Rolling Hills Rehab And Care Ctr

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure operations were conducted in a manner that supported and encouraged the highest level of resident care, as staff were prohibited from speaking freely with state agency personnel, which hindered their ability to advocate for residents without fear of retaliation. The facility administration also failed to ensure contracted staff were not asked to alter legal documents contained within resident medical records. This affected one resident (#7) and had the potential to affect all 52 residents residing in the facility.Findings include:During the onsite investigation the following concerns were identified related to administrative oversight in the facility and the ability for staff to openly communicate with state agency survey staff:a. Interview on 07/30/25 at 3:33 P.M. with Anonymous Staff Member (ASM) #707 revealed staff were targeted after surveys if they speak with the state survey agency. The interview revealed there was a fear of retaliation…

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 failed to maintain a clean, safe, comfortable and sanitary environment. This had the potential to affect all 52 residents residing in the facility. Findings include: During the onsite complaint survey, the following information was obtained:a. Interview with Certified Nursing Assistant (CNA) #104 on 07/30/25 at 8:51 A.M. revealed there was mold across the whole building. They have recently had several water leaks, on the north side. The water leaks included the washer. CNA #104 stated they were unsure if it was due to a leak, or an overflowing of water but regardless a large amount of water came out onto the floor of the laundry room, and the entire vending machine room carpet was soaked. CNA #104 confirmed the water mark on the carpet of the vending machine room and a strong musty smell. CNA #104 stated there was a musty foul odor throughout the building, however it is the strongest in the vending machine room. CNA #104 stated the AC units of the resident rooms…

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 interviews the facility failed to provide an effective pest management program. This had the potential to affect all 52 residents residing in the facility.Findings include:a. Interview on 07/30/25 at 9:00 A.M. with Certified Nursing Assistant (CNA) #104 confirmed the flies were horrible around the building. There was also an issue with the gnats however the flies were more prevalent. CNA #104 believed the flies and gnats were possibly due to the musty odor and the dampness of the carpeting and air conditioning units. CNA #104 stated the gnats and flies could also be from the lack of having a housekeeper daily. CNA #104 confirmed flies were often found in resident rooms.b. Interview on 07/30/25 with Licensed Practical Nurse (LPN) #61 at 4:40 P.M. revealed the flies in the building were horrible. There was a resident who had them in his room and he required cream on his legs. The flies will swarm around his legs, and you have to ensure the flies do not stick to them. Families have brought in bug spray because it's gotten so bad. LPN #61 stated staff are being…

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 resident agreement review the facility failed to ensure residents were transported to medical appointments. This affected one resident (Resident #17) of four residents reviewed.Findings include: Record review revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, vascular dementia, anemia, hypertension (HTN) and nicotine dependence.Review of the Minimum data set (MDS) revealed Resident #17 had a brief interview for mental status (BIMS) score of 13, out of a possible 15, indicating intact cognition.Medical record review revealed the facility was aware transportation was unavailable for Resident #17 as of 07/18/25 and there was no documentation to support attempts for alternate transportation were made so Resident #17 could attend the appointment.Interview on 07/31/25 at 10:55 A.M. with Resident #17 revealed on 07/21/25 he got up and got ready for an appointment regarding a cyst above his eye. Resident #17 stated he had been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy review, facility investigation review and interviews the facility failed to thoroughly investigate and report allegations of sexual abuse to the state survey agency. This affected two residents (Resident #7 and #54) of three residents reviewed for abuse. The facility census was 52.Findings Include:1. Record review revealed Resident #7 admitted to the facility on [DATE] with diagnoses of vascular dementia, alcohol use, flaccid bladder, hydronephrosis, major depressive disorder, hypertension, metabolic encephalopathy, and anxiety.Record review of Resident #7 quarterly Minimum Data Set(MDS) dated [DATE] revealed Resident #7 had severe cognitive impairment, exhibited behaviors and could independently walk at least 150 feet.Record review of Resident #7's assessment for behaviors completed 06/13/25 revealed Resident #7 wandered freely without interruption. Additional factors affecting the resident's behaviors included the resident would become frustrated due to problems…

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 maintain accurate care plans. This affected one (Resident #51) of nine residents reviewed. The census was 52.Findings include: Record review revealed Resident #51 admitted to the facility on [DATE] with diagnoses including respiratory failure, type two diabetes, (COPD), gastro-esophageal reflux disease (GERD) osteoarthritis, anemia, atherosclerotic heart disease, insomnia, schizophrenia hypercholesterolemia, overactive bladder, borderline personality disorder, hypothyroidism, pyoderma, hypertension, anxiety major depressive disorder, chronic kidney disease, kidney failure, and , renal dialysis dependent. Review of Resident #51 orders revealed an order for hemodialysis every Monday, Wednesday, and Friday for renal failure. Review of Resident #51 minimum data set (MDS) revealed a brief interview for mental status (BIMS) score of 15, indicating Resident #51 was cognitively intact. Review of Resident #51 care plan completed 04/11/25 revealed…

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

Based on observation and interview, the facility failed to ensure office spaces were clean and sanitary. This had the potential to affect all residents residing in the facility. The census was 55. Findings include: Observation and interview on 06/05/25 at 9:50 A.M. with Director of Maintenance (DM) # 100 revealed an approximate 12-inch section of peeling wallpaper was located near the baseboard of the back wall in Social Services Director (SSD) #84's office. DM #100 pulled back the peeling wallpaper and black areas were visible on the dry wall. DM #100 confirmed he was aware of the peeling wallpaper, but was not aware of the mold-like areas beneath the wallpaper. During observations of the SSD office on 06/05/25, residents were observed stopping at the office and speaking with the SSD. The SSD kept her office door open. Interview on 06/05/25 at 10:00 A.M. with Social Services Director (SSD) #84 stated on 05/05/25, she notified the Administrator of the peeling wallpaper in her office and of her concern regarding the air quality in her office. SSD #84 stated she was told by 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, interview, and policy review, the facility failed to ensure resident representatives were notified when there was a change in the residents' treatments/ medications as required. This affected three of three residents reviewed for changes in condition. Findings include: 1. Review of Resident #45's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included anoxic brain damage, epilepsy (seizures), major depressive disorder, and anxiety disorder. Review of Resident #45's profile under the electronic medical record (EMR) revealed the resident's emergency contacts were listed. Her sister was identified as the resident's emergency contact #1, with a contact phone number included. Review of Resident #45's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. She was able to make herself understood and was able to understand others. She was not known to display any behaviors…

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 policy review, the facility failed to ensure fall prevention interventions were implemented for residents at risk and with a history of falls as per their plan of care. This affected two (Resident #45 and #51) of three residents reviewed for falls. Findings include: 1. Review of Resident #45's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included anoxic brain damage, epilepsy (seizures), major depressive disorder, and anxiety disorder. Review of Resident #45's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have any communication issues and was cognitively intact. She required supervision to touching assistance with with transfers. She was indicated to have had one fall with injury (not major injury) since her prior assessment. Review of Resident #45's care plans revealed she had a care plan in place for being at risk for falls related to deconditioning, gait/ balance problems,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews and policy review, the facility failed to implement preoperative orders prior to a scheduled surgical procedure resulting in the procedure being rescheduled. This affected one resident (Resident #18) of five reviewed for physician orders. Findings include: Review of Resident #18's medical record revealed an admission date of 01/23/24 with diagnoses including aftercare following surgery on the nervous system, diabetes, major depression, hypertension and hyperlipidemia. Review of Resident #18's care plan revealed a care plan initiated on 07/23/24 for risk of bleeding related to antiplatelet use, indicating to monitor the resident for bleeding and increased bruising. Review of the physician orders revealed an order for aspirin 81 milligrams by mouth daily for a blood thinner started on 11/08/24. Review of Resident #18's progress notes revealed a note written on 01/27/25 at 10:00 A.M. indicating a call was received from the Neuroscience center to schedule a surgical date of…

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

Based on observation and staff interviews, the facility failed to maintain a clean and comfortable environment for the residents residing in the facility. This affected one resident (Resident #6) of five residents interviewed on the 100 and 200 units who utilized the community shower. The facility census was 63. Findings include: In an interview on 04/10/25 at 1:13 P.M. Resident #6 stated that she did not use the shower room on her unit but went to the shower on the other side of the building because the shower on her side had a bad odor and stains on the floor creating an unpleasant shower experience. Observation of the shower room shared by the 100 hall and 200 hall on 04/10/25 at 1:43 P.M. revealed a musty, rotten egg-like odor similar to sewage in the shower room and a gray-brown stain that was approximately an inch wide and four inches in length, on the floor along the wall at the edge of the shower stall, below the emergency call cord. In an interview on 04/10/25 at 1:43 P.M. Housekeeper #138 confirmed the odor and the stain on the floor in the shower room . In an interview on…

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

Based on record review, review of Quality Assurance Performance Improvement (QAPI) sign-in sheets, staff interview, and policy review, the facility failed to ensure the governing body was engaged and involved in the oversight of the functions of the facility in regards to the QAPI program. This affected all 50 residents in the facility. The facility census was 50. Findings include: Review of the facility's survey tracking history revealed the facility had an annual survey completed on 11/17/22 and complaint surveys on 10/17/24, 09/12/24, 05/13/24, 01/17/24, and 03/08/23 which all resulted in citations under the care areas of nursing services, quality of care, admission discharge and transfer, freedom from abuse neglect and exploitation, and food and nutrition services. Review of the facility quarterly QAPI attendance logs revealed the committee had not meet since before their last annual survey on 11/17/22. Interview on 11/21/24 at 3:00 P.M. with the facility's Administrator revealed the facility could not provide evidence of quarterly QAPI meetings since before last annual survey…

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 review of the facility arbitration agreement, the facility failed to ensure residents or their representative were educated regarding their right to communicate with local, state, or federal officials before signing an arbitration agreement or within thirty days of signing the agreement. This affected all residents residing in the facility. The facility census was 50. Findings include: Review of the facility's undated arbitration agreement revealed that the resident or representative did not have to sign the agreement to receive healthcare services and they could cancel the agreement by providing written notice of cancellation to the facility within thirty days after signing the agreement. There was no information regarding communication with local, state, and federal officials. Interview on 11/20/24 at 12:54 P.M. with the Administrator confirmed the arbitration agreement did not provide guidance to residents or representatives that they could reach out of local, state, and federal officials for guidance before signing the agreement or within…

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 review of the facility arbitration agreement, the facility failed to ensure their arbitration agreement allowed for a mutually agreeable arbitrator and venue. This had the potential to affect all residents residing in the facility. The facility was census was 50. Findings include: Review of the facility's undated arbitration agreement revealed matters would be resolved by binding arbitration administered by the American Arbitrators Association, under their rules and procedures. If the American Arbitrators Association did not enforce pre-dispute arbitration agreement, then any other reasonable arbitration association chosen solely by the facility would be an acceptable replacement. The agreement also indicated the venue for arbitration would be in a proper closer venue to the facility's principal place of business. Interview on 11/20/24 at 12:54 P.M. with the Administrator confirmed that the arbitration agreement clearly stated who the facility had chosen for an arbitrator. The Administrator also reported that she was not sure where the closest…

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, review of survey history, review of approved plans of corrections, and policy review, the facility failed to establish a Quality Assurance and Performance Improvement (QAPI) program that thoroughly evaluated identified areas in need of improvement, and monitored and evaluated the effectiveness of corrective action making revisions to systems and practices as needed to ensure ongoing compliance. This affected all 50 residents residing in the facility. Findings include: Review of the facility's survey tracking history revealed the facility had an annual survey completed on 11/17/22 and complaint surveys on 10/17/24, 09/12/24, 05/13/24, 01/17/24, and 03/08/23 which all resulted in citations under the care areas of nursing services, quality of care, admission discharge and transfer, freedom from abuse neglect and exploitation, and food and nutrition services. Review of the facility submitted plans of corrections revealed findings would be reported to QAPI for review and further intervention. Interview on 11/21/24 at 3:00 P.M. the facility's Administrator 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.

Based on review of Quality Assurance and Performance Improvement (QAPI) attendance logs, staff interview, and policy review, the facility failed to hold quarterly meetings composed of staff who understood the characteristics and complexities of the care and services delivered by each unit, and/or department including the director of nursing (DON), Medical Director, Infection Preventionist (IP), and at least three other staff, one of whom was the facility's administrator, owner, board member, or other individual in a leadership role who had knowledge of facility systems and the authority to change those systems. This affected all 50 residents residing in the facility. Findings include: Review of the facility's survey tracking history revealed the facility had an annual survey completed on 11/17/22 and complaint surveys on 10/17/24, 09/12/24, 05/13/24, 01/17/24, and 03/08/23 which all resulted in citations under the care areas of nursing services, quality of care, admission discharge and transfer, freedom from abuse neglect and exploitation, and food and nutrition services. Review of…

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

Based on record review, observation, interview, and policy review the facility failed to ensure privacy was maintained during the administration of an injectable medication and transdermal patch. This affected one resident (#160) out of four residents observed for medication administration. The facility census was 50. Findings include: Review of the medical record for Resident #160 revealed an admission date of 11/11/24. Diagnoses included diabetes mellitus (DM), acute respiratory failure, and asthma. Review of Resident #160's November 2024 physician orders revealed an order to inject Lovenox (a medication utilized for DM) 30 milligrams/0.3 milliliters to be injected subcutaneously every 12 hours and Lidocaine external patch four percent to be applied to the rib area topically one time a day for pain. Observation on 11/20/24 at 8:24 A.M. revealed Registered Nurse (RN) #351 gathered medication and entered Resident #160's room. Upon entering the room, RN #351 left the resident's door open and did not close the resident's individual curtain. Resident #160 was sitting in her wheelchair…

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 self-reported incident review, medical record review, resident interview, staff interview, and policy review, the facility failed to ensure allegations of abuse were reported to the state agency in a timely manner. This affected one (Resident #30) of three residents (Resident #14, Resident #30, and Resident #53) reviewed for abuse. The facility census was 50. Findings include: Review of the facility on-line self-reported incidents (SRI) revealed from January 2024 through November 2024 the facility had not filed an SRI with the state agency, indicating the facility was investigating an allegation of an incident involving misappropriation. Review of the medical record for Resident #30 revealed an admission date of 03/05/24. Diagnoses included diabetes mellitus, bipolar disorder, and anxiety disorder. Review of Resident #30's quarterly minimum data set (MDS) 3.0 assessment with a reference date of 09/12/24 revealed the resident had an intact cognition level and he had not experienced hallucinations or delusions during the review period. Interview on 11/18/24 at 11:08 A.M. with…

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

Based on self-reported incident review, medical record review, resident interview, staff interview, and policy review, the facility failed to investigate an allegation of misappropriation of resident property. This affected one (Resident #30) of three residents (Resident #14, Resident #30, and Resident #53) reviewed for abuse. The facility census was 50. Findings include: Review of the facility on-line self-reported incidents (SRI) revealed from January 2024 through November 2024 the facility had not filed an SRI with the state agency, indicating the facility was investigating an allegation of an incident involving misappropriation. Review of the medical record for Resident #30 revealed an admission date of 03/05/24. Diagnoses included diabetes mellitus, bipolar disorder, and anxiety disorder. Review of Resident #30's quarterly minimum data set (MDS) 3.0 assessment with a reference date of 09/12/24 revealed the resident had an intact cognition level and he had not experienced hallucinations or delusions during the review period. Interview on 11/18/24 at 11:08 A.M. with Resident #30…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure residents and/or the resident representatives were provided with transfer notices after the residents were transferred to the hospital. This affected two residents (#45 and #55) of three residents reviewed for hospitalization and discharge. The facility census was 50 residents. Findings include: 1. Medical record review revealed Resident #55 was admitted to the facility on [DATE] with diagnoses including orthopedic aftercare following surgical amputation, diabetes mellitus, psychoactive substance abuse, chronic kidney disease, heart failure, and chronic obstructive pulmonary disease. The resident was discharged on 11/15/24 following a hospitalization. Further review of the resident's electronic and paper based medical record revealed no evidence that a transfer/discharge form was completed and given or sent to the resident/resident representative. Interview on 11/19/24 at 12:05 P.M., the Director of Nursing (DON) confirmed there…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure residents and/or resident representatives were provided with bed hold notices following hospital transfers. This affected two residents (#45 and #55) of two residents reviewed for hospitalizations. The facility census was 50 residents. Findings include: 1. Medical record review revealed Resident #55 was admitted to the facility on [DATE] with diagnoses including orthopedic aftercare following surgical amputation, diabetes mellitus, psychoactive substance abuse, chronic kidney disease, heart failure, and chronic obstructive pulmonary disease. The resident was transferred to the hospital on [DATE]. Further review of the resident's electronic and paper based medical record revealed no evidence that a bed hold notice was given or sent to the resident/resident representative. Interview on 11/19/24 at 12:05 P.M. with the Director of Nursing (DON) confirmed there was no evidence that a bed hold notice was completed and given 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.

Based on medical record review and staff interview, the facility failed to ensure psychiatric progress notes were obtained from the provider, failed to ensure a new diagnosis of schizoaffective disorder was identified and added to the medical record and care plan, and failed to accurately transcribe changes to psychiatric medications. This affected one resident (#37) out of one resident reviewed for mood and behavior. The facility census was 50. Findings include: Review of the medical record for Resident #37 revealed an admission date of 12/22/23. Diagnoses included encephalopathy, post-traumatic stress disorder (PTSD), unspecified psychosis, major depressive disorder and anxiety disorder. The medical record did not indicate that the resident had a diagnosis of schizoaffective disorder. Continued review of the medical record revealed the facility had not obtained the residents psychiatric notes from her outside provider. Review of Resident #37's annual minimum data set (MDS) 3.0 assessment with a reference date of 10/13/24 revealed the resident was cognitively intact and 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.

Based on medical record review, staff interview and policy review, the facility failed to obtain a physician ordered urinalysis (UA) and culture and sensitivity (C&S) for Resident #38, delaying antibiotic treatment. This affected one resident (#38) out of two residents reviewed for urinary tract infections (UTI). The facility census was 50. Findings Include: Review of the medical record for Resident #38 revealed an admission date of 08/19/2024. Diagnoses included unspecified dementia, end stage renal disease, and muscle wasting and atrophy. Review of Resident #38's annual minimum data set (MDS) 3.0 assessment with a reference date of 10/16/24 revealed the resident had a severe cognitive impairment. Review of Resident #38's nursing progress note dated 10/24/2024 at 2:31 P.M. revealed the resident had complaints of pain upon urination and the resident complained of abdominal pain. The resident reported that his stomach hurt and he could not urinate. Review of Resident #38's nursing progress note dated 10/25/2024 at 4:08 P.M. revealed the nurse spoke with the Nurse Practitioner (NP)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, observation, and facility policy, the facility failed to ensure weights were obtained per the residents individual needs and as ordered for Resident #16, #25, and #158; Additionally, the facility failed to ensure nutritional supplements were received for Resident #16. This affected three residents (#16, #25, and #158) out of four residents reviewed for nutrition. The facility census was 50. Findings include: 1. Review of medical record for Resident #25 revealed an admission date of 05/03/23. Pertinent diagnoses include acute kidney failure, chronic obstructive pulmonary disease (COPD), morbid obesity, type two diabetes mellitus, heart failure, personal history of other malignant neoplasm of large intestine, and major depressive disorder. Review of Resident #25's physician orders revealed an order dated 02/01/24 for a no added salt diet, regular texture, and thin liquids, and an order dated 03/06/24 for monthly weights. Review of Resident #25's weights revealed a weight 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, staff and resident interviews, and facility policy, the facility failed to ensure the mask of a resident's nebulizer (a device which turns liquid medicine into a fine mist that can be inhaled) was properly stored after use. This affected two residents (#25 and #47) out of three residents reviewed for respiratory care. The facility identified eight residents (#2, #5, #19, #25, #30, #47, #159, and #161) as utilizing nebulizers. The facility census was 50. Findings include: 1. Review of medical record for Resident #47 revealed an admission date of 06/19/24. Diagnoses included chronic obstructive pulmonary disease (COPD) and nicotine dependence from cigarettes. Review of Resident #47's quarterly Minimum Data Set (MDS) assessment, dated 09/26/24, revealed the resident was cognitively intact with no refusal of care. Review of the care plan dated 06/20/24 revealed Resident #47 had Emphysema/COPD with an intervention to give the resident her aerosol or bronchodilator as ordered 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, observation, and policy review, the facility failed to ensure Resident #21 was provided pain gel medications as ordered for tooth pain. This affected one resident (#21) out of three residents (Resident #21, Resident #43, and Resident #51) reviewed for pain. The facility census was 50. Findings include: Review of the medical record for Resident #21 revealed an admission date of 12/22/23. Diagnoses included type two diabetes mellitus, chronic obstructive pulmonary disease, dysphagia, and muscle weakness. Review of Resident #21's Comprehensive Care Plan dated 12/27/23 revealed the resident had the potential for oral/dental health problems with a goal that the resident would be free of infection, pain or bleeding in the oral cavity. Interventions included to administer medications as ordered and to coordinate arrangements for dental care and transportation as needed/as ordered. Review of Resident #21's current physician orders revealed, and order dated 06/20/24 for Anbesol Maximum Strength Mouth/Throat Gel 20 percent with instructions for one…

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

Based on record review and staff interview, the facility failed to ensure a pharmacy recommendation for laboratory monitoring was addressed by the physician. This affected one (Resident #43) of five residents reviewed for unnecessary medications. Findings include: Review of the medical record for Resident #43 revealed an admission date of 06/28/24 with diagnoses including epilepsy, seizure disorder, dysphagia, chronic obstructive pulmonary disease, diabetes mellitus, and chronic kidney disease. Review of the Minimum Data Set (MDS) quarterly assessment, dated 11/05/24, indicated Resident #43's Brief Interview for Mental Status (BIMS) assessment was not conducted due to the resident rarely/never understood and the resident had a diagnosis of seizure disorder. Review of Resident #43's physician orders revealed an order, dated 06/28/24, for valproic acid (a medication used for seizures) oral solution 250 milligrams (mg)/5 milliliters (ml). Review of the Monthly Regimen Reviews (MRR), dated August 2024, September 2024, and October 2024, revealed the pharmacist recommended a valproic acid…

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, observation, record review, and policy review the facility failed to ensure Resident #21 received timely dental services after experiencing dental pain. This affected one out of two residents (Resident #21 and Resident #8) reviewed for dental services. The facility census was 50. Findings include: Review of the medical record for Resident #21 revealed an admission date of 12/22/23. Diagnoses included type two diabetes mellitus, chronic obstructive pulmonary disease, dysphagia, and muscle weakness. Interview on 11/18/24 at 1:25 P.M. with Resident #21 revealed she was in the process of getting dental work completed. She stated she started experiencing dental pain several months ago but just recently saw the dentist. Review of Resident #21's Comprehensive Care Plan dated 12/27/23 revealed Resident #21 had potential for oral/dental health problems. The resident's goal indicated the resident would be free of infection, pain or bleeding in the oral cavity by review date. Interventions included administer medications as ordered and to coordinate arrangements for dental…

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, staff interviews, review of the Ohio Dietetics website, and review of the nutritional consulting company's contract with the facility, the facility failed to ensure the nutritional staff member who was completing quarterly reviews was qualified to assess the nutritional status for resident quarterly reviews. This affected one (Resident #25) of three residents who were reviewed for nutrition and had the potential to affect all residents who required a nutritional quarterly review. The facility census was 50. Findings include: Review of medical record for Resident #25 revealed an admission date of 05/03/23. Pertinent diagnoses included acute kidney failure, chronic obstructive pulmonary disease (COPD), morbid obesity, type two diabetes mellitus, heart failure, personal history of other malignant neoplasm of large intestine, and major depressive disorder. Review of 10/27/24 quarterly Minimum Data Set (MDS) assessment revealed Resident #25 was cognitively intact, had no rejection of care, required set up or clean up assistance for eating, had no significant…

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

Based on record review, policy review, review of a respiratory care journal, personnel file review and interview, the facility failed to ensure only competent staff provided tracheostomy care/insertion to residents. This affected one (Resident #58) of two residents reviewed for tracheostomy care. Findings include: Review of Resident #58's closed medical record revealed diagnoses including anxiety disorder, history of malignant neoplasm of the larynx (voice box), acquired absence of the larynx, and tracheostomy ( a surgical procedure that creates an opening in the windpipe (trachea) through the front of the neck. A tube is then inserted through the opening to allow air to bypass the nose and mouth and go directly into the lungs) status. A nursing note dated 04/12/24 at 6:00 P.M. indicated upon Resident #58's arrival his son demonstrated how to put the tracheostomy tube in, get Resident #58 to cough, use of the ventilator over the tracheostomy, and how to clean the tracheostomy tube using water and peroxide. Review of the admission physician orders revealed to suction the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, interview, and policy review the facility failed to ensure infection control practices were maintained to prevent the spread of COVID-19 and failed to ensure enhanced barrier precaution were maintained during resident care. This had the potential to affect all 54 residents residing in the facility. Findings included: 1. Medical record review Resident #14 was admitted to the facility on [DATE] with diagnoses including respiratory failure, COVID-19, and diabetes. Review of Resident #14's progress note dated 09/08/24 revealed the resident was still complaining of not feeling well; chilled at this time. Resident tested positive for COVID-19. Resident moved to room [ROOM NUMBER]. Review of Resident #14's orders dated 09/08/24 revealed the resident was ordered strict droplet precautions for COVID-19 for ten days. Observation of Resident #14's room and interview on 09/12/24 at 8:10 A.M. with State Tested Nurse's Aide (STNA) #126, Director of Nursing (DON), and Assistant…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview the facility failed to ensure an admission skin assessment was completed timely and post trauma skin alteration treatments were administered as ordered. This affected one resident (#20) of three records reviewed for skin alterations. Findings include: Medical record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including orthopedic aftercare, diabetes, and multiple fractures. Review of Resident #20's hospital discharge order dated 08/29/24 revealed orders for triad (sterile coating that adheres to wet skin and keeps the wound covered) to coccyx and penis twice daily, mesalt rope (absorbs exudate) and dry dressing to right shin twice daily, hydrofera blue (dressing that kills bacteria and reduces bio-burden) ready with words facing out to the left upper arm wound , right buttocks, left axilla wound, left calf and left elbow to be changed every five days and as needed. Review of Resident #20's orders and treatment administration…

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 closed record review, review of email correspondence and interview the facility failed to ensure all requirements were met in issuing a discharge notice to Resident #51. This affected one resident (#51) of three residents reviewed for discharge. Findings include: Review of Resident #51's closed medical record revealed an admission date of 11/03/23 with diagnoses including morbid obesity, bipolar disorder, borderline personality disorder, muscle wasting and atrophy, and hypertension. Record review revealed on 04/17/24 the resident was transferred and admitted to an in-patient behavioral health unit for evaluation and treatment of suicidal ideations. Review of Resident #51's Minimum Data Set (MDS) 3.0 discharge assessment, dated 04/17/24, revealed the resident was cognitively intact. The MDS reflected the resident had an unplanned discharge to a short-term general hospital and no return was anticipated. On 05/13/24 an onsite investigation by the State agency revealed the facility was refusing to allow Resident #51 to return following her hospital course of treatment.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, policy review and interview the facility failed to ensure Resident #51 was permitted to return to the facility following a hospitalization. This affected one resident (#51) of three residents reviewed for hospitalization. The facility census was 50. Findings include: Review of Resident #51's closed medical record revealed an admission date of 11/03/23 with diagnoses including morbid obesity, bipolar disorder and borderline personality disorder. Review of Resident #51's care conference records revealed an admission/initial care conference was held on 11/16/23 with both Resident #51 and her grandmother attending and the resident was determined to be long term care placement at this time. On 03/12/24 a quarterly care conference was held with both Resident #51 and her grandmother attending. At this time, discharge planning had changed to discharging to the grandmother's home with the assistance of the Home Choice program (outside entity which assist residents in obtaining items in…

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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, interview, record review, facility investigation review and policy review the facility failed to ensure residents were free from staff physical abuse. This affected two residents (#38 and #56) of three residents reviewed for abuse. The facility census was 57. Finding include: 1. Review of the medical record for Resident #56 revealed an admission date of 01/30/24. Diagnoses included Asperger syndrome (a developmental disorder affecting ability to effectively socialize and communicate), bipolar disorder, anxiety disorder, and Wernicke's encephalopathy (an acute neurological condition characterized by a clinical triad of ophthalmoplegia, ataxia, and confusion). Review of Resident #56's admission Minimum Data Set (MDS) assessment, dated 01/31/24, revealed the resident had impaired cognition and a memory problem. The resident was dependent on staff for bed mobility and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, self- reported incident (SRI) review, interview, and policy review the facility failed to ensure a resident was free from verbal and physical abuse from a family member. This affected one resident (#22) of three residents reviewed. The facility census was 48. Findings included: Closed record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, type II diabetes mellitus, acute respiratory failure with hypoxia, dysphagia, gastrostomy status, hypertensive heart disease with heart failure, myocardial infarction, hyperlipidemia, hypertension, and hypothyroidism. Review of a SRI (reference number 239205) dated 09/15/23 revealed Resident #22 alleged her son hit her on top of the head during a visit at the facility. The category of the SRI was physical abuse and the alleged perpetrator was listed as family/visitor. The initial source of the allegation was listed as resident/victim. The brief description of the allegation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, self- reported incident (SRI) review, interview, and policy review revealed the facility failed to thoroughly investigate an allegation of resident abuse. This affected one resident (#22) of three residents reviewed. The facility census was 48. Findings included: Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, type II diabetes mellitus, acute respiratory failure with hypoxia, dysphagia, gastrostomy status, hypertensive heart disease with heart failure, myocardial infarction, hyperlipidemia, hypertension, and hypothyroidism. Review of a SRI (reference number 239205) dated 09/15/23 revealed Resident #22 alleged her son hit her on top of the head during a visit at the facility. Review of the SRI summary of the incident revealed Resident #22 and her son had raised voices which staff witnessed, and Resident #22 is hard of hearing and needs louder close tones to hear. The facility summary stated Resident #22's 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, observation, review of the guidance provided in the website for the National Library of Medicine, and interview, the facility failed to check a gastrostomy tube placement prior to administering a tube feed in order to prevent complications. This affected one resident (#62) of three residents reviewed for weight loss. The facility census was 48. Findings included: Record review revealed Resident #62 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia, muscle wasting and atrophy, epilepsy, spastic quadriplegic cerebral palsy, anemia, pneumonia, and gastrostomy status. Review of a Medication Administration Record (MAR) for January 2024 revealed Resident #62 had an order dated 01/15/24 for enteral tube feed five times a day, enteral feeding formula jevity 1.5 240 ml, bolus five times a day and flush 30 ml before and after tube feed, monitor every shift. Review of a care plan dated 11/15/23 revealed Resident #62 required tube feeding via PEG…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and review of facility policies, the facility did not prepare and serve food under sanitary conditions. This had the potential to affect all 45 Residents in the facility who received meals from the kitchen, as the facility identified no residents who did not receive meals from the kitchen. The facility census was 45. Findings included: 1. Observation on 11/14/22 at 8:10 A.M. of Dietary Aide (DA) #113 drying pans on a cart with a damp towel. DA #113 verified at the time she was not supposed to dry dishes or pans with a towel but was supposed to let the dishes and pans air dry before use. On 11/14/22 at 8:14 A.M. an interview with the Dietary Manger (DM) #111 verified the staff are not to dry items with towels due to cross contamination potential and DA #113 had been directed prior times to not dry pans and dishes with towels. Review of the facility policy titled, Sanitization, revised 12/28, revealed the food service area shall be maintained in a clean and sanitary manner. 2. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and facility policy review the facility failed to develop care plans for all Residents. This affected four Residents (#3, #4, #34, and #41) of 15 Residents reviewed for care plans. The facility census was 45. Findings included: 1. Review of Resident #3's medical record revealed she was admitted to the facility on [DATE] with the diagnoses of type two diabetes, with neuropathy, chronic obstructive pulmonary disease, essential hypertension, and bipolar disorder. Review of Resident #3's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was cognitively independent and her quarterly MDS dated [DATE] revealed she wore corrective lenses. Review of Resident #3's care plan revealed no care plan regarding vision concerns and the resident's need to use eye glasses. Observation and interview were conducted on 11/14/22 at 10:35 A.M. of Resident #3 who was speaking to the surveyor without wearing her eye glasses. Resident #3 revealed her glasses 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 interview, record review, and facility policy review the facility failed to ensure residents who were cognitively independent were included in care conferences. This affected one Resident (#6) of 15 residents reviewed for care planning. The facility census was 45. Findings included: Review of Resident #6's medical record revealed she was admitted to the facility on [DATE] with the diagnoses of unspecified fracture of the shaft of the right tibia, pain in the right thigh, essential hypertension, and muscle wasting and atrophy. Review of Resident #6's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was cognitively independent. Review of the facility's two forms titled, Care Conference Sign-in-Sheet for Resident #6 dated/timed 09/09/22 at 10:00 A.M. and 11/04/22 at 2:00 P.M. revealed no signature of Resident #6 to identify she was present at her care conferences. On 11/14/22 at 3:19 P.M. an interview with Resident #6 revealed she did not participate in her care planning. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and facility policy review the facility failed to ensure code status was consistent between the paper chart and electronic health record (EHR) for Resident #6. This affected one Resident (#6) of 16 Residents reviewed for advanced directive. The facility census was 45. Findings included: Review of Resident #6's medical record revealed she was admitted to the facility on [DATE] with the diagnoses of unspecified fracture of the shaft of the right tibia, pain in the right thigh, essential hypertension, and muscle wasting and atrophy. Review of Resident #6's admission minimum data set (MDS) 3.0 assessment dated [DATE] revealed she was cognitively independent. Review of the Resident #6's physician order dated 09/07/22 in the EHR revealed an order for do not resuscitate - comfort care (DNR-CC) which means staff do no life saving measures. Review of the do not resuscitate (DNR) order form of Resident #6 in her paper chart signed by the advanced level provider on 09/16/22 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 medical record review and staff interview, the facility failed to ensure preadmission screening for individuals with mental disorders were accurate. This affected three (Resident #3, Resident #41 and Resident #43) of four residents review for preadmission screening. The facility census was 45. Findings include: 1. Review of Resident #41's medical record revealed he was admitted to the facility on [DATE]. Admitting diagnoses included bipolar disorder and schizophrenia. Review of the quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed her cognition was intact, she required limited assistance of one staff member for transfers, bed mobility, and extensive assistance of one staff member for dressing, toilet use and personal hygiene. Review of the plan of care revealed she was admitted to the facility with a diagnosis of depression, and would maintain her baseline mood without decompensation. Interventions included medications as ordered, involve in making her own decisions, offer choices…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and policy review the facility failed to ensure care plans were revised after new fall interventions were implemented and when psychotropic medications were discontinued. This affected two (Residents #3 and #26) of 15 residents reviewed for care plans. The facility census was 45. Findings include: 1. Review of Resident #26's medical record revealed an admission date of 02/07/19 with diagnoses that included diabetes mellitus, lupus and hypertension. Further review of Resident #26's medical record revealed on 07/13/22 the resident sustained a fall in his bathroom during independent ambulation and transfer. Review of the fall investigation revealed a new intervention of non-skid strips to the bathroom floor in front of the toilet. Review of the fall care plan found no evidence of the new intervention of non-skid strips added to the fall care plan. Interview with Registered Nurse (RN) #154 on 11/16/22 at 9:55 A.M. verified Resident #26's fall care plan was not revised…

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 ensure a resident with loose stools was assessed and care provided. This affected one Resident (#36) of one Resident reviewed for general concerns. The facility census was 45. Findings included: Review of Resident #36's medical record revealed an admission date of 01/31/22 with diagnoses of chronic obstructive pulmonary disease with acute exacerbation, type two diabetes mellitus without complications, essential hypertension, and hyperlipidemia. Review of Resident #36's quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed she was cognitively impaired and always incontinent of stool. Review of Resident #36's admission assessment dated [DATE] revealed she had normal formed stool, and rarely/never depended on laxatives. Review of Resident #6's stool consistency dated 10/18/22 to 11/16/22 revealed twelve formed stools, twenty-one loose stools, and nineteen putty like stools. Review of physician orders revealed Resident #36 was not receiving…

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

Based on medical record review, observation and staff interview the facility failed to follow physician's orders for tube feeding infusing times and solution type. This affected one (Resident #25) of one residents reviewed for tube feeding. The facility identified one resident utilizing tube feedings. Findings include: Review of Resident #25's medical record revealed an admission date of 01/18/19 with diagnoses that included cerebrovascular accident, dysphagia and PEG tube (Percutaneuos Endoscopic Gastrostomy). Further review of the medical record revealed physician's orders dated 11/15/22 for tube feeding orders (tube placed through the abdominal wall into the stomach to provide liquid nutritional solution) which indicated Resident #25 was to receive Glucerna 1.5 (liquid nutritional solution) at a rate of 75 milliliters per hour (ml/hr) for 12 hours from 6:00 P.M. to 6:00 A.M. every day. Observation of Resident #25 on 11/16/22 at 7:38 A.M. revealed the resident connected to tube feeding and infusing at 75 ml/hr. The tube feeding solution in place was Glucerna 1.2. Interview with…

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

Based on medical record review, observation and staff interview, the facility failed to maintain a medication error rate of less than five percent. Three errors occurred within 25 opportunities for error resulting in a medication error rate of 12%. This affected one Resident (#33) out of six residents observed for medication administration. The facility census was 45. Findings include: Observation of the medication administration on 11/16/22 from 8:06 A.M. to 9:13 A.M. with Registered Nurse (RN) #130 and on 11/17/22 at 7:46 A.M. with Licensed Practical Nurse (LPN) #101 revealed 25 opportunities for medication error across six residents (#6, #20, #32, #33, #41 and #43). During the observation on 11/16/22 at 8:06 A.M. of medication administration to Resident #33 by Registered Nurse (RN) #130 revealed she administered Probiotic 250 mg (milligrams) to Resident #33. Resident #33 requested a Zofran for nausea and RN #130 replied to Resident #33 the Zofran was not available and she would have to order it. RN #130 revealed to the surveyor Resident #33 was ordered Lactulose (laxative) 30 ml…

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

Based on observation, staff interview, and review of the facility policy and procedure, the facility failed to ensure the medication cart was kept locked against unauthorized access. This had the potential to affect one Resident (Resident #41) identified by the facility as cognitively impaired and independently mobile out of 20 residents residing on the 300 and 400 unit hall way where the unlocked medication cart was kept. The facility census was 45. Findings include: On 11/14/22 at 9:24 A.M. the medication cart was observed in the hallway on the 400 unit unlocked, out of site of the nurse and accessable to Resident #41 directly outside of his room. This was verified with Registered Nurse (RN) #106 at 9:26 A.M. during the observation when she revealed the lock was broke, she could not lock the cart and would need to let the maintenance staff know it needed to be fixed. Additional observations on 11/16/22 from 8:06 A.M. to 8:43 A.M. revealed RN #124 was passing medications to three residents during this time frame and each time left the medication cart unlocked in the hallway and out…

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

Based on observation, interview and facility policy review the facility failed to ensure food did not lose nutritional value during the puree process. This had the potential to affect one Resident (#25) who was the only resident ordered a pureed diet. The facility census was 45. Findings included: Review of the facility's list of resident diets, printed 11/14/22, revealed Resident #25 was the only Resident in the facility who received a pureed diet. Observation on 11/15/22 at 10:15 A.M. of Dietary [NAME] (DC) #127 preparing puree. DC #127 put one serving of ham in the puree processor, turned it on, and then added water through the top of the processor. After completion of the ham puree, DC #127 then pureed one serving of carrots using a handheld puree processor. DC #127 added water to the carrots to obtain the consistency she wanted of the carrot puree. On 11/15/22 at 10:20 A.M. an interview with DC #127 verified she used water for pureeing both the ham and the carrots. This surveyor asked DC #127 if she ever used liquid from the protein and vegetables instead of water and DC #127…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and staff interview, the facility failed to ensure assistive devices were provided during meals. This affected one Resident (#13) of one Resident reviewed for nutrition. The census was 45. Findings include: Review of Resident #13's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included protein calorie malnutrition and hemiplegia. Review of the quarterly Minimum Data (MDS) 3.0 assessment dated [DATE] revealed his cognition was intact. He required extensive assistance of two or more staff members for bed mobility, transfers, and toilet use. He required extensive assistance of one staff member for dressing and personal hygiene. Functional limitation of range of motion upper and lower extremities (right side). Review of the plan of care dated 05/13/22 revealed the resident had potential nutritional problems related to subdural hemorrhage, gastrostomy, chronic obstructive pulmonary disease, COVID, constipation, vitamin deficiency, depression,…

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 follow antibiotic stewardship guidelines. This affected one Resident (#34) of five Residents reviewed for unnecessary medications. The facility census was 45. Findings include: Review of Resident #34's medical record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of muscle wasting and atrophy, not elsewhere classified, repeated falls, syncope and collapse, anxiety disorder, and major depressive disorder. Review of Resident #34's quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed she was cognitively independent. Review of Resident #34's physicians orders revealed an order dated 01/06/22 for Keflex (an antibiotic) 500 milligrams (mg), one capsule by mouth two times a day for a urinary tract infection for seven days. Review of Resident #34's 01/22 medication administration record (MAR) revealed Resident #34 received the Keflex 500 mg by mouth twice a day for seven…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure palatability of the orange juice. This affected one resident (#16) and had the potential to affect all 62 of 62 residents who received food/fluids from the kitchen with the exception of Resident #11 who received nothing by mouth. The facility census was 63. Findings include: Review of Resident #16's medical record revealed diagnoses including type 2 diabetes mellitus and vitamin deficiency. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #16 was able to be understood and was able to understand others. The MDS indicated Resident #16 was cognitively intact. On 03/10/20 at 2:09 P.M. during an interview with Resident #16 the resident voiced concerns about the facility orange juice. The resident stated when staff provided orange juice from the juice machine it was horrid tasting and separated. Resident #16 stated he had staff buy him good orange juice at a local grocery store and had two staff members taste…

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, policy review and interview the facility failed to ensure food and drinks stored in nourishment refrigerators and personal refrigerators were stored under sanitary conditions. This had the potential to affect all 62 or 62 residents who received food/fluids from the kitchen with the exception of Resident #11 who received nothing by mouth. The facility census was 63. Findings include: 1. On 03/10/20 at 10:00 A.M., observations of the 300/400 hall snack/nourishment refrigerator located in the 300/400 hall medication room with Registered Nurse (RN) #8 revealed a bag with a container on top of it. The container was labeled room [ROOM NUMBER] and was dated 01/13/20 and contained a potato. Inside the bag were two containers with neither container labeled with a name or date. One of the containers had what appeared to be a wilted salad. RN #8 agreed the food in the container appeared to be a wilted salad and disposed of it. The other container had pasta with sauce. RN #8 stated she assumed those…

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 5. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of depression and dementia. Review of the physician's orders dated 01/03/20 revealed an order for Zoloft, an antidepressant 50 milligrams (mg) daily. Review of the quarterly MDS assessment dated [DATE] revealed the facility failed to code the antidepressant on the MDS. This was verified during interview with the Director of Nursing on 03/12/20 at 10:30 A.M. 6. Review of Resident #51's medical record revealed diagnoses including cerebral infarction, spastic hemiplegia (paralysis of one side of the body) affecting the right dominant side, generalized muscle weakness and dementia. A nursing note dated 08/14/19 at 11:53 P.M. indicated Resident #51 rolled out of bed with no injury noted. Review of an annual MDS assessment dated [DATE] indicated Resident #51 did not have any falls since re-entry or the prior assessment. On 03/12/20 at 1:10 P.M., RN #12 verified Resident #51's annual MDS dated [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and interview the facility failed to promote Resident #1's dignity during meals and Resident #51's dignity related to urinary catheter use. This affected one resident (#51) of two residents reviewed for urinary catheters and one resident (#1) observed during meals. The census was 63. Findings include: 1. Medical record review revealed Resident #1 was admitted on [DATE] with diagnoses including bladder and prostate cancer. On 03/11/20 at 12:50 P.M., observation revealed Assistant Director of Nursing (ADON) #32 was observed standing next to Resident #1 in the main dining room. ADON #32 was observed standing while feeding the resident his lunch meal. Human Resources #64 and Administrator in Training #80 were observed in the dining room talking with ADON #32 and did not intervene. At the time of the above observation, the Director of Nursing verified the observation and stated staff should be sitting next to the resident when assisting them with meals. 2. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview the facility failed to complete required screenings and assessments as required. This affected one resident (#41) of one resident reviewed for Preadmission Screening and Record Review (PASARR). Findings include: Medical record review revealed Resident #41 was admitted on [DATE] with diagnoses including schizoaffective disorder, unspecified mood affective disorder and major depressive disorder. Review of the care plan titled At Risk for Behavior Problems related to Schizoaffective disorder revised 02/25/18 revealed to monitor for behaviors. Review of the annual Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #41 was not considered by the State to have a serious mental illness and the resident had active diagnoses included schizophrenia and depression. On 03/10/20 at 11:32 A.M. interview with Social Service Director #22 verified a PASARR should have been completed for Resident #41 and as of 03/10/20 there was no evidence this was completed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to ensure comprehensive care plans were developed for all residents. This affected three residents (#1, #31, and #57) of 25 residents reviewed for care plans. Findings include: 1. Review of the hospice Patient/Family Informed Consent dated 10/28/19 revealed Resident #1 had chosen to receive Hospice services. Medical record review revealed Resident #1 was admitted on [DATE] with diagnoses including carcinoma of the prostate and diabetes mellitus. The resident was ordered to continue receiving hospice services. Review of the admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #1 had been receiving hospice services prior to and since being admitted to the facility. Review of the Hospice Recertification dated 10/28/19 to 01/23/20 revealed Resident #1 continued to receive hospice services while a resident at the facility. On 03/11/20 at 11:49 A.M., interview with Registered Nurse (RN) #12 verified there was no comprehensive…

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 #17's care plan was revised. This affected one resident (#17) of five residents reviewed for activities of daily living. Findings include: Review of Resident #17's medical record revealed an admission date of 05/31/19 with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, chronic kidney disease and diabetes. Review of the maintenance program related to therapy plan of care initiated 08/09/19 revealed to walk the resident from the bed to the bathroom with one person physical assist, hemi-walker and gait belt twice a day initiated 10/15/19. Review of the physician orders revealed physical therapy to treat five times per week for therapeutic exercise and activities, neuromuscular re-education, gait training, group therapy and electrical stimulation from 01/02/20 to 02/20/20. Review of the quarterly MDS dated [DATE] revealed the resident was cognitively intact and required extensive assistance of one staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview the facility failed to complete a discharge recapitulation and summary as required. This affected one resident (#63) of one resident reviewed for discharge. Findings include: Medical record review revealed Resident #63 was admitted on [DATE] and was discharged to home on [DATE]. Review of the assessment: Discharge Instruction Form dated 01/21/20 revealed the assessment was not comprehensive. There was no evidence the following areas were completed on the assessment: Medicare information, pharmacy, home care, home services, medication education, prevention and disease management education, emergency information, brief medical history, current treatments, scheduled appointments and tests, medication list including name, action, dose, how to take, when to take it or notes were documented. Review of the nursing note dated 01/21/20 revealed resident to discharge at this time, reviewed all instructions with the resident and daughter. They had no questions or concerns and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and interview the facility failed to ensure non-pressure skin impairment was assessed and treated for Resident #8. This affected one resident (#8) of three residents reviewed for non-pressure related skin conditions. Findings include: Review of Resident #8's medical record revealed an admission date of 05/03/19. Diagnoses included congestive heart failure, depression, type 2 diabetes mellitus, hypertension and gout. A plan of care initiated 05/03/19 indicated Resident #8 was at risk for skin breakdown related to general weakness. An intervention dated 05/16/19 indicated nurses were to be notified of any redness. On 03/09/20 at 2:21 P.M. interview with Resident #8 revealed he had a rash on his legs which scaled and caused itching. Resident #8 stated staff had tried applying lotion without relief. Resident #8 stated staff had mentioned possibly providing medication for itching but he had not heard anything else about it. A weekly skin assessment dated [DATE] revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of the facility fall investigations and interview the facility failed to ensure fall interventions were implemented, failed to ensure staff were knowledgeable regarding a resident's needs and proper use of equipment, and failed to conduct timely thorough investigations into falls. This affected three residents (#8, #14, and #51) of four residents reviewed for accidents. Findings include: 1. Review of Resident #8's medical record revealed an admission date of 05/03/19. Diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) following a non-traumatic intracranial hemorrhage affecting the left non-dominant side, congestive heart failure, type 2 diabetes mellitus, and stroke. A care plan initiated 05/03/19 indicated Resident #8 had a self care deficit related to right sided weakness. A care plan initiated 05/03/19 indicated Resident #8 was at risk for falls related to right sided weakness and general weakness. 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 medical record review, policy review and interview the facility failed to implement interventions to restore and/or maintain bowel and bladder continence. This affected one resident (#31) of two residents reviewed for bladder and bowel incontinence. The facility identified no current residents on a bowel and/or urinary toileting program. Findings include: Medical record review revealed Resident #31 was admitted on [DATE] with diagnoses including chronic constipation and depression. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #31 was always continent of bowel and bladder with no toileting program. Review of the quarterly MDS assessment dated [DATE] revealed Resident #31 was occasionally incontinent of bladder and frequently incontinent of bowel with no toileting program. Review of the medical record revealed no evidence of a urinary or bowel incontinence assessment or care plan. Review of the Task: Urinary Continence dated 02/12/20 to 03/12/20 revealed…

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

Based on observation, medical record review and interview the facility failed to ensure residents were assessed for risk of entrapment from bed rails prior to installation and failed to document a review of the risk verses benefits of bed rails with residents or resident representatives. This affected two residents (#8 and #51) of four residents reviewed for accidents. Findings include: 1. Review of Resident #8's medical record revealed an admission date of 05/03/19. Diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) following a non-traumatic intracranial hemorrhage affecting the left non-dominant side and cerebral infarction. On 08/05/19 an order was written for an enabler bar to the left side of the bed for turning and repositioning. The enabler bar was to be checked daily. There was no evidence the risks and benefits were explained in order to obtain an informed consent for the bed rail use. There was no evidence of a risk for entrapment being performed prior to the bed rail installation. On 03/10/20 at 11:10 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.

Based on record review, medication reference review and interview the facility failed to ensure Resident #17 was monitored prior to medication administration known to affect resident heart rate to ensure the medication was justified and necessary. This affected one resident (#17) of six residents reviewed for unnecessary medication use. Findings include: Review of Resident #17's medical record revealed an admission date of 05/31/19 with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, chronic kidney disease and diabetes. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/08/20 revealed the resident was cognitively intact and required extensive assistance of one staff member with bed mobility, transfers, walk in room, walk in corridor, dressing, toilet use and personal hygiene. Review of the physician's orders revealed an order for Metoprolol 50 milligrams (mg) daily in the morning dated 01/15/20. Prior to the ordered dose, the resident received Metoprolol 25 mg three times a day. Due to a low heart rate and complaints of dizziness,…

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, medical record review and interview the facility failed to ensure bed rails were appropriate for use with air mattresses prior to installation. This affected two residents (#8 and #51) of four residents reviewed for accidents. Findings include: 1. Review of Resident #8's medical record revealed an admission date of 05/03/19. Diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) following a non-traumatic intracranial hemorrhage affecting the left non-dominant side and cerebral infarction. On 08/05/19, an order was written for an enabler bar to the left side of the bed for turning and repositioning. The enabler bar was to be checked daily. On 08/08/19, an order was written for an alternating pressure mattress. On 03/10/20 at 11:10 A.M., Resident #8 was observed lying in bed with a bed rail on the left side of the bed. Registered Nurse (RN) #8 confirmed Resident #8 had a bed rail on the left side of the bed with the width between the inner bars of the bed rail measuring 17 and 3/4 inches. Resident #8'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.