Ivy Woods Healthcare Center.

Based on record review and staff interview, the facility failed to have the Medical Director in attendance at the Quality Assurance and Performance Improvement (QAPI) meetings. This had potential to affect all 90 residents who resided in the facility. Findings include: Review of the QAPI quarterly meetings sign-in sheets dated 10/22/22, 01/15/23, 04/19/23 and 08/09/23, revealed no documented evidence the Medical Director attended the meetings. Interview with the Administrator on 10/05/23 at 2:32 P.M. verified the Medical Director did not attend the QAPI meetings on 10/22/22, 01/15/23, 04/19/23 and 08/09/23. The Administrator reported the Medical Director was required to attend all the QAPI Meetings as part of the required attendees.

Based on record review, observations, staff interviews, review of resident's diet lists, and review of facility policy, the facility failed to provide menus as planned by a Registered Dietitian (RD). This affected 13 Residents (#11, #62, #61, #60, #17, #12, #22, #35, #14, #78, #40, #69, and #06) of the 13 residents observed in the main dining room. The facility also failed to provide appropriate substitutions to residents. This affected four residents (70, # 53, #38 and #07) of the four residents identified by the facility as receiving puree diets. The facility census was 90. Findings Include: 1. Observation of the initial dining service in the main dining room on 10/04/23 from 12:00 P.M. through 12:30 P.M. revealed all 13 residents (#11, #62, #61, #60, #17, #12, #22, #35, #14, #78, #40, #69 and #06) received a four ounce (one-half cup) serving of salad. Review of the menu spreadsheet dated 10/04/23 revealed residents on regular diet, 2-gram sodium diet, carbohydrate-controlled diet and dysphagia advanced diets were ordered to receive eight ounces (one cup) of salad during the lunch…

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

Based on record review, observation and staff interview, the facility failed to store, prepare, distribute, and serve foods in accordance with professional standards for food service safety. This had the potential to affect 89 residents who received food from the kitchen. The facility census was 90. Findings include: 1. Observations of the kitchen on 10/02/23 from 9:05 A.M. through 12:30 P.M. revealed the following: a. There was a trash can under the preparation (prep) sink that had no lid and was full of food debris and trash. b. The 100-A, 100-B, 200-A, and 200-B unit meal delivery carts were noted to have a large buildup of brownish food debris in the corners and sticky substances on the interior cart racks where meal trays were being stored during delivery. During lunch meal service, staff were observed placing the resident's food tray in the dirty carts and the trays being delivered were observed touching the soiled areas of the food carts racks. c. Numerous ceiling tiles directly above the stove were soiled with brownish substances which appeared to be from splatters. d. Two…

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

Based on observation and interview, the facility failed to maintain essential kitchen equipment in a safe and sanitary condition. This affected all 89 residents who received meals from the kitchen. The facility total census was 90. Findings include: Observation of the kitchen on 10/04/23 at 12:00 P.M., revealed the steam table had electrical wires in three sections hanging two inches below the back covering. There was an on/off switch inside the lower cabinet and all four temperature control knobs were missing. The steam team table had a brownish, sticky substance covering most of the steam table. Continued observation revealed the renal diet ravioli appeared to be dry and sticking to the steam table pan. Interview with [NAME] #64 on 10/04/23 at 12:45 P.M. verified food dries out quickly on the steam table as the temperature knobs are not available to control the steam temperature. She verified the ravioli was dry and stuck to the pan, making it less palatable. Interview with the Diet Manager (DM) #55 on 10/04/23 at 12:50 P.M. verified the hanging wires should not be exposed 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 record review, observation, resident interview, and review of facility policy and documents the facility failed to ensure residents were treated with dignity and respect. This affected two residents (#28 and #81) of the 18 residents sampled. The facility census was 90 residents. Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 06/17/22 with diagnoses including encephalopathy, diabetes mellitus (DM), neuromuscular dysfunction of the bladder, and pressure ulcer of sacral region. Review of the Minimum Data Set (MDS) assessment 3.0 for Resident #28 dated 08/28/23, revealed the resident was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADLs.) During a random observation on 10/02/23 at 9:49 A.M., revealed Housekeeper #105 passed by Resident #28's door and called out Hey, light skin. Resident #28 did not respond. Interview with Resident #28 on 10/02/23 at 9:50 A.M. confirmed Housekeeper #105 routinely addressed him in this manner, and he felt it was disrespectful. Resident #28…

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, resident interview, and staff interview the facility failed to ensure residents had appropriate bedding and mobility devices to accommodate resident needs. This affected one resident (#140) of 18 residents sampled. The facility census was 90 residents. Findings include: Review of the medical record for Resident #140 revealed an admission date of 09/29/23 with diagnoses including sepsis, cellulitis, metabolic encephalopathy, chronic obstructive pulmonary disease (COPD), morbid obesity, hypertension (HTN), acute respiratory failure (ARF) with hypoxia. Review of the admission weight record for Resident #140 dated 09/29/23 revealed the resident weighed 350 pounds and was 71 inches tall. Review of an admission note for Resident #140 dated 09/29/23, revealed the resident had bilateral wounds to the lower extremities and his legs were wrapped. Review of a nurse progress note for Resident #140 dated 09/30/23, revealed the resident was up in a wheelchair, and he required assistance 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 record review, staff interview, and review of the facility policy the facility failed to ensure residents had their advanced directives /code status noted in the medical record. This affected two residents (#28 and #21) of the four residents sampled for advanced directives. The facility census was 90 residents. Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 06/17/22 with diagnoses including encephalopathy, diabetes mellitus (DM), neuromuscular dysfunction of the bladder, and pressure ulcer of sacral region. Review of the Minimum Data Set (MDS) assessment for Resident #28 dated 08/28/23 revealed the resident was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADLs.) Review of the hospital note for Resident #28 dated 06/17/22 revealed resident's code status was Do Not Resuscitate Comfort Care (DNRCC). Review of the care plan for Resident #28 dated 06/28/22 revealed the resident's code status was DNRCC.…

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 facility policy, the facility failed to ensure staff honored the residents' right to privacy by failing to knock prior to entering the resident's room and the resident's bathroom. This affected two residents (#09 and #140) of 18 residents sampled. The facility census was 90 residents. Findings include: Review of the medical record for Resident #09 revealed an admission date of 03/08/17 with a diagnosis of peripheral vascular disease (PVD), diabetes mellitus (DM), alcoholic cirrhosis of the liver, and unspecified dementia without behavioral disturbance. Review of the Minimum Data Set (MDS) assessment for Resident #09 dated 08/16/23 revealed the resident was cognitively intact and required limited assistance of one staff with activities of daily living. Review of the medical record for Resident #140 revealed an admission date of 09/29/23 with diagnoses including sepsis, cellulitis, metabolic encephalopathy, chronic obstructive pulmonary disease (COPD), morbid obesity, hypertension (HTN), acute…

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, and staff interview the facility failed to ensure resident room furnishings were in good repair and properly functional. This affected two residents (#18 and #06) of 18 residents sampled. The facility census was 90 residents. Findings include: 1. Review of the medical record for Resident #81 revealed an admission date of 09/06/23 with diagnoses including atherosclerotic, cocaine use, hypertension (HTN), malignant neoplasm of the esophagus, dysphagia, and anemia. Review of the Minimum Data Set (MDS) assessment 3.0 for Resident #81 dated 09/15/23 revealed the resident was cognitively intact and required supervision and set up help of one staff with activities of daily living (ADLs.) Observation of Resident #81's room on 10/03/23 at 12:41 P.M. revealed the resident's foot board was broken and had a jagged edge exposed approximately one foot in length. Resident #81's closet door had a hole in it which measured approximately three inches in diameter and the electrical outlet in the resident's bathroom was non-functional. Interview…

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, review of the facility's Self-Reported Incidents (SRIs) and review of facility policy and documents the facility failed to ensure the facility's abuse policy was implemented when allegations of abuse were initiated by residents. This affected one resident (#28) of the one resident reviewed for abuse. The facility census was 90 residents. Findings include: Review of the medical record for Resident #28 revealed an admission date of 06/17/22 with diagnoses including encephalopathy, diabetes mellitus (DM), neuromuscular dysfunction of the bladder, and pressure ulcer of sacral region. Review of the Minimum Data Set (MDS) assessment 3.0 for Resident #28 dated 08/28/23, revealed the resident was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADLs.) Observation on 10/02/23 at 9:49 A.M. revealed Housekeeper #105 passed by Resident #28's room and called out Hey, light skin. Resident #28 did not respond. Interview with Resident #28 on 10/02/23 at 9:50 A.M. confirmed Housekeeper #105…

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, review of facility's Self-Reported Incident (SRI) and review of facility policy and documents the facility failed to prevent further potential abuse while an abuse allegation investigation was in progress. This affected one resident (#28) of one resident reviewed for abuse. The facility census was 90 residents. Findings include: Review of the medical record for Resident #28 revealed an admission date of 06/17/22 with diagnoses including encephalopathy, diabetes mellitus (DM), neuromuscular dysfunction of the bladder, and pressure ulcer of sacral region. Review of the Minimum Data Set (MDS) assessment 3.0 for Resident #28 dated 08/28/23, revealed the resident was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADLs.) During a random observation on 10/02/23 at 9:49 A.M., revealed Housekeeper #105 passed by Resident #29's room and called out Hey, light skin. Resident #28 did not respond. Interview with Resident #28 on 10/02/23 at 9:50 A.M., confirmed Housekeeper #105 routinely…

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 interviews, the facility failed to ensure the Ombudsman was notified when residents were discharged to the hospital. This affected three residents (#36, #70, and #85) out of three residents reviewed for discharges. The facility census was 90. Findings include: 1. Review of the medical record for Resident #36 revealed an admission date of 02/22/23. Diagnoses included congestive heart failure (CHF), bipolar disorder, generalized anxiety disorder, and depression. Review of the Minimum Data Set (MDS) assessment 3.0 dated 08/17/23 for Resident #36, revealed the resident had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12. Review of the medical record for Resident #36, revealed the resident was sent to the hospital and admitted on [DATE] with no documented the Ombudsman was notified. Interview with the Administrator on 10/04/23 at 2:18 P.M., revealed notification to the Ombudsman had not been completed for Resident #36's discharge to 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.

Based on observation, interview, and policy review, the facility failed to ensure residents' fingernails were timed and clean. This affected one resident (#239) of three residents reviewed for activities of daily living (ADLs). The facility census was 90. Findings include: Review of the medical record for Resident #239 revealed an admission date of 08/01/23. Diagnoses included paranoid schizophrenia, type two diabetes mellitus (DM II), antisocial personality disorder, and schizoaffective disorder. Review of the admission Minimum Data Set (MDS) assessment 3.0 dated 08/09/23 for Resident #239, revealed the resident had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 13. This resident was assessed to require one-person extensive assistance with dressing, eating, toileting, personal hygiene, and bathing. Observation of Resident #239 on 10/02/23 at 3:40 P.M. revealed the resident was lying in bed. Resident #239's fingernails were observed to extend approximately a quarter of an inch to a half an inch beyond his fingertips and were yellow in color with…

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

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure a timely physician response to the monthly pharmacist drug regimen reviews. This affected one resident (#28) of five residents reviewed for medications. The facility census was 90 residents. Findings include: Review of the medical record for Resident #28 revealed an admission date of 06/17/22 with diagnoses including encephalopathy, diabetes mellitus (DM), neuromuscular dysfunction of the bladder, and pressure ulcer of sacral region. Review of the physician's orders dated 07/14/23 for Resident #28, revealed the resident was ordered to have the following laboratory (labs) tests drawn: complete blood count (CBC), comprehensive metabolic panel (CMP), thyroid stimulating hormone (TSH), fasting lipids, and hemoglobin A1C. Review of the pharmacist's recommendations dated 08/03/23 for Resident #28, revealed the resident had a physician's order on 07/14/23 to have labs completed which included CBC, CMP, TSH, fasting lipids, and hemoglobin A1C, but the lab results were not in 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.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure laboratory (labs) tests were completed in a timely manner as ordered by the physician. This affected one resident (#28) of 18 residents sampled. The facility census was 90 residents. Findings include: Review of the medical record for Resident #28 revealed an admission date of 06/17/22 with diagnoses including encephalopathy, diabetes mellitus (DM), neuromuscular dysfunction of the bladder, and pressure ulcer of sacral region. Review of the Minimum Data Set (MDS) assessment 3.0 for Resident #28 dated 08/28/23, revealed the resident was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADLs.) Review of the physician's orders dated 07/14/23 for Resident #28, revealed the resident was ordered to have the following labs completed: complete blood count (CBC), comprehensive metabolic panel (CMP), thyroid stimulating hormone (TSH), fasting lipids, and hemoglobin A1C. Review of the medical record for Resident #28 revealed the…

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

Based on medical review, observation, resident interview, and staff interview, and review of the facility policy the facility failed to ensure residents received routine dental services. This affected one resident (#28) of 18 residents sampled. The facility census was 90. Findings include: Review of the medical record for Resident #28 revealed an admission date of 06/17/22 with diagnoses including encephalopathy, diabetes mellitus (DM), neuromuscular dysfunction of the bladder, and pressure ulcer of sacral region. Review of the physician's order for Resident #28 dated 11/10/22, revealed the resident may have a dental consult. Review of the Minimum Data Set (MDS) assessment 3.0 for Resident #28 dated 08/28/23 revealed the resident was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADLs.) Observation of Resident #28 on 10/02/23 at 9:55 A.M. revealed the resident had a chipped upper front tooth. Interview with Resident #28 on 10/02/23 at 9:55 A.M. confirmed he had a chipped upper front tooth which was not painful, but it bothered…

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 was stored and prepared in a clean environment, failed to ensure food items were dated and labeled as to the day they were opened, and failed to discard expired food items. This involved all 78 residents in the facility who received food from the kitchen. Findings include: 1. Observation on 02/18/20 at 8:40 A.M. during the initial tour of the kitchen with [NAME] #93 revealed [NAME] #93 was standing at the prep table with a cell phone in her hand which she placed in her pocket when surveyor entered the kitchen. A cell phone was sitting on the corner of the prep table. The dry storage had a plastic bag of hamburger buns with no expiration date which had been ripped open exposing the buns to air. The dry storage had an open jug of liquid butter and an open jug of hot sauce which had not been dated upon opening. The walk-in refrigerator had two pitchers of orange juice, one pitcher of milk, one pitcher of fruit punch, two pitchers of apple juice, none of which were dated or labeled.…

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 upon record review, observation, staff interview, and review of facility policy, the facility failed to provide a dignified resident dining experience. This affected one (Resident #56) of 18 residents sampled. The census was 78. Findings include: Review of the medical record for Resident #56 revealed an admission date of 01/09/20. Diagnoses included hemiplegia and hemiparesis following cerebrovascular disease, cerebral palsy, and Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment, dated 02/05/20, revealed Resident #56 was cognitively impaired and required extensive assistance of one staff with eating. Observation on 02/18/20 at 12:47 P.M. revealed State Tested Nursing Assistant (STNA) #30 fed Resident #56 his lunch meal in his room with the door open. Resident #56 was sitting up in bed, and STNA #30 was standing over resident while feeding him. Interview on 02/18/20 at 12:59 P.M. with STNA #30 confirmed she stood over Resident #56 for the entirety of the lunch meal while feeding resident. STNA #30 further confirmed she stood for the entire meal because it was…

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

Based upon record review, staff interview, and review of facility policy, the facility failed to accurately document the code status for one (Resident #56) of 18 residents sampled. The census was 78. Findings include: Review of the medical record for Resident #56 revealed an admission date of 01/09/20. Diagnoses included hemiplegia and hemiparesis following cerebrovascular disease, cerebral palsy, and Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment, dated 02/05/20, revealed Resident #56 was cognitively impaired. Review of the medical record for Resident #56 revealed a form signed by the resident's attending physician indicating resident's code status was Do Not Resuscitate Comfort Care (DNRCC)-Arrest. Review of dashboard of the electronic medical record (EMR) for Resident #56 revealed resident's code status was listed as DNRCC. Review of the current physician orders in the EMR for Resident #56 revealed resident's code status was listed as DNRCC. Interview on 02/19/20 at 9:15 A.M. with Registered Nurse (RN) #22 confirmed Resident #56's correct code status was…

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

Based upon record review, observation, resident interview, and staff interview, the facility failed to maintain a homelike environment by storing wheelchairs and geri chairs in the room of one (#5) of 18 residents sampled. The census was 78. Findings include: Review of the medical record for Resident #5 revealed an admission date of 05/12/18. Diagnoses included hemiplegia and vascular dementia with behavioral disturbance. Review of the Minimum Data Set (MDS) for Resident #5 dated 02/05/20 revealed resident was cognitively impaired, required extensive assistance with activities of daily living, and used a wheelchair for mobility. Observation on 02/18/20 at 10:00 A.M. of Resident #5's room revealed two wheelchairs in the room to the left of his bed and a geri chair in front of the bathroom door. Observation on 02/18/20 at 12:57 P.M. of Resident #5's room revealed two wheelchairs in the room to the left of his bed and a geri chair in front of the bathroom door. Interview on 02/18/20 at 12:59 P.M. with Resident #5 confirmed one of the two wheelchairs in his room belonged to him, but 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 record review, observation, resident interview, and staff interview, the facility failed to ensure a Wander Guard restraining device was not used in the absence of wandering behaviors for one (#45) of two residents reviewed for restraints. The facility census was 78. Findings include: Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included altered mental status, legionella pneumonia, schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, hypertension, and anemia, Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/12/2020, revealed Resident #45 was cognitively intact. The resident required supervision and set up only for bed mobility, transfers, dressing, toileting, personal hygiene and bathing. Resident #45 was independent in eating and required supervision only for toileting. Review of the elopement risk assessment, dated 06/29/19, identified Resident #45 as a low risk 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 upon record review, observation, and staff interview, the facility failed to accurately code the presence of side rail usage on the bed of one (#38) of two residents reviewed for restraints. The census was 78. Findings include: Review of the medical record for Resident #36 revealed an admission date of 01/16/19 with a diagnosis of Alzheimer's disease. Review of hospice admission orders dated 09/12/19, revealed Resident #36 was admitted to hospice with a diagnosis of end stage Alzheimer's disease and an order for the hospice company to provide a bed with bilateral half side rails for the resident. Review of the Minimum Data Set (MDS) assessment, dated 12/17/19, revealed Resident #36 was cognitively impaired and required extensive assistance of two staff with bed mobility. Section P for the presence of side rails was coded as not used. Observation on 02/18/20 at 1:07 P.M. of Resident #36's bed revealed it had bilateral half side rails to the upper half of his bed. The bed had a sticker to the frame indicating it was the property of the hospice company. Interview on 02/19/20 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 record review, resident interview, and staff interview the facility failed to develop a plan to reflect the discharge goals for one (#45) of two residents reviewed for discharge. The facility census was 78. Findings include: Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included altered mental status, legionella pneumonia, schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, hypertension, and anemia, Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/12/2020, revealed Resident #45 was cognitively intact. The resident required supervision and set up only for bed mobility, transfers, dressing, toileting, personal hygiene and bathing. Resident #45 was independent in eating and required supervision only for toileting. Under section Q0500B does the resident desire to talk to someone about the possibility of leaving the facility and returning to the community to live it was coded…

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 facility policy, the facility failed to assess the need for the use of bilateral half side rails on the bed of one (Resident #38) of two residents reviewed for restraints. The census was 78. Findings include: Review of the medical record for Resident #38 revealed and admission date of 01/16/19 with a diagnosis of Alzheimer's disease. Review of side rail assessment for Resident #38 dated 01/16/19 revealed resident did not use side rails and resident had not expressed a desire to have side rails on his bed. Review of hospice admission orders for Resident #38 dated 09/12/19 revealed the resident was admitted to hospice with a diagnosis of end stage Alzheimer's disease and an order for the hospice company to provide a bed with bilateral half side rails for the resident. Review of the Minimum Data Set (MDS) assessment for Resident #38 dated 12/17/19 revealed resident was cognitively impaired and required extensive assistance of two staff with bed mobility. The MDS failed to code the presence 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.

Based on record review, staff interview, and review of the facility policy, the facility failed to attempt gradual dose reduction (GDR) or document clinical contraindications to GDR for an antipsychotic medication, and failed to document behaviors necessitating the need for the use of an antipsychotic medication for one (Resident #5) of six residents reviewed for unnecessary medications. The census was 78. Findings include: Review of the medical record for Resident #5 revealed an admission date of 05/12/18 with a diagnosis of vascular dementia with behavioral disturbance. Review of the physician orders for Resident #5 revealed an order dated 07/06/18 for the antipsychotic Seroquel 25 milligrams (mg) to be administered twice daily for treatment of vascular dementia with behavioral disturbance. Review of the Minimum Data Set (MDS) assessments dated 02/15/19, 05/21/19, 08/12/19, 11/06/19, and 02/05/20 revealed Resident #5 was cognitively impaired, had received an antipsychotic medication for seven days during the reference period, no dosage reduction of the antipsychotic 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, observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure respiratory equipment was cleaned for one (Resident #38) of two residents reviewed for respiratory care. The census was 78. Findings include: Review of the medical record for Resident #38 revealed and admission date of 01/16/19 with a diagnosis of Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment, dated 12/17/19, revealed Resident #38 was cognitively impaired and required extensive assistance of two staff with activities of daily living. Review of the physician orders for Resident #38 revealed an order dated 01/21/19 for resident to have a continuous positive airway pressure (CPAP) applied every night. Review of physician orders for Resident #38 revealed an order dated 02/19/20 for resident's CPAP tubing mask to be cleaned every week on Wednesday. Review of Medication Administration Record (MAR) for January 2020 and February 2020 revealed there was no documentation of cleaning of resident's CPAP mask until 02/19/20. Observation 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.