Gardens Of Belden Village

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to monitor and maintain adequate communication with the outside dialysis center to include vital signs and weights before and after dialysis and failed to ensure the facility had a dialysis policy. This affected one (Resident #7) of one resident reviewed for dialysis. The facility identified Resident #7 as the only resident receiving dialysis in the facility. The facility census was 80.Findings include:Review of the medical record for Resident #7 revealed an admission date of 11/28/25. Diagnoses included end stage renal disease, dependency on dialysis, type II diabetes mellitus with diabetic neuropathy, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, vascular dementia and cognitive communication deficit.Review of the physician orders for March 2026 revealed an order for hemodialysis every Tuesday, Thursday, and Saturday morning with transport pick up at 9:40 A.M. and chair time of 10:45 A.M. to an outside…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the American Diabetes Association's (ADA's) information on A1C and estimated average glucose (eAG), review of the facility policy and interview, the facility failed to ensure the physician provided comprehensive care for Resident #42. This affected one (Resident #42) out of three residents reviewed for physician's services. The facility census was 80.Findings include:Review of the medical record for Resident #42 revealed an admission date of 01/09/26 with diagnoses including type two diabetes mellitus, acute kidney failure, chronic kidney disease (CKD) Stage III, vascular dementia, and cognitive communication deficit.Review of the hospital records dated 12/29/25 through 01/09/26 (prior to admission) revealed Resident #42 had blood sugar levels ranging from 100 to 294 milligrams per deciliter (mg/dL), had a urine glucose reading of 3+, received insulin glargine (long-acting insulin)10 units daily at bedtime, insulin lispro (rapid-acting insulin) 0 to 5 units sliding scale with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure individual patient-controlled substance administration records and medication administration records were accurate for Resident #99. This affected one (Resident #99) out of six residents reviewed for unnecessary medications. The facility census was 80. Findings include: Review of the medical record revealed Resident #99 was admitted on [DATE] with diagnoses including encephalopathy, psychoactive substance abuse, obstructive hydrocephalus, nontraumatic subarachnoid hemorrhage, and schizoaffective disorder. Resident #99 was discharged home on [DATE]. The facility physician orders dated 08/03/25 revealed Resident #99 was ordered oxycodone (opioid for moderate to severe pain) 5 milligrams (mg) every eight hours as needed. The individual patient-controlled substance administration record date 08/03/25 revealed Resident #99 was ordered 1/2 tab (2.5 mg) every eight hours as needed; two half tablets (5 mg) every eight hours as needed. The medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the McGreer Criteria and interview, the facility failed to ensure Resident #33 did not receive unnecessary antibiotics. This affected one (Resident #33) out of six residents reviewed for unnecessary medications. The facility census was 80.Findings include:Review of the medical record revealed Resident #33 was admitted on [DATE] with diagnoses that included acute embolism and thrombosis deep vein of right lower leg, type II diabetes mellitus, and hemiplegia and hemiparesis. A physician order dated 03/03/26 revealed Resident #33 was ordered nitrofurantoin/Macrobid (antibiotic) 100 milligram (mg) every morning and at bedtime for urinary tract infection (UTI) prophylactic for prevention. The infection control log revealed Resident #33 had an onset date of a UTI on 03/03/26. There was an unknown pathogen and nitrofurantoin/Macrobid was ordered. The revised McGeer Criteria for infection surveillance checklist revealed the date of infection was 03/03/36 and the date of review 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, interviews, review of photos and facility policy review, the facility failed to ensure medications were not left at bedside of Resident #7. This affected one (Resident #7) of one resident reviewed for unsecured medications. The facility census was 80.Findings include:Review of the medical record for Resident #7 revealed an admission date of 11/28/25. Diagnoses included end stage renal disease, dependency on dialysis, type II diabetes mellitus with diabetic neuropathy, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, vascular dementia and cognitive communication deficit.Review of the physician orders for December 2025 revealed an order for Chlorhexidine Gluconate Mouth/Throat Solution 0.12% (antiseptic) to give 15 milliliters (ml) by mouth (PO) every morning and at bedtime for teeth extractions to swish and spit. Review of the photos provided by Resident #7's guardian, dated 12/20/25 at 7:32 A.M. revealed a medicine cup on Resident #7's over the bed tray with one capsule in it and a plastic drinking cup with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy review and interview, the facility failed to ensure Resident #7's medical record was accurate and complete. This finding affected one (Resident #7) of three residents reviewed for accuracy of medical records. The facility census was 80.Findings include:1. Review of Resident #7's medical record revealed the resident was admitted on [DATE] with diagnoses including end state renal disease with dependence on renal dialysis, chronic obstructive pulmonary disease (COPD), and diabetes. The medical record revealed the resident's daughter was the legal guardian and power-of-attorney (POA) for health care and financial.Review of Resident #7's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #7's physician orders revealed an order dated 01/01/26 (discontinued 01/05/26) for hospice services.Review of Resident #7's Hospice Patient Medication Cover Sheet form dated 01/01/26 revealed the resident was ordered…

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, facility policy review and interview, the facility failed to implement personal protective equipment (PPE) as required during care of Residents #45 and #62 who were in contact isolation precautions. The facility also failed to put the correct infection control precautions in place when Resident #62 was admitted . This finding affected two (Residents #45 and #62) of three residents reviewed for contact isolation precautions. The facility census was 80.Findings include: 1. Review of the medical record revealed Resident #62 was admitted on [DATE] with diagnoses that included cellulitis of right leg, type II diabetes, nondisplaced fracture of the head of the radius, and methicillin resistant staphylococcus aureus (MRSA) infection. Review of the hospital discharge records dated 03/16/26 revealed Resident #62 had several blood cultures and wound cultures positive for MRSA. A physician order dated 03/17/26 for Resident #62 to have enhanced barrier precautions (EBP) in place. A 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, interview, facility self-reported incident (SRI) review, police report review, and facility policy review, the facility failed to ensure Resident #77 was free from sexual abuse. This affected one resident (Resident #77) of three residents reviewed for abuse.Findings include:Review of the medical record for Resident #77 revealed an admission date of 01/09/26 with diagnoses including but not limited to dementia with psychotic disturbance, cognitive communication deficit and type 2 diabetes mellitus. Review of the care plan dated 01/09/26 revealed Resident #77 has impaired cognitive function/dementia or impaired thought process related to dementia. Interventions included administer medications as ordered, communicate with resident/family, identify self at each interaction, cue, reorient, supervise, keep resident routine consistent, monitor and document and report any changes.Review of Resident #77s 5-Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited…

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, interview, facility self-reported incident (SRI) review, police report, and facility policy review, the facility failed to thoroughly investigate a sexual abuse allegation for Resident #77. This affected one resident (Resident #77) out of three residents reviewed for abuse. The facility census was 92.Findings include:Review of the medical record for Resident #77 revealed an admission date of 01/09/26 with diagnoses including but not limited to dementia with psychotic disturbance, cognitive communication deficit and type 2 diabetes mellitus. Review of the care plan dated 01/09/26 revealed Resident #77 has impaired cognitive function/dementia or impaired thought process related to dementia. Interventions included administer medications as ordered, communicate with resident/family, identify self at each interaction, cue, reorient, supervise, keep resident routine consistent, monitor and document and report any changes.Review of Resident #77s 5-Day Minimum Data Set (MDS) 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, interviews, and facility policy review, the facility failed to ensure am individualized comprehensive nutrition plan was in place for Resident #5 and Resident #95 to properly monitor weights, nutritional status, and treat weight loss properly. This affected two residents (Resident #5 and #95) out of three residents reviewed for weights. Facility census was 92.Findings include:1.Review of the medical record for Resident #95 revealed an admission date of 12/19/25 and a discharge date of 02/16/26 to the hospital. Diagnoses included but not limited to Alzheimer's Disease, intermittent explosive disorder, and dementia.Review of the physician order for 12/19/25 revealed an order for regular diet, regular texture, thin liquids and for Med pass supplement 6 ounces (oz) with meals to give one container serving and record amount consumed. The order was discontinued on 02/13/26.Review of the care plan dated 12/19/25, revised on 12/27/25 revealed Resident #95 was at increased risk for malnutrition…

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 interview, staff interview, family interview, record review, and policy review, the facility failed to provide timely care and services to Resident #34 when she experienced a change of condition in the facility. This affected one resident (#34) out of three residents reviewed for change of condition. The facility census was 90. Findings include: Review of the medical record for Resident #34 revealed an admission date of 12/09/24. Diagnoses included unspecified fracture of the left and right calcaneus (heel), multiple fractures of the ribs on the right side, anxiety disorder, and depression. The record indicated she was in a motor vehicle accident prior to her admission to the facility. Review of Resident #34's admission Minimum Data Set, dated [DATE] revealed the resident was cognitively intact, utilized a wheelchair, and was dependent for toilet use and bathing and needed partial to moderate assistance for personal hygiene. Review of Resident #32's Physical Therapy (PT) Treatment Encounter…

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

Based on observation, interview and record review the facility failed to ensure the kitchen was maintained in a sanitary manner, foods were dated, labeled, and discarded when expired, and ensure the ware washing was completed appropriately to ensure sanitation. This affected all 87 residents receiving meals from the kitchen. The facility indicated there were no residents who received nothing by mouth. The facility census was 87. Findings include: Observation on 10/28/24 at 9:30 A.M. during the initial kitchen tour with Regional Culinary Director #932 revealed the following concerns. - The front of reach in refrigerator had visible caked on soiling on the front of the refrigerator and the handle. - An undated, open package of shredded cheddar cheese was found in the reach in refrigerator. - An unlabeled, undated roast beef sandwich was found in the reach in refrigerator - The reach in refrigerator was soiled with multiple spills and had various food particles spread across the bottom of it. - The steam table was visibly soiled in the front with dried spilled food items. - The three…

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 appropriate use of personal protective equipment. This had the potential to affect 47 residents who resided on the second floor including Residents #1, #4, #6, #9, #11, #12, #13, #16, #19, #20, #22, #24, #27, #28, #29, #30, #34, #36, #38, #39, #40, #41, #42, #44, #51, #52, #55, #56, #57, #58, #61, #65, #70, #71, #74, #75, #76, #77, #78, #79, #80, #81, #84, #137, #187, #189 and #190. The facility census was 87. Findings include: 1. Review of Resident #18's medical record revealed the resident was admitted on [DATE] with diagnoses including COVID-19, chronic diastolic congestive heart failure and major depressive disorder. Review of Resident #18's physician orders revealed an order dated 10/28/24 for droplet isolation for COVID-19 for ten days (to be discontinued 11/07/24). Observation on 10/28/24 at 10:25 A.M. revealed Housekeeping #842 coming out of Resident #18's room. Housekeeping #842 had on a blue surgical gown, gloves and 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 observation, interview, facility repair invoice and facility policy, the facility failed to ensure repairs were completed timely following identified concerns. This affected three residents ( #48, #59 and #69) of seven ( #7, #16, #48, #59, #69, #84 and #137) reviewed for environmental concerns requiring repairs. The facility census was 87. Findings include: 1. Observations on 10/28/24 at 9:46 A.M. with [NAME] President (VP) of Plant Operations #933 and Maintenance Director (MD) #864 revealed Resident #59's room had six ceiling tiles in the first row running perpendicular to the entrance door with dried water stains, three tiles above the dresser were water stained, a hole was cut in the back wall of the bathroom drywall which revealed an exposed pipe. Rust stains were observed on the floor behind and around the toilet. The linoleum flooring was noted to be curled up from the back wall where rust-colored stains were observed. The ceiling tile above the toilet was broken into two pieces Further…

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

Based on interview, record review, and facility policy review the facility failed to ensure monitoring prior to and following dialysis treatments for Resident #13. This affected one resident (#13) of one reviewed for dialysis. The facility census was 87. Findings include: Review of the medical record for Resident #13 revealed an admission date of 06/10/23. Diagnoses included end stage renal disease, dependence on renal dialysis, chronic obstructive pulmonary disease, type II diabetes mellitus, acute and chronic respiratory failure with hypoxia, and heart failure. Review of the physician's orders for Resident #13 revealed an order dated 06/19/24 for dialysis treatment at an off site dialysis center which began at 6:30 A.M. on Monday, Wednesday, and Friday. Resident #13 also had a physician order dated 12/05/23 for Resident #13's dialysis site be checked for signs and symptoms of infection every shift. Review of the pre and post dialysis assessments for Resident #13 in the electronic medical record revealed a no pre dialysis evaluations were completed from January 2024 through October…

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, record review and facility policy review, the facility failed to ensure perineal care was performed appropriately after an episode of urinary and bowel incontinence. This affected one (Resident #81) of one resident observed for incontinence care. The facility census was 81. Findings include: Review of the medical record for Resident #81 revealed an admission date of 05/22/20 with diagnoses including Alzheimer's disease, depression and anxiety. Review of the care plan dated 05/23/20 revealed Resident #81 had incontinence of bowel and bladder. Interventions included to check for incontinence and clean and dry skin if wet or soiled. Observation on 08/28/24 at 10:53 A.M. of incontinence care to Resident #81 by Licensed Practical Nurse (LPN) #200 and LPN #201 revealed Resident #81's brief was wet with urine and bowel. LPN #200 and LPN #201 unfastened Resident #81's brief and then rolled her on her right side. LPN #200 cleaned her rectum area and buttocks of bowel, rinsed and then dried her off. LPN #200 and LPN #201 then rolled Resident #81 on her back…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed medical record review, electronic communication document review, staff interview, and non-facility staff interview, the facility failed to ensure all discharge records were completed timely so residents who were discharged could fully use their insurance benefits. This affected one resident (#81) of three resident records reviewed. The facility census was 79. Findings Include: Review of the closed medical record revealed Resident #81 was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease, low back pain, chronic viral hepatitis, paranoid schizophrenia, anxiety disorder, other recurrent depressive disorder, neuromuscular dysfunction of bladder, neurogenic bowel, muscle weakness, adult failure to thrive, chronic pain syndrome, and other psychoactive substance abuse. Review of the Minimum Data Set (MDS) assessment, dated 09/11/23, revealed Resident #81 was cognitively intact. Review of Resident #81's medical records found that he was discharged from the facility…

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, observation, resident interview, and staff interview, the facility failed to inform residents of new orders and treatment plans. This affected one (Resident #36) of three residents reviewed for change in condition. The facility census was 76. Finding include: Review of the medical record for Resident #36 revealed an admission date of 01/23/24 with diagnoses including pleural effusion, cirrhosis of the liver, hepatitis C, hypertension, esophageal varices, diabetes, obstructive pulmonary disease, traumatic stress disorder, schizophrenia, and ascites (a condition in which fluid collects in spaces within your abdomen). Review of the progress note for Resident #36 dated 01/25/24 timed at 11:40 P.M. revealed the resident requested to go to the hospital to have immediate paracentesis (a procedure performed in patients with ascites, during which a needle is inserted into the abdomen to drain excess fluid), because she had increased abdominal pain, and she felt her liver was leaky. The nurse assessed the resident and noted the resident's abdomen was slightly…

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 Self-Reported Incident (SRI), interview with staff and review of the facility policy the facility failed to prevent misappropriation of resident narcotics. This affected one resident (R#9) of three residents reviewed for narcotic medication use. The facility census was 75. Findings include: Review of the medical record revealed Resident #9 was admitted to the facility on [DATE]. Diagnoses included alcohol abuse with withdrawal complications, diabetes, acute kidney failure, rhabdomyolysis, gout, anxiety disorder, depressive disorder, insomnia, and abnormality of plasma proteins. Review of the physician's orders revealed Resident #9 had orders for Percocet 5/325 milligrams (mg) every four hours as needed for pain dated 07/04/23. Review of the Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #9 had intact cognition and experienced pain frequently. The numeric pain rating was an eight on a zero to 10 pain scale with 10 being 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 review of the medical record and interview with staff the facility failed to provide timely diagnostic testing and treatment of a resident with an urinary tract infection. This affected one resident (#56) of three reviewed for infection control. The facility census was 75. Findings included: Review of the medical record revealed Resident #56 was admitted to the facility on [DATE]. Diagnoses included mental disorder, anxiety disorder, developmental disorders, and hypertension. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #56 had moderately impaired cognition. Review of the nursing note dated 07/28/23 at 11:56 A.M. revealed Resident #56 was complaining of burning during urination. A urinalysis (UA) and Culture Sensitivity (C&S) was ordered by the physician. There were no other notes regarding the UA/C&S until 08/04/23 at 8:26 A.M. revealing a UA and C&S was to be recollected. Review of the physician's orders revealed Resident #56 had an order for a urinalysis 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 review of the medical record and staff interview the facility failed to ensure a resident was free of a significant medication error. This affected one resident (#20) of three reviewed for medication administration. Findings included: Review of the medical record revealed Resident #20 was admitted to the facility on [DATE]. Diagnoses included psychosis, dementia, schizoaffective disorder, convulsions, insomnia, bipolar disorder, depressive disorders, anxiety disorder, mood affective disorder, vitamin D deficiency, diabetes, adult failure to thrive, restlessness, auditory hallucinations, hypertension, and symbolic dysfunction. Review of the June 2023 physician orders revealed Resident #20 did not have an order for insulin. Review of the medication error incident form dated 06/23/23 at 2:00 P.M. revealed Resident #20 received 24 units of Humalog insulin and 10 units of Novolog insulin at 9:30 A.M., which was given in error. The Director of Nursing and physician were notified and a new order was received…

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 upon interview and record review, the facility staff failed to treat all Residents with dignity and respect at all times. This affected two Residents (#53 and #71) of 30 residents interviewed for dignity and respect. The facility census was 71. Findings included: 1. Record review was conducted on Resident #53 who was admitted on [DATE] with diagnoses including acute kidney failure, type two diabetes, hemiplegia and hemiparesis following a cerebral infarction, recurrent depressive disorder and respiratory failure with hypoxia. The Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired with rejection of care, required extensive assistance of one for ADLs, had a urinary catheter and was frequently incontinent of bowels and received antidepressants. Review of the care plan of 07/07/22 revealed care areas included activity of daily living (ADL) self-care deficits, diarrhea, behaviors including hoarding and walking around naked with goals and interventions…

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 and record review, the facility failed to ensure resident funds were disbursed within 30 days of discharge for Resident #124. This affected one of one residents reviewed for closed resident fund accounts. The facility census was 71. Findings included: Resident #124 was admitted [DATE], with diagnoses including heart failure, pulmonary edema,and dementia. Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Resident #124 was discharged on 03/22/22. The facility provided documentation Resident #124's account was closed on 04/26/22 which included a check dated 04/26/22 and the Pay to the order of line blank. Interview on 07/21/22 at 2:45 P.M. with the Administrator verified the Pay to the order of line should have been filled in with Resident #124's name or the name of their representative and the funds should have been dispersed within 30 days of the resident's discharge

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure Residents #17 and #54 received showers/baths as scheduled. This affected two (#17 and #54) of three residents reviewed for bathing. The census was 71. Findings included: 1. Resident #17 was admitted on [DATE] with diagnoses including chronic respiratory failure, quadriplegia, anxiety disorder, major depressive disorder, acquired absence of left hip joint and both legs above the knee, colonostomy, suprapubic catheter and chronic osteomyelitis. Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident was cognitively intact, verbal behaviors towards others including rejection of care, and required extensive assist of two for activities of daily living (ADL) with no bathing activity during the seven day look back period. Review of the care plan dated 05/06/22 revealed care areas included refusal/noncompliance of care with interventions including anticipating and meeting the resident's needs, discussing risks benefits…

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 ensure Residents # 11, #66, and #123 were appropriately supervised while smoking cigarettes and in accordance with the smoking policy. This affected three residents of 18 residents the facility identified as smokers. The facility census was 71. Findings include: 1. Resident #66 was admitted on [DATE] with diagnoses including alcohol abuse, history of stroke, tobacco use and cannabis use. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and needed limited assistance of one staff for activities of daily living (ADL)s. Care plan of 07/07/22 included a care area for smoking with interventions including smoking safely in designated areas, at designated smoking times with staff supervision in accordance with the facility smoking policy. Smoking Assessment of 06/28/22 revealed Resident #66 was safe to smoke with supervision. Observation and interview on 07/18/22 at 1:27 P.M. with…

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