Wright Rehabilitation And Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and policy review the facility failed to ensure a resident was sent out to the hospital in a timely manner after a fall with a fracture. This affected one (#90) of three residents reviewed for falls. The facility also failed to ensure incontinent care was provided per standard this affected one, (#38) of three reviewed for incontinent care and had the potential to affect the 58 residents the facility identified as being incontinent. The census was 89. Findings included: Medical record review for Resident #90 revealed an admission date of 12/20/24. Admitting diagnoses were multiple fractures of ribs with routine healing, ulcerative colitis, non-Alzheimer's dementia, anxiety, and depression. Review of admission Minimum Data Set (MDS) dated [DATE] revealed Resident #90 was moderately cognitively impaired. Her functional status was set up or clean-up assistance for eating, toileting, bed mobility, and transfers were partial/moderate assistance. She was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview and policy review the facility failed to ensure an X-ray was ordered and implemented in a timely manner. This affected one (#90) of three residents reviewed for X-rays. The census was 89. Findings included: Medical record review for Resident #90 revealed an admission date of 12/20/24. Admitting diagnoses were multiple fractures of ribs with routine healing, ulcerative colitis, non-Alzheimer's dementia, anxiety, and depression. Review of admission Minimum Data Set (MDS) dated [DATE] revealed Resident #90 was moderately cognitively impaired. Her functional status was set up or clean-up assistance for eating, toileting, bed mobility, and transfers were partial/moderate assistance. She was frequently incontinent with her bowel and bladder. Review of the physician orders dated 01/17/25 revealed a Stat X-ray of left knee, left femur, left hip, and unilateral with pelvis when performed. Review of the progress notes from 01/17/25 at 4:45 P.M. to 01/18/25 11:48 A.M. there…

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 interview and policy review the facility failed to ensure proper infection control was maintained during incontinence care. This affected one (#38) of three residents reviewed for incontinence. The facility identified there were 58 residents who were incontinent. The census was 89. Findings included: Medical record review for Resident #38 revealed an admission date of 09/06/17. Medical diagnoses included diabetes, renal insufficiency, and seizure disorder. Review of the quarterly minimum Data Set (MDS) dated [DATE] revealed Resident #38 was severely cognitively impaired. Her functional status was substantial/maximal assistance for eating and transfers, dependent on toileting, partial/moderate assistance for bed mobility. She was coded on this assessment as being always incontinent for bowel and bladder. Review of the care plan dated 12/07/24 revealed Resident #38 was incontinent for bowel and bladder. Interventions included: assist for toileting needs, monitor…

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, interview, and policy review, the facility failed to follow physician orders for wound care dressing. This affected one (Resident #85) of three residents reviewed for wound care. The facility census was 83. Findings include: Review of the medical record revealed Resident #85 was admitted to the facility on [DATE] and was discharged on 08/03/24 . Diagnoses included unspecified fracture of the left lower leg, essential hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, hypothyroidism, hyperlipidemia, other heart failure, hypokalemia, generalized anxiety disorder, type II diabetes, and insomnia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. Resident #85 was at risk for skin breakdown. Review of the medical record revealed a physician's order dated 07/26/24 for ace wraps to stay on bilateral lower…

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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of Self-Reported Incidents, and staff interviews the facility failed to ensure resident medications were not misappropriated. This affected two (Residents #32, #84) of three reviewed for misappropriation. The facility census was 80. Findings include: 1. Review of the medical record for Resident #32 revealed an admission date of 06/11/22. Medical diagnoses included but were not limited to Chronic Obstructive Pulmonary Disease (COPD), type two diabetes mellitus, anxiety, and rheumatoid arthritis. Review of Resident #32's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 15, indicating intact cognition. Resident #32 required maximum assistance with toileting, bed mobility, transfers and supervision for eating. Review of physician orders for Resident #32 revealed an order for Oxycodone (pain…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure medications were given as ordered. This affected one (Resident #32) of three residents reviewed for medication administration. The facility census was 80. Findings include: Review of the medical record for Resident #32 revealed an admission date of 06/11/22. Medical diagnoses included but were not limited to Chronic Obstructive Pulmonary Disease (COPD), type two diabetes mellitus, anxiety, and rheumatoid arthritis. Review of Resident #32's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 15, indicating intact cognition. The resident required maximum assistance with toileting, bed mobility, transfers, and supervision for eating. Review of physician orders for Resident #32 revealed an order for Furosemide (diuretic) 40 milligrams (mg) daily, Levothyroxine (thyroid) 125 micrograms (mcg) daily, Omeprazole (reflux) 20 mg daily, Baclofen (pain) 10 mg every eight hours, Gabapentin…

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

Based on record review and staff interview, the facility failed to provide specific and specialized training staff working on the Memory Care unit. This had to potential to affect 15 (#11, #22, #23, #30, #40, #44, #47, #48, #49, #52, #53, #54 ,#58, #324 #325) of 15 residents residing on the Memory Care unit. The facility census was 78. Findings include: Employee record review revealed State Tested Nurse Assistant (STNA) #433 was hired on 10/18/21. Further review of the employee file for STNA #433 revealed no evidence of receiving training specific to the Memory Care Unit upon hire to the facility or since. Employee record review revealed STNA #479 was hired on 09/13/21. Further review of the employee file for STNA #479 revealed no evidence of receiving training specific to the Memory Care Unit upon hire to the facility or since. Employee record review revealed STNA #487 was hired on 02/27/23. Further review of the employee file for STNA #487 revealed no evidence of receiving training specific to the Memory Care Unit upon hire to the facility or since. Employee record review 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 observations, medical record reviews, staff and resident interviews, and policy review, the facility failed to ensure residents needs were met by answering call lights in a timely manner. This affected two (#124 and #126) of two residents reviewed for call lights. The facility census was 78. Findings included: 1. Medical record review for Resident #124 revealed an admission date of 03/0723, with diagnoses including stroke and arthritis. Review of 5-day admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #124 was cognitively intact. Her functional status was limited assistance for bed mobility and transfers. She was a supervision for eating and extensive assistance for toilet use. She was always continent for bowel and bladder. Observation on 03/13/23 at 1:49 P.M., revealed Resident #124 was in bed and pulled her call light because she had to go to the bathroom. At 1:54 P.M., Hospitality Aide (HA) #419 came into the room and asked what Resident #124 needed and Resident #124 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, staff interviews and policy review, the facility failed to honor a resident's choice and physician order related to advance directives. This affected one (#73) of three residents reviewed for advance directives. The facility census was 78. Findings include: Record review for Resident #73 revealed she was admitted to the facility on [DATE], and died at the facility on [DATE]. Her diagnoses included diabetes mellitus 2, hypoglycemia, cardiac murmur, altered mental status, essential primary hypertension, Alzheimer's Disease, and dysphagia. Review of Resident #73's care plan for code status, dated [DATE], revealed she was a full code. An intervention was listed as, periodically review advance directives with the resident/family, initiated [DATE]. Review of physician visit dated [DATE], for Resident #73 revealed the physician reviewed advanced directives during the visit. Implication of new code status reviewed with patient/representative and understanding was verbalized. Code status has been…

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 interviews, and policy review, the facility failed to complete an investigation related to potential misappropriation of a resident's personal belongings. This affected one (#46) of three residents reviewed for potential misappropriation. The facility census was 78. Findings include: Record review for Resident #46 revealed she was admitted to the facility on [DATE]. Her diagnoses included diabetes mellitus 2, cellulitis, benign neoplasm of colon, gastro-esophageal reflux disease, chronic kidney disease, pneumonia, osteomyelitis, and insomnia. Review of the admission Minimum Data Set (MDS) assessment, dated 01/24/23, revealed Resident #46 was cognitively intact. Further review of the MDS assessment revealed Resident #46 required extensive assistance from staff with transfers, dressing, toilet use, and personal hygiene. Resident #46 required limited assistance from staff with eating. Interview on 03/13/23 at 11:34 A.M., with Resident #46 revealed the resident reported…

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 the medical record and staff interview, the facility failed to ensure residents were screened for Preadmission Screening and Resident Review (PASARR) services upon admission and after new diagnoses for serious mental illness. This affected two(#36 and #59) of two residents reviewed for PASARR. The facility census was 78. Findings include: 1. Review of the medical record revealed Resident #36 admitted to the facility on [DATE], diagnoses that included chronic obstructive pulmonary disease, acute on chronic combined congestive heart failure, morbid obesity, type II diabetes, unspecified dementia, unspecified bipolar disorder, unspecified anxiety disorder, unspecified major depressive disorder and paranoid schizophrenia ([DATE]). Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 36 was cognitively intact, had no behaviors, did not wander, and did not reject care. Resident #36 was a two-person assist, required supervision with eating, and required…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff and resident interview, the facility failed to develop a care plan to meet a resident's dental needs. This affected one (#41) of 24 residents reviewed for care plans. The facility census was 76. Findings included: Review of the medical record for Resident #41 revealed an admission date of 06/23/21, with diagnoses that included cerebral infarction due to unspecified stenosis of the right middle cerebral artery, chronic obstructive pulmonary disease, unspecified protein calorie malnutrition, unspecified chronic kidney disease, and unspecified major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was cognitively intact, had no behaviors, did not wander and did not reject care. Resident #41 was a one-person assist. Resident #41 required extensive assistance with bed mobility and supervision with all other Activities of Daily Living (ADL's). Review of the care plans dated 06/06/22 revealed Resident #41 had no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interviews, and policy review, the facility failed to hold timely care conferences. This affected two (#21 and #36) of 24 residents reviewed for care conferences. The facility census was 78. Findings include: 1. Review of the medical record revealed Resident # 21 admitted to the facility on [DATE], with diagnoses that included hemiplegia/hemiparesis following nontraumatic subarachnoid hemorrhage, unspecified protein calorie malnutrition, chronic obstructive pulmonary disease, unspecified vascular dementia, and unspecified anxiety disorder. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Resident #21 was a one person assist, required extensive assistance with bed mobility, transfer, dressing, toileting, and personal hygiene, and supervision assistance with eating and locomotion. Review of the medical record revealed Resident #21 had…

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 policy review, the facility failed to ensure treatments were completed as ordered and obtain orders for a treatment. In addition, the facility failed to clean scissors prior to use and perform hand hygiene during wound care. This affected two (#6 and #46) of six residents reviewed for wound treatments. The facility census was 78. Findings include: 1. Review of the medical record revealed Resident #6 admitted to the facility on [DATE], with diagnoses that included unspecified interstitial pulmonary disease, type II diabetes, acute on chronic combined congestive heart failure, and unspecified stage III chronic kidney disease. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 6 was cognitively intact, had no behaviors, did not wander, and did not reject care. Review of the medical record revealed Resident #6 had physician orders dated 03/05/23, to cleanse right wrist skin tear with normal saline/pat…

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 to ensure wounds were assessed and staged timely and failed ot ensure pressure relieving devices were in place to prevent skin impairments. This affected two (#34 and #11) of five reviewed for pressure ulcers. The facility identified there were five pressure ulcers in the facility. The facility census was 78. Findings included: 1. Medical record review for Resident #34 revealed an admission of 09/07/22, with diagnoses that included other neurological conditions, heart failure, renal insufficiency, urinary tract infection, diabetes, hemiplegia and hemiparesis, cerebrovascular attack (CVA), anxiety, and depression. Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 revealed was cognitively intact, with functional status of extensive assistance for bed mobility, transfers, and toilet use with two-person assistance. Resident #34 eating was supervision and was frequently incontinent for bowel and…

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

Based on medical record review, observations, and staff interviews, the facility failed to implement fall prevention interventions for a resident. This affected one (#286) of one resident reviewed for accidents. The facility census was 78. Findings include: Record review for Resident #286 revealed an admission date of 12/27/22, with diagnoses that included cerebral infarction, anxiety, vascular dementia, polyarthritis, essential primary hypertension, and dysphagia. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 01/17/23 revealed Resident #286 had impaired cognition. Further review of the MDS assessment revealed Resident #286 required extensive assistance from staff with bed mobility, dressing, toilet use, and personal hygiene and required limited assistance from staff with eating. Review of the fall care plan for Resident #286 revealed, dycem to wheelchair, dated 03/15/23. Further review of the fall care plan for Resident #286 mat on floor next to floor next to bed when occupied, dated 12/28/22. Review of the fall report for Resident #286, dated 03/06/23 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, observation, staff interview, and policy review, the facility failed to provide care and treatment for incontinence care and ensure hand washing was completed post care. This affected one (#34) of one resident reviewed for incontinence care. The facility identified there was 51 incontinent residents. The facility census was 78. Findings included: Medical record review for Resident #34 revealed an admission of 09/07/22, with diagnoses that included other neurological conditions, heart failure, renal insufficiency, urinary tract infection, diabetes, hemiplegia and hemiparesis, cerebrovascular attack (CVA), anxiety, and depression. Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 revealed was cognitively intact, with functional status of extensive assistance for bed mobility, transfers, and toilet use with two-person assistance. Resident #34 eating was supervision and was frequently incontinent for bowel and bladder. Observation on 03/15/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and staff interview, the facility failed to ensure a resident received required dental services to meet the residents dental needs. This affected one (#41) of two residents reviewed for dental care. The facility census was 78. Findings include: Review of the medical record for Resident #41 revealed an admission date of 06/23/21, with diagnoses that included cerebral infarction due to unspecified stenosis of the right middle cerebral artery, chronic obstructive pulmonary disease, unspecified protein calorie malnutrition, unspecified chronic kidney disease, and unspecified major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was cognitively intact, had no behaviors, did not wander and did not reject care. Resident #41 was a one-person assist. Resident #41 required extensive assistance with bed mobility and supervision with all other Activities of Daily Living (ADL's). Review of the care plans dated 06/06/22…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, the facility failed to ensure residents meals do not include food identified as an allergy. This affected two (#21 and #42) of two residents reviewed for food allergies. The facility census was 78. Findings include: 1. Review of the medical record revealed Resident #21 admitted to the facility on [DATE], with diagnoses that included hemiplegia/hemiparesis following nontraumatic subarachnoid hemorrhage, unspecified protein calorie malnutrition, chronic obstructive pulmonary disease, unspecified vascular dementia, and unspecified anxiety disorder. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Resident #21 was a one person assist, required extensive assistance with bed mobility, transfer, dressing, toileting, and personal hygiene, and supervision assistance with eating and locomotion. Review of Resident #21's nutrition care plan,…

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

Based on observation, review of the facility's policy and staff interview, the facility failed to ensure a medication cart was locked. This had the potential to affect twenty-three of twenty-five residents who were independently mobile residing on the west hallway. The facility census was 75. Findings included: Observation on 02/09/20 at 9:11 A.M. of an unlocked and unattended medication cart on the west hall. There were two residents observed independently ambulating in their wheelchairs in the hallway at that time. Licensed Practical Nurse (LPN) #137 was observed sitting at the nursing station at the end of the hall. The medication cart was approximately half-way down the hallway. Interview on 02/09/20 at 9:12 A.M. with the Director of Nursing (DON) confirmed the west hall medication cart was unlocked and unattended. Review of the facility's policy titled, Storage and Expiration of Medications, Biologicals, Syringes and Needles, dated 12/01/07, revealed the facility should ensure all medications are securely stored in a locked cart or locked medication room that is inaccessible by…

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 the physician was notified of a resident's significant weight loss in a timely manner. This affected one (#35) of four residents reviewed for weight loss. The facility identified 10 residents with weight loss. Findings included: Medical record review for Resident #35 revealed an admission date of 09/13/19. Medical diagnoses included Alzheimer's disease. Review of Resident #35's weight history at the facility were as follows: • On 09/13/19, he weighed 167 pounds (lbs.) and this weight was striked out by Dietician #160 on 12/04/19 at 12:32 P.M. • On 10/03/19, he weighed 168 lbs. and this weight was striked out by Dietician #160 on 12/04/19 at 12:32 P.M. • On 10/05/19, he weighed 169 lbs. and this weight was striked out by Dietician #160 on 12/04/19 at 12:32 P.M. • On 11/01/19, he weighed 170 lbs. • On 11/02/19, he weighed 153 lbs. • On 12/01/19, he weighed 147 lbs. • On 12/02/19, he weighed 148 lbs. • On 01/02/20, he weighed 142 lbs. • On 01/20/20, he weighed 143 lbs. • On 02/02/20, he weighed 140 lbs. •…

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

Based on medical record review, staff interviews, review of the facility's Self-Reported Incident and review of the facility's abuse policy, the facility failed to implement their abuse policy by not thoroughly investigating an allegation of abuse and reporting an allegation of abuse to the State Survey Agency. This affected one (#35) of one resident reviewed for abuse. The facility census was 75. Findings included: Medical record review for Resident #35 revealed an admission date of 09/13/19. Diagnoses included Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/02/20, revealed he was moderately cognitively impaired. His functional status was extensive assistant for bed mobility, transfers, and toilet use and he was a supervision for eating. Review of Resident #35's progress notes, dated 12/23/19 at 6:55 A.M., written by Licensed Practical Nurse (LPN) #141, revealed at 6:50 A.M. a shower aide was about to give Resident #4 a shower when she heard the resident cursing at shower aide and Resident #35. Resident #4 called shower aide several vulgar…

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, review of the facility's Self-Reported Incident and policy review, the facility failed to ensure an allegation of abuse was reported to the State Survey Agency. This affected one (#35) of one resident reviewed for abuse. The facility census was 75. Findings included: Medical record review for Resident #35 revealed an admission date of 09/13/19. Diagnoses included Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/02/20, revealed he was moderately cognitively impaired. His functional status was extensive assistant for bed mobility, transfers, and toilet use and he was a supervision for eating. Review of Resident #35's progress notes, dated 12/23/19 at 6:55 A.M., written by Licensed Practical Nurse (LPN) #141, revealed at 6:50 A.M. a shower aide was about to give Resident #4 a shower when she heard the resident cursing at shower aide and Resident #35. Resident #4 called shower aide several vulgar names, including racial slurs. When LPN #141 attempted to intervene, the resident then called this 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 medical record review, staff interview, and policy review, the facility failed to ensure an allegation of abuse was thoroughly investigated. This affected one (#35) of one resident reviewed for abuse. The facility census was 75. Findings included: Medical record review for Resident #35 revealed an admission date of 09/13/19. Diagnoses included Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/02/20, revealed he was moderately cognitively impaired. His functional status was extensive assistant for bed mobility, transfers, and toilet use and he was a supervision for eating. Review of Resident #35's progress notes, dated 12/23/19 at 6:55 A.M., written by Licensed Practical Nurse (LPN) #141, revealed at 6:50 A.M. a shower aide was about to give Resident #4 a shower when she heard the resident cursing at shower aide and Resident #35. Resident #4 called shower aide several vulgar names, including racial slurs. When LPN #141 attempted to intervene, the resident then called this nurse a 'expletive'. Resident #4 was trying to stand up, out 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 observation, staff interview and record review, the facility failed to develop a person-centered plan of care for a resident who received oxygen. This affected one (Resident #32) of eighteen residents reviewed during the annual survey. The facility census was 75. Findings included: Review of Resident #32's medical record revealed an admission date of 03/13/16 with diagnoses including pneumothorax, generalized anxiety disorder, malignant neoplasm of the lungs, chronic obstructive pulmonary disease and dementia. Review of the physician order, dated 09/10/19, revealed orders to rinse and replace intake filter every week and to change oxygen tubing every twenty-eight days. On 11/29/19, an order to monitor oxygen saturation every shift. On 12/16/19, there were orders to have the humidification to the oxygen to be continuous and administer oxygen at two liters per minute per nasal cannula continuous. Review of the Minimum Data Set (MDS) assessment, dated 12/31/19, revealed the resident was ordered and received oxygen. Review of Resident #32's plan of care dated 12/31/19 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 record review, observation, review of the facility's policy and staff interview, the facility failed to hold activities that met the needs of the residents residing on the memory care unit. This affected three (Resident #10, #11, and #63) of three residents reviewed for activities. This had the potential to affect all 11 residents residing on the memory care unit. The facility census was 75. Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 08/10/16 with diagnoses including dementia with behavioral disturbance, Alzheimer's disease, and anxiety. Review of the quarterly Minimum Data S(MDS) assessment, dated 11/06/19, revealed the resident was rarely/never understood and required limited to extensive staff assist with all activities of daily living (ADL) aside from eating and walking in her room. Review of the activity care plan revealed the resident response to music activities, exercise, enjoys walking with staff, and interacting with other residents and needs one on one assistance in groups. The goal was for the resident 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, interview with staff and resident and policy review, the facility failed to ensure adequate supervision of a resident who had a history of smoking in the facility. This affected one (#6) of two residents reviewed for smoking. The facility identified eight residents who were independent smokers. Findings include: Medical record review for Resident #6 revealed an admission dated of 07/19/19. Medical diagnoses included coronary artery disease, heart failure, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/04/20, revealed the resident was cognitively intact. Review of the care plan, dated 7/19/19, revealed the resident was at risk for smoking related to disease and illness and/or injury. The smoking assessment was completed and the resident was deemed a safe and independent smoker. Interventions were to observe and report unsafe smoking practices. Review of the smoking assessments, dated 07/19/19 and 09/05/19, revealed he was…

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