East Park Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of the record for Resident #19 revealed an admission date of 09/09/24 with diagnoses including recurrent E. Coli, striatonigral degeneration, obstructive and reflux uropathy, type two diabetes, chronic obstructive pulmonary disease, hypothyroidism, atherosclerotic heart disease, occlusion and stenosis of carotid artery, aortic ectasia, generalized anxiety disorder, major depressive disorder, and panic disorder. Upon admission, Resident #19 presented with an indwelling urinary catheter related to the diagnoses of obstructive and reflux uropathy, a wound to her right lower extremity, and blanching in the perineal area. Review of the physician's order dated 09/10/24 indicated once daily wound care instructions for the right lower extremity wound and the open area at the intergluteal cleft. Review of the physician's orders dated 09/16/24 indicated Foley (indwelling urinary catheter) to continuous drainage for urinary retention along with orders for Foley care. Review of the comprehensive care plan for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure resident funds were conveyed timely upon a discharge or death. This affected one resident (#102) of one resident reviewed for personal funds conveyance upon death or discharge. The facility census was 50. Findings include: Resident #102 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, heart failure, and anxiety disorder. Review of census records revealed Resident #102 expired at the facility on [DATE]. Review of the account records revealed Resident #102's account was closed on [DATE], and $160.21 was disbursed to Resident #102's estate. Interview with Business Manager (BM) #301 on [DATE] at 4:30 P.M. revealed Resident #102's personal funds were not dispersed with in required time frames (30 days upon on a resident's death or discharge).

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of the medical record for Resident #20 revealed an admission date of 02/27/21 with diagnoses including cerebral infraction, a stroke affecting the right dominant side, dementia, aphasia, contracture of the right hand, atrial fibrillation, and legionnaires disease. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 had impaired cognition and required substantial to maximum assistance with showers and dressing. Review of the plan of care dated 09/24/24 revealed Resident #20 was recovering from legionnaires disease. Interventions included notifying the guardian and physician. In addition to assessing the resident's respiratory status. Review of the progress note dated 08/23/24 at 4:15 P.M. revealed Resident #20 was sent out to the hospital by emergency medical services (911) per physician order. Note dated 08/31/24 at 6:30 P.M. stated Resident #20 arrived by stretcher to the facility. The resident was alert and oriented and on two liters of oxygen. 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 facility policy review the facility failed to ensure comprehensive assessments were implemented and completed for Residents #7 and #204. This affected two residents (#7 and #204) of 17 sample residents reviewed for assessments. The facility census was 50. Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 09/01/20 with diagnoses including psychotic disorder, delusions, insomnia, and seizures. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had intact cognition and required partial to moderate assistance with rolling left and right. Review of the plan of care dated 09/24/24 revealed Resident #7 had a mobility deficit related to seizures, chronic obstructive pulmonary disease (COPD), asthma, and spinal stenosis. Interventions for bed mobility included supervision from one staff to turn and reposition in bed and bilateral grab bars to each side of the bed to assist with turning 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, staff interview, and facility policy review, the facility failed to complete a required Minimum Data Set (MDS) 3.0 assessment upon Resident #30's discharge from the facility. This affected one resident (#30) of two residents reviewed for discharge. The facility census was 50. Findings include: Resident #102 was admitted to the facility on [DATE] with diagnoses including Hepatitis C, cocaine abuse, chest pain, and kidney failure. Review of the census records and nursing progress notes, Resident #102 was discharged from the facility on 07/03/24. Review of the MDS records for Resident #102 revealed an initial MDS assessment was completed on 05/29/24. No other MDS assessments were completed for Resident #102 during his stay at the facility, including a required discharge assessment upon Resident #102 returning home from the facility. MDS Nurse #336 verified Resident #102's required discharge MDS assessment was not completed as required during an interview on 10/23/24 at 8:00 A.M. Review of…

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

Based on observation, resident interview, medical record review, staff interview and review of facility policy, the facility failed to ensure residents who required staff assistance with baths/showers received needed care. This affected two (#22 and #51) of five residents reviewed for activities of daily living (ADLs). The facility census was 50. Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 04/23/24. Diagnoses included left femur fracture, difficulty in walking, repeated falls, congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/11/24, revealed Resident #22 had impaired cognition, had no behaviors and required partial/moderate assistance from staff for showers and bathing. Interview on 10/21/24 at 3:47 P.M. with Resident #22 revealed he has not had a shower or bath in the last two weeks and the water in the bathroom was cold. Concurrent observation revealed a strong odor in the resident's room. Observation on 10/22/24 at 3:44 P.M. 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 medical record review, review of hospital documents, staff documents and review of facility policy, the facility failed to ensure an accurate weight was obtained to monitor nutritional status for a resident at risk for significant weight loss. This affected one (#201) of two residents reviewed for nutrition. The facility census was 50. Findings include: Review of the medical record for Resident #201 revealed an admission date of 10/08/24 with diagnoses including dementia with behavioral disturbance, Meniere's disease, hypertension, osteoarthritis, anemia, rheumatoid arthritis and major depressive disorder, severe, with psychotic features. Review of the care plan dated 10/15/24 revealed Resident #201 had a nutritional problem related to diagnoses, psychotropic medications, weight loss, underweight related to body mass index (BMI) and mechanically altered diet. Interventions included the following: weight per facility protocol; monitor, record and report to the physician signs/symptoms of malnutrition; and monitor, document and report to the physician signs/symptoms 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 resident and staff interview, medical record review and review of facility policy, the facility failed to accurately document and effectively manage resident's pain. This affected one (#204) of two residents reviewed for pain management. The facility census was 50. Findings include: Review of the record for Resident #204 revealed an admission date of 09/30/24 with diagnoses including polyneuropathy, subluxation of C3/C4 cervical vertebrae, mid-cervical region cervical disc disorder with myelopathy, cervical spine fusion, adult failure to thrive, bradycardia, generalized anxiety, history of alcohol abuse and chronic post-traumatic stress disorder. Review of the Minimum Data Set (MDS) assessment, dated 10/07/24, revealed Resident #204 was cognitively intact, used a wheelchair for mobility and required minimal staff assistance for all activities of daily living (ADLs.) Review of the comprehensive care plan initiated, 10/01/24, revealed no care plan was initiated for Resident #204's risk for pain due to his diagnosis of polyneuropathy and spinal issues. Review of 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, review of pharmacy recommendations, staff interview and review of facility policy, the facility failed to ensure pharmacy recommendations were addressed in a timely manner. This affected one (#14) of five residents reviewed for unnecessary medications. The facility census was 50. Findings include: Review of the medical record for Resident #14 revealed an admission date of 01/03/24. Diagnoses included dementia, schizoaffective disorder, suicidal ideation and major depressive disorder. Review of the October 2024 physician orders revealed active orders for: • Breo Ellipta Inhalation Aerosol Powder Breath Activated 100-25 microgram/actuation (mcg/act) one inhalation, inhale orally one time a day related to chronic obstructive pulmonary disease with a start date of 01/27/24. • Tiotropium Bromide Monohydrate Inhalation Aerosol Solution 2.5 mcg/act, two puff inhale orally one time a day related to chronic obstructive pulmonary disease with a start date of 01/27/24. • Seroquel oral tablet 50 milligrams (mg), give one tablet by mouth every eight hours as…

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

Based on medical record review, staff interview and review of the facility policy, the facility failed to ensure as needed (PRN) psychotropic medication orders had an end date. This affected one (#14) of five residents reviewed for unnecessary medications. The facility census was 50. Findings include: Review of the medical record for Resident #14 revealed an admission date of 01/03/24. Diagnoses included dementia, schizoaffective disorder, suicidal ideation and major depressive disorder. Review of the October 2024 physician orders revealed active orders for: Seroquel oral tablet 50 milligrams (mg), give one tablet by mouth every eight hours PRN for Schizophrenia with a start date of 08/20/24. The order had no end date. Ativan oral tablet one mg, give one tablet by mouth every six hours PRN for anxiety with a start date of 03/18/24. The order had no end date. Review of the Medication Administration Record (MAR) from April 2024 through October 2024 revealed Resident #14 received the PRN Ativan 27 times in April, six times in May, four times in June and no administration of the…

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

Based on observation, medical record review, staff interview, review of manufacturer's instructions and review of facility policy, the facility failed to ensure residents were free from significant medication errors during insulin administration. This affected one (#2) of five residents reviewed for medication administration. The facility census was 50. Findings include: Review of the medical record for Resident #2 revealed an admission date of 03/31/23 with diagnoses including aphasia, type II diabetes, traumatic brain injury, cerebral infraction (stroke) and anxiety. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 08/06/24, revealed the resident had impaired cognition and received insulin by injection. Review of the plan of care dated 10/04/24 revealed Resident #2 had diabetes mellitus. Intervention included to administer medication as ordered by the physician. Review of the physician's orders dated October 2024 revealed the resident had an order for Lispro (fast acting insulin) to be injected subcutaneous (into layer of skin) by pen prior to meals and before…

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, interviews, record review and review of the facility policy, the facility failed to ensure Resident #30 received timely and adequate dental services. This affected one resident (Resident #30) out of three residents reviewed for dental services. The facility census was 51. Findings include: Review of Resident #30's medical record revealed an admission date of 01/19/23 and diagnoses included syncope and collapse, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, heart failure, and hemiplegia (paralysis) affecting the left nondominant side. Review of Resident #30's care plan revised 04/22/24 included Resident #30 received hospice care from a local hospice agency. Diagnosis of dementia with prognosis of less than six months. Resident #30 would receive integrated care from the facility and hospice agency that would meet her physical, social, intellectual, emotional and spiritual needs. Interventions included hospice agency and facility staff to maintain open lines of communication to…

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

Based on medical record review, review of the hospital discharge documents and staff interview, the facility failed to ensure effective communication between attending physicians and administration to ensure adequate and appropriate resident care. This affected one (#20) of one resident reviewed for coordination of care. The facility census was 50. Findings include: Review of the medical record for Resident #20 revealed an admission date of 02/27/21 with diagnoses including cerebral infraction (stroke) affecting the right dominant side, dementia, aphasia, contracture of the right hand, atrial fibrillation and Legionnaires disease. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 09/13/24, revealed the resident had impaired cognition and needed substantial to maximum assistance with showers and dressing. Review of the plan of care dated 09/24/24 revealed Resident #20 was recovering from Legionnaires disease. Interventions included to notify the guardian and physician and to assess respiratory status. Review of the progress note dated 08/23/24 revealed Resident #20…

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 review of the facility Appointment and Transportation Form the facility failed to ensure Resident #53's frequent urinary tract infections were comprehensively assessed, care planned, and treated timely to assist in preventing re-occurring infection. This affected one resident (Resident #53) out of three residents reviewed for urinary tract infections. The facility census was 52. Findings include: Review of Resident #53's medical record revealed an admission date of 06/30/23 and diagnoses included displaced fracture of lateral end of right clavicle, subsequent encounter for fracture with routine healing, adjustment disorder with depressed mood, and paroxysmal atrial fibrillation. Review of Resident #53's care plan dated 08/07/23 included Resident #53 had mixed bladder incontinence related to impaired mobility. Resident #53 would remain free from skin breakdown due to incontience and brief use through the review date. Interventions included to encourage fluids during the day…

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, review of the Self-Reported Incident (SRI) log, personnel record review, court docket review, facility policy review, and interview, the facility failed to implement their abuse policy and procedure regarding reference checks. This had the potential to affect all residents who resided in the facility. The census was 55. Findings include: Review of the personnel record for State Tested Nurse Aide (STNA) #2 revealed a hire date of 09/27/22. Review of the Application for Employment dated 09/26/21 revealed STNA #2 answered no to the question of have you ever plead guilty to or been convicted of a crime other than a driving-related misdemeanor? There were two Verification of Employment forms referencing STNA #2's current and past skilled nursing facility (SNF) employers. The two Verification of Employment forms were incomplete and there was no evidence the forms were sent to the two employers to answer. Review of the State Nurse Aide Registry license verification form revealed STNA #2 was not eligible to work and was not in good standing due to committing abuse,…

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, closed medical record review, review of pest control invoices and interview, the facility failed to treat Resident #56 and Resident #57's power wheelchairs with respect. This affected two ( #56 and #57) of three residents reviewed for personal property. The census was 55. Findings include: Review of the closed medical record for former Resident #56 revealed an admission date of 01/31/23, discharge date of 12/12/23 with diagnoses of hemiplegia and hemiparesis, muscle weakness, cognitive communication deficit, reduced mobility, and homelessness. Review of the hospital social work assessment and discharge plan dated 01/25/23 revealed Resident #56 and Resident #56's son (Resident #57) were evicted that morning. Resident #56's case manager was told to present to the emergency department to help with placement. When Resident #56 and son arrived, they were found to have bed bugs and cockroaches. They were both decontaminated. Resident #56 had applied to multiple apartments since getting 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 closed medical record review, policy review and interview, the facility failed to provide an orderly discharge for former Resident #56. This affected one (Resident #56) of three former residents reviewed for discharging against medical advice (AMA). The census was 55. Finding include: Review of the closed medical record for former Resident #56 revealed an admission date of 01/31/23, discharge date of 12/12/23 with diagnoses of hemiplegia and hemiparesis, muscle weakness, cognitive communication deficit, reduced mobility, and homelessness. Review of the hospital social work assessment and discharge plan dated 01/25/23 revealed Resident #56 and Resident #56's son (Resident #57) were evicted that morning. Resident #56's case manager was told to present to the emergency department to help with placement. Resident #56 had applied to multiple apartments since getting the eviction notice and was on multiple wait lists and unable to stay with friends or family as there were not any in the community. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, infection control log review and interview, the facility to timely obtain lab services for Resident #43. This affected one (Resident #43) of three residents reviewed for infections. The census was 55. Findings include: Review of the medical record for Resident #43 revealed an admission date of 01/30/24 with diagnoses of parkinsonism, history of falling, rhabdomyolysis, metabolic encephalopathy and Clostridium difficile (C.diff) diarrhea. Review of the health status note dated 01/30/24 timed 5:45 P.M. revealed Resident #43 arrived via cot with admission diagnosis of C-difficile (a bacteria that causes diarrhea and colitis). Review of the health status note dated 01/30/24 timed 8:02 P.M. revealed contact precautions in effect for C.diff. Review of the Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] revealed Resident #43 was cognitively intact, needed partial/moderate assistance with toileting and was always incontinent of bowel. Review of the health status…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed medical record review, Centers for Disease Control (CDC) website review, pest control invoices review, policy review and interview, the facility failed to eradicate bed bugs in a resident room prior to Resident #60 being admitted to the room. This affected one (Resident #60) of eight residents reviewed for bed bugs. The census was 55. Findings include: Review of the closed medical record for Resident #62 revealed an admission date 01/04/24, discharge date to home of 02/04/24 with diagnoses of fracture of left femur, respiratory syncytial virus pneumonia, alcohol dependence and chronic embolism and thrombosis deep veins of left lower extremity. Resident #62 resided in private room [ROOM NUMBER] during his entire stay. Review of the closed medical record for Resident #60 revealed an admission date of 02/06/24, discharge date to home of 02/21/24 with diagnoses of cerebral infarction, aphasia, and hemiplegia and hemiparesis affecting left dominant side. Review of the Minimum Data Set (MDS) 3.0…

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

Based on observation and staff interview, the facility failed to ensure opened food products were dated and labeled. This had the potential to affect 43 of 45 residents receiving food from the kitchen. The facility identified Residents #21 and #30 as not receiving food by mouth. Findings include: A tour of the kitchen was completed on 05/02/22 at 8:30 A.M. through 9:00 A.M. with Dietary Manager (DM) #518. Observation of the food stored in the three door freezer in the room off the dry storage room on 05/02/22 at 8:40 A.M. revealed the following which were confirmed by DM #518: Open and undated bags of frozen hash browns, stuffed cabbage rolls, cookies, chicken tenders and fish. Observation of the two door freezer outside the dry storage room on 05/02/22 at 8:45 A.M. revealed the following which were confirmed by DM #518: An open bag of frozen spinach, not dated. Observation of the dry storage room on 05/02/22 at 8:50 A.M. revealed the following which were confirmed by DM #518: An open bag of spoons which should have been sealed per DM #518 and three open, undated bags of dry cereal.…

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 resident fund accounts and spend down letters and interview the facility failed to notify Residents #2, #33 and #41, who received Medicaid benefits, when the amount in the account reached $200.00 less than the Supplemental Security Income (SSI) limit of $2,000.00. This affected three of four residents reviewed for management of personal funds accounts. The facility census was 45. Findings include: Review of resident accounts revealed the facility managed personal accounts for Residents #2, #33 and #41, and all three received Medicaid benefits. Review of spend down letters dated 10/28/21 for Residents #2, #33 and #41 revealed they were notified their accounts were close to the $2,000.00 Medicaid eligibility limit and each residents' account exceeded the SSI limit at that time. Resident #2's letter indicated she had $3,210.27, Resident #33's letter indicated she had $3,521.15 and Resident #41's letter indicated he had #9,375.51 in their respective accounts. Their letters indicated if their assets reached or exceeded the $2,000.00 limit they would lose their Medicaid…

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 #23, Resident #29 and Resident #41 were comprehensively assessed and care plans were developed regarding health conditions, psychotropic medication use and activities of daily living. This affected three (Residents #23, #29 and #41) of 19 residents whose care plans were reviewed. The facility census was 44. Findings include: 1. Review of the medical record for Resident #23 revealed an admission date of 03/03/22 with diagnoses including anemia, non-Hodgkin lymphoma hypertension, arthritis and corneal transplant. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating Resident #23 was cognitively intact. She required extensive assistance in the areas of turning and repositioning in bed, moving between surfaces such as from a bed to a chair, dressing, and toilet use and was totally dependent on staff to move about her room and throughout the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure timely incontinence care for residents. This affected two (Residents #30 and #11) of three residents observed for incontinence care. The facility census was 45. Findings include: 1. Review of Resident #30's medical record revealed an admission date of 08/18/21 with diagnoses that included incontinence and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition, required extensive assistance with bed mobility, transfers, dressing and personal hygiene, and total dependence with toileting. She was incontinent of bowel and bladder. Review of the care plan dated 12/15/21 revealed self care deficits related to decreased mobility and weakness and interventions included provide a sponge bath when a full bath or shower cannot be tolerated. Resident #30 required assistance of one staff member and additional assistance as needed for increased weakness or fatigue. 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.

Based on observation and interview the facility failed to ensure medications were properly stored and discarded when expired. This had the potential to affect all 45 residents currently residing in the facility. Findings include: Observation on 05/02/22 at 10:37 A.M. with Licensed Practical Nurse (LPN) #502 revealed the medication cart contained a bottle of Geri-Tussin (liquid cough syrup) that had expired on 11/2021. Interview with LPN #502 at the time of the observation revealed she had not checked expiration dates prior to beginning medication administration. LPN #502 verified the Geri-Tussin should have been discarded as indicated by the expiration date. Observation on 05/02/22 at 11:06 A.M. with LPN #510 revealed various unidentifiable loose pills in different compartments of the medication cart, a bottle of Geri-Tussin with an expiration date of 11/2021, and a bottle of Docusate (liquid stool softener) with an expiration date of 04/2022. Interview with LPN #510 at the time of the observation revealed she had not checked expiration dates prior to beginning medication…

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

Based on observation, interview, facility policy review, review of the Centers for Disease Control (CDC) Considerations for Preventing Spread of COVID-19, and review of the CDC COVID Tracker website the facility failed to maintain proper infection control procedures to prevent the potential spread of infection including proper COVID screening, use of Personal Protective Equipment (PPE) and hand hygiene practices. This had the potential to affect all 45 residents currently residing in the facility. Findings include: 1. Observation on 05/02/22 at 7:35 A.M. revealed the front reception area did not have have a COVID screening questionnaire, thermometer for obtaining temperatures, or a sign in log. Interview with Licensed Practical Nurse (LPN) #504 revealed nothing was required prior to entry. A second interview with LPN #504 at 7:55 A.M. revealed a COVID questionnaire should be completed prior to entry into the facility. Observation revealed LPN #504 had a questionnaire that consisted of international travel, exposure, symptoms, cough or shortness of breath within the last 14 days and…

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

Based on observation, record review and interview the facility failed to ensure only pasteurized eggs were used for residents and failed to ensure all kitchen equipment was clean and stored in a sanitary manner. This had the potential to affect all 45 residents residing in the facility. Finding include: On 05/28/19 from 9:46 A.M. through 10:07 A.M. an initial tour of the kitchen was conducted with Dietary Supervisor (DS) #703. During the tour the following observations were made: In the refrigerator there was a carton of unpasteurized eggs. The stove knobs had accumulated grease and residue. On the shelf above the stove there was a thin layer of grease and dust. Several large pots were stored on the shelf with the open sides up. Dietary Supervisor #703 verified the above findings at the time of the observations. Review of the undated Dietary department responsibilities handout revealed only pasteurized eggs were to be used.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to develop and implement a comprehensive and individualized plan of care for Resident #147 related to incontinence. This affected one resident (Resident #147) of one resident reviewed for incontinence care. Findings include: Record review of Resident #147 revealed the resident was admitted to the facility on [DATE] and had diagnoses including hemiplegia, major depressive disorder, symbolic dysfunctions, and suspected elder physical abuse. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 05/16/19 revealed the resident was frequently incontinent of urine and always incontinent of bowels. No evidence could be found in the care plan of any acknowledgement the resident was incontinent or plan to provide appropriate care for their incontinence. Interview with State Tested Nursing Assistant (STNA) #701 on 05/29/19 at 10:46 A.M. revealed she was familiar with Resident #147 and confirmed the resident was incontinent. Interview with the Director of Nursing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to develop a comprehensive discharge summary for Resident #48. This affected one resident (Resident #48) of two residents reviewed for transfer/discharge. Findings include: Record review of Resident #48 revealed the resident was admitted to the facility on [DATE] with a diagnosis including a displaced fracture of left femur. The discharge Minimum Data Set (MDS) 3.0 assessment, dated 03/04/2019 revealed the resident was independent for transfers, to walk in the room, locomotion, dressing, eating, toilet use and personal hygiene. Limited assistance was needed for walking any distance. The resident was cognitively intact. The resident was discharged on 03/04/19. Review of the East Park Care Resident Discharge Summary Form revealed it had not been completed. The physician's name and the diagnosis were on the form but no other information. There was no overview of the resident's stay, post -discharge plan of care or discharge instructions. Interview with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure stop dates within 14 days were included in orders for as-needed (PRN) psychotropic medications for Resident #147 and Resident #33. The facility also failed to ensure duplicate entries were not in place for PRN psychoactive medications in the medication administration record (MAR) for Resident #147. This affected two residents (Resident #33 and #147) of five residents reviewed for unnecessary medication use. Findings include: 1. Record review for Resident #147 revealed the resident was admitted to the facility on [DATE] and had diagnoses including hemiplegia, major depressive disorder, anxiety disorder, symbolic dysfunctions, and suspected elder physical abuse. Record review revealed a physician order for the anti-anxiety medication, Lorazepam (Ativan) 0.5 milligrams (mg) to be given three times per day PRN for anxiety for 30 days. The start and end dates of the order were not identified on the order sheet. No evidence could be found identifying…

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

Based on observation, record review and interview the facility failed to maintain adequate infection control practices during meal delivery to prevent the spread of infection. This affected two residents (Resident #44 and Resident #148) of two residents observed receiving meal trays in their rooms. The facility census was 45. Findings Include: Observation of State tested nursing assistant (STNA) #600 delivering lunch meal trays to resident rooms on 05/28/19 at 12:38 P.M. revealed STNA #600 entered the room of Resident #44, placed the meal tray down and unfolded the paper surrounding a muffin without first washing her hands or using gloves. An interview with STNA #600 was made shortly after leaving the resident's room, STNA #600 verified she did not wash/sanitize her hands or wear gloves as she touched the food. Observation of STNA #601 on 05/30/19 at 12:45 P.M. revealed STNA #601 entered Resident #148's room, unwrapped a straw and holding it by the top, placed it into the resident's cup. STNA #601 did not wash/sanitize hands or wear gloves. An interview with STNA #601 verified…

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.