Altercare Of Nobles Pond, INC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure residents medication regimens had an appropriate indication for use. This affected one resident (Resident #4) of five residents reviewed for unnecessary medications. The facility census was 61.Findings include:Resident #4 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, peripheral vascular disease, a urinary tract infection, calculus of the kidney, and osteonecrosis to the left femur from a previous trauma. Resident #4's medical record did not include diagnoses of generalized anxiety disorder, depression, or any psychiatric conditions. Review of Resident #4's progress notes from 02/27/26 through 03/04/26 revealed no indication or record of Resident #4 exhibiting any signs or symptoms of anxiety. There was no documentation of Resident #4 being referred to the facility's psychiatric services. Review of Resident #4's admission psychiatric evaluation on 03/04/26 by Medical Doctor (MD) #950,…

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 ensure a medication error rate of 5% or less. A total of 26 medications were administered with six errors for a medication error rate of 23.08%. This affected two residents (Residents #27 and #37) of three residents observed for medication administration. The facility census was 61.Findings include:1. Review of Resident #37's medical record revealed the resident was admitted on [DATE] with diagnoses including muscle weakness, need for assistance with personal care and chronic obstructive pulmonary disease.Review of Resident #37's physician orders revealed an order dated 03/13/26 for Calcium Citrate (supplement) 250 milligrams (mg) once daily; an order dated 02/17/26 for Glucosamine-Chondroit-Vitamin C-minerals (supplement) 500-400 mg administer 200-250 mg twice daily; an order dated 02/20/26 for Miralax (laxative) 17 grams once daily; an order dated 03/02/26 for Preservision Areds (eye vitamin supplement) 200…

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, interview, and policy and procedure review the facility failed to ensure food was stored in a manner to protect from contamination/spoilage, the oven was maintained in a clean/sanitary manner, and food was prepared/served in accordance with standards for food service safety. This had the potential to affect 68 out of 69 residents receiving food from the kitchen. Resident #127 was identified as not receiving anything by mouth and received no food from the kitchen. The facility census was 69. Findings Include: Observation during tour of the kitchen on 06/09/25 at 8:10 A.M. with the Dietary Manager revealed in the dry goods storage room there was an open bag of cake mix and an open bag of instant mashed potatoes with no label or date as to when opened. Inside the walk-in freezer there were frozen french toast sticks in a zip lock bag and an opened bag of biscuits with no labels or dates. In the preparation area, the oven had food residue and food splatter on it. Observation on 06/10/25 from 11:30 to 12:53 P.M. during lunch meal service tray line revealed that at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide residents with their preferences during meals. This affected five ( #28, #30, #31, #32, and #40 ) of six residents reviewed for food and drink. The facility census was 69. Findings Include: 1. Review of Resident #28 medical record revealed the resident was admitted on [DATE] with diagnoses including anorexia, adult failure to thrive and anxiety disorder. Review of Resident #28's care plans revealed an intervention dated 11/25/24 to provide the diet per the physician's order and honor preferences. Review of Resident #28's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #28 exhibited moderate cognitive impairment. Review of Resident #28's physician orders for June 2025 revealed an order for a regular diet, thin liquid consistency. Observation on 06/09/25 at 1:36 P.M. revealed Resident #28's lunch ticket indicated the resident chose apple juice but received cranberry juice. This was verified by…

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 Resident #21's left palm protector was implemented as ordered to prevent skin breakdown and prevent deformity. This affected one (Resident #21) of one resident reviewed for position and mobility. Findings Include: Review of Resident #21's medical record revealed the resident was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, muscle weakness and vascular dementia. Review of Resident #21's physician orders revealed an order dated 01/23/25 for a left palm protector to be placed on in the morning and removed at bedtime and to check skin integrity twice daily. Review of Resident #21's Quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #21's care plans revealed an intervention dated 04/15/25 for a palm protector to the left hand. Review of Review of Resident…

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

Based on record review, observation, interview, and review of facility policy, the facility failed to provide enteral feeding as ordered for Resident #127. This affected one (#127) of one resident who received enteral feedings. The facility census was 69. Findings Include: Review of the medical record for Resident #127 revealed an admission date of 05/24/25 with diagnoses including dysphagia oropharyngeal phase, aphasia, and gastrostomy status. Review of the admission Minimum Data Set assessment, dated 05/31/25, revealed Resident #127 was cognitively intact, dependent on staff for activities of daily living, and received 51 percent or more of calories and 501 milliliter (ml) or more of fluids from tube feeding daily. Review of the physician's orders for June 2025 for Resident #127 identified an order dated 05/27/25 for continuous enteral feeding formula Isosource 1.5 at 55 ml per hour. There were no physician's orders for enteral feeding formula substitutions. Review of the medication administration record for 06/08/25 revealed continuous enteral feeding formula Isosource 1.5 at 55…

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 Resident #34's carbohydrates were monitored during meals, assisted with adding the carbohydrate count to the insulin pump, the resident's care plans were updated to reflect accurate interventions for caring for the resident's insulin pump, the resident's physician orders accurately reflected the amount of as needed insulin to be administered to the resident and the staff were knowledgeable in operating the resident's insulin pump. This resulted in significant insulin medication errors affecting one (Resident #34) of two residents reviewed for insulin administration. The facility census was 69. Findings Include: Review of Resident #34's medical record revealed the resident was admitted on [DATE] with diagnoses including unspecified nondisplaced fracture of the surgical neck of the right humerus, type one diabetes mellitus and spastic quadriplegic cerebral palsy. Review of Resident #34's admission Minimum Data Set 3.0 assessment dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to accurately document the details of a fall and fall investigation. This affected one resident (#10) out of two residents reviewed for falls. The facility census was 69. Findings Include: Review of the medical record for Resident #10 revealed an admission date of 03/17/25 and readmission date of 05/13/25 with diagnoses including bilateral osteoarthritis of the knee, atrial fibrillation, difficulty in walking, type two diabetes mellitus, chronic obstructive pulmonary disease, bipolar disorder, hypertension, acute and chronic respiratory failure with hypoxia, and weakness. Review of the admission assessment dated [DATE] revealed Resident #10 was at low risk for falls with a score of 4.0 (the assessment indicated high risk was a score of 10.0 or higher). Review of the fall investigation report dated 05/20/25 timed 6:00 A.M. indicated Resident #10 had a fall with injury. The question asking Was the patient injured? was answered Other: -states none. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure call lights were in working order. This affected one resident (#36) of one resident reviewed for call light placement. Findings Include: Review of Resident #36's medical record revealed the resident was admitted on [DATE] with diagnoses including pancytopenia, diabetes mellitus, and atherosclerotic heart disease.Review of Resident #36's admission Minimum Data Set 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition.Review of a plan of care dated 04/21/25 revealed Resident #36 was at risk for falls. Interventions included to encourage Resident #36 to use call light for transfer/ambulation assistance.Observation and interview on 06/10/25 at 12:57 P.M. revealed Resident #36 needed assistance. Resident #36 stated that he had been using the call light, and it was not working. He stated that he wanted to be positioned for when lunch arrived. An attempt to activate the call light at time of observation/interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on interview, record review, self-reported incident (SRI) review, and facility policy review the facility failed to protect Residents #70, #22, #21, #64, #71 from misappropriation of narcotic medication. This affected five residents (#70, #22, #21, #64, #71) of the 29 residents who received narcotic medication. The facility census was 82. Findings include: 1. Review of the medical record for Resident #70 revealed an admission date of 04/09/24 and was discharged from the facility on 04/13/24. Medical diagnoses included fracture of the neck of the left femur, aftercare following joint replacement, cardiomyopathy, atrial fibrillation, congestive heart failure, and severe protein calorie malnutrition. Review of Resident #70's physician orders dated 04/09/24 revealed an order to administer Oxycodone Hydrochloride (HCL) 5 milligrams (mg) (opioid pain medication) for severe pain every six…

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 review of the medical record, review of the facility stock medications, and interview with the staff the facility failed to ensure medications were obtained timely and initiated as ordered for Residents #26, #65, and #57. This affected three residents (#26, #57, and #65) of nine residents reviewed for medication administration. Findings include: 1. Review of the medical record revealed Resident #65 was admitted to the facility on [DATE]. Diagnoses included post hemorrhagic anemia, gastrointestinal hemorrhage, thrombocytopenia, vitamin D deficiency, diabetes, anxiety disorder, atherosclerotic heart disease, hypertension, nonalcoholic steatohepatitis (NASH), gout, low back pain, urinary tract infection, acute kidney disease, and osteoarthritis. She discharged home on [DATE]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #65 had intact cognition. Review of the December 2023 Medication Administration Record (MAR) revealed Resident #65 did not receive her morning…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, and staff interviews the facility failed to ensure aerosol masks and oxygen tubing were dated as to when they were last changed for Residents #27, #12, #42, #49 and #37, failed to place aerosol mask/mouthpieces in a protective barrier bag for Residents #27, #49 and #37, and failed to ensure the aerosol mask was cleaned for Resident #37. This affected five residents (#27, #12, #42, #49 and #37) of 19 residents with oxygen or aerosol treatments. Findings include: 1. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included cellulitis, sepsis, fluid overload, hypertension, acute respiratory failure, bacteremia, traumatic ischemia of the muscles, falls, and adult failure to thrive. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had intact cognition. An observation on 01/25/24 at 9:40 A.M. revealed the oxygen tubing and aerosol mask for Resident #27 were not dated as to when…

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 staff interview the facility failed to ensure urinary drainage bags for Residents #27, #40, and #62 were covered to maintain dignity. This affected three residents (#27, #40, and #62) of nine residents reviewed for dignity and respect. Findings include: 1. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included cellulitis, sepsis, fluid overload, hypertension, acute respiratory failure, bacteremia, traumatic ischemia of the muscles, falls, and adult failure to thrive. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had intact cognition and had an indwelling urinary catheter. An observation on 01/25/24 at 9:40 A.M. revealed the urinary drainage bag of Resident #27 was uncovered, and the urine in the bag was visible from the hallway. The drainage bag was secured to the bed frame. On 01/25/2 at 9:46 A.M. an interview with Nurse #100 verified the urinary drainage bag of Resident #27 should be…

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 staff interview the facility failed to maintain a clean sanitary environment for Resident #26. This affected one resident (#26) of three residents reviewed for facility sanitation. Findings include: Review of the medical record revealed Resident #26 was admitted to the facility on [DATE]. Diagnoses included displaced bimalleolar fracture of the right lower leg, falls, muscle weakness, abnormalities of gait, acute respiratory failure, COVID-19, thyrotoxicosis, acute pain due to trauma, hypertension, atherosclerotic heart disease, and osteoporosis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had intact cognition. She was dependent on staff for sitting up on the side of the bed and standing. She had not transferred at the time of the assessment. She was frequently incontinent of bladder and bowel. On 01/25/24 at 1:50 P.M. an interview with Resident #26 revealed when she was readmitted to the facility, she was placed in the room she was in…

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 review of the medical record and interview with the staff the facility failed to ensure showers were given to dependent Resident #26. This affected one resident (#26) of three residents reviewed for showers. Findings include: Review of the medical record revealed Resident #26 was admitted to the facility on [DATE]. Diagnoses included displaced bimalleolar fracture of the right lower leg, falls, muscle weakness, abnormalities of gait, acute respiratory failure, COVID-19, thyrotoxicosis, acute pain due to trauma, hypertension, atherosclerotic heart disease, and osteoporosis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had intact cognition. She was dependent on staff for sitting up on the side of the bed and standing and required substantial/maximal assist with bathing/showering. She was frequently incontinent of bladder and bowel. Review of the shower documentation revealed there was no documentation Resident #26 had a bath or shower from 12/27/23 through…

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, review of the medical record and interview with staff the facility failed to timely treat a urinary tract infection for Resident #26 and failed to have a physician's order for indwelling urinary catheters for Residents #27 and #40. This affected one resident (#26) of three residents reviewed for medications and two residents (#27 and #40) of nine residents reviewed for physician's orders. Findings include: 1. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE]. Diagnoses included displaced bimalleolar fracture of the right lower leg, falls, muscle weakness, abnormalities of gait, acute respiratory failure, COVID-19, thyrotoxicosis, acute pain due to trauma, hypertension, atherosclerotic heart disease, and osteoporosis. Review of the physician's orders revealed Resident #26 had an order for a bladder scan twice daily and to straight catheterize her if the bladder had more than 500 milliliters of urine dated 12/29/23. Review of the admission Minimum Data…

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 timely notify Resident #56's representative of a fall with injury. This affected one (#56) of seven residents reviewed for accidents. The census was 59. Findings include: Review of the closed medical record for Resident #56 revealed an admission date of [DATE] with diagnoses including inclusion body myositis, acute respiratory failure with hypercapnia, anemia, depression, hypertension, pneumonia, constipation, vitamin D deficiency, age related physical debility, anxiety disorder, gastrostomy status, altered mental status, and diabetes mellitus. The resident expired on [DATE]. There was no comprehensive Minimum Data Set (MDS) Assessment because Resident #56 was only in the facility for six days prior to his expiration. Review of the assessment titled Clinical admission Documentation 0419, dated [DATE], revealed Resident #56 was not at high risk for falls. The assessment also indicated there was no baseline care plan for falls. Review of the nurse note…

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 baseline care plans were completed for two (Residents #162 and #265) of 25 residents whose records were reviewed during the annual survey. The facility census was 59. Findings include: 1. Review of the medical record for Resident #162 revealed an original date of admission of 09/09/23 and a readmission date of 09/30/23. Diagnoses included infection following a procedure, other surgical site, subsequent encounter, altered mental status, unspecified, need for assistance with personal care, enterostomy malfunction, bacteremia, parastomal hernia, anal fistula, unspecified intestinal obstruction, retention of urine, personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus, encounter for surgical aftercare following surgery on the digestive system, unspecified cystostomy status, sepsis, unspecified organism, urinary tract infection, site not specified, and malignant neoplasm of lateral wall of bladder. Review of Clinical…

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 interview, record review, review of the facility investigation, review of the coroner's investigation, and review of facility policy, the facility failed to timely assess for injury of Resident #56 after he was found deceased on the floor, failed to timely notify the coroner of a potential head injury for Resident #56 which resulted in a delay of post-mortem evaluation, and failed to ensure a thorough investigation was completed for Resident #56's fall and death. This affected one (#56) of three residents reviewed for falls and one (#56) of three residents reviewed for death. In addition, the facility failed to ensure transfers were performed according to physician orders, which affected one (#28) of seven residents reviewed for accidents. The census was 59. Findings include: 1. Review of the closed medical record for Resident #56 revealed an admission date of [DATE] with diagnoses including inclusion body myositis, acute respiratory failure with hypercapnia, anemia, depression, hypertension, pneumonia,…

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 and post dialysis assessments were completed per the facility policy. This finding affected two (Residents #5 and #28) of two residents investigated for dialysis services. Findings include: 1. Review of Resident #5's medical record revealed the resident was admitted on [DATE] with diagnoses including end stage renal disease, mixed hyperlipidemia and diabetes. Review of Resident #5's physician orders revealed an order dated 07/20/23 for dialysis on Tuesday, Thursday and Saturday with pick up time of 10:45 A.M. and chair time of 11:00 A.M. Review of Resident #5's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #5's medical record from 09/01/23 to 10/04/23 did not reveal evidence the resident was assessed on 09/05/23 before or after dialysis, on 09/07/23 after dialysis, on 09/09/23 before or after dialysis, on 09/12/23 before or after dialysis which included a blood…

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 staff followed appropriate procedures following the fall and subsequent death of Resident #56. This affected one (#56) of three residents reviewed for death. The census was 59. Findings include: Review of the closed medical record for Resident #56 revealed an admission date of [DATE] with diagnoses including inclusion body myositis, acute respiratory failure with hypercapnia, anemia, depression, hypertension, pneumonia, constipation, vitamin D deficiency, age related physical debility, anxiety disorder, gastrostomy status, altered mental status, and diabetes mellitus. The resident expired on [DATE]. There was no comprehensive Minimum Data Set (MDS) Assessment because Resident #56 was only in the facility for six days prior to his expiration. Review of the assessment titled Clinical admission Documentation 0419, dated [DATE], revealed Resident #56 was not at high risk for falls. The assessment also indicated there was no baseline care plan 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, record review and interview, the facility failed to ensure the multi-use glucometer testing (BGT) machine was disinfected and sanitized after use per the facility policy and manufacturer's directions to prevent the risk of cross-contamination of blood-borne pathogens, failed to ensure respiratory equipment was stored effectively to prevent the potential for cross contamination of airborne pathogens and failed to ensure appropriate infection control was maintained during Resident #261's tracheostomy care This finding affected one resident (Resident #161) of two residents reviewed for blood glucose monitoring, one resident (Residents #13) of four residents investigated for respiratory care and one resident (Resident #261) of one resident investigated for tracheostomy care. Findings include: 1. Review of Resident #161's medical record revealed the resident was admitted on [DATE] with diagnoses including type two diabetes, anxiety disorder and essential hypertension. Review of Resident #161'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 record review, interview, and policy review, the facility failed to ensure medications were administered as ordered. This affected one resident (#69) of seven residents reviewed for medications being administered timely. The facility census was 67. Findings include: Review of the medical record for Resident #69 revealed an admission date of 06/13/23 with diagnoses including diabetes mellitus, chronic kidney disease, depression, anxiety, and hypertension. Review of the physician's orders for Resident #69 revealed she had orders dated 06/13/23 for Amlodipine 5 milligrams (mg) once daily between 6:30 A.M. to 10:30 A.M. for hypertension, Duloxetine 60 mg twice daily between 6:30 A.M. to 10:30 A.M. and between 6:30 P.M. to 10:30 P.M. for depression, Pantoprazole 50 mg twice daily between 6:30 A.M. to 10:30 A.M. and between 6:30 P.M. to 10:30 P.M. for acid reflux, Pravastatin 50 mg twice daily between 6:30 A.M. to 10:30 A.M. and between 6:30 P.M. to 10:30 P.M. for high cholesterol, and Toprol XL 25 mg twice daily between 6:30 A.M. to 10:30 A.M. and between 6:30 P.M. to 10:30 P.M…

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.