Arbors At Fairlawn The

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and facility policy review, the facility failed to ensure appropriate orders and monitoring were in place regarding a urinary catheter. This affected one resident (#112) of two residents reviewed for urinary catheters. The facility census was 59. Findings include: Review of Resident #112's record revealed an admission date of 05/22/24 and diagnoses including Parkinson's disease without dyskinesia, ulcerative colitis, hypertension, iron deficiency anemia, anxiety, insomnia, constipation, depression and bipolar disorder. Review of Resident #112's admission minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #112 was moderately cognitively intact and had an indwelling catheter. Review of Resident #112's current physician's orders revealed there were no orders to change the urinary catheter bag monthly or as needed, to monitor urine from the indwelling catheter or to change the catheter as needed prior to 06/10/24. Interview on 06/10/24 at 10:10 A.M.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and review of the facility policy, the facility failed to ensure respiratory equipment was dated and monitored for routine replacement. This affected three residents (#19, #35 and #113) of four residents reviewed for respiratory care. The facility census was 59. Findings include: 1. Review of Resident #35's medical record revealed an admission date of 06/25/23 and diagnoses including depression, acute and chronic respiratory failure, malignant neoplasm of lower lobe, right bronchus or lung, chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea. Review of Resident #35's annual minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 was cognitively intact and used oxygen. Review of Resident #35's physician's orders as of 06/10/24 revealed an order dated 06/25/23 for oxygen at three liters/minute via nasal cannula continuous every day and night shift for COPD. No orders for replacing oxygen tubing on a routine basis were available in the medical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review the facility failed to monitor residents using anticoagulant and psychotropic medications. This affected one resident (#113) out of five residents reviewed for unnecessary medications. The facility census was 59. Findings include: Review of Resident #113's medical record revealed an admission date of 05/24/24 and diagnoses including type two diabetes, chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, chronic congestive heart failure, depression, insomnia and hyperlipidemia. Review of Resident #113's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #113 was cognitively intact and was coded as taking an antidepressant, a hypnotic medication, an anticoagulant, an antibiotic, a diuretic, an opioid and a hypoglycemic medication. Review of Resident #113's physician's orders as of 06/10/24 revealed an order dated 05/24/24 for Eliquis (anticoagulant) oral tablet five milligrams (mg) and an order dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of the facility policy and review of guidance from the Centers for Disease Control (CDC), the facility failed to ensure adequate signage was posted to instruct staff and visitors of proper precautions to take for a resident on enhanced-barrier precautions (EBP). This affected one resident (#112) of three residents reviewed for transmission-based precautions. The facility census was 59. Findings include: Review of Resident #112's record revealed an admission date of 05/22/24 and diagnoses including Parkinson's disease without dyskinesia, ulcerative colitis, hypertension, iron deficiency anemia, anxiety, insomnia, constipation, depression and bipolar disorder. Review of Resident #112's physician's orders on 06/10/24 revealed an order dated 05/24/24 for enhanced barriers while performing high-contact activity with the resident. No rationale for enhanced barrier precautions (EBP) was specified in the order. Observation on 06/10/24 at 9:52 A.M. revealed 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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, interviews, policy review, and review of the investigation notes for self-reported incident (SRI) #243949 the facility failed to prevent staff to resident abuse. This affected one resident (#32) of three residents reviewed for abuse. The facility census was 56. Findings Include: Review of the medical record for Resident #32 revealed an admission date of 01/27/24 with diagnoses including chronic osteomyelitis (infection of bone) of the left thigh, local infection of the skin and subcutaneous tissue, unstageable pressure ulcer, Sjogren syndrome (an immune system illness that mainly causes dry eyes and dry mouth), major depression, and history of respiratory failure. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #32 had intact cognition and minimal signs of depression. Further review of the MDS assessment 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 observations, interview, and record review, the facility failed to maintain a clean and sanitary kitchen and nursing unit refrigerator and ensure proper food storage. This had the potential to affect all residents. The facility census was 58. Findings include: Observations during the initial tour of the kitchen on 08/08/22 from 8:21 A.M. to 8:33 A.M. revealed a large icicle was hanging from the fan unit onto a box of food on a shelf down to a box of buns underneath the fan unit that was sitting on a crate and onto the floor in the walk-in freezer. The walk-in cooler had a slight unpleasant odor and there was a large white bucket of pickles that was uncovered sitting on the top shelf on the left hand side of the cooler. There was food debris on the floor between the oven and steamer and on two light fixtures above the stove were heavily coated in greased dust. The reach-in cooler close to the kitchen door had a large white splatter on the inside bottom. Interview on 08/08/22 between 8:21 A.M. to 8:33 A.M. with [NAME] #164 verified the findings. Observation on 08/09/22 at…

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

Based on observation and interview, the facility failed to ensure the residents' environment was maintained in a clean, sanitary, homelike condition and in good repair. This had the potential to all residents. The facility census was 58. Findings include: Observation on 08/08/22 at 9:40 A.M. of Resident #50 privacy curtain revealed various dried stains. Observation on 08/08/22 at 3:21 P.M. of Residents #52 and #59's room revealed the door of the armoire to the right and the door of the armoire closer to the room door did not stay shut. Resident #52's bedside tray table was in disrepair. The hot water handle in the bathroom was missing and the floor was dirty. The blinds in the window were in disrepair and under the window near the molding, the wall was cracked. Observation and interview on 08/10/22 from 8:27 A.M. to approximately 8:35 A.M. with Housekeeping Supervisor (HS) #169 of Resident #59's bathroom revealed the floor was dirty. HS #169 verified the observation but stated the dark areas of the floor was floor damage but the dark areas in the entryway of the bathroom was wax…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain infection control and infection prevention guidelines for community equipment. This affected one resident (Resident #3) out of 15 residents (Residents #3, #14, #18, #20, #21, #24, #28, #33, #37, #45, #48, #49, #50, #57) with an active physician order to monitor blood sugar. The facility failed to ensure proper hand hygiene during medication administration. This affected one resident (Resident #3) and had the potential to affect all facility residents. The facility failed to ensure staff donned proper personal protective equipment (PPE). This affected one Resident (Resident #49) and had the potential to affect all facility residents. The facility census was 58. Findings include: 1. Observation on 08/10/22 at 7:40 A.M. of medication administration with Licensed Practical Nurse (LPN) #135 revealed no hand hygiene was observed after capillary blood draw of Resident #3. LPN #135 removed her protective gloves and proceeded to touch…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy the facility failed to ensure Residents #47 and #56 were treated with respect by facility staff. This affected two of three residents reviewed for respect and dignity, Resident's #47 and #56. The facility census was 58. Findings include: 1. Review of Resident #56's medical record revealed an admission date of 07/15/22 and diagnoses included dementia without behavioral disturbances, developmental disorder of scholastic skills, need for assistance with personal care and glaucoma. Review of Resident #56's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #56 was unable to complete an interview for cognitive status. Resident #56 required extensive assistance of two staff members for bed mobility, transfers, and toilet use. Review of Resident #56's care plan dated, 07/16/22 included Resident #56 had impaired cognitive function, dementia or impaired thought processes related to dementia, developmentally…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Resident #211 transfer notice contained the accurate state's information under the appeal rights. This affected one resident (#211) of two residents (#210 and #211) reviewed for hospitalizations. The facility census was 58. Findings include: Review of the medical record for Resident #211 revealed an admission date of 06/09/22 and a discharge date of 06/20/22. Diagnoses included acute embolism and thrombosis of deep veins of lower extremity, secondary malignant neoplasm of liver and intrahepatic bile duct, Alzheimer's disease, stage two pressure ulcer on the sacral region, and an unstageable ulcer on the right hip. Review of the admission minimum data set (MDS) assessment dated [DATE] revealed Resident #211 had severely impaired cognition and required extensive assistance of two staff for bed mobility, total dependence of two staff for transfers, and total dependence of one staff for toilet use. Review of the nurses' notes dated 06/20/22 timed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a bed hold notice was provided to Resident #211 upon hospitalization. This affected one resident (#211) of two residents (#210 and #211) reviewed for hospitalizations. The facility census was 58. Findings include: Review of the medical record for Resident #211 revealed an admission date of 06/09/22 and a discharge date of 06/20/22. Diagnoses included acute embolism and thrombosis of deep veins of lower extremity, secondary malignant neoplasm of liver and intrahepatic bile duct, Alzheimer's disease, stage two pressure ulcer on the sacral region, and an unstageable ulcer on the right hip. Review of the admission minimum data set (MDS) assessment dated [DATE] revealed Resident #211 had a severely impaired cognition and required extensive assistance of two staff for bed mobility, total dependence of two staff for transfers, and total dependence of one staff for toilet use. Review of the nurses' notes dated 06/20/22 timed 1:07 P.M. revealed therapy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, review of manufacturer instructions, and review of the facility policy, the facility failed to provide a safe mechanical lift transfer for Resident #24, ensure Resident #210 was provided appropriate assistance with bed mobility during incontinence care, and ensure vaping supplies were kept secured. This affected one resident (Resident #24) of 16 residents (Resident #1, #3, #4, #11, #13, #19, #22, #26, #41, #48, #49, #50, #51, #52, and #58) reviewed who required a mechanical lift for transfers, one resident (Resident #210) out of three residents reviewed for falls, and one resident (Resident #28) out of nine residents reviewed for smoking. The facility census was 58. Findings include: 1. Review of the medical record for Resident #24 revealed an admission date of 03/29/21 and a readmission date of 10/26/21. Diagnoses included respiratory failure, paraplegia (paralysis in the lower half of the body), chronic pain, morbid obesity, heart disease, Covid-19, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility policy the facility failed to ensure one resident (Resident #300) known for wandering did not walk out of the facility unaccompanied by a staff member. This affected one resident (Resident #300) out of six residents (Resident's #5, #6, #7, #17, #21, #23) reviewed who were at risk for elopement. The facility census was 58. Findings include: Review of Resident #300 medical record revealed an admission date of 12/21/21 and diagnoses included Alzheimer's disease, atrial fibrillation, and unsteadiness on feet. Resident #300 was transferred to a sister facility with a secured unit on 06/09/22. Review of Resident #300's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #300 had severe cognitive impairment and required extensive assistance of one person for locomotion on the nursing unit. Further review revealed Resident #300 was not steady when walking but able to stabilize without staff assistance. Review of 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 record review and interview, the facility failed to ensure an antipsychotic as needed medication was not ordered beyond 14 days without first re-evaluating the resident, and ensure all psychotropic medications were reviewed to ensure the appropriateness of their use. This affected one resident (Resident #44) of five residents reviewed for unnecessary medications. The facility census was 58. Findings include: Record review on 08/09/22 of Resident #44 revealed the resident was admitted to the facility on [DATE] with medical diagnoses including pathological fracture in neoplastic disease, right femur; malignant neoplasm of colon, liver and interscholastic bile duct; anxiety disorder; major depressive disorder, and retention of urine. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #44 had intact cognition. Review of physician orders for June, July and August 2022 revealed Resident #44 was ordered the antipsychotic medication Prochlorperazine Maleate (Prochlorperazine…

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

Based on observation, interview, and record review, the facility failed to prepare, store and distribute food in a sanitary kitchen environment. This affected 80 of 81 residents receiving meals from the kitchen. The facility identified Resident #52 as not receiving food by mouth. Findings include: 1. Observation of the kitchen on 08/12/19 from 8:30 A.M. to 8:53 A.M. with Dietary Manager (DM) #600 revealed in the walk-in cooler, three of the five blower fans were coated in dust. In the dry storage room, one box of cornbread was noted to be dated 09/24/18. Observation of the hood over the flat-top grill revealed a sticker indicating the hood had last been cleaned on 02/28/19 and a cobweb was noted on the right-most light over the hood. In the dish room, the log to left of the high-temperature dish machine to record dishwasher temperatures was incomplete. Observation of a dishmachine temperature log for August 2019 revealed there were spaces for staff to document temperatures three times daily. There were only breakfast temperatures recorded on 08/01/19, 08/02/19, 08/03/19, 08/04/19,…

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 observation, interview and menu spreadsheet review the facility failed to ensure meals were provided as planned on the menus. This affected three residents (Resident #43, Resident #62 and Resident #85) of three residents on a pureed diet and one resident (Resident #6) of one resident on a level-II mechanically altered diet. The facility census was 81 residents. Findings include: Review of the spreadsheet titled, Week 4, Day 3 corresponding to 08/13/19 revealed residents receiving a pureed diet were to receive a #12-scoop of pureed pork, a #8-scoop of pureed potatoes, a #16-scoop of pureed cauliflower, a #16-scoop of pureed bread and a #10-scoop of pureed peanut butter brownie. The spreadsheet indicated residents receiving a level-II mechanically altered diet were to receive ground garlic pork, soft mashed potatoes, soft mashed cauliflower, a #16-scoop of pureed bread and a #10-scoop of pureed peanut butter brownie. The level-II mechanically altered diet consisted of moist and soft foods; meats were to be minced and moistened with sauces or gravies. Observation of lunch tray…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to maintain clean, functional and sanitary shower rooms. This affected Resident #41, Resident #56 and Resident #61 and affected four of four facility shower rooms, which had the potential to affect all residents residing in the facility, except for 13 residents receiving only bed baths (Residents #8, 9, 15, 29, 35, 40, 43, 48, 50, 52, 62, 70 and 80). Findings include: On 08/12/19 at 10:10 A.M. interview with Resident #41 revealed the 200 hall shower room fan was not functioning and had not been since their admission [DATE]). Resident #41 indicated the shower room gets so hot it is difficult to breath and the nurse aides almost pass out from the heat. Observation on 08/12/19 at 10:20 A.M. in the room of Resident #56 and Resident #61 revealed significant chipped paint, scrapes and scuff marks on the walls by both resident's beds. A large unpainted patched hole was noted on the wall next to the window. An interview with Housekeeper #615 at the time of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the physician was notified of abnormal glucose levels for Resident #33. This affected one of five residents reviewed for medications. Findings include: Review of the record of Resident #33 revealed she was admitted to the facility on [DATE] with diagnoses including diabetes mellitus. Review of her care plan for diabetes mellitus dated 01/13/16 and updated through 10/21/19 revealed interventions to include administration of diabetes medications as ordered, fasting serum blood sugar as ordered by physician, and for staff to monitor/document/report to the physician as needed any signs or symptoms of hyperglycemia or hypoglycemia. Review of Resident #33's current physician orders revealed an order for Lantus insulin (a long acting insulin to treat high blood sugar) to be administered twice a day, and for a routine dose of Novolog insulin, 21 units, to be given three times a day with meals. She also had an order dated 08/31/18 for Novolog insulin (a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to provide treatment to Resident #52's pressure ulcer per the physician orders. This affected one of one resident reviewed for pressure ulcers. Findings include: Review of Resident #52's medical record revealed the resident was re-admitted to the facility on [DATE] with diagnoses including osteomyelitis (infection in the bone) of the vertebra, sacral and sacrococcygeal region, dementia without behavioral disturbance, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (stroke) affecting the right dominant side. Review of Resident #52's physician orders revealed an order dated 07/22/19 for nursing staff to gently cleanse the wound and wound bed with normal saline, pat dry, lightly pack wound with Dakin's solution soaked gauze, and cover with an adhesive foam dressing twice daily and as needed. Review of Resident #52's pressure ulcer wound grid dated 08/08/19 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure Resident #52's medical record contained a physician order for oxygen therapy. This affected one of two residents reviewed for respiratory care. Findings include: Review of Resident #52's medical record revealed the resident was re-admitted to the facility on [DATE] with diagnoses including muscle weakness, dementia without behavioral disturbance, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (stroke) affecting the right dominant side. Review of Resident #52's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #52's current respiratory care plan revealed an intervention dated 06/13/19 for oxygen settings via nasal cannula as ordered by the physician. Review of Resident #52's medical record did not reveal a physician order for oxygen therapy. Observations at 08/12/19 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, interview and record review the facility failed to ensure Resident #50's medications and renal diet were provided as ordered by the physician. This affected one resident of one resident reviewed for dialysis services. Findings include: Review of Resident #50's medical record revealed an admission date of 05/07/18 with diagnoses including obesity, anemia, end stage renal (kidney) disease with dependence on dialysis, diabetes, and hypotension (low blood pressure). Review of a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #50 was alert and oriented with intact cognition and rejected care one to three days in the seven day review period. Review of a care plan dated 05/16/18 revealed Resident #50 received dialysis treatments on Tuesdays, Thursdays and Saturdays. Review of Resident #50's current physician orders revealed an order dated 08/08/19 directing staff to send all morning and afternoon medications to dialysis with the resident every Tuesday, Thursday and Saturday;…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. The facility error rate was 18.51%, with 5 errors in 27 opportunities. This affected two of four residents observed for medication pass (Resident #'s 2 and 52). Findings include: 1. Review of the record of Resident #2 revealed he was admitted to the facility on [DATE] with diagnoses including myasthenia gravis, gastroesophageal reflux disease and iron deficiency. An observation of medication pass for Resident #2 was made on [DATE] at 8:25 A.M. with Licensed Practical Nurse LPN #613. LPN #613 could not find the correct dose of Ferrous Gluconate (an iron supplement, ordered [DATE]), so LPN # 611, who was nearby, found a box of the medication for LPN #613. LPN #613 popped a tablet into the cup for the resident from a blister sealed package that was in a box. The package and the blister package all were marked with an expiration date of 02/19, (February 2019). LPN #613 then individually put all…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure Resident #50's medications were appropriately stored and labeled. This affected one resident of one resident reviewed for dialysis. Findings include: Review of Resident #50's medical record revealed an admission date of 05/07/18 with diagnoses including obesity, anemia, end stage renal (kidney) disease with dependence on dialysis, diabetes, and hypotension (low blood pressure). Review of a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #50 was alert and oriented with intact cognition. Review of a care plan dated 05/16/18 revealed Resident #50 received dialysis treatments on Tuesdays, Thursdays and Saturdays. Interview with Resident #50 on 08/14/19 at 8:34 A.M. revealed the facility recently started sending medications with him to dialysis. Resident #50 stated he received medications when he returned to the facility after dialysis treatments and stated the dialysis center did not administer medications. 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.