Belpre Landing Nursing And Rehabilitation

Based on medical record review, staff interview and facility policy review, the facility failed to notify the mental health authority by completing a resident Pre-admission Screening and Resident Review (PASARR)Level II assessment for Resident #6 with a new diagnosis. This affected one resident (#6) of three residents reviewed for PASARR. The facility census was 52. Findings include: Review of the medical record for Resident #6 revealed an admission date of 11/01/23 with diagnoses including traumatic brain injury, schizoaffective disorder and dissociative conversion disorder. Review of the plan of care initiated on 12/12/23 revealed Resident #6 had a behavior problem related to belief in delusions that staff was abusive towards the resident, visual and auditory hallucinations and calling 911 (emergency). The goal stated Resident #6 would be free from behaviors by the review date of 02/11/25. The interventions included to administer medications as ordered, monitor for effectiveness of medication and potential side effects, intervene and redirect the resident as needed, monitor and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed ensure Residents #4, #19, and #36 or their representatives were provided with a copy of their baseline care plan. This affected three residents (#4, #19, #36) of three residents reviewed for baseline care plans. The facility census was 52. Findings include: 1. Record review revealed Resident #4 admitted to the facility on [DATE] with diagnoses including venous insufficiency, hypertension, and gastro-esophageal reflux disease. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4's cognition remained intact, and she had no behaviors. Review of the medical record revealed no documented evidence of a new admission care conference being completed within 48 hours of admission. Review of typed notes dated 06/11/24, 09/15/24, and 12/15/24, and signed by Social Services Director (SSD) #568 revealed a quarterly care conference was held but did not include a list of who was present for the meeting and if a copy of the care plan 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 3. Record review revealed Resident #19 admitted to the facility on [DATE] with diagnoses including malignant neoplasm of stomach and esophagus, muscle wasting and atrophy, and hypertension. Review of a MDS assessment completed 11/27/24 revealed Resident #19's cognition remained intact, and he had no behaviors. Interview on 12/30/24 at 9:42 A.M. with Resident #19 revealed he asks for showers but never gets them unless a certain aide is working. Review of EMR for showers and shower sheets from 12/02/24 through 12/30/24 revealed three scheduled showers were missed on 12/04/24, 12/20/24, and 12/25/24. Interview on 01/08/25 at 9:59 A.M. with LPN #557 confirmed three showers were missing for Resident #19. Based on record review, resident interview, staff interview, and policy review, the facility failed to ensure residents, who were dependent on staff for personal care, received the assistance needed to shower/ bathe when they were scheduled to receive them. This affected three (Resident #19, #147, and #149) of four…

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 record review, observations, and interviews, the facility failed to ensure Residents #4 and #19 were invited to participate in activities. This affected two residents (#4 and #19) of two residents reviewed for activities. The facility census was 52. Findings include: 1. Record review revealed Resident #4 admitted to the facility on [DATE] with diagnoses including venous insufficiency, hypertension, and gastro-esophageal reflux disease. Review of a care plan dated 03/16/24 revealed Resident #4 had an alteration in activity participation related to preferring independent activities and she preferred music, playing piano, reading, animals, and word puzzles. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4's cognition remained intact, and she had no behaviors. Interview on 12/30/24 at 3:32 P.M. with Resident #4 revealed she did not participate in activities or do anything other than lay in her bed. Interview on 12/31/24 at 1:10 P.M. with Certified Nurse Assistant (CNA) #503…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy review, the facility failed to address signs and symptoms of a urinary tract infection (UTI) in a timely manner for Resident #36. This affected one resident (#36) of one resident reviewed for UTIs. The facility census was 52. Findings include: Record review revealed Resident #36 admitted to the facility on [DATE] with diagnoses including displaced intertrochanteric fracture of left femur, difficulty in walking, muscle wasting and atrophy, and hypertension. Review of a care plan completed on 11/21/24 revealed Resident #36 had an alteration in elimination related to indwelling Foley catheter with an intervention to monitor for signs and symptoms of a UTI such as elevated temperature, dysuria, flank pain, hematuria, foul smelling urine and report to provider to seek diagnosis and treatment. Review of a Minimum Data Set (MDS) assessment completed on 12/02/24 revealed Resident #36's cognition remained intact, no behaviors, required setup or clean-up help for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, interview and policy review, the facility failed to ensure Resident #4's oxygen tubing was changed once per week as ordered by the physician. This affected one resident (#4) of two residents reviewed for respiratory services. The facility census was 52. Findings include: Record review revealed Resident #4 admitted to the facility on [DATE] with diagnoses including venous insufficiency, hypertension, and gastro-esophageal reflux disease. Review of a medication administrator record from December 2024 revealed Resident #4 had orders in place for oxygen at two liter per minute continuously via nasal canula as resident will allow (09/29/24), change oxygen tubing every week and as needed on Wednesdays (09/29/24), and change aerosol nebulizer set-up every week on Wednesday and as needed (09/29/24). Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4's cognition remained intact, and she had no behaviors. Observation on 12/30/24 at 3:28 P.M. 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 record review, interview and facility policy review, the facility failed to address signs and symptoms of pain Resident #36 in a timely manner. This affected one resident (#36) of one resident reviewed for pain. The facility census was 52. Findings include: Record review revealed Resident #36 admitted to the facility on [DATE] with diagnoses including displaced intertrochanteric fracture of left femur, difficulty in walking, muscle wasting and atrophy, and hypertension. Review of a care plan dated 11/21/24 revealed Resident #36 was at risk for an alteration in comfort related to generalized pain, gout, rheumatoid arthritis, and left femur fracture post-surgical repair. Interventions included, but were not limited to, medications as ordered to manage pain, monitor for increased levels of pain, and monitor for effectiveness of interventions. Review of a Minimum Data Set (MDS) assessment completed on 12/02/24 revealed Resident #36's cognition remained intact, no behaviors, and had a pain rating of seven,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and policy review, the facility failed to ensure Resident #37, who received an antipsychotic medication, had an abnormal involuntary movement scale (AIMS) assessment completed to monitor the resident for any extrapyramidal side effects of the medication. This affected one resident (#37) of five residents reviewed for unnecessary medications. The facility assessment was 52. Findings include: Review of Resident #37's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included unspecified psychosis, unspecified dementia, and anxiety disorder. Review of Resident #37's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was severely impaired. She was not known to have displayed any behaviors or reject care during the seven days of the assessment period. She was documented as having received antipsychotic medications during the seven-day assessment period. Review of Resident #37's physician's 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, staff interview and policy review, the facility failed to ensure stock medications were stored in its original packaging and in a manner that allowed the staff to identify the expiration date of that medication. This affected three (Resident #2, #6, and #12), who resided on the 200 hall and had orders to receive Tylenol Extra Strength medication and received medication from the 200-hall medication administration cart where the improperly stored stock medication was found. The facility census was 52. Findings include: On [DATE] at 8:07 A.M., a medication administration observation was made of Resident #12 receiving her morning medication. The medications were administered by Licensed Practical Nurse (LPN) #527. The resident was given Acetaminophen 500 milligram (mg) (analgesic/fever reducer) two tablets by mouth as ordered three times daily, among multiple other medications due at that time. The Acetaminophen was pulled from a small stock bottle stored in the top drawer of the 200-hall…

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 3. Review of Resident #11's medical record revealed an admission date of 04/25/23 and a reentry date of 06/12/24. Diagnoses include end stage renal disease, diabetes, morbid obesity, depression, cerebral infarction, and nontraumatic intracerebral hemorrhage. Review of the MDS assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating Resident #11 had intact cognition. Further review revealed Resident #11 had orders for hemodialysis every Monday, Wednesday and Friday since 06/13/24. Review of assessments titled Dialysis Pre and Post Evaluation revealed missing assessments on 06/17/24, 06/19/24, 06/28/24, 07/01/24, 07/03/24, 07/10/24, 07/19/24, 07/24/24, 07/26/24, 07/29/24, 07/31/24, 08/28/24, 08/30/24, 10/04/24, 10/11/24, 10/18/24, 10/23/24, 11/01/24,11/04/24, 11/20/24 and 11/27/24. In an interview with LPN Unit Manager #557 on 01/02/25 at 3:00 P.M. he revealed that when Resident #11 returns from dialysis the paperwork completed at the dialysis center accompanies the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, policy review and interview, the facility failed to initiate enhanced barrier precautions as required. This affected one (Resident #37) of three sampled residents and the potential to affect all 48 residents. The facility identified 21 residents on enhanced barrier precautions (EBP). Findings include: Medical record review revealed Resident #37 was admitted on [DATE] with diagnoses including Parkinson's disease, diabetes mellitus and a history of Extended-spectrum beta-lactamases (ESBL). Review of the Physician Orders dated 04/01/24 revealed the resident was on enhanced barrier precautions due to a history of ESBL and multi-drug resistant organism E-coli. On 05/06/24 at 9:00 A.M., observation revealed no EBP sign was posted outside Resident #37's room. On 05/08/24 at 10:01 A.M., observation revealed EBP sign was posted outside Resident #37's room and Licensed Practical Nurse (LPN) #16 was observed in the room removing a trash bag of soiled items without the use of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and interview, the facility failed to ensure dependent residents received assistance with activities of daily living (ADL) and grooming as needed. This affected two residents (#7, #53) of three sampled residents. The census was 48. Findings include: 1. Medical record review revealed Resident #7 was admitted on [DATE] with diagnoses including chronic respiratory failure with hypercapnia, end stage renal disease, hemodialysis and ventilator dependence. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact for daily decision-making. Review of the Shower Sheets and Bathing Daily Task List dated April and May 2024 revealed Resident #7 receives a bed bath daily. There was no documentation of her hair being washed or assistance provided to remove her facial hair. Review of the care plan: Require Assistance with ADL's related to debility and weakness dated 03/13/24 revealed Resident #7's ADL goal was to remain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and interview, the facility failed to ensure competent nursing staff administered intravenous medications. This affected one (#47) of five residents observed for medication admininstration. The census was 48. Findings include: Medical record review revealed Resident #47 was admitted on [DATE] with diagnoses including sepsis, diabetes mellitus, and history of embolism. Review of the electronic Physician Orders dated May 2024 revealed intravenous medications including Meropenem (antibiotic) 1000 milligrams (mg) intravenous (IV) every 12 hours. On 05/06/24 at 10:53 A.M., observation revealed Licensed Practical Nurse (LPN) #4 flushed Resident #47's left upper extremity PICC line (peripherally inserted central catheter) with 10 cc of normal saline and then administered Meropenem 1000 mg IV. Review of the eLicense Ohio Professional Licensure dated 05/09/24 revealed LPN #4's license was issued on 04/24/17 and was currently active for sub-category: medications. There was no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, policy review and interview, the facility failed to ensure medications were stored appropriately and administered when dispensed. This affected two residents (#1, #3) from one of three medication carts observed during medication administration. The census was 48. Findings include: Medical record review revealed Resident #1 was admitted on [DATE] with diagnoses including asthma and atrial fibrillation. Medical record review revealed Resident #3 was admitted on [DATE] with diagnoses including arteriosclerotic heart disease. On 05/06/24 between 7:12 A.M. and 7:16 A.M., interview and observation revealed the 100 hall medication cart top drawer was opened by Registered Nurse (RN) #2 and she stated unfortunately she had already pre-poured several resident medications for the morning medication administration. RN #2 stated she sometimes did this depending on what kind of day it was going to be and what all was going on. Observation of the top medication drawer revealed two…

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, policy review and interview, the facility failed to ensure medications were administered without error. This affected two (#5, #47) of five residents observed during 25 medication opportunities with four medications errors. The medication administration error rate was 16%. The census was 48. Findings include: 1. Medical record review revealed Resident #5 was admitted on [DATE] with diagnoses including atrial fibrillation, unspecified sequelae of cerebral infarction and constipation. Review of the electronic Physician Orders dated May 2024 revealed an order for Resident #5 to receive senna (laxative) 8.6 milligrams (mg) for bowel management. On 05/06/24 at 7:19 A.M., observation of Resident #5's morning medication administration revealed Registered Nurse (RN) #2 administered lisinopril, Hydralazine, toprol xl, benicar and senna plus (combination of a stool softener and laxative) 8.6 mg/50 mg. On 05/06/24 at 7:23 A.M., interview with RN #2 verified the above medications…

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

Based on observation, staff interview, and facility policy review, the facility failed to maintain sanitary conditions in the kitchen. This had the potential to affect all 44 residents residing in the building. Findings include: Observation on 01/08/24 at 8:53 A.M. revealed there was heavy dust/grease build-up on the sprinkler heads and piping located above the six-burner gas stove. The metal can opener attached to the side of the prep table revealed there were metal shavings on the point of the opener and also on the indentation behind the metal spike. Interview on 01/08/24 at 8:53 A.M. with [NAME] #1 confirmed the sprinkler heads and piping above the stove and the can opener were not clean. Observation on 01/10/24 at 7:08 A.M. of the kitchen dry stock room revealed there was a metal scoop inside a clear plastic bin that was half-full of white flour. Further observation revealed there was a 112 ounce can of apple pie filling and a 50 ounce can of cream of chicken soup which were dented on the bottom seam. Interview on 01/10/24 at 7:08 A.M. with Dietary Manager (DM) #2 there was 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 medical record review, staff interview, and review of Centers for Disease Control and Prevention (CDC) documents, the facility failed to provide education to residents regarding influenza and pneumonia vaccines and failed to ensure residents received the recommended pneumonia vaccines. This affected four (Residents #15, #20, #32 and #97) of four residents reviewed for immunizations. The facility census was 44. Findings included: 1.Review of the medical record for Resident #20 revealed an admission date of 10/31/23 with diagnoses including metabolic encephalopathy, weakness, protein-calorie malnutrition, congestive heart failure, hyperlipidemia and transient ischemic attacks (TIAs). Review of the vaccine consent form for Resident #20 dated 11/23/23 revealed the resident did not wish to receive the influenza or pneumococcal pneumonia vaccine. The record did not include documentation regarding education provided to the resident regarding risks and benefits of the vaccines. Interview on 01/10/24 at 1:09 P.M. with the Director of Nursing (DON) confirmed the facility did not have…

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

Based on record review and staff interview the facility failed to complete and submit a new Preadmission Screening and Resident Review (PASARR) for residents with a significant change in behaviors. This affected one (Resident #05) of two residents reviewed for PASARR screenings. The facility census was 44. Findings include: Review of the medical record for Resident #5 revealed an admission date of 10/19/23 with diagnoses including schizoaffective disorder, schizophrenia, psychological conversion disorder, anxiety disorder and history of traumatic brain injury. Review of the hospital discharge summary for Resident #05 dated 10/19/23 revealed the resident had diagnoses of anxiety and schizoaffective disorder and a history of psychiatric illness and had been on antipsychotic medications, Clozaril and Haldol, but was unable to take them while in the hospital. Review of the PASARR dated 11/02/23 revealed Resident #05 was admitted with diagnosis of mood disorder, schizophrenia and psychologic conversion disorder. The PASARR did not indicate Resident #05 was referred to state agency for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview the facility failed to ensure the development of comprehensive resident care plans. This affected two (Residents #15 and #20) of 12 residents reviewed for care plans. The facility census was 44. Findings include: 1.Review of the medical record for Resident #20 revealed an admission date of 10/31/23 with diagnoses including metabolic encephalopathy, transient ischemic attack (TIA) and congestive heart failure (CHF). Review of the physician orders for Resident #20 dated January 2024 revealed orders for order for oxygen at three liters per minute via nasal cannula. Review of the care plan for Resident #20 updated 11/29/23 revealed it did not include a plan of care related to oxygen therapy administration. Review of the nutritional progress note dated 12/28/23 at 3:31 P.M. the Dietary Technician #105 did not make any indications of Resident #20 using built up silverware with meals. Review of the care plan for Resident #20 updated 11/29/23 revealed 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 medical record review, observation, staff interview, and review of the facility policy, the facility failed to accurately assess residents' skin and obtain timely treatment for areas of impaired skin integrity. This affected two (Residents #01 and #35) of three residents reviewed for skin integrity. The facility census was 44. Findings include: 1.Review of the medical record for Resident #01 revealed an admission date of 02/27/23 with diagnoses including chronic respiratory failure with hypercapnia, type two diabetes mellitus, severe morbid obesity, chronic kidney disease and obstructive sleep apnea. Review of the plan of care for Resident #01 dated 11/28/23 revealed the resident was at risk for impaired skin integrity/pressure ulcers related to fragile skin, impaired mobility and diabetes mellitus with a goal for open areas to be healed without complications. Interventions included the following: inspect skin during routine daily care, skin assessment as ordered, treatments as ordered. Review of the weekly skin assessments for Resident #01 dated 12/05/23, 12/19/23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview and review of the facility policy, the facility failed to accurately assess resident risk for falls and failed to ensure fall prevention interventions were implemented to prevent falls. This affected one (Resident #11) of one resident reviewed for accidents. The facility census was 44. Findings include: Review of the medical record for Resident #11 revealed the resident was admitted on [DATE] with diagnoses including dementia, atrial fibrillation, coronary artery disease, heart failure, hypertension, diabetes mellitus and respiratory failure. Review of the care plan for Resident #11 dated 02/28/23 revealed the resident was at risk for falls and potential injury related to debilitation, weakness, dementia and unsteady gait. Interventions included the following: minimize potential risk factors, bed stabilizers, lock bed, encourage resident to wear non-skid footwear, have commonly used articles within easy reach, low bed, maintain a clear pathway, provide…

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, staff interview, and review of the facility policy the facility failed to ensure residents were provided with oxygen therapy as ordered. This affected one (Resident #11) of one resident reviewed for respiratory care. The facility census was 44. Findings include: Review of the medical record for Resident #11 revealed the resident was admitted on [DATE] with diagnoses including dementia, atrial fibrillation, coronary artery disease, heart failure, hypertension and respiratory failure. Review of the significant change Minimum Data Set (MDS) assessment for Resident #11 dated 09/24/23 revealed the resident was moderately impaired for daily decision-making and had a life expectancy of less than six months. Review of the hospice care plan for Resident #11 dated 11/11/23 revealed the resident utilized oxygen therapy. Interventions including the following: collaborate with facility staff to ensure proper oxygen flow is prescribed, ensure nasal cannula was connected, ensure oxygen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to provide necessary behavioral health services to residents. This affected one (Resident #5) of one resident reviewed for behavioral health. The facility census was 44. Findings include: Review of the medical record for Resident #05 revealed an admission date of 10/19/23 with diagnoses including schizoaffective disorder, schizophrenia, psychological conversion disorder, anxiety disorder and history of traumatic brain injury. Review of the hospital discharge instructions for Resident #05 dated 10/19/23 revealed the resident was admitted to the hospital on [DATE] for cough, shortness of breath, low oxygen saturations and history of recurrent pneumonia. The medication list upon admission to the hospital included Haloperidol 5 milligrams (mg), take one half tablet by mouth at bedtime, Clozapine 100 mg, take three tablets by mouth at bedtime and Clozapine 25 mg, take three tablets by mouth every morning. Resident #05 had diagnoses of anxiety 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 medical record review and staff interview the facility failed to ensure physicians documented a rationale indicating why consultant pharmacist medication regimen recommendations were rejected. This affected one (Resident #32) of five residents reviewed for unnecessary medications. The facility census was 44. Findings include: Review of the medical record for Resident #32 revealed an admission date of 11/27/23 with diagnoses including respiratory failure, morbid obesity, type two diabetes mellitus, hyperparathyroidism, anxiety and depression. Review of the physician orders for Resident #32 revealed Resident #an order dated 11/27/23 for Lexapro 20 milligrams (mg) by mouth in the morning for depression. Review of the medication regimen review (MRR) per the consultant pharmacist for Resident #32 dated 12/01/23 revealed a recommendation to decrease the dosage of Lexapro 20 mg by mouth daily. Further review of the MRR revealed according to new dosing guidelines, the antidepressant Lexapro should no longer be used at doses greater than 10 mg per day in patients over the age of 60…

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

Based on medical record review, observation, staff interview, review of alternate menu and review of the facility policy, the facility failed to ensure alternate menu items included a variety based on resident preferences, likes or dislikes and failed to ensure residents knew what was on the alternate menu and where to find it. This affected two (Residents #15 and #20) of two residents reviewed for food preferences. The facility census was 44. Findings include: 1.Review of the medical record for Resident #15 revealed an admission date of 01/24/23 with diagnoses including diabetes mellitus, Parkinson's disease, tremors, osteoarthritis, generalized anxiety, hyperlipidemia and atrial fibrillation. Review of the physician orders for Resident #15 dated January 2024 revealed the resident was ordered a consistent carbohydrate, no added salt, regular texture diet with thin liquids. Review of the plan of care revealed for Resident #15 dated 01/24/23 revealed the resident had a potential for alteration in nutrition and hydration related to chronic diseases, therapeutic diet and body mass…

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

Based on medical record review and staff interview the facility failed to ensure residents were educated regarding the risk and benefits of Coronavirus (COVID-19) vaccination. This affected three (Residents #20, #32, and #97) of four residents reviewed for vaccines. The facility census was 44. Findings include: 1. Review of the medical record for Resident #20 revealed an admission date of 10/31/23 with diagnoses including metabolic encephalopathy, weakness, protein-calorie malnutrition, congestive heart failure, hyperlipidemia and transient ischemic attacks (TIAs). Review of the vaccine consent form dated 11/23/23 revealed Resident #20 did not wish to receive the COVID-19 vaccine. The record did not include documentation regarding education provided to the resident regarding risks and benefits of the COVID-19 vaccine. Interview on 01/10/24 at 1:09 P.M. with the Director of Nursing (DON) confirmed the facility did not have documentation of education to Resident #20 regarding the risks and benefits of the COVID-19 vaccine. 2. Review of the medical record for Resident #97 revealed an…

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 3. Review of Resident #349's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including pneumonia, diabetes, severe protein calorie malnutrition, pacemaker, epilepsy, dementia, high blood pressure and anemia. Review of the admission MDS 3.0 assessment, dated 11/08/22 revealed the resident required staff assistance for activities of daily living. Review of the physician's orders for 11/2022 revealed an order to change aerosol nebulizer set-up every seven days and as needed (PRN) on night shift every Sunday. The resident also had an order for Ipratropium Bromide Solution 0.02 % 2.5 ml inhalation three times a day for COPD. On 11/07/22 at 12:30 P.M., 3:03 P.M. and 4:02 P.M. observation revealed the resident's nebulizer with tubing and mask were not dated or covered and laying on the resident's bed side stand uncovered. On 11/08/22 at 10:43 A.M. the nebulizer with tubing and mask were observed not dated or covered. On 11/08/22 at 10:57 P.M. interview with Licensed Practical…

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, facility policy and procedure and interview the facility failed to ensure Resident #43's physician was notified timely regarding the resident's discharge against medical advice. This affected one resident (#43) of four residents reviewed for hospitalization. Findings include: Review of Resident #43's medical record revealed an admission date of 09/07/22 with diagnoses including cellulitis, difficulty walking and cognitive communication deficit. Review of the five-day Minimum Data Set (MDS) 3.0 assessment, dated 09/12/22 revealed the resident had moderate cognitive impairment and required extensive staff assistance with activities of daily living. Review of the progress note, dated 09/12/22 at 3:27 P.M. revealed the resident insisted on going home against medical advice (AMA) with her son. The son set up home health through the resident's primary care physician (PCP). Review of an undated Discharge Against Medical Advice (AMA) document revealed the named resident was being discharged AMA of the attending physician and the facility administration. The document…

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 and procedure review and interview the facility failed to ensure written notification was provided related to bed hold procedures. This affected two residents (#27 and #44) of four residents reviewed for hospitalization. Findings include: 1. Review of Resident #27's medical record revealed an admission date of 11/02/22 with diagnoses including chronic obstructive pulmonary disease, history of lung transplant, chronic kidney disease and rectal cancer. Review of the resident's payer source revealed the resident received Medicare Part A services. Review of the progress note, dated 11/02/22 at 3:52 P.M. revealed the resident was sent to the emergency room due to an abrupt onset of change in mental status. A subsequent progress note revealed the resident was admitted to the hospital with diagnoses including urinary tract infection, renal failure and metabolic encephalopathy. Record review revealed the resident did return from the hospital. Further review of the medical record…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy and procedure review and interview the facility failed to ensure Resident #95's plan of care was accurate and updated to reflect the resident's advance directives. This affected one resident (#95) of one resident reviewed for advanced directives. Findings include: Review of the medical record for Resident #95 revealed an admission date of [DATE] with diagnoses including malignant neoplasm of upper lobe of right bronchus or lung, chronic obstructive pulmonary disease, and atherosclerotic heart disease of native coronary artery. Review of Resident #95's physician's orders for [DATE] revealed a Do Not Resuscitate-Comfort Care Arrest (DNRCCA) advanced directive. Continued review of Resident #95's medical record revealed a signed DNR Identification Form, dated [DATE] indicating Resident #95 selected to be a DNRCC-Arrest If this box is checked, the DNR Comfort Care Protocol is implemented in the event of a cardiac arrest or a respiratory arrest. Review of the plan of care, dated…

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

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #246, who required staff assistance for activities of daily living received adequate and timely assistance with nail care to maintain proper hygiene. This affected one resident (#246) of four residents reviewed for activities of daily living (ADL) care. Findings include: Review of Resident #246's medical record revealed an 10/20/22 admission date with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting left non dominant side, severe protein calorie malnutrition, hyperlipidemia, failure to thrive and anemia. Review of the 10/21/22 activities of daily living plan of care revealed the resident had a self care deficit related to debility, hemiplegia, shortness of breath and weakness. The goal was for the resident's needs to be met through the review date. Review of the 10/26/22 five-day Minimum Data Set (MDS) 3.0 assessment revealed the resident was moderately impaired for daily decision making, required extensive assistance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure physician ordered anti-embolism stockings/(TED) hose were in place for Resident #2. This affected one resident (#2) of one resident reviewed for hemodialysis. Findings include: Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, protein calorie malnutrition, anxiety, congestive heart failure (CHF), end stage renal disease, osteoarthritis. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 09/26/22 revealed the resident's cognition was moderately impaired, he required extensive assistance from one staff member for bed mobility, dressing, and personal hygiene, and required extensive assistance from two or more staff members for transfers and toilet use. Review of the physician's orders for 11/2022 revealed an order for TED hose (anti-embolism stockings) to be on in the morning and off at bedtime. On 11/08/22 at 12:02 P.M.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure wound care was provided using proper and adequate infection control techniques to decrease the risk of infection for Resident #349. This affected one resident (#349) of two residents reviewed for pressure ulcers. Findings include: Review of Resident #349's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including pneumonia, diabetes mellitus, severe protein calorie malnutrition, pacemaker, epilepsy, dementia, high blood pressure and anemia. Review of the plan of care , dated 11/04/22 revealed the resident had actual impaired skin integrity/pressure ulcer related to Stage I (non-blanchable erythema of intact skin) pressure ulcer to right buttock and left rear hip and unstageable (obscured full-thickness skin and tissue loss) pressure ulcer to coccyx (as documented on admission). Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 11/08/22…

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 and procedure review and interview the facility failed to ensure fall safety measures were in place for Resident #19 as planned. This affected one resident (#19) of three residents reviewed for accidents. Findings include: Review of Resident #19's medical record revealed a 09/27/22 admission and re-admission date of 10/13/22 with diagnoses including dementia without behavioral disturbance, psychotic disturbance and mood disturbance, and anxiety, difficulty walking, muscle wasting and atrophy, muscle weakness, cognitive communication deficit, muscle wasting and atrophy, insomnia, osteoporosis and anxiety disorder. Review of the new admission assessment revealed the resident was at risk for falls due to impaired decision making, delusions, vision impaired, wandering, restlessness/agitation, needing assistance in activity of daily living self performance, unsteady gait, use of assistive device for mobility, bladder incontinence and involuntary of bowel, osteoporosis and vertigo. Interventions included bed stabilizers, lock bed, 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, record review, facility policy and procedure review and interview the facility failed to ensure pureed food was prepared by the recipe to ensure it was served at the proper consistency. This affected two resident (#39 and #349) two residents who received pureed diets from the kitchen. Findings include: On 11/09/22 at 9:30 A.M. observation of the pureed food process revealed Dietary [NAME] (DC) #99 first obtained the temperature of the chicken (204.5 degrees Fahrenheit) and cauliflower (200 degrees Fahrenheit). DC #99 then placed the chicken in the food processor and added an unmeasured amount of hot water and broth. DC #99 pureed four ounces of chicken for both Resident #39 and Resident #349. Dietary [NAME] #99 then placed the cauliflower in the food processor and pureed two ounces of cauliflower without adding any additional liquids or items. DC #99 then placed the food items in bowls once completed. Review of the recipe, dated 10/13/22 for the pureed vegetable revealed when processing to gradually add food thickener and melted margarine to the vegetables…

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 Resident #21's medical record was maintained in an accurate manner related to wound care. This affected one resident (#21) of two residents reviewed for pressure ulcers. Findings include: Review of Resident #21's medical record revealed a 04/09/22 admission with diagnoses including orthopedic aftercare following surgical amputation, absence of right leg below knee, respiratory failure, peripheral vascular disease and anxiety. On 11/09/22 at 11:23 A.M. Resident #21 was observed sitting on the side of the bed dressed in street clothes. The resident's prosthetic leg was off and she had no dressing in place to the right stump. The resident had a dressing in place to her left heel. Review of the November 2022 treatment administration record revealed to monitor dressing to right medial amputation. The treatment order was signed off/documented as being completed twice a day. However, record review revealed a physician's order, dated 09/21/22 to discontinue the dressing to the resident's right stump. On 11/09/22…

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.