Carecore At Margaret Hall

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and policy review the facility failed to ensure staff wore appropriate personal protection equipment (PPE) while providing care to residents in Enhanced Barriers Precautions (EBP). This affected one (Resident #71) and had the potential to affect 13 facility-identified residents with orders for OBP. The facility census was 78 residents. Findings include: Review of the medical record for #71 revealed an admission date of 01/04/26 with diagnoses including encephalopathy, sleep apnea, heart failure, and severe sepsis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficits and required staff assistance with activities of daily living (ADLs.) Review of the physician's orders for Resident #71 revealed an order dated 01/07/26 for the resident to be in EBP due the presence of an enteral tube and wounds. Observation on 02/09/26 at 9:23 A.M. of medication administration per gastrostomy tube to Resident #71…

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, staff interview, and observation, the facility failed to ensure the phones were answered during the nighttime hours. This affected one (Resident #45) of three residents reviewed for communication with the staff via telephone. This had the potential to affect all of the residents. The facility census was 73 residents. Findings include: Review of the medical record for Resident #45 revealed an admission date of 12/20/24 with diagnoses including arthritis, malnutrition, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) assessment for Resident #45 dated 12/32/24 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.) Review of the progress note for Resident #45 dated 12/31/25 timed at 11:13 A.M. per Licensed Practical Nurse (LPN) #102 revealed at around 5:45 A.M. the resident's family entered the facility with emergency medical technicians (EMT's) because they weren't able to get in touch with the facility via telephone. Resident #45 had called the family because he…

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, and staff interview, the facility failed to ensure incontinence care was provided in a timely manner. This affected one (Resident #36) of three residents reviewed for incontinence care. The facility census was 73 residents. Findings include: Review of the medical record review for Resident #36 revealed an admission date of 08/12/24 with diagnoses including chronic respiratory failure with hypoxia and non-Alzheimer's dementia. Review of the care plan for Resident #36 dated 08/24/24 revealed the resident was at risk for urinary incontinence with the potential for impaired skin integrity. Interventions included the following: keep call light within reach and remind the resident to use it, check and change frequently and provide good peri-care, observe for signs and symptoms of restlessness which might indicate the need to void, offer assistance to the bathroom as needed. Review of the Minimum Data Set (MDS) assessment for Resident #36 dated 01/03/25 revealed the resident was cognitively intact, required substantial staff assistance 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 medical record review, staff interview, and review of the facility policy, the facility failed to ensure staff provided the appropriate level of supervision during resident transfers using the sit to stand lift. This affected one (Resident #36) of three residents reviewed for falls. The facility census was 73 residents. Findings include: Review of the medical record for Resident #36 revealed an admission date of 08/12/24 with diagnoses including chronic respiratory failure with hypoxia and non-Alzheimer's dementia. Review of care plan for Resident #36 dated 08/14/24 revealed the resident was at risk for falls related to impaired mobility. The care plan had not been updated to reflect the use of a sit to stand lift for transferring the resident. Review of the Minimum Data Set (MDS) assessment for Resident #36 dated 01/03/25 revealed the resident was cognitively intact and required substantial/maximal assistance of staff for for toileting, bed mobility, and transfers. Review of the sit to stand assessment for Resident #36 dated 01/11/25 revealed therapy recommended the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, resident interview, and review of the facility policy, the facility failed to ensure the temperature in resident rooms was satisfactory. This affected one (Resident #43) of three residents reviewed for the physical environment. The facility census was 73 residents. Findings include: Review of the medical record for Resident #43 revealed an admission date of 08/01/24 with diagnoses including [NAME] Syndrome, malnutrition, depression, respiratory disorder, and biliary cirrhosis. Review of the Minimum Data Set (MDS) assessment for Resident #43 dated 01/11/25 revealed the resident was cognitively intact and required assistance with activities of daily living (ADLs.) Observation on 01/22/25 at 1:12 P.M. of Resident #43 revealed the resident was sitting in her room wearing an oversized house coat and gloves. The heater was blowing out cold air. Interview on 01/22/25 at 1:14 P.M. with Resident #43 confirmed she was cold in her room and the heater was blowing…

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 use the proper lift for resident transfers. This affected one (Resident #10) of three residents reviewed for lift transfers. The facility census was 81 residents. Findings include: Review of the medical record for Resident #10 revealed an admission date of 07/31/24 with diagnoses including cerebral infarction, hemiplegia/hemiparesis, edema, sepsis, dementia, and diabetes mellitus, and a discharge date of 11/10/24. Review of the care plan for Resident #10 dated 09/29/24 revealed the resident had an activities of daily living (ADL) self-care performance deficit related to history of cerebral vascular accident with hemiplegia with an intervention dated 10/02/24 to transfer with Hoyer lift with assist of two to transfer. Review of the Minimum Data Set (MDS) assessment for Resident #10 dated 10/07/24 revealed the resident had moderate to severe cognitive deficits and required extensive assistance with ADLs. Review of occupational therapy discharge summary for Resident #10 dated 10/10/24 revealed therapy…

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, and staff and resident interview, the facility failed to ensure a resident who was dependent on staff with transferring out of bed received timely assistance with activities of daily living (ADL). This affected one (Resident #3) of one resident reviewed for ADLs. The facility census was 87. Findings include: Review of the medical record for Resident #3 revealed an admission date of 08/19/24. Her medical diagnoses included coronary artery disease, heart failure, and cerebrovascular attack (CVA). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was severely cognitively impaired. Her functional status was substantial/maximal from staff for bed mobility and dependent on staff for transfers. Observations and interviews on 09/29/24 at 8:51 A.M. revealed State Tested Nursing Aide (STNA) #227 was in the room and Resident #3 had her food in front of her. STNA #227 asked the resident if she would like to get out of bed after breakfast…

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, and family and staff interviews, the facility failed to ensure the residents who were at risk for developing pressure ulcer were turned and repositioned every two to three hours per their care plan interventions and failed to complete treatments to the right heel ordered by the physician at the hospital. This affected three (#10, #18, and #72) three residents reviewed for change of positioning. The facility census was 87. Findings include: 1. Medical record review for Resident #18 revealed an admission date of 09/04/24. Medical diagnoses included fracture of the right lower extremity for after care healing. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively intact. Review of the hospital orders for the right heel wound for Resident #18 dated 09/04/24 revealed there was mild drainage to the right heel and sutures were removed. The resident was advised to relieve pressure from the heel wound as she could…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and policy review, the facility failed to ensure the resident's bladder scans were completed for a trial after the indwelling catheter was removed per hospital discharge orders. This affected one (#18) of one resident reviewed for bladder scanning. The facility census was 87. Findings include: Medical record review for Resident #18 revealed an admission date of 09/04/24. Medical diagnoses included fracture of the right lower extremity for after care healing. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively intact. Her functional status was substantial/maximal assistance from staff for toileting and bed mobility, and supervision from staff for transfers. Review of the hospital orders dated 09/04/24 revealed Resident #18 had a indwelling catheter while at the hospital and it was removed and the plan was for Resident #18 to go to the nursing home for a trial. The orders were to obtain bladder scans every six…

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 ensure medications were administered via the physician ordered route. This affected one (#31) of five residents observed for medication administration observation. The facility census was 69. Findings include: Medical record review for Resident #31 revealed an admission on [DATE] with diagnoses including but not limited to cerebral infarction, hypertensive cerebral ischemic attack chronic pain and hemiplegia and hemiparesis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #31 revealed a severely impaired cognition. Resident #31 was dependent for eating, bed mobility, toileting, and transfers. Review of the physician orders for Resident #31 for the month of April 2024 revealed an order for fluoxetine oral solution 20 milligrams (mg)/milliliter (ml) give 2.5 ml via gastrostomy (g-tube) in the morning, hydrochlorothiazide oral tablet 25 mg give 1 tablet via g-tube in the morning,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff interviews and policy review, the facility failed to ensure medications were securely stored. This affected two (#22 and #19) of five residents observed for medication administration. The facility census was 72. Findings include: 1. Review of the medical record for Resident #22 revealed an admission on [DATE] with diagnoses including but not limited to cerebral infarction, transient cerebral ischemic attack and vascular dementia. Review of the quarterly Minimum Data Set assessment (MDS) for Resident #22 dated 03/20/24 revealed an intact cognition. Resident #22 required set up for eating, and maximum assistance for transfers, bed mobility and total dependence for toileting. Review of physicians orders for Resident #22 for the month of May 2024 revealed an order for ibuprofen 200 milligrams (mg) tablet administer two tablets every eight hours as needed for musculoskeletal pain. Further review of Resident #22's medical record revealed there was no order or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, observations, policy review, review of manufacture's recommendations and review of the Centers of Disease Control website, the facility failed to disinfect a glucose monitoring device after usage with an appropriate disinfectant. This had the potential to affect two residents (#13 and #6) residing on the B unit of the second floor who share the glucose monitoring device. Additionally, the facility failed to ensure staff completed hand hygiene after removing wound dressing on resident in enhanced barrier precaution. This affected one (#34) out of three residents reviewed for infection control practices. The facility census was 72. Findings include: 1. Medical record review for Resident #13 revealed an admission date on 06/23/23 with diagnoses that include but not limited to cerebral infarction, hypertension, obstructive sleep apnea, type two diabetes mellitus and obesity. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #13…

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

Based on record review, staff interview, and policy review, the facility failed to have a comprehensive water management plan to prevent water contamination. This had the potential to affect all residents residing in the facility. The census was 70. Findings include: Review of the facility's water management records revealed the facility lacked a water management plan that included specific control measures followed to monitor the water supply for contamination, such as monitoring of disinfectant levels in the water. Observations on 02/28/24 from 11:00 A.M. to 6:00 P.M. revealed filters were in place on sinks and showers, bottled water was available for use throughout the facility, and signs were posted indicating certain water sources were out of order. During an interview on 02/29/24 at 8:52 A.M., Maintenance Director #20 confirmed the facility lacked a comprehensive water management plan that included control measures that would be used to prevent water contamination, including disinfectant levels. Maintenance Director #20 reported the facility flushed sinks weekly and obtained…

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 facility policy, the facility failed to treat a resident with dignity and respect. This affected one (Resident #28) of one reviewed for dignity and respect. The facility census was 72. Findings include: Review of the medical record for Resident #28 revealed an admission date of 12/04/23. Diagnoses included fibromyalgia, hyperlipidemia, dorsalis, hypothyroidism, compression fracture, moderate calorie malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had a Brief Interview of Mental Status of 15 that indicated she was cognitively intact. Resident #28 required setup assistance for eating and supervision oral hygiene. Resident #28 was dependent upon staff for toileting, bathing, and transfers. Resident #28 required substantial maximum assistance for bed mobility. Resident #28 was frequently incontinent of bowel and bladder. Review of the verbal disciplinary action dated 01/12/24 revealed the Administrator informally met with State…

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, interview, and facility policy, facility failed to ensure a resident had access to their call light. This affected one (Resident #71) of three residents reviewed for call lights. The facility census was 72. Findings include: 1. Review of the medical record for Resident #71 revealed an admission date 12/07/23. Diagnoses included respiratory disorders diseases, acute respiratory failure with hypoxia, anxiety disorder, and chronic atrial fibrillation. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #71 was cognitively intact. Resident #71 was dependent upon staff for transfers, bathing, lower body dressing, and bed mobility. Observation and interview on 01/22/24 at 12:04 P.M. with Resident #71 verified she was sitting in her wheelchair and unable to reach the call light, which was on her bed, against the wall. Interview on 01/22/4 at 12:06 P.M. with Licensed Practical Nurse (LPN) #56 verified Resident #71's call light was in between the bed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to ensure advance directives were documented appropriately. This affected one (#37) out of eight residents reviewed for advance directives. The census was 72. Findings include: Review of the medical record for Resident #37 revealed she was admitted to the facility on [DATE]. Diagnoses included polyneuropathy, type two diabetes mellitus with diabetic polyneuropathy, chronic obstructive pulmonary disease, acute embolism and thrombosis of unspecified deep veins of left lower extremity, Alzheimer's Disease, sleep apnea, acute kidney failure, pure hypercholesterolemia, congestive heart failure, cardiomyopathy, hypercalcemia, overactive bladder, hypothyroidism, mixed hyperlipidemia, and anemia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 had severely impaired cognition. This resident was assessed to require moderate assistance with eating, oral hygiene, and personal hygiene, and maximal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an injury of unknown origin was reported to the state agency. This affected one (#51) of one resident reviewed for abuse. The facility census was 72. Findings include: Review of Resident #51's medical record revealed Resident #51 admitted to the facility on [DATE] with diagnoses including unspecified dementia unspecified severity without behavioral disturbance psychotic disturbance, mood disturbance, and anxiety, muscle weakness, gastro esophageal reflux disease without esophagitis, chronic rhinitis, constipation, unspecified osteoarthritis, hyperglycemia, adult failure to thrive, and diarrhea. Review of Resident #51's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required set up assistance with eating, and oral hygiene. Resident #51 required maximal assistance with toileting, showering, transfers, upper body dressing, lower body dressing, putting on and taking footwear,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure an injury of unknown origin was thoroughly investigated. This affected one (#51) out of one resident reviewed for abuse. The facility census was 72. Findings include: Review of Resident #51's medical record revealed Resident #51 admitted to the facility on [DATE] with diagnoses including unspecified dementia unspecified severity without behavioral disturbance psychotic disturbance, mood disturbance, and anxiety, muscle weakness, gastro esophageal reflux disease without esophagitis, chronic rhinitis, constipation, unspecified osteoarthritis, hyperglycemia, adult failure to thrive, and diarrhea. Review of Resident #51's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required set up assistance with eating, and oral hygiene. Resident #51 required maximal assistance with toileting, showering, transfers, upper body dressing, lower body dressing, putting on and taking footwear,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure resident care plans reflected the residents current status and behaviors. This affected one (#70) of one resident reviewed for care planning. The facility census was 72. Findings include: Review of Resident #70's medical record revealed Resident #30 admitted to the facility on [DATE] with diagnoses including other specified disorders of the brain, repeated falls, cognitive communication deficit, dysphagia, hypertension, hyperlipidemia, and muscle weakness. Review of Resident #70's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required set up assistance with eating, and oral hygiene. Resident #70 was dependent with toileting, lower body dressing and sitting to lying. Resident #70 also required maximal assistance with showering, personal hygiene, and putting on and taking off shoes, and moderate assistance with upper body dressing, and rolling left to right. Review of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interview, the facility failed to ensure a resident had access to hearing aids. This affected one (Resident #43) of one resident reviewed for hearing. The facility census was 72. Findings include: Review of Resident #43's medical record revealed Resident #43 admitted to the facility on [DATE] with diagnoses including urinary tract infection, radiculopathy, pain, lumbago with sciatica, other chronic pain, hypertension, other abnormalities of gait and mobility, unspecified fracture of shaft of unspecified tibia subsequent encounter for closed fracture with healing, unspecified fracture of shaft of unspecified fibula subsequent encounter for closed fracture with routine healing and generalized anxiety disorder. Review of Resident #43's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required set up assistance with oral hygiene. Resident #43 was independent with eating and dependent with toileting,…

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 residents received proper staff assistance with care to prevent falls. This affected one (#66) out of seven residents reviewed for accidents. The facility census was 72. Findings include: Review of the medical record for Resident #66 revealed she was admitted to the facility on [DATE]. Diagnoses included sciatica, hepatic encephalopathy, vitamin d deficiency, insomnia, bipolar disorder, atrial fibrillation, morbid obesity due to excess calories, anemia, hypokalemia, anxiety disorder, depression, and post-traumatic stress disorder. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #66 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 14. The resident was assessed to require setup assistance for eating, oral hygiene, maximal assistance for bathing and upper body dressing, and was dependent for toileting, lower body dressing, personal hygiene, bed mobility, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record, observation, interview, and facility policy, facility failed to provide timely incontinence care for two residents (#328 and #28) of four reviewed for incontinence care. Facility census was 72. Findings include: 1. Review of the medical record revealed Resident #328 was admitted on [DATE]. Diagnoses included aphasia, cognitive communication deficit, osteoporosis, and hypertension. Review of the plan of care dated 01/10/24 revealed Resident #328 was at risk for incontinence related to impaired mobility, cerebral vascular accident, cognitive communication deficit, pain related to compression fracture T-11-T12, and potential adverse side effects of medication received. Interventions included check Resident #328 routinely and as required for incontinence. Wash, rinse, and dry perineum during care. Resident #328 used an incontinent brief. Change clothing as needed after incontinence episodes. Monitor for signs and symptoms of urinary tract infection and report to physician. 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 Review of facility record, observation, interview, and facility policy, the facility failed to provide supervision when taking medication for one resident (#50) out of four residents reviewed for medication. Facility census was 72. Findings include: Review of the medical record revealed Resident #50 had an admission date 11/21/23. Diagnoses included muscle wasting and atrophy, anxiety disorder, depression, glaucoma, and macular degeneration. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #50 was cognitively intact. Observation and interview on 01/22/24 at 11:18 A.M. with Resident #50 in their room with a medication cup with five pills left on the bedside table unattended. Interview on 01/22/24 at 11:22 A.M. with Licensed Practical Nurse (LPN) #56 verified medications were left at Resident #50's bedside table unattended. LPN #56 reported medications left were Miralax in water, one Citalopram 20 milligram (mg), one Buspar 5 mg, one Robaxin 500 mg, and two Gabapentin 100 mg. Review of facility…

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