The Enclave at Cambridge

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of residents, review of medical records and facility policies, and interviews with residents and staff, the facility failed to provide adequate supervision during smoking sessions for residents. This affected two (#5, #47) of two residents reviewed for smoking safety. The facility census was 35.Findings include: Review of medical record for Resident #5 revealed admission to the facility on [DATE] with diagnoses including stroke affecting right side, diabetes, high blood pressure, anxiety, lung disease, bipolar (mood) disorder, aphasia (difficulty speaking), left above knee amputation, and right below knee amputation. Review of the comprehensive Minimum Data Set (MDS) assessment completed on 09/15/25 revealed Resident #5 had a brief interview for mental status and scored a 6/15 indicating moderate to severe cognitive deficit. Further review of the MDS revealed the resident was dependent for all care including bathing and dressing and required assistance for navigation of wheelchair. Review…

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

Based on resident observations, medical record review, and resident and staff interview the facility failed to provide timely incontinence care to a resident. This affected one (#10) of one resident reviewed for incontinence care. The facility census was 35.Findings include: Review of the medical record for Resident #10 revealed admission to facility on 05/04/22 with diagnoses including diabetes, bipolar (mood) disorder, atrial fibrillation (irregular heart rate), Alzheimer's Disease, heart failure, degenerative joint disease of thoracic spine, artificial heart valve with use of chronic blood thinner, morbid obesity, and chronic pain.Review of the quarterly Minimum Data Set (MDS) assessment completed on 09/03/25 revealed Resident #10 had a brief interview for mental status and scored a 13/15 indicating normal cognitive function. Further review of the MDS revealed the resident was dependent for all care including bathing, toileting, dressing, and required assistance with wheelchair navigation.Review of the MDS assessment also revealed Resident #10 to be incontinent of bowel and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, interview, and policy review the facility failed to ensure residents had orders for oxygen and a humidification bottle was filled. This affected two (#8 and #12) of four residents reviewed for respiratory care. The facility census was 35.Findings include: 1.Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, chronic obstructive pulmonary disease, and heart failure. Review of Resident #8's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #8 received oxygen therapy. Review of Resident #8's current orders dated 12/2025 revealed Resident #8 was ordered five liters per milliliters (LPM) continuously. Review of Resident #8's oxygen plan of care dated 04/04/19 and revised 04/22/25 revealed the resident uses oxygen related to chronic obstructive pulmonary disease, congestive heart failure, and shortness of breath (SOB). Refuses to wear oxygen at times. The resident has SOB upon exertion…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to assess and implement trauma informed care for a resident. This affected one (#2) of one resident reviewed for trauma informed care. The facility census was 35. Findings Include: Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including dementia, diabetes mellitus, depression, anxiety disorder, bi-polar disorder, and post-traumatic stress disorder (PTSD).Review of the Minimum Data Set (MDS) assessment, dated 10/13/25, revealed Resident #2 was cognitively intact and had a diagnosis of PTSD.Review of the Care Plan for Resident #2 revealed there was not a plan of care in place addressing the cause of PTSD, triggers which may cause re-traumatization, or interventions to reduce the risk of re-traumatization and provide care for PTSD.Further record review for Resident #2 revealed no assessment had been completed to identify the cause of PTSD and to identify potential triggers which may cause…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents were provided with dental services. This affected one (#14) of two residents reviewed for dental services. The facility census was 35. Findings include:Record review revealed Resident #14 admitted to the facility on [DATE] with diagnoses including Parkinson's disease and muscle weakness. Review of an order dated 11/18/25 revealed Resident #14 could receive podiatry care, dental care, ophthalmology care, and audiology care as needed. Review of a nursing admission assessment dated [DATE] revealed Resident #14 had upper dentures only. Interview on 12/17/25 at 1:44 P.M. with Resident #14 revealed his gums were sore from chewing and no one had offered dental services. Interview on 12/17/25 at 2:13 P.M. with Social Services Director (SSD) #400 revealed the nurses add residents to dental list. Interview on 12/17/25 at 2:20 P.M. with Director of Nursing (DON) revealed residents could be added to the dental list by emailing the in-house dental…

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

Based on medical record review and staff interview, the facility failed to ensure resident Preadmission Screening and Resident Review was resubmitted following a new mental health diagnosis added for a resident. This affected one resident (#2) of one resident reviewed for Preadmission Screening and Resident Review. The facility census was 31. Findings include: Review of Resident #2's medical record revealed an admission date of 04/30/18 with diagnoses that included dementia, cerebrovascular accident and bipolar disorder. A Preadmission Screening and Resident Review (PASARR) was completed on 04/30/18. Further review of the medical diagnoses for Resident #2 revealed a new diagnosis of anxiety added on 08/06/21. No evidence of a resubmission of PASARR for a new mental health diagnosis was found. On 08/07/24 at 10:50 A.M., interview with Licensed Practical Nurse (LPN) #11 revealed she would contact the local area agency on aging to determine if a PASARR is required to be resubmitted for a new diagnosis of anxiety for Resident #2. On 08/07/24 at 11:10 A.M., follow up interview with LPN…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interviews the facility failed to ensure therapy recommendation were implemented. This affected one resident (#5) of one resident reviewed for restorative services. Findings included: Record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including heart failure, diabetes, hip pain, heart disease, and chronic pain. Further review of Resident #5's paper medical record revealed there were Physical Therapy (PT) notes dated 09/26/23 to 11/20/23 that indicated the resident received therapy services. The PT discharge note dated 11/20/23 recommended the resident have a walker with a basket/bag and ambulation program established. The resident was currently able to walk to the dining room, balance was steady, and tier was functional with a Restorative Nursing Program. The resident will be able to walk in the corridor with two assists of two and balance will be steady, by performing the following restorative nursing intervention. Allow resident 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 and interview the facility failed to ensure the facility was free of pest. This affected two residents (#7 and #9) of 16 residents observed. Findings included: Observation on 08/05/24 at 10:56 A.M. of Resident #9's room revealed there were three flies flying around the resident. The resident reported flies have been an issue for five years. The resident had a flyswatter lying on his bed. Observation on 08/05/24 at 11:08 A.M. of Resident #7's room revealed there was one fly sticky strip hanging behind a closet. There were two flies flying around the resident's face. The resident reported flies have been an issue and staff gave him a flyswatter to use and they just took down the fly strips because state was in the building, but they must have missed one. Observation on 08/06/24 at 1:12 P.M., of Resident #7 and #9's room with Licensed Practical Nurse (LPN) #15 confirmed there was flies and gnats flying on and around the residents. Observation on 08/06/24 at 2:00 P.M., of Resident #7's wound care with LPN #17 and #18 revealed flies and gnats were flying around 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, dietary staffing and schedule review and staff interview, the facility failed to employ and maintain sufficient staffing in the kitchen to ensure resident meal service was provided as planned and without potential interruption. This had the potential to affect all 29 residents residing in the facility. Findings include: Review of the facility meal schedule revealed breakfast service was scheduled for 7:30 A.M. and 8:10 A.M. and lunch service was scheduled for 11:10 A.M. and 12:10 P.M. The second time noted was to finish the delivery of resident hall trays (for those residents who ate in their rooms) Upon entrance to the kitchen, on 03/15/24 at 8:30 A.M. Dietary [NAME] #49, State Tested Nursing Assistant (STNA), STNA #50 and STNA #45 were observed in the kitchen preparing the residents morning meal. The meal service was noted to be finishing at the time of the observation. Interview with [NAME] #49 on 03/15/24 at 9:21 A.M. revealed the dietary aide scheduled to work in the kitchen on this date had walked out after getting her paycheck this morning and did 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 record review, facility policy review, facility assessment review, and interviews, the facility failed to ensure an effective governing body, legally responsible to establish and implement policies regarding the management and operation of the facility, including but not limited to compliance with all financial obligations for the delivery of care. This had the potential to affect all 32 residents in the facility. Findings include: Review of the facility survey history revealed on 12/04/23 a complaint survey was completed which resulted in concerns related to financial solvency. An issue identified at that time was related to employee payroll. On 11/16/23 at 8:32 A.M., an interview with the Director of Nursing (DON) revealed some of the employee checks had been returned for insufficient funds but corporate (management located in Florida) had wired money to the employees the same day. Further interview revealed corporate also covered any fees that occurred at the employees' banks. At the time 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 record review, staff interview and policy review, the facility failed to ensure continuous evaluations were in place to verify financial obligations were met as planned to prevent a potential disruption in resident care and services through the Quality Assurance Performance Improvement (QAPI) program committee. This had the potential to affect all facility residents. The facility census was 32. Findings include: Review of the facility survey history revealed on 12/04/23 a complaint survey was completed which resulted in concerns related to financial solvency. An issue identified at that time was related to employee payroll. On 11/16/23 at 8:32 A.M., an interview with the Director of Nursing (DON) revealed some of the employee checks had been returned for insufficient funds but corporate (management located in Florida) had wired money to the employees the same day. Further interview revealed corporate also covered any fees that occurred at the employees' banks. At the time of the survey, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy review, facility assessment review, and interviews, the facility failed to ensure an effective governing body, legally responsible to establish and implement policies regarding the management and operation of the facility, including but not limited to compliance with all financial obligations for the delivery of care. This had the potential to affect all 30 residents in the facility. Findings include: Review of the facility survey history revealed on 12/04/23 a complaint survey was completed which resulted in concerns related to financial solvency. An issue identified at that time was related to employee payroll. On 11/16/23 at 8:32 A.M., an interview with the Director of Nursing (DON) revealed some of the employee checks had been returned for insufficient funds but corporate (management located in Florida) had wired money to the employees the same day. Further interview revealed corporate also covered any fees that occurred at the employees' banks. At the time 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, staff interview and policy review, the facility failed to ensure continuous evaluations were in place to verify financial obligations were met as planned to prevent a potential disruption in resident care and services through the Quality Assurance Performance Improvement (QAPI) program committee. This had the potential to affect all facility residents.The facility census was 30. Findings include: Review of the provided QAPI started 10/01/23 revealed the identified problem of vendors not being paid promptly. The root cause revealed invoices were not being entered electronically when received. Review of invoices and calls with administrator and business office manager were to be completed weekly. The QAPI did not identify any type of monitoring or ensuring staff were paid on the agreed payroll date. Review of the plan of correction dated 12/27/23 revealed action plan for ensuring staff received payroll on the agreed payroll date. a. During the onsite investigation, the facility provided a list of 14 employees who had paychecks returned from payroll on 01/19/24.…

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, review of billing statements, and interviews, the facility failed to respond to Resident #29 guardian's request for financial information in a timely manner and to maintain accurate financial records This affected one (Resident #29) out of three reviewed for request of records. Facility census was 30. Findings include: Review of the medical record revealed Resident #29 was admitted on [DATE] with diagnoses that included heart disease, cognitive communication deficit, dysphagia, and history of mental and behavioral disorders. Resident #29 had a court appointed guardian of person and estate (Guardian #400) dated 08/23/23. The medical record revealed since 04/02/22, Resident #29's payer source was Medicaid. Review of statements with account #137716 dated 10/01/23, 12/01/23, and 01/01/24 revealed a balance of $194.50 was owed. Interview on 01/29/24 at 9:35 A.M. Guardian #400 verified they had become Resident #29's guardian in August 2023 and had tried to get correct billing information from…

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, financial statements, interviews, and policy review the facility failed to ensure an overpayment of $4,200.00 from June of 2022 was refunded to a resident and/or family. This affected one (Resident #31) out of three residents reviewed for proper billing and accounting of resident accounts. The facility census was 30. Findings include: Review of the medical record revealed former Resident #31 was admitted on [DATE] and expired at the facility on [DATE] with diagnoses that included Alzheimer's disease, atrial fibrillation, and glaucoma. Power-of-attorney (POA) papers dated [DATE] revealed Resident #31's daughter was appointed POA in all business, financial, legal, and all other matters. Review of the medical record revealed Resident #31 was private pay from [DATE] until [DATE]. Resident #31's payor source was Medicare A from [DATE] through [DATE]. On [DATE], Resident #31's payor source was hospice-private. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #31 had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy review and interview, the facility failed to establish an effective governing body, legally responsible to establish and implement policies regarding the management and operation of the facility, including but not limited to compliance with all financial obligations for the delivery of care and maintenance. This had the potential to affect all 31 residents in the facility. Findings include: Review of the facility's undated Governing Body policy revealed the Governing Body had a fiduciary duty, duty of care, and duty of loyalty to act in the best interests of the Facility. The governing body should be comprised of the operator (s), c-suite level executives, and other individuals who were legally responsible for the establishment and implementation of policies regarding management and operations of the facility. The Governing Body member responsibilities included to be active, engaged, and involved in the affairs of the facility and to have direct access to the administrator…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure functioning equipment was maintained in the kitchen. This had the potential to affect all 31 residents. The census was 31. Findings include: A tour of the kitchen on 11/16/23 at 8:53 A.M. revealed the walk-in cooler was being used for storage. A freestanding commercial refrigerator was observed to be unplugged and not being used. Dietary Director (DD) #48 verified the walk-in cooler and the freestanding commercial refrigerator were not working. DD #48 stated the walk-in cooler had not worked since sometime in June and the freestanding commercial refrigerator stopped working 11/05/23. DD #48 stated residential refrigerators being used to replace the commercial refrigerators. The facility provided two estimates for the walk-in cooler. The first estimate was dated 07/19/23 for $18,125 with full payment required prior to installation. The second estimate was dated 07/27/23 for $10,568 with 50-percent prior to ordering and the balance…

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, review of resident fund information, and interviews the facility failed to notify Resident #19 and/or the resident's responsible party when the account balance was two hundred dollars less than the maximum resource limit. The facility also failed to convey personal funds after Resident #33 and #34 no longer resided at the facility. This affected three (Resident #19, #33, and #34) residents of 13 residents reviewed for resident fund accounts. The census was 31. Findings include: 1. Review of Resident #19's medical record revealed an admission date of [DATE] with diagnoses that included cerebral ischemia, dementia, anxiety, bipolar disorder, and type 2 diabetes mellitus. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #19 was cognitively impaired. Review of the resident fund account revealed Resident #19's payer source was Medicaid. Resident #19's balance since [DATE] had been more than $4,197.94 which exceeded the maximum resource limit of $2,500. Interview on [DATE] at…

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

Based on observation and interview, the facility failed to ensure the kitchen grill hood, stove, and floor were clean and free of grease build up. This had the potential to affect all 24 residents. Facility census was 24. Finding include: Observation on 08/02/23 at 8:48 AM revealed the kitchen hood exhaust system was dirty with what appeared to be grease on the hood and running down the wall. Grease buildup was noted from the top of the stove, down the side of the stove, and on the floor next to the stove. At the time of the observation, interview with Dietary Manager #105 verified the kitchen hood needed cleaned and there was a grease buildup that had run down the side of the stove and was on the floor. This deficiency represents non-compliance investigated under Complaint Number OH00144874.

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure meals were prepared and served as per the planned menu. This affected all 26 residents residing in the facility. Findings include: Review of the meal spreadsheet, dated Spring/Summer 2022 revealed the dinner menu for Monday included pureed soft, cooked vegetables for resident's receiving pureed diets, soft, cooked vegetables for the resident's receiving mechanical soft diets, and lettuce and tomato salad for the resident's receiving regular diets. The spreadsheet revealed the alternative main dish was creamy chicken spaghetti. Review of the meal tickets, dated 07/11/22 revealed no evidence of a pureed or mechanical soft vegetable or lettuce and tomato salad for regular diets, or the alternative main dish of creamy chicken spaghetti. On 07/11/22 at 4:31 P.M. observation of dinner meal revealed no evidence of a pureed or soft vegetable, lettuce and tomato salad, or creamy chicken spaghetti was prepared and available. At the time of the observation, interview with…

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

Based on record review and interview the facility failed to ensure information contained on Notice of Medicare Provider Non-Coverage forms issued to Resident #15, #19, #26 and #330 was accurate. This affected four residents (#15, #19, #26 and #330) of four residents reviewed for liability/beneficiary notices. Findings include: 1. Review of the Notice of Medicare Provider Non-Coverage form, revealed Resident #15 was receiving skilled services which were scheduled to end on 02/17/22. The information on the form included the incorrect name and phone number for the Quality Improvement Organization. The form had information for KePro, not the current QIO (Livanta). On 07/12/22 at 12:28 P.M. interview with Social Service Designee #25 verified the Notice of Medicare Provider Non-Coverage form had the incorrect information indicating KePro was the QIO not Livanta for Resident #15. 2. Review of the Notice of Medicare Provider Non-Coverage form, revealed Resident #19 was receiving skilled services which were scheduled to end on 06/15/22. The information on the form included the incorrect name…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure Resident #8 and Resident #15's personal funds were deposited in an interest bearing account. This affected two residents (#8 and #15) of two residents reviewed for personal funds. Findings include: 1. Record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, cerebral infarction, retention of urine, major depressive disorder, diabetes, cardiac arrhythmia, hypertension, dementia, anxiety disorder and benign prostatic hyperplasia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/28/22 revealed Resident #8 had moderately impaired cognition. Review of the personal fund account documentation for Resident #8 revealed the resident's personal funds account balance was $100.00, had not been deposited in an interest bearing account and had not accrued any interested from 04/12/22 to 07/13/22. On 07/13/22 at 3:10 P.M. interview Business Office Manger #19 revealed there was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy and procedure review and interview the facility failed to ensure communication/notification to Hospice as ordered when Resident #3's blood glucose level was elevated (above 401). This affected one resident (#3) of five residents reviewed for unnecessary medication use. Findings include: Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM) and chronic kidney disease, stage 5. Record review revealed the resident received Hospice services. Review of Resident #3's Hospice plan of care, dated 01/03/22 revealed to notify Hospice nurse of changes. The care plan revealed staff would communicate with Hospice to keep up to date on (resident's) condition. A Hospice certification, dated 06/18/22 revealed the resident was ordered Novolog insulin via a sliding scale. The orders indicated if the resident's blood glucose/sugar was 401 or higher to administer eight units of insulin and call Hospice. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure the justified use of a psychoactive medication for Resident #3. This affected one resident (#3) of five residents reviewed for unnecessary medication use. Findings include: Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including major depressive disorder and Alzheimer's disease. Review of a pharmacy recommendation, dated 01/03/22 revealed Resident #3 was receiving the anti-psychotic medication, Quetiapine (Seroquel) for agitation but lacked an allowable diagnosis to support its' use. The recommendation included a list of appropriate diagnoses/conditions listed including refractory major depression. The recommendation noted the facility nurse practitioner chose a diagnosis of refractory major depression on the form. However, there was no evidence of refractory major depression (treatment-resistant depression that doesn't respond to an adequate course of least two antidepressants) listed as a diagnosis 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.