Unger Park Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record, staff interview, and policy review, the facility failed to ensure care plans were timely initiated and revised for new wounds. This affected one (#28) of one resident reviewed for wound care. The facility identified five residents with wounds. The facility census was 67. Findings include:Review of the medical record for Resident #28 revealed an admission date of 06/13/25. Diagnoses included dementia, depressive disorder, type two diabetes mellitus, anxiety, and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. The resident was dependent on staff for bed mobility, toileting, and transfers. Review of a wound nurse practitioner progress note dated 04/22/26 revealed the resident had a diabetic ulcer to the left heel measuring one centimeter (cm) in length, one cm in width, with an undetermined depth. The wound was 100 percent scabbed and crusted with no exudate and described as dry and callused with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, staff interview, and policy review the facility failed to ensure a procedure was in place to determine which residents required ancillary services. This affected one (#51) of one resident reviewed for dental services. The facility census was 67.Findings include:Review of Resident #51's medical record revealed an admission date of 12/04/25. Diagnoses included muscle wasting and atrophy, type two diabetes mellitus, osteoarthritis, gastro-esophageal reflux disease without esophagitis, and ataxia. Review of Resident #51's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15. Furthermore, Resident #51 did not have dental pain. Review of Resident #51's care plan dated 02/08/26 revealed Resident #51 was at risk for difficulty chewing related to broken teeth with interventions that included dental consultation and follow-up as indicated and to notify the physician 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 staff interview, review of employee files, review of the Bureau of Criminal Investigation (BCI) log and review of the facility policy, the facility failed to ensure employee background checks were completed prior to employment. This had the potential to affect all 56 residents residing in the facility. The facility census was 56.Findings include:Review of Dietary Aide (DA) #238's employee file revealed a start date of 02/16/25. Further review revealed no evidence a BCI check was completed for DA #238.Review of the facility's BCI log revealed DA #238 was not logged as having a background check completed. Interview on 07/15/25 at 1:28 P.M. with Human Resource Director (HRD) #253 verified DA #238 did not have a background check completed. Review of the facility policy titled, Background Screening Investigations, revised March 2019, revealed the facility conducted employment background screening checks, reference checks, and criminal conviction investigation checks on all applicants for positions with direct access to residents. Direct access employee meant any individual who…

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 reviews, staff interviews, review of the facility's infection control logs, review of facility in-services, and review of the facility's policy, the facility failed to prevent and respond to an increased pattern of urinary tract infections (UTIs). This affected two (#16 and #60) of two residents reviewed for UTIs. The facility census was 74. Findings include: Review of the medical record revealed Resident #16 was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, chronic obstructive pulmonary disease, shortness of breath, asthma, dysphagia, need for assistance with personal care, insomnia, hyperlipidemia, adult failure to thrive, osteoarthritis, infestation, low back pain, hypertension, anxiety, and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], identified Resident #16 was cognitively intact. The resident was frequently incontinent of urine and occasionally incontinent of bowel. Review of the infection control logs…

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 interviews, record review, policy review, the facility failed to ensure care conferences were completed timely. This affected six residents (#05, #07, #08, #12, #19, #29, and #45) of the 19 residents reviewed for care conferences. The facility census was 74. Findings include: 1) Review of medical record for Resident #07 revealed an admission date of 05/12/17 with diagnoses including but not limited to hemiplegia/hemiparesis following cerebral vascular accident (CVA/stroke) affecting non-dominant right side, post-traumatic stress disorder (PTSD), bipolar disorder, schizophrenia, anxiety, and altered mental status. Review of Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #07 had moderate cognitive impairment. Review of progress notes including social service notes for Resident #07, revealed no documented evidence care conferences were held in May 2024 or August of 2024. 2) Review of medical record for Resident #08 revealed an admission date of 01/18/15 with diagnoses including but not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, review of the activity calendar, and policy review the facility failed to ensure activities on memory care unit met the needs and preferences of the residents. This affected all 13 residents (#02, #04, #11, #13, #19, #24, #35, #40, #41, #46, #58, #174, and #175) on the memory care unit. The facility census was 74. Findings include: Review of medical record for Resident #04, revealed an admission date of 01/15/24 with diagnoses including but not limited to Alzheimer's disease with late onset, dementia with other behavioral disturbance, and cognitive communication deficit. Review of care plan dated 10/16/24, revealed Resident #04 had the potential for decreased activity participation, involvement and or social isolation related to illness/disease process, immobility, and impaired decision making. Interventions included assist with arranging community activities and arrange transportation, encourage attendance and participation in activities, if the resident is…

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 physician and nurse practitioner (NP) progress notes, and staff interview, the facility failed to ensure physician visits were completed as required. This affected five (#60, #04, #12, #29, and #45) of the nine residents reviewed for physician visits. The facility census was 74. Findings include: 1) Review of the medical record revealed Resident #60 was admitted to the facility on [DATE]. Diagnoses included fibromyalgia, hypokalemia, hyperlipidemia, spinal stenosis, anxiety, upper abdominal pain, nausea with vomiting, gastro-esophageal reflux disease, diverticulitis of intestine, osteoporosis, osteoarthritis, chronic pain syndrome, unsteadiness on feet, muscle weakness, pain in right leg, pain in left leg, difficulty walking, and depression. Resident #60 was cognitively intact. Further review of the medical record, revealed Resident #60 was seen by the NP monthly from 02/29/24 through 12/16/24. There was no evidence of a physician visit with Resident #60 from 02/26/24…

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 interviews, staff interviews, and policy review, the facility failed to ensure residents received food that was palatable and appetizing to them and which met their nutritional recommendations. This affected four (#57, #05, #62 and #61) residents out of the four residents reviewed for lunch. This had the potential to affect all but one resident (#174) who was identified by the facility as not receiving meals from the kitchen. The census was 74. Findings include: Review of medical record for Resident #57, revealed an admission date of 01/16/24. The resident was diagnosed with type 2 diabetes mellitus, peripheral vascular disease, and unspecified convulsions. Resident #57 was cognitively intact. Review of medical record for Resident #05, revealed an admission date of 09/30/21. The resident was admitted with diagnoses including paranoid schizophrenia, type 2 diabetes mellitus, and morbid obesity. Review of medical record for Resident #62, revealed an admission date of 05/08/24. The resident was admitted with diagnoses including type 2 diabetes mellitus,…

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, and policy review, the facility failed to maintain the kitchen in a clean and sanitary condition. This affected all but one resident (#174) who was identified by the facility as not receiving meals from the kitchen. The census was 74. Findings Include: Observation of the kitchen on 12/16/24 at 10:59 A.M. with Dietary Manager (DM) #333, revealed the wall across from dishwasher had splattered food debris all over it and parts of the wall were chipping. Interview with DM #333 at the same time, verified the findings. Observation of the kitchen on 12/16/24 at 11:20 A.M. with DM #333, revealed the ventilation hood above the clean pan rack and stove top has paint strips hanging down from it. DM #333 verified the findings and stated someone cleaned too hard and now paint is hanging down. Follow up observation of the kitchen on 12/18/24 at 11:14 A.M. with District Manager #666, revealed the white paint strips were chipping from the ventilation hood above the stove top and clean dish rack. Interview with District Manager #666 at the same time verified 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, staff interviews, record review, and policy review the facility failed to ensure the kitchens walk-in cooler and reach-in cooler were working in a safe operable condition. This had the potential to affect all but one resident (#174) who was identified by the facility as not receiving meals from the kitchen. The census was 74. Findings include: Observation of the kitchen on 12/16/24 at 10:04 A.M. with the Dietary Manager (DM) #333, revealed the reach-in cooler had an ambient internal temperature of 44 degrees Fahrenheit (F). Interview with DM #333 at the same time, verified the reach-in cooler was 44 degrees F. Observation of the kitchen on 12/16/24 at 10:09 A.M. with DM #333, revealed the walk-in cooler had an ambient internal temperature of 47 degrees F. Interview with DM #333 at the same time verified the walk-in cooler was 47 degrees F. Observation of the walk-in cooler on 12/16/24 at 10:17 A.M. with DM #333, revealed the following temperatures: a) The cottage cheese was 44 degrees F. b) The cream cheese was 47 degrees F. c) The whole milk was 45 degrees F.…

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 policy review, the facility failed to ensure the code status matched the medical record and the physician's order. This affected one (#12) of the 19 residents reviewed for code status. The facility census was 74. Findings include: Review of medical record for Resident #12 revealed an admission date of 11/19/18 with diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), type two diabetes, congestive heart failure, narcolepsy, anxiety, post-traumatic stress disorder, convulsions, depression, bipolar disorder, and paranoid schizophrenia. Review of Advanced Directives in the hard/paper chart for signed and dated 10/23/24 for Resident #12, revealed a code status document of Do Not Resituate Comfort Care Arrest (DNRCCA). Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was cognitively intact. Review of the physician orders in the electronic medical record (EMR) dated 12/16/24 for Resident #12, revealed the resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, record review, and review of the facility policy, the facility failed to ensure residents had a safe, clean, comfortable and homelike environment. This affected one (#37) of two residents reviewed for physical environment. The facility census was 74. Findings include: Review of the medical record revealed Resident #37 was admitted to the facility on [DATE]. Diagnoses included anxiety, heart failure, and weakness. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], identified Resident #37 was cognitively intact. The resident was always continent of bladder and bowel. An interview on 12/16/24 at 2:53 P.M. with Resident #37, revealed the bathroom was not thoroughly cleaned on a regular basis. Observation at the same time with Resident #37, revealed there was dried feces on the lower left side of the toilet. There was also a towel on the floor on the left side of the toilet, and a brown paper towel behind the toilet. A follow-up observation 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, observation, and resident and staff interview, the facility failed to administer tube feedings in accordance with physician orders. This affected one (#130) of the one resident reviewed for administration of tube feedings. The facility census was 74. Findings include: Review of the medical record revealed Resident #130 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, shock, severe protein-calorie malnutrition, pleural effusion, diverticulitis of intestine, thrombocytopenia, other disorders of electrolyte and fluid imbalance, acute embolism and thrombosis of left femoral vein, cutaneous abscess, altered mental status, obstructive and reflux uropathy. Review of Resident #130's physician orders identified an order dated 12/08/24 for Osmolite 1.2 Cal (nutritional supplement) oral liquid give 80 milliliters (mL) per hour via nasogastric tube (NG) one time per day, turn on at 6:00 P.M. and turn off at 6:00 A.M. The resident also had an order dated 12/09/24…

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 provide medications as ordered by the physician which resulted in significant medication errors. This affected one (#29) of one resident reviewed for insulin. The facility census was 74. Findings include: Review of medical record for Resident #29 revealed an admission date of 10/25/21 with diagnoses including but not limited to disorders of muscle, chronic obstructive pulmonary disease, type two diabetes, panic disorder, major depressive disorder, chronic pain, arthritis, depression, anxiety, and claustrophobia. Review of Minimum Date Set (MDS) assessment dated [DATE], revealed Resident #29 was cognitively intact. Review of the active physician orders for Resident #29, revealed an order for Humulin 70/30 (insulin) KwikPen subcutaneous (SQ) pen injector give 88 units SQ on time a day at 8:00 A.M. If blood sugar (BS) is greater than 150 milligrams per deciliter (mg/dL) then increase the supper dose by two units. If less than 100 mg/dL then…

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, review of Self Reported Incidents (SRI), review of facility investigations, review of the local police report, and review of policies and procedures, the facility failed to prevent an inappropriate resident to resident altercation that was sexual in nature. This affected one resident (#105) out of three residents reviewed for abuse. Findings Include: Review of the medical record for Resident #105 revealed an admission date of 11/21/24. The resident was discharged on 11/25/24. Diagnoses included hemiplegia and hemiparesis following other cerebrovascular disease affecting the right dominant side, cerebrovascular disease, dysphagia following cerebral infarction, and type two diabetes mellitus with chronic kidney disease. The resident was only admitted for a short term respite stay. Review of the Discharge Return Not Anticipated Minimum Data Set (MDS) assessment, dated 11/25/24, revealed Resident #105 did not have a brief interview for mental status (BIMS), cognitive…

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, staff interview, and facility policy review the facility failed to ensure medications were fully ingested and not left at the bedside. This affected one resident (#21) and had the potential to affect eight residents (#65, #20, #45, #6, #31, #68, #57, and #60) the facility identified as independently mobile and cognitively impaired residing on the memory care unit. The facility census was 68. Findings include: Review of the medical record for Resident #21 revealed an admission date of 01/15/24 with diagnoses of Alzheimer and dementia with behavior disturbance. Review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #21 revealed she is cognitively impaired. Review of the care plan revised 07/24 for Resident #21 revealed she had impaired cognitive function and impaired thought process related to dementia. Review of the current physician orders for 07/24 for Resident #21 revealed for the morning medications she was to receive Actos (thiazolidinediones)15…

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 observations, staff interview, record review, policy review, and staff interview, the facility failed to ensure dishes and utensils were sanitized properly. This had the potential to affect 64 residents that received meals from the facility. One resident (#1) of 65 residents received nothing by mouth. The census was 65. Findings include: Observation on 02/14/24 at 10:30 A.M., of the high temperature dish machine with Dietary Manager (DM) #203 revealed the dish machine registered 158 degrees Fahrenheit (F) for the wash cycle and 178 degrees F for the final rinse. Interviews with Dietary Aide (DA) #244, at the time of the observation, stated she had never seen the final rinse dish machine temperature at 180 degrees F. The temperatures were verified by DM #203 at the time of observation. Observation on 02/14/24 at 3:55 P.M., dish machine was at proper temperature for the final rinse. Review of the dish machine log for February 2024 revealed that the final rinse temperature for the dish machine was not at the required 180 degrees F for 02/12/24 and 02/13/24. 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.

Based on record review and staff interview, the facility failed to ensure residents were offered the COVID-19 vaccination/booster and provided education on vaccinations. This affected three (#8, #15, and #69) of five reviewed for vaccination. Additionally, the facility failed to have a policy and procedure related to residents receiving the COVID-19 Vaccination, which affected all facility residents. Findings census was 65. Findings include 1. Review of the medical record for Resident #8 revealed an admission date of 08/24/21. Diagnoses included stroke, hepatic failure, diabetes, schizophrenia, depressions and anemia. Review of the vaccination records revealed Resident #15 was given the COVID-19 vaccination (2 dose) dated 12/09/21 and 01/07/22. Chart review revealed no evidence of the COVID-19 vaccination booster was offered and no evidence education was provided in relation to risks and benefits of receiving the COVID vaccine booster. 2. Review of the medical record for Resident #15 revealed an admission date of 09/12/23. Diagnoses included dementia, obesity, stenosis of coronary…

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 2. Review of Resident #8's medical record revealed an admission date of 08/24/21, with diagnoses of stroke, schizophrenia, major depression and anemia. Review of Resident #8's activities plan of care identified she enjoys cards, games (rummy and Bingo) art/crafts, coloring, computer/tablet games, cooking, country music, religious involvement, travel, outings, movies, parties and socials events. The plan identified she needs assistance to and from activities. Observations on 02/12/24 at 7:41 P.M. and 02/13/23 at 11:25 A.M., revealed Resident #8 was awake and staring at the television in the room. Resident #8's room was observed to have no independent items in the room to do activities. The room had no games, coloring books and or radio to enjoy her identified preferred activities. Review of the facility's activity calendar dated 02/13/24 identified at 2:00 P.M., for a Mardi gras party. Observation on 02/13/24 at 2:05 P.M., revealed Resident #8 was in bed. Resident #8 was asked if she would like to attend 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, staff interview, and policy review, the facility failed to serve pureed foods at a smooth consistency for safe swallowing. This potentially affected nine residents, eight who were prescribed puree diets (#8, #12, #28, #40, #44, #58, #65 and #224) and one resident (#59) who was prescribed meat must be pureed. The census was 65. Findings include: Interview on 02/13/24 at 11:09 A.M., with Dietary Manager (DM) #203 revealed the kitchen used premade molds for most food items but on 12/14/24 they will puree a cold ham sandwich for the lunch meal. Observation of puree preparation on 12/14/24 at 10:50 A.M., revealed [NAME] #209 pureed ham salad for lunch. Taste test revealed that the pureed ham had small pieces of ham in it. DM #203 tasted the pureed ham salad and told [NAME] #209 to puree the meat more. [NAME] #209 pureed the ham salad more and pieces of the rind that were found. Pureed ham was at proper consistency prior to service at 11:15 A.M. Review of the policy titled Diet and Nutrition Care Manual- Dysphagia Puree (Level 1) Diet, dated 2015, revealed all pureed…

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, Centers for Disease Control Prevention (CDC) guideline review, policy review and staff interview, the facility failed to ensure residents were offered vaccinations and provided education on vaccinations. This affected two (#8 and #15) for influenza (flu) vaccines and one (#13) for pneumococcal (pneumonia) vaccines of five residents reviewed for vaccines. Findings census was 65. Findings include 1. Review of the medical record for Resident #8 revealed an admission date of 08/24/21. Diagnoses included stroke, hepatic failure, diabetes, schizophrenia, depressions and anemia. Review of the vaccination records revealed no evidence of the flu vaccinations being offered, refused or accepted for the 2023 flu season. Chart review also revealed no evidence that education was provided in relation to risks and benefits of receiving the flu vaccine. 2. Review of the medical record for Resident #15 revealed an admission date of 09/12/23. Diagnoses included dementia, obesity, stenosis of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, resident interview, and staff interview, facility failed to ensure resident and/or a representative and members of the interdisciplinary team were included in the quarterly care conferences. This affected one (#13) of two residents reviewed for care conferences. Facility census was 65. Findings include: Review of the medical record for the Resident #13 revealed an admission date of 11/19/18. Diagnoses included chronic obstructive pulmonary disease, diabetes type two, heart failure, anxiety, bipolar disorder, and paranoid schizophrenia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively intact. Review of the interdisciplinary care conference notes dated 03/21/23 revealed no indication of resident POA being included in the meeting or discussion. Review of the interdisciplinary care conference dated 06/28/23, 09/28/23, and 12/28/23, revealed no evidence that any member of the interdisciplinary team participated in the quarterly…

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, resident interview, and staff interview, the facility failed to ensure call lights were within reach and accessible for two (#12 and #34) residents. In addition, the facility failed to ensure a resident (#6) was provided the opportunity to smoke or the necessary interventions to cease smoking. This affected three (#6, #12 and #34) of 65 residents reviewed for accomodation of needs. The facility census was 65. Findings include: 1. Review of Resident #34's medical record revealed an admission date of 12/12/18, with diagnoses including to diabetes mellitus, dementia, and trigeminal neuralgia. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was severely cognitively impaired and required extensive assistance for activities of daily living. Review of the care plan dated 10/19/23 revealed that Resident #34 was at risk for falls with the intervention of call light within reach when in room. Observation on 02/12/24 at 7:22 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record reviews, review of a facility self reported incident (SRI), resident and staff interviews, the facility failed to promote and facilitate a resident to have visitors of their choosing and where they want to meet. This affected one (#8) of 18 sampled for residents rights. The facility census was 65. Findings include: Review of Resident #8's medical record revealed an admission date of 08/24/21, with medical diagnoses including: stroke, schizophrenia, major depression and anemia. Review of the most recent annual assessment dated [DATE], revealed the resident was moderately cognitively impaired. Review of Resident #8's plan of care identified she will visit with her sons in a common area. The record and plan of care identified no reason to require Resident #8 to visit family in a common area. Review of Resident #8's nurse notes dated 02/08/24 at 7:13 P.M., documented two of her children had come to visit. The notes documented Resident #8 did not want to get out of bed as she just got back…

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

Based on record review, policy review and staff interview, the facility failed to ensure residents had an accurate code status documented in the medical record. This affected one (#5) of two reviewed for advanced directives. Facility census was 65. Findings include: Review of the medical record for the Resident #5 revealed an admission date of 10/23/18. Diagnoses included diabetes type two, chronic obstructive pulmonary disease, legal blindness, and muscle weakness. Review of a paper/ hard chart revealed physician order dated 10/24/18 revealed an order for full code. Review of the paper (hard copy) medical record revealed a code status of full code with a bright colored paper Review of the electronic medical record revealed a code status of DNRCC-A (do not resuscitate comfort care arrest) Interview on 02/13/24 at 10:30 A.M., with Licensed Practical Nurse (LPN) #269 and Director of Nursing (DON) confirmed code status did not match between the electronic and paper medical record. They revealed the paper chart had full code orders and colored directive and the electronic record had a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the Resident Assessment Instrument (RAI) manual and staff interview, the facility failed to ensure the Minimum Data Sets (MDS) and fall risk assessments were completed accurately. This affected three (#8, #29, #68) of 18 sampled residents assessments reviewed. The facility census was 65. Findings include: 1. Review of Resident #29's medical record revealed an admission date of 10/06/22. Review of the annual MDS dated [DATE] under section K; identified Resident #29 had significant weight loss of 5% or more in the last month or loss of 10% in the last 6 months. Review of Resident #29's weights in the previous 6 months revealed on 05/01/23 her weight was 216 and on 10/01/23 a weight of 229 pounds. This was a 5.68% weight gain over that time period. 2. Review of Resident #68's medical record revealed admission date of 12/13/23. The admission MDS dated [DATE] identified under section K significant weight loss. Resident #68's weight records identified an admission weight of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, facility failed to ensure pre-admission screening and resident review (PASARR) were completed accurately and corrected as needed. This affected two (#7 and #13) of two residents reviewed for PASARR. Facility census was 65. Findings include 1. Review of the medical record for the Resident #7 revealed an admission date of 09/30/21. Diagnoses included paranoid schizophrenia, diabetes, depression, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact with a BIMS of 15 and required assistance for ambulation and activities of daily living. Review of the PASARR dated 11/07/21 revealed only mood disorder was documented. 2. Review of the medical record for the Resident #13 revealed an admission date of 11/19/18. Diagnoses included chronic obstructive pulmonary disease, diabetes type two, heart failure, anxiety, bipolar disorder, and paranoid schizophrenia. Review of the Minimum Data Set (MDS) assessment dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to update care plans regarding elopement and advanced directives. This affected one (#25) of 18 sampled residents care plans reviewed. The facility census was 65. Findings include: Review of medical record for Resident #25 revealed an admission date of 12/13/23, with diagnoses including dementia with agitation, Alzheimer's disease, epileptic seizures, altered mental status, and major depressive disorder. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview of mental status (BIMS) score of zero which indicated severely cognitively impaired. No behaviors noted during the look back period. Review of Care Plan dated 02/02/24 revealed resident/family had chosen advanced directive of Full Code. Review of care plan revealed Resident #25 wanders aimlessly/elopement risk related to impaired safety awareness, dementia. Interventions include wander guard to right ankle, check placement per protocol. Review of physician orders 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 observations, medical record reviews, resident and staff interviews, the facility failed to ensure a resident was provided the necessary glasses to maintain vision. In addition, ensure a system was in place for staff to identify which resident requires assistive devices. This affected one (#8) of 18 sampled residents. The facility census was 65. Findings include: Review of Resident #8's medical record revealed an admission date of 08/24/21, with medical diagnoses including: stroke, schizophrenia and major depression. Review of Resident #8's Minimal Data Set (MDS) assessment dated [DATE] and 01/20/24, under section B identified vision with no corrective lenses. The record identified no plans of care related to Resident #8's vision/glasses. Interview and observation on 02/12/24 at 7:41 A.M., revealed Resident #8 stated she has glasses but does not know where they are. Resident #8's room was observed with an empty glass case. Review of a vision consult note dated 07/18/23, identified Resident #8 was noted…

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, and staff interviews, the facility failed to ensure a resident was accurately assessed after an elopement attempted, ensure staff was informed to monitor resident after an elopement attempt, and a resident's fall interventions were implemented. This affected two (#15 and #46) of two residents reviewed for accidents and hazards. Facility census was 65. Findings include 1. Review of the medical record for the Resident #46 revealed an admission date of [DATE]. Diagnoses included: chronic obstructive pulmonary disease, diabetes, respiratory failure, and muscle weakness and cognitive communication deficit. Review of admission elopement assessment dated [DATE] revealed resident had no cognitive impairment or poor decision making skills, no diagnosis of dementia, did not ambulate independently, resident without desire to go home, no history of elopement or exit seeking behavior, resident did not wander aimlessly, and resident was not wandering or exit seeking to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record reviews, dietary meal cards review, and staff interviews, the facility failed to ensure a physician ordered fluids restriction was being provided as ordered. This affected one (#40) of one resident identified with fluid restriction. The facility census was 65. Findings include: Review of Resident #40's medical record revealed admission date on 12/21/23, with medical diagnoses including pneumonia, end stage renal disease, fractured 5th lumbar vertebra, major depression and hyperkalemia. Review of physician orders dated 12/27/23, identified a fluid restriction for the resident that included: fluid restriction of 1500 ml (milliliter) daily divided 540 ml for nursing and 960 ml for dietary and no water pitcher at the bedside. Review of Resident #40's nutritional assessment dated [DATE] revealed the resident was a new resident at the facility. The assessment identified Resident #40 was on a 1500 ml fluid restriction and is able to feed himself. The notes identified Dietician #264…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, policy review, fire department run sheet review, resident and staff interviews, the facility failed to document accurate pertinent changes that occurred in Resident #69 condition. This affected one (#69) of 18 sampled residents. The facility census is 65. Findings include: Review of Resident #69's medical record revealed an admission date of [DATE], with a diagnoses of cellulitis of left limb, unspecified convulsions, conversion disorder with seizures or convulsions, and is a full code. Review of the most recent admission assessment dated [DATE] revealed Resident #69 was cognitively intact and requires a staff assist of one person for activities of daily living. Review of progress note dated [DATE] (no time) revealed Resident #69 was found in the restroom sitting on the toilet fully clothed. Resident #69 began jerking, yet his arms and legs were limp. Vital signs were taken. Resident #69 went limp in Licensed Practical Nurse (LPN) #266's arms, and Resident #69's head fell forward.…

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.