Embassy Of Winchester

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and policy review the facility failed to ensure personal hygiene was completed for one resident (#52) who was dependent on staff. This affected one resident (#52) of three residents reviewed for activities of daily living (ADL). The facility census was 86. Findings include: Review of the medical record for Resident #52 revealed an admission date of 06/22/23 with diagnoses including metabolic encephalopathy, hypertension, hyperlipidemia, vascular dementia, dysphagia, and cognitive communication deficit. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #52 had severe cognitive impairment. Additionally, the resident required the extensive assistance of one person for personal hygiene. Review of the care plan dated 07/18/23 revealed Resident #52 required assistance for ADL related to cognitive impairment and immobility. Interventions included inspecting skin during personal care, staff assist with daily hygiene,…

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 maintain sufficient levels of nursing staff to meet the total care needs of all residents in a timely manner. This affected eight residents (#128, #123, #33, #103, #113, #19, #98 and #105) and had the potential to affect all 134 residents residing in the facility. Findings include: 1. Review of the closed medical record for Resident #128 revealed an admission date of [DATE] with diagnoses including COVID-19, heart disease, congestive heart failure, chronic kidney disease stage three, and atrial fibrillation. Record review revealed the resident was a Full Code related to advance directives. The resident expired in the facility on [DATE]. Review of the Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) of 12 indicating the resident had moderate cognitive impairment. The assessment revealed the resident required extensive assistance from one staff for bed mobility and toilet use,…

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 it was administered in a manner to ensure all residents received the care and services necessary to attain or maintain their highest practicable physical, mental and psychosocial well-being. This had the potential to affect all 134 residents residing in the facility. Findings include: During the annual recertification, extended and complaint survey completed from [DATE] through [DATE] the following concerns were identified through observation, record review, facility policy and procedure review and interview: a. The facility failed to ensure all residents (including Resident #11, #13, #65 and #85) who required staff assistance with activities of daily living (ADL) care received timely and appropriate care and services to maintain proper hygiene and grooming. See findings at F677. b. The facility failed to initiate timely and adequate Cardio-pulmonary Resuscitation (CPR) for Resident #128 who was a full-code and required CPR after…

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 residents were treated with respect and dignity. This affected six residents (#11, #35, #45, #53, #87 and #117) of 134 residing in the facility. Findings include: 1. On 10/25/21 at 12:50 P.M. observation of the lunch meal revealed State Tested Nursing Assistant (STNA) #445 was observed passing meal trays on Hall A. At 12:50 P.M. Resident #117, who was observed in the dining room was served a meal tray. There were four other residents, Resident #11, #35, #45 and #53 at the table who were not served at that time. STNA #445 then passed more trays on Hall A leaving the dining room to do so. At 1:04 P.M. STNA #445 had Resident #48 come to the dining area and served him his tray and Resident #35 was also served at this time. STNA #445 again left the dining room and passed more trays on the hall A. Resident #11, #45 and #53 watched the other residents eat until 1:06 P.M. when they were finally served their tray. Interview with STNA #445…

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 maintain a safe, clean and comfortable environment for all residents. This affected six residents (#34, #24, #71, #385, #46 and #11) of 14 residents reviewed for physical environment. Findings include: 1. On 10/25/21 at 10:46 A.M. Resident #34 was observed sitting on a bedside commode as if it were a chair. The bed side commode was next to the head of Resident #34's bed. Resident #34 was fully dressed and gazing out the window. There was not a personal (sitting) chair located in Resident #34's room. Additional observations on 10/27/21 at 8:38 A.M. and on 11/03/21 at 8:50 A.M. revealed the bedside commode remained beside Resident #34's bed and no other chair was observed to be in the resident's room. On 10/27/21 at 10:47 A.M. interview with State Tested Nursing Assistant (STNA) #485 confirmed there was no chair available for Resident #34 or any visitors in the resident's room. STNA #485 revealed she thought the resident was OK sitting on a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure Pre-admission Screening and Resident Reviews (PASARR) were completed for residents diagnosed with a new mental diagnosis at the time of or after their admission to the facility. This affected five residents (#11, #63, #64, #98, and #109) of eight residents reviewed for PASRR. Findings include: 1. Review of the medical record for Resident #63 revealed an admission date of [DATE] with diagnoses including aphasia, anxiety disorder, dementia, chronic obstructive pulmonary disease, major depression disorder. A new diagnosis (dated [DATE]) for unspecified psychosis not due to a substance or known physiological condition was also included on the resident's diagnoses list. Review of the Preadmission Screening/Resident Review Identification Screen, dated [DATE] revealed Resident #63 had a mood disorder and depression. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed the resident had impaired cognition. On [DATE]…

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, facility policy and procedure review and interview the facility failed to ensure all residents who required staff assistance with activities of daily living (ADL) care received timely and appropriate care and services to maintain proper hygiene and grooming. This affected five residents (#11, #13, #18, #65 and #85) of nine residents reviewed for ADL care. Findings include: 1. Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia with behaviors, schizophrenia, major depression and anemia. Review of the plan of care, dated 09/24/20 revealed staff would assist as needed with daily hygiene and assist with showering resident as per facility policy weekly. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 10/04/21 revealed the resident exhibited cognitive impairment, required extensive assistance of two plus staff members for bed mobility and extensive assistance of one plus staff…

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, facility policy and procedure review and interview the facility failed to provide appropriate urinary catheter care to prevent the risk of urinary tract infections for residents. This affected four residents (#61, #383, #87 and #11) of five residents reviewed for urinary catheters and/or urinary tract infections. Findings include: 1. Review of the medical record for Resident #61 revealed an admission date of 03/03/21 with diagnoses including encounter for orthopedic aftercare following surgical amputation, muscle weakness, paraplegia, neuromuscular dysfunction of bladder, urinary tract infection, adult failure to thrive, diabetes, dementia, major depressive disorder and personal history of cerebral infarction. Review of the plan of care, dated 05/03/21 revealed Resident #61 had potential for complications related to suprapubic catheter. Interventions for Resident #61 included to assist with catheter care as needed, educate resident on signs and symptoms of urinary tract…

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, review of facility self-reported incidents (SRIs), review of facility investigations and interview the facility failed to develop and implement comprehensive and individualized behavior management programs for residents with dementia to prevent resident to resident altercations and to ensure each resident maintained their highest practicable physical, mental, and psychosocial well-being. This affected five residents (#10, #19, #113, #126 and #127) with the potential to affect all 21 residents residing on D hall/East Building and two residents (#13 and #111) with the potential to affect all 19 residents residing on A hall/East Building. The facility census was 134. Findings include: 1. Review of the medical record revealed Resident #113 admitted to the facility on [DATE] with diagnoses including aphasia, metabolic encephalopathy, Alzheimer's disease, major depressive disorder, essential hypertension, type two diabetes mellitus, dysphagia, obsessive-compulsive disorder, 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 observation, facility policy and procedure review and interview the facility failed to ensure medications were stored and labeled properly and were disposed of following expiration. This affected four residents (#61, #115, #128 and #59) of 21 residents who resided on the F Hall. Findings include: On [DATE] at 1:15 P.M. observation of the F Hall medication cart revealed several medications were observed to be without open or expiration dates. Several insulin pens, including Novolog insulin pens for Residents #61 and #115, were observed sitting loosely in the top drawer of the medication cart and were not stored in a bag or box. Novolog insulin pens were observed to be labeled for Residents #61 and #115 with no expiration dates written on the pens. Further observation revealed a Novolog insulin pen labeled for Resident #59 was penned with an expiration date of 09/28. A Humalog insulin pen was observed to be labeled for Resident #128 (who expired in the facility on [DATE]), with no expiration date.…

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 and interview the facility failed to maintain a safe, functional and sanitary environment for all residents. This affected Resident #383 who resided on the F hall and had the potential to affect all 21 residents who resided on the D hall/East Building and all 19 residents who resided on the A hall/East Building. The facility census was 134. Findings include: 1. On 11/02/21 at 1:30 P.M. Resident #383 was observed to be resting in bed A of her room. At the time of the observation, the privacy curtain in the room was observed bunched in the middle corner of the L shaped track for bed A, and partially blocking the view of Resident #383 from the door. When attempting to pull the privacy curtain to the side, to gain entrance to the room and observe and interview Resident #383, the curtain was observed to feel lose and flimsy, and spring up and down several inches. Further observation revealed the metal, L shaped track that was connected to the ceiling and holding up the privacy curtain, 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.

Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #87 and Resident #93's call lights were within reach to accommodate the residents' need to obtain staff assistance by ringing the call light. This affected two residents (#87 and #93) of 51 sampled residents. Findings include: 1. Review of Resident #87's medical record revealed an original admission date 02/01/21 with the latest readmission of 10/19/21. Resident #87 had diagnoses including pseudobulbar affect, aphasia, urinary tract infection (UTI), urine retention, peripheral vascular disease, gastro-esophageal reflux disease, Alzheimer's disease, osteoarthritis, psychosis, major depressive disorder, hyperlipidemia, anxiety disorder, hypertension, bipolar disorder, atrial fibrillation and dysphagia. Review of the plan of care, dated 02/05/21 revealed the resident required assistance for activities related to cognitive/communication deficits, no awareness of needs or limitations and incontinence of bowel and bladder. Interventions included to keep call light…

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 provide quarterly statements for residents they managed personal fund accounts for. This affected two residents (#15 and #71) of seven residents reviewed for accounting of funds. The facility identified 84 residents for whom they managed personal fund accounts. Findings include: On 10/25/21 at 10:35 A.M. interview with Resident #15 revealed the facility had never provided him with an account statement for his personal funds account and he didn't know how much money he had. On 10/25/21 at 11:06 A.M. interview with Resident #71 revealed the facility managed personal funds for him and he had never received a balance statement. Review of the personal fund account documentation for Resident #121, #11, #112, #48, #39, #15 and #71 revealed no evidence quarterly statements were provided to the residents and/or their representatives each quarter. On 10/26/21 at 1:29 P.M. interview with Business Office Manager #550 verified there was no documentation/ evidence quarterly statements were issued to Resident #121, #11, #112, #48, #39,…

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 #21 and Resident #87's advance directives were accurate and based on the residents' current wishes. This affected two residents (#21 and #87) of five residents reviewed for advance directives. Findings include: 1. Review of Resident #87's medical record revealed an original admission date [DATE] with the latest readmission of [DATE]. Resident #87 had diagnoses including pseudobulbar affect, aphasia, urinary tract infection (UTI), urine retention, peripheral vascular disease, gastro-esophageal reflux disease, Alzheimer's disease, osteoarthritis, psychosis, major depressive disorder, hyperlipidemia, anxiety disorder, hypertension, bipolar disorder, atrial fibrillation and dysphagia. Review of the Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed the resident had clear speech, sometimes understood others, sometimes made herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure privacy was provided during wound care for Resident #27 and during urinary catheter care for Resident #58. This affected one resident (#58) four residents reviewed urinary catheter use and one resident (#27) of three residents reviewed for pressure ulcers. Findings include: 1. Review of Resident #58's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia with behaviors, obstructive and reflux uropathy (urine regurgitates from the bladder back into the ureter) chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/04/21 revealed the resident was cognitively impaired, he required supervision with set up assistance and supervision from one staff for bed mobility, transfers and dressing with one person physical assist. Review of the current physician's orders revealed an order, initiated 02/05/21 for…

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

Based on record review and interview the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) Level I screen was completed accurately for Resident #126 upon admission. This affected one resident (#126) of eight residents reviewed for PASARR. Findings include: Review of the medical record for Resident #126 revealed an admission date of 05/20/21 with diagnoses including personal history of malignant neoplasm of unspecified digestive organ, encephalopathy, altered mental status, hyperlipidemia, unspecified dementia without behavioral disturbance, cognitive communication deficit and aphasia. The diagnosis of delusional disorders was dated 05/20/21. Review of the review results, dated 05/21/21 revealed the Pre-admission Screening (PAS) determination had no indications of serious mental illness nor a developmental disability. Review of the PASARR for Resident #126 dated 05/21/21 revealed no mental illness was noted. On 10/26/21 from 4:36 P.M. to 4:48 P.M. interview with Social Worker (SW) #481 revealed she was responsible for completing the PASARR forms 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 2. Review of Resident #117's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia, chronic kidney disease, high blood pressure and anemia. Review of the admission MDS 3.0 assessment, dated 09/23/21 revealed the resident's cognition was moderately impaired, he required extensive assistance of two staff members for bed mobility, transfers, dressing and toilet use and extensive assistance from one staff member for personal hygiene. The assessment revealed the resident had an indwelling urinary catheter and was frequently incontinent of bowel. Review of the physician's orders for 10/2021 revealed an order for Foley catheter care every shift and as needed, empty urinary catheter bag every shift and as needed (prn) and record output and total every 24 hours. Review of the plan of care, dated 10/16/21 revealed to obtain urine output each shift and total for 24 hour period. Further review of the medical record revealed the urine output and total was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to accurately assess and monitor areas of non-pressure related skin impairment for Resident #46 and failed to ensure physician ordered skin treatments were documented only when completed. This affected one resident (#46) of three residents reviewed for skin treatments. Findings include: Review of the medical record revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, hemiplegia and hemiparesis following cerebral infarction affecting right dominants side, muscle weakness, hypertension, atrial fibrillation and need for assistance with personal care. Review of the physician's orders dated 04/29/21 revealed an order to apply DermaSarra Anti-Itch Lotion 0.5-0.5 % (Camphor-Menthol) every shift for itching for Resident #46. Review of the plan of care, dated 06/04/21 revealed Resident #46 had the potential for alteration in skin integrity related to cognitive communication deficit, hand…

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 Resident #123 received a vision follow up for complaints of double vision. This affected one resident (#123) of two residents reviewed for vision services. Findings include: Record review for Resident #123 revealed an admission date of 02/12/21 with diagnoses including heart failure, anxiety, diabetes type two, depression, weakness and chronic pain syndrome. Review of the care plan, dated 02/15/21 revealed the resident was at risk for visual decline/undetected eye diseases, or currently exhibited deficits as evidenced by diabetes type two. Interventions included to arrange eye appointments if increased visual deficits were noted Review of an eye exam, dated 08/23/21 revealed the resident's right and left eyes were in stable condition, the resident denied changes in vision and eye pain. There was no active diabetic retinopathy in either eye. Hypertensive retinopathy noted with mild retinal changes consistent with high blood pressure and minimal occlusive risk. New orders to return in six to nine months for a follow…

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, facility policy and procedure review and interview the facility failed to assess and implement weight loss interventions for Resident #87, a resident identified with a a significant weight loss following a hospitalization. This affected one resident (#87) of six residents reviewed for nutrition. Findings include: Review of Resident #87's medical record revealed an original admission date 02/01/21 with the latest readmission of 10/19/21. Resident #87 had diagnoses including pseudobulbar affect, aphasia, urinary tract infection (UTI), urine retention, peripheral vascular disease, gastro-esophageal reflux disease, Alzheimer's disease, osteoarthritis, psychosis, major depressive disorder, hyperlipidemia, anxiety disorder, hypertension, bipolar disorder, atrial fibrillation and dysphagia. Review of the plan of care, dated 02/05/21 revealed Resident #87 was at risk for alteration in nutrition and/or hydration related to behavioral problems, edentulous, need for feeding assistance and mechanically altered diet. Interventions included to address any…

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, facility policy review and interview the facility failed to ensure Resident #92's oxygen equipment was maintained in a clean and sanitary manner and failed to ensure oxygen tubing was changed per physician order. This affected one resident (#92) of three residents reviewed for respiratory care. Findings include: Review of Resident #92's medical record revealed an admission date of 09/02/21 and diagnoses of acute respiratory failure and oxygen dependence. Review of the physician's orders, dated 09/03/21 revealed staff were to change the resident's oxygen tubing and set up every Friday. On 09/02/21 the resident was ordered oxygen on one liter via nasal cannula. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 09/09/21 revealed the resident had a Brief Interview of Mental Status (BIMS) of 02, indicating impaired cognition. The assessment revealed the resident required limited assistance from one staff for bed mobility, transfers, locomotion via walker and personal hygiene and the resident utilized oxygen therapy. Review of the care plan,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure ongoing communication with the hemodialysis center regarding care and services for Resident #109. This affected one resident (#109) of one resident reviewed for hemodialysis. Findings include: Review of Resident #109's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including end stage renal disease, dependence on renal dialysis and schizoaffective disorder. Review of the plan of care, dated 06/15/21 revealed communicate with dialysis center staff regarding plan of care, lab values and diet/fluid restriction recommendations. Nurse to utilize dialysis communication form for pre-dialysis assessment including obtaining vital signs. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/16/21 revealed the resident's cognition was moderately impaired. The assessment revealed the resident required supervision from staff with set up assistance for dressing and personal hygiene. 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 and procedure review and interview the facility failed to ensure medications were available for administration as ordered. This affected three residents (#31, #91 and #282) of 51 sampled residents. Findings include: 1. Review of the medical record for Resident #91 revealed an admission date of 08/26/21 with diagnoses including intellectual disabilities, psychosis, mood disorder, weakness, insomnia, difficulty walking, need for assistance with personal care and paranoid schizophrenia. Review of the care plan, dated 08/26/21 revealed Resident #91 had impaired cognitive process for daily decision making and she was at risk for further decline in cognitive function. Interventions included to encourage the resident to make routine daily decisions and administer medications as ordered. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 09/08/21 revealed a Brief Interview of Mental Status (BIMS) of 11 indicating impaired cognition. The assessment revealed the resident 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.

Based on record review and interview the facility failed to timely clarify conflicting physician recommendations from a pharmacy medication regimen review dated 06/23/21 to ensure Resident #79 received appropriate care and treatment related to the use of an anti-anxiety medication. This affected one resident (#79) of six residents reviewed for unnecessary medication use. Findings include: Review of the medical record for Resident #79 revealed an admission date of 08/06/16 with diagnoses of anxiety, depression, psychosis, dementia with behavior disturbances, encephalopathy and insomnia. Review of the care plan, dated 06/10/20 revealed the resident had the potential for mood swings and behavioral issues related to depression, psychosis and anxiety. Interventions included to administer as needed medications as ordered when the resident exhibited any increased agitation, anxiety, pacing, hallucinations, mood changes, restlessness, wandering or abusive behaviors, etc. Review of the resident's physician orders revealed from 06/19/21 through 07/07/21 the resident had an order for Ativan…

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, facility policy and procedure review and interview the facility failed to ensure as needed (PRN) psychotropic medications were limited to 14 days without a rationale extending the medication for Resident #79 and failed to ensure non-pharmacological interventions were attempted prior to the use of an as needed psychotropic medication for Resident #87. This affected two residents (#79 and #87) of six residents reviewed for unnecessary medications use. Findings include: 1. Review of the medical record for Resident #79 revealed an admission date of 08/06/16 with diagnoses including anxiety, depression, psychosis, dementia with behavior disturbances, encephalopathy and insomnia. Review of the care plan, dated 06/10/20 revealed the resident had the potential for mood swings and behavioral issues related to depression, psychosis and anxiety. Interventions included to administer as needed medications as ordered when the resident exhibited any increased agitation, anxiety, pacing, hallucinations, mood changes, restlessness, wandering or abusive behaviors, etc. 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 record review and interview the facility failed to obtain dental services in a timely manner for Resident #11, Resident #18 and Resident #98. This affected three residents (#11, #18 and #98) of three residents reviewed for dental services. Findings include: 1. Review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia with behaviors, schizophrenia, major depression and anemia. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 10/04/21 revealed the resident was cognitively impaired. The assessment revealed the resident required extensive assistance of two plus staff members for bed mobility and extensive assistance of one plus staff member for toilet use, dressing and personal hygiene. Review of the dental record revealed on 05/20/21 an emergency exam was completed and the resident was to be seen for further dental care. Record review revealed no further dental care had been provided for the resident as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure Resident #117's medical record was maintained in a complete and accurate manner related to monitoring the resident's output. This affected one resident (#117) of 51 sampled residents whose medical records were reviewed. Findings include: Review of Resident #117's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia, chronic kidney disease, high blood pressure and anemia. On 09/19/21 a physician's orders was received to record output every shift (qshift). Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 09/23/21 revealed the resident's cognition was moderately impaired, he required extensive assistance of two staff members for bed mobility, transfers, dressing and toilet use and extensive assistance from one staff member for personal hygiene. The assessment revealed the resident had an indwelling urinary catheter and was frequently incontinent of bowel. 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.