Pleasant Ridge Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure catheter care and incontinence care was provided correctly to a resident. This affected one (#6) of three residents reviewed for catheter care and one (#6) of one resident reviewed for incontinence care. The facility identified there were four residents who required catheter care. The facility census was 76. Findings include: Medical record review for Resident #6 revealed an admission date of 07/28/23. Diagnoses included quadriplegic from a traumatic spinal cord dysfunction, pressure ulcer to sacral region on admission, and neurogenic bladder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively intact. Resident #6 was dependent on staff for toileting and had an indwelling catheter. Observation on 12/13/23 at 10:04 A.M. revealed State Tested Nursing Aide (STNA) #79 was providing incontinence care to Resident #6. STNA #79 took a wet washcloth 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 observation, medical record review, staff and resident interview, the facility failed to ensure a resident's pain was managed. This affected one (#26) of one resident reviewed for pain. The facility census was 76. Findings include: Medical record review for Resident #26 revealed an admission date of 11/07/22. Diagnoses included cerebrovascular attack with paralysis, diabetes mellitus, and arthritis. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was cognitively intact. Review of the physician's order dated 12/22/22 revealed Buralbital-APAP-Caffeine (also known as Fioricet) oral tablet 50-325-40 milligram (mg) to give one tablet every six hours as needed for migraine headache. Review of the care plan dated 05/03/23 revealed Resident #26 has complaints of acute and chronic pain. Interventions were to observe for pain every shift, provided medication per orders, and monitor for side effects. Review of the progress notes dated 12/03/23 through 12/11/23, 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 observation, medical record review, and resident and staff interview, the facility failed to ensure drinks were available on the meal trays for the residents. This affected two (#6 and #15) of two residents reviewed for meals. The facility census was 76. Findings include: 1. Medical record review for Resident #6 revealed an admission date of 07/28/23. Diagnoses included quadriplegic from a traumatic spinal cord dysfunction and neurogenic bladder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively intact and he was dependent on staff for eating. Interview with Resident #6 on 12/11/23 at 11:05 A.M. revealed the kitchen runs out of juices and coffee at the end of his hall due to it being the last hall in the facility to get served for meals. Observation of the lunch meal service on 12/11/23 at 1:15 P.M. revealed Resident #6's hall was the last to be served. The lunch was delivered to the resident's room at 1:25 P.M. and there wasn't coffee or juice…

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 foods were stored in a manner to prevent the potential spread of foodborne illness. This had the potential to affect all 86 residents in the facility. Findings include: Observation on 08/07/23 at 9:25 A.M. of the facility's walk-in cooler revealed two unlabeled metal pans covered in foil. Culinary Director (CD) #285 present at the time of the observation and identified one pan as pureed eggs and the other as pureed sausage. CD #285 verified neither pan was labeled or dated and stated all foods should be labeled and dated. Observation on 08/07/23 at 9:27 A.M. of the facility's walk-in freezer revealed the following: a. Two boxes of shakes stored directly on the floor. b. A bag of corn open and not sealed nor dated. c. A bag of hamburger patties open and not sealed nor dated. d. A bag of cheese omelets open and not sealed nor dated. e. A plastic pitcher of unidentifiable yellow frozen substance without a label nor date. Interview at the time of the observations, CD #285 verified the two boxes 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, staff interview, and policy review, the facility failed to ensure a baseline care plan was completed within 48 hours of admission. This affected eight residents (#41, #243, #26, #244, #27, #89, #61, and #140) of the eleven residents reviewed for baseline care plans. The facility census was 86. Findings include: 1) Review of the medical record of Resident #26 revealed an admission date of 01/31/23. Diagnoses included cerebral infarction, psychotic disorder with delusions, cocaine abuse, schizophrenia, and bipolar disorder. Review of the quarterly [NAME] Data Set (MDS) assessment 3.0 dated 06/07/23 revealed the resident had moderately impaired cognition. The resident exhibited one to three days of verbal behavioral symptoms directed towards others during the assessment period. The resident required limited assistance of one staff for bed mobility, extensive assistance of two for transfers, extensive assist of one for toileting, and supervision for eating. Review of the 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.

Based on record review, staff interview, and review of the facility policy, the facility failed to provide care conferences to residents/resident representatives to discuss the resident's care plan. This affected four residents (#24, #41, #44, and #67) of the 20 residents sampled. The facility census was 86. Findings include: 1) Review of the medical record for Resident #24 revealed an admission date of 05/18/19 with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), atherosclerotic heart disease, atrial fibrillation, anxiety disorder, polyosteoarthritis, hyperlipidemia, and hypertension (HTN.) Review of the Minimum Data Set (MDS) assessment 3.0 for Resident #24 dated 06/04/23 revealed the resident was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADLs.) Review of the medical record for Resident #24 revealed it did not include documentation of care conferences for the resident from August 2022 to August 2023. Interview with Resident #24 on 08/07/23 at 11:29 A.M. confirmed the facility did…

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 personnel files, staff interview, and review of job descriptions, the facility failed to ensure the services of a qualified Activity Director (AD). This had the potential to affect all residents residing in the facility with the exception of the 42 residents (#1, #3, #5, #7, #9, #11, #13, #15, #21, #22, #23, #26, #30, #31, #32, #34, #35, #39, #40, #41, #42, #44, #47, #50 #52, #61, #62, #64, #67, #68, #71, #72, #73, #75,#80, #84,#140, #240, #241, #243, #243, #244) who the facility identified as not participating in any facility led activities. The facility census was 86. Findings include: Review of personnel record for Interim AD #145, revealed the employee changed positions from that of Activity Assistant (AA) on 05/20/23 to the AD. Review of personnel record for AD #145 revealed employee did not meet the qualifications required of an AD. Interview on 08/09/23 at 9:35 A.M. of Interim AD #145 confirmed she was asked to fill in as Interim AD when the former AD left employment in May 2023. Interim AD #145 confirmed she did not meet the qualifications required of an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, resident interview, staff interview, review of the facility policy, and review of Social Worker (SW) job description, the facility failed to provide medically related social services including provision of written notification of Medicare non-coverage to residents, notification to the Ombudsman of resident transfers to the hospital, arrangement of care conferences, and arranging for the provision of dental services. This affected two residents (#48 and #65) of three residents reviewed for notice of Medicare non-coverage (NOMNC), two (Residents #48 and #88) of two residents reviewed for Ombudsman notification of resident transfers to the hospital, four (Residents #24, #41, #44, and #67) of four residents reviewed for care conference, and two (Residents #24 and #49) of four residents reviewed for dental services. The facility census was 86. Findings include: 1) Review of the medical record for Resident #48 revealed an admission date of 01/17/23 with diagnoses including…

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, resident interview, staff interview, and policy review, the facility failed to honor a resident's request to get out of bed to smoke. This affected one resident (#25) of three residents reviewed for choices. The facility census was 86. Findings include: Review of the medical record for Resident #25 revealed an admission date of 05/05/23. The resident transferred to the hospital on [DATE] and was readmitted to the facility on [DATE]. Diagnoses included vascular dementia, hemiplegia and hemiparesis following cerebral infarction, affecting left non-dominant side, cerebrovascular disease, chronic obstructive pulmonary disease (COPD), congestive heart failure, paraplegia, pulmonary hypertension, and chronic respiratory failure with hypoxia. Review of the quarterly Minimum Data Set (MDS) assessment 3.0 dated 07/25/23, revealed the resident had intact cognition. The resident was assessed as not exhibiting behaviors during the assessment period. The resident required extensive assistance of two…

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

Based on medical record review, staff interview, and policy review, the facility failed to ensure an accurate code status was in the medical records. This affected two residents (#03 and #67) of the 18 residents reviewed for advance directives. The facility census was 86. Findings include: 1) Review of the medical record of Resident #03 revealed an admission date of 05/20/22. Diagnoses included Parkinson's disease and essential hypertension. Further review of the medical record revealed no signed Do Not Resuscitate (DNR) was able to be located. Review of the care plan dated 06/01/23 for Resident #03, revealed the resident was a DNR code status. Review of the quarterly Minimum Data Set (MDS) assessment 3.0 dated 06/07/23 revealed the resident had intact cognition. The resident did not reject care during the assessment period. The resident required extensive assistance of one staff for personal hygiene. Review of a physician's order dated 08/07/23 revealed an order for the resident to be a DNR. No additional information was noted in the order. Further review of physician orders…

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, resident interview, and staff interview, the facility failed to provide required Notification of Medicare Non-Coverage (NOMNC) to two Residents (#48 and #65) of the three residents reviewed for notification to Medicare beneficiaries. The facility census was 86. Findings include: 1) Review of the medical record for Resident #48 revealed an admission date of 01/17/23 with diagnoses including paraplegia and pyogenic arthritis. Review of the Minimum Data Set (MDS) assessment 3.0 for Resident #48 dated 07/11/23 revealed resident was cognitively intact and required extensive assistance with activities of daily living. Review of the form completed by the facility titled Skilled Nursing Facility (SNF) Beneficiary Notice Review revealed Resident #48 had Medicare Part-A service episode starting on 06/13/23 and was discharged from Medicare Part-A services on 07/25/23 with Medicare days remaining. Further review of the form revealed the facility did not provide Resident #48 with Center for Medicare Medicaid Services (CMS) Form SNF Advanced Beneficiary Notice nor CMS Form…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure the Ombudsman was notified when residents were transferred to the hospital. This affected two Residents (#48 and #88) of two residents reviewed for hospitalization. The facility census was 86. Findings include: 1) Review of the medical record of Resident #48 revealed an admission date of 01/17/23. Diagnoses included paraplegia, moderate protein-calorie malnutrition, osteomyelitis of vertebra, sacral, and sacrococcygeal region, generalized anxiety disorder, schizophrenia, major depressive d/o, post-traumatic stress disorder, psychosis, and cachexia. Review of the 5-day Minimum Data Set (MDS) assessment 3.0 dated 07/11/23 revealed the resident had intact cognition. Review of the medical record for Resident #48 revealed the resident discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. There was no documentation to indicate the ombudsman was notified of the resident's transfer. Interview on 08/10/23 at 9:19…

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

Based on medical record review and staff interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed correctly. This affected one resident (#26) of one resident reviewed for PASARRs. The facility census was 86. Findings include: Review of the medical record of Resident #26 revealed an admission date of 01/31/23. Diagnoses included cerebral infarction, psychotic disorder with delusions, cocaine abuse, schizophrenia, and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) assessment 3.0 dated 06/07/23 revealed the resident had moderately impaired cognition. The resident exhibited one to three days of verbal behavioral symptoms directed towards others during the assessment period. The resident required limited assistance of one staff for bed mobility, extensive assistance of two for transfers, extensive assist of one for toileting, and supervision for eating. Review of the Preadmission Screening and Resident Review identification screen dated 03/03/23, revealed the resident was reassessed due to an expiring hospital…

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, interviews, and policy review, the facility failed to develop a comprehensive care plan. This affected one resident (#41) of the 11 residents reviewed for care plans. The facility census was 86. Findings include: Review of the medical record for Resident #41 revealed an admission date of 05/21/23. Diagnoses included Guillian-Barre syndrome, atrial fibrillation, type two diabetes mellitus (DM II), depression, chronic kidney disease, and hypertension. Review of the Quarterly Minimum Data Set (MDS) assessment 3.0 dated 07/17/23 revealed Resident #41 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require independent with transfers, dressing, eating, toileting, and bathing. Review of the medical record for Resident #41 revealed the facility did not complete a comprehensive care plan based on the resident's needs including diabetes and psychotropic medications. Interview on 08/10/23 at 11:03 A.M. with Regional Director of Clinical Operations (RDCO) #510 verified Resident #41 did not have an…

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

Based on record review and staff interview the facility failed to complete a discharge summary of recapitulation of resident's stay for two residents (#49 and #87) of three residents sampled for discharge rights. The facility census was 86. Findings include: 1) Review of the medical record for Resident #49 revealed an admission date of 02/09/23 with diagnoses including cerebral infarction, viral hepatitis, chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), hypertension (HTN), and depression. Review of the Minimum Data Set (MDS) assessment 3.0 for Resident #49 dated 05/26/23 revealed resident was cognitively intact and was independent with activities of daily living (ADLs.) Further review of the MDS for Resident #87 dated 07/28/23, revealed the resident was discharged with a return not anticipated. Review of a nurse's progress note dated 07/28/23 for Resident #49, revealed the resident was discharged from the facility and received education of self-administration of medications. Review of the medical record for Resident #49 revealed it did not include a discharge…

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, and policy review, the facility failed to ensure resident's fingernails were trimmed and clean. This affected two residents (#03 and #61) of four residents reviewed for Activities of Daily Living (ADLs.) The facility census was 86. Findings include: 1) Review of the medical record of Resident #03 revealed an admission date of 05/20/22. Diagnoses included Parkinson's disease and essential hypertension. Review of the quarterly Minimum Data Set (MDS) assessment 3.0 dated 06/07/23 revealed the resident had intact cognition. The resident did not reject care during the assessment period and the resident required extensive assistance of one staff for personal hygiene. Observation on 08/07/23 at 12:24 P.M. revealed Resident #03 was lying in bed. Resident #03's fingernails were observed to extend approximately a half inch beyond his fingertips. Further observation revealed the underside of Resident #03's fingernails was coated in a brown substance. 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.

Based on record review, observation, and staff interview, the facility failed to ensure splints were applied as ordered. This affected one resident (#47) of two residents reviewed for splints/contracture management. The facility identified six residents with contractures. The facility census was 86. Findings include: Review of the medical record for Resident #47 revealed an admission date of 06/18/20 with diagnoses including cerebral infarction (stroke), hemiplegia and hemiparesis, hypertension (HTN), vascular dementia, and major depressive disorder. Review of occupational therapy (OT) discharge note for Resident #47 dated 07/31/21, revealed the resident had a goal to tolerate appropriate positioning device to the right upper extremity (RUE) to reduce further contracture and had progressed in therapy to tolerating eight hours of wearing time per day with no complaints of pain. Review of the physician's order for Resident #47 dated 12/06/21, revealed an order for resident to have RUE resting hand splint donned each day for three to four hours at a time in order to maintain range of…

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

Based on record review, staff interviews, review of fall investigations, and policy review, the facility failed to conduct a thorough fall investigation. This affected two residents (#41 and #48) residents reviewed for falls. The facility census was 86. Findings include: 1) Review of the medical record for Resident #41 revealed an admission date of 05/21/23. Diagnoses included Guillian-Barre syndrome, atrial fibrillation, diabetes mellitus (DM), depression, chronic kidney disease, and hypertension. Review of the Quarterly Minimum Data Set (MDS) assessment 3.0 dated 07/17/23 revealed Resident #41 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to be independent with transfers, dressing, eating, toileting, and bathing. Review of the progress note dated 06/01/23 at 1:32 P.M. revealed Resident #41 had an unwitnessed fall in the shower room. Staff responded to a call light in the shower room where Resident #41 was lying on the floor complaining of right hip and head pain. An assessment was completed. Emergency…

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, interviews, and policy review, the facility failed to have medications available for medication administration of scheduled medications. This affected one resident (#41) of the five residents reviewed for unnecessary medications. The facility census was 86. Findings include: Review of the medical record for Resident #41 revealed an admission date of 05/21/23. Diagnoses included Guillian-Barre syndrome, atrial fibrillation, type two diabetes mellitus (DM II), depression, chronic kidney disease, and hypertension. Review of the Quarterly Minimum Data Set (MDS) assessment 3.0 dated 07/17/23 revealed Resident #41 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require independent with transfers, dressing, eating, toileting, and bathing. Review of the physician order dated 05/21/23 revealed Resident #41 was ordered Lyrica oral capsule 100 milligrams (mg), give one capsule by mouth every eight hours for pain. Review of the progress note dated 07/19/23 at 1:39 A.M. revealed Lyrica was not…

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 the facility policy, the facility failed to ensure residents were free from significant medication errors. This affected one resident (#27) of five residents reviewed for unnecessary medications. The facility census was 86. Findings include: Review of the medical record of Resident #27 revealed an admission date of 03/22/23. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, atrial fibrillation, essential hypertension (HTN), oropharyngeal dysphagia, and depression. Review of the quarterly Minimum Data Set (MDS) assessment 3.0 for Resident #27 dated 07/05/23, revealed the resident had intact cognition. The resident was not assessed as having any behaviors during the assessment period. The resident was independent with bed mobility and required supervision for transfers, eating, and toileting. Review of the physician orders for Resident #27 dated 03/23/23, revealed the resident was ordered to receive Metoprolol tartrate oral tablet 100 milligram (mg) tablet every morning (9:00 A.M.) and at bedtime (9:00…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to arrange for resident dental services. This affected two residents (#24 and #49) of six residents reviewed for dental services. The facility census was 89. Findings include: 1) Review of the medical record for Resident #24 revealed an admission date of 05/18/19 with diagnoses including chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), atherosclerotic heart disease, atrial fibrillation, anxiety disorder, polyosteoarthritis, hyperlipidemia, and hypertension (HTN.) Review of the Minimum Data Set (MDS) assessment 3.0 for Resident #24 dated 06/04/23, revealed the resident was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADLs.) Review of physician's orders for Resident #24, revealed an order dated 05/17/19 for resident to be seen by the dentist. Review of the care plan for Resident #24 updated 11/01/22, revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and policy review, the facility failed to provide double portions as ordered. This affected one resident (#81) of the 22 residents reviewed for diet orders. The facility census was 86. Findings include: Review of the medical record for Resident #81 revealed an admission date of 04/07/23. Diagnoses included displaced intertrochanteric fracture of left femur, DM II, major depressive disorder, osteomyelitis, and HTN. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] Resident #81 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 14. This resident was assessed to require supervision with transfers, dressing, eating, toileting, and bathing. Review of the care plan dated 04/26/23 revealed Resident #81 had diabetes and was insulin dependent. Interventions included to administer insulin injections per orders and rotate sites. Staff to administer medications per physician orders. Staff to offer bedtime snacks. Staff 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 record review, interviews, and policy review, the facility failed to maintain a controlled substance record. This affected one resident (#41) reviewed for medication administration. The facility census was 86. Findings include: Review of the medical record for Resident #41 revealed an admission date of 05/21/23. Diagnoses included Guillian-Barre syndrome, atrial fibrillation, type two diabetes mellitus (DM II), depression, chronic kidney disease, and hypertension. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to require independent with transfers, dressing, eating, toileting, and bathing. Review of the physician order dated 05/21/23 revealed Resident #41 was ordered Lyrica oral capsule 100 milligrams (mg), give one capsule by mouth every eight hours for pain. Review of the medication administration record (MAR) dated July 2023 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 observation and interview, the facility failed to ensure the roof was maintained in a safe and functional manner to prevent water leaks. This affected all 80 residents at the facility. Findings include: Interview on 10/10/19 at 7:49 A.M. with Licensed Practical Nurse (LPN) #39 revealed the roof leaked throughout the building during rain. It always leaked near the 100 hall vending machines and in the hallways. Buckets were placed to catch the water leaks. Other random roof leaks were located throughout the facility during time of rain. During interview on 10/10/19 at 9:11 A.M., Resident #21 reported there were a couple of roof leaks but none had leaked directly on him. During interview on 10/10/19 at 10:08 A.M., State Tested Nursing Assistant (STNA) #60 reported the roof leaked every now and then. During interview on 10/10/19 at 10:23 A.M., STNA #62 reported during time of rain, the roof leaked throughout the building including in the dining room. Observation on 10/10/19 at 12:08 P.M. during a facility…

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 ensure an effective pest control program was maintained to eradicate mice. This affected all 80 residents at the facility. Findings include: Record review revealed a nursing progress note dated 08/08/19 at 12:36 A.M. that documented Resident #32 was seated in the hallway and refused to go into her room and stated there were at least two mice in the room. During interview on 10/10/19 at 7:40 A.M., Resident #74 reported there were two mice in her room the other day, one went into the closet and the resident wasn't sure what happened to the other one. A man came into the room and caught the mouse in the closet in a bag and placed a glue board behind the door. Resident #74 also reported a mouse was seen near the bathroom door. During interview on 10/10/19 at 7:49 A.M., Licensed Practical Nurse (LPN) #39 reported two to three mice had been observed, at least one a day for the past three days. The mice had been running in and out of resident…

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

Based on observation, staff interview, policy review and manufacturer's recommendation review, the facility failed to ensure a blood glucose machine was properly disinfected between resident use. This affected one (Resident #75) of three residents reviewed for medication administration and had the potential to affect four (Residents #14, #18, #48 and #76) who had fingerstick blood sugar monitored on the 300 hall. The facility identified 28 residents in the facility with physician orders for fingerstick blood sugar monitoring. The facility census was 80. Findings include: Observation of medication administration on 10/09/19 at 8:08 A.M. revealed Licensed Practical Nurse (LPN) #48 used a blood glucose machine to obtain a fingerstick blood sugar for Resident #48. At 8:27 A.M. revealed LPN #47 donned gloves and prepared to prick the finger of Resident #75. LPN #47 was stopped and stated during interview at that time the blood glucose machine was not cleaned in between resident use. LPN #47 stated typically the blood glucose machine was not cleaned until after morning use of 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 observation, record review and interview, the facility failed to ensure residents were treated in a dignified manner while being assisted with eating and when being served in the dining room. This affected three (Residents #57, #29 and #15) of six residents reviewed for dignity. The facility census was 80. Findings include: 1. Record review revealed Resident #57's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be severely cognitively impaired and require extensive assistance with eating. Observation of the main dining room on 10/07/19 at 11:49 A.M. revealed Stated Tested Nurse Aide (STNA) #62 standing over Resident #57 feeding him. 2. Record review revealed Resident #15's quarterly MDS assessment dated [DATE] revealed the resident was severely cognitively impaired and require extensive assistance with eating. Observation of the main dining room on 10/08/19 at 12:27 P.M. revealed STNA #88 standing over Resident #15 feeding her. 3. Record review revealed Resident #29'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 interview, observation and record review, the facility failed to report an allegation of physical abuse as dictated by their policy. This affected one (Resident #32) of one resident reviewed for abuse. The facility census was 80. Findings include: Review of Resident #32's record revealed an admission date of 03/29/16 with diagnoses including dementia without behavioral disturbance, delusions, hallucinations and paranoia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment, hallucinations, delusions and exhibited verbal behaviors directed at others Review of the initial psychiatric evaluation dated 08/15/19 revealed resident was evaluated for mood, medication, psychosis, and paranoia. She had a long history of mental illness, some agitation, mood swings, some delusions and hallucinations and some paranoia. During interview on 10/07/19 at 9:30 A.M. Resident #32 stated that Registered Nurse (RN) #29 became angry with her when she…

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 interview, observation and record review, the facility failed to report an allegation of abuse to the State Agency. This affected one (Resident #32) of one resident reviewed for abuse. The facility census was 80. Findings include: Review of Resident #32's record revealed an admission date of 03/29/16 with diagnoses including dementia without behavioral disturbance, delusions, hallucinations and paranoia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment, hallucinations, delusions and exhibited verbal behaviors directed at others Review of the initial psychiatric evaluation dated 08/15/19 revealed resident was evaluated for mood, medication, psychosis, and paranoia. She had a long history of mental illness, some agitation, mood swings, some delusions and hallucinations and some paranoia. During interview on 10/07/19 at 9:30 A.M. Resident #32 stated that Registered Nurse (RN) #29 became angry with her when she wouldn't take her…

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 interview, observation, and record review the facility failed to ensure an allegation of abuse was thoroughly investigated. This affected one (Resident #32) of one resident reviewed for abuse. The facility census was 80. Findings include: Review of Resident #32's record revealed an admission date of 03/29/16 with diagnoses including dementia without behavioral disturbance, delusions, hallucinations and paranoia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment, hallucinations, delusions and exhibited verbal behaviors directed at others Review of the initial psychiatric evaluation dated 08/15/19 revealed resident was evaluated for mood, medication, psychosis, and paranoia. She had a long history of mental illness, some agitation, mood swings, some delusions and hallucinations and some paranoia. During interview on 10/07/19 at 9:30 A.M. Resident #32 stated that Registered Nurse (RN) #29 became angry with her when she wouldn't…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure staff intervened when a resident exhibited agitated behavior. This affected two (Residents #10 and #20) of 20 residents reviewed for implementation of care plans. The facility census was 80. Record review revealed Resident #10 had diagnoses including anxiety disorder, vascular dementia with behavioral disturbance and mood disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Record review revealed Resident #20 had diagnoses including dementia, Alzheimer's disease and delusional disorder. Review of the quarterly MDS assessment dated [DATE] revealed the resident was severely cognitively impaired. Review of Resident #20's behavior care plan, dated 09/30/14, revealed the resident was verbally and physically aggressive. Interventions were for staff to intervene before agitation escalates when the resident becomes agitated and to guide the resident away…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a resident received the assistance of two State Tested Nursing Assistants (STNA) during care, which resulted in an avoidable fall from the bed. This affected one (Resident #38) of three residents reviewed for falls. The facility census was 80. Findings include: Record review revealed Resident #38 was admitted to the facility on [DATE] with diagnoses including hemiparesis following an intracranial hemorrhage affecting the left side. Review of the plan of care for activities of daily living, dated 03/20/19, documented the resident required extensive assistance to turn left in bed and was dependent to turn right in bed. Resident #38 was also dependent with the assistance of two staff to reposition in bed. The resident was able to use a grab bar when turning to the left side. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and require extensive physical assistance of two staff 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.