Mohun Health Care Center

Based on interview and record review the facility failed to ensure resident care plans included use of hospice services. This affected one (Resident #8) out of eight residents reviewed for care plans. The facility census 62. Findings include:Review of the medical record for Resident #8 revealed an admission date of 11/28/16 with diagnoses of Alzheimer's, Parkinson's, hypertensive heart disease, ischemic cardiomyopathy, and dysphagia.Review of the quarterly minimum data set (MDS) 3.0 assessment completed 09/05/25 revealed Resident #8 is severely cognitively impaired.Review of physician order dated 09/26/25 revealed admit to hospice for Alzheimer's disease, weight loss, Parkinson's disease, and failure to thrive.Review of level of care evaluation dated 09/26/25 for Resident #8 revealed a diagnosis of Alzheimer's disease with an election to receive hospice care.Review of Resident #8's care plan dated 03/24/26 revealed no mention of receiving hospice services.Interview on 03/24/26 at 11:01 A.M. with Minimum data set (MDS) Nurse #301 confirmed Resident #8's care plan does not include…

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 ensure physician ordered medications were administered under specified parameters, physician was notified of administration and weight changes. This affected one (Resident #1) out of seven resident records reviewed. The facility census was 62. Findings include:Review of the medical record for Resident #1 revealed an admission date of 06/14/16 with diagnoses including paroxysmal atrial fibrillation, presence of a cardiac pacemaker, cardiomyopathy, heart failure, nonrheumatic aortic valve stenosis, and hypertensive heart and chronic kidney disease with heart failure.Review of a physician order dated 11/28/24 directed staff to weigh the resident daily at 6:30 A.M. and notify the heart failure clinic for a weight loss or gain of two pounds overnight.Review of physician order dated 07/15/25 directed staff to administer metolazone (diuretic) 2.5 milligrams (mg) by mouth as needed for weight gain over two pounds overnight or increased swelling.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 medical record review, staff interview, and facility policy review, the facility failed to ensure antibiotic stewardship protocol was followed for the use of an antibiotic medication. This affected one (Resident #35) of one residents reviewed for the use of antibiotics. The census was 62.Findings Include: Resident #35 was admitted to the facility on [DATE]. Her diagnoses were Type II Diabetes, functional urinary incontinence, blepharitis, hypothyroidism, hyperlipidemia, vitamin D deficiency, decreased white blood cell count, anemia, dysphagia, venous insufficiency, kyphosis, anxiety disease, muscle wasting and atrophy, cognitive communication deficit, muscle weakness, depression, dorsalgia, and osteoarthritis. Review of her minimum data set (MDS) assessment, dated 01/15/26, revealed she was cognitively intact. Review of Resident #35 care plan for antibiotic use, dated 04/23/25, revealed she could be at risk for adverse effects and/or side effects of antibiotic medication therapy. The only monitoring…

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.

2. Observations on a tour of the facility's kitchen on 03/31/25 between 8:35 A.M. and 8:59 A.M. revealed a red and black substance inside the white plastic backboard of ice machine which was easily removed with a cleansing towel. A crate of bananas on floor of the dry storage room. A fuzzy gray and brown substance on the walk-in refrigerator's ceiling, near the internal fans. In the walk-in freezer there were opened and undated packages of crinkle carrots. There was also an unlabeled and undated cup of a brown substance. On the freezer floor there were two crates of bread loaves, a package of fire roasted sweet potatoes and a bag of tater tots. In the walk-in freezer ceiling there were icicles present, and evidence of ice formed on one package of frozen cheese manicotti. On 03/31/25 at 8:37 A.M. [NAME] #374 revealed that she opened the undated frozen carrots but could not recall the date that she opened them. She stated that the brown substance was a chocolate milkshake but unsure when it was made. She also confirmed the food items sitting on the freezer floor. She acknowledged 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 5. Review of Resident #4's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses osteoarthritis, high blood pressure, and major depressive disorder. Review of Resident #4's physician orders and medication administration records revealed the resident received Clindimycin HCL, an antibiotic, prior to any dental appointments. Review of Resident #4's care plan revealed no focus areas, goals, or interventions for the antibiotic medication. Interview on 04/03/25 at 11:03 A.M. with ADON confirmed Resident #4's care plan did not reflect the antibiotic medications the resident was receiving. 3. Review of the medical record for Resident #65 revealed she was admitted to the facility on [DATE] with diagnoses that included intracranial cerebral hemorrhage, disorder of the urinary system, and need for assistance with personal care. Review of Resident #65's Bowel and Bladder Program Screener assessment dated [DATE] revealed she was a good candidate for bladder retraining. Review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Medical record review revealed Resident #4 was admitted to the facility on [DATE]. Diagnoses included, major depressive disorder, polyoteoarthritis and hypertension. Review of the comprehensive Minimum Data Set assessment, dated 03/25/25, revealed the resident's cognition was intact. Review of a physician order, dated 03/20/24, revealed Resident #4 was ordered Nortriptyline (an antidepressant medication) three capsules daily at bed time for neck pain. Review of the Resident #4's Medication Administration Record (MAR) revealed the resident received Nortriptyline, as ordered, beginning 03/20/24. Review of Resident #4's medical record revealed there was no monitoring the resident for depressed and withdrawn behaviors. Interview on 04/03/25 at 3:09 P.M. with LPN #50 confirmed behavior monitoring was not being tracked and/or documented for Resident 's depression and behaviors. 3. Review of Resident #40's medical record revealed that she was admitted to the facility on [DATE] with diagnoses that included depressive…

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 ensure medications were properly stored to ensure medications did not exceed the expiration date on stock medication supplies. This affected 28 residents living on the first and second floor. The facility census was 68. Findings include: Observation of the second floor medication room on [DATE] at 1:35 P.M. revealed a single medication cabinet in which nursing staff stores over the counter medication for residents of the first and second floor. The cabinet also stores medications residents have in possession prior to admission, to be held until the residents are discharged . The cabinet had various scattered medications and empty boxes. Pulls of medication revealed Ferrous Gluconate (iron replacement) 240 mg with an expiration date of 05/2024. Additionally pulled from the cabinet were Systane drops (ophthalmic lubricant) with an expiration date of 11/24. Interview on [DATE] at 1:37 P.M. with Licensed Practical Nurse (LPN) #160 confirmed the 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, financial record review, resident interview, staff interview, facility/resident handbook review, and facility policy review, the facility failed to ensure residents/representatives were aware and agreed to the donation of money from their resident fund accounts. This affected two (Residents #21 and #37) of five resident financial accounts reviewed. The census was 68. Findings Include: 1. Resident #21 was admitted to the facility on [DATE]. Her diagnoses were encephalopathy, Parkinson's disease, sciatica, congestive heart failure, muscle weakness, vitamin D deficiency, polyneuropathy, chronic kidney disease, GERD, hypertension, hyperlipidemia, Alzheimer's disease, hypothyroidism, dysphagia, hypokalemia, Parkinsonism, cognitive communication deficit, lack of coordination, and peripheral vascular disease. Review of her MDS assessment, dated 03/11/25, revealed she had a severe cognitive impairment. Review of Resident #21's financial/trust statements, dated 01/30/24 to 03/31/25,…

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, staff attestation statements and time clock record review, the facility failed to keep an accurate medical record for one resident. This affected one resident (Resident #5) and had the potential to affect 28 residents (Resident #37, #4, #65, #29, #66, #21, #45, #47, #171, #68, #39, #55, #54, #40, #59, #53, #26, #5, #69, #33, #22, #8, #64, #58, #38, #56, and Former Residents #200 and 201) that were residing on the first and second floors of the facility on 01/9/25. Findings include: Review of Resident #5's medical record revealed that she was admitted to the facility on [DATE] with diagnoses that included hypertension (HTN), gastroesophageal reflux disease (GERD), polyarthritis, major depressive disorder, primary osteoarthritis, chronic kidney disease (CKD), Vitamin B-12 deficiency, and Vitamin D deficiency. Review of Resident #5's physician orders revealed that effective on 03/01/24, she was prescribed Amlodipine Besylate 5 milligrams (mg) one tablet once daily…

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 have accurate Minimum Data Set (MDS) assessments for four (Resident #3, #36, #44, and #61) of 10 residents who received injectable hyperglycemic medication and for one (Residents #13) of 20 residents whose records were reviewed that required assistance for eating. The census was 67. Findings include: 1. Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included displaced fracture of the second vertebra, major depression, high blood pressure, osteoarthritis, diabetes, and repeated falls. Review of the quarterly MDS assessment dated [DATE] revealed Resident #3's cognition was intact. Resident #3 was independent with set up help only for bed mobility and eating. Resident #3 required extensive assistance of one staff member for dressing. The quarterly MDS assessment dated [DATE] also indicated Resident #3 was on insulin. Review of the physicians orders dated 08/12/21 revealed an…

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 interview the facility failed to ensure accurate advanced directive information was present throughout the medical record. This affected one (Resident #41) of one resident reviewed for advanced directives. The facility census was 67. Findings include: Medical record review revealed Resident #41 was admitted to the facility on [DATE] with diagnoses that included type two diabetes mellitus, chronic kidney disease, generalized anxiety disorder, depression hyponatremia, hypokalemia, and iron deficiency anemia. Review of the signed documents section of Resident 41's medical record revealed a signed do not resuscitate comfort care- arrest (DNRCC-A) consent dated [DATE]. Review of the most recent Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #41 was cognitively intact and required extensive assistance with one-person physical assistance for activities of daily living. Review of Resident #41's care plan dated [DATE] revealed the resident was a DNRCC-A code 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, interview and record review, the facility failed to serve food at the proper portion size to meet the nutritional needs of residents who received the alternate entrée. This affected two residents (#13 and #24) out of eleven (Residents #6, #13, #21, #24, #33, #37, #46, #51, #52, #56 and #119) who selected to receive a full portion of the alternate. The facility census was 67. Findings include: Medical record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses that included but were not limited to unspecified dementia, diabetes mellitus, unspecified psychosis, and Alzheimer's disease. Review of the most recent Minimum Data Set 3.0 assessment dated [DATE] revealed the resident required extensive assistance with one staff for activities of daily living. Review of the physicians' orders for January 2023 revealed Resident #13 was on a regular diet with no restrictions. Review of Resident #13's diet ticket revealed a five-ounce chicken Caesar wrap. Medical record…

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.