Crawford Manor Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on record review, review of a facility self-reported incident, facility policy review and interview, the facility failed to prevent unauthorized videos from being taken and shared on social media by a staff member of Resident #20 and Resident #23. This affected two residents of three residents reviewed for abuse. Findings include: Record review for Resident #23 revealed an admission date of 11/09/23 with diagnoses including syncope and collapse. Record review of the Medicare Five Day Minimum Data Set (MDS) dated [DATE] revealed Resident #23 was cognitively intact. The assessment revealed Resident #23 had no behaviors of inattention or disorganized thinking. Review of the closed medical record for Resident #20 revealed an admission date of 11/22/23 with diagnoses including chronic pulmonary embolism, asthma, schizoaffective disorder, gastroesophageal reflux disease, depression,…

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, resident interview, staff interview, and review of facility policy, the facility failed to ensure care planning conferences were conducted at least quarterly. This affected two (Residents #6 and #27) of three reviewed for care planning. The facility census was 39. Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of 11/22/18 with diagnoses including alcohol dependence with alcohol induced persisting dementia, muscle weakness, foot drop, and personal history of COVID-19. Review of care plan conference summary dated 10/26/23 revealed Resident #6 had signed as an attendee. Further review of the medical record revealed there was no documentation of care conferences conducted for Resident #6 between October 2022 and October 2023. Interview on 12/26/23 at 10:24 A.M. of Resident #6 confirmed he had not been invited to care planning conferences. Interview on 12/27/23 at 11:03 A.M. with Admissions Coordinator/Social Worker Designee (AC/SWD) #842 confirmed…

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 and resident interview, and review of the facility policy, the facility failed to complete assessments and care plans regarding resident smoking. This affected one (Resident #42) of three residents reviewed for smoking. The facility census was 39. Findings include: Review of the medical record for Resident #42 revealed an admission date of 11/10/23 with diagnoses including hemiplegia and hemiparesis following cerebral vascular disease affecting left dominant side, pathological fracture of the hip, and chronic obstructive pulmonary disease (COPD.) Review of the admission Minimum Data Set (MDS) assessment for Resident #42 dated 11/16/23 revealed the resident was cognitively intact and required substantial assistance with upper body dressing and personal hygiene and was dependent for lower body dressing. Review of the care plan for Resident #42 undated revealed there was no care plan for smoking. Review of safe smoking assessment for Resident #42 dated 11/10/23 completed by Licensed Practical Nurse (LPN) #901 revealed the resident did 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and resident interview, the facility failed to provide suprapubic catheter site care for one (Resident #5) of one resident reviewed for catheter care. The facility census was 39. Findings include: Review of the medical record for Resident #5 revealed an admission date of 10/27/23 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and neuromuscular dysfunction of the bladder. Record review of the admission Minimum Data Set (MDS) assessment for Resident #5 dated 11/15/23 revealed the resident had moderate cognitive impairment and functional impairment to the upper and lower extremity on one side and required substantial assistance with personal hygiene. Review of the care plan for Resident #5 dated 10/31/23 revealed the resident had a neurogenic bladder. Interventions included staff should provide catheter care per routine. Review of the physician orders for Resident #5 dated 11/08/23 revealed an order to cleanse…

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 interview and record review, the facility failed to ensure pharmacy recommendations were followed up on in a timely manner. This affected three residents (#22, #25, and #26) of five residents reviewed for unnecessary medications. The facility census was 39. Findings include: 1. Review of the medical record for Resident #22 revealed admission date of 11/09/23 with diagnoses including anxiety disorder, chronic obstructive pulmonary disease, and viral hepatitis. Review of the pharmacy consultation report dated 11/13/23 revealed the pharmacy recommended discontinuing Famotidine (acid reducer) medication as Resident #22 was already receiving Omeprazole (acid reducer), and evidence supporting combination gastroprotective therapy was limited. There was no physician signature; however, it was noted the physician was contacted via phone on 12/26/23 and agreed to discontinue Famotidine. Review of the physician orders revealed Famotidine 20 milligrams (mg) remained an effective order as of 12/28/23 at 8:01 A.M. Interview on 12/28/23 at 8:45 A.M. with Regional Registered Nurse (RN)…

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 ensure weights were documented accurately for Resident #41. This affected one resident (#41) of three residents reviewed for nutrition. The facility census was 39. Findings include: Review of the medical record for Resident #41 revealed an admission date of 11/27/23 with diagnoses including third degree burns to multiple sites of the left shoulder and upper limb, third degree burns to the left lower limb, gastrostomy status, hypertension, morbid obesity, protein-calorie malnutrition, and history of pulmonary embolism. Review of the hospital summary dated 11/28/23 revealed Resident #41's weight was measured at 238 pounds on 11/25/23. Review of the facility weight records for Resident #41 indicated she weighed 238 pounds on 11/28/23, 239 pounds on 12/05/23, 215 pounds on 12/12/23, and 215 pounds on 12/19/23. On 12/28/23 at 10:08 A.M., interview with Registered Dietitian (RD) #847 and the Administrator stated Resident #41's initial weight on 11/28/23 was obtained from the 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 interview, record review, review of the facility policy and Centers for Disease Control and Prevention (CDC) guidelines the facility field to ensure pneumococcal vaccinations were offered and provided as recommended by the CDC. This affected three residents (#11, #21, and #26) of five residents reviewed for pneumococcal vaccinations. The facility census was 39. Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 06/09/23 with diagnoses including diabetes mellitus, cerebral infarction, chronic kidney disease, moderate protein calorie malnutrition, congestive heart failure, and chronic obstructive pulmonary disease. Review of the progress note dated 12/18/23 revealed Resident #11 was noted to be lethargic, had a productive cough, and had rattling sounds audible upon breathing with continuous oxygen. The Nurse Practitioner assessed Resident #11 and provided prophylactic treatment for pneumonia due to worsening respiratory symptoms. Review of the physician's order dated 12/18/23 revealed Resident #11 was receiving Levaquin…

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, test tray, interview and policy review, the facility failed to serve food that was appealing, palatable and served at an appetizing temperature. This had the potential to affect all 36 residents residing in the facility. Findings include: 1. The dining observation on the second floor on 01/18/22 beginning at 12:12 P.M. when the food cart arrived on the second floor. State Tested Nurse Aide (STNA) #633 poured coffee into mugs and added cream and sugar to each mug. She reported most of the residents wanted cream and sugar, so she added it ahead of time. General interviews with residents on the second floor on 01/18/22 at 12:55 P.M. when all the meal trays were served revealed some complained of the taste and some complained of the temperature of the food but there was little plate waste. Interviews with Resident's #5, #9, #25 and #30 between 01/18/22 at 11:29 A.M. and 01/19/22 at 8:37 A.M. complained the food tasted bad and was always cold. Interview with Resident #88's family on 01/19/22 at…

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, interview and review of cleaning schedules, the facility failed to ensure food surfaces in the main kitchen were clean and sanitary. This had the potential to affect all 36 residents residing in the facility. Findings include: The initial tour of the kitchen conducted with Dietary Manager #620 on 01/18/22 beginning at 8:50 A.M. revealed food storage areas, food preparation areas, and storage under the steam table were moderately soiled with dried food and other debris. Interview with Dietary Manager #620 on 01/18/22 at 8:55 A.M. reported it was kitchen staff's responsibility to clean the kitchen but sometimes there was only one kitchen staff, and they were unable to clean the kitchen properly. Review of the morning and afternoon cook daily cleaning list for 01/16-17/22 indicated the following items were cleaned: stove back splash and shelf, right oven/outside, steam table well left side, under steam table shelf, table by the stop top and bottom shelf. Review of the afternoon aide cleaning list for 01/16-17/22 indicated the floor mats, sweep, and mop the dietary…

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, facility policy review, Centers for Disease Control and Prevention (CDC) guidance and interview, the facility failed to timely report and coordinate with the Local Health Department (LHD) regarding employee and resident COVID-19 positive cases to prevent further spread of COVID-19 within the facility. This had the potential to affect all 36 residents residing in the facility. Findings include: Interview on 01/20/22 at 1:40 P.M. with Regional Director of Clinical Services #636 and Director of Nursing (DON) revealed they thought Former Administrator #951 was making notification to the LHD of positive COVID-19 cases for employees and residents, but Former Administrator #951 was no longer employed at the facility, and they had no documented evidence of notifications to the LHD but would check with the LHD to obtain documentation. Interview on 01/20/22 at 3:21 P.M. with Regional Director of Clinical Services #636 revealed she had contacted the LHD to obtain verification that the LHD was notified of employee and resident COVID-19 positive cases and Epidemiologist…

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, record review and policy review the facility failed to ensure staff properly wore appropriate personal protective equipment (PPE) including eye protection when in the facility as the county positivity rate was at 36.4 percent indicating high transmission rate, visitors were properly screened for sign and symptoms of COVID-19 prior to entrance into the facility, residents were provided with clean masks to wear, staff performed proper hand hygiene during meal service, staff were properly screened for tuberculosis or administered tuberculin skin test per facility protocol, and the facility had a Legionella prevention - water management policy and procedure, a legionella risk assessment, and a water management program to reduce risk, growth, and spread of legionella. This had the potential to affect all 36 residents residing in the facility. Findings include: 1. Observation on 01/18/22 at 8:15 A.M. of [NAME] #626 assisted with screening process of surveyors into the facility and 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 interview, observation, record review and policy review, the facility failed to ensure staff were tested per COVID-19 outbreak testing guidelines, staff had COVID-19 competency testing signed off per trainer/ evaluator, and staff wore a gown when they completed COVID-19 testing on residents. This had the potential to affect all 36 residents residing at the facility. Findings include: Review of the undated and untitled COVID-19 testing log revealed the facility employee testing included the name of the employee, position, date of testing, and results of testing. Outbreak testing was initiated on 11/23/21 after Housekeeper/ Personal Care Assistant #611 tested positive for COVID-19. Review of the COVID-19 testing log from 11/23/21 to 01/18/22 revealed Minimum Data Set (MDS)/ Licensed Practical Nurse (LPN) #622 was tested on [DATE] and was negative but then no further testing per the testing log was completed until 12/13/21 when she then tested positive for COVID-19. Review of the COVID-19 testing log from…

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 interviews, the facility failed to maintain a clean and sanitary living environment and kitchen environment. This had the potential to affect all 36 residents in the facility. Findings include: On 01/18/22 beginning at 8:50 A.M. the kitchen tour was conducted with Dietary Manager #620 who verified the following observations: The perimeter of the kitchen had an excessive amount of greasy, dried food and liquid debris, the walls behind the appliances and the dish washing area were heavily soiled with grease, food, and other debris. The floor mats were heavily soiled. Interview with Dietary Manager #620 reported the kitchen was short staffed, and it was the kitchen staff's responsibility to clean the kitchen. Observations of the second floor on 01/18/22 beginning at 10:00 A.M. Resident #6 and #12's floor of their room was littered with debris and pieces of paper. Resident #6's over bed table was soiled and in need of repair. Resident #5 and #11's floor of their room had a moderate amount of nonfood debris on the floor. Resident #5 reported his bed was hard 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, staff interview and facility bed hold policy review, the facility failed to ensure adequate notification in writing of the discharges to the hospital. This deficient practice affected eleven (Resident's #8, #26, #29, #35, #38, #137, #138, #139, #140, #142 and #143) of eleven residents reviewed for bed hold notification. The facility identified 11 residents who were transferred from the facility in the last five months. The facility census was 36. Findings include: 1. Record review for Resident #8 revealed the resident was admitted to the facility on [DATE]. Diagnosis included malignant neoplasm of the colon. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 10/15/21, revealed the resident's cognition was intact. Further record review revealed Resident #8 was sent to the hospital on [DATE]. The record was silent for any written notification of the resident's discharge to the hospital and the reason for the discharge to Resident #8 and 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 review, staff interview and facility bed hold policy review, the facility failed to ensure adequate notification of available bed hold days was provided to residents at the time of discharge to the hospital. This deficient practice affected eleven (Resident's #8, #26, #29, #35, #38, #137, #138, #139, #140, #142 and #143) of eleven residents reviewed for bed hold notification. The facility identified 11 residents who were transferred from the facility in the last five months. The facility census was 36. Findings include: 1. Record review for Resident #8 revealed the resident was admitted to the facility on [DATE]. Diagnosis included malignant neoplasm of the colon. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 10/15/21, revealed the resident's cognition was intact. Further record review revealed Resident #8 was sent to the hospital on [DATE]. The record was silent for any written notification of the facility's bed hold policy to the resident and 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 interview and record review, the facility failed to accurately complete comprehensive assessments Minimum Data Set (MDS) 3.0 for five residents: Resident #1 (sections C, D, E and O), Resident #4 (sections C and E), Resident #16 (section C and E), Resident #19 (section C) and Resident #32 (sections F and K) of 29 MDS 3.0's reviewed (Resident's #1, #3, #4, #9, #11, #12, #13, #15, #16, #17, #18, #19, #25, #28, #27, #29, #30, #31, #32, #33, #35, #36, #38, #39, #88, #187, #189, #190 and #191) reflecting the resident's status at the time of the assessment. The facility census was 36. Findings include: 1. Review of Resident #1's MDS 3.0 assessment dated [DATE] indicated he was not receiving dialysis services; however, he was receiving this service. The MDS 3.0 dated 12/30/21 revealed sections C, D, and E were not assessed. Interview with Admission/Social Service/Activity Director/ State Tested Nurse Aide (STNA) #616 and MDS/Licensed Practical Nurse (LPN) #622 on 01/20/22 at 2:56 P.M. verified the sections…

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 interviews, observations, record and activity calendar review, the facility failed to implement individualized activity program providing stimulation or solace to create opportunities for a meaningful life based on the individual assessment. This affected three (Resident's #17, #18 and #32) of three residents reviewed for activities and four (Resident's #5, #19, #22 and #25) who attended the group meeting. The facility census was 36. Findings include: 1. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including diabetes, respiratory failure with hypoxia, vascular dementia, sleep apnea, major depressive disorder, heart failure, blindness, and chronic obstructive pulmonary disease. The medical record lacked an activity assessment and lacked the development of an activity plan of care. Resident #32 was observed on 01/18/22 at 10:45 A.M., 01/19/22 at 2:00 P.M. and 01/20/22 at 11:19 A.M., 12:43 P.M. and 3:06 P.M. lying in bed with the head of the 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 interview, record review and policy review, the facility failed to ensure residents or resident families were notified of positive COVID-19 cases of employees and residents in the facility. This affected six (Resident's #25, #15, #5, #22, #35 and #19) of six residents reviewed for facility notification of positive COVID-19 cases and had the potential to affect all 36 residents residing at the facility. Findings include: 1. Review of the medical record for Resident #25 revealed an admission date of 12/2/21 with diagnoses including acute embolism, hypertension, cerebral infarction, and bipolar disorder. Review of the medical record revealed Resident #25 was his own responsible party. Review of the nursing notes dated 12/02/21 to 01/18/22 revealed there was no documented evidence Resident #25 was notified of employee and/or resident positive COVID-19 cases. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #25 had intact cognition. Interview on 01/18/22 at 11:28…

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, record review and policy review, the facility failed the ensure call lights were functioning properly. This affected six (Resident's #4, #13, #15, #19, #31 and #88) of 36 residents residing in the facility. Findings include: During the initial tour of the second floor beginning on 01/18/22 at 10:00 A.M. Resident's #31 and #88 confirmed Resident #88's call light did not work. Resident #31 reported she had to activate her call light to get help for Resident #88 when she fell. They reported the call light had not functioned since she was admitted on [DATE] and made an aide aware. Resident #31 reported she would normally notify maintenance staff, but the facility did not currently have any maintenance staff. Review of Resident #88's medical record lacked documented evidence her call light was not functioning. In fact, there were multiple notes encouraging and reminding her to use her call light that was not functioning. She sustained two falls (01/15/22 and 01/19/22) prior to being…

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, record review and policy review, the facility failed to consistently implement smoking policies and ensure congruence between the policy, assessment, care plan, and smoking contracts. This affected all nine residents identified as smokers (Resident's #1, #3, #11, #12, #13, #15, #28, #35 and #90) and had the potential to affect all 36 residents residing in the facility. Findings include: 1. Observation on 01/19/22 at 2:33 P.M. Resident #13 was smoking outside the back door of the facility. There was no ashtray nearby and no staff present. Resident #13 was observed throwing his two cigarettes on the ground. Outside the door there were multiple cigarette butts on the ground. There were smoking receptacles about ten feet away. After Resident #13 was done smoking, he was observed entering the code to allow himself back into the facility. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including tobacco use, history of COVID-19…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and policy review, the facility failed ensure Resident #32 ate in a dignified manner and failed to provide a privacy cover for Resident #187's indwelling urinary catheter bag. This affected two (Resident's #32 AND #187) reviewed for dignity and of 36 residents observed or interviewed related to dignity. The facility census was 36. Findings include: 1. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including diabetes, respiratory failure with hypoxia, vascular dementia, major depressive disorder, visual loss, and chronic obstructive pulmonary disease. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #32 was moderately cognitively impaired, required the extensive assistance of two plus staff for toilet use and was always incontinent of bladder. Review of the incontinence care plan indicated Resident #32 was incontinent and to provide incontinence care as needed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Resident #88's choice of shower schedule was obtained and preferences honored. This affected one (Resident #88) of three (Resident's #33, #36 and #88) reviewed for activities of daily living. The facility census was 36. Findings include: Review of the medical record revealed Resident #88 was admitted to the facility on [DATE] with diagnosis including hypertension, old myocardial infarction, atherosclerotic heart disease, chronic kidney disease, hyperosmolality and hypernatremia, rhabdomyolysis, major depressive disorder, schizophrenia, gastro-esophageal reflux disease, migraine, history of COVID-19, and cerebrovascular disease. Review of the admission evaluation dated 01/15/22 at 12:10 A.M. indicated Resident #88 required two-staff assistance with transfers, toileting, and bathing. There was no documented evidence Resident #88's preference for how often she preferred to be showered was obtained. Review of the self-care deficit plan of care…

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

Based on interview and review of resident accounts, the facility failed to notify the resident/responsible party when the amount reached less than $200.00 than the supplemental security income resource limit. This affected two (Resident's #14 and #33) of five (Resident's #5, #12, #14, #33 and #91) accounts reviewed of 19 accounts managed by the facility. The facility census was 36. Findings include: Review of four active accounts for Resident's #5, #12, #14 and #33 revealed two had balances beyond the resource limit. Resident #14 had $3,282.66 and Resident #33 had $6,668.33 in their accounts. Interview with Business Office Manager (BOM) #640 on 01/24/22 at 1:35 P.M. reported she was to notify the resident/representative when the account was $200.00 less than the resource limit of $2,000.00. She also reported residents received $1400.00 from the stimulus and should not be counted toward the total. BOM #604 verified Resident #14's total minus the stimulus was at $1,882.66 and Resident #33's total minus the stimulus was at $5,268.33 both exceeding the amount of when a spend down letter…

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, record review and policy review, the facility failed to notify Resident #88's first emergency contact following falls and a room change. This affected one (Resident #88) of three family interviews conducted. The facility census was 36. Findings include: Review of the medical record revealed Resident #88 was admitted to the facility on [DATE] with diagnosis including hypertension, old myocardial infarction, atherosclerotic heart disease, chronic kidney disease, hyperosmolality and hypernatremia, rhabdomyolysis, major depressive disorder, schizophrenia, gastro-esophageal reflux disease, migraine, history of COVID-19, and cerebrovascular disease, Review of the profile section of the electronic health record revealed Resident #88's sister was listed as the first emergency contact. Review of the plan of care revealed Resident #88 had mental illness/intellectual disabilities. Review of the progress notes dated 01/15/22 at 4:45 A.M. indicated Resident #88 was trying to ambulate of her own to 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 interview, review of Self-Reported Incident (SRI) tracking number (#)196872, record review and policy review, the facility failed to ensure Resident #19 was free from being physically restrained. This affected one (Resident #19) of three (Resident's #5, #19 and #193) reviewed for abuse/SRI's. The facility census was 36. Findings include: Review of medical record for Resident #19 revealed an admission date of 04/27/17 with diagnoses including congestive heart failure, cocaine abuse, chronic obstructive pulmonary disease, chronic respiratory failure, hypertension, and difficulty walking. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 had impaired cognition with a Brief Interview for Mental Status (BIMS) score was a seven. Resident #19 had no behaviors and required extensive assist of one staff for bed mobility. Resident #19 was totally dependent of two staff for transfers and was unable to ambulate. Review of the physician's orders for September 2020 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 interview, review of the facility Self-Reported Incident (SRI) Form with tracking number (#)196872, review of personnel files, record review and policy review, the facility failed to implement the abuse policy as State Tested Nurse Aide (STNA) #646 failed to report she physically restrained Resident #19. This affected one (Resident #19) of three (Resident's #5, #19 and #193) reviewed for abuse/ SRI's. The facility census was 36. Findings include: Review of medical record for Resident #19 revealed an admission date of 04/27/17 with diagnoses including congestive heart failure, cocaine abuse, chronic obstructive pulmonary disease, chronic respiratory failure, hypertension, and difficulty walking. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 had impaired cognition with a Brief Interview for Mental Status (BIMS) score was a seven. Resident #19 had no behaviors and required extensive assistance of one staff with bed mobility. Resident #19 was totally dependent…

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 and record review, the facility failed to comprehensively assess Resident #32's activity pursuit using the resident assessment instrument. This affected one (Resident #32) of three (Resident's #17, #18 and #32) reviewed for activities. The facility assessment was 36. Findings include: Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including diabetes, respiratory failure with hypoxia, vascular dementia, major depressive disorder, and blindness. The medical record lacked any activity assessment and lacked the development of an activity plan of care. Review of the initial comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #32 was alert, oriented and able to make daily decisions. However, Section F preferences for routine and activities, was not completed. Interview with Admission/Social Service/Activity Director/State Tested Nurse Aide #616 and assessment nurse/Licensed Practical Nurse #622 on 01/20/22 at…

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, record review, the facility failed to provide showers to Resident's #33 and #88 who were dependent on staff for care. This affected two (Resident's #33 and #88) of three (Resident's #33, #36 and #88) reviewed for activities of daily living. The facility census was 36. Findings include: 1. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including epilepsy, systolic congestive heart failure, polyneuropathy, acute kidney failure, and history of COVID-19. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #33 was alert, oriented and independent in daily decision-making ability. It was very important to Resident #33 for the choice in clothing, choosing between tub, shower, bed bath or sponge bath. Resident #33 required limited assistance of one-staff for hygiene and physical help in part of the bathing activity with one-staff physical assistance. Review of the annual MDS 3.0…

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 provide foot care for Resident #33. This affected one (Resident #33) of three (Resident's #33, #36 and #88) reviewed for activities of daily living. The facility census was 36. Findings include: Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including epilepsy, systolic congestive heart failure, polyneuropathy acute kidney failure, and history of COVID-19. Review of the annual comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #33 was moderately cognitively impaired and required the extensive assistance of two staff for personal hygiene. Review of the plan of care revised on 06/30/21 related to self-care deficit indicated to assist with activities of daily living as needed. The care plan did not address nail care. Review of the shower sheets revealed Resident #33 received one shower in the last 30 days on 12/27/21 and it did not include nail care.…

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

Based on observation, interview, record review and policy review the facility failed to ensure unsecured medications were not left unattended on Resident #187's bedside table. This affected one (Resident #187) of eight (Resident's #27, #25, #10, #29, #6, #14, #18 and #187) observed for unsecured medications. This had the potential to affect all 36 residents residing in the facility. Findings include: Review of the medical record for Resident #187 revealed an admission date of 01/14/22 with diagnoses including diabetes, heart failure, atrial fibrillation, sleep apnea, and surgical aftercare following surgery on the digestive system, and chronic obstructive pulmonary disease. Observation on 01/18/22 at 10:31 A.M. revealed Resident #187 was in bed and a medication souffle cup containing four pills was sitting on his bedside table. There were also two inhalers on his bedside table, and the label on both inhalers was faded and unable to clearly read. Interview on 01/18/22 at 10:31 A.M. with Resident #187 revealed the nurse recently brought in his medications in the medication souffle cup…

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 interview, record review and policy review, the facility failed to ensure Resident's #4, #25 and #27 were offered and/ or the facility had documentation the resident or resident's responsible party was educated regarding the benefits and potential risks of the influenza and pneumococcal vaccines. This affected three (Resident's #3, #25 and #27) of five (Resident's #4, #15, #25, #27 and #29) reviewed for immunizations. The facility census was 36. Findings included: 1. Review of the medical record for Resident #4 revealed an admission date of 01/12/11 with diagnoses including severe protein-calorie malnutrition, diabetes, dementia with behavioral disturbances, and chronic respiratory failure. Resident #4 had a guardian assigned due to cognitive impairment. Review of the nursing notes dated 09/01/21 through 01/18/22 revealed no documented evidence Resident #4's representative was provided with education regarding the benefits and potential risks of the influenza vaccine, or any documented evidence Resident #4's guardian refused the influenza vaccine for Resident #4. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents had accurate advance directive orders and information in place through out the medical record for Resident #12. This affected one of one residents reviewed for advanced directives. Findings include: Review of Resident #12's medical record revealed the resident was admitted to the the facility on 07/27/92 with diagnoses that included dementia, depressive disorder and high cholesterol . Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #12 was severely cognitively impaired and required extensive assistance for activities of daily living. Review of the physician's orders for Resident #12 revealed an order dated 03/14/18 for a Do Not Resuscitate Comfort Care (DNRCC) code status (meaning only comfort measures would be initiated in the event of a medical emergency). Review of the social service progress noted dated 11/25/18 revealed, Resident is a DNRCC and a LTC (long term care) resident. 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 and interview, the facility failed to ensure comprehensive care plans were developed related to substance abuse for Resident #18 and for oxygen level monitoring for Resident #5. This affected two residents of 14 residents whose care plans were reviewed. Findings include: 1. Resident #5 was admitted to this facility on 01/06/17. His admitting diagnoses included chronic obstructive pulmonary disease (COPD), type II diabetes, cirrhosis of the liver, and supraventricular tachycardia. According to the minimum data set 3.0 (MDS) assessment dated [DATE], Resident #5 was alert, oriented and cognitively intact. The health condition section of this MDS showed that the resident did have shortness of breath and trouble breathing with exertion, while sitting at rest and when lying flat. His therapy and treatments showed that the resident was receiving oxygen. Functionally, this resident was totally dependent on staff for toilet use, personal hygiene, locomotion on and of the unit and walking in 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.