McNaughten Pointe Nursing And Rehab

Based on review of medication storage refrigerator daily temperature logs, observation, staff interview, and facility policy review, the facility failed to ensure medication storage refrigerators were maintained at an appropriate temperature and the temperature was routinely monitored. This affected one (South Unit) medication storage room out of three medication storage rooms in the facility and had the potential to affect all 25 residents (#1, #4, #5, #6, #8, #9, #11, #12, #13, #15, #19, #20, #38, #39, #56, #57, #59, #64, #78, #85, #87, #91, #92, #98, and #108) who received medications from the South Unit medication storage room. The census was 117. Findings include: Review of the South Unit medication storage refrigerator daily temperature log for January 2024 and February 2024 revealed four daily temperature entries for the entire month of January 2024 and no daily temperatures for the entire month of February 2024 Observation of the medication storage room located on the South Unit on 03/06/24 at 11:10 A.M. revealed the medication storage refrigerator daily temperature log…

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, resident interview, staff interview, and review of meal choice sheets, the facility failed to ensure residents were consistently offered meals according to their choices and preferences. This affected two (Residents #34 and #46) out of two residents reviewed for food choices and had the potential to affect all eight Residents (#33, #34, #46, #52, #89, #95, #97, #107) living on the North Hall who receive meals from the kitchen. The census was 117. Findings include: 1. Review of the medical record for Resident #34 revealed an admission date of 06/13/23. Diagnoses included chronic respiratory failure, vent dependence, diabetes, and dysphagia. Review of Resident #34's physician orders, dated 08/22/23, revealed an active order for a regular textured diet with low concentrated sweets and no added salt. Review of the Minimum Data Set (MDS) assessment, dated 02/08/24, revealed Resident #34 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and required set up assistance for eating. Review of the Plan of Care, dated 02/11/24,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interview and staff interviews, the facility failed to ensure a homelike environment was provided for two Residents (#8 and #9) of two reviewed for homelike environment. Facility census was 117. Findings include 1. Review of the medical record for Resident #8 revealed an admission date of 12/29/21. Diagnoses included quadriplegia c5-c7 incomplete, respiratory failure, dysphagia, and contracture of multiple unspecified sites. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15 and required substantial/maximum assistance dependence on staff for mobility and hygiene. Review of the plan of care dated 02/14/24 revealed resident had oral intake with help of tube feeds with interventions to provide tube feeding as ordered, dressing changes to the tube site and flushes as ordered. Observation and interview on 03/04/24 at 10:49 A.M. revealed resident had a metal cart 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 resident interview, staff interviews, and record review ,the facility failed to ensure care conferences were held with members of the interdisciplinary team including resident participation. This affected two Residents (#57 and #64) of three reviewed for care conferences. Facility census was 117. Findings include: 1. Review of the medical record for Resident #57 revealed an admission date of 04/18/23. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, diabetes, and muscle wasting and atrophy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15 and required substantial/maximal assist and dependence on staff for activities of daily living. Review progress notes dated 01/09/23 revealed a care conference was held with son upon request as well as a meeting on 02/07/23. Progress note dated 06/30/23 revealed family was sent an invitation to schedule a care conference. Progress…

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 and record review, facility failed to ensure a resident with hand contracture's was provided with nail trimming and care. This affected one Resident (#8) of one reviewed for nail care for dependent residents. Facility census was 117. Findings include: Review of the medical record for Resident #8 revealed an admission date of 12/29/21. Diagnoses included quadriplegia c5-c7 incomplete, respiratory failure, dysphagia, and contracture of multiple unspecified sites. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15 and required substantial/maximum assistance dependence on staff for mobility and hygiene. The MDS also revealed resident had an upper extremity impairment. Review of the plan of care dated 02/14/24 revealed resident required total assistance with activities of daily living (ADL) due to decreased self-performance with diagnoses of spinal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of skin grid assessments, review of the wound Certified Nurse Practitioner (CNP) notes, review of an After Visit Summary, staff interviews, and facility policy review, the facility failed to complete timely and accurate skin grid assessments, implement treatment changes timely, and follow up on the wound CNP recommendations timely for one resident (Resident #71). The facility also failed to follow up on discharge recommendations as indicated in the After Visit Summary following a hospitalization for one resident (Resident #71). This affected one resident (Resident #71) of one reviewed for non-pressure skin care. The facility census was 117. Findings include: Review of the medical record for Resident #71 revealed an initial admission date on 01/29/24 and a discharge date on 03/08/24. Medical diagnoses included chronic respiratory failure with hypoxia, asthma, dependence on respirator (ventilator) status, tracheostomy status, anoxic brain damage, and persistent vegetative state.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, interviews, observations, and facility policies, the facility failed to ensure accurate and timely wound assessments and care was provided for three residents (#51, #71, and #89) out of four residents reviewed for wounds. The facility census was 117. Findings include: 1. Review of the medical record for Resident #51, revealed an admission date of 10/20/23. Diagnoses included: moderate protein-calorie malnutrition, vascular dementia, unspecified severity, without behavioral disturbance, psychosis disturbance, mood disturbance and anxiety, and end stage renal disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of resident is rarely/never understood. The resident was assessed to be dependent with all bed mobility. Review of nursing admission skin assessment for Resident #51 dated 10/20/23 revealed three wounds. Wound #1 was sacrococcygeal moisture-associated skin damage (MASD), wound #2 was a left heel…

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, observations, staff interview, and policy review, the facility failed to ensure fall interventions were implemented in a timely manner. This affected one (Resident #85) out of two residents reviewed for falls. The census was 117. Findings include: Review of the medical record for Resident #85 revealed an admission date of 12/07/22. Diagnoses included hypercholesterolemia, osteoporosis, mild cognitive impairment, artificial right and left hip joints, insomnia, and muscle weakness. Review of the progress note, dated 12/20/23, revealed Resident #85 was observed on the floor in a sitting position. The STNA informed the nurse who came to assess the resident. Resident #85 had reported she was coming from the bathroom and wanted to get in bed. An assessment was completed and no injuries were identified. The new intervention was for a call don't fall sign. Resident #85 was educated to ask for assistance when going to the bathroom. Review of the fall investigation, dated 12/20/23, revealed Resident #85 was found sitting on her bottom on the floor in her room…

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 ventilator setting checks were completed as ordered. This affected one (Resident #71) out of four residents reviewed for respiratory care. The facility also failed to ensure respiratory equipment was clean and changed as ordered. This affected one (Resident #83) out of four residents reviewed for respiratory care. The census was 117. Findings include: 1. Review of the medical record for Resident #71 revealed an initial admission date of 01/29/24 and a discharge date of 03/08/24. Medical diagnoses included chronic respiratory failure with hypoxia, asthma, dependence on respirator (ventilator) status, tracheostomy status, anoxic brain damage, and persistent vegetative state. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/10/24, revealed Resident #71 was in a persistent vegetative state with no discernible consciousness. Resident #71 was totally dependent on one to two…

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 residents were free from significant medication errors. This affected one (Resident #48) out of five residents reviewed for unnecessary medications. The census was 117. Findings include: Review of Resident #48's medical record revealed Resident #48 was admitted to the facility on [DATE] with the diagnoses including diabetes mellitus (DM), heart disease, congestive heart failure, Chronic Obstructive Pulmonary Disease, and chronic kidney disease. Review of Resident #48's signed physician order, dated 06/01/22, revealed an order for insulin lispro solution (fast acting insulin) inject five units subcutaneously before meals for DM. The medication was to be held for blood sugar (BS) less than 120. Review of Resident #48's Medication Administration Record (MAR), dated January 2024, revealed on 01/01/24 at 11:00 A.M. Resident #48's BS reading was 117 and five units of insulin lispro was administered, on 01/03/24 at 4:00 P.M. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and facility policy and procedure, the facility failed to maintain infection control, related to personal protective equipment (PPE) use, proper hand hygiene, and glove use. This affected two residents (Resident #67 and Resident #220) with the potential to affect all residents in the facility. Findings include: 1. Review of the medical record for Resident #220 revealed an admission date of 03/18/22 and the diagnoses of metabolic encephalopathy, Parkinson disease, insomnia, muscle weakness, ataxic gait, malaise, and chronic kidney disease. Review of the admission nursing assessment dated [DATE] revealed Resident #220 was alert and oriented, but confused, and her lungs were clear with a regular respiratory rate. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview of Mental Status (BIMS) of 10 indicating impaired cognition and the resident required extensive two staff assistance for bed…

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 record review, the facility failed to honor Resident #22, Resident #38, Resident #59, Resident #80, and Resident #102's preferences in getting in and out of bed. This affected five (Resident #22, Resident #38, Resident #59, Resident #80, and Resident #102's ) of five residents reviewed for choices. Findings include: 1. Review of the medical record for Resident #59 revealed an admission date of 10/30/21. Diagnoses for Resident #59 included spondylosis, cervical region, spinal stenosis, cervical region, chronic obstructive pulmonary disease, neuralgia and neuritis, major depressive disorder and dependence on wheelchair. Review of the Minimum Data Set 3.0 (MDS) assessment dated [DATE], revealed Resident #59 was noted to require extensive assistance of two staff for transfers. Review of the plan of care dated 01/31/22, revealed Resident #59 required total assistance with activities of daily living (ADLs). Interventions included to assist with bathing, grooming and 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 observation, interview and record review, the facility failed to ensure Resident #52 and Resident #59 received sufficient bathing assistance, Resident #3 and Resident #59 received assistance with nail care, Resident #71 received assistance with dressing, Resident #119 received assistance with hair washing, and Resident #21 received assistance with personal hygiene. This affected six residents (Resident #3, Resident #21, Resident #52, Resident #53, Resident #59, and Resident #118) of seven residents reviewed for activities of daily living (ADLs) care. Findings include: 1. Review of the medical record for Resident #59 revealed an admission date of 10/30/21. Diagnoses for Resident #59 included spondylosis, cervical region, spinal stenosis, cervical region, chronic obstructive pulmonary disease, neuralgia and neuritis, major depressive disorder and dependence on wheelchair. Review of the Minimum Data Set 3.0 (MDS) assessment dated [DATE], revealed Resident #59 to have mildly impaired cognition. Resident #59…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, review of activity calendar, and record review, the facility failed to provide activities based on the resident preferences and comprehensive assessments. This affected six residents (Resident #12, Resident #22, Resident #66, Resident #80, Resident #102, and Resident #118) of seven residents reviewed for activities. Findings include: 1. Medical record review for Resident #66 revealed an admission date of 08/27/21. Medical diagnoses included traumatic brain dysfunction. Review of Resident #66's care plan dated 08/29/21, revealed the resident was unable to to pursue her interests due to her physical condition. The resident was willing to interact with others and participate in activities as her condition allowed. The following interests were important to the resident: arts and crafts, bingo, computer activities, gardening, music, religious activities, and spending time outside. Interventions were to offer activity program directed toward specific interests and needs of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff interview, resident interview, and facility policy and procedure review, the facility failed to ensure Resident #25 and #44's oxygen tubing was dated or changed per physician orders, failed to ensure Resident #44's respiratory medications were available and able to be administered per physician orders, and failed to ensure a Ambu breathing bag was placed in Resident #66's room. This affected two residents (Resident #25 and Resident #44) out of two residents reviewed for oxygen therapy, and one Resident (Resident #66) out of two residents reviewed for respiratory care. Findings include: 1. Review of the medical record for Resident #25 revealed an admission date of 11/11/21 and the diagnoses of dementia with lewy bodies, need for assistance with personal care, morbid obesity, depression, and acute and chronic respiratory failure. Review of the Resident #25's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, observation, and facility policy review, the facility failed to food was properly stored. This had the potential to affect 85 residents who received meals from the kitchen, as 31 residents in the facility received nothing by mouth. The facility census was 116. Findings include: Observation on 03/21/22 at 7:44 A.M. revealed an opened, unsealed, undated, frozen bag of [NAME] dean sausage links. Interview at this time with Diet Technician #302 confirmed the observation. Observation on 03/21/22 at 7:49 A.M. of the walk-in refrigerator revealed an open and unsealed bag containing heads of lettuce. Observation on 03/21/22 at 7:52 A.M. of the free-standing refrigerator revealed an open and undated gallon of orange pineapple drink and unlabeled and undated yellow liquid in pitcher. Observation on 03/21/22 at 7:53 A.M. of the other side of the free-standing refrigerator revealed opened and undated cottage cheese and chicken salad. Interview on 03/21/22 at 7:54 A.M. with Dietary Manager #290…

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, review of infection control logs, review of Food and Drug Administration (FDA) information, review of a HealthDay News Study, and facility policy review, the facility failed to provide adequate justification for the use of antibiotics as a treatment measure for COVID-19. This affected 13 residents (#11, #13, #15, #24, #33, #34, #43, #59, #224, #225, #226, #227, and #228) out of 31 residents who tested positive for COVID-19 from December 2021 through February 2022. Findings include: Review of the infection control logs and medical record reviews from December 2021 through February 2022 revealed 13 residents (#11, #13, #15, #24, #33, #34, #43, #59, #224, #225, #226, #227, and #228) in December 2021 and January 2022 who tested positive for COVID-19 were prescribed Azithromax/Azithromycin. Interview on 03/29/22 at 10:40 A.M. with Director of Nursing (DON) and the Infection Preventionist/Registered Nurse #293 revealed their COVID-19 positive protocol included Zinc, Vitamin C, Pepcid, an antibiotic, and a steroid. They stated their normal…

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, resident interview, medical record review, and facility policy review, the facility failed to accurately reflect Resident #21 and Resident #119's chosen advanced directives in the residents' medical records. This affected two residents (Resident #21 and Resident #119) of two residents reviewed for advanced directives. Findings include: 1. Review of the medical record for Resident #119 revealed an admission date of 08/24/20. Diagnoses included cerebral infarction (stroke), pressure ulcer, anxiety disorder, chronic obstructive pulmonary disease (COPD), stable burst fracture of the fourth lumbar vertebra, type two diabetes mellitus (DM2), chronic kidney disease, seizures, atrial flutter, noncompliance with other medical treatment and regimen, disorder of kidney and ureter, chronic pain, hyperlipidemia, hypertension (HTN), and other symptoms and signs concerning food and fluid intake. Review of Resident #119's quarterly Minimum Data Set (MDS) assessment, dated 03/07/22, revealed the resident had intact cognition with a Brief Interview of Mental Status (BIMS)…

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, resident interview, observation, medical record review, and facility policy review, the facility failed to assist Resident #57 with her communication needs due to her hearing impairment. This affected one resident (#57) of three resident reviewed for communication/sensory needs. Findings include: Review of the medical record for Resident #57 revealed an admission date of 06/24/21. Diagnoses included Chronic Obstructive Pulmonary Disease (COPD), heart failure, schizophrenia, bipolar disorder, major depressive disorder, dementia without behavioral disturbance, anxiety disorder, and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/07/21, revealed the resident had moderate difficulty with the use of a hearing aid or other hearing appliance. Further review of the MDS revealed the resident was sometimes understood and sometimes understood verbal communication. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/07/22, revealed the resident had intact cognition with a Brief Interview of Mental Status…

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, and staff interview the facility failed to ensure range of motion was provided for Resident #118 who had impairment to her upper extremities, and failed to ensure Resident #3's splint devices were in place as ordered. This affected two residents (Resident #3 and Resident #118) out of seven reviewed for range of motion. Findings include: 1. Medical record review for Resident #118 revealed an admission date of 11/07/19. Medical diagnoses included a traumatic spinal cord dysfunction. Review of Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #118 developed impairment in her upper extremities for the first time since admission into the facility. Review of MDS assessment dated [DATE], revealed Resident #118 was rarely or never understood. Functional status was total dependence for bed mobility, transfers, eating, and toilet use. She had impairment to her upper extremities. Review of Resident #118's restorative passive range of motion (PROM) nursing program…

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 failed to ensure Resident #29's urinary tract infection (UTI) was identified and treated promptly. This affected of one resident (Resident #29) of two residents reviewed for UTI's. Findings include: Review of the medical record revealed Resident #29 was admitted on [DATE]. Diagnoses for Resident #29 included major depressive disorder, chronic obstructive pulmonary disease, diabetes, obesity, congestive heart failure, and chronic kidney disease. Review of the physician progress note dated 11/16/21 revealed Resident #29 was seen by a nurse practitioner (NP) for altered mental status and multiple recent falls. Labs, including basic metabolic panel (BMP), complete blood count (CBC), arterial blood gases (ABG), and a urine analysis culture and sensitivity (UA C&S) were ordered for Resident #29. A UA C&S is a urine culture to check for UTI. Review of the lab results dated 11/17/21 revealed no concerns. However, the UA C&S was not available in the medical record. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, the facility failed to ensure Resident #80's peripherally inserted central (PICC) line dressing was changed before it was charted as completed in the Treatment Adminstration Record (TAR). This affected of one resident (Resident #80) one reviewed for PICC line dressings. Findings include: Medical record review for Resident #80 revealed an admission date of 11/04/20. Medical diagnoses included traumatic brain dysfunction. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #80 was moderately impaired. His functional status was extensive assistance for bed mobility, independent for eating, total dependence for toileting, and transfers did not occur on this assessment. He was coded for oxygen, suctioning, tracheostomy, and ventilator treatment. Review of physician orders dated 03/21/22 revealed to change the PICC line dressing every seven days. Review of Treatment Administration Record (TAR) dated 03/21/22 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 record review, interview, and observation, the facility failed to monitor for psychotropic side effects and provide planned behavioral health interventions for Residents #29. This affected one resident (Resident #29) of two residents reviewed for mood and behavior. Findings include: Review of the medical record revealed Resident #29 was admitted on [DATE]. Diagnoses for Resident #29 included major depressive disorder, chronic obstructive pulmonary disease, obesity, congestive heart failure, and chronic kidney disease. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #29 to have intact cognition and did not note any concerns with mood or behaviors. a. Review of the plan of care dated 01/05/22 revealed Resident #29 to be at risk for adverse effects related to psychoactive medication use for depression and anxiety. Interventions include to assess for adverse effects including sedation and non-drug approaches to deal with problem behaviors report changes in behavior or mood.…

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, resident interview, observation, medical record review, and facility policy review, the facility failed to ensure medication was secured at all times. This had the potential to affect two residents (Resident #23 and Resident #58) of two residents reviewed for medication storage. Findings include: Review of the medical record for Resident #23 revealed an admission date of 07/26/17. Diagnoses included paranoid schizophrenia, type II diabetes mellitus (DM2), hyperlipidemia, hypertension (HTN), generalized anxiety disorder, and unspecified psychosis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/07/21, revealed Resident #23 had impaired cognition with a Brief Interview of Mental Status (BIMS) score of seven out of 15 (severe cognitive impairment). His behaviors included other behavioral symptoms not directed towards others. The resident was independent with all activities of daily living (ADL's) except required supervision and set up for bed mobility and eating. He did not require any mobility devices. He was always continent of bowel 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 and staff interview, the facility failed to ensure labs were drawn for Resident #76 and Resident #118. This affected two residents (Resident #76 and Resident #118) out of six residents reviewed for labs. Findings include: 1. Medical record review for Resident #76 revealed an admission date of 01/29/19. Medical diagnoses included debility and cardiorespiratory conditions. Review of Resident #76's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed he was cognitively intact. Review of Resident #76's physician orders dated 02/27/22 revealed Thyroid Stimulating Hormone (TSH), Complete Blood Count (CBC), and Basic Metabolic Panel (BMP) labs were to be collected on the first Wednesday of the month. Review of standing order daily log dated 03/02/22 revealed Resident #76's BMP and CBC labs were drawn on 03/02/22. The was no evidence the TSH lab was drawn and no evidence the results of CBC and BMP lab draws were reported. Interview with Director of Nursing (DON) on 03/28/22…

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.