Eastland Rehabilitation And Nursing Center

Based on record review, staff interview, review of Self-Reported Incident (SRIs), and review of the facility policy, the facility failed to ensure allegations of physical abuse were reported immediately to the state agency as required. This affected one (Resident #3) of three residents reviewed for abuse. The facility census was 87 residents. Findings include: Review of the medical record for Resident #3 revealed an admission date of 08/08/20 with diagnoses including chronic systolic heart failure, type two diabetes mellitus, atrial fibrillation, hypertension, and anxiety disorder and a discharge date of 11/20/24. Review of the Minimum Data Set (MDS) assessment for Resident #3 dated 11/17/24 revealed the resident had intact cognition and required supervision or touching assistance with activities of daily living (ADLs.) Review of the hospital note for Resident #3 dated 11/20/24 timed at 9:47 P.M. revealed the resident was admitted with complaints of back pain and alleged he had been pushed by an employee at the facility during an altercation on 11/18/24 which caused the resident 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.

Based on record review, staff interview, review of Self-Reported Incident (SRIs), and review of the facility policy, the facility failed to ensure residents were protected from further potential abuse during abuse investigations. This affected one (Resident #3) of three residents reviewed for abuse. The facility census was 87 residents. Findings include: Review of the medical record for Resident #3 revealed an admission date of 08/08/20 with diagnoses including chronic systolic heart failure, type two diabetes mellitus, atrial fibrillation, hypertension, and anxiety disorder and a discharge date of 11/20/24. Review of the Minimum Data Set (MDS) assessment for Resident #3 dated 11/17/24 revealed the resident had intact cognition and required supervision or touching assistance with activities of daily living (ADLs.) Review of the hospital note for Resident #3 dated 11/20/24 timed at 9:47 P.M. revealed the resident was admitted with complaints of back pain and alleged he had been pushed by an employee at the facility during an altercation on 11/18/24 which caused the resident to fall…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to complete a comprehensive assessment of continence for a resident. This affected one of three residents reviewed for incontinence (Resident #27). The facility census was 88. Findings include: Review of the medical record for Resident #27 revealed an admission date of 03/29/24 and diagnoses including diabetes, bipolar disorder, and septic arthritis of the left leg. Review of a nursing admission assessment dated [DATE] revealed a question: How long has the resident been incontinent or had a catheter? it was documented N/A Continent. It further stated the resident was wet during day and night time, small amounts. It stated the resident was continent of bowel. No further information was documented related to bowel or bladder incontinence. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed it stated Resident #27 had a brief interview for mental status score of 15, indicating intact cognition. It stated 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 and staff interview, the facility failed to ensure laboratory testing was completed as ordered, the physician was notified timely of the results after completed, and physician's orders were followed related to medication administration for one of five sampled residents (Resident #2). The facility census was 88. Findings include: Review of the medical record for Resident #2 revealed the resident was admitted [DATE] from the hospital where she had been treated for C-difficile colitis (inflammation of the colon caused by bacteria) with diarrhea, weakness, decreased appetite and malnutrition. The resident had additional diagnoses including adult failure to thrive, hypothyroidism, dysphagia, rheumatoid arthritis, cerebral vascular accident, and bipolar disorder. Review of a nursing progress note on 04/15/24 at 4:12 P.M. revealed the nurse was notified by physical therapy about a change in the resident's condition. The resident was assessed. Resident alert to self and denied pain.…

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, medical record review, staff interview, resident interview, and policy review, the facility failed to ensure a resident maintained acceptable parameters of nutritional status including body weight. This affected one of three residents reviewed for meal assistance (Resident #2). The facility census was 88. Findings include: Review of the medical record for Resident #2 revealed the resident was admitted [DATE] from the hospital where she had been treated for C-difficile colitis (inflammation of the colon caused by bacteria) with diarrhea, weakness, decreased appetite and malnutrition. The resident had additional diagnoses including adult failure to thrive, dysphagia, rheumatoid arthritis, cerebral vascular accident, and bipolar disorder. The resident was noted with a pressure ulcer on the right buttock on admission. The resident weighed 153.7 pounds on admission and had a physician's order dated 03/20/24 to weigh weekly for four weeks then monthly. Review of a nutritional assessment 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, interview, and facility policy review the facility failed to report allegations of misappropriation to the state agency. This affected one resident (#86) of five residents reviewed for misappropriation. The facility census was 84. Findings Include: Review of the closed record for Resident #86 revealed an admission date of 10/09/22 and discharge date [DATE]. Diagnoses included paraplegia, chronic obstructive pulmonary disease (COPD), intermittent explosive disorder, cocaine abuse, opioid abuse, cannabis abuse, and depression. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #86 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15 (no impairment). The assessment revealed Resident #86 had behaviors towards staff, was frequently incontinent of urine and bowel, used a wheelchair for self-propelling, nursing care for a diabetic skin impairment and required limited assist from staff for activities of daily living (ADL)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review the facility failed to investigate an allegation of misappropriation. This affected one resident (#86) of five residents reviewed for misappropriation. The facility census was 84. Findings Include: Review of the closed record for Resident #86 revealed an admission date of 10/09/22 and discharge date [DATE]. Diagnoses included paraplegia, chronic obstructive pulmonary disease (COPD), intermittent explosive disorder, cocaine abuse, opioid abuse, cannabis abuse, and depression. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #86 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15 (no impairment). The assessment revealed Resident #86 had behaviors towards staff, was frequently incontinent of urine and bowel, used a wheelchair for self-propelling, nursing care for a diabetic skin impairment and required limited assist from staff for activities of daily living (ADL) including transfers…

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, policy review, and interview, the facility failed to provide and document sufficient preparation, coordination and orientation for Resident #86 to ensure the resident had a safe and orderly transfer/discharge from the facility to an appropriate location that could meet his total care needs. This affected one resident (#86) of three residents reviewed for discharge. The facility census was 84. Findings Include: Review of the closed medical record for Resident #86 revealed an admission date of 10/09/22 and a discharge date [DATE]. Resident #86 had diagnoses including paraplegia, chronic obstructive pulmonary disease (COPD), intermittent explosive disorder, cocaine abuse, opioid abuse, cannabis abuse, and depression. Review of a care plan dated 10/10/22 revealed Resident #86 was at risk for skin breakdown related to fragile skin, incontinence, and venous ulcer to lower legs and feet. A care plan dated 10/10/22 revealed Resident #86 had an activities of daily living (ADL) self-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 medical record review, staff interview, and facility policy review the facility failed to ensure all resident Pre-admission Screening and Resident Review (PASRR) documents were accurate to resident current conditions and diagnoses. This affected ten residents (#59, #28, #68, #37, #14, #19, #56, #75, #42, and #55) of 13 residents reviewed for PASRR documents. The facility census was 84. Findings include: 1. Resident #14 was admitted to the facility on [DATE]. Her diagnoses were osteomyelitis of vertebra, type II diabetes, chronic obstructive pulmonary disease (COPD), acute respiratory failure, dysphagia, muscle wasting and atrophy, hypokalemia, acute kidney failure, dementia, alcohol abuse, retention of urine, acidosis, bipolar disorder, altered mental status, hypotension, chronic kidney disease (stage III), cognitive communication deficit, schizophrenia, major depressive disorder, insomnia, pressure ulcer left heel, hypertension, anxiety disorder, adjustment disorder, atrial fibrillation, anemia, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy review the facility failed to ensure all significant mental health changes were communicated to the state mental health agency. This affected ten residents (#59, #28, #68, #37, #14, #19, #56, #75, #42, and #55) of 13 residents reviewed for Pre-admission Screening and Resident Review (PASRR) documents. The facility census was 84. Findings include: 1. Resident #14 was admitted to the facility on [DATE]. Her diagnoses were osteomyelitis of vertebra, type II diabetes, chronic obstructive pulmonary disease (COPD), acute respiratory failure, dysphagia, muscle wasting and atrophy, hypokalemia, acute kidney failure, dementia, alcohol abuse, retention of urine, acidosis, bipolar disorder, altered mental status, hypotension, chronic kidney disease (stage III), cognitive communication deficit, schizophrenia, major depressive disorder, insomnia, pressure ulcer left heel, hypertension, anxiety disorder, adjustment disorder, atrial fibrillation, anemia, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, financial record review, and staff interview, the facility failed to provide spend down notices to all residents who received Medicaid benefits. This affected three residents (#2, #3, and #19) of four resident financial records reviewed. The facility census was 84. Findings include: 1. Resident #2 was admitted to the facility on [DATE]. His diagnoses were chronic respiratory failure, type II diabetes, morbid obesity. unspecified focal traumatic brain injury, cognitive communication deficit, chronic kidney disease, peripheral vascular disease, hypertension, hyperlipidemia, insomnia, thrombocytopenia, dementia, congestive heart failure, tachycardia, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 09/30/23, revealed Resident #2 had a significant cognitive impairment. Review of Resident #2's financial statements, dated 10/01/22 to 09/30/23, revealed his total was above $2000 for the entire time. The totals varied between $2,096.49 and $3,552.39. 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, facility staff interviews, and facility policy review, the facility failed to ensure resident code status was accurate and consistent throughout medical records for two residents (#8 and #74). The deficient practice affected two residents (#8 and #74) of two residents reviewed for advanced directives. The facility census was 84. Findings include: 1. Review of the medical record for Resident #8 revealed an initial admission date on 08/01/2014 and a readmission date on 03/02/21. Medical diagnoses included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), unspecified protein-calorie malnutrition, emphysema, type II diabetes mellitus, cognitive communication deficit, heart failure, Alzheimer's Disease, and other specified peripheral vascular diseases. Resident #8's code status was listed as Do Not Resuscitate Comfort Care (DNRCC) on the resident's face sheet in the electronic medical record. Review of the annual Minimum Data Set (MDS) 3.0 assessment…

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, financial record review, and staff interview, the facility failed to notify residents/representatives in a timely manner when there was a change in Medicaid benefits. This affected one resident (#3) of four residents reviewed for Medicaid benefits. The facility census was 84. Findings include: Resident #3 was admitted to the facility on [DATE]. Her diagnoses were hemiplegia and hemiparesis, type II diabetes, acute respiratory failure, aphasia, cerebral infarction, vascular dementia, metabolic encephalopathy, peripheral vascular disease, epilepsy, osteoporosis, hydronephrosis, hypertension, hyperlipidemia, and atrial fibrillation. Review of her Minimum Data Set (MDS) assessment, dated 10/15/23, revealed she had a significant cognitive impairment. Review of Resident #3's financial records revealed the facility received notification about her needing to send in documentation and verification for the need of Medicaid services, known as the redetermination. There was no documentation…

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 facility policy review the facility failed to complete thorough neurological checks for Resident #8 after a fall. This affected one resident (#8) of two residents reviewed for accidents. The facility census was 84. Findings include: Review of the medical record for Resident #8 revealed an admission date of 08/01/14 with diagnoses including chronic obstructive pulmonary disease (COPD), peripheral vascular disorder (PVD), age related nuclear cataract bilateral, age-related macular degeneration, congestive heart failure, Alzheimer's disease, and cardiac arrhythmias. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had severe cognitive impairment with hallucinations and delusions. Resident #8 required extensive assistance of one person for bed mobility, toileting, and personal hygiene and extensive assistance of two persons for transfers. Resident #8 had an unsteady balance and gait and was incontinent of bowel and bladder.…

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, financial record review, and staff interview, the facility failed to provide an adequate plan to spend down resident finances when it was above the Medicaid allowable limit. This affected three residents (#2, #3, and #19) of four resident's financial records reviewed. Also, the facility failed to provide adequate social services to ensure residents didn't lose their Medicaid benefits. This affected one resident (#3) of four resident's financial records reviewed. The facility census was 84. Findings Include: 1. Resident #2 was admitted to the facility on [DATE]. His diagnoses were chronic respiratory failure, type II diabetes, morbid obesity. unspecified focal traumatic brain injury, cognitive communication deficit, chronic kidney disease, peripheral vascular disease, hypertension, hyperlipidemia, insomnia, thrombocytopenia, dementia, congestive heart failure, tachycardia, and anxiety disorder. Review of his Minimum Data Set (MDS) assessment, dated 09/30/23, revealed he had 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to adequately address the pharmacy recommendations and have proper diagnosis for medications for Resident #28 and did not write contraindication for recommendations to decrease a medication for Resident #20. This affected two residents (#28 and #20) of five residents reviewed for unnecessary medications. The facility census was 84. Findings include: 1. Review of the medical record for Resident #20 revealed an admission date of 01/06/18 with diagnoses including type II diabetes mellitus, epilepsy, congestive heart failure, anxiety disorder, bipolar disorder, and post-traumatic stress disorder. Review of the current physician orders dated 11/23 revealed Resident #20 received clonazepam (antianxiety) 0.5 milligrams (mg) by mouth daily for major depressive disorder, buspirone hydrochloride (antianxiety) 7.5 mg by mouth two times per day for anxiety, aripiprazole 5 mg by mouth daily for insomnia related to schizoaffective disorder, and duloxetine hydrochloride…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy review, the facility failed to obtain proper parameters for as needed pain medications. This affected one Residents (#11) of five residents reviewed for unnecessary medications. The facility census was 84. Findings include: Resident #11 was admitted to the facility on [DATE]. Her diagnoses were type II diabetes, unspecified protein calorie malnutrition, cognitive communication deficit, muscle wasting and atrophy, muscle weakness, peripheral vascular disease, hyperlipidemia, hypothyroidism, anemia, nicotine dependence, paraplegia, depression, polyneuropathy, cachexia, hypertension, and chronic kidney disease (stage IV). Review of the Minimum Data Set (MDS) assessment, dated 10/23/23, revealed Resident #11 was cognitively intact. Review of Resident #11's medical records revealed her current physician orders included Percocet 10-325 milligrams (mg) every eight hours as needed for pain, Acetaminophen 325 mg every six hours as needed for mild pain,…

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, resident medical records, staff interview, and facility policy review, the facility failed to ensure pureed food was maintained in a manner that met the resident's health and safety needs. This affected two residents (#8 and #235) of two residents who had orders for puree diets. The facility census was 84. Findings include: Observation on 11/27/23 from 11:25 A.M. to 11:35 A.M. revealed [NAME] #202 placed approximately five scoops of chicken and noodles in the blender to make it pureed texture. After blending for approximately 45 seconds, she obtained the proper texture. She started to pour the pureed texture chicken and noodles back into the pan that had regular textured chicken and noodles, which still had full pieces of chicken and noodles in the pan. As she lifted the blending pan to pour the pureed food back into the original pan, the surveyor stopped her so the two textured food items would not be mixed. Review of Resident #8 and Resident #235's medical records confirmed both were on a puree texture diet order. Interview with [NAME] #202 on 11/27/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to maintain accurate medical records. This affected one resident (#37) of 27 residents medical records reviewed. The facility census was 84. Findings include: Resident #37 was admitted to the facility on [DATE]. His diagnoses were chronic obstructive pulmonary disease (COPD), chronic bronchitis, dysphagia, muscle wasting and atrophy, muscle weakness, nicotine dependence, hypomagnesemia, hypocalcemia, hypocalcemia, dementia, post-traumatic stress disorder (PTSD), age related physical debility, anxiety disorder, major depressive disorder, adult failure to thrive, hypokalemia, acute kidney failure, hypertension, pneumonia, hyperlipidemia, toxic encephalopathy, and hypo-osmolality and hyponatremia. Review of his Minimum Data Set (MDS) assessment, dated 10/13/23, revealed he was cognitively intact. Review of Resident #37 medical records revealed he had dental appointment records, dated 11/10/23, that were not actually his records. The dental…

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

Based on observation, interview, review of the manufacturers guidelines, and facility policy review the facility failed to follow proper infection control procedures regarding cleaning a glucometer. This had the potential to affect two residents (#2 and #235) on the 300-memory care hall that received fingerstick blood sugars using the glucometer. The facility census was 84. Findings include: During the medication administration observation on 11/27/23 at 11:45 A.M. Licensed Practical Nurse (LPN)#164 obtained fingerstick blood sugar for Resident #235. After the procedure, LPN #164 cleaned the glucometer with a Micro-Kill bleach wipe by wiping it off and placing on the medication cart. LPN #164 stated she kept the glucometer wet for a few seconds (did not monitor the time). LPN #164 reviewed the instructions on the container of Micro-Kill bleach wipes that stated to kill viruses or bacteria keep the glucometer wet with the Micro-Kill bleach wipe for 30 seconds and let air dry. LPN #164 confirmed she did not keep the glucometer wet for 30 seconds. LPN #164 stated she did not have…

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 interviews, the facility failed to provide bathing as scheduled and per resident preference. This affected three residents (#5, #6, and #86) out of eight residents reviewed for bathing. The facility census was 86. Findings include: 1. Review of the medical record revealed Resident #5 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis, type two diabetes mellitus, and chronic respiratory failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was cognitively intact and required extensive assistance of two staff for bed mobility and transfers and one staff assistance with bathing. Review of the bathing documentation for Resident #5 revealed the resident was scheduled to be bathed on Wednesdays and Saturdays. There was no documented evidence of Resident #5 being bathed on 08/02/23, 08/19/23, 08/23/23, and 08/26/23. Interview on 08/30/23 at 10:58 A.M. Resident #5 revealed she was scheduled to be bathed twice a week but was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interviews, and policy review the facility failed to provide appropriate incontinence care for Resident #50. This affected one resident (#50) out of three residents reviewed for incontinence. The facility census was 86. Findings include: Review of the medical record revealed Resident #50 was admitted on [DATE] with diagnoses including heart failure, type two diabetes mellitus, legal blindness, and polyneuropathy. Review of the care plan dated 05/26/23 revealed Resident #50 was incontinent of bowel and bladder. Interventions included to check for incontinence, clean and dry skin if wet or soiled, document when incontinent, and use pads/briefs to manage incontinence. The care plan dated 06/30/23 revealed Resident #50 had activities of daily living self-care performance deficit. Interventions included checking for incontinence every two hours and as needed, clean and dry skin if wet or soiled, and use pad/briefs to manage incontinence. Review of the quarterly Minimum Data Set…

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 interview, the facility failed to ensure complete and accurate documentation related to 30-day discharge notices were contained in each resident's medical records. This affected two residents (#83 and #85) of three residents reviewed for discharge. The facility census was 81. Findings include 1. Review of the closed medical record for Resident #83 revealed an admission date of 05/31/23 and discharge date of 07/28/23. Diagnoses included fracture of lateral condyle of left tibia, diabetes and alcohol induced dementia. Review of a 30-day discharge notice revealed Resident #83 was given a 30-day discharge notice notice on 07/25/23 with a date to discharge on [DATE]. The notice was signed by Resident #83. There was no documentation in the resident's record reflecting she was given a notice to discharge or that the discharge notice had been rescinded. Interview on 08/02/23 at 10:58 A.M. with Regional Director of Operations (RDO) #101 revealed the staff on a corporate level did not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed record review, policy review, and interview, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This affected three residents (#83, #84, and #85) of three residents reviewed for discharge. Facility census was 81. Findings include 1. Review of the closed medical record for Resident #83 revealed an admission date of [DATE] and discharge date of [DATE]. Diagnoses included fracture of lateral condyle of left tibia, diabetes and alcohol induced dementia. Review of a progress notes dated [DATE] revealed the resident was observed drinking alcohol. The physician was updated on [DATE]. Review of skilled charting dated [DATE] revealed the resident required limited assistance and one personal physical assist with bed mobility and limited assist with toilet usage and used pads and briefs. The note revealed the resident was not receiving therapy services from physical, occupational or speech…

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 the medical record for Resident #63 revealed an admission date of 01/02/20 with diagnoses including sepsis, depression, and dementia. Review of the nurse's note for Resident #63 dated 01/12/20 at 2:43 P.M. revealed Resident #63 was admitted to the hospital with a diagnosis of sepsis, possible pneumonia, and hypotension. Review of the nurse's note dated Discharge Minimum Data Set assessment dated [DATE] revealed Resident #63 was expected to return to the facility from the hospital. Review of the bed hold notice provided to Resident #63 and his representative dated 01/12/20 revealed Resident #63 was private pay and there was no per diem bed hold rate included on the bed hold notice. Interview with the Regional Director on 02/05/20 at 2:46 P.M. verified the per diem bed hold rate was not included on Resident #63's bed hold notice dated 01/12/20. Review of facility, Bed Hold and Returns policy, dated March 2017, revealed prior to transfer and therapeutic leaves, residents or resident representatives…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents were invited to and included in care conference meetings. This affected one (Resident #50) of one resident reviewed for care conferences. The census was 75. Findings Include: Review of the medical record for Resident #50 revealed an admission date of 03/24/17 with diagnoses including multiple sclerosis, bipolar disorder, and schizophrenia. Review of the annual Minimum Data Set assessment dated [DATE] revealed the resident was moderately cognitively impaired. Review of the care conference note dated 01/17/20 revealed a care conference was held on 01/17/20 and social services, nursing, and Resident #50's brother attended the care conference. The note did not include evidence Resident #50 was invited to or attended the care conference on 01/17/20 nor did it include any input from Resident #50. Interview with Interim Unit Manager (IUM) #168 on 02/05/20 at 4:31 P.M. revealed she attended the care conference and remembers Resident #50 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility policy review, the facility failed to monitor for significant weight change in an appropriate manner. This affected two (Resident #2 and #24) of five residents reviewed for nutrition. The census was 75. Findings Include: 1. Record review revealed Resident #2 was admitted on [DATE]. Her diagnoses were dementia, acute kidney failure, polyosteoarthritis, history of falling, pain in left knee, urinary tract infection, unspecified protein calorie malnutrition (01/29/20), peripheral vascular disease, pain in right knee, hypertension, and hyperlipidemia. Her Brief Interview for Mental Status (BIMS) score was five, which indicated she was severely cognitively impaired. The assessment was completed on 01/24/20. Review of Resident #2 medical records revealed significant changes in her weights. The following are documented weights from the facility: 09/03/19 (184.2 pounds), 10/07/19 (175.6 pounds), 11/07/19 (175.4 pounds), 12/09/19 (175.3 pounds), 01/22/20…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and facility contract review, the facility failed to complete on-going monitoring and assessments of residents who attend dialysis appointments. This affected one (Resident #24) of one resident reviewed for dialysis. The census was 75. Findings Include: Record review revealed Resident #24 was admitted to the facility on [DATE]. Her diagnoses were acute kidney failure, cognitive communication deficit, difficulty walking, muscle weakness, need for assistance with personal care, anemia, type II diabetes, hyperlipidemia, hypertension, vitamin D deficiency, abdominal pain, arthropathy, hypothyroidism, mitral valve insufficiency, end stage renal disease, dependence on renal dialysis, personal history of transient ischemic attacks, and thrombocytopenia. Her Brief Interview for Mental Status (BIMS) score was 15, which indicated she was cognitively intact. The assessment was completed on 12/12/19. Review of Resident #24 medical records revealed she attends dialysis three…

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, review of dietary spread sheet, the facility failed to provide diet textures as ordered by a physician. This affected one (Resident #63) of five residents reviewed for nutrition. Findings Include: Review of the medical record for Resident #63 revealed an admission date of 01/02/20 with diagnoses including dysphagia, dementia, and protein-calorie malnutrition. Review of the active physician orders for Resident #63 revealed an order dated 01/30/20 for a regular diet with mechanical soft, ground textures and regular consistency liquids. Observation of Resident #63's lunch tray on 02/05/20 at 12:49 P.M. revealed he received a pulled pork sandwich, mixed vegetables, and baked beans. The pulled pork sandwich was not ground and was partially eaten. Interview with Registered Dietitian #301 on 02/05/20 at 12:52 P.M. verified Resident #63 received a pulled pork sandwich, mixed vegetables, and baked beans and the pulled pork sandwich was partially eaten. The interview further revealed Resident #63 had not choked as a result of eating the pulled…

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

Based on observation, interview, and record review, the facility failed to ensure nutritional supplements and honey thickened water were dated as to when they were opened. This had the potential to affect two (Resident #10 and #128) out of 17 Residents who have orders for Med Pass supplements and honey thickened liquids. The census was 75. Findings Include: 1. Observation of the 400 hall unit refrigerator on 02/05/20 at 12:03 P.M. revealed two opened containers of vanilla Med Pass supplements both undated as to when they were opened. Interview with Director of Nursing (DON) on 02/05/20 at 12:03 P.M. verified the two opened partially empty containers of vanilla Med Pass supplements were undated as to when they were opened. Interview with DON on 02/05/20 at 4:46 P.M. revealed there is a chance a nurse covering the 400 hall would administer the vanilla Med Pass supplement to residents with physician orders for Med Pass supplements on the 400 hall. The DON verified Residents #10 and #128 received Med Pass and/or honey thickened liquids. Review of the vanilla Med Pass supplement…

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.