University Manor Health & Reha

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of the facility policy and procedure, the facility failed to ensure individualized care plans were developed and accurate for three residents (#40, #92, and #133) of 29 sampled residents whose care plans were reviewed. The facility census was 148. Findings include: 1. Review of the medical record for Resident #133 revealed an admission date of 02/02/24. Diagnoses included post-traumatic stress disorder (PTSD), end stage renal disease, dependence on renal dialysis, and schizophrenia. Further review of Resident #92's medical record on 12/03/24 at 8:56 A.M. revealed no care plan related to PTSD. On 12/04/24 the facility provided a copy of Resident #133's plan of care. Review of this plan of care revealed it was created on 12/04/24 and indicated Resident #92 had a diagnosis of PTSD. The care plan indicated Resident #40 (another resident) has or had potential for intrusive thought, flashbacks, avoidance behaviors, negative changes in mood and cognition. The care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure Resident #44's care plans were updated to reflect the resident's behaviors and interventions which required the resident to sleep on a flat yoga mat on the floor with no furniture in the room. The facility also failed to ensure Residents #13 and #29's care conferences were conducted at least quarterly. This affected three (Residents #13, #29 and #44) of four residents reviewed for care plans. Findings include: 1. Review of Resident #29's medical record revealed the resident was admitted on [DATE] with diagnoses including paranoid personality disorder and schizophrenia. Further review of the medical record revealed Resident #29 had a legal guardian who was the emergency contact and responsible for the resident's finances. Review of Resident #29's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #29 exhibited severe cognitive impairment. Review of Resident #29's Care Conference Report form dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, bathing/showering documentation review, facility policy review and interview, the facility failed to ensure bathing/showering was completed as required for one Resident #110 who required total assistance with activities of daily living. This affected one (#110) of one resident reviewed for bathing. The facility census was 148. Findings include: Review of the medical record for Resident #110 revealed an admission date of 07/22/24. Diagnoses included but were not limited to acute respiratory failure, chronic obstructive pulmonary disease, and atrial fibrillation. Review of Resident #110's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #110 had intact cognition and was dependent for all activities of daily living (ADLs) including bathing. Review of Resident #110's care plan last reviewed on 11/18/24 revealed Resident #110 had a self-care deficit and required total assistance with ADLs. The care plan did not include specific information related to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure assessment and monitoring of a wound to Resident #79's left great toe. This affected one (Resident #79) of four residents reviewed for wounds. Findings include: Review of Resident #79's medical record revealed the resident was admitted on [DATE] with diagnoses including Huntington's disease, acute respiratory failure with hypoxia and muscle weakness. Review of Resident #79's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #79's physician orders revealed an order dated 10/22/24 to cleanse the great toe of the left foot with normal saline, pat dry, apply an abdominal dressing and wrap with a gauze roll until healed once daily on night shift. Further review of Resident #79's medical record revealed no evidence of monitoring or assessment of Resident 79's left great toe wound. Observation of Resident #79 on 12/02/24 at 11:50 A.M. with Licensed…

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 pre and post dialysis communication was completed. This affected two residents (#100 and #133) of two residents reviewed for dialysis. The facility census was 148. Findings include: 1. Review of Resident #100's medical records revealed an admission date 04/07/23. Diagnoses included end stage renal disease and acute kidney failure. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #100 had intact cognition. Review of the care plan dated 11/18/24 revealed Resident #100 required dialysis. Review of physician orders for December 2024 revealed an order to complete Resident #100's dialysis observation tool prior to dialysis and print and send with resident to dialysis. Interview on 12/04/24 at 8:05 A.M. with Licensed Practical Nurse (LPN) #425 revealed dialysis communication was to be completed prior to residents leaving for dialysis and was to be sent with the residents. Review of dialysis communication forms for Resident #100…

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 Resident #19's as-needed antipsychotic medications were limited to fourteen days until the physician evaluated the resident, and non-pharmacological interventions were attempted prior to administering as-needed antipsychotic medications. This affected one (Resident #19) of five residents reviewed for medication administration. Findings include: 1. Review of Resident #19's medical record revealed the resident was admitted on [DATE] with diagnoses including schizoaffective disorder, bipolar disorder and generalized anxiety. Review of Resident #19's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited a memory problem and received antipsychotic medications. Review of Resident #19's physician orders revealed an order dated 11/11/24 for olanzapine (antipsychotic) 2.5 mg intramuscularly (IM) every six hours as needed for agitation. There was no stop date on the order. Review of Resident #19's Pharmacy Consultation Report…

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, record review, and interview the facility failed to ensure the coordination of services to make certain residents received the correct diets. This affected two residents (#19 and #29) of seven residents (#19, #29, #31, #100, #119, #134, and #143) reviewed for nutrition. The facility census was 148. Findings include: Observation of lunch on 12/02/24 at 12:50 P.M. revealed Resident #29's meal ticket indicated regular double protein diet and listed beef stew, mixed vegetables, biscuit, margarine, tropical fruit cup, whole milk, and beverage of choice. Observation of Resident #29's meal revealed no double protein. Medical record review revealed Resident #29 was to receive double protein with meals. Interview on 12/02/24 at 12:55 P.M. with Agency Certified Nurse Aide (CNA) #500 confirmed Resident #29 did not have double protein for his meal. Observation of lunch on 12/03/24 at 12:30 P.M. revealed Resident #19's meal ticket indicated regular, renal diet and listed cheese pizza, salad garden with dressing, fortified potatoes, chocolate chip cookie, two percent milk,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review the facility failed to ensure Resident #95 was provided education and offered the influenza and pneumococcal vaccines. This affected one (Resident #95) of five residents reviewed for immunizations. Findings include: Review of Resident #95's medical record revealed the resident was admitted on [DATE] with diagnoses including essential hypertension, other chronic pain and history of falling. Review of Resident #95's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Further review of Resident #95's medical record did not reveal evidence the resident was offered or educated on the influenza and pneumococcal vaccines. Interview on 12/05/24 at 11:03 A.M. with Registered Nurse Infection Preventionist #320 and Regional Registered Nurse #467 confirmed Resident #95 was not offered or educated on the influenza or pneumococcal vaccines. Review of the Influenza Vaccine Policy (Resident) revised 08/19/20 revealed 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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, facility self-reported incident (SRI) review, and facility policy review the facility failed to prevent an incident of staff to resident emotional abuse, based on the reasonable person concept, when State Tested Nurse Aide (STNA) 314 posted a video showing Resident #5 on social media. This affected one resident (#5) of six residents reviewed for abuse. The facility census was 144. Findings include: Review of the medical record revealed Resident # was admitted to the facility on [DATE] with diagnoses including severe intellectual disabilities, seizures, schizophrenia, and dementia The resident was discharged on 10/04/24 to a group home. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition. Resident #5 had behaviors including delusions, physical behavioral symptoms directed at others,…

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 facility policy, the facility did not ensure garbage was properly disposed of to prevent the harborage pests. This had the potential to affect all 144 residents. The facility census was 144. Findings include: Observation on 08/28/24 at 9:30 A.M. with Maintenance Director #539 revealed the three outside dumpsters near the facility kitchen doors did not have lids covering trash, a sour smell permeated around the dumpsters with wet boxes and leaf and twig debris piled up around the dumpsters. Maintenance Director #539 verified the findings on 08/28/24 at 9:30 A.M. and stated it was difficult to get behind the dumpsters to pick up the boxes and clean the area, and there should be lids to cover the trash. Interview with Exterminator #646 on 08/28/24 at 12:31 P.M. revealed garbage containment and sanitation was important to prevent and control pests. Review of the facility policy titled Pest Control dated 8/12/18 revealed routine pest control would be placed to prevent pest infiltration. Maintenance of the garbage storage area to prevent…

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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and interview, the facility did not ensure the physician and/or nurse practitioner was notified of abnormal laboratory results for Resident #113. This affected one resident (#113) of three residents reviewed for physician notification of laboratory results. The facility census was 144. Findings include : Review of the medical record for Resident #113 revealed an admission date of 02/22/24. Diagnoses included intracranial hemorrhage, hyperparathyroidism, cocaine abuse, hypertension, chronic kidney disease stage four, and hemiplegia. Review of the Minimum Data Set ( MDS) 3.0 assessment dated [DATE] revealed cognition was intact and the resident needed substantial assistance to walk ten feet, transfer from the toilet, and transfer from bed to chair. Review of physician orders dated 07/17/24 revealed an order for CBC ( complete blood count) with differential,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of facility self-reported incidents (SRIs), review of the Facility Assessment, and policy review, the facility failed to ensure adequate behavioral health services and person-centered care planning were in place to address the individualized needs of residents with history of mental disorders and history of violent behaviors against other residents. This affected one (#2) of three residents reviewed for behaviors. The facility census was 143. Findings Include: Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia, paranoid personality disorder, anxiety disorder, and violent behavior. Review of Resident #2's admission paperwork prior to arriving at the facility on 02/18/20 revealed Resident #2 was placed in a psychiatric hospital for physically assaulting another resident and staff person at another nursing facility causing broken arms in both the staff person…

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 observation, the facility failed to provide pressure ulcer wound care as ordered. This affected two (#48 and #56) of three residents reviewed for wound care. The facility identified 13 residents (#26, #46, #48, #50, #56,#57, #60, #65, #69, #80, #95, #99, and #135) with wounds. The facility census was 142. Findings include: 1. Review of Resident #56's medical records revealed an admission date of 03/23/23. Diagnoses included wounds of the scrotum and testes and Fournier Gangrene (necrotic tissue of the genitalia). Review of Resident #56's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 had intact cognition. Resident #56 required supervision with bed mobility, toileting and personal hygiene. Resident #56 had a stage four pressure ulcer (deep wound that exposes muscle or other structures). Review of Resident #56's care plan dated 07/28/23 revealed Resident #56 had a potential for skin breakdown and pressure ulcers. Interventions included administer…

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 and interview the facility failed to use appropriate infection control techniques when providing wound care. This affected two (#48 and #56) of two residents observed for wound care. The facility identified 13 residents (#26, #46, #48, #50, #56,#57, #60, #65, #69, #80, #95, #99, and #135) with wounds. The facility census was 142. Findings include: Review of Resident #56's medical records revealed an admission date of 03/23/23. Diagnoses included wounds of the scrotum and testes and Fournier Gangrene (necrotic tissue of the genitalia). Review of Resident #56's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 had intact cognition. Resident #56 required supervision with bed mobility, toileting and personal hygiene. Resident #56 had a stage four pressure ulcer (deep wound that exposes muscle or other structures). Review of Resident #56's care plan dated 07/28/23 revealed Resident #56 had a potential for skin breakdown and pressure ulcers. Interventions included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Facility Assessment, personnel record review, and interview, the facility failed to provide behavioral health training on hire. This had the potential to affect all 138 residents in the facility. Findings include: Review of the facility's Facility assessment dated [DATE] included under staff training, education and competencies training would be provided for caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder and implementing non-pharmacological interventions. Review of personnel record for State Tested Nursing Assistant (STNA) #526 revealed a hire date of 12/21/22 with no documentation of behavioral training. Review of personnel record for State Tested Nursing Assistant (STNA) #439 revealed a hire date of 08/28/23 with no documentation of behavioral training. Review of personnel record for State Tested Nursing Assistant (STNA) #550 revealed a hire date of 02/06/23 with no documentation 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, staff interview, review of facility Self-Reported Incidents (SRIs) and review of the facility policy, the facility failed to ensure Resident #140 was free from abuse. This affected one resident (#140) of two residents two residents reviewed for physical abuse. The facility census was 138. Findings include: Resident #32's medical record revealed an admission date of 04/28/23 and a readmission date of 06/01/23 with diagnoses that included but not limited to altered mental status, diabetes mellitus, and depression. Review of Resident #32's care plan dated 04/28/23 revealed Resident #32 had a psychiatric disorder with a goal of no behaviors or maintain behavioral manifestation to a minimum. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #32 was severely cognitively impaired and had hallucinations. Review of Resident #32's nursing note dated 07/10/23 at 2:03 A.M. revealed Resident #32 had a history of physical aggression. Resident #32…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview the facility failed to ensure their abuse policy was implemented to prevent abuse toward Resident #140, to ensure Resident #140 was assessed properly after being abused, and to ensure the allegation of abuse was reported to the state agency. This affected one resident (#140) of two residents two residents reviewed for abuse. Findings include: Resident #32's medical record revealed an admission date of 04/28/23 and a readmission date of 06/01/23 with diagnoses that included but not limited to altered mental status, diabetes mellitus, and depression. Review of Resident #32's care plan dated 04/28/23 revealed Resident #32 had a psychiatric disorder with a goal of no behaviors or maintain behavioral manifestation to a minimum. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #32 was severely cognitively impaired and had hallucinations. Review of Resident #32's nursing note dated 07/10/23 at 2:03 A.M. revealed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure an allegation of physical abuse was reported to the State Agency timely. This affected one resident (Resident #140) of two residents reviewed for abuse. Findings include: Resident #32's medical record revealed an admission date of 04/28/23 and a readmission date of 06/01/23 with diagnoses that included but not limited to altered mental status, diabetes mellitus, and depression. Review of Resident #32's care plan dated 04/28/23 revealed Resident #32 had a psychiatric disorder with a goal of no behaviors or maintain behavioral manifestation to a minimum. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #32 was severely cognitively impaired and had hallucinations. Review of Resident #32's nursing note dated 07/10/23 at 2:03 A.M. revealed Resident #32 had a history of physical aggression. Resident #32 was standing inside another resident's room near the doorway. Resident #32 was told by…

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

Based on record review and staff interview the facility failed to ensure tuberculosis screening was completed for newly hired employees as required. This affected six facility employees of nine employees whose personnel files were reviewed and had the potential to affect all 119 residents residing in the facility. Findings include: Review of the personnel file for the Director of Nursing (DON) revealed a hire date of 07/06/21. Review of the personnel file for the Activity Director (AD) #590 revealed a hire date of 05/17/21. Review of the personnel file for Human Resources (HR) #506 revealed a hire date of 02/01/22. Review of the personnel file for Business Office Manager (BOM) #543 revealed a hire date of 02/14/22. Review of the personnel file for Licensed Practical Nurse (LPN) #531 revealed hire date of 05/17/21. Review of personnel files for State Tested Nursing Assistant (STNA) #557 revealed hire date of 03/23/22, STNA #559 revealed hire date of 09/15/21, and STNA #572 revealed hire date of 02/05/21. Review of the employees' personnel files revealed no tuberculosis screening had…

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

Based on record review and interview, the facility failed to initiate timely spend-down notifications and assistance for two of five residents reviewed for facility-managed funds (Resident #68 and #11). The total census was 119. Findings included: 1. Record review revealed Resident #68 had $3401.24 in their personal funds account as of 05/16/22. Review of his last quarterly statement revealed from January 2022 through March 2022 his balance maintained consistently between $2,600 and $4,000. No evidence could be found of any significant effort to spend the accumulated money. 2. Record review revealed Resident #11 had $10,598.00 in their personal funds account as of 05/16/22. Review of his last quarterly statement revealed from January 2022 through March 2022 his balance maintained consistently between $9,000 and $12,000. No evidence could be found of any significant effort to spend the accumulated money. Review of a facility e-mail dated 05/13/22 revealed a list of residents (including Resident #11 and #68) were in need of a spend-down to bring them below $2,000.00 in their accounts.…

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 interview, the facility failed to ensure residents received quarterly care-plan conferences. This affected one of one residents reviewed for care plan conferences (Resident #15). The total census was 119. Findings include: Record review of Resident #15 revealed he was admitted to the facility 04/05/2007. A social work progress note dated 12/09/21 saying a care plan conference was scheduled for 12/13/21. No documentation of a care conference on this or any later date could be found. Interview with Licensed Social Worker #588 on 05/18/22 at 2:47 P.M. confirmed the above findings. She verified she had no recollection of a care plan conference for Resident #15 and could not find any information indicating one was done in the last six months.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to draw recommended and ordered blood labs to monitor the nutrition status of Resident #105. This affected one of four residents reviewed for nutrition. The total census was 119. Findings include: Record review of Resident #105 revealed he was admitted to the facility 08/06/19 and had diagnoses including anemia, bipolar disorder, dependence on renal dialysis, type two diabetes mellitus, and hypothyroidism. His most recent dietary assessment dated [DATE] noted he had 'no new labs.' Record review of Resident #105's lab draw orders revealed the following: An order was in place for an HGBA1C (monitoring effectiveness of diabetes control) lab every six months, with a start date of 03/01/21. An order was in place for a CBC (complete blood count), CMP (comprehensive metabolic panel), and valproic acid lab every six months with a start date of 11/01/20. An order was in place for a CBC, CMP, valproic acid, and TSH (thyroid stimulating hormone) every six months,…

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 interview, the facility failed to monitor lab values for Resident #105, including those needed to track the effectiveness of medications. This affected one of five residents reviewed for unnecessary medications. The total census was 119. Findings include: Record review of Resident #105 revealed he was admitted to the facility 08/06/19 and had diagnoses including anemia, bipolar disorder, dependence on renal dialysis, type 2 diabetes mellitus, and hypothyroidism. Record review of Resident #105's lab draw orders revealed the following: An order was in place for a HGBA1C (monitoring effectiveness of diabetes control) lab every six months, with a start date of 03/01/21. An order was in place for a CBC (complete blood count), CMP (comprehensive metabolic panel), and valproic acid lab every six months with a start date of 11/01/20. An order was in place for a CBC, CMP, valproic acid, and TSH (thyroid stimulating hormone, monitoring the dose of levothyroxine) every six months, with a start date of 04/19/22. Record review of Resident #105's medications revealed he…

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, record review and interview the facility failed to ensure resident snacks were stored in a safe and sanitary manner to prevent contamination and/or potential food borne illness. This had the potential to affect all 143 of 143 residents receiving meals from the kitchen. Findings include: Observation of the kitchen and snack areas on 04/15/19 from 9:07 A.M. to 10:00 A.M. with Kitchen Manager (KM) #400 and Registered Dietitian (RD) #401 revealed the following: The fifth floor snack refrigerator had a temperature of 49 degrees Fahrenheit (F) and no temperature log. Two sandwich halves, a cake and sausage links were not labeled or dated. The fourth floor snack refrigerator did not have a temperature log. A bottle of Pepsi (soda) had been placed in the freezer compartment of the refrigerator and had burst, covering the freezer and refrigerator in a sticky brown substance. Sauerkraut, fruit salad, pickles and hummus were not labeled or dated. A can of pineapple had been opened and the food had been stored inside the can and this was not labeled or dated. An expired…

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 maintain a safe, functional, sanitary and comfortable environment for all residents. This had the potential to affect all 143 residents residing in the facility. Findings include: Observation on 4/15/19 at 11:54 A.M. of room [ROOM NUMBER] revealed a wooden chair with the arm broken off exposing a jagged wood post extending up from front end of the cushion. Interview on 4/15/19 at 11:55 A.M. with Licensed Practical Nurse (LPN) #175 verified above findings and revealed he did not know how long the chair was broken. Observation during an environmental tour of the facility on 04/18/19 from 2:28 P.M. through 3:05 P.M. with the Environmental Director revealed the following: The second floor had a tile that was cracked and partially missing in the hallway. The dinning room had large gouges in the wall that need patching and to be repainted. A window sill in the dining room had dust and dead insects. The brown paint on the hand rails had worn off in areas…

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 4. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease requiring dialysis and diabetes. The quarterly MDS 3.0 assessment, dated 01/09/19 revealed the resident required the extensive assistance from one person for dressing and personal hygiene. The resident was assessed to have mild cognitive impairment. Record review revealed no evidence of resistance to any personal hygiene care in the care plan. Observation on 04/16/19 at 9:17 A.M. revealed Resident #23 was in a wheelchair waiting to be picked up for an appointment. The resident had a large amount of long facial hair on her chin. Interview on 04/16/19 at 9:17 A.M. with Resident #23 revealed she did not want to have chin hair and had not realized it was that long. The resident stated her daughter would often take care of it when she had time. Interview on 04/17/19 at 8:40 A.M. with STNA #404 revealed the STNA stated she had offered to remove the resident's chin hair but the…

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

Based on observation, record review and interview the facility failed to ensure kitchen staff followed menu spreadsheets as written. This affected five residents receiving pureed meals (Resident #9, #41, #86, #106 and #295) and 10 residents receiving mechanical soft meals (Resident #6, #7, #16, #33, #60, #65, #90, #120, #126 and #292) who resided on the second floor during the dinner meal service on 04/16/19. The facility census was 143 residents. Findings include: Review of the menu spreadsheet titled, Week Four, Day Three which correlated to 04/16/19 revealed residents on pureed diets were to receive a #10 scoop of pureed chicken, a #8 scoop of pureed macaroni and cheese, a #10 scoop of pureed stewed tomatoes and a #20 scoop of pureed bread. The spreadsheet showed residents on a mechanical soft diet were to receive a #10 scoop of mechanically-altered chicken and a #20 scoop of pureed bread in addition to the regular consistency half cup of macaroni and cheese and half cup of stewed tomatoes. Observation of the dinner meal on the second floor with Kitchen Manager (KM) #400 and…

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

Based on observation, record review and interview the facility failed to ensure Resident #138, who was dependent on staff for personal care received appropriate and complete incontinence care. This affected one resident (Resident #138) of one resident reviewed for incontinence care. Findings include: Record review of Resident #138 revealed he had diagnoses including chronic embolism, paraplegia, and bipolar disorder. Record review revealed the resident was assessed to be totally dependent on staff for toileting assistance. Interview with Resident #138 on 04/15/19 at 10:54 A.M. revealed he was dependent on staff for all activities of daily living, including incontinence care. The resident stated staff did not always provide adequate cleaning when he had bowel movements, resulting in fecal matter remaining after their care. Observation of an incontinence care procedure by State Tested Nursing Aide (STNA) #205, STNA #206, and Registered Nurse (RN) #202 for Resident #138 on 04/17/19 at 11:32 A.M. revealed that during the procedure, the staff brushed soiled towels used to clean fecal…

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 interview the facility failed to develop a person-centered plan to address Resident #114's dementia. This affected one resident (Resident #114) of two residents reviewed for dementia care. Findings include: Review of Resident #114's medical record revealed an admission date of 08/01/16 with diagnoses including dementia without behavioral disturbance, heart disease, delusional disorders, dysphagia (difficulty swallowing), psychotic disorder with delusions and Parkinson's disease. Review of Resident #114's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/12/19 revealed the resident was cognitively impaired and required extensive assistance from staff for dressing, hygiene and toilet use. Review of Resident #114's plan of care revised 02/27/19 revealed the resident had impaired cognitive function related to a diagnosis of dementia and noted cognitive impairment. Listed interventions included administering medications as ordered with monitoring side effects/effectiveness; assess, document and report to physician any changes in cognitive function;…

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, record review and interview the facility failed to maintain a medication error rate of less than five percent. The medication error rate was calculated to be 32 percent and included eight medication errors of 25 medication administration observations. This affected two residents (Resident #63 and #291) of three residents observed for medication administration. Findings include: 1. Observation of medication administration by Registered Nurse (RN) #202 for Resident #63 on 04/16/19 at 8:46 A.M. and subsequent record review revealed the nurse did not administer an ordered dose of one tablet, Potassium chloride 20 milliequivalents, due at 9:00 A.M. The surveyor reviewed the above finding with RN #202 on 04/16/19 at 9:03 A.M. RN #202 confirmed she should have given the Potassium and had accidentally missed it. Following surveyor intervention, RN #202 administered the potassium to Resident #63. 2. Observation of a medication pass by Licensed Practical Nurse (LPN) #203 for Resident #291 on 04/16/19 at 9:46 A.M. and subsequent record review revealed the nurse 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.

Based on record review and interview the facility failed to ensure medical records were maintained in a complete and accurate manner for all residents. This affected one resident (Resident #138) of one resident reviewed for incontinence care, one resident (Resident #39) of one resident reviewed for edema and one resident (Resident #240) of two residents reviewed for catheters. Findings include: 1. Record review for Resident #138 revealed the resident had diagnoses including chronic embolism, paraplegia, and bipolar disorder. He had active orders in his chart dated 12/04/18 for zinc oxide cream to be applied topically to his buttocks every shift and as needed. Review of his treatment administration record (TAR) for the month of 04/2019 revealed no documentation of any administration of this order. The above findings were confirmed with the administrator on 04/18/19 at 10:12 A.M. 2. Record review for Resident #39 revealed she had diagnoses including dementia, obesity, lymphedema, and hypothyroidism. She had active orders in her chart dated 09/05/18 for Tubigrips (a brand 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.