Embassy Of Woodview

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, family interview, resident interview, and policy review, the facility failed to ensure Resident #110's family and the Office of the State Long-Term Care Ombudsman was timely notified of the resident's facility-initiated 30-day discharge notice, emergency transfer and subsequent emergency discharge. This affected one (#110) of three residents reviewed for discharges. The facility census was 72. Findings include: Review of the closed medical record for Resident #110 revealed an original admission date of 04/29/24. Medical diagnoses included bipolar disorder, anxiety, and depression. Resident #110 was emergently transferred to out outside hospital on [DATE] and did not return to the facility. Review of Resident #110's Minimum Data Set (MDS) quarterly assessment, dated 08/24/24, revealed the resident had a Brief Interview for Mental Status score of 15 which indicated intact cognition. Resident #110 was not recorded as having any hallucinations, delusions, or behaviors…

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, record review, and policy review, the facility failed to ensure safe and sanitary infection control practices were maintained during a dressing change. This affected one (#27) and had the potential to affect sixteen residents who the facility identified as receiving wound care. The facility census was 72. Findings include: Review of Resident #27's medical record revealed an admission date of 07/13/24. Medical diagnoses included sepsis, chronic kidney disease stage III, and peripheral vascular disease. Review of Resident #27's Minimum Data Set (MDS) admission assessment, dated 07/20/24, revealed the resident was identified as cognitively intact. He had no recorded behaviors or rejection of care. Resident #27 was identified to require partial/moderate to dependent assistance with activities of daily living and utilized a wheelchair for mobility. Review of Resident #27's care plan, dated as initiated 07/13/24 and revised on 09/12/24, revealed the resident had actual areas of skin impairment as the resident was admitted with vascular wounds to his…

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 of video footage, record review, and interviews, the facility failed to ensure one resident (#66) was treated with respect and dignity. This affected one (Resident #66) of three residents reviewed for dignity. The facility census was 74. Findings Include: Review of the medical record for Resident #66 revealed an initial admission date of 02/03/23 with diagnoses including cerebrovascular accident (CVA) with left sided hemiplegia, aphasia, dysphagia, hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), polyneuropathy, vascular dementia with behavioral disturbances, major depressive disorder, constipation, cannabis use, nicotine dependence, and history of COVID-19. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive deficit. Review of the mood and behavior revealed the resident displayed no behaviors. The resident required extensive assistance of two residents for bed mobility, transfers, toilet…

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, observation of video footage, staff interviews, and review of facility policy and procedure, the facility failed to ensure a resident was free from abuse. This affected one (#66) of three residents reviewed for abuse. The facility census was 74. Findings Include: Review of the medical record for Resident #66 revealed an initial admission date of 02/03/23 with diagnoses including cerebrovascular accident (CVA) with left sided hemiplegia, aphasia, dysphagia, hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), polyneuropathy, vascular dementia with behavioral disturbances, major depressive disorder, constipation, cannabis use, nicotine dependence, and history of COVID-19. Review of the plan of care dated 02/13/23 revealed the resident required assistance with activities of daily living (ADL) related to CVA with left sided hemiplegia. Interventions included assist in choosing appropriate clothing as needed, check nails daily for length and cleanliness, trim 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 observation, record review, interview and facility policy review, the facility failed to ensure one resident (#66), who was dependent on staff received routine nail care. This affected one (Resident #66) of three residents reviewed for activities of daily living (ADL). The facility census was 74. Findings Include: Review of the medical record for Resident #66 revealed an initial admission date of 02/03/23 with diagnoses including cerebrovascular accident (CVA) with left sided hemiplegia, aphasia, dysphagia, hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), polyneuropathy, vascular dementia with behavioral disturbances, major depressive disorder, constipation, cannabis use, nicotine dependence, and history of COVID-19. Review of the plan of care dated 02/13/23 revealed the resident required assistance with activities of daily living (ADL) related to CVA with left sided hemiplegia. Interventions included assist in choosing appropriate clothing as needed, check nails daily 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 observation of video footage, record review, interviews, and facility policy review, the facility failed to ensure one resident (#66) who was at high risk for falls and had a history of falls received the care and supervision for safe transfers. This affected one (Resident #66) of three residents reviewed for transfers. The facility census was 74. Findings Include: Review of the medical record for Resident #66 revealed an initial admission date of 02/03/23 with diagnoses including cerebrovascular accident (CVA) with left sided hemiplegia, aphasia, dysphagia, hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), polyneuropathy, vascular dementia with behavioral disturbances, major depressive disorder, constipation, cannabis use, nicotine dependence, and history of COVID-19. Review of the plan of care dated 02/13/23 revealed the resident required assistance with activities of daily living (ADL) related to CVA with left sided hemiplegia. Interventions included assist in choosing…

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 menus, staff interview, and facility policy review, the facility failed to ensure the menu was followed to meet the nutritional needs of the residents. This had the potential to affect all 64 residents who received meals from the kitchen. The facility identified two residents (Resident #5 and Resident #30) who did not eat anything by mouth. The facility census was 66. Findings include: Review of the menu for the lunch meal on 11/16/22 revealed the menu included: egg salad sandwich, macaroni salad, cucumber salad, a cookie, and milk. Interview on 11/16/22 at 10:43 A.M. with [NAME] #301 revealed the menu was changed since the cucumber salad was not delivered. The interview revealed the substitution would be potato salad. Interview on 11/16/22 at 10:54 A.M. with Dietary Manager (DM) #401 confirmed potato salad was not an appropriate nutritional substitute for cucumber salad due to the high carbohydrate content. Observation of the lunch meal tray service on 11/16/22 at 11:47 A.M. revealed the foods served included an egg salad sandwich, macaroni salad,…

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 ensure food was stored and dated properly. This had the potential to affect all 64 residents who received meals from the kitchen. The facility identified two residents (Resident #5 and Resident #30) who did not eat anything by mouth. The facility census was 66. Findings include: Initial tour of the kitchen with Dietary Manager (DM) #401 revealed the following items were improperly stored and were not dated: In the freezer: A bag of frozen chicken breasts which was opened and was not dated. A bag of frozen hash brown patties which was opened and was not dated. A frozen bag of green beans which was opened and was not dated. In the refrigerator: A half-full bottle of Garlic Parmesan wing sauce which was not dated. A half-full tub of Sweet & Sour sauce which was not dated. A half-full tub of Gourmet Sweet Relish which was not dated. A quarter-full bottle of mustard which was not dated. A quarter-full tub of Mayonnaise which was not dated. Interview on 11/14/22 at 1:40 P.M. with DM #401 confirmed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident, family and staff interviews, and policy review, the facility failed to include residents in the care planning process. This affected five ( #22, #24, #28, #38 and #117) of five reviewed for care planning. The total facility census was 66 Findings include: Review of Resident #22's medical record revealed an admission date of 11/15/19, with diagnoses of dysphagia, hypoxic ischemic encephalopathy, weakness, diabetes type two, anoxic brain damage, spastic hemiplegia affecting the right dominant side, depression, anxiety and contracture right elbow. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was coded to have both short and long term memory problems. Resident #22 had no delusions, hallucinations or behaviors during the review period. Resident #22 was dependent on staff for bed mobility, transfers, toileting, required extensive assist with dressing and personal hygiene, and was supervision with eating. Resident received seven days 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 observations, resident and staff interviews, medical record review, and policy review, the facility failed to ensure the residents resided in a safe, sanitary and homelike environment when there was wallpaper missing on the walls of a resident room affecting two (#59 and #24) and the facility failed to repair a hole in the back hallway floor, that was utilized by residents this had the potential to affect the 52 residents the facility identified as not being bedfast. The total facility census was 66. Findings include: 1. Review of Resident #59's medical record revealed the resident was admitted on [DATE] to the facility and the resident was moved into his current room on 05/27/22 and has remained in the current room since 05/27/22. Observations on 11/14/22 at 1:10 P.M., of Resident #59's room revealed the wall paper border in the room was torn and missing in large pieces around 75 percent of the room. Interview on 11/14/22 at 1:10 P.M., with Resident #59 stated the wallpaper has been that way since he…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interview, staff interviews, and medical record review, the facility failed to ensure a bed rail was installed as ordered to assist with bed mobility. The deficient practice affected one (#61) of one record reviewed for accommodations of needs. The facility census was 66. Findings include: Review of the medical record for Resident #61 revealed and original admission date on 07/13/22 and a re-admission date on 09/20/22. Medical diagnoses included end stage renal disease, anxiety disorder, obesity, and personal history of stroke. Review of the physician orders dated November 2022 revealed Resident #61 had the following order: attach bed rails to bed approved by hospice dated 10/21/22. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #61 required total dependence on two staff for bed mobility, transfers, and toileting. 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 medical record review and staff interview, the facility failed to provide an appropriately completed Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN). This affected one (#61) of the three residents reviewed for Beneficiary Notices. The facility census was 66. Finding include: Review of the medical record for Resident #61 revealed an admission date of 07/13/22 with an re-entry date of 09/20/22. Diagnoses included end stage renal disease, transient ischemic attach, and cerebral infarction. Review of Resident #61's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating an intact cognition for daily decision making abilities. Resident #61 was noted to reject care 1 to 3 days a week. Required total dependence from two staff members for bed mobility, transfers, toilet use, extensive assistance from two staff members for dressing, personal hygiene, supervision with set up help for eating. No noted…

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, this facility failed to ensure residents received accurate bed hold notices/reserve bed payment information and establish a written bed-hold and reserve bed payment policy. This affected two (#35 and #44) of the three residents reviewed for bed hold notices/ reserve bed payment. The facility census was 66. Findings include: 1. Review of medical record for Resident #35 revealed an initial admission date of 08/12/22 and a re-entry date of 11/08/22. Diagnosis included heart failure, chronic kidney disease stage 3, chronic obstructive pulmonary disease, and Atrial fibrillation. Review of Resident #35's medical record revealed in the resident's admission Paperwork dated 08/12/22, documented the resident had indicated that she would like the facility to hold her bed at the facility when transferred to the hospital, visits with friends or family, or any other leaves of absences. Review of progress note dated 11/02/22 at 5:20 P.M., created by Licensed Practical 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 medical record reviews and staff interviews, the facility failed to ensure assessments accurately reflected resident's condition. This affected two (#59 and #65) of 22 resident assessments reviewed. The total facility census was 66. Findings include: 1. Review of Resident #59's medical record revealed an admission date of 02/17/22, with diagnoses including: schizophrenia, insomnia, and weakness. Review of the most recent quarterly Minimum Data Set (MDS) assessment completed on 10/14/22, revealed the resident is cognitively intact, had no delusions, hallucinations or behaviors. The assessment had the resident coded as receiving seven days of antibiotics during the assessment look back period. Review of Resident #59's medication administration record (MAR) for October 2022 revealed the resident had no antibiotics used in his care during the entire month of October 2022. Review of physician orders revealed there were no orders for the resident to receive antibiotics during the month of October 2022.…

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 completed an updated PASARR screening when a Resident was diagnosed with a new mental illness. This affected one (#36) of the three residents reviewed for accurate PASARR screenings. The facility census was 66. Findings include: Review of medical record for Resident #36 revealed an admission date of 11/01/17 with a re-entry date of 11/08/19. Diagnoses included schizoaffective disorder identified on 04/06/21, major depressive disorder identified on 06/03/20, psychosis, and psychoactive substance dependence. Review of Resident #36's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident with a modified independence for daily cognitive decision making abilities. No behaviors noted with this assessment review. Resident #36 noted to receive antidepressants and opioids 7 days a week. No antipsychotics were received. Review of plan of care dated 11/13/17 revealed Resident #36 uses antidepressant 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.

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 full resident review for a resident who enter the facility under the hospital exemption and remained in the facility longer than 30 days. This affected one (#59) of two residents reviewed for preadmission screening. The total facility census was 66. Findings include: Review of Resident #59's medical record revealed an admission date of [DATE], with diagnoses including schizophrenia, insomnia, and weakness. Review of the most recent quarterly Minimum Data Set assessment completed on [DATE], revealed the resident is cognitively intact, had no delusions, hallucinations or behaviors during the review period. The assessment had the resident coded with the diagnosis of schizophrenia. The resident received seven days of antipsychotic, antidepressant, and antibiotic medication and four days of opioid medication. Review of the resident medical record revealed the resident had a hospital exemption review 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 observation, record review, staff interviews, and policy review, the facility failed to ensure residents had comprehensive care plans developed to addressed their individualized needs. This affected four ( #49, #59, and #38) of 22 residents reviewed for care plans. The total facility census was 66. Findings include: 1. Review of Resident #49's medical record revealed an admission date of 06/30/22, with diagnoses including myocardial infarction, tracheostomy status, and type two diabetes. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident did not have a mental status change. The resident was coded as having a tracheostomy tube. Review of Resident #49's care plan revealed a care plan was in place related to the resident having a tracheostomy and the risk and complications of respiratory distress related to the tracheostomy tube. The care plan was silent to the type and size of tracheostomy tube the resident utilized and to what steps to take in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interview, and policy review the facility failed to timely address a resident's constipation. This affected one (#117) of one reviewed for constipation. The facility census was 66. Findings include: Review of Resident #117's medical record revealed an admission date of 10/27/22, from another skilled nursing facility to be closer to family. Resident #117's diagnoses included Parkinson's disease, type two diabetes, obesity, paroxysmal atrial fibrillation, dysphagia, anxiety and depression. Review of most recent admission MDS assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, resident was assessed as dependent on staff for transfers and toileting. Resident was assessed as always incontinent of bowel and bladder. Review of current monthly physician orders revealed orders for Miralax 17 grams daily, and an ordered Bisacodyl 10 milligram (mg), one suppository rectally every 24 hours as needed for constipation. Interview on 11/14/22 at 1:00…

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, family and staff interviews, and policy review, the facility failed to ensure vision services were arranged and received timely. The deficient practice affected two (#28 and #38) of two residents reviewed for communication and sensory services. The facility census was 66. Findings include: 1. Review of the medical record for Resident #38 revealed an admission date of 01/14/21. Diagnoses included generalized anxiety disorder, malignant neoplasm of breast, malignant neoplasm of right kidney, edema of left orbit, cognitive communication deficit and unspecified dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #38 had impaired cognition and required extensive assistance from one staff to complete personal hygiene task and supervision with set up help only to one staff to complete other Activities of Daily Living (ADLs). Review of the optometry consent form dated 05/25/21 revealed Resident #38 consented to receive optometrist…

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, observation of wound care, resident and staff interview, and review of hospice notes, National Pressure Injury Advisory Panel (NPIAP) guidelines review, the facility failed to identify a new pressure area, assess the wounds, and provides treatments. The deficient practice affected one (#61) of one reviewed for pressure ulcers. The facility census was 66. Findings include: Review of the medical record for Resident #61 revealed an original admission date on 07/13/22 and a re-admission date on 09/20/22. Medical diagnoses included end stage renal disease, anxiety disorder, obesity, and personal history of stroke. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #61 required total dependence on two staff for bed mobility, transfers, and toileting. Resident #61 had one unstageable deep tissue injury noted on the assessment 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 medical record review, observations, family and staff interviews, and review of therapy notes, the facility failed to ensure a resting hand splint was applied as ordered. This affected one (Resident #5) of three residents reviewed for position and mobility. The facility census was 66. Findings include: Review of the medical record for Resident #5 revealed an admission date on 04/19/22. Medical diagnoses included cognitive communication deficit, contracture of left hand, cerebral infarction (stroke) affecting left non-dominant side, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and muscle weakness. Review of Resident #5's physician orders revealed Resident #5 had an order, dated 10/26/22, for occupational therapy (OT) to issue a left handed resting hand splint for patient to wear up to eight hours a day as well as skin checks after removing the splint. Review of Resident #5's physician orders revealed Resident #5 had an order, dated 02/23/22, for Resident #5…

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, observation, staff interview, and policy review, the facility failed to ensure emergency tracheostomy supplies were readily available. This affected one (#49) of two residents reviewed for tracheostomy services. The facility census was 66. Findings include: Review of Resident #49's medical record revealed the resident was admitted on [DATE] with diagnoses which included but were not limited to myocardial infarction, tracheostomy status, and type two diabetes. Review of the most recent quarterly Minimum Data Set assessment, dated 10/13/22, revealed Resident #49 was coded as having a tracheostomy tube. Review of Resident #49's physician orders revealed there was no order to address what to do with the tracheostomy tube in an emergency, or what type or size of tracheostomy tube Resident #49 utilized in her care. Review of Resident #49's care plan revealed a care plan was in place related to the resident having a tracheostomy and the risk and complications of respiratory distress…

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 provide psychiatric services and/or alcohol counseling services as care planned for a resident with substance seeking behavior. This affected one (Resident #58) out of the one resident reviewed for behavioral health services. The facility census was 66. Findings include: Review of the medical record for Resident #58 revealed an admission date of 03/11/22. Diagnoses included hypertension, difficulty in walking, and chronic obstructive pulmonary disease. Review of Resident #58's quarterly Minimum Data Set assessment, dated 08/29/22, revealed Resident #58 had moderate cognitive impairment. Review of the plan of care, dated 08/09/22, revealed Resident #58 did not conform to or understand boundaries of socially accepted behaviors. Resident #58 was verbally abusive towards staff and used profanity with staff and residents. Resident #58 had the potential for continued behaviors. Interventions included to discuss with the resident in a straight forward, but kind manner, that his/her behavior…

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 adequately monitor residents who received psychotropic medications. This affected one (#59) out of five residents reviewed for unnecessary medications. The facility census was 66. Findings include: Review of Resident #59's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included but were not limited to schizophrenia, insomnia, and weakness. Review of the most recent quarterly Minimum Data Set assessment, completed on 10/14/22, revealed Resident #59 was cognitively intact, had no delusions, no hallucinations and no behaviors during the review period. Resident #59 was coded as having received seven days of antipsychotic and antidepressant during the review period. Review of Resident #59's physician orders revealed Resident #59 had orders for Remeron (antidepressant) 7.5 mg daily for depression, Trazodone (antidepressant) 100 mg daily for insomnia, and Haloperidol…

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 interview, and policy review, the facility failed to perform laboratory tests as ordered. This affected one (#22) out of five residents reviewed for unnecessary medications. The facility census was 66. Findings include: Review of Resident #22's medical record revealed the resident was admitted on [DATE] with diagnoses including diabetes type two, anoxic brain damage, and spastic hemiplegia affecting the right dominant side. Review of Resident #22's physician orders revealed Resident #22 had an order for a Hemoglobin A1C (lab test that measures average blood glucose over the past three months) level. Additionally, Resident #22 had an order for a Depakote level every six months. Review of Resident #22's laboratory test results revealed Resident #22 had a Depakote level obtained on 03/09/22, and there was no evidence a Hemoglobain A1C level was obtained. Interview with the Director of Nursing on 11/17/22 at 1:44 P.M. confirmed the facility did not complete laboratory…

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, family and staff interview, and policy review, the facility failed to provide timely dental services. This affected one (#22) of three residents reviewed for dental services. The facility census was 66. Findings include: Review of Resident #22's medical record revealed the resident was admitted on [DATE] with diagnoses which included but were not limited to dysphagia, anoxic brain damage, spastic hemiplegia affecting the right dominant side, and depression. Review of the annual Minimum Data Set assessment dated [DATE] revealed Resident #22 was not in a persistent vegetative state, had unclear speech, was usually able to express ideas and wants, and understands others verbal content. Resident #22 was coded to have both short and long term memory problems. Review of Resident #22's Dental Summary Report dated 03/11/22 revealed Resident #22 was seen on this day by the dentist and had several maxillary teeth which were decayed and according to the resident caused pain when…

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 a written bed hold notice to one Resident (#66) of three reviewed for transfers and discharges. The facility census was 69. Findings include Review of the medical record revealed Resident #66 was admitted to the facility on [DATE] with diagnoses including right below the knee amputation, end stage renal disease with dialysis, and diabetes. Review of the progress note dated 12/13/19 revealed Resident #66 complained of flank pain on the right side and increasing pain in the right lower leg stump. Resident #66 wanted to go to the emergency department (ED). The resident's physician and representative were notified, and the resident was sent to the hospital. Resident #66 was readmitted to the facility on [DATE]. There was no evidence the resident received a written bed hold policy notice. Interview on 03/12/20 at 12:53 P.M. with the Regional Director of Clinical Services #92 verified the facility did not provide a bed hold policy…

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 accurately complete the Minimum Data Set (MDS) assessment. This affected two Residents (#37 and #57) of 17 reviewed for MDS accuracy. The facility census was 69. Findings include 1. Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including hydrocephalus, dysphagia, and type two diabetes. Review of Resident #37's physician's order dated 12/03/19 revealed the resident was ordered Lantus (insulin), 10 units, two times each day for diabetes. Review of the comprehensive assessment dated [DATE] revealed the resident was not receiving insulin. Interview on 03/12/20 at 8:51 A.M., with the Minimum Data Set (MDS) Coordinator #59 verified Resident #37 was receiving insulin during the MDS look back period and an error had been made when coding the MDS. 2. Medical record review revealed Resident #57 was admitted to the facility on [DATE] with extreme cognitive deficits, schizophrenia and…

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

Based on medical record review, observation, and staff interview, the facility failed to ensure a resident with a pressure ulcer received the necessary treatment to promote healing and prevent new ulcers from developing. This affected one Resident (#7) of one reviewed for pressure ulcers. The facility census was 69. Findings include: Review of the medical record for Resident #7 revealed an admission date of 08/10/19 with diagnoses including dementia, spinal enthesophathy, diabetes, and severe protein-calorie malnutrition. Further review of the record revealed the resident was admitted with three pressure ulcers as follows: 1. A stage four (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur) on the coccyx measuring 6.0 centimeters (cm) long by 6.8 cm wide by 0.8 cm deep with tunneling. 2. An unstageable (Full-thickness skin and tissue loss in which the extent of tissue…

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 review of facility policy, the facility failed to date insulin pens when they were opened. This affected three Residents (#37, #56, and #67) of seven insulin pens observed. The facility census was 69. Findings include Observation on 03/12/20 at 6:30 A.M. revealed three insulin pens were identified as being open and used for Resident #37, #56, and #67. None of the tree pens had an open date identified on the pens. Interview on 03/12/20 at 6:30 A.M. with Registered Nurse (RN) #93 verified the insulin pens for Residents #37, #67, and Resident #56 did not indicated the date the pens were opened. Review of the facility's policy titled Medication Storage, dated 01/1/14, under the heading of Multi-Dose Vials, revealed vials must be dated upon opening and discarded within 30 days unless otherwise specified by manufacturer.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interview, the facility failed to assist a resident with obtaining dental services. This affected (#35) of three reviewed for dental services. The facility census was 69. Findings include: Medical record review revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including diabetes, hemiplegia, and chronic obstructive pulmonary disease. Review of Resident #35's plan of care revealed the resident had natural teeth and was at risk for oral issues related to obvious broken natural teeth. An intervention was to coordinate arrangements for dental care and transportation as needed. Review of Resident #35's nurse progress noted dated 03/26/19 at 3:05 P.M. revealed Resident #35 had returned from a dental appointment and had six lower teeth removed. Review of the nurse progress note dated 04/13/19 at 1:38 P.M. revealed the resident had teeth extracted recently and was scheduled for remaining teeth to be extracted. Review of Resident #35's annual…

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.