Embassy Of Winchester

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, self-reported incident (SRI) investigation review, staff interview, and review of the facility's abuse policy and procedure, this facility failed to ensure an allegation of resident-to-resident sexual abuse was submitted to the appropriate state agency as required. This affected two (Resident #410 and #510) of the three residents reviewed for sexual abuse. The facility census was 87. Findings include:1.Review of the medical record for Resident #510 revealed an initial admission date of 07/31/2025 with a re-entry date of 08/20/2025 and a discharge date of 11/202/2025. Diagnoses included cognitive communication deficit, anxiety disorder, mood disorder, and need for assistance with personal care. Review of Resident #510's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a BIMS score of 10 out of 15 indicating a moderately impaired cognition for daily decision-making abilities. Review of the nursing progress note dated 11/14/25 at 2:44 P.M. created by the Director…

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

Based on observation, interview, medical record review, and facility policy review the facility failed to perform hand hygiene during incontinence care. This affected one (Resident #374) of one resident observed during incontinence care . The census was 87.Findings include:Review of Resident #374's medical record revealed an admission date of 11/27/23. Medical diagnoses include unspecified dementia, moderate with psychotic disturbance, moderate-protein calorie disturbance, essential (primary) hypertension, hyperlipidemia, anxiety, depression, atrial fibrillation, personal history of transient ischemic attack and cerebral infarction without residual deficits, dysarthria and anarthria, low back pain, and irritable bowel syndrome with constipation.Review of Resident #374's quarterly Minimum Data Set (MDS) 3.0 dated 01/09/26 revealed a Brief Interview for Mental Status (BIMS) score of 06 out of 15. Resident #374's functional abilities revealed Resident #374 was dependent on staff for toileting hygiene.Review of Resident #374's care plan dated 10/14/25 revealed Resident #374 always…

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, staff interview, and facility policy review, the facility failed to maintain a clean, safe, and comfortable living environment for residents. This had the potential to affect all residents in the facility. The facility census was 94. Findings include: An observation on 08/04/25 from 8:57 A.M. to 9:12 A.M. was conducted throughout multiple hallways and common areas. Upon entrance to the building, a large stain was noted on the ceiling tile above the second door on the right. In Hallway G, light fixtures two, six and seven contained debris and light shades on fixtures six and seven were cracked. Peeling ceiling drywall was observed after light fixture three. Outside Resident #74's room, the ceiling showed damaged paint and unfinished ceiling texture. Outside Resident #72's room, peeling ceiling was identified around the fire sprinkler and a ceiling stain was visible above the beauty shop door.Continued observation revealed in Hallway H, damaged drywall shaped like a removed hand sanitizer…

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

Based on interview and record review, the facility failed to ensure discharge Minimum Data Set (MDS) 3.0 assessments were completed accurately and a correction was submitted timely to reflect Resident #90's disposition. This affected one resident (#90) out of four residents reviewed for MDS assessments. The facility census was 94.Findings include:Review of the medical record for Resident #90 revealed an admission date of 06/17/19, with diagnoses including hypertension, cognitive communication deficit, depression, polyneuropathy, chronic pain, dementia, gastroesophageal reflux disease (GERD), benign prostatic hyperplasia, acquired absence of the right leg above the knee, and schizoaffective disorder.Review of a progress note dated 03/02/25 revealed Resident #90 was enroute to a local hospital by critical transport, and the power of attorney was notified of the intended location.Review of the Discharge Minimum Data Set (MDS) 3.0 assessment, completed on 03/02/25, revealed the discharge status was coded as discharge - return anticipated and marked as an unplanned discharge.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.

Based on observation, interview and record review the facility failed to ensure pressure reducing devices were free from soil. This affected one (Resident #33) out of three residents reviewed for pressure reducing measures. The facility census was 94. Findings include:Review of the medical record for Resident #33 revealed an admission date of 05/06/25 with diagnoses of acute respiratory failure with hypoxia, type two diabetes mellitus, severe protein-calorie malnutrition, severe sepsis with septic shock, metabolic encephalopathy and a stage 2 pressure ulcer on the left heel.Review of the care plan dated 05/07/25 revealed Resident #33 has an actual area of skin impairment with interventions including use of an air mattress, encouragement to wear boots on both feet, evaluation for pain, completion of wound treatments, nursing observation of the wound dressing to ensure it remains intact, monitoring for clinical changes in the wound and completion of skin observations on shower days and as ordered.Review of physician orders dated 05/08/25 revealed the resident is to wear boots on both…

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, interviews, and policy review, the facility failed to ensure name badges were worn at all times by facility staff. This affected all 93 residents at the facility. Facility census was 93. Findings include: Observation on 06/30/25 at 9:48 A.M. of Certified Nurse Assistant #1111 revealed no name badge present. Concurrent interview verified no name badge was present and has not had a permanent one since being hired. The temporary badges that are being used fall off a lot as they are just a sticker. Observation on 06/30/25 at 10:29 A.M. of Activities Aide #1000 revealed no name badge present. Concurrent interview verified that no name badge was present and had not had a permanent one since she lost it. Will obtain a temporary sticker one now. Interview on 06/30/25 at 10:31 A.M. with Resident #301 revealed the staff at the facility rarely have name badges on. Interview on 06/30/25 at 10:42 A.M. with Resident #302 revealed the staff at the facility rarely have name badges on and she can't keep them straight because of that. Interview on 06/30/25 at 10:47 A.M. with…

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

Based on interviews, observation and policy review, the facility failed to ensure scheduled activities were completed as well as ensuring evening activities were scheduled. This affected 92 residents (except for Resident #233) who attend/participate in activities. The facility census was 93. Findings include: Interview on 06/30/25 at 10:31 A.M. with Resident #301 in the activities room revealed the facility rarely does the activities that are posted on the board and stated They just sit out stuff on the table for us to do on our own. No activities in the evening so he gets bored a lot. Interview on 06/30/25 at 10:42 A.M. with Resident #302 revealed there are really never any activities occurring. There are items on the tables, but when it comes to the scheduled events, they rarely happen. There are no evening activities to do as well. She goes into the activities room a lot and can never find anyone with activities in there. Observation on 06/30/25 at 11:30 A.M. of the activities room revealed no move and groove activity being conducted as per schedule with a total of 9 residents…

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 personnel record review and staff interview, the facility failed to complete staff performance evaluations as required. This had the potential to affect 88 of 88 residents. Findings Include: Review of Certified Nursing Assistant (CNA) #165 and CNA #179 personnel records found they did not have a completed 90 day performance evaluation completed. Interview with Visiting Administrator #600 on 12/04/24 at 10:30 A.M. confirmed they have no evidence to support the above staff had performance evaluations completed as required.

Based on observations , and staff interviews the facility failed to ensure the steam warmer and two compartment sink was maintained in a safe and operating condition . This had the potential to affect 85 residents. The census was 88. Findings include: Observation on 12/04/24 at 10:24 A.M. of the kitchen's two compartment sink omitted a strong odor of sewage. The sink was empty. Verified by dietary Aide #105. Observation on 12/4/24 at 10:28 A.M. behind the serving line the steam oven was dripping water from the bottom left side of the door. The water dripped approximately 2 feet down to a 11 x 11 serving metal bin. [NAME] # 217 revealed when she uses the steamer the water drips out . The staff must empty the water filled bin every one to two hours. Dietician #168 verified the water and confirmed she reported the issue to corporate in November 2024. Interview on 12/04/24 03:16 P.M. with the Administrator regarding the steam oven, he confirmed it had been replaced once in the past. The maintenance man must change the seals to prevent the water from dripping. Interview on 12/05/24 01:08…

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, staff interviews, record review, and facility policy review, the facility failed to implement Enhanced Barrier Precautions (EBP) for one resident (Resident #189) who had a feeding tube in place. The facility also failed to follow infection control procedures during wound care for two residents (Residents #81 and #300) and did not follow infection control procedures during catheter care for one resident (Resident #10). The deficient practices affected four residents (#10, #81, #189, #300) of four reviewed for infection control. The facility census was 88. Findings Include: 1. Review of the medical record for Resident #81 revealed an initial admission date of 05/28/24 with the diagnoses including but not limited to acute respiratory failure with hypoxia, diabetes mellitus, dependence on respirator, obstructive sleep apnea, bladder neck obstruction, obstructive and reflux uropathy, congestive heart failure, spinal stenosis lumbar region, hypertension and depression. Review of the resident'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.

Based on interviews, and resident council meeting notes the facility failed to document in writing its responses and rationale to resident council grievances and recommendations. This had the potential to affect eight (#1, #9, #24, #14, #42, #51, #58 and # 66) residents who attend the meetings monthly. The census was 88. Findings include: Review of the Resident Council monthly meeting minutes from 12/26/23 to 11/24/24 revealed old business issues are discussed with no details documented. The meetings do discuss any concerns the residents have and are listed in the meeting minutes, however, there is no documentation from administration of addressing the residents' questions and concerns. Interview on 12/4/24 at 3:29 PM with Resident Council President #42 reported she is not aware of any written responses to the questions and concerns voiced at Resident Council . It is her understanding Activity Director #182 takes care of all the details. Interview on 12/04/24 at 3:45 P.M. with the Activity Director #182 revealed they report concerns from Resident Council in stand up administrative…

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, facility record review, staff interview, and facility policy review, the facility failed to provide the opportunity to view or receive resident medical records in a timely manner. This affected one (Resident #65) of one resident reviewed for medical record release. The census was 88. Findings Include: Resident #65 was admitted to the facility on [DATE]. His diagnoses were end stage renal disease, emphysema, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, alcoholic cirrhosis of liver without ascites, anemia, gout, type II diabetes. other psychoactive substance abuse, cognitive communication deficit, lack of coordination, dysphagia, congestive heart failure, atherosclerotic heart disease, pure hypercholesterolemia, low back pain, neuropathy, major depressive disorder, hyperlipidemia, adult failure to thrive, esophagitis, anxiety disorder, and allergic rhinitis. Review of facility Minimum Data Set (MDS) assessment, dated 09/05/24, revealed he 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, staff interview, and policy review, the facility failed to notify the physician after a significant weight change occurred for Resident #66. This affected one (Resident #66) of five residents reviewed for nutrition. The facility census was 88. Findings include: Review of the medical record for Resident #66 revealed an admission date of 03/16/23 with diagnoses including type 2 diabetes, metabolic encephalopathy, and unspecified dementia. Review of the Minimum Data Set (MDS) dated [DATE] indicated the resident was rarely/never understood, and Section K triggered weight loss concerns without a prescribed weight-loss regimen. A brief interview for mental status (BIMS) assessment revealed a score of 8 out of 15, indicating moderate cognitive impairment. Review of Resident #66's care plan included maintaining adequate nutritional status and addressing weight changes, with interventions including fortified foods twice daily and boost glucose control supplementation. Review of the physician…

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, resident interview, and policy review, the facility failed to complete a timely and thorough grievance investigation and resolution for resident #9's grievances. This affected one (Resident #9) of two residents reviewed for grievance handling. The facility census was 88. Findings include: Review of the medical record for Resident #9 revealed an admission date of 02/15/23 and readmitted on [DATE] with diagnoses including chronic systolic heart failure, morbid obesity with alveolar hypoventilation, asthma, chronic obstructive pulmonary disease, dependence on respirator/ventilator status, obstructive sleep apnea, essential hypertension, chronic venous insufficiency, unspecified depression, anxiety disorder, gastro-esophageal reflux disease, anemia, paroxysmal atrial fibrillation, generalized muscle weakness, and stenosis of a coronary artery stent. Review of the Minimum Data Set (MDS) 3.0 assessment revealed a brief interview for mental status (BIMS) score of 15 out of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and staff interview, the facility failed to develop a comprehensive plan of care for residents. This affected three (#10,#18, and #69) of 24 sampled residents. The facility census was 88. Findings Include: 1. Review of the medical record for Resident #10 revealed an initial admission date of 09/15/22 with the latest readmission of 01/12/23 with the diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), severe protein calorie malnutrition, diabetes mellitus, congestive heart failure (CHF), depression, psychosis, dependence on respiratory ventilator, insomnia, hyperlipidemia, auditory hallucinations, allergic rhinitis, dysphagia, benign prostatic hyperplasia with lower urinary tract symptoms, schizophrenia, anemia, anxiety disorder and hypertension. Review of the plan of care dated 01/12/23 revealed the resident utilized a non-invasive ventilator dependent related to respiratory failure with hypercapnia and COPD. Interventions included keep…

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, interviews and policy and procedure review the facility failed to invite residents' family and or resident representative to a residents' Care Conference. This had the potential to affect two residents (#50 and #70) . The census was 88 . Findings include: 1. Review of the medical record for the Resident #50 revealed an admission date of 07/21/21 with sever cognitive deficits. Diagnoses included Alzheimer's disease, chronic kidney disease, depression and anxiety. Resident #50 requires one person assist with activities of daily living. Review of Resident #50 Care Conference Summary on 07/11/24 revealed Resident #50's Health Care Power of Attorney was not invited to the care conference. Interview on 12/02/24 at 2:05 P.M. with Resident #50's family representative revealed she has not been invited to Resident #50's Care conferences. She confirmed she is the Health Care and Financial Power of Attorney. Interview on 12/04/24 with the Social Services Designee # 112 confirmed she has no documentation indicating Resident #50's representative had been invited 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 observation, medical record review, staff interview and facility policy review, the facility failed to ensure one resident (#10), who was dependent on staff received routine nail care. This affected one resident (#10) of four resident reviewed for activities of daily living (ADL). The facility census was 88. Findings include: Review of the medical record for Resident #10 revealed an initial admission date of 09/15/22 with the latest readmission of 01/12/23 with the diagnoses including but not limited to COPD, severe protein calorie malnutrition, diabetes mellitus, CHF, depression, psychosis, dependence on respiratory ventilator, insomnia, hyperlipidemia, auditory hallucinations, allergic rhinitis, dysphagia, benign prostatic hyperplasia with lower urinary tract symptoms, schizophrenia, anemia, anxiety disorder and hypertension. Review of the plan of care dated 11/03/22 revealed the resident required assistance with activities of daily living (ADL) related to new admission, weakness, depression,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy review, the facility failed to follow physician orders for as needed pain medication administration. This affected one (Resident #65) of three residents reviewed for opioid use. Also, the facility failed to follow wound care orders. This affected one (Resident #70) of three residents reviewed for wound care. The census was 88. Findings Include: 1. Resident #65 was admitted to the facility on [DATE]. Her diagnoses were end stage renal disease, emphysema, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, alcoholic cirrhosis of liver without ascites, anemia, gout, type II diabetes. other psychoactive substance abuse, cognitive communication deficit, lack of coordination, dysphagia, congestive heart failure, atherosclerotic heart disease, pure hypercholesterolemia, low back pain, neuropathy, major depressive disorder, hyperlipidemia, adult failure to thrive, esophagitis, anxiety disorder, and allergic rhinitis. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and staff interview, the facility failed to ensure off-loading skin interventions were in place as physician ordered for one resident. This affected one resident (#10) of two residents reviewed for pressure ulcers. The facility census was 88. Findings Include: Review of the medical record for Resident #10 revealed an initial admission date of 09/15/22 with the latest readmission of 01/12/23 with the diagnoses including but not limited to COPD, severe protein calorie malnutrition, diabetes mellitus, CHF, depression, psychosis, dependence on respiratory ventilator, insomnia, hyperlipidemia, auditory hallucinations, allergic rhinitis, dysphagia, benign prostatic hyperplasia with lower urinary tract symptoms, schizophrenia, anemia, anxiety disorder and hypertension. Review of the plan of care dated 11/03/22 revealed the resident required assistance with activities of daily living (ADL) related to new admission, weakness, depression, cognition. Interventions included…

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

Based on observation, record review, and staff interview, the facility failed to ensure appropriate enteral feeding services were provided Resident #189. This affected one (Resident #189) of one resident reviewed for tube feeding services. The facility census was 88. Findings include: Review of the medical record for Resident #189 revealed an admission date of 11/18/24 with diagnoses including unspecified fracture of the fourth lumbar vertebra, Type 2 diabetes mellitus with hyperglycemia, severe protein-calorie malnutrition, chronic obstructive pulmonary disease (COPD), dysphagia, and other complex conditions. Review of Resident #189's Minimum Data Set (MDS) 3.0 assessment indicated severe cognitive impairment and the need for maximum assistance with activities of daily living (ADLs), including dressing, toileting, and mobility. Review of the physician orders for Resident #189 revealed orders to clean the peg tube site with normal saline and apply split gauze daily starting 11/19/24. Additionally, Enteral feeding was ordered once daily via PEG tube, with a specified rate of 50…

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 provision of appropriate equipment was at the bedside for immediate access for two residents (#9 and #69) and failed to ensure one resident's (#10) nasal cannula oxygen delivery equipment was dated. This affected three residents ( Resident #9,#10 and #69) of three residents reviewed for respiratory care. The facility census was 88. Findings Include: 1. Review of the medical record for Resident #10 revealed an initial admission date of 09/15/22 with the latest readmission of 01/12/23 with the diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), severe protein calorie malnutrition, diabetes mellitus, congestive heart failure (CHF), depression, psychosis, dependence on respiratory ventilator, insomnia, hyperlipidemia, auditory hallucinations, allergic rhinitis, dysphagia, benign prostatic hyperplasia with lower urinary tract symptoms, schizophrenia, anemia, anxiety…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to have all dialysis communication and records were in the facility to ensure full care could be provided. This affected one (Resident #65) of one resident reviewed for dialysis. The census was 88. Findings Include: Resident #65 was admitted to the facility on [DATE]. His diagnoses were end stage renal disease, emphysema, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, alcoholic cirrhosis of liver without ascites, anemia, gout, type II diabetes. other psychoactive substance abuse, cognitive communication deficit, lack of coordination, dysphagia, congestive heart failure, atherosclerotic heart disease, pure hypercholesterolemia, low back pain, neuropathy, major depressive disorder, hyperlipidemia, adult failure to thrive, esophagitis, anxiety disorder, and allergic rhinitis. Review of facility Minimum Data Set (MDS) assessment, dated 09/05/24, revealed he was cognitively intact. Review of Resident #65…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to properly monitor residents psychotropic medications to ensure the need/appropriate dose of psychotropic medications. This affected one (Resident #7) of five residents reviewed for unnecessary medications. The census was 88. Findings include: Resident #7 was admitted to the facility on [DATE]. Her diagnoses were schizoaffective disorder, asthma, type II diabetes, anxiety disorder, major depressive disorder, hypertension, dementia, lack of coordination, schizoaffective disorder, shortness of breath, osteoporosis, aphasia, dysphagia, hypertensive heart disease, moderate intellectual disabilities, hypothyroidism, hyperlipidemia, and diffuse traumatic brain injury. Review of her minimum data set (MDS) assessment, dated 10/02/24, revealed she had a severe cognitive impairment. Review of Resident #7 physician orders found she was prescribed the following psychotropic medications: Olanzapine 15 milligrams (mg), Depakote 250 mg twice daily,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interview, the facility failed to ensure adequate monitoring was completed for a medication as ordered for Resident #9. This affected one (Resident #9) of six residents reviewed for unnecessary medications. The facility census was 88. Findings include: Review of the medical record for Resident #9 revealed an admission date of 2/15/23 and readmitted on [DATE] with diagnoses including chronic systolic heart failure, morbid obesity with alveolar hypoventilation, asthma, chronic obstructive pulmonary disease, dependence on respirator/ventilator status, obstructive sleep apnea, essential hypertension, chronic venous insufficiency, unspecified depression, anxiety disorder, gastro-esophageal reflux disease, anemia, paroxysmal atrial fibrillation, generalized muscle weakness, and stenosis of a coronary artery stent. Review of the Minimum Data Set (MDS) 3.0 assessment revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating no cognitive impairment. 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 medical record review and staff interview, the facility failed to properly monitor resident behaviors to ensure the need/appropriate dose of psychotropic medications. This affected one (Resident #7) of five residents reviewed for unnecessary medications. The census was 88. Findings include: Resident #7 was admitted to the facility on [DATE]. Her diagnoses were schizoaffective disorder, asthma, type II diabetes, anxiety disorder, major depressive disorder, hypertension, dementia, lack of coordination, schizoaffective disorder, shortness of breath, osteoporosis, aphasia, dysphagia, hypertensive heart disease, moderate intellectual disabilities, hypothyroidism, hyperlipidemia, and diffuse traumatic brain injury. Review of her minimum data set (MDS) assessment, dated 10/02/24, revealed she had a severe cognitive impairment. Review of Resident #7 physician orders found a new order for Olanzapine 15 milligrams (mg) for schizoaffective disorder was started on 11/18/24. Prior to this order, she was on…

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

Based on record review, staff interview, resident interview, and policy review, the facility failed to ensure timely collection of a urine sample for a urinary tract infection (UTI) as ordered for Resident #81. This affected one (Resident #81) out of one resident reviewed for labs. The facility census was 88. Findings include: Review of the medical record for Resident #81 revealed an admission date of 5/28/24 with diagnoses including acute respiratory failure with hypoxia, type II diabetes, obesity, dependence on respirator, lack of coordination, obstructive sleep apnea, bladder-neck obstruction, obstructive and reflux uropathy, difficulty walking, edema, combined systolic heart failure, spinal stenosis, and several other chronic conditions. Review of the most recent Minimum Data Set (MDS) 3.0 assessment revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 (Additionally, a BIMS assessment on 12/02/24 with a score of 15), indicating no cognitive impairment. Resident #81 was dependent on a wheelchair and required assistance with toileting, bathing, and personal…

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 one resident (#18) oral assessments were accurate and dental services were arranged to address the resident's poor dental status. This affected one resident (Resident #18) of one resident reviewed for dental. The facility census was 88. Findings Include: Review of the medical record for Resident #18 revealed an initial admission date of 08/07/24 with the most recent admission of 10/11/24 with the diagnoses including but not limited to diabetes mellitus, neuromuscular dysfunction of bladder, fibromyalgia, arthritis, major depressive disorder with psychotic features, obstructive sleep apnea, gastro-esophageal reflux disease, paraplegia, pain, constipation, osteoarthritis, dysphagia and urinary tract infection (UTI). Review of the plan of care dated 09/05/24 revealed the resident required assistance for activities of daily living (ADL) related to fibromyalgia and paraplegia. Interventions included apply…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review,staff interview, and facility policy review, the facility failed to follow their antibiotic stewardship processes for Residents #81 and #43. This affected two (Resident's #81 and #43) out of three residents reviewed for antibiotic use. The facility census was 88. Findings include: 1. Review of the medical record for Resident #81 revealed an admission date of 5/28/24 with diagnoses including acute respiratory failure with hypoxia, type II diabetes, obesity, dependence on respirator, lack of coordination, obstructive sleep apnea, bladder-neck obstruction, obstructive and reflux uropathy, difficulty walking, edema, combined systolic heart failure, spinal stenosis, and several other chronic conditions. Review of the most recent Minimum Data Set (MDS) 3.0 assessment revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 (Additionally, a BIMS assessment on 12/02/24 with a score of 15), indicating no cognitive impairment. Resident #9 was dependent on a wheelchair and required…

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

Based on medical record review, review of immunization records, staff interview, and facility policy review, the facility failed to administer the influenza vaccine to one resident (Resident #20) and the facility failed to administer the pneumococcal vaccine to one resident (Resident #6) after the residents consented to receive the vaccinations. The deficient practice affected two residents (Residents #6 and #20) of five reviewed for immunizations. The facility census was 88. Findings Include: 1. Review of the medical record for Resident #20 revealed an initial admission date on 01/18/24 and a readmission date on 03/08/24. Medical diagnoses included Type II Diabetes Mellitus without complications, metabolic encephalopathy, vascular dementia, essential hypertension, and cognitive communication deficit. Review of the Vaccine Administration Record Informed Consent for Vaccination dated 10/25/24 revealed Resident #20's representative consented for the resident to receive an influenza vaccine. There was no evidence in the medical record Resident #20 received the influenza vaccination…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, interview and facility policy review, the facility did not keep an accurate record of skin wound assessments in the medical record for one (Resident #101) out of three residents with skin wounds. The facility census was 87. Findings include: Review of the medical record for Resident #101, revealed an admission date of 01/18/24. Diagnoses included metabolic encephalopathy, bacteremia, vascular dementia, and type 2 diabetes. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 4 out of 15 which indicates severe cognitive impairment. The resident was determined to not have a pressure ulcer but at risk for developing them. Review of the nursing admission assessment dated [DATE] for Resident #101 revealed no skin alterations for his left and right buttock and his groin area. Review of the skin observation dated 01/21/24 for Resident #101 revealed skin was intact with no new areas opened. Review of…

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

Based on observation, interview, and facility policy review, the facility failed to keep clean drying dishware in a clean dry location and not exposed to dust or other contamination. This had the potential to affect 87 out of 88 residents who receive beverages from the facility. The facility census was 88. Findings include: Observation on 11/13/23 at 11:27 A.M. revealed a recently cleaned rack of mugs and cups air drying on the end of the dishwasher line. Observed a ceiling tile with light pink insulation and dust hanging down from both ends of the ceiling tile and a ceiling vent next to the ceiling tile that was covered in dust. The tiles were above the clean rack of mugs and cups. Interview on 11/13/23 at 11:27 A.M. with Corporate Food Service Director #208 confirmed the ceiling area could be cleaner and there is pink dust at the end of the ceiling vents. Review of the undated Dish Machine Cleaning policy and the weekly Cleaning chart both do not indicate the area above where air drying is taking place.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy review, the facility failed to export resident assessments in a timely manner. This affected 16 (Residents #5, #16, #25, #35, #38, #39, #40, #44, #48, #50, #51, #52, #56, #67, #74, and #83) of 19 resident assessments reviewed. The census was 88. Findings Include: 1. Resident #5 was admitted to the facility on [DATE]. Her diagnoses were dementia, anemia, type II diabetes, depression, COPD, schizoaffective disorder, hyperlipidemia, hypothyroidism, dysphagia, schizophrenia, hypokalemia, aphasia, osteoarthritis, hypertension, cognitive communication deficit, altered mental status, and psychosis. Review of her Minimum Data Set (MDS) assessment, dated 07/06/23, revealed she had a severe cognitive impairment. Review of Resident #5 MDS assessments revealed the last assessment submitted to the Center for Medicare and Medicaid Services (CMS) was on 07/06/23. The facility had started/completed the her most recent MDS on 10/06/23, but due to the electronic…

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 interviews, and facility policy review, the facility failed to ensure pureed food was an appropriate smooth texture prior to serving to residents on a pureed diet and required surveyor intervention for safety. This had the potential to affect nine residents (Residents #7, #49, #39, #5, #75, #4, #81, #64, and #52) who were on a prescribed pureed diet. The facility census was 88. Findings Include: 1. Observation on 11/15/23 at 10:48 A.M. with [NAME] #117 revealed the cook was preparing pureed Italian blend vegetables. [NAME] #117 confirmed the menu for lunch was Italian blend mixed vegetables and barbeque chicken. The recipes were observed to the left of [NAME] #117 during preparation. Vegetables in the Italian vegetable mix include carrots, green beans, cauliflower, and broccoli. Dietary Manager (DM) #178 was present for observation. Observation and interview on 11/15/23 at 10:54 A.M. revealed [NAME] #117 stopped puree machine and stated the vegetable mix was the proper texture for serving to residents. The surveyor present tasted the vegetable mix 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 observation, resident and staff interview, and facility policy review, the facility failed to appropriately confirm one resident's (Resident #71's) code status. This affected one resident (Resident #71) of one resident reviewed for advanced directives. The facility census was 88. Findings Include: Review of the resident record for Resident #71 revealed an admission date on [DATE]. Medical diagnoses included cerebral vascular accident (CVA) (stroke), cognitive communication deficit, encephalopathy, aphasia, seizures, and unspecified mood (affective) disorder. Review of the Durable Power of Attorney for Management of Property and Personal Affairs dated [DATE] revealed Resident #71 named his wife to be Power of Attorney (POA) for finances only. There was not a POA for healthcare decisions named for Resident #71. Review of Resident #71's facesheet revealed the resident was his own responsible party and guarantor. Resident #71's wife was listed as an emergency contact only. Review of the admission Assessment…

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 staff interviews, record review, and facility policy review, the facility failed to accurately assess one resident's (Resident #71) cognition. This affected one resident (Resident #71) of one reviewed for appropriate cognitive status. The facility census was 88. Findings Include: Review of the resident record for Resident #71 revealed an admission date on 06/03/22. Medical diagnoses included cerebral vascular accident (CVA) (stroke), cognitive communication deficit, encephalopathy, aphasia, seizures, and unspecified mood (affective) disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #71 had severely impaired cognition and scored two out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #71 had severely impaired cognition and scored two out of 15 on the BIMS assessment. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #71 had impaired…

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, interview and facility policy review, the facility failed to develop and implement a comprehensive plan of care for three residents (#33, #53, #61) in the area of contractures and antipsychotic medication use. This affected one (Resident #61) of one resident reviewed for contractures and two (Resident #33 and Resident #53) of five residents reviewed for unnecessary medications. The facility census was 88. Findings Include: 1. Review of the medical record for Resident #53 revealed an initial admission date of 10/30/20 with the latest readmission of 06/12/22 with diagnoses including fracture of upper end of right tibia, severe morbid obesity, dependence on respirator, bipolar disorder, osteoarthritis, spinal stenosis lumbar region, obstructive sleep apnea, dysphagia, major depressive disorder, pain, chronic respiratory failure, polyneuropathy, chronic allergic conjunctivitis, overactive bladder, gastro-esophageal reflux and on 06/01/22 the diagnoses of schizophrenia was added.…

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 interviews, and facility policy review, the facility failed to revise a comprehensive care plan to specifically address one resident's (Resident #71) cognitive status changes and whether or not a legal resident representative was needed for healthcare decision making. This affected one resident (Resident #71) of 20 residents reviewed for care plans. The facility census was 88. Findings Include: Review of the resident record for Resident #71 revealed an admission date on 06/03/22. Medical diagnoses included cerebral vascular accident (CVA) (stroke), cognitive communication deficit, encephalopathy, aphasia, seizures, and unspecified mood (affective) disorder. Review of the Durable Power of Attorney for Management of Property and Personal Affairs dated 01/24/22 revealed Resident #71 named his wife to be Power of Attorney (POA) for finances only. There was not a POA for healthcare decisions named for Resident #71. Review of Resident #71's facesheet revealed the resident was his…

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 resident and staff interviews, record review, and facility policy review, the facility failed to ensure one resident's (Resident #239) vital signs were checked upon returning from dialysis treatments. This affected one resident (Resident #239) of one reviewed for dialysis. The facility census was 88. Findings Include: Review of the medical record for Resident #239 revealed and initial admission date on 10/24/23 and a readmission date on 11/03/23. Medical diagnoses included cognitive deficit deficit, end stage renal disease, and acute kidney failure. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #239 had intact cognition and scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #239's function level varied from supervision with eating to total dependence with personal hygiene. Resident #239 required maximal assistance with lower dressing, bathing, and toileting. Resident #239 did not require dialysis 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 medical record review, staff interview, review of pharmacy recommendations, and facility policy review, the facility failed to timely address a pharmacy recommendation for one resident (Resident #33) and failed to provide a rationale for declining a Gradual Dose Reduction (GDR) for two residents (Residents #28 and #33). This affected two residents (Residents #28 and #33) of five reviewed for unnecessary medications. The facility census was 88. Findings Include: 1. Review of the medical record for Resident #33 revealed an admission date on 09/16/21. Medical diagnoses included Alzheimer's Disease, mood (affective} disorder, vascular dementia with other behavioral disturbance, and major depressive disorder. Review of the pharmacy recommendation dated 04/10/23 revealed Resident #33 received a current dose of Seroquel (Quetiapine) 75 milligrams once daily without an attempted Gradual Dose Reduction (GDR). The recommendation was to consider a GDR while monitoring for re-emergence of behavioral and/or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure parameters for when the physician should be notified were provided for one resident's (Resident #33) insulin orders. This affected one resident (Resident #33) of five reviewed for unnecessary medications. The facility census was 88. Findings Include: Review of the medical record for Resident #33 revealed an admission date on 09/16/21. Medical diagnoses included Alzheimer's Disease, Type II Diabetes Mellitus with neuropathy and chronic kidney disease, mood (affective} disorder, vascular dementia with other behavioral disturbance, and major depressive disorder. Review of the physician orders dated November 2023 revealed Resident #33 had the following insulin orders: Humalog Infection Solution inject five units subcutaneously at bedtime dated 06/22/23, Insulin Glargine Solution inject 20 units subcutaneously one time a day upon rise dated 07/29/23, Insulin Glargine Solution inject 30 units subcutaneously at bedtime dated 07/28/23, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to identify target behaviors for the use of antipsychotic medications for three residents (#28, #33, #53) and failed to monitor for side effects of antipsychotic medication use for one resident (#33). This affected three of five residents reviewed for unnecessary medications. The facility census was 88. Findings Include: 1. Review of the medical record for Resident #28 revealed an initial admission date of 11/27/17 with the most recent readmission of 01/23/18 with the diagnoses including chronic obstructive pulmonary disease (COPD), traumatic brain injury, schizoaffective disorder, right sided hemiplegia, epilepsy, major depressive disorder, cardiomyopathy, dementia with mild behavioral disturbance, vitamin D deficiency, post traumatic stress disorder (PTSD) and psychosis. Review of the plan of care dated 05/01/20 revealed the resident had potential for adverse side effects of psychotropic drug use, antidepressant, TBI and major depressive disorder,…

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 obtain laboratory tests for residents as physician ordered. This affected two (Resident #28 and Resident #53) of five residents reviewed for unnecessary medications. The facility census was 88. Findings Include: 1. Review of the medical record for Resident #28 revealed an initial admission date of 11/27/17 with the most recent readmission of 01/23/18 with the diagnoses including chronic obstructive pulmonary disease (COPD), traumatic brain injury, schizoaffective disorder, right sided hemiplegia, epilepsy, major depressive disorder, cardiomyopathy, dementia with mild behavioral disturbance, vitamin D deficiency, post traumatic stress disorder (PTSD) and psychosis. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive deficit. Review of the monthly physician orders for November 2023 identified orders dated 02/10/22 Depakote level and liver function test (LFT), every three months,…

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 interviews, the facility failed to maintain one resident's (Resident #239) wheelchair in proper working order. This affected one of 22 sampled residents. The facility census was 88. Findings Include: Review of the medical record for Resident #239 revealed an initial admission date of 10/24/23 with the latest readmission of 11/03/23 with diagnoses including cognitive communication deficit, retention of urine, end stage renal disease, dependence on hemodialysis and acute kidney failure. Review of the resident's comprehensive Minimum Data Set (MDS) dated [DATE] revealed the resident had no cognitive deficit. On 11/13/23 at 4:22 P.M., interview with Resident #239 revealed she had two different foot pedals to her wheelchair and the left foot pedal would not latch causing her legs spread when moved. Resident #239 revealed this caused her pain to her hips and legs. The resident revealed her transport driver who transports her to dialysis three times a week, as well as herself 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.

Based on medical record review, resident and staff interview, observation, policy review, and review of a Centers for Medicare and Medicaid Services (CMS) memo, the facility failed to ensure activities were provided to meet the needs of the residents. This affected three (#38, #40, and #86) of three residents reviewed for activities. The census was 87. Findings include: 1. Review of the medical record for Resident #40 revealed an admission date of 07/15/21. Resident #40's medical diagnoses included bipolar disorder, diabetes, non-Alzheimer's dementia, and psychotic disorder. Review of Resident #40's annual Minimum Data Set (MDS) assessment, dated 07/03/23, revealed Resident #40 was cognitively intact. Review of the activities care plan, dated 08/02/23, revealed Resident #40 needed encouragement to participate in activities and was dependent on staff for activities. Interventions included to encourage Resident #40 to participate in activities. Review of Resident #40's Record of One on One Activities, dated September 2023, revealed Resident #40 was documented as having a active…

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.