Greenbriar Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and observation the facility failed to ensure medications were administered as ordered by the physician. This affected two residents (Resident #70 and #357) of eight residents reviewed for medication administration. The facility census was 95. Findings include: 1. Review of Resident #357's medical record revealed an admission date of 03/07/2025 with diagnoses that included, acute and subacute infective endocarditis, septic arterial embolism, chronic kidney disease, stage two, ST elevation myocardial infarction (STEMI), other psychoactive substance abuse, uncomplicated intravenous drug use with Suboxone, bacteremia, methicillin resistant staphylococcus aureus infection, nicotine dependence. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #357 had intact cognition. Review of Resident #357 care plan dated 03/08/25 revealed a focus of substance use disorder with interventions to administer medications per medical provider's orders and evaluate 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, and record reviews, the facility failed to ensure Residents #53, #55, and #89 were smoking in a safe smoking area and not an area designated as non-smoking. This affected all three Residents #53, #59, and #89 who were reviewed for smoking. The facility census was 95. Findings include: 1.Review of the medical record for Resident #53 revealed an admission date of 10/28/24. Diagnoses included chronic respiratory failure with hypoxia, hemiparesis following cerebral infarction, and atrial fibrillation. Review of the entry Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #53 had severe cognitive impairment with a memory problem. Resident #53 required extensive assistance for all activities of daily living. Review of the smoking assessments completed 10/28/24, 01/28/25, and 02/22/25 revealed Resident #53 was an independent smoker. Review of the care plan dated 01/06/25 revealed Resident #53 utilizes nicotine products. Interventions included she will use the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the facility's self-reported incident (SRI), interviews and review of the facility policy, the facility failed to ensure timely and appropriate reporting of suspected verbal abuse and rough handling of Resident #75 by staff. This affected one resident (#75) of 33 residents residing on the Regency unit of the facility. The facility census was 100. Findings include: Review of the medical record revealed Resident #75 revealed an admission date of 09/24/19 with diagnoses including Alzheimer's disease, dementia, mild intellectual disabilities, asthma, atherosclerotic heart disease of the native coronary artery, essential hypertension, iron deficiency anemia, obstructive reflux uropathy, bipolar disorder, muscle weakness, glaucoma, and unspecified chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed 11/04/24 revealed Resident #75 had severe cognitive impairment and was dependent for toileting hygiene, dressing lower body, application…

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, review of controlled drug administration records and interview, the facility failed to ensure accuracy of records regarding medication administration. This affected one (Resident #60) of six residents reviewed for pain. Findings include: Review of Resident #60's medical record revealed diagnoses including osteoarthritis of the hips and osteonecrosis of the left femur. On 11/01/24, an order was written for ultram (pain medication) 50 milligrams (mg) to be administered every eight hours as necessary for pain. Comparison of the November Medication Administration Record (MAR) and the controlled drug administration record revealed discrepancies described below. The MAR indicated ultram was administered on 11/05/24 at 9:34 A.M. There was no documentation of the withdraw of the ultram for that date and time. The MAR indicated ultram was administered on 11/06/24 at 8:37 P.M. The controlled drug administration record indicated ultram was removed at 10:00 (what appeared to be 10 A.M.). The MAR indicated Resident #60 received ultram on 11/07/24 twice (at 10:51…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility policy the facility failed to ensure Resident #48, who had an order to self-medicate, kept his medications stored appropriately. This affected one resident (#48) who the facility identified as the only resident in the facility that self-medicated. The facility census was 92. Findings include: Review of the medical record for Resident #48 revealed an admission date of 06/12/24. Diagnoses included type two diabetes mellitus, hypertension, and schizophrenia. Review of the physician's order dated 06/12/24 revealed that Resident #48 may keep his medications at his bedside and administer his medications to himself. Review of the self-administration of medication assessment dated [DATE] revealed that Resident #48 demonstrated secure storage for medication in his room. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #38 had intact cognition. Resident #48 required minimal assistance with all activities…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review the facility failed to administer medications to Resident #31 in accordance with professional standards of practice. This affected one resident (#31) of two residents observed for medication administration. The facility census was 92. Findings include: Review of the medical record for Resident #31 revealed an admission date of 08/08/23. Diagnoses included chronic kidney disease, type two diabetes mellitus, chronic obstructive pulmonary disease, and peripheral vascular disease. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had intact cognition. Resident #31 required extensive assistance for all activities of daily living and had an indwelling urinary catheter and was always incontinent of bowel. Review of the care plan dated 08/14/24 revealed Resident #31 required assistance with all activities of daily living. Interventions included to provide set up and clean up assistance for eating and 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 interview, medical record review, and review of facility policy, the facility failed to ensure bathing was completed for Resident #55 and Resident #87 as scheduled. This affected two residents (Residents #55 and #87) of three residents reviewed for bathing. The facility census was 114. Findings include: 1. Review of the medical record for Resident #55 revealed an admission date of 02/24/24 with diagnoses including primary hypertension, atrial fibrillation, type two diabetes mellitus, dysphagia, osteoarthritis, cerebral infarction affecting the left non-dominant side, and hemiplegia. Review of the care plan dated 02/25/24 revealed Resident #55 required assistance with activities of daily living (ADLs) related to pain, impaired mobility, weakness, and hemiplegia. Interventions included two staff for all shower transfers and one, sometimes two, staff to complete all the effort for bathing. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 06/07/24 revealed Resident #55 had intact cognition and impaired range of motion of the upper and lower extremities…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview and facility policy review, the facility failed to ensure resident smoking materials were maintained by the facility staff. This affected four (Residents #15, #64, #77 and #346) of four residents reviewed for smoking. The facility census was 94. Findings include: 1. Review of the medical record for Resident #15 revealed an admission date of 03/09/20 with diagnoses including spinal cord disease, paraplegia (paralysis to his legs), chronic obstructive pulmonary disease and nicotine dependence. Review of the Smoking Acknowledgement form revised on 03/30/16, revealed smoking materials could present a safety hazard and the facility had adopted a safety policy and procedure to provide a safe smoking area. Resident #15 signed this form on 06/13/23. Review of the quarterly smoking assessment dated [DATE] revealed Resident #15 was an independent smoker. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #15 had impaired cognition.…

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, menu spreadsheet review and policy review the facility failed to serve palatable meals at appetizing temperatures. This affected 91 residents receiving meals from the kitchen as three residents (Residents #23, #86 and #296) were ordered nothing-by-mouth (NPO). The facility census was 94. Findings include: Review of a menu for Day 17 Week Three Tuesday corresponding to 02/13/24 revealed the following for the dinner meal: Rancher's Chicken Thigh, country style tomatoes, oven browned potatoes, cornbread and peanut butter cookie. Interview on 02/12/24 at 7:56 P.M. with Resident #56 revealed food was really cold. Interview on 02/12/24 at 8:01 P.M. with Resident #54 revealed the food was cold more often that not and you would not want to eat it. Interview on 02/12/24 at 8:12 P.M. with Resident #25 revealed the food was sometimes cold. Interview on 02/12/24 at 8:22 P.M. with Resident #31 revealed the food was cold because his room was at the very end of the facility. Interview on 02/13/24 at 8:58 A.M. with Resident #32 revealed the food at dinner was cold.…

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 policy review, the facility failed to ensure foods were labeled, dated and not retained when expired. This had the potential to affect 91 residents receiving food from the facility's kitchen as three residents (Residents #23, #86 and #296) were ordered nothing-by-mouth (NPO). The facility census was 94. Findings include: Observation of the facility's nourishment refrigerators on 02/12/24 starting at 7:24 P.M. with Culinary Supervisor (CS) #274 revealed the following areas of concern: • On the Providence unit, there was a food container with Resident #347's room number and no date. • On the Lifestyles unit, in the freezer there was a freezerburnt container of ground beef dated 10/13/23. In the refrigerator, there was a container of ice cream with Resident #61's name on it dated 06/14, a peanut butter and jelly sandwich dated 02/03/23, two peanut butter and jelly sandwiches without dates, an additional half of a peanut butter and jelly sandwich that was hard to touch and lacked a date, a clear container with a staff member's name on it with half of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to ensure the resident's call light was within reach. This affected one (Resident #8) of five residents reviewed for call lights. The facility census was 94. Findings include: Review of the medical record for Resident #8 revealed an admission date of 10/25/22 with diagnoses including hemiplegia (paralysis) to the left side and dementia. Review of Resident #8's care plan dated 10/26/22 stated she required assistance with activities of daily living related to balance problems, impaired cognition, safety awareness and weakness. The staff were to place her call light within reach so she could call for assistance. Review of Resident #8's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had impaired cognition and was dependent on staff for activities of daily living. Observation on 02/13/24 at 8:44 A.M. of Resident #8 revealed her call light cord to be wrapped around the side rail but the call button dangling on the floor.…

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 showers were completed as scheduled. This finding affected two residents (Residents #54 and #350) of five residents reviewed for activities of daily living (ADLs). The facility census was 94. Findings include: 1. Review of Resident #350's medical record revealed the resident was admitted on [DATE] with diagnoses including difficulty in walking, radiculopathy and pain in the right hip. Review of Resident #350's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition and required substantial/maximal assistance with shower/bathing. Review of Resident #350's shower documentation revealed the resident was scheduled for showers on Tuesday, Thursday and Saturday on nightshift and he had received a bed bath on 02/06/24, refused on 02/09/24 and received a bed bath on 02/10/24. Interview on 02/12/24 at 7:33 P.M. with Resident #350 confirmed he was admitted for approximately two weeks and staff had not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed failed to ensure Resident #347's intravenous (IV) fluids were discontinued after use and Resident #26's right foot dressing was completed as ordered. This finding affected one (Resident #347) of one resident reviewed for IV therapy and one (Resident #26) of three residents reviewed for general skin conditions. The facility census was 94. Findings include: 1. Review of Resident #347's medical record revealed the resident was admitted on [DATE] with diagnoses including encounter for surgical aftercare following surgery on the genitourinary system, unspecified intestinal obstruction and essential hypertension. Review of Resident #347's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #347's physician orders revealed an order dated 02/09/24 for dextrose-sodium chloride intravenous solution 5-0.45% (percent), use 75 ml (milliliters) per hour intravenously…

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 failed to ensure Resident #347's intravenous (IV) fluids were discontinued after use. This finding affected one (Resident #347) of one resident reviewed for IV therapy. Findings include: Review of Resident #347's medical record revealed the resident was admitted on [DATE] with diagnoses including encounter for surgical aftercare following surgery on the genitourinary system, unspecified intestinal obstruction and essential hypertension. Review of Resident #347's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #347's physician orders revealed an order dated 02/09/24 for dextrose-sodium chloride intravenous solution 5-0.45% (percent), use 75 ml (milliliters) per hour intravenously every shift for an ileus for two days. Review of Resident #347's IV team form dated 02/10/24 at 12:45 P.M. revealed a new peripheral IV line was started in the resident's…

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

Based on record review and staff interviews, the facility failed to ensure complete and accurate documentation for Residents #15 and #62. This affected one of three residents reviewed for restorative care (#62) and one of one record reviewed for transmission-based precautions (#15). The facility census was 94. Findings Include: 1. Review of medical records for Resident #15 revealed an admission date of 10/07/20. Resident #15 was diagnosed with MRSA (Methicillin Resistant Staphylococcus Aureus) in the urine on 06/13/23 and was subsequently placed on transmission-based precautions (contact precautions). Contact Precautions were not discontinued after completion of the appropriate antibiotic therapy. Review of Resident #15's medical records revealed the order for contact precautions was discontinued on 02/14/24. Review of the Medication Administration Record (MAR) indicated Resident #15 remained on contact precautions from 06/13/23 through 02/13/24. Nursing staff was documenting on the MAR daily the resident was currently on contact precautions. Observation on 02/14/24 at 12:13 PM…

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, review of the medical record and interview with the staff, the facility failed to ensure blood sugar tests and insulin was administered as ordered for Resident #78, failed to ensure the call light was answered timely for Resident #15 and failed to ensure an intravenous antibiotic was initiated timely after admission for Resident #99. This affected two residents (Resident #78 and #99) of three reviewed for medication administration and one resident (Resident #15) of three reviewed for staffing. The facility census was 97. Findings included: 1. Review of the medical record revealed Resident # 78 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, anemia, acute cystitis, severe protein calorie malnutrition, encephalopathy, diabetes, diabetic neuropathy, cognitive communication, hemiplegia, gastrostomy, and weakness. Review of the Five-Day Medicare Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #78 had moderately impaired cognition, he 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the medical record and interview with the staff the facility failed to maintain a medication error rate of less than five percent. The medication error rate was calculated to be 13.3 percent and included four medication errors of 30 opportunities for error. This affected one resident ( Resident #55) out of four residents observed during medication administration. The facility census was 97. Findings include: Review of the medical record revealed Resident #55 was admitted to the facility on [DATE]. Diagnoses included respiratory failure, COVID-19, hypoxemia, polyneuropathy, chronic kidney disease, benign prostatic hyperplasia, Alzheimer's disease, glaucoma, abdominal aortic aneurysm, atrial fibrillation, adult failure to thrive, weakness, cognitive communitive deficit, and major depressive disorder. Review of the Significant Change Minimum Data Set 3.0 assessment dated 11/2023 revealed Resident #55 had intact cognition. Review of the December 2023 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, review of the medical record and interviews with staff the facility failed to ensure a clean sanitary environment while providing resident care to Resident #55 and during a dressing change for resident #78. This affected two residents ( Resident #55 and #78) of three residents reviewed for infection control. The facility census was 97. Findings include: 1. Review of the medical record revealed Resident # 78 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, anemia, acute cystitis, severe protein calorie malnutrition, encephalopathy, diabetes, diabetic neuropathy, cognitive communication, hemiplegia, gastrostomy, and weakness. Review of the Five-Day Medicare Minimum Data Set (MDS) 3.0 assessment dated [DATE] Resident #78 had moderately impaired cognition, he had a tube feed for nutrition and received insulin. Review of the December 2023 physician's orders revealed Resident #78 had an order to cleanse his sacral wound with normal saline, apply hydrogel and silver…

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

Based on observation, interview, record review, and facility policy review the facility failed to provide a clean and sanitary environment where food was being prepared. This had the potential to affect all 92 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39 #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #79, #80, #81, #82, #83, #84, #85, #86, #87, #88, #89, #90, #91, #92, #93, #94, and #95) who receive their meals from the kitchen. The facility census was 96. Findings include: Observation on 09/06/23 at 8:15 A.M. revealed [NAME] #500 in the kitchen with no hair net covering his beard and mustache. [NAME] #500 was preparing lunch and cleaning up breakfast food service. Interview on 09/06/23 at 8:25 A.M. with [NAME] #500 confirmed he had not and was not wearing his beard and mustache hair net and it was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure food was served in a sanitary manner. This affected one resident (Resident #77) and had the potential to affect all 107 residents residing in the facility. Findings Include: Review of the medical record for Resident #77 revealed an admission date of 05/05/20 with diagnoses including type 2 diabetes, dysphagia, pleurisy, chronic kidney disease (CKD) stage 3 and peripheral vascular disease. Review of the care plan, dated 01/10/22 revealed Resident #77 had a nutritional deficit related to dysphagia and feeding difficulties. Interventions included adaptive equipment such as a two-handle sipper cup, weighted utensils and a scoop plate with all meals. Food intake was to be monitored and recorded at every meal and staff was to provide feeding assistance as necessary. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident required the extensive assistance of one staff member for eating. On 02/08/22…

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, interview, facility policy and procedure review and review of the Centers for Disease Control (CDC) guidance the facility failed to maintain adequate infection control practices after providing incontinence care to Resident #45 and related to screening procedures for COVID-19 to prevent the spread of infection including COVID-19. This affected one resident (#45) and had the potential to affect all 107 residents. Findings Include: 1. On 02/08/22 at 1:30 P.M. State Tested Nursing Assistant (STNA) #820 was observed providing incontinence care to Resident #45. After the care was completed, STNA #820 was observed touching the resident's over bed table to move it, assisting Resident #45 to move up in bed using linen and handled the bed remote to raise the head of the bed with the same gloved hands as were used during incontinence care. On 02/08/22 at 1:45 P.M. interview with Licensed Practical Nurse (LPN) #235, who was present during the provision of incontinence care verified the above observations. LPN #235 revealed the STNA should have removed the gloves 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, review of infection surveillance logs, facility policy review and interview the facility failed to ensure an effective antibiotic stewardship program was maintained. This affected one resident (#34) and had the potential to affect all 107 residents residing in the facility. Findings Include: 1. Review of Resident #34's medical record revealed diagnoses including dementia, congestive heart failure, and cerebral infarction. A quarterly Minimum Data Set (MDS) 3.0 assessment, dated 12/07/21 revealed Resident #34 required extensive assistance from staff for toilet use and was always incontinent of bowel and bladder. A nursing note, dated 02/06/22 at 7:43 P.M. indicated the nurse attempted to straight cath Resident #34 per the resident's son's request because he (the son) believed the resident had a urinary tract infection. Another nurse had attempted to catheterize Resident #34 three times unsuccessfully on 02/01/22. Resident #34's son reported the resident was experiencing itching in her perineal area and had a urine smell. The nursing note indicated the son was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure Resident #5's wishes regarding advance directives/code status was clear and consistently noted in both the resident's electronic health record (EHR) and medical chart record (binder). This affected one resident (#5) of 32 residents reviewed for advance directives. Findings Include: Review of Resident #5's medical record revealed diagnoses including chronic obstructive pulmonary disease (COPD), epilepsy, human immunodeficiency virus (HIV), hyperlipidemia and peripheral vascular disease (PVD). An annual Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed Resident #5 was able to make himself understood and was able to understand others. Resident #5 was assessed as cognitively intact. A signed Do Not Resuscitate (DNR) form (not dated) was in the resident's medical chart record (binder) on the unit at the nursing station. The EHR indicated Resident #5 wished to have cardiopulmonary resuscitation (full code status). On [DATE] at 11:47 A.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 record review and interview the facility failed to provide required transfer/discharge notifications. This affected three residents (#4, #68, and #87) of 32 residents reviewed for hospitalizations. Findings Include: 1. Review of Resident #68's medical record revealed diagnoses including type 2 diabetes mellitus, heart failure, borderline personality disorder, and mild intellectual disabilities. A nursing note, dated 02/04/22 at 4:49 P.M. indicated Resident #68 was vomiting, had garbled speech and weak hand grasps. The note indicated Resident #68 was only alert to person but was usually alert and oriented to person, place and time. Resident #68 was transported to the hospital. There was no evidence of a transfer/discharge notice being provided to Resident #68 or her representative. On 02/09/22 at 4:40 P.M. interview with Regional Director of Clinical Services #1190 revealed the facility did not provide a transfer notice to Resident #68. The Ombudsman was given a list of residents' with discharge date s…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were accurate for all residents. This affected three residents (#3, #44 and #95) of 29 resident records reviewed for comprehensive assessments. Findings Include: 1. Review of Resident #44's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia, major depressive disorder and weakness. Review of Resident #44's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 12/21/21 revealed the resident received seven doses of a hypnotic medication and zero doses of an anticoagulant medication. Review of Resident #44's medication administration records from 12/15/21 to 12/21/21 revealed the resident did not receive any hypnotic medications and received seven doses of an anticoagulant medication. Interview on 02/09/22 at 9:05 A.M. with Minimum Data Set (MDS) Registered Nurse (RN) #1150 revealed she marked the doses of the anticoagulant medication on 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 staff interview the facility failed to refer Resident #57 for Pre-admission Screening and Resident Review (PASARR) Level Two after a new mental health diagnoses was identified. This affected one resident (#57) of three residents reviewed for PASARR. Findings Include: Record review revealed Resident #57 was admitted to the facility on [DATE] with diagnoses including diabetes insipidus, lymphedema, schizoaffective disorder (added 05/09/19), primary osteoarthritis, left knee, hypothyroidism, type 2 diabetes mellitus, and history of coronavirus disease (Covid-19). Review of Resident #57's PASARR application/form, completed on 05/17/16 revealed Section D, titled indications of serious mental illness was marked no. No other PASARR application/form was completed after 05/17/16. Review of Resident #57's medical records revealed a PASARR application/Level 2 was not completed after the resident was diagnosed with schizoaffective disorder on 05/09/19. Review of the Minimum Data Set (MDS) 3.0…

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 fall interventions were in place for Resident #7 as ordered by the physician and care plan to prevent falls. The facility also failed to implement safe smoking practices to prevent accidents/injuries associated with resident smoking. This affected three residents (#7, #44 and #49) of four residents reviewed for accidents. The facility identified 12 residents (#4, #7, #20, #44, #49, #56, #67, #70, #82, #87, #96 and #98) who smoked in the facility. Findings Include: 1. Review of Resident #7's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including unspecified dementia without behavioral disturbance, major depressive disorder and difficulty in walking. Review of Resident #7's fall care plan interventions revealed an intervention updated 11/02/20 to encourage the resident to wear socks with shoes daily, encourage the resident to sit back in her wheelchair, assure no items were placed between…

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 medications were stored properly. This affected two residents (#100 and #154) of six residents reviewed for medication storage. Findings Include: 1. Review of Resident #100's medical record revealed the resident was readmitted to the facility with diagnoses including diabetes, morbid obesity and weakness. Review of Resident #100's annual Minimum Data Set (MDS) 3.0 assessment, dated 01/19/22 revealed the resident exhibited intact cognition On 02/09/22 at 7:38 A.M. interview with the Director of Nursing (DON) revealed Resident #100's bedside table had six medication bottles including Fish oil, Vitamin D3, Heal-n-soothe (supplement for relieving joint and back pain), Testosterone support (supplement), Exipure supplement (nutritional supplement that aids in weight loss by improving brown adipose tissue) and Coenzyme Q (COQ10 which improves heart health and blood sugar regulation). Interview on 02/09/22 at 7:40 A.M. with the DON confirmed…

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

Based on record review and interview the facility failed to provide timely dental services for Resident #19 with identified decaying teeth. This affected one resident (#19) of 32 residents reviewed for dental condition. Findings Include: Review of Resident #19's medical record revealed diagnoses including dementia with behavioral disturbance, legal blindness, and anxiety disorder. Record review revealed the most recent dental consult was dated 02/19/21. An annual Minimum Data Set (MDS) 3.0 assessment, dated 11/17/21 indicated Resident #19 was sometimes able to make herself understood and was sometimes able to understand others. The assessment revealed Resident #19 required extensive assistance from staff for personal hygiene. The MDS indicated Resident #19 did not have obvious or likely cavities. Nurse practitioner notes, dated 11/23/21 at 4:37 P.M., 12/10/21 at 2:57 P.M., 12/21/21 at 2:57 P.M., 01/28/22 at 1:56 P.M., 01/31/22 at 10:40 A.M. and 02/04/22 at 6:39 P.M. indicated Resident #19 had decayed teeth. On 02/09/22 at 10:44 A.M., Social Service Assistant #525 revealed 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.