Mayfair Village Nursing Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to follow infection control procedures for a resident requiring enhanced barrier precautions this affected one (#04) and the facility failed to ensure staff followed neutropenic precautions which affected one (#42) . Five residents were reviewed for infection control procedures. The facility census was 82. Findings Include: 1.Resident #04 was admitted [DATE] and had diagnoses that include obstructive uropathy, chronic kidney disease (stage IIIA), and chronic systolic congestive heart failure. Review of the Resident's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident was cognitively intact and had an indwelling catheter. Review of the Resident #04's care plan completed 02/05/26 revealed Resident #04 had an indwelling catheter related to urinary retention and was at risk of infections. Enhanced Barrier Precautions (EBP) are an intervention listed to reduce the risk of infections…

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 maintain a medication error rate of five percent or less. This affected one resident (#45) of six residents observed during medication administration. The facility census was 86.Findings include: 1. On 11/26/25 at 9:00 A.M. through 11:16 A.M. and 12/01/25 from 8:08 A.M. through 8:21 A.M. medication pass was observed for six residents (#2, #30, #45, #73, #75, and #76) provided by five facility staff nurses. A total of 26 observations were made with two errors resulting in an error rate of 7.69%.Record review of Resident #45's medical record revealed an admission date of 04/02/2019. Diagnoses include unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, chronic kidney disease stage III, unspecified atrial fibrillation, other specified peripheral vascular diseases, essential (primary) hypertension, anemia, presence of cardiac pacemaker, dysphagia oropharyngeal phase,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and facility policy review the facility failed to administer medications as ordered for Resident #45. This affected one of five residents observed during medication administration. The facility census was 86.Findings include:Record review of Resident #45's medical record revealed an admission date of 04/02/2019. Diagnoses include unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, chronic kidney disease stage III, unspecified atrial fibrillation, other specified peripheral vascular diseases, essential (primary) hypertension, anemia, presence of cardiac pacemaker, dysphagia oropharyngeal phase, muscle weakness, edema, vitamin deficiency, nail dystrophy, presence of intraocular lens, and long term (current) use of anticoagulants.Review of Resident #45's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) could not be completed due to resident is rarely/never understood and confirms…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and facility policy review the facility failed to properly label and store medications. This had the potential to affect all residents who receive medications from the facility. The census was 86.Findings include: 1. Observation on [DATE] at 9:39 A.M. with Licensed Practical Nurse (LPN) #52 during medication administration revealed a facility stock bottle of Thiamine B1 (vitamin) 100 milligram (mg) tablet which was opened and undated, a facility stock bottle of Famotidine (decreases acid in the stomach) 20 mg bottle which was opened and undated, and container of MiraLAX (laxative)17 mg which was opened and undated. Other facility stock medication bottles were observed in medication cart had open dates written on top of lid of medication bottle.Interview on [DATE] at 9:45 A.M. with LPN #52 confirmed the bottles of Thiamine, Famotidine, and MiraLAX were open but were not labeled with the open date. LPN #52 was observed labeling the bottles. 2. Observation on [DATE] at 11:25 A.M. of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to provide assistance with bathing and shaving. This affected (Residents #42 and #44) of three residents reviewed for showers. The facility census was 80. Review of the medical record revealed Resident #42 was admitted on [DATE] with diagnoses that included acute embolism and thrombosis of left iliac vein, pulmonary embolism, severe protein-calorie deficiency, schizoaffective disorder, dementia, depression, and bipolar. The annual Minimum Data Set (MDS) dated [DATE] revealed it was very important for Resident #42 to choose the type of bathing. A care plan for activities of daily living dated 01/26/24 revealed Resident #42 required supervision with bathing/showering. Review of the electronic record, therapy notes, and paper documentation revealed in the last 30-days Resident #42 received a bed bath on 09/08/25 and 09/11/25, refused bathing with occupational therapy on 09/18/25, and received a sponge bath on 09/21/25. An observation and interview 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 interview and record review, the facility failed to thoroughly assess a resident after a fall and timely notify the physician. This affected one resident (#3) of three residents reviewed for falls. The facility census was 80.Findings include: Review of Resident #3's medical record revealed an admission date of 07/10/25 with diagnoses including cognitive communication deficit, dementia, depression, anxiety and fracture of left femur on 08/21/25.Review of Resident #3's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had severely impaired cognition. Since the previous assessment Resident #3 had two falls or more without injury, two falls or more with injury, and one fall with major injury.Review of Resident #3's plan of care dated 07/11/25 revealed the resident was at risk for falls related to impaired balance and lack of safety awareness due to cognitive deficit related to dementia. Interventions included assisting out of bed before meals, assisting with toileting before…

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, medical record review, and policy review, the facility failed to ensure Resident #3's pain was timely and appropriately addressed. This affected one resident (#3) of four residents reviewed for falls. The facility census was 80.Findings include: Review of Resident #3's medical record revealed an admission date of 07/10/25 with diagnoses including cognitive communication deficit, dementia, depression, anxiety and fracture of left femur on 08/21/25.Review of Resident #3's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had severely impaired cognition. Since the previous assessment Resident #3 had two falls or more without injury, two falls or more with injury, and one fall with major injury.Review of Resident #3's physician order dated 07/10/25 revealed an order for Acetaminophen Tablet 325 milligrams (mg) two tablets by mouth every four hours as needed for a fever above 101 degrees Fahrenheit.Review of Resident #3's physician order dated 07/10/25 revealed an order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed medical record review, hospital record review, toxicology report review, review of the facility admission policy, review of the facility assessment and interviews, the facility failed to ensure Resident #82 received adequate, timely and appropriate treatment and continuity of care following admission to the facility resulting in a situation of neglect. This resulted in Immediate Jeopardy and serious life-threatening harm/subsequent death beginning on [DATE] at 8:30 P.M. when Resident #82, who had been hospitalized prior to admission, arrived at the facility for placement and staff failed to obtain physician orders for medications/treatments or contact the physician/medical director regarding the resident's admission. From [DATE] through [DATE] the resident was not ordered and did not receive medications including blood pressure medication, blood thinning medication, or insulin. In addition, Resident #82 presented to the facility with a history of illegal drug use; however, the facility failed to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed ensure care plans were comprehensive and addressed problems as stated in a self-reported incident (SRI). This affected one resident (#43) of three residents reviewed for care plans. The facility census was 81. Findings include. Review of the medical record for Resident #43 revealed an admission date of 01/28/25. The resident was admitted with diagnoses including idiopathic aseptic necrosis of left femur, unsteadiness on feet, history of falling, type II diabetes mellitus, and memory deficit following a cerebral infarction. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 was moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) of 11 out of a score of 15, indicating moderate cognitive impairment, and was dependent for showering/bathe self and lower body dressing. Resident #43 was independent for oral hygiene, toileting hygiene, putting on/taking off footwear, and personal hygiene.…

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 facility policy review, the facility failed to ensure comprehensive care related to tracheostomy care. This affected two (Resident #65 and #66) of three resident records reviewed for tracheostomy care. The census was 81. Findings include: 1. Review of Resident #65's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure, cerebral aneurysm, liver transplant, tracheostomy, dysphagia and Hepatitis C. Review of the quarterly MDS (minimum data set) assessment dated [DATE] revealed her cognition was rarely/never understood, she was dependent on staff for eating, oral hygiene, toileting, shower/bathing, dressing, personal hygiene and turning and repositioning. She was always incontinent of bowel and bladder. Review of the physician's orders dated 03/25 revealed no orders for tracheostomy care. There was no documented evidence of a plan of care for tracheostomy care or documentation on the…

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

Based on observation, staff interview and review of facility policy and procedure, the facility failed to ensure medications were secured to prevent unauthorized access. This had the potential to affect seven (Residents #35, #42, #43, #48, #50, #56 and #58) of 24 residents on 300 hallway identified as cognitively impaired and independently mobile. The census was 81. Findings include: Observation on 03/10/25 at 8:28 A.M. of medication administration by Licensed Practical Nurse (LPN) #25 revealed while preparing medication for Resident #38, she left the medication cart unattended leaving cards of hydroxide HCL(antihistamine) 25 milligrams (mg), Potassium Chloride ER (extended release) 20 meq (milliequivelants), Spironalactone (blood pressure medication) 25 mg, toresmide (diuretic) 20 mg, Venlafaxine (antidepressant) HCL 100 mg, Venlafaxine HCL 25 mg and a bottle of Miralax on top of the medication cart unattended and out of her sight. Interview with LPN #25 on 03/10/25 at 8:34 A.M. verified she had left the medications on top of the medication cart unattended and out of her sight.…

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 facility policy and procedure review, the facility failed to ensure proper infection control guidelines were maintained during tracheostomy care. This affected one (Resident #65) of two residents reviewed for tracheostomy care. The census was 81. Findings include: Review of Resident #65's medical record (SR #3) revealed she was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure, cerebral aneurysm, liver transplant, tracheostomy, dysphagia and Hepatitis C. Review of the quarterly MDS dated [DATE] revealed her cognition was rarely/never understood, she was dependent on staff for eating, oral hygiene, toileting, shower/bathing, dressing, personal hygiene and turning and repositioning. Review of the physician's orders dated 03/25 revealed no orders for tracheostomy care. There was no documented evidence of a plan of care for tracheostomy care or documentation on the treatment record tracheostomy care had been completed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to protect the privacy of medical information for a resident. This affected one (#3) of three residents reviewed for privacy. The current census is 83. Findings include: Review of Resident #3's medical record revealed an admission date of 01/19/24. Diagnoses for Resident #3 included: acute necrotizing hemorrhagic encephalopathy, hypertension, Diabetes type two, and dementia. Review of Resident #3's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Observation on 10/21/24 at 8:30 A.M., during a medication administration on the 100-hall, revealed on the wall in the hallway, on the right side of the door for Resident 3's room, was a piece of paper with private medical information for Resident #3. The sign read, Resident #3, nothing by mouth after midnight, pick up for his surgery will be 10/21/24 at 8:00 A.M. Resident #3 was not in the room and had already left. At the same time of the observation of the sign,…

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 medical record review, the facility failed to provide resident dignity with use of an indwelling urinary catheter. This deficient practice affected two (#5 and #27) of four residents reviewed for indwelling urinary catheters. The facility census was 81. Findings Include: 1. Review of the medical record for Resident #5 revealed an admission date 05/14/19 with diagnoses including chronic obstructive pulmonary disease (COPD), muscle weakness, high blood pressure, and obstructive uropathy. Resident #5 required assistance from staff for activities of daily living (ADL) tasks, and was assessed as cognitively intact. Review of the physician orders for Resident #5 revealed an order dated 04/11/22 for a suprapubic catheter to straight drain due to chronic tubulointerstitial nephritis, and an order dated 01/28/23 for a dignity bag to cover the catheter drainage bag. Observation on 09/03/24 at 10:45 A.M. revealed Resident #5 was resting in bed with the urinary catheter drainage bag hung from the bed frame. The urinary catheter collection bag 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.

Based on medical record review and staff interview, the facility failed to ensure professional standards were maintained when a medication ordered for one (#74) was administered to another (#33) resident. This deficient practice affected two (#33 and #74) of two residents reviewed for staff borrowing medications. The facility census was 81. Findings Included: 1. Review of the medical record for Resident #74 revealed an admission date of 08/01/19 with diagnoses including dementia, type two diabetes mellitus, bipolar disorder, and schizoaffective disorder. Resident #74 had impaired cognition and required assistance with activities of daily living (ADL) tasks and medication administration. Review of the physician orders for Resident #74 revealed a one-time order dated 08/07/24 for the antipsychotic medication Zyprexa 10 milligrams (mg) to be given via intramuscular (IM) injection. Further review of Resident #74 medication administration record (MAR) dated 08/07/24 revealed the order for Zyprexa 10 mg was refused by Resident #74 for administration. 2. Review of the medical record for…

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

Based on medical record review, staff interview, and review of a facility policy, the facility failed to prevent the administration of an unnecessary antipsychotic medication. This deficient practice affected one (#33) out of two resident reviewed for antipsychotic medication use. The facility census was 81. Findings Include: Review of the medical record for Resident #33 revealed an admission date for 09/09/22 with a readmission date 08/31/24. Diagnoses included epilepsy, high blood pressure, schizoaffective disorder, and traumatic brain injury. Resident #33 was assessed with impaired cognition, impaired decision making, and physical behaviors towards others. Review of the physician orders for Resident #33 revealed a one-time order dated 08/12/24 for the antipsychotic medication Zyprexa 10 milligrams (mg) to be given via intramuscular (IM) injection for increased agitation. Further review of Resident #33's medication administration record (MAR) dated 08/12/24 revealed the order for Zyprexa 10 mg was administered at 6:02 P.M. and was effective. Further review of the MAR revealed…

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 and staff interview, the facility failed to have a carbon monoxide detector in the kitchen with a gas stove present. This had the potential to affect all 90 residents residing in the facility. Findings Include: Observation on 08/05/24 at 9:30 A.M. revealed in the facility main kitchen, there was a gas stove within the kitchen area. There was no carbon monoxide detector in this area. Interview with Food Service Director #195 on 08/05/24 at 9:32 A.M. confirmed they did not have a carbon monoxide detector in the kitchen with a permanently installed fuel burning appliance (stove). She confirmed there is a designated spot in place to have a carbon monoxide detector, but it was not in place. She confirmed she did not know how long it had not been in place.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interview, staff interview, medical record review, and facility policy review, the facility failed to maintain smoking products. This affected one (Resident #20) of one reviewed for smoking. The facility census was 90. Findings include: Resident #20 was admitted on [DATE] with diagnoses that included quadriplegia, chronic obstructive pulmonary disease, abnormal posture, neuromuscular dysfunction, panic disorder, chronic fatigue and chronic pain disorder. Review of the Minimum Data Set 3.0 (MDS 3.0) assessment on 05/24/24 revealed Resident #20 had a Brief Interview for Mental Status (BIMS) of 15, revealing intact cognition, and confirmed that Resident #20 received oxygen therapy. Review of current physician's orders revealed Resident #20 received oxygen at two liters per minute every night shift. Observation on 08/08/24 at 8:51 A.M. revealed Resident #20 had a lighter and a package of cigarettes containing three cigarettes at his bedside. His oxygen was running at two liters per…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to protect the privacy of Resident #18 and Resident #12's medical records. This affected two of twenty-two medical records reviewed for the annual survey. The facility census was 90. Findings include: 1. Resident #18 was admitted on [DATE] with diagnoses that included senile degeneration of brain, muscle weakness, encephalopathy, bipolar disorder and schizophrenia. Observation on 08/05/24 from 4:04 P.M. through 4:14 P.M. revealed Resident #18's electronic medical record was open on the medication cart, which was unattended by the nurse on duty. The screen was visible to passersby's and revealed Resident #18's medication schedule. Interview with Registered Nurse (RN) Unit Care Coordinator #131 on 08/05/24 at 4:14 P.M. confirmed Resident #18's electronic health record was unattended, open and easily viewable to any person who passed by. Interview with Licensed Practical Nurse (LPN) Unit Nurse #154 on 08/05/24 at 4:15 P.M. confirmed LPN Unit…

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 all resident Pre-admission Screening and Resident Review (PASRR) documents were completed as required. This affected one (Resident #78) of three residents reviewed for PASRR documents. The census was 90. Findings Include: Resident #78 was admitted to the facility on [DATE]. His diagnoses were moderate protein-calorie malnutrition, hypotension, muscle weakness, mood disorder, dysphagia, catatonic disorder due to known physiological condition, cognitive communication deficit, major depressive disorder, hyperlipidemia, altered mental status, post traumatic stress disorder. anxiety disorder, hypertension, suicidal ideations, acute kidney failure, hypothyroidism, and encephalopathy. Review of his Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. Review of Resident #78's PASRR document dated 03/28/24, revealed this was the first PASRR document that was completed for him. He was admitted to the facility 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 resident interview, medical record review and facility policy review, the facility failed to create a care plan related to Post Traumatic Stress Disorder (PTSD) for residents. This affected one (Resident #7) of two residents reviewed for care plans. The facility census was 90. Findings include: Resident #7 was admitted on [DATE] with diagnoses that included absence right below knee amputation, cerebral palsy, muscle weakness, bipolar disorder, post-traumatic stress disorder, and homelessness. Review of the Minimum Data Set (MDS) 3.0 assessment on 07/17/24 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognitive status. She was assessed as having a PTSD diagnosis. Review of the medical record for Resident #7 revealed that she was assessed for trauma informed care on 03/13/24 and no events were listed or checked as being experienced by the resident. The events included sexual assault, which was listed as not being experienced by Resident #7. Further…

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 staff interview, record review, policy review, and resident interview, the facility failed to conduct quarterly care conferences. This affected three (Residents #4, #40 and #65) of three residents reviewed for care conferences. The facility census was 90. Findings include: 1. Record review of Resident #4 revealed an admission date of 07/10/22 with pertinent diagnoses of: Parkinson's disease, cognitive communication deficit, and hypertension. Review of the 07/03/24 annual Minimum Data Set (MDS) assessment revealed the resident was cognitively intact and used a wheelchair to aid in mobility and was always incontinent of bladder and frequently incontinent of bowel. Interview with Resident #4 on 08/05/24 at 2:50 P.M. revealed she is not invited to attend quarterly care conferences to discuss her care in the facility. Review of the medical record on 08/08/24 revealed within the last year an interdisciplinary care conference was held on 03/05/24 where the resident and staff attended. There was no evidence that a care conference was attended by an interdisciplinary team any other…

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, interviews, and observations, the facility failed to properly monitor and accurately document skin abnormalities. This affected one (Resident #56) out of the one reviewed for skin conditions. The facility census was 90. Findings include: Review of the medical record for Resident #56 revealed he was admitted on [DATE] with diagnoses including cirrhosis of the liver, chronic venous insufficiency, atrial fibrillation, and skin vasculitis. Review of the Minimum Data Set (MDS) 3.0 assessment for Resident #56, completed on 07/22/24, indicated that he was cognitively intact, at risk for developing pressure ulcers, and had been ordered a pressure-relieving bed. Review of the care plan for Resident #56 dated 06/22/24 revealed he is on anticoagulant therapy for atrial fibrillation and is at risk for abnormal bleeding. Interventions included monitoring for and reporting adverse reactions to anticoagulant therapy, such as blood-tinged urine, nausea, muscle or joint pain, and bruising. 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 resident interview, medical record review and facility policy review, the facility did not effectively assess residents for Post Traumatic Stress Disorder (PTSD). This affected one (Resident #7) of five residents reviewed for trauma informed care. The facility census was 90. Findings include: Resident #7 was admitted on [DATE] with diagnoses that included absence right below knee amputation, cerebral palsy, muscle weakness, bipolar disorder, post-traumatic stress disorder, and homelessness. Review of the Minimum Data Set (MDS) 3.0 assessment on 07/17/24 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognitive status. She was assessed as having a PTSD diagnosis. Review of the medical record for Resident #7 revealed that she was assessed for trauma informed care on 03/13/24 and no events were listed or checked as being experienced by the resident. The events included sexual assault, which was listed as not being experienced by Resident #7. Further…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, family interviews, staff interviews, and review of facility policies, the facility failed to assist with discharge planning. This affected one (Resident #82) of three residents reviewed for discharge planning. Additionally, the facility failed to document discharge planning efforts and include the residents in discharge planning. This affected three (Residents #82, #31, and #50) of three residents reviewed for discharge planning. The facility census was 77. Findings include: 1. Review of the medical record for Resident #82 revealed an admission date of 10/20/23 and discharge date of 11/08/23. Diagnoses included metabolic encephalopathy, respiratory failure with hypoxia, muscle weakness, unsteadiness on feet, dependence on oxygen, diabetes, chronic obstructive pulmonary disease, pulmonary hypertension, and altered mental status. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #82 was cognitively intact and required substantial and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, family interview, and staff interviews, the facility failed to ensure a resident was provided with oxygen as ordered at discharge. This affected one (Resident #82) of three reviewed for oxygen. Facility census was 77. Findings include: Review of the medical record for Resident #82 revealed an admission date of 10/20/23 and discharge date of 11/08/23. Diagnoses included metabolic encephalopathy, respiratory failure with hypoxia, muscle weakness, unsteadiness on feet, dependence on oxygen, diabetes, chronic obstructive pulmonary disease, pulmonary hypertension, and altered mental status. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #82 was cognitively intact and required substantial and maximum assistance for activities of daily living including toileting and bathing. Review of the plan of care dated 10/20/23 revealed Resident #82 was at risk for respiratory illness with interventions for oxygen settings via nasal cannula to be administered as ordered.…

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 resident and staff interviews, the facility failed to honor a resident's preference for bathing time. This affected one (#74) of three residents reviewed for bathing. The facility census was 74. Findings include: Review of Resident #74's medical record identified admission to the facility on [DATE] with medical diagnoses including anemia, diabetes, chronic pain, and encephalopathy. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #74 was assessed with moderate cognitive impairment, and was dependent on staff for bathing. Further review of the MDS assessment revealed Resident #74 indicated it was very important to choose his own bedtime. Review of Resident #74's plan of care for activities of daily living (ADLs) identified bathing would occur every Monday and Thursday night, and staff were to provide a sponge bath when a full bath or shower could not be tolerated. Interview with Resident #74 on 11/30/23 at 6:07 A.M. stated he received…

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 resident interview, the facility failed to ensure resident rooms were maintained in a safe, clean, and homelike manner. This affected three residents (#11, #47, and #48) out of five residents reviewed for the environment. The facility census was 76. Findings include: 1. Review of Resident #11's medical record revealed Resident #11 was admitted on [DATE] with diagnoses which included arthritis, type two diabetes mellitus, dysphagia, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/05/23, revealed Resident #11 was cognitively intact. Observation on 10/25/23 at 9:40 A.M. revealed there was cracked and chipped paint along with chunks of plaster missing along the baseboard heating unit in Resident #11's room. Additionally, the privacy curtain in Resident #11's room had brown specks splashed on it. Interview with State Tested Nurse Aide (STNA) #400 on 10/25/23 at 9:45 A.M. verified there was cracked 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, resident interview, and staff interview, the facility failed to accommodate residents cultural preferences for meals. This affected one (Resident #11) out of three residents reviewed for meals. The facility census was 76. Findings include: Review of the medical record for Resident #11 revealed Resident #11 was admitted on [DATE] with diagnoses which included arthritis, type two diabetes mellitus, dysphagia, and major depressive disorder. Review of the quarterly Minimum Data Set assessment, dated 09/05/23, revealed Resident #11 was cognitively intact and required supervision and set-up assistance with eating. Review of Resident #11's physician order, dated 03/29/21, revealed Resident #11 had a physician order for a consistent carbohydrate diet. Review of Resident #11's comprehensive care plan revealed it did not address Resident #11's cultural preferences and requests related to meals. Review of Resident #11's medical record revealed no evidence the facility had asked Resident #11…

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 staff interview and record review, the facility failed to ensure the surety bond remained adequate to cover all resident account totals. This had the potential to affect all 30 Residents (#1, #7, #9, #11, #16, #17, #18, #21, #22, #23, #30, #34, #35, #36, #39, #42, #48, #53, #54, #55, #56, #57, #58, #59, #61, #66, #67, #68, #69, #74) who had an open resident fund account. The facility census was 77. Findings Include: Review of the surety bond dated 05/15/20 revealed the surety bond capacity was $30,000. Review of monthly balance information revealed the Resident account balances totaled over $30,000 each month since 05/2020. In 05/2020, the balance was $45,762.70. In 06/2020, the balance was $46,477.93. In 07/2020, the balance was $41,722.65. In 08/2020, the balance was $43,836.74. In 09/2020, the balance was $38,335.02. In 10/2020, the balance was $36,022.80. In 11/2020, the balance was $34,233.47. In 12/2020, the balance was $31,815.33. In 01/2021, the balance was $38,717.46. In 02/2021, the balance was $36,898.56. In 03/2021, the balance was $31,793.88. In 04/2021, the…

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

Based on observation and staff interview, the facility failed to ensure residents had a clean, homelike environment, and the room, furniture, and privacy curtain were clean and in good repair. This affected eight (Resident #4, #5, #6, #11, #25, #38, #46 and #432) out of 77 residents residing in the facility. The census was 77. Findings include: 1. Observation on 02/07/22 between 9:55 A.M. and 3:58 P.M. revealed the following findings: • Resident #4 and Resident #38's shared privacy curtains were soiled with black marks along the bottom third of the curtains. Both curtains had three to four areas of dried brown liquid on them. • Resident #4's overbed table was in disrepair and was delaminating. • Resident #4's right wheelchair arm was loose, slanted, and the material was peeling off of the armrest. • Resident #4's side table was cracked and broken on the left front. The banding around the top of the side table was loose and detached. • Resident #11's overbed table was in disrepair and was delaminating. • Resident #11's room wall next to his bed had paint peeling along half the width…

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 the Ombudsman was notified of resident transfers and discharges. This affected four (Resident #32, #40, #46, and #330) of five residents reviewed for transfer/discharge. The facility census was 77. Findings Include: 1. Review of the medical record for Resident #32 revealed an admission date of 11/16/21. Resident #32's diagnoses included diabetes type two, COVID-19, and fractured nasal bones. Review of the medical record for Resident #32 revealed Resident #32 was discharged to the hospital on [DATE]. There was no documented evidence to indicate the Ombudsman was notified of Resident #32's discharge to the hospital on [DATE]. 2. Review of the medical record for Resident #40 revealed an admission date of 02/05/21. Resident #40's diagnoses included type two diabetes, osteomyelitis or vertebra, and atherosclerotic heart disease. Review of the medical record for Resident #40 revealed Resident #40 was discharged…

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 and resident interview, and review of facilty policy, the facility failed to ensure nail care and oral care was provided for dependent residents. This affected five (Residents #5, #12, #56, #65 and #72) out of five residents reviewed for nail and oral care. The census was 77. Findings include: 1. Review of medical record for Resident #5 revealed an admission date of 02/21/17 with diagnoses including visual loss, mixed receptive language disorder, dementia with behavioral disturbance, and moderate protein-calorie malnutrition. Review of Resident #5's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely impaired for daily decision making, required extensive assist of two for bed mobility and transfers, and was totally dependent of one for personal hygiene. Review of Resident #5's activity of daily living (ADL) self-care performance deficit plan of care dated 08/03/20 revealed Resident #5 had an ADL self-care performance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, review of manufactures instructions, and review of facility policy, the facility failed to ensure medications were stored properly, not stored with food, and expired medication and laboratory vials were disposed of. This affected nine (Resident #2, #3, #27, #34, #39, #45, #48, #55, and #435) out of 77 residents in the facility. The census was 77. Findings include: 1. Observation on 02/09/22 at 12:23 P.M. of the 400 back hall medication cart revealed Resident #48's Dorzolamide HCL ophthalmic solution two percent (%), Resident #55's Combigan 0.2% ophthalmic solution, rhopressa topical eye drops, Dorzolamide HCL two percent eye drops, and two open boxes of latanoprost ophthalmic solution 0.005% (one undated when opened) were in the same compartment of the top drawer as Resident #48's calcitonin salmon nasal spray, Resident #34's Ventolin 90 microgram (mcg) inhaler, Resident #27's Albuteral Sulfate 90 mcg inhaler, and Debrox ear wax removal with no resident name on the box. 2.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and policy review, the facility failed to ensure resident advanced directives were accurate. This affected one (Resident #53) out of one resident reviewed for advanced directives. The facility census was 77. Findings Include: Review of the medical record for Resident #53 revealed an admission date of 07/04/20. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, Parkinson's disease, dementia without behaviors, bipolar disorder, and schizophrenia. Review of the Annual Minimum Data Set assessment dated [DATE] revealed Resident #53 was rarely or never understood. Review of Resident #53's physician orders dated 12/13/21 revealed an order to change Resident #53's code status to Do Not Rescuscitate Comfort Care (DNRCC). Review of Resident #53's physician orders dated 12/23/21 revealed an order to admit to hospice services with terminal diagnosis of protein calorie malnutrition. Review of documentation in the advanced directives tab in Resident #53's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of a facility self-reported incident, staff interview, and policy review, the facility failed to implement their abuse policy and thoroughly investigate an allegation of physical abuse. This affected one (Resident #56) out of one resident reviewed for abuse. The facility census was 77. Findings include: Review of the medical record for the Resident #56 revealed an admission date of 01/03/18. Diagnoses included diabetes type two, unspecified mood disorder, and delusional disorder. Review of the Annual Minimum Data Set assessment dated [DATE] revealed Resident #56 was cognitively intact, required supervision set up assistance for transfers and bed mobility, and required one person assistance with personal hygiene. Review of the Resident #56's electronic medical record revealed no documentation of an altercation with his roomate on 01/24/22. Review of the self-reported incident (SRI) #217060, dated 01/25/22, revealed Resident #54 had a recent history of exhibiting sexual 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, review of a facility self-reported incident, staff interview, and policy review, the facility failed to thoroughly investigate an allegation of physical abuse. This affected one (Resident #56) out of one resident reviewed for abuse. The facility census was 77. Findings include: Review of the medical record for the Resident #56 revealed an admission date of 01/03/18. Diagnoses included diabetes type two, unspecified mood disorder, and delusional disorder. Review of the Annual Minimum Data Set assessment dated [DATE] revealed Resident #56 was cognitively intact, required supervision set up assistance for transfers and bed mobility, and required one person assistance with personal hygiene. Review of the Resident #56's electronic medical record revealed no documentation of an altercation with his roomate on 01/24/22. Review of the self-reported incident (SRI) #217060, dated 01/25/22, revealed Resident #54 had a recent history of exhibiting sexual and aggressive behaviors toward staff…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of facility policy, the facility failed to ensure bed hold notices were provided upon transfer to the hospital. This affected one (Resident #46) of four residents reviewed for bed hold notices. The census was 77. Findings include: Resident #46 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of unspecified site of right female breast, COVID-19, and secondary malignant neoplasm of liver and intrahepatic bile duct. Review of the medical record for Resident #46 revealed an order dated 01/16/22 to send Resident #46 to the emergency room for evaluation. Resident #46 was readmitted to the facility on [DATE]. Review of the Bed Hold Authorization dated 01/24/21, with the added date of 01/16/22 written above the 01/24/22 date, revealed the bed hold authorization for Resident #46's discharge to the hospital on [DATE] was signed on 01/24/21 by Resident #46's representative. Interview on 02/09/22 at 9:02 A.M. with Receptionist #86 revealed…

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

Based on medical record review, staff interview, and review of facility policy, the facility failed to accurately complete Pre-admission Screening and Resident Review (PASRR) documents. This affected two (Resident #53 and #56) of three residents reviewed for PASRR's. The facility census was 77. Findings include: 1. Review of the medical record for Resident #53 revealed an admission date of 07/04/20. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, Parkinson's disease, dementia without behaviors, major depression, anxiety, bipolar disorder, and schizophrenia. Review of the plan of care dated 12/29/21 revealed Resident #53 had depression, anxiety, bipolar disorder and schizophrenia with interventions to provide medications as ordered, have a regular routine, and consult psychiatry services if indicated. Review of Resident #53's PASRR dated 12/04/14 revealed the resident's diagnosis of anxiety and schizophrenia were not included on the PASRR. Interview on 02/08/22 at 12:44 P.M. and 12:56 P.M. with Social Worker (SW) #71 revealed Resident #53's most recent…

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

Based on medical record review, staff interview, observation, and review of facility policy, the facility failed to ensure plans of care were revised to include accurate fall interventions. This affected two (Resident #32 and #72) of four residents reviewed for falls. The census was 77. Findings include: 1. Review of the medical record for Resident #72 revealed an admission date of 10/29/21 with diagnoses including cerebral infarction, hemiplegia and hemiparesis, and non-traumatic intracranial hemorrhage. Review of Resident #72's medical record revealed on 01/17/22, the resident was found on the floor in a supine position. There was no evidence of a new intervention until 02/08/22, when an intervention to encourage to be in common area when out of bed was added to the plan of care. Further review of Resident #72's medical record revealed on 01/25/22, the resident was found on the floor on his back. Interventions included for Resident #72's bed to be in the lowest position, a fall mat, and to use the call light. Review of Resident #72's falls plan of care dated 11/01/21 revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, and staff interview, the facility failed to ensure daily weights were completed as ordered. This affected one (Resident #66) out of five residents reviewed for weight records. The facility census was 77. Findings include: Review of Resident #66's medical record revealed an admission date of 03/24/17 and re-admission date of 09/12/21. Resident #66 had medical diagnoses including congestive heart failure (CHF) and diastolic heart failure with a pacemaker. Review of Resident #66's medical record revealed on 01/22/22, Resident #66 went to a heart disease management appointment for a check up and returned with new physician orders. The new physician orders, dated 01/22/22, included monitor weight daily and notify heart disease management for weight gain of three pounds in two days or five pounds in one week. Review of the most recent comprehensive Minimum Data Set assessment dated [DATE] revealed Resident #66 was cognitively intact. Review of Resident #66's medical…

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 policy review, the facility failed to ensure falls were documented and interventions were in place. This affected one (Resident #72) of four residents reviewed for accidents. The facility census was 77. Findings include: 1. Review of the medical record for Resident #72 revealed the resident was admitted on [DATE] with diagnoses including cerebral infarction, hemiplegia and hemiparesis, and non traumatic intracranial hemorrhage. Review of Resident #72's Minimum Data Set assessment dated [DATE] revealed the resident was moderately impaired for daily decision making, required extensive assist of two for bed mobility and transfer, did not walk, required extensive assist of one for eating and personal hygiene, and had a fall with major injury. Review of Resident #72's care plan dated 11/01/21 revealed Resident #72 was at risk for falls related to cerebral infarction, history of falls, type two diabetes, hypertension, muscle weakness, hyperlipidemia, incontinence,…

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 review of facility policy, the facility failed to ensure gastrostomy syringes were rinsed after use and resident's had a dressing around their tube feeding site. This affected two (Resident #65 and #72) of two residents reviewed for tube feeding. The facility census was 77. Findings include: 1. Review of Resident #65's medical record revealed the resident was readmitted on [DATE] with diagnoses including muscle weakness, atherosclerotic heart disease, epilepsy, and gastro-esphageal reflux disease without esophagitis. Review of Resident #65's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was rarely or never understood, was totally dependent on two staff for bed mobility, toilet use, personal hygiene, transfers, dressing, and required extensive assistance of one staff for eating, and had a tube feeding. Review of Resident #65's activities of daily living (ADL) care plan dated 08/28/20 revealed Resident #65 had an 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 medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure oxygen supplies were dated and tracheostomy (trach) supplies were available at bedside as ordered. This affected one (Resident #65) of one resident reviewed for respiratory care. The facility identified 10 Residents who received respiratory treatments. The facility census was 77. Findings include: Review of the medical record for Resident #65 revealed the resident was readmitted on [DATE] with diagnoses including muscle weakness, atherosclerotic heart disease, epilepsy, and gastro-esophageal reflux disease without esophagitis. Review of Resident #65's Annual Minimum Data Set assessment dated [DATE] revealed the resident was rarely or never understood, was totally dependent of two staff for bed mobility, toilet use, personal hygiene, transfers, dressing, and had oxygen and a tracheostomy. Review of Resident #65's medical record revealed the resident was decannulized by respiratory therapy 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.

Based on medical record review, review of pharmacy monthly medication reviews, resident interview, and staff interview, the facility failed to ensure resident drug allergies were identified and addressed during monthly pharmacy medication regimen reviews. This affected two (Resident #32 and #66) out of five residents reviewed for unnecessary medications. The facility census was 77. Findings include: 1. Review of Resident #32's medical record revealed an admission date of 11/16/21. Resident #32 had medical diagnoses including dysphagia, stroke, and major depression. Review of Resident #32's electronic medical record and paper chart drug allergies revealed Neurontin was listed as a drug allergy. Review of Resident #32's medications orders for February 2022 revealed an order for Neurontin 300 mg every bedtime. Resident #32 had been receiving the Neurontin 300 mg medication since 11/30/21. Review of Resident #32's pharmacy medication regimen review dated 12/07/21, 01/10/22, and 02/08/22, revealed none of the pharmacy medication regimen reviews identified Resident #32 had a listing of…

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

Based on record review and staff interview, the facility failed to ensure laboratory tests were completed as ordered. This affected one (Resident #5) of five residents reviewed for unnecessary medications. The facility census was 77. Findings include: Review of the medical record for Resident #5 revealed an admission date of 02/21/17 with diagnoses including anemia, hypernatremia, abnormal liver function, vitamin D deficiency, and vitamin B-12 deficiency. Review of the medical record for Resident #5 revealed the last magnesium level was completed on 09/24/20 and was 1.8 milligrams per deciliter (mg/dl) which was within the normal range of 1.3-2.1 mg/dl. Review of Resident #5's physician orders revealed an order with a start date of 11/16/20 for Magnesium Oxide Tablet 400 milligrams twice a day. Review of Resident #5's physician orders dated 06/10/21 revealed an order for a magnesium level on the first of the month and every six months. Review of Resident #5's medical record revealed there was no evidence of a magnesium level having been completed since 09/24/20. Interview 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.

Based on medical record review, staff interview, resident interview, and review of a dental appointments log, the facility failed to ensure dental services were provided to residents in a timely manner. This affected one (Resident #53) of one resident reviewed for dental services. The facility census was 77. Findings include: Review of the medical record for Resident #53 revealed an admission date of 07/04/20. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, Parkinson's disease, dementia without behaviors, and vascular disease. Review of Resident #53's plan of care dated 12/29/21 revealed Resident #53 had potential oral health problems with no natural teeth and wore upper dentures. Resident #53 was to be seen by the dentist to get lower dentures with interventions to consult the dietitian as needed, and provide oral and denture care daily. Review of Resident #53's progress notes dated 04/09/21 revealed Resident #53 was edentulous and wore upper dentures. Resident #53 revealed he did not have his lower denture and would like a new one. Social services 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.

Based on record review and staff interview, the facility failed to ensure hospice records including the hospice plan of care were accessible and maintained in the facility. This affected one (Resident #53) of one resident reviewed for hospice. The facility census was 77. Findings include: Review of the medical record for Resident #53 revealed an admission date of 07/04/20. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, Parkinson's disease, dementia without behaviors, and vascular disease. Review of Resident #53's physician orders dated 12/13/21 revealed an order to change Resident #53's code status to Do Not Rescuscitate Comfort Care (DNRCC). Review of Resident #53's physician orders dated 12/23/21 revealed an order to admit to hospice services with a terminal diagnosis of protein calorie malnutrition. Review of Resident #53's medical record revealed no hospice notes were found in either an electronic medical record or hard chart. Interview on 02/10/22 at 10:35 A.M. with Licensed Practical Nurse (LPN) #134 revealed the facility does not have hospice…

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.