Madeira Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure residents were served meals in a dignified manner. This affected one (Resident #47) out of 74 residents in the facility who receive meals from the kitchen. The facility identified one resident (#50) who did not receive meals from the kitchen. The census was 75. Findings include: Review of the medical record for Resident #47 revealed an admission date of 02/01/22 with a diagnosis of epilepsy. Review of Resident #47's Minimum Data Set assessment dated [DATE] revealed Resident #47 was cognitively impaired, and required supervision and set up help with eating. Observation on 03/28/22 at 12:26 P.M. revealed Resident #47 was sitting in the common area with Resident #31 and Resident #182. Resident #31 and Resident #182 were seated with overbed tables in front of them in preparation for the lunch meal. There was no table or surface to serve Resident #47's meal tray. Further observation 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and resident interview, the facility failed to ensure resident advanced directives included the required signatures and followed the wishes of the residents. This affected three residents (#1, #38, #72) of eighteen residents reviewed for advanced directives. The facility census was 75. Findings included: 1. Review of Resident #72's medical record revealed an admission date of [DATE] and a readmission date of [DATE]. Resident #72's diagnoses included congestive heart failure, adult failure to thrive, hypertension, presence of cardiac pacemaker, and depression. Review of Resident #72's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 had severe cognitive impairment. Review of Resident #72's plan of care dated [DATE] revealed Resident #72 was a Do Not Resuscitate Comfort Care (DNRCC) code status. The interventions included to obtain medical provider order for code status, obtain copies to have on file, and review the code status quarterly and as needed.…

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 the ombudsman was notified of resident discharges. This affected three (Resident #25, #50, and #83) of three residents reviewed for hospitalization. The facility census was 75. Findings include: 1. Review of the medical record for Resident #83 revealed an admission date of 01/11/22. Resident #83 discharged from the facility on 02/15/22 and did not return. Diagnoses included malignant neoplasm of bronchus or lung, atrial flutter, type two diabetes mellitus with hyperglycemia, essential hypertension, and hyperlipidemia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #83 had intact cognition. Review of the medical record for Resident #83 revealed no evidence of the ombudsman having been notified of Resident #83's discharge. Interview on 03/30/22 at 3:39 P.M. with Social Worker (SW) #633 revealed he was aware of the need to notify the ombudsman of discharges, however he was unsure who 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 medical record review and staff interview, the facility failed to ensure the resident and/or resident representative was notified of the facility's bed hold policy in writing upon transfer to the hospital. This affected three (Resident #25, #50, and #83) of three residents reviewed for hospitalization. The facility census was 75. Findings include: 1. Review of the medical record for Resident #83 revealed an admission date of 01/11/22. Resident #83 discharged from the facility to the hospital on [DATE] and did not return. Resident #83 had diagnoses including malignant neoplasm of bronchus or lung, atrial flutter, type two diabetes mellitus with hyperglycemia, essential hypertension, and hyperlipidemia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #83 had intact cognition. Review of Resident #83's medical record revealed no evidence of Resident #83 nor Resident #83's representative having been notified of the facility bed hold policy in writing 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews, observations and review of the facility policy, the facility failed to conduct care planning conferences. This affected one (Resident #10) of three residents reviewed for care planning. The facility census is 75. Findings included: Medical record review for Resident #10 revealed an admission on [DATE] with diagnoses which included but were not limited to post traumatic osteoarthritis, hypertension, and overactive bladder. Review of Resident #10's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #10 had intact cognition. Review of the progress notes for Resident #10 dated 12/25/21 to 03/30/22 revealed they were silent for any documentation the resident and/or resident representative was given advance notice for a care conference appointment. Further review of progress notes for Resident #10 revealed they were silent for a care conference meeting. Interview with Social Worker (SW) #633 on 03/29/22 at 10:25 A.M. verified no care conferences have…

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 2. Review of the medical record for Resident #70 revealed an admission date of 01/20/22. Diagnoses included adult failure to thrive, cognitive communication deficit, need for assistance with personal care, and weakness. Review of the Resident #70's quarterly MDS asssessment revealed Resident #70 had severely impaired cognition and did not exhibit any behaviors during the assessment period. Review of Resident #70's care plan dated 03/11/22 revealed the resident had an ADL self-care performance deficit related to adult failure to thrive. Interventions included to provide limited assistance with grooming, bathing, and hygiene. Observation on 03/28/22 at 9:24 A.M. revealed Resident #70 resting in bed. Resident #70's fingernails were observed to extend approximately half of an inch beyond the finger tip. Concurrent interview with Resident #70 revealed he wanted his fingernails cut. Observation on 03/29/22 at 8:34 A.M. revealed Resident #70 walking on the unit with a walker. The resident's fingernails were observed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interviews, the facility failed to complete weekly skin assessments as ordered by the physician. This affected two (Resident #36 and #75) of nineteen residents reviewed for skin assessments. The facility census was 75. 1. Review of the medical record for Resident #36 revealed an admission date of 01/04/19. Resident #36's medical diagnoses included cerebral palsy, diabetes mellitus, respiratory failure, history of traumatic brain injury, mood disorder, and major depressive disorder. Review of Resident #36's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was severely cognitive impaired. Resident #36 required total two-person physical assist for bed mobility, transfers, toilet use, and personal hygiene, and required total dependence one-person physical assist for dressing and bathing. Review of Resident #36's plan of care dated 02/20/22 revealed Resident #36 was at risk for developing a pressure ulcer related to deconditioned and muscle…

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

Based on record review, observation, resident interview, and staff interview, the facility failed to arrange for vision and hearing services. This affected one (Resident #51) of three residents reviewed for communication and sensory needs. The census was 75. Findings include: Review of the medical record for Resident #51 revealed an admission date of 11/26/21 with diagnoses including end stage renal disease (ESRD) and diabetes mellitus (DM). Review of the Minimum Data Set (MDS) assessment for Resident #51 dated 02/16/22 revealed Resident #51 was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADLs). Further review of the MDS for Resident #51 revealed it was coded negative for Resident #51 wearing eyeglasses. Review of the March 2022 monthly physician orders for Resident #51 dated 02/02/22 revealed an order for Resident #51 to have an optometry or ophthalmology consult. Observation on 03/28/22 at 2:42 P.M. of Resident #51 revealed Resident #51 was wearing prescription glasses. Interview on 03/28/22 at 2:42 P.M. with Resident #51…

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, observation, resident interview, and staff interview, the facility failed to order and implement a hand splint as documented for a resident with impaired range of motion. This affected one (Resident #38) of two residents reviewed for positioning and mobility. The census was 75. Findings include: Review of the medical record for Resident #38 revealed an original admission date of 09/10/20 with a diagnosis of spina bifida. Review of the Minimum Data Set (MDS) for Resident #38 dated 02/16/22 revealed Resident #38 was cognitively intact and was totally dependent on assistance of staff with bed mobility, transfer, and hygiene. Review of the care plan for Resident #38 dated 02/22/22 revealed it was silent regarding the use of a hand splint. Review of the nurse progress notes for Resident #38 dated 07/01/21 through 03/28/22 revealed the notes were silent regarding the use of a hand splint for Resident #38. Review of the Resident #38's Treatment Administration Record (TAR) for March 2022 revealed it did not include the use of a hand splint. Review of 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, staff interview, and review of facility policy the facility failed to ensure fall prevention interventions were implemented according to evaluations and the care plan. This affected two (Resident #41 and #72) of five residents reviewed for accidents. The census was 75. Findings include: 1. Review of the medical record for Resident #41 revealed an admission date of 05/13/21 with a diagnosis of acute respiratory failure (ARF). Review of the Minimum Data Set (MDS) for Resident #41 dated 02/09/22 revealed Resident #41 was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADL). Review of the care plan for Resident #41 dated 02/22/22 revealed Resident #41 was at risk for falls related to diagnoses including, vascular dementia with behaviors, metabolic encephalopathy, depression, schizophrenia, and epilepsy. Interventions included anticipate Resident #41's needs and assist with positioning. Review of occupational therapy (OT)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure resident oxygen tubing was dated as well as ensure handheld nebulizer (HHN) machines and continuous positive airway pressure (CPAP) machines in resident rooms had physician orders for use. This affected two (Residents #21 and #40) of two residents reviewed for respiratory care. The census was 75. Findings include: 1. Review of the medical record for Resident #40 revealed an admission date of 01/05/22 with a diagnosis of malignant neoplasm of the lung. Review of the Minimum Data Set (MDS) assessment for Resident #40 dated 02/09/22 revealed Resident #40 was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADLs). Review of the March 2022 monthly physician orders for Resident #40 revealed an order dated 01/06/22 for resident to receive oxygen two liters per minute (LPM) continuously per nasal cannula (NC) as well as an order dated…

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

Based on medical record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure residents received effective pain management and staff adequately assessed residents for pain. This affected one (Resident #40) of five residents reviewed for unnecessary medications. The census was 75. Findings include: Review of the medical record for Resident #40 revealed an admission date of 01/05/22 with a diagnosis of diabetes mellitus. Review of the Minimum Data Set for Resident #40 dated 02/09/22 revealed Resident #40 was cognitively impaired and required extensive assistance of two staff with activities of daily living (ADLs). Review of the care plan for Resident #40 dated 02/22/22 revealed Resident #40 had complaints of acute/chronic pain. Interventions included to provide medication per orders, monitor for side effects, evaluate effectiveness of medication, and observe for pain every shift. Review of the March 2022 monthly physician order for Resident #40 revealed an order dated 01/07/22 for Norco four times per day routinely for pain. 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 4. Review of the medical record for Resident #82 revealed an admission date of 03/04/22 at approximately 3:00 P.M. Resident #82 discharged from the facility on 03/05/22 at approximately 12:00 P.M. Diagnoses included dementia with behavioral disturbance, difficulty in walking, type one diabetes mellitus, anxiety disorder, and weakness. Review of a nursing progress note dated 03/05/22 at 12:29 P.M. revealed Resident #82's son arrived at the facility and informed staff he was taking Resident #82 home. The nurse informed the son that Resident #82 admitted the day prior and none of her medications had arrived yet and would probably not be delivered until later in the evening. Review of the medication administration record (MAR) for March 2022 revealed Resident #82 had orders for the following routine medications: amlodipine besylate (antihypertensive) daily at 8:00 A.M., atorvastatin calcium (antihyperlipidemic) daily at 9:00 P.M., clopidogrel bisulfate (anticoagulant) daily at 6:00 P.M., insulin glargine…

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 appropriate indications for the use of antipsychotic medications as well as complete appropriate monitoring after starting an antipsychotic medication. This affected two (#08 and #36) of five residents reviewed for unnecessary medications. The facility census was 75. Findings include: 1. Review of the medical record of Resident #08 revealed an admission date of 04/26/20. Diagnoses included type two diabetes mellitus, acute kidney failure, neuromuscular dysfunction of bladder, major depressive disorder, insomina, peripheral vascular diseases, generalized anxiety disorder, alzheimer's disease, dementia without behavioral disturbance, gastro-esophageal reflux disease, and benign prostatic hyperplasia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #08 had severely impaired cognition. The resident did not exhibit behaviors during the assessment period. Review of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of the medical record of Resident #82 revealed an admission date of 03/04/22 at approximately 3:00 P.M. The resident discharged from the facility on 03/05/22 at approximately 12:00 P.M. Diagnoses included dementia with behavioral disturbance, difficulty in walking, type one diabetes mellitus, anxiety disorder, and weakness. Review of a nursing progress note dated 03/05/22 at 12:29 P.M. revealed Resident #82's son arrived at the facility and informed staff he was taking Resident #82 home. The nurse informed the son that Resident #82 admitted the day prior and none of her medications had arrived yet and would probably not be delivered until later in the evening. Review of the medication administration record (MAR) for March 2022 revealed Resident #82 had orders for the following routine medications: insulin glargine daily at 6:00 P.M., and insulin lispro three times daily at 8:00 A.M., 12:00 P.M. and 5:00 P.M. Further review of the MAR revealed none of the medications listed were administered. 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 observation, staff interview, and medical record review the facility failed to ensure urinary catheter drainage bags were not stored directly on the floor. This affected one (Resident #50) of seven facility identified residents with urinary catheters. The census was 75. Findings Include: Medical record review for Resident #50 revealed an admission on [DATE] with diagnoses that included but were not limited to Alzheimer's disease, neuromuscular dysfunction of bladder, type two diabetes, and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #50 revealed Resident #50 had impaired cognition. No behaviors were coded during the assessment period. Resident #50 had an indwelling urinary catheter. Review of the plan of care for Resident #50 dated 01/17/22 revealed Resident #50 had an indwelling catheter due to neurogenic bladder. Interventions included change catheter per orders, observe for pain and discomfort related to catheter, provide catheter 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.

Based on record review and staff interviews, the facility failed to have a complete water management plan to monitor for the risk, growth, and spread of Legionella. This had the potential to affect all 63 residents residing in the facility. Findings include: Review of the facility's Legionella plan revealed no water line tracking and/or tracking for high risk areas including but not limited to dead leg areas, ice machines, and/or tubs. The facility maintained no physical controls, temperature management including acceptable ranges for control measures, no disinfectant level controls, no visual inspection monitoring, no environmental testing for pathogens, and/or no documented results of the testing and/or corrective actions taken when control limits are not maintained. Interview conducted on 04/25/19 at 11:20 A.M. the Maintenance Supervisor (MS) #4 stated he had never received any training related to Legionella prevention in the facility. Interview conducted on 04/25/19 at 11:43 A.M. Corporate Director of Nursing (DON) #3 stated she was over the Legionella prevention for 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 and interview, the facility failed to convey funds of residents upon discharge(discharge/death/eviction). This affected 20 (Residents #101, #102, #103. #104, #105, #106, #107, #108, #109, #110, #112, #116, #120, #121, #122, #124, #125, #126, #129, and #130) of 30 residents who discharged from the facility with remaining funds in their accounts. The facility census was 63. Findings include: Review of medical record and facility funds record reviews revealed Resident #101 was admitted to the facility on [DATE], discharged [DATE], with a remaining balance in the funds account of $134.24 Review of the medical record and facility funds records reviews revealed Resident #102 was admitted to the facility on [DATE], discharged on [DATE], with a remaining balance in the funds account of $85.00. Review of the medical record and facility funds records reviews revealed Resident #103 was admitted to the facility on [DATE], discharged on [DATE], with a remaining balance in the funds account 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 and resident interview, and review of facility policy, the facility failed to treat a resident with dignity and respect when he attempted to contact the kitchen to make food choices and was hung up on three times. This affected one Resident #8 of 24 resident's reviewed for dignity during the initial pool sample of the annual survey. The facility census was 63. Findings include: During interview with Resident #8 on 04/22/19 at 11:08 A.M. and again on 04/25/19 at 9:05 A.M., the resident stated on Sunday 04/21/19, he called the kitchen around 5:30 P.M. to see why the menu was changed and why he didn't get what he ordered for dinner. The resident stated earlier that day he was told by staff that dinner consisted of roast beef and he received sausage instead, and he didn't get the vegetable soup he requested. Resident #8 stated the first time he called, a male answered the phone and hung up on him. He stated he called right back and the same male answered the phone again, Resident #8 stated he said also, and the man hung up on him again. Resident #8 stated…

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

Based on observation, and interview, the facility failed to serve food to residents in a homelike environment. This directly affected two (Residents #13 and #53) and had the potential to affect all 14 residents present at the time of the observation. The facility census was 63. Findings include: The main dining room on Plaza 1 was observed during the lunch time meal on 04/22/19. There were 14 residents present. All 14 residents were served their food and beverage items on trays, the trays placed directly in front of the residents, and the food and beverages not removed from the tray. Resident #13 eating at a table my himself was observed removing the menu items from the tray and placing them on the table in front of where he was going to sit. In the process he dropped his bowl of tossed salad on the floor. An interview was conducted with Resident #13 on 04/22/19 at 12:32 P.M. regarding his food being served on trays. He stated that they usually place the food on the table, but not always, and he preferred to have it served on the table. Resident #53 eating lunch in the Plaza 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility failed to accurately assess one resident's contractures with subsequent limitations in range of motion. This involved one(Resident #33) of three residents reviewed for positioning and mobility. The facility census was 63. Findings include: Resident #33 was admitted to the facility on [DATE] with diagnoses including altered mental status, cerebral infarction, dysphagia, metabolic encephalopathy, aphasia, age-related physical debility, and diabetes mellitus. The facility completed a Medicare 30 day minimum data set (MDS) assessment of Resident #33's cognitive and physical functional status dated 04/09/19. The 04/09/19 assessment identified the resident as have short and long term memory problems, severely impaired cognitive sills, and requiring the physical assistance of one to two staff persons to complete all activities of daily living including eating. The resident was assessed as having no limitations in range of motion of the upper or…

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, medical record review, and staff interview, the facility failed to ensure that residents who were unable to feed themselves reviewed the necessary services to maintain good nutrition. This affected two (Residents #18 and #33) of six residents reviewed for nutrition. The facility census was 63. Findings include: 1. Resident #18 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, chronic pain, insomnia, depressive episodes, schizophrenia, and dysphagia. The quarterly minimum data set assessment (MDS) dated [DATE] identified the resident as having poor short and long term memory, severely impaired cognitive skills, and requiring the physical assistance of one staff person to eat. On 04/22/19 at 1:16 P.M. State Tested Nurse Aide (STNA) #102 finish passing trays on one section of rooms on Plaza 1 including Resident #18's room. On 04/22/19 at 1:28 P.M. Resident #18 was observed lying in a low bed with her meal tray covered and out of reach on an over bed table in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility failed to ensure bed rails continued to be safe and appropriate to use when a new specialty mattress overlay was applied to the mattress. This affected one (Resident #18) of two residents reviewed for accidents. The facility census was 63. Findings include: Resident #18 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, chronic pain, insomnia, depressive episodes, schizophrenia, and dysphagia. The quarterly minimum data set assessment (MDS) dated [DATE] identified the resident as having poor short and long term memory, severely impaired cognitive skills, and requiring the physical assistance of one to two staff persons for bed mobility, transferring, and walking in her room and corridor. Resident #18 had two falls since the prior MDS assessment without serious injury. Review of Resident #18's current physician's orders revealed an order for bilateral assist bars while in bed for assistance with turning 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.