Shady Lawn Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to provide comprehensive and individualized treatment and maintenance plans for residents with indwelling urinary catheters to prevent potential urinary tract infections. This affected two residents (Resident #33 and #43) of two residents reviewed for indwelling catheters. The census was 77. Findings include: Record review for Resident #33 revealed an admission date of 01/10/25. Diagnosis included retention of urine, cognitive communication deficit, muscle weakness, and need for assistants with personal care. Review of the Medicare five-day Minimum Data Set (MDS) dated [DATE] revealed Resident #33 was cognitively intact. Resident #33 had an indwelling catheter and required partial/moderate assistants with toileting hygiene and transfers. Review of the progress note for Resident #33 dated 02/28/25 at 12:00 P.M. completed by Registered Nurse (RN) #529 revealed Resident left at this time for a urology appointment. 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, record review, interview, and policy review, the facility failed to administer oxygen per physician order for Resident #230. This affected one (Resident #230) of two residents reviewed for respiratory care. Facility census was 77. Findings include: Review of the medical record revealed Resident #230 was admitted on [DATE] with diagnoses that included acute and chronic respiratory failure with hypoxia, anxiety, congestive heart failure, and pneumonia. A physician order dated 04/04/25 at 5:54 P.M. revealed Resident #230 was ordered oxygen via nasal cannula at two to three liters per minute every shift. A plan of care dated 04/08/25 revealed Resident #230 had altered respiratory status and difficulty breathing. Interventions included to provide oxygen as ordered. A plan of care dated 04/23/25 revealed Resident #230 had signs and symptoms of pneumonia. Interventions included to obtain oxygen saturation and administer oxygen as ordered and indicated. Observations on 04/28/25 at 9:49 A.M.,…

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, facility investigation review, facility assessment review, time punch review, and interviews, the facility failed to maintain adequate staffing levels to meet the needs of residents related to medication administration. This affected three residents (Resident #26, #37 and #61) of nine residents reviewed for medication administration preferences. The facility census was 77. Findings include: 1. Review of a facility investigation revealed Licensed Practical Nurse (LPN) #815 was scheduled to work 05/05/25 from 6:00 P.M. to 6:00 A.M. Review of the time punches for Licensed Practical Nurse (LPN) #815 revealed she clocked in on 05/05/25 at 6:31 P.M. and clocked out on 05/06/25 at 1:09 A.M. LPN #815 was scheduled on 05/05/25 from 6:00 P.M. to 05/06/25 at 6:00 A.M. on Resident #26's unit. LPN #534 clocked in on 05/05/25 at 11:55 P.M. and clocked out on 05/06/25 at 6:56 A.M. Review of the facility investigation revealed a statement dated 05/06/25 by Certified Nursing Assistant (CNA) #589 that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility assessment review the facility failed to ensure Resident #70 and the resident representative were provided timely and appropriate transition of care assistance from social services related to locating alternate placement better equipped to address Resident #70's medical and physical needs. This affected one resident (Resident #70) of two residents reviewed for discharge planning. The facility census was 77. Findings include: Review of the medical record revealed Resident #70 was admitted on [DATE] with diagnoses that included lymphedema, Milroy's disease (also known as primary congenital lymphedema, it is a rare, genetic condition that affects the lymphatic system and causes fluid build up in the legs. It is preset at birth and usually affects the tops of the feet. Symptoms include swelling in the legs (usually below the knees), prominent veins in the lower legs, slanted toenails, noncancerous growths and digestive issues. The severity of swelling can vary within…

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 policy review, the facility failed to ensure misappropriation of controlled medication did not occur when Resident #49's medication was administered to Resident #60. This affected one (Resident #49) out of five three residents reviewed for medication administration. Findings include: Review of the medical record revealed Resident #49 was admitted on [DATE] with diagnoses that included neurocognitive disorder with Lewy Bodies, anxiety, and depression. Review of physician orders revealed Resident #49 was ordered Ativan (antianxiety medication) one milliliter (ml) intramuscularly every three minutes as needed for seizures from 01/16/25 and discontinued on 01/30/25. The quarterly Minimum Data Set, dated [DATE] revealed Resident #49 was cognitively intact. Review of the controlled drug receipt/record/disposition sheet for Resident #49 revealed one ml of Ativan was administered on 05/06/25 at 6:00 A.M. Interview on 05/07/25 at 1:38 P.M. with the Director of Nursing (DON) verified…

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 policy review the facility failed to ensure pharmacy recommendations were addressed in a timely manner. This affected one (Resident #60) of five residents reviewed for unnecessary medications. Facility census was 77. Findings include: Review of the medical record revealed Resident #60 was admitted on [DATE] with diagnoses that included major depressive disorder, dementia, hypertension, hypothyroidism, type 2 diabetes, malignant neoplasm of pituitary gland, dysphagia, anxiety, and vitamin D deficiency. A physician order dated 03/14/25 revealed Resident #60 was ordered Trazodone (antidepressant) 25 milligram (mg) at bedtime. Review of the pharmacy recommendation dated 03/21/25 revealed Trazodone 25 mg was ordered for insomnia. Resident #60 did not have a diagnosis of insomnia. The use of psychotropic medications required a specific condition as diagnosed and documented in the medical record. On 04/29/25 the physician agreed with the diagnosis of insomnia being added 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, interview, and review of the facility policy, the facility failed to assure one resident, Resident #10's psychotropic medication was decreased as ordered. This affected one Resident, Resident #10 of three residents reviewed for unnecessary drugs. The facility census was 77. Findings include: Record review for Resident #10 revealed an admission date of 03/15/19. Diagnosis included anxiety disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #10 was cognitively intact. Resident #10 had anxiety disorder. Review of the physician orders for Resident #10 revealed an order dated 05/09/24 for Vistaril oral capsule (hydroxyzine pamoate) give 25 milligrams (mg) by mouth at bedtime for itching. Review of the medical record and progress notes for Resident #10 from 05/01/24 through 05/09/24 revealed no indication or observation of Resident #10 itching. Review of the Consultant Pharmacy Recommendation to Physician/Prescriber #900 printed 12/18/24 revealed Resident #10…

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, interview and facility assessment review the facility failed to ensure residents were provided transportation to medical appointments as ordered. This affected one (Resident #70) of one residents reviewed for transportation. The facility census was 77. Findings include: Review of the medical record revealed Resident #70 was admitted on [DATE] with diagnoses that included lymphedema, Milroy's disease, autistic disorder, attention deficit hyperactive disorder, and expressive language disorder. The medical record revealed Resident #70 had an appointment with a cardiologist on 12/11/24 and a plastic surgeon on 01/15/25. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #70 was cognitively intact and was dependent for activities of daily living. A health status note dated 02/07/25 at 5:19 A.M. revealed Resident #70's mother visited the first part of the shift. The resident's mother reminded staff Resident #70 needed a signed referral sent to the Cleveland Clinic prior…

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, policy review, and staff interview the facility failed to ensure Resident #64 was offered the influenza (flu) vaccine from 02/27/25 to 03/31/25. This affected one resident (#64) of five residents reviewed for influenza immunizations. The facility census was 77. Findings include: Record review revealed Resident #64 was admitted to the facility on [DATE]. Diagnoses include altered mental status, need for assistance with personal care, muscle weakness, cognitive communication deficit, and major depressive disorder. Review of the Minimum Data Set (MDS, a clinical assessment of a resident's functional capabilities) dated 03/07/25 revealed Resident #64 had intact cognition. Further review of the medical record revealed no evidence the resident was offered the influenza vaccine after admission. Interview on 04/30/25 at 1:40 P.M. with Regional Director of Clinical Services #704 revealed the facility was unable to locate any information regarding Resident #64's consent or refusal of the influenza…

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, policy review, and staff interview the facility failed to ensure the Covid-19 immunization was offered to residents. This affected four (#15, #58, #63, and #64) of five residents reviewed for Covid-19 immunizations. The facility census was 77. Findings include: 1. Record review for Resident #15 revealed an admission date of 02/26/25. Diagnoses include cerebral palsy (a group of disorders that impact movement, muscle tone, or posture), need for assistance with personal care, anxiety disorder, chronic obstructive pulmonary disease (COPD, a lung condition that limits airflow into and out of the lungs), heart failure, and type 2 diabetes mellitus. Record review of the Minimum Data Set (MDS, a clinical assessment of resident's functional capabilities) dated 03/13/25 revealed Resident #15 had intact cognition. Review of the medical record revealed no evidence the resident was offered the COVID-19 immunization. Interview on 04/30/25 at 1:40 P.M. with Regional Director of Clinical Services RDCS)…

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 interviews, the facility failed to ensure Resident #70 was able to be transferred and evacuated from his room in the event of an emergency. This affected one (Resident #70) out of one reviewed for emergency transfer and evacuation. Facility census was 77. Findings include: Review of the medical record revealed Resident #70 was admitted on [DATE] with diagnoses that included lymphedema, Milroy's disease, autistic disorder, attention deficit hyperactive disorder, and expressive language disorder. A general progress note dated 10/24/24 at 4:52 P.M. revealed Resident #70 was alert and oriented times one and was primarily nonverbal. A bariatric mattress was provided but currently displayed error sounds due to the weight of Resident #70. Resident #70's weight was unable to be obtained due to Resident #70's weight exceeded the weight limit on the bariatric Hoyer (mechanical) lift. A general progress note dated 10/24/24 at 10:27 P.M. revealed four staff attempted to do a skin sweep on 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 record review, interview, self-reported incident (SRI) review, and facility policy review the facility failed to ensure Resident #72, who was on an anticoagulant (blood thinner), was monitored and treated timely for bruising. This affected one resident (#72) out of three residents reviewed for quality of care. The facility census was 66. Findings include: Review of the medical record for Resident #72 revealed an admission date of 10/29/18 and a discharge date of 04/11/24. Diagnoses included cerebral infarction, unspecified dementia, polyp of colon, and age-related osteoporosis. Review of the Significant Change Minimal Data System (MDS) assessment dated [DATE] revealed Resident #72 had severely impaired cognition. Review of the care plan dated 10/20/18 revealed Resident #72 was care planned for the potential for bleeding or hemorrhage related to the use of medications that have blood-thinning effects. Interventions included observe for signs of bleeding, black tarry stools, bruising, hematuria,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy review the facility failed to ensure documentation was completed on the treatment administration records (TAR) as required after treatment is provided for Resident #73. This affected one resident (#73) out of three residents reviewed for wounds. The facility census was 66. Findings include: Review of the closed medical record for Resident #73 revealed an admission date of 03/18/24 and a discharge date of 04/01/24. Diagnoses included metabolic encephalopathy, type II diabetes mellitus (DM), sleep apnea, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and sepsis. Review of the admission wound assessment dated [DATE] revealed Resident #73 was admitted to the facility with multiple wounds. The wound on the sacrum was a stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon, or muscle. Slough may be present on some parts of the wound bed. Often include undermining and tunneling.) measuring 12.9…

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 its medical director or designee attended all required quality assurance (QA) meetings (at least quarterly) as required. This had the potential to affect all 65 residents residing in the facility. Findings include: Review of the facility sign-in sheets for its QA meetings for the second quarter of the year 2022 revealed meetings were held on the following dates: • 04/27/22 • 05/03/22 • 06/01/22 • 06/14/22 • 06/28/22 • 07/12/22 • 07/26/22 There was no documented evidence the medical director or designee was in attendance in any of the above meetings. The Administrator verified that the facilities medical director was not in attendance for any of the QA meetings during the second quarter of 2022 during an interview on 08/03/22 at 3:15 P.M.

Based on observation and interview, the facility failed to ensure the smoking areas were maintained in a clean and sanitary manner. This finding affected three residents (Resident's #6, #10 and #64) and had the potential to affect an additional five residents (Resident's #15, #22, #47, #58 and #65) the facility identified as smokers who were identified as smokers by the facility. The facility census was 65. Findings include: Observation on 08/02/22 at 9:09 A.M. of the Beechwood smoking patio revealed Resident's #10 and #64 were in the smoking area and both were assessed to smoke independently. Approximately eleven cigarette butts were observed on the ground and grass areas, and no staff were present in the smoking area at the time of the observation. Observation on 08/02/22 at 9:18 A.M. of the Beechwood smoking patio with Maintenance Director #66 confirmed the area had multiple cigarette butts on the concrete walkway and grass areas. Observation on 08/02/22 at 9:24 A.M. with Maintenance Director #66 of the Dogwood patio revealed assorted cigarette butts were on the ground and grass…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure comprehensive assessments were complete and accurate. This finding affected three residents (Resident's #6, #12 and #15) of 21 residents reviewed for comprehensive assessments. The facility census was 65. Findings include: 1. Review of Resident #6's medical record revealed he was admitted on [DATE] with diagnoses including anxiety disorder, essential hypertension, and major depressive disorder. Review of Resident #6's Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] revealed, during the seven-day look back period from 07/02/22 to 07/08/22, he did not receive hypnotics or diuretics. Review of Resident #6's physician orders revealed an order dated 05/12/22 for Restoril (hypnotic) 7.5 mg (milligrams) give one tablet by mouth at bedtime for insomnia and an order dated 05/04/22 for Lasix (diuretic) give 60 mg by mouth two times a day related to essential hypertension. Review of Resident #6's medication administration records (MAR)…

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, review of the manufacturer's directions, and facility policy review the facility failed to ensure a medication error rate of 5% (percent) or less. This finding affected two residents (Resident's #49 and #39) of six residents observed for medication administration. A total of 27 medications were administered with three errors for a medication error rate of 11.1%. The facility census was 65. Findings include: 1. Review of Resident #49's medical record revealed he was admitted to the facility on [DATE] with diagnoses including diabetes and hypoglycemia. Review of Resident #49's physician orders revealed an order dated 11/18/21 for Lantus (long-acting insulin) KwikPen inject 34 units subcutaneously (SQ) one time a day for diabetes and an order dated 07/05/22 for Humalog (short-acting insulin) KwikPen inject 15 units SQ with meals related to diabetes. Observation on 08/01/22 at 8:16 A.M. with Licensed Practical Nurse (LPN) # 92 of Resident #49's medication…

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

Based on review of personnel files, review of the facility new hire list, review of the facility abuse policy and staff interview the facility failed to ensure all potential new staff hires were checked against the Nurse Aide Registry (NAR) prior to employment to ensure the employee did not have a finding entered into the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property and failed to complete a background check and fingerprinting with the Bureau of Criminal Identification and Investigation for Registered Nurse (RN) #600. This affected one RN, five supervisor employees, 15 housekeeping staff, four laundry staff, 11 dietary staff, three maintenance staff and one administrative staff member and had the potential to affect all 81 residents residing in the facility. Findings include: 1. Review of the new hire list dated 06/28/19 to 08/13/19 and review of employee personnel files revealed the following employees had been hired within this time period: Laundry staff #801, #804, #805, #806, Housekeeping staff #807,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to effectively implement their abuse policy and procedure to ensure narcotic medications and funds were not misappropriated for Resident #50 and Resident #52 and to ensure all proper and required screening procedures were completed at the time of hire to ensure no employee had a finding entered into the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation or had a disqualifying offense based on a criminal background check. This affected one RN, five supervisor employees, 15 housekeeping staff, four laundry staff, 11 dietary staff, three maintenance staff and one administrative staff member. In addition, this affected two residents (#50 and #52) and had the potential to affect all 81 residents residing in the facility. Findings include: 1. Review of the medical record revealed Resident #50 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease and calculus 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 interview the facility failed to prevent the misappropriation of narcotic medication for Resident #50 and Resident #52 and failed to prevent misappropriation of funds for Resident #52. This affected two residents (#50 and #52) of four residents reviewed for abuse, neglect and misappropriation. Findings include: 1. Review of the medical record revealed Resident #50 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease and calculus of kidney with ureter. Review of physician's orders for November 2018 revealed Resident #50 was ordered Percocet (narcotic pain medication) 5/325 milligram (mg) every six hours. Review of a facility self-reported incident, dated 11/11/18 A.M. at 6:30 A.M. revealed Resident #50 stated he had not received his 6:00 A.M. pain medication. Review of the controlled drug record form dated 11/04/18 through 11/11/18, revealed Registered Nurse (RN) #600 signed out a Percocet for Resident #50 at 6:00 A.M. A written statement, dated…

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 interview the facility failed to ensure Resident #9 and Resident #33, who required staff assistance for activities of daily living including personal hygiene and nail care received timely and adequate care. The affected two residents (#9 and #33) of three residents reviewed for activities of daily living (ADL) care. Findings include: 1. Review of the medical record for Resident #9 revealed the resident was admitted to the facility on [DATE] with a diagnosis including dementia. Review of the plan of care, dated 02/10/16 revealed the resident needed assistance for activities of daily living. Interventions included staff would assist as needed with daily hygiene. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/13/19 revealed the resident had impaired cognition. The resident required supervision of one staff for personal hygiene. Observation on 08/12/19 at 2:50 P.M., 08/13/19 at 8:54 A.M. and 2:49 P.M. and 08/14/19 at 8:08 A.M. of Resident #9 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 observation, record review and interview the facility failed ensure geriatric (geri) sleeves were provided as ordered for Resident #33 as ordered by the physician. This affected one resident (#33) of one reviewed for skin conditions. Findings include: Review of Resident #33's medical record revealed the resident was admitted to the facility on [DATE] with the diagnoses of chronic obstructive pulmonary disease, Alzheimer's disease, syndrome of inappropriate secretions of antidiuretic hormone, hypertension, rheumatoid arthritis, macular degeneration, major depressive disorder, presence of intraocular lens, viteous degeneration, xerosis cutis, peripheral vascular disease, dementia, hallucination, and anxiety disorder. Review of nurse's notes, dated 06/26/19 at 2:24 P.M. revealed the resident had a skin tear to her left elbow area. The injury occurred while transferring from wheelchair to the bed. The measurements were 1.5 centimeters in diameter. The edges were not approximated. An order was obtained 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 observation, record review and interview the facility failed to properly fill the humidifier bottle on the oxygen concentrator for Resident #33 with distilled water. This affected one resident (#33) of 19 residents who received oxygen therapy. Findings include Review of Resident #33's medical record revealed the resident was admitted to the facility on [DATE] with the diagnoses of chronic obstructive pulmonary disease, Alzheimer's disease, syndrome of inappropriate secretions of antidiuretic hormone, hypertension, rheumatoid arthritis, macular degeneration, major depressive disorder, presence of intraocular lens, viteous degeneration, xerosis cutis, peripheral vascular disease, dementia, hallucination, and anxiety disorder. Review of the significant change Minimum Data Set (MDS) 3.0 assessment, dated 07/22/19 revealed Resident #33 had severely impaired cognition and required extensive assistance from staff with all activities of daily living. Review of the August 2019 physician's orders 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 and interview the facility failed to have a current physician's order before administering the antipsychotic medication, Haldol to Resident #65 and failed to ensure the resident had an appropriate diagnosis for the use of the antipsychotic medication Seroquel. This affected one resident (#65) of five residents reviewed for unnecessary medication use. Findings include: Review of Resident #65's medical record revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Parkinson's disease, dementia, major depressive disorder, psychosis, hallucinations, and anxiety. The quarterly Minimum Data Set (MDS) 3.0 assessment, dated 05/29/19 revealed Resident #65 had severe cognitive impairment. The MDS also revealed the resident had not exhibited any behaviors during the assessment period. Review of the physician's orders revealed an order, dated 07/24/19 for the antipsychotic medication, Haldol 2.5 milligram (mg) intramuscular injection (IM) as…

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.