Lakeridge Villa Health Care Center

Based on review of the menu, review of the substitution log, observation, staff interview, and policy review, the facility failed to ensure the menu was followed. This affected all 90 residents who received meals from the kitchen. Resident #13 received no food by mouth. The facility census was 91. Findings include: Review of the breakfast menu, dated 05/06/24, revealed residents on a regular diet were to be served six ounces of hot or cold cereal, a number sixteen scoop or two ounces of cheesy scrambled eggs, and one slice of toast. Residents on a mechanical diet were to be served six ounces of hot or cold cereal, a number sixteen scoop or two ounces of cheesy scrambled eggs, and one slice of toast. Residents on a pureed diet were to be served six ounces of pureed cereal, a number sixteen scoop or two ounces of pureed cheesy scrambled eggs, and a number sixteen scoop or two ounces of pureed toast. Review of the substitution log from 02/23/24 to 05/06/24 revealed English muffins as a substitution for toast was not on the substitution log. Observation of Dietary Manager (DM) #68…

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 the kitchen was maintained in a sanitary manner and the dishwasher had the appropriate level of chemicals in order to prevent foodborne illness. This had the potential to affect all 90 residents who received meals from the kitchen. Resident #13 received no food by mouth. The facility census was 91. Findings include: 1. Observation of the kitchen on 05/06/24 at 8:15 A.M. revealed there were food debris built up in the oil and on the edges of the fryer. There was also food debris on the fryer basket and a brown splatter on the side of the fryer. There was brown water on the floor of the kitchen on the opposite side of the steam table where food was served during tray line. Interview with Dietary Manager (DM) #68 on 05/06/24 at 8:15 A.M. verified there was food debris built up in the oil, food basket and on the edges of the fryer. DM #68 also confirmed there was brown splatter on the side of the fryer and brown water on the floor of the kitchen on the opposite side of the steam table where food 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 on observation, record review and staff interview, the facility failed to ensure food items were stored in a sanitary manner, the ice machine was kept in a sanitary manner and food items were held at the proper temperature. This affected all residents except Resident #9 that received no food by mouth. The facility census was 94. Findings include: Observation of the facility's ice machine located outside of the kitchen doors on 03/07/22 at 7:36 A.M. revealed there to be a brown and red substance on the white ledge on the inside of the ice machine. Further observation of the kitchen revealed [NAME] #347 took a paper towel and wiped the white ledge of the ice machine and the brown and red substance came off the inside of the ice machine and onto the paper towel. Interview with [NAME] #347 on 03/07/22 at 7:36 A.M. verified there was a brown and red substance on the inside of the ice machine. Observation of the kitchen on 03/08/22 at 4:45 P.M. revealed Dietary Manager #306 to take the temperature of the pureed soup on the tray line. The pureed soup was 120 degrees Fahrenheit (F).…

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 Centers for Disease Control and Prevention (CDC) guidance and review of the facility's policy, the facility failed to perform proper hand hygiene during a dressing change for a pressure ulcer. This affected one (Resident #23) of four facility-identified residents with pressure ulcers. The facility also failed to implement quarantine precautions for Resident #486 which had the potential to affect all of the residents residing in the facility. The facility also failed to ensure staff performed appropriate hand hygiene while serving the resident meals which affected seven residents (Resident #16, #30, #55, #57, #75, #83, and #536). The facility census was 94. Findings include: 1. Review of the medical record for Resident #23 revealed an admission date of 04/15/99 with diagnoses including multiple sclerosis (MS) and diabetes mellitus (DM). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively impaired and 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 review of the facility's policy, observation, record review and staff interview, the facility failed to residents were treated in a dignified manner. This affected three (#8, #35, and #50) of four residents reviewed for dignity. The facility census was 94. Findings include: 1. Review of the Resident #50's medical record revealed Resident #50 admitted to the facility on [DATE]. Diagnoses included aphasia, altered mental status, unspecified dementia without behavioral disturbance, chronic obstructive pulmonary disease, schizoaffective disorder, and major depressive disorder. Review of Resident #50's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Review of Resident #50's Medication Administration Record (MAR) for March 2022 revealed Resident #50 had a regular diet with mechanical soft texture and thickened liquids. Observations of Resident #50's room on 03/07/22 at 11:24 A.M. and on 03/08/22 at 3:45 P.M. revealed a sign on Resident #50's…

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

Based on observation, staff interview, resident interview, and review of facility policy and documents, the facility failed to ensure resident rooms and common areas on the second floor of the facility were clean and sanitary. This affected Residents #10, #23, #26, #55, #62, and #77. This had potential to affect all 44 residents who resided on the second floor. The facility census was 94. Findings include: Observation on 03/07/22 at 8:02 A.M. revealed the floors in the hallways and common areas on the second floor has visible debris, stains, and were sticky throughout. The trash receptacles in the dining area where residents were seated and awaiting breakfast were overflowing with waste which was spilling onto the floor. Interview on 03/07/22 at 8:02 A.M. with Licensed Practical Nurse (LPN) #353 confirmed the floors in the hallways and the dining area were dirty and needed to be cleaned and the trash was overflowing. LPN #353 confirmed she didn't think they had housekeeping staff over the weekend. Interview on 03/07/22 at 8:07 A.M. with Floor Technician (FT) #334 confirmed he worked…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility policy, and staff interview, the facility failed to ensure a resident's pharmacy recommendations were addressed in a timely manner. This affected five (#26, #40, #49, #53, and #71) of five residents reviewed for unnecessary medications. The facility census was 94. Findings include: 1. Review of the Resident #71's medical record revealed Resident #71 was admitted to the facility on [DATE] with diagnoses including vascular dementia without behavioral disturbance, major depressive disorder, and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 was cognitively intact. Review of Resident #71's pharmacy recommendation dated 01/08/22 revealed Resident #71 was on Buspirone 10 milligrams (mg) twice a day for depression and Sertraline 50 milligrams daily for depression. The pharmacy recommendation stated a dose evaluation was due per regulations and to please evaluate the continued need and consider a dose…

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, staff interviews, and review of the facility's policy, the facility failed to secure a medication room on the second floor. This had potential to affect all 44 residents who resided on the second floor. The facility also failed to ensure prescription medications were properly stored and labeled with dates. This affected eight residents (#23, #30, #40, #48, #51, #53, #58, and #77). The facility also failed to ensure medication carts were locked when unattended. This had the potential to affect all 50 residents who resided on the first floor. The facility censes was 94. Findings included: 1. During an observation of the second floor medication room on 03/07/22 at 8:00 A.M. with Licensed Practical Nurse (LPN) #353 revealed the door was unsecured. Further observation revealed a magnetic across the door lock assembly and paper stuffed in the door lock opening. Interview with Licensed Practical Nurse (LPN) #353 on 03/07/22 at 8:01 A.M. verified the medication door was unsecured. LPN #353 stated the door should always be secure and additionally stated the night shift…

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 provide drinks per resident preference. This affected four residents (Resident #25, #62, #85, and #536) of 93 residents who received drinks with meals. The facility census was 94. Findings: An observation of breakfast trays being passed on 03/07/22 at 8:30 A.M. revealed coffee was not being served. Resident #25 was observed at 8:35 A.M. requesting coffee and was told by State Tested Nurse Aide (STNA) #342 there was no coffee available. At 8:48 A.M., Resident #62 also requested coffee. During an interview on 03/09/22 at 8:39 A.M., STNA #342 reported she had asked the kitchen for coffee for the resident's breakfast and was told they had run out. An observation on 03/07/22 at 12:17 P.M., revealed Resident #85 asked an unidentified staff member for coffee. The unidentified staff member stated there was no coffee available for the residents to have with their lunch meal. An interview on 03/07/22 at 1:58 P.M. with Resident #536 confirmed coffee was not available with the breakfast and lunch meal, and he was upset because he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and review of the facility's policy, the failed to ensure when a resident formulated an advanced directive, the resident's advanced directive was accurately recorded in all locations of the medical record to ensure the resident's wishes would be followed as directed in the event of an emergency. This affected three (Residents #26, #40 and #489) of 18 residents reviewed for advance directives. The facility census was 94. Findings include: 1. Review of the medical record for the Resident #26 revealed an admission date of 12/08/20. Diagnoses included Parkinson's disease, bradycardia, congestive heart failure, cardiomyopathy, atherosclerotic heart disease (ASHD), acute kidney disease, dementia, psychosis, hemiplegia, cardiomyopathy, contracture of left hand, cardiac implants, mental disorder, and moderate protein calorie malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was cognitively intact. Review of the plan of care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of the facility's policy, the facility failed to ensure staff notified the resident's representative of seizure activity and the resident's transfer to the hospital. This affected one (Resident #49) of three residents reviewed for notification of change in condition. The facility census was 94. Findings include: Review of the medical record for Resident #49 revealed an admission date of 07/20/21 with a diagnosis of seizure disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADLs). Review of the face sheet for Resident #49 revealed Resident #49 had a family representative who was designated as her emergency contact. Review of the nursing progress note for Resident #49 dated 01/22/22 revealed Resident #49 had a seizure starting at 5:28 P.M. Resident #49 was sitting in her wheelchair and the nurse called 911 and Resident…

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

Based on medical record review, staff interview, and policy review, the facility failed to ensure an admission Minimum Data Set (MDS) assessment was completed within 14 days of admission. This affected three (#486, #487, and #489) of four residents reviewed for new admission to the facility. Findings include: 1. Review of the medical record for Resident #486 revealed an admission date of 02/24/22. Diagnoses included hemiplegia affecting right dominant side, gastro-esophageal reflux disease without esophagitis, essential hypertension, hypothyroidism, and hyperlipidemia. Review of the medical record revealed an admission MDS assessment had not yet been completed. Interview on 03/10/22 at 11:48 A.M. with Assistant Regional Director of Clinical Operations (ARDCO) #400 verified Resident #486's MDS assessment was not completed by the fourteenth day following her admission. 2. Review of the medical record of Resident #487 revealed an admission date of 02/17/22. Diagnoses included partial traumatic amputation of right great toe, essential hypertension, anxiety, disorder, post-traumatic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, review of facility policy, resident interview, and staff interview, the facility failed to ensure the resident's who required assistance from staff received assistance with personal hygiene. The facility failed to ensure the resident's fingernails were trimmed and clean and ensure female residents did not have facial hair. This affected three (#23, #71, and #72) of three residents reviewed for activities of daily living (ADL). The facility identified 91 residents who require assistance with one or more ADL tasks. The facility census was 94. Findings include: 1. Review of the medical record of Resident #72 revealed an admission date of 06/14/19. Diagnoses included cerebral infarction due to unspecified occlusion or stenosis of right anterior cerebral artery, morbid obesity, left hand contracture, and chronic obstructive pulmonary disease (COPD). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 had intact cognition. 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, staff interview, and review of the facility's policy, the facility failed to ensure the staff changed the resident's peripherally inserted central catheter (PICC) line dressings as ordered by the attending physician. This affected one (Resident #487) of one facility-identified residents with PICC lines. The facility census was 94. Findings include: Review of the medical record for Resident #487 revealed an admission date of 02/17/22 with a diagnosis of osteomyelitis. Review of the admitting physician orders for Resident #487 revealed an order to change the dressing to resident's PICC line weekly and as needed. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) from 02/17/22 to 03/06/22 for Resident #487 revealed the dressing change to resident's PICC line was not documented as being completed. Observation on 03/07/22 at 11:24 A.M. of Resident #487 revealed resident had a PICC line to her right arm with a dressing…

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

Based on record review, observation, staff interview, and review of the facility's policy, the facility failed to provide dressing changes to a pressure ulcer as ordered by the physician. This affected one (Resident #9) of four facility-identified residents with pressure ulcers. The facility census was 94. Findings include: Review of the medical record for Resident #9 revealed an admission date of 03/30/21 with a diagnosis of cerebral infarction. Review of the Minimum Data Set (MDS) assessment, dated 02/18/22, revealed Resident #9 was cognitively impaired and was totally dependent on staff for activities of daily living (ADLs). Review of the wound physician note for Resident #9 dated 03/02/22 revealed the resident had an unstageable pressure ulcer (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar) to his right heel which measured 2.3 centimeters (cm) by 2.7 centimeters. Review of the physician orders for Resident #9 revealed an order dated 03/03/22 to cleanse the pressure ulcer to the right heel with normal saline or sterile water,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interviews, and review of the facility policy, the facility failed to conduct a thorough investigation of a resident's falls. The facility also failed to ensure a resident who was ordered bed rails, had the bed rails in place. This affected one (Resident #26) of two residents the facility identified as having bed rails ordered. This affected one (Resident #290) of five residents reviewed for accidents and falls. The facility census was 94. Findings include: 1. Review of the medical record for Resident #290 revealed an admission date of 03/03/22. Diagnoses included cerebral infarction. Review of the admission assessment for Resident #290 dated 03/03/22 revealed the resident was alert and oriented to person place and time with periods of confusion. Resident #290 required limited assistance of staff with activities of daily living (ADLs). Review of the fall risk assessment for Resident #290 dated 03/04/22 revealed resident was at high risk for falls. 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, observation, staff interview, and review of facility policy, the facility failed to ensure staff labeled and dated tube feeding solution and syringe used for tube feeding. This affected one (Resident #9) of four residents with tube feedings. The facility census was 94. Findings include: Review of the medical record for Resident #9 revealed an admission date of 03/30/21 with a diagnosis of cerebral infarction. Review of the tube feeding order for Resident #9 dated 12/04/21 revealed an order for Fiber Source 75 milliliters (ml) per hour continuous and flush with 150 ml of water every four hours. Observation on 03/07/22 at 1:41 P.M. of Resident #9 revealed a bag of tube feeding was infusing via tube feeding pump at 75 ml per hour and bag was not labeled regarding contents of tube feeding bag or date the tube feeding was hung. Further observation revealed the piston syringe used for medication administration via tube was at resident's bedside and was not dated when opened. Interview on 03/07/22 at 1:41 P.M. with Licensed Practical Nurse (LPN) #353 confirmed…

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

Based on medical record review, resident interview, staff interview, and policy review, the facility failed to ensure residents received medications as prescribed by the physician. This affected one (#486) of five resident reviewed for medications. The facility census was 94. Findings include: Review of the medical record for Resident #486 revealed an admission date of 02/24/22. Diagnoses included hemiplegia affecting right dominant side and gastro-esophageal reflux disease without esophagitis. Review of the Brief Interview for Mental Status (BIMS) score dated 02/25/22 revealed Resident #486 had intact cognition. Review of Resident #486 physician's orders, dated 03/04/22 at 5:55 A.M., revealed an order for Penicillin V Potassium tablet (antibiotic)-500 milligrams (mg) every six hours for infection for seven days. Review of the March 2022 medication administration record (MAR) revealed Resident #486 received the first dose of the antibiotic on 03/07/22 at 12:00 P.M. Interview on 03/07/22 at 8:19 A.M. with Resident #486 stated she obtained a script for an antibiotic for a tooth…

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 ensure the resident's received their medications without any significant medication errors. Resident #442 did not receive his anti-seizure medication, Vimpat and Resident #290 did not receive her MS Contin (a strong prescription paid medication). This affected one (Resident #442) of three facility identified residents with orders for Vimpat and one (Resident #290) of one facility-identified residents with orders for MS Contin. The facility census was 94. Findings include: 1. Review of the medical record for Resident #442 revealed an admission date of 02/28/22 with a diagnosis of encephalopathy and acute respiratory failure with hypoxia. Review of Minimum Data Set (MDS) assessment for Resident #442 dated 03/02/22 revealed the resident had a death in the facility. Review of the admitting orders for Resident #442 dated 02/28/22 revealed an order for the anti-seizure medication, Vimpat, to be administered twice daily…

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 facility policy, observation, record review, and resident and staff interview, the facility failed to ensure a resident received routine dental services. This affected one (#6) of two residents reviewed for dental care. The facility census was 94. Findings include: Review of Resident #6's medical record revealed Resident #6 admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, major depressive disorder, fibromyalgia, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively intact and Resident #6 required limited with personal hygiene. Resident #6 also required supervision with eating and Resident #6 had no mouth pain or difficulty chewing. Review of Resident #6's dental care plan dated 06/15/21 revealed Resident #6 had missing teeth and complained of trouble with chewing her food. Resident #6 would like her teeth pulled and to be fitted for dentures. Interventions included dental or oral exams…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, medical record review, and facility policy review, the facility failed to ensure the resident was provided the correct diet as ordered. This affected one (Resident #26) of the 10 residents who was ordered a puree diet. The facility census was 94. Findings include: Review of the medical record for Resident #26 revealed an admission date of 12/08/20. Diagnoses included Parkinson's disease, dementia, cerebral vascular accident (CVA/stroke) with hemiplegia, and moderate protein calorie malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was cognitively intact, had no behaviors, and did not reject care. Review of the plan of care for Resident #26 revealed the resident had a swallowing impairment, had potential for aspiration, choking, swallowing difficulties and the resident had an alteration in completing required activities of daily living (ADLs). Interventions included to provide ordered puree diet/honey thick liquids. 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.

Based on record review, staff interview, and review of the facility policy, the facility failed to ensure staff documented intravenous (IV) medications administered. This affected one (Resident #487) of 19 residents reviewed for medical record accuracy. The facility census was 94. Findings include: Review of the medical record for Resident #487 revealed an admission date of 02/17/22 with a diagnosis of osteomyelitis. Review of the admitting physician orders, dated 02/17/22, revealed an order for Resident #487 to receive the intravenous (IV) antibiotic Ertapenem once daily until 03/24/22. Review of the February and March Medication Administration Records (MARs) for Resident #487 revealed the following daily doses of Ertapenem were not documented as given on the four following dates: 02/21/22, 02/26/22, 03/03/22, and 03/04/22. Interview on 03/08/22 at 4:17 P.M. with the Assistant Regional Director of Clinical Operations (ARDCO) #600 confirmed the doses of IV antibiotic for Resident #487 for 02/21/22, 02/26/22, 03/03/22, and 03/04/22 doses were not documented as completed. ARDCO #600…

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 reviews, review of facility policy, observations, and staff interviews, the facility failed to ensure residents had call lights. This affected two residents (#9 and #60) of 24 residents reviewed for call lights. The facility census was 94. Findings include: 1. Review of the Resident #60's medical record revealed Resident #60 admitted to the facility on [DATE]. Diagnoses included muscle weakness, vascular dementia with behavioral disturbance, contracture of the left hand and contracture of the left knee. Review of Resident #60's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 was severely cognitively impaired and Resident #60 required extensive assistance for bed mobility, dressing, and personal hygiene. Resident #60 required total dependence for transfers and toileting and limited assistance for eating. Review of the care plan for Resident #60 dated 02/09/22 revealed resident was at risk for falls. Interventions included to keep call light within reach and encourage…

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, observation, record review, and staff interview, the facility failed to ensure a resident's oxygen tank was stored in a secured manner. This affected one (#71) of nine residents that used oxygen at the facility. The facility census was 94. Findings include: Review of Resident #71's medical record revealed Resident #71 admitted to the facility on [DATE]. Diagnoses included congestive heart failure, acute respiratory failure and vascular dementia without behavioral disturbance. Review of Resident #71's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 was cognitively intact and Resident #71 required extensive with dressing, toileting, bed mobility, transfers and personal hygiene. Resident #71 also required one person physical assistance with bathing. Review of Resident #71's physician order dated 06/01/21 revealed Resident #71 may be oxygen at two to three liters per minute per nasal cannula as needed to maintain oxygen saturation above 90…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure residents received written notice which specified the duration of the bed-hold policy upon hospitalization. This affected six (Resident #10, Resident #49, Resident #55, Resident #68, Resident #83 and Resident #87) of seven residents reviewed for discharge notification. The facility census was 98. Findings include: 1. Record review revealed Resident #68 was admitted to the facility on [DATE] with the following diagnoses; altered mental status, dementia in other diseases classified elsewhere without behavioral disturbance, peripheral vascular disease, essential hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, hypertensive chronic kidney disease, gastro esophageal reflux disease without esophagitis, dysphagia, primary osteoarthritis, hyperlipidemia polyneuropathy chronic angle closure glaucoma, non traumatic acute subdural hemorrhage, other abnormalities of gait and mobility, unsteadiness on feet,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews and policy review, the facility failed to implement their abuse policy for a resident with an injury of unknown origin. This affected one (Resident #68) of three residents reviewed for abuse. The facility census was 98. Findings include: Review of Resident #68's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including altered mental status, dementia in other diseases classified elsewhere without behavioral disturbance, peripheral vascular disease, essential hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, hypertensive chronic kidney disease, other abnormalities of gait and mobility, unsteadiness on feet, and other lack of coordination. Review of Resident #68's medical record indicated the resident had a fall on 02/23/19. The resident hit his left eye on the bottom of the bed and had left eye swelling and a small scratch. Resident #68 was started on neurological checks with no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure a resident's injury of unknown origin was reported to the state survey agency. This affected one (Resident #68) of three residents reviewed for abuse. The facility census was 98. Findings include: Review of Resident #68's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including altered mental status, dementia in other diseases classified elsewhere without behavioral disturbance, peripheral vascular disease, essential hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, hypertensive chronic kidney disease, other abnormalities of gait and mobility, unsteadiness on feet, and other lack of coordination. Review of Resident #68's medical record indicated the resident had a fall on 02/23/19. The resident hit his left eye on the bottom of the bed and had left eye swelling and a small scratch. Resident #68 was started on neurological checks with no issues noted.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to complete pre-admission screening and resident review (PASARR) for a newly admitted resident. This affected one (Resident #17) of two residents reviewed for PASARR. The facility census was 98. Findings include: Record review revealed Resident #17 was admitted to the facility on [DATE] with the following diagnoses; toxic effect of keystones, other symbolic dysfunctions, other abnormalities of gait and mobility, end stage renal disease, dementia in other disease classified elsewhere with behavioral disturbance, mood disorder due to known physiological condition, legal blindness, impulse disorder, personal history of traumatic brain injury, type two diabetes mellitus with diabetic neuropathy, other chronic pain, weakness, hyperlipidemia, dementia in other disease classified elsewhere without behavioral disturbance, schizoaffective and unspecified atrial fibrillation. Review of Resident #17's quarterly Minimum Data Sets (MDS) assessment dated [DATE]…

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 notify the state mental health authority with a significant change pre-admission screening and resident review (PASARR) for a resident that a had a psychiatric hospitalization. This affected one (Resident #87) of one resident reviewed for significant change PASARR. The facility census was 98. Findings include: Record review revealed Resident #87 was admitted to the facility on [DATE] with the following diagnoses; delirium due to known physiological condition, unspecified psychosis not due to a substance or known physiological condition, lymphangioma, hyperglycemia, major depressive disorder, multiple sclerosis, neoplasm of unspecified behavior of respiratory system, dissociative identify disorder, hyperlipidemia, other osteoporosis without current pathological fracture, other symbolic dysfunctions, dementia in other diseases classified elsewhere with behavioral disturbance and other lack of coordination. Review of Resident #87's PASARR…

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.