Majestic Care of Bryan

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation of medication administration, and review of facility policy, the facility failed to ensure a seizure medication was administered as ordered which resulted in a significant medication error. This affected one (Resident #20) of nine residents observed for medication administration. The facility census was 77.Findings include:Review of the medical record for Resident #20 revealed she was admitted to the facility on [DATE] with diagnoses including congestive heart failure, type two diabetes mellitus, hyperlipidemia, and unspecified convulsions.Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact and displayed no behaviors at the time of the review.Review of admission paperwork for Resident #20 revealed a past medical history including seizures.Review of physician orders for Resident #20 revealed an order dated 11/04/25 for 300 milligrams (mg) of oxcarbazepine to be administered by mouth every evening at bedtime…

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 review of Self-Report Incidents (SRI), review of open and closed medical records, review of facility incident reports, staff interview and review of facility policy, the facility failed to prevent resident to resident sexual abuse. This affected two (#8 and #12) of three residents reviewed for abuse. The facility census was 79. Findings include: 1. Review of the closed medical record revealed Resident #8 was admitted to the facility on [DATE] and discharged on 11/25/24. Diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris, essential hypertension, hyperlipidemia and paroxysmal atrial fibrillation. Review of the Minimum Data Set (MDS) assessment, dated 10/22/24, revealed Resident #8 was moderately cognitively impaired. Review of Self-Reported Incident #253805, dated 11/07/24 at 10:12 A.M., revealed at approximately 8:45 A.M. Resident #9…

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 ongoing interventions were implemented to promote discharge from the facility were provided. This affected one (#4) of four sampled residents reviewed for discharge opportunity. The facility census was 82. Findings include: Resident #4 admitted to the facility on [DATE] with the diagnoses including, quadriplegia, cervical spinal cord injury, hypertension, type two diabetes mellitus, history of urinary tract infection, depression, colostomy, and urostomy. Review of the most current minimum data set assessment dated [DATE] Resident #4 was assessed with intact cognition, dependent on staff for activities of daily living including bed mobility, rejection of care four to six days during assessment period, received a therapeutic diet, had no identified weight loss, and admitted with a stage IV pressure ulcer. Review of the baseline care plan documentation dated 04/13/24 Resident #4 had an discharge goal to assist 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, and staff interview, the facility failed to ensure interventions and monitoring were provided to a resident following difficulty consuming meal. This affected one (#3) of three sampled residents reviewed for meal time assistance in a facility census of 82. Findings include: Resident #3 admitted to the facility on [DATE] with the diagnoses including, chronic obstructive pulmonary disease, vascular dementia, repeated falls, chronic kidney disease, neuropathy, hypothyroidism, depression and cognitive communication deficit. Review of the most current minimum data set assessment dated [DATE] revealed Resident #3 had moderately impaired cognition, required set-up or clean-up assistance with eating, substantial to maximal assistance with activities of daily living, was incontinent of bowel and bladder, and received a mechanically altered diet. Review of nursing progress notes revealed on 08/03/24 at 6:56 P.M. at lunch today, resident struggled to eat a burrito that was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff and resident interview, and facility bowel and bladder management policy, the facility failed to provide and implement interventions to address specific resident incontinence needs. This affected one (#1) of three sampled residents reviewed for incontinence maintenance. The facility census was 82. Findings include: 2. Resident #1 admitted to the facility on [DATE] with the diagnoses including, cerebral infarction, hemiplegia affecting left side, traumatic hemorrhage right cerebrum, hypertension, morbid obesity, dysarthria, anarthria, hypothyroidism, and dysphagia. Review of the most current minimum data set assessment dated [DATE] Resident #1 had intact cognition, limited range of motion to upper and lower extremities of one side, utilized a wheelchair for mobility propelled by staff, required substantial to maximal assistance with activities of daily living (ADL) including bed mobility, dependent on staff for transfer to and from bed, and was always incontinent…

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 staff interview and review of staffing schedules, the facility failed to ensure staffing included the services of a registered nurse (RN) in-house for at least eight consecutive hours a day, seven days a week. This had the potential to affected all 90 residents residing in the facility. The facility census was 90. Findings include: Review of facility staffing schedules between 06/01/24 and 06/30/24 identified three dates lacking RN coverage for eight consecutive hours. The were no RN hours on 06/09/24, 06/20/24, and 06/27/24 during a 24-hour period. On 07/02/24 at 11:20 A.M., interview with the Director of Nursing (DON) during review of the facility staffing schedules verified three days the facility did not have an RN scheduled in the facility during a 24-hour period. The DON confirmed there was no RN hours on the 06/09/24, 06/20/24, and 06/27/24 staffing schedules for a 24-hour period. This deficiency represents non-compliance investigated under Master Complaint Number OH00154646 and Complaint Number OH00154464.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and review of the facility wound care policy, the facility failed to ensure pressure ulcer wound dressings and preventative interventions were implemented as ordered by the physician. This affected one (#1) of three sampled residents reviewed for skin integrity and wound prevention in a facility census of 90. Findings include: Review of the medical record revealed Resident #1 admitted to the facility on [DATE] with diagnoses including quadriplegia, cervical spinal cord injury, hypertension, type two diabetes mellitus, history of urinary tract infection, depression, colostomy, and urostomy. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] Resident #1 was assessed with intact cognition, was dependent on staff for activities of daily living including bed mobility, received a therapeutic diet, was identified with no weight loss, and was admitted with a stage three (full-thickness skin loss) and a stage four (full-thickness skin…

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, staff interview, and review of the facility administration and documentation of medication policy, the facility failed to ensure medications were provided as ordered by the physician. This resulted in a significant medication error when a resident was not administered an antipsychotic medication as prescribed. The affected one (#4) of three residents reviewed for medications in a facility census of 90. Findings include: Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including, seizure disorder, major depressive disorder with recurrent severe psychotic symptoms, type two diabetes mellitus, anxiety disorder, chronic obstructive pulmonary disease, schizoaffective disorder, borderline intellectual functioning, delusional disorders, hypertension, and visual hallucinations. Review of the Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #4 with intact cognition, a depressed mood two to six days during…

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 staff interview, resident interview, record review and review of the facility policy, the facility failed to ensure residents dependent for care received showers as scheduled or per request. This affected one (#14) of four residents reviewed for showers. The facility census was 90. Findings include: Review of the medical record for Resident #14 revealed an admission date of 10/06/23. Diagnoses included fracture of right lower leg, spinal stenosis and heart failure. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/26/24, revealed Resident #14 had intact cognition, did not reject care, and was dependent for transfers and showers. Review of the shower task documentation for the previous 30 days revealed Resident #14 was scheduled for routine showers on Mondays and Thursdays and received showers 05/02/24, 05/06/24, 05/16/24, and 05/27/24. Further review revealed Resident #14 refused a shower on 05/20/24. There was no evidence Resident #14 received showers on 05/09/24, 05/13/24 or 05/23/24 as scheduled or on 05/24/24 as requested. Interview on 05/29/24 at 2:00…

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, the facility failed to remove molded foods from the refrigerator, store food off the floor, and discard expired foods. This had the potential to affect all 100 residents who received food from the kitchen. There was one resident (#84) identified by the facility as not receiving food from the kitchen. The facility census was 101. Findings include: Observation and interview on 03/18/24 from 6:20 P.M. through 6:45 P.M. during the initial kitchen tour with [NAME] #310 revealed a partially aluminum foil covered metal pan approximately 11 inches by 15 inches filled with slider type sandwiches, 15 boxes of frozen food items sitting on the floor of the walk-in freezer, 15 boxes of produce items sitting on the floor in the walk-in cooler, four boxes of bread and buns sitting on the floor next to the bread cooler, and two containers of molded strawberries in the walk-in cooler. Cook #310 verified the partially covered sliders, the boxes of frozen food items in the walk-in freezer sitting on the floor, the boxes 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 review of resident funds records and staff interview, the facility failed to ensure resident's funds were maintained under the Medicaid limit. This affected three residents (#02, #25, and #47) of five residents reviewed for personal funds. The facility census was 101. Findings include: 1. Review of Resident #02's personal funds revealed a balance of $,3390.68 as of 03/20/24. The balance on 09/30/23 was $2,937.52. The facility had sent a Resident Fund Balance Notification on 01/03/24 to the resident's representative indicating they were to notify the Social Worker within the next seven days to discuss ways to assure continuance of Medicaid benefits. No record of discussion with the representative was located in the medical record. 2. Review of Resident #25's personal funds revealed a balance of $6,790.21 as of 03/20/24. The balance on 09/30/23 was $7,481.77. The facility had sent a Resident Fund Balance Notification on 01/03/24 to the resident's representative indicating they were to notify the Social Worker within the next seven days to discuss ways to assure continuance 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 observations, medical record reviews, resident and staff interviews, and review of the facility policy, the facility failed to timely address the resident's skin impairments and failed to implement physician orders routinely to address the resident's skin conditions. This affected two (#21 and #68) of four residents reviewed for skin integrity. The facility census was 101. Findings include: 1. Review of Resident #68's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus and coronary artery disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #68 had intact cognition. Resident #68 required set-up assistance from staff with activities of daily living, had no refusal of treatment, was independently mobile utilizing a walker or wheelchair, and was at risk for pressure ulcer development with no current skin breakdown. Review of the physician order dated 11/01/23 revealed an order to apply (Tubigrips)…

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 review of facility policy, the facility failed to administer medications per physician which resulted in a significant medication error for one (#94) of three residents reviewed for medication administration. The facility census was 101. Findings include: Review of the medical record for Resident #94 revealed an admission date of 08/23/23. Diagnosis included pulmonary hypertension (medical condition where the heart and lungs do not pump effectively and can cause significant fluid build up in the pulmonary system, the lungs. This can cause significant difficulty in breathing.) Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 was cognitively intact. Review of the physician orders for November 2023, December 2023, and January 2024 revealed Resident #94 was ordered sildenafil 20 milligrams (mg) every six hours for pulmonary hypertension. Review of the care plan, revised 11/27/23, revealed Resident #94 was care planned 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.

Based on observation, medical record review, staff interview and review of facility policy, the facility failed to ensure timely pharmacy response for medication refill requests. This affected one #40) of seven residents reviewed for medication administration. The facility census was 105. Finding include: Review of the medical record for Resident #40 revealed an admission date of 05/21/23. Diagnoses included diabetes mellitus type II, hypertension, hydronephrosis with renal and ureteral calculous obstruction and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/17/23, revealed Resident #40 had moderate cognitive impairment, was dependent on staff for activities of daily living (ADLs), had a metabolic diagnosis of diabetes mellitus and received insulin on a daily basis. Review of the care plan, revised 11/27/23, revealed Resident #40 had diabetes mellitus. Interventions included for diabetes medication to be provided as ordered, monitor and document side effects and effectiveness of the medications, fasting blood sugar as ordered, and monitor 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.

Based on observation, medical record review, staff interview, and review of the pharmacy services provider agreement, the facility failed to ensure medication prescribed to assist with lowering blood sugar was available and administered as ordered. This affected one (#40) of seven residents reviewed for medication administration. The facility census was 105. Findings include: Review of the medical record for Resident #40 revealed an admission date of 05/21/23. Diagnoses included diabetes mellitus type II, hypertension, hydronephrosis with renal and ureteral calculous obstruction and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/17/23, revealed Resident #40 had moderate cognitive impairment, was dependent on staff for activities of daily living (ADLs), had a metabolic diagnosis of diabetes mellitus and received insulin on a daily basis. Review of the care plan, revised 11/27/23, revealed Resident #40 had diabetes mellitus. Interventions included for diabetes medication to be provided as ordered, monitor and document side effects 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, resident interview, staff interview, and review of facility policy, the facility failed to ensure medications were kept secure at all times. This affected one (#97) of one residents reviewed for medication storage. The facility census was 105. Findings include: Review of the medical record for Resident #97 revealed an admission date of 11/12/23. Diagnoses included chronic osteomyelitis, diabetes mellitus, type II, chronic obstructive pulmonary disease, hypertension, heart failure and depression. Review of the Minimum Data Set (MDS) assessment, dated 11/16/23, revealed Resident #97 was cognitively intact. Review of the current physician orders revealed Resident #97 had the following medications ordered for morning administration: • Ascorbic Acid 500 milligrams (mg), one tablet • Cholecalciferol 5000 units, one tablet • Daily-Vite multivitamin, 400 micrograms (mcg), one tablet • Lasix 20 mg, one tablet • Metoprolol Succinate extended release 25 mg, one tablet • Sertraline 50 mg, two tablets and Sertraline 180 mg, one tablet • Tamsulosin hydrochloride 0.4 mg, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and review of facility policy the facility failed to ensure physician ordered laboratory services were completed in a timely manner. This affected one (#18) of three residents reviewed for laboratory services. The facility census was 105. Findings include: Review of the medical record for Resident #18 revealed an admission date of 10/06/23. Diagnoses included a displaced bimalleolar fracture of right lower leg, hypertension, osteoarthritis, heart failure, retention of urine, morbid obesity, spinal stenosis, cor pulmonale, dilated cardiomyopathy, and lymphedema. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 10/13/23, revealed Resident #18 was cognitively intact and was dependent for activities of daily living (ADLs). Review of the care plan dated, 10/15/23, revealed Resident #18 was on diuretic therapy related to hypertension and heart failure. Interventions included to administered medications as ordered and report pertinent laboratory…

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, staff interview and review of facility policy, the facility failed to ensure timely physician notification of laboratory (lab) results. This affected one (#110) of three residents reviewed for physician notification. The facility census was 105. Findings include: Review of the medical record for Resident #110 revealed an admission date of 10/31/23. Diagnoses included spina bifida with hydrocephalus, anxiety disorder, pseudobulbar affect, and a tongue abscess. Resident #110 had a history of frequent urinary tract infections. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #110 had moderate cognitive impairment and had an indwelling catheter and a colostomy. Review of the care plan for Resident #110, dated 11/06/23, revealed Resident #110' had a suprapubic catheter related to a diagnosis of spina bifida and was at risk for developing urinary tract infections and trauma related to the catheter. Interventions included staff 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 observation, medical record review, staff interview and review of facility policy, the facility failed to maintain proper infection control practices during wound care. This affected three (#9, #40 and #85) of three residents reviewed for wound care. The facility census was 105. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 04/26/22. Diagnoses included peripheral vascular disease, type II diabetes mellitus, chronic kidney disease, and hypothyroidism. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/20/23, revealed Resident #9 was cognitively intact. Review of the care plan for Resident #9, revised on 10/06/23, revealed a potential for skin impairment related to fragile skin. Interventions included to follow facility protocols for treatment of injury, monitor and document location, size, and treatment for skin injury. Review of Resident #9's current physician orders revealed an order written on 12/29/23 for a skin tear to the left elbow to be cleansed with wound cleaner, have xeroform applied, cover with 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.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, review of the facility Self-Reported Incident (SRI), review of facility corrective action documents, and policy review, the facility failed to ensure a resident was not physically restrained. This affected one (#57) of five residents reviewed for abuse. The facility census was 107. Findings include: Review of Resident #57's medical record revealed an admission date of 04/24/23. Diagnoses included frontotemporal neuro cognitive disorder, dementia, motor neuron disease, aphasia, depression, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 11/08/23, revealed Resident #57 was assessed with severe cognitive impairment, was independent with mobility and required supervision with Activities of Daily Living (ADLs) after set up. Review of a plan of care focus area, initiated 10/16/23, revealed Resident #57 demonstrated inappropriate behavior related to dementia, could be verbally and physically…

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, review of the medical record and review of facility policy, the facility failed to ensure wound treatments were completed as ordered. This affected one (#56) of four residents reviewed for wound care. The facility census was 107. Findings include: Review of the medical record for Resident #56 revealed an admission date of 10/04/22. Diagnoses included Chronic Obstructive Pulmonary Disease (COPD), atrial fibrillation, acute posthemorrhagic anemia, and Zenker's diverticulum. Review of the annual Minimum Data Set (MDS) assessment, dated 10/10/23, revealed Resident #56 was cognitively intact, was at risk for developing skin injury, and required the application of non-surgical dressings. Review of current physician orders revealed Resident #56 had an order dated 11/12/23 for the abdomen to be cleansed with normal saline, patted dry, followed by an application of Mesalt and to cover with dry sterile dressing every day and every eight hours as needed if gastrostomy site was leaking. Review of a wound care note date 11/15/23 revealed the gastrostomy…

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, medical record review, review of facility policy and review of manufacturer's instructions, the facility failed to ensure medications were administered as ordered. This affected one (#90) of six residents reviewed for medication administration. The facility census was 107. Findings include: Review of the medical record for Resident #90 revealed an admission date of 02/11/14. Diagnoses included hypertension, type II diabetes mellitus, heart failure, vascular dementia, atrial fibrillation, hemiplegia, hemiparesis, and aphasia following a cerebral infarction. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/06/23, revealed Resident #90 was cognitively intact. Review of a physician order, dated 11/02/23, revealed Resident #90 was ordered Victoza Solution (used to treat type II diabetes), per pen-injector, 18 milligrams (mg) per three milliliters (ml), inject 1.8 mg subcutaneously each morning. Observation on 11/21/23 at 8:30 A.M. of Licensed Practical Nurse (LPN) #200 prepare to administer insulin to Resident #90 revealed 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.

Based on review of the medical record, staff interview, and policy review, the facility failed to ensure resident preferences for showers were honored. This affected one (Resident #6) of three residents reviewed for bathing/showers. The facility census was 105. Findings include: Review of the medical record revealed Resident #6 had an admission date of 10/05/22. Diagnoses included type two diabetes, peripheral vascular disease, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment completed 07/10/23 revealed Resident #6 had intact cognition. The resident required the extensive assistance of one staff for bed mobility. The resident was independent for transfers and toilet use. The resident required supervision for walking and personal hygiene. The resident was independent for bathing requiring set-up help only. Review of the activities of daily (ADL) plan of care last revised 12/22/22 revealed Resident #6 required set up and clean up assistance for bathing. Review of the shower schedule revealed Resident #5 was scheduled for showers on Tuesdays and Fridays…

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 trust account records, review of receipts, review of a withdrawal record document, and staff interview, the facility failed to ensure funds were withdrawn from the appropriate resident account. This affected two (#12 and #123) of three residents reviewed for resident trust accounts. The facility census was 109. Findings include: Review of the resident trust account for Resident #12 revealed a handwritten receipt for a withdrawal of $55.00 on 06/06/23. Review of the itemized statement for Resident #12 dated between 01/03/23 and 08/23/23 revealed no corresponding withdrawal for $55.00 on 06/06/23. Review of a withdrawal record dated 06/06/23 revealed $55.00 was withdrawn from Resident #123's trust account. Interview on 08/31/23 at 11:20 A.M. with Receptionist #361, who verified she was responsible for managing withdrawals from resident trust accounts, confirmed Resident #12's trust account had no corresponding withdrawal for the handwritten receipt on 06/06/23 for $55.00. Follow-up interview on 08/31/23 at approximately 12:30 P.M. with Receptionist #361…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of a facility investigation, staff interview, review of self-reported incidents, and review of a facility policy, the facility failed to report an allegation of sexual abuse to the State Survey Agency. This affected two (#12 and #105) of four residents reviewed for abuse. The facility census was 109. Findings include: Review of the medical record for Resident #12 revealed an admission date of 02/02/20 with diagnoses of schizoaffective disorder and insomnia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had intact cognation and was independent for transfers and walking. Review of a progress note dated 07/19/23 in Resident #12's medical record revealed a report to staff that Resident #12 was outside smoking with a female resident when Resident #12 pulled his pants down in front of the female resident, and Resident #12 asked the female resident if she could pull her shirt up. Review of the medical record for Resident #105 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, and staff interview, the facility failed to ensure a cognitively impaired resident received adequate assistance with eating. This affected one (#61) of three residents reviewed for assistance with meals. The facility census was 109. Findings include: Review of the medical record for the Resident #61 revealed an admission date of 02/14/23 with diagnoses of left femur fracture, type II diabetes mellitus, and Alzheimer's disease. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 had impaired cognition and required supervision with setup for meals. Review of the current care plan for Resident #61 revealed she had an activities of daily life deficit due to Alzheimer's disease. Interventions included encouraging the resident to participate to the fullest extent possible with each interaction. Observation on 08/30/23 at 8:09 A.M. revealed State Tested Nurse Aide (STNA) #200 provided Resident #61 with her breakfast tray. STNA #200 used…

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, staff interview, and facility policy review, the facility failed to ensure a resident at risk for incontinence received timely and adequate incontinence care following an episode of urinary incontinence. This affected one (#61) of three residents reviewed for incontinence. The census was 109. Findings include: Review of Resident #61's medical record revealed the resident admitted to the facility on [DATE] with the diagnoses including, left femur fracture, type II diabetes mellitus, hypertension, chronic kidney disease stage III, Alzheimer's disease, vitreous degeneration, depression, dysphagia, dementia, history of urinary tract infection, transient ischemic attack, and cerebral infarction. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 was assessed with severe cognitive impairment, was dependent on staff for the completion of activities of daily living including bed mobility, transfers, dressing, and hygiene, was incontinent of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to obtain weights per the plan of care and per the facility policy to assess residents for unplanned weight loss. This affected one (#61) of one residents reviewed for weight loss. The facility census was 109. Findings include: Review of the medical record for Resident #61 revealed an admission date of 02/14/23 with diagnoses of left femur fracture, type II diabetes mellitus, and Alzheimer's disease. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 had impaired cognition and required extensive assistance of two people for bed mobility and transfers. Further review revealed Resident #61 exhibited no rejection of care. Review of the progress notes dated between 05/02/23 and 08/30/23 revealed no concerns related to facility staff obtaining weights for Resident #61. There was no documentation of Resident #61 refusing to be weighed. Review of the current…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record reviews, policy review, resident and staff interviews, the facility failed to promote dignity by ensuring a resident (#27) was provided with grooming and clean clothing and a dignified experience when responding to a resident's (#42) request for incontinence care. In addition, the facility failed to ensure seven (#12, #14, #18, #32, #42, #49, #61) were provided with eating assistance in a dignified manner. This affected eight (#12, #14, #18, #32, #27, #42, #49, #61) of 21 residents observed for the promotion of resident dignity. The facility census was 91. Findings include: 1. Review of Resident #27's medical record revealed admission date of 01/14/22, with the diagnoses including: history of urinary tract infection, chronic obstructive pulmonary disease, dementia, hypertension, hyperlipidemia, dysphagia, weakness, and insomnia. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #27 had severe cognitive impairment, dependent on staff for the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations record reviews, policy reviews, interviews with resident representative, residents and staff, the facility failed to provide adequate staff to meet the residents needs. This affected twelve (#7, #12, #14, #18, #22, #27, #32, #42, #49, #61, #69) of 91 residents discovered to experience the lack of care and treatment related to insufficient nursing service staffing levels. The census was 91. Findings include: Review of the Resident Census and Condition of Residents Form 672, dated 04/05/22 the facility identified the resident level of care needs as follows; 66 residents require assistance from staff with bathing and 21 are dependent, 85 residents require assistance with dressing and one is dependent, 60 residents require assistance with transferring and 26 are dependent, 80 residents require toileting assistance and two are dependent, 88 residents require assistance with eating and three are dependent. The facility listed 72 residents frequently incontinent of bladder, 48 residents frequently…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, facility census review, meal ticket reviews, food menus and spreadsheet review, resident and staff interviews, the facility failed to provide appropriate food servings sizes to residents who received the regular and pureed main lunch meal. This affected 25 (#4, #7, #9, #19, #25, #30, #31, #39, #40, #44, #47, #51, #53, #55, #58, #59, #63, #67, #68, #78, #79 #80, #83, #88, and #441) residents on the 100, 300, and 500 hall. In addition, the facility failed to honor Resident #10's food choices. The facility census was 91. Findings include: 1. Interview on 04/06/22 at 11:15 A.M., with Dietary Manager #500 prior to serving resident meals verified using 6-ounce scoop for the pureed baked ziti and regular baked ziti. Observation on 04/06/22 at 11:18 A.M., revealed Dietary Manager #500 serving residents the main dish of the baked ziti with four cheeses with a 6 ounce scoop. Dietary Manger #500 served all meals to residents in halls 100, 300, and 500. Interview on 04/06/22 at 11:48 A.M., with Dietary…

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

Based on observation, staff interview, and facility policy the facility failed to store food in a safe and sanitary manner in the unused kitchen, main kitchen, and unit refrigerators. The facility identified one resident (#13) that does not receive food from the kitchen. The facility failed to ensure residents were provided with eating assistance in a manner to prevent food borne illness, infection, or cross contamination. This affected five residents (#12, #14, #18, #32, and #61) observed during meals. The facility census was 91. Findings include: Observation on 04/04/22 at 6:29 P.M., of the main kitchen freezer revealed a box of garlic breadsticks, potato fries, and a bag of snap peas on the freezer floor. Observation on 04/04/22 at 6:36 P.M., of the stand alone refrigerator revealed two trays of prepared drinking cups with chocolate milk, white milk, juice, and tea were undated and unlabeled. Interview on 04/04/22 at 6:45 P.M., with Dietary Aide #502 verified packaged food directly on the freezer floor and undated and unlabeled drinks in the stand alone refrigerator. Observation…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and review of exterminator invoices, the facility failed to effectively ensure there were no gnats in the facility. This affected 38 of 38 residents residing on the 500, 700, and 800 hall. The facility census was 91. Findings include: Observation on 04/05/22 at 11:18 A.M., revealed a gnat was flying around a resident in room [ROOM NUMBER]. Interview with Resident #86 on 04/05/22 at 11:18 A.M., verified there have been gnats in the facility for a long time. Interview on 04/05/22 between 11:00 A.M. to 1:00 P.M., gnats were flying around the nursing station located between the 700 and 800 hallways. Observations on 04/05/22 at 2:00 P.M., revealed gnats were observed in the 500 hallway. Review of the exterminating reports dated 12/22/21 stated treatment for insects was completed in the common areas, kitchen 1&2 and rooms. Review of the exterminating reports dated 01/27/22 stated treatment for insects was completed in the common areas Kitchen 1&2 and rooms 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, resident and staff interviews, and policy review, the facility failed to ensure call lights were provided to residents to alert staff to needs. This affected two (#41 and #60) of 91 residents in the facility. The facility census was 91. Finding included : Observation on 04/05/22 10:20 A.M., upon entering Resident #41 and 60's room, revealed two soft touch call lights lying on the floor in between Resident #41 and Resident #60 bed. Resident #60 asked the surveyor where her call light was because she wanted the staff to be repositioned her in bed. Interview on 04/05/22 at 10:22 A.M., with State Tested Nursing Assistant (STNA) #580 and STNA #628, upon entering the room, verified both residents were in bed with their call lights on the floor. Review of the policy titled, Answering the Call Light, dated April 2018, stated when the resident is in bed or confined to a chair the staff should be sure the call light is within easy reach of the resident.

Based on medical record review, resident and staff interviews, and policy reviews, the facility failed to ensure a resident's requests to get out of bed were honored. This affected one (#7) of one residents reviewed for choices. The facility census was 91. Findings include: Review Resident #7's medical record revealed and admission date of 05/14/21. Diagnoses included: traumatic spondylopathy, spinal stenosis, pain in thoracic spine, personal history of transient ischemic attack and cerebral infarction without residual deficits, spastic hemiplegia affecting left dominant side, spondylosis without myelopathy or radiculopathy other cervical disc degeneration, abnormal posture, fibromyalgia, central pain syndrome, bipolar disorder, and other intervertebral disc degeneration lumbar region. Review of the Minimum Data Set (MDS) assessment, dated 01/11/22, revealed Resident #7 was cognitively intact and required two person assistance of total dependent for transfer. Review of the safety smoking screen, dated 01/26/22, revealed Resident #7 was safe to smoke without supervision. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, personal funds account review, policy review, resident and staff interviews, the facility failed to ensure a resident was free from misappropriation. This affected one (#6) of seven residents reviewed for personal funds. The facility census was 91. Findings include: Review of Resident #6's medical record revealed an admission date of 08/15/20, with diagnoses that included: diabetes mellitus, heart failure, coronary heart disease, atrial fibrillation, hypertension, hyperlipidemia and anxiety. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was alert, oriented, cognitively intact and required supervision for activities of daily living. Interview with Resident #6 on 04/04/22 at 7:00 P.M., revealed concerns regarding personal funds. Resident #6 stating he had around $1100.00 in his account and when he went to get cash in early March, he was told he only had $98.00 in his account. Review of Resident #6's personal funds account on 04/06/22…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, personal funds account review, policy review, resident and staff interviews, the facility failed to timely report the potential misappropriation of property to the appropriate state agency. This affected one resident (#6) of seven residents reviewed for personal funds. The facility census was 91. Findings include: Review of Resident #6's medical record revealed an admission date of 08/15/20, with diagnoses that included: diabetes mellitus, heart failure, coronary heart disease, atrial fibrillation, hypertension, hyperlipidemia and anxiety. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was alert, oriented, cognitively intact and required supervision for activities of daily living. Interview with Resident #6 on 04/04/22 at 7:00 P.M., revealed concerns regarding personal funds. Resident #6 stating he had around $1100.00 in his account and when he went to get cash in early March, he was told he only had $98.00 in his account. 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, personal funds account review, policy review, resident and staff interviews, the facility failed to complete an investigation of possible misappropriation of personal funds. This affected one (#6) of seven residents reviewed for personal funds. The facility census was 91. Findings include: Review of Resident #6's medical record revealed an admission date of 08/15/20, with diagnoses that included: diabetes mellitus, heart failure, coronary heart disease, atrial fibrillation, hypertension, hyperlipidem and anxiety. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was alert, oriented, cognitively intact and required supervision for activities of daily living. Interview with Resident #6 on 04/04/22 at 7:00 P.M., revealed concerns regarding personal funds. Resident #6 stating he had around $1100.00 in his account and when he went to get cash in early March, he was told he only had $98.00 in his account. Review of Resident #6's personal funds…

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, resident representative and staff interview, and review of policy, the facility failed to ensure residents were provided with timely and adequate bathing. This affected three (#7, #32, and #69) of seven residents reviewed for activities of daily living (ADLs). The facility identified 66 residents that required assist of one or two staff for bathing and 21 residents who were dependent with bathing activities. The census was 91. Findings include: 1. Review of Resident #32's medical record revealed an admission date of 12/16/16. Diagnoses included Parkinson's disease, transient cerebral ischemic attack, unspecified dementia without behavioral disturbance, hyperlipidemia, muscle weakness, supraventricular tachycardia, and chronic kidney disease. Review of a Minimum Data Set (MDS) assessment completed 02/01/22 revealed Resident #32 had severely impaired cognition and was assessed to require physical help with part of the bathing activity with a two-plus persons assistance. Review of 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, observations, and staff interviews, the facility failed to accurately assess and treat an existing pressure ulcer, implement care planned and physician ordered pressure relieving interventions, and accurately document wounds. This affected two (#22 and #61) of three residents reviewed for pressure ulcers. The facility identified a total of four residents with pressure ulcers. The facility census was 91. Findings include: 1. Review Resident #22's medical record revealed an admission date of 08/19/22, with diagnoses including gangrenous hernia with obstruction resulting in colostomy placement, anemia, contractures of knees legs. Resident was admitted to the hospital on [DATE], with readmission to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed moderate cognitive deficit, required total assistance of two staff for bed mobility and extensive assistance of two staff members for all other activities of daily living. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, facility policy review, and staff interview, the facility failed to ensure timely incontinence care was provided. This affected two (#14 and #42) of six residents reviewed for the provision of incontinence interventions and assistance. The facility census was 91. Findings include: 1. Review of Resident #14's medical record revealed an admission date of 05/13/19, with the diagnoses including: Alzheimer's disease, dementia, anxiety disorder, major depression, psychotic disorder with delusions, anemia, malignant neoplasm of breast, secondary malignant neoplasm of bone, macular degeneration, hypothyroidism, cardiac murmur, and osteoarthritis. Review of the minimum data set (MDS) assessment dated [DATE], identified Resident #14 with severe cognitive impairment, dependent on staff for the completion of activities of daily living including bed mobility, transfer, incontinent of bowel and bladder, utilizes a wheelchair propelled by staff, receives mechanically altered…

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 nutritional supplements were provided as ordered by the physician. This affected one (#61) of four residents reviewed for the provision of nutritional interventions. The facility census was 91. Findings include: Resident #61 admitted to the facility on [DATE] with the diagnosis including, chronic obstructive pulmonary disease, rheumatoid arthritis, thoracic aortic aneurysm, chronic kidney disease, contracture to right and left knee, dementia with behavior disturbance, hypertension, constipation, and Alzheimer's disease. Review of the minimum data set assessment (MDS) dated [DATE], identified the resident with severe cognitive impairment, dependent on staff for completion of activities of daily living including bed mobility, transfer, incontinent of bowel and bladder, utilizes a wheel chair propelled by staff, at risk for skin breakdown with no current skin concerns. Review of a nursing plan of care revealed the plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, policy review, resident and staff interviews, the facility failed to ensure a resident on a fluid restriction had the fluid restriction noted on their meal ticket and properly communicated with staff providing meals. This affected one (#10) of one reviewed for dialysis. The facility identified one resident receiving dialysis. The facility census was 91. Findings include: Review of Resident #10's medical record revealed an admission date of 10/04/21. Diagnoses included chronic kidney disease, emphysema, morbid obesity, anxiety disorder, and lymphedema. Review of Resident #10's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact and required extensive assistance with bed mobility, dressing, toilet use and personal hygiene. Resident #10 was receiving dialysis at the time of the review. Resident #10 was on a mechanically altered diet and a therapeutic diet. Review of Resident #10's care plan revised 01/05/22 revealed Resident #10…

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, policy review and staff interview, the facility failed to administer medications as ordered by the physician. This affected one (#23) of five residents reviewed for unnecessary medications. The census was 91. Findings included: Review of Resident #23's medical record revealed an admission date of 10/25/21. Diagnoses included Parkinson's disease, cerebral infarction, unspecified dementia without behavioral disturbances, idiopathic hypotension, major depression, other psychotic disorder, adjustment disorder with depressed mood, and anxiety. Review of the most recently completed Minimum Data Set (MDS) assessment completed 01/27/22 revealed Resident #23 was assessed with moderately impaired cognition. Review of a physician order dated 10/26/21 revealed Resident #23 was ordered the blood pressure medication hydralazine 10 milligrams (mg) by mouth three times daily with instructions to hold the medication if Resident #23's systolic blood pressure (pressure on the heart while it is beating) was less than 150 millimeters of mercury (mmHg) or if Resident #23's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interview, and policy review, the facility failed to ensure lost dentures were replaced timely for a resident. This affected one (#86) of one resident reviewed for dental care. The facility census was 91. Findings include: Review of Resident #86's medical record revealed an admission date of 12/01/21, with diagnoses including: congestive heart failure, diabetes type II and morbid obesity. The resident was admitted to the hospital on [DATE] with re-entry to the facility on [DATE]. Review of the annual Minimum Data Set (MDS) assessment, dated 03/22/22 revealed the resident had moderate cognitive deficits and did not display any behaviors. She had no significant weight loss. She was assessed with being edentulous without ill fitting or broken dentures. Review of the plan of care dated 03/22/22 stated the resident has a potential risk for altered nutrition/hydration. There is no mention of dentures in the resident's plan of care. Review of the Transfer Sheet dated…

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

Based on observation, medical record review, and staff interview the facility failed to ensure a resident received a meal served at a palatable, safe, and appetizing temperature. This affected two (#33 and #61) of 90 residents identified to received food from the facility kitchen. The facility census was 91. Findings include: Interview with State Tested Nurse Aide (STNA) #623 on 04/05/22 at 8:55 A.M., revealed the STNA was assigned to the resident's remaining in their rooms for meals. STNA #623 stated he was unable to assist in the Alzheimer's unit dining room due to residents with heavy needs on the unit requiring care and assist with breakfast. STNA #623 verified Resident #61 and #33 have not been provided with breakfast yet. Observation on 04/05/22 at 9:15 A.M., revealed STNA #623 was observed to provide Resident #33 with complete eating assistance providing bites and drinks by hand with bare hands. At 9:39 A.M, without washing hands STNA #623 proceeded to Resident #61 bedside, handled the resident with bare hands without handwashing, and sat the resident in the seated up right…

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.