Bella Terrace Rehabilitation And Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure an accurate assessment was completed for Resident #68. This affected one (Resident #68) out of 28 resident record reviews. Facility census was 90. Findings include: Review of the medical record revealed Resident #68 was admitted on [DATE] with diagnoses that included encephalopathy, disseminated mycobacterium avium-intracellulare complex, human immunodeficiency viruses, severe protein-calorie malnutrition, dysphagia, congenital cytomegalovirus, pressure ulcer of sacral region, dementia, and sensorineural hearing loss. The admission/readmit form dated 03/12/25 revealed Resident #68 had impaired vision, wore glasses, and was deaf. The admission Minimum Data Set (MDS) date 03/15/25 revealed Resident #68 had cognitive impairment, had highly impaired hearing, impaired vision, and did not wear glasses. The quarterly MDS dated [DATE] revealed Resident #68 had adequate hearing, impaired vision, and did not wear glasses. An observation on 06/23/25 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 medical record review, staff interview and review of the Minimum Data Set (MDS) Resident Assessment Instrument (RAI) manual the facility failed to complete a significant change MDS required for a resident admitted to hospice services. This affected one resident (Resident #2) of two residents reviewed for hospice services. The facility census was 90. Findings Include: A review of Resident #2's medical record revealed admission date 12/05/23 with the following diagnoses including but not limited to depression, high blood pressure, heart failure, anxiety, and schizoaffective disorder. Resident #2 had impaired cognition and required assistance from staff to complete activities of daily living (ADL) tasks. A review of Resident #2's physician orders revealed a revised order dated 03/13/25 to be admitted to Hospice with the diagnosis of metabolic encephalopathy. A review of Resident #2's hospice admission paperwork revealed an admission date of 01/30/25 to Hospice for metabolic encephalopathy. A review of Resident #2's completed MDS listing revealed an entry MDS was completed on…

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 assessments were accurately completed. This affected two (Resident #5 and Residents #40 ) of twenty eight residents reviewed for Minimum Data Set (MDS) 3.0 assessments. The facility census was 90. Findings include: 1. Review of the medical record revealed Resident #5 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included generalized idiopathic epilepsy and epileptic syndromes, schizophrenia, hypertension, anxiety disorder, disruptive mood dysregulation disorder, repeated falls, restlessness and agitation, senile degeneration of brain and glaucoma. Review of the Annual MDS 3.0 assessment dated [DATE] for Section J1800 revealed Resident #5 did not have any falls since admission/entry or prior assessment. Review of facility fall investigations revealed Resident #5 had falls on 12/16/24, 12/21/24, 03/11/25, 03/21/25, and 03/26/25. Interview on 06/30/25 at 01:52 PM with Regional MDS #703 verified MDS did not reflect the residents…

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, policy review and interview, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASARR) review was completed with a new psychiatric diagnosis. This affected one (Resident #61) of two residents reviewed for PASARR. The census was 90. Findings include: Review of Resident #61's medical record revealed a 02/09/23 admission with diagnoses including dementia, alcohol induced amnesic disorder, hypertension, type 2 diabetes, conversion disorder with seizures or convulsions, psychosis not due to a substance or known physiological condition, restlessness and agitation, anxiety disorder, post traumatic stress disorder and major depressive disorder. Review revealed the last PASARR submitted for the resident was a 01/13/24 Significant Change for the addition of Post Traumatic Stress Disorder (PTSD) diagnosis. Record review revealed on 08/12/24 Resident #61 had a diagnosis of psychosis not due to a substance or known pathological condition added to her list of diagnoses. Review revealed there was no evidence of a subsequent PASARR…

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 develop a dental plan of care and identify triggers for Post Traumatic Stress Disorder (PTSD). This affected two (Resident #10 and #40) of 27 residents reviewed. The census was 90. Findings include: 1. Review of Resident #10's medical record revealed a 05/21/24 admission with diagnoses including chronic obstructive pulmonary disease, type 2 diabetes, asthma, epileptic seizures, mood disorder, dysthymic disorder, post-traumatic stress disorder, major depressive disorder, malignant neoplasm of lung and bronchus, history of malignant neoplasm of pancreas, insomnia, and nicotine dependence. Review of the 05/23/25 Quarterly Minimum Data Set (MDS) Assessment revealed the resident was independent for daily decision making. Review of the residents' plans of care revealed two plans of care related to Post Traumatic Stress Disorder. A 06/23/25 plan of care revealed the resident had a past traumatic event of transportation accident (car accident/boat accident/train wreck/plane crash) related to a transportation accident.…

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, interview, and policy review, the facility failed to ensure Resident #60, #68, and #72 had comprehensive care plans addressing preferences. This affected three (Residents #60, #68, and #72) out of 28 records reviewed. Facility census was 90. Findings include: 1. Review of the medical record revealed Resident #60 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included tracheostomy, paralysis of vocal cords and larynx, and anxiety. A care plan dated 05/24/23 revealed Resident #60 had a tracheostomy. Interventions included tracheostomy care as ordered. The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #60 was cognitively intact. An interview on 06/23/25 at 1:20 P.M. Resident #60 stated he did his own tracheostomy care except for suctioning. An observation on 06/25/25 at 3:32 P.M. tracheostomy care was provided by Registered Nurse #228. The Director of Nursing was present and stated Resident #60 had been educated and provided his own…

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, policy and interview, the facility failed to ensure nail care was provided to dependent residents. This affected two (Resident #61 and #78) of four residents reviewed for activities of daily living. The census was 90. Findings include: 1. Review of Resident #78 revealed a 05/01/25 admission with diagnoses including fracture of T11-T12 vertebra, protein calorie malnutrition, fracture of first lumbar vertebra, valve endocarditis, lumbosacral radiculopathy, lumbar spondylosis, muscle wasting and atrophy, difficulty walking, cognitive communication deficit, low back pain, and mood disorder Review of the 05/06/25 admission Minimum Data Set (MDS) Assessment revealed the resident was independent for daily decision. The resident had no functional impairment and was in need of partial/moderate assistance with personal hygiene. Interview and observation on 06/24/25 at 12:20 P.M. with Resident #78 revealed he asked staff for fingernail clippers and did not get them. He said he had ripped off his fingernails and they were jagged. He showed that his thumb…

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, policy and interview, the facility also failed to remove a resident's surgical staples and administer antibiotics to meet professional standards. This affected two residents (#134 and #234) out of 29 residents reviewed for appropriate care and services. Facility census was 90. Findings include: 1. Review of the medical record revealed Resident #234 was admitted on [DATE] with diagnoses that included staphylococcal arthritis right hip, osteomyelitis of vertebra, type 2 diabetes, protein-calorie malnutrition, asthma, hypertension, major depressive disorder, and anxiety disorder. The quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #234 was cognitively intact. Review of the after visit summary (AVS) from the hospital dated 06/16/25 revealed Resident #234's surgical staples would be removed at the skilled nursing facility two weeks post operative on 06/20/25. An interview on 06/23/25 at 11:58 A.M. Resident #234 stated he recently had surgery and needed staples…

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 2. Review of Resident #61 revealed a 02/09/23 admission with diagnoses including dementia, alcohol induced amnesic disorder, hypertension, type 2 diabetes, conversion disorder with seizures or convulsions, psychosis not due to a substance or known physiological condition, restlessness and agitation, anxiety disorder, post traumatic stress disorder and major depressive disorder. Review of the 06/01/25 Quarterly Minimum Data Set Assessment (MDS) revealed the resident was moderately impaired for daily decision making with no behaviors. She has minimal difficulty hearing with no hearing aide, had the ability to understand. Clear speech, and is understood. She had adequate vision without corrective lenses. Interview 06/24/25 at 10:34 A.M. with Resident #61 revealed she wore glasses for distance vision but had not seen an eye doctor since she was admitted to the facility. The resident indicated she wore glasses while driving and for distance vision before admission. The resident was unable to find her glasses in her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to provide a comprehensive, resident centered treatment plan for the prevention and/or management of pressure ulcers. This affected one (Resident #68) out of two residents reviewed for pressure ulcer care. Findings include: Review of the medical record revealed Resident #68 was admitted on [DATE] with diagnoses that included encephalopathy, disseminated mycobacterium avium-intracellulare complex, human immunodeficiency viruses, severe protein-calorie malnutrition, dysphagia, congenital cytomegalovirus, a stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed) pressure ulcer of sacral region, dementia, and sensorineural hearing loss. The nursing admit/readmit care plan dated 03/12/25 revealed Resident #68 had a pressure ulcer to the right buttock and sacrum. There was no documentation of the size or any description of the wounds. The comments revealed Resident #68…

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, observation and policy review the facility failed to provide a comprehensive, resident centered fall prevention plan and failed to adequately assess residents after a fall. This affected two (Resident #5 and #135) of three residents reviewed for appropriate care and services. Facility census was 90. Findings include: 1. Review of the medical record revealed Resident #5 was admitted on [DATE] and readmitted on [DATE] with diagnosis that included generalized idiopathic epilepsy and epileptic syndromes, schizophrenia, hypertension, anxiety disorder, disruptive mood dysregulation disorder, repeated falls, restlessness and agitation, senile degeneration of the brain and glaucoma. Review of the physicians orders dated 05/21/25 revealed a low bed with mat beside the bed was ordered. The plan of care dated 06/17/22 revealed Resident #5 was at risk for falls with an added intervention dated 05/08/25 for a low bed with a mat beside the bed (on the floor). Observations on 06/24/25 at 1:07…

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, medical record review, and staff interview the facility failed to store respiratory equipment in a safe and sanitary manner. This affected one resident (Resident #80) of two residents reviewed for respiratory care. The facility census was 90. Findings Include: A review of Resident #80's medical record reviewed admission date 05/30/25 with the following diagnoses including chronic obstructive pulmonary disease (COPD), respiratory failure, anxiety, high blood pressure, and type two diabetes. Resident #80 had intact cognition and required limited assistance from staff to complete activities of daily living (ADL) tasks. A review of Resident #80's physician orders revealed an order dated 05/31/25 for the use of a Bilevel Positive Airway Pressure (BIPAP- a type of non-invasive ventilation that helps people with breathing difficulties) with settings at 12/6 (the amount of inspiratory and expiratory support provided to assist with easier breathing) at bedtime as needed (PRN) and an order date 05/31/25 to Clean BIPAP mask, after use daily and PRN, with soap and water,…

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

Based on medical record review and interview, the facility failed to ensure a resident was provided with identified pain was provided with adequate pain control. This affected one resident (#78) of 29 residents reviewed for care and treatment. The facility census was 90. Findings include: Review of Resident #78's medical record revealed a 05/01/25 admission with diagnoses including fracture of T11-T12 vertebra, protein calorie malnutrition, fracture of first lumbar vertebra, valve endocarditis, lumbosacral radiculopathy, lumbar spondylosis, muscle wasting and atrophy, difficulty walking, cognitive communication deficit, idiopathic peripheral neuropathy, low back pain, mood disorder, fatty liver, intervertebral disc degeneration lumbosacral, hypertension, and irritable bowel. Review of the 05/06/25 admission Minimum Data Set (MDS) Assessment revealed the resident was independent for daily decision making with no signs or symptoms of delirium and was often socially isolated. The resident had no functional impairment. He used a walker. The resident was in need of partial/moderate…

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

Based on medical record review, observation, interview and review of facility policy the facility failed to ensure medications were stored securely and failed to remove expired medications from the third-floor medication storage room. This affected one resident (Resident #80) of six residents reviewed for medication administration and the potential to affect 46 residents residing on the third floor. The facility census was 90. Findings Include: 1. A review of Resident #80's medical record reviewed admission date 05/30/25 with the following diagnoses including chronic obstructive pulmonary disease (COPD), respiratory failure, anxiety, high blood pressure, and type two diabetes. Resident #80 had intact cognition and required limited assistance from staff to complete activities of daily living (ADL) tasks. A review of Resident #80's physician orders revealed an order dated 05/31/25 for Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally every 4 hours as needed (PRN) for wheezing and an order dated 05/31/25 for…

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

Based on record review and interview, the facility failed to provide routine dental care. This affected one (Resident #61) of three residents reviewed for dental care. Findings include: Review of Resident #61 revealed a 02/09/23 admission with diagnoses including dementia, alcohol induced amnesic disorder, hypertension, type 2 diabetes, conversion disorder with seizures or convulsions, psychosis not due to a substance or known physiological condition, restlessness and agitation, anxiety disorder, post traumatic stress disorder and major depressive disorder. Review of the 01/15/25 Annual Minimum Data Set Assessment (MDS) revealed no dental issues. Review of the 06/01/25 Quarterly Minimum Data Set Assessment (MDS) revealed the resident was moderately impaired for daily decision making with no behaviors. She sometimes felt socially isolated. She has minimal difficulty hearing with no hearing aide. Has the ability to understand. Clear speech, and is understood. She had adequate vision without corrective lenses. She had trouble concentrating and falling asleep, feeling down, depressed or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews and facility policy review, the facility failed to initiate therapy services for skilled residents. This affected two residents (#5, #285) out of two residents reviewed for rehab and restorative services. The facility's census was 90. Findings Include: 1. A review of the medical record for Resident #285 revealed admission date 06/18/25 with the following diagnoses including but not limited to aftercare following joint replacement of left hip, high blood pressure, and depression. Resident #285 had intact cognition and required limited assistance from staff to complete activities of daily living (ADL) tasks. A review of Resident #285's physician orders revealed an order dated 06/19/25 to be admitted to skilled level of care. A review of Resident #285's hospital discharge paperwork dated 06/18/25 revealed physical therapy and occupational therapy orders were recommended for Resident #285 related to left hip joint replacement. A review of Resident #285's physical…

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, facility documentation review, and staff interview the facility failed to ensure resident activity documentation was accurate. This affected one resident (#72) of one resident reviewed for activities. Facility census was 90. Findings include: Review of the medical record for Resident #72 revealed an initial admission date of 06/01/25 and readmitted on [DATE] with diagnoses including periprosthetic fracture around internal prosthetic right hip joint, other mechanical complication of other internal joint prosthesis, fibromyalgia, protein-calorie malnutrition, repeated falls, major depressive disorder, chronic pain and opioid use. Review of the facility staff daily activity documentation for June 2025 revealed Resident #72 attended and was provided activities. Resident #71 was not in the facility from 06/15/25 to 06/19/25 due to hospitalization. Interview on 06/26/25 at 2:18 P.M. with Activity Director #216 verified the staff documentation was inaccurate and Resident #72 was out of the…

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

2. Review of Resident #10's medical record revealed a 05/21/24 admission with diagnoses including chronic obstructive pulmonary disease, type 2 diabetes, asthma, epileptic seizures, mood disorder, dysthymic disorder, post-traumatic stress disorder, macular degeneration, major depressive disorder, neuropathy, arthritis, malignant neoplasm of lung and bronchus, chronic obstructive pulmonary disease, hyperlipidemia, history of malignant neoplasm of pancreas, insomnia, gastroesophageal reflux disease, and nicotine dependence. On 02/15/25 at 5:01 P.M. the emergency squad arrived at the facility stating they received a 911 call from the resident due to nausea, vomiting and diarrhea. The resident's temperature was normal 98.6 degrees Fahrenheit on discharge. The resident was admitted with a diagnosis of diarrhea. The resident was readmitted to the facility 02/19/25 at 8:00 P.M. with an order for Sulfamethoxazole-Trimethoprim Oral Tablet 800-160 milligrams (mg) (Bactrim) (antibiotic medication) by mouth two times a day for bacterial infection. There was no stop date. On 02/21/25 the order…

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

Based on observation, staff interview, and facility policy review the facility failed to perform hand hygiene during medication administration. This deficient practice affected three residents (Resident #7, #26, and #42) of three residents observed for medication administration. The facility census was 81. Findings Include: Observation on 11/25/24 from 8:10 A.M. to 8:35 A.M. revealed Licensed Practical Nurse (LPN) #381 completing morning medication administration for the third floor unit of the facility. LPN #381 prepared medications for Resident #7. LPN #381 did not wash or sanitize their hands prior to removal of the medications into the medication cup. LPN #381 then entered Resident #7's room and administered the medications, exited the room and returned to the medication cart without washing or sanitizing their hands. LPN #381 began preparing medications for administration for Resident #26 without washing or sanitizing their hands. LPN #381 then donned a gown and gloves following Enhanced Barrier Precautions (EBP) ordered for Resident #26, entered the room and administered…

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

Based on medical record review, family interview, staff interview, and facility policy review, the facility failed to timely notify all resident representatives/guardians of a temporary discharge. This affected 61 residents (#83, #84, #85, #82, #87, #86, #62, #51, #55, #56, #6, #88, #29, #12, #63, #50, #73, #3, #28, #20, #75, #89, #61, #46, #90, #24, #32, #34, #35, #52, #15, #22, #23, #68, #91, #2, #76, #16, #36, #69, #39, #33, #7, #78, #60, #4, #5, #17, #13, #11, #79, #19, #14, #43, #41, #42, #8, #57, #92, #40, and #9) of 91 residents residing in the facility at the time of the emergency temporary discharge. Findings Include: Interview with Administrator on 07/30/24 at approximately 10:30 A.M. revealed the facility had an emergency which resulted in the temporary evacuation of all residents beginning on 07/22/24 around 12:30 P.M. due to the electricity to the facility being shut off. The Administrator revealed some of the resident family members/representatives were contact during that time, but the facility was not able to contact all family members/representatives until the next…

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

Based on observations, review of the facility policy, staff interviews, and review of the health departments' food inspection reports, the facility failed to ensure the kitchen was in a sanitary condition. This had the potential to affect all 95 residents who received food from the kitchen. The facility identified one resident (#32) who received nothing by mouth. The facility census was 96. Findings include: Review of the City of Columbus Inspection Report dated 06/11/24 revealed the inspection was a standard visit. The facility received a violation for food contact services were dirty and noted there were observations of dust hanging from the vents in dish area, specifically above the clean dishes part of dishwasher. Review of the State of Ohio Food Inspection Report dated 06/26/24 revealed it was a follow up visit. The facility received a violation for the presence of insects, rodents, and other pest is not being adequately controlled or minimized. The sanitarian observed roughly 20 to 30 cockroaches of all life stages throughout the kitchen: -under three compartment/ware wash…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, family and staff interviews, review of the facility's policy, review of the State of Ohio Food Inspection Report, and record review of work orders and pest control report, the facility failed to maintain an effective pest control program to ensure it was reasonably free from cockroaches. This had the potential to affect all 96 residents residing in the facility. Findings include: 1. Review of the State of Ohio Food Inspection Report dated 06/26/24 revealed it was a follow up visit. The facility received a violation for the presence of insects, rodents, and other pest is not being adequately controlled or minimized. The sanitarian observed roughly 20 to 30 cockroaches of all life stages throughout the kitchen: -under three compartment/ware wash sink-under the prep sink-around and under the cooking equipment-inside of the stand mixer cover-in the ceiling of the dish washer. Review of the City of Columbus Emergency Notice of Violation and Order to Correct dated 06/26/24 revealed the recent…

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 resident interview, the facility failed to ensure residents who were dependent on staff assistance received baths/showers as scheduled/requested. This affected two (Residents #68 and #73) of three residents reviewed for bathing. The census was 89. Findings include: 1. Review of the medical record for Resident #68 revealed Resident #68 was admitted to the facility on [DATE]. Resident #68's diagnoses included but were not limited to cerebral infarction, hemiplegia, neurologic neglect syndrome, dysarthria and anarthria, aphasia, dysphagia, and cognitive communication deficit. Review of Resident #68's Minimum Data Set (MDS) assessment, dated 02/02/24, revealed he was cognitively intact and required substantial/maximal assistance with baths/showers. Review of Resident #68's active shower schedule revealed he was to receive a bath or shower on Mondays and Thursdays during the day shift. Review of Resident #68's shower logs and documentation, dated 01/01/24 to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide radiology services as ordered for Resident #5. This affected one resident (#5) of three residents reviewed for the provision of outside/diagnostic services. The census was 90. Findings include: Review of medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including diabetes and venous insufficiency. Further review of the medical record revealed the resident was transferred from the facility to the emergency room on [DATE]. Resident #5 returned to the facility with a physician order for a vascular duplex venous sonogram of the bilateral lower extremities. The order was dated 09/10/23 at 7:05 A.M. and revealed Resident #5 was scheduled to have the ultrasound at the hospital on [DATE] at 9:45 A.M. Interview on 09/12/23 at 9:33 A.M. with Resident #5 revealed the resident had gone to the emergency department over the weekend (09/09/23). Resident #5 stated an ultrasound had been scheduled to be done at the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to update Preadmission Screening and Resident Review (PASARR)'s for residents with new mental health diagnoses. This affected four (Residents #50, #52, #59, and #65) of the four residents reviewed for accurate PASARRs. The facility census was 82. Findings include: 1. Review of the medical record for Resident #52 revealed an admission date of 07/03/21. Diagnoses included delusional disorder, mood disorder, restlessness and agitation, and encephalopathy. Review of the PASARR for Resident #52 with the file date of 08/04/21 indicated under section D that resident did not have a mental health diagnosis. Review of the care plan dated revised 07/07/23 revealed Resident #52 has a behavior problem related to threatening self harm, picks things up from around the facility and puts them in own room, makes written signs on door saying No One to Enter. Interventions include to administer medication as ordered and monitor for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to develop and/or implement care plans for five (Residents #19, #47, #66, #67, and #284) of the seven residents reviewed. The facility census was 82. Findings include: 1. Review of the medical record for Resident #284, revealed an admission date of 05/23/23. Diagnoses included: chronic obstructive pulmonary disease with acute exacerbation, tracheostomy status, anxiety disorder and chronic pain syndrome with a code status of full code and no known drug allergies. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 13 out of 15 indicating intact cognition. This resident was assessed to require extensive assistance with one person physician assist with bed mobility and transfers, and supervision with one person assist for eating and dressing. Review of physician orders dated for 08/10/23 revealed this resident was receiving the following medication: Haloperidol 5 milligram (mg)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record reviews and staff interviews, the facility failed to revise comprehensive care plans for four (Residents #20, #66, #284, and #289) out of the five residents reviewed. The facility census was 82. 1. Review of the medical record for Resident #66, revealed an admission date of 06/07/22. Diagnoses included: fusion of the spine in the cervical region, cord compression, alcohol abuse with intoxication, nicotine dependence with cigarettes and unspecified mood affective disorder with a code status of full code with no known allergies. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating intact cognition. This resident was assessed to require supervision with one-person physical assist with bed mobility, transfers, dressing and toileting with independent with set up help only for eating. Review of the MDS also revealed this resident has a pain numeric rating score of a 07 out of a 00-10 scale…

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, review of facility accident investigations, review of the facility incident/accident log, review of hospital records, resident and staff interviews, and facility policy review, the facility failed to ensure one resident (Resident #30) was supervised while smoking, the facility failed to complete neurological checks following an unwitnessed fall for one resident (Resident #56), the facility failed to complete a comprehensive investigation when one resident (Resident #67) required the administration of Narcan (a medication to reverse the effects from a drug overdose), the facility failed to ensure fall interventions were in place for one resident (Resident #47), the facility failed to reassess the effectiveness of fall interventions following multiple falls for one resident (Resident #289), and the facility failed to complete a through investigation following a fall for one resident (Resident #284). This affected six residents (Residents #30, 47, 56, 67, 284, and 289) of nine…

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 staff interviews, medical record reviews, and the facility policy, the facility failed to offer non-pharmacological interventions and/or pain descriptions prior to administration of pain medications. This affected five residents (#50, #66, #67, #71, and #289) out of the five residents receiving pain medication reviewed. The facility census was 82. Findings include: 1. Review of the medical record for Resident #289, revealed an admission date of 08/09/23. Diagnoses included: radiculopathy of the lumbar region, psychoactive substance abuse, chronic embolism and thrombosis of unspecified deep veins of right lower extremity with a code status of Full Code and amoxicillin allergies. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating intact cognition. This resident was assessed to require supervision with set up only for bed mobility, transfers, locomotion off and on the unit, dressing and eating. 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 interview and record review the facility failed to provide appropriate diagnoses or monitoring for the use of psychotropic medications for Resident #19, #47, #66, #71, and #284. This affected five residents (#19, #47, #66, #71, and #284) of seven residents reviewed for unnecessary medications. The facility census was 82. Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 12/26/22 with diagnoses including Alzheimer's disease, dysphagia, hypertension, anemia, depression, mood disorder, visual hallucinations, osteoarthritis, and muscle weakness. Review of the comprehensive Minimum Data Set (MDS) 3.0 dated 06/06/23 revealed Resident #19 had severely impaired cognition. She was noted to have delusions and no other behaviors. Review of the plan of care dated 01/12/23 revealed Resident #19 used antidepressant medication related to depression. Interventions included administering antidepressants as ordered and monitoring for adverse reactions. Review of the plan 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, resident and staff interviews, and facility policy review, the facility failed to notify the physician when one resident's (Resident #6) blood sugar levels were over 400 as ordered. The facility also failed to notify the physician and resident representative of a change in condition for one resident (Resident #284). This affected two residents (Residents #6 and #284) of two reviewed for notification of changes. The facility census was 82. Findings Include: 1. Review of the medical record for Resident #6 revealed an admission date on 12/06/22. Medical diagnoses included type II diabetes mellitus, obesity, hypertension (high blood pressure), anxiety disorder, and major depressive disorder-recurrent. Review of the physician orders dated August 2023 revealed Resident #6 had an order to notify the physician if blood sugar (BS) was under 60 or over 400. The order was dated 01/10/23. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 had mildly…

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 timely complete and provide written transfer notices for Resident #47 and Resident #284 who were hospitalized . This affected two (Resident #47 and #284) of three residents reviewed for transfers. The facility census was 82. Findings include: 1. Review of the medical record for Resident #47 revealed an admission date of 07/05/23 with diagnoses including Parkinson's disease, unspecified dementia, heart failure, depression, type two diabetes mellitus, and chronic kidney disease stage three. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #47 had severely impaired cognition. Review of the hospital documentation dated 07/29/23 revealed Resident #47 was admitted to the hospital on [DATE] and discharged on 07/30/23. Review of the transfer to the hospital form dated 08/02/23, revealed it was not completed until after Resident #47's return from the hospital. Interview on 08/23/23 at 4:30 P.M. with Regional Nurse…

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 provide timely follow up treatment for Hepatitis C for Resident #49 and failed to ensure timely wound monitoring and care for Resident #47's leg wound. This affected two residents (#47 and #49) of four residents reviewed for quality of care. The facility census was 82. Findings include: 1. Review of the medical record for Resident #49 revealed an initial admission date on 02/06/21 and a readmission date on 06/18/21. Medical diagnoses included end stage renal disease, dependence on renal dialysis, and other specified abnormal findings of blood chemistry. There was not a diagnosis of viral Hepatitis C included in the diagnosis list. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 had intact cognition and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #49 required supervision from one staff to complete Activities of Daily Living (ADLs). Review of physician orders…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review revealed the facility failed to ensure Resident #47 saw podiatry in a timely manner. This affected one resident (#47) of two residents reviewed for activities of daily living. The facility census was 82. Findings include: Review of the medical record for Resident #47 revealed an admission date of 07/05/23 with diagnoses including Parkinson's disease, unspecified dementia, heart failure, depression, type two diabetes mellitus, and chronic kidney disease stage three. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #47 had severely impaired cognition. Review of the medical record for Resident #47 revealed no evidence he had been seen by a podiatrist. Review of the podiatry list revealed the last visit was on 07/17/23 and Resident #47 was not seen. Observation on 08/21/23 at 11:16 A.M., 12:33 P.M., 1:32 P.M., and 4:41 P.M. of Resident #47 revealed he his toenails were observed to be long, extending several…

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 dialysis communication forms, and review of facility policy, this facility failed to ensure post dialysis weights were obtained as per order. This affected one (Resident #15) of one residents reviewed for dialysis services. Facility census was 82. Findings include: Review of the medical record for Resident #15 revealed an admission date of 08/25/22. Diagnoses included chronic kidney disease and neuropathy, chronic viral Hepatitis C, and end stage renal disease with dependence on renal dialysis. Review of Resident #15's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicating a moderately impaired cognition for daily decision making abilities. Resident #15 was noted to be receiving dialysis services. Review of Resident #15's physician orders revealed a order for staff to log post dialysis weights every day shift on Tuesdays, Thursdays, and Saturdays. Review of the medication…

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

Based on interview, review of resident medical records and pharmacy recommendations revealed the facility failed to timely address pharmacy recommendations for Resident #19 and #71. This affected two residents (#19 and #71) of seven residents reviewed for unnecessary medications. The facility census was 82. Findings include: 1. Review of the medical record for Resident #71 revealed an admission date of 12/1/22 with diagnoses including hemiplegia and hemiparesis affecting right dominant side, metabolic encephalopathy, dysphagia, aphasia, other psychoactive substance abuse, and anxiety. Review of the pharmacy recommendation dated 01/24/23 revealed the pharmacist recommended discontinuing the 'as needed' medication Quetiapine or reordering for a specific number of days. The physician indicated that this was something psych addressed, however, their comments were undated. Review of the pharmacy recommendation dated 02/17/23 revealed the pharmacist recommended discontinuing the 'as needed' medication Quetiapine or reordering for a specific number of days. The physician did not choose an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to monitor blood pressure consistently prior to administering medications for Resident #20 and #47 additionally they failed to monitor for side effects of medications for Resident #289. This affected three residents (#20, #47 and #289) of seven residents reviewed for unnecessary medications. The facility census was 82. Findings include: 1. Review of the medical record for Resident #20 revealed an admission date of 06/08/21 with diagnoses including senile degeneration of brain, type one diabetes mellitus, unspecified dementia, cognitive communication deficit, epilepsy, alcohol abuse, and hypertension. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed severely impaired cognition. Review of the plan of care dated 10/26/20 revealed Resident #20 had hypertension. Interventions included avoiding taking blood pressure after physical activity, educating about compliance, giving antihypertensive's as ordered and monitoring for side…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure current hospice plan of care and documentation was on site. This had the affected one resident (#20) of one resident reviewed for hospice. The facility census was 82. Findings include: Review of the medical record for Resident #20 revealed an admission date of 06/08/21 with diagnoses including senile degeneration of brain, type one diabetes mellitus, unspecified dementia, cognitive communication deficit, epilepsy, alcohol abuse, and hypertension. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed severely impaired cognition. Review of the plan of care dated 12/02/21 revealed Resident #20 was enrolled in hospice services related to senile degeneration of the brain. Interventions included administering medications as ordered, allowing resident to discuss feelings, assisting with activity of daily living care per care plan, honoring advanced directives, and notifying hospice of changes. Interview on 08/22/23 at 3:05…

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 care plans were revised for residents following a change in condition/status. This affected four residents (#10, #11, #23 and #32) of 14 residents reviewed for comprehensive care plans. Findings include: 1. Review of Resident #10's medical record revealed an admission date of 02/10/10 with diagnoses including other specified mental disorders due to a known physiological condition, nicotine dependence, alcohol abuse, myocardial infarction, chronic obstructive pulmonary disease (COPD), cognitive communication deficit, Type 1 diabetes mellitus, hypertension, epilepsy and coronary artery disease (CAD). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had mildly impaired cognition and scored an 11 of 15 on the Brief Interview for Mental Status (BIMS) assessment. The resident required limited assistance with the help of one person for most activities of daily living (ADL's). The resident did not require…

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 promote the dignity of Resident #20 by not removing a hospital identification bracelet upon readmission to the facility. This affected one resident (#20) of one resident reviewed for dignity. Findings include: Review of the medical record for Resident #20 revealed an admission date of 12/12/18 with diagnoses including unspecified dementia without behavioral disturbance, insomnia, major depressive disorder, anxiety and pneumonia. Review of Resident #20's nursing progress note, dated 10/07/19 at 2:15 P.M. revealed the resident was very weak and unable to stand up. A new order from the physician was obtained to send the resident to the emergency room and the resident left via squad at that time. Review of Resident #20's hospital continuity of care paperwork with a print date of 10/11/19 confirmed an admission date of 10/07/19 to the emergency room and a diagnosis of right upper clavicle abrasion. Review of Resident #20's nursing progress note, dated 10/11/19 at 11:21 A.M. revealed the resident returned 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.

Based on observation, record review and interview the facility failed to ensure Resident #11's privacy was maintained while receiving care and Resident #28's room had window curtains to provide privacy. This affected two residents (#11 and #28) of two residents reviewed for privacy. Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 07/27/17 with diagnoses including dementia, congestive heart failure and hypertension. Observation on 12/02/19 at 11:50 A.M. revealed Resident #11 was in her bathroom on the toilet while State Tested Nurse Assistant (STNA) #112 was in the bathroom assisting her. Neither the bathroom door nor the hallway door were closed during the observation and Resident #11 could be seen; visible from the hallway. Interview with STNA #112 on 12/02/19 at 12:02 P.M. verified she was assisting Resident #11 in the bathroom and did not shut the bathroom door nor the hallway door to promote privacy for the resident. Review of the policy titled Resident Privacy, last revised September 2019 revealed it was the policy of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to develop and implement a comprehensive and individualized dental care plan for Resident #7. This affected one resident (#7) of three residents reviewed for dental care. Findings include: Review of the medical record for Resident #7 revealed an admission date of 01/26/18 with diagnoses including dementia with behavioral disturbance, paranoid schizophrenia, major depression, pseudobulbar affect, anxiety and bipolar disorder. Review of annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had some cognitive deficits, was on regular diet, had no chewing or swallowing difficulties and no dental concerns. Review of quarterly MDS 3.0 assessment, dated 09/19/19 revealed Resident #7 had no cognitive issues and no dental concerns. Review of dental assessments dated 03/22/19 and 05/22/19 revealed Resident #7 was edentulous. Review of a dental exam note, dated 10/03/19 revealed the exam was limited due to discomfort from a bone spur 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 record review and interview the facility failed to ensure ordered dental treatment was provided to Resident #7. This affected one resident (#7) of three residents reviewed for dental care. Findings include: Review of the medical record for Resident #7 revealed an admission date of 01/26/18 with diagnoses including dementia with behavioral disturbance, paranoid schizophrenia, major depression, pseudobulbar affect, anxiety and bipolar disorder. Review of annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had some cognitive deficits, was on regular diet, had no chewing or swallowing difficulties and no dental concerns. Review of quarterly MDS 3.0 assessment, dated 09/19/19 revealed Resident #7 had no cognitive issues and no dental concerns. Review of dental assessments dated 03/22/19 and 05/22/19 revealed Resident #7 was edentulous. Review of a dental exam note, dated 10/03/19 revealed the exam was limited due to discomfort from a bone spur to the lower gum and identified 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 record review and interview the facility failed to timely implement a pharmacy recommendation for Resident #23 that was approved by the physician related to a psychotropic medication. This affected one resident of six residents reviewed for unnecessary medication use. Findings include: Review of Resident #23's medical record revealed an admission date of 07/28/17 with diagnoses including chronic combined systolic and diastolic congestive heart failure, pain, disorder of the skin and subcutaneous tissue, constipation, cough, headache, chronic obstructive pulmonary disease (COPD), history of malignant neoplasm of breast, major depressive disorder-recurrent, anxiety disorder, insomnia, chronic kidney disease, Type 2 diabetes mellitus and hypertension. Review of Resident #23's most current annual Minimum Data Set (MDS) 3.0 assessment revealed the resident had mild cognitive impairment and scored a nine of 15 on the Brief Interview of Mental Status (BIMS) assessment. The resident did not display any signs of depression or behaviors. The resident required extensive assistance…

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

Based on closed record review and staff interview the facility failed to ensure a psychoactive medication, administered to Resident #24 was justified and ordered by the physician at the time of administration. This affected one resident (#24) of six residents reviewed for unnecessary medication use. Findings include: Review of the closed medical record for Resident #24 revealed an admission date of 10/29/19 with diagnoses including dementia with behavioral disturbance, anxiety and chronic obstructive pulmonary disease. Resident #24 was discharged from the facility on 11/25/19. Review of the active physician's orders revealed an order to give Haloperidol one five milligram tablet by mouth every eight hours as needed. Review of the written physician order, dated 11/12/19 revealed the order for as needed Haloperidol was to be discontinued on this date. However, the order was not written to discontinue the medication. Review of Resident #24's Medication Administration Record, dated November 2019 revealed the as needed Haloperidol order was never discontinued and Resident #24 received a…

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