Norwood Towers Post-Acute

Based on observation, staff interview, and policy review, the facility failed to ensure food was stored in a manner to prevent the potential spread of foodborne illness. This had the potential to affect 108 out of 111 residents in the facility who received food from the kitchen. The facility identified three residents (#9, #17 and #89) who did not receive food from the kitchen. The facility census was 111. Findings include: Initial tour of kitchen on 12/01/25 at 8:30 A.M. with Dietary Supervisor (DS) #272 revealed several issues with food storage in the dry storage area, the walk-in refrigerator, the walk-in freezer as well as the first floor, the second floor, and the third floor kitchenette refrigerators. Observation on 12/01/25 at 8:43 A.M. of dry storage area with DS #272 revealed a bag of undated and open to air flour tortillas and undated pasta. DS #272 confirmed the open to air and undated tortillas and the undated pasta. Observation on 12/01/25 at 9:02 A.M. of the walk-in refrigerator with DS #272 revealed three individual serving sized yogurts with expiration dates 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 observation, staff interviews, and policy review, the facility failed to provide a homelike environment. This affected seven (#114, #47, #25, #50, #17, #71, and #73) out of seven residents reviewed for the environment. In addition, the facility failed to ensure the elevator was clean and had appropriate lighting. This had the potential to affect any resident who used the elevator. Additionally, the facility failed to ensure the memory care unit (MCU) was free from odors. This had the potential to affect all residents who resided in rooms 251, 252, 253, 254, 255, 256, 257, 258, and 259. The facility census was 111.Findings included:Observation of Resident #17's room on 12/01/25 at 11:12 A.M. revealed his tube feeding pole had a dried brownish substance running down the pole. His blind on the window was broken. The privacy curtain that was in the room had brown spots on it. Interview with the certified nursing assistant (CNA) #279 on 12/01/25 at 11:19 A.M. confirmed the tube feeding pole was dirty and had not been cleaned in some time. She confirmed the blind was broken and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff and resident interviews and review of facility policy, the facility failed to provide privacy and dignity for three (Residents #39, #94, and #100) out of seven residents reviewed for dignity. The facility census was 111. Based on medical record review, observation, staff and resident interview and policy review, the facility failed to provide privacy and dignity for three (Residents #39, #94, and #100) out of seven residents reviewed for dignity. The facility census was 111. Findings Included: 1. Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with diagnoses of asthma, anorexia, major depressive disorder, and dementia. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed that Resident #39 had moderate cognitive impairment and required setup and clean-up assistance for meals, partial to moderate assistance for bathing, and was dependent for toileting, personal hygiene, dressing upper and lower body, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to notify the physician, registered dietician, and resident's representative when Resident #24 had a change of condition. This affected one resident (#24) out of three residents reviewed for change of condition. The facility census was 111.Based on record review, staff interview, and policy review, the facility failed to notify the physician, the registered dietician, and the resident's representative when Resident #24 had a change of condition. This affected one resident (#24) out of three residents reviewed for change of condition. The facility census was 111.Findings include:Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease with late onset, aphasia and protein-calorie malnutrition. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #24 had severe cognitive impairment and was frequently incontinent of bowel and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, Minimum Data Set (MDS) review, staff interview, review of the Resident Assessment Instrument (RAI) manual, and policy review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) was completed when a resident received a new diagnosis of bipolar disorder and when a resident had a severe weight loss. This affected two (Residents #3 and #24) of three residents reviewed for a significant change in condition. The facility census he was 111.Based on medical record review, staff interview, review of the Resident Assessment Instrument (RAI) manual, and policy review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) was completed when a resident received a new diagnosis of bipolar disorder and when a resident had a severe weight loss. This affected two (Residents #3 and #24) of three residents reviewed for a significant change in condition. The facility census he was 111. Findings include: 1. Review of the medical record 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 and staff interview, the facility failed to ensure residents with newly evident or possible serious mental disorders were referred for level II resident review upon a significant change in status assessment. This affected one (Resident #3) of four residents reviewed for pre-admission screening and resident review (PASARR). The facility census was 111.Based on record review and staff interview, the facility failed to ensure residents with newly evident or possible serious mental disorders were referred for level II resident review upon a significant change in status assessment. This affected one (Resident #3) of four residents reviewed for pre-admission screening and resident review (PASARR). The facility census was 111.Findings include: Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of Guillain Barre Syndrome, abnormalities of gait and mobility, long term drug therapy, obesity, asthma, malnutrition, respiratory failure, 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, Pre-admission Screening and Resident Review (PASARR) review, staff interviews, and policy review, the facility failed to make notification to the state mental health agency for a significant change in mental health diagnosis for one (Resident #3) of three residents reviewed for notification of change process. The facility census was 111.Based on medical record review, Pre-admission Screening and Resident Review (PASARR) review, staff interviews, and policy review, the facility failed to make notification to the state mental health agency for a significant change in mental health diagnosis for one (Resident #3) of three residents reviewed for notification of change process. The facility census was 111.Findings include:Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of Guillain Barre Syndrome, abnormalities of gait and mobility, long term drug therapy, obesity, asthma, malnutrition, respiratory failure, pulmonary edema, spinal…

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, resident interview, and policy review, the facility failed to ensure residents were provided with necessary assistance for Activities of Daily Living (ADL's). This affected three (Residents #17, #73 and #76) of five residents reviewed for ADL's. The facility census was 111. Based on medical record review, staff interview, resident interview, observation, and policy review, the facility failed to ensure residents were provided with necessary assistance for Activities of Daily Living (ADL's). This affected three (Residents #17, #73 and #76) of five residents reviewed for ADL's. The facility census was 111. Findings included: 1.Medical record review for Resident #17 revealed an admission date of 08/13/24. Medical diagnoses included diabetes, cerebrovascular attack, dysphagia, cognitive communication deficit, and gastrostomy. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #17 was severely cognitively impaired. Functional status 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 observations, medical record review, staff and resident interviews, and policy review, the facility failed to ensure residents were safely smoking on the facility property. This affected two (#47 and #103) of two residents reviewed for smoking. The facility identified there were fifteen residents who required assistance with smoking. The facility census was 111. Findings include: 1. Review of the medical record for Resident #103 who revealed an admission date 08/09/22. Diagnoses included mood affective disorder, major depressive disorder, anxiety disorder, bipolar disorder, and prediabetes. Review of the smoking observation and assessment dated [DATE] revealed Resident #103 had smoking device use was cigarettes, was cognitive impaired, and had visual impairment. Resident #103 had dexterity impairments. Resident #103 can light his own smoking device. Smoking adaptive equipment needed was smoking apron. Level of assistance during smoking revealed supervision was required. Review of the plan of care dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, resident and staff interviews, and review of the facility policy, the facility failed to ensure the resident's medications were properly stored. This affected one (Resident #100) of 37 residents reviewed for medication storage. The facility census was 111.Findings include: Medical record review revealed Resident #100 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #100 had intact cognition. The medical record, including physician orders, assessments, and plan of care, revealed Resident #100 had not been assessed or approved for self-administration of medications. Observation and interview on 12/02/25 at 9:42 A.M. with Resident #100 revealed a plastic cup containing various colored medications sitting in front of Resident #100 on the overbed table along with a cup of water. There was no labeling on the cup with the various colored medications. Resident #100 revealed he often consumed 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, interview, and facility policy review, the facility failed to ensure the call light was within reach for three (#22, #39, and #84) out of 25 residents reviewed. The facility census was 111. Findings Included: 1. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, seizures, epilepsy, hemiplegia, and dementia. Review of Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed that Resident #22 had severe cognitive impairment and required setup or clean-up assistance for eating, oral care, bathing, dressing upper body, dressing lower body, putting on and off feet, and personal hygiene. Review of the plan of care for Resident #22 dated 10/20/25 revealed Resident #22 was at risk for activity of daily living self-care performance deficit and required staff supervision for ambulation, assist one person for morning and evening care, encouraged to participate in care to promote independent,…

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, resident and staff interviews, medical record review, and review of the facility policy, the facility failed to ensure medications were not left at the bedside in a secured memory care unit. This affected one (Resident #9) of two residents reviewed for accidents. The facility identified 27 residents (#6, #10, #12, #13, #17, #20, #21, #23, #26, #30, #33, #37, #40, #44, #45, #52, #58, #66, #67, #72, #73, #81, #92, #93, #97, #99, and #100) who were cognitively impaired and independently mobile on the secured unit. The facility census was 110. Findings include: Review of the medical record for Resident #9 revealed an admission date of 05/30/23. Diagnoses included convulsions, schizoaffective disorder, mood disorder, vascular dementia, major depressive disorder, personal history of traumatic brain injury, and hypertension. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was cognitively intact. Resident #9 required supervision/touching assistance for activities…

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 medications were stored in a proper and safe manner. This had the potential to affect all residents in the facility except the 40 residents residing on the secure unit. The facility census was 110. Findings include: 1. Observation of the medication storage room on the third floor of the facility on 06/26/24 at 2:46 P.M. with Licensed Practical Nurse (LPN) #526 revealed the door was unlocked and accessible to anyone. The medication storage room had the following expired medications: two bottles of aspirin 81 milligrams (mg) with expiration date of 01/2024, a bottle of Senna plus with expiration date of 06/2024, but written in black ink on the bottle was 04/06/23. The inner seal had been removed. A bottle of stool softeners with expiration date of 08/2023. The room designated as the nurse's station on the third floor was unable to be locked. LPN #526 retrieved a grey plastic bag of medications from under the desk. The bag held numerous daily medication packs for the residents on the third floor 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 observations, resident and staff interviews, medical record review, and policy review, the facility failed to ensure a resident who was dependent on staff for personal hygiene received adequate nail care. This affected one (Resident #78) of six residents reviewed for activities of daily living (ADLs). The facility census was 110. Findings include: Review of the medical record for Resident #78 revealed an admission date of 05/30/23. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, type II diabetes mellitus, anxiety, schizophrenia, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #78 had intact cognition and was dependent on staff for personal hygiene. Resident #78 did not refuse care during the assessment period. Review of the care plan dated 06/01/23 revealed Resident #78 had an ADL self-care performance deficit related to activity intolerance, disease process, fatigue, hemiplegia, impaired balance, and stroke.…

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 timely act on pharmacy recommendations. This affected two (Residents #16 and #32) of five residents reviewed for unnecessary medications. The facility census was 110. Findings include: 1. Review of the medical record for Resident #32 revealed an admission date of 07/06/23. Diagnosis included migraine. Review of the document titled Note to Attending Physician/Prescriber dated 02/19/24 revealed a recommendation to include the phrase a maximum daily dose of 30 milligrams (mg) per 24 hours be added to the order for Rizatriptan Benzoate 10 mg tablet for migraine and give 10 mg by mouth every two as needed for migraine. May repeat after original dose in two hours as needed. The option of agree was indicated and the document was signed on 02/23/24. Review of the medication administration record (MAR) and physician orders from 02/23/24 to 06/25/24 revealed the phrase a maximum daily dose of 30 milligrams (mg) per 24 hours had not been added 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 observation, medical record review, staff interview, review of facility policy, and review of Centers for Disease Control (CDC) guidelines, the facility failed to ensure newly admitted residents were quarantined when indicated and proper precautions implemented, as well as not ensuring personal protective equipment (PPE) was readily available. Additionally, the facility failed to ensure residents were encouraged to remain socially distant during activities and smoking to prevent the potential spread of Covid-19. This had the potential to affect all 75 residents of the facility. Findings include: 1. Review of the medical record revealed Resident #125 was admitted to the facility on [DATE]. Diagnoses included urinary tract infection, paranoid schizophrenia, schizoaffective disorder, and major depressive disorder. Review of immunization records for Resident #125 failed to reveal if the resident had received the Covid-19 vaccine. Review of Resident #125's physician's orders revealed no evidence the need 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 review of Resident Council Meeting notes, resident interview, review of response forms, and staff interview, the facility failed to provide specific and appropriate resolution to resident concerns expressed during the meetings. The had the potential to affect 12 residents (#63, #41, #70, #54, #122, #30, #34, #60, #44, #23, #35 and #41) who attended the meetings in 2021. The facility census was 75 residents. Findings include: Review of the Resident Council meetings conducted in 2021 and response forms revealed: -On 01/20/21 resident #63 requested more activities. Residents #41 and #70 had concerns about the food quality and variety. There was no evidence of a response to address the resident's concerns. -On 2/18/21 resident #122 had complaints about her meals, wanted more activity crafts and did not like the way staff talked to her. Resident #34 had some missing clothing in the laundry and would like some different snacks. Resident #30 had clothing missing in the laundry. The response to this meeting revealed menu ideas were brainstormed and labeling ideas for clothing was…

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

Based on review of the facility's surety bond, review of the resident personal fund trust account balance, and staff interview, the facility failed to ensure the amount of the resident funds surety bond was sufficient to assure the security of the amount of the resident's funds deposited with the facility. This had the potential to affect all 54 residents (#35, #59, #03, #17, #21, #45, #48, #53, #05, #54, #47, #04, #38, #32, #44, #46, #50, #06, #27, #63, #57, #40, #25, #60, #26, #58, #61, #10, #41, #09, #30, #19, #16, #62, #68, #28, #64, #07, #322, #18, #66, #55, #42, #67, #29, #69, #33, #11, #13, #20, #08, #71, #31, and #02) who had authorized the facility to manage their personal funds. The facility census was 75. Findings include: Review of Resident personal funds with Business Office Manager (BOM) #75 on 05/24/21 at 11:26 A.M. revealed there was a solitary trust account for both the residents of the nursing facility and the adjoining licensed residential care facility. The total amount of the resident funds being managed as of 05/18/21 was $241,214.57. Review of the facility's…

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

Based on observation, staff interview, resident interview, and review of facility policy, the facility failed to provide each resident with housekeeping and/or maintenance services necessary to maintain a sanitary and orderly environment to ensure protection of one resident's personal belongings from loss. This affected 12 residents (#7, #68, #59, #30, #27, #28, #67, #29, #47, #14, #71, and #32) of 12 residents reviewed for environment. The facility census was 75. Findings include: 1. A tour of the first floor of the facility was conducted with Maintenance Director (MD) #08 on 05/19/21 at 11:13 A.M. While touring the first floor the following was observed: a) In the private room occupied by Resident #7 revealed a substantial accumulation of dust, dirt, paper and plastic debris on the floor behind and to the left and right of the head of the resident's bed. There were what appeared to be numerous dried on splashes of liquid debris on the walls to the left and right of the resident's television, and on the wall where the window was. The frame and padding of the resident's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record reviews, staff interview, resident interview, and facility policy review, the facility failed to provide bed hold notices for residents sent to the hospital. This affected five residents (#6, #7, #75, #122, and #322) of seven reviewed for bed hold notifications. The facility census was 75. Findings include: 1. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, tracheostomy, and anoxic brain damage. The record revealed Resident #6 was transferred to the hospital on [DATE] and 04/30/21. There was no evidence the resident or resident's representative was given a bed hold notice on either date of being transferred to the hospital. 2. Medical record review revealed Resident #322 was admitted to the facility originally on 12/01/17, with diagnoses including Covid-19, Chronic Obstructive Pulmonary Disease (COPD), end stage renal disease, stage 5, and heart failure. Further review of Resident #322's medical record…

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 Pharmacy Consultation Reports, and staff interview, the facility failed to act upon pharmacy recommendations for the gradual dose reduction (GDR) and discontinuation of anxiety medications. This affected three residents (#16, #32, and #42) of five reviewed for unnecessary medications. The facility census was 75. Findings include: 1. Medical record review revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including acute kidney failure, altered mental status, dementia, anxiety, and and psychosis. Review of Resident #16's physician orders dated 07/08/20 revealed an order for Ativan 0.5 milligrams (mg) every 12 hours as needed, for severe agitation related to unspecified dementia with behavioral disturbance. Review of repeated Pharmacy Consultation Report dated 07/15/20, 09/02/20, 11/27/20, 02/18/21, and 04/14/21, revealed to please discontinue as needed Ativan. If medication cannot be discontinued at this time, current regulations require that the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy review, the facility failed to ensure when a resident formulated an advanced directive it 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 one resident (#68) of one reviewed for Advanced Directives. The facility census was 75. Findings include: Medical record review revealed Resident #68 was admitted to the facility on [DATE] with diagnoses including schizophrenia, diabetes mellitus type 1, anxiety disorder, anemia, neuropathy, and obesity. Review of Resident #68's five day Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. Review of Resident #68's current physician orders in the electronic health record (EHR) revealed an order for the resident to be Full code. Review of the hard paper record for Resident #68 revealed no evidence of the designation of the resident's code status on the front of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff and resident interview, the facility failed to develop and/or implement a comprehensive plan of care for each resident for assessed problems/needs relating to urinary incontinence, activities of daily living (ADLs), contractures, and the need to reside on a secured unit. This affected three residents (#68, #7, #29) of 31 reviewed for care plans. The facility census was 75. Findings include: 1. Medical record review revealed Resident #68 was admitted to the facility on [DATE] with diagnoses including schizophrenia, diabetes mellitus type 1, anxiety disorder, anemia, neuropathy, and obesity. Review of Resident #68's admission incontinent assessment completed on 02/22/21 revealed the resident as being incontinence of urine at night time only, both urge and stress mixed incontinence, and that the resident had some incontinence and wore a pull up brief at night. Review Resident #68's care area assessment (CAA) dated 03/04/21 revealed the resident as being incontinent…

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 a resident with a limited range of motion received appropriate treatment and services, including splinting, to improve and/or prevent further decline in range of motion (ROM). This affected one resident (#7) of one reviewed for ROM. The facility census was 75. Findings include: Medical record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, intracranial injury, quadriplegia, spastic hemiplegia affecting left dominant side, contracture left hand, and muscle wasting. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had moderately impaired cognitive skills. He was non verbal, however able to make his basic needs known via gestures/nodding. The resident was totally dependent on staff for all activities of daily living. He was assessed as having functional limitations in both his left and right upper and lower…

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 review of the personnel files and staff interview, the facility failed to provide annual performance evaluations and 12 hours of inservice education for two State Tested Nursing Assistants (STNAs) of four reviewed. The facility census was 75. Findings include: Review of the personnel file for STNA #3 who was hired on 01/20/16 and STNA #17 hired 12/18/13 revealed there was no evidence of an annual evaluation since 01/14/19. Additionally, the STNAs had no evidence of inservice training or education since 01/01/20. Interview with Administrator In Training (AIT) #200 on 05/24/21 at 4:45 P.M. verified STNA #3 and #17 had no evidence of an annual evaluation since 01/14/19. The AIT further verified there was no record STNAs completed inservice training to meet the 12 hour annual requirement since 01/01/20.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interview, the facility failed to ensure a resident received the necessary behavioral health care and services to maintain their highest practicable mental and psychosocial well being. This affected one resident (#68) of one reviewed for behavioral health. The facility census was 75. Findings include: Medical record review revealed Resident #68 was admitted to the facility on [DATE] with diagnoses including schizophrenia, diabetes mellitus type 1, anxiety disorder, anemia, and neuropathy. The resident had resided in the adjoining Residential Care Facility (RCF) prior to being admitted to the facility. Review of an initial psychiatry visit for Resident #68 dated 11/24/20, while she was a resident of the RCF, revealed the psychiatrist who visited with the resident documented the resident had fixed non bizarre delusional beliefs concerning her marriage to a doctor who runs the facility. The psychiatrist diagnosed the resident with delusional disorder, 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.