Centerburg Pointe

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure Resident #4's nails were maintained in a clean manner and at a good length. This affected one resident (#4) of three residents reviewed for activities of daily living (ADL). The facility census was 70. Findings include: Review of Resident #4's medical record revealed an admission date of 09/16/24 with diagnoses including transient cerebral ischemic attack, contracture of left elbow, neoplasm of brain, heart failure, type two diabetes mellitus, dysphagia, depression, and unspecified convulsions. Review of Resident #4's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was rarely or never understood. She was dependent for personal hygiene. Review of Resident #4's plan of care dated 03/11/25 revealed she had a self care deficit related to ADL limitation, restlessness and agitation, and her diagnoses. Interventions included monitoring toenails and fingernails with ADL care daily for need of trimming or additional…

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, and facility policy review, the facility failed to ensure physician orders were present for therapy services prior to delivering services to one (#42) of one reviewed for hospice services, and the facility failed to follow practitioner recommendation for vascular surgery consult for one (#35) of one reviewed for non pressure skin condition. The census was 70. Findings Include: 1. Review of the medical record for Resident #42 revealed an admission date of 06/29/21, diagnoses included Alzheimer's Disease, dementia, anxiety, bi-polar disorder and a history of falling. Resident #42 admitted to hospice services on 10/31/23 and was a Do Not Resuscitate Comfort Care (DNR-CC). Observation on 03/18/25 at 11:30 A.M. revealed Resident #42 was in bed, and Certified Occupational Therapist Aide (COTA) #102 was present and revealed she had just finished working with Resident #42 to improve her sitting position in her wheelchair. Resident #42 appeared to be very restless with involuntary head…

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 monitor Resident #4 and Resident #20's use of a splint. This affected two residents (#4 and #20) of two residents reviewed for limited range of motion. The facility census was 70. Findings include: 1. Observation on 03/17/25 at 12:01 P.M. revealed a splint in Resident #4's room. Review of Resident #4's medical record revealed an admission date of 09/16/24 with diagnoses including transient cerebral ischemic attack, contracture of left elbow, neoplasm of brain, heart failure, type two diabetes mellitus, dysphagia, depression, unspecified convulsions. Review of Resident #4's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was rarely or never understood. Review of Resident #4's occupational therapy discharge evaluation dated 02/28/25 revealed a discharge recommendation to tolerate a left elbow splint for six hour intervals. Review of Resident #4's medical record from 02/28/25 to 03/16/25 revealed no indication…

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 facility policy review, the facility failed to ensure fall interventions were in place and falls were documented for one (#11) of two residents reviewed for falls. The facility census was 70. Findings include: Review of Resident #11's medical record revealed an admission date of 03/04/22, diagnoses included dementia, major depressive disorder, epilepsy, other chronic pain, paroxysmal atrial fibrillation, fracture of one rib on left side (12/03/24), and glaucoma. Review of Resident #11's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed severely impaired cognition. Review of Resident #11's plan of care dated 02/14/25 revealed she was at risk for falls related to her diagnoses, history of falls, lack of coordination, and impaired mobility. Interventions included but were not limited to removing regular socks from her room and providing non-skid socks, maintaining the call light in reach, and nonskid socks. Review of Resident #11'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 interview, medical record review, and facility policy review the facility failed to ensure an indwelling foley catheter was inserted correctly and monitored after insertion. This had the potential to affect one (#24) of two reviewed for catheter care. The census was 70. Findings include: Review of the medical record for Resident #24 revealed an admission date of 08/08/24 with sever cognitive deficits. Diagnoses included hypertensive chronic kidney disease, depression, overactive bladder, neuromuscular dysfunction of bladder and anxiety. Review of Resident #24 nurses progress notes revealed on 10/22/24 at 6:41 P.M. the nurse changed her catheter with 22 french (FR) 10 cc balloon, because the resident was found playing in her stool, pulling her catheter, and having spasms. The nurse followed the sterile technique protocol. When the procedure was completed Resident #24 was resting in her bed. Review of Resident #24 progress notes on 10/23/24 at 10:11 A.M. the nurse was notified by the Certified Nursing Assistant (CNA) that the resident did not have any urine output overnight.…

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, resident interview, and staff interview, the facility failed to maintain availability of ordered pain management medications for one resident (Resident #33) out of two residents reviewed for pain management. The facility census was 70. Findings include: 1. Resident #33 was admitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia, cellulitis of right lower limb, dysphagia, tracheostomy, acute pancreatitis, acute myocardial infarction, depression, squamous cell carcinoma of skin, anxiety disorder, obstructive sleep apnea, hypertension, atrial fibrillation, and chronic congestive heart failure. Review of the minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #33 was cognitively intact with mild depression. Resident #33 received antianxiety, antidepressant, anticoagulant, diuretic, and opioid medications with indications noted. Review of physician's orders revealed Resident #33 had an order for a Fentanyl patch (opioid) 100 micrograms (mcg) per…

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 pre and post dialysis assessments were completed for Resident #20. This affected one resident (#20) of one resident reviewed for dialysis. The facility census was 70. Findings include: Review of Resident #20's medical record revealed an admission date of 03/29/24 with diagnoses including end stage renal disease with dependence on renal dialysis, contracture of left hand, hepatic encephalopathy, type one diabetes mellitus, chronic diastolic heart failure, liver disease, adjustment disorder with depressed mood, Parkinson's disease, protein calorie malnutrition, epilepsy, anxiety disorder, and cirrhosis of liver. Review of Resident #20's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition. Review of Resident #20's plan of care dated 02/21/25 revealed the resident required dialysis three times a week and the facility provided transportation. Her chair time and location for dialysis were provided.…

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 #20's medication was held as ordered by the physician This affected one resident (#20) of five residents reviewed for unnecessary medications. The facility census was 70. Findings include: Review of Resident #20's medical record revealed an admission date of 03/29/24 with diagnoses including end stage renal disease with dependence on renal dialysis, contracture of left hand, hepatic encephalopathy, type one diabetes mellitus, chronic diastolic heart failure, liver disease, adjustment disorder with depressed mood, Parkinson's disease, protein calorie malnutrition, epilepsy, anxiety disorder, and cirrhosis of liver. Review of Resident #20's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition. Review of Resident #20's physician order dated 01/03/25 revealed an order for Enulose (Lactulose) (osmotic laxative) 30 milliliters (ml) three times a day. Review of Resident #20's physician order 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 interview and record review the facility failed to follow medication parameters for one (#20) of five reviewed for unnecessary medication. The facility census was 70. Findings include: Review of Resident #20's medical record revealed an admission date of 03/29/24 with diagnoses including end stage renal disease with dependence on renal dialysis, contracture of left hand, hepatic encephalopathy, type one diabetes mellitus, chronic diastolic heart failure, liver disease, adjustment disorder with depressed mood, Parkinson's disease, protein calorie malnutrition, epilepsy, anxiety disorder, and cirrhosis of liver. Review of Resident #20's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she had intact cognition. Review of Resident #20's physician order dated 03/30/24 revealed an order for Metoprolol tartrate (relaxes blood vessels to slow heart rate and decrease blood pressure) 25 mg one tablet twice a day. Hold for systolic blood pressure below 110 mmHg (millimeters of mercury) 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 interview and record review the facility failed to ensure fluid restrictions were followed as ordered for two residents (#20 and #34) out of three residents reviewed for conditions that required fluid restrictions. The facility census was 70. Findings include: 1. Resident #34 was admitted on [DATE] with diagnoses that included acute and chronic congestive heart failure, acute and chronic respiratory failure, dependence on respirator [ventilator], fluid overload, hypothyroidism, anxiety disorder, major depressive disorder, chronic catheter for diuresis, dependence on supplemental oxygen, chronic pain syndrome, cognitive communication deficit, chronic kidney disease, depression, hypertension, obstructive sleep apnea, congenital central alveolar hypoventilation syndrome, and heart failure. Review of the minimum data set (MDS) 3.0 dated 01/24/25 revealed Resident #34 was cognitively intact with moderately severe depression and a numeric pain level of six on a scale of 0-10. Resident #34 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 THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interviews, review a facility investigation, review of hospital documentation and facility policy review the facility failed to use a mechanical lift sling pad correctly resulting in a fall from a mechanical lift. This affected one resident (Resident #73) of two residents reviewed for accidents. The facility census was 71. Findings Include: A review of Resident #73's medical record revealed admission date 10/02/24 with diagnoses including but not limited to respiratory failure with ventilator dependency, tracheostomy, dysphagia, chronic obstructive pulmonary disease (COPD), and high blood pressure. A review of Resident #73's admission fall risk assessment revealed Resident #73 was at risk for falls related to impaired mobility. A review of Resident #73's admission [NAME] Data Set (MDS) dated [DATE] revealed Resident #73 had moderate cognitive impairment and was dependent on staff 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.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and staff interview the facility failed to have eight consecutive hours daily of Registered Nurse (RN) coverage in the facility. This had the potential to affect the 59 residents who resided at the facility. Findings include: Review of the payroll based journal information revealed the facility failed to have eight consecutive hours of Registered Nurse (RN) coverage in the facility on 01/01/23, 01/07/23, 01/21/23, 02/04/23 and 02/05/23. Interview with Assistant Administrator (AA) #131 on 10/10/23 at 4:40 P.M. confirmed there was no RN in the facility on 01/01/23, 01/07/23, 01/21/23, 02/04/23 and 02/05/23. AA #131 stated the Director of Nursing (DON) during that time stated she was available and on call on those days. AA #131 stated the DON did not realize having a RN available and on call did not meet the requirement. AA #131 stated the facility had prioritized the hire of RN's even for Licensed Practical Nurse (LPN) positions and the…

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

Based on record review, review of the staffing tool and resident and staff interviews, the facility administration failed to ensure there was sufficient direct care staff at all times in the facility to meet the minimum staffing requirement of two point five (2.5) hours of direct care per resident per day. This had the potential to affect all 59 residents living in the facility. Findings include: Review of the staffing tool completed for 09/24/23 through 09/30/23 revealed on 09/24/23 the facility only provided two point two seven (2.27) hours of direct care per resident per day. Interview with Resident #106 on 10/10/23 at 10:14 A.M. revealed staff are all nice, but when the facility was short staffed it takes a long time to answer the call light. The resident stated she needed assistance to complete her daily care needs and one time staff attempted to weigh her at 12:00 A.M. and she refused to be weighed at that time and was weighed the next day. Interview with Resident #107 on 10/10/23 at 10:25 A.M. revealed the facility was short in nurse aides which affected the 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 interview and record review the facility failed to ensure residents or their responsible parties received education and signed consent for influenza and pneumococcal immunizations. This affected four residents (#17, #6, #106, and #16) of five residents reviewed for immunizations. The facility census was 59. Findings include: 1. Review of the medical record for Resident #17 revealed an admission date of 02/05/21 with diagnoses including depression, type two diabetes, hypertension, chronic obstructive pulmonary disease, and anemia. Review of the immunization report for Resident #17 revealed they received the Influenza vaccine on 10/25/22. Review of the medical record revealed no evidence Resident #17 received education or signed consent to receive the immunization. Interview on 10/12/23 at 11:00 A.M. with the Director of Nursing (DON) verified she could not locate education and a signed consent form for the immunization. 2. Review of the medical record for Resident #6 revealed an admission date of 04/14/22 with diagnoses including fibromyalgia, unspecified mood 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 resident and staff interviews, the facility did not ensure Resident #105 participated in and received a copy of her baseline care plan within 48 hours of admission. This affected one resident (Resident #105) of two residents reviewed for baseline care plans. The facility census was 59. Findings Include: Review of Resident #105's medical record revealed the resident admitted on [DATE] with diagnoses including diabetes, atrial fibrillation, hypertension and displaced intertrochanteric fracture of left femur. The resident discharged on 10/11/23. Resident #105 was listed as her own guarantor, and no other responsible parties were listed. Further review of the medical record revealed there was no baseline care plan, nor comprehensive plan of care in lieu of the baseline care plan, signed by Resident #105 to serve as evidence Resident #105 agreed to initial care goals and services and treatments that would be provided by the facility and personnel acting on behalf of the facility. There was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility failed to ensure physician orders were obtained to provide treatment to an area of skin impairment for Resident #40. The affected one (#40) resident of seven residents reviewed for wounds. The facility census was 59. Review of Resident #40's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cellulitis and chronic venous hypertension with ulcer and inflammation to lower left leg. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, had no hallucinations, required supervision for activities of daily living, was occasionally incontinent of bladder and always continent of bowel. The resident was coded as being at risk for pressure ulcers but as not having any pressure ulcers. Review of a progress note dated 10/09/23 at 1:25 P.M. revealed Resident #40 had dry skin caught in her sock and a skin tear occurred when the podiatrist removed…

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, record review, and review of facility policies, the facility failed to ensure pressure reducing interventions were in place for Resident #9, #10, and #305. This affected three residents (#9, #10, and #305) of seven residents reviewed for skin impairment or pressure ulcers. The facility census was 59. Findings include: 1. Review of the medical record for Resident #9 revealed an admission date of 12/01/10 with diagnoses including major depressive disorder, type two diabetes mellitus, sleep disorder, dissociative and conversion disorders, Alzheimer's disease, and mild cognitive impairment. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was rarely or never understood. Review of the plan of care dated 12/02/20 revealed Resident #9 was at risk for impaired skin integrity related to incontinence, fragile skin, impaired mobility, impaired cognition, and diagnoses. Interventions biweekly skin checks, barrier cream after incontinence, cushion 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, interview, record review, and review of facility policies, the facility failed to ensure fall interventions were in place for Resident #1 and #38 and failed to ensure Resident #29 had smoking assessment upon admission and quarterly This affected three residents (#1, #38, and #29) of six residents reviewed for accidents/hazards. The facility census was 59. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 09/02/16 with diagnoses including schizophrenia, dysphagia, dementia, depression, anxiety, type two diabetes mellitus, heart failure, and cerebral palsy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #1 had severely impaired cognition. She'd had one fall since the previous assessment. Review of the plan of care dated 10/01/16 revealed Resident #1 was at risk for falls characterized by history of falls, injury, and or multiple risk factors related to impaired balance, non-ambulatory, receives…

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 facility policy and interviews, the facility failed to ensure weights were completed as ordered and the physician was notified of weight changes for Resident #22 and Resident #305. This affected two residents (#22 and #305) out of five residents reviewed for nutrition. The facility census was 59. Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 08/25/23 with diagnoses including chronic pulmonary edema, anxiety disorder, acute and chronic respiratory failure, cognitive communication deficit, and acute on chronic diastolic heart failure. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #22 had intact cognition. Review of the physician order dated 08/26/23 to 08/29/23 revealed Resident #22 was to be weighed every day shift at the same time each morning. The heart failure center and primary care physician were to be notified of weight gain or loss of more than two pounds overnight or five…

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 interviews, the facility failed to ensure pain was addressed timely and appropriately for Resident #258. This affected one (Resident #258) of four residents reviewed for pain. Facility census was 59. Findings include: Review of the medical record for Resident #258 revealed an admission date of 10/09/23 and discharge date on 10/11/23. Diagnoses included fracture of fibula, fracture of tibia, osteoarthritis, depression, anxiety, and osteoporosis. Review the admission assessment dated [DATE] revealed Resident #258 arrived to the facility at 6:00 P.M. from the hospital. Review of the care plan dated 10/09/23 revealed Resident #258 had potential for pain with interventions to administer pharmacological interventions as ordered and assess residents pain for verbal and non verbal indicators. Review of physician orders dated 10/09/23 revealed an order for oxycodone-acetaminophen (pain medication containing narcotics) oral tablet 10-325 mg to be given every six hours as needed. Review of EBOX…

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 did not ensure an assessment for the appropriateness of use of bed rails versus alternatives was completed for Resident #259. This affected one resident (#259) of four residents reviewed for accidents/hazards. The facility census was 59. Findings include: Review of the medical record for Resident #259 revealed an admission date of 10/09/23. Diagnoses included fracture of humerus, diabetes, anxiety, fatigue, and dementia. Review of the Minimum Data Set (MDS) 3.0 assessment revealed the MDS had not yet been completed due to new admission. Review of physician orders revealed no evidence of order for bed rails of any kind. Review of assessments revealed no evidence of a bed rail or safety assessment being completed prior to Resident #259 being given bed rails. Review of the care plan revealed no evidence of bed rails being included in the care plan. Interview and observation on 10/10/23 at 11:54 A.M. with Resident #259 revealed she had bilateral bed rails on her bed, resident was lying in bed 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 interview and record review the facility failed to monitor blood pressure according to medication parameters and failed to ensure parameters were in place for pain medication for Resident #35. This affected one resident (#35) of six residents reviewed for medications. The facility census was 59. Findings include: 1. Review of the medical record for Resident #35 revealed an admission date of 09/10/21 with diagnoses including depression, anxiety, Parkinson's disease, hypertension, and chronic atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 had intact cognition. Review of the plan of care dated 08/24/22 revealed Resident #35 was at risk for altered cardiac status, atrial fibrillation, and hypertension. Interventions included providing medications as ordered, monitoring for signs of decreased cardiac output, notifying the physician as needed with any changes, and vital signs as ordered. Review of the physician order dated 10/11/22…

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 interviews, the facility did not ensure Resident #258 was administered medications in accordance with physician orders and therefore free of significant medication errors. This affected one resident (#258) of six residents reviewed for medication administration. The facility census was 59. Findings include: Review of the medical record for Resident #258 revealed an admission date of 10/09/23 and discharge date on 10/11/23. Diagnoses included fracture of fibula, fracture of tibia, osteoarthritis, depression, anxiety, surgical wound infection, and osteoporosis. Review of the nursing admission assessment dated [DATE] revealed Resident #258 arrived to the facility at 6:00 P.M. from the hospital. Resident #258 had an elevated,. above normal blood pressure of 147/90. Review of the Hospital Discharge summary dated [DATE] revealed instructions to take these meds which included Carvedilol (cardiac medication used to treat high blood pressure and heart conditions) 12.5 milligrams (mg) by mouth…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interview, the facility did not keep an accurate record of skin impairment and wound status in the medical record for Resident #10. This affected one (Resident #10) of seven residents reviewed for skin impairments. The facility census was 59. Findings include: Review of the medical record for Resident #10 revealed an admission date of 07/08/23 with readmission on [DATE]. Diagnoses included chronic kidney disease, bipolar disorder, depression, vascular disease, muscle weakness and heart failure. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 was cognitively intact and required extensive assistance of two staff members for bed mobility and was totally dependent for transfers. Review of the care plan dated 07/10/23 revealed Resident #10 was at risk of skin impairments with interventions including administer medications and treatments as ordered, assess and document the status of the area (healing or declining), monitor document and…

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

Based on interview and record review the facility failed to ensure residents or their responsible parties received education and signed consent for COVID-19 immunization. This affected three residents (#17, #6, and #16) of five residents reviewed for immunizations. The facility census was 59. Findings include: 1. Review of the medical record for Resident #17 revealed an admission date of 02/05/21 with diagnoses including depression, type two diabetes, hypertension, chronic obstructive pulmonary disease, and anemia. Review of the immunization report for Resident #17 revealed they received the Moderna Bivalent Booster on 09/22/22. Review of the medical record revealed no evidence Resident #17 received education or signed consent to receive the immunization. Interview on 10/12/23 at 11:00 A.M. with the Director of Nursing verified she could not locate evidence of education for the immunization. 2. Review of the medical record for Resident #6 revealed an admission date of 04/14/22 with diagnoses including fibromyalgia, unspecified mood disorder, chronic obstructive pulmonary disease,…

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 comfortable sound levels throughout the facility when Resident #17 frequently played his music too loud and Resident #293 could frequently be heard yelling out. This affected eight residents (#293, #17, #2, #26, #28, #30, #37 and #342) and had the potential to affect 11 additional residents (#41, #294, #194, #33, #3, #242, #343, #35, #34, #7 and #15) who resided on the B and D units of the facility. The facility census was 41. Findings include: 1. Review of the medical record for Resident #293 revealed the resident was admitted to the facility on [DATE] with diagnoses including catatonic disorder due to known physiological condition, psychotic disorder with delusions due to physiological condition, catatonic schizophrenia, unspecified psychosis not due to a substance or known physiological condition, depression and anxiety. Review of the plan of care, dated 08/06/21 revealed the resident had a psychiatric disorder. 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.

Based on record review, staff interview and facility policy and procedure review the facility failed to develop a care plan for Resident #37 related to the use of adaptive equipment. This affected one resident (Resident #37) of 14 residents reviewed for care plans. Findings include: Review of the medical record for Resident #37 revealed an admission date of 09/30/17 with diagnoses including muscle spasm, contracture, multiple sclerosis and abnormal posture. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 07/09/21 revealed the resident was cognitively impaired, required extensive assistance from one person for bed mobility, dressing and eating and total assistance from staff for transfers, toileting, personal hygiene and bathing. Review of the physician's orders for August 2021 revealed Resident #37 had an order for an air mattress, pillow between the knees at all times, an order that her heels should never lay directly on the mattress, turn side to side every two hours, short heel booties only, bilateral spacer wedge to be on four hours per shift as 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 observation, record review, facility policy and procedure review and interview the facility failed to ensure adaptive equipment, including an elbow splint, blue bilateral spacer wedges and pillow between the resident's knees were provided to maintain the resident's functional mobility and failed to ensure staff only documented the delivery of care when it was actually provided. This affected one resident (#37) of three residents reviewed for adaptive equipment. Findings include: Review of the medical record for Resident #37 revealed an admission date of 09/30/17 with diagnoses including muscle spasm, contracture, multiple sclerosis and abnormal posture. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 07/09/21 revealed the resident was cognitively impaired, required extensive assistance from one person for bed mobility, dressing and eating and total assistance from staff for transfers, toileting, personal hygiene and bathing. Review of the physician's orders for August 2021 revealed Resident #37 had orders for an air mattress, pillow between the knees 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, record review and interview the facility failed to ensure Resident #28 was instructed to rinse his mouth with water following the administration of Flovent inhalation medication to decrease the resident's risk of developing oropharyngeal candidiasis. This affected one resident (#28) of ten residents observed for medication administration. Findings include: Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with diagnoses of malignant neoplasm of the bronchus and ling, dementia, chronic pain, major depressive disorder, hypertension and chronic obstructive pulmonary disease (COPD). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/01/21 revealed Resident #28 had moderately impaired cognition. Review of the August 2021 physician's order revealed Resident #28 had an order (dated 04/02/21) for one puff/inhalation of Flovent Diskus 100 micrograms (mcg) twice daily for COPD. The order indicated to rinse the mouth out with water after 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 adequately monitor areas of skin impairment/breakdown for Resident #30 and failed to ensure Resident #20 had physician ordered heel suspension boots in place for prevention of skin break down. This affected two residents (#20 and #30) of four residents reviewed for skin conditions. Findings include: 1. Review of the medical record for Resident #30 revealed an admission date of 06/25/21 with diagnoses including chronic heart failure, borderline personality disorder, anxiety, depression, chronic respiratory failure and attention deficit hyperactivity disorder. Review of the annual Minimum Date Set (MDS) 3.0 assessment, dated 07/02/21 revealed Resident #30 had intact cognition. The resident required extensive assistance of two persons for bed mobility, toilet use and personal hygiene and was totally dependent on two persons for transfers. The assessment indicated the resident was at risk for developing pressure ulcers and injuries.…

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 review and interview the facility failed to check for proper gastrostomy tube placement for Resident #293 prior to administering medications to prevent complications. This affected one resident (#293) of ten residents observed for medication administration. Findings include: Review of the medical record revealed Resident #293 was admitted to the facility on [DATE] with diagnoses of catatonic disorder psychotic disorder with delusions, catatonic schizophrenia, depression and anxiety. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #293 had severely impaired cognition, required total assistance for all activities of daily living and had enteral tube for feeding. On 08/17/21 at 11:37 A.M. Licensed Practical Nurse (LPN) #304 was observed to administer medications to Resident #293 via gastrostomy tube. Prior to administering medications, LPN #304 did not check for placement of the gastrostomy tube and did not check 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 record review, facility policy and procedure review and interview the facility failed to implement an effective and individualized pain management program for Resident #243, including the administration of pain medication as ordered by the physician. This affected one resident (#243) of 10 residents reviewed for procuring ordered medications. Findings include: Review of the medical record for Resident #243 revealed an admission date of 07/23/21 with diagnoses including liver and anal cancer, colostomy, hypertension, diabetes mellitus and pain. Review of physician's orders, dated 07/23/21 revealed an order for the narcotic analgesic, Oxycodone 10 milligrams (mg) every six hours as needed (prn) for pain. Review of the plan of care, dated 07/23/21 revealed Resident #243 had pain. Interventions included to administer pharmacological interventions as indicated per physician and monitor the effectiveness, assess for verbal and nonverbal signs and symptoms related to pain: grimacing, guarding, moaning, crying,…

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 monitor behaviors and/or for side effects of medication for Resident #30 and Resident #40, who were prescribed psychotropic medication. The affected two residents (#30 and #40) of five residents reviewed for unnecessary medication use. Findings include: 1. Review of the medical record for Resident #40 revealed an original admission date of 09/04/19 and a readmission date on 04/30/21 with diagnoses including chronic pain syndrome, other symbolic dysfunctions, unspecified tremor, vertigo of central origin, other idiopathic peripheral autonomic neuropathy, recurrent major depressive disorder, fibromyalgia and chronic obstructive pulmonary disease with acute exacerbation. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 07/02/21 revealed the resident had intact cognition. The resident required extensive assistance from one staff with activities of daily living (ADLs), except eating. The Patient Health Questionnaire (PHQ-9) revealed no signs of depression. There…

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, staff interview and facility policy review the facility failed to ensure Resident #20's room was maintained in a clean and sanitary manner. This affected one resident (#20) of 41 residents whose rooms were observed. Findings include: On 08/16/21 at 1:14 P.M., 2:16 P.M. and 3:09 P.M., on 08/17/21 at 8:48 A.M., 11:30 A.M. and 2:30 P.M. and on 08/18/21 at 7:25 A.M. and 9:32 A.M. observations of Resident #20's room revealed several black dirt spots the size of golf balls on Resident #20's floor and a white substance spilled all over the fall mat on the floor. Resident #20 was observed sleeping during the observations made and was identified to be not interviewable. On 08/18/21 at 9:37 A.M. interview with Housekeeping Aide #350 revealed resident rooms were to be cleaned everyday. Housekeeping Aide (HA) #350 revealed she was responsible to swept, mop, spray and wipe down all hard surface areas in the resident rooms. HA #350 also indicated housekeeping staff were responsible to clean the fall mats for residents also. At the time of the interview, HA #350 verified 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.