Aristocrat Berea Healthcare And Rehabilitation

Based on observation, staff interview and policy review the facility failed to ensure ice machines were maintained in a clean and sanitary condition. This had the potential to affect all residents. The facility census was 140. Findings include: Observation of the facility's ice machine on 08/01/24 at 7:45 A.M. with Dietary Manager (DM) #924 revealed the main ice machine was not working and had been out of service since 06/24/24. DM #924 explained that the facility was awaiting parts to replace the unit and the facility was temporarily using the ice machine on the second floor to meet its needs. Observation of the second floor ice machine on 08/01/24 at 9:11 A.M. with DM #924 revealed the top portion of the ice machine had a large area of slimly brown and green mold. The machine also had a noticeable musty smell when opened. DM #924 verified the condition of the ice machine at the time of observation. Review of the policy clean schedules dated 10/01/21 revealed culinary manager or designee monitors sanitation of department and assigns correction as needed.

Based on interview and observations the facility failed to maintain a safe and sanitary resident environment. This affected 68 residents who used the showers (#1, #4, #5, #13, #17, #22, #23, #29, #31, #32, #35, #41, #46, #48, #52, #55, #56, #70, #71, #73, #75, #87, #88, #89, #93, #96, #97, #100, #102, #104,#112, #113, #114, #129, #132, #134, #135, #10, #14, #19, #26, #34, #37, #43, #44, #45, #47, #60, #61, #63, #67, #72, #77, #79, #80, #82, #85, #98. #107, #116, #119, #122, #123, #124, #128, #130, #131, #133, and #137) and 21 residents who ate in the dining room on the third-floor secured unit (#7, #9, #20, #24, #27, #28, #30, #33, #38, #51, #57, #59, #64, #65, #78, #92, #99, #101, #110, #118, and #126). Facility census was 140. Findings include: Interview on 07/31/24 at 9:17 A.M. with Resident #32 who resided on the third-floor unit revealed the shower was nasty. Resident #32 said a resident with a colostomy bag used the shower room leaving feces all over the toilet and shower floor. Observation on 07/31/24 at 9:30 A.M. of the third-floor dining room revealed staff and residents…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure timely assessment of residents and review of the risks and benefits of bed rails with the residents after removing all bed rails that were currently in place and being used by the residents. This affected six (Resident #7, #12, #16, #85, #131, and Resident #133) of 19 residents whose side rails and grab bars were removed. Based on observation, record review and interview the facility also failed to provide timely incontinence care to prevent incontinence dermatitis. This affected one (Resident #66) of three reviewed for incontinence care. Findings include: 1. Interview on 07/31/24 at 9:32 A.M. with Licensed Practical Nurse (LPN) #202 revealed management removed all the bed rails from resident beds leaving residents dependent on staff for mobility and transfers. LPN #202 stated it made it more difficult on staff because the residents were leaning and grabbing on the staff for help. Interview on 07/31/24 at 10:00 A.M. with LPN #211 revealed all the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to develop a comprehensive care plan for Resident #133 related to the use of bed side rails which assisted Resident #133 with bed mobility and getting in and out of bed. This affected one (Resident #133) of six residents whose care plans were reviewed. Findings include: Review of the medical record for Resident #133 revealed an admission date of 03/21/17. Diagnoses included unspecified abnormalities of gait and mobility, schizophrenia, and unsteadiness on feet. Review of the plan of care dated 07/28/22 revealed Resident #133 had an activities of daily living (ADL) self-care performance deficit related to schizophrenia, muscle weakness and use of psychoactive medications. The interventions listed did not include use of side rails or grab bars to the bed. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/06/24, revealed Resident #133 had intact cognition, was independent for rolling left to right while in bed and required touch 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 record review and interview the facility failed to ensure residents were redirected from safety hazards affecting Resident #135 and failed to ensure bed rails were not removed prior to assessing the resident's ability to exit the bed safely without the rails affecting Resident #133. This affected two of six residents reviewed for falls. Findings include: 1. Review of the medical record for Resident #133 revealed an admission date of 03/21/17. Diagnoses included unspecified abnormalities of gait and mobility, schizophrenia, and unsteadiness on feet. Review of the plan of care dated 07/28/22 revealed Resident #133 had an activities of daily living self-care performance deficit related to schizophrenia, muscle weakness and use of psychoactive medications. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/06/24, revealed Resident #133 had intact cognition. Resident #133 was independent for rolling left to right while in bed. Review of the facility Side/Bed Rail Utilization assessment dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and observation the facility did not ensure there was sufficient linens including washcloths, towels and fitted sheets available. This affected 117 residents (all residents on unit one, all residents on unit two South and West, and all residents on unit three including Residents #1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #13, #15, #16, #17, #19, #20, #21, #22, #23, 24, #25, #27, #28, #29, #30, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #48, #50, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #64, #65, #67, #68, #69, #72, #73, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #86, #87, #88, #89, #90, #93, #94, #95,#96, #97, #98, #99, #100, #101, #102, #103, #104, #107, #108, #109, #110, #111, #112, #113, #114, #115, #116, #117, #118, #119, #120, #122, #123, #125, #126, #127, #129, #130, #131, #132, #133, #134, #135, #136, #137, #242, #243, and #292). The facility census was 138. Findings included: 1. Review of medical record for Resident #50 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.

Based on observation, interview, and record review, the facility failed to ensure safe and even flooring for dietary staff who provide meal service for residents. This had the potential to affect 137 out of 138 residents in the facility as Resident #72 received nothing by mouth. Findings Include: Observation on 01/09/24 at 12:38 P.M. during lunch meal service revealed the floor in the kitchen had a depressed area for equipment. Part of the area no longer contained any food preparation equipment. The food plating area butted up against the area. The person serving had to step in and out of the uneven area. Interview on 01/09/24 at 12:38 P.M. with Dietary Manager #377 verified there was uneven flooring and the person serving meals stepped in and out of the area. Interview on 01/09/24 at 12:42 P.M. Administrator #444 verified the uneven flooring. Review of a facility list of resident diets revealed Resident #72 received nothing by mouth.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, record review and review of facility incontinence policy ,the facility did not ensure timely incontinence care was completed for Resident #50. This affected one resident (Resident #50) out of two residents (Residents #50 and #96) reviewed for incontinence care. The facility census was 138. Findings included: Review of medical record for Resident #50 revealed an admission date of 10/20/23 and diagnoses included cerebral infarction, diabetes, congestive heart failure, and neuromuscular dysfunction of bladder. Review of care plan dated 10/23/23 revealed Resident #50 had an activities of daily living (ADL) self-care performance deficit related to schizophrenia and psychosis. Interventions included she was dependent on staff for her toileting, hygiene, dressing, and bed mobility needs. Review of admission Minimum Data Set (MDS) dated [DATE] revealed Resident #50 had intact cognition. She was dependent on staff assistance with toileting and rolling left and right. She was frequently…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and policy review, the facility failed to offer Resident #111 an influenza and pneumococcal vaccine. This affected one resident (Resident #111) out of five residents (Resident #34, #38, #69, #111, #242) reviewed for influenza and pneumococcal vaccines. The facility census is 138. Findings include: Record review revealed Resident #111 admitted on [DATE] with diagnosis of unspecified dementia with behavioral disturbances, unspecified psychosis, cerebral palsy and Parkinson's. Resident #111's Brief Interview Mental Status (cognitive assessment) revealed Resident #111 was moderately impaired for cognition. Record review completed on 01/08/24 of Resident #111's immunizations revealed Resident #111 had not been offered the influenza or pneumococcal vaccine. Interview with Director of Nursing on 01/10/24 at 2:20 P. M. revealed Resident #111's Power of Attorney was asked for consent for the Influenza and Pneumococcal Vaccine on 01/09/24. The Power of Attorney agreed for the resident 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.

Based on a test tray and interview the facility failed to provide palatable meals. This had the potential to affect all residents, except Resident #84 who was identified as not receiving meals from the kitchen related to a nothing by mouth (NPO) status. The facility census was 133. Findings include: A test tray was requested on 11/06/23 at 12:21 P.M. The test tray left the kitchen at 12:24 P.M. and was on the floor at 12:26 P.M. The test tray was completed at 1:02 P.M. after the last resident received their meal tray. The test tray consisted of a pork chop, cheesy hashbrowns and Brussels sprouts. The pork chop was cold, dry and lacked flavor, the hashbrowns were undercooked, cold, had clumps of unmelted cheese on top, and lacked flavor, the Brussels sprouts were cold, mushy and lacked flavor. Dietary Manager (DM) #301, who was present during the test tray, did not test the food but indicated she did not need to taste the food, she knew the food was cold. DM #301 stated she was aware of resident complaints regarding food and had been trying to make improvements since she began…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and and policy review, the facility failed to ensure Resident #6 was treated in a [NAME] that enhanced his quality of life and promoted his rights. The facility also failed to ensure residents had private unrestricted communications including the telephone, mail, and newspaper delivery. This affected all 19 (Residents #2, #6, #17, #26, #32, #50, #52, #54, #55, #59, #66, #68, #71, #76, #81, #88, #117, #124, and #133) residents residing on the second floor secured unit. The facility census was 141 residents. Findings include: Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including major recurrent depressive disorder, post-traumatic stress disorder, psychosis not due to a substance or physiological condition, generalized anxiety disorder, bipolar disorder in partial remission mixed, hypertension, hyperlipidemia, insomnia, chronic fatigue, chronic migraine, and alcohol dependence uncomplicated. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and policy review, the facility failed to ensure residents had private unrestricted communications including telephone use. This affected all 19 (Residents #2, #6, #17, #26, #32, #50, #52, #54, #55, #59, #66, #68, #71, #76, #81, #88, #117, #124, and #133) residents residing on the second floor secured unit. The facility census was 141 residents. Findings include: Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including major recurrent depressive disorder, post-traumatic stress disorder, psychosis not due to a substance or physiological condition, generalized anxiety disorder, bipolar disorder in partial remission mixed, hypertension, hyperlipidemia, insomnia, chronic fatigue, chronic migraine, and alcohol dependence uncomplicated. Review of the comprehensive Minimum Data Set assessment dated [DATE] revealed he was alert, oriented, and independent in daily decision-making ability. He displayed indicators 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 interview, record review, and policy review, the facility did not ensure nursing staff administered medications within the acceptable parameters of time. This affected three (Residents #6, #24, and #76) of seven residents reviewed for unnecessary medications. The facility census was 141 residents. Findings include: Review of the medication administration audit reports revealed Resident #6 received 190 doses of routinely scheduled doses of anti-anxiety, anti-flatulence and laxative medications beyond 60 minutes after the physician ordered times. There was evidence the resident received two doses of anti-anxiety medications at the same time on seven days, anti-flatulence medications on seven days and laxative medications on five days since 04/01/21. Review of the medication administration audit reports revealed Resident #24 received 167 doses of routinely scheduled doses of anticholinergic medication, three antipsychotic medications and phenyltriazine medications beyond 60 minutes after the physician ordered times. Review of the medication administration audit reports…

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 review of manufacturer's guidelines on insulin storage, the facility failed to ensure multi-dose insulin vials were dated with the date they were opened. This affected two (Residents #42 and #90) of three residents reviewed for insulin administration. The facility census was 141 residents. Findings include: Observation on 05/19/21 at 2:30 P.M. of the the front medication cart on the one East Wing of the facility revealed an insulin vial for Resident #42 and an insulin injection pen for Resident #90 that were not dated with the date these insulins were opened. Another insulin injection pen that did not have a resident's name on it was also opened and not dated with the date it was first opened. Observation of the back cart on the East Wing revealed a lantus insulin pen which did not have a resident's name on it, and was also not dated with the date it was opened. Interview on 05/19/21 at 3:00 P.M. with Licensed Practical Nurse #587 verified the above insulins were not dated. Review of the facility policy titled Administration and Documentation 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 record review, the facility failed to ensure staff wore face mask per guideline from the Centers for Disease Control and Prevention (CDC). This had the potential to affect all 37 residents (Residents #4, #8, #11, #13, #16, #18, #24, #25, #29, #34, #35, #37, #40, #44, #45, #46, #65, #70, #74, #77, #78, #86, #97, #100, #104, #107, #110, #114, #116, #118, #119, #123, #124, #125, #129, #137, and #139) who resided on the third floor secured unit. The facility census was 141 residents. Findings include: Observation on 05/18/21 at 11:15 A.M., upon coming onto the third floor secured unit from the elevator walking toward the nurses station, the surveyor observed Licensed Practical Nurse (LPN) #575 leaving the dining room, not wearing a facemask, and stop at the nurse's cart. The surveyor also observed State Tested Nurse Aide (STNA) #540 sitting in a chair behind the mobile computer, next to the nurse's cart, face mask pulled down under chin, eating a bag of potato chips. LPN #575 then asked STNA #540 to pull up her mask. Interview on 05/18/21 at 11:18…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to promote and facilitate resident self-determination through support of resident choice in psychiatrist, interact with members of the community outside the facility, and choose schedules of medication and appointments with providers of his their choosing. This affected one (Resident #6) of seven residents reviewed for choices. The facility census was 141 residents. Findings include: Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including major recurrent depressive disorder, post-traumatic stress disorder, psychosis not due to a substance or physiological condition, generalized anxiety disorder, bipolar disorder in partial remission mixed, hypertension, hyperlipidemia, insomnia, chronic fatigue, chronic migraine, and alcohol dependence uncomplicated. Review of the comprehensive assessment Minimum Data Set 3.0 assessment dated [DATE] revealed he was alert, oriented, and independent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and review of facility investigation reports, the facility failed to ensure policies and procedures were implemented relative to reporting allegations of abuse to adminstration, initiating abuse allegations timely, and protecting residents from further abuse while an investigation is in process. This affected two (Residents #70 and #80) of five residents reviewed for abuse allegations. The facility census was 141 residents. Findings include: 1. Review of the medical record of Resident #70 revealed an admission date of 09/09/16. Diagnoses included schizophrenia, schizoaffective disorder, bipolar, and major depressive disorder. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition, had verbal behaviors, and required extensive assistance of one staff for bed mobility, and supervision with set up help only for transfers, eating, and toilet use. Interview on 05/10/21 at 1:26 P.M. with Resident #70 revealed State Tested Nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure a residents plan of care included interventions for physical immobility. This affected one (Resident #112) of 10 residents reviewed for restorative services. The facility census was 141 residents. Findings include: Resident #112 was admitted to the facility on [DATE]. Her admitting diagnoses included schizophrenia, pressure ulcer of sacral region (Stage 4), gastrostomy, dementia and blindness of one eye. Review of this resident's Minimum Data Set 3.0 Assessment (MDS) dated [DATE] revealed this resident had severe cognitive impairment. She needed extensive assistance of two people for all activities of daily living including toileting and personal hygiene. Review of this resident's MDS dated [DATE] revealed this resident had severe cognitive impairment. She needed extensive assistance of two people for all activities of daily living including toileting and personal hygiene. At the time of this survey, this resident was bed bound with a urinary…

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. Resident #112 was admitted to the facility on [DATE]. Her admitting diagnoses included schizophrenia, pressure ulcer of sacral region (Stage 4), gastrostomy, dementia, and blindness of one eye. Review of this resident's Minimum Data Set Assessment (MDS) dated [DATE] revealed this resident had severe cognitive impairment. She needed extensive assistance of two people for all activities of daily living including toileting and personal hygiene. Review of this resident's plan of care for nutrition dated 04/03/19 revealed the resident had a nutritional problem related to past medical history of acute respiratory failure, type II diabetes, constipation, hypotentions and schizophrenia. She was receiving a tube feeding at the present time that runs continuously. Review of the interventions for this plan of care included: Administer medications as ordered; Obtain and monitor lab/diagnostic work as ordered; Provide and serve diet as ordered; and Monitor for intake record every meal. On 05/13/21 at 12:30 P.M. a copy of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure a restorative program was implemented to further meet the needs of its residents. This affected one (Resident #112) of 10 residents reviewed for restorative services. The facility census was 141 residents. Findings include: Resident #112 was admitted to the facility on [DATE]. Her admitting diagnoses included schizophrenia, pressure ulcer of sacral region (Stage 4), gastrostomy, dementia, and blindness of one eye. Review of this resident's Minimum Data Set assessment dated [DATE] revealed this resident had severe cognitive impairment. She needed extensive assistance of two people for all activities of daily living including toileting and personal hygiene. At the time of this survey, this resident was bed bound with a urinary catheter in place and a wound vac. She did not get out of bed and was dependent on staff for repositioning and exercising. Review of this resident's Restorative Care Program Notes from therapy, dated 05/06/21, revealed she was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure proper pericare was provided to Resident #112. This affected one (Resident #112) of two residents reviewed who had urinary catheters. The facility census was 141 residents. Findings include: Resident #112 was admitted to the facility on [DATE]. Her admitting diagnoses included schizophrenia, pressure ulcer of sacral region (Stage 4), gastrostomy, dementia, and blindness of one eye. Review of this resident's Minimum Data Set 3.0 assessment dated [DATE] revealed this resident had severe cognitive impairment. She needed extensive assistance of two people for all activities of daily living including toileting and personal hygiene. The bowel and bladder section of this MDS showed the resident did have an indwelling urinary catheter to gravity drainage. On 05/19/21 at 1:15 P.M. the surveyor observed catheter care for this resident which was completed by Unit Manager (UM) #654. During the cleaning of the catheter, this nurse also cleaned her perineal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to monitor the nutritional status for one resident (Resident #59). This affected one (Resident #59) of seven residents reviewed for nutrition. The facility census was 141 residents. Findings include: Review of the medical record revealed Resident #59 was admitted to the facility on [DATE] with diagnoses including schizophrenia, Parkinson's disease, chronic obstructive pulmonary disease, dysphgia, diabetes, major depression, seizures, and dementia with behavioral disturbance. Review of the annual comprehensive Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #59 was rarely understood and was severely cognitively impaired. The resident required extensive assistance with one staff member for eating and had sustained weight loss and was not on a prescribed weight loss regimen. Review of Resident #59's weight history revealed on 09/21/20 she weighed 136 pounds and on 03/03/21 she weighed 115 pounds indicating a 15.44 percent…

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 tube feedings were stopped while laying a resident flat to provide care. This affected one (Resident #112) of three residents who were receiving a tube feeding. The facility census was 141 residents. Findings include: Resident #112 was admitted to the facility on [DATE]. Her admitting diagnoses included schizophrenia, pressure ulcer of sacral region (Stage 4), gastrostomy, dementia, and blindness of one eye. Review of this resident's Minimum Data Set assessment dated [DATE] revealed this resident had severe cognitive impairment. She needed extensive assistance of two people for all activities of daily living including toileting and personal hygiene. Review of this resident's physician orders dated 04/10/21 revealed the physician ordered a tube feeding of Diabetasource which was to be administered 80 cc continuously. There was also a physician's order dated 04/15/21 for the head of the resident's bed to be elevated 30 degrees or greater while…

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

Based on record review and interview, the facility failed to ensure there was sufficient trained staff available to supervise and effectively implement interventions for residents who have mental disorders and demonstrated behaviors affecting other residents at the facility. This affected two (Residents #112 and #142) of five residents reviewed for behavioral needs. The facility census was 141 residents. Findings include: Review of the medical records of Resident #142 revealed an admission date of 03/08/21 and a discharge date of 03/25/21. The resident's diagnoses included paranoid schizophrenia, symbolic dysfunction, and hearing loss. Review of the Minimum Data Set 3.0 (MDS) assessment, dated 03/15/21, revealed Resident #142 was moderately cognitively impaired, highly hearing impaired and required supervision with setup help only. Review of Resident #142's care plan revealed resident had a behavior problem related to yelling/screaming out, demonstrating threatening behavior, and demonstrating repeat movements. An intervention, initiated on 03/16/21, was to intervene as necessary 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 interview and record review, the facility failed to identify the source of Resident #6's post-traumatic stress disorder (PTSD) to provide appropriate treatment and services to identify triggers and possible interventions. This affected one (Resident #6) of three residents reviewed for mood and behavior. The facility census was 141 residents. Findings include: Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including major recurrent depressive disorder, post-traumatic stress disorder, psychosis not due to a substance or physiological condition, generalized anxiety disorder, bipolar disorder in partial remission mixed, hypertension, hyperlipidemia, insomnia, chronic fatigue, chronic migraine, and alcohol dependence uncomplicated. Review of the comprehensive Minimum Data Set 3.0 assessment dated [DATE] revealed he was alert, oriented, and independent in daily decision-making ability. He displayed indicators of psychosis including hallucinations and…

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

Based on record review, interview and policy review, the facility failed to implement a comprehensive abuse policy and procedure to ensure adequate screening systems were in place for all employees prior to hire. The facility failed to implement their abuse policy to ensure all employees were checked against the Nurse-Aide Registry (NAR). This affected six of 18 employees whose personnel files were reviewed (Administrator, Director of Nursing (DON), Licensed Practical Nurse (LPN) #281, LPN #292, Registered Nurse (RN) #370 and RN #371). In addition, the facility identified six additional nurses (LPN #298, LPN #297, LPN #293, LPN #286, RN #306 and RN #361) who had been hired since 09/10/18 who had not been checked against the nurse aide registry. This had the potential to affect all 163 residents residing in the facility. Findings include: Review of the personnel list and personnel files revealed six of 18 employees whose personnel files were reviewed had not been checked against the State NAR at the time of hire. The Administrator was hired on 08/26/19. The DON was hired on 09/16/19.…

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 stored and prepared under sanitary conditions to prevent contamination and/or food borne illness. This had the potential to affect all 163 residents who resided in the facility, as all residents consumed food by mouth. Findings include: Observation on 11/18/19 from 8:45 A.M. to 9:02 A.M. during the initial kitchen observation, with Dietary Manager (DM) #374 present revealed the following concerns: 1. There was one carton of unopened thickened dairy with a best use by date of 11/02/19. 2. The vents over the oven and stove tops had black debris on them. 3. In the dry storage room, there was a large bag of opened bread crumbs that were not closed or sealed. DM #374 confirmed these observations at the time. DM #374 revealed the hood system was cleaned every six months, and maintenance would be cleaning the vents in November 2019 at some point. 4. Observation on 11/20/19 at 8:45 A.M. of [NAME] #382 pureeing roast beef, revealed she wore gloves, and continued to touch the outside of blender with her gloved hand and…

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

Based on observation, record review, interview and policy review, the facility failed to ensure all residents were provided a dignified dining experience and failed to ensure staff interacted with residents in a dignified manner. This affected four residents (#303, #56, #37 and #12) of 163 residents residing in the facility who were observed during dining and for dignity. Findings include: On 11/18/19 at 12:27 P.M. observation of the lunch meal in the third floor dining room revealed State Tested Nursing Assistant (STNA) #221 and STNA #200 were assisting residents to eat. Both STNAs conversed with each other but did not converse with the residents, Resident #56 and Resident #12 who they were assisting. STNA #221 stood up from the table and directed other residents in a firm voice to sit down and sit there. Resident #303 requested her meal be re-heated as it was cold. STNA #221 told Resident #303 that it would be a while, she was busy. The above findings was verified by STNA #221 at the time of the observation. On 11/18/19 at 12:38 P.M. interview with STNA #221 revealed she should…

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, interview and review of the food temperature guidelines, the facility failed to ensure food items were served at appropriate temperatures. This affected five residents (#25, #134, #106, #107 and #303) and had the potential to affect all 43 residents residing on the third floor of the facility. The facility census was 163. Findings include: 1. On 11/18/19 at 12:27 P.M. observation of the lunch meal on the third floor revealed the facility of used a food cart with one side (left) of the cart refrigerated for cold foods and the other side (right) insulated for hot foods. The lunch meal trays for five residents, Resident #25, #134, #106, #107 and #303) were observed to be on the cold side of the cart. The trays were very cold to touch resulting in the food items on the trays being cold. This was verified by State Tested Nursing Assistant (STNA) #221 at the time of the observation. There was no evidence the facility obtained new hot meal trays for these five residents but rather they were served the meal trays from the cold side of the cart. The lunch…

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 #21 and Resident #120's rooms were maintained at a comfortable temperature. This affected two residents (#21 and #120) of 44 residents who were interviewed related to environmental concerns. Findings include: Record review revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including depression, chronic obstructive pulmonary disease, high blood pressure, and anxiety. Review of the Minimum Data Set (MDS) 3.0 annual comprehensive assessment dated [DATE] revealed the resident was cognitively intact and independent for the majority of his personal care. Record review revealed Resident #120 was admitted to the facility on [DATE] with diagnoses including schizophrenia, diabetes, dementia, psychosis, and a stroke. Review of the MDS 3.0 quarterly comprehensive assessment dated [DATE] revealed the resident was severely cognitively impaired. The resident was identified to be non-interviewable. On 11/18/19 at…

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

Based on record review, interview and policy review, the facility failed to notify Resident #35 or the resident's representative when the resident's personal fund account was within $200.00 of the eligibility limit for Medicaid. This affected one resident (#35) of five residents reviewed for personal funds. Findings include: Review of the personal fund account statement for Resident #35 from 04/01/19 through 11/18/19 revealed he had received a check in the amount of $5,371.02 made out to the facility in his name. The check was dated 04/09/19. This brought the balance of his personal funds account to $5,471.02. The account balance remained at a minimum amount of $5,168.23 to a maximum amount of $6,404.07 until 11/18/19. On 11/18/19, a care cost payment of $4,000.00 was withdrawn from this account bringing the balance to $1,168.23. An interview on 11/20/19 at 1:10 P.M. with [NAME] President of Financial Management #400 revealed a notice should have been issued when the balance of Resident #35's account was within $200.00 of the maximum amount allowed. She stated, the facility would…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to provide Resident #352 personal privacy while performing tracheostomy care. This affected one resident (#352) of one resident reviewed for tracheostomy care. Findings include: Record review revealed Resident #352 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, a tracheostomy (a surgically implanted tube in the throat to allow a person to breathe), pneumonia, a gastrostomy (a surgically implanted device to provide nutrition) and chronic obstructive pulmonary disease. Tracheostomy (trach) care was observed on 11/20/19 at 11:35 A.M. with Licensed Practical Nurse (LPN) #290. LPN #290 entered the room and explained to Resident #352 she was going to do his trach care then proceeded to set up her equipment. The door to the resident's room was open and the privacy curtain was not pulled to prevent people in the hallway from observing care. LPN #290 performed the entire procedure in full view of people…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to ensure Resident #124 was free from misappropriation. This affected one resident (#124) of one resident reviewed for misappropriation of property. Findings include: Review of the medical record for Resident #124 revealed the resident was admitted to the facility on [DATE] with diagnosis including heart failure and chronic kidney disease. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 10/17/19 revealed the resident had impaired cognition. Review of a facility self-reported incident (SRI), dated 11/03/19 revealed an allegation of misappropriation involving Resident ##124. The SRI revealed State Tested Nursing Assistant (STNA) #401 had two of Resident #124's credit cards in her purse. On 11/20/19 4:10 P.M. interview with the Administrator revealed STNA #401 had been terminated for misappropriation of resident property after she had been found with Resident #124's credit cards in her possession. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure a timely Preadmission Screening/ Resident Review (PAS/RR) assessment was completed at the time of the 30 day Hospital Exemption for Resident #146. This affected one resident (#146) of one resident reviewed for PAS/RR screening. Findings include: Record review revealed Resident #146 was admitted to the facility on [DATE] with a diagnosis including Down Syndrome. Record review revealed Resident #146 was admitted with a Hospital Exemption from Preadmission Screening Notification screen (Job and Family Services Form (JFS) 07000). This screen was completed by the discharging hospital and indicated Resident #146 required fewer than 30 days of nursing facility services. The JFS 07000 form stated the facility accepted responsibility for requesting a resident review (if required) prior to the 30th day following admission from the hospital. Resident #146's record review and electronic record review were silent as to a resident review secondary to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure Resident #125, who required staff assistance for personal care received adequate and timely assistance with personal hygiene including shaving. This affected one resident (#125) of three residents reviewed for activities of daily living. Findings include: Record review revealed Resident #125 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, muscle weakness, and chronic pain. Resident #125's five day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident's cognition was intact and she required extensive two person assistance with personal hygiene. Review of Resident #125's medical record revealed no evidence the resident declined assistance with shaving facial hair. Observation on 11/18/19 at 2:19 P.M. revealed Resident #125 had facial hair on her upper lip and chin. Interview with Resident #125 at the time of the observation revealed her son used to shave her, but he does not…

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

Based on observation, record review and interview the facility failed to ensure Resident #120 and Resident #131 were served the right portion size of pureed cabbage casserole. This affected two residents (#120 and #131) of four residents reviewed for pureed meal service. Findings include: Review of the Portion Control Chart revealed a number 16 scoop size was 1/4 cup and a number eight scoop size was 1/2 a cup. Review of the lunch Menu Extension spreadsheet for 11/18/19 revealed residents on a pureed diet should be served pureed stuffed cabbage casserole with a number eight scoop. Observation on 11/18/19 at 12:15 P.M. revealed Resident #120 and Resident #131 were served a pureed lunch in the dining room. Observation on 11/18/19 at 12:17 P.M. with [NAME] #382 revealed the cook served Resident #120 and Resident #131 a pureed diet stuffed cabbage casserole using a number 16 scoop (1/4 cup) instead of the required number eight scoop (1/2 cup) identified on the menu spreadsheet. [NAME] #382 confirmed this was not the correct serving size and revealed Resident #120 and Resident #131 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 record review and interview the facility failed to ensure Resident #74 received timely assistance in scheduling an ear, nose, and throat specialist appointment. This affected one resident (#74) of two residents reviewed for vision and hearing. Findings include: Record review revealed Resident #74 was admitted to the facility on [DATE] with diagnoses including major depressive disorder with psychotic symptoms, bipolar disorder and unspecified ear tinnitus. Interview on 11/18/19 at 2:40 P.M. with Resident #74 revealed she told facility staff she was dealing with dizziness. Resident #74 revealed before she was admitted her doctor said she had water in her ears and if it did not get better she would have to get tubes in her ears. Resident #74 revealed when she gets up and raises her head, the room spins. Resident #74 revealed the facility said they would get her in to see a doctor as she has been reporting these symptoms since admission. Record review revealed Resident #74's physician orders included 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 Based on observation, record review, interview and policy review, the facility failed to maintain acceptable infection control practices for Resident #146 related to the storage of respiratory equipment and during wound care, for Resident #352 during tracheostomy care and while handling Resident #149's dirty linens to prevent the spread of infection. This affected two residents (#146 and #352) related to respiratory care, one resident (#146) of two residents reviewed for pressure ulcers and one resident (#149) of 33 residents observed for general infection control procedures. Findings include: 1. Record review revealed Resident #146 was admitted to the facility on [DATE] with a diagnoses including respiratory failure, surgical aftercare following surgery on the digestive system, Down syndrome and pressure ulcer of sacral region. Resident #146's five day Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed her cognition was severely impaired for decision making. a. Resident #146's physician's orders 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.