Englewood Health And Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and policy review, the facility failed to ensure appropriate written authorization were obtained to manage a resident's personal funds. This affected one (#246) of five residents reviewed for personal funds. The facility census was 83. Findings include: Review of the medical record revealed Resident #246 was admitted to the facility on [DATE] with a primary diagnosis of unspecified heart failure and was discharged on 01/12/24. Review of document titled Authorization and Agreement to Handle Resident Funds revealed Resident #246 had a non-transferring resident Fund account. The form was unsigned and undated. Review of the Resident statement revealed Resident #246's account was opened on 12/14/23 with a cash deposit of $245.00. The account was paid out and closed on 01/22/24. During an interview conducted on 04/25/24 at 9:09 A.M. Business Office Manager #49 stated someone had given the resident cash and turned it over to the business office to open the account. BOM #49 stated…

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, observations, resident and staff interviews, review of Resident Assessment Instrument (RAI) Manual and policy review, the facility failed to ensure an Minimum Data Set (MDS) assessment was completed/coded accurately. This affected two (#59 and #57) out of 22 residents sampled during the survey for MDS assessments. The facility census was 83. Findings include 1. Medical record review for Resident #59 revealed the resident was admitted to the facility on [DATE]. Diagnoses include acute kidney failure, chronic heart failure, respiratory failure, hypertension, obesity, sleep apnea, spinal stenosis, pressure ulcer sacral region, gastroesophageal disease, peptic ulcer, irritable bowel syndrome, anxiety, polyneuropathy, restless leg syndrome diabetes mellitus, insomnia, low back pain, depression. Review of the quarterly MDS dated [DATE] revealed Resident #59 impaired cognition. Resident # 59 independent with eating. Resident #59 required supervision for bed mobility, transfers, and toileting.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff interviews, policy review and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure the comprehensive plan of care included dental care. This affected one (#7) of four residents reviewed for dental services. The facility census was 83. Findings included: Medical record review for Resident #7 revealed an admission on [DATE] with diagnoses including end stage renal disease, hypertensive chronic kidney disease, altered mental status, chronic obstructive pulmonary disease, hypertension, heart failure, gastroesophageal disease, and type 2 diabetes. Review of the annual Minimum Data Set (MDS) dated [DATE] for Resident #7 revealed cognitive impairment. Resident #7 required set up assistance for oral hygiene. Resident #7 had no broken of loosely fitting dentures or mouth pain or difficulty chewing. Review of the plan of care for Resident #7 was silent for dental services. Review of dental services for Resident #7 dated 08/10/23…

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, observations, resident and staff interviews, and policy review, the facility failed to provide nail care for dependent residents. This affected one (#57) of two residents reviewed for Activities of Daily Living (ADL) care. The census was 83. Findings include: Resident #57 was admitted on [DATE] with diagnoses of cerebral infarction affecting right dominant side, aphasia, dysphagia, vascular dementia, psychotic disturbance, and chronic hepatitis. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #57 had severely impaired cognition, impaired range of motion on the right side, and a required a two-person mechanical lift for transfers. Resident #57 was dependent for bowel and bladder incontinence, bathing, personal hygiene, and dressing, and moderate assistance for eating and oral hygiene. Review of the Care Plan dated for review on 05/03/24 for Resident #57 revealed facility staff are to monitor ADL's for assistance and render care as needed.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff and Physician interviews and policy review, the facility failed to accurately assess, monitor, and implement wound care interventions for a newly identified non-pressure skin condition. This affected one (#24) of four residents reviewed for wound care. The facility census was 83. Findings included: Review of Resident #24's chart revealed Resident #24 admitted to the facility on [DATE] with diagnoses including congestive heart failure, abnormal posture, localized edema, hyperlipidemia, hypertension, anxiety disorder and calculus of kidney. Review of Resident #24's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be cognitively intact and Resident #24 required set up assistance with eating. Resident #24 required supervision with oral hygiene, and Resident #24 was dependent with toileting hygiene, showering, lower body dressing, putting on and taking off footwear, personal hygiene, chair transfers, toilet transfers, and tub…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff and Physician interviews and policy review, the facility failed to timely assess, provide ongoing monitoring and timely implement treatments for a resident's pressure ulcers. Additionally, the facility failed to implement a wound physicians recommendations for a specialty mattress to promote healing of a resident's pressure ulcers. This affected one (#24) out of four residents reviewed for pressure ulcer care. The facility census was 83. Findings included: Review of Resident #24's chart revealed Resident #24 admitted to the facility on [DATE] with diagnoses including congestive heart failure, abnormal posture, localized edema, hyperlipidemia, hypertension, anxiety disorder and calculus of kidney. Review of Resident #24's pressure ulcer care plan dated 06/13/23 revealed Resident #24 had a history of pressure ulcer related to the sacrum, left posterior upper thigh, right posterior upper thigh, left distal buttock, and right distal buttock related to impaired…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, staff and resident interviews and policy review, the facility failed to ensure a wrist/hand splint was applied as recommended per therapy. This affected two (#57 and #59) of two residents reviewed for position and mobility. The census was 83. Findings include: 1. Resident #57 was admitted on [DATE] with diagnoses of cerebral infarction affecting right dominant side, aphasia, dysphagia, vascular dementia, psychotic disturbance, and chronic hepatitis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #57 had severely impaired cognition, impaired range of motion on the right side, and a required a two-person mechanical lift for transfers. Resident #57 was dependent for bowel and bladder incontinence, bathing, personal hygiene, and dressing, and moderate assistance for eating and oral hygiene. It was revealed Occupational Therapy (OT) started 03/08/24 and no documentation of a brace or splint being utilized. Review of the OT Evaluation for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff and Nurse Practitioner interviews and policy review, the facility failed to document a physician's orders for catheter care in a resident's medical record. This affected one (#71) out of one resident reviewed for urinary catheter care. The facility census was 83. Findings include: Medical record review for Resident #71 revealed an admission [DATE] with diagnosis including but not limited to ileus, diabetes type two, cerebral infarction, paralytic syndrome, stroke, neuromuscular dysfunction of bladder, hemiplegia affecting right side, chronic kidney disease, hypertension, and methicillin resistant staphylococcus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #71 revealed the resident had impaired cognition. Resident #71 was coded as having an indwelling urinary catheter during the look back period. Review of the plan of care for Resident #71 dated 01/25/23 revealed resident has an indwelling catheter due to neuromuscular…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews and policy review, the facility failed to adequately monitor resident weight loss and implement weight loss interventions. This affected two (#28 and #84) out of three residents reviewed for nutrition. The facility census was 83. Findings include: 1. Review of Resident #28's chart revealed the resident was admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus with diabetic chronic kidney disease, insomnia, chronic kidney disease stage three, other low back pain, anxiety disorder, depression, opioid dependence, weakness, other irritable bowel syndrome, mixed hyperlipidemia, foot drop, morbid obesity due to excess calories and acute kidney failure. Review of Resident #28's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be moderately cognitively impaired and Resident #28 required supervision with toileting, upper body dressing, lower body dressing, putting on and taking off footwear, sitting to standing,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interview, and review of the facility policy, the facility failed to ensure a resident received medications as physician ordered. This affected one (#45) of one resident reviewed for medications. The facility census was 83. Findings include: Review of medical record reveals Resident #45 was admitted on [DATE] with diagnoses of encounter for surgical aftercare following surgery on the circulatory system (right above knee amputation with wound vac in place on stump), acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and moderate protein-calorie malnutrition. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 is cognitively intact and has an enteral feeding tube (PEG) through the abdomen for nutrition. Resident #45 requires supervision for oral hygiene, maximal assistance for dressing, bed mobility, toileting, and transfers, and dependent for bathing. Review of physician orders for April 2024 revealed Resident #45…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews and review of medication information, the facility failed to psychotropic medication were given with adequate indications for use and a resident's as needed anti-anxiety medication order had a stop date. This affected three (#28, #42 and #55) out of five residents reviewed for unnecessary medications. The facility census was 83. Findings include: 1. Review of Resident #28's chart revealed the resident was admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus with diabetic chronic kidney disease, insomnia, chronic kidney disease stage three, other low back pain, anxiety disorder, depression, opioid dependence, weakness, other irritable bowel syndrome, mixed hyperlipidemia, foot drop, morbid obesity due to excess calories and acute kidney failure. Review of Resident #28's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be moderately cognitively impaired and Resident #28 required supervision with toileting,…

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, observations, resident and staff interviews and policy review, the facility failed to ensure medications were properly stored. This affected two (#24 and #63) out of 83 residents in the facility. The facility census was 83. Findings include: 1. Review of Resident #24's chart revealed the resident was admitted to the facility on [DATE] with diagnoses including congestive heart failure, abnormal posture, localized edema, hyperlipidemia, hypertension, anxiety disorder and calculus of kidney. Review of Resident #24's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident to be cognitively intact and Resident #24 required set up assistance with eating. Resident #24 required supervision with oral hygiene, and Resident #24 was dependent with toileting hygiene, showering, lower body dressing, putting on and taking off footwear, personal hygiene, chair transfers, toilet transfers, and tub transfers. Resident #24 required maximal assistance with upper body dressing, sitting…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and hospice staff interviews and policy review, the facility failed to collaborate with hospice in the development of a comprehensive plan of care. This affected one (#55) of one reviewed for hospice services. The facility census is 83. Findings include Medical record review for Resident #55 revealed the resident was admitted to the facility on [DATE] with diagnosis that include but not limited to dementia, apraxia, attention and concentration deficit, adult failure to thrive, altered mental status, depression, dehydration, pseudobulbar, malnutrition. Review of the significant modification of Minimum Data Set (MDS) assessment dated [DATE] for Resident #59 revealed resident was admitted into the hospice program. Review of the recertification of hospice plan of care revealed the resident admitted to hospice on 6/19/23. Review of the most recent quarterly assessment dated [DATE] for resident #55 revealed an impaired cognition. Resident had no behaviors. No impairments. 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 medical record review, observations and staff interviews, the facility failed to ensure resident medications were handled in a sanitary manner during medication administration pass. This affected two (#70 and #63) out of six residents observed for medication administration. The facility census was 83. Findings include: 1. Review of the medical record for Resident #70 revealed an admission date of 9/16/22 with diagnoses including but not limited to type two diabetes, hypertensive urgency, heart disease and anemia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #70 revealed the resident had impaired cognition. Resident #19 required maximal assistance for bed mobility, toileting, and transfers. Resident #19 is independent for eating. Review of the active physicians orders for Resident #70 revealed orders for Levothyroxine Sodium oral tablet 50 micrograms (mcg)- give 1 tablet by mouth in the morning for hypothyroidism dated 02/14/2023, Imodium A-D oral tablet 2…

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

Based on medical record review, observation, and staff interview, the facility failed to ensure residents were assisted with eating in a dignified manner. This affected two (Residents #77 and #78) out of eight residents observed in public dining areas. The facility census was 87. Findings include: 1. Review of the medical record for Resident #77 revealed an admission date of 12/06/21. Diagnoses included but were not limited to unspecified Alzheimer's disease. Review of the most recent Minimum Data Set (MDS) 3.0 assessment, dated 06/20/23, revealed Resident #77 had severely impaired cognition. Resident #77 required one-staff total assistance with eating. 2. Review of the medical record for Resident #78 revealed an admission date of 01/25/19. Diagnoses included but were not limited to unspecified sequelae of cerebral infarction. Review of the most recent MDS 3.0 assessment, dated 07/08/23, revealed Resident #78 had severely impaired cognition. Resident #78 was a one-person physical assist and required supervision assistance with eating. Observation on 09/07/23 at 8:11 A.M. 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 interview, observation, record review, and policy review, the facility failed to ensure medications were administered as ordered. There were three medication errors out of 34 opportunities, resulting in a medication error rate of 8.82%. This affected three (Residents #24, #77, and #78) of four residents observed for medication administration. The facility census was 87. Findings include: 1. Review of the medical record for Resident #24 revealed an admission date of 09/04/21. Diagnoses included but were not limited to unspecified cerebral infarction, unspecified vascular dementia, chronic obstructive pulmonary disease, and type two diabetes. Review of the medical record revealed Resident #24 had a physician order dated 01/12/23 for Vitamin B12 2000 units by mouth once daily. Observation and interview on 09/07/23 from 9:43 A.M. to 10:01 A.M. revealed Licensed Practical Nurse (LPN) #39 did not have enough Vitamin B12 500 microgram (mcg) tablets available to administer 2000 mcg as ordered and was unable to locate an additional supply of the medication after searching the…

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

Based on observation, staff interview, and policy review, the facility failed to ensure medications were stored appropriately. This had the potential to affect one (Resident #51) out of one resident who received Nitroglycerin from the Magnolia medication cart. The facility census was 87. Findings include: Observation on 09/07/23 at 9:56 A.M. revealed the Magnolia medication cart had a souffle cup labeled Nitroglycerin which contained three white oblong tablets in the top drawer. Interview on 09/07/23 at 9:57 A.M. with Licensed Practical Nurse (LPN) #39 verified the Nitroglycerin tablets (vasodilator medication) were stored improperly. LPN #39 stated Nitroglycerin tablets should be stored in a dark bottle which protected the medication from light. Review of the policy titled Medication Storage, dated 09/29/22, revealed all drugs which required light protection while in storage will remain in the original package, in a closed drawer or cabinet, or in a specially wrapped manner until the time of administration, according to manufacturer's recommendations.

Based on medical record review, observation, resident and staff interview, and policy review, the facility failed to ensure residents were provided assistive devices as ordered. This affected one (Resident #46) out of one resident identified as using assistive devices during meals. The facility census was 87. Findings include: Review of the medical record for Resident #46 revealed an admission date of 12/16/20. Resident #46's diagnoses included but were not limited to unspecified seizures, unspecified dementia, and frontal lobe/executive function deficit following cerebral vascular accident. Review of Resident #46's care plan, dated 06/14/23, revealed Resident #46 was at risk for malnutrition and dehydration due to use of a mechanically altered diet, advanced age, and potential for decline related to dementia. Interventions included built up spoons, a divided plate, and a handled cup. Review of the medical record revealed Resident #46 had physician orders, dated 08/31/23, for a regular diet, dysphagia/mechanical soft texture, regular liquids, and fortified foods with a divided…

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 wounds were assessed regularly and dressing changes were completed as ordered. This affected one (Resident #38) out of three residents reviewed for skin conditions. The facility census was 92. Findings include: Review of Resident #38's clinical record revealed Resident #38 was admitted to the facility on [DATE]. His diagnoses which included but was not limited to cellulitis, acquired absence of the right leg below the knee, local infection of the skin and subcutaneous tissue, bacteremia, type two diabetes with diabetic chronic kidney disease, acquired absence of the left toe, and unstageable pressure ulcer of the sacral region. Review of Resident #38's quarterly Minimum Data Set (MDS) assessment, dated 03/31/23, revealed he had a Brief Interview for Mental Status (BIMS) score of 12 indicating he had moderate cognitive impairment. Review of the physician note, dated 12/30/23, revealed Resident #38 was seen by the Medical Director.…

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, resident interview, and staff interview, the facility failed to ensure a hand splint and palm protector were applied as ordered. This affected one (Resident #53) out of two residents reviewed for position and mobility. The census was 92. Findings include: Review of Resident #53's medical record revealed an admission date of 08/16/22. Resident #53's diagnoses included muscle weakness, convulsions, hemiplegia, hypertension, major depressive disorder, and post-traumatic stress disorder. Review of Resident #53's annual Minimum Data Set (MDS) assessment, dated 04/19/23, revealed Resident #53 was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 10, required extensive assistance with personal hygiene, and had an upper extremity impairment of the left side. Review of Resident #53's physician orders revealed an order, dated 05/12/23, for a left palm protector at all times except during personal hygiene. Monitor Resident #53's skin for any signs and symptoms of breakdown. Notify MD (physician) of changes. Further review…

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, observation, and policy review, the facility failed to properly check a gastrostomy tube placement. This affected one (Resident #57) of three residents reviewed for enteral feeding. The census was 92. Findings include: Review of the medical record for Resident #57 revealed Resident #57 admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, oropharyngeal dysphagia, and unspecified dementia. Review of Resident #57's care plan, dated 01/25/2023, revealed Resident #57 was dependent on tube feeding for intake due to diagnoses of cerebrovascular accident and dysphagia. Interventions included check tube feed placement every feeding, hold feedings if residual was above 100 ml, and provide enteral feedings as ordered. Observation on 06/13/2023 at 1:50 P.M. revealed Licensed Practical Nurse (LPN) #238 used a piston syringe to check the residual stomach contents for Resident #57'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, staff interview, and policy review, the facility failed to ensure medications were secured properly when left unattended. This had the potential to affect two (Residents #7 and #14) of 18 residents who resided on the [NAME] unit and were identified as cognitively impaired and ambulatory. The facility census was 92. Findings include: Observation on 06/13/2023 from 1:50 P.M. to 1:57 P.M. revealed the medication cart on the [NAME] unit was left unlocked and unsupervised while Licensed Practical Nurse (LPN) #238 and the Director of Nursing (DON) were administering medications to Resident #57. During an interview on 06/13/2023 at 1:57 P.M., the DON verified the medication cart on the [NAME] unit had been unlocked and was unsupervised while LPN #238 administered medications. Review of the policy titled Medication Storage, dated 09/29/2022, revealed during a medication pass, medications were under the direct observation of the person administering medications or locked in the medication cart.

Based on review of personnel records, staff interview, and review of facility policy the facility failed to ensure all staff were checked against the Nurse Aide Registry prior to employment to ensure the employee did not have a finding entered into the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property. This had the potential to affect all 93 residents residing in the facility. Findings include: Review of personnel records revealed no evidence of employees being checked against the State Nurse Aide Registry prior to employment for the following employees: the Administrator hired on 02/21/19, Activities Assistant #36 hired on 05/29/19, Licensed Practical Nurse (LPN) #13 hired on 12/31/19, LPN #21 hired on 04/18/19, LPN #23 hired on 06/27/19 , LPN #37 hired on 06/14/19, LPN #47 hired on 11/20/19, LPN #76 hired on 07/15/19, LPN #82 hired on 06/04/19, LPN #87 hired on 08/01/19, LPN #89 hired on 05/31/19, LPN #93 hired on 12/19/19, LPN #100 hired on 12/10/19, Minimum Data Set (MDS) Nurse #75 hired on 10/14/19,…

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 personnel record review, staff interview, and facility policy review, the facility failed to ensure State Tested Nursing Aides (STNAs) received 12 hours of training a year. This affected three (#14, #17 and #83) of six STNA's reviewed for education. This had the potential to affect all the residents in the facility. The census was 93. Findings include: 1. Review of personnel records for STNA #14 who was hired on 07/24/14 revealed no evidence of 12-hours in-service training. 2. Review of personnel records for STNA #17 who was hired on 05/17/12 revealed no evidence of 12-hours in-service training. 3. Review of personnel records for STNA #83 who was hired on 08/23/18 revealed no evidence of 12-hours in-service training. Interview with Payroll Specialist #70 on 01/14/20 at 12:15 P.M. verified the above STNA's did not have the 12-hour inservice training. She stated she had been auditing the personnel files since she was a new employee herself and had some of the training for the employees but not all of it. Review of facility policy entitled Competencies dated 03/01/17 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure the medical record and the nurse's report sheet matched a resident's wishes regarding Advanced Directives. This affected one Resident (#77) of two reviewed for Advance Directives. The facility census was 93. Findings include: Medical record review revealed Resident #77 was admitted to the facility on [DATE] with medical diagnoses including diabetes and pneumonia. Review of code status form in the medical record dated 02/03/07 revealed Resident #77 was a Do Not Resuscitate (DNR/no cardio-pulmonary resuscitative measures to be instituted in the event of cardiac arrest and /or respiratory arrest). The form was signed by the resident's responsible party and a representative from the facility. Interview with Licensed Practical Nurse (LPN) #82 confirmed Resident #77's code status was listed as a Full Code on the Report Sheet. She revealed she would refer to a resident's status on the report sheet to determine…

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

Based on medical record review and staff interview, the facility failed to ensure a resident was provided a safe and orderly discharge. This affected one Resident (#338) of three residents reviewed for discharges. The facility census was 93. Findings include: Review of the medical record for Resident #338 revealed an admission date of 05/13/19 with diagnoses including chronic obstructive pulmonary (COPD), and generalized muscle weakness. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 05/20/19, revealed the resident had intact cognition. Review of Resident #338's physician order dated 06/13/19 revealed an order for the resident to discharge to home with home health care, nursing, and physical/occupational/speech therapy as needed, and seven days of medication. Review of provider note dated 06/13/19 revealed Resident #338's vital signs were obtained and they were within normal limits. There was no documentation as to how the resident was transported, if any education was given, if any medications were given, or any information regarding any follow 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 medical record review and staff interview the facility failed to assure the accuracy of the preadmission screening and resident review (PASARR) upon admission. This affected two (#13, and #21) of four residents reviewed for PASARR screens. The facility census was 93. Findings include: 1. Medical record review for Resident #21 revealed the resident was admitted [DATE]. Diagnoses included dementia with behavioral disturbance, anxiety disorder, insomnia, and schizophrenia. Review of the PASARR completed 03/28/18 in the hospital prior to admission to the facility noted the resident had a diagnosis of dementia but did not reflect the additional mental disorders listed on the cumulative diagnoses list. The PASARR was not updated on admission to accurately reflect the residents diagnoses of serious mental disorders and the resident was not been screened by the State-designated authority to receive Level II services. In addition, on 05/09/18 the diagnosis of major depressive disease had been added and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and resident and staff interview the facility failed to ensure care conferences were conducted on a quarterly basis and in addition the facility failed to update the care plan to reflect peripheral edema and use of ace wraps. This affected three (#26, #70, and #83) of three residents reviewed for care conferences and care plan revisions. The census was 93. Findings included: 1. Medical record review for Resident #70 revealed an admission date of 06/08/13 with diagnoses of chronic obstructive pulmonary disease, muscle weakness, anemia, Diabetes Mellitus Type II, hypokalemia, dysphagia, urinary incontinence, retention of urine, altered mental status, anxiety disorder, chronic allergic conjunctivitis, secondary hypertension, gastro-esophageal reflux disorder, cellulitis, and neuromuscular dysfunction of the bladder. Review of an annual comprehensive assessment dated [DATE] identified the resident with moderately impaired cognitive skills. Review of a physician order dated 11/08/18…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident and staff interview and review of the facility position summary for certified nursing assistants, the facility failed to ensure qualified staff provided treatments. This affected one (Resident #70) of 22 residents reviewed for care and services during the investigative phase of the survey. The facility census was 93. Findings include: Medical record review for Resident #70 revealed an admission date of 06/08/13 with diagnoses: chronic obstructive pulmonary disease, muscle weakness, anemia, Diabetes Mellitus Type II, hypokalemia, dysphagia, urinary incontinence, retention of urine, altered mental status, anxiety disorder, chronic allergic conjunctivitis, secondary hypertension, gastro-esophageal reflux disorder, cellulitis, and neuromuscular dysfunction of the bladder. Review of an annual comprehensive assessment dated [DATE] revealed the resident had moderately impaired cognitive skills. Review of a physician progress note dated 11/08/19 revealed the 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 medical record review, observation, resident and staff interview and review of the facility position summary for certified nursing assistants, the facility failed to ensure a physician order was implemented correctly and failed to ensure the appropriate staff provided treatments. This affected one (Resident #70) of 22 residents reviewed for care and services during the investigative phase of the survey. The facility census was 93. Findings include: Medical record review for Resident #70 revealed an admission date of 06/08/13 with diagnoses: chronic obstructive pulmonary disease, muscle weakness, anemia, Diabetes Mellitus Type II, hypokalemia, dysphagia, urinary incontinence, retention of urine, altered mental status, anxiety disorder, chronic allergic conjunctivitis, secondary hypertension, gastro-esophageal reflux disorder, cellulitis, and neuromuscular dysfunction of the bladder. Review of an annual comprehensive assessment dated [DATE] revealed the resident had moderately impaired cognitive skills.…

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, observations, and staff interview, the facility failed to properly care for a resident's urinary catheter. This affected one (Resident #36) of two residents reviewed for urinary tract infections (UTIs). The census was 93. Findings include: Review of Resident #36's medical record revealed an admission date of 07/27/19. Diagnoses included urinary retention, stage three kidney disease, neoplasm of prostate, neuropathic bladder, obstructive uropathy, and UTI. Review of Resident #36's careplan for alteration in elimination of bladder indwelling urinary catheter dated as revised 11/13/19 revealed urinary drainage bag should be kept off the floor and tubing should be checked for proper positioning. Further review of the medical record revealed Resident #36 was currently being treated for a UTI, and had been treated for a UTI since admission to the facility. During an observation on 01/13/20 at 11:00 A.M. Resident #36 was ambulating in the hallway in his wheelchair. Resident #36's urinary catheter tubing was dragging on the floor beneath his wheelchair.…

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

Based on medical record review and staff interview the facility failed to provide enteral nutritional supplements per the physician orders. This affected one (Resident #21) of two residents reviewed for nutritional status. The total facility census was 93. Findings include: Medical record review for Resident #21 revealed an admission date of 04/26/18 with diagnoses of dementia with behavioral disturbance, major depressive disorder, hypertension, dysphagia, hyperlipidemia, age-related debility, gastro-esophageal reflux disorder, anxiety disorder, insomnia, hyperglycemia, paroxysmal atrial fibrillation, hemiplegia and hemiparesis, schizophrenia, and acute respiratory failure with hypoxia. Review of weight records revealed the resident weighed 132.1 pounds on 12/07/19 and 124.4 on 01/02/20, which was a significant weight loss of 5.83 percent (%) in 30 days. Review of physicians order dated 12/31/19 indicated tube feed TwoCal HN (a nutritionally complete, high calorie formula) as needed if the resident consumes less than 50% of meal by mouth. Review of current physician orders 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.

Based on closed medical record review, observation, staff interview, and review of medication information insert and review of facility policy, the facility failed to properly store medications. This affected one of two medication rooms and one former Resident's (#239) whose medications were being stored in a plastic bag in an office. The census was 93. Findings include: 1. Observation of the Oak and [NAME] medication room refrigerator on 01/16/20 art 1:28 P.M. revealed an opened bottle of influenza vaccine (Afluria) dated as opened 08/28/19. Review of an informational insert included in the Afluria medication box revealed after the stopper of the vial was pierced the vial should be discarded. Licensed Practical Nurse (LPN) #15 confirmed during an interview on 01/16/20 at 1:30 P.M. that the opened Afluria bottle was outdated and should be discarded. 2. Review of Resident #239's closed medical record revealed an admission date of 12/24/19. Diagnoses included hypertension, hyperlipidemia, type II diabetes mellitus, aphasia, and cholecystitis. Resident #239 was discharged on 12/29/19.…

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 medical records and staff interview, the facility failed to ensure accurate documentation of medications and treatments provided. This affected two (#64 and #70) of 22 residents reviewed during the investigative phase of the annual survey. The census was 93. Findings include: 1. Review of Resident #64's medical record revealed an admission date of 02/06/19. Diagnoses included end stage renal disease, diabetes mellitus type one, and right below the knee amputation. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 was cognitively intact. Review of physician orders dated 11/28/19 revealed to give Veltassa (potassium binding medication) on non-dialysis days, every day and night shift. Further review revealed an order dated 06/01/19 for dialysis chair time at 5:30 P.M. on Tuesdays, Thursdays, and Saturdays. Review of medication administration records (MAR) for December 2019 revealed Veltassa was documented as being administered in the morning and night…

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

Based on medical record review, staff interview, and review of the hospice contract, the facility failed to ensure the hospice plan of care and visit notes were available in the facility. This affected one (Resident #18) of one resident reviewed for hospice services. The facility identified four residents who received hospice services. The facility census was 93. Findings include: Medical record review for Resident #18 revealed an admission date of 08/08/17. Review of physician orders dated 05/15/19 revealed the resident was admitted to Hospice care with Hospice entity #103 with a terminal diagnosis of cerebral atherosclerosis. On 01/16/20 at 8:50 A.M., interview with Staff Licensed Practical Nurse (LPN) #82 and Unit Manager LPN #3 was conducted. They provided a notebook in which Hospice entity #103 left a check off list of when Hospice nurse aides and hospice licensed nurses were in the facility to visit and care for Resident #18. Both indicated the Hospice nurses enter their progress notes into the Hospice laptop. Both LPN's indicated the Hospice nurses did not leave progress…

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 medical records, observation, interviews and review of facility policy, the facility failed to follow infection control practices during medication administration. This affected one (Resident #8) of six residents observed during medication administration. The census was 93. Findings include: Review of Resident #8's medical record revealed an admission date of 01/30/14. Diagnoses included encephalitis, bipolar disorder, schizoaffective disorder, and muscle weakness. Medications being administered to Resident #8 was observed on 01/16/20 at 8:50 A.M. by Licensed Practical Nurse (LPN) #88. LPN #88 was observed leaving another residents room and pushing the medication cart to outside Resident #8's room. LPN #88 began removing medications from the medication cart for Resident #8. LPN #88 did not wash or sanitize his hands. LPN #88 popped medications from bubble pack medication cards into his bare hands and then placed them into a medication cup. LPN #88 removed four medications. These medications were sertraline 50 milligrams (mg), sertraline 25 mg, omeprazole 10 mg,…

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