Centerville Health And Rehab

Based on interview, record review, facility document review, and facility policy review, the facility failed to prevent staff verbal abuse for two (Resident #25 and Resident #66) of three residents reviewed for abuse. The facility census was 84. Findings included:1. Review of the medical record revealed the facility admitted Resident #25 on 01/17/2025. The resident had a medical history that included diagnoses of personal history of traumatic brain injury and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/18/2025, revealed Resident #25 had intact cognition. Review of the care plan revealed a focus area initiated on 01/27/2025 indicating the resident was at risk for impaired neurological status related to a history of traumatic brain injury. Interventions included staff to explain all procedures and reasons before performing them, monitor the resident for changes in condition, and have pleasant interactions, which reassures the resident when they were confused. During an interview on 07/05/2025 at 9:19 AM, Resident #25 stated…

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 interview, record review, facility document review, and facility policy review, the facility failed to report allegations of abuse to the administrator and the state survey agency for two (Resident #25 and Resident #66) of three residents reviewed for abuse. The census was 84. Findings include:1. Review of the medical record revealed the facility admitted Resident #25 on 01/17/2025. The resident had a medical history that included diagnoses of personal history of traumatic brain injury and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/18/2025, revealed Resident #25 had intact cognition. Review of the care plan revealed a focus area initiated on 01/27/2025 indicating the resident was at risk for impaired neurological status related to a history of traumatic brain injury. Interventions included staff to explain all procedures and reasons before performing them, monitor the resident for changes in condition, and have pleasant interactions, which reassures the resident when they were confused. During an interview on 07/05/2025…

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 interview, record review, facility document review, and facility policy review, the facility failed to ensure allegations of abuse were investigated and failed to prevent further abuse by removing the emoployee from duty after an allegation of abuse. This affected two (Resident #25 and Resident #66) of three residents reviewed for abuse. The facility census was 84. Findings included:1. Review of the medical record revealed the facility admitted Resident #25 on 01/17/2025. The resident had a medical history that included diagnoses of personal history of traumatic brain injury and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/18/2025, revealed Resident #25 had intact cognition. Review of the care plan revealed a focus area initiated on 01/27/2025 indicating the resident was at risk for impaired neurological status related to a history of traumatic brain injury. Interventions included staff to explain all procedures and reasons before performing them, monitor the resident for changes in condition, and have pleasant…

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, record review, and a review of the facility's policy, the facility failed to notify the Office of the State Long Term Care Ombudsman and failed to provide written bed-hold notices for two (Resident #22 and Resident #17) of two residents reviewed for hospitalization. The facility census was 84 Findings include: 1. Review of the medical record revealed the facility admitted Resident #22 on [DATE]. The resident had a medical history that included a diagnosis of multiple sclerosis. Resident #22's progress notes dated [DATE] at 12:00 PM indicated the resident was transferred to the emergency room (ER) for an evaluation and treatment. Resident #22's progress notes dated [DATE] at 10:38 PM that indicated the resident returned to the facility from the hospital at 7:30 PM. Resident #22's progress notes dated [DATE] at 11:51 PM indicated the resident's family member called emergency medical services (EMS) due to suspecting the resident was having a stroke. The note revealed EMS took the resident to a…

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 revise a care plan for one (Resident #19) of one resident reviewed for tube feedings. The facility census was 84. Findings include: Review of the medical record revealed Resident #19 was admitted on [DATE]. Diagnoses included multiple sclerosis and oropharyngeal dysphagia (a disorder or impairment in initiating a swallow). Review of the Minimum Data Set assessment, dated 04/17/2025, revealed Resident #19 had severe impairment in cognitive skills for daily decision-making and had a short-term and long-term memory problem. The MDS indicated the resident had a feeding tube while they were a resident at the facility. Resident #19's current physician orders included an order dated 01/02/2025 for nothing by mouth (NPO) diet and enteral feeding of 2calorie formula at 60 milliliters (ml) an hour continuously with a 50 ml an hour fluid flush every shift with a 1320 ml total based on a 22-hour runtime. Review of Resident #19's care plan…

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, record review, staff, and resident interviews, and review of facility policy, the facility failed to ensure a clean, safe, comfortable environment for all residents. This affected 11 (#02, #06, #19, #31, #32, #35, #38, #44, #53, #70, and #71) residents who resided in the facility. The facility census was 77. Findings include: Review of the medical record for Resident #53 revealed the resident was admitted on [DATE]. Diagnoses included hypoxemia, amyotrophic lateral sclerosis (ALS), gastro-esophageal reflux disease (GERD), essential primary hypertension, obstructive sleep apnea (OSA), and diabetes mellitus (DM). Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #53 was cognitively intact. Resident #53 was dependent on staff for Activities of Daily Living (ADLs). Observation of the facility on 05/13/25 at 11: 30 A.M. with the Director of Housekeeping and Laundry #134 revealed the following findings: a) Resident #02's bathroom was heavily soiled with dirt, debris…

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, resident and staff interview, medical record review, and policy review, the facility failed to ensure the facility was free from pests. This affected one (#26) of four residents reviewed for effective pest control. The facility census was 78. Findings include: Review of the medical record for Resident #26 revealed an admission date of 07/09/24. Diagnoses included cerebral infarction, bipolar disorder, personal history of traumatic brain injury, insomnia, hyperlipidemia, epilepsy, osteoarthritis, aphasia, hemiplegia and hemiparesis following a cerebral infarction, and cerebellar ataxia. Review of Resident #26's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed as cognitively intact. Interview on 05/06/25 at 3:04 P.M. with a Registered Nurse (RN) #204 and Certified Nurse Aide (CNA) #224 reported they both saw live roaches in Resident #26's bathroom. Observation and interview on 05/06/25 at 3:06 P.M. with the Administrator confirmed the presence of five to six…

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, resident and staff interview, medical record review, and policy review, the facility failed to ensure the facility was free from pests. This had potential to affect all 81 facility residents. The census was 81. Findings include: 1. Review of Resident #11's medical record revealed the resident admitted to the facility on [DATE] with diagnoses including multiple fractures of the ribs right side, pain in unspecified joint, congestive heart failure, chronic obstructive pulmonary disease unspecified, legal blindness, urinary tract infection, angina pectoris and heartburn. Review of Resident #11's admission assessment dated [DATE] revealed the resident was oriented to person, place, time, and situation. Interview with Resident #11 on 04/04/25 at 8:14 A.M. revealed the resident saw a large cockroach in her bathroom a few days ago that was over one inch long. 2. Review of Resident #19's medical record revealed the resident admitted to the facility on [DATE] with diagnoses including type 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.

Based on observations, staff and resident interviews, interview with the Pest Control Representative, review of pest control notes, and review of facility policy, the facility failed to maintain the kitchen and dining room area free from pests. This had potential to affect all 74 facility residents. Findings include: Review of pest control notes dated 09/30/24, 10/22/24, 11/27/24, 01/03/25 and 01/27/25 revealed the facility had treatments completed for roaches and mice traps were monitored. Observation and interview on 03/04/25 from 9:40 A.M. to 10:05 A.M. with Kitchen Manager (KM) #205 revealed facility had mice a few weeks ago but they had been treated. Observation of the food area found an extremely large amount of brownish black pellets. KM #205 verified these to be mouse excrement. These were found on baking sheets; in the roboku; in boxes of paper products; in boxes and containers of food such as chips, gelatin, condiments, and packaging with pop cans; on cookie sheets with food on it; and on the silverware holder. KM #205 could not confirm if the mouse droppings were new or…

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

Based on observations, staff interview, and resident interviews, facility failed to ensure resident rooms were maintained in clean, working order. This affected three (#23, #46, and #50) of three residents reviewed for environment. The facility census was 74. Findings include 1. Observation on 03/04/25 at 11:51 P.M. in Resident #46's room with Licensed Practical Nurse (LPN) #220 revealed the floor around the packaged terminal air conditioner (PTAC) heating and cooling unit had several floor tiles which were loose. The floor on the right and left side was dark and appeared to be missing a floor surface. The left side had a hole about the size of a thumb in the flooring. A built-in shelf to the right of the PTAC machine was broken and caved in. Interview at the time of the observation with LPN #220 confirmed the observations. 2. Observation on 03/04/25 at 9:40 A.M. of Resident #50's room revealed a floor board was loose and had fallen off the closet/wall and was sitting upside down on the floor. Both closet doors were broken and off the hinges. Interview on 03/04/25 at 11:53 P.M. 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 observations, review of the facility pest control invoices, and staff and resident interviews, the facility failed to ensure effective pest control measures were in place. This had the potential to affect all 69 residents residing in the facility. The facility census was 69. Findings include: Interview on 11/24/24 at 7:49 A.M. with State Tested Nursing Assistant (STNA) #170 confirmed she worked on the secure unit and stated she observed a cockroach in the dining area that morning. STNA #170 stated the cockroach crawled under the baseboard on the floor. Interviews on 11/24/24 between 9:45 A.M. to 10:36 A.M. with Licensed Practical Nurse (LPN) #199, #223, and #250 stated they have observed large insects and cockroaches in the facility hallways and on the secured unit within the past two weeks. Interview on 11/24/24 at 10:17 A.M. with Resident #43 stated he had observed insects and mice in his room. Resident #43 stated she hasn't seen a mouse recently but had seen beetles or large black insects from time…

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

Based on medical record review, observation, staff and resident interviews, and policy review, the facility failed to provide care and services to ensure fingernails were trimmed and free of dirt and debris. This affected one (#30) out of three residents reviewed for Activities of Daily Living (ADL's). The facility census was 69. Findings include: Review of the medical record for Resident #30 revealed an admission ate of 12/11/18 with medical diagnoses of multiple sclerosis (MS), joint contracture's, and dysphagia. Review of the medical record for Resident #30 revealed a quarterly Minimum Data Set (MDS) assessment, dated 09/27/24, which indicated Resident #30 was cognitively intact and was dependent for all activities of daily living (ADL's) and had limited ROM to one upper extremity. Review of the medical record for Resident #30 revealed documentation to support Resident #30 received a bath or shower on 11/11/24, 11/18/24, and 11/22/24 but did not contain documentation to support nail care was provided. Observation with interview on 11/25/24 at 1:27 P.M. of Resident #30 revealed…

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

Based on medical record reviews, staff and resident interviews, and policy review, the facility failed to ensure splints/braces were applied as ordered. This affected two (#30 and #75) out of three residents reviewed for cares and services to prevent decline in range of motion (ROM). The facility census was 69. Findings include: 1. Review of the medical record for Resident #30 revealed an admission ate of 12/11/18 with medical diagnoses of multiple sclerosis (MS), joint contracture's, and dysphagia. Review of the medical record for Resident #30 revealed a quarterly Minimum Data Set (MDS) assessment, dated 09/27/24, which indicated Resident #30 was cognitively intact and was dependent for all activities of daily living (ADL's) and had limited ROM to one upper extremity. Review of the medical record for Resident #30 revealed a physician order dated 10/24/24 to apply left resting hand splint up to eight hours at night and to discontinue use with any redness or skin breakdown. The order was discontinued on 11/25/24. Review of the medical record for Resident #30 revealed no documentation…

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 the medical record reviews, observations, staff and resident interviews, and policy review, the facility failed to ensure medications were administered as ordered resulting in two medications errors out of 28 opportunities or a 7.14 percent (%) medication error rate. This affected two (#50 and #62) out of three residents reviewed for medication administration. The facility census was 69. Findings include: 1. Review of the medical record for Resident #50 revealed an admission date of 10/21/24 with medical diagnoses of atrial fibrillation, depression, congestive heart failure (CHF), moderate protein calorie malnutrition, and bipolar disorder. Review of the medical record for Resident #50 revealed an admission Minimum Data Set (MDS) assessment, dated 10/28/24, which indicated Resident #50 was cognitively intact and required supervision with transfers and toilet hygiene and was independent with bed mobility. Review of the medical record for Resident #50 revealed a physician order dated 11/22/24 for Ativan one milligram (mg) to give one tablet by mouth daily. 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.

Based on observations, staff interviews, review of infection control logs, review of dishwasher logs and review of service invoices, the facility failed to ensure the dishwashing machine had the appropriate rinse temperature and chemicals to sanitize dishes. This had the potential to affect all 60 residents who receive food from the kitchen. The facility census was 60. Findings include: On 04/11/22 at 9:00 A.M. observation of the dishwasher in the dishwasher room revealed the dishwasher heat temperature was 148 degrees Fahrenheit (F) and the rinse temperature gauge did not move. Testing of the chemicals with the chemical strips revealed no chlorine was detected in the dishwasher. On 04/11/22 at 9:18 A.M. observation of the recommendations label located on the dishwasher revealed for Chemical Dishwasher the Final Rinse Minimum temperature is 120 degrees F with recommended being 140 degrees F. Wash tank minimum temperature is 120 degrees F with recommended being 140 degrees F. Minimum sanitizer required is 50 parts per million (PPM) of chlorine. On 04/11/22 at 9:15 A.M. an interview…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff interview, facility policy review and review of information from the Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid Services (CMS), the facility failed to implement infection control practices by ensuring staff wore appropriate personal protective equipment (PPE) to potentially prevent the spread of Coronavirus Disease 2019 (COVID-19). This had the potential to affect all 60 residents residing at the facility. The facility census was 60. Findings include: 1. Medical record review for Resident #413 revealed an admission date of 04/08/22. Her diagnosis included hypertensive urgency, diabetes mellitus 2, fracture of upper end of right humerus, cerebral infarction, dysphagia, hypokalemia, congestive heart failure, anemia, pleural effusion, hyperlipidemia, irritable bowel syndrome, osteoarthritis, and depression. Review of the 5-day minimum data set (MDS) assessment, dated 04/12/22, revealed Resident #413 scored a seven on her…

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 4. Review of Resident #43's medical record revealed the resident was admitted on [DATE] with a readmission on [DATE] from a hospital stay from 01/18/22 through 01/20/22. Diagnoses include epilepsy and seizures. Further medical record review for Resident #43 revealed there was no documented evidence the Ombudsman was notified of the hospital transfer. Interview on 04/13/22 at 11:38 A.M. with the Social Service Director (SSD) #22 revealed she has not notified the Ombudsman of discharges from the facility because the facility was given a new Ombudsman and she was waiting for them to give her their email address. SSD #22 confirmed there was no evidence of the Ombudsman being notified of Resident #14, #28, #43 or #61's transfers to the hospital. Interview on 04/13/22 at 1:28 P.M. with the Director of Nursing (DON) confirmed the facility has not been providing discharge notifications to the Ombudsman. The DON stated the facility is working on putting a program in place to notify the Ombudsman of discharges. 2. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of Resident #28's medical record revealed she was admitted on [DATE]. Diagnoses included but not limited to repeated falls, lack of coordination, type 2 diabetes mellitus without complications, altered mental, major depressive disorder recurrent, and chronic obstructive pulmonary disease. Resident #28 is her own responsible person. Review of the MDS assessment dated [DATE] revealed Resident #28 to have intact cognition and required extensive assistance with one person physical assist for Activities of Daily Living, (ADL's). Record review of the electronic medical record revealed Resident #28 was discharged to the hospital on [DATE] via emergency medical transport. Further medical record review for Resident #28 revealed there was no documented evidence the resident received the bed hold notice. Interview on 04/11/22 at 2:01 P.M., revealed Resident #28 reported she went hospital in February 2022 for bowel problems. Resident #28 denies been given bed hold notice when discharged to hospital. Based on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and staff and resident interview, the facility failed to ensure a resident was afforded with the choice of personal care for showering/bathing. This affected one (#53) out of three residents reviewed for choices. The facility census was 60. Findings include: Review of Resident #53's medical record revealed an admission date of 12/11/18 with diagnoses including multiple sclerosis, hyperlipidemia, cognitive communication deficit, difficulty in walking not elsewhere, lack of coordination, major depressive disorder, neuromuscular dysfunction bladder, dysarthria and anarthria, and voice resonance disorders. Review of the Minimum Data Set (MDS) 3.0 annual assessment dated [DATE] revealed Resident #53 is cognitive intact. He required two persons plus for bed mobility, transfers, dressing and one person person physical assist for bathing. Review of Resident #53's electronic record revealed showers were scheduled to be given Mondays and Thursdays from 7:00 PM until 7:00 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.

Based on medical record review, staff interviews, review of facility self-reported incidents and policy review, the facility failed to report an allegation of sexual abuse to the state survey agency. This affected one (#5) of three residents reviewed for abuse. The census was 60. Findings Include: Review of Resident #1's medical record revealed an admission date of 08/27/18 and a readmission date of 04/01/22. Diagnoses included dementia, psychosis, and lung disease. The most recent quarterly Minimum Date Set (MD'S) dated 03/22/22 revealed the resident was severely cognitively impaired and required assistance of one with all care. The resident requires limited assist with ambulation. Review of the behavior plan of care dated 10/05/21 revealed the resident was sexually inappropriate by comments and request. Interventions included diversional activity, redirect, refer to psychiatrist as needed. Review of the Nurses Notes dated 03/12/22 revealed the resident was seen lifting the pants of a female resident (#5) and rubbing a female resident's thigh. The resident was removed from the…

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

Based on medical record review, staff interviews, review of facility self-reported incidents and policy review, the facility failed to investigate an allegation of sexual abuse. This affected one (#5) of three residents reviewed for abuse. The census was 60. Findings Include: Review of Resident #1's medical record revealed an admission date of 08/27/18 and a readmission date of 04/01/22. Diagnoses included dementia, psychosis, and lung disease. The most recent quarterly Minimum Date Set (MD'S) dated 03/22/22 revealed the resident was severely cognitively impaired and required assistance of one with all care. The resident requires limited assist with ambulation. Review of the behavior plan of care dated 10/05/21 revealed the resident was sexually inappropriate by comments and request. Interventions included diversional activity, redirect, refer to psychiatrist as needed. Review of the Nurses Notes dated 03/12/22 revealed the resident was seen lifting the pants of a female resident (#5) and rubbing a female resident's thigh. The resident was removed from the area. The nurse charted…

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 records and staff and resident interviews, the facility failed to ensure residents were invited to care conferences to allow them to provide input in their care. This affected two (#28 and #42) out of three residents reviewed for care conferences participation. Facility census was 60. Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 05/28/21 with diagnoses including but not limited to encounter for surgical aftercare following surgery on the digestive system, altered mental status, repeated falls, lack of coordination, type 2 diabetes mellitus without complications Review of admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15. Review of the medical record for Resident #28 revealed there was no documentation of care conference. Interview with Resident #28 on 04/11/22 at 1:59 P.M., revealed she could not remember the last time she had…

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 and staff interview, the facility failed to ensure care planned interventions were in place for prevention of falls/accidents. This affected one (#31) of three residents reviewed for falls. The facility census was 60. Findings: Review of medical record for Resident #31 revealed admission date of 07/15/15 with a brief interview mental status (BIMS) score of 14 indicating intact cognition. Diagnoses include rheumatoid arthritis, chronic obstructive pulmonary disorder, contracture, and insomnia. The annual minimum data set (MDS) dated [DATE] revealed extensive two assist for bed mobility, transfers, dressing, toileting and supervision for eating. Record review of the care plan revealed Resident #31 was at risk for falls/injury related to weakness, impaired mobility, contractures and non compliance with interventions for therapy evaluations and treatment. Interventions included bed in low position, call light and personal items within reach, resident to use call light…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations and staff and resident interviews, the facility failed to ensure dialysis resident received meals before dialysis appointments. This affected one (#48) of one residents reviewed for dialysis. Facility census was 60. Findings include: Review of the medical record for Resident #48 revealed an admission date of 03/12/22 with diagnoses include protein-calorie malnutrition hypertensive heart, failure and with stage 5 chronic kidney disease or end stage renal disease, chronic diastolic (congestive) heart failure, dependence on renal dialysis, convulsions, hyperlipidemia, anemia in chronic kidney disease, type 2 diabetes with other circulatory complications, and type 2 diabetes mellitus with other diabetic ophthalmic complication. Resident #48 is his own responsible party. Review of admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact. Review medical records revealed Resident #48 attends dialysis on Mondays, Wednesdays 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, observations and staff and resident interviews, the facility failed to ensure an assessment was completed regarding the use of bedrail's on a residents bed. This affected one (#14) out of three residents reviewed for the use of bedrail's. The facility census was 60. Findings include: Review of medical record for Resident #14 revealed admission date of 12/26/19 with no memory impairment cognition modified independence. Diagnoses include congestive heart failure, type 2 diabetes, hypertension, reflux and contracture to left knee. The quarterly minimum data set (MDS) dated [DATE] revealed extensive two assist for bed mobility, transfers, and independent for eating. Review of the care plan revealed Resident #14 has a physical functional deficit related to mobility impairment, and range of motion limitations. Interventions included assistance of one staff member with noted activities of daily living fluctuations. Record review revealed Resident #14 had intact cognition and was unable…

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 and staff interview the facility failed to provide State Tested Nursing Assistant (STNA) annual performance reviews. This affected three STNA's (#9, #99 and #115) of three STNAs who worked at the facility longer than a year. This had the potential to affect all the residents at the facility. The facility census was 103. Findings include: 1. Review of STNA #9's personnel file revealed a date of hire of 12/30/15. Further review of the personnel file did not reveal a performance review in the past year. 2. Review of STNA #99's personnel file revealed a date of hire of 11/09/15. Further review of the personnel file did not reveal a performance review in the past year. 3. Review of STNA #115's personnel file revealed a date of hire of 05/19/16. Further review of the personnel file did not reveal a performance review in the past year. Interview on 06/20/19 at 10:52 A.M. with Human Resource (HR) #106 confirmed annual performance reviews were not completed for STNAs #9, #99 and #115. The facility did not provide a policy related to annual performance…

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

Based on observation, staff interview, and review of manufacture's directions, the facility failed to ensure that mobile and stationary food preparation equipment was properly sanitized, and nutritional supplements and thickened liquids stored in unit refrigerators were stored in a manner to ensure that resident's were not served outdated/spoiled supplements and thickened liquids. This had the potential to affect all 103 residents of the facility. Findings include: 1. A tour of the central kitchen was conducted on 06/17/19 at 8:20 A.M. Dietary staff were in the process of finishing assembling resident breakfast trays. Dietary Supervisor (DS) #60 arrived shortly thereafter. While touring the central kitchen two buckets filled with a quaternary ammonia sanitizing solution were checked with a test strip for proper concentration by DS #60. Both buckets of sanitizing solution registered at 150 parts per million (ppm). Both DS #60 and [NAME] #33 reported that the sanitizing solution was checked when it was dispensed into the buckets and that 150 ppm was acceptable. There was a log near…

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 each resident was treated in a manner and environment that promoted their individuality and dignity during dining. This had the potential to affect all 15 residents (#3, #4, #5, #21, #25, #40, #51, #55, #56, #57, #62, #81, #90, #93, and #100) of the secured 400/[NAME] unit. The facility census was 103. Findings include: 1. On 06/17/19 dining observations were conducted on the secured 400 unit dining room from 11:45 A.M. through 12:30 P.M. The 400/[NAME] unit was a secured unit for resident's with dementia. State Tested Nurse Aide (STNA) #70 was present in the dining room at that time attempting to get 12 of the 15 residents on the unit seated at tables. Shortly thereafter STNA #66 appeared in the dining room. STNA #66 stated she was not typically on this unit and she was was filling in for a call off. One additional resident came to the dining room making a total of 13 residents in the dining room. STNA #66 and #70 then began serving trays…

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 provide necessary maintenance and housekeeping services to maintain a sanitary, orderly, and comfortable interior. This involved 15 of 15 residents (#3, #4, #5, #21, #25, #40, #51, #55, #56, #57, #62, #81, #90, #93, and #100) who resided on the secured 400/[NAME] unit . The facility census was 103. Findings include: 1. On 06/17/19 at 11:24 A.M. resident of the 400/[NAME] unit were observed getting ready to be served their lunch in the unit dining room. The wall of the room above and below the wooden chair rails were observed with areas of paint scraped off and gouges in the dry wall in quantities too numerous to count. 2. On 06/17/19 at 2:22 P.M., observation of the resident sleeping room occupied by Resident #21 and #55 revealed Resident #21's call light was broken and non-functioning, the closet drawers had been removed from the closet and were leaning against the wall representing a potential accident hazard, the drawer handle was missing from…

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 interview, the facility failed to ensure the residents or the Ombudsman were provided with a written notice of the reason for discharge or transfer. This affected five (#12, #50, #58, #64 and #302) of six residents reviewed for discharge notification. The facility census was 103. Findings include: 1. Closed edical record review revealed Resident #12 was admitted to the facility on [DATE] with the following diagnoses; heart failure, benign prostatic hyperplasia with lower urinary tract symptoms, mood disorder due to known physiological condition with depressive features, type two diabetes mellitus, anemia, cerebral infarction, hyperlipidemia, glaucoma, pain in left shoulder and muscle weakness. Review of Resident #12's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, dressing, personal hygiene and toileting. Resident #12 also required total dependence with transfers and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interview, and review of facility policy, the facility failed to timely provide written bed-hold notices to residents when hospitalized . This affected four (#12 #50, #58 and #302) of six residents reviewed for hospitalizations. The facility census was 103. Findings include: 1. Review of the medical record revealed Resident #58 was admitted [DATE] with diagnoses including chronic kidney disease, sepsis, obstructive and reflux uropathy, malignant neoplasm of lateral wall of bladder, encephalopathy, acute kidney failure, anxiety disorder, hyperlipidemia, calculus of kidney, essential hypertension, diabetes mellitus, attention-deficit hyperactivity disorder, bipolar disorder, chronic obstructive pulmonary disease, hydronephrosis, anemia in chronic kidney disease, calculus of ureter. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident required supervision for bed mobility, transfers, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and review of activity calendar, the facility failed to provide an ongoing program of activities for each resident that met their individual needs and preferences. This directly affected two resident (#55, #81) and had the potential to affect all 15 residents (#3, #4, #5, #21, #25, #40, #51, #55, #56, #57, #62, #81, #90, #93, and #100) of the secured 400/[NAME] unit for resident's with dementia related diagnoses. The facility census was 103. Findings include: 1. Resident #55 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dysphagia, major depressive disorder, anxiety, abnormal posture, and hypertension. The facility completed a quarterly minimum data set (MDS) assessment dated [DATE]. The assessment identified the resident had short and long term memory problems, severely impaired cognitive skills, and requiring supervision and the physical assistance of one to two staff persons to complete all activities of daily living. Review 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 medical record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure resident's Do No Resuscitate (DNR) code status designation was documented on a valid form and failed to ensure resident's code status matched throughout the medical record. This affected two (#10 and #50) of 32 residents reviewed during the initial pool screening of the annual survey. The facility census was 103. Findings include: 1. Review of the medical record revealed Resident #50 was admitted [DATE]. Diagnoses included acute kidney failure, generalized anxiety disorder, pancytopenia, acute myeloblastic leukemia, hyperosmolality and hypernatremia, dysphagia, hypothyroidism, hypertension, major depressive disorder, hyperlipidemia, Barrett's esophagus with dysplasia, gastro-esophageal reflux disease, polyneuropathy, arthropathy, anemia, chronic obstructive pulmonary disease, squamous cell carcinoma of skin, and malignant neoplasm of the mouth. Review of the quarterly Minimum Data Set…

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 interview the facility failed to ensure residents that were discharged from Medicare Part A services were notified of the potential liability for payment. This affected two (#79 and #306) of three residents reviewed for beneficiary notices. The facility census was 103. Findings include: 1. Review of the medical record revealed Resident #79 was admitted to the facility on [DATE] with the following diagnoses; chronic ischemic heart disease, muscle weakness, difficulty in walking, unspecified abnormalities of gait and mobility, sepsis due to Escherichia coli, personal history of transient ischemia attached, cerebral atherosclerosis, anxiety disorder, chest pain, other specified conduct disorder, convulsions, dementia without behavioral disturbance, hypertension, type two diabetes mellitus, atrial fibrillation, legal blindness and major depressive disorder. Review of Resident #79's quarterly Minimum Data Sets (MDSs) assessment dated [DATE] revealed the resident was severely…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interview, and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the facility failed to ensure resident's Minimum Data Set (MDS) assessments were completed accurately for required Preadmission Screening and for discharge planning. This affected two residents (#39 and #58) of 32 reviewed during the annual survey. The facility census was 103. Findings include: 1. Resident #58 was admitted [DATE] with diagnoses including chronic kidney disease, sepsis, obstructive and reflux uropathy, malignant neoplasm of lateral wall of bladder, encephalopathy, acute kidney failure, anxiety disorder, hyperlipidemia, calculus of kidney, essential hypertension, diabetes mellitus, attention-deficit hyperactivity disorder, bipolar disorder, chronic obstructive pulmonary disease, hydronephrosis, anemia in chronic kidney disease, and calculus of ureter. Review of the admission MDS assessment dated [DATE] revealed the resident had intact…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interviews, the facility failed to accurately complete pre-admission screening and resident review (PASARR) for newly admitted residents. The facility also failed to notify the state mental health authority of significant changes in a resident's mental health. This affected three (#37, #58, and #99) of three residents reviewed for PASARR. The facility census was 103. Findings include: 1. Record review revealed Resident #99 was admitted to the facility on [DATE] from another skilled nursing facility with the following diagnoses; major depressive disorder, generalized anxiety disorder, insomnia, unspecified psychosis, multiple sclerosis, hyperlipidemia, polyneuropathy, hypertension, low back pain, other abnormal involuntary movements, other lack of coordination, hyperthyroidism and muscle weakness. Review of Resident #99's PASARR dated 05/30/19 revealed mood disorder, panic or other severe anxiety disorder and other psychotic disorder were not marked on the PASARR. Interview 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 record review and staff interview, the facility failed to develop accurate baseline care plans for residents within 48 hours of their admission. This affected two (#10 and #27) of 23 residents reviewed for baseline care plans. The facility census was 103. Findings include: 1. Review of Resident #27's medical record revealed the resident was admitted to the facility on [DATE] with the following diagnoses; hypotension, difficulty in walking, hypertension, chronic kidney disease, cataract, adjustment disorder with mixed anxiety and depressed mood, unspecified symptoms and signs involving cognitive functions and awareness, unsteadiness on feet, type two diabetes mellitus without complications, dementia without behavioral disturbance, vitamin D deficiency, pure hypercholesterolemia, restlessness and agitation, muscle weakness and syncope and collapse. Review of Resident #27's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed resident was severely cognitively impaired and required supervision…

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, review of activity schedules and participation records, the facility failed to develop and implement a comprehensive person-centered plan of care for activities for two residents (#55 and #81) and develop a comprehensive plan of care regarding anticoagulation use and dementia care for one resident (#27). The deficit practice affected three residents (#27, #55, and #81) of 26 care plans reviewed during the investigative phase. The facility census was 103. Findings include: 1. Resident #55 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dysphagia, major depressive disorder, anxiety, abnormal posture, and hypertension. The facility completed a quarterly minimum data set (MDS) assessment dated [DATE]. The assessment identified the resident had short and long term memory problems, severely impaired cognitive skills, and requiring supervision and the physical assistance of one to two staff persons to complete all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, and resident and staff interview, the facility failed to ensure residents' discharge goals were included in the comprehensive care plan. This affected one (#39) of three residents reviewed for discharge planning. The facility census was 103. Findings include: Review of the medical record revealed Resident #39 was admitted [DATE]. Diagnoses included hypertensive heart disease with heart failure, anemia, major depressive disorder, irritable bowel syndrome, bipolar disorder, paroxysmal atrial fibrillation, atherosclerotic heart disease, diabetes mellitus, chronic kidney disease, and peripheral vascular disease. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident had adequate hearing and vision with corrective lenses, made self understood and understood others, and had moderately impaired cognition. The assessment also documented the resident required extensive physical assistance for bed mobility, transfers, and toilet use. Review of the comprehensive…

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, and staff interview the facility failed to provide dependent residents with the necessary personal care consistent with needs and preferences. This involved one resident (#7) of three reviewed for Activities of Daily Living (ADL). The facility census was 103. Findings include: Resident #7 was originally admitted to the facility on [DATE] with diagnoses including acute respiratory failure, quadriplegia, chronic pain, neuromuscular dysfunction of bladder, anxiety disorder, and schizophrenia. The facility completed a quarterly minimum data set (MDS) on 03/28/19. The assessment identified the resident had good memory and recall, no behaviors of rejection of care, and the resident required the physical assistance of one to two staff persons to complete all ADLs including bathing and personal hygiene. Further review of the medical record revealed under the task for State Tested Nurse Aides (STNAs) that the resident preferred baths/showers on Tuesdays and Fridays during 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 and staff interview, the facility failed to ensure a resident had a physician's order to discharge from the facility. This affected one (#102) of 23 residents reviewed for physician's orders. The facility census was 103. Findings include: Review of Resident #102's medical record revealed the resident was admitted to the facility on [DATE] with the following diagnoses; abnormal coagulant profile, personal history of other diseases of circulatory system, other transient cerebral ischemic attacks and related syndromes, non-traumatic subarachnoid hemorrhage, unspecified fall, difficulty in walking, cystitis, insomnia, pain, type two diabetes, major depressive disorder, osteoarthritis, cerebral infarction, essential hypertension and cognitive communication deficit. Further review of Resident #102's medical record revealed the resident discharged from the facility to an assisted living on 05/10/19. Review of Resident #102's annual Minimum Data Set (MDS) assessment dated [DATE] revealed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, pharmacy recommendation review, and staff interview, the facility failed to ensure psychotropic medications ordered on an as needed basis were not ordered for an indefinite period of time. This affected one (#75) of five residents reviewed for unnecessary medications. The census was 103. Findings include: Review of the medical record revealed Resident #75 was admitted [DATE]. Diagnoses included major depressive disorder ,paranoid personality disorder, and general anxiety disorder. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident had moderately impaired cognition and required extensive two-person assistance with activities of daily living. Review of Resident #75's current physician's orders revealed an order dated 05/10/19 for Xanax (psychotropic medication used for anxiety) 0.5 milligrams (mg) by mouth every six hours as needed (PRN) for anxiety. There was no stop date attached to the medication. The 14th day of the PRN order was 05/24/19. Review…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview and review of facility policy the facility failed to appropriately label opened bottles of eye medications. This directly affected one resident (#252) during observation. The facility reported 29 residents received eye drops in the facility. The facility also failed to ensure medications were secure. This affected one resident (#64) of three residents reviewed for medication administration. The facility census was 103. Findings include: Review of Resident #252's medical record revealed the resident was admitted on [DATE] with diagnoses including methicillin resistant staphylococcus aureus infection, blindness in one eye and diabetes. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition. Review of the plan of care dated 04/09/19 revealed the resident was legally blind, and medications were to be administered as ordered. Review of Resident #252's physician orders dated 06/12/19 revealed Betimol solution 0.5…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interview, the facility failed to ensure each resident received their mechanically altered therapeutic diets as ordered by the physician. This involved one resident (#55) of 15 residents observed during dining who resided on the secured 400 unit ([NAME] Unit). The facility census was 103. Findings include: Review of Resident #55's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dysphagia, major depressive disorder, anxiety, abnormal posture, and hypertension. The facility completed a quarterly minimum data set (MDS) assessment dated [DATE]. The assessment identified the resident had short and long term memory problems, had severely impaired cognitive skills, required supervision and the physical assistance of one staff person to eat. Review of Resident #55's current physician's orders revealed an order for the resident to receive a regular diet with pureed texture. On 06/17/19 at 4:37…

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.