Hopewell Grove Rehabilitation and Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and facility policy review, the facility failed to ensure residents were treated in a dignified manner. This affected three residents (#43, #48, #49) of three residents reviewed for indwelling urinary catheter. The facility census was 67. Findings Include: 1. Review of the medical record for Resident #43 revealed an initial admission date of 01/22/25 with the latest readmission of 02/05/25 with the diagnoses including but not limited to cellulitis of right lower limb, pressure induced deep tissue damage of sacral region sacral region, hypertension, neurogenic bowel, benign prostatic hyperplasia neuromuscular dysfunction of bladder, anemia, bipolar disorder, anxiety disorder, post-traumatic stress disorder, osteoarthritis, gastro-esophageal reflux disease, retention of urine, edema, pain, Rhabdomyolysis, insomnia, spondylosis lumbar region, obesity, colostomy status and polyneuropathy. Review of the resident's admission evaluation dated 01/22/25 revealed the 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 and interview, the facility failed to ensure one resident's (#43) bed accommodated his size and had physician ordered enabler bars to enhance bed mobility. This affected one (Resident #43) of three residents reviewed for pressure ulcers. The facility census was 67. Findings Include: Review of the medical record for Resident #43 revealed an initial admission date of 01/22/25 with the latest readmission of 02/05/25 with the diagnoses including but not limited to cellulitis of right lower limb, pressure induced deep tissue damage of sacral region sacral region, hypertension, neurogenic bowel, benign prostatic hyperplasia neuromuscular dysfunction of bladder, anemia, bipolar disorder, anxiety disorder, post-traumatic stress disorder, osteoarthritis, gastro-esophageal reflux disease, retention of urine, edema, pain, Rhabdomyolysis, insomnia, spondylosis lumbar region, obesity, colostomy status and polyneuropathy. Review of the resident's monthly physician orders for February 2024 identified an order dated 01/23/25 enabler bars to enhance bed mobility.…

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

Based on record review and staff interview, the facility failed to complete a comprehensive admission assessment on admission for two residents (#43, #49). This affected two (Resident #43 and #49) of three residents reviewed for pressure ulcers. The facility census was 67. Findings Include: 1. Review of the medical record for Resident #43 revealed an initial admission date of 01/22/25 with the latest readmission of 02/05/25 with the diagnoses including but not limited to cellulitis of right lower limb, pressure induced deep tissue damage of sacral region sacral region, hypertension, neurogenic bowel, benign prostatic hyperplasia neuromuscular dysfunction of bladder, anemia, bipolar disorder, anxiety disorder, post-traumatic stress disorder, osteoarthritis, gastro-esophageal reflux disease, retention of urine, edema, pain, Rhabdomyolysis, insomnia, spondylosis lumbar region, obesity, colostomy status and polyneuropathy. Review of the progress note dated 02/05/25 at 6:10 P.M. revealed the resident was readmitted to the facility at 6:00 P.M. Review of the medical record revealed a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy review, the facility failed to ensure one resident (#72) who was dependent on staff received routine bathing. This affected one (Resident #72) of three residents reviewed for bathing. The facility census was 67. Findings Include: Review of the closed medical record for Resident #72 revealed an initial admission date of 01/24/25 with the diagnoses including but not limited to acute respiratory failure with hypoxia, multiple sclerosis (MS), chronic obstructive pulmonary disease (COPD), severe protein calorie malnutrition, right bundle branch block, urinary tract infection, pneumonitis due to inhalation of food and vomit, dysphagia, other disorders of lung, history of falling, pain, slow transit constipation, migraine, vitamin D deficiency, intervertebral disc displacement lumbar region, neuromuscular dysfunction of bladder, slurred speech, osteoarthritis, dependence on supplemental oxygen, anxiety disorder and functional quadriplegia. The resident was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure an indwelling urinary catheter was changed as physician ordered for Resident #43. Additionally, the facility failed to ensure one resident (#73) received routine indwelling catheter care. This affected two (Resident #43 and #73) of three residents reviewed for indwelling urinary catheter. The facility census was 67. Findings Include: 1. Review of the medical record for Resident #43 revealed an initial admission date of 01/22/25 with the latest readmission of 02/05/25 with the diagnoses including but not limited to cellulitis of right lower limb, pressure induced deep tissue damage of sacral region sacral region, hypertension, neurogenic bowel, benign prostatic hyperplasia neuromuscular dysfunction of bladder, anemia, bipolar disorder, anxiety disorder, post-traumatic stress disorder, osteoarthritis, gastro-esophageal reflux disease, retention of urine, edema, pain, Rhabdomyolysis, insomnia, spondylosis lumbar region, obesity,…

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

Based on observation, record review and interview, the facility failed to maintain two residents (#50, #72) enteral feeding tube in proper working order. This affected two (Resident #50 and #72) of three residents reviewed for enteral feedings. The facility census was 67. Findings Include: 1. Review of the closed medical record for Resident #72 revealed an initial admission date of 01/24/25 with the diagnoses including but not limited to acute respiratory failure with hypoxia, multiple sclerosis (MS), chronic obstructive pulmonary disease (COPD), severe protein calorie malnutrition, right bundle branch block, urinary tract infection, pneumonitis due to inhalation of food and vomit, dysphagia, other disorders of lung, history of falling, pain, slow transit constipation, migraine, vitamin D deficiency, intervertebral disc displacement lumbar region, neuromuscular dysfunction of bladder, slurred speech, osteoarthritis, dependence on supplemental oxygen, anxiety disorder and functional quadriplegia. The resident was discharged to another local skilled nursing facility (SNF) on 02/07/25.…

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.

Based on record review, interview and facility policy review, the facility failed to ensure one resident (#72) was provided the physician ordered chest vest (help clear patients ' airways. It dislodges mucus from the bronchial walls, and helps move secretions and mucus from smaller to larger airways, where it can be coughed or suctioned out.) for chest physiotherapy. This affected one (Resident #72) of one resident reviewed for chest vest use. The facility census was 67. Findings Include: Review of the closed medical record for Resident #72 revealed an initial admission date of 01/24/25 with the diagnoses including but not limited to acute respiratory failure with hypoxia, multiple sclerosis (MS), chronic obstructive pulmonary disease (COPD), severe protein calorie malnutrition, right bundle branch block, urinary tract infection, pneumonitis due to inhalation of food and vomit, dysphagia, other disorders of lung, history of falling, pain, slow transit constipation, migraine, vitamin D deficiency, intervertebral disc displacement lumbar region, neuromuscular dysfunction of bladder,…

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

Based on observation, record review and interviews, the facility failed to maintain a complete and accurate record for one resident (#43) in the area of physician ordered treatments. This affected one (Resident #43) of three residents reviewed for pressure ulcers. The facility census was 67. Findings Include: Review of the medical record for Resident #43 revealed an initial admission date of 01/22/25 with the latest readmission of 02/05/25 with the diagnoses including but not limited to cellulitis of right lower limb, pressure induced deep tissue damage of sacral region sacral region, hypertension, neurogenic bowel, benign prostatic hyperplasia neuromuscular dysfunction of bladder, anemia, bipolar disorder, anxiety disorder, post-traumatic stress disorder, osteoarthritis, gastro-esophageal reflux disease, retention of urine, edema, pain, Rhabdomyolysis, insomnia, spondylosis lumbar region, obesity, colostomy status and polyneuropathy. Review of the medical record revealed a comprehensive readmission assessment was not completed until 02/07/25. Further review revealed the assessment…

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

Based on observation, record review, interview, and facility policy review, the facility failed to maintain infection control practices to prevent the potential spread of infection during pressure ulcer dressing change for one resident (#43). Additionally, the facility failed to implement enhance barrier precautions for one resident (#50) with an indwelling medical device. This affected one resident (#43) of three residents reviewed for pressure ulcers and one resident (#50) of three residents reviewed for enteral feeding tubes. The facility census was 67. Findings include: 1. Review of the medical record for Resident #43 revealed an initial admission date of 01/22/25 with the latest readmission of 02/05/25 with the diagnoses including but not limited to cellulitis of right lower limb, pressure induced deep tissue damage of sacral region sacral region, hypertension, neurogenic bowel, benign prostatic hyperplasia neuromuscular dysfunction of bladder, anemia, bipolar disorder, anxiety disorder, post-traumatic stress disorder, osteoarthritis, gastro-esophageal reflux disease, retention…

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 and staff and Hospice Director Physician #100 interviews, the facility failed to ensure a resident's pain medication order was transcribed correctly resulting in medication errors. This affected one (Resident #64) of three residents reviewed for medications. The facility census was 63. Findings include: Record review of Resident #64 revealed an admission date of 10/27/24. Resident #64 passed away in the facility on hospice care on 12/17/24. The resident had pertinent diagnoses of cerebral palsy and reflux uropathy. Review of the 08/22/24 quarterly Minimum Data Set (MDS) assessment revealed the resident was moderately cognitively impaired and used a wheelchair to aid in mobility. The resident required substantial to maximum assistance for personal hygiene, rolling left to right, sit to lying, lying to sitting, and sit to stand. The resident had an indwelling catheter and was occasionally incontinent of bowel. Resident #64 was admitted to hospice services on 12/15/24 with a diagnosis of sepsis. Review of the 12/16/24 Hospice Client Medication Report…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, observation, policy review, and record review, the facility failed to follow Enhanced Barrier Precautions (EBP) for a resident with a wound. This affected one (Resident #37) of three residents reviewed for wounds. The facility census was 63. Findings include: Record review of Resident #37 revealed an admission date of 11/23/24 with a discharge 12/02/24 and readmission on [DATE]. The resident had pertinent diagnoses of cerebral infarction, hemiplegia and hemiparessis following cerebrovascular disease affecting right non dominant side, type two diabetes mellitus, anxiety disorder, hypertension, and hyperlipidemia. Review of the 11/27/24 Minimum Data Set (MDS) assessment revealed Resident #37 is cognitively intact. The resident has an unstageable pressure ulcer. Review of the 01/09/25 wound evaluation revealed the resident had a stage two pressure ulcer on his left heel. Observation of Resident #37 on 01/14/25 at 2:14 P.M. revealed Registered Nurse (RN) #20 performing wound care. RN #20…

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, staff interview, and review of facility policy, the facility failed to ensure toileting assistance was provided in a timely manner to a dependent resident. This affected one (Resident #57) of three residents reviewed for activities of daily living (ADL) care. The facility census was 72 residents. Findings include: Review of the medical record for Resident #57 revealed an admission date of 08/28/24 with diagnoses including dementia, need for assistance with personal care, and difficulty walking. Review of the admission Minimum Data Set (MDS) assessment for Resident #57 dated 09/04/24 revealed the resident had moderately impaired cognition, was dependent upon staff for transfers to the toilet, and was occasionally incontinent of bowel and bladder. Review of the care plan for Resident #57 dated 08/28/24 revealed the resident had a self-care deficit related to impaired physical functioning and medical conditions as evidenced by the need for staff assistance for adequate completion of ADLs. Interventions included staff provide hands-on…

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

Based on medical record review, observation, staff interview, resident interview, review of Resident Council meeting minutes, and review of call light audits, the facility failed to provide timely toileting services to dependent residents. This affected one (Resident #24) of three residents reviewed for call light response time. The facility census was 58 residents. Findings include: Review of the medical record for Resident #24 revealed an admission date of 07/28/24 with diagnoses including orthopedic after care, surgical repair on spine, and hypertension. Review of the admission Minimum Data Set (MDS) assessment for Resident #24 dated 08/02/24 revealed the resident was cognitively intact and required limited assistance with activities of daily living (ADLs.) Interview on 08/05/24 at 10:00 A.M. with the Administrator confirmed resident call lights should be answered within a reasonable time frame but did not indicate an expectation of minutes within which staff should respond. The Administrator confirmed the facility completed call light audits from 07/23/24 to 07/29/24 as a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to timely submit Minimum Data Set (MDS) assessments for residents. This affected four (#16, #52, #57, and #61) of six residents reviewed for assessments. The facility census was 61. Findings include: 1. Review of Resident #16's medical record revealed an admission date of 12/04/23 and a discharge date of 12/21/23. Resident #16 had diagnoses of encephalopathy, schizophrenia, peripheral vascular disease, chronic obstructive pulmonary disease, and retention of urine. Review of Resident #16's MDS assessment on 05/22/24 revealed there was no discharge MDS completed on 12/21/23. Interview on 05/22/24 at 4:23 P.M., with Licensed Practical Nurse (LPN) #40, verified Resident #16 discharged on 12/21/23 and there was not a discharge MDS completed. 2. Review of Resident #52's medical record revealed an admission date of 12/05/23 and a discharge date of 01/08/24. The resident had pertinent diagnosis of: diverticulitis of intestine, fibromyalgia, acute myocardial…

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

Based on observations, medical record review, staff interview and policy review, the facility failed to ensure resident were placed in enhanced barrier precautions appropriately and failed to ensure staff were wearing appropriate personal protective equipment (PPE) when interacting with residents in enhanced barrier precautions. This affected six (#10, #14, #47, #51, #55, and #376) of six residents the facility identified to be in enhanced barrier precautions. The facility census was 61. Findings include: Observations on 05/20/24 between 8:00 A.M. and 8:30 A.M., revealed no residents were identified as requiring enhanced barrier precautions (EBP) when care was provided. 1. Observation and interview on 05/20/24 at 8:35 A.M., with Restorative Aide #403 revealed she was doing range of motion exercise with Resident #51 including exercising the upper and lower body and placing hand splints on and off for bilateral upper extremities. Restorative Aide #403 revealed she was not aware of Resident #51's isolation status and if he were in enhanced barrier precautions it was only for staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure a resident was provided assistance in obtaining a resident representative to make appropriate decision on behalf of the resident, concerning exercising resident rights and care and treatment at the faciltiy. This affected one (#56) of one resident reviewed for decision making. Facility census was 61. Findings include Review of the medical record for Resident #56 revealed an admission date of 01/22/24. Diagnoses included vascular dementia without behavioral disturbances, unsteadiness on feet, generalized weakness, failure to thrive, and malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 had significant cognitive impairment. Review progress notes dated 02/08/24, revealed Resident #56 had a significant other at the facility who wanted to take him out of the building. Staff educated Resident#56's girlfriend that Resident #56 was not to be out of the building without family. Progress note…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN), and staff interview, the facility failed to ensure the resident notice letter was accurately completed. This affected three (#41, #66, and #71) of three residents reviewed for Beneficiary Notification. The facility census was 61. Findings include: 1. Review of the medical record revealed Resident #41 was admitted on [DATE], with diagnoses of fracture of right femur neck, Parkinson's disease, cognitive communication deficit, dysphagia, neuropathy, anemia, acute embolism and thrombosis of right femoral vein, hypertension, and osteoporosis. The last covered day of Part A service for Resident #41 was 05/03/24 who then transitioned to long-term care. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident#41 was moderately cognitively impaired, was always incontinent of bowel and bladder, and had no range of motion impairment in upper and lower…

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, policy review, and staff interview, the facility failed to ensure the medical record contained documentation reflecting the reason resident was transferred to the hospital. This affected one (#64) of one resident reviewed for hospitalization. The facility census was 61. Findings include: Review of the medical record for Resident #64 revealed an admission date of 03/18/23, with diagnoses of acute metabolic acidosis, sepsis, fatty (change of) liver, post-traumatic stress disorder, personality disorder, ulcerative colitis, attention-deficit hyperactivity disorder, anxiety disorder, alcohol use with intoxication, major depressive disorder, hypertension, fibromyalgia, and alcoholic liver disease. Resident #64 was discharged from the facility on 05/03/24 to a non-specified location. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 was cognitively intact and continent of bowel and bladder. Resident #64 required set up assistance for eating and personal…

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

Based on record review and staff interview, the facility failed to complete an accurate comprehensive annual Minimum Data Set (MDS) assessment when they failed to include a diagnosis of post traumatic stress disorder. This affected one (#25) of six residents reviewed for comprehensive assessments. The facility census was 61. Findings include: Review of Resident #25's medical record revealed an admission date of 11/10/23, with diagnoses of: post traumatic stress disorder, iron deficiency anemia, cellulitis of right lower limb, unsteadiness on feet, morbid obesity, chronic obstructive pulmonary disease, anxiety disorder, bipolar disorder, hypertension, and hyperlipidemia. Review of the 09/03/23 and 11/08/23 discharge Minimum Data Set (MDS) assessments revealed section I (active diagnoses section) was coded with a diagnosis of post traumatic stress disorder (PTSD) Review of the 02/15/24 annual comprehensive MDS assessment revealed the resident had no coded diagnosis of post traumatic stress disorder in section I (active diagnoses section). Review of Resident #25's face sheet revealed 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.

Based on record review and staff interview, the facility failed to develop a comprehensive care plan for a resident identifed with the diagnosis of post traumatic stress disorder. This affected one (#25) of 19 residents reviewed for care plans. The facility census was 61. Findings include: Review of Resident #25's medical record revealed an admission date of 11/10/23, with diagnoses of: post traumatic stress disorder, iron deficiency anemia, cellulitis of right lower limb, unsteadiness on feet, morbid obesity, chronic obstructive pulmonary disease, anxiety disorder, bipolar disorder, hypertension, and hyperlipidemia. Review of the 09/03/23 and 11/08/23 discharge Minimum Data Set (MDS) assessments revealed section I (active diagnoses section) was coded with a diagnosis of post traumatic stress disorder (PTSD) Review of Resident #25's face sheet revealed a diagnoses of post traumatic stress disorder. Review of Resident #25 medical record on 05/22/24 at 3:30 P.M., revealed she did not have a care plan for PTSD. Interview on 05/22/24 at 3:42 P.M., with Licensed Practical Nurse (LPN)…

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 resident care plans were updated and to include appropriate interventions for elopement for Resident #56 and for nutrition and weight loss prevention for Residents #23 and #51. This affected three (#23, #51, and #56) of 16 residents care plans reviewed. The facility census was 61. Findings include: 1. Review of the medical record for Resident #56 revealed an admission date of 01/22/24. Diagnoses included vascular dementia without behavioral disturbances, unsteadiness on feet, generalized weakness, failure to thrive, and malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 had significant cognitive impairment and required assistance for transfers. Review of the plan of care dated 02/08/24 revealed the resident was at risk for elopement due to exit seeking behavior with interventions to monitor battery of wander guard, check wander guard placement, each shift and functionality daily, monitor…

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 recognize and timely address severe resident weight loss. This affected one (#27) of three residents reviewed for nutrition. The facility census was 61. Findings include: Review of the medical record for Resident #27 revealed an admission date of 01/19/24. Diagnoses included Parkinson's disease, muscle weakness, depression, diabetes, and spinal stenosis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], Resident #27 was cognitively intact, was 66 inches tall and weight was 229 pounds (lbs.). Review of the quarterly MDS assessment dated [DATE] revealed Resident #27 was cognitively intact and weighed 193 pounds. The MDS indicated there was no weight loss or gain. Review of the monthly physician orders for January 2024 to May 2024 revealed the resident was to receive a carb-controlled diet with regular texture. Review of Resident #27's weights revealed from 01/19/24 to 03/01/24, Resident #27's weight…

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

Based on record review and staff interview, the facility failed to ensure resident drug regimen were free from unnecessary medications when there was not a valid diagnosis for the use of antibiotics. This affected one (#325) of six residents reviewed for unnecessary medications. The facility census was 61. Findings include: Review of Resident #325's medical record revealed an admission date of 05/16/24 with pertinent diagnoses of: cerebral infarction and unsteadiness on feet. Review of a physician order dated 05/16/24 revealed take by mouth amoxicillin-potassium clavulanate (an antibiotic) tablet; 875 milligrams (mg)-125 mg; amount: one tablet; oral Administer one tablet by mouth twice daily x 11 days for infection. Review of a physician order dated 05/16/24 revealed take by mouth doxycycline monohydrate (an antibiotic) capsule; 100 mg; amount: one capsule; oral Special Instructions: Administer one capsule by mouth twice daily x 11 days for infection. Review of the medical record on 05/21/24 revealed no documented supporting diagnosis for the antibiotic orders 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 and staff interview, the facility failed to ensure influenza and pneumonia vaccinations were offered and provided to residents. This affected two (#47 and #56) of five residents reviewed for influenza and pneumonia vaccination. The facility census was 61. Findings include. 1. Review of the medical record for Resident #47 revealed an admission date of 03/22/22. Diagnoses included sepsis, vascular disease, heart failure, diabetes, and Parkinson's. Review of the vaccination consent form dated 09/25/23 revealed he consented for flu but not for pneumonia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was cognitively intact. Review of vaccination preventative health listing revealed Resident #47 had received pneumococcal vaccine on 02/04/21 in an outside setting. Review of the undated vaccination record revealed Resident #47 had received the pneumococcal PPV23 on 02/04/21. Review of the Centers for Disease Control Pneumococcal Vaccine Recommendations revealed…

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, family interview, staff interview, and policy review, the facility failed to hold care conferences where the resident and resident representatives were invited to discuss the resident's care. This affected two (#31 and #157) of two residents reviewed for care plan conferences. The facility census was 48. Finding include: 1. Review of medical record for Resident #31 revealed an admission date of 12/23/20, with diagnoses including acute kidney failure, Alzheimer's disease, and type two diabetes. Review of Minimum Data Set (MDS) assessment of Resident #31 revealed Resident #31 had a Brief Interview of Mental Status 14 that indicated she was cognitively intact. Interview on 04/26/23 at 11:52 A.M., with family of Resident #31 stated she had only had one care conference offered to her which was on 01/03/23. Resident #31 family stated the facility had not called her or informed her at the facility, of care conferences being held. Resident #31 family stated she would like to ask questions about her mother's care. Review of care conferences notes for Resident #31…

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, observations, family and staff interviews and policy review, the facility failed to inform a resident's family of an injury/change in condition. This affected one (#157) of one resident reviewed for change in condition. The facility census was 48. Findings include: Review of the medical record for the Resident #157 revealed an admission date of 04/18/23, with diagnoses including cellulitis of the left lower limb, and pain. Review of the Minimum Data Set (MDS) assessment revealed the assessment had not yet been completed for Resident #157 but was in process dated 04/25/23, for a new admission. Resident #157 is assessed as having cognitive impairiment. Review of the progress note dated 04/20/23 revealed the resident was switched from her regular bed into a bariatric bed with side rails. Resident had right side weakness and had difficulty holding herself up in bed without them. A progress note dated 04/23/23 revealed. resident was receiving care and was turned on her left side for peri care when the bed moved and resident's hand was caught between moved, side…

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

Based on observations, staff interviews, resident and family interviews and policy review, the facility failed to maintain a homelike environment in a resident room. This affected one (#157) of five residents reviewed for environment. The facility census was 48. Findings include: Review of the medical record for the Resident #157 revealed an admission date of 04/18/23, with diagnoses including cellulitis of the left lower limb, and pain. Review of the Minimum Data Set (MDS) assessment had not yet been completed for Resident #157 but was in process dated 04/25/23, for a new admission. Resident #157 is assessed as having cognitive impairiment. Observation on 04/24/23 at 9:00 A.M., 12:20 P.M., 2:33 P.M., and 4:40 P.M., revealed Resident #157 was sitting in bed or in the wheelchair during several observations. A Hoyer lift was observed stored int he room during these observations. Observation and interview on 04/25/23 at 9:00 A.M., with Resident #157 and Resident #157's family revealed the Hoyer lift had been kept in the room most days since admission. Observation of the family member…

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, staff interviews and policy reviews, the facility failed to ensure a resident with a wound was assessed timely and evaluate the wound for treatment. This affected one (#157) of two residents reviewed for wound care. The facility identified seven current residents with wounds. The facility failed to correlate hospice services with the facility service for a resident on hospice. This affected one (#106) of one resident reviewed for hospice service. The facility identified three current residents receiving hospice services. The facility census was 48. Findings include: 1. Review of the medical record for the Resident #157 revealed an admission date of 04/18/23, with diagnoses including cellulitis of the left lower limb, and pain. Review of the Minimum Data Set (MDS) assessment revealed the assessment had not yet been completed for Resident #157 but was in process dated 04/25/23, for a new admission. Resident #157 is assessed as having cognitive impairment. Review of KCI wound vacuum (vac) order form dated 04/17/23 revealed resident wound measured…

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

Based on observations, record review, staff and resident interviews and policy review, the facility failed to ensure residents remained free of accidents/ hazards and failed complete a thorough fall investigation. This affected two (#157 and #45) of five residents reviewed for accidents and hazards. The facility census was 48. Findings include: 1. Review of the medical record for the Resident #157 revealed an admission date of 04/18/23, with diagnoses including cellulitis of the left lower limb, and pain. Review of the Minimum Data Set (MDS) assessment revealed the assessment had not yet been completed for Resident #157 but was in process dated 04/25/23, for a new admission. Resident #157 is assessed as having cognitive impairment. Review of the progress note dated 04/20/23 revealed the resident was switched from her regular bed into a bariatric bed with side rails. Resident #157 had right side weakness and had difficulty holding herself up in bed without them. Review of therapy notes dated 04/20/23 revealed the resident required max assistance of two staff to roll and bed mobility.…

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

Based on record review and staff interview, the facility failed to timely act upon a pharmacy drug regimen review to draw laboratory test. This affected one (#45) of five residents reviewed for unnecessary medications. The facility census was 48. Findings include: Record review of Resident #45 revealed an admission date of 03/30/21, with diagnoses including: osteomyelitis of vertebra, sacral and sacrococcygeal region, muscle weakness, type 2 diabetes mellitus without complications, generalized anxiety disorder, anemia, schizoaffective disorder, altered mental status, and visual hallucinations. Review of a pharmacy recommendation dated 01/03/23 revealed a recommendation to monitor lipid panel and liver function tests every six months. The Physician Assistant agreed with the recommendation to draw the lab. Review of Resident #45 medical record on 04/27/23 revealed no documentation of a lipid panel and liver function tests being completed. Interview on 04/27/23 at 10:32 A.M., with the Director of Nursing (DON) verified there was not a lipid panel and liver function completed for…

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

Based on observations, record review, staff interviews, and policy review, the facility failed to maintain infection control practices during a dressing change. This affected one (#157) of one resident observed for dressing change. The facility identified seven residents who currently have wounds. The facility census was 48. Findings include: Review of the medical record for the Resident #157 revealed an admission date of 04/18/23, with diagnoses including cellulitis of the left lower limb, and pain. Review of the Minimum Data Set (MDS) assessment revealed the assessment had not yet been completed for Resident #157 but was in process dated 04/25/23, for a new admission. Resident #157 is assessed as having cognitive impairment. Review of KCI wound vacuum (vac) order form dated 04/17/23 revealed resident wound measured 5.3-centimeter (cm) x 6.2 cm x 0.5 cm. Review of hospital record dated 04/18/23 revealed the resident had been diagnosed with Left Lower Extremities (LLE) cellulitis and hematoma requiring debridement of eschar and evacuation of hematoma on 04/14/23 and wound vac 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.