Fox Run Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and review of facility policy the facility failed to ensure adequate infection control measures for indwelling catheters. This affected one (#22) of three residents reviewed for infection control. The facility census was 76. Findings include: Review of the medical record for Resident #22 revealed the resident was admitted on [DATE]. Diagnoses included chronic multifocal osteomyelitis right femur, pressure ulcer of right hip stage 4, quadriplegia, chronic kidney disease stage I, essential hypertension, major depressive disorder, and neuromuscular dysfunction of bladder. Review of the Minimum Data Set (MDS) assessment, dated 10/18/24, revealed the resident interview was not successful. Resident #22 required substantial assistance with eating, oral hygiene, and upper and lower body dressing. The resident had an indwelling catheter. Review of the most recent care plan revealed Resident #22 had a suprapubic catheter. The resident insists the catheter bag…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to ensure a resident was provided dignity during meal service. This affected one resident (#12) of one resident reviewed for meal assistance. The facility census was 78. Findings include: Review of medical record for Resident #12 revealed an admission date of 03/30/23 with diagnoses including but not limited to Alzheimer' disease, abnormal posture, depression, anxiety, dysphagia, and pseudobulbar affect. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had severe cognitive impairment. Resident #12 was dependent on staff for eating. Observation on 10/15/24 at 12:10 P.M. of meal time revealed State Tested Nursing Assistant (STNA) #302 placed Resident #12 at the table to feed the resident lunch. STNA #12 stood on the residents left side and began to feed Resident #12 applesauce. STNA #302 stopped feeding the resident to take another resident from the dining room. STNA #302 returned to the resident and resumed feeding 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 observations, resident and staff interviews, and review of the facility assessment, the facility failed to ensure there was sufficient staff to timely meet the resident's needs. This affected 13 residents (#1, #12, #15, #21, #31, #38, #56, #62, #65, #70, #72, #73, and #82) and had the potential to affect all 77 residents residing in the facility. Findings include: 1. Review of the resident council meeting minutes dated 01/25/24, 02/29/24, and 03/28/24, revealed concerns every month regarding nurses and state tested nursing aides (STNAs) turning off call lights, telling residents they will be back and do not come back, and with call lights not being answered timely. Interviews on 04/01/24 from 8:00 A.M. to 5:15 P.M. with Residents #1, #31, #38, #65, #73, and #82 revealed the residents had concerns related to long call light times with some reports stating call lights were up to two hours long. Resident #65 stated she really had to wait to have her call light answered. Resident #65 stated she takes herself to the bathroom because no staff were available, even though she knows…

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

Based on observations, staff interview, and review of facility policy, the facility failed to ensure adequate hand hygiene was performed during food service and failed to monitor food temperatures before serving meals. This had the potential to affect all residents in the facility except Resident #40 identified to receive no food from the kitchen. Findings include: 1. Observation on 04/01/24 at 11:52 A.M. revealed lunch meal service being served in the C hall kitchenette. Dietary Aide #212 was observed wearing disposable gloves while handling sandwich buns. While wearing disposable gloves, Dietary Aide #212 was observed leaving the kitchenette and using the gloved hand to use the door keypad and enter the storage/dish room. Dietary Aide #212 reentered the kitchenette and changed gloves without hand washing. After applying new disposable gloves, Dietary Aide #212 was observed touching drawer handles, microwave handles and keypad while wearing the gloves then picked up sandwich buns to continue serving lunch Interview on 04/01/24 at 12:52 P.M. with Dietary Aide #212 verified the lack…

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

Based on observations, resident interview and staff interview, the facility failed to serve residents in the dining room in a dignified manner. This affected five residents (#6, #8, #18, #39, and #66) of 23 residents in the dining room. The facility census was 76. Findings include: Observation in the A-hall dining room on 04/01/24 at approximately 11:50 A.M. revealed Resident #58, Resident #66, and Resident #8 were seated together at a table, Resident #39, Resident #37, and Resident #6 were seated together at a table,, and Resident #54, Resident #67, and Resident #18 were seated together at a table. Additional observation at that time revealed State Tested Nurse Aide (STNA) #319 handed a stack of meal order tickets to Dietary Aide #210 and stated the meal order tickets were in order by table. Observation and interview n 04/01/24 at 12:06 P.M. revealed Resident #58 was seated at a table with Resident #66 and Resident #8. Resident #58 received his meal. 12 minutes later on 04/01/24 at 12:18 P.M., an interview with STNA #272 confirmed Resident #58 had his meal and Resident #66 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 review of resident council minutes and staff and resident interviews, the facility failed to ensure resident concerns were resolved timely. This affected four residents (#12, #15, #21, and #62) who regularly attended the resident council meetings. The facility census was 77. Findings include: Review of the resident council meeting minutes dated 01/25/24, 02/29/24, and 03/28/24, revealed concerns every month regarding nurses and state tested nursing aides (STNAs) turning off call lights, telling residents they will be back and do not come back and with call lights not being answered timely. There was no evidence the facility responded to the resident's concerns regarding call lights. Interview on 04/01/24 at 10:37 A.M. with Resident #65 confirmed having to really wait to have call lights answered. Resident #65 stated she takes herself to the bathroom because no staff were available, even though she knows she shouldn't. Interviews on 04/03/24 at 1:26 P.M. during the Resident Council meeting, Residents #12 and #62 stated staff turns call lights off and say they will return but…

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

Based on observation and staff interview, the facility failed to ensure call lights were installed in every stall in a common restroom. This had the potential to affect 13 ambulatory residents (#5, #9, #15, #17, #21, #37, #47, #48, #59, #66, #67, #75 and #232) who could self-transfer. The facility census was 76. Findings include: Observation on 04/09/24 at approximately 7:30 A.M. revealed two accessible restrooms in the common area of the facility. One was designated for males and one for females. No other signage was posted around the restrooms. The access doors were unable to be locked. Further observation revealed the women's restroom had three stalls. A pull-cord was installed in the largest stall. No pull cord was accessible from the two smaller stalls. No pull cord was in the common bathroom area. Interview on 04/09/24 at 1:48 P.M. with Resident #21 revealed he used the common bathroom during Bingo. Interview on 04/09/24 at 2:00 P.M. with Resident #66 revealed she used the public restroom during group activities and would use whichever stall was available. Interview 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, medical record review, resident interview, and staff interview, the facility failed to timely respond to the resident's call light. This affected one (#70) of 18 residents observed for call lights. The facility census was 77. Findings include: Review of the medical record revealed Resident #70 was initially admitted on [DATE] and readmitted on [DATE]. Diagnoses included muscle weakness, difficulty in walking, pressure ulcer of left heel, right buttock, and left buttock, and osteoarthritis. Review of the Minimum Data Set (MDS) assessment, dated 03/06/24, revealed Resident #70 was cognitively intact. Resident #70 was dependent on staff for toileting, shower/bathing, upper and lower body dressing, and personal hygiene. The resident as frequently incontinent of urinary continence and bowel incontinence. Review of the most recent care plan revealed Resident #70 had an activities of daily living (ADL) self-care performance due to decreased mobility and incontinence. Resident #70 required one…

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

Based on record review, staff interview, and policy review, the facility failed to ensure the physician was notified of the resident's significant weight change. This affected one (Resident #27) of two residents reviewed for nutrition. The facility census was 77. Findings include: Review of the medical record for Resident #27 revealed a readmission date of 02/19/24. Diagnoses included acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure. Review of the Minimum Data Set (MDS) assessment, dated 02/23/24, revealed the resident was cognitively intact. Review of Resident #27's weights revealed the following weights were obtained: 192.0 pounds on 02/19/24 and 179.4 pounds on 03/20/24. This was a 6.56 percent (%) significant weight loss in less than one month. There was no documentation indicating the physician was notified of Resident #27's significant weight loss from 03/20/24 to 04/03/24. Interview on 04/04/24 at 12:03 P.M. with Dietary Tech #346 confirmed she reviews weight changes weekly and reports significant changes to the physician. Dietary Tech…

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 interview, the facility failed to develop a baseline care plan with the minimum necessary information to include activities of daily living (ADL) information for two residents (Resident #57 and #332), skins concerns, psychotropic medications and anticoagulation medication information for one resident (Resident #332). This affected two residents (Resident #57 and #332) of two residents reviewed for baseline care plan. The facility census was 77. Findings include: 1. Record review of Resident #57 revealed she admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, pain in right hip bursitis, and cerebral infarction due to unspecified occlusion or stenosis of unspecified middle cerebral artery. Review of the physician orders dated 01/12/24 revealed a pressure reducing cushion to chair when out of bed for prevention, monitor for signs and symptoms of bruising / bleeding-anticoagulant 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 record review, observation, staff interview, and policy review, the facility failed to ensure Resident #57 had a complete comprehensive care plan. This affected one (Resident #57) of 18 residents reviewed for comprehensive care plans. The facility census was 77. Findings include: Record review of Resident #57 revealed an admission date to the facility of 01/12/24. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, pain in right hip bursitis, and cerebral infarction due to unspecified occlusion or stenosis of the middle cerebral artery. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #57 was cognitively intact and had functional limitation impairment in range of motion to bilateral upper and lower extremities, required substantial assistance from staff with toileting hygiene, bathing, dressing, personal hygiene and was dependent on staff for bed mobility and transfers. Review of the current…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interview, record review, and review of the facility policies, the facility failed to ensure comprehensive care plans were updated timely. This affected two (#56 and #67) of 18 residents reviewed for comprehensive care plans. The facility census was 77. Findings included : 1. Review of the medical record for Resident #56 revealed an admission date of 11/17/22. The resident was admitted with diagnoses including urinary tract infection (UTI) and muscle weakness. The resident was discharged on 03/23/24 to hospital and readmitted on [DATE]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 had moderately impaired cognition. The resident required substantial or maximum assistance from staff for toileting and was always incontinent of bowel and bladder. Review of the physician's orders revealed an order dated 03/31/24 for check and change brief every two hours and as needed. Review of the care plan relative to bowel and bladder incontinence 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, resident and resident representative interview, and staff interview, the facility failed to ensure residents who were dependent on staff for activities of daily living (ADL) had their personal care needs met. This affected two (#10 and #64) of seven residents reviewed for ADL. The facility census was 77. Findings include: 1. Review of the medical record revealed Resident #10 was admitted on [DATE]. Diagnoses included muscle weakness, major depressive disorder, and psychotic disorder with hallucinations due to known physiological conditions. Review of the Minimum Data Set (MDS) assessment, dated 01/26/24, revealed the resident was severely cognitively impaired and required substantial/maximum assistance from staff with personal hygiene. Review of the most recent care plan revealed Resident #70 had ADL self care performance due to weakness and had impaired cognitive function/dementia or impaired though processes due to advanced age. Review of the shower task…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and review of the facility policies, the facility failed to ensure the interdisciplinary team reviewed falls timely, and interventions were developed and implemented timely. This affected one (#67) of two residents reviewed for falls. The facility census was 76. Findings include: Review of the medical record for Resident #67 revealed an admission date of 11/22/22 with diagnoses of dementia and hypertension. Review of the Nursing Fall Review assessment dated [DATE] revealed Resident #67 was at moderate risk for falls. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 had impaired cognition. Resident #67 had no falls since the previous assessment completed 11/30/23. Review of the current care plan for Resident #67 revealed she was at risk for falls and fall related injuries. An intervention was added 04/02/24 for assistance of one staff with toileting. Review of the progress notes dated 03/16/24 revealed Resident #67 was found on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident interview and staff interview, the facility failed to ensure the residents were provided incontinence care timely. This affected two (#56 and #72) of three residents reviewed for incontinence care. The facility census was 77. Findings include: 1. Review of the medical record for Resident #56 revealed admission date of 11/17/22. The resident was admitted with diagnoses including urinary tract infection (UTI) and muscle weakness. The resident was discharged on 03/23/24 to hospital and readmitted on [DATE]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 had moderately impaired cognition. The resident required substantial or maximum assistance from staff for toileting and was always incontinent of bowel and bladder. Review of the physician's orders revealed an order dated 03/31/24 to check and change brief every two hours and as needed. Review of the care plan relative to bowel and bladder incontinence revealed interventions…

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 interviews, and policy review, the facility failed to ensure staff used appropriate personal protective equipment (PPE) while in Resident #332's room who was positive for extended spectrum beta lactamase (ESBL) resistance. Additionally, the facility failed to ensure a resident's catheter bag was not on the floor. The affected two residents (Resident #34 and #332) observed during the annual survey. The facility census was 77. Findings include: 1. Review of the medical record for Resident #332 revealed an admission date of 03/27/24. Diagnoses included sepsis, urinary tract infection, extended spectrum beta lactamase (ESBL) resistance, infection and inflammatory reaction due to indwelling urethral catheter. Review of Resident #332's physician orders dated 03/27/24 revealed an order for Ertapenem (antibiotic) 1,000 milligrams intravenously daily related to sepsis, organism unspecified. Review of the Brief Interview for Mental Status (BIMS) dated 03/29/24 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 Based on medical record review, call light response log review, and resident and staff interview, the facility failed to ensure call lights were answered in a timely manner. This affected two (#8 and #14) of three residents reviewed for call light response times. The facility census was 75. Findings include: 1. Review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included diabetes, urinary tract infections, anemia, and sepsis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact and able to make all needs known. Interview with Resident #8 on 09/12/23 at 6:59 A.M. stated her call light can take up to one hour for staff to respond to and was too long to wait for help. Resident #8 stated she recently moved rooms, and call light response times were a bit better in her current location, but still took a long time for staff to answer. Review of facility call light response logs between 09/02/23 and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, review of infection control signage, and review of a facility policy, the facility failed to follow infection control precautions for a resident placed on enhanced barrier precautions. This affected one (#8) of three residents reviewed for infection control measures. The facility census was 75. Findings include: Review of Resident #8's medical record revealed the resident was re-admitted to the facility on [DATE]. Diagnoses included diabetes, sepsis, urinary tract infection, and anemia. Observation of Resident #8's room on 09/12/23 at 6:59 A.M. and 7:54 A.M. revealed the room did not have infection control signage posted on the door or near the room. Further observation of Resident #8 revealed the resident had a urinary catheter and the collection bag was located on the left side of the bed. Observation of Resident #8's room on 09/12/23 at 9:33 A.M. with Licensed Practical Nurse (LPN) #104 revealed there was a newly added sign which read, Enhanced Barrier Precautions,…

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

Based on observations, medical record review, resident and staff interviews, and policy review, the facility failed to assist residents who required assistance with activities of daily living (ADL) with showers and personal hygiene needs. This affected two (#19 and #39) of three residents reviewed for ADLs. The facility identified 70 residents who required assistance with bathing. The facility census was 73. Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 11/11/19. Diagnoses included atrial fibrillation, chronic obstructive pulmonary disease (COPD), anxiety, chronic kidney disease, and hypertension (HTN). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/07/23, revealed Resident #19 had moderate cognitive impairment and required extensive staff assistance with personal hygiene and was dependent upon staff for bathing. Review of the ADL care plan revealed Resident #19 required extensive staff assistance for bathing and personal hygiene. Review of the bathing records from 05/01/23 to 06/06/23 revealed Resident #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 medical record review, observation, staff interview, review of facility policy, and review of Centers for Disease Control and Prevention (CDC) guidance the facility failed to implement transmission based precautions for a resident when positive for a multi-drug resistant organism (MDRO) and receiving wound care. This affected Resident #4 of seven reviewed for transmission based precautions. The census was 73. Findings include: Review of Resident #4's medical record revealed an admission date of 12/31/18. Diagnoses included methicillin resistant staphylococcus aureus (MRSA) infection. Review of the physician orders revealed there was an order for culture drainage from left stump wound. Review of wound culture results dated 04/13/23 revealed light growth of MRSA. Further review of physician orders revealed no order for any transmission based precautions to be implemented on 04/13/23. Further review of the medical record revealed Resident #4 was discharged from the facility to a local hospital on [DATE]…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the facility's policy and staff and resident interview, the facility failed to follow their policy when resident's personal items were missing. This affected one resident (#90) of three residents reviewed for personal property. The facility identified seven residents with missing personal items in the last 60 days. The facility census was 104. Findings include: Review of the medical record for Resident #90 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cellulitis of the right lower leg, chronic kidney disease, difficulty walking, spinal stenosis, pain and muscle weakness. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/07/20, revealed the resident had no cognitive deficits, abnormal behaviors or rejection of care. The resident required extensive assistance with bed mobility, locomotion, dressing and personal hygiene and limited assistance with transfers, walking and toileting. Interview with Resident #90 on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview and review of facility policy, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurately completed regarding residents care needs. This affected two residents (#2 and #10) of 22 residents reviewed for accurate MDS assessments. The facility census was 104. Findings Include: 1. Review of Resident #2's medical record revealed an admission date of 06/30/17. Diagnoses included hemiplegia right side, aphasia, and cognitive communication deficit. Review of the MDS assessment, dated 01/13/20, revealed the resident as having clear speech. Review of Resident #2's current care plan revealed the resident has a communication problem related to expressive aphasia. Interventions included communication completed by lip reading, writing, communication board, and gestures. Observation on 02/04/20 at 1:41 P.M. of Resident #2 revealed the resident was unable to verbally express her needs. The resident had a communication picture book in her…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of the facility's policy and staff and resident interview, the facility failed to ensure a resident's plan of care had been updated to reflect the resident's non-compliance. This affected one (#12) of 22 residents reviewed for care plan accuracy. The facility census was 104. Findings include: Review of the medical record for Resident #12 revealed the resident was admitted to the facility on [DATE]. Diagnoses included hypertension, hydronephrosis with kidney and urethral stone obstruction and end stage renal disease, dependence on renal dialysis. Review of the physician orders, dated 04/12/18, revealed the resident was to be provided a renal diabetic diet. It further revealed the resident received dialysis services on Tuesdays, Thursdays and Saturdays. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/21/19, revealed the resident had no cognitive deficits, required supervision with eating with set up assistance, and received dialysis. Review of the 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident and staff interview, and facility policy review, the facility failed to implement a pressure relief device to prevent the development pressure sores for one resident (#10) and failed to accurately monitor a pressure ulcer for one resident (#47). This affected two (#10 and #47) of five residents reviewed for pressure ulcers. The facility identified eight residents who have pressure ulcers. The facility census was 104. Findings include: 1. Record review for Resident #10 revealed the resident was admitted to the facility on 01/03/ 19 with diagnoses including end stage renal disease with dialysis, Parkinson's disease, vascular dementia, seizure disorder and diabetes mellitus. Review of the annual Minimum Data Set (MDS) assessment, dated 01/09/20, revealed the resident had moderate cognitive impairment and he had no behaviors or rejection of care. The assessment stated he was at risk for skin breakdown with no current skin breakdown. Review of the plan of care,…

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

Based on record review, observation, staff interview, and review of the manufactures instructions for Flex Pen use, the facility failed ensure needles were primed prior to administration of insulin when using an insulin pen resulting in a significant medication error for one resident ( #11) of seven residents (#1, #11, #46, #65, #66, #88 and #90) identified as having insulin Flex Pens on the Aspen Hall. The facility census was 104. Findings include: During an observation of medication administration for Resident #11 on 02/04/20 at 5:00 P.M. revealed Registered Nurse (RN) # 224 placed a new needle on the Novolog Insulin flex pen. She dialed the amount to be injected to four units and injected the insulin into the residents left lower abdomen. She obtained a new needle for a Humulin 70/30 flex pen, dialed the the amount to 18 units, and injected the insulin into the resident's left lowered abdomen. During an interview with RN #224 at 5:10 P.M., she verified she did not prime the flex pen needles before administration of the Novolog and Humulin Insulin. She stated she did not know she…

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 communicate with the hospice provider to provide continuity of care for a resident. This affected one (#47) of one resident reviewed for hospice services. The facility identified four residents receiving hospice services. The facility census was 104. Findings include: Record review for Resident #47 revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, anxiety, hypertension, diabetes, major depression disorder and Vitamin B12 anemia. Review of the admission Minimum Data Set (MDS) assessment, dated 02/11/19, revealed the resident had short and long term memory loss. She was nonambulatory and was totally dependent on staff for all activities of daily living, She was assessed as receiving hospice services prior to admission to the facility and continues to receive services. Review of the plan of care, updated 12/04/19, stated Resident #47 has a terminal prognosis due to advanced Alzheimer'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.

Based on observation, resident and staff interviews, and facility policy review, the facility failed to clean a glucometer between use on two residents (#11 and #88). The facility identified seven residents as using the glucometer for finger stick blood sugars on the Aspen Unit. In addition, the facility failed to ensure infection control protocol was implemented for one resident (#16) observed to have a dinner tray served next to an urinal. The facility census was 104. Findings include: 1. Observation on 02/04/20 at 5:00 P.M. on the Aspen unit revealed Registered Nurse (RN) #224 lanced Resident #11's right thumb and obtained a drop of blood placing it on a glucometer strip. She disposed of the lancet and placed the glucometer on top of the medication cart. She did not clean the glucometer. After administering the resident's medication, she used the same glucometer to obtain a finger stick blood sugar on Resident #88. After obtaining a drop of blood on the glucometer strip from Resident #88, she placed the glucometer back on the medication cart. She administered medication 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.