Westmoreland Place

Based on staff interview, and record review the facility failed to ensure the accuracy of Pre-admission Screening and Resident Review (PASARR) assessments for Residents #7, #32 and #81 for mental health diagnosis. This affected three (Resident #7, #32 and #81) of five residents reviewed for PASARR. The facility census was 94. Findings include: 1. Record review of Resident #7 revealed an admission date of 11/20/18 with pertinent diagnoses of: chronic obstructive pulmonary disease, cerebral infarction, delusional disorders, restlessness and agitation, insomnia due to other mental disorder, sexual dysfunction, schizoaffective disorder bipolar type, major depressive disorder with psychotic symptoms, mild cognitive impairment of uncertain etiology, hypothyroidism, atrial fibrillation, dysphagia following cerebral infarction, type two diabetes mellitus, acute and chronic respiratory failure with hypoxia, aphasia, cardiomyopathy, atherosclerotic heart disease, congestive heart failure, major depressive disorder, hyperlipidemia, hypertension, weakness, repeated falls, and personal history…

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 Review of the medical record, interview, and facility policy review, the facility failed to complete a Preadmission Screening and Resident Review (PASARR) within 30 days following admission for one resident. This affected one (Resident #18) of five residents reviewed for PASARR. The facility census was 94. Findings Include: Review of the medical record for Resident #18 revealed an initial admission date of 09/16/24 with the diagnoses including but not limited to wedge compression fracture of thoracic 11 and thoracic 12 vertebra, neuropathy, severe morbid obesity, vitamin D deficiency, obstructive sleep apnea, dorsalgia, dipolar disorder, insomnia, overactive bladder, major depressive disorder, anxiety disorder, spinal stenosis, hypertension, hyperlipidemia, diabetes mellitus and restless leg syndrome. Review of the plan of care dated 09/11/24 revealed the resident's discharge plans were undetermined, new/recent admission to facility with possible long term care placement. Interventions include encourage follow…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and facility policy review, the facility failed to develop and implement a comprehensive plan of care in the area of smoking, activities of daily living (ADL) and dental. This affected three residents (#6, #75, #89) of 19 sampled residents. The facility census was 94. Findings Include: 1. Review of the medical record for Resident #89 revealed an initial admission date of 07/25/24 with the latest readmission of 01/11/25 with the diagnoses including but not limited to cerebral infarction, intervertebral disc degeneration of lumbosacral region, visual loss, acute kidney failure, encephalopathy, slow transit constipation, subdural hemorrhage, history of traumatic brain injury, dementia, anemia, osteoarthritis, obstructive and reflux uropathy, hypertension, hydronephrosis, anxiety disorder, hearing loss, chronic pain, hyperlipidemia, malignant neoplasm of overlapping sites of right female breast. Review of the admit complete admission review dated 07/25/24 revealed 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 staff interview, record review, and policy review, the facility failed to ensure care plan interventions were updated. This affected two residents (#13 and #67) who were involved in a resident to resident altercation and a third resident (#17) after a fall out of 25 resident careplans reviewed. Facility census was 94. Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of 08/11/21. Diagnoses included chronic obstructive pulmonary disease, diabetes, dysphasia, muscle weakness, schizophrenia and kidney disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively impaired with a brief interview for mental status (BIMS) of 0 (rarely/never understood) out of 15. Review of the plan of care dated 01/28/25 revealed resident had potential for altered mood pattern related to schizophrenia with interventions for one to one visits as needed, give comfort measures with calm approach, and try different approaches including walk…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and facility policy review, the facility failed to provide meal assistance for one resident (#9) and provide nail care for one resident (#89), who was dependent on staff. This affected two (Resident #9 and #89) of four residents reviewed for activities of daily living (ADL). The facility census was 94. Findings Include: 1. Review of the medical record for Resident #9 revealed an initial admission date of 12/21/21 with the diagnoses including but not limited to cerebrovascular accident with right sided hemiplegia, anorexia, hyperlipidemia, palliative care, age related physical debility, osteoporosis, hypertension, psychotic disorder with delusions and hallucinations. Review of the plan of care dated 12/27/21 revealed the resident had an activities of daily living (ADL) self care performance deficit related dementia, impaired balance, limited mobility, need for assist/support may fluctuate based on fatigue, time of day and motivation. Interventions included assess 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 record review, family and staff interviews, the facility failed to maintain hospice records. This affected one Resident (#67) of one reviewed for hospice. Facility census was 94. Findings include Review of the medical record for Resident #67 revealed an admission date of 08/13/24. Diagnoses included encephalopathy, chronic obstructive pulmonary disease, respiratory failure, dementia, epilepsy, schizophrenia, muscle weakness and cognitive communication deficit, dysphasia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 was cognitively impaired. Review of the plan of care dated 01/27/25 revealed resident was receiving hospice services. Review of the medical record on 01/30/25 found no evidence of hospice notes being uploaded directly to the residents medical record. Review of the hospice binder maintained by the facility, resident was admitted to hospice 06/2024 and only three visit notes were documented. Interview on 01/28/25 at 9:13 A.M. with resident family 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 observation, record review, interview, and facility policy review, the facility failed to ensure safe smoking for two residents (#6, #75). Additionally the facility failed to ensure safe hot water temperatures for three residents (#9, #79, #89). This affected two ( Resident #6 and #75) of three resident reviewed for smoking and three ( Resident #9, #79, and #89) of 19 sampled residents for water temperatures. The facility census was 94. Findings Include: 1. On 01/27/25 at 12:38 P.M., observation of Resident #9's room water temperature revealed a temperature of 131.2 degrees. On 01/27/25 at 12:45 P.M., interview with Maintenance Director (MD) #228 verified the water temperature was above the maximum 120 degree limit. 2. On 01/27/25 at 12:23 P.M., observation of Resident #89's water temperature in the bathroom revealed a temperature of 125.7 degrees. On 01/27/25 at 12:45 P.M., interview with Maintenance Director (MD) #228 verified the water temperature was above the maximum 120 degree limit. 3. On 01/27/25 at 12:34 P.M., observation of Resident #79's room water temperature…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and facility policy review, the facility failed to ensure residents had access to fluids and bedside. Additionally, the facility failed to ensure one resident received beverages with meals. This affected three ( #8, #9, and #89) of four residents reviewed for hydration. The facility census was 94. Findings Include: 1. Review of the medical record for Resident #8 revealed an initial admission date of 11/11/23 with the diagnoses including but not limited to fibromyalgia, chronic respiratory failure, chronic pulmonary edema, cerebrovascular accident (CVA) with hemiplegia, dorsalgia, congestive heart failure, diabetes mellitus, chronic obstructive pulmonary disease (COPD), spinal stenosis, obstructive sleep apnea, restless leg syndrome, hypertension, chronic kidney disease, peripheral vascular disease, irritable bowel syndrome with constipation, spondylosis, dementia, osteoarthritis, hyperlipidemia, anxiety disorder, gout, hypothyroidism, osteoporosis and depressive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to monitor one resident's blood pressure prior to the administration of the medication Hydralazine (a medication used to lower blood pressure). This affected one ( Resident #70) out of five residents reviewed for unnecessary medications. The facility census was 94. Findings Include: Review of the medical record for Resident #70 revealed an initial admission date of 02/07/24 with the latest readmission of 08/28/24 with the diagnoses including but not limited to Rhabdomyolysis, diabetes mellitus, chronic obstructive pulmonary disease (COPD), benign prostatic hyperplasia, hyperlipidemia, pain, dementia, peripheral vascular disease, intellectual disabilities, major depressive disorder, nicotine dependence, legal blindness, schizoaffective disorder, hypertension, acquired absence of left foot, insomnia, major depressive disorder and anxiety disorder. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had 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 staff interview, record review, and policy review, the facility failed to obtain Physician ordered labs for residents. This affected two (Resident #70, and #81) of five residents reviewed for medications. The facility census was 94. Findings include: 1. Record review of Resident #81 revealed an admission date of 08/13/24 with pertinent diagnoses of: dementia with psychotic disturbance, malignant neoplasm of prostate, deficiency of B group vitamins, hyperlipidemia, hypertension, gastro-esophageal reflux disease, edema, anxiety disorder, and psychotic disorders with delusions. Review of the 11/22/24 modification of quarterly Minimum Data Set (MDS) revealed the resident is rarely or never understood. Review of a Physicians Order dated 08/13/24 revealed complete blood count (CBC, a lab to check blood cells) and basic metabolic panel (BMP, a lab to check chemical balance and metabolism) laboratory values one time only for new admit. Review of a Physicians Order dated 08/23/24 revealed complete blood count…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and facility policy review, the facility failed to ensure one resident received dental services. This affected one resident (#89) of two residents reviewed for dental. The facility census was 94. Findings Include: Review of the medical record for Resident #89 revealed an initial admission date of 07/25/24 with the latest readmission of 01/11/25 with the diagnoses including but not limited to cerebral infarction, intervertebral disc degeneration of lumbosacral region, visual loss, acute kidney failure, encephalopathy, slow transit constipation, subdural hemorrhage, history of traumatic brain injury, dementia, anemia, osteoarthritis, obstructive and reflux uropathy, hypertension, hydronephrosis, anxiety disorder, hearing loss, chronic pain, hyperlipidemia, malignant neoplasm of overlapping sites of right female breast. Review of the admit complete admission review dated 07/25/24 revealed the resident had her own teeth but the question of broken or carious teeth was…

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

Based on observation, record review, policy review ,and staff interview, the facility failed to maintain an infection prevention and control program to help prevent the transmission of infections when they failed to use proper hand hygiene during a dressing change, and failed to follow enhanced barrier precautions. This affected one (Resident #74) of two residents reviewed for wounds. The facility census was 94. Findings include: Record review of Resident #74 revealed an admission date of 12/18/24 with pertinent diagnoses of: sepsis due to streptococcus, type two diabetes mellitus, chronic respiratory failure with hypoxia, encephalopathy, moderate intellectual disabilities, hypertension, heart failure, morbid obesity due to excess calories, type two diabetes mellitus with diabetic neuropathy, acute respiratory failure with hypoxia, benign prostatic hyperplasia, hyperlipidemia, venous insufficiency chronic peripheral, lymphedema, type two diabetes mellitus with foot ulcer, cardiomyopathy, iron deficiency anemia, solitary pulmonary nodule, and unspecified hydronephrosis. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain an adequate resident call system to allow residents to call for staff assistance. This affected two residents (Residents # 48 and #20) of the 30 residents reviewed for call light function in the facility. The facility census was 94. Findings include: 1. Record review of Resident #48 revealed an admission date of 12/26/21 with diagnoses that included inflammatory neuropathy, heart failure, paraplegia and chronic obstructive pulmonary disease. 2. Record review of Resident #20 revealed an admission date of 03/13/23 with diagnoses of radiculopathy, polyneuropathy, type II diabetes mellitus and chronic obstructive pulmonary disease. Interview on 01/29/25 at 2:30 P.M. with Residents #48 and #20 revealed that the call light system was not functioning properly and had not been for months. Resident #48 reported that when the call light was activated the light in the hallway did not come on and did not alert staff of need for assistance. 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 observation, staff interview, and resident interview, the facility failed to provide a functional comfortable environment when the walls were in disrepair. This affected one (Resident #65) of two residents reviewed for environmental issues. The facility census was 94. Findings include: Record review of Resident #65 revealed an admission date of 02/16/22 with pertinent diagnoses of: atrial fibrillation, type two diabetes mellitus, peripheral vascular disease, congestive heart failure, and insomnia. Observation and Interview with Resident #65 on 01/27/25 at 11:28 A.M. revealed his room has multiple wall marks that need sanded and painted over by the bed. Resident #65 stated the walls have been like that since he was in the room. Observation on 01/30/25 at 02:38 P.M. with Maintenance Director #228 verified the wall marks in Resident #65 room that need sanded and painted.

Based on observation, staff and resident interview, and review of the facility menu, the facility failed to follow weekly menus and have requested items available. This had the potential to affect 90 residents who receive their meals from the kitchen. The facility census was 94. Findings include: Observation on 12/18/23 at 11:42 A.M. of the lunch meal revealed Resident #67 was served a shredded chicken sandwich, hash browns, a piece of chocolate cake and two six-ounce glasses of orange colored juice. Resident #67 told State Tested Nursing Assistant (STNA) #95 he did not like chicken, and he wanted the alternate entree. STNA #95 stated the substitute was a bratwurst on a bun, and Resident #67 stated that would be fine. STNA #95 then returned to the dining room and told Resident #67 the kitchen did not have bratwurst available and that the only alternative available on 12/18/23 was a peanut butter and jelly sandwich. Observation on 12/18/23 at 11:45 A.M. revealed Resident #11 was served a grilled chicken sandwich, hash browns, a piece of chocolate cake and two six-ounce glasses 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 resident interview, staff interview, medical team interview, medical record review, and policy review, the facility failed to ensure residents were given the ability to be informed and make choices related to how a laboratory sample was collected. This affected one resident (#28) of three reviewed for choice. Facility census was 97. Findings include: Review of the medical record for the Resident #28 revealed an admission date of 01/11/22. Diagnoses included chronic obstructive pulmonary disease, respiratory disease, pulmonary embolism, schizoaffective disorder, weakness, pain and acute fracture of medial malleolus. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive response) and required extensive assistance of one to two staff members for transfers and mobility. Review of physician orders dated 06/30/23 to 07/07/23 revealed a Foley catheter was placed due to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, and record review, the facility failed to ensure residents were treated with dignity and respect and residents were agreeable to a room search without pressure or threat of police involvement. This affected four residents (#34, #28, #12, and #13) reviewed for dignity. Facility census was 97. Findings include: 1. Review of the medical record for the Resident #34 revealed an admission date of [DATE]. Diagnoses included diabetes, encephalopathy, right below the knee amputation, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive response) required limited assist of one staff for transfer and mobility. A progress note dated [DATE] revealed multiple types of medications were found in the resident's room. The physician was notified of the medications and drug paraphernalia found and new orders were received to hold her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, medical record review, and poilicy review, the facility failed to ensure a care plan was updated with smoking interventions after smoking materials were found in a resident's room. This affected one resident (#34) of three reviewed for care plans. Facility census was 97. Findings include: Review of the medical record for the Resident #34 revealed an admission date of 12/26/22. Diagnoses included diabetes, encephalopathy, right below knee amputation, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and required limited assist of one staff for transfer and mobility. Review of the plan of care dated 08/01/23 revealed no information related to the resident storing illicit items in her room including non-prescribed medications and over the counter medications, or smoking materials. The resident's care plan reported she smoked and had…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, medical provider interview, medical record review, and policy review, the facility failed to ensure a resident's pain was adequately monitored and treated for two residents (#34 and #28) of two reviewed for pain. Facility census was 97. Findings include: 1. Review of the medical record for the Resident #34 revealed an admission date of [DATE]. Diagnoses included diabetes, encephalopathy, right below knee amputation, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and required limited assist of one staff for transfer and mobility. Review of the plan of care dated [DATE] revealed no information related to residents storing illicit items in her room including non-prescribed medications and over the counter medications, or smoking materials. Review of physician orders for [DATE] revealed an order for a one time 10 panel drug screen…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, and medical record review, revealed the facility failed to ensure a laboratory result was followed up on in a timely manner. This affected one resident (#34) of two reviewed for laboratory results. Facility census was 97. Findings include: Review of the medical record for the Resident #34 revealed an admission date of 12/26/22. Diagnoses included diabetes, encephalopathy, right below knee amputation, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and required limited assist of one staff for transfer and mobility. Review of physician orders for 07/26/23 revealed a one time order for a 10 panel drug screen with instructions to straight catheterize if needed. Review of a progress note dated 07/26/23 revealed multiple types of medications were found in the resident's room. The physician was notified of the medications and drug…

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 foods were stored in at appropriate temperatures in order to prevent foodborne illness. This had the potential to affect all 109 residents who consumed foods prepared and stored in the kitchen. The facility identified one resident (#97) who did not receive foods prepared/stored in the kitchen and was to receive nothing by mouth. The census was 110. Findings include: Observations with [NAME] #151 during the tour of the kitchen on 07/25/22 at 8:15 A.M., revealed the reach in refrigerator #2's internal thermometer read 48 degrees Fahrenheit, and contained three large trays of portioned pudding as well as three large pans of raw chicken. Reach in refrigerator #3's internal thermometer read 50 degrees Fahrenheit, and contained a half pan of very hot oatmeal and small pan of hot sausage gravy. There were three cases of liquid eggs stored in reach in refrigerator #3. [NAME] #151 confirmed the internal thermometer readings of reach in refrigerators #2 and #3 at that time. Observations on 07/26/22 at 7:25…

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 observations, staff interviews, medical record review, review of facility census, review of COVID tracking log, review of the facility staff and visitor COVID-19 screening questionnaire log and policy reviews, the facility failed to ensure staff used the proper personal protective equipment (PPE) when providing care to residents who were either positive for COVID-19 or in quarantine for possible COVID-19; failed to ensure staff sanitized or wash their hands after removing gloves; failed to ensure proper signage was posted for residents in isolation/quarantine; failed to properly quarantine residents with possible COVID-19 exposure; and failed to properly screen residents and visitors for symptoms of COVID-19. This had the potential to affect 110 of 110 residents residing at the facility. The facility census was 110. Findings include: 1. Review of the medical record for Resident #405 revealed an admission date of 07/22/22. Review of hospital records revealed the resident tested positive for COVID-19 by…

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

Based on observation and staff and family interviews, the facility failed to maintain a clean homelike environment. This affected 22 residents (#08, #18, #35, #50, #56, #58, #80, #86, #26, #43, #35, #52, #51, #53, #88, #39, #01, #61, #69, #77, #03, and #207) of 110 residents environment observed. The facility census was 110. Findings include: 1. Observation of Resident #50's room on 07/25/22 at 1:48 P.M. revealed the windows have what appears to be dark paint dripping down the panes and appeared hazy. An empty resident bed with no mattress in place was observed. Plastic and metal silverware, cups, and bowls were observed on the windowsill, on the small chair ledge around the room, on the floor of the closet, and on the bathroom floor. 2. Observation of Resident #18's room on 07/25/22 at 1:58 P.M. revealed scratches on the wall by the bed were grooved into the dry wall. The windows had what appeared to be dark paint dripping down the panes and were hazy. The floor was sticky when walked across and dark pieces of debris were observed on the floor. 3. Observation of Resident #35's room…

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, resident and staff interview, and policy review, the facility failed to ensure staff transferred a resident who was non weight bearing on one leg safely. This affected one resident (#404) of five residents reviewed for falls. In addition, the facility failed to ensure adequate supervision of smoking materials for resident's who smoked. This affected three residents (#30, #66, and #451) of three residents reviewed for smoking. The facility identified 27 residents (#02, #09, #10, #12, #14, #16, #21, #30, #33, #38, #47, #48, #64, #65, #67, #70, #74, #76, #77, #78, #79, #83, #88, #89, #94, #100, and #457) who smoked at the facility. Residents #66 and #451 were not identified by the facility as smokers. In addition, the facility failed to provide adequate supervision of medication administration to ensure medications were not left at bedside. This affected one resident (#95) of one residents reviewed for accidents related to medications. The facility census was 110.…

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 maintain acceptable parameters of nutritional status, which included monitoring weight status and following up on nutritional recommendations. This affected five residents (#25, #33, #61, #97, and #404) of 11 residents reviewed for nutrition. The facility census was 110. Findings include: 1. Review of the medical record for Resident #404 revealed an admission date of 07/17/22. The resident had diagnoses including chronic kidney disease with dialysis three times weekly, diabetes mellitus, and positive for COVID-19. The resident had physician's orders on 07/17/22 for a regular diet and daily weights. Review of weight records revealed Resident #404 had a weight of 258.5 pounds on 07/18/22. Review of a dietary progress note by the dietetic technician on 07/20/22 at 1:43 P.M. revealed Resident #404 was receiving a regular diet. Weight fluctuations expected due to dialysis. A recommendation was made to add a house liquid…

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 and policy review, the facility failed to follow the policy of disposing of food waste in the kitchen in containers with tight fitting lids. The finding potentially affected 109 residents who consumed foods prepared in the kitchen except for Resident #97 who consumed nothing by mouth. The census was 110. Findings include: Kitchen observation on 07/25/22 at 8:30 A.M. revealed two trash containers half full of food waste in dish room and production areas with no lids to cover the trash. The trash containers were not in use by staff at that time. Interview with Dietary Manager #100, at that time of the observation, verified the two trash containers with garbage and no lids. Observation on 08/02/22 at 8:45 A.M., revealed two trash containers half full of food waste in dish room and production areas with no lids to cover the trash. The trash containers were not in use by staff at that time. Interview with Dietary Manager #100, at that time of the observation verified the two trash containers with garbage and no lids. Review of the policy titled…

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 Resident COVID-19 Vaccination Log, staff interview, and review of facility policy, the facility failed to ensure residents and/or their representatives were offered COVID-19 vaccines and/or boosters and were provided education regarding the COVID-19 vaccines. This affected 11 (Residents #25, #30, #33, #34, #35, #50, #56, #58, #86, #95, and #453) out of 11 residents reviewed for COVID-19 vaccinations. The facility census was 110. Findings include: 1. Review of the Resident COVID-19 Vaccination Log revealed it contained 105 resident names. Of those 105 residents, 56 residents were documented as receiving a primary vaccination series. Of the 56 residents who had received a primary vaccination series, only 11 residents had received one booster vaccine. No resident had received two booster vaccines. The following five residents had not received any COVID-19 vaccination: Resident #30 was was admitted on [DATE], Resident #35 who was admitted on [DATE], Resident #50 who was…

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

Based on observation, staff interview, and family interview, the facility failed to maintain a safe and comfortable environment on the Three [NAME] Unit. This had the potential to affect all 22 residents (#8, #11, #15, #18, #19, #26, #31, #35, #42, #43, #45, #50, #56, #58, #68, #72, #80, #81, #85, #86, #96, and #351) residing on the Three [NAME] Unit. The facility census was 110. Findings include: Observation on 07/27/22 at 9:03 A.M. revealed two large gray trash cans in the middle of hallway on the Three [NAME] Unit outside of the medication room with blankets wrapped around the bottom of each trash can. A clear fluid was dripping from a vent in the ceiling above the trash cans and was dripping from the metal supports of the ceiling. Observation on 07/27/22 at 11:05 A.M. revealed a small black trash can in the hallway of the Three [NAME] Unit outside of the medication room with clear fluid dripping from the ceiling into the trash can. The large gray trash cans observed on 07/27/22 at 9:03 A.M. remained in place. Further observation of hallway area revealed an electrical panel cover…

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 complete a comprehensive assessment using the resident assessment instrument (RAI) within 14 calendar days after admission. This affected one resident (#404) of three residents reviewed who were admitted within the past 30 days. The facility census was 110. Findings include: Review of the medical record for Resident #404 revealed an admission date of 07/17/22. The resident had diagnoses including fracture of right tibia, chronic kidney disease with dialysis three times a week, diabetes mellitus, rheumatoid arthritis, hypertension, and positive for COVID-19. Review of a Minimum Data Set (RAI) assessment dated [DATE], which documented it was in progress, revealed it only had sections C, D, E, and K completed. The other sections were not complete. The assessment had an assessment reference date of 07/30/22 and the facility system stated the assessment was two days past due. A comprehensive RAI had not been completed since admission.…

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 interview, the facility failed to accurately document a residents assessment on the resident assessment instrument. This affected one resident (#03) of 35 resident assessments reviewed. The facility census was 110. Findings Include: Review of Resident #03's medical record revealed an admission date of 09/25/18. Diagnoses included Parkinson's disease, dementia without behaviors, congestive heart failure, osteoporosis and history of falls. Review of the physician orders for July 2022 revealed Resident #03 received passive range of motion for movement and prevention of contractures, admitted to hospice services, a regular pureed texture diet with thin liquids, double portions for weight loss and a Boost (supplement) 240 milliliters by mouth three times daily for weight loss. Review of the recorded monthly weights revealed Resident #03 weighed 150 pounds on 12/02/21, 145 pounds on 12/08/21, 148 pounds on 01/08/22, 138 pounds on 03/08/22, 133 pounds on 04/18/22, 128…

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 interview, the facility failed to accurately complete the Preadmission Screening and Resident Review (PASRR) for an individual with a mental disorder. This affected one resident (#25) of five residents reviewed for PASRR. The facility census was 110. Findings include: Review of the medical record for Resident #25 revealed an admission date of 12/30/21. The resident had a diagnosis of Schizophrenia (08/07/16) upon admission. An admission Minimum Data Set assessment completed 01/06/22 included a diagnosis of Schizophrenia. Review of a PASRR result notice dated 12/29/21 revealed a section for indications of serious mental illness, which included Schizophrenia. Schizophrenia had not been marked as a diagnosis for Resident #25. The result notice stated the resident had no indications of serious mental illness. Interview with Social Service Director #103 on 07/26/22 at 2:15 P.M. confirmed the PASRR review had not been accurately completed by the previous admission director. She confirmed Resident #25 had a diagnosis of Schizophrenia upon admission,…

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 self-reported incident (SRI), interview, and policy review, the facility failed to ensure residents were discharged to a safe location. This affected one resident (#73) of four residents reviewed for discharge. The facility census was 110. Findings include: Review of the medical record for Resident #73 revealed an admission date of 03/05/22 from acute hospital and was discharged on 07/06/22 to the local emergency department. Diagnoses included cerebral infarction, dissection of vertebral artery, type one diabetes mellitus with neuropathy, hypertension, anxiety, depression, chronic viral hepatitis C, hemiplegia affecting left non dominant side, ataxia, hypothyroidism, hyperlipidemia, muscle weakness, abnormalities of gait and mobility, needs assistance with personal care and other psychoactive substance abuse. Review of the unplanned discharge return not anticipated Minimum Data Set (MDS) dated [DATE] indicated Resident #73 was cognitively intact and independent 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 medical record review, observation, and staff and resident interview, the facility failed to provide assistance with adequate nail care, hair care and bathing. This affected one resident (#95) of three residents reviewed for activities of daily living. The facility census was 110. Findings include: Review of the medical record for Resident #95 revealed an admission date of 09/30/19 with diagnosis of exacerbation of chronic obstructive pulmonary disorder, weakness, congestive heart failure and hypertension. Review of the annual Minimum Data Set (MDS) dated [DATE] indicated Resident #95 had mild cognitive impairment with behaviors. Resident #95 required extensive assistance of two persons for bed mobility, transfers, dressing, and toilet use. Resident #95 required extensive assistance of one person for bating and limited assistance of one person for personal hygiene. Review of Resident #95's shower/bathing documentation from 07/01/22 through 07/26/22 revealed the resident refused a shower/bath on 07/01/22…

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.

Based on medical record review, review of personal finances, resident and staff interviews, the facility failed to provide medically-related social services for a resident who needed assistance with financial matters. This affected one (#70) of 35 sampled residents. The facility census was 110. Findings include: Review of the medical record for Resident #70 revealed an admission date of 09/24/20 and a readmission date of 09/29/21. Review of the Minimum Data Set (MDS) assessment completed on 06/07/22 revealed a Brief Interview for Mental Status score of 12, indicating moderately impaired cognitive status. The resident had diagnoses including vision loss in both eyes and anxiety disorder. Review of Social Service note on 06/29/22 at 5:30 P.M.,stated Resident #70 was alert and oriented and required assistance with activities of daily living related to his blindness and receives hospice services. Interview on 07/25/22 at 10:47 A.M., with Resident #70 revealed he had not received his pension check for several months. He stated he had asked to see social services, who had not visited.…

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, resident and staff interview, and policy review, the facility failed to provide an effective pest control program. This affected two (Resident #17 and #41) out of three residents reviewed for pest control. The census was 110. Findings include: 1. Observation on 07/25/22 at 11:35 A.M. of Resident #17's room revealed multiple flying insects in the room and around the Resident #17. At that time, Resident #17 stated the flies bothered him while he ate his meals. Observation on 07/28/22 at 8:13 A.M. of Resident #17's room revealed there were multiple flying insects in the room. Interview with Housekeeping Supervisor #101 at the time of the observation revealed there were multiple flies in Resident #17's room while he was eating breakfast. 2. Observation on 07/25/22 at 12:23 P.M. revealed multiple flying insects in Resident #41's room. Interview with Resident #41 at that time revealed the flies bothered him especially when he was trying to sleep. Observation on 07/28/22 at 8:41 A.M. revealed there were multiple flying insects in Resident #41's room. Interview 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.

Based on observation and interview the facility failed to provide a sanitary and comfortable environment for residents as all carpeted areas on all floors in the facility were stained and worn. This had the potential to affect all 120 residents residing in the facility. Furthermore, the facility failed to ensure walls were in good repair in one resident's room. This affected one Resident (#54) who's wall was scraped. The facility census was 120. Findings include: Multiple observations were conducted of all three floors of the facility during the annual survey from 08/19/19 through 08/22/19 and observed worn down carpeted areas with multiple dark colored stains. An observation was conducted on 08/22/19 at 3:07 P.M. of Resident #54's wall behind her bed and noted multiple scraped areas. Interview was conducted on 08/22/19 at 3:07 P.M. with Resident #54. She stated her wall was awful and that it was like that when she moved into the room. She denied that she had scraped the wall. Interview was conducted on 08/22/19 at 4:00 P.M. with Maintenance Staff #168 and he verified the carpets…

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, interview, review of facility Self-Reported Incident (SRI) and facilities policy review the facility failed to update and revise residents care plans. The facility also failed to involve and invite residents to their care conference meetings and to involve the residents in their care plan. This affected six Residents (#23, #59, #60, #68, #77, and #87) out of 27 residents reviewed for accuracy of care plans and care planning participation. The facility census was 120. Findings include: 1. Review of the medical record for Resident #23 revealed an admission date of 05/21/18 with diagnoses including intracranial injury with loss of consciousness, dysphagia, bipolar, depression, acute respiratory failure, pneumonitis due to inhalation of food, and secondary malignant neoplasm of lung. Review of quarterly minimum data set (MDS) assessment dated [DATE] revealed he had no cognitive deficits and received a mechanically altered diet. Review of nurses notes dated 06/19/19…

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

Based on observation, interview, and facilities policy review the facility failed to maintain an effective pest control program so that the facility was free of flies. This had the potential to affect 38 residents residing on the first floor. The facility census was 120. Findings include: Observation was made on 08/19/19 at 11:05 A.M. of the first floor and noted two fly traps hanging from the ceiling of Resident #86's room with one by her bed and one by the doorway. She stated flies were bad and that her husband had hung up the strips. There were two flies flying around her bed. Interview was conducted on 08/19/19 at 11:23 A.M. with Resident #59 and he stated he had flies in his room. Observation was made on 08/19/19 at 11:38 A.M. of Resident #6 and he was swatting flies in his room with a fly swatter. He stated the flies were bad. Interview also conducted with Resident #6's room mate, Resident #4, and he stated the flies were bad right now. Observation was made on 08/20/19 at 9:16 A.M. of Resident #19 and a fly was on his bed on top of his blankets and roommate (Resident #62)…

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 notify the physician of changes in a resident's condition. This affected one Resident (#87) of one reviewed for behavior and mood. The facility census was 120. Findings include: Review of Resident #87's electronic medical chart revealed a admission date of 01/08/19 with the following diagnoses: personal history of traumatic brain injury, moderate protein-calorie malnutrition, anxiety disorder, opioid dependence-in remission, unspecified convulsions, hydrocephalus, and bipolar disorder. Review of Resident #87's care plan dated 09/11/18 revealed the resident was at risk for adverse reactions and side effects due to receiving psychotropic medication related to bipolar disorder. The interventions included document mood and behavior changes when they occur, monitor and record the occurrence of targeted behaviors including violence or aggression towards staff or others and document per facility protocol. Review of Nurse's progress notes revealed on 07/03/19 a family member was visiting a loved one last night on this unit…

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 and staff interview the facility failed to complete baseline care plans. This affected two Residents (#77 and #114) of 24 residents reviewed for baseline care plans. The facility census was 120. Findings include: 1. Review of the electronic medical record for Resident #77 revealed an admission date of [DATE] with the following diagnoses: acute kidney failure, other fatigue, chronic obstructive pulmonary disease (COPD), essential hypertension (high blood pressure), other sequelae of other cerebrovascular disease, and hyperlipidemia. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #77 had moderate cognitive impairment. No behaviors were exhibited by the resident. Resident #77 required total dependence with the assistance of two persons for bed mobility, transfers, dressing, and toileting. The resident required total dependence with assistance from one person for personal hygiene and bathing. The resident was non-ambulatory 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 record review, observation, and resident and staff interview, the facility failed to develop a comprehensive care plan for residents. This affected one (#58) of 24 residents reviewed for care plans. The facility census was 120. Findings include: Review of Resident #58's electronic medical record revealed an admission date of 07/02/18 with the following diagnoses: Parkinson's Disease, primary generalized osteoarthritis, dementia in other diseases classified elsewhere without behavioral disturbance, polyneuropathy, other chronic pain, major depressive disorder, and insomnia. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #58 had moderate cognitive impairment. The resident required limited assistance with one person assistance for activities of daily living. Review of the progress notes dated 07/30/19 revealed the nurse spoke with Resident #58's physician about restarting Glycopyrrolate medication. The medication was only written for a 30 day order and it had…

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 interview the facility failed to provide assistance with eating during lunch meal. This affected one (#76) of 13 residents observed who were eating in the first floor dining room during lunch. The facility census was 120. Findings include: Review of Resident #76's electronic medical record revealed an admission date of 12/21/16 with the following diagnoses: Parkinson's Disease, dementia in other diseases classified elsewhere without behavioral disturbance, altered mental status, unspecified psychosis not due to a substance or known physiological condition, endocarditis, major depressive disorder, and essential hypertension. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] showed the resident had severely impaired cognition. The resident required supervision with eating for set up only. No swallowing or nutrition concerns were noted. Review of Resident #76's care plan dated 01/19/18 revealed the resident was a potential nutritional risk. 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 record review and staff interview the facility failed to properly monitor resident behaviors following a documented incident. This affected one (#87) of one resident reviewed for behavior changes. The facility census was 120. Findings include: Review of Resident #87's electronic medical chart revealed an admission date of 01/08/19 with the following diagnoses: personal history of traumatic brain injury, moderate protein-calorie malnutrition, anxiety disorder, opioid dependence-in remission, unspecified convulsions, hydrocephalus, and bipolar disorder. Review of physician's orders dated 07/22/19 revealed Seroquel tablet 50 milligram (mg) give one tablet via peg tube at bedtime for bipolar disorder. Review of Resident #87's care plan dated 09/11/18 revealed the resident was at risk for adverse reactions and side effects due to receiving psychotropic medication related to bipolar disorder. The interventions included document mood and behavior changes when they occur, monitor and record the occurrence of targeted behaviors including violence or aggression towards staff 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.

Based on record review, observation and staff interview the facility failed to provide needed adaptive equipment for eating. This affected one (#23) of 13 residents observed in the first floor dining room. The facility census was 120. Findings include: Review of Resident #23's electronic medical record revealed an original admission date of 05/21/18 and a readmission date of 07/19/19 with the following diagnoses: unspecified intracranial injury with loss of consciousness of unspecified duration, malignant neoplasm of unspecified testis, secondary malignant neoplasm of unspecified lung, unspecified cirrhosis of liver, dysphagia-oropharyngeal phase, epilepsy, facial weakness, bipolar disorder, major depressive disorder-severe with psychotic symptoms, anxiety disorder, diabetes mellitus due to underlying condition without complications, personal history of malignant neoplasm of bladder, and vitamin deficiency. Review of physician's orders dated 08/2019 revealed an order for a regular diet, regular texture, nectar consistency, a nosey cup at meal times per speech therapy, and a red…

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, interview, and facilities policy review the facility failed to follow infection control practices during a pressure ulcer wound dressing change. This affected one Resident (#81) of three residents reviewed for pressure ulcers. Furthermore, the facility failed to maintain effective urinary catheter infection control procedures when they had the urinary catheter bag above the level a residents bladder. This affected one Resident (#99) of two reviewed for catheters. The facility identified three Residents (#86, #99, and #163) who had indwelling catheters. The facility census was 120. Findings include: 1. Review of the medical record for Resident #81 revealed an admission date of 04/10/18 with diagnoses including ischemic cardiomyopathy, diabetes mellitus, chronic kidney disease, and osteoarthritis. Review of physician orders dated 08/2019 revealed to cleanse coccyx with normal saline or wound cleanser, apply honey paste to wound bed then cover with calcium alginate 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.