Countryside Manor Nursing And Rehabilitation LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, the facility failed to ensure resident beds were properly maintained in a safe manner. This affected two (#5, #9) of 20 residents reviewed for safe integrity of beds in a facility census of 65. Findings include:1. Review of the medical record revealed Resident #5 admitted to the facility on [DATE]. Diagnoses included congestive heart failure, obesity, panic disorder, chronic respiratory failure, venous insufficiency, depression, atrial fibrillation, type 2 diabetes mellitus, hypertension, venous thrombosis and embolism. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 with intact cognition. no recorded behaviors and dependent on staff for the completion of activities of daily living including bed mobility. Review of the nursing plan of care dated 01/13/25 addressed activity of daily living (ADL) self-care performance deficit with an intervention including quarter upper bilateral side rails for bed mobility 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 observation, staff interview, and review of facility policy, the facility failed to ensure an adequate supply of clean linen was available to meet the residents' needs. This had the potential to affect all 46 (#32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, and #78) residents who resided on the third floor. The facility census was 76. Findings include:Interview on 02/26/26 at 7:27 A.M. with Certified Nursing Assistant (CNA) #137 revealed there was no linen available to wash the residents. CNA #137 revealed, at times, towels were used instead of wash cloths. Interview on 02/26/26 at 7:33 A.M. with CNA #189 revealed it was common to not have linens available and stated pillowcases have been used to wash residents. Observation on 02/26/26 at approximately 7:40 A.M. of the third floor linen storage revealed there were six towels and no wash cloths available for 46 residents. Interview on 02/26/26 at 8:04…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure residents were free from significant medication errors. This affected one (#47) of two residents reviewed for medication administration. The facility census was 76.Findings include:Review of the medical record revealed Resident #47 was admitted on [DATE]. Diagnoses included multiple sclerosis, Alzheimer's disease with late onset, essential hypertension, and hypertensive heart disease with heart failure. Review of the Minimum Data Set (MDS) assessment, dated 01/07/26, revealed the resident was moderately cognitively impaired and did not receive insulin. Review of a nursing progress note, dated 10/18/25 at 9:09 P.M., revealed the resident was given 15 milligram (mg) of glargine Lantus (long acting insulin) and it was not prescribed. The Nurse Practitioner (NP) was notified and gave an order to check the residents bp (not specified what this meant) every hour for six hours. The resident's current blood…

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, review of pharmacy documentation, and facility policy review, the facility failed to store resident insulin in a safe and sanitary manner. This affected nine of (#16, #22, #36, #41, #44, #53, #56, #59, and #272) 14 residents identified by the facility to receive insulin administration in a facility census of 69. Findings include: 1. Observation on 05/27/25 at 12:29 P.M. with Licensed Practical Nurse (LPN) #525 during review of medication storage of the third floor C medication cart discovered two insulin pens. One Lantus insulin pen prescribed to Resident #16 was open with no date when it was opened. A second insulin aspart pen prescribed for Resident #41 was marked as opened on 04/01/25. Interview with LPN #525 at the time of the observation identified pharmacy guidance documentation on the medication cart binder. The pharmacy guidance listed medications with shortened expiration dates. This included instructions indicating Lantus insulin and aspart insulin expired 28 days after opening or removing from refrigerator. LPN #525 confirmed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure services required by the state-designated mental health authority were provided to residents. This affected one (#18) of two residents reviewed for pre-admission screening and resident review (PASARR) requirements. The facility census was 69. Findings include: Review of the medical record revealed Resident #18 was admitted to the facility on [DATE]. Diagnoses included anxiety, depression, bipolar disorder, and psychophysiologic insomnia. Review of Resident #18's PASARR results, dated 12/16/24, revealed the resident was referred for a level II evaluation. Review of Resident #18's PASARR level II evaluation results dated 01/13/25 revealed a determination was made that the resident was approved for a nursing facility with specialized services. The nursing facility was required to provide the resident with specialized behavioral health services including a comprehensive psychiatric assessment in order 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, resident and staff interview, medical record review, and review of a facility policy, the facility failed to to ensure residents who required staff assistance with activities of daily living received adequate and timely care to maintain appropriate personal hygiene including nail care. This affected one (#46) of four residents reviewed who required assistance with nail care and personal hygiene. The facility census was 69. Findings include: Review of Resident #46's medical record revealed an admission date of 10/27/21. Diagnoses included profound intellectual disability, cerebral palsy, seizures, scoliosis, lactose intolerance, and gluten sensitivity. Review of Resident #46's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #46 was cognitively intact. Resident #46 required supervision or touching assistance with toilet use, bathing, dressing, and personal hygiene. Resident #46 displayed no behaviors during the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and interview, medical record review, review of a facility policy, and review of the Facility Assessment, the facility failed to provide an individualized activity program designed to meet the interests and care needs of residents with intellectual disabilities. This affected one (#46) of one residents reviewed for activities. The facility census was 69. Findings include: Review of Resident #46's medical record revealed an admission date of 10/27/21. Diagnoses included profound intellectual disability, cerebral palsy, seizures, scoliosis, lactose intolerance, and gluten sensitivity. Review of Resident #46's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #46 was cognitively intact. Resident #46 required supervision or touching assistance with toilet use, bathing, dressing, and personal hygiene. Resident #46 displayed no behaviors during the review period. Review of Resident #46's care plan revised…

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 interview, and facility policy review, the facility failed to ensure pressure ulcer prevention interventions were implemented as ordered by the physician. This affected one (#39) of three residents reviewed for pressure ulcer care and treatment in a facility census of 69. Findings include: Review of Resident #39's medical record revealed the resident admitted to the facility on [DATE] with the diagnoses including, Parkinson's disease with dyskinesia, transient ischemic attack, contracture of the right and left lower leg, vascular dementia, major depressive disorder, and normal pressure hydrocephalus. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was assessed with severe cognitive impairment, had resistive behaviors interfering with care, was assessed with delusions and hallucinations, had bilateral upper and lower extremity range of motion impairment, was dependent on staff for the completion of activities of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview, medical record review, and review of therapy documentation, the facility failed to ensure an individualized restorative program was implemented to ensure residents maintained range of motion and mobility. This affected one (#35) of one residents reviewed for limited range of motion and mobility. The facility census was 69. Findings include: Review of the medical record revealed Resident #35 was admitted to the facility on [DATE]. Diagnoses included acute and chronic respiratory failure, acute on chronic diastolic (congestive) heart failure, depression, and hemiplegia and hemiparesis following unspecified cerebrovascular disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], the quarterly MDS assessment dated [DATE], the quarterly MDS assessment dated [DATE], the significant change MDS assessment dated [DATE], and the quarterly MDS assessment dated [DATE], revealed Resident #35 had limited mobility on one side in both the upper 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, staff interview, and facility policy review, the facility failed to ensure timely incontinence care was provided. This affected one (#39) of three residents reviewed for incontinence care and treatment in a facility census of 69. Findings include: Review of Resident #39's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Parkinson's disease with dyskinesia, transient ischemic attack, contracture of the right and left lower leg, vascular dementia, major depressive disorder, and normal pressure hydrocephalus. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was assessed with severe cognitive impairment, had resistive behaviors interfering with care, had delusions and hallucinations, had bilateral upper and lower extremity range of motion impairment, was dependent on staff for the completion of activities of daily living, was incontinent of bowel and bladder, was at risk for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, dialysis communication documentation, and facility policy, the facility failed to ensure residents received physician ordered medication for residents receiving hemodialysis. This affected one (#38) of two residents reviewed for the administration of hemodialysis in a facility census of 69. Findings include: Review of Resident #38's medical record revealed the resident admitted to the facility on [DATE] with diagnoses including end stage renal disease, dependence on renal dialysis, chronic anemia, heart failure, hypotension, chronic pain, asthma, hypertension, and cardiac defibrillator. Review of the most current Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #38 with intact cognition and required partial to moderate assistance with activities of daily living. Review of the nursing plan of care dated 07/25/24 revealed the plan of care was revised to address Resident #38's risk for developing complications secondary to needing…

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 interview, and therapy documentation review, the facility failed to ensure residents received timely rehabilitation services. This affected one (#272) of three residents reviewed for rehabilitation services. The facility census was 69. Findings include: Review of the medical record for Resident #272 revealed an admission date of 05/15/25 with diagnoses of type II diabetes mellitus, bipolar disorder, and depression. Review of the comprehensive admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #272 had intact cognition, had limited range of motion to both sides of her lower extremities, was dependent for transfers and toileting, and required partial/moderate assistance for bed mobility. Review of the physician order dated 05/15/25 revealed Resident #272 should receive a physical therapy (PT), occupational therapy (OT), and speech therapy (ST) evaluation and treatment as needed. Review of Resident #272's PT evaluation and plan of treatment…

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 a McGeer criteria checklist, and policy review, the facility failed to ensure the facility's antibiotic stewardship program was appropriately implemented with use of antibiotic medications. This affected two (#22 and #59) of three residents reviewed for antibiotic use. The facility census was 69. Findings include: 1. Review of the medical record for Resident #22 revealed an admission date of 02/27/20 with diagnoses of dementia, hypertension, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/18/25, revealed Resident #22 was cognitively intact. Review of the urine culture obtained on 03/19/25, and reported on 03/22/25, revealed Resident #22's urine was positive for 10-15,000 colony forming units (CFU) per milliliter (ml) of Pseudomonas aeruginosa and 10-15,000 CFU/ml of Enterococcus faecalis. Interview on 05/29/25 at 11:31 A.M. with the Assistant Director of Nursing (ADON) revealed Resident #22 received the antibiotic doxycyline to treat a urinary tract infection (UTI) identified on 03/19/25.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility staff interview, and policy review, the facility failed to provide comprehensive nephrostomy care to a resident. This affected one (#47) of one resident reviewed for nephrostomy tubes. The facility identified one resident who had a nephrostomy tube used in his care at the facility. The facility census was 67. Findings include: Review of Resident #47's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included hydronephrosis, mild protein calorie malnutrition, and acute kidney failure. Review of the admission Minimum Data Set (MDS)3.0 assessment dated [DATE] revealed Resident #47 had mild cognitive impairment with no behaviors, nephrostomy tubes and was always continent of bowel. Resident #47 required maximal assistance with toileting, lower body dressing, and chair to bed transfers, moderate assistance with showering, and supervision with personal hygiene and bed mobility. Review Resident #47's care plan revealed the resident had nephrostomy…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, review of written statements, review of self-reported incidents, and review of a facility policy, the facility failed to report an allegation of potential abuse to the State Survey Agency as required. This affected one (#74) of three residents reviewed for abuse. The facility census was 73. Findings include: Review of Resident #74's medical record identified admission to the facility occurred on 02/14/24 with medical diagnoses including chronic obstructive pulmonary disease (COPD), emphysema, and history of methamphetamine withdraw. Review of Resident #74's medical record revealed on 02/28/24 at 6:17 P.M. the resident was noted with increased weakness and confusion. Further review of the progress notes 02/28/24 revealed Resident #74's confusion began on 02/27/24 following a fall. Resident #74 was sent to the hospital on [DATE] and was admitted with aspiration pneumonia. Resident #74 returned to the facility on [DATE], and review of hospital records revealed 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 THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, policy review, and review of facility corrective action, the facility failed to provide adequate supervision to prevent a resident elopement. This affected one (#38) of three residents reviewed for elopement. The facility census was 73. Findings include: Review of Resident #38's medical record identified she was admitted to the facility on [DATE] with medical diagnoses including Alzheimer's disease, schizoaffective disorder, schizophrenia, emphysema, and vascular dementia. Review of Resident #38's plan of care dated 02/07/20 revealed the resident was at risk for elopement and had interventions in place to prevent elopement included admission to the secured unit on the third floor and an electronic alarming devise placed to the resident's ankle. Further review of the plan of care revealed Resident #38 was not cognitively capable of making safe…

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 interview, review of a facility self-reported incident (SRI), and review of the facility investigation, the facility failed to ensure resident preferred bathing schedules were honored. This affected one (#09) of three residents reviewed for activities of daily living (ADLs). The facility census was 65. Findings include: Review of the medical record revealed Resident #09 was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus with foot ulcer, cellulitis, heart disease, dysphagia, arthritis, pain in left foot, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/18/23, revealed Resident #09 was cognitively intact. The resident was dependent on staff assistance for toileting, bathing, dressing, and putting on/taking off footwear. The resident had a diabetic foot ulcer with applications of ointments/medications and dressings to feet. Review of the plan of care, revised 10/09/23,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of a facility self-reported incident (SRI), review of the facility investigation, review of the witness statements, review of nursing staff schedules, review of local law enforcement records, resident interview, staff interview, review of a facility policy, and review of facility corrective action, the facility failed to ensure a resident received assistance with incontinence care in a timely manner. This affected one (#05) of three residents reviewed for incontinence care. The facility census was 65. Findings include: Review of Resident #05's medical record revealed the resident was originally admitted to the facility on [DATE]. Diagnoses included permanent atrial fibrillation, hypertension, epilepsy, vertigo, heart failure, muscle weakness, anxiety, and end stage renal disease. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident and staff interview, review of a facility self-reported incident (SRI), and review of the facility investigation, the facility failed to maintain adequate staffing to ensure a resident's preferred bathing schedule was honored. This affected one (#09) of three residents reviewed for activities of daily living (ADLs). The facility census was 65. Findings include: Review of the medical record revealed Resident #09 was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus with foot ulcer, cellulitis, heart disease, dysphagia, arthritis, pain in left foot, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/18/23, revealed Resident #09 was cognitively intact. The resident was dependent on staff assistance for toileting, bathing, dressing, and putting on/taking off footwear. The resident had a diabetic foot ulcer with applications of ointments/medications and dressings to feet. Review 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 medical record review, staff interview, and policy review, the facility failed to ensure care plans provided accurate activities of daily living (ADL) interventions. This affected four residents (#19, #39, #51, and #57) out of 16 resident care plans reviewed. The facility census was 64. Findings include: 1. Review of the medical record revealed Resident #19 was admitted on [DATE]. Diagnoses included cellulitis, COVID-19, paroxysmal atrial fibrillation, other forms of angina pectoris, visual hallucinations, chronic obstructive pulmonary disease, edema, chronic venous hypertension, anxiety disorder, major depressive disorder, hypertension, hyperlipidemia, and Barrett's esophagus with dysphasia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Resident #19 was identified as requiring extensive two person assistance for bed mobility and transfers. Review of the care plan dated 01/21/23 revealed Resident #19 was care planned for having ADL self-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 observation, staff interview, review of the facility's temperature logs, and review of the facility's posted guidance, the facility failed to ensure food items reached the appropriate internal temperature before serving the items to residents. This affected 12 residents (#04, #14, #15, #16, #17, #18, #34, #36, #42, #54, #57, and #214) out of 64 residents receiving meals in the facility. The facility census was 64. Findings include: Observation on 02/22/23 at 11:20 A.M. revealed the Dietary [NAME] (DC) #402 taking temperatures of all food items on the tray line in preparation for meal service. The temperature of mechanical soft Salisbury steak was 150 degrees Fahrenheit (F) and the temperature of the reheated, leftover lasagna was 148 degrees F. Interview on 02/22/23 at approximately 11:25 A.M. with the Dietary Manager (DM) #01 revealed the mechanical soft meat should be at least 155 degrees F. The DC #402 acknowledged the information but did not reheat the mechanical soft Salisbury steak. Interview on 02/22/23 at approximately 11:27 A.M. with the DC #402 confirmed the…

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

Based on observation, resident and staff interview, and policy review, the facility failed to ensure resident rooms were maintained in good repair. This affected one resident (#17) out of 64 residents reviewed. The facility census was 64. Findings include: Observation on 02/21/23 at 10:44 A.M. of the wall behind Resident #17's bed revealed the base of the head of the bed was in the wall, inside crumbing plaster. There was no plaster or debris on the floor. Observation on 02/22/23 at 11:32 A.M. revealed the wall behind Resident #17's bed continued to be in disrepair with a large hole in the plaster. Subsequent interview with Resident #17 revealed she had been concerned for mice, rats, and bugs coming through the wall but had not seen or heard any. Resident #17 stated her wall had been repaired once a while ago but has now been damaged for an unknown amount of time with no repair. Interview on 02/22/23 at 11:34 A.M. with State Tested Nursing Assistant (STNA) #702 verified there was a large deep hole at the head of Resident #17's bed. STNA #702 verified there was no debris on the floor…

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 family and staff interview, review of the medical record, review of the grievance log, review of the self reported incidents, and policy review, the facility failed to investigate allegations of misappropriation. This affected one resident (#01) out of one resident reviewed for misappropriation. The facility census was 64. Findings include: Review of the medical record for Resident #01 revealed an admission date of 04/18/19 with diagnoses of cerebral palsy, chronic obstructive pulmonary disease, depression, and type II diabetes mellitus. Review of the comprehensive minimum data set (MDS) assessment dated [DATE] revealed Resident #01 had slightly impaired cognition and required extensive assistance of two people for bed mobility, dressing, toilet use, and hygiene, was totally dependent on two staff for transfers, and was totally dependent on one staff for eating. Review of a progress note dated 12/25/22 revealed Resident #01's family spoke with staff about missing items in Resident #01's room. Further…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure resident assessments were accurate. This affected three residents (#20, #57, and #61) out of 22 residents reviewed for accurate assessments. The facility census was 64. Findings include: 1. Review of the medical record revealed Resident #20 was admitted on [DATE]. Diagnoses included unspecified diastolic (congestive) heart failure, hypoxemia, malignant neoplasm of endometrium, acute respiratory failure with hypoxia, heart failure, hypertension, chronic pain, generalized anxiety disorder, hypothyroidism, benign neoplasm or uterine tubes and ligaments. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of Section O of the assessment revealed hospice was not selected as a current special treatment, procedure, or program. Review of the physician order dated 11/02/22 revealed an order for hospice to follow resident care. Interview on 02/23/23 at approximately 9:00 A.M., with…

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, resident and staff interview, review of the medical record, and policy review, the facility failed to ensure a wound dressing was completed per physician orders. This affected one resident (#22) out of six residents reviewed for wound care. The facility census was 64. Findings include: Review of the medical record for Resident #22 revealed an admission date of 02/27/20 with diagnoses of acute respiratory failure with hypoxia, anxiety disorder, chronic fatigue, and neuromuscular dysfunction of bladder. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #22 had intact cognition and required extensive assistance of two people for bed mobility and dressing, extensive assistance of one person for hygiene, and was independent with setup help only for eating. Review of the a physician order dated 02/15/23 revealed Resident #22 should receive silvadene cream to open red areas on abdomen, and cover with bordered gauze dressing twice daily, once on each shift.…

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, review of the medical record, and review of the facility in-service, the facility failed to ensure staff reheated food to a safe temperature to prevent burns. This affected one resident (#16) out of one resident reviewed for hazards. The facility census was 64. Findings include: Review of the medical record for Resident #16 revealed an admission date of 01/15/19 with diagnoses of congestive heart failure, difficulty in walking, and unspecified dementia. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #16 had intact cognition and required extensive assistance of two people for bed mobility, transfers, dressing and toileting, extensive assistance of one person for hygiene, and was independent with setup help only for eating. Review of a physician order dated 12/16/22 revealed Resident #16 received a diet order of consistent carbohydrate and renal restrictions, mechanical soft textures, thin liquids, and chopped meats. Interview 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 observation, medical record review, staff interview, and facility urinary catheter care policy, the facility failed to ensure appropriate technique was implemented to prevent cross contamination. This affected one resident (#22) out of three residents identified with an indwelling urinary catheter. The facility census 64. Findings include: Resident #22 admitted to the facility on [DATE] with diagnosis including acute respiratory failure with hypoxia, anxiety disorder, chronic fatigue, neuromuscular dysfunction of bladder and other specified abnormal findings of blood chemistry. According to the minimum data set assessment (MDS) dated [DATE] assessed Resident #22 with intact cognition and required extensive assistance of two people for bed mobility and dressing, extensive assistance of one person for hygiene, and was independent with setup help only for eating. Further review revealed Resident #22 had an indwelling catheter. On 04/20/20 the physician ordered indwelling urinary catheter (Foley catheter)…

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 provide accurate documentation of wound care completed in the medical record. This affect resident two residents (#19 and #22) out of six residents reviewed for wound care. The facility census was 64. Findings include: 1. Review of the medical record revealed Resident #19 was admitted on [DATE]. Diagnoses included cellulitis, COVID-19, paroxysmal atrial fibrillation, other forms of angina pectoris, visual hallucinations, chronic obstructive pulmonary disease, edema, hypertension, anxiety disorder, major depressive disorder, hyperlipidemia, and Barrett's esophagus with dysphasia. Review of the Minimum Data Set (MDS) assessment, dated 01/24/23, revealed the resident was cognitively intact. Resident #19 required limited assistance with toilet use, personal hygiene and dressing and extensive assistance with bed mobility and transfers. Resident #19 was frequently incontinent of bowel and bladder and had a stage four pressure…

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

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure advanced directives listed in the medical record were accurate. This had the potential to affect two residents (#19 and #45) of three reviewed for advanced directives. The facility census was 54. Findings include: 1. Review of Resident #19's medical record revealed an admission date of 08/29/19 with diagnoses including pulmonary fibrosis, depressive disorder, epilepsy, chronic kidney disease, and pneumonia. Review of Resident #19's physician order dated 08/29/19 revealed an order for the resident to be a Full Code. Review of Resident #19's Do Not Resuscitate (DNR) identification form dated 09/18/19, revealed the resident was identified as having Do No Resuscitate Comfort Care (DNRCC). The DNRCC form was signed by the physician. Review of Resident #19's Medication Administration Record (MAR) dated November 2019 listed the resident as a Full Code. Review of Resident #19's information profile of the electronic medical record identified the resident's code status as full code.…

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 interview, staff interview, and review of facility policy, the facility failed to ensure all residents were given an opportunity to take part in the planning of his/her own care. This affected two residents (#22 and #39) of 25 residents reviewed. The facility census was 54. Findings include: 1. Medical record review revealed Resident #22 admitted to the facility on [DATE] with diagnoses including chronic ischemic heart disease, diabetes mellitus and hypertension. Further review revealed no documented evidence the resident was invited to attend and/or attended a care planning conference. Interview on 11/24/19 at 10:16 A.M., with Resident #22 revealed she had no recollection of being invited to or attending a care planning conference since her admission on [DATE]. Interview on 11/25/19 at 1:25 P.M., with the Social Service Director (SSD) #220 revealed she was responsible for scheduling care planning conferences with residents and/or resident's representatives. SSD #220…

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

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure a resident's pulse oximetry levels were monitored as ordered by a physician. This affected one Resident (#19) of six reviewed who were ordered to monitor pulse oximetry levels. The facility census was 54. Findings include: Review of Resident #19's medical record revealed an admission date of 08/29/19 with diagnoses including pulmonary fibrosis, chronic kidney disease, and pneumonia. Review of Resident #19's care plan dated 09/10/19 revealed the resident had been addressed as having altered respiratory status/difficulty breathing related to pulmonary fibrosis. Interventions included to monitor for increased respirations, decreased pulse oximetry, and increased heart rate. Review of Resident #19's physician order dated 11/16/19 revealed an order to wean off oxygen and keep pulse oximetry above 92%. Review of Resident #19's Treatment Administration Record (TAR) dated November 2019 revealed no evidence of any pulse oximetry levels documented. Interview on 11/25/19 at 9:34 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.