Kenwood Terrace Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, and medical record review, the facility failed to ensure residents were provided with prompt and appropriate dental services upon the discovery of a resident with missing dentures. This affected one (#62) of six residents reviewed for personal property. The facility census was 82. Findings include: Review of Resident #62's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizoaffective bipolar disorder, depression, dysphagia, extrapyramidal and movement disorder, cognitive communication disorder, difficult ambulation, muscle weakness, dementia, gastro-esophageal reflux disease, and hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 had minimal cognitive impairments with no behavior symptoms. Review of Resident #62's medical record contained no item inventory list upon admission to determine if the resident had full set of dentures upon arrival 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interview, observation, record review, and policy review, the facility failed to develop comprehensive care plans for pain management to include indwelling medical devices. This affected one (Resident #69) of ten residents reviewed for care plans. The facility census was 87. Findings include: Review of the medical record revealed Resident #69 was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, chronic kidney disease, obesity, and non-pressure chronic ulcer of the let hell and mid-foot. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #69 was cognitively intact, had no behaviors, did not reject care, and did not wander. Review of the hospitals' After Visit Summary dated 05/21/24 revealed Resident #69 had a Past Surgical History including thoracic laminectomy with paddle lead and rechargeable battery in left hip performed 03/14/22. Review of the care plan dated 05/09/24 revealed Resident #69 had complaints…

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, medical record review, and policy review, the facility failed to ensure medications were stored in appropriate containers in the medication cart. This had the potential to affect three (Residents #59, #61, and #62) of three residents prescribed iron on the 500-Hall. The facility census was 87. Findings include: Review of the medical record revealed Resident #59 had physician orders for ferrous sulfate 325 milligrams (mg) by mouth twice daily with meals for anemia. Review of the medical record revealed Resident #61 had physician orders for ferrous sulfate 325 mg by mouth in the morning with breakfast for anemia. Review of the medical record revealed Resident #62 had physician orders for ferrous sulfate 325 mg by mouth once daily with breakfast for anemia. Observation on 11/18/2024 at 10:17 A.M. revealed the 500-Hall medication cart had an unlabeled plastic medication cup containing multiple green round tablets. During an interview on 11/18/24 at 10:17 A.M., Licensed Practical Nurse (LPN) #162 verified the cup full of green pills she identified…

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

Based on observation, staff interview, and policy review, the facility failed to ensure staff prepared food in a sanitary manner. This affected one (Resident #3) of one resident reviewed during tray line service. The facility census was 87. Findings include: Observation on 11/18/24 at 12:32 P.M. revealed Dietary Manager #142 touched two hamburger buns with bare hands during lunch meal preparation. During an interview on 11/18/24 at 12:55 P.M., Dietary Manager #142 verified she had used her bare hands to open hamburger buns while preparing Resident #3's lunch tray. Dietary Manager #142 acknowledged she was not supposed to touch food with her bare hands. Review of the policy titled Food Preparation dated 09/2017 revealed all staff used serving utensils appropriately to prevent cross contamination. This was an incidental finding discovered during the course of the complaint investigation.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, medical record review, and policy review, the facility failed to implement appropriate infection prevention procedures during medication administration. This affected two (Residents #63 and #79) of five residents reviewed for medication administration. The facility census was 87. Findings include: 1. Review of the medical record revealed Resident #79 was admitted to the facility on [DATE]. Diagnoses included major depressive disorder and mixed hyperlipidemia. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Resident #79 had physician's orders for routine morning medications including Amlodipine (treats high blood pressure) 10 milligrams (mg) by mouth once daily and Galantamine (treats dementia) eight mg by mouth once daily. Observation of medication administration on 11/18/24 at 9:36 A.M. revealed while preparing medications 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to notify residents of Medicaid account balances. This affected three residents (#28, #29 and #61) out of three residents reviewed for notification of Medicaid account balances. The facility census was 94. Findings include: 1. Review of the medical record revealed Resident #28 was admitted on [DATE] with diagnoses of schizoaffective disorder, alcohol use, unspecified psychosis, diabetes mellitus type II and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #28 had intact cognition. Review of the Resident Fund Management Service (RFMS) Trial Balance report dated 10/03/24 revealed Resident #28 had a balance of $27,554.84. The current Supplemental Security Income (SSI) resource limit is $2,000.00. Interview on 10/03/24 at 2:20 P.M. with Resident #28 revealed he had not received a notification letter from the facility of being within $200 of the Social Security…

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, interview and policy review, the facility failed to properly investigate grievances and provide a summary of the findings to the resident or resident representative. This affected two residents (#55 and #8601) out of three residents reviewed for grievances. The facility census was 94. Findings include: 1. Review of the medical record revealed Resident #55 was admitted on [DATE] with diagnoses of schizoaffective disorder, depression, anxiety, diabetes mellitus type II, morbid obesity, chronic obstructive pulmonary disease and tracheostomy. Review of the Minimum Data Set (MDS) significant change assessment dated [DATE] revealed Resident #55 had moderate cognitive impairment and was always incontinent of bowel and bladder. The resident required set- up assistance with eating and oral hygiene, maximal assistance with bed mobility and was dependent for toileting, bathing, dressing, personal hygiene and transfers. Review of grievances/concerns revealed a concern was initiated on 09/30/24 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, interviews and policy review, the facility failed to ensure medications were securely stored. This affected three (#56, #24 and #54) residents of three reviewed for medication storage. The facility census was 86. Findings include: Medical record review for Resident #56 revealed an admission date of 06/01/23 with diagnoses including but not limited to schizoaffective disorder, major depression, personality and behavioral disorder due to known physiological condition. Review of the quarterly MDS dated [DATE] revealed an intact cognition. Resident #56 requires supervision for eating, toileting, bed mobility and transfers. Review of the plan of care for Resident #56 dated 12/08/22 revealed resident uses psychotropic medication for diagnoses of schizophrenia. Interventions include aims testing, pharmacy consults, monitoring of adverse side effects, and consistent daily routines when possible. Review of the active physician orders for Resident #56 for July 2024 revealed an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and staff interviews, the facility failed to accommodate resident food preferences. This affected one (#30) out of three residents reviewed for food preferences. The census was 89. Findings include: Review of the medical record for Resident #30 revealed he was admitted to the facility on [DATE]. Diagnoses included mild persistent asthma with acute exacerbation, congestive heart failure, hypertension, chronic viral hepatitis c, acute respiratory failure with hypoxia, gout, type two diabetes mellitus with other specified complication, hypokalemia, vitamin d deficiency, hypertensive urgency, chronic pain syndrome, major depressive disorder, and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 02/20/24, revealed Resident #30 had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require setup assistance for eating and oral hygiene, and moderate assistance 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and resident interview, and policy review, the facility failed to ensure physician orders were followed correctly. This affected one (#17) out of three residents reviewed for medications. The facility census was 100. Findings included: Review of the medical record for Resident #17 revealed an admission date of 05/19/23. Diagnoses included cerebrovascular attack (CVA/stroke) with hemiplegia affecting left dominant side, renal insufficiency, and non-Alzheimer's dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #17, revealed the resident was cognitively intact. Her functional status was impairment of her upper and lower extremities, and she was independent for activities of daily living (ADLs). Review of the physician's orders dated 10/13/23 for Resident #17 revealed the resident ordered to have Metro Vaginal Gel one tube applied intravaginally at bedtime for bacterial vaginitis times six days. Review of the Medication Administration…

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 and resident interviews, the facility failed to ensure their pharmacy services provided resident's medication in a timely manner. This affected one (#17) out of three residents reviewed for medication administration. The census was 100. Findings included: Review of the medical record for Resident #17 revealed an admission date of 05/19/23. Diagnoses included cerebrovascular attack (CVA/stroke) with hemiplegia affecting left dominant side, renal insufficiency, and non-Alzheimer's dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #17, revealed the resident was cognitively intact. Her functional status was impairment of her upper and lower extremities, and she was independent for activities of daily living (ADLs). Review of the physician's orders dated 10/13/23 for Resident #17 revealed the resident ordered to have Metro Vaginal Gel one tube applied intravaginally at bedtime for bacterial vaginitis times six days. 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.

Based on record review, resident and staff interviews, the facility failed to ensure residents who were unable to carry out activities of daily living, received the necessary services to perform them when Resident #4 did not receive showers twice a week. This affected one (Resident #4) of three residents reviewed for showers. The facility census was 86. Findings include: Record review of Resident #4 revealed an admission date of 05/19/23 with pertinent diagnoses of: hemiplegia, muscle weakness, need for assistance with personal care, history of malignant neoplasm of kidney, hypertension, chronic kidney disease stage three, chronic pain syndrome, osteoarthritis of left and right knee, pan due to internal orthopedic prosthetic devices, visual disturbance, hyperlipidemia, vascular dementia, acquired absence of kidney, pulmonary embolism, diverticulosis of the large intestine, and gastroesophagel reflux disease. Review of the 07/18/23 quarterly Minimum Data Set (MDS) assessment revealed the resident was cognitively intact and required total dependence for transfer, toilet use, 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 record review the facility failed to ensure med error rate was less than 5% when Resident #55 and Resident #53 did not receive their medications as ordered. This affected two (Resident #53, and #55) of four residents reviewed for medication administration. There was 29 opportunities for error with five errors for a 17.24% error rate. The facility census was 86. Findings include: 1. Record review of Resident #53 revealed an admission date of 07/08/21 with pertinent diagnoses of: unstable angina, chronic obstructive pulmonary disease, type two diabetes mellitus, chronic kidney disease, depression, hypertension, and heart failure. Review of a physicians order dated 10/03/23 revealed dapagliflozin propanediol tablet 10 milligram (mg)s give 10 mg by mouth in the morning for diabetes. Observation of a medication pass for Resident #53 on 10/19/23 at 9:30 A.M. revealed Licensed Practical Nurse (LPN) #10 passing medications including amlodipine 10 mgs, aspirin 81 milligrams, coreg 25 mgs, eliquis 5 mgs, lasix 20 mgs, pantoprazole 40 mgs, pravastatin…

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, manufactures directions, and record review the facility failed to ensure they were free from significant medication errors when the nurse did not prime the insulin pen prior to administering the dosage to Resident #34. This affected one (Resident #34) of four residents reviewed for medication administration. The facility census was 86. Findings include: Record review of Resident #34 revealed an admission date of 11/12/22 with pertinent diagnoses of: encounter for orthopedic aftercare, diabetes mellitus, end stage renal disease, hypertension, and heart failure. Review of the medical record revealed a physician order dated 08/30/23 for humalog sliding scale subcutaneously before meals and at bedtime for diabetes mellitus. Give 150-199 =2 units, 200-249= 4 units, 250-299= 6 units, 300-349= 8 units. Observation on 10/23/23 at 11:45 A.M. revealed Licensed Practical Nurse (LPN) #20 administering humalog Kwikpen insulin 6 units for Resident #34 blood sugar of 280. LPN #20 did not prime the insulin pen with two units prior to administering the insulin.…

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 store medications appropriately when Resident #47 had medications in her room and Resident #55 had medications and multiple eye drops in her room. This affected two (Resident #47 and #55) of four reviewed for medication administration. The facility census was 86. Findings include: 1. Record review of Resident # 47 revealed an admission date of 10/09/23 with pertinent diagnoses of: chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, malignant neoplasm, cerebral edema, atrial fibrillation, depression, and hypertension. Observation on 10/19/23 at 8:57 A.M. revealed there was a pill cup on her bedside table with three medications inside. Interview with Licensed Practical Nurse (LPN) #15 on 10/19/23 at 9:00 A.M. verified the pills were Keppra (seizure medication) 500 milligrams (mgs) , eliquis (blood thinner) 5 mg, and depakote (seizure medication) 125 mgs, in the medicine cup on Resident #47 bedside table. LPN #15 stated the pills must of been given on another shift but not taken by…

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

Based on observation, staff interview, blood glucose machine reference manual, and record review the facility failed to failed to follow infection control procedures when they did not appropriately clean the blood glucose machine after use for Resident #34. This affected one (Resident #34) of four residents reviewed for medication administration. The facility identified five residents (Resident #1, #34, #46, #63, and #70) on the 600 hallway with blood sugar checks. The facility census was 86. Findings include: Record review of Resident #34 revealed an admission date of 11/12/22 with pertinent diagnoses of: encounter for orthopedic aftercare, diabetes mellitus, end stage renal disease, hypertension, and heart failure. Observation on 10/23/23 at 11:40 A.M. revealed Licensed Practical Nurse (LPN) #20 checking the blood sugar of Resident #34 and it was 280 deciliter (d/L). LPN #20 went and administered the insulin and cleaned the glucometer with an alcohol pad. LPN #30 stated that was the proper way to clean it and verified there was no bleach wipes in the cart to appropriately clean…

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 the facility's policy, the facility failed to maintain a sanitary kitchen and acceptable food storage practices. This had the potential to affect 67 residents who received food from the kitchen. The facility census was 68. Findings include: Tour of kitchen on 04/25/22 at 6:35 P.M. revealed in the walk-in refrigerator, there was meat in a container, and vegetables in a container unlabeled and dated 04/03/22. There were tomatoes in a box with gray furry substance with the box dated 02/24/22. In the walk-in refrigerator and in the under counter refrigerator, there were nine unopened and one open half gallon carton of lactose free milk with expiration date of 04/20/22. There were 10 unlabeled and undated individual portioned wrapped pieces of meat in the undercounter refrigerator. Interview on 04/25/22 at 6:40 P.M. with [NAME] #230 verified the food should have been labeled and dated and expired food should have discarded. Observation on 04/26/22 at 12:30 P.M. with Dietary Manager #610 revealed Unit 400 clean utility room's ice…

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, and resident and staff interviews, the facility failed to provide a safe, clean comfortable and homelike environment. This affected four (Residents #2, #12, #21, and #52) of 18 residents reviewed for a homelike environment. The facility census was 68. Findings include: Interview and observation on 04/25/22 at 7:29 P.M. with Resident #2 reported there was a dark brown/black mold looking substance at the bottom of her toilet on the floor and her closet door was broken. Observations revealed Resident #2's closet door was broken and the bottom of the toilet had black looking substance around the base of toilet. Resident #2 stated the closet door and has been in disrepair for a long time. Interview and observations on 04/25/22 at 7:40 P.M. revealed Resident #52's bathroom light makes loud noises when turned on. The bathroom was positioned in front of his bed. Resident #52 reported the sound becomes a problem when his roommate gets up in the middle of the night and turns on the light. Resident #52 stated the issue has been reported. Observation and interview 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 record review, observation, resident interview, staff interview, and review of the facility's policy, the facility failed to offer a resident a choice in method of bathing. This affected three (Residents #2, #47, and #419) of three residents reviewed for choices. The facility identified 65 residents who required staff assistance or were dependent on staff with bathing. The facility census was 68. Findings include: 1. Review of the medical record for Resident #47 revealed an admission date of 12/09/21 with a diagnosis of paraplegia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was cognitively intact, was coded negative for behavioral symptoms including refusal of care and was totally dependent on the assistance of staff with bathing. Review of the MDS assessment section F, dated 12/15/21, revealed Resident #47 considered it somewhat important to be able to choose between a tub bath, shower, bed bath, or sponge bath. Review of the care plan dated 01/28/22 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 record review and staff interview, the facility failed to ensure the residents were informed in writing of being cut from Medicare services. This affected two (Residents #117 and #118) of three residents reviewed for beneficiary notice. The facility census was 68. Findings include: A review for beneficiary notices for Resident #117 and Resident #118, who were identified as residents discharged from a Medicare covered Part A stay with benefit days remaining, was conducted. Resident #117 was discharged on 02/12/22 and Resident #118 was discharged on 03/07/22. They did not receive a beneficiary notice regarding being cut from Medicare services. An interview was conducted with the Business Office Manager #820 on 04/28/22 at 12:55 P.M. She verified there were no cut letters provided for Residents #117 and #118.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure the residents who discharged to the hospital received a transfer/discharge notice. This affected two (Residents #8 and #68) of two residents reviewed for hospitalization. The facility census was 68. Findings include: 1. Review of Resident #8's medical record revealed Resident #8 was admitted to the facility on [DATE]. Diagnoses included end stage renal disease and vascular dementia without behavioral disturbance. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had moderate cognitive impairment. Review of the medical record revealed on 03/31/22, Resident #8 was sent to the emergency room for treatment and evaluation after indicating he was not feeling well. He was admitted to the hospital for a pacer placement. There was no evidence Resident #8's legal guardian was notified in writing of Resident #8's transfer to the hospital. 2. Review of Resident #68's medical record revealed Resident #68 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, family interview, and staff interview, the facility failed to ensure a care conference was provided for the residents and/or family member. This affected two (Residents #12 and #51) of three residents reviewed for care planning. The facility census was 68. Findings include: 1. Review of Resident #51's medical record revealed Resident #51 was admitted to the facility on [DATE]. Her diagnoses included heart failure, dementia with behavioral disturbance, major depressive disorder severe with psychotic symptoms, anxiety disorder, hypertension, primary generalized osteoarthritis, major depressive disorder, peripheral vascular disease, dysphagia, hypertensive retinopathy, hyperlipidemia, anemia, dysthymic disorder, scoliosis, Alzheimer's disease, dementia without behavioral disturbance, urge incontinence, open angle with borderline findings, history of falling, cardiomegaly, psychosis, age-related osteoporosis, muscle weakness, mild intellectual disabilities, hypokalemia, and insomnia. 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 staff interviews, medical record review, review of the hospice contract, and review of the facility's policy, the facility failed to coordinate hospice services with the facility for Resident #14. This affected one (#14) of one resident reviewed for hospice services. The facility identified five residents receiving hospice care. The facility census was 68. Findings include: Review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #14 included congestive heart failure, chronic kidney disease, and chronic embolism. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had impaired cognition. Review of the physician orders dated 01/13/22 revealed Resident #14 had a new physician order for hospice services. Review of the plan of care, dated 01/20/22, revealed Resident #14 was identified to receive hospice services. The interventions included to coordinate facility care with the hospice provider. Review 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, observation, staff interview, review of the facility's policy, and review of a professional wound care resource, the facility failed to ensure preventative devices were in place to prevent further skin breakdown as ordered by the physician. This affected one (Resident #15) of nine facility-identified residents with pressure ulcers. The facility census was 68. Findings include: Review of the medical record for Resident #15 revealed an admission date of 10/08/21 with a diagnosis of cerebral infarction. Review of the physician orders dated 10/08/21 revealed an order for Resident #15 to have Sage boots (heel protectors) on at all times as tolerated. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was severely cognitively impaired and required extensive assistance of one to two staff with activities of daily living (ADLs.) Review of the care plan, last updated on 01/22/22, revealed Resident #15 had impaired skin integrity and had been admitted with pressure…

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, staff interview, and review of the facility's policy, the facility failed to implement treatment measures and devices to prevent and minimize the risk of further contractures. This affected one (Resident #15) of two residents reviewed for contractures. The facility identified five residents with contractures. The facility census was 68. Findings include: Review of the medical record for Resident #15 revealed an admission date of 10/08/21 with a diagnosis of cerebral infarction. Review of the admission Minimum Data Set (MDS) assessment, section V, dated 09/26/21 revealed Resident #15 had a activity of daily livings (ADL) functional rehabilitation potential and had contractures. Review of the MDS assessment dated [DATE] revealed Resident #15 was severely cognitively impaired, required extensive assistance of one to two staff with ADLs, and had functional impairment on both sides to his upper and lower extremities on both sides. Review of the physical therapy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility's policy, staff interview, and record review, the facility failed to provide tube feeding equipment required for tube feeding administration for Resident #366 upon admission. This resulted in Resident #366's hospitalization. This affected one (Resident #366) of one resident reviewed for tube feeding administration. The facility identified two residents who receive tube feeding. The facility census was 68. Findings include: Review of Resident #366's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included encephalopathy, Crohn disease, and protein calorie malnutrition. Review of the Minimum Data Set (MDS) assessment, dated 04/17/22, revealed Resident #366 had impaired cognition. Review of the hospital discharge physician orders, dated 04/17/22, revealed Resident #366 had orders for continuous tube feeding from the hospital. Review of nurse's notes dated 04/17/22 at 6:33 P.M. revealed Resident #366 was admitted to the facility. On 04/17/22 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 observation, staff interview, review of the facility's policy, and record review, the facility failed to date oxygen tubing per physician orders for Resident #48. This affected one (#48) of nine residents reviewed for oxygen administration. The facility identified 15 residents receiving respiratory treatments. The facility census was 68. Findings include: Review of Resident #48's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cerebrovascular disease and bradycardia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 had impaired cognition. Review of the physician orders revealed Resident #48 required oxygen as needed via nasal cannula to maintain saturation greater than 90% and to change out oxygen tubing and cannula and label with date and initials every night shift every Sunday. Observation on 04/26/22 at 11:39 A.M. of Resident #48's oxygen concentration at bedside revealed the oxygen tubing was dated 03/14/22.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interview, observation, and review of the facility's policy, the facility failed to maintain a physician-ordered fluid restriction for a resident dependent on hemodialysis. This affected one (Resident #59) of one resident reviewed for dialysis. The facility-identified one resident (#59) who was dialysis with a fluid restriction. The facility census was 68. Findings include: Review of the medical record for Resident #59 revealed an admission date of 03/12/22 with a diagnosis of end stage renal disease (ESRD.) Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADLs). Review of the dietary progress note for Resident #59 dated 03/30/22 revealed dialysis clinic recommended a fluid restrictions for Resident #59 of 1,500 milliliters (ml) per day. The registered dietitian (RD) notified the nurse practitioner (NP), Director of Nursing (DON) 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, staff interview, and review of the facility's policy, the facility failed to implement an appropriate stop date for as needed anti-anxiety medication and failed to offer non-pharmacological medications prior to administration of as needed anti-anxiety medications. This affected one (Resident #64) of five residents reviewed for unnecessary medications. The facility identified eight residents with orders for anti-anxiety medications. The facility census was 68. Findings include: Review of the medical record for Resident #64 revealed an admission date of 03/16/22 with diagnoses including fracture of the femur, dementia, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 was cognitively impaired and required extensive assistance of one staff with activities of daily living. Review of the care plan dated 03/23/22 revealed Resident #64 received anti-anxiety medication and could become restless and anxious when alone. Interventions included…

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 the medical record, and staff interviews, the facility failed to ensure residents received liquids according to their physician orders. This affected one (Resident #12) of four residents reviewed for nutrition. The facility identified two residents on thickened liquids. The facility census was 68. Findings include: Review of the medical record for Resident #12 revealed an admission date of 10/29/20. Diagnoses included Barrette's esophagus without dysplasia, dysphagia oropharyngeal phase, and vascular dementia with behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/14/22, revealed Resident #12 had severe cognitive impairment. Resident #12 required supervision with eating. Review of the physician orders, dated 04/21/22, revealed Resident #12's diet was to be downgraded to mechanical soft with nectar thickened liquids. Observation on 04/26/22 at 10:55 A.M. revealed Resident #12's breakfast meal tray was sitting on the bedside table. Resident #12's meal ticket read nectar thick. Resident #12's orange juice and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview, review of the facility's policy, and review of online resources per the Centers for Disease Control and Prevention (CDC), the facility failed to ensure staff wore facemasks covering their nose, mouth, and chin in resident areas and within close proximity to residents in order to help prevent the spread of Coronavirus (COVID-19). This affected two (Residents #47 and #64) of 68 residents in the facility. The facility census was 68. Findings include: 1. Review of the medical record for Resident #64 revealed an admission date of 03/16/22 with diagnoses including fracture of the femur, dementia, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADL). Observation on 04/25/22 at 6:15 P.M. revealed Receptionist #730 was seated at the front desk which was accessible to residents and greeted the survey team upon…

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, review of the planned menus approved by the Registered Dietitian (RD), and staff interview, the facility failed to follow the planned menus for pureed and mechanically soft diets. This had the potential to affect 13 of 13 residents on pureed or mechanically soft diets (#50, #5, #70, #75, #65, #13, #57, #20, #18, #76, #35, #133, and #62). The facility census was 78. Findings include: Food preparation and service for the evening meal on 04/02/19 was observed beginning at 4:00 P.M. with Dietary Manager (DM) #43. Dietary Staff (DS) #35 had prepared the evening meal and was getting ready to serve assemble resident meal trays. The steam table was set up and the food temperatures had been taken and all were in acceptable range. At 4:32 P.M. DS #35 started tray assembly and the portion sizes of each menu items being served was verified with DS #35. Observation of the mechanically soft food and pureed food revealed that DS #35 was serving a #10 scoop, or approximately three ounces, each of pureed polish sausage, pureed peas, and mechanically soft (chopped) polish…

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

Based on observation and staff interview the facility failed to ensure walls, floors, and ceilings were maintained in good condition. This affected 22 Residents (#3, #6, #11, #12, #17, #18, #19, #20, #26, #32, #35, #36, #42, #44, #45, #52, #57, #63, #64, #66, #68, #73) residing on the 300 hall. The facility census was 78. Findings include: Observation on 04/01/19 from 11:58 A.M. to 12:12 P.M. of the 300 unit revealed the bottom of Resident #52's bathroom wall, in front of the toilet, was crumbling onto the floor. An approximate one foot piece of baseboard had detached from the wall and was on the floor next to the toilet. There was a large brown water stain to Residents #18 and #19's bathroom ceiling. The carpet throughout the 300 hall had numerous black stains and brown discoloration from high traffic. The hallways did not have any baseboards and had deep scrapes on the bottom two inches of the surrounding hall walls. In the common area, directly in front of the television, a light fixture had been removed leaving a hole in the ceiling. Surrounding the hole was a large water stain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and records review, the facility failed to obtain resident or Power of Attorney signatures to manage resident funds. This affected three (#29, #40 and #138) of six residents reviewed. The facility identified 47 residents whose funds are managed by the facility. The census was 78. Findings include: During review of the records for resident funds there was no signed authorization for Resident #29, Resident #40 and Resident #138. Two residents (Resident #29 and Resident #40) currently had funds in accounts being managed by the facility. Resident #138 was deceased and the facility was in the process of disbursing her funds. During an interview with the Administrator on [DATE] at 2:50 P.M., she verified there were no signed authorizations for these residents and stated she was not sure why signatures were missing.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of a facility Self-Reported Incident (SRI), staff, resident, and detective interviews and police review, the facility failed to ensure that each resident's physician was notified when a significant change occurred in their physical status. This involved one (#40) of five residents reviewed for abuse and neglect. The facility census was 78. Findings include: Resident #40 was admitted to the facility on [DATE], and recently readmitted from the hospital on [DATE]. Diagnoses include unspecified multiple injuries, unspecified fracture of lower end of right femur, initial encounter for closed fracture, pain in left leg, pain in right leg, unsteadiness on feet, atherosclerotic heard disease, atrial fibrillation, hypertension, osteoarthritis, and vascular dementia without behavioral disturbance. The facility completed a quarterly minimum data set assessment (MDS 3.0) of Resident #40's current physical and cognitive functional status dated 01/22/19. The facility identified 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 and policy review, the facility failed to ensure a resident that was discharged from Medicare Part A services was notified of the potential liability for payment. This affected one (#327) of three residents reviewed for beneficiary notices. The facility census was 78. Findings include: Record review of Resident #327's chart revealed resident was admitted to the facility on [DATE] with the following diagnoses: displaced intertrochanteric fracture of right femur, long term use of anticoagulants, essential primary hypertension, age related osteoporosis with current pathological fracture, history of falling, acute kidney failure, muscle weakness, dysphagia and chronic kidney disease. Further review of Resident #327's chart revealed resident discharged from the facility on 03/05/19. Review of Resident #327's chart revealed resident was admitted to Medicare Part A skilled services on 12/20/18 and had a last covered day of skilled services on 01/06/19. Further review 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 medical record review, observations, review of facility Self-Reported Incident (SRI)/investigations, staff, resident, and detective interviews and policy review, the facility staff failed to immediately report allegations of abuse, neglect, or mistreatment to the Administration. This affected two (#40 and #55) out of five residents reviewed for abuse and neglect. The facility census was 78. Findings include: 1. Review of Resident #40's medical record revealed the resident was admitted to the facility on [DATE], and recently readmitted from the hospital on [DATE]. Diagnoses include unspecified multiple injuries, unspecified fracture of lower end of right femur, initial encounter for closed fracture, pain in left leg, pain in right leg, unsteadiness on feet, atherosclerotic heart disease, atrial fibrillation, hypertension, osteoarthritis, and vascular dementia without behavioral disturbance. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 had good memory and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure a written notice including reasons for transfer/discharge and appeal rights was provided to the resident, resident's representative, and ombudsman prior to transfer/discharge. This affected two (#52 and #77) of two Residents reviewed for hospitalization. The facility census was 78. Findings include: 1. Medical record review revealed Resident #52 was admitted to the facility on [DATE] with a re-entry date of 06/04/18. Diagnosis included metabolic encephalopathy, chronic kidney disease, and dementia with behavioral disturbance. Review of significant change minimum data set (MDS) assessment dated [DATE] revealed moderately impaired cognitive skills for daily decision making and extensive assistance was required with bed mobility, transfers, eating, toileting, and personal hygiene. Further medical record review revealed Resident #52 was discharged to the hospital from [DATE] to 02/21/19. A written notice explaining reasons for transfer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and policy review, the facility failed to ensure a discharge Minimum Data Sets (MDS) assessments were transmitted to Centers for Medicare and Medicaid Services (CMS) system. This affected one (#2) out of one resident reviewed for resident assessment. The facility census was 78. Findings include: Record review revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses include wedge compression fracture of first vertebra, other abnormalities of gait and mobility, adult failure to thrive, muscle weakness, anxiety disorder, low back pain, hypertension, constipation and dementia with behavioral disturbance. Resident #2 discharged from the facility to the hospital on [DATE]. Review of Resident #2's discharge Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident to be cognitively impaired and require extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Resident #2 also required supervision with eating…

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.