picked it up and put it the trash can. His hand made contact with the swinging trash lid. DA #250 then went back to the steam table and grabbed a dessert bowl. He was instructed…

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 and interview, the facility failed to ensure Resident #92's call light was within reach. This affected one of 36 sampled residents. The facility census was 222. Findings include: Review of the record revealed Resident #92 was admitted on [DATE] with diagnoses including dementia, anxiety disorder, and depressive disorder. The care plan for falls dated 03/09/17 indicated the resident had interventions including non-skid socks when up out of bed, restorative referral, lay resident down after meals, and be sure the resident's call light is within reach and encourage her to use it for assistance. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #92 had severe cognitive deficits with short and long-term memory impairments. The resident had no behaviors, no refusal of care, and required extensive assistance for bed mobility, transfers, toilet use, and locomotion on the unit. On 03/02/20 at 11:00 A.M., an observation revealed Resident #92 was lying in 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 observation, interview, and record review, the facility failed to ensure interventions were in place for Resident #219's pressure ulcers as ordered. This affected one of seven residents reviewed for pressure ulcers (Residents #35, #41, #78, #170, #190, #200, and #219). The facility identified 16 residents as having pressure ulcers. Finding include: Review of the record revealed Resident #219 was admitted on [DATE] with diagnoses including dementia, chronic peripheral venous insufficiency, and rheumatoid arthritis. The quarterly Minimum Data Set 3.0 assessment dated [DATE] indicated she had severe cognitive deficits and required extensive assistance with bed mobility, transfers, and walking. Review of the Braden Scale for Predicting Pressure Sore Risk dated 10/03/19 indicated she was at high risk for the development of pressure sores. Review of a progress note dated 11/15/19 indicated the nurse observed Resident #219 to have purplish-black colored area to both heels. The resident reported the areas were…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility's policy on hand hygiene the facility failed to ensure staff washed or cleansed their hands between the dirty and clean phases of dressing changes to prevent potential cross-contamination. This affected three (Residents #34, #170, and #219) of four residents observed for dressing changes (Residents #34, #42, #170, and #219). The facility census was 222. Findings include: 1. Review of the record revealed Resident #219 was admitted on [DATE] with diagnoses including dementia, chronic peripheral venous insufficiency, and rheumatoid arthritis. Review of a progress note dated 11/15/19 indicated the nurse observed Resident #219 to have purplish-black colored area to both heels. The resident reported the areas were slightly painful. On 11/15/19, the nurse practitioner ordered to cleanse bilateral heels with normal saline, apply ABD pad, and wrap with Kerlix daily and prn (as needed). On 02/19/20, the wound care consultant changed the treatment…

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.