Village At The Greene

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility skills documentation form, the facility failed to ensure tracheostomy care/oral care was completed as ordered. This affected one (#13) of one resident reviewed for tracheostomy care. The facility census was 76. Findings included: Review of the medical record for Resident #13 revealed an admission date of 10/14/10 with medical diagnoses of persistent vegetive state, respiratory failure, epilepsy, anoxic brain injury, quadriplegia, and tracheostomy. Review of the medical record for Resident #13 revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE] which indicated Resident #13 was in a persistent vegetative state and was dependent upon staff for all activities of daily living. Review of the MDS revealed Resident #13 had a tracheostomy. Review of the medical record for Resident #13 revealed an order dated 01/25/25 for tracheostomy care/oral care three times per day and an order dated 01/15/25 to change inner cannula two 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 Based on medical record review, staff interview, and policy review, the facility failed to ensure dialysis communication forms were completed and sent to the dialysis center prior to dialysis. This affected one (#47) resident who attended hemodialysis. The facility census was 76. Findings included: Review of the medical record for Resident #47 revealed an admission date of 11/08/24 with medical diagnoses of end stage renal disease, dependence on dialysis, diabetes mellitus, and hypertension. Review of the medical record for Resident #47 revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE], which indicated Resident #47 was cognitively intact and required substantial/maximum assistance with toilet hygiene, bed mobility, and transfers and dependent upon staff for bathing. The MDS indicated Resident #47 received dialysis. Review of the medical record for Resident #47 revealed a physician order dated 11/05/24 to attend dialysis Monday, Wednesday, and Friday with pick up time at 6:00 A.M. and an order…

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 reviews, observations, staff interviews, and policy review, the facility failed to ensure resident's medications were administered as ordered resulting in three medication errors out of 29 opportunities or a 10.34 percent (%) medication error rate. This affected two (#33 and #62) residents out of the four residents reviewed for medication administration. The facility census was 76. Findings included: 1. Review of the medical record for Resident #33 revealed an admission date of 04/23/17 with medical diagnoses of chronic kidney disease Stage III, morbid obesity, left hemiplegia, diabetes mellitus, heart failure, depression, and spina bifida. Review of the medical record for Resident #33 revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE], which indicated Resident #33 was cognitively intact and was dependent for toilet hygiene, bathing, and transfers and required substantial/maximum assistance with bed mobility. Review of the medical record for Resident #33 revealed 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 observation, medical record review, and staff interview, the facility failed to prevent a significant medication errors when staff did not prime an insulin pen prior to administration. This affected one (Resident #33) of four residents observed for medication administration. The facility census was 76. Findings include: Review of the medical record for Resident #33 revealed an admission date of 04/23/17 with medical diagnoses of chronic kidney disease Stage III, morbid obesity, left hemiplegia, diabetes mellitus, heart failure, depression, and spina bifida. Review of the medical record for Resident #33 revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE], which indicated Resident #33 was cognitively intact and was dependent for toilet hygiene, bathing, and transfers and required substantial/maximum assistance with bed mobility. Review of the medical record for Resident #33 revealed a physician order dated 01/21/25 for Novolog solution 100 units per milliliter (ml) to inject 28 units…

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 reviews, observations, staff interviews, review of insulin pen checklist, and policy review, the facility failed to ensure over the counter medication bottle and insulin pen were dated after opened and failed to ensure medications were not left at the bedside. This affected two (#33 and 51) residents out of the four residents reviewed for medications. The facility census was 76. Findings included: 1. Review of the medical record for Resident #33 revealed an admission date of 04/23/17 with medical diagnoses of chronic kidney disease Stage III, morbid obesity, left hemiplegia, diabetes mellitus, heart failure, depression, and spina bifida. Review of the medical record for Resident #33 revealed a quarterly Minimum Data Set (MDS) assessment, dated 12/06/24, which indicated Resident #33 was cognitively intact and was dependent for toilet hygiene, bathing, and transfers and required substantial/maximum assistance with bed mobility. Review of the medical record for Resident #33 revealed 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.

Based on medical record review, observation, staff interview, and policy review, the facility failed to follow infection control procedures during tracheostomy care. This affected one (#13) resident of one resident observed for tracheostomy care. The facility census was 76 Findings include: Review of the medical record for Resident #13 revealed an admission date of 10/14/2010 with medical diagnoses of persistent vegetive state, respiratory failure, epilepsy, anoxic brain injury, quadriplegia, and tracheostomy. Review of the medical record for Resident #13 revealed a quarterly Minimum Data Set (MDS) assessment, dated 02/01/25 which indicated Resident #13 was in a persistent vegetative state and was dependent upon staff for all activities of daily living. Review of the MDS revealed Resident #13 had a tracheostomy. Review of the medical record for Resident #13 revealed a physician order dated 01/25/25 for tracheostomy care/oral care three times per day and an order dated 01/15/25 to change inner cannula two times per day. Review of the physician orders revealed no documentation to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of facility self-reported incidents, and policy review the facility failed to ensure the abuse policy was implemented. This affected one (#57) of three residents reviewed for abuse. The census was 73. Findings include: Medical record review for Resident #57 revealed an admission date of 04/27/23. Diagnoses included non-traumatic brain dysfunction, renal insufficiency, Alzheimer's disease, and dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #57 was severely cognitively impaired. Resident #57's functional status required setup and clean-up for eating, moderate assistance for toileting, and supervision for bed mobility and transfers. Resident #57 was always incontinent for bladder and frequently incontinent for bowel. Interview with Certified Nursing Assistant (CNA) #116 on 12/31/24 at 10:59 A.M. revealed at the end of her shift on 12/29/24 a message was sent over What's AP (which is a program the facility used to send…

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, review of facility self-reported incidents, and policy review the facility failed to ensure the abuse policy was implemented. This affected one (#57) of three residents reviewed for abuse. The census was 73. Findings include: Medical record review for Resident #57 revealed an admission date of 04/27/23. Diagnoses included non-traumatic brain dysfunction, renal insufficiency, Alzheimer's disease, and dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #57 was severely cognitively impaired. Resident #57's functional status required setup and clean-up for eating, moderate assistance for toileting, and supervision for bed mobility and transfers. Resident #57 was always incontinent for bladder and frequently incontinent for bowel. Interview with Certified Nursing Assistant (CNA) #116 on 12/31/24 at 10:59 A.M. revealed at the end of her shift on 12/29/24 a message was sent over What's AP (which is a program the facility used to send…

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, review of facility self-reported incidents, and policy review the facility failed to ensure the abuse policy was implemented. This affected one (#57) of three residents reviewed for abuse. The census was 73. Findings include: Medical record review for Resident #57 revealed an admission date of 04/27/23. Diagnoses included non-traumatic brain dysfunction, renal insufficiency, Alzheimer's disease, and dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #57 was severely cognitively impaired. Resident #57's functional status required setup and clean-up for eating, moderate assistance for toileting, and supervision for bed mobility and transfers. Resident #57 was always incontinent for bladder and frequently incontinent for bowel. Interview with Certified Nursing Assistant (CNA) #116 on 12/31/24 at 10:59 A.M. revealed at the end of her shift on 12/29/24 a message was sent over What's AP (which is a program the facility used to send…

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 family interview the facility failed to ensure bathing was provided for residents at least twice a week. This affected two (#27 and #17) of three residents reviewed for bathing. The census was 74. Findings include: 1. Medical record review for Resident #27 revealed an admission date of 02/20/24. Diagnoses included chronic obstructive pulmonary disease (COPD), cancer, neurogenic bladder, cerebrovascular attack (CVA), non-Alzheimer's dementia, hemiplegia, or hemiparesis, and respiratory failure. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #27 was severely cognitively impaired, had impaired functional status on one side for both upper and lower extremities, used a wheelchair, required maximal assistance for bathing, and was dependent for bed mobility, and transfers. Review of care plan dated 02/21/24 for Resident #27 revealed the resident required one to two person assistance for bathing in the bed and two-person for showering.…

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 policy review, the facility failed to provide care and services to prevent a resident fall. This affected one (#32) resident of the three residents reviewed for falls. The facility census was 78. Findings include: Review of the medical record for the Resident #32 revealed an admission date of 02/28/2020 with medical diagnoses of diabetes mellitus, vascular dementia, chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD) stage IV, hypertension, and history of transient ischemic attack. Review of the medical record for Resident #32 revealed the resident was hospitalized on [DATE], returned to the facility on [DATE], and then discharged to the hospital on [DATE]. Review of the medical record for Resident #32 revealed a quarterly Minimum Data Set (MDS) assessment, dated 05/22/24, which indicated Resident #32 had severe cognitive impairment and required supervision to light touching for eating, ambulation up to ten feet, and bed mobility. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the Medication Administration checklist, the facility failed to ensure medications were administered as ordered. This affected two (#18 and #32) residents out of the five residents reviewed for medication administration. The facility census was 78. Findings include: 1. Review of the medical record for Resident #18 revealed an admission date of 10/23/22 with medical diagnoses of paraplegia, spinal stenosis, asthma, depression, and morbid obesity. Review of the medical record for Resident #18 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #18 was cognitively intact and required substantial/maximum staff assistance for toileting hygiene, bathing, and transfers and was supervision with eating. Review of the medical record for Resident #18 revealed a physician order dated 01/25/23 for Lisinopril (antihypertensive medication) 5 milligram (mg) by mouth daily and to hold if systolic blood pressure (SBP) less than 120…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and facility policy review, the facility staff failed to follow infection control procedures during medication administration. This affected one (#18) resident out of the three residents reviewed for medication administration. The facility census was 78. Findings include: Review of the medical record for Resident #18 revealed an admission date of 10/23/22 with medical diagnoses of paraplegia, spinal stenosis, asthma, depression, and morbid obesity. Review of the medical record for Resident #18 revealed a quarterly Minimum Data Set (MDS), dated [DATE], which indicated Resident #18 was cognitively intact and required substantial/maximum staff assistance for toileting hygiene, bathing, and transfers and was supervision with eating. Review of the medical record for Resident #18 revealed physician orders dated 10/24/22 for Calcium Carbonate with Vitamin D (supplement) 500-50 mg one tablet by mouth two times per day, 12/25/22 for Aspirin (analgesic) 81…

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, medical record review, and policy review, the facility failed to ensure staff provided a resident assistance with feeding. This affected one (#56) of the three residents reviewed for assistance with meals. The facility census was 74. Findings include: Review of the medical record for Resident #56 revealed an admission date of 11/16/23 with medical diagnoses of metabolic encephalopathy, chronic obstructive pulmonary disease, Alzheimer's disease, gastroenteritis, and anxiety. Review of a quarterly Minimum Data Set (MDS) assessment, dated 03/19/24, indicated Resident #56 had severe cognitive impairment and was dependent for eating, toilet hygiene, bathing, bed mobility, and transfers. Review of a physician order dated 11/22/23 revealed Resident #56 was to have one-to-one feeding assistance. Review of a physician order dated 12/18/23 revealed Resident #56 was to have a regular diet with pureed texture and regular liquids. Review of a physician order dated 02/09/24 revealed Resident #56 was ordered a divided plate with meals, and an order dated…

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

Based on record review, staff and physician interviews, and facility policy review, the facility failed to notify the physician of a change in the resident's condition. This affected one (Resident #200) of three residents reviewed for a change of condition. The facility census was 79. Findings include: Review of the medical record for Resident #200 revealed an admission date of 10/30/23. Diagnoses included acute respiratory failure, liver transplant, chronic obstructive pulmonary disease, atrial fibrillation, and emphysema. Review of Resident #200 respiratory progress notes from 01/22/24 at 9:12 A.M. revealed Resident #200 was on five liters of oxygen via nasal cannula. The respiratory progress note dated 01/22/24 at 9:25 A.M. revealed Resident #200's oxygen saturation was re-checked on room air, and oxygen saturation was 77%. Resident #200 was breathing shallow and tachypneic gave treatment on six liters, oxygen tank stats held for a couple of minutes but started to fall again. Respiratory therapist notified the nurse on duty and placed Resident #200 on five-liter nasal cannula.…

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, review of facilities investigation, review of witness statements, and review of facility's policy, the facility failed to ensure a resident's fall intervention was in place to prevent a fall. This affected one resident (#18) out of three residents reviewed for falls. The facility census was 75. Findings include: Review of the medical record for Resident #18, revealed the resident was admitted to the facility on [DATE] with diagnoses including unspecified dementia, chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, depression, chronic kidney disease, and unspecified abnormalities of gait and mobility. Review of the quarterly Minimum Data Set (MDS) assessment 3.0 dated 06/08/23 for Resident #28, revealed the resident was severely cognitively impaired and Resident #18 required extensive assistance with activities of daily living (ADLs.) Resident #18 was assessed as not having any falls. Review of a fall review assessment dated [DATE] for Resident #18,…

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 record review, the facility failed to implement an action plan when they identified pressure ulcers and falls as an area of quality concern, resulting in a substandard quality of care deficiency. Failure to implement an action plan directly affected six (Residents #11, #29, #38, #46, #61, and #81) out of seven falls reviewed who had falls with injuries when the facility had not identified patterns, trends, root cause analysis or implement appropriate interventions. (See findings under F689). Four (Residents #08, #05, #02, and #20) out of six residents reviewed for pressure ulcers were identified when the facility didn't ensure proper care, treatment, assessments and care plan interventions were in place. (See findings under F686). The facility failed to identify catheters as a concern and implement an action plan when one (Resident (#10) out of three residents reviewed for indwelling catheters went with no urinary output and the facility physician was not notified to prevent hospitalization. (See findings under F690). This had the potential to…

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

Based on record review, review of the medical director reports, staff interview, and policy review, the facility failed to implement an effective Quality Assurance (QA) program to ensure accidents, pressure ulcers, and catheters were comprehensively reviewed and timely initiate corrective actions to prevent the incidents. This affected 11 (Residents #11, #29, #38, #46, #61, #81, #08, #05, #02, #20 and #10) out of 30 reviewed. This had the potential to affect all 89 residents in the facility. The facility census was 89. Findings included: Review of the adverse events of the facility revealed six residents (#11, #29, #38, #46, #61 and #81) out of seven falls reviewed who had falls with injuries when the facility had not identified patterns, trends, root cause analysis or implement appropriate interventions which resulted in substandard quality of care under (F689). Four residents (#08, #05, #02, and #20) out of six residents reviewed for pressure ulcers were identified when the facility had not ensured proper care, treatment, assessments and care planned interventions were in place…

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 notify family/residents of hospital transfer/discharge in writing and send a copy to the Ombudsman. This affected seven (Residents #39, #05, #63, #65, #10, #286 and #58) of seven residents reviewed for hospitalizations. The facility census was 89. Findings include: 1. Review of the medical record for Resident #65 revealed admission date of 04/26/22, with diagnoses including: diabetes mellitus, congestive heart failure, and chronic obstructive pulmonary disease. Review of the progress notes dated 07/13/22 revealed Resident #65 was admitted to the hospitalized . Further review of the medical record revealed no documentation to suggest the transfer/discharge paperwork was given to the resident or the Ombudsman was notified of the discharge. 2. Review of the medical record for Resident #286 revealed admission date of 10/25/19, with diagnoses including: peripheral vascular disease, atherosclerosis of native arteries of extremities right and left,…

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 provide family/residents of bed hold notice upon discharge to the hospital. This affected seven (Residents #39, #5, #63, #65, #10, #286 and #58) of seven residents reviewed for hospitalizations. The facility census was 89. Findings include: 1. Review of the medical record for Resident #65 revealed admission date of 04/26/22, with diagnoses including: diabetes mellitus, congestive heart failure, and chronic obstructive pulmonary disease. Review of the progress notes dated 07/13/22 revealed Resident #65 was admitted to the hospitalized . Further review of the medical record revealed no documented evidence of a bed hold notification or policy was provided. 2. Review of the medical record for Resident #286 revealed admission date of 10/25/19, with diagnoses including: peripheral vascular disease, atherosclerosis of native arteries of extremities right and left, depression and dementia. Review of the progress notes revealed Resident #249 was admitted…

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, resident interviews, staff interviews, and policy review, the facility failed to provide assistance with activities of daily living (ADL) for bathing for residents who required assistance. This affected four (Residents #08, #26, #56, and #64) of four residents reviewed for ADL care. The facility census was 89. Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 05/03/22. Diagnoses included: chronic kidney disease stage 3 unspecified, type two diabetes mellitus without complications, other reduced mobility, hypertension, congestive heart failure, sick sinus syndrome, atherosclerotic heart disease of native coronary artery without angina pectoris, gout, adjustment disorder with mixed anxiety and depressed mood, chronic atrial fibrillation, and morbid (severe) obesity due to excess calories. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/09/22, revealed this resident had intact cognition evidenced by 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 observation, interview and record review, the facility failed to ensure sufficient staff to provide personal care and ensure accident prevention. This affected four (Residents #8, #64, #56 and #5), of six residents reviewed for personal hygiene care and two (Residents #29 and #11) of 11 residents reviewed for accident prevention. The total facility census was 89. Findings include: 1. Review of the Facility Assessment, dated 04/01/22, revealed all staffing assignments are reviewed as needed to ensure continued coordination and continuity of care for the residents with a minimum of 2.5 hours of direct care hours per resident per day. The facility identified a total of 20 secured unit beds. Review of the Resident Council Minutes dated 10/04/22 revealed six residents who attended the meeting reported inconsistent call light response times. Review of staffing schedule on 01/28/22, with a census of 76 during 7:00 A.M to 3:00 P.M. shift, there was one STNA on the secured unit of 16 residents and a nurse split…

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 interview, the facility failed to ensure food was properly stored in the kitchenette refrigerators to prevent contamination and food borne illness . This had the potential to affect all 85 residents who received food from the kitchenettes. The total facility census was 89. Findings include: Observation on 11/09/22 from 8:16 A.M through 8:32 A.M. with Diet Server #269, revealed the following sanitation violations in the resident refrigerator in the kitchenettes: In the Pine Glen resident refrigerator, there was opened thickened apple juice with no open or use by date. In the Juniper unit refrigerator, there were three thickened juice containers with no open or use by dates. In the Cypress unit refrigerator, there was a plate of breakfast foods, uncovered, undated and unlabeled. There were six cups of unidentifiable liquid with no date or label. In the [NAME] View unit refrigerator, there was no thermometer inside the refrigerator. There were 14 cups of unidentified dessert not dated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, family and staff interview, the facility failed to conduct care conferences as required and invite residents or resident representatives. This affected three (Residents #10, #63, and #26) of four residents reviewed for care planning. The facility census was 89. Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 05/03/22. Diagnoses included chronic kidney disease stage 3 unspecified, type two diabetes mellitus without complications, other reduced mobility, hypertension, congestive heart failure, sick sinus syndrome, atherosclerotic heart disease of native coronary artery without angina pectoris, gout, adjustment disorder with mixed anxiety and depressed mood, chronic atrial fibrillation, and morbid (severe) obesity due to excess calories. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/09/22, revealed this resident had intact cognition. This resident was assessed to require extensive assistance for bed mobility, transfer,…

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, Power of Attorney (POA) interview and policy review, the facility failed to ensure notification was made to the POA for removal of a urinary catheter and when a tube feeding was restarted continuously. This affected one (Resident #63) of one reviewed for notification of change. The census was 89. Findings include: Review of Resident #63's medical record revealed an admission date of 09/19/22, with medical diagnoses included: coronary artery disease, renal insufficiency, diabetes and respiratory failure. Review of admission Minimum Data Set (MDS) dated [DATE] revealed Resident #63 was severely cognitively impaired. Resident #63's functional status was extensive assistance for bed mobility, total dependence for transfers, eating, and toilet use. Resident #63 was coded for urinary catheter, suctioning, tracheostomy care and oxygen. Review of progress notes dated 09/19/22 revealed Resident #63 came into the facility with a urinary catheter. Resident #63 went out to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, family interview and staff interviews, the facility failed to accurately document a resident's hearing status on the Minimum Data Set (MDS) assessment. This affected one (Resident #08) of 30 MDS assessments reviewed. The facility census was 89. Findings include: Review of medical record for Resident #08 revealed admission date of 01/01/19, with diagnoses including: Alzheimer's Disease with late onset, acute diastolic congestive heart failure, peripheral vascular disease, chronic venous hypertension with inflammation of the bilateral lower extremities' atherosclerosis of autologous vein bypass graft of the left extremity with gangrene, left at knee level imputation of the left leg. Record review of ear care exam by Service Provider #10 dated 03/24/22, revealed the reason for visit was Resident #08 had an apparent hearing loss with normal conversation tones and was interested in a visit. Auditory referral was made. A follow-up audiology appointment by Service Provider #10…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed prior to admission was accurate. This affected one (Resident #39) of two residents reviewed for PASARR. The facility census was 89. Findings include: Review of Resident #39's medical record revealed an admission date of 07/25/22, discharged on 08/17/22, and re-admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy, dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, paroxysmal atrial fibrillation, peripheral vascular disease, chronic kidney disease, obstructive and reflux uropathy, benign prostatic hyperplasia without lower urinary tract symptoms, hyperlipidemia, hypertension, congestive heart failure, iron deficiency anemia, atherosclerotic heart disease of native coronary artery without angina pectoris, hemorrhagic disorder due to extrinsic circulating anticoagulants, hypertensive…

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 there was a baseline care plan for a resident who utilized a tracheostomy and ventilator. This affected one (Resident #05) of 30 residents reviewed for baseline care plans. The census was 89. Findings included: Review of Resident #05's medical record revealed an admission date of 07/13/22, with diagnoses including acute and chronic respiratory failure, neurogenic bladder, Parkinson's disease, and malnutrition. Review of admission Minimum Data Set, dated [DATE] revealed Resident #05 was cognitively intact. Her functional status was total dependence for bed mobility, transfers, and toilet use with two-person assistance. She was total dependence for eating with one-person physical help. She has an indwelling urinary catheter and was frequently incontinent for bowel. She had one, stage two pressure ulcer. She was on oxygen, required suctioning, tracheostomy, and a mechanical ventilator. Review of baseline care plan dated 07/13/22, 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 policy review, the facility failed to ensure comprehensive care plans were completed. This affected three (Residents #05, #56 and #10) of 30 resident care plans reviewed. The facility census was 89. Findings include: 1. Review of Resident #05 medical record review revealed an admission date of 07/13/22. Medical diagnoses included acute and chronic respiratory failure, neurogenic bladder, Parkinson's disease, and malnutrition. Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #05 was cognitively intact. Her functional status was total dependence for bed mobility, transfers, and toilet use with two-person assistance. She was total dependence for eating with one-person physical help. She has an indwelling urinary catheter and was frequently incontinent for bowel. She had one stage two pressure ulcer. She was on oxygen, required suctioning, tracheostomy, and a mechanical ventilator. The MDS revealed it was somewhat important 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.

Based on medical record review, staff and family interview, and policy review, the facility failed to ensure proper discharge planning was completed. This affected one (Resident #42) of one resident reviewed for discharge. The census was 89. Findings include: Review of the closed medical record for Resident #42 revealed an admission date of 08/05/22, with diagnoses including: pneumonia, heart failure, diabetes, and respiratory failure. Review of physician progress note dated 10/25/22, revealed the resident was admitted to hospice this week per family's preference with comfort medications in place. The plan was to transition to long term care with hospice. Review of the progress notes on 10/31/22 revealed there was not any discharge plan for the resident. Review of the daily census revealed the resident was discharged on 10/31/22. Interview on 11/02/22 at 12:44 P.M., with the Administrator, revealed the family came in and took him home and there was not any discharge paperwork given to him because the facility didn't know he was going to be discharge. The Administrator stated he…

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 and family interview, and policy review, the facility failed to ensure a discharge summary was prepared and provided to a resident or resident representative. This affected one (Resident #42) of one resident reviewed for discharge. The census was 89. Findings include: Review of the closed medical record for Resident #42 revealed an admission date of 08/05/22, with diagnoses including: pneumonia, heart failure, diabetes, and respiratory failure. Review of physician progress note dated 10/25/22, revealed the resident was admitted to hospice this week per family's preference with comfort medications in place. The plan was to transition to long term care with hospice. Review of the progress notes on 10/31/22 revealed there was not a discharge summary. Review of the daily census revealed the resident was discharged on 10/31/22. Interview on 11/02/22 at 12:44 P.M., with the Administrator revealed the family came in and took him home and there was not any discharge paperwork given to him because the facility didn't know he was going to discharge. 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, interview, and record review, the facility failed to ensure activities were provided for residents. This affected two (Residents #29 and #39) of four residents reviewed for activities. The census was 89. Findings include: 1. Record review revealed Resident #5 was admitted on [DATE]. Medical diagnoses included acute and chronic respiratory failure, neurogenic bladder, Parkinson's disease, and malnutrition. Review of admission Minimum Data Set (MDS) assessment, dated 07/18/22, revealed Resident #05 was cognitively intact. She was totally dependent for bed mobility and transfers. She had a tracheostomy and was on a mechanical ventilator. It was somewhat important for the resident to listen to music she liked and favorite activities. Review of activity assessment dated [DATE], revealed the assessment was not completed. The resident had no care plan for activities. Review of the activity participation documentation from 09/20/22 through 10/16/22; 10/31/22 through 11/05/22; and 11/07/22 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 record review, observation, interview and policy review, the facility failed to ensure residents received proper foot care. This affected one (Resident #26) of one resident reviewed for foot care. The facility census was 89. Findings include: Review of the medical record for Resident #26 revealed he was admitted to the facility on [DATE]. Diagnoses included chronic kidney disease stage 3 unspecified, type two diabetes mellitus without complications, other reduced mobility, hypertension, congestive heart failure, sick sinus syndrome, atherosclerotic heart disease of native coronary artery without angina pectoris, gout, adjustment disorder with mixed anxiety and depressed mood, chronic atrial fibrillation, and morbid (severe) obesity due to excess calories. Review of the plan of care, initiated 05/04/22, revealed Resident #26 had an activities of daily living self-care performance deficit related to weakness, arthritis, and chronic kidney disease. Interventions included praise efforts at self-care,…

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 observation, the facility failed to ensure tube feeding were given per physician orders. This affected two (#5 and #63) out of three reviewed for tube feeding. The facility identified there were seven tube feeding residents. The census was 89. Findings included: Medical record review for Resident #5 revealed an admission date of 07/13/22. Medical diagnoses included acute and chronic respiratory failure, neurogenic bladder, Parkinson's disease, and malnutrition. Review of admission Minimum Data Set (MDS) dated [DATE] revealed Resident #5 was cognitively intact. Her functional status was total dependence for bed mobility, transfers, and toilet use with two-person assistance. She was total dependence for eating with one-person physical help. She has an indwelling Foley catheter and was frequently incontinent for bowel. She had one stage two pressure ulcer. She was on oxygen, required suctioning, tracheostomy, and a mechanical ventilator. Observation of the tube…

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 policy review, the facility failed to ensure staff properly performed Peripherally Inserted Central Catheter (PICC) line care for one (Resident #286) out of one resident reviewed with a PICC line and urinary catheter care for one (Resident #39) out of three reviewed for urinary catheter use to prevent potential infection of the resident. The facility identified one resident with a PICC line and six residents with indwelling urinary catheters. The facility census was 89. Findings include: 1. Review of the medical record for Resident #39 revealed he was admitted to the facility on [DATE], discharged on 08/17/22, and re-admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy, dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, paroxysmal atrial fibrillation, peripheral vascular disease, chronic kidney disease, obstructive and reflux uropathy, benign prostatic hyperplasia…

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, review of the consent forms, and policy review, the facility failed to maintain an effective immunization program for pneumococcal (pneumonia) and influenza (flu). This affected three (Residents #32, #34, and #48) out of five residents reviewed for immunizations. The facility census was 89. Findings include: 1. Review of the medical record for Resident #32 revealed he was admitted to the facility on [DATE]. Diagnoses included cerebral infarction due to unspecified occlusion or stenosis of left carotid arteries, aphasia following cerebral infarction, chronic embolism and thrombosis of unspecified deep veins of lower extremity, bilateral, hypertension, alcohol dependence with withdrawal, and cerebral edema. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 was unable to complete the Brief Interview for Mental Status (BIMS). The resident required extensive assistance for bed mobility, transfer, dressing, toilet use, 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.

Based on medical record review and staff interview, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment. This affected one (Resident #2) of two residents reviewed for resident assessments. The census was 97. Findings include: Review of Resident #2's medical record revealed an admission date of 05/09/19. Diagnoses listed included dementia, Down syndrome, anxiety disorder, and hypothyroidism. Review of the MDS assessments revealed a MDS assessment was last completed on 08/30/19. During an interview on 01/02/20 at 10:30 A.M. Registered Nurse (#99) confirmed that a MDS assessment had not been completed since 08/30/19 and that a quarterly MDS assessment was pass due.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed medical record review and staff interview, the facility failed to complete a discharge Minimum Data Set (MDS) assessment. This affected one (Resident #1) of two residents reviewed for resident assessments. The census was 97. Findings include: Review of Resident #1's closed medical record revealed an admission date of 06/17/19. Diagnoses included acute kidney failure, sepsis, hypothryoidism, and type II diabetes mellitus. Resident #1 was discharged on 08/22/19. Review of MDS assessments revealed a discharge MDS assessment was not completed for Resident #1's discharge on [DATE]. During an interview on 01/02/20 at 10:30 A.M. Registered Nurse (#99) confirmed that a MDS assessment had not been completed when Resident #1 was discharged form the facility on 08/22/19.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review, observation, staff interview, and facility policy review; the facility failed to develop a comprehensive care plan for the use of antianxiety and antibiotic medication. Additionally, the facility failed to develop a comprehensive care plan to address the use of a urinary catheter. This affected two Resident's (#8 and #59) of 23 residents reviewed for the development and implementation of comprehensive care plans. The census was 97. Findings include: 1. Review of the medical record for Resident #8 revealed the resident was admitted to the facility on [DATE]. Diagnoses includes Parkinson's disease, anxiety disorder, agitation, muscle weakness, cognitive communication deficit, diabetes mellitus type two, obstructive sleep apnea, major depressive disorder, hypertension, constipation osteoarthritis. Review of a physician order dated 10/06/19, revealed Resident #8 was ordered clonazepam (antianxiety medication) one milligram (mg) by mouth three times a day. Review of a physician order…

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 revise a resident's care plan. This affected one (Resident #50) of two residents reviewed for fall. The census was 97. Findings include: Review of Resident #50's medical record revealed an admission date of 09/07/17. Diagnoses included hyperlipidemia, muscle weakness, Alzheimer's disease, major depressive disorder, and bone density disorder. Review of Resident #50's fall care plan dated as last revised 10/22/19 revealed staff were to encourage Resident #50 to use a walker when ambulating. Review of section G of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #50 did not walk in room or corridor and did not use a walker. Interview with Licensed Practical Nurse (LPN) #50 on 01/09/20 at 7:35 A.M. revealed Resident #50 was not able to use a walker, but used a wheelchair. Interview with the Director of Nursing (DON) on 01/09/20 at 8:32 A.M. confirmed Resident #50's care plan was not updated for not using walker.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff and resident interview and facility policy review, the facility failed to ensure a dependent resident received hygiene assistance on a regular basis. This affected one (Resident #43) of two reviewed during the annual survey. The census was 97. Findings included: Medical record review for Resident #43 revealed an admission date of 10/04/19. Medical diagnoses included heart failure, diabetes and renal insufficiency. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact. Functional status was limited assistance for bed mobility, transfers and eating were supervision, and she was extensive assistance for toilet use. Further review of the MDS revealed the resident required physical help in part for bathing activity with one-person physical assistance. Review of progress notes dated 11/10/19 through 01/08/20 revealed there wasn't any documentation the resident refused her showers. Review of care plans revealed no concerns of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interviews, the facility failed to ensure a resident's splint device was in place per therapy recommendations. This affected one (Resident #82) of one resident reviewed for limited range of motion. The facility census was 97. Findings include: Medical record review for Resident #82 revealed an admission date of 08/22/09. Diagnoses included dementia with behavioral disturbance, bipolar disorder, contracture left hand, systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction, atherosclerotic heart disease, phlebitis and thrombophlebitis of unspecified deep vessels of lower extremity, sick sinus syndrome, mild cognitive impairment, dysphagia, edema, muscle wasting and atrophy, abnormal posture, paraphilia, hyperlipidemia, major depressive disorder, benign prostatic hyperplasia with lower urinary tract symptoms, hypothyroidism, generalized muscle weakness, osteoarthritis, transient cerebral ischemic attack,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review, observation, resident representative interview, and staff interview; the facility failed to have fall interventions in place as ordered by the physician. This affected one (Resident #27) of two residents reviewed for falls. The census was 97. Finding include: Review of the medical record for Resident #27 revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia, muscle weakness, anemia, hypertension, atrial fibrillation, osteoporosis, osteoarthritis, atrial fibrillation, anxiety, heart failure, hypothyroidism, zoster complications, glaucoma, scoliosis, and syncope. Review of a progress noted dated 01/13/19, revealed Resident #27 was found on the floor by staff. The resident was observed lying on the floor on the resident's left side, wrapped up in bed covers. Documentation revealed the left side of the air mattress was hanging off the bed and it appeared the resident rolled off the bed. New interventions included fall mat and low bed at all times.…

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 and resident interview and facility policy review the facility failed to ensure physician catheter orders were entered, a baseline care plan was initiated for an indwelling catheter, and catheter care was provided. This affected one (Resident #192) of two residents reviewed for indwelling catheter. The facility identified six residents who had indwelling catheters. The census was 97. Findings include: Medical record review for Resident #192 revealed an admission date of 12/30/19. Medical diagnoses included cancer and benign prostatic hyperplasia. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. His functional status was limited assistance for bed mobility and transfers. He was a supervision for eating and extensive assistance for toilet use. The MDS further identified he had an indwelling catheter. Review of physician orders from 12/30/19 through 01/06/20 revealed no orders for an indwelling catheter.…

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 staff interview, the facility failed to properly sanitize the blood glucose monitoring system between resident use. This affected one (Resident #73) of two residents observed during medication administration. The facility identified three residents who use the glucometer from the medication cart on the Willow/Juniper halls. The census was 97. Findings included: Observation on 01/07/20 at 11:32 A.M. revealed Licensed Practical Nurse (LPN) #41 was walking down the hallway on [NAME] from Resident #6's room with a glucometer machine. The glucometer machine had a used strip sticking out of it. LPN #41 also had a Novolog Pen in her hand. She dropped the Novolog pen on the floor and left it there. She proceeded to remove the used strip and placed in the sharps container. She then placed a new strip into the machine. Resident #73 was seated next the medicine cart and LPN #41 began to assess the residents blood sugar. The surveyor stopped the LPN #41 and questioned her about the cleaning of the machine. The LPN stated she had cleaned the machine before she went to…

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