New Dawn Rehabilitation And Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, policy review, and record review, the facility failed to maintain a call light system that was readily accessible to its residents. This affected two (Residents #19 and #30) of three residents reviewed for call light accessibility. The facility census was 67.Findings include:1. Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, schizophrenia, and major depressive disorder.Review of the care plan dated 07/09/20 revealed Resident #19 was at risk for falls related to diagnoses. Interventions included to be sure the resident's call light was within reach and have a sign in place in sight to remind Resident #19 to use her call light for assistance.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 was moderately cognitively impaired and was dependent on staff for activities of daily living (ADLs).Observation and interview on 02/23/26 at 10:09…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview and review of policy and procedure, the facility failed to maintain proper infection control procedures during incontinence care. This effected one (Resident #63) of six residents reviewed for urinary tract infections. The census was 72. Findings include: Review of Resident #63's medical record revealed an admission date of 07/13/23. Diagnoses included congestive heart failure (CHF), depression, morbid obesity, diabetes, obstructive sleep apnea, and erythema intertrigo. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed cognition was intact. She required set up or clean up assistance with eating and oral hygiene, dependent for toileting, shower, bathing and dressing and substantial maximal assistance with personal hygiene. The resident was occasionally incontinent of urine and always incontinent of bowel.Observation of incontinence care to Resident #63 on 08/26/25 at 11:10 A.M. revealed Certified Nurse's Aide (CNA) #111 brought 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 interview, and record review the facility failed to ensure physician notification occurred related to elevated blood glucose levels resulting in the potential for inadequate diabetes management. This affected one resident (Resident #39) of five residents reviewed for medication management. Findings include: Record review revealed Resident #39 was admitted to the facility on [DATE] with diagnoses including, malnutrition, end stage renal disease, type one diabetes, [NAME] disease, chronic kidney disease, hypertension, and major depressive disorder.Review of minimum data set revealed a brief interview for mental status score of 12 out of a possible 15 points indicating some cognitive impairment. Review of Resident #39 care plan dated 06/23/25 revealed the resident has diabetes mellitus. Interventions included diabetes medication as ordered by doctor.Record review of Resident #39 vital signs revealed on 07/25/25 at 8:00 P.M. Resident #39 blood sugar check was 578. On 07/26/25 at 5:17 A.M Resident #39 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.

Based on observation, review of physician orders, review of drug manufacturer information, and interview, the facility failed to ensure medications were administered in accordance with physician orders and drug manufacturer directions. Four errors were identified out of 37 opportunities for error, resulting in a 10.8% medication error rate. This affected two (Residents #30 and #51) of five residents observed having medications administered by staff. Findings include: 1. On 02/18/25 at 7:40 A.M., Licensed Practical Nurse (LPN) #105 was observed administering medication to Resident #51. Among the medications administered were amlodipine (a calcium channel blocker used to treat hypertension, coronary artery disease and some angina) 10 milligrams (mg), hydralazine (vasodilator used to treat high blood pressure) 50 mg, and metoprolol succinate (beta blocker) 25 mg. The medications were administered during the process of obtaining vital signs. On 02/18/25 at 7:50 A.M., LPN #105 was questioned regarding if there were parameters set for administration of the medications. Resident #51's…

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 consultant reports, review of hospital records, and interview, the facility failed to write/transcribe orders resulting in a resident receiving ongoing treatment with an anti-neoplastic medication beyond ordered duration. This affected one (Resident #69) of three residents reviewed for medication use. Findings include: Review of Resident #69's closed medical record revealed an admission date of 11/19/24. Diagnoses included pleural effusion, pneumonia, difficulty walking, abnormal posture, generalized muscle weakness, essential hypertension, hyperlipidemia, atrial fibrillation, sick sinus syndrome, vitamin D deficiency, hypothyroidism, moderate protein-calorie malnutrition, presence of a cardiac pacemaker, metabolic encephalopathy, non-rheumatic aortic stenosis, congestive heart failure, gastrointestinal hemorrhage and hematemesis (vomiting blood). A social service progress note dated 12/27/24 at 11:15 A.M. indicated a call was received from Resident #69's daughter who…

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, policy review and interview, the facility failed to ensure medication administration records were maintained in an accurate and complete manner for one (Resident #63) of three residents reviewed for medication administration. Findings include: Review of Resident #63's medical record revealed diagnoses including hypertension, type two diabetes mellitus with diabetic neuropathy, intervertebral disc disorders, and arthropathies of the right shoulder. Review of Resident #63's January 2025 Medication Administration Record (MAR) revealed no donning of the ordered lidocaine patch on 01/04/25 or 01/31/25. There was no documentation lidocaine patches were removed in accordance with physician orders on 01/14/25, 01/19/25 or 01/31/25. Resident #63 had an order for blood glucose monitoring with sliding scale insulin coverage four times a day. No results were recorded on 01/12/25 at 5:00 A.M. or on 01/19/25 and 01/30/25 at 5:00 P.M. It was unable to be determined if the sliding scale insulin should have been administered. The February 2025 MAR revealed no…

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

Based on resident interview, staff interview, Computer Aided Dispatch (CAD) call report review, Self-Reported Incident (SRI) review, and medical record review, the facility failed to ensure Resident #72 received timely care and services which resulted in the resident reaching out to an outside entity for assistance. This affected one (Resident #72) out of three residents reviewed for quality of care and treatment. The facility census was 71. Findings include: Review of Resident #72's medical record revealed an admission date of 12/20/24 and discharge date of 01/02/25. Diagnoses included diabetes mellitus type two, depression, and acquired absence of right leg below the knee. Review of Resident #72's History and Physical dated 12/23/24 revealed the resident had decreased mobility, painful movement, poor strength, and had a right below the knee amputation. The resident was noted to be alert and oriented. Review of Resident #72's care plan dated 12/23/24 revealed the resident had diabetes mellitus with interventions to monitor, document, and report to the physician signs 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 review of Controlled Medication Shift Change Log, controlled medication signature sheets, record review, review of the staff schedule, policy review, and interview, the facility failed to prevent misappropriation of resident medications. This had the potential to affect 11 residents (#7, #8, #11, #16, #17, #23, #25, #26, #28, #29 and #71) who received narcotic medication and resided on the 200 hall. The facility census was 70. Findings include: On [DATE] at 3:19 P.M. review of the 200 front hall Controlled Medication Shift Change Log revealed the staff was counting the medication cards/containers and controlled medication signature sheets at the change of shift and signing the log. However, staff were not consistently writing the number of medications and signature sheets counted and the new medications delivered or medications removed from the cart. Review of the November (2024) Controlled Medication Shift change log for the 200 front hall medication cart revealed the amount of cards/containers and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of facility policy, and staff interview the facility failed to ensure accurate reconciliation of controlled medications. This affected 33 residents (#2, #3, #5, #6, #7, #8, #10, #11, #16, #17, #20, #22, #23, #24, #25, #26, #28, #29, #37, #43, #44, #46, #48, #49, #51, #53, #59, #60, #61, #62, #65, #66 and #67) who were ordered controlled medications. The facility census was 70. Findings include: 1. On [DATE] at 2:13 P.M. review of the 100 hall Controlled Medication Shift Change Log revealed there was no record of controlled medication reconciliation the morning of [DATE]. Review of the Controlled Medication Shift Change Log revealed staff was to count the number of cards/containers of medication in the locked controlled medication staff drawer and the number of sign off sheets for each medication. The staff was to write down the resident's name, medication, strength and quantity when a controlled medication is delivered from the pharmacy as well as the adjusted card 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, observation, and interview, the facility failed to ensure care and treatment was completed of diabetic foot ulcers. This affected one resident (#8) of three residents reviewed for skin impairment. The facility census was 70. Findings include: Review of the medical record revealed Resident #8 was admitted on [DATE] with diagnoses including fractured neck of right femur, chronic lymphocytic leukemia of B-cell type in remission, abnormal posture, difficulty walking, muscle weakness, falls, obstructive sleep apnea, type 2 diabetes, hypertension, mixed hyperlipidemia, atherosclerotic heart disease, gastroesophageal reflux disease and cardiac pacemaker. The resident was admitted with a right and left plantar diabetic foot ulcers. Review of the 09/24/24 admission Minimum Data Set Assessment revealed the resident was independent for daily decision making. Physician orders included a 09/25/24 treatment to bilateral plantar wounds to cleanse wound with normal saline, apply prism, and cover with dry…

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, policy review, and interview, the facility failed to ensure care and treatment of pressure ulcers was completed and consistent with professional standards of practice to promote healing, This affected one resident (#32) of three residents reviewed for skin impairment. The facility census was 70. Findings include: Review of Resident #32's medical record revealed the resident was re-admitted on [DATE] with diagnoses including hyperkalemia, congestive heart failure, cerebral infarction, dementia, depression, atrial flutter, peripheral vascular disease, anemia, type II diabetes, chronic obstructive pulmonary disease, Stage IV pressure ulcer (defined as full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) to the sacrum, and cardiac pacemaker. Record review revealed the resident was originally admitted on [DATE] with osteomyelitis of left foot, methicillin resistant staphylococcus aureus infection,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure adequate monitoring with the administration of narcotic pain medication. This affected two residents (#8 and #26) of four residents reviewed for narcotics. The census was 70. Findings include: 1. Review of Resident #8 's medical record revealed a 09/17/24 admission with diagnoses including fractured neck of right femur, chronic lymphocytic leukemia of B-cell type in remission, abnormal posture, difficulty walking, muscle weakness, muscle weakness, falls, obstructive sleep apnea, type 2 diabetes, hypertension, mixed hyperlipidemia, atherosclerotic heart disease, gastroesophageal reflux disease and cardiac pacemaker. Physician orders revealed an order dated 09/17/24 for Oxycodone 5 milligrams (mg) give one tablet every six hours as needed for pain. Review of the 09/24/24 admission Minimum Data Set Assessment revealed the resident was independent for daily decision making. On 11/14/24 at 1:48 P.M. interview with Resident #8 revealed he just gets…

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 controlled medication reconciliation records, observation, medical record review, and interview, the facility failed to ensure a narcotic medication was labeled to meet professional standards. This affected two residents (Resident #26 and #62) of 33 residents with controlled medications. The facility census was 70. Findings include: 1. On 11/14/24 at 2:45 P.M. review of the 400 hall Controlled Medication Shift Change Log revealed the staff was counting the medication cards/containers and controlled medication signature sheets at the change of shift and signing the log. Review and observation of the signature sheets for the controlled medications in the locked drawer revealed Resident #62 had a prescription for Tramadol, a Class IV narcotic. The label read: Tramadol HCL tablet 50 milligrams (mg) one tablet once daily: one tablet by mouth every 24 hours as needed. Review of the medical record revealed the resident had a physician's order dated 01/26/24 for Tramadol 50 mg by mouth every 24 hours as needed for pain. On 01/26/24 there was also an order to give Tramadol…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review the facility failed to ensure accurate medical records. This affected two residents (#16, #71) of nine residents reviewed. The facility census was 70. Findings include: 1. Review of Resident #71's closed medical record revealed a [DATE] admission with diagnoses including malignant neoplasm of anus. The resident expired [DATE]. Review of an Individual Patient Controlled Substance Administration Record for Morphine Sulfate 15 mg Immediate Release delivered [DATE] revealed one tablet was ordered every six hours for pain as needed. Review revealed on [DATE] at 11:30 P.M. two doses of morphine were signed out by Registered Nurse (RN) #174 instead of one dose without explanation. Review revealed on [DATE] at 4:00 A.M. two doses of morphine were signed out by RN #174. One dose stated the resident dropped the medication. There was no evidence of RN #174 wasting the medication with a witness. Review of an Individual Patient Controlled Substance Administration Record…

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, policy review, and interview, the facility failed to ensure infection control measures were followed as ordered during a dressing change. This affected one resident (#32) of three residents reviewed for skin impairment. The facility census was 70. Findings include: Review of Resident #32's medical record revealed a 05/03/22 admission with diagnoses including hyperkalemia, congestive heart failure, cerebral infarction, dementia, depression, atrial flutter, peripheral vascular disease, anemia, type II diabetes, chronic obstruction pulmonary disease, Stage IV (defined as full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) pressure ulcer to sacrum, and cardiac pacemaker. Review of a quarterly 09/21/24 Minimum Data Set Assessment revealed the resident was moderately impaired for daily decision making. The resident required substantial/maximum assist to roll from side to side. The resident had one Stage IV pressure ulcer. Physician orders included on 05/14/24 a low air…

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 interviews and completion of a test tray the facility did not ensure food was served at palatable temperatures. This had the potential to affect all 59 residents who ate food prepared in the kitchen. Findings include: Interviews on 07/01/24 from 9:00 A.M. through 3:00 P.M. with Residents #3, #13, #14, #119 and #218 during the screening process revealed concerns with palatability of food indicating it was often cold. Observation on 07/02/24 at 11:15 A.M. revealed the food temperatures on the steam table were above 165 degrees Fahrenheit (F). A test tray was requested and plated at 12:22 P.M. The residents' meal trays and test tray were delivered to the floor at 12:31 P.M. Staff began passing the meal trays at 12:32 P.M. At 12:43 P.M., after the last resident received their meal tray, the temperature of the food on the test tray was measured and the food tasted. The BBQ ribs were 98 degrees (F) and the sweet potato fries were 94.3 degrees F. [NAME] #821 verified the temperatures. The food felt cool to touch and tasted luke warm.

Based on observation, record review and interview the facility failed to ensure dishes and eating utensils were sanitized appropriately when the high temperature dish machine was not meeting the hot water temperature required for sanitization. This had the potential to affect all 59 residents who used dishes and cutlery from the kitchen. Findings include: Interview on 07/01/24 at 8:30 A.M. with [NAME] #821 revealed the dish machine sanitized via high temperature. [NAME] #821 also said the kitchen staff noticed the water temperature to the dish machine was lower when the laundry washing machine was running at the same time the dish machine was being used. Laundry staff was to hold running the washing machine until late morning. The facility was waiting for the hot water tank to be replaced. Observation of on 07/01/24 at 8:48 A.M. revealed a dietary aide rinsing and scrubbing dishes in a large grey colored bus tub filled with water and another tub labeled rinse prior to placing plates, cups and trays in a rack then sending the rack through the dish machine. Observation of the digital…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interview, the facility failed to ensure facial protection was available in areas where staff would spray soiled linens, failed to ensure the facility's water management program for legionella prevention was implemented, and failed to utilize the most current tuberculosis rates when reviewing their tuberculosis risk assessment. This had the potential to affect all 76 residents. Findings include: 1. During observations of the laundry room on 07/03/24 at 11:50 A.M. with Housekeeping staff #838, it was verified there was no facial shield available to avoid splatter from soiled linens. On 07/03/24 between 12:05 P.M. and 12:15 P.M., Housekeeper #838 stated there was no need to have a face shield in the laundry room because if laundry was soiled it was sent back to the floor for aides to rinse the laundry out. Observations of two of the four soiled utility rooms revealed hoppers for rinsing laundry but there were no shields for use. This was verified by Housekeeper #838 at 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, observation and interview, the facility failed to ensure all medications were secured in an appropriate manner and discarded when expired. This affected three residents (Residents #21, #36 and #37) but had the potential to affect all 25 residents residing on the 200 unit. The facility census was 76. Findings include: 1. Review of the medical record for Resident #21 revealed an admission date of [DATE] with diagnoses including diabetes mellitus. Review of the physician's orders for Resident #21 revealed an order for Insulin Glargine (Lantus) (medication for high blood sugar) 15 units one time a day dated [DATE]. Review of the Medication Administration Record for Resident #21 for [DATE] and [DATE] revealed she received the Lantus as ordered. Observation and interview on [DATE] at 11:19 A.M. of the 200 unit medication cart with Licensed Practical Nurse (LPN) #801 revealed a bottle of Lantus for Resident #21 that was dated [DATE] when it was opened. LPN #801 verified the medication 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Residents #227 and #228's personal funds were forwarded to the residents' estate within 30 days. This affected two (Residents #227 and #228) of two residents reviewed for personal funds after death. The facility census was 76. Findings include: 1. Review of the medical record for Resident #227 revealed an admission date of 06/04/22 with diagnoses including altered mental status, diabetes mellitus and hypertension. Resident #227 passed away on 12/08/23. Review of Resident #227's personal funds statement dated from 01/01/20 through 06/30/24 revealed on 07/01/24 Resident #227 had a balance of $50.15. The facility debited her account on 07/01/24 for $50.15 which closed her account. A check was made out to the facility on [DATE] for $50.15. Interview with the Administrator on 07/03/24 at 1:21 P.M. verified Resident #227 passed away on 12/08/23 and her personal funds were not dispersed until 07/01/24 to the facility. The Administrator stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, policy review, and interview, the facility failed to ensure a resident's wish for receipt of cardiopulmonary resuscitation (CPR) was clearly established in the medical record. This affected one (Resident #128) of 24 residents reviewed for code status. Findings include: Review of Resident #128's medical record revealed an admission date of [DATE] with an order for Do Not Resuscitate - Comfort Care - Arrest - Do Not Intubate (DNRCCA - DNI). DNR-CCA orders healthcare providers not to perform cardiopulmonary resuscitation (CPR) and to provide comfort care in case of cardiac or respiratory arrest. Review of an Advance Directive Questionnaire dated [DATE] and signed by Resident #128 revealed she did want CPR provided. Review of a social service progress note dated [DATE] timed 2:15 P.M. revealed Resident #128 requested her advance directive be changed to full measures. Nursing was notified. On [DATE] at 3:44 P.M., the discrepancy between the order for DNRCCA-DNI and the signed Advance…

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 and medical record review, the facility failed to ensure comprehensive care plans were established. This affected two Residents (#14 and #54) of 18 residents reviewed for care plans. The facility census was 76. Findings include: 1. Review of the medical record for Resident #14 revealed an admission date of 04/23/23 and diagnoses including congestive heart failure, depression, and chronic kidney disease. Review of the physician's order dated 04/08/24 revealed Resident #14 was on Vistaril 50 milligrams every eight hours for anxiety. Review of the current care plan for July 2024 revealed no evidence Resident #14's anxiety diagnosis or anti-anxiety medication use was addressed in the care plan. Interview on 07/03/24 at 9:41 A.M. with the Director of Nursing confirmed there was no care plan established for Resident #14's anxiety diagnosis or anti-anxiety medication use. 2. Review of the medical record for Resident #54 revealed an admission date of 11/15/23 and diagnoses including fracture of 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.

Based on record review and interview, the facility failed to ensure Residents #43 and #55's care plans were revised to reflect all fall interventions. This affected two (Residents #43 and #55) of three residents reviewed for falls. The facility census was 76. Findings include: 1. Review of the medical record for Resident #55 revealed an admission date of 11/13/23 with diagnoses including syncope and collapse, difficulty in walking and repeated falls. Review of the care plan dated 11/15/23 and last updated on 06/17/24 for Resident #55 revealed the facility did not revise her care plan for the fall on 03/01/24 to reflect a new fall intervention of hipsters (impact absorbing pads that are worn to reduce the risk of fractures). Review of the fall investigation dated 03/01/24 revealed Resident #55 had a fall, and the new intervention was to have the resident wear hipsters. Review of the physician's orders for July 2024 revealed Resident #55 did not have an order for hipsters to be worn as a fall intervention. Interview on 07/03/24 at 10:40 A.M. with the Director of Nursing verified…

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

Based on observations, medical record review, review of the facility's activity calendar, and interview, the facility failed to ensure an individualized activity program was provided and group activities were scheduled to permit participation by one (Resident #121) of two residents reviewed for activities. Findings include: Review of Resident #121's medical record revealed diagnoses including anxiety disorder and metabolic encephalopathy. An Exceeding Expectations form indicated Resident #121 preferred group activities. Review of a modification of admission/Medicare five day Minimum Data Set (MDS) assessment revealed Resident #121 was able to make herself understood and was able to understand others. Resident #121 was assessed as cognitively intact with a brief interview for mental status score of 15 (out of a possible 15). The activity preference section of the MDS was completed with input by Resident #121 who indicated it was somewhat important to have reading material, listen to the music she liked, do things with groups of people, and do favorite activities. Resident #121…

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 review, the facility failed to ensure non-pharmacological interventions were attempted prior to the administration of an anti-anxiety medication ordered on an as necessary basis. This affected one (Resident #130) of five residents reviewed for medication use. Findings include: Review of Resident #130's medical record revealed diagnoses including Parkinson's disease, neurocognitive disorder with Lewy bodies (Lewy bodies are the inclusion bodies/ abnormal aggregations of protein, that develop inside nerve cells affected by Parkinson's disease, the Lewy body dementias, and some other disorders.), cerebrovascular disease, generalized anxiety disorder, and major depressive disorder. On 06/20/24, an order was written for Ativan (anti-anxiety) one half milligram (mg) every eight hours as needed for anxiety. On 06/21/24, a clarification to the order limited the use to a 14 day duration. Review of the June 2024 Medication Administration Record (MAR) revealed the Ativan was administered on 06/20/24 at 10:56 P.M., 06/21/24 at 11:00 P.M.,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to offer pneumococcal vaccinations in accordance with recommended vaccination schedules from the Centers for Disease Control (CDC). This affected two (Residents #130 and #226) of five residents reviewed for immunizations. Findings include: 1. Review of Resident #226's medical record revealed an admission assessment dated [DATE] which indicated Resident #226 was up to date on pneumococcal vaccinations with the last date of administration being 01/24/18. Review of Resident #226's immunization records revealed a pneumovax PPV 23 was administered on 01/27/17 when he was [AGE] years old and a dose of Prevnar 13 on 01/24/18 when he was [AGE] years old. During an interview with Licensed Practical Nurse (LPN) #808 on 07/01/24 at 5:35 P.M., she stated she believed since Resident #226 had a history of receiving both the PPV 23 and Prevnar 13 vaccines he was up to date and did not need any further pneumococcal vaccines offered. After reviewing the CDC…

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 and interview, the facility failed to ensure the environment was maintained in a safe and sanitary manner. This had the potential to affect all residents on 100 hall (Residents #1, #2, #3, #4, #5, #6, #7, and #8) and one (Resident #41) of three residents observed for incontinence care. The facility census was 69. Findings include: 1. During tour of the facility on 05/06/24 between 4:22 A.M. and 4:55 A.M., a towel and bath blanket were observed on the floor in the 100 hall bathroom. A bath blanket was observed on the floor in the 100 hallway with safety cones. Resident #4 was observed sitting in her room, dressed in personal clothes, and coloring. During an interview on 05/06/24 during the tour after observations had been made on the 100 hall, State Tested Nursing Assistant (STNA) #100 reported the bath towel on the floor in the hall was due to a leak. The towel and bath blanket in the 100 hall bathroom were from Resident #4's shower and she had not had the opportunity to remove them from the floor. No leaks were observed during multiple observations on 05/06/24…

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, review of fall investigations, and interviews, the facility failed to implement fall interventions for three (Residents #45, #46, and #56) of five residents reviewed for falls. The facility census was 69. Findings include: During general observations on 05/06/24 and 05/07/24, Residents #45 and #46 were observed with mats placed beside their beds, when the residents were lying down in bed. 1. Review of Resident #45's open medical record revealed diagnoses including encephalopathy, restless and agitation, vascular dementia, generalized muscle weakness, abnormal posture and cerebral infarction. Review of Resident #45's fall risk assessment dated [DATE] indicated Resident #45 had one to two falls over the prior six months. Other risk factors for falls included medication use, confusion, total incontinence, confinement to a chair, inability to independently rise to a standing position and need for hands on assistance to move from place to place. Review of 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.

Based on observation, medical record review, policy review and interview, the facility failed to store nebulizer equipment in a sanitary manner for one (Resident #51) of three residents reviewed for use of nebulizer equipment. The facility census was 69. Findings include: Review of Resident #51's medical record revealed diagnoses including cerebral infarction, congestive heart failure, and heart disease. Review of Resident #51's medical record revealed the following orders dated 01/26/24 albuterol sulfate 0.083%: three milliliters (ml) via nebulizer every six hours as needed; and also dated 01/26/24 nebusal inhalation nebulization solution 3%: give 3 ml via nebulizer twice a day. Observations on 05/06/24 at 7:55 A.M. revealed the nebulizer mask was not stored in a bag. This was verified by State Tested Nursing Assistant (STNA) #145 during the observation. Observations on 05/08/24 at 8:28 A.M. revealed Resident #51's nebulizer mask was sitting on the night stand. The machine was not running. Resident #51 indicated the mask came apart from the tubing the last time he was using 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, review of the medical record, interview with staff and review of facility policy the facility failed to ensure Resident # 24, #32 and #68 received their physician ordered adaptive equipment for meals. This affected three residents (Resident #24, #32 and #68) of five residents reviewed for nutrition. The facility census was 71. Findings included: 1. Review of the medical record revealed Resident #68 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, hypertension, ischemic cardiomyopathy, atrial fibrillation, congestive heart failure, prostate cancer, and bladder cancer. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #68 had intact cognition. Review of the April 2024 physician's orders revealed Resident #68 had an order for two-handles cups and built-up silverware with all meals dated 03/07/24. Review of the meal ticket dated 04/04/24 revealed Resident #68 was to receive a two-handled cup with a lid and built-up…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews the facility did not ensure Resident #17, #40 and #48 had safe and appropriate transportation services provided to them to get to their dialysis treatments at a dialysis center outside of the facility. This affected three residents (#17, #40, and #48) of four reviewed for transportation to dialysis. The facility identified four residents (#17, #24, #40 and #48) who required transportation to dialysis. The facility census was 71. Findings included: Observation was conducted on 04/10/24 at 7:30 A.M. of the distance and path of travel between the facility and the dialysis center. The path exited out the front doors of the facility, through the parking lot and up a road approximately 1000 feet from the facility. The road was a sub-road off of a main road between the facility and the dialysis center and was the road traffic needed to travel to get to various medical buildings spread out within the area. The traffic was light at the time of the observation. There were…

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, observation, and air temperature, the facility failed to ensure the 300 hall central shower room was a comfortable temperature. This affected 17 residents (Residents #2, #7, #12, #16, #25, #28, #33, #36, #39, #46, #49, #51, #53, #57, #59, #63 and #317) on the 300 hall who utilized the shower. The facility census was 63. Findings include: Interview 03/13/23 at 11:32 A.M. with Resident #2 revealed she was cold in the facility. Interview 03/13/23 at 2:44 P.M. with Resident #33 revealed it was cold in the shower room because the heater was broken. Interview 03/15/23 at 9:29 A.M. with State Tested Nurse Aide (STNA) #145 revealed she began working at the facility since December 2022 and the heater in the 300 hall central shower room had been broken since she started. The control knob was off. Interview 03/15/23 at 9:34 A.M. with Licensed Practical Nurse (LPN) #95 revealed she did not know anything about the 300 hall central shower room heater being broken but she had been told it was cold in the shower room. LPN #95 included maintenance was very responsive so if they…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of the medical record, interviews with staff and facility policy review, the facility failed to ensure aerosol nebulizer masks were properly stored in a protective barrier for Residents #15, #49, #167, #168, and #169 and did not ensure the humidifier bottle was filled and oxygen orders were obtained for Resident #49. This affected five residents (Residents #15 #49, #167, #168, and #169) of five reviewed for respiratory therapy. Findings include: 1. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE]. Resident #15 had diagnoses including respiratory failure, muscle weakness, hypertension, atherosclerotic heart disease, chronic kidney disease, hypothyroidism, obstructive sleep apnea, diabetes, congestive heart failure, and erythema intertrigo. Review of physician's orders revealed Resident #15 had an order for Formoterol Fumarate Nebulization Solution 20 micrograms (mcg) every 12 hours for shortness of breath dated 12/23/22. Review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop comprehensive care plans in the areas of activities and activity of daily living. This affected two residents (Residents #12 and #217) of 17 residents reviewed. Findings include: 1. Review of Resident #12's medical record revealed a 09/18/20 admission with diagnoses including dementia, congestive heart failure, acquired absence of left toes, cerebral infarction, anemia, cardiomyopathy, type two diabetes, peripheral vascular disease, hypertension, and pressure ulcers. Review of Resident #12's quarterly Minimum Data Set Assessment (MDS) assessment dated [DATE] revealed Resident #12 was moderately impaired for daily decision making, had adequate vision with no glasses, required extensive assist of two for bed mobility, dressing, transfers and toileting, did not walk, was independent for eating, required extensive assist of one for personal hygiene, and was totally dependent on two for bathing, and had two pressure ulcers. Interview 03/13/23 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 observation, record review and interview, the facility failed to ensure residents received the assistance required to keep their fingernails clean and trimmed. This affected two (Residents #2 and #217) of three residents reviewed for activities of daily living. Findings include: Review of Resident #2's medical record revealed a 11/30/22 admission with diagnoses including wedge compression fracture of second lumbar vertebra, type 2 diabetes, hypertension, fibromyalgia, rheumatoid arthritis, congestive heart failure, age related physical, and depression. Resident #2 had an admission comprehensive Activity of Daily Living Self Care Performance Deficit plan of care related to weakness, repeated falls, rheumatoid arthritis and age related debility. Interventions included Resident #2 required staff participation with personal hygiene. Review of the 02/10/23 quarterly Minimum Data Set Assessment (MDS) assessment revealed Resident #2 was independent for daily decision making, felt tired and down, had trouble falling asleep and little interest in doing things 12-14 days in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure pressure reducing orders were written timely for Resident #8, dressing changes were completed and/or documented as completed for Residents #8, and #12, pressure reducing devices were in place as ordered for Residents #53 and a pressure ulcer dressing was applied after a shower, and ensure Resident #12's air mattress was supported to ensure his feet were not in a dependent position. This affected three (Residents #8, #12 and #53) of five residents reviewed for pressure ulcers. Findings include: 1. Review of Resident #12's medical record revealed a 09/18/20 admission with diagnoses including dementia, stage 3 (full-thickness loss of skin that extends to the subcutaneous tissue but does not cross the fascia beneath it) pressure ulcer, stage 4 (full-thickness skin loss extending through the fascia with considerable tissue loss) sacral ulcer, congestive heart failure, acquired absence of left toes, cerebral infarction, anemia,…

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 medical record review the facility failed to ensure orders where in place for Resident #47's dialysis treatments and ensure the dialysis access site was assessed. This affected one out of one resident reviewed for dialysis. The facility identified two residents who received dialysis (Residents #47 and #49). The facility census was 63. Findings include: Review of Resident #47's medical record revealed an admission date of 09/03/21. Diagnoses included end stage renal disease, dependence on renal dialysis, and peripheral vascular disease. Review of Resident #47's the quarterly Minimum Data Set (MDS) assessment, dated 01/23/23, revealed Resident #47 had intact cognition. Review of Resident #47's care plan, dated 03/10/23, revealed Resident #47 required dialysis related to end stage renal disease. Interventions included check and change dressing daily at access site as ordered, encourage resident to go for the scheduled dialysis appointments on Tuesday, Thursday, and Saturday, monitor bruit and thrill as ordered, monitor for any signs or symptoms 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 interview, record review and pharmacy recommendation review the facility did not ensure pharmacy recommendations were addressed timely for Residents #2 and #47. This affected two of five residents reviewed for unnecessary medications (Resident #2, Resident #7, Resident #1, Resident #15, Resident #26). The facility census was 63. Findings include: 1. Review of Resident #47's medical record revealed an admission date of 09/03/21. Diagnoses included end stage renal disease, dependence on renal dialysis, and peripheral vascular disease. The record revealed allergies to acetaminophen, meloxicam, and oxycodone. Review of Resident #47's the quarterly Minimum Data Set (MDS) assessment, dated 01/23/23, revealed Resident #47 had intact cognition. Review of a Pharmacy Recommendation dated 12/07/22 for Resident #47 revealed allergies to acetaminophen (severe), oxycodone (severe-psychosis), and meloxicam (cutaneous-pruritus). The recommendation further indicated Resident #47 was receiving acetaminophen 325…

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

Based on observation and interview, the facility failed to blend pureed food to a smooth consistency. This affected one (Resident #8) of one resident on a pureed diet. The facility census was 63. Findings include: Observation of the pureed process 03/14/23 at 4:02 P.M. with [NAME] #122 revealed [NAME] #122 placing one two ounce serving of ham into the robot coup and adding water then blending. After blending [NAME] #122 placed the ham in a bowl. [NAME] #122 said he already pureed a serving of sweet potatoes for Resident #8, the only resident in the facility who received a pureed diet. The sweet potatoes were tasted and found to be lumpy. When [NAME] #122 tasted the pureed sweet potatoes he stated it was stringy. Interview on 03/14/23 at 4:18 P.M. with [NAME] #122 verified the sweet potatoes were stringy and lumpy, not a smooth consistency.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to complete a comprehensive significant change Minimum Data Set 3.0 (MDS) assessment as required. This affected one (Resident #31) of 24 residents reviewed for comprehensive assessments. The facility census was 57 residents. Findings include: Medical record review revealed Resident #31 was admitted on [DATE] with diagnoses including unspecified dementia without behavioral disturbances, anxiety, and major depressive disorder. Review of the Medicare-5 day MDS assessment dated [DATE] revealed Resident #31 required limited assist with bed mobility, transfers and toilet use, was independent with eating, had no behaviors and was continent of bowel. The resident's mood was not assessed. Review of the quarterly MDS assessment dated [DATE] revealed Resident #31 required extensive assist with bed mobility, transfers and toilet use, required supervision with eating, behavioral symptoms occurred up to four to six days and the resident was occasionally…

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 accurately complete resident comprehensive assessments. This affected three (Residents #31, #37, and #45) of 24 residents reviewed for comprehensive assessments. The facility census was 57 residents. Findings include: 1. Medical record review revealed Resident #31 was admitted on [DATE] with diagnoses including dementia without behavioral disturbances, anxiety, and major depressive disorder. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #31's mood and influenza vaccination was not assessed/no information. Review of Resident #31's care plans revealed the resident had mood problems. On 05/04/21 at 7:40 A.M., Assistant Administrator #567 verified via electronic mail Resident #31's quarterly MDS assessment was not accurate. 2. Medical record review revealed Resident #37 was admitted on [DATE] with diagnoses including muscular dystrophy, diabetes mellitus, and history of urinary tract infections.…

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 representatives with written baseline care plans. This affected one (Resident #31) of five newly admitted sample residents. The facility census was 57 residents. Findings include: Medical record review revealed Resident #31 was admitted on [DATE] with diagnoses including unspecified dementia without behavioral disturbances, anxiety, and major depressive disorder. Review of the Baseline Care Plan dated 12/15/2020 revealed the resident representative was provided the baseline care plan verbally. Further review of the Baseline Care Plan dated 12/15/2020 revealed no date/time documented as to when and who provided the information to the representative. There was also no evidence the representative was mailed or provided a written copy of the baseline care plan. On 05/04/21 at 11:14 A.M., the Administrator verified via electronic mail there was only verbal review of the baseline care plan on 12/15/2020 with Resident #31's…

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 ensure resident care plans were accurate. This affected two (Residents #31 and #37) of 24 residents reviewed. The facility census was 57 residents. Findings include: 1. Medical record review revealed Resident #31 was admitted on [DATE] with diagnoses including unspecified dementia without behavioral disturbances, anxiety, and major depressive disorder. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #31 required extensive assist with bed mobility, transfers and toilet use, required supervision with eating, behavioral symptoms occurred up to four to six days and the resident was occasionally incontinent bowel. Review of the care plan: ADL Self-Care Performance Deficit revised 12/16/2020 revealed no evidence of amount of assist with ADL's decline and/or new interventions to prevent further decline. Review of the care plan: Antipsychotic Medication related to Behavior Management…

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 interview, the facility failed to assist dependent residents with the removal of unwanted facial hair. This affected one (Resident #42) of two residents sampled for Activities of Daily Living (ADL). The facility census was 57 residents. Findings include: Medical record review revealed Resident #42 was admitted on [DATE] with diagnoses including Alzheimer's disease, dementia, atrial fibrillation, and muscle weakness. Review of the ADL Self-Care Performance Deficit dated 12/17/19 revealed the resident required staff assistance with personal hygiene due to activity intolerance, dementia, and fatigue. Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #42 was severely impaired for daily decision-making and required extensive assist with personal hygiene. On 04/27/21 at 11:42 A.M., observation revealed inch long, white whiskers observed extending from Resident #42's chin. On 05/03/21 at 12:38 P.M., observation of Resident #42…

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, operator manual review, policy review, and interview, the facility failed to ensure pressure relief interventions were implemented. This affected one (Resident #37) of two residents reviewed for pressure ulcers. The facility census was 57 residents. Findings include: Medical record review revealed Resident #37 was admitted on [DATE] with diagnoses including muscular dystrophy, diabetes mellitus, and history of urinary tract infections. As of 04/20/21, Resident #37 weighed 150 pounds. Review of the care plan: Potential for Pressure Ulcer Development dated 09/30/2020 revealed Resident #37 had the potential for pressure ulcer development due to weakness, impaired mobility, friction/shearing, spends the majority of her time in bed, and diagnosis of Muscular Dystrophy. Interventions included to encourage and assist resident to float heels when in bed, pressure relieving device on bed and treatments as ordered. Review of the quarterly Minimum Data Set assessment dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and interview, the facility failed to ensure positioning boots to prevent contractures were available for use as ordered. This affected one (Resident #37) resident reviewed for positioning. This facility census was 57 residents. Finding include: Medical record review revealed Resident #37 was admitted on [DATE] with diagnoses including muscular dystrophy, diabetes mellitus, and history of urinary tract infections. Review of the Physical Therapy Evaluation & Plan of Treatment dated 03/04/21 through 03/17/21 revealed staff was educated in lower extremity range of motion (ROM) exercise and application of bilateral ankle braces to prevent contractures, left ankle passive ROM (PROM) to prevent contractures and improve right knee flexion, active assist ROM (AAROM), and left knee flexion AAROM/PROM to enable the resident to position lower extremities to assist with bed mobility tasks. Review of the Physical Therapy Discharge summary dated [DATE] revealed discharge…

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 interview, the facility failed to provide adequate care and services for a resident diagnosed with dementia with behavioral disturbances. This affected one (Resident #31) of three residents reviewed for dementia. The facility census was 57 residents. Findings include: Medical record review revealed Resident #31 was admitted on [DATE] with diagnoses including unspecified dementia without behavioral disturbances, tremor, and major depressive disorder. On 03/02/21, the resident was diagnosed with anxiety, and on 03/22/21, the resident was diagnosed with dementia with behavioral disturbances. Review of the care plan: Antipsychotic medication for behavior management dated 03/25/21 revealed the resident recently displayed marked aggression (physical and verbal) towards staff. Interventions included to administer medications as ordered; monitor/document for side effects and effectiveness; monitor/record occurrence of target behavior symptoms: inappropriate response 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, medical record review, and interview, the facility failed to provide adequate care and services to psychotropic drugs administered to residents with dementia. This affected one (Resident #31) of three residents reviewed for dementia. The facility census was 57 residents. Findings include: Medical record review revealed Resident #31 was admitted on [DATE] with diagnoses including unspecified dementia without behavioral disturbances, tremor, and major depressive disorder. On 03/02/21, the resident was diagnosed with anxiety and on 03/22/21, the resident was diagnosed with dementia with behavioral disturbances. Review of the Medicare-5 day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 was severely impaired for daily decision-making; required limited assist with bed mobility, transfers and toilet use; was independent with eating; had no behaviors, no psychosis, no wandering; and was continent of bowel. The resident's mood was not assessed. Review of the quarterly MDS…

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, medication guideline review, policy review, and interview, the facility failed to administer medications without error. This affected two (Resident #50 and #157) of eight residents observed for 26 medication opportunities. The medication error rate was 7.69%. The facility census was 57 residents. Findings include: 1. Medical record review revealed Resident #50 was admitted on [DATE] with diagnoses including unspecified anemia. Review of the electronic physician orders dated April 2021 revealed Resident #50 received ferrous sulfate (iron) 325 milligrams (mg) twice a day. On 04/28/21 at 4:10 P.M., observation revealed Licensed Practical Nurse (LPN) #515 administered medications including ferrous sulfate 325 mg to Resident #50. LPN #515 crushed the ferrous sulfate tablet, mixed it food and administered it to the resident. On 04/28/21 at 4:59 P.M., interview with LPN #515 verified she crushed ferrous sulfate and administered it to Resident #50. Review of the medication…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure multi-dose medications were labeled with date when opened and not outdated. This affected two (Residents #36 and #162) of 11 resident receiving insulin. The facility census was 57 residents. Findings include: 1. On 05/03/21 at 3:32 P.M. an observation of the 100/200 hall medication cart revealed an opened Tresiba (insulin) Flex pen belonging to Resident #162. The insulin was brought from home and there was no date when insulin was opened. There was also a Humalog (insulin) flex pen belonging to Resident #162, which was bought from home and there was no date indicating when insulin was opened. In addition, the Humalog flex pen belonging to Resident #162 arrived to the facility on [DATE] with a sticker on the packing indicating to refrigerate until ready to use, however, this was being stored in the medication cart and not in the refrigerator. Interview on 05/03/21 at 3:38 P.M. with Licensed Practical Nurse (LPN) #518 verified insulin is to be…

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, policy review, and interview, the facility failed to maintain comprehensive and accurate medical records. This affected two (Residents #31 and #37) of 12 residents reviewed. The facility census was 57 residents. Findings include: Medical record review revealed Resident #37 was admitted on [DATE] with diagnoses including muscular dystrophy, diabetes mellitus, and history of urinary tract infections. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #37 was cognitively intact and received oxygen. Review of the care plan: Oxygen Therapy related to Respiratory illness diagnosed COVID dated 06/18/2020 revealed the resident was on continuous humidified oxygen at 6 liters. On 04/26/21 at 2:41 P.M., observation revealed Resident #37 was not wearing oxygen and did not have an oxygen concentrator/equipment in her room. At the time of the observation, Resident #37 stated she has not worn oxygen since recovering from COVID-19 last year. On…

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

Based on observation, staff interview, and record review revealed the facility failed to maintain acceptable standards of infection control during a dressing change. This affected one (Resident #27) of two residents reviewed for pressure ulcers. The facility census was 57 residents Findings include: Review of the medical record for Resident #27 revealed an admission date of 02/01/21. Diagnosis including pressure ulcer, adult failure to thrive and surgical amputation. Review of Orders for April 2021 revealed dressing change for right lateral distal knee; cleanse with normal saline (NS); apply puracol ag (collagen wound dressing) to wound bed; cover with foam dressing; and change daily and as needed. Observation on 04/29/21 at 2:30 P.M. of Resident #27's dressing change with Licensed Practical Nurse (LPN) #518 revealed LPN #518 washed her hands and applied two sets of gloves (double gloving), then placed a barrier down on bed and put dressing material on it. LPN #518 proceeded to remove the old dressing dated 04/29/21, and place it on the clean barrier. She then opened a 4x4 gauze 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.