Carecore At The Meadows

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure nursing staff used appropriate hand hygiene when performing blood glucose monitoring. This affected one (#329) of two residents reviewed for blood glucose monitoring. The facility census was 77. Findings include: Review of the medical record revealed Resident #329 was admitted to the facility on [DATE] and had a primary diagnosis of type II diabetes with diabetic neuropathy. Review of the admission Minimum Data Set (MDS) assessment completed on 04/23/24 revealed Resident #329 was cognitively intact. Observation on 05/06/24 at 8:15 A.M. revealed Licensed Practical Nurse (LPN) #603 obtained Resident #329's blood glucose level and left the room without washing her hands with soap and water. During an interview on 05/06/24 at 8:22 A.M. LPN #603 verified she did not wash her hands after obtaining Resident #329's blood glucose level. Review of a policy titled, Obtaining a Fingerstick Glucose Level, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, staff and resident interview, and policy review, the facility failed to ensure the toilets were in good working order. This affected one (#10) of one resident reviewed for toilets. The facility also failed to ensure the showers in the facility were safe. This had the potential to affect all of the residents who resided in the facility. The facility also failed to ensure the floors were clean and the smells of incontinence were eradicated on the memory care unit (MCU). This had the potential to affect 29 residents who resided on the MCU. The facility census was 76. Findings include: 1. Medical record review for Resident #10 revealed an admission date of 06/15/22. Diagnoses included heart failure and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was moderately cognitively impaired. Interview with Resident #10 on 03/05/24 at 8:12 A.M. revealed her toilet had been stopped up for a few days and she hasn't been able…

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 facility's Self-Reported Incidents, staff and resident interview, review of a grievance form, and policy review, the facility failed to timely report an allegation of neglect of a resident to the State Survey Agency. This affected one (#64) of three residents reviewed for neglect. The facility census was 76. Findings include: Medical record review for Resident #64 revealed an admission date of 01/04/24. Diagnoses included stroke, diabetes mellitus, and heart failure. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 was cognitively intact. Resident #64 was dependent on staff for toileting and was frequently incontinent for bowel and bladder. Review of her care plan dated 01/29/24 revealed she had urinary incontinence. Interventions included to check and change the resident every two hours to keep clean and dry. Review of the bladder incontinence form for Resident #64 dated 02/16/24 revealed the resident was changed at 2:48…

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 and resident interview, review of a grievance form, and policy review, the facility failed to complete an investigation into a resident's allegation of neglect. This affected one (#64) of three residents reviewed for neglect. The facility census was 76. Findings include: Medical record review for Resident #64 revealed an admission date of 01/04/24. Diagnoses included stroke, diabetes mellitus, and heart failure. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 was cognitively intact. Resident #64 was dependent on staff for toileting and was frequently incontinent for bowel and bladder. Review of her care plan dated 01/29/24 revealed she had urinary incontinence. Interventions included to check and change the resident every two hours to keep clean and dry. Review of the bladder incontinence form for Resident #64 dated 02/16/24 revealed the resident was changed at 2:48 P.M. and 9:26 P.M. Review of a Resident Concern/Grievance form…

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 review of staffing schedules, staff interviews, and review of the facility policy, the facility failed to ensure there was a Registered Nurse (RN) scheduled for at least eight consecutive hours daily. This had the potential to affect all residents residing in the facility. The facility census was 76 residents. Findings include: Review of the staffing schedules revealed there was no RN scheduled on the following dates: 08/06/23, 08/11/23, 08/14/23, and 08/15/23. Interview with the Administrator 08/16/23 at 2:25 P.M., confirmed the facility did not have an RN working for eight consecutive hours on the following dates: 08/06/23, 08/11/23, 08/14/23, and 08/15/23. Review of the facility policy titled Staffing dated October 2017, revealed the facility would provide sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment.

Based on record review, observation, resident interview, staff interview, review of Resident Council minutes, and review of the facility policy, the facility failed to ensure residents had a dignified dining experience. This affected all residents in the facility with the exception of two residents (#31 and #46) identified by the facility as not receiving food prepared in the facility kitchen. The facility census was 76 residents. Findings include: Review of the medical record for Resident #14 revealed an admission date of 10/25/16 with diagnoses including chronic obstructive pulmonary disease, cerebral infarction, dysphagia, hemiplegia and hemiparesis, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment 3.0 for Resident #14, revealed the resident was cognitively impaired and required limited assistance of one staff with eating. Observation of the breakfast meal on 08/15/23 at 8:39 A.M., revealed the breakfast trays were delivered with plastic cutlery instead of silverware. Resident #14 was observed feeding herself breakfast in the common area using a…

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

Based on medical record review, resident interview, staff interview, review of dietary staff schedules, review of menus, and review of the facility policy, the facility failed to ensure residents were fed meals per the facility menu. This affected all residents in the facility with the exception of two residents (#31 and #46) identified by the facility as not receiving food prepared in the facility kitchen. The facility census was 76 residents. Findings include: Review of the medical record for Resident #19 revealed an admission date of 12/02/22 with diagnoses including diabetes mellitus (DM), osteomyelitis, hyperlipidemia, and chronic kidney disease (CKD.) Review of the Minimum Data Set (MDS) assessment 3.0 for Resident #19 dated 07/03/23, revealed the resident was cognitively impaired and required supervision and set up help with eating. Review of the Dietary Schedule for 08/12/23, revealed [NAME] #410 and Dietary Aide (DA) #395 were scheduled to work in the kitchen for the breakfast meal on 08/12/23. Review of the time clock records for 08/12/23, revealed [NAME] #410 and DA #395…

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, review of facility documents (temperature and sanitation logs), staff interview, and review of facility policy, the facility failed to adequately monitor the water temperature of the dishwashing machine in the kitchen and failed to adequately monitor the sanitizer level for the three-compartment sink in the kitchen. This had the potential to affect all resident residing in the facility with the exception of two residents identified by the facility residents (#31 and #46) who did not receive food prepared in the facility kitchen. The facility census was 76. Findings include: Review of the July 2023 facility dishwashing machine temperature log revealed there were no temperatures recorded during the dinner meals from 07/19/23 through 07/31/23. Observation of the kitchen on 08/15/23 at 11:18 A.M., revealed Laundry Aide (LA) #485 was pulling silverware out of the dishwashing machine and told [NAME] #410 it was ready for the lunch meal. Further observation revealed there were pans drying on the rack next to the three -compartment sink. LA #485 left the kitchen when…

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, staff interview, and review of facility policy, the facility failed to ensure fall prevention interventions were in place as ordered by the physician. This affected two residents (#50 and #59) of three residents reviewed for falls. The facility census was 76. Findings include: 1) Review of the medical record for Resident #50 revealed an admission date of 01/25/22 with diagnoses including rhabdomyolysis, major depressive disorder, osteoarthritis (OA) hypothyroidism, and hypertension (HTN.) Review of the fall risk assessment for Resident #50 dated 02/22/23, revealed the resident was at risk for falls. Review of the physician orders for Resident #50, revealed an order dated 02/23/23 for the resident to have fall mats to bilateral sides of the bed. Review of the Minimum Data Set (MDS) assessment 3.0 for Resident #50 dated 07/07/23, revealed the resident was cognitively impaired and required extensive assistance with activities of daily living (ADLs.) Review of the care plan for Resident #50 updated 08/01/23, revealed the resident had a potential for…

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

Based on review of facility documents, staff interview, and review of the facility policy, the facility failed to ensure the Medical Director participated regularly as a member of the facility's Quality Assessment Performance Improvement (QAPI) Committee. This had the potential to affect all residents in the facility. The census was 63. Findings include: Review of facility QAPI meeting minutes sign-in sheets for July 2021 to August 2022 revealed the facility held QAPI meetings on the following dates: 07/21/21, 10/19/21, 11/18/21, 01/19/22, 04/20/22, 07/27/22. The only meeting sign in sheet which included a signature of Medical Director (MD) #585 was the meeting dated 04/20/22. Interview on 08/04/22 at 2:00 P.M. with the Director of Nursing confirmed the facility had no record of MD #585's involvement with the QAPI Committee. MD #585 only participated in the meeting on 04/20/22. Review of the facility policy titled QAPI Program-Governance and Leadership; dated March 2020, revealed the Medical Director should serve on the committee which meets at least quarterly.

Based on observation, staff interview and review of facility policy, the facility failed to ensure residents had a safe and clean environment. This affected nine residents (#7, #8, #11, #20, #21, #22, #23, #24, and #25) who were identified by the facility as smoking. The facility census was 69. Findings include: Observations on 09/27/22 at 1:01 P.M. revealed nine Residents (#7, #8, #11, #20, #21, #22, #23, #24, and #25) smoking on the outside patio. Further observations revealed numerous cigarette butts which littered the area and numerous cigarette butts in the trashcan. Interview with Activities Staff #50 on 09/27/22 at 1:01 P.M. revealed she was tasked with monitoring the smokers. Activities Staff #50 verified the numerous cigarette butts littering the smoking area. Review of the undated facility policy titled Smoking revealed the facility would allow residents the ability to smoke while maintaining facility safety. This deficiency is a recite to the annual survey completed on 08/15/22.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, medical records review, and review of facility policy, the facility failed to ensure residents environment was free of accident hazards for two (#56 and #60) residents reviewed for falls. Additionally the facility failed to complete quarterly smoking assessments and utilize identified protective aprons while smoking for four (#44, #56, #27 and #29) of 13 residents identified by the facility who smoked. Lastly the facility failed to ensure hazardous chemicals and items were secured on a secured unit. This had the potential to affect all 21 Residents (#61, #62, #17, #364, #21, #40, #37, #32, #363, #55, #09, #59, #43, #35, #14, #52, #02, #04, #28, #54, and #01) who resided in the secured unit who the facility identified as being cognitively impaired and independently mobile. The facility census was 63. Findings include: 1. Review of medical record for Resident # 56 revealed an admission date of 12/13/19. Diagnoses included cerebral infarction with hemiplegia, lack 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.

Based on record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure resident call lights were in reach and footrests were placed on wheelchair per resident's preference. This affected two (#10 and #60) of 17 residents sampled. The census was 63. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 05/12/22 with a diagnosis of paraplegia. Review of the Minimum Data Set (MDS) assessment, dated 05/16/22, revealed Resident #10 was mildly cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADLs). Review of the care plan dated 05/16/22 revealed Resident #10 had an ADL self-care performance deficit related to activity intolerance, disease process paralysis due to gunshot wound, hemiplegia, impaired balance, limited mobility, limited range of motion, musculoskeletal impairment, pain, shortness of breath. Interventions included staff to assist resident with mobility and adaptive devices. Review of the care plan dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of the facility policy, the facility failed to ensure the record accurately reflected the resident's preferred code status for two (#25 and #263) of four residents reviewed for advanced directives. The census was 63. Findings include: 1. Review of the medical record for Resident #25 revealed and admission date of 10/16/19 with a diagnosis of cerebral infarction. Review of Resident #25 physician order, dated 09/01/21, revealed the resident's code status was Do Not Resuscitate Comfort Care (DNRCC)-Arrest. Review of the care plan for Resident #25, dated 05/05/22, identified an advanced directive. Interventions included: resident had a court appointed legal guardian, resident had memory and cognitive issues and needed help in making important decisions, resident's code status was DNRCC-Arrest. Review of progress note per nurse practitioner (NP) for Resident #25 dated 07/13/22 revealed resident's code status was DNRCC-Arrest. Review of paper medical record for…

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

Based on observation, record review, staff interviews, and policy review, the facility failed to ensure an injury of unknown origin was reported to the administrator and to the state agency in a timely manner. This affected one (#43) out of one resident reviewed for abuse. The facility census was 63. Findings include: Review of the medical record for Resident #43 revealed an admission date of 06/08/18. Diagnoses included repeated falls, hyperlipidemia, major depressive disorder, dementia in other diseases classified elsewhere with behavioral disturbance, hypertension, muscle weakness, insomnia, and hypotension. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/18/22, revealed this resident had severely impaired cognition. This resident was assessed to require extensive assistance for bed mobility, transfer, dressing, toileting, and personal hygiene as well as supervision for eating. Review of the nursing progress note dated 07/17/22 revealed the resident was found on the floor in the hallway in front of a doorway on her left side. The resident was assessed 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, observations and staff interviews the facility failed to ensure care plans were updated or revised for residents residing on the secured unit. This affected three Residents (#17, # 28 and #52) of the 17 sampled residents. The facility identified 21 residents who resided on the secured unit. The facility census was 63. Findings included: 1. Review of medical record for Resident #17 revealed an admission date of 04/27/22. Diagnosis included dementia, suicide attempts, multiple fractures secondary to motor vehicle accident (MVA), schizoaffective disorder, and anxiety. The resident was placed in the secured unit upon admission. Review of health elopement risk screening dated 04/27/22 and 06/03/22 revealed Resident #17 was cognitively impaired with poor decision-making skills, had diagnosis of dementia, ambulated independently with no hearing vision problems. Review of plan of care for Resident #17 did not identify the resident required a secured unit. Observations on 08/01/22 from 9:30 A.M. to 4:30 P.M. and 08/02/22 from 6:30 A.M. to 4:30 P.M. 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, medical record review, staff interview and review of facility policy, the facility failed to ensure bed rails to assist with bed mobility were applied to the bed for one (#60) of 17 residents sampled for activities of daily living (ADLs). The facility census was 63. Findings included: Review of medical record for Resident #60 revealed an admission date of 12/13/19. Diagnosis included schizoaffective disorder, bipolar, dementia with behavioral issues, falls, anxiety, and weakness. Review of quarterly side rail screening, dated 07/07/22 by Licensed Practical Nurse (LPN) #285, revealed Resident #60 had weakness and requested side rails for sense of security, to move up and down in bed, entering bed more safely, transferring more safely and to avoid rolling out of bed. Assessment indicated side quarter side rails were recommended to help resident position self. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 07/08/22, revealed Resident #60 had severely impaired cognition, had no behaviors, did not reject care, and was dependent or required extension…

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, resident interview, staff interview, and review of the facility policy, the facility failed to ensure residents received proper nail care. This affected three (Resident #7, #25, #42) of four residents sampled for activities of daily living (ADLs.) The facility census was 63. Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 04/27/22 with a diagnosis of myopathy. Review of the Minimum Data Set (MDS) assessment, dated 08/03/22, revealed Resident #7 was cognitively impaired and required extensive assistance of one staff with ADLs. Review of the care plan for Resident #7, dated 08/02/22, revealed an ADL self-care deficit. Interventions included assist with ADLs and keep nails short and clean. Review of the care plan for Resident #7, dated 08/02/22, revealed the resident had the potential for impaired skin integrity and was at risk for skin tears. Interventions included staff should assist with hygiene and general skin care. Observation on 08/01/22 at 3:31 P.M. of Resident #7 revealed the resident's…

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

Based on record review, staff interview, and review of the facility policy, the facility failed to assess and monitor a pressure ulcer for one (#10) resident. The facility identified four residents with pressure ulcers. The census was 63. Findings include: Review of the medical record for Resident #10 revealed an admission date of 05/12/22 with a diagnosis of paraplegia. Review of the Minimum Data Set (MDS) assessment, dated 05/16/22, revealed resident was mildly cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADLs). Resident was coded as negative for the presence of pressure ulcers and was at risk for the development of pressure ulcers. Review of the pressure ulcer risk assessment for Resident #10 dated 05/12/22 revealed the resident was at low risk for the development of pressure ulcers. Review of the care plan for Resident #10 dated 05/16/22 revealed a potential for impairment of skin integrity and at risk for skin tears, poor tissue integrity, potential for infection related to altered nutritional state, disease…

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

Based on record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure medications were secured and not left at the residents' bedside for two (#8 and #46) residents observed during the survey. The facility census was 63. 1. Review of the medical record for Resident #8 revealed an admission date of 04/29/22 with a diagnosis of paraplegia. Review of the Minimum Data Set (MDS) assessment, dated 08/03/22, revealed Resident #8 was cognitively impaired. Review of the August 2022 monthly physician's orders for Resident #8 revealed an order dated 04/29/22 for Zofran every eight hours as needed for nausea and vomiting. Observation on 08/02/22 at 9:56 A.M. of Resident #8's room revealed there was a plastic cup with a white pill sitting on top of resident's overbed table. Interview on 08/02/22 at 9:56 A.M. with Resident #8 confirmed there was plastic cup with a white pill on his overbed table and he thought the nurse had brought it in last night because he was sick to his stomach, but he didn't want to take any pills.…

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 review of facility policy, the facility failed to ensure food items in the kitchen, nourishment refrigerators and the facility food thermometer were maintained in a manner to prevent and protect food against contamination and spoilage. This affected all residents residing in the facility except for two residents (Resident #10 and #65) who received nothing by mouth (NPO). The facility census was 79. Findings include: 1. Observation of the kitchen on 07/29/19 at 9:35 A.M. revealed a bag of open undated strawberries and a bag of open undated blueberries to be in the ice cream freezer. There was also a plastic tub of cooked chicken breasts, dated 07/29/19, with no lid on them and a plastic tub of stir fry, dated 07/27/19, with no lid on it in the refrigerator. Interview with Dietary Director #35 on 07/29/19 at 9:35 A.M. verified there to be a bag of open undated strawberries and a bag of open undated blueberries to be in the ice cream freezer. Dietary Director #35 also confirmed there was a plastic tub of cooked chicken breasts dated 07/29/19…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and review of the activity calendar, the facility failed to provide an ongoing program of activities for each resident that met their individual needs and preferences. This affected four (Resident #10, Resident #15, Resident #24 and Resident #39) residents and had the potential to affect all 20 residents of the secured unit for residents with dementia related diagnoses. The facility census was 79. Findings include: 1. Record review revealed Resident #15 was admitted to the facility on [DATE]. Review of Resident #15's activity interview for daily and activity preferences dated 02/13/19 revealed listening to music, being around animals, going outside and getting fresh air were somewhat important to Resident #15. Review of Resident #15's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Review of Resident #15's activities care plan revealed staff should assist resident in developing a program of activities that are…

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 record review, the facility failed to ensure the portion sizes reflected in the menu spreadsheet were followed to ensure residents received adequate nutrition. This affected nine (Resident #9, #23, #24, #56, #62, #72, #74, #81 and #83) of 79 residents residing in the facility that received pureed diets. The facility census was 79. Findings include: Review of the dietary menu spreadsheet revealed residents on pureed diets were to get four oz. of pancake. Observation of Dietary Director #35 on tray line on 07/31/19 at 7:34 A.M. revealed Dietary Director #35 gave Resident #72 and Resident #9 an ivory scoop or 3.2 ounces (oz.) of pureed pancake. Interview with Dietary Director #35 on 07/31/19 at 7:34 A.M. verified he was using an ivory scoop to serve the pureed pancakes. Interview with Dietician #500 on 07/31/19 at 2:45 P.M. verified the ivory scoop used to serve the pureed pancakes on 07/31/19 was a 3.2 oz scoop. Dietician #500 also confirmed the dietary menu spreadsheet reported pureed diets were to get four oz of pureed pancakes on 07/31/19.…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents who were served breakfast in the dining room were treated in a dignified manner that promoted their quality of life at the facility. This affected one (Resident #82) resident. The facility census was 79 residents. Findings include: Review of Resident #82's record revealed she was admitted to the facility on [DATE], with pertinent diagnoses of Alzheimer's disease, dementia with behavioral symptoms, and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the cognitively impaired resident required supervision of staff with eating tasks. The resident was on a pureed diet. A care plan dated 07/13/19 revealed the resident was at nutritional risk related to diagnoses of dementia requiring a mechanically altered diet. Pertinent interventions included monitoring for any signs of dysphagia, pocketing, choking, coughing, or holding food in mouth, providing supplements as ordered, providing…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure a resident's physician and resident representative were notified of an accident that resulted in a bruise to a resident's forehead. This affected one (Resident #9) of three residents reviewed for accidents. The facility census was 79. Findings include: Record review revealed Resident #39 was admitted to the facility on [DATE] with diagnoses including frontotemporal dementia. Review of Resident #39's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively impaired and required supervision with bed mobility, transfers and eating and required extensive assistance with dressing, toileting and personal hygiene. Review of Resident #39's progress notes and shower sheets from 06/01/19 to 07/31/19 revealed no documentation regarding bruising on Resident #39's forehead. Observation of Resident #39 on 07/29/19 at 11:50 A.M. revealed a light yellow colored bruise approximately one inch by one half inch 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure residents received timely incontinence care. This affected two (Residents #56 and #61) of 19 sampled residents The facility census was 79 residents. Findings include: 1. Record review revealed Resident #56 was admitted to the facility on [DATE] with diagnoses including diabetes, vascular dementia, arthropathy, osteoporosis, dysarthria, cerebral vascular accident with hemiplegia, dysphagia, hypertensive retinopathy, glaucoma, major depressive disorder, seizures, aphasia, hypertension, and cerebral infarction. A care plan was developed on 07/23/17 that stated the resident was at risk of developing complications secondary to having functional bladder incontinence related to dementia and impaired mobility. Interventions included coordinating care with hospice team, checking for incontinence during rounds, washing, rinsing, and drying his perineum after incontinence episodes, and monitor for symptoms of urinary tract infections. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure a resident who sustained a bruise to her forehead received appropriate assessment, treatment and monitoring. This affected one (Resident #39) of three residents reviewed for accidents. The facility census was 79. Findings include: Record review revealed Resident #39 was admitted to the facility on [DATE] with diagnoses including dementia. Review of Resident #39's quarterly Minimum Data Set assessment dated [DATE] revealed the resident was cognitively impaired and required supervision with bed mobility and transfers and required extensive assistance with dressing, toileting and personal hygiene. Review of Resident #39's progress notes and shower sheets from 06/01/19 to 07/31/19 revealed no documentation regarding bruising on Resident #39's forehead. Observation of Resident #39 on 07/29/19 at 11:50 A.M. revealed resident to have a light yellow colored bruise approximately one inch by one half inch on the right side of her forehead.…

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 their treatments consistently to promote healing. This affected two (#65 and #81) of four residents reviewed for pressure sores. The facility identified three residents with pressure sores. The facility census was 79 residents. Findings include: 1. Review of Resident #65's record revealed she was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, anxiety state, depression, kidney disease, chronic obstructive pulmonary disease and urinary incontinence. Review of a care plan, developed on 04/07/17, revealed the resident had the potential for impairment of skin integrity related to diabetes mellitus, immobility and incontinence. Pertinent interventions included assistance with repositioning, assisting with hygiene and general skin care including the application of barrier cream to the buttocks and skin prep to the heels and the use of a low air loss mattress. Review of the annual Minimum Data Set…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure a resident received sliding scale insulin in accordance to physician orders. This affected one (#18) of five residents reviewed for unnecessary medications. The facility identified 17 residents on insulin. The facility census was 79 residents. Findings include: Review of the record Resident #18 revealed the resident was admitted to the facility on [DATE] with diagnoses including diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/15/19, revealed the resident was cognitively intact. Review of the physician orders, dated 11/10/18, revealed the resident received Novolog Insulin 10 units subcutaneously before meals for diabetes mellitus. He also was to receive Novolog Insulin in accordance to the sliding scale results before meals which stated if blood sugar test results were 150 - 200 administer five units Novolog Insulin; 201 - 250 administer 10 units Novolog Insulin; 251 - 300 administer 15 units Novolog…

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 pharmacy recommendations were addressed timely by the physician. This affected two (Resident #5 and #24) of five residents reviewed for unnecessary medications. The facility census was 79. Findings include: 1. Record review for Resident #5 revealed the resident was admitted to the facility on [DATE] with the following diagnoses dementia with behavioral disturbance, major depressive disorder, psychosis and insomnia. Review of Resident #5's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be severely cognitively impaired and received antipsychotics and antidepressants. Review of Resident #5's physicians orders revealed resident was prescribed Seroquel 50 milligrams (mg.) by mouth at bedtime for dementia on 06/08/18 and Seroquel 50 mg. by mouth in the afternoon for dementia on 06/08/18. Review of Resident #5's pharmacy recommendation, dated 04/11/19, revealed a trialed decrease of Seroquel was recommended.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure a resident received adequate monitoring for the use of an anticoagulant. This affected one (Resident #34) of five residents reviewed for unnecessary medications. The facility identified 13 residents on anticoagulants. The facility census was 79 residents. Findings include: Review of Resident's #34's admission record, revealed he was admitted to the facility on [DATE] with diagnoses including cerebral vascular accident (CVA) and cerebral infarction. Review of the annual Minimum Data Set (MDS) assessment, dated 06/07/19, revealed the resident had intact cognition. Review of the care plan, dated 04/17/17, revealed the resident needed monitoring for the use of Coumadin, an anticoagulant, with the potential for uncontrolled bleeding. Pertinent interventions included administering the Coumadin as ordered, monitoring his labs as ordered and adjusting the Coumadin dosage per physician orders, and monitoring for any bruising, blood in urine, 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, review of facility policy and staff interviews, the facility failed to provide a gradual dose reduction for two residents who were receiving psychotropic medications and failed to provide rationale for extended use of an as needed psychotropic drug for one resident. This affected three residents (#5, #18 and #24) of five resident reviewed for unnecessary medications. The resident census was 79. Findings include: 1. Record review revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included dementia with behavioral disturbance, major depressive disorder and psychosis. Review of Resident #5's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be severely cognitively impaired and received antipsychotics and antidepressants during the seven-day look back period of the assessment date. Review of the physician orders, dated 06/08/18, revealed the resident was prescribed Seroquel 50 milligrams (mg.) by mouth at bedtime for dementia, Seroquel 50…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and resident and staff interview, the facility failed to ensure one (#34) of five residents reviewed for dental services, received his dentures timely. The facility census was 79 residents. Findings include: Review of Resident #34's record, revealed he was admitted to the facility on [DATE] with diagnoses including cerebral vascular accident (CVA), degenerative joint disease, anxiety, and depression. Review of the annual Minimum Data Set (MDS) assessment, dated 06/07/19, revealed the cognitively aware resident, required extensive assistance with personal hygiene tasks. The MDS also revealed the resident had no natural teeth and was edentulous. Review of the care plan, dated 04/17/17, revealed the resident had a potential for or altered dental status related to the need for assistance with dental hygiene. Interventions included assisting with oral care as needed, notifying the nurse of any chewing problems or complaints of discomfort, assist with referrals as needed, consult…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, the facility failed to ensure a resident's code status was accurately documented in the care plan and hard chart. The facility also failed to ensure an incident that caused a bruise to a resident's forehead was documented in the chart. This affected two (Resident #9 and #39) of 24 residents reviewed for complete and accurate medical records. The facility census was 79. Findings include: 1. Record review revealed Resident #9 was admitted to the facility on [DATE] with the diagnoses including dementia in other diseases classified elsewhere with behavioral disturbance, Alzheimer's disease with early onset, type two diabetes mellitus with diabetic neuropathy and recurrent depressive disorders. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/30/19, revealed the resident to be cognitively impaired. Review of Resident #9's chart revealed Resident #9 to have a full resuscitation paper signed by Resident #9's representative on 09/06/19. 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.