The Convalarium Of Dublin

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to timely assess and implement treatment for non-pressure skin conditions. This affected one (#56) of three residents reviewed for wounds. The facility census was 80.Findings include:Review of Resident #56's medical record revealed an admission date of 09/02/25. Diagnoses included respiratory failure with hypoxia, cerebral edema, protein-calorie malnutrition, cerebral infarction, metabolic encephalopathy, hypokalemia, convulsions, paroxysmal atrial fibrillation, peripheral vascular disease, and pneumonia. Review of the Resident #56's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was unable to complete the Brief Interview of Mental Status due to severe cognitive impairment. Further review revealed the resident was fully dependent on staff for all activities of daily living (ADLs).Review the Resident #56's care plan last revised on 11/19/25 revealed the resident was at risk for skin alteration related 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 staff interview, the facility failed to ensure pressure ulcer preventative interventions were in place as ordered. This affected one (#35) of five residents reviewed for pressure ulcers. The facility census was 80.Findings include:Record review for Resident #35 revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, diabetes mellitus, chronic obstructive pulmonary disease, schizophrenia, peripheral vascular disease.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 08. The resident was assessed to require self-care and mobility assistance.Review of the care plan dated 11/05/25 revealed Resident #35 previously had a right heel pressure ulcer and was at risk for additional skin breakdown related to her immobility.Review of Resident #35's physician orders revealed an order dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of a risk assessment, resident and resident family interviews, staff interview, and review of an incident log, the facility failed to complete a thorough investigation into a resident accident with injury. This affected one (#92) of three residents reviewed for accidents and injuries. The facility census was 80. Findings include: Review of the medical record for Resident #92 revealed an admission date of 02/18/25 and discharge date of 03/04/25. Diagnoses included respiratory failure with hypoxia, sepsis, heart failure, heart disease, displaced fracture of the scapula, cognitive communication deficit, and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #92 had a Brief Interview of Mental Status (BIMS) of 12 indicating moderately impaired cognition and required supervision and touching assist. The assessment revealed the resident had no falls since admission. Review of the plan of care dated 03/10/25 revealed Resident #92 was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of a concern form, review of written statements, staff interview, and policy review, the facility failed to ensure adequate transportation was provided to residents for outside appointments. This affected one (#96) of three residents reviewed for transportation to outside appointments. The census was 80.Findings include:Review of the medical record for Resident #96 revealed an admission date of 10/03/24. Diagnoses included acute chronic systolic heart failure, type II diabetic mellitus morbid obesity, chronic respiratory failure, and major depression bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #96 was cognitively intact and was dependent on staff for toileting, showers/bath, putting on footwear, and turning side-to-side in bed. She used a wheelchair to transfer throughout the facility. Review of the nursing progress notes for Resident #96 confirmed she had multiple appointments arranged outside the facility. On 04/03/25,…

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, review of a concern form, and staff interview, the facility failed to ensure dental services were provided in a timely manner. This affected one (#8) of two residents reviewed for dental services. The facility census was 80.Findings include: Review of Resident #8's medical record revealed an admission date of 08/01/25 and medical diagnoses of chronic obstructive pulmonary disease, hemiplegia, congestive heart failure, major depressive disorder, anxiety disorder, dementia, unspecified hallucinations, and muscle weakness. Review of Resident #8's concern form dated 10/30/25 revealed the resident filed a concern form reporting that his teeth (dentures) were missing. Further review of the concern form revealed Resident #8's dentures were found broken and lodged in the toilet. The guardian was notified on 11/04/25 and indicated they would contact the dental company for Resident #8 to be seen by the dentist. Review of Resident #8's care plan dated 11/03/25 revealed to monitor and notify the medical provider as needed of signs and symptoms of oral/dental…

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, resident and staff interview, and policy review, the facility failed to provide recommended eating equipment and utensils during meals as specified. This affected one (#21) of four residents reviewed for nutrition. The census was 80. Findings include:Review of the medical record for Resident #21 revealed an admission date of 10/16/25. Diagnoses included atrial fibrillation, chronic obstructive pulmonary disease, diabetes, dysphagia, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had a Brief Interview of Mental Status (BIMS) score of 12 indicating moderately impaired cognition and required set up assist with eating.Review of the care plan dated 10/29/25 revealed Resident #21 was at risk for malnutrition or alteration in nutritional status with interventions for adaptive equipment as ordered, assist with meals as ordered, monitor the resident's ability to chew/swallow, and report changes to the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, resident and staff interview, review of facility's infection control surveillance log, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to ensure proper personal protective equipment (PPE) was available for staff providing care for a resident (#24) with COVID-19 infection. Additionally, the facility failed to ensure a resident (#25) with known exposure to a COVID-19 resident followed appropriate guidance and physician orders to prevent potential spread of the virus. This had the potential to affect all 83 residents residing in the facility. The census was 83. Findings include: 1. Review of the medical record for Resident #24 revealed an admission date of 12/15/24. Diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure, type II diabetes mellitus, and pneumonia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 was cognitively intact required limited assistance…

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

Based on observations, staff interviews, and review of facility policies and procedures, the facility failed to maintain sanitary food storage and preparation conditions. This had the potential to affect 55 residents who ate food prepared from the facility. The facility census was 79. Findings include: Observation of the kitchen walk in refrigerator on 11/25/24 at 8:38 A.M. revealed that a container that appeared to contain de-stemmed grapes, a container that appeared to contain shredded lettuce and a container that contained a small diced yellow fruit were unlabeled and undated on the refrigerator shelves. Interview on 11/25/24 at 8:38 A.M. with Dietary Manager #235 confirmed that three containers of food in the walk in refrigerator were unlabeled and undated. Dietary Manager #235 was unable to verify when the food items were initially opened. Observation on 11/25/24 at 8:43 A.M. revealed that there was approximately one inch thick of ice and snow like frost build up on the bottom left freezer when the walk in freezer door was opened. There were boxes of food with ice and frost 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 record review, review of immunization records, staff interview, and facility policy review, the facility failed to educate residents on the risks and benefits and/or offer influenza vaccinations to residents as required. This affected five (Residents #42, #44, #61, #72, and #89) of five reviewed for immunizations. The facility census was 79. Findings Include: 1. Review of the medical record for Resident #42 revealed an admission date on 10/29/24. Medical diagnoses included encephalopathy, acute and chronic respiratory failure with hypoxia, type II Diabetes Mellitus with hyperglycemia, and morbid obesity. Review of immunization records revealed Resident #42 received the influenza (flu) immunization on 11/23/22. There was no further evidence Resident #42 had been offered the vaccination since admission. There was no evidence Resident #42 had been educated on the risks and benefits of receiving the flu vaccination. 2. Review of the medical record for Resident #44 revealed an initial admission date on 05/13/23 and a readmission date on 09/23/24. Medical diagnoses included…

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

Based on record review, review of immunization records, staff interview, and facility policy review, the facility failed to educate on the risks and benefits and/or offer COVID-19 vaccinations to residents as required. This affected five (Residents #42, #44, #61, #72, and #89) of five reviewed for immunizations. The facility census was 79. Findings include: 1. Review of the medical record for Resident #42 revealed an admission date on 10/29/24. Medical diagnoses included encephalopathy, acute and chronic respiratory failure with hypoxia, type II Diabetes Mellitus with hyperglycemia, and morbid obesity. Review of immunization records revealed Resident #42 received COVID-19 vaccinations on 03/04/21, 04/01/21, and 11/10/21. There was no evidence Resident #42 and/or the resident's representative was educated on the COVID-19 vaccination upon admission. There was no evidence the COVID-19 vaccination was offered to Resident #42 or the resident's representative upon admission. 2. Review of the medical record for Resident #44 revealed an initial admission date on 05/13/23 and a readmission…

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 follow resident code status orders. This affected one (Resident #90) of one resident reviewed for code status. Also, the facility failed to follow physician orders regarding resident weight status. This affected one (Resident #44) of five residents reviewed for nutritional orders. The census was 79. Findings include: 1. Resident #90 was admitted to the facility on [DATE]. Her diagnoses were congestive heart failure, muscle weakness, chronic respiratory failure, acute pulmonary edema, asthma, morbid obesity, atrial fibrillation, hypertension, anxiety disorder, insomnia, depression, hypothyroidism, osteoarthritis, and obstructive sleep apnea. Review of her Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. Review of Resident #90's physician orders and code status form found she had a code status of Do Not Resuscitate (DNR) Comfort Care Arrest (CCA). Review of Resident #90's progress notes 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident medical record review, interviews with staff, and review of facility policy, the facility failed to provide proper wound monitoring for Resident #61. This affected one resident (#61) out of five residents reviewed for wound care. The facility census was 79 residents. Findings include: Resident #61 was admitted on [DATE] with diagnoses that included chronic respiratory failure, protein calorie malnutrition, paraplegia, disease of spinal cord, tracheostomy, and person injured in a motor vehicle accident. Review of Resident #61's Minimum Data Set (MDS) assessment dated [DATE] revealed that resident had four stage four pressure ulcers, all of which were present upon admission to the facility. Review of Resident #61's medical record revealed the resident was seen by the wound care nurse and wound nurse practitioner on 09/18/24 and measurements of his wounds were recorded. On 09/24/24, Resident #61 had a brief hospitalization and he was readmitted to the facility on [DATE]. On 09/25/24, 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 interview, and review of the facility policy, the facility failed to ensure medications were not left at bedside. This affected one resident (#55) of one resident observed for medications left at bedside. The census was 79. Findings include: Review of medical record for Resident #55 revealed an admission date of 02/14/20. The resident was admitted with diagnosis of acute and chronic respiratory failure. Observation on 11/27/24 at 8:50 A.M. upon entering Resident #55's room, revealed the resident was asleep with bipap upon his face. The nightstand beside the bed had a pill cup with eight tablets of medications. There was not a nurse in the room at this time. There was a certified nurse aide who came into the room with his breakfast tray and the resident removed the bipap then grabbed at the pill cup to take them. The resident stated they were the pills from the night time. This surveyor asked the resident to wait until the nurse could come to the room to verify the medications. Interview with Licensed Practical Nurse (LPN) #187 on 11/27/24 verified 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, staff interview, and review of the facility policy, the facility failed to prevent a medication error rate of less than five percent. There were two medication errors out of 25 opportunities, resulting in an eight percent error rate. This affected one (Resident #20) of six residents observed for medication administration. The census was 79. Findings include: Review of the medical record revealed Resident #20 was admitted on [DATE]. Review of the physician orders dated 07/17/24 for Resident # 20 revealed an order for Tylenol 325 milligrams (mg), give two tablets every six hours for general discomfort and an order dated 09/30/24 for Morphine Sulfate oral solution 20 mg per 5 milliliters (ml) to give 0.5 mg by mouth four times a day and to give 0.5 ml by mouth every two hours for pain and short of breath. Observation of Licensed Practical Nurse (LPN) #119 on 11/26/24 at 2:15 P.M. revealed LPN #119 prepared medications for Resident # 20 which included Tylenol 500 mg, two tablets and Morphine…

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 interview, resident interview, and policy review, the facility failed to prevent significant medication errors. This affected two (Resident's #44 and #23) of five residents reviewed for medication administration. The facility census was 79. Findings include: 1. Review of the medical record for Resident #44 revealed an admission date of 05/13/23 and a re-entry admission date of 09/23/24. Medical diagnoses include chronic obstructive pulmonary disease (COPD), morbid obesity due to excess calories, type two diabetes mellitus with diabetic polyneuropathy, and unspecified protein-calorie malnutrition. Review of Resident #44's Minimum Data Set (MDS) 3.0 assessment revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Review of the physician orders for Resident #44 revealed an order for insulin glargine solostar subcutaneous solution pen-injector 100 unit, inject 45 units subcutaneously two times a day related to type two diabetes melluitus with diabetic polyneuropathy with a start date of 09/24/24.…

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 observation, interview, medical record reveiw, and policy review, the facility failed to ensure catheter bags were stored in a sanitary manner to prevent infection. This affected one (Resident #20) of one resident observed for catheter storage. Additionally, the facility failed to ensure Enhanced Barrier Precautions (EBP) were in place for Resident #96. This affected one (Resident #96) of one resident observed for EPB. The facility census was 79. Findings include: 1. Resident #20 was admitted on [DATE] with diagnoses including Parkinsonism, neuromuscular dysfunction of bladder, personal history of malignant neoplasm of prostate, and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that resident had an indwelling catheter. Review of Resident #20's orders dated 06/17/24 revealed that Resident #20 had scheduled catheter and foley care monitoring on every shift daily. Observation of Resident #20 on 11/26/24 from 6:59 A.M. until 7:16 A.M. revealed that his catheter bag…

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

Based on record review, review of facility policy, and staff interview, the facility failed to notify Resident #21's family of a resident's fall in a timely manner. This affected one (Resident #21) of three residents reviewed for family notification. The facility census was 83. Findings include: Review of the medical record for Resident #21 revealed an admission date of 08/15/23 with diagnoses of Parkinson's disease without dyskinesia, muscle weakness, and vascular dementia. Review of the Minimum Data Set (MDS) 3.0 assessment completed 09/26/24 revealed Resident #21 was cognitively intact. Review of Resident #21's General Durable Power of Attorney (POA) form dated 04/20/23 revealed the resident's wife was the POA for healthcare and listed in the medical record as emergency contact number one. Review of the Resident Preferences Evaluation dated 08/26/24 revealed It is very important for the resident to have their family or a close friend involved in discussions about their care. Review of the incident report dated 09/28/24 revealed Resident #21 was exiting the restroom when he slid…

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

Based on record review, review of the facility policy, and staff interview, the facility failed to ensure physician ordered laboratory services for a resident were completed in a timely manner. This affected one (Resident #10) of three residents reviewed for laboratory services. The facility census was 88. Findings include: Review of the medical record for Resident #10 revealed an admission date of 10/20/22 with diagnoses including Alzheimer's disease, diabetes Mellitus (DM) and dementia. Review of the Minimum Data Set (MDS) assessment completed 07/18/24 revealed Resident #10 had a memory problem and had a diagnosis of DM. Review of Resident #10's physician orders dated 07/18/24 revealed hemoglobin A1C (HbA1c) (a blood test that measures average blood sugar levels over the past two to three months) and basal metabolic panel (BMP) (checks the body's fluid balance and levels of electrolytes) every six months on the second Wednesday in August and January due to a diagnosis of DM. Review of the physician notes dated 07/18/24 revealed a new order received from certified nurse…

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 the facility policy, and staff interview, the facility failed to complete hand hygiene during medication administration to residents in enhanced barrier precautions. This affected two (Resident #24 and #70) of four residents observed for medication administration. The facility census was 88. Findings include: Observation on 09/12/24 at 12:07 P.M. with Licensed Practical Nurse (LPN) #999 revealed prior to preparing medication for Resident #70, hand hygiene was not performed, and gloves were not worn. LPN #999 began preparing Resident #70's medication, directly from the medication card into the medication cup. LPN #999 then returned the medication card to the cart, locked it, and entered Resident #70's room, which had an enhanced barrier sign posted on the door. Resident #70 needed moderate assistance with medication administration, including spoon-feeding the medication with applesauce. Resident #70 took medications without difficulty. Upon exiting, hand hygiene was not performed by LPN #999. Observation on 09/12/24 at 12:15 P.M. with LPN #999 revealed…

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

Based on staff interview, review of employee files, review of Bureau of Criminal Investigation (BCI) log, and policy review the facility failed to ensure background checks for staff were completed prior to employment. This affected three (State Tested Nursing Assistant [STNA] #230 and STNA #122, and Occupational Therapist [OT] #356) of the five employee files reviewed for background checks. This had the potential to affect all residents residing in the facility. The facility census was 81. Findings include: Review of employee file for STNA #230, revealed a hire date of 07/26/23. There was no documented evidence a background check was completed, and STNA #230 was not listed on the BCI background check log. Review of employee file for STNA #122, revealed a hire date of 07/29/22. There was no documented evidence a background check was completed, and STNA #122 was not listed on the BCI background check log. Review of employee file for OT #356, revealed a hire date of 07/26/23. There was no documented evidence a background check was completed, and OT #356 was not listed on the BCI…

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

Based on record review, review of personnel files, and staff interview, the facility failed to ensure performance evaluations were completed for State Tested Nursing Assistants (STNAs). This affected two (STNA #122 and STNA #230) of the four employees' files reviewed but had the potential to affect all residents. The facility census was 81. Findings include: Review of STNA #122's personnel file, revealed a hire date of 07/29/22. There was no documented evidence of a performance review being completed since being hired. Review of STNA #230's personnel file, revealed a hired date of 07/28/23. There was no documented evidence of a performance review being completed. Interview with the Administrator on 07/31/24 at 1:23 P.M., revealed the facility had no documented evidence that STNA #122 and STNA #230 had any performance evaluations completed. Interview with Human Resources (HR) #366 on 07/31/24 at 11:10 A.M., verified there was no documented evidence of any performance evaluations being completed for STNA #122 and STNA #230. This deficiency represents noncompliance investigated under…

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 staff interview, review of employee's personnel files, the facility failed to ensure State Tested Nursing Assistants (STNAs) received at minimum, 12 hours of training to ensure continuing competence. This affected two (State Tested Nursing Assistant [STNA] #230 and STNA #122) of the five employee's files reviewed. This had the potential to affect all residents residing in the facility. The facility census was 81. Findings include: Review of the STNA #230's personnel file, revealed a hire date of 07/26/23. There was no documented evidence STNA#230 received at minimum, 12 hours of training to ensure continuing competence. Review of STNA #122's personnel file, revealed a hire date of 07/29/22. There was no documented evidence STNA#230 received at minimum, 12 hours of training to ensure continuing competence. Interview with Human Resources (HR) #366 on 07/31/24 at 11:10 A.M. verified STNA #230 and STNA #122 and STNA had documented evidence they received at minimum, 12 hours of training to ensure continuing competence. This deficiency represents noncompliance investigated under…

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 policy review, the facility failed to follow the prepared menu. This had the potential to affect all residents who received meals from the kitchen. The facility identified eight (#58, #59, #66, #72, #76, #77, #80, and #83) residents who did not receive meals from the kitchen. The facility census was 81. Findings include: Review of the prepared lunch menu for 07/30/24, revealed chicken Parmesan, cauliflower, garlic toast and tiramisu for dessert. Observation on 07/30/24 at 11:56 A.M., revealed the lunch trays for Unit One, with a test tray on an open cart left the kitchen. The last lunch tray was delivered to a resident at 12:46 P.M. and the test tray was removed. Observation of the resident's tray revealed mixed vegetables instead of cauliflower and there was no garlic bread or a substitute. Observation of the lunch test tray on 07/30/24 at 12:47 P.M., revealed the tray consisted of chicken parmesan, mixed vegetables and tiramisu for dessert. There was no garlic bread or substitute. Interview on 07/30/24 at 2:06 P.M. with Dietary Manager…

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 mealtimes, staff and resident interviews, the facility failed to ensure no more than 14 hours elapsed between the evening meal and breakfast. This had the potential to affect all residents who receive food from the kitchen. The facility identified eight residents (#58, #59, #66, #72, #76, #77, #80, and #83) who did not receive meals from the kitchen. The facility census was 81. Findings include: Review the facility's mealtimes revealed the evening meal was served on Unit One at 4:50 P.M., Unit Two at 5:10 P.M., and the dining room at 5:30 P.M. Breakfast was served on Unit One at 7:50 A.M., Unit Two 8:10 A.M. and dining room at 8:30 P.M. There was 15 hours noted between the evening meal and breakfast. Interview with Dietary Manager (DM ) #140 on 07/29/24 at 1:46 P.M, verified there were 15 hours between the evening meal and breakfast and there were no substantial snacks being offered. Interview with three Residents (#03, #05, and #68) on 08/01/24 at 9:11 A.M., revealed the time between supper and breakfast was too long. Residents (#03, #05 and #68) stated that 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, resident interview, and staff interview, review of facility policy, the facility failed to provide scheduled showers/baths for residents. This affected two (#25 and #68) residents out of the five residents reviewed for showers. The current census is 81. Findings include: 1) Review of the medical record for Resident #25, revealed the resident was originally admitted to the facility on [DATE] and had a re-admission on [DATE]. Diagnoses included diabetes, hyperkalemia, hyperglycemia, pressure ulcer wounds, and obesity. Review of Resident #25's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had intact cognition and required staff assistance with bathing. Review of Resident #25's shower task worksheets completed by State Tested Nursing Assistants (STNAs) from 07/18/24 to 07/31/24 revealed the resident only had one shower documented on 07/29/24. Review of Resident #25's progress notes from 07/18/24 to 07/31/24 revealed no documentation of the resident refusing any care…

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

Based on observations, resident and staff interviews, the facility failed to provide a safe outside environment for the residents. This affected two (#04 and #50) of two residents reviewed for the physical environment and had the had the potential to affect all 82 residents residing in the facility. Finding include: Observation on 03/14/24 at 6:28 A.M. revealed there was an identified resident in a wheelchair with a neon yellow shirt on in the facility's parking lot. When you drive into the facility's property there is a driveway with pot holes and there was a parking lot to the left of the building. There several pot holes in the driveway and parking lot. There were orange cones noted on the sidewalk of the facility. Interview and observations of the main entrance, parking lot/driveway and sidewalk on 03/14/24 at 10:45 A.M. with Maintenance Director #115 revealed there were areas of hazards on the sidewalk marked with six large orange cones. Maintenance Director #115 stated some areas of repair had been completed, and some areas still needed to be repaired. The facility was working…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility failed to ensure Resident #15, who was status post brain surgery, received the appropriate care and services to attend to his scheduled neurologist appointments. This affected one (Resident #15) of three residents reviewed for physician appointments. The facility census was 82. Findings include: Review of the medical record for Resident #15 revealed an admission date of 03/20/23. Diagnoses included acute respiratory failure, seizures, cerebrospinal fluid drainage device, hydrocephalus, and chronic pain. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15's cognition was unable to be assessed. Review of Resident #15's after care visit summary dated 03/20/23 revealed Resident #15 had status post cranioplasty on 01/23/23 and had hydrocephalus (water on the brain) with shunt placement on 02/20/23. Resident #15 was transferred to another hospital on [DATE] for neurology evaluation and fever work up. On 03/20/23, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility failed to ensure Resident #15 was provided with dental services. This affected one (Residents #15) of three residents who were reviewed for dental services. The facility census was 82. Findings include: Review of the medical record for Resident #15 revealed an admission date of 03/20/23. Diagnoses included acute respiratory failure, tracheostomy, cerebrospinal fluid drainage device, dysphagia, anemia, and transient ischemic attack. Review of Resident #15's admission agreement dated 03/20/23 revealed the responsible party for Resident #15 signed an authorization form for Resident #15 to be provided with dental services. Review of Resident #15's care plan dated 04/03/23 revealed Resident #15 had the potential for oral/dental health problems having natural teeth in poor condition related to anemia, dysphagia, fluids/nutrition provided by gastric tube and tracheostomy. Individualized interventions included to coordinate arrangements for dental care and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, resident interview, and record review, the facility failed to ensure proper Personal Protective Equipment (PPE) was worn when staff entered a COVID-19 positive rooms. This affected two (Residents #34 and #35) of three reviewed for COVID-19. Additionally, the facility failed to complete contact tracing during a COVID-19 outbreak. This had the potential to affect all residents residing in the facility. Facility census was 76. Findings include 1. Review of the medical record for Resident #34 revealed an admission date of 10/24/23. Diagnoses included chronic obstructive pulmonary disease, COVID-19, respiratory failure with hypoxia, diabetes, and encephalopathy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was cognitively intact and required partial to moderate assistance for lower body dressing and hygiene. Review the progress note dated 01/31/24 revealed the resident tested positive for COVID-19 and was placed in isolation. 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, staff interview, and policy review, the facility failed to complete a thorough investigation related to sexual abuse. This affected one (Resident #100) of three residents reviewed for abuse. This had the potential to affect nine (Residents #35, #52, #80, #6, #7, #51, #2, #63 and #101) Maintenance Man (MM) #150 had contact with. Additionally, the facility failed to investigate an allegation of misappropriation. This affected one (Resident #65) of three residents reviewed for abuse. The facility census was 79. Findings included: 1. Closed medical record review for Resident #100 revealed an admission date of 09/13/23. Diagnoses included bilateral trans radial amputation, Cystic Fibrosis, anemia, heart failure, pneumonia, diabetes, anxiety, depression, bilateral trans radial amputation, and respiratory failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #100 was cognitively intact. Her functional status was partial/moderate assistance 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 observations, resident interviews, staff interviews, and record review, facility failed to ensure call lights were answered in a timely manner. This affected one (Resident #34) of one resident observed for call lights. Facility census was 76. Findings include 1. Review of the medical record for Resident #34 revealed an admission date of 10/24/23. Diagnoses included chronic obstructive pulmonary disease, Covid-19, respiratory failure with hypoxia, diabetes, and encephalopathy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was cognitively intact and required partial to moderate assistance for lower body dressing and hygiene. Review of the plan of care dated 11/22/23 revealed Resident #34 was at risk for pain with intervention to encourage resident to call for assistance when in pain. The resident had an activity of daily living self-care deficit with interventions to use the call bell for assistance. Review the progress notes dated 01/31/24 revealed Resident #34 tested…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and policy review, the facility failed to ensure an allegation of sexual abuse was reported to the state agency in a timely manner. This affected one (Resident #100) of three reviewed for abuse. The census was 79. Findings included: Closed medical record review for Resident #100 revealed an admission date of 09/13/23. Diagnoses included bilateral trans radial amputation, Cystic Fibrosis, anemia, heart failure, pneumonia, diabetes, anxiety, depression, bilateral trans radial amputation, and respiratory failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #100 was cognitively intact. Her functional status was partial/moderate assistance for eating and toileting and she required supervision for transfers and bed mobility. The resident had impairment to bilateral upper extremities. Review of the investigation dated 01/03/24 revealed Resident #100 reported her cell phone was missing and blamed it on the Maintenance Man (MM)…

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, resident interviews and staff interviews, the facility failed to ensure resident's maintained quality of life while in COVID-19 isolation. This affected Residents #34 and #35 of two review for COVID-19 isolation. The facility identified seven residents (#3, #34, #35, #50, #59, #69) with COVID-19 positive diagnosis. Facility census was 76. Findings include 1. Review of the medical record for the Resident #34 revealed an admission date of 10/24/23. Diagnoses included chronic obstructive pulmonary disease, COVID-19, respiratory failure with hypoxia, diabetes, and encephalopathy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 was cognitively intact and required partial to moderate assistance for lower body dressing and hygiene. Review the progress note dated 01/31/24 revealed Resident #34 tested positive for COVID-19 and was placed in isolation. Physician order dated 02/02/24 revealed an order for the resident to remain on isolation precautions until…

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, resident interviews, staff interviews, and record reviews, the facility failed to ensure showers were offered twice weekly according to resident preference. This affected three (Residents #3, #35, and #55) of three reviewed for showers. Facility census was 76. Findings include 1. Review of the medical record for Resident #3 revealed an admission date of 11/11/22. Diagnoses included chronic obstructive pulmonary disease, COVID-19, diabetes, acute respiratory failure, bipolar disorder, and post-traumatic stress disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively intact and required partial moderate assistance with ambulation and activities of daily living. Review of the care plan dated 02/05/24 revealed the resident required assistance of one staff for bathing. Review of the shower sheets from 12/05/23 to 02/05/24 revealed showers were only offered on 12/11/23, 12/14/23, 01/19/24, and 01/29/24. Interview and observation on 02/05/24 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident representative interview, staff interviews, and record review, facility failed to ensure dietitian recommendations were followed to maintain a resident's nutrition status. This affected one (Resident #55) of three reviewed for nutrition. Resident census was 76. Findings include Review of the medical record for Resident #55 revealed an admission date of 09/05/23. Diagnoses included osteomyelitis of left foot and ankle, anorexia, dementia without behaviors, cognitive communication deficit, traumatic amputation of left foot and vascular disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 was cognitively impaired and required two person assistance for bed mobility. Review of the care plan dated 12/23/23 revealed the resident was at risk of potential nutritional problem related to osteomyelitis with interventions to administer medications as ordered, monitor for signs of malnutrition and weight loss, obtain labs and diagnostic work as ordered and report 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, hospital record review, laboratory testing result review, and staff interview, this facility failed to implement Foley catheter care and maintenance orders and failed to change the Foley catheter per physician order prior to obtaining a urine sample. This affected one (Resident #2) of the three residents reviewed for Foley catheter care. The facility census was 81. Findings include: Review of the medical record for Resident #2 revealed and admission date of 08/03/23. Diagnoses included type two diabetes mellitus, bipolar disorder, dependence on respiratory ventilator, and cardiomegaly. Review of Resident #2's hospital assessment and plan note dated 07/11/23 revealed under section 11. Foley status: present on admission, will need to be removed in 1-2 days. Review of Resident #2's handoff to skilled nursing facility provider note dated 08/03/23 revealed under section 11. Foley status: present on admission, patient refuses removal multiple times indicating Purewick's (a non-invasive…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of video surveillance, and facility policy review, the facility failed to ensure direct care staff wore the required personal protective equipment while providing incontinent care for a resident in contact isolation. This affected one (Resident #1) of the five residents reviewed for incontinence care. The facility census was 81. Findings include: Review of the medical record for Resident #1 revealed and initial admission date of 11/17/22 and a re-entry date of 12/27/22. Diagnosis included chronic respiratory failure with hypercapnia, bipolar disorder, PTSD, adjustment disorder with depressed mood, borderline personality disorder, and chronic pain syndrome. Review of Resident #1's Significant Change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating resident had an intact cognition for daily decision making abilities. Resident #1 was noted to reject care or evaluation.…

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 store and thaw foods in a sanitary manner. This had the potential to affect 41 out of 43 residents who received meals from the kitchen. The facility identified two residents (#8 and #38) who received no food by mouth. The facility census was 43. Findings include: 1. Observation on 04/25/22 from 7:14 A.M. to 7:30 A.M. of the reach-in refrigerator revealed a serving tray of cups filled with eight glasses of milk and three lemonades, a serving tray filled completely with individual cups of orange juice, and a third serving tray with six to seven additional cups of orange juice. None of the cups of beverages were dated. Interview with Dietary Supervisor #95 at that time of the observation confirmed the beverages were undated and Dietary Supervisor #95 stated they were probably poured today. 2. Observation on 04/25/22 from 7:14 A.M. to 7:30 A.M. of the dry storage room revealed two large bins filled with cheerios and bran flakes cereal which were undated, a bin of raisin bran cereal which was dated for 02/11/22 or 02/15/22,…

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 review of Resident Council meeting minutes, staff interview, resident interview, and facility policy review, the facility failed to timely address and follow up on resident concerns expressed during Resident Council meetings. This affected seven (Residents #4, #14, #19, #20, #24, #30, and #32) of seven residents who regularly attended Resident Council meetings. The facility census was 43. Findings Include: Review of Resident Council meeting minutes dated 04/26/22, 03/25/22, 02/23/22, 01/25/22, 12/28/21, 10/28/21, 09/30/21, 09/08/21, and 07/22/21 revealed the residents had recurrent concerns of staff not wearing nametags, snacks not being passed, staff not checking their floors for dirty laundry, medication administration, requests for ice water to be passed more frequently, and call light response times. Residents #4, #14, #19, #20, #24, #30, and #32 attended the meetings regularly. Further review of the Resident Council meeting minutes revealed there was no evidence of any follow up from the facility staff regarding the resident concerns having been addressed. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to provide written notification of transfer to residents and/or resident representatives. This affected seven (Resident #2, #4, #6, #10, #16, #21, and #23) of eight residents reviewed for hospitalization and discharge. Additionally, the facility failed to provide written notification of resident transfer or discharge to the ombudsman. This affected eight (#2, #4, #6, #10, #16, #21, #23, and #42) out of eight residents reviewed for hospitalization and discharge. The facility census was 43. Findings include: 1. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] and passed away on 04/26/22. Resident #6 had diagnoses including Parkinson's disease, quadriplegia, anemia, spinal stenosis, unspecified dementia, dysphagia, lymphedema, dysphagia, gastrointestinal hemorrhage, contracture of muscle of multiple sites, hypertension and anxiety disorder. Review of the Minimum Data Set (MDS) assessment 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to provide notice of bed hold policies to residents and/or their representative upon transfer to the hospital. This affected seven residents (#2, #4, #6, #10, #16, #21, and #23) of seven residents reviewed for hospitalization. The facility census was 43. Findings include: 1. Review of the medical record for Resident #6 revealed Resident #6 admitted to the facility on [DATE] and passed away on 04/26/22. Resident #6 had diagnoses including Parkinson's disease, quadriplegia, unspecified dementia, dysphagia, gastrointestinal hemorrhage, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had severely impaired cognition. Review of the progress note dated 04/08/22 revealed Resident #6 suffered a fall and was transferred to the hospital. Review of the progress note dated 04/13/22 revealed Resident #6 had returned from the hospital. Review of the medical record for Resident #6 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the beneficiary notice worksheet, the facility failed to ensure residents received a Notice of Medicare Non-Coverage (NOMNC) prior to being cut from therapy services. This affected two (Resident #295 and #297) of three residents reviewed for beneficiary notices. The facility census was 43. Findings Include: 1. Review of the closed medical record for Resident #295 revealed an admission date on 10/23/21. Resident #295 discharged to home on [DATE]. Medical diagnoses for Resident #295 included COVID-19, Type two diabetes mellitus without complications, acute and chronic respiratory failure with hypoxia (lack of oxygen), muscle weakness, and need for assistance with personal care. Review of the admission Minimum Data Set (MDS) assessment revealed Resident #295 had mildly impaired cognition. Resident #295 required extensive assistance from one staff to complete transfers, dressing, and personal hygiene tasks and required supervision from one staff for all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of Pre-admission Screenings and Resident Reviews (PASARR), the facility failed to ensure PASARR's were completed accurately. This affected two (Residents #2 and #10) of two residents reviewed for PASARR screenings. The facility census was 43. Findings Include: 1. Review of the medical record for Resident #2 revealed an original admission date on 11/13/21 and a readmission date on 01/04/22. Resident #2 had medical diagnoses with dates of 11/13/21 which included schizophrenia and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had intact cognition and required extensive assistance from one to two staff to complete Activities of Daily Living (ADLs). Review of Resident #2's PASARR screening dated 10/08/21 revealed the screening included mental health diagnoses of schizophrenia, suicidal ideations, and depression. Review of Resident #2's medical record revealed there was no evidence another PASARR…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and medical record review, the facility failed to timely identify and address resident pressure ulcers. This affected one (Resident #22) of three residents reviewed for pressure ulcers. The facility census was 43. Findings include: Review of the medical record for Resident #22 revealed the resident admitted on [DATE] with diagnoses including lymphedema, chronic obstructive pulmonary disease, and chronic pulmonary embolism. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #22 had intact cognition. Review of the plan of care revised on 01/07/22 revealed Resident #22 was at risk for impaired skin integrity related to generalized weakness, decreased strength and endurance, decreased activity tolerance, impaired mobility, chronic rashes, and diagnoses. Interventions included administering medications and treatments according to physician orders, encourage to reposition, monitor nutrition status, pressure reducing mattress, preventative skin care…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, medical record review, and review of a hospice binder, the facility failed to ensure residents with limited range of motion received appropriate treatment and services. This affected one (Resident #35) of one resident reviewed for range of motion. The facility census was 43. Findings include: Review of the medical record revealed Resident #35 had an admission date of 12/30/16 with diagnoses including Alzheimer's disease, type two diabetes mellitus, major depressive disorder, anemia, anxiety disorder, contracture of left and right knee, adult failure to thrive, dysphagia, and essential hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was rarely or never understood. Resident #35 had limited range of motion on both sides of upper and lower extremities. Review of the physician's orders revealed Resident #35 utilized hospice services since 11/17/19. Review of Resident #35's physician orders, medication administration…

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 resident medications and wound cleansers were acquired from the pharmacy in a timely manner. This affected two (Resident #6, Resident #39) out of five residents reviewed for medications. The facility census was 43. Findings Include: 1. Review of Resident #6's medical record revealed she was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, quadriplegia, anemia, severe protein calorie malnutrition, dysphagia, and dementia. Resident #6 was receiving hospice services. Resident #6 passed away on 04/26/22. Review of the Minimal Data Set (MDS) assessment dated [DATE], revealed Resident #6 had severe cognitive impairment. Review of the care plan dated 04/22/22, revealed Resident #6 used anti-anxiety medications related to anxiety. Interventions included give medications as order by the physician and monitor for signs/symptoms of medication. Review of the physician orders dated 04/2022, revealed Resident #6…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure the physician reviewed/addressed pharmacy recommendations in a timely manner. This affected two (Resident #4 and #22) out of five residents reviewed for unnecessary medications. The facility census was 43. Findings include: 1. Review of the medical record for Resident #22 revealed the resident was admitted on [DATE] with diagnoses including lymphedema, dysphagia, polyneuropathy, chronic obstructive pulmonary disease, anxiety disorder, irritable bowel syndrome, obstructive sleep apnea, hypertension, major depression, and chronic pulmonary embolism. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had intact cognition. Review of the physician recommendation form dated 08/03/21 for Resident #22 revealed the pharmacist recommended evaluating sertraline (antidepressant medication) 50 milligrams (mg) every day and trazodone (antidepressant medication) 50 mg every night. This was not addressed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, and staff interview, the facility failed to ensure medications were stored properly. This affected two (Resident #22 and #242) out of four residents observed during medication administration. The facility census was 43. Findings Include: 1. Review of the medical record for Resident #22 revealed an admission date of 10/26/16. Resident #22's diagnoses included lymphedema, morbid obesity, chronic obstructive pulmonary disease, dysphagia, chronic pulmonary embolism, and anxiety and depressive disorders. Review of the quarterly Minimal Data Set (MDS) dated [DATE] revealed Resident #22 was cognitively intact. Resident #22's functional status was independent to limited one person assist for all activities of daily living. Review of the physician ordered morning medications revealed Resident #22 was ordered Aspirin Enteric Coated Tablet Delayed Release 81 milligrams (MG), give one tablet by mouth in the morning, Celecoxib (nonsteroidal anti-inflammatory medication) capsule…

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, resident interview, and staff interview, the facility failed to ensure routine dental appointments were arranged for residents. This affected two (Resident #15 and #21) out of three residents reviewed for dental services. The facility census was 43. Findings include: 1. Review of the medical record for Resident #15 revealed she admitted on [DATE] with diagnoses including type two diabetes mellitus, unspecified severe protein-calorie malnutrition, and encephalopathy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition. Review of the plan of care dated 05/03/20 revealed Resident #15 had the potential for dental or oral cavity deficits related to having her own teeth. Interventions included assisting her with oral care as needed, completing oral assessment according to facility policy, and provide follow up with dentist as recommended. Review of Resident #15's physician's order dated 02/07/22 revealed 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 observation, interview, and record review, the facility failed to provide appropriate foods in order to honor resident preferences for a vegetarian diet. This affected one (Resident #30) out of two residents reviewed for food preferences. The facility census was 43. Findings include: Review of the medical record revealed Resident #30 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side, type two diabetes, and hypertension. Review of the comprehensive Minimum Data Set assessment dated [DATE] revealed Resident #30 had intact cognition. Resident #30 was identified as being on a therapeutic diet. Review of the plan of care revised on 11/19/21 revealed Resident #30 was at risk for malnutrition and hydration deficits related to diagnoses, being on a therapeutic diet with supplements, and vegetarian food preferences. Interventions included monitoring nutritional labs, monitoring percent of meals consumed, monitoring 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.