Mt Airy Gardens Rehabilitation And Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and resident interview, the facility failed to ensure residents received care and services for management of contractures and impaired mobility. This affected three (Residents #9, #72, #51) of three residents reviewed for range of motion services. The facility census was 77 residents. Findings include: 1. Review of the medical record for Resident #9 revealed an admission on [DATE] with diagnosis including peripheral vascular disease, diabetes mellitus, traumatic brain injury, and schizophrenia. Review of the Minimum Data Set (MDS) assessment for Resident #9 dated 12/25/24 for Resident #9 revealed the resident had impaired cognition and required supervision with activities of daily living (ADLs). Review of the care plan for Resident #9 dated 11/22/22 revealed the resident had an ADL self-care performance deficit related to cardiovascular disease. Interventions included staff to apply a left-hand resting hand orthotic as ordered. 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, observation and staff interviews, the facility failed to ensure residents had fluids available at bedside. This affected one Resident (#08) reviewed for hydration. The facility census was 77. Findings include Medical record for Resident #08 revealed an admission on [DATE] with diagnoses including but not limited to dementia with behavioral disturbances and psychotic disorders with delusions. Review of the plan of care for Resident #08 revealed the resident is currently on hospice with diagnoses of moderate protein-calorie malnutrition. Interventions include to provide and serve diet as ordered, monitor and report any signs and symptoms of pocketing, drooling, multiple attempts with swallowing and refusing to eat. Resident #08 received a mechanically altered diet with regular liquids. Review of the physician order for Resident #08 dated 08/02/23 revealed an order for regular diet, mechanical soft texture and thin liquids consistency. Review of the nutritional assessment 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 3) Review of the medical record of Resident #06 revealed an admission date of 01/05/22. Diagnoses included dementia with agitation, memory deficit following cerebrovascular disease, type 1 diabetes, history of traumatic brain injury, post-traumatic stress disorder, unspecified convulsions, anxiety, depression, violent behavior, and mood disorder. Review of the physician orders for Resident #06 revealed an order dated 12/23/24 to check laboratory results (labs), including a Depakote level. The frequency of the need for the labs was not specified. Further review of physician orders revealed orders dated 01/07/22 for Depakote tablet Delayed Release (DR) 500 milligrams (mg) twice per day for unspecified convulsions and 08/01/24 for Rexulti (atypical antipsychotic) Oral Tablet two mg one time a day for dementia with agitation. Review of the quarterly MDS assessment for Resident #06 dated 01/24/25, revealed the resident had intact cognition. The resident required set-up assistance with eating, supervision for oral…

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 interviews, the facility failed to ensure medications were stored in accordance with professional standards. This affected one Resident (#237) of four resident reviewed for medication administration. The facility was 77. Findings include: Review of the medical record revealed Resident #237 was admitted to the facility on [DATE] with diagnoses of acute respiratory failure with hypoxia, tracheostomy, metabolic encephalopathy, diabetes mellitus type II, schizophrenia, bipolar disorder, opioid dependence and congestive heart failure. Review of the admission Minimum Data Set (MDS) assessment for Resident #237 dated 02/18/25 was not completed at the time of the survey. Review of the plan of care for Resident #237 was incomplete due to recent admission. Review of the physician orders for the month of February 2025 for Resident #237 revealed an order dated 02/12/25 for Lidocaine external patch 5 percent apply to affected area topically in the evening 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 Based on medical record review, staff interview, review of hospice plan of care and hospice contract, the facility failed to jointly collaborate to develop a comprehensive plan of care that identified services to be provided by both providers. This affected one Resident (#08) of two reviewed for hospice services. The facility census was 77. Findings include: Medical record for Resident #08 revealed an admission on [DATE] with diagnoses including but not limited to dementia with behavioral disturbances and psychotic disorders with delusions. Review of the plan of care for Resident #08 revealed resident has an advanced directive do not resuscitate comfort care (DNR-CC) order dated 02/02/2020 with a revision date of 01/30/2024. Resident #08 is currently on hospice with diagnoses of moderate protein-calorie malnutrition. Interventions included to provide and serve diet as ordered, monitor and report any signs and symptoms of pocketing, drooling, multiple attempts with swallowing and refusing to eat. Resident #08…

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, staff interview, and review of the facility policy, the facility failed to ensure the resident bedrooms provided full visual privacy. This affected one (Residents #8) of four residents reviewed for physical environment. The facility census was 77 residents. Findings include: Review of the medical record for Resident #8 revealed an admission date of 08/03/18 with diagnoses including Alzheimer's dementia, psychotic disorder with delusions, and depressive disorder. Review of the Minimum Data Set (MDS) assessment for Resident #8 dated 01/29/25 revealed the resident had severe cognitive impairment and was dependent on staff assistance with activities of daily living (ADLs). Observation on 02/18/25 at 12:29 P.M. revealed Resident #8's room window overlooked the facility parking area, and the window curtains were of a material which permitted observation from the parking lot into the resident's room. In addition, the window curtains were ripped and torn. There was no privacy curtain in the room even though privacy curtain tracking was in place.…

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, family interview, and staff interview, the facility failed to ensure residents had a safe, clean, comfortable environment. This affected one (Resident #8608) and eight additional residents (#29, #30, #4, #5, #10,#11, #14 and #15) of nine residents' rooms observed. The facility census was 81. Findings include: Review of the medical record revealed Resident #8608 was admitted on [DATE] with diagnoses of paranoid schizophrenia, cerebral infarction with right sided hemiplegia and hemiparesis, anemia and congestive heart failure. The resident discharged to the hospital on [DATE] and bed hold was discontinued on 08/04/24. Review of the Minimum Data Set (MDS) discharge return anticipated assessment dated [DATE] revealed Resident #8608 had severe cognitive impairment and was frequently incontinent of bowel and bladder. The resident required set up assistance for eating and was dependent for all other activities of daily living which included oral and personal hygiene, toileting, bathing, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, hospital record review, staff interview, and policy review, revealed the facility failed to ensure residents medications were ordered and administered following a hospital discharge resulting in a significant medication error. This affected one (#11) of three Residents (#11, #12, and #13) reviewed of use of anti-coagulants. The facility census was 83. Findings include: Review of Resident #11's closed medical record revealed the resident was admitted to the facility on [DATE] Diagnoses included myocardial infarction (heart attack) with cardiac and vascular implants (stents), history of transient ischemic attacks (TIAs), human immunodeficiency virus (HIV), and cerebrovascular disease. Resident #11 was discharged to a local hospital on [DATE]. Review of the Discharge Return Anticipated Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 had cognitive deficits and required set up assistance with activities of daily living (ADLs). Review of Resident #11's Hospital After Visit…

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, resident interviews, record review, and review of the facility policy, the facility failed to ensure the elevators were maintained in good working order and failed to ensure cigarette butts were disposed of in appropriate containers. This had the potential to affect all residents residing in the facility except the 27 residents who resided on the secured unit of the facility. The facility census was 89. Findings include: 1. Observation on 05/13/24 at 10:00 A.M. revealed there were numerous cigarette butts lying on the ground in front of the facility entrance doors. Observation on 05/14/24 at 8:00 A.M. revealed there continued to be numerous cigarette butts lying on the ground in front of the facility entrance doors, in the mulch across from the facility entrance doors, and in the rocks located beside the facility entrance doors. Observation on 05/14/24 at 4:00 P.M. revealed there were three residents sitting outside within ten feet of the facility entrance doors smoking cigarettes. When finished with the cigarettes, the residents disposed 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 medical record review, review of the facility policy, and staff interview, the facility failed to timely notify the resident's representative of a resident's elopement from the facility. This affected one (Resident #26) of three residents reviewed for notification of change. The facility census was 88. Findings include: Review of the medical record for Resident #26 revealed an initial admission date of 07/12/23. Resident #26 had diagnoses including dementia, altered mental status, cognitive communication deficits, and high blood pressure. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/01/24, revealed Resident #26 had moderate cognitive impairment. Review of the nursing notes revealed no recollection or documentation providing information on the events of 04/20/24. Review of the social service progress notes from 05/02/24 revealed a late entry note was created for 04/22/24 which documented Social Services Director #200 called to speak with the niece of Resident #26 to discuss future placement of the resident on the secure unit. This was two days after…

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, interview, and record review the facility failed to have handrail tightly and properly attached to walls. This had the potential to affect 58 Residents (#1, #2, #3, #4, #5, #6, #7, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57 #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78, #79, #80, #81, and #81) identified by the facility as being independently mobile. The facility census was 74. Findings include: Observations of the facility on 02/08/24 from 11:00 A.M. to 11:30 A.M. with the Administrator revealed the handrails were loose and/or missing pieces in the following areas: • Near rooms 116, 126, 200, 117, 222, 203, 204, 219, 200, 225, and 235. • The area between rooms [ROOM NUMBERS], between rooms [ROOM NUMBERS], between rooms [ROOM NUMBERS], between rooms [ROOM NUMBERS], between rooms [ROOM NUMBERS], and between rooms [ROOM NUMBERS]. • Near the medication…

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

Based on observation and staff interview the facility failed to ensure the resident care environment was free of accident hazards. This had the potential to affect the 21 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, and #21) who resided on the secured dementia unit and were identified by the facility as being confused and able to ambulate or propel themselves independently. The facility census was 74. Findings include: Observation on 11/19/23 at 11:00 A.M. on the secured dementia unit of the facility revealed there was a portable space heater approximately three feet long and six inches tall on the floor with the cord taped to the floor and wall of Resident #1's room. The portable spaced heater was plugged into the outlet in the wall and was turned on with heat being put out into the room. There was a warning printed on the top of the portable space heater which read Caution - high temperatures, keep electrical cords, drapes and other furnishings away from the heater. Fire hazard, do not operate without feet attached.…

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 facility policies, the facility failed to ensure resident rooms and common areas were clean and well-maintained. This had the potential to affect the 21 residents (#1, #2, #3, #4, #5, #6. #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, and #21) who resided on the secured dementia unit. The facility census was 74. Findings include: Observation on 11/19/23 at 11:00 A.M. revealed there was dried, red juice on the floor in Resident #1's room. The closet doors were broken and hanging off the tracks. The toilet handle was broken and hanging down. The toilet seat was broken off and lying on the floor beside the toilet. The bathroom light switch cover was missing. Interview on 11/19/23 at 11:25 A.M. with Licensed Practical Nurse (LPN) #200 confirmed the maintenance and cleanliness concerns observed in Resident #1's room. Observation on 11/19/23 at 11:27 A.M. revealed the dining room floor in the secured dementia unit had black stains across the majority of the floor. The kitchenette located in the dining room 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 record review, staff interview, and review of the facility policy, the facility failed to provide adequate preparation for resident transfer/discharge from the facility. This affected one resident (Resident #70) out of three residents reviewed for transfers and discharges. The facility census was 74. Findings include: Review of the medical record for Resident #70 revealed the resident was admitted on [DATE] with diagnoses including cerebral palsy, diabetes mellitus, bipolar disorder, schizophrenia, and hypertension. Review of the Minimum Data Set (MDS) assessment for Resident #70 dated 09/29/23 revealed the resident was cognitively intact and able to make her needs known. Review of nursing and social services notes for Resident #79 revealed they did not include documentation of the resident's request to transfer to another facility. Interview on 11/19/23 at 1:00 P.M. with the Director of Nursing (DON) confirmed Resident #70 had requested a transfer to a specific facility in the last two weeks. Interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview, review of hospital record, review of the facility policy, and review of the online resources the facility failed to implement COVID-19 isolation precautions during resident smoke breaks for Resident #315 which had the potential to affect four residents (#04, #35, #59, #60). The facility failed to perform proper hand hygiene during meal tray pass which had the potential to affect the 24 residents residing on the dementia unit. Also, the facility failed to implement their tuberculosis (TB) control plan for four newly hired employees (Dietary #380, State Tested Nursing Assistant (STNA) #530, Licensed Practical Nurse (LPN) #605 and STNA #640) of nine newly hired employees since the last annual reviewed for having two-step tuberculin skin tests (TSTs). This had the potential to affect all residents residing in the facility. In addition, the facility failed to implement transmission based precautions for two newly admitted residents which had the potential 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.

Based on observations, medical record reviews, staff and resident interview, and review of facility policy, the facility failed to ensure residents received services to accommodate needs and preferences related to room arrangements allowing access to their environment independently, for accessing their call lights when needed and access to their eyeglasses. This affected five (#12, #18, #55, #57, and #165) of five reviewed for accommodation of needs. The facility census was 63. Findings include: 1. Review of Resident #12's medical record revealed an admission date of 01/03/11, with diagnoses including: hemiplegia and hemiparesis following following cerebral vascular disease affecting left non-dominant side, epilepsy, chronic pain, anxiety disorder, contracture left upper arm, contracture left hand, and primary generalized osteoarthritis. Review of a quarterly Minimum Data Set (MDS) assessment of the resident dated 04/01/21 revealed the resident had good memory and recall, and required the extensive assistance of staff to completed activities of daily living with the exception 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 observations, medical record reviews, staff interviews, activity calendar review and policy review, the facility failed to ensure activities were provided for cognitively impaired residents. This affected four (#19, #27, #46, and #57) of six residents on the unit reviewed for activities during the annual survey. The facility identified 24 residents residing on the unit. The facility census was 63. Findings included: 1. Review of Resident #19's medical record revealed an admission date of 02/27/18, with diagnoses of type 2 diabetes mellitus and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #19 was moderately impaired. Functional status was supervision from staff for bed mobility and transfers. Review of the Care Plan, dated 04/21/21, revealed he was at risk for decreased activity involvement secondary to Coronavirus restrictions. Interventions were to complete an activity assessment on resident if confined for more than 2-3 days to ensure…

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 reocrd review, staff and resident interview, review of the water temperature logs, and review of the facility's policy, the facility failed to ensure the resident environment was free of accident hazards, including maintaining hot water temperatures was within the recommended range, ensure a resident at high risk for aspiration was supervised during meals and resident's falls were investigated. This affected two (Resident #12 and #32) of 24 residents reviewed for accident hazards, one (Resident #33) of one resident reviewed for supervision of meals, and two (Resident #70 and #169) of four residents reviewed for falls. The facility census was 63. Findings include: 1. On 05/03/21 at 5:47 P.M., an observation of the hot water temperature at Resident #12's hand sink was found to be 125 degrees Fahrenheit (F). Interview with the resident stated she adjusted the water temperature herself and denied any problems with the hot water. 2. On 05/03/21 at 5:50 P.M., an observation of the 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.

Based on observation, staff interview, and policy review the facility failed to ensure the food was stored and prepared under sanitary conditions consistent with professional standards for food service safety. This had the potential to affect all 61 residents who received meals from the kitchen. The facility identified two residents (#52 and #63) who received enteral feedings only. The facility census was 63. Findings include: A tour of the central kitchen was completed on 05/03/21 beginning at 8:46 A.M. While touring the kitchen the following was observed: a) In the dry storage room there was a large bag of flour opened with a Styrofoam bowl in the the flour apparently used for scooping the flour out of the bag. In addition, there was a large opened box of rice on a shelf with a scooping device down in the rice. This was verified by Dietary Supervisor (DS) #700 while touring with the surveyor. b) In the dry storage room there was a four pound jar of grape jelly located on a shelf that had been opened and partially used. The label on the jelly specified to refrigerate the jelly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure a 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 two (#17and #65) of two residents reviewed for advanced directives. The facility census was 63. Findings include: Review of Resident #17's medical record revealed an admission date of 01/10/13, with diagnoses including: peripheral vascular disease, moderate protein calorie malnutrition, hypertension, alcohol dependence with alcohol-induced persisting dementia, and major depressive disorder. Review of a quarterly minimum data set assessment of the resident dated 04/01/21 revealed the resident had severe cognitive impairments, and was dependent on staff assist in completion of all activities of daily living other than eating. Review of the resident's physician's order in the electronic health record (EHR) revealed an order 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.

Based on medical record review, staff interview, and review of facility documents, the facility failed to ensure the resident's physician documented reasons for resident discharge from the facility in the medical record. This affected one (#169) of four residents reviewed for discharge. The census was 63. Findings include: Review of the medical record for Resident #169 revealed an admission date of 05/04/13 with a diagnosis of hemiplegia and a discharge date of 06/11/20. Review of the Minimum Data Set (MDS) for Resident #169 dated 04/15/21 revealed resident was cognitively intact and required supervision with activities of daily living. Review of the MDS for Resident #169 dated 06/11/20 revealed resident was discharged with a return not anticipated. Review of the care plan for Resident #169 updated 03/09/20 revealed resident did not show potential for discharge and goal was for resident to have needs met at the facility. Review of the 30-day discharge notice for Resident #169 dated 05/21/20 revealed resident was notified of his upcoming involuntary discharge from the facility by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure resident assessments included accurate resident body weights. This affected one (#55) of five residents investigated for nutrition. The census was 63. Findings include: Review Resident #55's medical record revealed an admission date of 02/19/21 and a diagnosis of cerebral infarction. Review of preadmission hospital records for Resident #55 dated 02/06/21 revealed resident weighed 145 pounds. Review of the Minimum Data Set (MDS) assessment for Resident #55 dated 02/23/21 revealed the resident was cognitively impaired and required extensive assistance with two staff with activities of daily living (ADLs) and weighed 174 pounds. Review of the MDS for Resident #55 dated 03/05/21 revealed weighed 175 pounds. Review of the MDS for Resident #55 dated 03/12/21 revealed weighed 174 pounds. Review of the MDS for Resident #55 dated 04/23/21 revealed weighed 139 pounds. Review of the facility weight records for Resident #55 revealed a weight of 175…

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 notify the state mental health authority when a resident with a mental illness had a change of condition and was admitted to hospice. This affected one (#9) of two residents reviewed for significant change Pre-admission Screening and Resident Review (PASARR). The facility census was 63. Findings include: Review of Resident #9's medical record revealed an admission date of 08/21/18, with diagnoses including: bipolar disorder, end stage renal disease, dependence on renal dialysis, unspecified dementia without behavioral disturbance, chronic obstructive pulmonary disease, and muscle weakness. Review of Resident #9's significant change Minimum Data Sets (MDS) assessment dated [DATE] revealed resident to be cognitively impaired and required extensive assistance with bed mobility, dressing, transfers, toileting, and personal hygiene. Resident #9 also required supervision with eating on the 04/01/21 MDS. Review of Resident #9's hospice admission…

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, and staff interview, the facility failed to provide assistance to a resident who was dependent on staff for grooming and dressing. This affected one (#57) of three residents reviewed for activities of daily living. The facility census was 63. Findings include: Review of Resident #57's medical record revealed an admission date of 08/03/18, with medical diagnoses including: dementia with behavioral disturbance, psychotic disorder with delusions due to known physiological condition, and Alzheimer's Disease. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was dependent on one staff member to provide bathing and occasionally incontinent of bladder and always continent of bowels. No behaviors toward others occurring and no rejection of care. Review of Resident #57's care plan, dated 03/22/21, revealed a goal of Activities of Daily Living (ADL) will be met daily. Care plan dated 03/22/21 focus was on Resident #57's self-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 observation, record review, staff interview, and review of the facility's policy, the facility failed to ensure each resident with a limited range of motion received appropriate treatment and services, including the use of splinting devices, to increase their range of motion and/or to prevent decline. This affected two residents (#33 and #52) of five residents reviewed for limited range of motion. The facility identified 16 residents with contractures. The facility census was 63. Findings include: 1. Review of Resident #33's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including vascular dementia with behavioral disturbance, bipolar disorder, hemiplegia, major depressive disorder, muscle weakness, peripheral vascular disease, and rheumatoid arthritis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/29/21, revealed the resident had severe cognitive impairments, and was required extensive to total assistance from staff to complete all…

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 appropriately monitor a resident's dialysis access site. This affected one (Resident #3) of one resident reviewed for dialysis. The facility identified three residents receiving dialysis services. The facility census was 63. Findings include: Review of the medical record for Resident #3 revealed an admission date of 05/24/19 with a diagnosis of end stage renal disease (ESRD). Review of the Minimum Data Set (MDS) assessment, dated 04/01/21, revealed the resident was cognitively impaired. Review of the physician's order, dated 05/28/19, revealed the staff should monitor dialysis site to the left upper arm. There was no physician order to monitor the new site to the resident's right arm that was placed May 2020. Review of the nursing progress note, dated 05/05/20, revealed the resident needed to have a new dialysis access site created via a graft to his right arm. Further review of the note revealed the resident was to have new site to right arm created on 05/13/20. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of facility policy, the facility failed to administer medications as ordered by the physician. This affected two (Residents #169 and #52) of 26 residents sampled. The census was 63. Findings include: 1. Review of the medical record for Resident #169 revealed an admission date of 05/04/13 with a diagnosis of hemiplegia and a discharge date of 06/11/20. Review of the Minimum Data Set (MDS) for Resident #169 dated 04/15/21 revealed resident was cognitively intact and required supervision with activities of daily living. Review of the May 2020 Medication Administration Record (MAR) for Resident #169 revealed the resident did not receive his 6:00 P.M. dose on 05/02/20, 05/07/20, 05/21/20, 05/26/20 of the following medications: Flomax (a medication to improve urination), Keppra (an anti-epileptic medication), Norvasc (a blood pressure medication), metoprolol (a blood pressure medication). Review of the nurse progress notes for Resident #169 dated 05/02/20 through…

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, review of the hospital records, staff interview, review of online medication resource Medscape, and policy review, the facility failed to appropriately monitor residents for the administration of anticoagulant and anti-seizure medication. This affected two residents (#55 and #52) of six residents reviewed for unnecessary medications. The census was 63. Findings include: Review of the medical record for Resident #55 revealed an admission date of 02/19/21 and a diagnosis of cerebral infarction. Review of the MDS for Resident #55 dated 03/05/21 revealed the resident was cognitively impaired and required extensive assistance with two staff with activities of daily living (ADLs). Review of the hospital continuity of care form dated 02/19/21 for Resident #55 revealed the resident was to receive Coumadin three milligram (mg) tablet once per day. Review of admission physician orders for Resident #55 dated 02/19/21 revealed an order for Coumadin three mg once daily. Review of admission…

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, review of the online medication resource Medscape, and policy review the facility failed to ensure the use of antipsychotic medications appropriately. This affected two residents (#55 and #64) of six residents reviewed for unnecessary medications. The census was 63. Findings include: 1. Review of the medical record for Resident #55 revealed an admission date of 02/19/21 and a diagnosis of cerebral infarction. Review of the face sheet for Resident #55 revealed resident was [AGE] years of age. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively impaired, required extensive assistance with two staff with activities of daily living (ADLs), was coded negative for the presence of behavioral symptoms, received antipsychotic medication on seven out of seven days during the review period, and was not coded for any psychiatric diagnoses. Review of the May 2021 physician orders for Resident #55 revealed an order for the antipsychotic…

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, review of the hospital records, staff interview, review of online medication resource Medscape, and policy review, the facility failed to administer anticoagulant medication as ordered by the physician resulting in a significant medication error. This affected one resident (#55) of six residents reviewed for unnecessary medications. The census was 63. Findings include: Review of the medical record for Resident #55 revealed an admission date of 02/19/21 and a diagnosis of cerebral infarction. Review of the MDS for Resident #55 dated 03/05/21 revealed the resident was cognitively impaired and required extensive assistance with two staff with activities of daily living (ADLs). Review of the hospital continuity of care form dated 02/19/21 for Resident #55 revealed the resident was to receive Coumadin three milligram (mg) tablet once per day. Review of admission physician orders for Resident #55 dated 02/19/21 revealed an order for Coumadin three mg once daily. Review of admission note…

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 facility documents and policy, the facility failed to provide resident with a snack when he went to outpatient dialysis treatments. This affected one resident (#3) of one reviewed for dialysis. The census was 63. Findings include: Review of the medical record revealed Resident #03 was admitted to the facility on [DATE]. Diagnosis included end stage renal disease (ESRD). Review of the Minimum Data Set (MDS) for Resident #03 revealed resident was cognitively impaired and required supervision with activities of daily living (ADLs). Review of the physician order for Resident #03 dated 05/28/19 revealed the resident attended dialysis three times weekly on Tuesday, Thursday, and Saturday. Review of the care plan for Resident #03 dated 10/30/20 revealed resident was at nutritional risk related to ESRD and required hemodialysis three times weekly and was underweight. Interventions included the facility would provide the resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, review of the dietary tray card, and staff interview, the facility failed to ensure that each resident's medical record contained accurately documented information regarding nutritional supplements ordered and provided, skin care documented, and care planned advanced directive information. This affected three (#33 and #169) residents of 26 resident records reviewed. Findings include: 1. Resident #33 was admitted to the facility on [DATE] with diagnoses including vascular dementia with behavioral disturbance, bipolar disorder, hemiplegia, major depressive disorder, muscle weakness, peripheral vascular disease, diabetes mellitus type 2, rheumatoid arthritis, hypertension, and heart failure. Review of a quarterly minimum data set assessment completed for the resident dated 01/29/21 revealed the resident had severe cognitive impairment, and required extensive to total assistance of staff to completed all activities of daily living. Review of the resident's physician…

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 interview the facility failed to ensure a resident had a working call light. This affected one (#215) of 26 residents reviewed. The facility census was Findings include: Review of the medical record revealed Resident #215 was admitted to the facility on [DATE]. Diagnoses included heart failure and dementia. Review of Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment and required extensive assistance for all activities of daily living except eating, which he only required supervision of one person. Observation on 05/03/21 at 10:05 A.M. revealed Resident #215 was yelling for help from his room. At 10:15 A.M., Resident #215 turned the call light on however, the light on the outside of the door would not light up. Interview on 05/03/21 at 10:20 A.M., State Tested Nursing Assistant (STNA) #365 verified the call light over Resident #215's door was not working. Interview on 05/05/21 at 9:10 A.M., STNA #730 verified the call light…

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 personnel file review, education record review and staff interview, the facility failed to ensure adequate nurse aide in-servicing was provided based on performance review. This had the potential to affect all 87 residents residing in the facility. Findings include: Review of personnel file for State Tested Nursing Assistant (STNA) #10 revealed a hire date of 01/30/04. Further review of the personnel file for STNA #10 revealed the employee had a satisfactory annual performance review on 02/01/19. Review of the education records for STNA #10 revealed the employee had only one hour of in-service education in a 12 month period from February 2018 through February 2019. Interview with Human Resources Director #227 on 03/06/19 at 1:54 P.M. confirmed STNA #10 had only one hour of in-service education in a 12 month period from February 2018 through February 2019.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. Review of the medical record revealed Resident #25 was admitted on [DATE]. Diagnoses included chronic kidney disease, schizoaffective disorder, diabetes mellitus, morbid obesity, antisocial personality disorder, diabetic neuropathy, conversion disorder, chronic obstructive pulmonary disease, delusional disorders, heart failure, mastopathy of unspecified breast, chronic respiratory failure with hypoxia, bipolar disorder. Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition, displayed no verbal or physical behavioral symptoms or rejection of care, and required supervision for activities of daily living (ADL's). Further review of Resident#25's medical record revealed the pharmacist conducted monthly regimen reviews from 10/2018 through 02/2019. The medical record contained no evidence that the pharmacist reviewed the resident's drug regimen from admission [DATE] through 09/2018. Interview on 03/06/19 at 5:11 PM, the DON verified the medical record contained no evidence…

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 interview, observation, resident and staff interview and facility policy review the facility failed to ensure a resident was treated in a dignified manner in regards to leaving a hospital bracelet on. This affected one Resident (#67) of one reviewed for dignity. The facility census was 87. Findings include: Review of the medical record revealed Resident #67 was admitted to the facility on [DATE] with the following diagnoses; non traumatic subarachnoid hemorrhage, acquired absence of other organs, unspecified intracranial injury with loss of consciousness of unspecified duration, other acquired deformity of head, major depressive disorder, gastro-esophageal reflux disease without esophagitis, hypertension, neurovascular disease, brief psychotic disorder, pedestrian injured in unspecified traffic accident, pulmonary embolism, cocaine abuse and peripheral vascular disease. Review of Resident #67's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident was cognitively intact…

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 fund account review and staff interview, the facility failed to notify Medicaid residents when the amount in their resident's funds account reached 200 dollars of the eligibility limit. This affected two (#29 and #75) of five residents reviewed for resident funds accounts. The facility census was 87 Findings include: 1. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with the following diagnoses; altered mental status, dysphagia, protein calorie malnutrition, personal history of traumatic brain injury, psychosis, acute respiratory failure with hypoxia, essential hypertension, acute and subacute endocarditis, gastrostomy status, chronic kidney disease, muscle weakness, anemia, atherosclerotic heart disease of native coronary artery without angina pectoris and dementia without behavioral disturbance. Review of Resident #29's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident had severe cognitive…

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, hospital record review, observation, staff interview and facility policy review, the facility failed to notify each resident's physician when there was a significant weight loss and a need to alter nutrition interventions. This affected one Resident (#65) of five reviewed for nutrition. The facility census was 87. Findings include: Review of the medical record revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including vascular dementia with behavioral disturbance, pneumonia, diabetes mellitus type 3, old myocardial infarction, cerebral infarction, hypertension, conversion disorder with seizures and convulsion, weakness, bipolar disorder, dysphagia following cerebral infarction, and encounter for attention to gastrostomy. Review of the minimum data set (MDS) dated [DATE] identified the resident as having short term and long term memory problems, severely impaired cognitive skills, and requiring the physical assistance of one to two staff persons 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, observation and resident and staff interview, the facility failed to ensure the heat in a resident's room was working and the temperature was maintained to provide comfort to the resident. This affected one Resident (#51) of 24 residents reviewed for comfortable room temperatures. The facility census was 87. Findings include: Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with the following diagnoses; diabetes mellitus due to underlying condition with diabetic neuropathy, malignant neoplasm of the bladder, hypertension, symbolic dysfunctions, difficulty in walking, unspecified focal traumatic brain injury without loss of consciousness, hyperlipidemia and intestinal malabsorption. Review of Resident #51's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required limited assistance with bed mobility, toileting and personal hygiene. Resident #51 also required supervision with eating,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews, and facility policy review the facility failed to notify the ombudsman of discharges from the facility. This affected three Resident's (#24, #62 and #65) of five residents reviewed for discharge notification. The facility census was 87. Findings include: 1. Review of the medial record revealed Resident #24 was admitted to the facility on [DATE] with the following diagnoses; hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, muscle spasm, chronic pain, generalized osteoarthritis, personal history of malignant neoplasm of breast, contracture, major depressive disorder, cognitive communication deficit, allergic rhinitis, gastro esophageal reflux disease without esophagitis, epilepsy, dysphagia, cerebrovascular disease, muscle weakness, biliary acute pancreatitis with infected necrosis and hyperlipidemia. Review of Resident #24's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident 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 medial record review, observation, and resident and staff interview, the facility failed to ensure resident medications and mobility statuses were accurately coded on the Minimum Data Set (MDS) assessment. This affected two Resident's (#8 and #68) of 18 residents reviewed for accuracy of assessments. The facility census was 87. Findings include: 1. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with the following diagnoses; hypovolemia, atrial fibrillation, cerebral infarction, weakness, fall, hemiplegia and hemiparesis, mixed hyperlipidemia, major depressive disorder, collapsed vertebra, wedge compression fracture of first lumbar vertebra, low back pain and hypertension. Review of Resident #8's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, dressing, toileting and personal hygiene. Resident #8 also required supervision with eating and total dependence…

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, shower documentation review, and resident and staff interviews, the facility failed to ensure a comprehensive care plan was implemented for resident bathing and skin care needs. This affected two Resident's (#24 and #32) of 18 residents reviewed for care planning. The facility census was 87. Findings include: 1. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with the following diagnoses; gastro esophageal reflux disease without esophagitis, epilepsy, dysphagia, major depressive disorder, chronic pain., hemiplegia and hemiparesis, muscle spasm, muscle weakness, contracture cerebrovascular disease, primary generalized osteoarthritis, personal history of malignant neoplasm of breast, allergic rhinitis, hyperlipidemia and biliary acute pancreatitis with infected necrosis. Review of Resident #24's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required total dependence with bed…

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 resident and staff interview, the facility failed to ensure resident bathing and nutritional care plans were reviewed and revised. This affected two Resident's (# 65 and #78) of 18 residents reviewed for care planning. The facility census was 87. Findings include: 1. Review of the medical record review revealed Resident #78 was admitted to the facility on [DATE] with the following diagnoses; hypothyroidism, secondary hypertension, pain, change in bowel habit, nausea, migraine without aura, major depressive disorder and allergy unspecified. Review of Resident #78's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment and required extensive assistance with bed mobility and transfers. Resident #78 also required total dependence with personal hygiene, toileting and dressing and supervision with eating. Further review of the MDS revealed the resident required total dependence with a two plus person assistance…

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, shower documentation review, resident and staff interview, and facility policy review the facility failed to ensure residents were provided adequate assistance with activities of daily living (ADL) related to bathing. This affected three Resident's #24, #25 and #78 of three reviewed for ADL's. The facility census was 87. Findings include: 1. Review of the medical record revealed Resident #24's was admitted to the facility on [DATE] with the following diagnoses; gastro esophageal reflux disease without esophagitis, epilepsy, dysphagia, major depressive disorder, chronic pain., hemiplegia and hemiparesis, muscle spasm, muscle weakness, contracture cerebrovascular disease, primary generalized osteoarthritis, personal history of malignant neoplasm of breast, allergic rhinitis, hyperlipidemia and biliary acute pancreatitis with infected necrosis. Review of Resident #24's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required…

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 interviews, the facility failed to ensure each resident received adequate care for an existing skin condition, and for proper positioning when seated in a wheel chair. This affected two Residents (#29 and #32) of 22 residents reviewed for quality of care. The facility census was 87. Findings include: 1. Review of the medical record revealed Resident #32 was admitted to the facility in March of 2014 with current diagnoses including dementia without behavioral disturbance, cerebral infarction, hyperlipidemia, hypertension, hemiplegia, anemia, expressive language disorder, and other specified disorder of bone density and structure. Review of the minimum data set assessment (MDS) dated [DATE] identified the resident as having short and long term memory problems, severely impairer cognitive skills, and requiring the physical assistance of at least one staff person for all activities of daily living. the resident had limitations in her range of motion on one side…

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 ensure each resident received timely interventions to address significant weight loss and maintain acceptable parameters of nutritional status. This involved one Resident (#65) of five residents reviewed for nutrition. The facility census was 87 Findings include: Review of the medical record revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including vascular dementia with behavioral disturbance, pneumonia, diabetes mellitus type 3, old myocardial infarction, cerebral infarction, hypertension, conversion disorder with seizures and convulsion, weakness, bipolar disorder, dysphagia following cerebral infarction, and encounter for attention to gastrostomy. Review of the minimum data set (MDS) dated [DATE] identified the resident as having short term and long term memory problems, severely impaired cognitive skills, and requiring the physical assistance of one to two staff persons to complete all…

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, review of employee files, review of staff inservice records, review of facility policy, and review of Centers for Disease Control (CDC) guidelines the facility failed to ensure a resident's tracheostomy care was performed in a manner consistent with professional standards and that appropriate signage was posted on the doors of resident's rooms where oxygen was stored or in use in a facility that permits smoking on the premises. This affected one (#7) of one resident the facility identified as requiring tracheostomy care and two (#25 and #233) of eight residents the facility identified as using oxygen. The facility census was 87. Findings include: 1. Review of the medical record revealed Resident #7 was admitted [DATE] with diagnoses including including chronic respiratory failure, osteoporosis with pathological fracture, gastrostomy, tracheostomy, effusion of unspecified knee, joint contracture, chronic obstructive pulmonary disease, asthma, heart…

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 facility had sufficient staff to perform bathing services. This affected three Resident's (#24, #25 and #78) of 18 residents reviewed for staffing. The facility census was 87. Findings include: 1. Review of the medical record revealed Resident #24's was admitted to the facility on [DATE] with the following diagnoses; gastro esophageal reflux disease without esophagitis, epilepsy, dysphagia, major depressive disorder, chronic pain., hemiplegia and hemiparesis, muscle spasm, muscle weakness, contracture cerebrovascular disease, primary generalized osteoarthritis, personal history of malignant neoplasm of breast, allergic rhinitis, hyperlipidemia and biliary acute pancreatitis with infected necrosis. Review of Resident #24's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required total dependence with bed mobility, transfers, dressing, and toileting. Resident #24 also…

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, review of employee files, review of staff inservice records, review of facility policy, and review of Center for Disease Control (CDC) guidelines the facility failed to ensure a resident's tracheostomy care was performed in a manner consistent with professional standards. This affected one (#7) of one resident the facility identified as requiring tracheostomy care. The facility census was 87. Findings include: Review of the medical record revealed Resident #7 was admitted [DATE] with diagnoses including including chronic respiratory failure, osteoporosis with pathological fracture, gastrostomy, tracheostomy, effusion of unspecified knee, joint contracture, chronic obstructive pulmonary disease, asthma, heart failure, kidney failure, anemia, hemiplegia left side, aphasia, dysphagia, diabetes mellitus with diabetic neuropathy, specified cardiac arrhythmias, and persistent vegetative state. Review of the quarterly Minimum Data Set (MDS) 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 ensure staff attempted non pharmacological interventions prior to the administration of a pain medication. This affected one Resident (#8) of six reviewed for unnecessary medications. The facility census was 87. Findings include: Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with the following diagnoses; hypovolemia, atrial fibrillation, cerebral infarction, weakness, fall, hemiplegia and hemiparesis, mixed hyperlipidemia, major depressive disorder, collapsed vertebra, wedge compression fracture of first lumbar vertebra, low back pain and hypertension. Review of Resident #8's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, dressing, toileting and personal hygiene. Resident #8 also required supervision with eating and total dependence with transfers. Per the MDS the resident received one…

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 ensure resident's receiving psychotropic medications had adequate indications for use, and received monitoring for possible side effects. This affected two Residents (#54 and #70) of seven residents reviewed for unnecessary medications. The facility census was 87. Findings include: 1. Review of the medical record revealed Resident #70 was admitted to the facility on [DATE] with current diagnoses of major depressive disorder recurrent moderate, dementia without behavior disturbance, gastro-esophageal reflux disease, glaucoma, hyperlipidemia, diabetes mellitus, and alcohol abuse. Review of a quarterly minimum data set (MDS) assessment dated [DATE] identified the resident as having significant memory and recall problems, but without hallucinations, delusions, or behaviors. The resident required the physical assistance of at least one nursing staff person to complete all activities of daily living with the exception of 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 observation, staff interview, review of list of residents and review of the facility's medication storage policy, the facility failed to ensure a resident's medications were given and stored in a secured manner. This affected one Resident (#14) who was observed with loose medications in his room. The facility identified two Residents (#12 and #54) as being cognitively impaired and independently mobile residents on the second floor. The facility census was 87. Findings include: Review of the medical record for Resident #14 revealed the resident was admitted on [DATE]. Diagnosis included hypertension, diabetes mellitus, dementia, hyperlipidemia, manic schizophrenia, and asthma. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had severe impaired cognition. During observation of medication administration on 03/06/19 at 9:17 A.M. with Licensed Practical Nurse (LPN) #34, revealed various loose medications inside a residents room. When LPN #34 entered residents room to administer 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 and staff interview, the facility failed to ensure a resident's Medication Administration Record (MAR), Treatment Administration Record (TAR) and dialysis documentation was complete and accurate in his medical record. This affected one Resident (#62) of 18 residents reviewed for complete and accurate medical records. The facility census was 87. Findings include: Review of the medical record revealed Resident #62 was admitted to the facility on [DATE] with the following diagnoses; chronic kidney disease, paraplegia, pressure ulcer of other site, colostomy status, neuromuscular dysfunction of bladder, cardiac arrhythmia, pyoderma, disorder of kidney and ureter, gastro esophageal reflux disease without esophagitis and acquired absence of unspecified leg above knee. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required supervision with bed mobility, transfers, eating, dressing, toileting and personal hygiene.…

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, review of facility policy, review of Centers for Disease Control guidelines and review of facility census of the second floor the facility failed to ensure a resident's tracheostomy care was performed in a manner to limit the risk of infection. This affected one (#7) of one resident the facility identified as requiring tracheostomy care. The facility also failed to secure and dispose of used disposable razors in a manner that promoted infection control. This had the potential to affect eight Residents (#14, #18, #27, #51, #53, #58, #60 and #284) whom the facility identified as being independent with showers on the second floor. The facility census was 87. Findings include: 1. Review of the medical record revealed Resident #7 was admitted [DATE] with diagnoses including including chronic respiratory failure, osteoporosis with pathological fracture, gastrostomy, tracheostomy, effusion of unspecified knee, joint contracture, chronic obstructive pulmonary…

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 resident and staff interview, the facility failed to ensure resident's call lights were functioning to allow residents them to call staff for assistance. This affected one (#235) of 24 residents reviewed for call light function. The facility census was 87. Findings include: Review of the medical record revealed Resident #235 was admitted on [DATE] with diagnoses including cerebrovascular vascular disease, fracture of right tibia legal blindness, muscle wasting, and need for assistance with personal care. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The assessment documented the resident was dependent on staff for activities of daily living including one-person extensive assistance for bed mobility, dressing, and toilet use; and required two-person extensive assistance for transfers. Review of the care plan dated 02/06/19 revealed Resident #235 had a self-care deficit related to fracture 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.