Capital City Gardens Rehabilitation And Nursing Ce

Based on medical record review, staff interview and policy review, the facility failed to ensure all resident Pre-admission Screening and Resident Review (PASARR) documents were accurate to resident current conditions and diagnoses. This affected three (#3, #15, and #59) of four residents reviewed for PASARR documents. The census was 89. Findings include: 1. Review of Resident #3's medical record revealed an admission date of 03/05/19. Her diagnoses included acute bronchitis, epileptic seizures, pulmonary embolism, post traumatic stress disorder, conversion disorder, phantom limb syndrome, bipolar disorder, unspecified protein calorie malnutrition, hypothyroidism, hypertension, other cervical disc degeneration, vitamin D deficiency, insomnia, atrial fibrillation, nonrheumatic mitral valve prolapse, muscle weakness, hypotension, repeated falls, pain, type II diabetes, depression, macular degeneration, hypermetropia, hyperlipidemia, anxiety disorder, acquired absence of right leg below knee, and epilepsy. Review of her Minimum Data Set (MDS) assessment, dated 12/09/24, revealed she…

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

Based on medical record review, staff interview and policy review, the facility failed to ensure all significant mental health changes were communicated to the state mental health agency. This affected three (#3, #15, and #59) of four residents reviewed for Pre-admission Screening and Resident Review (PASARR) documents. The census was 89. Findings include: 1. Review of Resident #3's medical record revealed an admission date of 03/05/19. Her diagnoses included acute bronchitis, epileptic seizures, pulmonary embolism, post traumatic stress disorder, conversion disorder, phantom limb syndrome, bipolar disorder, unspecified protein calorie malnutrition, hypothyroidism, hypertension, other cervical disc degeneration, vitamin D deficiency, insomnia, atrial fibrillation, nonrheumatic mitral valve prolapse, muscle weakness, hypotension, repeated falls, pain, type II diabetes, depression, macular degeneration, hypermetropia, hyperlipidemia, anxiety disorder, acquired absence of right leg below knee, and epilepsy. Review of her Minimum Data Set (MDS) assessment, dated 12/09/24, revealed she…

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

Based on record review, staff interview, and policy review, the facility failed to ensure weekly weights were obtained per physician orders. This affected two (#77 and #92) of five reviewed for nutritional monitoring. The facility census was 96. Findings include: 1. Review of the medical record for Resident #92 revealed an admission date of 11/12/24, with diagnoses of acute and subacute infective endocarditis, bacteremia, viral hepatitis, presence of heart valve replacement, rheumatic tricuspid insufficiency, shortness of breath, psychoactive substance use, hypertension, pulmonary embolism without acute cor pulmonale and edema. Review of nutritional assessment review dated 11/15/24 revealed Resident #92's most recent weight measurement for Resident #92, taken on 11/12/24, showed a weight of 178 pounds. To help maintain a stable weight, interventions included fluid restriction, protein supplements three times daily, double protein with meals, a no-added-salt diet, and weekly weight monitoring. Review of the medical record for Resident #92 revealed the only weight taken by facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of hospital records and staff interviews, the facility failed to ensure a resident's respiratory needs were being met. This affected the one resident (#196) of one resident reviewed for oxygen use. The facility census was 89 residents. Findings include: Review of Resident #196's medical record revealed an admission on [DATE], with diagnoses that included chronic obstructive pulmonary disease, unspecified asthma, pulmonary embolism and heart failure. Review of Resident #196's census revealed she was hospitalized from [DATE] until 02/28/25. Review of Resident #196's physician orders revealed she was ordered to have a Bilevel Positive Airway Pressure (BiPap) face mask, humidified, oxygen at 3 liters per minute at bedtime starting on 01/30/25 and ending on 02/27/25. On 03/04/25, Certified Nurse Practitioner #350 entered orders for Resident #196 to have BiPap to be worn at bedtime. Resident #196's record was silent for BiPap orders from 02/28/25 until 03/04/25. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff interviews and review of policy, the facility failed to ensure communication between the facility and dialysis vendor regarding dialysis treatments was on going for continuity of care. This affected one (#24) of one resident reviewed for dialysis. Seven residents currently receive dialysis treatments. The facility census was 89 residents. Findings include: Review of Resident #24's medical record revealed an admission on [DATE], with diagnoses that included chronic kidney disease, end stage renal disease, chronic viral hepatitis C, hypertension and dependence on renal dialysis. Review of Resident #24's physician orders revealed a standing appointment for dialysis at an outside dialysis clinic three times weekly. Orders for nursing to complete a pre- and post-dialysis communication form on Mondays, Wednesdays and Fridays. Observation of Resident #24's hard chart on 03/04/25 at 3:24 P.M., revealed some post dialysis forms in the hard chart, but not in completion.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to provide parameters for as needed pain medication. This affected one (#3) of five residents reviewed for unnecessary medications. The census was 89. Findings Include: Review of Resident #3's medical record revealed an admission on [DATE]. Her diagnoses included acute bronchitis, epileptic seizures, pulmonary embolism, post traumatic stress disorder, conversion disorder, phantom limb syndrome, bipolar disorder, unspecified protein calorie malnutrition, hypothyroidism, hypertension, other cervical disc degeneration, vitamin D deficiency, insomnia, atrial fibrillation, nonrheumatic mitral valve prolapse, muscle weakness, hypotension, repeated falls, pain, type II diabetes, depression, macular degeneration, hypermetropia, hyperlipidemia, anxiety disorder, acquired absence of right leg below knee, and epilepsy. Review of her Minimum Data Set (MDS) assessment, dated 12/09/24, revealed she was cognitively intact. Review of Resident #3 physician…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interviews, and policy review, the facility failed to secure and store medications appropriately. This affected one (#72) of 24 residents observed during the annual survey. The facility census was 89. Findings include: Review of Resident #72's medical record revealed an admission date of 10/06/23, with diagnoses that included cerebral infarction, dysphagia, major depressive disorder, psychoactive substance abuse, disorientation, anxiety disorder and pain. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #72 was cognitively intact, mild depression, with no signs of psychosis noted. Review of records for Resident #72 revealed no assessment or screening for self - medication documented and there was no physician's order to administer self-medications. Observations on 03/04/25 at 9:12 A.M. noted a medicine cup with several tablets and capsules on the over bed table for Resident #72. Interview on 03/04/25 at 9:12 A.M. with…

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, review of facility investigations, staff interviews, and facility policy and procedure, the facility failed to ensure allegations of abuse and misappropriation had thorough investigations and documentation of the investigation. This affected three residents (#86, #94, and #95) out of four residents reviewed for allegations of abuse and misappropriation. The facility census was 89. Findings include 1. Review of the medical record for Resident #94 revealed an admission date of 11/12/24 and a discharge date of 12/09/24. Diagnoses included surgical aftercare, endocarditis, bacteremia, shortness of breath, anxiety, and edema. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 was cognitively intact with a BIMS of 15 and was independent with mobility. Review of the online Self-Reported Incident (SRI) #254189 dated 11/18/24 revealed Resident #94 reported, during a care conference with social services staff, that he had to wake up Certified Nursing Aide (CNA) #55…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, record review and policy review, the facility failed to implement infection control procedures during a dressing change and while storing soiled laundry. This affected one (Resident #92) of three residents reviewed for wounds and had the potential to affect all residents residing in the facility. The facility census was 93. Findings include: 1. Review of the medical record for Resident #92, revealed an admission date of 12/10/22. Diagnoses included but were not limited to type 2 diabetes mellitus with diabetic neuropathy, human immunodeficiency virus disease, pneumonia due to other gram-negative bacteria and methicillin susceptible staphylococcus aureus infection as the cause of diseases classified elsewhere. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of resident is rarely/never understood. The resident was assessed to require total dependence on all aspects of assisted with daily living care.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interviews, review of plumbing invoices, and review of facility policy, the facility failed to maintain a safe, functional, and sanity environment in the shower room for the B hallway. This deficient practice had the potential to affect all residents residing in the facility. The facility census was 93. Findings Include: Review of the plumbing company invoice #143340436 dated 11/12/24 revealed plumbing company arrived at the customers property for a shower drain back up. After attempting to cable the shower drain, the blockage was removed and restored flow to the drain. Review of the plumbing company invoice #143544314 dated 11/13/24 revealed the facility was experiencing emergency flooding in the B hallway over the course of three days. The plumbing company attempted to clear the main line using high pressure jetter and a camera to evaluate the line. Observation on 11/14/24 at 10:10 A.M. revealed the shower room located on the B hallway there were multiple ceramic tiles…

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, observation of facility video footage, review of the facility submitted Self-Reported Incident (SRI), and facility policy review, the facility failed to report an incident of potential neglect when the facility failed to timely implement fire protocol regarding rescuing residents, containing the fire and extinguishing and evacuating residents. This affected one Resident (#19) who had a fire in her room on 09/26/24 and had the potential to affect the other nine residents (Resident #11, #15, #16, #17, #18, #20, #21, #22, and #23) living in the same smoke compartment as Resident #19. The total facility census was 88. Findings included: Review of Resident #19's medical record revealed the resident was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease, peripheral vascular disease, depression, anxiety, and suicidal ideation. Review of physician order dated 09/16/24 revealed Resident #19 had an order for oxygen at five liters per minute via…

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, staff interviews, review of facility camera footage, observation, review of a job description, review of the facility Self-Reported Incident (SRI), and facility policy review, the facility failed to be administered in a manner that enabled the facility to utilize available resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This included failure to prevent neglect of residents by staff during a fire that occurred on 09/26/24, failure to ensure residents utilizing oxygen therapy were not able to possess lighters and smoking materials unsupervised, failure to timely and appropriately implement emergency procedures, when a fire occurred in Resident #19's room and ignited the resident's mattress/bedding on fire which ultimately activated the sprinkler system, including: rescuing residents in and near the fire, containing the fire from potentially spreading, alerting emergency personnel timely, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to ensure fall interventions were in place. This affected one (Resident #22) of three residents reviewed for falls. The facility census was 94. Findings include: Record review revealed Resident #22 admitted to the facility on [DATE] with diagnoses including seizures, delirium, hemiplegia and hemiparesis following cerebral infarction, edema, major depression, hyperlipidemia, and mild cognitive impairment. Review of a Morse Fall Scale assessment completed on 07/17/24 revealed Resident #22 was at high risk for falling. Review of the care plan revealed Resident #22 required assistance of one to two staff for transfers and was at risk for falls related to an unsteady gait with fall interventions including but not limited to bright colored tape to call light, defined perimeter mattress, non-skid footwear, fall mat to right side of bed, bed in lowest position, and keeping call light in reach. Observation on 08/16/24 at 1:05 P.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.

Based on medical record review, observation, staff interview and review of the facility policy the facility failed to maintain proper infection control measures during medication administration. This affected two (Residents #22) of four residents observed for medication administration. The facility also failed to implement enhanced barrier precautions (EBP) when appropriate. This one resident (Resident #28) of three residents reviewed for isolation precautions. The facility census was 95 residents. Findings include: 1.Review of the medical record for Resident #22 revealed an admission date of 05/05/23 with diagnoses of respiratory failure and muscle weakness. Resident #22 was dependent on staff for activities of daily living (ADL) tasks including medication administration and had moderate cognitive impairment. Review of the physician orders for Resident #22 dated July 2023 revealed orders for the following medications to be given in the morning: Tylenol, Baclofen, Colace, folic acid, multivitamin, Zoloft, thiamine, vitamin D3, Gabapentin. Observation on 07/23/24 at 8:15 A.M. of…

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

Based on observation, record review, interview, and photographs, the facility was not maintained in a clean, homelike environment and was not in good repair. This affected all 87 residents residing in the facility. The census was 87. Findings include: Review of Resident Council Meeting minutes dated 06/06/24 revealed room B27's sink had been broken for three months. Grievance sheet dated 06/12/24 revealed the sink was repaired on 06/14/24. Observations on 06/21/24 during the initial tour of the facility with Administrator present to confirm revealed the following: - 10 A.M. a missing transition strip to the dining room, the door frame was dirty and chipped, the dining room had peeling wallpaper, splatter marks throughout the dining room walls, two rusting ceiling vents with dust across the ceiling near the vents. - 10:03 A.M. the door to the therapy gym was chipping and jagged with a sharp edge, the wallpaper near the trashcan in the therapy gym was peeling and stained brown. - 10:05 A.M. on the C hallway revealed room C10's floor was dirty with mud and tire marks from a motorized…

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, policy review, and interview, the facility failed to assist one female resident with shaving her face. This affected one resident (#44) of three residents reviewed for activities of daily living (ADLs). The facility census was 87. Findings include: Record review revealed Resident #44 admitted to the facility on [DATE] with diagnoses including other sequela of cerebral infarction, hemiplegia and hemiparesis following cerebrovascular disease affecting left dominant side, depression, chronic obstructive pulmonary disease, and type II diabetes. Review of an admission minimum data set (MDS) completed on 06/03/24 revealed Resident #44's cognition was intact, she did not refuse care, and was dependent on staff for personal hygiene including combing hair, shaving, applying makeup, washing face and hands. Observation and interview on 06/21/24 at 12:13 P.M. with Resident #44 revealed she had not been shaved since her admission because there were no supplies. Resident #44 stated an aide…

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 the facility policy, the facility failed to ensure medications were administered without significant errors. This affected one (Resident #96) of three residents reviewed for medications. The facility census was 91. Findings include: Review of the medical record for Resident #96 revealed an admission date of 01/11/24, with diagnoses including seizure disorder, chronic obstructive pulmonary disease (COPD), and dependence on respirator(ventilator). Review of the comprehensive Minimum Data Set (MDS) assessment for Resident #96 dated 01/17/24 revealed the resident was cognitively impaired and was dependent on staff for all activities of daily living (ADLs). Review of the care plan for Resident #96 dated 01/12/24 revealed the resident had a seizure disorder. Interventions included to give seizure medication as ordered by doctor and to monitor for side effects and effectiveness. Review of physician orders for Resident #96 revealed an order dated 02/03/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure the contact information for the practitioner responsible for the care of the resident, resident representative information, advanced directives information, all special instructions or precautions for ongoing care and all other necessary information to ensure a safe and effective transition of care was communicated to the receiving health care institution or provider upon transfer/discharge. This affected three (Residents #90, #91, and #92) out of three residents reviewed for hospitalization. The facility census was 85. Findings include: 1. Review of Resident #90's medical record revealed an admission date of [DATE] with diagnoses which included respiratory failure, tracheostomy, dependence on respirator (ventilator), history of Covid-19, type two diabetes mellitus, congestive heart failure, and hypertension. Resident #90 was discharged to the hospital on [DATE]. Review of Resident #90's progress notes, dated [DATE], revealed 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 and staff interview, the facility failed to ensure resident representatives were notified of medication changes. This affected one (Resident #1) out of three residents reviewed for medications. The census was 91. Findings include: Review of the medical record for Resident #1 revealed an initial admission date of 10/10/23 with diagnoses including but not limited to chronic respiratory failure with hypoxia, end stage renal disease, dependence on dialysis, tracheostomy, gastrostomy, type one diabetes mellitus, and seizures. Review of Resident #1's acute care hospital discharge instructions revealed orders, dated 10/10/23, for Keppra (medication used to control seizures) 100 milligrams (mg)/milliliter (ml) with the special instructions to give five ml via peg-tube twice daily and Keppra 100 mg/ml with special instructions to give 2.5 ml via peg-tube daily every Tuesday, Thursday and Saturday. Review of Resident #1's physician orders, dated 10/11/23, revealed an order for Keppra 100 mg/ml with special instructions to give 2.5 ml via peg-tube daily every…

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 closed record review and staff interview, the facility failed to develop a recapitulation of a resident's stay when the resident had a planned discharge. This affected one (Resident #93) out of one sampled resident who had a planned discharge to the community. The census was 91. Findings include: Review of the closed medical record for Resident #93 revealed an initial admission date of 08/15/23 with diagnoses including acute and subacute endocarditis, cerebral infarction, congestive heart failure, psychoactive substance abuse, hypertension, chronic viral hepatitis C, edema, diarrhea, gastro-esophageal reflux disease, muscle wasting, generalized muscle weakness, depression and pain. Resident #93 was discharged home with her daughter on 09/16/23. Review of the plan of care, dated 08/16/23, revealed Resident #93 would have a discharge plan. Interventions included all discharges were to be documented as well as document all discussions with family and resident regarding discharge plans. Review of Resident…

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

Based on medical record review, staff interview, and facility policy review, the facility failed to routinely assess pressure ulcers as well as ensure wound assessments included a description of the wound. This affected three (#48, #92, and #93) out of three residents reviewed for pressure ulcers. Additionally, the facility failed to initiate treatment for a pressure ulcer in a timely manner. This affected one (#92) out of three residents reviewed for pressure ulcers. The census was 91. Findings include: 1. Review of the medical record for Resident #92 revealed an initial admission date of 05/19/23 with a latest readmission date of 08/27/23. Resident #92's diagnoses included but were not limited to end stage renal disease (ESRD), diabetes mellitus, vascular dementia, dependence on renal dialysis, seizures, muscle wasting, and congestive heart failure. Review of the plan of care, dated 05/22/23, revealed Resident #92 was at risk for skin breakdown related to decreased mobility. Interventions included encourage Resident #92 to float heels as tolerated, house barrier cream with each…

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 there was a receipt of disposition for narcotic pain medication upon discharge from the facility. This affected one (Resident #93) out of one resident reviewed for planned discharge. The census was 91. Findings include: Review of the closed medical record for Resident #93 revealed an initial admission date of 08/15/23 with diagnoses including acute and subacute endocarditis, cerebral infarction, congestive heart failure, psychoactive substance abuse, hypertension, chronic viral hepatitis C, edema, diarrhea, gastro-esophageal reflux disease, muscle wasting, generalized muscle weakness, depression and pain. Resident #93 was discharged home with her daughter on 09/16/23. Review of Resident #93's comprehensive Minimum Data Set (MDS) assessment, dated 08/22/23, revealed Resident #93 had no cognitive impairment. Review of the resident's progress note dated 09/16/23 at 3:45 P.M. revealed the resident was discharged home at 2:30 P.M. The resident was provided discharge instructions and a list of their orders…

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

Based on observations and staff interviews, the facility failed to ensure a clean and comfortable living environment. This affected five (#10, #32, #33 and #34) of 85 residents residing in the facility. The census was 85. Findings include: Observation during a tour of the facility, on 08/10/23 from 10:10 A.M. to 10:30 A.M., revealed a strong urine-like odor in the hallway of rooms of Resident #10, #22, #32, #33 and #34. Observation of Resident #32's room confirmed the strong odor emanates from her room. Observation and interview on 08/10/23 at 12:55 P.M., with Unit Manager #100 confirmed there was a urine odor in the hallway in front of the Resident #10, #32, #33 and #34's rooms. Observation and interview on 08/10/23 at 4:00 P.M., with Housekeeping Supervisor #104 and Administrator verified the urine odor in the hallway outside of Resident #10, #32, #33 and #34 rooms. The Administrator confirmed the odor emanates from Resident #32's room. The housekeeper Supervisor #104 explained the rooms are cleaned frequently and it is the responsibility of her staff to indicate if a deep…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and policy review, the facility failed to complete quarterly care conferences for residents. This affected two (Residents #16 and #18) of two residents reviewed for care plans. The facility census was 87. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 04/12/22. Diagnoses included chronic obstructive pulmonary disease (COPD), schizoaffective disorder, type two diabetes mellitus, depression, mood disorder, and atrial fibrillation. Review of the Medicare Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #16 had moderate cognitive impairment evidenced by a Brief Interview for Mental Status (BIMS) score of nine. Resident #16 was assessed to require two-person extensive assistance with transfers, one-person extensive assistance with dressing, toileting, and bathing, and was independent with eating. Review of the care plan dated 07/20/22 revealed Resident #16 had hemiplegia/hemiparesis. Interventions included to assist…

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, resident interview, hospital staff interview, and staff interview, the facility failed to ensure a resident attended scheduled medical appointments. This affected one (Resident #71) of three residents reviewed for medical appointments. The census was 87. Findings include: Resident #71 was admitted to the facility on [DATE]. Diagnoses included venous insufficiency, peripheral vascular disease, lymphedema, type II diabetes, atherosclerosis, cardiomyopathy, atherosclerotic heart disease, hypertension, heart failure, and other psychoactive substance. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #71 was cognitively intact. Review of Resident #71's hospital records dated 05/19/22, revealed the resident was admitted to the facility for therapy and follow-up services related to a right lower leg wound. Review of Resident #71's progress notes revealed he complained of shortness of breath on 02/13/23, 02/27/23, and 03/07/23. Further review revealed 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.