Mount Washington Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and record review, the facility failed to provide timely dental care services. This affected one Resident (#58) of one resident reviewed for dental services. The facility total census was 80. Findings Include: Record review of Resident #58 revealed the resident was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Diagnoses included hemiplegia, cerebral infarction, dysphagia, chronic obstruction pulmonary disease, diabetes, and malnutrition. Review of a physician order dated 09/01/23, revealed the resident may see dental services as needed. Review of a care conference dated 12/04/24, revealed Resident #58 requested a dental appointment to have dentures repaired. There was no documented evidence that the resident had a dental appointment since admission of 09/01/23. Review of Dental Service Contract dated 12/16/24, revealed Resident #58's Power of Attorney, (POA) signed an authorization for the resident to have dental services. Review of the Minimum…

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 medical record, observations, staff interviews, review of online resources from the Centers for Disease Control (CDC), and policy review, the facility failed to provide appropriate infection control measures while performing incontinence care and failed to ensure enhanced barrier precautions (EBPs) were implemented and followed according to guidelines. This affected one Resident (#17) of the 17 residents reviewed for incontinence care and being on EBPs. The facility census was 80. Findings include: Review of the medical record for Resident #17 revealed an admission date of 06/18/16. Diagnoses included Alzheimer's disease, type two diabetes mellitus, paranoid schizophrenia, and major depressive disorder. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #17 was unable to complete a Brief Interview for Mental Status (BIMS) because he was rarely/never understood. This resident was dependent on staff for activities of daily living (ADLs). Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview with the physician, and review of the facility policy, the facility failed to timely notify the physician when Resident #78 had abnormal vital signs during the time Resident #78 was exhibiting a change in condition and being treated for an infection. This affected one (Resident #78) of three residents reviewed for change in condition. Findings include: Review of the medical record revealed Resident #78 was re-admitted to the facility on [DATE]. Diagnoses included cholecystitis, severe protein-calorie malnutrition, vascular dementia, and urine retention. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #78 was severely cognitively impaired. Review of the plan of care dated 11/21/23 revealed Resident #78 was at risk for activity of daily living and self-care performance deficit related to intolerance, dementia, and fatigue. Interventions included to obtain and record all vital signs per orders and as needed, and report changes from usual 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 staff interview, record review, and review of the facility's policy, the facility failed to investigate resident falls and determine the root cause of the resident's falls. This affected three (#25, #82, and #86) of three residents reviewed for falls. The facility census was 82. Findings include: 1. Review of the closed medical record revealed Resident #86 had an admission date on [DATE]. Resident #86 discharged from the facility on [DATE]. Diagnoses included hypertension and systolic congestive heart failure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #86 was moderately cognitively impaired. Review of the plan of care dated [DATE] revealed Resident #86 was at risk for falls related to confusion, gait and balance problems, hypotension, poor communication, and comprehension and unawareness of safety needs. Interventions included non-skid socks as tolerated and ensure the resident was wearing appropriate non-skids in bed. Review of the fall risk tool 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 staff interviews, observation, record review, and review of the facility policy, the facility failed to provide timely incontinence care for a resident. This affected one (Resident #80) of three residents reviewed for incontinence care. The facility census was 82. Findings include: Review of Resident #80's medical record revealed an admission date of 12/10/21. Diagnoses included dementia severity, anxiety disorder, and atherosclerotic heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #80 was severely cognitively impaired. Resident #80 required substantial maximum assistance from staff for toileting. Review of the plan of care dated 12/01/23 revealed Resident #80 was at risk for incontinence and wearing disposable briefs, required and received assistance with toileting and incontinence care, and was at increased risk for skin breakdown and urinary tract infections. Interventions included to monitor and document signs and symptoms of urinary tract infection 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 medical record review and staff interview, the facility failed to coordinate care with the home health agency to ensure a smooth and safe resident discharge. This affected one (#90) of three residents reviewed for discharge planning. The facility census was 89. Findings include: Review of the medical record for Resident #90 revealed an admission date of 09/21/23, with diagnoses including chronic osteomyelitis, atherosclerotic heart disease, presence of cardiac pacemaker, atrial fibrillation, epilepsy, anxiety disorder, and major depressive disorder. Review of the Minimum Data Set (MDS) for Resident #90 dated 10/06/23 revealed resident was discharged to home with a return not anticipated. Review of MDS revealed resident was cognitively intact and required supervision and touching assistance with activities of daily living. Review of the discharge paperwork for Resident #90 with home health services revealed the resident was discharged with an order dated 09/21/2, for Vancomycin once daily via intravenous (IV) for 36 days and an order for a Vancomycin level to be drawn every…

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, interviews, and policy review the facility failed to ensure refrigerator temperatures were checked routinely, specifically refrigerators holding medications. Additionally, failed to ensure residents' refrigerated foods were properly labeled. This affected all 84 residents who reside in the facility. The facility census was 84. Findings include: Observation on 01/27/22 at 9:24 A.M., revealed medicine storage room refrigerator on first floor had no monthly temperature log. Two thermometers were in the refrigerator with prescribed medications. The temperature in the refrigerator was appropriate at this time, but no monthly temperature log was present. Interview on 01/27/22 at 9:35 P.M., revealed Licensed Practical Nurse (LPN) #85 reported she was not sure who was responsible for keeping medicine refrigerator temperatures and had no knowledge of monthly temperature log sheet. LPN #85 verified there was no monthly temperature log to document daily temperatures. Observation on 01/27/22 at 10:34…

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, resident and family interview, observations, review of the staffing schedules for room assignments and policy review the facility failed to ensure residents received care and services according to the plan of care. This affected five residents (#09, #16, #37, #43 and #48) of six reviewed for activities of daily living (ADL). The facility census was 84. Findings include: 1. Medical record review for Resident #37 revealed an admission date of 09/01/2019. Diagnoses included stroke with hemiplegia and hemiparesis, contractures, communication deficit, hypertension, and convulsions. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #37 revealed impaired cognition. Resident #37 required extensive assistance for bed mobility and toilet use from one staff member, total assistance for transfers and supervision for eating. Resident #37 was assessed as always incontinent of bowel and bladder. Resident was last treated by physical therapy on 08/21/19.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff and resident interview and policy review. The facility failed to ensure medications were safely stored. This affected five residents (#08, #56, #58, #70 and #382) out of five residents reviewed. The facility census was 84. 1. Review of the medical record for Resident #70 he admitted to the facility on [DATE]. His diagnosis included essential primary hypertension, hyperlipidemia, anemia, arthritis, pressure ulcer of the left heel, and COVID-19. Review of the Minimum Data Set (MDS) assessment for Resident #70 dated 12/23/21 revealed he had intact cognition. Resident #70 was independent with eating and did not require any assistance from staff. Review of the Medication Administration Record (MAR) dated January 2022 revealed Resident #70 was ordered the following morning medications: ferrous sulfate (iron supplement) 365 mg , folic acid (a supplement) tablet one mg, lactobacillus (probiotic) capsule, senna (a medication for constipation) two tablets, thiamine (a…

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

Based on medical record review, staff interview and resident interview, observation and policy review, the facility failed to ensure residents had appropriate clothing to wear. This affected one resident (#434) of three residents (#09, #78, and #434) reviewed for dignity. The facility census was 84. Findings include: Review of the medical record for Resident #434 revealed an admission date of 01/14/22. Diagnoses included displaced comminuted fracture of shaft of right femur, subsequent encounter for closed fracture with routine healing, unspecified fracture of right lower leg, subsequent encounter for closed fracture with routine healing, benign prostatic hyperplasia with lower urinary tract symptoms, morbid obesity due to excess calories, obstructive sleep apnea and hypertension. Review of the admission Minimum Data Set (MDS) assessment, dated 01/21/22 revealed Resident #434 had intact cognition. The resident required limited assistance for bed mobility, total dependence for transfer, extensive assistance for dressing, personal hygiene, and toilet use and supervision for 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.

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 resident advance directives were accurate. This affected one resident (#02) of three residents (#02, #09 and #49) reviewed for advance directives. The facility census was 84. Findings include: Review of the medical record for Resident #02 revealed an admission date of 02/19/21. Diagnoses included pulmonary embolism, cognitive communication deficit, other cerebral infarction due to occlusion or stenosis of small artery, chronic obstructive pulmonary disease, hypertensive encephalopathy, atrial fibrillation, and insomnia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #02 had moderate impaired cognition. The resident required extensive assistance for bed mobility, transfer, dressing, toilet use, personal hygiene and supervision for eating. Review of the electronic health record revealed the resident had an order for a Full Code status dated 02/19/21. Review of the paper chart…

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 and family interview, and policy review the facility failed to maintain resident room environment in a clean, sanitary and comfortable manner. This affected three residents (#07, #25 and #48) of eight residents who resided in the seven rooms observed. The facility census was 84. Findings include: Observation on 01/24/22 at 11:36 A.M., revealed Resident #25's floors was covered with debris, loose straw wrappings, dead flower leaves and wipes. Interview on 01/24/22 at 11:45 A.M., revealed Resident #25 reported she has not had her room cleaned in a few days. Observation on 01/24/22 at 11:56 A.M., revealed Resident #07's floors were stained, and paper was on the floor. Resident #07 was unable to answer interview questions. Observation on 01/24/22 at 12:00 P.M., revealed Resident #48's floors were dirty with debris and the bedside table was stained. Interview on 01/24/22 at 12:02 P.M., revealed Resident #48's family member reported staff mopped over the dirty floors and they do not clean the bed side tables. Interview on 01/24/22 at 12:28 P.M., 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, interview and policy review the facility failed to ensure a valid Pre-admission Screen and Resident Review (PASRR) was in place. This affected one resident (#382) out of three residents (#68, #70, and #382 residents reviewed for PASRR status. The facility census was 84. Findings include: Record review revealed Resident #382 was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction, anemia, pulmonary edema, acute embolism, chronic obstructive pulmonary disease, major depressive disorder, COVID-19, essential primary hypertension, and cognitive communication deficit. Review of the Minimum Data Sheet (MDS) 5-day assessment, dated 12/20/21, revealed Resident #382 required limited assistance from staff with bed mobility, transfers, dressing and extensive assistance from staff with e. Resident #382 was independent with eating. Review of the medical record revealed no evidence a new PASRR was submitted for approval to the State agency following the expiration of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review the facility failed to develop a baseline care plan for residents. This affected two residents (#68 and #382) of three residents reviewed for baseline care plans. The facility census was 84. Findings include: 1. Review of the medical record for resident #68 admitted to the facility on [DATE]. Diagnoses included, non-displaced fracture of medial malleolus of right tibia, Covid 2019 (Covid 19), gastro-esophageal reflux disease, major depressive disorder, essential primary hypertension, hypothyroidism, and type 2 diabetes mellitus. Review of the Minimum Data Set (MDS) admission assessment for Resident #68 dated 12/28/21 revealed the resident had moderately impaired cognition. Resident #68 required limited assistance from staff for bed mobility, however, he required extensive assistance from staff with toilet use, personal hygiene. Resident #68 required supervision from staff with eating and he was totally dependent on staff with bathing. Further review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and resident interview and observations the facility failed to ensure residents received specialized range of motion appliances as ordered by the physician. This affected two residents (#43 and #37) of two residents reviewed for splints and palm protector placement. The facility census was 84. Findings include: 1. Medical record review for Resident #37 revealed an admission on [DATE]. Diagnoses included stroke with hemiplegia and hemiparesis, contractures, communication deficit, hypertension, and convulsions. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #37 revealed impaired cognition. Resident #37 required extensive assistance for bed mobility and toilet use from one staff member, total assistance for transfers and supervision for eating. Resident #37 had functional limitations in range of motion on one side. Resident #37 was last treated by physical therapy on 08/21/19. Review of the plan of care for Resident #37 revealed resident had…

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, observation and review of the incident report the facility failed to ensure an intravenous (IV) catheter was initiated on the correct resident. This affected one resident (#50) of two residents reviewed for intravenous fluid. The facility census was 84. Findings include: 1. Medical record review for Resident #50 revealed an admission date on 12/19/19. Diagnoses included hemiplegia and hemiparesis following a stroke, type two diabetes, high blood pressure, depression, and convulsions. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #50 revealed intact cognition. Resident #50 required extensive assistance with bed mobility, toilet use and transfers occurred once or twice during the assessment period. Review of the plan of care for Resident #50 had no plan related for IV fluid administration. Review of the active physician's orders for the month of January 2022 had no orders for any IV fluid 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, staff interview and observations the facility failed to monitor for adverse side effects for residents receiving psychotropic medications. This affected one resident (#57) of five residents reviewed for unnecessary medication. The facility census is 84. Findings include: Medical record review for Resident #57 revealed an admission date on 01/01/20. Diagnoses included type two diabetes, metabolic encephalopathy, stage three kidney disease, dry eye syndrome, anxiety disorder, polyarthritis, depression, hypothyroidism, osteoporosis, history of mental and behavioral disorders. Review of the significant change Minimum Data Set (MDS) dated [DATE] for Resident #57 revealed intact cognition. Resident #57 required extensive assistance for bed mobility, transfers, eating and toilet use. Resident #57 received antianxiety medication (two days out of seven days during the assessment period) and antipsychotic medications daily during the assessment period. Review of the plan of care 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 interview and observations the facility failed to ensure residents receiving as needed psychotropic medications was limited to 14 days and not continued unless the prescribing physician evaluated the appropriateness of the medication. This affected one resident (#57) of five residents reviewed for unnecessary medication. The facility census is 84. Findings include: Medical record review for Resident #57 revealed an admission date on 01/01/20. Diagnoses included type two diabetes, metabolic encephalopathy, stage three kidney disease, dry eye syndrome, anxiety disorder, polyarthritis, depression, hypothyroidism, osteoporosis, history of mental and behavioral disorders. Review of the significant change Minimum Data Set (MDS) dated [DATE] for Resident #57 revealed an intact cognition. Resident #57 required extensive assistance for bed mobility, transfers, eating and toilet use. Resident #57 received antianxiety medications during the assessment period. 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 medical record review, staff interview, observations, and policy review the facility failed to ensure staff was available to assist dependent residents with eating after meals trays were delivered to resident rooms. This affected one resident (#36) of four reviewed for dependent residents requiring meal assistance. The facility census was 84. Findings include: Medical record review for Resident #36 revealed an admission on [DATE]. Diagnoses included Alzheimer's disease, anxiety, hypertension, allergic rhinitis, gastroesophageal reflux disease, pulmonary fibrosis, stroke, malignant neoplasm of brain, major depressive disorder, malignant neoplasm of lungs, carcinoma of male genital organs and dementia with behavioral disturbances. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had impaired cognition. Resident #36 required extensive assistance from two staff members for bed mobility. Resident #36 required extensive assistance for eating from one staff member.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview and policy review the facility failed to ensure a resident food preferences were accommodated. This affected one resident (#15) of three residents reviewed for meal preferences. The facility census was 84. Findings include: Review of Resident #15's medical record revealed an admission date of 11/17/21. Diagnoses included hypertensive heart disease without heart failure, insomnia, hypertension, anxiety, hearing loss, major depressive disorder, disorder of bone density and structure, hypothyroidism, atrial fibrillation and nonexudative age-related macular degeneration and bilateral, early dry stage. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had intact cognition. No rejection of care and the resident required supervision for eating. Observation on 01/24/22 at 12:22 P.M., revealed Resident #15's lunch meal was served and included a grilled cheese sandwich, tomato soup, potato chips, pickle chips, fruit…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and staff interview the facility failed to provide each resident with a therapeutic diet as ordered by their physician. This affected one resident (#54) of three residents reviewed for nutrition. Findings include: Review of Resident #54's medical record revealed the resident was admitted on [DATE]. Diagnoses included major depressive disorder, muscle weakness, unspecified dementia without behavioral disturbance, type two diabetes mellitus without complications, and gastro-esophageal reflux disease without esophagitis. Review of the quarterly minimum data set assessment (MDS) of the resident dated 12/16/21 revealed Resident #54 had severe cognitive impairment and required extensive assistance of one staff for bed mobility and transfer and required supervision for eating. No rejection of care noted. Review of the physician's orders revealed Resident #54 had an order for a Health Nutritional Shake (HNS) daily at lunch due to weight loss. Review of the resident's current…

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 when a resident formulated an advanced directive, the information regarding the advanced directive was accurate in all areas where advanced directive information was included in the medical record. This affected one (#107) out of 24 residents reviewed for Advanced Directives. The facility census was 123. Findings include: Review of Resident #107's medical record revealed the resident was admitted to the facility in August of 2012 with current diagnoses including pneumonia, sepsis, peptic ulcer perforation, chronic kidney disease, diabetes mellitus type 2, acute gastritis with bleeding, major depressive disorder, and personality disorder. The facility completed an annual minimum data set assessment (MDS) of Resident #107's cognitive status on 04/04/19. The 04/04/19 assessment identified the resident as having good memory and recall, and good cognitive skills for daily decision making. 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.

Based on observation, medical record review, and staff interview, the facility failed to implement one resident's plan of care to prevent potential elopement from the facility. This affected one (#20) out of two resident reviewed for Accidents. The facility census was 123. Findings include: Review of Resident #20's medical record revealed the resident was admitted to the facility in September of 2016 with current diagnoses including Parkinson's disease, unspecified dementia with behavioral disturbance, repeated falls, difficulty in walking, major depressive disorder, and degenerative diseases of the nervous system. The facility completed a quarterly minimum data set (MDS) assessment of the resident's cognitive and physical functional status dated 03/04/19. The 03/04/19 assessment identified the resident as having moderately impaired cognitive skills, behavioral symptoms not directed towards others, required limited assistance to transfer, and was able to self-propel her wheel chair with supervision and oversight. Resident #20 was observed propelling herself about in her room, and 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.

Based on observation, medical record review, and staff interview, the facility failed to implement one resident's plan of care to prevent potential elopement from the facility. This affected one (#20) out of two resident reviewed for Accidents. The facility census was 123. Findings include: Review of Resident #20's medical record revealed the resident was admitted to the facility in September of 2016 with current diagnoses including Parkinson's disease, unspecified dementia with behavioral disturbance, repeated falls, difficulty in walking, major depressive disorder, and degenerative diseases of the nervous system. The facility completed a quarterly minimum data set (MDS) assessment of the resident's cognitive and physical functional status dated 03/04/19. The 03/04/19 assessment identified the resident as having moderately impaired cognitive skills, behavioral symptoms not directed towards others, required limited assistance to transfer, and was able to self-propel her wheel chair with supervision and oversight. Resident #20 was observed propelling herself about in her room, and 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.