Delhi Post-Acute

Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to ensure medications were ordered and available for administration as ordered by the physician. This affected one (Resident #40) of 19 sampled residents. The facility census was 95 residents. Findings include: Review of the medical record for Resident #40 revealed an admission date of 05/04/22 with a diagnosis of anxiety disorder. Review of the care plan for Resident #40 initiated on 06/08/22 and revised on 01/30/24 revealed the resident received psychotropic medications that included antianxiety medications. Interventions included staff were to give medications as ordered. Review of the medication review report for Resident #40 revealed a physician's order dated 06/30/23 for Ativan (an antianxiety medication) one milligram (mg) by mouth every six hours for anxiety disorder. Review of the annual Minimum Data Set (MDS) assessment for Resident #40 dated 04/19/24 revealed the resident was cognitively intact and had received antianxiety medication during the last…

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 facility document and review of the facility policy, the facility failed to ensure residents were free from significant medication errors. This affected one (Resident #40) of 19 sampled residents. The facility census was 95 residents. Findings include: Review of the medical record for Resident #40 revealed an admission date of 05/04/22 with a diagnosis of anxiety disorder. Review of the care plan for Resident #40 initiated on 06/08/22 and revised on 01/30/24 revealed the resident received psychotropic medications that included antianxiety medications. Interventions included staff were to give medications as ordered. Review of the medication review report for Resident #40 revealed a physician's order dated 06/30/23 for Ativan (an antianxiety medication) one milligram (mg) by mouth every six hours for anxiety disorder. Review of the annual Minimum Data Set (MDS) assessment for Resident #40 dated 04/19/24 revealed the resident was cognitively intact and had received antianxiety medication during the last seven days of the assessment…

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

Based on record review, staff interview, and review of the facility policy, the facility failed to ensure staff accurately documented medication administration. This affected one (Resident #40) of 19 sampled residents. The facility census was 95 residents. Findings include: Review of the medical record for Resident #40 revealed an admission date of 05/04/22 with a diagnosis of anxiety disorder. Review of the care plan for Resident #40 initiated on 06/08/22 and revised on 01/30/24 revealed the resident received psychotropic medications that included antianxiety medications. Interventions included staff to give medications as ordered. Review of the medication review report for Resident #40 revealed a physician's order dated 06/30/23 for Ativan (an antianxiety medication) one milligram (mg) by mouth every six hours for anxiety disorder. Review of the annual Minimum Data Set (MDS) assessment for Resident #40 dated 04/19/24 revealed the resident was cognitively intact and received antianxiety medications during the assessment period. Review of the Medication Administration Record (MAR)…

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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, record review, interviews, and facility incident report, the facility failed to administer medication as ordered. This affected one (Resident #95) of three residents reviewed for medication administration. The facility census was 94. Findings include: Review of the medical record for Resident #95 revealed an admission date of 01/09/24 and a discharge date of 01/28/24 with diagnoses of lung disease, type II diabetes, osteoporosis, and heart disease. Review of the most recent Minimum Date Set (MDS) assessment dated [DATE] revealed the resident was cognitively impaired and required moderate assistance with care. Review of the physician's orders dated 01/09/24 noted an order for Prolia 60 mg (a medication that helps stop the development of bone removing cells) per injection every six months on the 12th of the month. Review of the 01/24 Medication Administration Record…

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, staff interview and policy review the facility failed to ensure expired medication was timely discarded from the medication carts and the nursing station storage areas. This have the potential to affect all residents residing on the memory care unit and the third floor. The facility censes was 62. Findings include: 1. Observation on [DATE] at 6:31 A.M. of the dementia units' medication cart revealed the following opened expired stock medications: a bottle of calcium citrate plus vitamin D3 expired on 04/21, a bottle of senna-plus with an expiration date of 05/21 and a bottle of aspirin 81 milligrams (mg) with an expiration date of 04/21. 2. Observation on [DATE] at 6:45 A.M. of treatment cart in the dementia unit revealed an opened, expired, and unlabeled tube of hemorrhoidal ointment dated 02/21, opened expired tube of hydrocortisone cream 2.5 % for Resident #32, opened expired tube of desonide cream 0.5 % for Resident #27 with an expiration dated on 08/2020, an expired tube 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 observation and interview, the facility failed to maintain a sanitary homelike environment. This affected two of eight residents (#3 and #46) sampled for ADL assistance. Facility census was 62. Findings include: 1. Resident #3 admitted on [DATE] with diagnoses that included but were not limited to unspecified dementia with behavioral disturbance, insomnia, hypertension, and major depressive disorder. 2. Resident #46 admitted on [DATE] with diagnoses that included but were not limited to unspecified dementia without behavioral disturbance, unspecified atrial fibrillation, and supraventricular tachycardia. Interview on 06/21/21 at 12:26 PM revealed State Tested Nurse Aide (STNA) #123 stated she had lad emptied the bedside commode in the morning, but did not check the bedside commode before passing lunch trays. STNA #123 verified the bedside commode was full of urine. Interview on 06/21/2021 at 1:42 P.M. STNA # 123 confirmed Resident #46's bedside commode still had urine inside, and STNA #123 confirmed she…

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, interview and policy review, the facility failed to ensure toenails of dependent residents were trimmed. This affected one (Resident #28) of 17 residents sampled. The census was 62. Findings include: Review of the medical record for Resident #28 revealed an admission date of 12/28/20 with a diagnosis of chronic obstructive pulmonary disease (COPD) and diabetes mellitus (DM). Review of the Minimum Data Set (MDS) for Resident #28 dated 04/20/21 revealed resident was cognitively intact and required limited assistance of one staff with personal hygiene and grooming. Review of care plan for Resident #28 dated 03/08/21 revealed resident was at risk for complications with activities of daily living (ADL) self-care performance related to impaired respiratory status, impaired mobility, and mood/behavioral disturbances. Interventions included staff to provide nail care as needed. Review of the medical record for Resident #28 revealed no documentation regarding podiatry visits or refusal of foot care. Review of facility documented dated 04/07/21 signed 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 record review, observation, and interview, the facility filed to failed to ensure residents received vision services. This affected one (Resident #28) of 17 residents sampled. The census was 62. Findings include: Review of the medical record for Resident #28 revealed an admission date of 12/28/20 with a diagnosis of chronic obstructive pulmonary disease (COPD) and diabetes mellitus. Review of the Minimum Data Set (MDS) for Resident #28 dated 04/20/21 revealed resident was cognitively intact and required limited assistance of one staff with activities of daily living . Review of a facility document dated 04/07/21 and signed by the attending physician revealed the resident was approved to be seen by the facility eye doctor for decreased vision. Review of the medical record for Resident #28 revealed no documentation regarding eye doctor visits. Observation of Resident #28 on 06/21/21 at 1:30 P.M. revealed the resident did not wear prescription glasses. During interview at this time the resident stated her vision needed checked and she thought she might need prescription…

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, interview and policy review, the facility failed to ensure pressure relieving devices were in place to the feet for a resident with unavoidable pressure ulcers. This affected one (Resident #23) of four facility identified residents with pressure ulcers. The census was 62. Findings include: Review of the medical record for Resident #23 revealed and admission date of 02/08/18 with a diagnosis of schizophrenia. Review of Minimum Data Set (MDS) for Resident #23 revealed resident was cognitively impaired and required extensive assistance with activities of daily living. Resident #23 had a physician order dated 03/01/21 for multi-podus boots to both feet as tolerated every shift. Review of the care plan for Resident #23, updated 03/09/21, revealed resident had actual impaired skin integrity as evidenced by pressure ulcers to her bilateral heels. Interventions included the following: administer medications as ordered, monitor/document for side effects and effectiveness, administer treatments as ordered and monitor for effectiveness, pressure reducing…

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, interview and policy review, the facility failed to ensure nebulizer tubing and masks were changed as ordered by the physician. This affected one (Resident #28) of 11 residents receiving respiratory treatment. The census was 62. Findings include: Review of the medical record for Resident #28 revealed an admission date of 12/28/20 with a diagnosis of chronic obstructive pulmonary disease (COPD) and diabetes mellitus. Review of June 2021 physician orders for Resident #28 revealed orders for albuterol per handheld nebulizer every six hours as needed for shortness of breath and an order to change nebulizer tubing and mask once per week on Sundays. Observation of Resident #28 on 06/21/21 at 1:30 P.M. revealed resident's nebulizer tubing was dated 05/24/21. During interview on 06/21/21 at 1:35 P.M., Licensed Practical Nurse (LPN) #139 confirmed the tubing to Resident #28's nebulizer was dated 05/24/21 and it was supposed to be changed weekly on Sundays by night shift staff. Review of facility policy titled Administering Medications via a Small Volume…

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 facility policy the facility filed to failed to ensure pharmacy recommendations were addressed by the attending physician in a timely manner. This affected one (Resident #28) of six residents reviewed for medications. The census was 62. Findings include: Review of the medical record for Resident #28 revealed an admission date of 12/28/20 with a diagnosis of chronic obstructive pulmonary disease (COPD) and diabetes mellitus (DM). Review of the pharmacy recommendations for Resident #28 dated 01/14/21 revealed resident was at risk for venous thromboembolism (VTE) and had COVID-19. Further review of the recommendation revealed it was marked as urgent with a prompt response needed and recommended the attending physician consider temporary anticoagulant therapy due to resident's increased risk of VTE. The recommendation had not been addressed by the physician. Interview on 06/24/21 at 2:00 P.M. with the Director of Nursing (DON) confirmed the facility failed to ensure the pharmacy recommendation for the anticoagulant had been…

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

Based on record review, interview and policy review, the facility failed to ensure orders for as needed anti-anxiety medication had a duration for the order. This affected one (Resident #23) of 19 residents with orders for anti-anxiety medication. The census was 62. Findings include: Review of the medical record for Resident #23 revealed and admission date of 02/08/18 with a diagnosis of schizophrenia. Review of Minimum Data Set (MDS) for Resident #23 revealed resident was cognitively impaired and required extensive assistance with activities of daily living. Review of June 2021 monthly physician orders for Resident #23 revealed resident had an order dated 04/23/21 for as needed Ativan every two hours. Review of the June 2021 Medication Administration Record (MAR) for Resident #23 revealed the resident received as needed doses of Ativan on the following dates: 06/01/21, 06/02/21, 06/03/21, 06/04/21, 06/05/21, 06/06/21, 06/08/21, 06/09/21, 06/10/21, 06/11/21, 06/14/21, 06/17/21, 06/19/21. Interview on 06/24/21 at 3:01 P.M. with Registered Nurse (RN) #190 confirmed Resident #23's as…

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 policy review, the facility failed to provide assistance with adaptive feeding equipment ordered by the physician. This affected one (Resident #314) of 17 residents sampled. The census was 62. Findings include: Review of the medical record for Resident #314 revealed a readmission date of 06/16/21 with diagnoses including seizure disorder, aphasia, and dysphagia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed resident was cognitively impaired and required supervision with eating. Review of care plan for Resident #314 dated 05/27/21 revealed had a nutritional problem or potential nutritional problem and was at risk for significant weight change. Interventions included to provide diet as ordered and assistance with eating as needed. Review of June 2021 physician orders revealed an order for resident to have sip cup with meals and supplements Review of speech therapy evaluation dated 06/02/21 revealed resident was recommended to use sip cup…

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 and interview, the facility failed to have functioning call light available to all residents. This affected one (Resident #3) of 24 residents sampled for call lights. The facility census was 62. Findings include: Resident #3 admitted on [DATE] with diagnoses including unspecified dementia with behavioral disturbance, insomnia, hypertension, and major depressive disorder. Review of most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively intact, had no behaviors, did not wander, and did not reject care. Resident #3 required no physical staff assistance and supervision/set-up assistance with all ADL's. Record review revealed Resident #3 transferred to their current room on 05/26/2021. Observation on 06/21/21 at 1:50 P.M. revealed the room was occupied by two residents (#3 and #46), and had one call light attached to the bed of Resident #46. Resident #3 had no access to a call light. Observation on 06/22/2021 at 1:10 P.M. revealed Resident #3 had no call…

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 dispose of expired and/or out dated medication. This affected one medication storage refrigerator and the central storage supply room, reviewed for medication storage during the annual survey. This had the potential to affect all 73 residents residing in the facility. The facility census was 73. Findings include: 1) Observation and interview conducted on 02/28/19 at 2:20 P.M. with Registered Nurse (RN) #75 of the third floor medication storage refrigerator revealed an open vial of Tuberculin Purified Protein Derivative (PPD) (used to test for Tuberculosis) dated 12/18/18. RN #75 verified the opened PPD should have been discarded 30 days after opening. 2) Observation and interview conducted 02/28/19 at 3:05 P.M. with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #89 reviewed medication storage located in the central supply room. During observation, two bottles of Sodium Bicarbonate (treats acid indigestion) 325 milligram (mg.) was observed 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 record review, observation, family, resident and staff interviews, the facility failed to maintain residents' environment in a sanitary and comfortable manner. This affected five Residents (#2, #29, #59, #60 and #73) of 25 residents during the initial pool sample of the annual survey. The facility census was 73. Findings include: 1. Medical record review revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses included cognitive communication deficit, muscle weakness, lack of coordination, cerebral palsy, intellectual disabilities and cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/17/19, revealed Resident #2 was cognitively impaired. Observation on 02/25/19 at 10:45 A.M., revealed Resident #2 with sitting in his wheelchair watching television and observed his wheelchair was dirty. Further Observation on 02/25/19 at 12:20 P.M., revealed Resident #2 sitting in his wheelchair 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.

Based on observation, staff interview and facility policy review, the facility failed to label and date food items on the unit refrigerators and freezers and failed to keep unit refrigerators and freezers clean and kept at appropriate temperature. This had the potential to affect the 32 residents residing on the fourth and fifth floor who receive food from the kitchen. The facility census was 73. Findings include: Observation on 02/27/19 at 10:44 A.M. with Registered Nurse (RN) #200 revealed the refrigerator and freezer on the fifth floor were dirty and stained with food. The refrigerator thermometer was at 45 degrees Fahrenheit (F). RN #200 verified the findings at this time. Interview on 02/27/19 at 10:50 A.M. with Assistant Director of Nursing (ADON) reported housekeeping was responsible for cleaning the refrigerators on each unit. Observation on 02/27/19 at 10:56 A.M. with Licensed Practical Nurse (LPN) #210 revealed the refrigerator and freezer on the fourth floor had a 20-fluid ounce of Santa Orange Pop opened and no name, 20 fluid ounce [NAME] Tea opened with no name, and 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, observations, facility job description review and staff interviews, the facility failed to ensure residents were treated in a dignified manner. This affected one (#1) of three residents reviewed for dignity during the investigation stage of the survey. The facility census was 73. Findings include: Review of Resident #1's medical record revealed an admission date of 06/26/16. Diagnoses included psychotic disorder with delusions, altered mental status, dementia and symbolic dysfunctions. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/22/19, revealed the resident had severe cognitive impairment, difficulty focusing attention, and no behaviors. The assessment revealed the resident was always incontinent of urine and bowel and required one to two person extensive physical assistance with most activities of daily living (ADLs). Observation on 02/26/19 at 9:41 A.M. revealed State Tested Nursing Assistant (STNA) #2, while in the common area of the memory unit, where 12 residents were participating in a trivia activity, asked residents…

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 review of facility policy, the facility failed to verify and document code status for a resident. This affected one (Resident #44) of 25 reviewed during the initial pool sample of the annual survey. The facility census was 73. Findings include: Review of the medical record revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including dementia without behaviors, dysphagia, hypertension, anxiety disorder, insomnia, malignant neoplasm of prostate, and and type two diabetes mellitus. Review of the admission Minimum Data Set (MDS) assessment, dated 12/11/18, revealed the resident had severe cognitive impairment. Review of Resident #44's Electronic Health Record (ELH) and Hard Chart revealed no physician orders for the residents code status, no Iowa Physician Orders for Scope of Treatment (IPOST) (a medical order for using or forgoing medical treatment), and/or no advanced directives were noted in either health record. Further 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 medical record review, staff interview, physician interview and review of facility policy, the facility failed to timely notify of the physician of a resident's significant weight loss. This affected one (Resident #56) of three residents reviewed for nutrition. The facility identified 13 residents who have had unplanned significant weight loss or gain. The facility census was 73. Findings include: Review of the medical record revealed Resident #56 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury, anxiety disorder, unstageable pressure ulcer of the buttock, altered mental status, chronic obstructive pulmonary disorder, diabetes mellitus, paranoid schizophrenia, mood disorder, schizoaffective disorder, intellectual disabilities and dementia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/14/19, revealed the resident's long-term memory was impaired and the resident required extensive one-person assistance with eating. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interview, and review of the facility Self-Reported Incident and facility policy, the facility failed to implement their policy when a resident alleged verbal abuse. This affected one (Resident #65) of 25 residents reviewed in the initial pool sample of the annual survey. The facility census was 73. Findings include: Review of the resident record revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including epilepsy, major depressive disorder, chronic leukemia, overactive bladder, hydrocephalus, persistent mood disorder, and difficulty walking. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/29/19, revealed the resident was moderately cognitively impaired, had no noted behaviors during the look back period and the resident required extensive one-person assistance with toileting. Interview on 02/25/19 at 10:10 A.M. with Resident #65 stated State Tested Nursing Assistant (STNA) #67 called him a, son of a explicit 'word' last…

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, resident and staff interview, and review of the facility Self-Reported Incident and facility policy, the facility failed to thoroughly investigate an allegation of verbal abuse. This affected one (Resident #65) of 25 residents reviewed in the initial pool sample of the annual survey. The facility census was 73. Findings include: Review of the resident record revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including epilepsy, major depressive disorder, chronic leukemia, overactive bladder, hydrocephalus, persistent mood disorder, and difficulty walking. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/29/19, revealed the resident was moderately cognitively impaired, had no noted behaviors during the look back period and the resident required extensive one-person assistance with toileting. Interview on 02/25/19 at 10:10 A.M. with Resident #65 stated State Tested Nursing Assistant (STNA) #67 called him a, son of a explicit 'word' last week 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to inform the State Long Term Care Ombudsman when residents were hospitalized . This affected three (#19, #56, and #62) of five residents reviewed for hospitalizations. The facility census was 73. Findings include: 1. Record review for Resident #19 revealed the resident was admitted [DATE] and had a readmission dated of 12/28/18. Diagnoses included chronic kidney disease, malignant neoplasm of the prostate, chronic obstructive pulmonary disease, and heart failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had intact cognition and required extensive to total assistance with activities of daily living (ADLs). Review of the medical record revealed the resident was transferred via 911 to an acute care hospital after a change in condition on 01/11/19 and returned to the facility on [DATE]. The medical record contained no evidence that the facility informed the Office of the State Long Term Care…

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 interviews, the facility failed to timely identify and assess a resident's skin ulcer. This affected one (Resident #44) of four residents reviewed for skin conditions. The facility census was 73. Findings include: Review of the medical record revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including dementia without behaviors, hypertension, anxiety disorder, malignant neoplasm of prostate, and type two diabetes mellitus. Review of the admission Minimum Data Set (MDS) assessment, dated 12/11/18, revealed the resident had severe cognitive impairment, had no noted behaviors and the resident required extensive two-person assistance with bed mobility and transfer. The resident required extensive assistance with one-person assistance with personal hygiene and the resident had no noted pressure or other ulcers, wounds, and/or skin problems noted, however he was at a high risk for development of pressure. Review of the Electronic Health…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident, family and staff interview and observation, the facility failed to ensure a resident received the proper assistive devices to maintain the resident's vision. This affected one (Resident #2) of one resident reviewed for vision during the annual survey. The facility census was 73. Findings include: Medical record review revealed Resident #2 was admitted on [DATE]. Diagnoses included hypotension, cognitive communication deficit and intellectual disabilities. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/17/19, revealed Resident #2 was cognitively impaired and the resident's vision was adequate which meant Resident #2 has the ability to see fine detail, including regular print in newspaper and books. Review of the resident's plan of care revealed there was no comprehensive person -centered plan for eye care or eye wear. Interview on 02/26/19 at 9:39 A.M. with a family member for Resident #2 reported the resident had a pair of glasses but rarely wears…

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 and resident interview and facility manual review, the facility failed to ensure a resident did not keep his own cigarettes and lighter in his room. This affected one (Resident #7) of 15 residents who smoke within the facility property. The facility census was 73. Findings include: Medical record review revealed Resident #7 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, cognitive communication deficit, muscle weakness, lack of coordination, chronic fatigue, bipolar disorder and depression disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/23/19, revealed Resident #7 was cognitively intact. Review of the plan of care, dated 02/26/19, revealed Resident #7 smoked and it stated the resident would maintain smoking safety with staff supervision. Observation on 02/25/19 at 3:50 P.M., revealed Resident #7 walked out of his room, went on the elevator and went into the smoking area alone without…

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 interviews, the facility failed to ensure residents received timely incontinence care. This affected one (#2) of one residents reviewed for incontinence care. The facility census was 73. Findings include: Medical record review revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses included cognitive communication deficit, need for assistance with personal care, muscle weakness, cerebral palsy, intellectual disabilities, and cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/17/19, revealed Resident #2 was cognitively impaired and required extensive assistance for bed mobility, transfer and for toileting required two persons physical assist. Resident #2 was always incontinent of bladder and bowel with no toileting program. Review of nursing notes from 10/2018 through 02/28/19 revealed no notes indicating that Resident #2 refused 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 medical record review and staff interview, the facility failed to ensure licensed nurses were knowledgeable of how to provide necessary services described in the physician's orders and the care plan for a resident who received hemodialysis. This affected one (Resident #62) of two residents the facility identified as receiving hemodialysis. Findings include: Record review for Resident #62 revealed the resident was admitted to the facility on [DATE] and had a readmission date of 04/09/18. Diagnoses included chronic kidney disease, neuromuscular dysfunction of the bladder, paraplegia, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident required extensive assistance with bed mobility and toilet use, was totally dependent upon staff for transfers, and received dialysis services. Review of the care plan, dated 12/13/17, revealed Resident #62 required hemodialysis related to renal failure, refused dialysis at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure irregularities and recommendations noted by the pharmacist during the monthly regimen review process were reviewed and addressed by the physician. This affected one (Resident #66) of five residents reviewed for unnecessary medications. Findings include: Record review revealed Resident #66 was admitted to the facility on [DATE] and had a readmission date of 09/16/17. Diagnoses included low back pain, major depressive disorder, type two diabetes mellitus without complications, and neoplasm of the brain. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/29/18, documented the resident had intact cognition. Review of the physician's orders sheet, dated 02/2019, revealed an order dated 05/28/18 for Venlafaxine Extended Release (a psychoactive medication used for the treatment of depression) 150 milligrams (mg.) daily for major depressive disorder. Review of a multi-resident pharmacy monthly regimen review report…

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