Riverside Nursing And Rehabilitation Center

Based on medical record review, Nurse Practitioner (NP) interview, and policy review, the facility failed to administer medication as ordered which resulted in a significant medication error. This affected one (#02) resident out four residents reviewed for medication administration. The facility census was 164. Review of the medical record for Resident #02 revealed an admission date of 02/09/23 with medical diagnoses of right hemiplegia, chronic obstructive pulmonary disease, end stage renal disease, dependence on dialysis, and bipolar disorder. Review of the medical record for Resident #02 revealed a Minimum Data Set (MDS) assessment, dated 07/07/25, which indicated Resident #02 was cognitively intact and was dependent upon staff for toilet hygiene, showers/bathes, transfers and bed mobility. Review of the medical record for Resident #02 revealed a physician order dated 11/30/24 for Midodrine (hypotension medication) oral tablet 2.5 milligram (mg) one tablet by mouth every eight hours as needed for hypotension. Hold if systolic blood pressure (SBP) is greater than 110 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 observations, staff interviews, record review, review of facility policy and review of online resources from the Centers for Disease Control (CDC), the facility failed to provide a safe and sanitary environment. This had the potential to affect all 44 Residents (#128, #129, #130, #131, #132, #133, #134, #135, #136, #137, #138, #139, #140, #141, #142, #143, #144, #145, #146, #147, #148, #149, #150, #151, #152, #153, #154, #155, #156, #157, #158, #159, #160, #161, #162, #163, #164, #165, #166, #167, #168, #169, #170, and #171) who resided on the 200-hall (East). The facility census was 172. Findings include: Review of medical record for Resident #128 revealed the resident was admitted on [DATE]. Diagnoses included dementia, polyneuropathy, schizoaffective disorder, chronic obstructive pulmonary disease (COPD), diabetes mellitus, anxiety disorder, and edema. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #128 had impaired cognition. Resident #128 required supervision 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 observation, staff interview, and record review, the facility failed to provide a safe, clean, and homelike environment. This affected four (#10, #128, #138, and #149) out of the five residents reviewed. The facility census was 172. Findings include, 1) Review of medical record for Resident #10 revealed the resident was admitted on [DATE]. Diagnoses included diabetes mellitus, hypertension, squamous cell carcinoma, schizoaffective disorder, chronic obstructive pulmonary disease (COPD), anxiety disorder, conversion disorder, dysphasia, bipolar disorder, osteoarthritis, and major depressive disorder. Review of the most recent Minimum Data Set (MDS) assessment for Resident #10, dated 07/18/24, revealed she was mildly cognitively impaired. Resident #10 required supervision for activities of daily living (ADLs). Observation of Resident #10's on 09/24/24 at 8:50 A.M., revealed the resident was lying in bed. There was an oxygen concentrator across the room with an attached nasal cannula laying across the floor…

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, record review, and facility policy review, the facility failed to treat residents with dignity and respect. This affected two (#70 and #73) out of three residents reviewed. The facility census was 172. Findings include: 1) Review of medical record for Resident #70 revealed an admission dated of 08/26/24 and expired at the facility with hospice services in place on 10/01/24. Diagnoses included, amnesia, malignant neoplasm of bone, chronic hepatitis, essential primary hypertension, chronic kidney disease, hydronephrosis, anemia, gout, vascular dementia, anxiety, gastro-esophageal reflux disease (GERD), and dysphasia. Review of the Minimum Data Set (MDS) assessment for Resident #70, dated 09/02/24, revealed the resident was severely cognitively impaired. Resident #70 was dependent on staff for activities of daily living (ADLs). Observation of Resident #70 on 09/26/24 at 9:59 A.M. revealed the resident was seated in a wheelchair at a table in the common area for other residents. Resident #70 was only wearing a hospital type gown that was hanging…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and facility policy review, the facility failed to ensure a resident's guardian and physician were notified timely following a change in condition. This affected one (#10) out of three residents reviewed. The facility census was 172. Findings include: Review of medical record for Resident #10 revealed the resident was admitted to the facility on [DATE]. Diagnoses included diabetes mellitus, hypertension, squamous cell carcinoma, schizoaffective disorder, chronic obstructive pulmonary disease (COPD), anxiety disorder, conversion disorder, insomnia, dysphasia, bipolar disorder, osteoarthritis, and major depressive disorder. The resident had a guardian on file. Review of the most recent Minimum Data Set (MDS) assessment for Resident #10, dated 07/18/24, revealed the resident mildly cognitively impaired. Resident #10 required supervision for activities of daily living (ADLs). Review of a census record for Resident #149, revealed the resident was moved to Resident #10's room…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and facility policy review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This affected one (#68) of the five residents reviewed for dining. The facility census was 172. Findings include: Record review for Resident #68 revealed she was admitted on [DATE]. Diagnoses included anemia, hypothyroidism, hyperlipidemia, major depressive disorder, anxiety, Alzheimer's disease, insomnia, sleep antenna, essential primary hypertension, and dysphasia. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #68 had impaired cognition. Resident #68 required supervision from staff with eating. Observation of the main dining room on 10/01/24 at 12:39 P.M. revealed State Tested Nursing Assistant (STNA) #348 deliver a food tray to Resident #68. STNA #328 removed her N-95 respirator and used her teeth to open a package of ranch dressing for Resident #68. STNA #328 handed the package…

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

Based on observation and interview, the facility failed to provide a homelike environment. This affected seven (Residents #34, #170, #153, #136, #10, #131, and #171) of seven residents reviewed for homelike environment. The census was 170. Findings include: 1. During an observation on 08/28/24 at 12:45 P.M., Resident #34;s room had an outlet behind the head of the bed that was dangling on the wall. During an interview at the time of the observation, Resident #34 stated she reported it to the maintenance man and he didn't come and fix it. During an interview on on 08/28/24 at 3:00 P.M., Maintenance Man (MM) #252 confirmed the resident told him about the dangling outlet and he had not fixed it yet. 2. During an observation on 08/28/24 at 1:03 P.M., Resident #170's had a brown substance on the floor, the top of the heater was rusted, the wall in the bathroom had holes by the paper towel holder and a light bulb was out. The paint on the ceiling was peeling. 3. During an observation on 08/28/24 at 1:10 P.M., Resident #153's room had scuff marks by the right side of her bed and the window…

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, interview and policy review, the facility failed to ensure a refrigerator was provided for residents to use if they wished. This affected six (Residents #71, #43, #69, #173, #88 and #90) of six residents reviewed for the storage of resident food. The census was 170. Findings include: During an interview on 09/04/24 at 1:11 P.M., Resident #88 stated her family brought in a bottle of homemade lemonade. She asked the kitchen if they could keep it cold for her and they said yes. She stated an aide brought the lemonade back to her and yelled at her because the lemonade was in the kitchen. She said she had to throw out the lemonade. She stated there wasn't a place to store something cold for the residents. During an interview on 09/04/24 at 1:24 P.M., Resident #173 stated there was a refrigerator at the nursing station, but there was limited space for resident's food and the residents aren't permitted to have appliances in their rooms. During an interview on 09/04/24 at 2:35 P.M., Resident #71 stated she had bottles of soda sitting in her room. She stated 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 ensure a resident was able to use his electric wheelchair and failed to ensure a resident could leave the building unattended. This affected one (Resident #173) of one resident reviewed for resident rights. The facility census was 170. Findings include: 1a. Record review revealed Resident #173 was admitted on [DATE]. Medical diagnoses included a stroke with left sided weakness. Resident #173 was his own person. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/01/24, revealed Resident #173 was cognitively intact. He needed set-up or clean-up assistance for eating, dependent or toileting, partial/moderate assistance for bed mobility and transfers. He had no behaviors. Review of a progress note dated 07/26/23 revealed Resident #173 was observed on multiple occasions driving his electric wheelchair to unauthorized areas on facility grounds including driveways, shipping and receiving area, rummaging through…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and policy review, the facility failed to ensure the residents were treated with dignity and respect. This affected three (Residents #153, #143 and #39) of three residents reviewed for dignity and respect. The facility census was 170. Findings include: 1. Record review revealed Resident #153 was admitted on [DATE]. Medical diagnoses included peripheral autonomic neuropathy and heart failure. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/14/24, revealed she was cognitively intact. Review of functional status revealed she was set-up or clean-up assistance for eating, supervision or touching assistance for toileting, bed mobility, and for transfers. During an observation on 08/28/24 at 1:10 P.M., Resident #153 came to the nursing station and asked Licensed Practical Nurse (LPN) #363 for a bottle of shampoo out of the shower room. The nurse told the resident to go back to her room and she would get the shampoo when she could, and stated there…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff and resident interview the facility failed to ensure choices were respected. This affected one (Resident #27) of one resident reviewed for choices. The facility census was 170. Findings include: Record review revealed Resident #27 was admitted on [DATE]. Her medical diagnoses included chronic obstructive pulmonary disease, renal failure, and diabetes. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/20/24, revealed Resident #27 was cognitively intact. She required supervision/touching assistance for eating, substantial/maximal assistance for bed mobility, transfers and toileting. During an observation on 09/05/24 at 6:48 A.M., Resident #27 was asleep with her head on the dining room table with her pillow under her head. During an interview on 09/05/24 at 6:49 A.M., State Tested Nurse Aide (STNA) #283 stated she got the resident up at about 6:00 A.M. because she is on the list of residents who need to get up before first shift comes to work.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and policy review, the facility failed to ensure a resident cleansed in the proper manner after he was incontinent. This affected one (Resident #137) of three residents reviewed for incontinence. The facility census was 170. Findings include: Record review revealed Resident #137 was admitted on [DATE]. Medical diagnoses included cerebrovascular disease, diabetes and non-Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/06/24, revealed Resident #137 was severely cognitively impaired. He was dependent for eating, toileting, bed mobility and transfers was not assessed on this assessment. He was always incontinent for bowel and bladder. During observation on 08/28/24 at 7:44 A.M., State Tested Nurse Aide (STNA) #309 performed incontinent care on Resident #135. STNA #309 pulled down the incontinent brief and washed down each side of the perineum. She turned him over and situated the clean incontinent brief. She didn't cleanse 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 ensure a resident was medicated for pain during a dressing change. This affected one (Resident #50) of three residents reviewed for pressure ulcers. The facility identified four residents with pressures ulcers in the facility. Th census was 170. Findings include: Record review revealed Resident #50 was admitted on [DATE]. His medical diagnoses included Parkinson's disease, and renal disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/13/24, revealed Resident #50 was moderately cognitively impaired. He was impaired for his upper and lower extremities. He was dependent for toileting and bed mobility. He was a Hoyer lift for transfers. During an observation on 09/04/24 at 12:48 P.M., Licensed Practical Nurse (LPN) #275 completed a dressing change to the resident's left heel with assistance from the Director of Nursing (DON). LPN #275 tried to reposition the resident in the chair and he said I am…

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

Based on medical record review, staff interview and review of the facility policy, the facility failed to ensure residents were free of significant medication errors. This affected one (Resident #169) of three residents reviewed for medication administration. The facility census was 169 residents. Findings include: Review of the medical record for Resident #169 revealed an admission date of 07/18/24 with diagnoses of chronic obstructive pulmonary disease and pressure ulcer of sacral region. Review of the preadmission paperwork from Resident #169's prior skilled nursing facility dated 07/18/24 revealed the resident was to receive the following medications: aspirin 81 milligrams (mg) once daily, lisinopril 10 mg at bedtime for hypertension, hold if systolic blood pressure was less than 110 or if pulse was less than 60, methocarbamol 750 mg every six hours. Review of the admitting physician's orders for Resident #169 dated 07/18/24 and transcribed from the preadmission paperwork provided by the resident's previous facility revealed the order for aspirin was omitted and was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews and policy review, the facility failed to ensure staff accurately documented the administration of a resident's narcotic medications in the medical record. This affected one (#802) out of three residents reviewed for medication administration. The facility census was 172. Findings include: Review of medical record for Resident #802 revealed an admission date of 03/05/24 with diagnoses of paraplegia, incomplete, and pain in thoracic spine. Review of the plan of care dated 03/06/24 revealed Resident #802 is a paraplegic and to administer medications per medical providers orders and to observe for side effects and effectiveness. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #802 cognitively intact. Review of physician's order dated 03/07/24 revealed and order for Oxycodone HCl Oral Capsule 5 milligram (mg) give 2 capsules by mouth every 4 hours as needed for pain. Review of the Narcotic Sheet for Oxycodone HCl Oral Capsule 5 milligram (mg) for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure a resident met criteria for admission to the facility's secure unit and was in the least restrictive environment available. This affected one (#6) of three residents reviewed who resided in the secure or locked unit. The census was 173. Findings include: Review of Resident #6's closed medical record revealed an admission date of 02/09/24. Diagnoses listed include anxiety disorder, major depressive disorder, hypokalemia, and hypertension. Resident #6 was transferred to a local hospital on [DATE] for stroke like symptoms and had not returned to the facility. Review of an admission Minimum Data Set (MDS) dated [DATE] revealed Resident #6 was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of a possible 15. Resident #6 was not having hallucinations or delusions, was not verbally of physically aggressive towards others, and had not wandered. Review of behavioral hospital…

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, medical record review, resident interviews, staff interviews, policy review, and review of the Agency for Clinical Innovation Urology Network, the facility failed to ensure physician ordered treatments were completed for surgical and non pressure wounds; failed to accurately monitor and asses wounds; and provide care and treatment of a resident with a nephrostomy tube. This affected three (#50, #51, and #157) residents out of the four residents reviewed for wound care. The facility census was 170. Findings included: 1. Review of the Resident #51's medical record revealed an admission date of 06/23/23, with medical diagnoses of pulmonary fibrosis, Hepatitis C, right hip necrosis wound status post right hip antibiotic hip spacer, psychosis, and osteoarthritis. Review of the medical record revealed Resident #51 discharged to the hospital on [DATE] for right hip arthroplasty and returned to the facility on [DATE]. Further review of the medical record revealed Resident #51 was admitted to 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 observations, medical record review and staff interview, the facility failed to ensure physician ordered pressure wound treatments were completed. This affected one ( #50) of three residents reviewed for wounds. The facility census was 170. Findings include: Review of medical record for Resident #50 revealed admission date of 07/9/19, with diagnoses including stroke, spastic hemiplegia, chronic obstructive pulmonary disease, contracture of right and left wrist and urinary retention. The resident was admitted to hospice on 01/02/24. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed dependent for bed mobility, transfers and toileting hygiene. Review of the wound note dated 01/25/24, for Resident #50 revealed an unstageable sacral wound measuring 6.8 centimeters (cm) by (x) 6.0 cm x 0.2 cm and unstageable left buttock wound measuring 3.0 cm x 2.9 cm x 0.3 cm. Review of the physician orders revealed an order dated 12/21/23, to cleanse sacrum with wound cleanser, pat…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview and review of the Agency for Clinical Innovation Urology Network website, the facility failed to ensure staff was educated and trained to provide care for a nephrostomy tube. This affected one (#50) of one resident in the facility identified as having a nephrostomy tube. The facility census was 170. Findings include: Review of medical record for Resident #50 revealed an admission date of 07/9/19, with diagnoses including stroke, spastic hemiplegia, chronic obstructive pulmonary disease, contracture of right and left wrist and urinary retention. The resident was admitted to hospice on 01/02/24. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitive intact and was dependent for bed mobility, transfers, and toileting hygiene. Review of the progress note dated 01/30/24 revealed Registered Nurse (RN) #318 documented at 3:56 P.M. she discovered a large amount of urine on the mattress of Resident…

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

Based on observation, record review, resident interview, staff interviews and review of policy, the facility failed to ensure medications were available for administration. This affected two (#52 and #56) of six residents records reviewed for medications. The facility census was 170. Findings include: 1. Review of medical record for Resident #52 revealed admission date of 06/26/23, with diagnoses including stroke, anxiety, and hepatic (liver) failure. Review of the physician orders for Resident #52 revealed an order for Rifaximin 550 milligram (mg) one tablet every morning and at bedtime with a start date of 09/20/23. Observation on 01/30/24 at 10:13 A.M., of medication administration by Registered Nurse (RN) #318 for Resident #52 revealed Rifaximin (a medication for hepatic encephalopathy) 550 milligrams (mg) was not in the medication cart and not administered. Interview with RN #318, at the time of the observation, revealed the medication was not ordered timely and voiced a concern for the frequency medication was unavailable at the facility. 2. Review of the medical record for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, policy review, and [NAME] journal review, the facility failed to change gloves and/ or wash hands between cleansing wound and applying treatment; and change gloves between different wounds to prevent possible cross contamination. This affected one (#157) of three residents reviewed for wound care. The facility census was 170. Findings include: Review of medical record for Resident #157 revealed admission date of 07/27/23, with diagnoses including bilateral at knee level amputation and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively intact and required supervision for eating and supervision, dependent for bed mobility, transfers, and toileting hygiene. Observation on 01/31/24 at 1:03 P.M., of wound treatment revealed Licensed Practical Nurse (LPN) #304 cleansed the midline abdominal dehisced wound with a wound cleanser, patted dry with a four (4) by (x) 4 gauze.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and resident interviews, and policy review, the facility failed to provide adequate staff assistance when transferring a resident who required two persons assist with transfers resulting in a fall without injuries. This affected one (#58) out of the three residents reviewed for mechanical (hoyer) lift transfers. The facility census was 166. Findings included: Review of the medical record for Resident #58 revealed an admission date of 04/30/23 with medical diagnoses of chronic pain, chronic Hepatitis C, hyperlipidemia, and protein calorie malnutrition. Review of the medical record for Resident #58 revealed an Activities of Daily Living (ADL) self-care performance deficit care plan, dated 05/01/23, which indicated Resident #58 was dependent (helper does all the effort or two or more helpers assist) for chair/bed to chair transfers, for tub/shower transfers, and for rolling to left and right while in bed. Review of the ADL care plan revealed an intervention was initiated 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 observation, staff interview, medical record review, and policy reviews, the facility failed to ensure infection control procedures were followed when administering medications. This affected one (#53) out of the two residents observed for medication administration. The facility census was 166. Findings included: Review of the medical record for Resident #53 revealed an admission date of 07/09/19 with medical diagnoses of history of cerebral infarction with left sided hemiplegia, chronic obstructive pulmonary disease, chronic kidney disease stage II, and schizoaffective disorder. Review of the medical record for Resident #53 revealed an annual Minimum Data Set (MDS), dated [DATE], which indicated Resident #53 was cognitively intact and was dependent upon staff for toilet hygiene, bathing, bed mobility, and transfers. Review of the medical record for Resident #53 revealed physician orders dated 12/13/23 for senna 8.6 milligram (mg) by mouth two times per day, gabapentin 300 mg by mouth three times per…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, resident and staff interviews, review of the facility's Self-Reported Incident (SRI) and investigation, and review of the facility policy, the facility failed to prevent the misappropriation of the resident's funds by staff. This affected one (Resident #1) of three residents reviewed for misappropriation and abuse. Findings include: Review of the medical record for Resident #1 revealed an admission date of 02/11/23. Diagnoses included cerebral palsy, Alzheimer's disease, dementia with behaviors, and heart failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had impaired cognition. Review of the facility's SRI control number 238137 revealed Resident #1 alleged her debit card was misappropriated on 08/15/23. Resident #1 stated there were $1,839.52 spent on her debit card and she did not authorize the use of 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 Based on medical record review, observation, staff interview, and review of facility policy, the facility failed to maintain a clean and sanitary environment for residents. This affected five Residents (#3, #30, #48, #63, and #155) of five residents reviewed for environment. The census was 168. Findings include: 1. Review of Resident #63's medical record revealed an admission date of 02/11/22. Diagnoses included alcohol abuse, altered mental status, hypertension, and schizoaffective disorder. Resident #63 was assessed as being cognitively intact and requiring supervision for activities of daily living (ADLs) in a quarterly Minimum Data Set (MDS) assessment dated [DATE]. Observation of Resident #63's bathroom on 06/13/22 at 10:34 A.M. revealed a small waste basket filled with what appeared to be human waste. The bathroom had a very pervasive odor and gnats were observed flying in the room. The toilet was full of human waste and toilet paper. The toilet and sink were covered in debris. During observation 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 3. Record review of Resident #35 revealed an admission date of 07/20/17 with pertinent diagnoses of chronic obstructive pulmonary disease with exacerbation, acute respiratory failure with hypoxia, acquired absence of left leg below knee, chronic combined systolic congestive and heart failure, delusional disorders, gastroesophagael reflux disease, schizophrenia, peripheral vascular diseases, hyperlipidemia, allergic rhinits, lactose intolerance, brief psychotic disorder, insomnia, hereditary and idiopathic neuropathy, and benign prostatic hyperplasia. Review of the 03/14/22 annual Minimum Data Set (MDS) assessment revealed the resident was cognitively intact and required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene. He uses a walker, wheelchair and prosthetic limb to aid in mobility. The Resident was frequently incontinent of bowel and bladder. Further review of Resident #35's medical record revealed no documented instance of care conferences. Interview on 6/13/22 at 11:10…

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.

Based on observations, staff interviews, and review of facility policy, the facility failed to ensure food was stored in a safe and sanitary manner. This affected all residents but two residents (#38 and #129) residing in the facility who received meals from the kitchen. The facility census was 168. Findings include: Observations on 06/13/22 from 9:03 A.M. through 9:21 A.M. of the kitchen revealed the following: • Nine liquid pasteurized egg cartons sitting in at least a half-inch liquid substance, milky white in color, on a large metal tray in the refrigerator. • Three containers of tenacious tonic pumpable powders in dry storage room with an expiration date of May 2022. Interview on 06/13/22 with Registered Dietician #232 verified the above findings and discarded the items. Review of the facility policy titled, Food Storage: Dry Goods, dated September 2017 revealed all dry goods will be appropriately stored in accordance with the FDA Food code. All items will be stored on shelves at least six inches above the floor. The Dining Services Director or designee regularly inspects 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 and staff interview, the facility failed to issue appropriate Medicare beneficiary liability protection notices to residents. This affected two Residents (#39 and #60) of two reviewed for receiving Medicare Part A services. The census was 168. Findings include: 1. Review of Resident #39's medical record revealed an admission date of 08/21/21. Diagnoses included type II diabetes, schizoaffective disorder, and delusional disorders. Review of a Notice of Medicare Non-Coverage (NOMNC) dated 02/08/22 revealed Resident #39 was being cut from Medicare services on 02/10/22. Further review of Resident #39's medical record revealed she remained in the facility after 02/10/22. There was no documentation of Resident #39 being issued a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN). 2. Review of Resident #60's medical record revealed an admission dated of 11/07/19. Diagnoses listed included bipolar disorder, paranoid schizophrenia, and anxiety disorder. Further review of Resident #39's medical record revealed he received Medicare part…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to provide bed hold notices to resident/resident representatives within 24-hours of transferring the resident to the hospital. This affected one (#129) of six residents reviewed for hospitalization. The facility census was 168. Findings include: 1. Review of the medical record of Resident #129 revealed an admission date of 07/09/19. Diagnoses included cerebral infarction, spastic hemiplegia affecting left non-dominant side, chronic obstructive pulmonary disease, pressure ulcer of sacral region, stage four, generalized anxiety disorder, and schizoaffective disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #129 had mild cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of eight. The resident was assessed to require two-person extensive assistance with dressing and toileting, one-person extensive assistance with eating, and two-person total…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and medical record review, the facility failed to monitor acceptance of nutritional supplements. This affected one (Resident #48) of four residents reviewed for nutritional supplements. The facility identified 14 residents with unplanned significant weight loss or gain. The facility census was 163. Findings include: Medical record review for Resident #48 revealed resident was admitted on [DATE]. Diagnoses included bipolar disorder, alcohol induced persisting dementia, schizophrenia, high blood pressure, high cholesterol and reflux disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/27/19, revealed Resident #48 had impaired cognition. Review of recorded weights for Resident #48 revealed 04/01/19 was 126.5 pounds (lbs.), 03/04/19 was 133 lbs., 02/19/19 was 130 lbs., 02/04/19 was 132 lbs., 01/11/19 was 131.5 lbs., 12/01/18 was 145 lbs. and 11/11/18 was 144 lbs. Review of the dietary progress notes for Resident #48 dated 04/02/19 revealed a weight loss of 6.5 lbs. in…

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 resident and staff interview, review of facility policy and medical record review, the facility failed to monitor and assess for new onset of pain. This affected one (Resident #137) of one resident reviewed for pain management. The facility identified 67 residents on a pain management program. The facility census was 163. Findings include: Medical record review for Resident #137 revealed an admission date of 07/20/17. Diagnoses included chronic obstructive pulmonary disease, paranoid schizophrenia and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/05/19, revealed Resident #137 had intact cognition. Review of the plan of care for Resident #137, with an initiation date of 11/18/18 and a revision on 03/28/19, revealed a potential for pain due to diabetic complications to circulation, morbid obesity and stress to joints of lower extremities and back. Interventions included to administer medications as ordered and monitor effectiveness and side effects, complete pain assessment on admission, quarterly and with significant change in…

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, review of facility policy and staff interview, the facility failed to asses and monitor the resident's vital signs before and after dialysis. This affected one (Resident #34) of one resident reviewed for dialysis treatment. The facility identified two residents receiving dialysis services. The facility census was 163. Findings include: Medical record review for Resident #34 revealed an admission date of 02/15/17. Diagnoses included chronic kidney disease and dependence on renal dialysis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/11/19, revealed the resident had impaired cognition. The resident was also coded as receiving dialysis on the MDS. Review of the dialysis plan of care with an initiation date of 02/17/17 revealed Resident #34 received hemodialysis related to renal failure. Interventions include administration medication as ordered, check dressing for bleeding and reinforce as needed, check the present of pulses, color and temperature of left upper extremity every shift, monitor for bruit and thrill every shift and before and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interview, and policy review, the facility failed to ensure dental recommendations were scheduled/provided in a timely manner. This affected one (#10) of four residents reviewed for dental services. The facility census was 163. Findings include: Review of the medical record for Resident #10 revealed the resident was admitted to the facility on [DATE]. Diagnoses included bipolar disorder and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/15/19, revealed the resident had intact cognition. Review of a dental consult, dated 08/07/18, revealed Resident #10 was assessed by a dentist and a recommendation was made for lower teeth extractions due to decay. Review of a dental consult, dated 12/05/18, revealed the resident was assessed by the dentist and a recommendation was made for teeth extractions. Review of the medical record for Resident #10 revealed no documentation the resident was provided follow up dental services for 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.