Arbors At Delaware

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure appropriate care and services to treat a residents new non-pressure related wounds. This deficient practice affected one resident (#2) of one resident reviewed for non-pressure related wounds. The facility census was 90.Finding include: Medical record review for Resident #2 revealed an admission date of 10/17/25 and medical diagnosis of osteomyelitis, chronic obstructive pulmonary disease, type two diabetes, atherosclerotic heart disease, heart failure, anemia, need for assistance with personal care, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side.Review of Resident #2's Care Plan, last updated 11/10/25, revealed an impaired cardiovascular status related to congestive heart failure, heart failure, atherosclerotic heart disease, hypertension and anemia. Interventions included to observe for side effects and report to physician, nurse practitioner, or physician assistant. The care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, record review, and review of the restorative nursing program, the facility failed to ensure a restorative splinting program was implemented. This affected one (Resident #49) out of one resident reviewed for mobility and limited range of motion. The facility identified 10 residents as receiving range of motion programming. The facility census is 90. Findings include:Review of the medical record for Resident #49 revealed an admission date of 12/27/18 with diagnoses of [NAME] Sequard syndrome, quadriplegia, venous insufficiency, contracture of muscle and reduced mobility.Review of physician spine visit summary dated 01/21/25 revealed the Resident #49's contractures appeared stable at this time.Review of care plan dated 02/05/25 revealed Resident #49 would benefit from a restorative splinting program related to contractures and limitation in range of motion. Interventions included to provide splinting program, wear right and left-hand carrot finger orthosis, to be applied with…

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

Based on interview, record review, observation, and policy review, the facility failed to ensure catheters were maintained in a sanitary manner for Resident #7. This affected one resident (Resident #7) out of three residents reviewed for bladder and bowel services. The facility census was 90.Findings include: Review of the medical record for Resident #7 revealed an admission date of 11/06/25 with diagnoses including stage three pressure ulcer of the right buttock, altered mental status, gastroesophageal reflux disease, bladder neck obstruction, and weakness. Review of the care plan dated 12/19/25 revealed Resident #7 required a Foley catheter related to obstructive uropathy. Interventions included observing for signs and symptoms of infection, assisting with indwelling catheter care, changing catheter and drainage system as clinically indicated, monitoring for obstruction, infection or compromise of the closed system, and maintaining the drainage bag below bladder level. Review of physician order dated 12/20/25 revealed Resident #7 had orders for a Foley catheter to straight drain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to implement dietary orders for Resident #75. This affected one resident (Resident #75) out of five residents reviewed for nutrition services. The facility census was 90. Findings include: Review of Resident #75's medical record revealed an admission date of 06/28/25 and the following medical diagnoses: acute kidney failure, malignant neoplasm of prostate, unspecified protein calorie malnutrition, dementia, major depressive disorder, Bell's palsy, muscle weakness, dysphagia, urine retention, abdominal aortic aneurysm, weakness, and adult failure to thrive. Review of the most recent Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. Review of the care plan with a review start date 01/08/26 for Resident #75 revealed the resident was at risk for altered nutritional status related to advanced age, edentulous status, history of significant weight…

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 reviews and staff interviews, the facility failed to ensure residents with a history of trauma received trauma-informed care by identifying and addressing trauma-related triggers. This affected three residents (Resident #49, Resident #76, and Resident #99) out of twelve residents identified with post-traumatic stress disorder. The facility census was 90.Findings include: 1. Review of the medical record revealed Resident #76 was admitted on [DATE] with diagnoses including post-traumatic stress disorder (PTSD) and unspecified dementia, along with additional comorbid conditions. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score indicating cognitive impairment, requiring staff assistance with decision-making and care. Review of the Annual Social Service Progress Review (V10) dated 10/02/25 (signed 10/03/25) documented that trauma-informed care screening was completed, and Resident #76 met criteria for a trauma…

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 interview, staff interview, and record review, the facility failed to ensure that a binding arbitration agreement was explained to the resident in a form and manner the resident understood and failed to ensure the resident acknowledged understanding of the agreement prior to execution. This deficient practice affected one resident (Resident #81) out of twenty-four residents reviewed, with a facility census of 90.Findings include:Review of the medical record revealed Resident #81 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #81 had a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating intact cognition at the time of admission.Review of the MDS 3.0 assessment dated [DATE] revealed Resident #81 had a BIMS score of 13 of 15, indicating the resident was cognitively intact.On 01/27/26 at approximately 12:30 PM, this surveyor interviewed Resident #81 regarding an arbitration agreement with the facility.…

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, staff interview and facility policy review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented in accordance with national infection control standards for a resident with risk factors indicating the need for such precautions. Specifically, the facility failed to post required signage or provide visual cues to alert staff to use EBP during high-contact care activities for Resident #6, despite the resident having open, draining skin lesions and other conditions placing the resident at increased risk for transmission of infectious organisms. This affected one resident (#6) of one resident reviewed for EBP. Additionally, the facility failed to ensure appropriate assistance for incontinence care was provided for Resident #15, resulting in the lack of infection control when the resident was seen walking around with feces on his shoes. This affected one resident (Resident #15) out of three residents reviewed for bladder and bowel services. The facility…

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, observation, resident interview, staff interview, and policy review, the facility failed to maintain a clean, safe, comfortable homelike environment. This affected 25 (#5, #6, #8, #13, #14, #15, #16, #19, #22, #23, #25 #28, #29, #30, #34, #46, #50, #54, #55, #56, #70, #72, #82, #83 and #91) residents residing on hall 300 and 16 (#2, #12, #20, #21, #24, #31, #32, #37, #39, #40, #42, #48, #62, #71, #76 and #78) residents residing on the on the Memory Care Unit. The facility census was 89. Observation during the initial tour on 11/24/25 from 8:51 A.M. to 9:07 A.M. revealed a black substance on the ceiling in the shower room on the hall 300. Observation also revealed loose plaster in the left corner of the shower room over the tub, a grate in the ceiling that was loose with cracked plaster around it., a black/brown substance on the ceiling on opposite side of the room near a sprinkler head that was by the door of the shower room. The black substance by the door appeared to have been painted over and was now showing through.Observation on 11/25/25 at 10:12 A.M. of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, resident interview, staff interview, and policy review, the facility failed to maintain a clean, safe, comfortable homelike environment. This affected one (#68) of three residents reviewed for environment. The facility census was 89. Review of Resident #68 ' s medical record revealed an admission date of 12/28/22. Diagnoses included heart failure, type two diabetes mellitus, hypertension, and bipolar disorder. Review of Resident #68 ' s quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #68 had intact cognition. Observation on 11/24/25 at 11:44 A.M. of Resident #68 ' s room revealed an air conditioner that was not functioning, a large puddle of water on the bathroom floor under the sink, and a hole in the tile near the bathroom door. Interview on 11/24/25 at 11:45 A.M. with Resident #68 revealed her air conditioner did not function at all and her room would become hot, and it would make her uncomfortable. Resident #68 also reported in her bathroom 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 record review, pharmacy delivery slips, pharmacy return slips, staff interviews, and policy review the facility failed to ensure residents were discharged with adequate amount of medications. This affected one (#93) of two residents reviewed for discharge. The facility census was 89. Review of medical record for Resident #93 revealed an admission date of 01/04/25 and discharge date of 02/27/25 with diagnoses including but not limited to epilepsy intractable with status epilepticus, severe intellectual disabilities, post-traumatic stress disorder, bipolar disorder, and conversion disorder with seizures or convulsions.Review of discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact with no behaviors.Review of care plan dated 01/05/25 revealed the resident plans to discharge to home with family after completion of stay. Interventions included encourage resident/family to participate in the discharge planning process, involve specialized home care agencies 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, staff interview, and policy review the facility failed to ensure a complete and thorough resident assessment was completed for a resident with a change in condition. This affected one (#92) of five residents reviewed for change in condition. The facility census was 89.Review of medical record for Resident #92 revealed an admission date of 03/29/25 and discharge date of 04/23/25 with diagnoses including but not limited to wedge compression fracture of second lumbar vertebra, nondisplaced fracture of lateral end of right clavicle, rotator cuff tear or rupture of right shoulder, Alzheimer's disease, and age-related osteoporosis with current pathological fracture vertebrae.Review of Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition with no behaviors.Review of Situation, Background, Assessment, and Recommendation (SBAR) dated 04/23/25 at 10:34 P.M. revealed Resident #92 had uncontrolled pain in right foot starting on 04/23/35, the physician…

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, review of facility investigation, review of personnel files, review of inservice logs, resident and family interiews, and staff interview, the facility failed to ensure residents were treated with dignity and respect. This affected two (#83 and #75) residents of six residents reviewed for respect and dignity. The facility census was 84. Findings include: 1. Record review of Resident #83 revealed an admission on [DATE]. Diagnoses included congestive heart failure, obstructive sleep apnea, type II diabetes, and morbid obesity. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #83 had intact cognition. Review of the physician's orders dated 09/05/24 revealed Resident #83 can receive diphenhydramine (Benadryl) 50 milligrams (mg) orally every six hours as needed (prn) and oxycodone 10 mg orally every six hours prn for pain relief. Review of Licensed Practical Nurse (LPN) #138's personnel record revealed Performance Improvement Form dated 08/05/24 for LPN…

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 policy review, the facility failed to notify a physician of change in resident's status. This affected one (#88) out of three residents reviewed for catheter care. The facility census was 85. Findings include: Review of the medical record for Resident #88 revealed an admission date of 06/07/24 with medical diagnoses of congestive heart failure (CHF), diabetes mellitus (DM), hypertensive heart disease, atherosclerosis heart disease (ASHD), cerebral infarction, and obstructive uropathy, Review of the medical record for Resident #88 revealed a discharge date of 07/31/24. Review of the medical record revealed Resident #88 received Hospice services effective 06/27/24. Review of the medical record for Resident #88 revealed an admission Minimum Data Set (MDS) assessment, dated 07/02/24, which indicated Resident #88 had moderate cognitive impairment and required set-up assistance for eating and was dependent for toilet hygiene, bathing, bed mobility and transfers. The MDS indicated Resident #88 had an indwelling catheter. Review of the…

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

Based on observations, staff and resident interviews, and policy review, the facility failed to maintain a clean and homelike environment. This affected three (#24, #4, and #8) of three residents reviewed for the physical environment. The facility census was 85. Findings include: 1. Observation on 08/19/24 at of privacy curtain in middle of room for Resident #4 revealed curtain had small brown streaks scattered over the curtain. 2. Observation on 08/19/24 at 11:75 A.M. of the curtains in Resident #24's room revealed a brown streak on the middle of the curtain midway up, with black streaks and spots scattered along the bottom of the curtain. 3. Observation on 08/20/24 at 8:37 A.M. of privacy curtain for Resident #8 revealed curtain dirty with white spots and brown streaks scattered on the curtain. Interview on 08/20/24 at 8:37 A.M. with Resident #8 confirmed curtain in room was dirty with white spots and streaks of brown scattered across the privacy curtain. Resident #8 confirmed if they were at home they would not allow their curtains to look like that and they would clean them.…

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

Based on medical record review, staff interviews, Hospice nurse interview, and review of the Resident Assessment Instrument (RAI) manual 3.0, the facility failed to ensure care plan was updated to include accurate Activities of Daily Living (ADL) information. This affected one (#88) out of the three residents reviewed for feeding assistance. The facility census was 85. Findings include: Review of the medical record for Resident #88 revealed an admission date of 06/07/24 with medical diagnoses of congestive heart failure (CHF), diabetes mellitus (DM), hypertensive heart disease, atherosclerosis heart disease (ASHD), cerebral infarction, and obstructive uropathy, Review of the medical record for Resident #88 revealed a discharge date of 07/31/24. Review of the medical record revealed Resident #88 received Hospice services effective 06/27/24. Review of the medical record for Resident #88 revealed an admission Minimum Data Set (MDS) assessment, dated 07/02/24, which indicated Resident #88 had moderate cognitive impairment and required set-up assistance for eating and was dependent 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 interviews, Hospice nurse interview, and policy review, the facility failed to ensure activity of daily living (ADL) assistance was provided for dependent resident. This affected one (#88) out of the three residents reviewed for feeding assistance. The facility census was 85. Findings include: Review of the medical record for Resident #88 revealed an admission date of 06/07/24 with medical diagnoses of congestive heart failure (CHF), diabetes mellitus (DM), hypertensive heart disease, atherosclerosis heart disease (ASHD), cerebral infarction, and obstructive uropathy, Review of the medical record for Resident #88 revealed a discharge date of 07/31/24. Review of the medical record revealed Resident #88 received Hospice services effective 06/27/24. Review of the medical record for Resident #88 revealed an admission Minimum Data Set (MDS) assessment, dated 07/02/24, which indicated Resident #88 had moderate cognitive impairment and required set-up assistance for eating and was dependent for toilet hygiene, bathing, bed mobility and transfers. The…

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

Based on medical record review, staff interviews, Hospice nurse interview, and policy review, the facility failed to properly assess and treat a resident's skin breakdown. This affected one (#88) out of three residents reviewed for skin breakdown. The facility census was 85. Findings include: Review of the medical record for Resident #88 revealed an admission date of 06/07/24 with medical diagnoses of congestive heart failure (CHF), diabetes mellitus (DM), hypertensive heart disease, atherosclerosis heart disease (ASHD), cerebral infarction, and obstructive uropathy, Review of the medical record for Resident #88 revealed a discharge date of 07/31/24. Review of the medical record revealed Resident #88 received Hospice services effective 06/27/24. Review of the medical record for Resident #88 revealed an admission Minimum Data Set (MDS) assessment, dated 07/02/24, which indicated Resident #88 had moderate cognitive impairment and required set-up assistance for eating and was dependent for toilet hygiene, bathing, bed mobility and transfers. The MDS indicated Resident #88 had an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record reviews, staff interviews, and policy review, the facility failed to ensure residents were from significant med errors. This affected two (#20 and #85) residents out of the six residents reviewed for medication administration. The facility census was 85. Findings include: 1. Review of medical chart for Resident #85 revealed and admission date of 07/19/24. Diagnoses include Parkinson's, cerebral infarction, atrial fibrillation, hypertension, abdominal aortic aneurysm, and anemia. Review of the Minimum Data Set (MDS) dated [DATE] for Resident #85 revealed resident cognitively impaired. MDS for Resident #85 indicates resident requires extensive assistance with transfers, eating, toileting, and bed mobility. Review of orders for Resident #85 revealed orders including an order dated 07/19/24 for lisinopril oral tablet 20 milligrams (mg), give one tablet by mouth one time a day related to essential hypertension. Hold for systolic blood pressure less than 110. Review of blood pressure (BP)…

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, Hospice nurse interview, and policy review, the facility failed to ensure coordination of care and services with the Hospice provider. This affected one (#88) out of the three residents reviewed for catheter care. The facility census was 85. Findings include: Review of the medical record for Resident #88 revealed an admission date of 06/07/24 with medical diagnoses of congestive heart failure (CHF), diabetes mellitus (DM), hypertensive heart disease, atherosclerosis heart disease (ASHD), cerebral infarction, and obstructive uropathy, Review of the medical record for Resident #88 revealed a discharge date of 07/31/24. Review of the medical record revealed Resident #88 received Hospice services effective 06/27/24. Review of the medical record for Resident #88 revealed an admission Minimum Data Set (MDS) assessment, dated 07/02/24, which indicated Resident #88 had moderate cognitive impairment and required set-up assistance for eating and was dependent for toilet hygiene, bathing, bed mobility and transfers. The MDS indicated 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 observations, staff and resident interviews, and policy review, the facility failed to maintain pest control in hallways and resident rooms. This affected two (#4 and #24) of three residents reviewed for the effective pest control. The facility census was 85. Findings included: 1. Observation and interview on 08/19/24 at 11:48 A.M. with Resident #4 revealed a lot of flies and a few gnats in the room especially around the privacy curtain in the middle of the room. Resident #4 confirmed the flies really bothered them and they want them gone from the room. 2. Observation and interview on 08/19/24 at 11:57 A.M. with Resident #24 revealed some flies and gnats in the room, especially by the privacy curtain in the middle of the room. Resident #24 said the flies drive them crazy and they have to sleep with a blanket over their head to keep the flies off of them. Resident #24 revealed they had asked staff to please get them a fly strip to get rid of the flies. Interview on 08/19/24 at 2:32 P.M. with State Tested Nursing Assistant (STNA) #111 confirmed the presence of flies and gnats…

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, resident interview, family interview, medical record reviews, and policy reviews, the facility failed to ensure residents were free from significant medication errors. This affected two (#85 and #14) of six residents reviewed for medication administration. The facility census was 86. Findings include: 1. Review of the medical record for Resident #85 revealed an admission date of 12/05/23. Medical diagnoses included neurocognitive disorder with lewy bodies, dementia, hypertension, and bradycardia (low heart rate of less than 60 beats per minute). Review of Resident #85's Minimum Data Set (MDS) quarterly assessment, dated 06/13/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 09 indicating moderately impaired cognition. Review of Resident #85's physicians orders revealed an order dated 07/19/24, for metoprolol tartrate (an antihypertensive medication used to lower blood pressure and/or heart rate) 25 milligrams (mg) by oral route twice daily. The order specified to hold the medication for a systolic blood…

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, resident and staff interview, and policy review, the facility failed to provide comprehensive urostomy care for one (#40) of four residents reviewed for indwelling urinary drainage device. The facility identified one resident (#40) who had a urostomy used in his care. The facility census was 85. Findings Include: Review of the medical record for Resident # 40, revealed the resident was admitted to the facility on [DATE]. Diagnoses included unspecified hydronephrosis, perinephric abscess and diabetes mellitus type two. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #40 was cognitively intact and was to have an indwelling catheter for his urinary elimination. Observation of Resident #40 on 06/24/24 at 2:40 P.M. revealed the resident had a bath basin lying on the floor on the left side of his bed that had a nephrostomy drainage bag lying on the bottom of the basin covered in liquid. The resident had a nephrostomy drainage bag anchored…

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, staff interview, and policy review the facility failed to ensure residents were free from significant medication errors. This affected one (#29) of the six residents observed for medication administration. The facility census was 85. Findings Include: Review of the medical record for Resident #29's revealed the resident was admitted on [DATE]. Diagnoses included diabetes mellitus, dementia, cerebrovascular accident (CVA/stroke) and coronary artery disease. Review of the Minimum Data Set (MDS) assessment dated [DATE], Revealed Resident #29 was cognitively intact. Review of a physician's order dated [DATE], revealed Resident #29 was ordered to receive Regular Insulin (short acting insulin) 100 units/milliliter (mL) per sliding scale subcutaneously before meals and at bedtime for diabetes. If finger stick blood glucose (FSBG) is 151 milligrams per deciliter (mg/dL) to 200 mg/dL give two units; 201 mg/dL to 250 mg/dL give four units; 251 mg/dL to 300 mg/dL give six units; 301…

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, activity calendar review, resident interview, family interview, staff interview, and review of policy, the facility failed to ensure residents were provided with activities to meet the needs and interests of the residents. This affected five (#100, #300, #400, #500, and #600) of five residents reviewed for activities. The census was 82. Findings: Review of the April 2024 activity calendar provided by the facility revealed there was a lack of variety of activities scheduled. The daily calendar included: 9:00 A.M. Daily Chronicle (IR), 10:00 A.M. Exercise (A), 10:30 A.M. Hit 21 (A), 1:30 P.M. UNO (A), 3:00 P.M. Bingo (DR), and 6:30 P.M. Resident Led Cards (A). Observation on 04/01/24 at 8:10 A.M., on the locked memory care unit, in the common area/dining room found 7 Residents of which 5 of which were sitting in wheelchairs, and 2 in a strait back chair all faced towards a large wall of plastic with holes and a zipper open to an area under construction, with no music…

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, resident interviews, and staff interviews, the facility failed to provide an environment free from potential hazards of unsecured chemicals and sharps in a construction area. This had potential to affect 21 confused and independently mobile resident (#112, #113, #114, #300, #115, #116, #117, #118, #119, #120, #121, #122, #124, #125, #126, #127, #128, #129, #130, #131 and #400) of 23 residents who resided on the memory care unit. The facility census was 82. Findings include: Observation on 04/01/24 at 8:02 A.M., on the locked memory care unit, revealed a doorway that opened to a common area with a doorway that connected to a dining room. Seven residents, of which five were sitting in wheelchairs, on the left side of the common area. The five residents were facing a falling down piece of clear plastic that was attempting to cover the entire wall. The large piece of plastic was taped with blue tape on the fluorescent ceiling lights at the left side of the zipper. The bottom portion of the plastic was taped into the walking path of the common area into the entry…

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 interview, staff interview, and policy review, the facility failed to ensure resident complaints and concerns were documented and followed up on in a timely manner. This affected two (Residents #103 and #222) of three residents reviewed for follow up on resident concerns. The census was 82. Findings: Review of the resident council meeting minutes dated 02/08/24 documented residents complained of laundry not being returned in a timely manner. 1. Review of the medical record for Resident #222 revealed an admission date of 09/23/22, with diagnoses including atrial fibrillation, chronic obstructive pulmonary disease, morbid obesity, diabetes mellitus type 2, obstructive sleep apnea, major depressive disorder, and chronic lymphocytic leukemia of B cell. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed for Resident #222 a Brief Interview Mental Status (BIMS) score of 14. She requires substantial/maximal assistance for upper body dressing and was dependent…

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 interview, staff interviews, and interview with Oncology Social Services staff, the facility failed to ensure a resident was provided assistance to and arrange transportation to medical appointments, when the resident required supplement oxygen, resulting in the resident missing physician appointments a medical treatments and not having supplemental oxygen available. This affected one (#200) of three residents reviewed for assistance with outside medical services. The facility census was 82. Finding include: Review of medical record for Resident #200 revealed admission date of 02/01/24. Medical diagnoses included chronic obstructive pulmonary disease, secondary malignant neoplasm of lung, atrial fibrillation, hypothyroidism, pulmonary hypertension, major depression, weakness, need for assistance with personal care, abnormalities of gait and mobility, muscle weakness, low back pain, bipolar disorder, and alcohol abuse. Review of the admission Minimum Data Set (MDS) dated [DATE]…

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, resident interview, staff interview and review of facility policy, the facility failed to ensure foods were maintained at preferred temperatures during serving. This had the potential to affect all 79 residents of the facility. The facility census was 79. Findings include: Interview on 12/04/23 at 10:18 A.M. with Resident #25 revealed the facility food was cold when served and breakfast was exceptionally bad. Interview on 12/04/23 at 2:23 P.M. with Resident #37 revealed the facility food was cold when served. Observation on 12/07/23 at 8:06 A.M. with District Manager (DM) #94 and Food Director (FD) #95 of the breakfast tray line revealed all hot breakfast foods, including sausage, biscuits and gravy, and eggs, were of an appropriate temperature of 135 degrees Fahrenheit (F) or warmer. Continued observation on 12/07/23 at 8:28 A.M. of the breakfast tray line revealed the 400 Hall tray cart left the kitchen for distribution to residents. Additional observation at 8:46 A.M., with DM #94 and FD #95, revealed the last tray removed from the 400 Hall cart was a test…

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 maintain the activity room refrigerator and freezer in a clean and sanitary manner. This had the potential to affect all 79 residents of the facility. The facility census was 79. Findings include: Observation on 12/05/23 at 12:27 P.M. of the activity room refrigerator and freezer combination unit revealed the refrigerator compartment was dirty, with food debris and a black and brown substance in the corners. Beverages, assorted syrups, and sprinkles were stored in the refrigerator. The freezer compartment had an abundance of ice growing on the top and sides. Ice cream was stored in the freezer. Interview on 12/05/23 at 12:27 P.M. with Activities Director (AD) #54 verified the items stored in the refrigerator/freezer unit were for resident use. Additionally, AD #54 confirmed the unit needed cleaned, including defrosting the freezer. AD #54 stated she had been employed by the facility for nearly a year and the refrigerator and freezer had not been cleaned in that time. Interview on 12/07/23 at 2:35 P.M. with the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to complete thorough root cause analysis following falls. This affected three (Residents #16, #19, and #181) of five residents reviewed for falls. Additionally, the facility failed to have fall interventions in place as ordered. This affected three (Residents #16, #181, and #37) of five residents reviewed for falls. The facility census was 79. Findings include: 1. Review of Resident #19's medical record identified admission to the facility on [DATE] with medical diagnoses including high blood pressure, anemia, trouble swallowing, muscle weakness and reduced mobility. Review of Resident #19's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Further review of Resident #19's medical record revealed he suffered a fall with femur fracture on 06/08/23 and was at high risk for further falls. Review of Resident #19's December 2023 physician orders for fall interventions revealed orders 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 and staff interviews, the facility failed to ensure pharmacy recommendations approved by the Certified Nurse Practitioner (CNP) were acted upon in a timely manner. This affected two (Residents #19 and #37) of five reviewed for unnecessary medications. The facility census was 79. Findings include: 1. Review of Resident #19's medical record identified admission to the facility on [DATE] with medical diagnoses including high blood pressure, anemia, trouble swallowing, muscle weakness, and reduced mobility. Review of Resident #19's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of the Pharmacy Medication Regimen Review dated 08/11/23 revealed a recommendation to change Resident #19's Namenda (medication to slow progression of Alzheimer's) from 10 milligrams (mg) to 5 mg, because the manufacturer's guidelines identified any doses greater than 5 mg should be divided into two doses. The pharmacy recommendation was…

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 medication administration observations, staff interviews, and review of facility policy, the facility failed to ensure medications were administered as ordered resulting in three medication errors out of 26 opportunities or a 11.5 percent (%) medication error rate. This affected three (Resident #18, #82, #79) of five residents observed for medication administration. The facility census was 79. Findings include: 1. Observation on 12/06/23 at 7:56 A.M. revealed Licensed Practical Nurse (LPN) #18 gathering medications for Resident #54. LPN #18 gathered Paxlovid 150 milligrams (mg) and Zinc 50 mg and headed to Resident #54's room. LPN #18 was stopped before entering the room and asked to re-check the physician orders. LPN #18 confirmed the order for Resident #54's Zinc was 220 mg and confirmed she had a 50 mg tablet. LPN #18 confirmed she does not have Zinc available to administer the ordered 220 mg. LPN #18 would have to get the order clarified to be able to give the medication to Resident #54. 2. Observation on 12/06/23 at 8:23 A.M. revealed Registered Nurse (RN) #82 gathered…

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, facility policy, and staff interviews, the facility failed to notify a resident's representative of weight loss and start of a medication. This affected one (#25) of three residents reviewed for notification of change in condition. The facility census 79. Findings include: Review of Resident #25's medical record identified admission to the facility occurred on 05/08/20 with medical diagnoses including high blood pressure, pain, mini stroke, previous hip fracture (08/30/22) and weakness. Further review of the medical record revealed Resident #25's daughter was listed as the resident's Power of Attorney (POA). Review of the nursing note dated 11/15/23 at 1:00 P.M. identified Resident #25's daughter requested an immediate care conference in regards to her concerns regarding her mother's care. Resident #25's daughter revealed she does not believe her Power of Attorney (POA) is being honored. She identified in previous discussions she had asked for her mother not to be placed on any medications. The notes identified Resident #25 did identify she wanted 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 observations, medical record reviews, and staff interviews, the facility failed to ensure a resident had geri-sleeves applied as ordered. This affected one (Resident #2) of one resident observed for use of Geri-sleeves. Additionally, the facility failed to complete daily weights as ordered. This affected one (Resident #9) of one resident reviewed for weight monitoring. The facility census was 79. Findings include: 1. Review of Resident #2's medical record identified admission to the facility occurred on 01/15/13 with diagnoses including stroke, high blood pressure, dementia and anemia. Review of Resident #2's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed he had fragile skin with no current skin tears. Resident #2 was dependent upon staff for dressing. Review of Resident #2's December physician orders identified an order dated 04/06/23 for Resident #2 to have Geri-sleeves (sleeves that provide protection to sensitive skin) on at all times. Observation of Resident #2 on 12/05/23 at…

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 gain clarification on a medication order. This affected one (Resident #235) of five residents observed for medication administration. The facility census was 79. Findings include: Observation on 12/06/23 at 7:30 A.M. of Licensed Practical Nurse (LPN) #26 gathering medications for Resident #235 revealed a total of six pills were pulled for administration. LPN#26 administered the six pills to Resident #235, which included one Guaifenesin Mucinex 400 milligrams (mg) tablet. Review of Resident #235's physician order dated 11/24/23 identified Guaifenesin Oral Liquid (Guaifenesin) Give 1200 ml by mouth two times a day for productive cough. Interview on 12/06/23 at 7:37 A.M. with Licensed Practical Nurse (LPN) #235 confirmed the physician's order for Guaifenesin 1200 ml (over a liter of fluid) was a large amount of fluid and verified no one had clarified the physicians order.

Based on medical record review, observation, staff interview, and review of policy, the facility failed to ensure medications were appropriately stored and secured. This affected one (Resident #14) of one observed with medications unattended at the bedside. The facility census was 79. Findings include: Review of the medical record revealed Resident #14 had an admission date of 12/27/18. Diagnoses included quadriplegia, cerebrovascular disease, benign, prostatic hyperplasia, contracture of muscle, chronic pain syndrome, idiopathic progressive neuropathy, and dysphagia. Observation on 12/04/23 at 12:10 P.M. in Resident #14's room revealed there was one small clear plastic cup containing five pills next to the resident on a tray table. Interview with Resident #14 verified staff sometimes leave his pills for him. Interview on 12/04/23 at 12:57 P.M. with Assistant Director of Nursing (ADON) #75 verified medications were left at Resident #14's bedside. ADON #75 verified leaving pills at bedside is not part of their protocol. Review of the policy, Medication Administration, dated 01/01/22,…

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 facility policy, the facility failed to obtain physician ordered laboratory (lab) testing for one (#19) of five residents reviewed for unnecessary medications. The facility census was 79. Findings include: Review of Resident #19's medical record revealed an admission date of 10/23/14. Diagnoses included seizures, high blood pressure, anemia, trouble swallowing, muscle weakness and reduced mobility. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/08/23, revealed Resident #19 was severely cognitively impaired. Review of a physician order dated 10/02/23 revealed Resident #19 was to have lab testing every six months, in April and October, to include basic metabolic panel (BMP - used to evaluate kidney function, body fluid balance and electrolyte levels), Keppra level (medication used to treat seizures), lipid panel (measures cholesterol and other fats in the blood), and HgBA1C (measures average blood sugar levels over the previous three months). Additional review of the medical record revealed no evidence…

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 facility policy, the facility failed to ensure timely physician notification of laboratory (lab) results for Resident #33, which required a change in treatment, and critical lab results for Resident #37. This affected two (#33 and #37) of five residents reviewed for unnecessary medications. The facility census was 79. Findings include: 1. Review of Resident #33's medical record revealed an admission date of 03/13/23. Diagnoses included depression, Alzheimer's disease and chronic obstructive pulmonary disease (COPD). Review of a nursing note dated 11/30/23 at 10:38 A.M. revealed Resident #33 had a low grade fever, increased incontinence episodes and confusion. Certified Nurse Practitioner (CNP) #300 was notified regarding the change in condition and ordered Augmentin 875 milligrams (mg) twice daily for five days and a urine swab test. Review of a lab report, dated 11/30/23, revealed Resident #33's urine sample was received by the lab on 12/01/23 and resulted on 12/02/23. Further review revealed Resident #33 had a urinary…

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 ensure the 300-hall central bath, 400-hall central bath, common areas, and resident rooms were maintained in a clean and safe manner. This affected Resident #60 and had the potential to affect all 84 residents. The facility census was 84. Findings include: 1. Observation on 10/26/23 at 10:30 A.M. in Resident #60's room revealed a large two-foot hole in the wall at the head of the Resident #60's bed with insulation showing through in the center. Additionally, the positioning bar on the right-hand side of Resident #60's bed was not secure at both ends and would move/swing away from the bed when pressure was applied by Resident #60. Interview on 10/26/23 at 2:50 P.M. with the Administrator verified the positioning bar on Resident #60's bed was not properly secured. Additionally, the Administrator verified there was a hole in the wall above Resident #60's bed 2. Observation on 10/31/23 at 5:15 A.M. of the 300-hall central bath revealed there was a black substance on the grout where the wall meets the floor along the entire…

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, facility assessment review, licensure staffing tool, and facility policy review, the facility failed to ensure sufficient staffing was in place to meet resident needs. This had the potential to affect all 73 residents that resided in the facility. Findings include: 1. Review of the medical record for Resident #16 revealed an admission date of 12/27/18. Diagnosis included quadriplegia, brown-Sequard syndrome, need assistance with personal care, generalized anxiety disorder, contracture, chronic pain, constipation, post-traumatic stress disorder, major depressive disorder, and tobacco use. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. He required extensive assistance with two- person assistance for bed mobility, transfers, dressing, toileting, and personal hygiene. He was supervision with one person assistance with eating and bathing. He had limited range of motion and was impaired…

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 facility policy and procedure, the facility failed to appropriately store and dispense medications. This affected eight residents (Resident #11, #12, #30, #31, #43, #47, #57, and #523) of eight residents reviewed for medication storage. Findings include: 1. Medical record review for Resident #31 revealed an admission date of 06/04/20 and the diagnoses of morbid obesity, myocardial infarction, tremors, atrial fibrillation, and high blood pressure. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was intact, required extensive assistance of two staff for bed mobility, total dependence of two staff for transfers, and locomotion via wheelchair. Review of Resident #31's physician orders for August 2021 revealed the resident was ordered Atorvastatin 40 milligrams (mg) daily for hyperlipedemia, Carbidopa-Levodopa 25-250 mg daily for tremors, Lisinopril 5 mg daily for high blood pressure, and Primidone 50 mg…

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 interviews, and policy and procedure review, the facility failed to prepare pureed foods per the recipe. This had the potential to affect seven residents (Resident #25, Resident #34, Resident #41, Resident #58, Resident #60, Resident #66,and Resident #69) out of seven resident who were on a pureed diet. Findings include: Observation on 08/31/21 at 3:43 P.M. of Dietary Worker #310 preparing pureed dinner items revealed she took seven garlic rolls and placed them in the food processor and added four pieces of white bread. She then added eight cups of chicken broth to puree the rolls. Realizing she did not obtain a correct texture, she added three scoops of thickener. A taste test revealed the garlic rolls tasted like chicken broth cubes and were very sticky in texture. It stuck to the roof of the mouth of the taster. Further observation revealed the vegetable for the dinner was baked Italian zucchini, and the zucchini was portioned for seven servings and placed in the food processor for puree. Dietary worker #310 put two pieces of white bread in blender…

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, resident and staff interviews, and facility policy review, the facility failed to ensure Resident #43's dignity was maintained at all times. This affected one resident (Resident #43) of one resident reviewed for respect and dignity. Findings include: Observation on 09/01/21 at 9:45 A.M. revealed Resident #43 was sitting at the nurse's stations in his wheelchair. He had a T-shirt and pink and brown plaid pajamas pants on. His pants were halfway down exposing his brief from the backside and the sides of his wheelchair. Interview on 09/01/21 at 9:50 A.M. with Activity Director #250 verified Resident #43 was sitting in the common area in his wheelchair with his pants not pulled up correctly in the back, exposing his incontinence brief covering his buttocks. Interview on 09/01/21 at 10:30 A.M. with Resident #43 revealed he was embarrassed his brief was showing. Review of the facility policy titled, Promoting/Maintaining Resident Dignity, dated 01/01/21, revealed the practice of this facility was to protect and promote resident rights and treat each resident with…

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

Based on record review, staff and resident interviews, and facility policy review, the facility failed to ensure Resident #16 received showers per his preference. This affected one resident (Resident #16) of three residents reviewed for showers. Findings include: Review of the medical record for Resident #16 revealed an admission date of 12/27/18. Diagnosis included quadriplegia, brown-sequard syndrome, need assistance with personal care, generalized anxiety disorder, contracture, chronic pain, constipation, post-traumatic stress disorder, major depressive disorder, and tobacco use. Review of Resident #16's quarterly Minimum Data Set (MDS) assessment, dated 06/28/21, revealed the resident was cognitively intact. He required extensive assistance with two- person assistance for bed mobility, transfers, dressing, toileting, and personal hygiene. He was supervision with one person assistance with eating and bathing. He had limited range of motion and was impaired on both sides for upper and lower extremities. It was very important to the resident to choose between tub bath, shower, bed…

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

Based on review of facility Self-Reported Incidents, review of facility investigations, staff interviews, and facility policy review, the facility failed to report potential crimes to law enforcement. This affected four residents (Residents #75, #76, #77, and #78) of 20 residents reviewed for allegations of abuse, neglect, misappropriation, and exploitation. Findings Include: Review of facility Self-Reported Incident (SRI) history revealed the following: Review of SRI number 189760, dated 03/09/20, revealed Resident #75 family made an allegation that he had $100 taken from his wallet while it was in the facility. Review of SRI number 173478, dated 05/14/19, revealed Resident #76 made a sexual abuse allegation against a facility staff member. Review of SRI number 196649, dated 09/10/20, revealed Resident #77 made a sexual abuse allegation against an unknown male while in the facility. Review of SRI number 183714, dated 11/12/19, revealed Resident #78 made an allegation that someone took $52 from him while in the facility. While the facility reported these allegations through SRI's 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 and staff interview, the facility failed to provide Resident #73 a bed hold notification. This affected one resident (Resident #73) of two residents reviewed for bed hold notifications when discharged to the hospital. Findings include: Review of Resident #73's medical record identified admission to the facility occurred on 04/22/21. Resident #73's payor source was Medicare. Resident #73 was discharged to the hospital on [DATE]. The record identified on upon admission Resident #73 signed a form identifying in the event of a hospitalization he did not want the facility to place a hold on his bed. The record however had no evidence Resident #73 was provided the facility bed hold notice at the time of the 06/14/21 hospitalization. Interview with SSD #200 occurred on 08/31/21 at 2:37 P.M. confirmed the business office does the bed hold letters but there was not one completed for Resident #73 at the time of the hospitalization. The facility believed since he signed a request at admission…

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 interviews, the facility failed to provide Resident #130 assistance with transportation when discharging to home, when they were leaving against medical advice (AMA). This affected one resident (Resident #130) of four residents reviewed for discharge. Findings include: Review of Resident #130's medical record identified admission occurred on 02/15/20 with medical diagnosis including perforation and abscess or large intestine, peritonitis, dysphagia and anxiety. The record identified on 03/04/20 Resident #130 and her family requested assistance with transportation home for 03/06/20. Review of the social services progress notes dated 03/04/20 identified Resident #130 and spouse wanted an ambulance to transport her home due to needing assistance into her house and to her bed. SSD explained that since it is against medical advice (AMA), the facility would not provide assistance with transportation. Interview with SSD #200 on 08/31/21 at 2:38 P.M. confirmed she was not working in the facility in 2020. SSD #200 confirmed she would assist any…

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, interview, and policy and procedures review, the facility failed to provide Resident #19 constipation treatment when not having bowel movements. This affected one resident (Resident #19) out of one resident reviewed for constipation. Findings include: Review of medical record for Resident #19 revealed admission an date of 09/25/20 with minimal cognitive deficits. The resident was admitted with diagnoses of type two diabetes, absence of left leg below the knee, chronic kidney disease, depression, and constipation. Review of Resident #19's Plan of Care revealed Resident #19 would have a normal bowel movement at least every three days. Interventions included the facility would administer medications as ordered, would follow the facility bowel protocol for bowel management, would monitor medications for side effects of constipation, and would keep the physician informed of any problems. Review of Resident #19's August 2021 physician orders, revealed the resident was ordered Lactulose Solution 10 GM/15ML, give 30 milliliters (ml) by mouth every 24 hours as…

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

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure physician orders were obtained to provide appropriate care and services to manage Resident #42's Intravenous (IV) Peripherally Inserted Central Catheter (PICC). This affected one resident (Resident #42) of two residents reviewed for management of PICC lines. Findings Include: Review of Resident #42's medical record revealed an admission date of 01/03/19 with diagnoses including urinary tract infection (UTI), obstructive and reflux uropathy, urethral fistula, chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/28/21, revealed Resident #42 had no cognitive impairment and required limited assistance with bed mobility, transfers, extensive assistance with dressing and personal hygiene, and supervision with eating and locomotion using wheelchair. Review of Resident #42's physician orders revealed on 08/28/21 an order for a Peripherally Inserted Central Catheter (PICC) line to be placed and Cefepime HCL solution (antibiotic) 1 gram (GM)/ 50…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, and facility policy review of the facility policy, the facility failed to ensure Resident #30 received lunch on scheduled dialysis treatment days. The affected one resident (Resident #30) out of one resident reviewed for dialysis. Findings include: Medical Record Review revealed Resident #30 was admitted on [DATE] with diagnosis included infection of amputation stump, right lower extremity, type two diabetes mellitus with other specified complication, methicillin resistant staphylococcus aureus (MRSA) infection, chronic systolic congestive heart failure, other forms of systemic lupus erythematosus, osteomyelitis, atrial fibrillation, essential hypertension, and end stage renal disease. Review of the admission Minimal Data Set (MDS), dated [DATE], revealed the resident had intact cognition. The resident required supervision setup help only for eating. The resident had a therapeutic diet. Review of Dietary Progress notes dated 08/19/21 at 10:38 A.M. revealed the facility…

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 facility policy and procedure, the facility failed to administer medications routinely. This affected one resident (Resident #11) out of 19 residents observed in the survey sample. Findings include: Medical record review for Resident #11 revealed an admission date of 09/12/19 and the diagnoses of peripheral vascular disease, benign prostatic hypertension (BPH), hemiplegia, atherosclerotic heart disease, hyperlipedemia, high blood pressure, chronic pain, diabetes type two, and gastro esophageal reflux disease (GERD). Review of Resident #11's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was intact, required extensive one staff assistance for bed mobility, limited assistance of one staff for transfers, and supervision with eating. Review of Resident #11's physician orders for September 2021 revealed the resident was to receive three Sodium Chloride 1 gram tablets for hypo-osmolality and hyponatremia, Gabapentin 300…

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.