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NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interviews, and policy review, the facility failed to schedule dental services for teeth extractions per physician orders for a resident. This affected one (Resident# 54) of one resident reviewed for dental services. The facility census was 112. Findings include: Review of the medical record for Resident #54 revealed an admission date of 09/17/17 with diagnoses of major depressive disorder and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 was cognitively intact and required substantial assistance with oral hygiene. Resident #7 did not have broken or loosely fitting full or partial dentures and did not have mouth or facial pain, discomfort or difficulty with chewing. Review of the physician orders dated 12/14/23 revealed an order for Resident #54 to have order to extract broken teeth and root tips. The resident was planned for upper complete denture and lower partial. Resident #54 would like to keep tooth…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of the medical record for Resident #26 revealed an admission date of 11/27/22 with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of the physician orders revealed an order for Artificial Tears one drop in each eye daily. Observation on 07/17/24 at 8:46 A.M. revealed Licensed Practical Nurse (LPN) #110 administered Resident #26's Artificial Tears one drop in each eye without wearing gloves. Interview on 07/17/24 at 8:54 A.M. with LPN #110 confirmed she did not use gloves to administer Resident #26's Artificial Tears one drop in each eye. Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure proper enhanced barrier precautions (EBP) were followed for Resident #60 and the facility failed to ensure gloves were worn when administering eye drops for Resident #26. The facility census was 112. Findings include: 1. Review of the medical record for Resident #60 revealed admission date of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to ensure influenza and pneumococcal immunizations were offered to residents. This affected four (#19, #51, #66, and #74) out of five residents reviewed for immunizations. The facility census was 112. Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 04/27/24. Diagnoses included other sequela of cerebral infarction and type two diabetes mellitus. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had severely impaired cognition. Further review of the medical record revealed no evidence that the facility offered the pneumococcal immunization or provided education to the resident or resident representative. Interview on 07/18/24 at 1:30 P.M. with the Director of Nursing verified the lack of immunization documentation for Resident #19. 2. Review of the medical record for Resident #51 revealed an admission date of 09/15/21. Diagnoses included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to ensure COVID-19 immunizations were offered to residents. This affected three (#19, #66, and #74) out of five residents reviewed for immunizations. The facility census was 112. Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 04/27/24. Diagnoses included type two diabetes mellitus and hypertensive heart disease with heart failure. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had severely impaired cognition. Further review of the medical record revealed no evidence that the facility offered the COVID-19 vaccine or provided education to the resident or resident representative. Interview on 07/18/24 at 1:30 P.M. with the Director of Nursing verified the lack of immunization documentation for Resident #19. 2. Review of the medical record for Resident #66 revealed an admission date of 01/06/24. Diagnoses included dementia, congestive heart…

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, and policy review, the facility failed to act in a timely manner to protect residents from abuse. This affected one (Resident #10) of five residents reviewed for abuse. The facility census was 102. Findings include: Review of the medical record for Resident #10 revealed an admission date of 01/31/24. Diagnoses included atherosclerotic heart disease, dysphagia, and the need for assistance with personal care. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition, had no behaviors, did not reject care, and did not wander. Review of the progress note dated 02/24/24 at 6:23 P.M. revealed staff heard screaming from the hallway. Upon entering Resident #10's room, Licensed Practical Nurse (LPN) #122 and State Tested Nurse Aide (STNA) #103 observed the resident's daughter forcing food into Resident #10's mouth. The daughter stated she was wiping blood from the resident's mouth. The nurse assessed, but could not…

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, staff interviews, and policy review, the facility staff failed to report allegations of abuse in a timely manner. This affected one (Resident #10) of five residents reviewed for abuse. The facility census was 102. Findings include: Review of the medical record for Resident #10 revealed an admission date of 01/31/24. Diagnoses included atherosclerotic heart disease, dysphagia, and the need for assistance with personal care. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition, had no behaviors, did not reject care, and did not wander. Review of the progress note dated 02/24/24 at 6:23 P.M. revealed staff heard screaming from the hallway. Upon entering Resident #10's room, Licensed Practical Nurse (LPN) #122 and State Tested Nurse Aide (STNA) #103 observed the resident's daughter forcing food into Resident #10's mouth. The daughter stated she was wiping blood from the resident's mouth. The nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews, and policy review, the facility failed to investigate allegations of abuse. This affected one (Resident #10) of five residents reviewed for abuse. The facility census was 102. Findings include: Review of the medical record for Resident #10 revealed an admission date of 01/31/24. Diagnoses included atherosclerotic heart disease, dysphagia, and the need for assistance with personal care. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition, had no behaviors, did not reject care, and did not wander. Review of the progress note dated 02/24/24 at 6:23 P.M. revealed staff heard screaming from the hallway. Upon entering Resident #10's room, Licensed Practical Nurse (LPN) #122 and State Tested Nurse Aide (STNA) #103 observed the resident's daughter forcing food into Resident #10's mouth. The daughter stated she was wiping blood from the resident's mouth. The nurse assessed, but could not locate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure a residents colostomy care was completed as ordered. This affected one (#10) of three residents reviewed. The facility census was 113. Findings include: Review of medical record for Resident #10 revealed admission date of 09/28/23. Diagnoses include right tibia fracture, diabetes mellitus type two, colostomy, reflux, depression, anxiety and alcohol induced pancreatitis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had a a Brief Interview Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. Resident #10 was independent for eating, dependent for toileting, transfers were not attempted. Documentation revealed Resident #10 had an indwelling catheter and ostomy present. Record review of the physician orders revealed orders to apply skin barrier to surrounding skin as a protectant with no start date. A second order to gently clean the stoma with soap and water and to change…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff interviews and policy review, the facility failed to ensure residents received written documentation explaining the reason for transfers to hospital at the time of transfer. This affected two residents (#112 and #119) of two residents reviewed for hospital transfer requirements. The facility census was 123. Findings included: 1. Medical record review for Resident #112 revealed an admission on [DATE] with a discharge on [DATE] and a readmission on [DATE]. Diagnoses that include high blood pressure, stroke, hemiplegia and hemiparesis, epilepsy, kidney failure, vascular dementia, major depressive disorder, osteoarthritis, anxiety, obesity, and history of falls. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident was assessed as rarely or never understood. Verbal behaviors were coded one to three days for verbal behaviors directed at others and behaviors not directed at others. Resident #112 requires extensive assist for bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and review of policy, the facility failed to provide written notification to the resident or resident's representative of their bed hold policy. This affected one (#119) of four reviewed for bed holds. The census was 123. Findings include: Review of the closed record review for Resident #119 revealed she was admitted on [DATE] and discharged on 05/02/21. Diagnoses included muscle weakness, unsteadiness on feet, history of falling, osteoarthritis, pulmonary fibrosis, disorientation, anxiety, anemia, cataract extraction status right eye, acquired absence of both cervix and uterus, and hypertension. Review of the nursing note, dated 05/01/21 at 9:30 P.M., revealed the resident was transferred to the emergency department of the hospital. Further review of the record revealed there were no notices of the bed hold policy in the resident's charts and the resident was responsible for herself. Interview on 06/02/21 at 11:53 A.M., revealed the Director of Nursing (DON) confirmed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff interviews, review of the Pre-admission Screening and Resident Review (PASRR) and review of the Centers of Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Manual, the facility failed to ensure the Minimum Data Set assessments were accurate. This affected two (#48 and #16) of 24 residents assessments reviewed for accuracy. The facility census was 123. Findings include: 1. Review of Resident #48's medical record revealed an admission date on 02/17/21 and readmitted on [DATE], with diagnoses including hemaplegia, hemaparesis, cerebral infarction affecting the right side, weakness, dysphagia, mixed receptive expressive language disorder, aphasia, facial weakness, umbilical hernia, ventral hernia, hypertensive heart disease, falls, history of urinary tract infections, atherosclerotic heart disease, chronic bronchitis, hypothyroidism, rheumatoid arthritis, atrial septal defect, cardiac murmur, depressive disorder, osteoporosis, knee joint…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to implement a baseline care plan within 48 hours of admission. This affected two (#33, and #119) of four residents reviewed for new admission. The census was 123. Findings include: 1. Review of the medical record revealed Resident #33 was admitted on [DATE], with diagnoses including dizziness and giddiness, age-related osteoporosis without current pathological fracture, Alzheimer's Disease and muscle weakness. Further review revealed Resident #33 did not have a baseline care plan implemented. 2. Review closed record review for Resident #119 was admitted on [DATE], with diagnoses including muscle weakness, unsteadiness on feet, history of falling, osteoarthritis, pulmonary fibrosis, disorientation, anxiety, anemia, cataract extraction status right eye, acquired absence of both cervix and uterus, and hypertension. Further review revealed Resident #119 did not have a baseline care plan implemented. Interview with the Director of Nursing on 06/02/21 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 medical record review, resident and staff interviews, the facility failed to initiate comprehensive care plans for residents. This affected two (#48 and #66) of 24 sampled residents. The facility census was 123. Findings included: 1. Review of Resident #48's medical record revealed an admission date on 02/17/21 and readmitted on [DATE], with diagnoses including hemaplegia, hemaparesis, cerebral infarction affecting the right side, weakness, dysphagia, mixed receptive expressive language disorder, aphasia, facial weakness, umbilical hernia, ventral hernia, hypertensive heart disease, falls, history of urinary tract infections, atherosclerotic heart disease, chronic bronchitis, hypothyroidism, rheumatoid arthritis, atrial septal defect, cardiac murmur, depressive disorder, osteoporosis, knee joint replacement, atrial septal defect, heart valve replacement, gastro-esophageal reflux disease and hyperglycemia. Review of the 5-day Minimum Date Set (MDS) assessment dated [DATE] revealed no diagnoses for and no…

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 reviews, staff, resident family member and resident interviews, and policy review, the facility failed to include residents in initial and quarterly care conferences when planning the residents care. This affected three (#55, #66, and #75) of five sampled residents for care planning. The facility census was 123. Findings included: 1. Review of Resident #66's medical record revealed an admission date of 03/31/21 and a re-admission date of 04/27/21, with diagnoses including malignant neoplasm of the prostate with malignant neoplasm of the bone, difficulty walking, pathological fractures of the right humrerous and left femur, weakness, bacterial pneumonia, pain, type two diabetes, obesity, anemia, disorders of the adrenal gland, acute kidney failure, hyperlipidemia, and a history of polymyelitis. Review of the Medicare -5 Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was assessment as cognitive intact with no cognitive issues and no mood or behavior issues. Resident #66…

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 staff interviews, the facility failed to obtain a physician order for the use of an indwelling Foley catheter and a supporting diagnosis. This affected one (#48) of 24 sampled residents. The facility identified seven residents with indwelling Foley catheters. The facility census was 123. Findings included: Review of Resident #48's medical record revealed an admission date on 02/17/21 and readmitted on [DATE], with diagnoses including hemaplegia, hemaparesis, cerebral infarction affecting the right side, weakness, dysphagia, mixed receptive expressive language disorder, aphasia, facial weakness, umbilical hernia, ventral hernia, hypertensive heart disease, falls, history of urinary tract infections, atherosclerotic heart disease, chronic bronchitis, hypothyroidism, rheumatoid arthritis, atrial septal defect, cardiac murmur, depressive disorder, osteoporosis, knee joint replacement, atrial septal defect, heart valve replacement, gastro-esophageal reflux disease 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 medical record review, observations, staff interviews and policy review, the facility failed to ensure residents receiving psychoactive medications were being adequately monitored for adverse side effects. This affected two (#16 and #75) of five reviewed for psychoactive medication usage. The facility census was 123. Findings Include: 1. Medical record review for Resident #16 revealed an admission date on 06/12/15 with diagnoses including unspecified intellectual disabilities, cerebral palsy, high blood pressure, anxiety, hypotension, dental caries, hypothyroidism, major depressive disorder, hearing loss, repeated falls, long term drug therapy and personal history of infectious and parasitic disease. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #16 revealed resident was coded as rarely or never understood. No behaviors were assessed during the look back period. Resident #16 requires supervision for bed mobility, transfers, and toileting. Eating was coded as extensive…

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 and sampling of a food test tray, review of resident council minutes and staff and resident interviews the facility failed to ensure the food was palatable and was served at the correct temperature. This affected 143 residents out of 145. The facility identified two Residents (#34 and #128) who ate nothing by mouth. The census was 145. Findings include: Observation of a lunch test tray on 01/30/19 at 12:32 P.M. revealed a grilled ham and cheese, a mix of zucchini and squash, beef and noodle soup, orange juice and 2% milk were being served. The temperatures taken by Dietary Supervisor (DS) #397, with his thermometer, the revealed orange juice was 57 degrees, the 2% milk was 48 degrees. When DS #397 took the temperature of the grilled cheese he lifted the sandwich with his left ungloved hand. Sampling of the above test tray on 01/30/19 at 12:34 P.M. revealed the orange juice and milk were warm. The grilled ham and cheese was limp and soggy. Interview with DS #397 on 01/30/19 at 12:40 P.M. agreed the grilled ham and cheese was limp and soggy. He also agreed 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 observation, staff interview and policy review, the facility failed to ensure items in the kitchen had expiration dates on them, failed to date items that were opened, failed to discard items that were opened and out of date, failed to change gloves in between handling food and dirty surfaces and failed to wash hands between change of gloves. This had the potential to affect 143 resident of a census of 145. The facility identified two Resident's (#34 and #128) who could have nothing by mouth. Findings include: 1. An observation of the servery kitchen conducted in the facility on 01/28/19 at 9:18 A.M. revealed the following items did not have an expiration date on them: two cases of sugar free syrup 1.1 ounce one case of regular syrup 2.1 ounce one case of peanut butter two cases of assorted jelly one case of sugar free jelly half a case of ketchup 1.0 ounce packets one case of ranch packets 1.1 ounce one case of tarter sauce 1 ounce packets one case mayonnaise 1 ounce packets one case of seafood sauce 2.1 ounce packets one half case parmesan cheese 1.5 ounce packets one…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, review of the Resident Assessment Instrument (RAI) and review of facility policy the facility failed to encode the Minimum Data Set (MDS) within the correct time frames. This affected four Residents (#27, #98, #107 and #345) of six reviewed for correct completion timing. The facility census was 145. Findings include: 1. Medical record review revealed Resident #27 was admitted on [DATE]. Diagnosis included infection of right arm, need for assistance with personal care, heart failure, lung cancer, enlarged lymph nodes, diabetes, kidney disease, rheumatoid arthritis, pain syndrome. depression, cancer of the breast, and history of falls. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident did not have any cognitive impairment. Resident #27 required limited assist with bed mobility, transfers, bathing and personal hygiene. She required supervision with eating. Review of Section K of the MDS, revealed the signed completion date was 01/30/19 at 5:25…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, resident and staff interview the facility failed to complete and implement person-centered comprehensive plans of care. This affected four Residents (#27, #52, #98, and #345) of six reviewed for patient centered care plans. The facility was 145. Findings include: 1. Medical record review revealed Resident #27 was originally admitted on [DATE] and readmitted on [DATE]. Diagnosis included cellulitis of right arm, difficulty in walking, need for assist with personal care, hypertensive heart disease, kidney disease, rheumatoid arthritis, fibromyalgia, depression, hypothyroid disorder, overactive bladder, constipation, history of breast cancer, and diabetes. Review of the admission Minimum Data Set (MDS) assessment dated of 01/21/19, revealed Resident #27 was not cognitively impaired. Review of Section F (interview for activity preferences) revealed Resident #27 indicated it was very important that she have music to listen to, participate in religious services and to do…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and staff interview the facility failed to ensure activities were provided according to resident interest for three (#27, #98 and #345) of four residents reviewed for activities. The facility census was 145. Findings include: 1. Medical record review revealed Resident #27 was originally admitted on [DATE] and readmitted on [DATE]. Diagnosis included cellulitis of right arm, difficulty in walking, need for assist with personal care, hypertensive heart disease, kidney disease, rheumatoid arthritis, fibromyalgia, depression, hypothyroid disorder, overactive bladder, constipation, history of breast cancer, and diabetes. Review of the admission Minimum Data Set (MDS) assessment dated of 01/21/19, revealed Resident #27 was not cognitively impaired. Review of Section F (interview for activity preferences) revealed Resident #27 indicated it was very important that she have music to listen to, participate in religious service and to do her favorite activities while in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and resident's family and staff interview, the facility failed to ensure a physician order to document urinary output from an indwelling catheter was followed. This affected one Resident (#35) of two reviewed for urinary catheter. The census was 145. Findings include: Medical record review revealed Resident #35 was admitted on [DATE]. Medical diagnoses included heart failure and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #35 was severely cognitively impaired. Functional status was extensive assistance for bed mobility, transfers, toilet use and eating. She was coded for an indwelling catheter. Review of physician order dated 11/01/18 revealed to measure urine output every shift. Review of care plan for Resident #35 revealed the resident had an indwelling Foley catheter related to comfort care and the intervention was to record Foley output every shift. Review of the Treatment Administration Record (TAR) from 11/01/18 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 medical record review, observation, staff interviews and facility policy review, the facility failed to ensure fall interventions were in place for residents who sustained falls with injuries. This affected two Residents (#17 and #71) of six reviewed for accidents. The census was 145. Findings include: 1. Medical record review revealed Resident #17 was admitted on [DATE]. Medical diagnoses included diabetes, cerebral palsy, and aphasia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #17 was cognitively intact. Functional status was extensive assistance for bed mobility, transfers, toileting and supervision for eating. Review of care plan dated 07/14/17 revealed Resident #17's was at risk for falls. Interventions were to place a fall mat to bedside and have call light within reach. Review of progress notes dated on 12/29/18 revealed the resident had a fall and sustained a questionable fracture to the right medial malleolus and was sent out to the hospital. Observation of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and policy review the facility failed to ensure non-pharmacological interventions were attempted before an as needed pain medication was administered. This affected one Resident (#71) of five reviewed for unnecessary medications. The census was 145. Findings included: Medical record review revealed Resident #71 was admitted on [DATE]. Medical diagnoses included dislocation of internal left hip prosthesis, and pain in left hip. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #71 was cognitively impaired. He was coded for an extensive assistance for bed mobility, transfers, and for toilet use. He was also coded for impairment on one side for lower extremity. Review of care plan for Resident #71 revealed he was at risk for experiencing pain in the left hip. The interventions were to provide non medication interventions for pain like hot packs, cold packs, soothing touch, rest periods and re-positioning. Review of physician orders (PO) 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 medical record review and staff interview, the facility failed to ensure to document an assessment for pain and a treatment for a pressure ulcer. This affected one Resident (#89) of two reviewed for pain. The census was 145. Findings include: Medical record review revealed Resident #89 was admitted on [DATE]. Medical diagnoses included coronary artery disease, history of falls, and renal insufficiency. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #89 was cognitively intact. Functional status was an extensive assistance for bed mobility, transfer, toileting and supervision for eating. Observation of wound care on 01/30/19 at 11:35 P.M. was completed by Licensed Practical Nurse (LPN) #321. Interview with LPN #321 on 01/30/19 at 11:50 A.M. revealed she asked Resident #89 if he needed any pain medication 30 minutes before the treatment and she said he refused. Review of the pain assessment on the Treatment Administration Record (TAR), wound care in the progress notes 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.